Fatal exertional rhabdomyolysis. Literature review and our experience in forensic thanatology

Methamphetamine-induced profound rhabdomyolysis and myoglobin cast nephropathy: A case report and a literature review

A 46-year-old male with a history of substance abuse was found dead in custody 30 hours post incarceration for a minor offense. The scene demonstrates the body lying in a prone position in the cell room, locked from the outside. No signs of violence were found at the scene. External examination revealed no significant injuries, except for multiple minor contusions and abrasions. The autopsy demonstrated only a moderate degree of bilateral pulmonary edema. No internal injuries were found, except for fractures in the three lower left ribs. Dark reddish-brown urine was detected in the urinary bladder. Histological examination revealed a diffuse tubular injury with intraluminal eosinophilic granular casts. The myoglobin cast demonstrated pale PAS staining with a granular appearance, Masson Trichrome staining demonstrated fuschinophilic deposits on the casts, and immunoperoxidase staining for myoglobin was strongly positive in the casts (the images will be displayed). Blood myoglobin and creatine kinase levels were elevated. These findings revealed profound rhabdomyolysis caused by several factors. Blood toxicology tests revealed lethal methamphetamine and amphetamine levels. All the findings were consistent with methamphetamine-induced severe rhabdomyolysis. Therefore, forensic pathologists should carefully search for gross and histological findings and conduct thorough laboratory investigations to diagnose this condition for complete medicolegal examination.

A case report of rhabdomyolysis and osteofascial compartment syndrome in a patient with hypothyroidism and diabetes

BACKGROUND

Hypothyroidism is frequent and has various forms of muscle involvement. We report the diagnosis and treatment of a case of rhabdomyolysis, bilateral osteofascial compartment syndrome (OCS) of the lower extremities, and peroneal nerve injury causing bilateral foot drop in a diabetic patient with hypothyroidism.

CASE PRESENTATION

A 66-year-old man with diabetes for 22 years was admitted because of drowsiness, tiredness, facial swelling, and limb twitching for 2 months, and red and swollen lower limb skin for 3 days. Serum creatinine kinase (CK), CK-MB, myoglobin (Mb), blood glucose, and HbA1c were elevated. TSH, thyroid peroxidase antibodies, and antithyroglobulin antibodies were elevated. FT3 and FT4 were low. Urine was dark brown. He was diagnosed with hypothyroidism, rhabdomyolysis, and OCS. CK, CK-MB, and Mb returned to normal after treatment with thyroid hormone, insulin, albumin infusion, ceftriaxone, ulinastatin, and hemofiltration, and the redness and swelling of the lower limbs were relieved, but the patient developed dropping feet. The patient recovered well but had to undergo rehabilitation.

CONCLUSION

Hypothyroidism may induce rhabdomyolysis, OCS, and other complications. This case reminds us of the importance of screening for hypothyroidism and strengthens the clinicians' understanding of the disease.

Electrocution Stigmas in Organ Damage: The Pathological Marks

BACKGROUND

Diagnostic criteria for electrocution related death are still a challenge in forensic pathology and it seems that the electrical mark is the only reliable evidence.

METHODS

A comparison of histological and morphological findings of skin and internal organs from an autopsy series of electrocution deaths with those mostly reported in literature as representative for electrocution.

RESULTS

The morphological changes of heart, brain and other main internal organs are still unspecific. Organ's damage observed in electrocution deaths shows a wide variability, not reliable for a certain diagnosis of electrocution. The electrical mark is still the golden standard for diagnosis of electrocution.

CONCLUSIONS

In electrocution related deaths, pathological findings of the main internal organs are not enough evidence to support with certainty a post-mortem diagnosis that a victim suffered an electrical damage. Although the organ histological changes are undoubtedly the starting point for a better understanding of the fatal even, the diagnosis of death from electrical damage is still a dark and unsolved chapter. The electrical mark still represents a fundamental indicator above all in the medical-legal field, but the identification of pathognomonic elements and signs not limited to the skin alone could be a valid help in the future, especially in unclear cases.

Neurological Sequelae in Patients with COVID-19: A Histopathological Perspective

BACKGROUND

Neuroinvasive properties of SARS-CoV-2 have allowed the hypothesis of several pathogenic mechanisms related to acute and chronic neurological sequelae. However, neuropathological correlates have been poorly systematically investigated, being retrieved from reports of single case or limited case series still.

METHODS

A PubMed search was carried out to review all publications on autopsy in subjects with "COronaVIrus Disease-19" (COVID-19). Among them, we focused on histological findings of the brain, which were compared with those from the authors' autoptic studies performed in some COVID-19 patients.

RESULTS

Only seven studies reported histological evidence of brain pathology in patients deceased for COVID-19, including three with reverse transcription-quantitative polymerase chain reaction evidence of viral infection. All these studies, in line with our experience, showed vascular-related and infection-related secondary inflammatory tissue damage due to an abnormal immune response. It is still unclear, however, whether these findings are the effect of a direct viral pathology or rather reflect a non-specific consequence of cardiovascular and pulmonary disease on the brain.

CONCLUSIONS

Notwithstanding the limited evidence available and the heterogeneity of the studies, we provide a preliminary description of the relationship between SARS-CoV-2 and brain sequelae. Systematic autoptic investigations are needed for accurate detection and adequate management of these patients.

Neurological Sequelae in Patients with COVID-19: A Histopathological Perspective

BACKGROUND

Neuroinvasive properties of SARS-CoV-2 have allowed the hypothesis of several pathogenic mechanisms related to acute and chronic neurological sequelae. However, neuropathological correlates have been poorly systematically investigated, being retrieved from reports of single case or limited case series still.

METHODS

A PubMed search was carried out to review all publications on autopsy in subjects with "COronaVIrus Disease-19" (COVID-19). Among them, we focused on histological findings of the brain, which were compared with those from the authors' autoptic studies performed in some COVID-19 patients.

RESULTS

Only seven studies reported histological evidence of brain pathology in patients deceased for COVID-19, including three with reverse transcription-quantitative polymerase chain reaction evidence of viral infection. All these studies, in line with our experience, showed vascular-related and infection-related secondary inflammatory tissue damage due to an abnormal immune response. It is still unclear, however, whether these findings are the effect of a direct viral pathology or rather reflect a non-specific consequence of cardiovascular and pulmonary disease on the brain.

CONCLUSIONS

Notwithstanding the limited evidence available and the heterogeneity of the studies, we provide a preliminary description of the relationship between SARS-CoV-2 and brain sequelae. Systematic autoptic investigations are needed for accurate detection and adequate management of these patients.

COVID-19: Brief check through the pathologist's eye (autopsy archive)

During the COVID-19 pandemic, many deaths occurred especially among the old patients with cardiovascular comorbidities. Many questions have been asked and few simple answers have been given. The autopsy data are few and the aspects often observed are pulmonary diffuse alveolar damage (DAD), myocarditis, acute myocardial infarction (AMI), and disseminated intravascular coagulation (DIC); these aspects are not only in COVID-19 but also in other viral infections and in sepsis. It should be considered that coronavirus with its pathological organ changes have already been described in the years preceding the pandemic.

Can COVID 2019 induce a specific cardiovascular damage or it exacerbates pre-existing cardiovascular diseases?

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SARS-CoV-2 causes acute respiratory distress syndrome (ARDS) and multiple organ failure until death.

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Myocarditis, myocardial infarction, arrhythmias, embolism, and DIC are the main complications in patients with cardiovascular comorbidities.

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SARSCoV-2 can worsen the clinical status of patients with pre-existing cardiovascular diseases and this may interfere with therapies.

A novel coronavirus SARS-CoV-2 causes acute respiratory distress syndrome (ARDS) with cardiovascular and multiple organ failure till death. The main mechanisms of virus internalization and interaction with the host are down-regulation or upregulation of the ACE2 receptor, the surface glycoprotein competition mechanism for the binding of porphyrin to iron in heme formation as well as interference with the immune system. The interference on renin–angiotensin–aldosterone system (RAAS) activation, heme formation, and the immune response is responsible for infection diffusion, endothelial dysfunction, vasoconstriction, oxidative damage and releasing of inflammatory mediators. The main pathological findings are bilateral interstitial pneumonia with diffuse alveolar damage (DAD). Because ACE receptor is also present in the endothelium of other districts as well as in different cell types, and as porphyrins are transporters in the blood and other biological liquids of iron forming heme, which is important in the assembly of the hemoglobin, myoglobin and the cytochromes, multiorgan damage occurs both primitive and secondary to lung damage. More relevantly, myocarditis, acute myocardial infarction, thromboembolism, and disseminated intravasal coagulation (DIC) are described as complications in patients with poor outcome. Here, we investigated the role of SARSCoV-2 on the cardiovascular system and in patients with cardiovascular comorbidities, and possible drug interference on the heart.

From quail to earthquakes and human conflict: a historical perspective of rhabdomyolysis

Rhabdomyolysis is a common cause of acute kidney injury, featuring muscle pain, weakness and dark urine and concurrent laboratory evidence of elevated muscle enzymes and myoglobinuria. Rhabdomyolysis is often seen in elderly and frail patients following prolonged immobilization, for example after a fall, but a variety of other causes are also well-described. What is unknown to most physicians dealing with such patients is the fascinating history of rhabdomyolysis. Cases of probable rhabdomyolysis have been reported since biblical times and during antiquity, often in the context of poisoning. Equally interesting is the link between rhabdomyolysis and armed conflict during the 20th century. Salient discoveries regarding the pathophysiology, diagnosis and treatment were made during the two world wars and in their aftermath. 'Haff disease', a form of rhabdomyolysis first described in 1920, has fascinated scientists and physicians alike, but the marine toxin causing it remains enigmatic even today. As a specialty, we have also learned a lot about the disease from 20th-century earthquakes, and networks of international help and cooperation have emerged. Finally, rhabdomyolysis has been described as a sequel to torture and similar forms of violence. Clinicians should be aware that rhabdomyolysis and the development of renal medicine are deeply intertwined with human history.

The dating of thrombus organization in cases of pulmonary embolism: an autopsy study

Background

Pulmonary embolism (PE) is associated to high mortality rate worldwide. However, the diagnosis of PE often results inaccurate. Many cases of PE are incorrectly diagnosed or missed and they are often associated to sudden unexpected death (SUD). In forensic practice, it is important to establish the time of thrombus formation in order to determine the precise moment of death. The autopsy remains the gold standard method for the identification of death cause allowing the determination of discrepancies between clinical and autopsy diagnoses. The aim of our study was to verify the morphological and histological criteria of fatal cases of PE and evaluate the dating of thrombus formation considering 5 ranges of time.

Methods

Pulmonary vessels sections were collected from January 2010 to December 2017. Sections of thrombus sampling were stained with hematoxylin and eosin. The content of infiltrated cells, fibroblasts and collagen fibers were scored using a semi-quantitative three-point scale of range values.

Results

The 30 autopsies included 19 males (63.3%) and 11 females (36.7%) with an average age of 64.5 ± 12.3 years. The time intervals were as follows: early (≤1 h), recent (> 1 h to 24 h), recent-medium (> 24 h to 48 h), medium (> 48 h to 72 h) and old (> 72 h). In the first hour, we histologically observed the presence of platelet aggregation by immunofluorescence method for factor VIII and fibrinogen. The presence of lymphocytes has been identified from recent thrombus (> 1 h to 24 h) and the fibroblast cells were peripherally located in vascular tissue between 48 and 72 h, whereas they resulted central and copious after 72 h.

Conclusions

After a macroscopic observation and a good sampling traditional histology, it is important to identify the time of thrombus formation. We identified histologically a range of time in the physiopathology of the thrombus (early, recent, recent-medium, medium, old), allowing to determine the dating of thrombus formation and the exact time of death.

Clinical trial number

NCT03887819.

Trial registration

The trial registry is Cliniclatrials.gov, with the unique identifying number NCT03887819. The date of registration was 03/23/2019 and it was “Retrospectively registered”.