Distinguishing true from pseudo hematoma in the cervical spinal canal using postmortem computed tomography

Spinal cord injury is difficult to detect directly on postmortem computed tomography (PMCT) and it is usually diagnosed by indirect findings such as a hematoma in the spinal canal. However, we have encountered cases where the hematoma-like high-attenuation area in the cervical spinal canal was visible on PMCT, while no hematoma was observed at autopsy; we called it a "pseudo hematoma in the cervical spinal canal (pseudo-HCSC)." In this retrospective study, we performed statistical analysis to distinguish true from pseudo-HCSC. The cervical spinal canal was dissected in 35 autopsy cases with a hematoma-like high-attenuation area (CT values 60-100 Hounsfield Unit (HU)) in the spinal canal from the first to the fourth cervical vertebrae in axial slices of PMCT images. Of these 22 had a hematoma and 13 did not (pseudo-HCSC). The location and length of the hematoma-like high-attenuation and spinal cord areas were assessed on reconstructed PMCT images, true HCSC cases had longer the posterior hematoma-like area and shorter the spinal cord area in the midline of the spinal canal (P < 0.05). Furthermore, we found that true HCSC cases were more likely to have fractures and gases on PMCT while pseudo-HCSC cases were more likely to have significant facial congestion (P < 0.05). We suggest that pseudo-HCSC on PMCT is related to congestion of the internal vertebral venous plexus. This study raises awareness about the importance of distinguishing true HCSC from pseudo-HCSC in PMCT diagnosis, and it also presents methods for differentiation between these two groups.

Kinetics and distribution of benzalkonium compounds with different alkyl chain length following intravenous administration in rats

Benzalkonium chloride is widely used in disinfectants. Several toxicological and fatal cases have been reported; however, little is known about its kinetics and distribution. We investigated the kinetic characteristics and distribution of benzalkonium cation (BZK) based on the length of the alkyl chains C12, C14, and C16. Rats were treated intravenously with BZK solution (dose, 13.9 mg/kg) containing equal amounts of the three homologues. Kinetic parameters in the blood were assessed, and BZK distribution in the blood and tissues was examined both in rapid intravenous (IV) and drip intravenous (DIV) administrations. BZK concentrations were analysed by liquid chromatography-tandem mass spectrometry (LC-MS/MS). BZK with longer alkyl chains showed lower elimination tendencies and remained in the blood for a longer duration. Concentrations of BZK were higher in the heart, lung, spleen, and kidney than those in the blood, and lower in the brain and fat. In both the IV and DIV groups, the lung, liver, spleen, and fat samples showed higher concentrations of the longer alkyl chains (BZK-C12 < -C14 < -C16), and the opposite trend was observed in the kidney (BZK-C16 < -C14 < -C12). Only the heart and muscle samples displayed the homologues in ratios comparable to the original administered solutions. Differences between IV and DIV groups could be identified by comparing concentrations of BZK homologues in the heart, lung, spleen, and kidney samples. We found that the kinetics and distribution of BZK were influenced by the alkyl chain length, and analysing each BZK homologues in blood and tissue samples may provide useful information.

The derivation of predictive equations to speculate the post-mortem interval using cases with over 20-mL pleural effusion: A preliminary study

Often, pleural effusion is noted at autopsy when the cause of death is drowning or diseases such as heart, renal and liver failure. Several studies have established a correlation between the concentrations of electrolytes in pleural effusion and the post-mortem interval (PMI) or those concentrations and drowning site. The present study aims to investigate the relationship between the amount of pleural effusion, concentrations of electrolytes and total protein in pleural effusion, by integrated interpretation using various factors such as the deceased's gender, age, cause of death, drowning site, PMI and body temperature. We included 40 cadavers (26 male, 14 female) with >20-mL pleural effusion, which were categorised into four groups as follows: freshwater drowning; brackish water drowning; seawater drowning (drowning group); and not drowning. An equation derived to assess the lung weight revealed that the drowning site affected the lung weight. An equation for the amount of pleural effusion in the drowning group for the first time revealed that the amount of pleural effusion was directly proportional to the PMI. Using an equation to assess the PMI, we could estimate the PMI within 13.0-13.2 h in cases with >20-mL pleural effusion. Despite a small number of cases in the present study, we attained exciting results from the integrated statistical analysis.

Predictive equation for post-mortem interval using spectrophotometric values of post-mortem lividity: A pilot study

The colour of post-mortem lividity and control skin of 86 cadavers was measured spectrophotometrically to obtain L^* (value), a^* (chroma) and b^* (hue) values. In addition, left heart blood (n = 58), right heart blood (n = 57) and blood from the femoral vein (n = 21) were measured. Using these data, we analysed the relationship between post-mortem lividity, control skin and blood colours. L^* of post-mortem lividity (L^*_p) and control skin (L^*_c) were strongly correlated ( r = 0.64). a^* and b^* of post-mortem lividity (a^*_p and b^*_p) significantly increased with an increasing post-mortem interval (PMI) but r² values were low (0.11 and 0.070, respectively). Predictive equations for post-mortem lividity colour (L^*_p, a^*_p and b^*_p) were developed using control skin colour (L^*_c, a^*_c and b^*_c) and autopsy findings for the first time. The predictive equation for L^*_p explained almost 65% of the observed L^*_p. We created predictive equations for PMI with and without blood colour values, and the most accurate equation, which did not use blood colour values, made it possible to estimate PMI within ± 10.29 h. Further study of these equations will help us to understand the factors that affect post-mortem lividity colour and increase the accuracy of equations for predicting post-mortem lividity colour and PMI.

Predictive equation to estimate post-mortem interval using spectrophotometric blood-colour values

Forensic pathologists use post-mortem phenomena to estimate the post-mortem interval (PMI). We have reported on the usefulness of post-mortem lividity spectrophotometric values to estimate PMIs. Here, we focused on blood colour, looking for associations between blood colour, age and PMI. We generated predictive equations for blood-colour values and the PMI. We included data from a total of 129 cadavers (84 males and 45 females). We measured the colour of 124 left ventricular blood ( L*_l, a*_l, b*_l), 123 right ventricular blood ( L*_r, a*_r, b*_r) and 57 femoral blood ( L*_f, a*_f, b*_f) samples. We found no significant associations between blood colour and age or between blood colour and the PMI, but the values of a*_l, b*_l, a*_r and b*_r were significantly increased with increased age, and those of L*_f, a*_f and b*_f were significantly decreased with increased PMI. We created equations to estimate blood colour. The equations for femoral blood colour had higher adjusted R² values and lower root mean square error values than those for left and right ventricular blood colours. We generated equations to estimate PMIs using blood-colour values and autopsy findings. Our estimated PMIs up to 67 hours had accuracies within 8.84 hours, without measuring post-mortem lividity colour or considering the age of the deceased. This is the first study to estimate PMIs based on blood-colour spectrophotometric values.

A fatal case of poisoning related to new cathinone designer drugs, 4-methoxy PV8, PV9, and 4-methoxy PV9, and a dissociative agent, diphenidine

A woman in her thirties was found dead on a bed. Considerable amounts of "aroma liquid" and "bath salt" products and hypnotic drug tablets were scattered beside the bed. Autopsy showed pulmonary congestion and edema. Gas chromatography-mass spectrometry (GC-MS) and liquid chromatography-mass spectrometry (LC-MS) analyses of "aroma liquid" and "bath salt" products showed the presence of new cathinone designer drugs, 4-methoxy PV8 (4-methoxy PHPP), PV9 (α-POP), and 4-methoxy PV9 (4-methoxy α-POP), and a dissociative agent, diphenidine. Drug screening in stomach contents, blood and hydrolyzed urine of the woman by GC-MS and liquid chromatography-tandem mass spectrometry (LC-MS/MS) revealed the presence of the above 4 types of drugs and 3 types of benzodiazepines, triazolam, flunitrazepam, and nitrazepam, and their metabolites. The above 7 drugs and 3 benzodiazepine metabolites were simultaneously determined by LC-MS/MS after modified QuEChERS (Quick, Easy, Cheap, Effective, Rugged, Safe) extraction using diazepam-d5 as the internal standard. The concentrations of 4-methoxy PV8, PV9, 4-methoxy PV9, and diphenidine in the femoral blood were 2.69, 0.743, 0.261, and 1.38μg/ml, respectively, which were significantly higher than concentrations reported in previous cases. Alcohol concentration in the femoral blood was 1.52mg/ml. Based on the pathological and toxicological findings, the cause of death was determined to be 3 types of cathinone drugs, 4-methoxy PV8, PV9, and 4-methoxy PV9, and diphenidine poisoning under the influence of 3 benzodiazepines and alcohol.

[An Autopsy Case of Abnormal Behaviour Induced by Zolpidem]

Zolpidem is a widely used ultrashort-acting non-benzodiazepine in clinical practice; compared with benzodiazepines, it does not have side effects such as daytime hangover, rebound insomnia, and development of tolerance. We report an autopsy case of abnormal behaviour induced by zolpidem. A man in his 60's had suffered from postherpetic neuralgia about 2 months ago and had been prescribed zolpidem for insomnia. According to his family, he had no memory of his actions such as striking a wall, taking his futon outside, and eating 5 times a day after he took zolpidem. Because his postherpetic neuralgia did not improve, he was hospitalized and treated with an epidural block. During hospitalization, he took off his clothes, removed the epidural block catheter by himself, and slept on others' beds. He disappeared from the hospital one day; the next day, he was found dead in a narrow water storage tank 10 km away from the hospital. He was thought to have driven a car by himself to reach the place. Forensic autopsy revealed that the cause of death was drowning. Zolpidem and several other drugs were detected by toxicological analysis of his blood; the concentrations of these drugs were within therapeutic range. There are several reports about somnambulism induced by zolpidem such as sleepwalking, sleep driving, and eating. Considering the strange episodes following zolpidem administration, his behaviour on the day of his death was considered abnormal behaviour induced by zolpidem.

Medical neglect death due to acute lymphoblastic leukaemia: an autopsy case report

We report the case of 2-year-old girl who died of precursor B-cell acute lymphoblastic leukaemia (ALL), the most common cancer in children. She had no remarkable medical history. She was transferred to a hospital because of respiratory distress and died 4 hours after arrival. Two weeks before death, she had a fever of 39 degrees C, which subsided after the administration of a naturopathic herbal remedy. She developed jaundice 1 week before death, and her condition worsened on the day of death. Laboratory test results on admission showed a markedly elevated white blood cell count. Accordingly, the cause of death was suspected to be acute leukaemia. Forensic autopsy revealed the cause of death to be precursor B-cell ALL. With advancements in medical technology, the 5-year survival rate of children with ALL is nearly 90%. However, in this case, the deceased's parents preferred complementary and alternative medicine (i.e., naturopathy) to evidence-based medicine and had not taken her to a hospital for a medical check-up or immunisation since she was an infant. Thus, if she had received routine medical care, she would have a more than 60% chance of being alive 5 years after diagnosis. Therefore, we conclude that the parents should be accused of medical neglect regardless of their motives.

A familial case of ABO phenotype-genotype discrepancy

In the present study, we detected a familial case of ABO phenotype-genotype discrepancy. Although the observed phenotypes were B and O, the corresponding ABO genotypes were AB and AOG, respectively, by routine examination. Exons 6 and 7 of the ABO gene were sequenced and subsequently, the sequence of the allele responsible for ABO phenotype-genotype discrepancy was examined. Our results indicated that the Ax allele was present in 3 family members. By employing traditional serological methods, we further identified and confirmed that the allele Ax and the resulting Ax phenotype are responsible for ABO phenotype-genotype discrepancy.

An autopsy case of misdiagnosis based on postmortem computed tomography findings

A middle-aged man was found lying beside his bicycle on an early winter morning. The cause of death was diagnosed by clinicians as traumatic intracerebral hemorrhage and cerebral contusion with frontal bone fracture based on the findings of Computed Tomography (CT) of the head. However, forensic autopsy revealed that there were no evidences of intracerebral hemorrhage and left frontal bone fracture but the defect of golf ball size on the frontal lobe which was considered to be a complication from the old cerebral contusion and old bone fracture. The bleeding and pooling blood from subarachnoid hemorrhage (SAH) to the frontal lobe defect had the appearance of an intracerebral hemorrhage. Disruption of left renal artery was found and the cause of death was diagnosed as massive hemorrhage due to this rupture. Although postmortem CT is a useful tool for obtaining information on the body prior to conducting an autopsy, it should be used with extreme caution.

Expression of material mRNA in the hypothalamus and frontal cortex in a rat model of fatal hypothermia

Diagnosis of fatal hypothermia is considered to be difficult in forensic practice because of the lack of any specific pathological findings. The mechanism that induces abnormal behavior such as undressing or hiding during the state of hypothermia has not been clarified. In order to solve these problems, we made a rat model of fatal hypothermia and investigated the expression of some mRNA within the hypothalamus and the frontal cortex. The expression of aldehyde dehydrogenase 6 family, member A1 (ALDH6A1), cocaine- and amphetamine-regulated transcript peptide (CARTPT), desmin (DES), heat shock 70kDa protein 4 (HSPA4), serotonin receptor 2A (HTR2A), opioid receptor, delta 1 (OPRD1) and transthyretin (TTR) supposedly related to fatal hypothermia was determined using quantitative real-time PCR. The expression of OPRD1 in the hypothalamus of fatal hypothermia was significantly increased, while the expression of TTR within the frontal cortex was significantly decreased compared to that in the control. These findings suggest that OPRD1 and TTR may be involved in thermoregulation at a low ambient temperature.

A simple and sensitive method for the determination of propofol in human solid tissues by gas chromatography-mass spectrometry

Propofol is a widely used intravenous agent for induction and maintenance of anesthesia and for sedation in intensive care patients, but it is also associated with abuse and dependency. A simple and sensitive method for the determination of propofol in human whole blood, brain, liver, and adipose tissue by gas chromatography-mass spectrometry using selected-ion monitoring mode is described. Propofol was extracted from 0.2-mL or 0.2-g sample size by a single-step basic extraction procedure using 100 microL heptane with thymol (50 ng) as an internal standard. The calibration curves of the specimens were linear in the concentration range of 10-5000 ng/mL or ng/g, and the limit of detection was 2.5 ng/mL in blood, 5.0 ng/g in brain and liver, and 10 ng/g in adipose tissue. Absolute recovery of propofol was determined in three samples and averaged over 95% for blood and brain, 66% for liver, and 51% for adipose tissue. Within-day and between-day precision was measured in five samples each at 50 and 500 ng/mL or ng/g in all specimens and was determined to be less than 10%. The developed propofol method was applied to a forensic autopsy case where a suspected propofol misinjection occurred eight days prior to death, and the tissue analysis was vital to the case.

Survival case of colchicine intoxication following ingestion of a lethal dose

INTRODUCTION

There have been few reports of cases where the ingestion of colchicine was utilized as a method of suicide and accordingly, its effect on the human body is not fully understood. It has been reported that all individuals who ingested more than 0.8 mg/kg of colchicine died of shock within 72 hours.

CASE REPORT

A 46-year-old man was sent to the hospital after ingesting a lethal amount of colchicine (total dose, 71 mg; body weight, about 70 kg) in a suicide attempt. On admission, his vital signs were stable and physical examination was unremarkable. Laboratory findings were normal. He was admitted to the intensive care unit, and severe diarrhea and vomiting commenced approximately 4 hours after ingestion, accompanied by electrolyte disturbance, coagulopathy and renal dysfunction. Bone marrow suppression, bradycardia, alopecia and myoneuropathy also occurred, these findings being the typical symptoms of colchicine poisoning. The symptoms were almost resolved after about 1 week and he was discharged on the 19th day of admission.

CONCLUSION

Immediate and precise care for colchicine poisoning successfully saved the patient's life.

A silent allele in the locus D19S433 contained within the AmpFlSTR Identifiler PCR Amplification Kit

We present two cases where a single locus mismatch was found in the locus D19S433 using the AmpFlSTR Identifiler PCR Amplification Kit (Applied Biosystems) (Identifiler Kit) during paternity and maternity tests. This mismatch differed from the mismatch pattern where there is usually a one repeat difference. We designed forward and reverse primers so that they were positioned further away from the primer set contained in the Identifiler Kit. The results showed the existence of a silent allele 13 in both families, due to a point mutation that changed guanine to adenine at 32 nucleotides downstream from the 3' end of the AAGG repeat sequences in all four members. A single locus mismatch due to a silent allele may occur in any locus using any kit. Accordingly, we should pay attention to this silent allele when carrying out human identification and parentage analysis.

Estimation of postmortem interval based on the spectrophotometric analysis of postmortem lividity

The color of postmortem lividity and control skin in 21 adult cadavers whose postmortem interval was within 72h, was measured by spectrophotometry in order to estimate the postmortem interval, objectively. The L *a *b * system, which has been widely used for the digital expression of skin color, was used and linear regression analysis was performed to determine the relationship between the postmortem interval and 31 color factors including L * (Value), a * and b * (Chroma and Hue) and C * (Chroma). The difference in Chroma between postmortem lividity and control skin (DeltaC * and DeltaC( *)/C(c)( *)) was only weakly correlated with the postmortem interval. We propose a new equation for calculating the postmortem interval using several color factors obtained by measurement of postmortem lividity, together with some autopsy findings that are known to affect the formation of postmortem lividity. The new equation makes it possible to estimate the postmortem interval within +/-4.76h.

[An unusual case of fatal airbag injury]

We report an unusual case of fatal airbag injury. A woman in her forties was driving a light car when it was involved in an accident. When the car was found, the left front wheel had dropped into the gutter, the front bumper was dented and the airbag had deployed. Forensic autopsy revealed that the right subclavian artery and the left vertebral artery were ruptured and 1,570 ml and 360 ml of blood with clots were observed in the left and the right thoracic cavity, respectively. It was considered that the unusual collision produced by deployment of the airbag had caused these ruptures and massive hemorrhaging. Although an airbag is an effective tool for ensuring the safety of a driver and the passengers, it may injure and occasionally kill the occupants if they do not remain in the appropriate and restrained seating position.