[Arrhythmogenic right ventricular dysplasia/cardiomyopathy (ARVD/C) as a cause of sudden death]

Common cause of sudden death in children and teenagers are primary cardiomyopathies, mostly hypertrophic. The authors refer to arrhythmogenic right ventricular dysplasia/cardiomyopathy as a possible cause of sudden death. The disease is not limited to the right hearth only, the presence of fat and scar tissue in the in the hearth muscle is variable.

[Trauma of cervical spinal cord--an immunohistochemical study]

The histologica and immunohistochemical examination of cervical spinal cord were used in the group of 11 deceased of violent death. The positivity of neuron-specific enolase (NSE) in axons of cervical spinal cord was examined, and findings in the group of deceased on craniocervical injury (7 cases) and the group of deceased without cranio-cervical trauma (4 cases) were compared. While a routine histological examination including Palmgren's staining showed no significant differences between bouth groups, we noticed an increased frequency of appearance of NSE deceased with craniocervical injury.

Diagnosis of traumatical and hypoxial changes of the CNS--immunohistochemical study

The immunohistochemical detection of neuron-specific enolase and b-amyloid percursor protein were used in the group of deceased on craniocerebral injury and those who died of prolonged hypoxy without mechanical injury of the brain. Neuron-specific enolase (NSE) is produced by nerve cells and is a suitable marker for both the damage of neurons and axons. While undamaged nerve cells show immunoreactivity with the antibody anti-NSE, a significant decrease of this protein substance was noticed within two hours both in mechanical injury and in cases of prolonged hypoxy. We noticed the presence of NSE in damaged axons already several minutes after the injury whereas the hypoxy of brain without mechanical injury didn't show any or a very slight reaction of axons when examined with anti-NSE without topographic link to axonal lesion. b-amyloid percursor protein (b-APP) is a low molecular protein which the normal values of are not to be found in axons detected by standard immunohistochemistry. We noticed an increased frequency of appearance of this protein substance in axons changed by injury, while a reactive positivity to anti-body b-APP was to be found only rarely at the brain hypoxy without mechanical injury CNS.

[Immunohistochemical findings in prolonged cerebral hypoxia]

In the development of secondary changes of brain damage caused by injury, tumour and hypoxia of different origin with unconsciousness also the activity of the metalloproteinase matrix (MMP) may participate. Their activation occurs first in the vascular wall which they damage and it may be assumed that MMP potentiate thus secondary changes in the sense of interfering with the haematoencephalic barrier with development of vasogenic cerebral oedema. In the cells of the vascular wall and in glial elements already after two days MMP-2 and MMP-9 activity was proved. While in focal injuries the findings were in particular at the site of contusion foci, in prolonged hypoxia for various reasons these changes were diffuse.

[Immunohistochemical detection of lung damage]

Important risk factors associated with sudden infant deaths include in addition to the prone position also other exogenous factors which influence the respiratory function of the infant, in particular during the first half of his life. The negative action of maternal smoking during pregnancy damages foetal development and the child can suffer damage also from cigarette smoke in the environment. The investigation indicates possible toxic effects of activated matrixins by nitrogen oxides in pulmonary tissue caused by their presence in the environment.

[Morphologic findings in chronic abuse of heroin and pervitine]

In a deceased 39-year-old man with a history of 10-year consumption of heroin and pervitin the authors made histological and immunohistochemical examinations of organs focused on detection of old and recent pathological changes. In the brain they detected oedema, venostasis, inflammatory infiltrates in the wall and surroundings of some vessels and hypoxic changes of neurons with a drop or disappearance of neuron-specific enolase. The myocardium was marked by oedema of the interstitium, focal diminution to disappearance of basophilia of myocyte nuclei with increased eosinophilia of some fibres and smaller and larger foci of fibrosis formed by mature and less mature connective tissue. Immunohistochemical examination revealed focal fibrinogen deposits in myocytes. A surprise was to a certain extent the finding of dispersely distributed caspase-8 in myocytes, caspase being one of the substances signalizing apoptosis. On microscopic examination of the lungs severe haemorrhagic oedema dominated. In the liver they found acute venostasis and chronic inflammatory changes with connective tissue proliferation in the portal areas. The finding in the kidneys suggested acute tubular nephrosis. The authors discuss the problem of direct toxicity of the ingested drugs, the influence of repeated states of hypoxia and infection.

[Detection of caspase as a sign of tissue damage]

Caspases are cysteine proteases which participate in different stages of apoptosis. Apoptosis, cell death, programmed by its nucleus is associated also with a number of diseases and tissue damage. To this process increasing attention is paid also in the sphere of forensic medicine, in particular to make use of the diagnostic contribution in investigation of cause of death, vital reaction and time when the injury developed. In damaged tissues by immunohistochemical methods caspase activity was assessed. Caspase 8 activity (Flice) was detected in the heart muscle in congenital heart disease in a two-week old infant but also in ischaemia in a 58-year old woman with thrombosis of the coronary artery or in acute circulatory failure after an overdosage of pervitin in a 39-year-old drug addict. In the liver there was a positive finding in hepatocytes in chronic inflammatory changes caused by chronic alcohol abuse. An early caspase 8 reaction after an injury is suggested by positive findings in skeletal muscles of the neck and larynx in a 47-year-old man who was strangled. A positive reaction was proved only at the site of the line caused by the strangulation tool. However macroscopically nor by common histological staining the muscle tissue did not display any signs of injury at the mentioned sites. The results suggest that immunohistochemical evidence of caspase 8 can be used as a suitable complementary examination not only for detection of damaged tissue but also for evaluation of early stages of the vital reaction.

[Detection of metalloproteinases in pulmonary tissue after sudden and violent death]

During early stages of chronic hypoxia under experimental conditions in the lungs alveolar macrophages are activated and in the latter an increased amount of matrix-metalloproteinase-collagenolytic enzymes is produced. Their presence was assessed in the present study in the lungs of infants who died suddenly (SIDS) and also in subjects who died from a violent death incl. acute and protracted external suffocation. The positive findings of these matrixins, in particular MMP-9 (gelatinase) were assessed in alveolar macrophages not only after protracted suffocation but also in the majority of sudden infant deaths. These findings supplement the mosaic of changes which indicate that sudden infant deaths are preceded by a period when the infant was exposed to hypoxia.

[Differences in immunohistochemical findings in traumatic and hypoxic changes in the central nervous system]

The authors made in a group of deceased subjects with craniocerebral injuries and subjects with protracted hypoxia without mechanical brain injury immunohistochemical investigations of neuron-specific enolase and beta-amyloid protein precursor. Neuron-specific enolase (NSE) is produced by nerve cells and is a suitable marker of neuron as well as axon damage. While the bodies of intact nerve cells display immunoreactivity with the anti-NSE antibody, in damaged neurons already within two hours after injury a marked drop of this protein substance was observed after mechanical injury as well as after protracted hypoxia. In axons altered by injury the authors observed the presence of NSE already within several tens of minutes after injury while hypoxia of the brain without mechanical injury did not produce any or only a very weak reaction of axons on examination with anti-NSE without a topographic link to the axonal lesion. Beta-amyloid protein precursor (beta-APP) is a low molecular protein the normal values of which are not detectable in axons by standard immunochemistry. In axons altered by injury the authors observed an increased incidence of this protein substance while in cerebral hypoxia without mechanical injury of the CNS only in rare instances a positive reaction with anti-beta-APP antibody was found.

[Effect of autolysis on histochemical examinations of the central nervous system]

The objective of the study was to explain the effect of autolysis on immunohistochemical detection of neurone-specific enolase (NSE), beta-amyloid protein precursor (beta-APP) and ubiquitine in cerebral tissue. The examination was made in 6 deceased subjects without mechanical injury of the CNS and 6 subjects with a craniocerebral injury who survived from 6 hours to 3 days. In all deceased subjects the post-mortem examination was made within 24 hours after death. For immunohistochemical examination tissue excisions were taken from standard sites of the brain. The first tissue excisions were immersed into 10% formol after a post-mortem interval of 24 hours. The remaining tissue slices were subjected to autolysis at room temperature and gradually immersed into formol after 24-hour intervals, the longest post-mortem interval being 168 hours, i.e. 7 days. For visualization of the linked primary antibody the biotin-streptavidin system labelled with alkaline phosphatase was selected. In the group of 6 subjects who died after a craniocerebral injury in 4 instances axonal lesions were detected, i.e. axonal oedema or formation of retraction spheroids. The damaged axons were positive on examination with all investigated antibodies, whereby it was possible even after a 168-hour post-mortem interval to differentiate damaged and not damaged axons. In the group of 6 subjects without mechanical injury of the CNS in 5 instances axonal oedema was found, however, it was not positive with anti-NSE antibodies nor with anti-beta-APP. After the 24-hour post-mortem interval in this group in 3 instances ubiquitine positivity was found in axons but already after a post-mortem interval exceeding 2 days the axons were ubiquitine positive in all 6 subjects. Lumpy deposits of this substance could be detected in axons also beyond axonal structures.

Lethal burn trauma in children

The aims of this retrospective study covering the years 1984-1998 were: 1. to survey burn injuries in children at the present time and 2. to compare the current results with the conclusions of an analogous study performed in the years 1964-1983. A decline in the occurrence of lethal burn wounds was found, as well as in burn shock as a direct cause of death. Children 1-4 years old continue to be the most frequent victims of fatal accidents. The most common cause of burn injury in this group remains scalding in the household.

[Immunohistochemical methods in the differential diagnosis of primary traumatic and subsequent secondary cerebral changes]

In a 22-year-old man, driver of a personal motor vehicle, who died within 39 hours after a traffic injury, the authors made histological and immunohistochemical examinations of the brain focused on differentiation of primary traumatic and subsequent secondary changes. In haematomas the authors revealed the presence bi- and trivalent iron by Turnbull's and Perl's reaction as well as glycophorin by immunohistochemical reactions. White matter lesions were evaluated histologically by staining according to Palmgren and immunohistochemically by detection of neuron-specific enolase, beta-amyloid protein precursor and low molecular neurofilaments. Minor contusion foci in the corpus callosum and in the peripheral portion of the pons revealed the presence of extracellular bivalent iron and exceptionally also the presence of intracellular iron. Glycophorin was present not only in erythrocyte membranes but also in the form of lumps signalizing haemolysis. In the haematoma in the median portion of the pons neither iron nor free glycophorin were detected. At all investigated sites (subcortical areas of the white matter of the hemispheres, capsula interna, corpus callosum, pons Varolii) the authors detected numerous axonal deformities (oedema or formation of retraction spheroids) which revealed on immunohistochemical examination an intense reaction with antibodies in particular against neuron-specific enolase and beta-amyloid protein precursor, and to a smaller extent against low-molecular neurofilaments. The combination of the mentioned immunohistochemical examinations seemed a suitable method for differentiating primary cerebral injury (diffuse axonal injury and minor contusion foci in the corpus callosum and the margin of the pons) from secondary changes (haemorrhages in the median portion of the pons) which developed shortly before death as a manifestation of haemodynamic disorders associated with cerebral oedema).

[Glycophorin in forensic medicine]

Immunohistological evidence of glycophorin from paraffin sections of tissues fixed with formol, makes its possible to visualize membranes of preserved erythrocytes and fragments after their disintegration. This fact permits even after development of post-mortem changes to differentiate actual extravasation, manifested by a positive finding of glycophorin from mere infiltration of tissue by blood pigment after death, where glycophorin is lacking. The method is very sensitive and can reveal even very discrete haemorrhage. From different grades of erythrocyte disintegration in haematomas in the same subject sometimes conclusions can be drawn also on the different time of development of traumatic tissue changes.

[The effect of autolysis on the interpretation of results of immunohistochemical detection of myoglobin and fibrinogen in the myocardium]

Immunohistochemical detection of myoglobin and fibrinogen in the myocardium makes it possible to diagnose very early stages of ischaemic/hypoxic changes of the heart muscle. The authors demonstrate on the myocardium of a 58-years-old female patients who died suddenly with the finding of acute infarction of the anterior wall of the left ventricle with transmural rupture and cardiac tamponade the effect of autolysis on this examination. Tissue excision taken from the close vicinity of the rupture were subjected to autolysis at room temperature and immersed in formol for fixation within an interval of 24 hours. The control series of examinations was made in a similar way on the heart muscle of a 20-years-old woman who died from violent death, and ischaemic changes of the heart muscle were not anticipated. While in the early stages of autolysis it was possible to use combined immunohistochemical detection of myoglobin and fibrinogen, after a longer postmortal interval extensive artificial losses of myoglobin were observed, and the method of detection of fibrinogen deposits in damaged cardiomyocytes seemed more suitable. Even after a postmortal interval of 168 hours it was possible to differentiate reliably damaged myocytes with fibrinogen deposits from intact muscle fibres, where fibrinogen deposits were not observed.

[Autopsy and biopsy findings in disorders of mitochondrial beta-oxidation of fatty acids. Role of the pathologist in the diagnostic process]

Basic problems of the group of hereditary mitochondrial beta oxidation (BOX) disorders are presented with evaluation of the role of pathologists in the diagnostic process. The disorders manifest themselves clinically as usual by recurrent Reye-like episodes (acute hepatopathy and encephalopathy) typically in low age levels. Integral part of the clinical picture is often a myopathic symptomatology which at some cases may display even persisting character. The findings at the tissue level are dominated mostly by steatosis of the organ set with a high beta oxidation level (liver, heart, skeletal muscle, kidney) and toxic effects of the intermediate metabolic products of the derranged beta oxidation process. So far eighteen enzyme defects have been described affecting either transport of fatty acids across the mitochondrial membranes or their oxidative degradation at various levels, pointing to an absolute dependence of the final diagnosis on biochemical analysis. Pathologist's conclusion in cases dying without diagnosis is limited to suspicion of a BOX disorder only. However, pathologists can contribute significantly to unraveling and specification of the underlying BOX defect by collecting adequate samples of body fluids and of unfixed organs. Nevertheless, the validity of these samples, even if widely recognized, is limited. The best approach is to provide samples enabling to perform biochemical evaluation of the whole BOX process in integral mitochondrias. This requirement is fulfilled solely by establishing fibroblast tissue culture post mortem.

[Determination of the ABH blood group system in the placenta]

Blood group substances A, B, H were detect in placental tissue paraffin cuts (after 10% formaline fixation) by immunohistochemistry using indirect immunoperoxidase-two-layers technology or biotin-streptavidin complex signed by alkaline phosphates. Both fetal and maternal part of placenta are to be investigated which enables their group markers to be identified. Immunohistochemical detection of the A, B, H blood group substances in placenta can give conclusion about the blood group of fetus and of fetus and of mother as well.

[Detection of eosinophilic cationic protein in the lungs in sudden infant death]

In a comparative study the authors detected presence of eosinophilic protein in infant's lung at sudden death. Degranulation of eosinophillic leucocytes and extracellular foci of this protein were found in a case of such sudden death. Discussion concerned possibility that the release of eosinophilic cationic protein could represent one of the triggering moments of infant sudden death.

[Immunohistochemical findings in the central nervous system in sudden infant death]

In a group of 7 infants suddenly dying at the age up to 1 year a histological and immunohistochemical investigation was performed aimed to prove possible chronic hypoxic and latent traumatic changes. Presence of ubiquitin and neuron-specific enolase (NSE) was detected in axon and neurons. In six suddenly dying infants an immunohistochemical positivity was found with antibodies against ubiquitin in brain stem neurons. Antibodies against NSE showed positivity of the white matter was lacking in the detection both of ubiquitin and NSE. Among 12 persons dying of craniocerebral injury an intensive NSE immunopositivity was found in traumatized axons of 7 cases and ubiquitin positivity in 5 cases while brain stem neurons did not show any ubiquitin positivity. Bain stem neurons at sudden death were strongly NSE positive in 5 case, weakly positive in 3 cases and negative in 4 deceased. The combined proof of ubiquitin and NSE in neurons and axons at infant sudden death appears to he advantageous because it combines the detection of traumatic changes and chronic hypoxic lesions as well.

[Immunohistochemical findings in the heart conduction system]

Immunohistochemical investigation of heart conductive system showed that degenerative changes described by James (9) in some cells of the system had a nature of programmed death. Extinction of certain of number of cells of a reducted part of the system was found in membranous septum. Apoptotic antigen (21) could be proved in some destructed cells by using anti-Bax and anti-bcl-2 antibodies.

Mortality in pediatric burns in the Prague Burns Centre (1994-1997)

The authors evaluate the mortality of severely burned children hospitalized in the Intensive Care Unit, Prague Burns Centre from 1994 till 1997. There were hospitalized 345 children (aged 3 months-15 years, 1%-88% TBSA, mixed superficial and deep burns). No child died from burn shock during the early postburn period. Five children who died suffered deep burns greater than 50% of TBSA and at necropsy there were identified signs of multiple organ system failure which was related to infection.

[Histochemistry and immunohistochemistry of the lung in sudden infant death]

Histochemical and immunohistochemical findings in respiratory tract of suddenly deceased infants were a bit different from those with violent death immediately after trauma. The bronchial wall inflammatory infiltration and foci of peribronchial lymphatic tissue did not show any substantial difference in both groups but findings in lung interstitium proper did. A regular finding was the presence of activated macrophages in interstitium and alveolar lumina and an increase of B and T lymphocytes in lung tissue as well. Lung findings in suddenly deceased infants do not have character of a shock lesion bud represents an initial phase of acute inflammation.

[Risk factors and sudden death in infancy]

The author analyzed data obtained by means of questionnaires from 58 children who died of the diagnosis of SIDS in the Central Bohemian region. A total of 81 data were evaluated pertaining to pregnancy, delivery, case-history of the mother and child, living and conditions and the death. The assembled data were compared with data in the literature. The authors confirmed the multifactorial etiology of SIDS. The questionnaire used was recommended for nationwide investigations of sudden infant deaths.

[Causes of death in fatal cases of child abuse 1964-1988]

BACKGROUND

Abuse and/or neglect of children can lead not only to serious health damage but in extreme cases to death. A lethal outcome in the abused child is an incomplete group of seriously damaged children; it, however, makes possible not only numerical comparison but also assessment of trends. The objective of the present work was an analysis of deaths of children who died in conjunction with the use of force in the family.

METHODS AND RESULTS

The author analyzed a group of 75 children, 47 boys (63%) and 28 girls (37%) aged less than five years: it covers the period of 25 years (1964-1988) and administrative area of the capital of Prague and former Central Bohemian region with a total number of 2 million population. Newborn babies killed by the mother during delivery or immediately after delivery (63 subjects) were not included in the group. According to analysis by age the following number of deaths was recorded in different groups: 0-1 year 45 deaths (60%), 1-2 years 13, 2-3 years 11, 3-4 years similarly as 4-5 years 3 deaths each. The ratio of boys:girls was 47:28. The most frequent cause of death were head injuries (31-41%), followed by suffocation 15x, injury of abdominal organs 6x, intoxications (4x, incl. 3x carbon monoxide), multiple injuries 4x, injuries of thoracic organis 3x, starvation 2x, hypothermia 2x, thermal damage 1x. The findings on necropsy are not useful only for assessing the cause of death, the mechanism of damage and the time when the damage was inflicted but the spectrum of types of damage can help clinical and social workers in the prevention of the battered child syndrome.

CONCLUSIONS

Child abuse and neglect in families can lead not only to serious health damage but it can be also fatal. In an area with a population of 2 millions in the course of 1964-1988 75 deaths of children aged less than five years were recorded (ratio: 2.5:1 million per year). Mechanical injuries predominate (89%) in particular head injuries (41%).

Histochemistry of the atrioventricular conducting system during postnatal development

The atrioventricular conduction system of 27 infants coming to autopsy was examined by histochemical methods. Twenty one were sudden infant deaths; six were explained deaths. A decrease of oxidoreductases and hydrolases activities was found in clusters of conducting cells protruding from the atrioventricular (AV) node and His bundle left into the collagen of the septum. These findings reflect regressive changes connected with reduction of the AV conducting system during postnatal development.

[Histochemical findings in the atrioventricular conduction system in congenital heart defects]

The authors examined, using histochemical methods, the AV conduction system in five infants and two children who died unexpectedly with a congenital heart disease. The activity of "glycogen dependent" phosphorylase in the AV conduction system was mostly negative or weak. The probable cause of this finding is hypoxia, although the effect of hypotrophy must be admitted. In groups of cells penetrating into connective septal tissue a decrease of oxidoreductases and hydrolases was found. These findings may be associated with regressive changes in the postnatal reduction of the AV conduction system.

[Findings in the atrioventricular node and the bundle of His in sudden and unexpected death in childhood. Histochemical study]

In 21 sudden and unexpected deaths of infants and three young children who died unexpectedly with known pathological conditions the authors examined by histochemical methods the atrioventricular node and bundle of His. The activity of "glycogen dependent" phosphorylase and the PAS reaction was in the majority week or negative. The probable cause of this finding is hypoxia, although other influences cannot be ruled out (inflammation, hypotrophy, autolysis). The activities of other enzymes (oxido-reductases ATPase, acetylcholine sterase, non-specific 1-naphtyl acetate esterase and acid phosphatase) were similar as in the normal conduction system.

[Enzyme activity in the normal atrioventricular node and in the bundle of His in young children]

The authors examined by histochemical methods the atrioventricular node and the bundle of His in five infants who died from unnatural deaths and in a four-and-half-year-old child who died immediately following haemorrhagic infarction of the gut. Both structures differed, similarly as in adult age, from working muscle by a lower oxidation capacity, higher activity of the pentose-phosphate shunt and a high acetylcholine esterase activity.

[Virologic and morphologic study in sudden and unexpected death in children]

The authors examined a group of 47 children who died at the age of 1-9 months, incl. 19 female and 28 male children. In 23 the death was described as sudden and in 24 as unexpected. From 19 dead children a virus was isolated: in 14 one or two serotypes of enterovirus were found, in two the virus of parainfluenza 3 in two adenoviruses (type 2, 7). A total of 46 viral strains were isolated. By immunofluorescence in tissues antigens of the parainfluenza virus 3 and adenovirus were detected. Immune complexes were not detected in tissues. The distribution of vaccination polioviruses in organs and tissues after a known interval following vaccination was recognized. In some of the infants a possible causal relationship between the virological and morphological findings was found and the authors discuss the possible pathogenetic role of the revealed changes in sudden death.

[Evaluation of the incidence of waves in myocardial muscle cells in children]

In a group of 84 children who died at the age of 3 weeks to 15 years, icl. 37 sudden deaths, 16 unexpected deaths, 12 deaths immediately after an accident and 19 children who died some time after an accident, the authors investigated and evaluated by statistical methods the incidence of waves of myocardial cells in left and right ventricle. Waves in the right ventricle were significantly more marked (at the 5% level) than in the left ventricle. Their presence was inversely related to the presence of haemorrhage and cellular infiltration of the myocardial interstitium. The author did not detect a significant relationship with sex, age, duration of the disease, diagnosis, manifestations of cardiac failure and oedema or pneumonia. The findings suggest that waves of myocardial cells cannot be considered quite specific for ischaemic heart damage.

[Diagnostic problems in poisoning with the agaric Cortinarius orellanus Fr. having a nephrotoxic effect]

The authors present a case of fungus poisoning involving nephrotoxic effects. Diagnosis was derived from the typical course of the conditions as well as from the postmortem and mycological investigations of intestinal contents. This is the first case of death due to this kind of poisoning ever described in Czechoslovakia.

Clinical forms of endotoxemia in burns

Two groups of patients in whom endotoxemia was suspected were studied with respect to the laboratory data, clinical picture and autopsy findings. The first group showed the signs of gram-negative septicemia (age range 3 to 54 years with burns of 25 to 80% TBSA) and the second group (age range 20 to 76 years with burns not greater than 20% TBSA) showed an unexpected deterioration of the patient's condition. In 15 patients we established the diagnosis of endotoxemia on positive Limulus test as well as on other laboratory examinations and on the clinical signs. Five different forms of endotoxemia were distinguished varying in the evoking circumstance, clinical manifestation and pathological findings at autopsy: (1) the so called laboratory form--all survived; (2) the pulmonary form displaying the most brief and fulminant course--all died; (3) the form of disseminated intravascular coagulopathy; (4) the form of endotoxic shock due to administration of antibiotics; (5) the form of endotoxic shock as terminal stage of protracted gram-negative septicemia--the fatal outcome was inevitable in all cases. The authors stress the importance of minding and preventing all circumstances that might provoke the endotoxic (septic) shock.