Significance of levels of IL-6 and IL-8 after trauma: a study of 11 cytokines post-mortem using multiplex immunoassay

PURPOSE

To identify cytokines useful for diagnosis of traumatic death.

METHODS

Post-mortem serum levels of 11 cytokines were assayed for 43 people who died of traumatic injury or from non-traumatic causes. Levels of granulocyte-macrophage colony stimulating factor, gamma interferon, interleukin IL-1beta, IL-2, IL-4, IL-5, IL-6, IL-8, IL-10, IL-13, and tumour necrosis factor-alpha were measured using multiplex immunoassay.

RESULTS

Levels of granulocyte-macrophage colony stimulating factor (p<0.01), IL-6 (p<0.001), and IL-8 (p<0.01) among the traumatic group were significantly higher than those among the non-traumatic group. Anatomical trauma severity was also estimated using the total abbreviated injury scale and injury severity score, revealing significant positive correlations between the former and IL-6 (rs=0.6523, p<0.01) and IL-8 levels (rs=0.6584, p<0.01).

CONCLUSIONS

Levels of IL-6 and IL-8 assist differentiation between traumatic and non-traumatic death, are useful objective indices of trauma severity and can support a diagnosis of traumatic death.

An accidental death due to Freon 22 (monochlorodifluoromethane) inhalation in a fishing vessel

A case of accidental Freon 22 (monochlorodifluoromethane) poisoning in a fishing vessel is reported. Forensic autopsy revealed severe pulmonary edema and congestion (left lung; 576 g, right lung; 740 g). GC-MS analysis clearly showed that the deceased inhaled Freon 22 gas prior to his death. Freon 22 concentration was 169+/-7.0 microg/ml in the heart blood. The distribution pattern of Freon 22 in tissue samples was similar to that in previously reported cases. The brain had the highest concentration of Freon 22 followed by the spleen, liver, kidney and lung, respectively. Histopathologically, Oil red O staining of the liver showed many small, positive red areas in the cytosol, which have been reported in other cases of Freon 22 poisoning. However, Schmorl staining revealed that most areas of Oil red O positivity were lipofuscin granules. Lipofuscin in the liver, which closely relates to aging and other cell stresses, could have a relevance to Freon 22 exposure, but further experimental studies are needed to confirm it.

[Two cases of diphenhydramine related suicide]

Two suicidal cases associated with ingestion of diphenhydramine (DPH) were reported. Case 1 is a typical DPH overdose case of a young man with the blood DPH concentration of 12.2 microg/ mL. Case 2 is a double suicide of a man and a woman. They ingested DPH and fell asleep in a vehicle which had a cooking clay charcoal stove. Their blood DPH concentrations were 0.4 and 0.7 microg/mL, which were high enough to make them sleep. Their cause of death, however, was carbon monoxide poisoning with blood CO-Hb concentration of 14 and 19%. DPH is a low toxic agent and is available as an OTC drug in Japan. Similar fatal cases can be expected to happen in Japan.

Sudden death of a young woman due to aortic dissection caused by Turner's syndrome

A 24-year-old woman was found dead in her bed. There had been an episode of fainting with cervicodynia 1 day before death but no significant past medical history, except for menstrual irregularities. Post-mortem examination revealed that death was due to hemopericardium caused by rupture of the ascending aorta by thoracic aortic dissection (Stanford type A). Microscopically, weakness of the aorta was due to cystic medial necrosis. On external examination, short stature, a short neck and multiple pigmented nevi were observed, while internal examination revealed coarctation of the aorta and funicular ovaries. Examination of the X chromatin showed a decrease in numbers of Barr bodies in the tissues, and a 45,X/46,XX mosaicism was suspected. It is concluded that the cause of death was aortic dissection due to Turner's syndrome.

Immunohistochemical demonstration of the distribution of chloroquine (CQ) and its metabolites in CQ-poisoned mice

Chloroquine (CQ) distribution in tissues of acutely poisoned mice was demonstrated by immunohistochemistry using anti-CQ polyclonal antibodies (PAC). PAC recognized 4-amino-7-chloro-quinoline structure and sufficiently reacted with CQ and CQ's metabolite bisdesethyl-chloroquine. In the brain, CQ and its metabolites (CQs) localized in the region of the choroids plexus, indicating an important role in the blood-cerebrospinal barrier system. In the heart, most regions showed diffused positive staining, and relatively strong reaction was observed in Purkinje cells, indicating an important role in acute CQ toxicity. In the lungs, CQs were observed in the bronchial epithelium, type II pneumocytes, and on the surface of alveolar walls. It was suggested that CQs were excreted to the alveolar wall with surfactant phospholipids, which are produced by type II pneumocytes. In the liver, CQs were concentrated in the centrolobular area rather than in the periportal area, in agreement with CQ's metabolic pathway. In the kidneys, tubular cells were strongly stained compared to glomerular capsules, and the distal part of renal tubules was better stained than the proximal tubules. These findings suggested that CQs were predominantly excreted or reabsorbed through the distal tubules and the collecting duct. Distribution of CQs in tissues presented here were mostly consistent with the physico-chemical properties of CQ and its metabolites. However, the elucidation of CQs' localization in Purkinje cells remains open. Further experimental studies at the level of microorganella will be needed to clarify the present result.

Postmortem cytokine levels and severity of traumatic injuries

The relationship between postmortem serum cytokine levels and severity of traumatic injuries was studied. The postmortem serum levels of interleukin-6 (IL-6) and interleukin-8 (IL-8) of 131 victims who died from traumatic injury were measured by an enzyme-linked immunosorbent assay method and compared with scores of total abbreviated injury scale (total AIS) and injury severity score (ISS) calculated from detailed autopsy reports. A significant positive correlation was observed between IL-6 and total AIS (rs=0.4508, p<0.0001), between IL-6 and ISS (rs=0.3337, p<0.0001), between IL-8 and total AIS (rs=0.6593, p<0.0001), and between IL-8 and ISS (rs=0.5305, p<0.0001). The significant correlation between cytokine levels and anatomical traumatic severity indicated that the cytokine levels are useful objective indexes of traumatic severity. In addition, the total AIS is a suitable marker to evaluate traumatic severity as the coefficient of correlation between the cytokine levels and the total AIS was higher than that for the ISS values.

Estimation of early postmortem intervals by a multiple regression analysis using rectal temperature and non-temperature based postmortem changes

Five general methods based on rectal temperature and a multiple regression analysis using rectal temperature and non-temperature based postmortem changes were applied to 212 postmortem cases of within 24h postmortem (PM) intervals. Non-temperature based postmortem changes of rigidity, hypostasis and corneal turbidity were numerically categorized and used with rectal temperatures as four statistical variables in the multiple regression analysis. The correlation coefficient values between true and calculated postmortem intervals were 0.78-0.82 in the five general methods based on rectal temperature. The multiple regression analysis produced a multiple correlation coefficient value of 0.89 and according to the error ranges of the PM intervals, 72% of the cases were estimated within the error of +/-1.0 h and 92% within +/-5.0 h. Although assessments of non-temperature based PM changes are mostly subjective and have a wide variation, the present study demonstrated a usefulness of non-temperature based PM changes in the estimation of PM intervals.

Neuropathology of human immunodeficiency virus infection: a forensic autopsy study in Dar Es Salaam, Tanzania

The objective of this study was to examine the neuropathological changes in the brain of patients infected with human immunodeficiency virus (HIV) in the Tanzanian capital Dar Es Salaam, and investigate whether the prevalence of different forms of HIV-related neuropathology varies from other countries. The subjects were patients with risk factors for HIV infection in whom forensic autopsies were performed between 1997 and 1999. In Dar Es Salaam, forensic autopsy constitutes more than 90% of all autopsies, because hospital autopsy is limited due to socio-cultural and religious reasons. HIV infection was identified in 52 of 143 patients selected from forensic autopsies. Neuropathological findings were observed in 31 of 52 HIV-infected patients; these include lymphocytic meningitis 19, bacterial meningitis 3, tuberculous brain abscess 3, cryptococcal meningitis 3, basal ganglia calcification 3, and toxoplasma encephalitis 1. HIV encephalitis, lymphoma, and cytomegalovirus encephalitis could not be found in this study. Whereas the findings should be interpreted cautiously because of possible autopsy bias and a low percentage of cases examined compared to the total number of HIV-infected patients in Tanzania, our observations provide information on the likely diagnostic possibilities to be considered in the evaluation and management of HIV-infected patients with neurological symptoms in Tanzania. In the face of decreased hospital autopsy, most studies have focused mainly on the end-stage HIV disease; forensic autopsy is a potential source of materials for studies on HIV disease spectrum at different stages.

HPLC analysis of anti-malaria agent, chloroquine in blood and tissue from forensic autopsy cases in Tanzania

HPLC analysis of anti-malaria agent, chloroquine (CQ) in blood and tissues with a simple HCl back extraction method was applied to three forensic autopsy cases in Dar es Salaam, Tanzania. CQ concentrations in femoral vein blood were 8.5, 48.4 and 43.8 microg/ml in three cases, respectively, which were high enough to attribute the cause of deaths to an acute CQ poisoning. There were great site dependent variations in blood CQ levels. The right heart blood samples were very high, which may be explained by incomplete distribution of the drug before death or postmortem diffusion from liver and its surrounding blood, as high CQ levels were remarkable in the liver. Suicidal and accidental CQ poisonings are very common and CQ is a very important chemical in the field of forensic toxicology in Tanzania.

Interrupted aortic arch with ventricular septal defect: an unsuspected fatal congenital anomaly in forensic pathology

Interrupted aortic arch (IAA) is a relatively rare cardiovascular anomaly worldwide and is very rarely encountered in forensic pathology. A case of clinically unsuspected fatal IAA in a 5-day old neonate is described. A full term female baby was declared dead on arrival at an emergency hospital few hours after having been discharged from a maternity hospital following delivery. There were no noticeable signs and symptoms reported during the short postnatal period. Antenatal medical history was unremarkable and there were no abnormalities noticed at birth. Autopsy revealed an unsuspected IAA arch with ventricular septal defect (VSD) as cause of sudden unexpected death. Although amenable to surgical intervention, IAA may not produce obvious clinical symptoms as was the case for this baby. Such sudden unexpected deaths raise medico-legal questions as to the manner and the precise cause of death. The importance of a full forensic autopsy to clarify such a sudden death was re-emphasized.

Fatal intussusception in infancy: an experience in forensic autopsy

Intussusception, although a common cause of pediatric surgical emergencies, is a rarely fatal condition. A 7-month-old infant who was discovered in her cot was unresponsive and pronounced dead after 2 h of uneventful cardiopulmonary resuscitation in an emergency hospital. Forensic autopsy which was performed in order to clarify the circumstances surrounding the death revealed intussusceptions at two sites of the ileum. Although morbidity and mortality rates from the condition have progressively declined in recent decades but avoidable deaths still occur as was experienced in the present case. The forensic pathology significance in this case was the occurrence of 'painless intussusception' whereby the affected child clinically exhibited no discomfort or characteristic features of acute abdomen until death. In summary, the present case has exhibited an uncommon fatal occurrence and demonstrated the importance of forensic autopsy in such unexpected sudden infant deaths.

Inhibitory activity of epigallocatechin gallate (EGCg) in paraquat-induced microsomal lipid peroxidation--a mechanism of protective effects of EGCg against paraquat toxicity

Recently we have reported that epigallocatechin gallate (EGCg), a major component of Japanese green tea, significantly increased the survival rate of paraquat (Pq) poisoned mice. This paper describes two biochemical activities of EGCg, which relate to its protective effects against Pq toxicity. EGCg inhibited Pq-induced microsomal malondialdehyde (MDA) productions in rat liver microsome system containing 40 microM FeSO(4). Forty micromolar EGCg inhibited MDA production significantly. EGCg may inhibit the Pq-induced MDA production by at least two mechanisms. One may be iron-chelating activity as the inhibition disappeared when excess amounts of FeSO(4) were added to the reaction mixture, which indicated that EGCg reduced iron driven lipid peroxidation by pulling out available irons in the reaction mixture. The other is radical scavenging activity. EGCg scavenged DMPO-OOH spin adducts generated by the microsome-Pq system. The dose response curve of EGCg was similar to that obtained by ascorbic acid which is a typical water-soluble radical scavenger. Although ascorbic acid had a potential activity of scavenging superoxide radicals, it can not be recommended to use for the treatment of Pq poisoning, because ascorbic acid acts as a pro-oxidant in the presence of free transition metal ions by accelerating the Fenton reaction (Fe(2+)+H(2)O(2)-->Fe(3+)+OH(-)+OH*), which is responsible for lipid peroxidation. On the contrary, EGCg inhibited iron-driven lipid peroxidation presumably not only by chelating to Fe ions but also by scavenging superoxide radicals, which are responsible for the reduction of ferric (Fe(3+)) to ferrous (Fe(2+)) that catalyzes the Fenton reaction. Chelating and radical scavenging activity of EGCg can be expected simultaneously in the occurrence of Pq toxicity, which may explain the protective effects of EGCg against Pq toxicity.

A simple dot enzyme-linked immunosorbent assay for ABO blood typing of biological fluid and stains: effects of heating samples

A simple dot enzyme-linked immunosorbent assay (Dot-ELISA) using commercially available monoclonal anti-A and anti-B antibodies and biotinylated anti-H lectin was developed for ABO blood typing of biological fluid and stains. Its application to forensic practice was examined with 117 saliva samples and their stains, and practical case samples of 8 seminal, 6 vaginal and 45 aged salivary stains. In the simple Dot-ELISA, a new step to heat biological samples was introduced in the system in order to block unfavorable non-specific reactions of the samples with secondary enzyme conjugate. The simple Dot-ELISA could determine accurately the ABO blood type of a small amount of secretor's and non-secretor's salivary samples. In practical tests of seminal, vaginal and salivary stains, all results were confirmed to be identical to those determined by the conventional absorption-inhibition test and the absorption-elution test. The simple Dot-ELISA is considered to be accurate, rapid, simple, sensitive and easy to perform in routine forensic practice. It is also a unique and helpful method to determine the ABO blood types of various biological samples.

Neuropathological diagnosis of Alzheimer's disease in forensic autopsy of elderly persons with fatal accident

Cognitive dysfunction in Alzheimer's disease may lead to accidental deaths in the elderly. Neuropathological diagnosis of the disease is, therefore, an important issue in forensic autopsy to determine the causal relation to accidents. To evaluate the suitability of the current histopathological diagnostic criteria for Alzheimer's disease by Khachaturian and Mirra et al. in elderly persons dying from accidents and coming for forensic autopsy, we studied the brains of nine demented and 12 non-demented persons by silver stain and immunohistochemistry. When the density of senile plaque was applied to the criteria, only four out of nine demented persons met the criteria for definite Alzheimer's disease. The demented persons had significantly higher density of diffuse plaque and higher frequencies of amyloid angiopathy, neurofibrillary tangle and neuropil thread than the non-demented persons. These results indicated that the current diagnostic criteria do not always diagnose Alzheimer's disease in forensic autopsy of elderly persons with fatal accident. The presence of abundant diffuse plaque, neurofibrillary tangle, amyloid angiopathy and neuropil thread may help to diagnose Alzheimer's disease in forensic autopsy.

[Ethanol concentrations in multi-site sampling blood in forensic autopsy cases--a retrospective analysis over a period of six years (1994-1999) in Kumamoto University]

Ethanol and n-propanol concentrations in forensic autopsy cases determined in Department of Forensic Medicine, Kumamoto University School of Medicine were reviewed retrospectively. Out of 388 autopsies in 6 years (1994-1999), ethanol was positive in 88 (22.7%) cases. Higher positive rates were observed in bleeding and burning cases compared to other cases. Histograms of the blood ethanol concentrations in all ethanol positive cases had two peaks at 0.1 mg/ml to 0.5 mg/ml and 1.5 mg/ml to 2.0 mg/ml ranges, which indicated that not only an intermediate but also a weak drunkenness level could be a risk factor of being involved in forensic fatalities. There were no differences in mean ethanol concentrations in the blood samples of the right, left and whole heart blood collected from each victim. The femoral blood, however, was slightly higher than those of heart blood. N-Propanol, an indicator for postmortem ethanol production, was detected in 14.7% of stomach contents samples as early as 6 to 12 hours of post mortem intervals, whereas it was not remarkable in urine and femoral vein blood.

Unusual homicide by air gun with pellet embolisation

A homicidal case by an air gun involving a 73-year-old woman who was found dead in her home is described. At autopsy, two gunshot wounds were observed on the left anterior chest and the right back. There was neither exit wound nor powder burns. The fatal pellet, 0.9 g and 5.5mm diameter, penetrated the left anterior chest and the heart to cause cardiac tamponade (200 ml) before lodging in the left subclavian artery. Death was due to cardiac tamponade. This case has exhibited two rare phenomena: homicide by an air gun and pellet embolisation. This is the first homicide case by use of air gun in Japan and demonstrates that although it may be rare, air guns can be used as potential homicidal weapons. This experience will alert our society and others on the potential hazards of air guns we have tended to regard as toys.

Accidental injury by a grass strimmer: an unusual fatality

The body of a 61-year-old woman was found in the morning lying near a wire fence at her farm where she was cutting grass using a motor-powered strimmer. Autopsy revealed a laceration of the heart apex, haemopericardium and left haemothorax caused by a U-shaped wire projectile which was found lodged in the left thoracic cavity. The mechanistic analysis of the injuries and manner of death, however, were conclusive after a scene visit following the autopsy. The farm was surrounded by a wire fence to prevent wild pigs from entering in. The wire projectile was cut by unshielded blade of the strimmer and struck her chest. This case represents an unusual accidental fatality and indicates the need for improved user education and safety when using such implements. This case also reemphasizes scene investigation as an important part of medicolegal autopsy for proper determination of mechanisms of injuries and precise manner of death. We hope this report will increase awareness and alert the general public to the dangers of the grass strimmer operated without proper safety precautions.

Clocapramine-related fatality. Postmortem drug levels in multiple psychoactive drug poisoning

A suicide caused by ingestion of multiple psychoactive drugs is reported. A 42-year-old man with a history of psychosis was found dead in a blood pool in his room. The forensic autopsy revealed two stab wounds on his chest. However, these wounds could not explain the cause of death. Eighty-six tablets were found in his stomach. Four psychoactive drugs; clocapramine (CC), chlorpromazine (CP), promethazine (PM) and clotiazepam (CT) were detected in blood and tissues. The concentrations of CC, CP, PM and CT in the femoral vein (FV) blood were 0.39, 0.61, 1.23 and 0.09 microg/ml, respectively. The cause and manner of death were attributed to suicidal multiple psychoactive drug poisoning. Postmortem drug redistribution showed great site-dependent variations with the lowest level in the FV blood. Remarkable variations were observed in CC, CP and PM, but not in CT compared to other three drugs. The variations were dependent on the volume of distribution (Vd) of the drugs. Our human case has demonstrated drugs with higher Vd values showed higher degree of postmortem redistribution of the drug and vice versa.

Toxoplasma encephalitis in HIV: case report

In Tanzania, no data are available on the prevalence of brain infection by toxoplasma in HIV-infected patients. A case of a 35-year old man with fulminant toxoplasma encephalitis (TE) is reported for the first time. TE was not suspected clinically in our patient who presented with a one week history of severe headache and treated empirically with antimalarial drugs. TE was diagnosed postmortem histologically by haematoxylin-eosin and immunohistochemical stain with P30 antibody for toxoplasma antigen. The findings in our case support the suggestion that a high index of suspicion for TE should be maintained in HIV-infected patients presenting with focal neurological symptoms. The case highlights the importance of autopsy studies in not only documenting a toxoplasma brain lesion but also in increasing the awareness for its diagnosis in HIV-infected patients in Tanzania and other developing countries.

Discrepancy of clinical symptoms and prognosis of a patient--forensic significance of "talk and die" head injury

Deaths of patients who had talked after sustaining a head injury and were then assumed clinically to be recovering from the head trauma raise medicolegal questions about the precise causes of deaths. A forensic autopsy on a 77-year-old man who had been talking after a road traffic accident and died on the sixth day showed slight subdural hematoma, bifrontal cerebral contusions and diffuse axonal injury. No natural diseases or delayed complications of injury were found. The cause of death was certified as head injury due to a traffic accident. This is a case of "talk and die" head injury. Forensic autopsy is important in patients with "talk and die" to clarify the causal relation to the head trauma in relation to any further forensic dispute.

Medico-legal implications of acute subdural haematoma in boxing

A 16-year-old male high school student with a history of fever (38-39 degrees C) for 4 days lost consciousness following the end of a three round boxing match. He was transferred to a neurosurgical unit located 48 km away 1 h 36 min after injury. Clinical assessment at the unit revealed a comatose patient with a left acute subdural haematoma, but because of advanced brain oedema surgical management was deemed futile. At autopsy an acute subdural haematoma and a severe brain oedema were confirmed. Evaluation of physical conditions before the fight should have been more rigorous in our patient. The observations in our case support the published literature that boxing matches should be held only where neurosurgical expertise is readily available.

[Aircraft crashes in sky sports. Report of two autopsy cases and review of the accidents during 1981 to 1997 in Japan]

The authors report two forensic autopsy cases of pilots who died in glider and ultra-light plane crashes in Aso, Kumamoto and review sky sports accidents in Japan (1981-1997). In the glider crash, sharp abdominal pain due to gallstones in a 78-year-old pilot was a possible cause of the accident. In the ultra-light plane crash, unskillful control of the plane by a 38-year-old pilot was the cause of the accident. The incidence of sky sports accidents increased from 12 cases in 1981 to 62 cases in 1997. The mortality rate of the victims of the accidents is very high. Investigation of natural diseases in pilots as a cause of accidents and the mechanisms of fatal injuries will help to assess preventive measures against sky sports accidents.

Pink spots of Hedley-White in the brain. Evaluation of the significance in the forensic autopsy

Pink spots are sharply demarcated round to oval discolorations with a white center in the deeper areas of the formalin-fixed brain. In 152 forensic autopsies with neuropathological examinations, the authors observed pink spots in three of 16 patients with bacterial infectious diseases. Pink spots could not be found in 136 patients without bacterial infectious diseases. These results verify the concept that pink spots correlate with bacterial infections. The presence of pink spots will be used as an indication of infectious diseases in the forensic autopsy.

Japanese monozygotic twins with familial amyloidotic polyneuropathy (FAP) (ATTR Val30Met)

Twenty-nine-year-old twin brothers having the amyloidogenic transthyretin (ATTR) Val30Met gene developed the clinical symptoms of familial amyloidotic polyneuropathy (FAP) in 1995. The twins had the same educational background and lived in the same district. FAP manifestations were similar in both cases, although electromyographic examinations revealed sensorimotor polyneuropathy in No. 1 and sensory polyneuropathy in No. 2. DNA analysis revealed that they were monozygotic twins. In addition to environmental factors, genetic factors may play an important role in determining the onset of FAP.

Traumatic basal subarachnoid hemorrhage due to rupture of the posterior inferior cerebellar artery--case report

A 20-year-old male presented with traumatic basal subarachnoid hemorrhage after being involved in a fight. Antemortem clinical examinations could not exclude the possibility of rupture of abnormal blood vessels because of the absence of external injuries. Careful postmortem examination of the head and neck regions and histological examination of the intracranial arteries demonstrated traumatic rupture of the left posterior inferior cerebellar artery due to a fist blow to the jaw. This case indicates the need for careful autopsy examination for the differentiation of traumatic and non-traumatic basal subarachnoid hemorrhages.

Fatalities by inhalation of volcanic gas at Mt. Aso crater in Kumamoto, Japan

Volcanic gas is one of the hazards which tourists rarely meet in mountains. We present six fatalities due to volcanic gas inhalation on Mt. Aso, an active volcano in Kumamoto, Japan, over a period of nine years (1989-1997). One accident occurred at the lip of the crater and the other five within a distance of 250 m from the lip of the crater. Four of the six fatalities had a history of bronchial asthma. A forensic autopsy was performed for a fatality with a history of hypertensive heart disease; pulmonary emphysema was disclosed for this victim. These findings supported the idea that individuals with chronic lung diseases were at higher risk of death by volcanic gas inhalation. Safety precautions are effected through regular surveillance of the area and monitoring of volcanic gas levels. The criterion for sulfur dioxide levels has been changed to a more rigorous one (from >5.0 ppm to >0.2 ppm) according to our advice based on the autopsy. Further forensic analyses will help to design additional preventive measures so as to reduce mortality resulting from inhalation of toxic volcanic gas.

Neuropathology of human immunodeficiency virus 1 infection. Significance of studying in forensic autopsy cases at Dar es Salaam, Tanzania

OBJECTIVE

In sub-Saharan Africa, only a few studies of neurologic complications of human immunodeficiency virus 1 (HIV-1) infection have been done. The authors studied neuropathology of HIV-1 infection in Tanzania.

DESIGN

Forensic autopsy study at Dar es Salaam, Tanzania.

SETTING

A joint research project between Dar es Salaam, Tanzania, and Kumamoto, Japan.

PATIENTS

Thirty patients with risk factors for HIV-1 infection.

MAIN OUTCOME MEASURES

Human immunodeficiency virus 1 infection was evaluated by HIV-1 antibody test on postmortem serum samples. The brains of HIV-1-infected persons were studied histopathologically.

RESULTS

Infection with HIV-1 was identified on postmortem serum samples in 10 of 30 forensic autopsy cases. Neuropathologic changes of the brain were observed in 8 of the 10 HIV-1-infected persons; these changes consisted of lymphocytic meningitis, bacterial meningoencephalitis, cryptococcal meningoencephalitis, tuberculous meningitis with brain abscesses, and intracerebral hemorrhage.

CONCLUSIONS

Because none of the persons studied was suspected to have had brain diseases before autopsy, the results suggest that brain diseases of HIV-1-infected patients are likely to go unrecognized in Tanzania. In addition, the high incidence of neuropathologic findings in HIV-1-infected persons indicates that HIV-1-related brain diseases are common in Tanzania, as they are in developed countries. Further forensic autopsy study will determine the range and prevalence of brain complications and have immediate impact on the management of HIV-1-infected patients in Tanzania and other developing countries.

Accidental decapitation: an unusual injury to a passenger in a vehicle

A case of decapitation of a vehicle passenger in an accident on a highway is reported. Evaluation of roadside evidence and the deceased's injuries revealed that the victim was partially ejected from a broken passenger-side window as the vehicle spun out of control, decapitation being due to the impact of his head against a barrier stanchion on the shoulder of the road. An unfastened seat-belt, high-speed driving and the construction of the road barrier were contributory factors.

Death as a result of heat stroke in a vehicle: an adult case in winter confirmed with reconstruction and animal experiments

A 54-year-old man was found dead in the driver's seat of his vehicle on a winter's day. Investigations of the vehicle revealed that the engine was running, and the car heater was left on with the maximum temperature and velocity. The body was found excessively sweating. Rectal temperature of the body was 43 degrees C at 10 h post mortem. In autopsy, several superficial skin burns were observed on the face, the shoulders and the legs. The lungs were heavily congested and hemorrhagic. The liver showed typical alcohol-induced micronodular cirrhosis. The alcohol concentrations were 0.17% in the blood of both the left and the right heart, 0.17% in the femoral-vein blood, 0.21% in the bladder urine and 0.34% in the gastric contents. A reconstruction experiment demonstrated that the temperature inside the vehicle rose rapidly and reached 50-58 degrees C in 3 h. Animal experiments showed that the temperature threshold for rats to succumb to heat was between 40 and 45 degrees C. This case shows that heat stroke in a vehicle can occur in adults with chronic diseases or alcoholism, such as in this particular case, even in the winter.

[Practice and research of forensic medicine learned from the dead]

Practice and Research of Forensic Medicine Learned from the Dead' is presented by looking back my 29 years' carrier as a forensic pathologist. After joining in Department of Forensic Medicine, Kumamoto University in 1969, I had spent several happy years with studying on postmortem corneal clouding. Soon I began to have doubts on a purpose of forensic autopsy in my department then, which seemed to be only to/under the police. I spent one year at Department of Forensic Medicine, Leeds University in England in 1979-1980 and experienced Forensic Medicine not only for the police but also for the society in general. Visiting several university departments in Europa at that time, I felt confident that Forensic Medicine is one special field of medical sciences and will be worth a subject to devote my life. Clinical Forensic Medicine is one field of forensic medicine. Its importance has been recognized in the society by increasing numbers of felonious crimes and campaigns of human rights throughout the world. In 1996, the 4th International Conference of World Police Medical Officers in Clinical Forensic Medicine was ended in a great success in Kumamoto, Japan. Now evaluation and development of Clinical Forensic Medicine are very essential for both forensic pathologists and clinicians to serve for the society. My own activities of teaching traffic safety and preventing child abuse and neglect were cited as examples of 'Practice of Forensic Medicine Learned from the Dead'. Studies on differentiation of postmortem discoloration and antemortem bleeding by glycophorin A or erythrocyte membranes and an international joint research project with Tanzania on neuropathology of AIDS were examples of 'Research of Forensic Medicine Learned from the Dead'. It is an important mission for a forensic pathologist to work for/with the police to solve crimes by hearing a voice of the dead on an autopsy table. Through friendship with foreign colleagues, however, I have learned much about what should be a forensic pathologist and have been inspired with a phrase, 'The information learned from studying the dead could be used to help the living.' by Dr. T.A. Gonzales of the Chief Medical Examiner's Office of New York. Because social activities of preventing crimes and accidents are very much important matters indeed, every forensic pathologist must devote his/her forensic practice and research to achieve a peaceful end of life for every citizen, I believe.

[Forensic medicine in Dar-es-Salaam, United Republic of Tanzania]

The authors had opportunities to visit and see the present state of forensic medicine in Dar-es-Salaam, a capital city of United Republic of Tanzania. In this city, Department of Histopathology and Morbid Anatomy in Muhimbili University College of Health Sciences is in charge of education and practice of forensic medicine. All bodies of unusual death, about 3,000 cases per year, are brought to the university mortuary and examined by pathologists. An order of forensic autopsy from the Tanzanian police is submitted to the department with details of the case, i.e. circumstances of death, witnesses, weapons, etc. In each case, a pathologist signs out a death certificate and issues an autopsy report which is standardized throughout the country. Embalming after autopsy is essential in a tropical country. Tanzania in particular, to prevent both putrefaction of the body and dispersion of pathogens during its transportation. Preventive measures against biohazards from human immunodeficiency virus-infected bodies are considered in the autopsy room and laboratory. Although Tanzania is one of the developing countries in the world, the forensic medicine in the capital city is rendering great services in the promotion of public health.

Binswanger's disease. A rare cause of dementia in elderly persons

A 80-year-old in-patient with abnormal behaviors was strangulated in a hospital bed by another in-patient while he could not escape from the violence because of being restrained to the bed with safety belts. Neuropathological examination of the victim's brain showed characteristic pathological changes of Binswanger's disease (BD), a rare cause of dementia inducing abnormal behaviors. The authors methodically documented BD of the victim and at least justified the restraint as a preventive measure of his abnormal behaviors. Although the etiology of BD is unknown, immunostaining for glial fibrillary acidic protein of the white matter lesions showed neither hyperplasia nor hypertrophy of astrocytes. This result suggested that astrocytes may play an important role in the pathogenesis of BD.

[Neuropathological diagnosis of senile dementia of Alzheimer's type in forensic autopsy cases]

Senile dementia of Alzheimer's type is frequently an underlying cause of accidental death of elderly persons. Neuropathological diagnosis of dementia is therefore crucial to assess the contribution of dementia to the cause of accident. The authors applied two conventional neuropathological criteria described by Khachaturian and Mirra, et al. to three forensic autopsy cases of dementia-related accidental death. In all cases, the number of neocortical senile plaque, a hallmark of dementia, could not fulfill both criteria. This result indicates that foregoing neuropathological criteria derived from fully developed dementia are hardly applicable to elderly persons who died in an early stage of dementia in forensic settings. Further investigation will be required to establish a diagnostic criterion of early stage of dementia.

[The 4th international conference of World Police Medical Officers in Clinical Forensic Medicine in Kumamoto, Japan]

The World Police Medical-Officers in Clinical Forensic Medicine (WPMO) is an international conference on practice of forensic medicine and clinical forensic medicine to be taken place every three years. Its 4th international conference (WPMO-1996-KUMAMOTO) was held on 19-23 August 1996 in Kumamoto, Japan. A total of 294 participants, 89 overseas from 18 countries and 205 domestic, were attended. Four plenary lectures and 67 free papers were presented in the conference. Such social programs as welcome reception, one-day-tour, citizen's home visit, banquet etc were carried out. The two plenary entitled 'Current Status of Practice of Forensic Medicine in U.S.A.' by Prof. Thomas T. Noguchi and 'Origins and Development of the Police Surgeon Services in U.K.' by Dr. Reginald A. Bunting were tape-recorded and presented in this report as references of future activities of forensic medicine in Japan.

[Application of AmpliType PM kit to forensic sciences]

Five genetic loci, low density lipoprotein (LDLR), glycophorin A (GYPA), hemoglobin G gammaglobin (HBGG), D7S8 and group specific component (GC), can be identified in a single step by the AmpliType PM kit. The kit uses multiplex PCR amplification and hybridization by a reverse dot blot method. To introduce the new marker system in forensic caseworks in Japan, a relevant Japanese population database must be established. In this context, the allele frequencies of the 5 genetic loci were determined for 246 unrelated Japanese. The allele frequencies were LDLR*A 0.173, LDLR*B 0.827, GYPA*A 0.528, GYPA*B 0.472, HBGG*A 0.352, HBGG*B 0.648, HBGG*C 0.000, D7S8*A 0.612, D7S8*B 0.388, GC*A 0.258, GC*B 0.504 and GC*C 0.238, respectively. In all 5 systems, the genotype frequencies are in good accordance with the Hardy-Weinberg expectations. The power of discrimination (PD) of LDLR, GYPA, HBGG, D7S8 and GC were 0.449, 0.624, 0.600, 0.612 and 0.788, respectively, resulting in a combined PD of 0.993, while these 5 DNA types could be determined from slaiva and semen. And the GYPA or GC genotypes were observed to have good relations with the MN and serum Gc phenotypes. The AmpliType PM kit was confirmed to be a reliable DNA typing system which was well suited for use in forensic sciences.

[Recommendations for preventing transmission of infection with biohazard in the practice of legal medicine (2). Equipment and practical applications. The Medico-Legal Society of Japan, Committee on Expert Opinions]

In May, 1993, our committee of the Medico-Legal society of Japan published an article entitled "Recommendations for Preventing Transmission of Infection with Biohazard in the Practice of Legal Medicine" in The Japanese Journal of Legal Medicine. Concerning this article, we received a lot of useful comments and opinions from many members of the society, for which we are very grateful. We also received a lot of requests for further information concerning details on the equipment and its practical applications. Since a lot of departments of Legal Medicine at several universities throughout Japan at present are remodelling their facilities in order to be able to perform autopsies, with respect to such circumstances, our committee felt the need to provide information on basic conditions concerning the prevention of transmission of infections with hazards.

[Two unusual cases of half-sibling test with DNA polymorphism]

In usual paternity cases, the putative man and the mother-child couple are alive. However, there are some cases in which putative man and mother were deceased and only children were available for analyses. It is difficult to determine the presence or absence of half-sibling relationship from analyses of conventional blood group markers (CBGM). In this study, five kinds of single locus DNA probes were applied to 2 half-sibling cases. To decide usefulness of single locus DNA probes, we defined likelihood ratio of half-sibling (LRHS) based on the likelihood ratio of paternity (LRP) and also investigated the distribution curves of log10 LRHS in cases of unrelated combinations and half-sibling combinations. Distribution curves of log10 LRHS from DNA analyses in the cases of unrelated combinations and half-sibling combinations is more clearly separated than from CBGM. Single locus DNA probes are considered to be more informative for half-sibling cases.

Differentiation between bruises and putrefactive discolorations of the skin by immunological analysis of glycophorin A

In a differential study to distinguish bruises from putrefactive discoloration, glycophorin A, a component of the erythrocyte membrane, was extracted from discolored skins and detected by immunological methods utilizing an anti-glycophorin A serum. Skin samples of 18 bruises, 8 postmortem hypostasises and 7 putrefactive discolorations were removed from 27 bodies in which postmortem intervals ranged from 4 h to 2.5 months. In 13 out of the 18 bruises (72.2%), glycophorin A was detected by the immunological methods. It was noted that glycophorin A was detectable even in a severely putrefied body 10 days after death. In contrast, no glycophorin A was detected in any of the postmortem lividities or the putrefactive discolorations. These results suggest that the absence of glycophorin A does not always indicate a skin discoloration of postmortem origin, but a positive glycophorin A reaction does indicate a skin discoloration due to bruise.

Purification of blood-group substances in human hepatic bile (HHB) and immunological characterization of anti-HHB serum

Blood-group substances (BGS) in human hepatic bile (HHB) of blood type A were purified 3657-7314-fold by ethanol sedimentation and column chromatography with DEAE Sephadex A-50 and Concanavalin A Sepharose 4B. An anti-HHB serum was raised by immunizing rabbits with the purified BGS in the HHB. Cross-reactions of the native anti-HHB serum with such human materials as type A blood cell, plasma, seminal fluid and saliva were eliminated by stepwise sequential absorptions with type A red blood cells, type O seminal fluid and type AB plasma. Precipitin titers of the native anti-HHB serum were x 320 and x 80 and those of the absorbed anti-HHB serum x 80 and x 20 against the immunogen and HHB, respectively. Organ and species specificity of the absorbed anti-HHB serum was checked by counter immunoelectrophoresis. It reacted specifically only with the immunogen and HHBs of various ABO blood types. No reactions with animal gallbladder biles were observed. In practical examinations, the specific anti-HHB serum identified 15 out of 20 (75%) HHB samples and 41 out of 46 (89%) human faeces samples. No reactions with animal gallbladder biles and animal faeces were observed.

[Recommendations for preventing transmission of infection with biohazard in the practice of legal medicine. The Medico-Legal Society of Japan, Committee on Expert Opinions]

In Japan recently there arose a sudden need for special guidelines concerning medicolegal autopsy and the handling of medicolegal materials. In this respect, the Medico-legal Society of Japan, Committee on Expert Opinions has produced a guideline, entitled "Recommendations for Preventing Transmission of Infection with Biohazard in the Practice of Legal Medicine", which was then introduced to all members in Legal Medicine. This guideline contains First: Explanations about the most important types of Biohazard diseases, the dangers and ways of transmission. Second: Explanations concerning preventive measures in medicolegal autopsy, for handling of medicolegal materials and investigation samples, also concerning the equipment and tools within the autopsy room, as well as measures for correct disinfection. These guidelines, form the base on each department of the Medico-Legal Society of Japan, are asked to adjust their own practical manual in order to improve the safety of autopsy conditions.

[Studies on quantitative analysis of paraquat in whole blood--the evaluation of pre-treatments and analytical methods]

Paraquat and diquat are bipyridylium herbicide, which fatal poisoning cases have been reported in recent years. There are a number of methods for the pre-treatment and analysis of paraquat in body fluids and postmortem tissues. But the combined evaluation of these pre-treatments and analytical methods can be hardly found in literatures. We have carried out quantification of paraquat in whole blood with various combinations of pre-treatments and analytical methods, and evaluated those with respect to the sensitivity, recovery, time and cost. Non-treatment sample was a diluted solution of whole blood containing an aliquot of paraquat. The pre-treatments were achieved using two sorts of protein precipitants or Sep-Pak C18 cartridge. HPLC, second-derivative spectroscopy and ELISA were selected as analytical methods for quantification of paraquat. The most sensitive methods were combination of protein precipitants or Sep-Pak C18 and ELISA, but a combination of protein precipitant of sulfosalicylic acid and second-derivative spectroscopy was found to be more rapid and economical method. These methods would be applicable in forensic and clinical laboratories.

Differentiation of discolouration in a body by an erythrocyte membrane component, glycophorin A

In a differential study to distinguish antemortem bruise from postmortem infiltration of haemoglobin on the skin, a component of erythrocyte membrane, glycophorin A was extracted from experimental bruise and haemoglobin infiltration lesions over set periods of time. This extraction was accomplished by utilising anti-glycophorin A serum, after which the difference between the two lesions was evaluated. The glycophorin A was recovered from the bruise lesions satisfactorily up to the ninth to twelfth days and showed good resistance to putrefaction. In contrast, no glycophorin A was detected in haemoglobin infiltration lesions taken at any time. Glycophorin A was also detectable in human vital bruises which were taken in autopsies of four hours to ten days postmortem. These results suggest that a differential diagnosis of antemortem bruise and postmortem haemoglobin infiltration is possible in advanced stages of death.

Studies of felonious crimes by the University Department of Forensic Medicine in Kumamoto Prefecture, Japan

This paper gives an understanding of Japan in the respect of forensic medicine. The fight against felonious crimes in Kumamoto is introduced by reference to the police system, crime statistics, an association of police surgeons and medico-legal autopsy in Kumamoto Prefecture. The police have 23 local police stations with 2,670 police officers and the unique Hashutsu-sho and Chyuzai-sho systems. The crime rate is not very high, but crimes committed by Yakuza groups and traffic accidents are major problems in Kumamoto. Medico-legal autopsy is performed in the university department on only criminal and suspected cases after examination of the body externally by a police surgeon. Two illustrative cases are also introduced in this report, which shows good cooperation among the police force, the university department of forensic medicine, and police surgeons in Kumamoto, Japan.

Genetic polymorphism of complement component C6, C7 and C8(1) in Chinese Han population in northeast China

Distributions of complement phenotypes, C6, C7, and C8(1) were studied using thin agarose gel isoelectric focusing (AGIEF) or ultra-thin polyacrylamide gel isoelectric focusing (PAGIEF) and subsequent immunoblotting techniques in 203 Chinese Han population in Liaoning Province of northeast China. The gene frequencies were as follows: C6*A 0.4704, C6*B 0.5049, C6*B2 0.0148, C6*B3 0.0049, and C6*M 0.0049; C7*1 0.8251, C7*2 0.1108, C7*3 0.0320, and C7*4 0.0320; C8(1)*A 0.5567 and C8(1)B 0.4433, respectively. All the observed numbers of the phenotypes were in agreement with the expected numbers under the Hardy-Weinberg equilibrium. The gene frequencies among Chinese subpopulations and other various populations were compared.

Genetic polymorphism of human factor H (HF, beta 1H globulin) in Chinese Han population in northeast China

The distribution of human factor H of serum phenotypes were studied using ultrathin polyacrylamide gel isoelectric focusing (PAGIEF) and subsequent immunoblotting techniques in 203 Chinese of Han population in Liaoning Province of northeast China. The gene frequencies of HF*A and HF*B were 0.4828 and 0.5172, respectively. All the observed numbers of the phenotypes were in agreement with the expected numbers under the Hardy-Weinberg equilibrium. The gene frequencies among Chinese, Japanese, and Caucasian populations were compared.