Fatal dengue hemorrhagic fever imported into Germany.

Dengue virus (DENV) is an arthropod-borne virus (family Flaviviridae) causing dengue fever or dengue hemorrhagic fever. Here, we report the first fatal DENV infection imported into Germany. A female traveler was hospitalized with fever and abdominal pain after returning from Ecuador. Due to a suspected acute acalculous cholecystitis, cholecystectomy was performed. After cholecystectomy, severe spontaneous bleeding from the abdominal wound occurred and the patient died. Postmortem analysis of transudate and tissue demonstrated a DENV secondary infection of the patient and a gallbladder wall thickening (GBWT) due to an extensive edema.

The decrease of pigment concentration in red tattooed skin years after tattooing.

BACKGROUND: Tattooing entails the injection of high amounts of colourants into skin. Excepting black inks, red azo pigments are the most frequent colourant used. Part of the pigment is transported away via lymphatic system. Another part can be decomposed in skin, which might be responsible for many known adverse skin reactions. OBJECTIVE: The aim of this study was to estimate the extent of decomposition and transportation by measuring the decrease of pigment concentration in human skin under in vivo conditions. METHODS: Red pigments were extracted from nine tattooed skin specimen and attempted quantification by using HPLC technology. To optimize quantification, we synthesized five common red azo pigments with purity at 98% and used them as HPLC reference substances. RESULTS: In five of the nine skin specimens, we were able to identify and subsequently to quantify the red tattoo pigments such as Pigment Red 22 or Pigment Red 112. The mean pigment concentration in skin was 0.077 ± 0.046 mg/cm². As the pigment concentration in skin ranges from 0.60 to 9.42 mg/cm² (mean: 2.53) directly after tattooing, we estimate a decrease of 87 to 99% of pigment concentration in skin after tattooing. CONCLUSION: Millions of people have many and large tattoos, whereas a single tattoo frequently covers a skin area of more than 300 cm². Thus, the major part of more than 760 mg of azo pigments either decomposes in skin or migrates in the body. That may pose a health risk on tattooed individuals, in particular may cause severe skin reactions.

[Typical findings of maltreated children]. / So differenzieren Sie zwischen Unfall und Cewalttat. Indizien der Kindesmisshandlung.

Childhood maltreatment manifests in a variety of forms and the underlying causes are manifold. In contrast to other offences involving physical injury, reporting behavior has, statistically speaking, remained unchanged. Patterns of injury must first be established and documented, and this involves a complete examination of the child's body. Depending on the constellation of findings, a radiological diagnosis is usually necessary. When all the findings have been collected, the further steps to be taken--where indicated a report to the police--must be discussed. All the evidence must be recorded, and photos obtained of all externally visible injuries before they fade. It is not the task of the physician to develop criminalistic ambitions, for example, by grilling (a parent) on the cause of the injuries. However, he/she has a duty to do everything necessary to protect the well-being of the child.

Fatal poisoning in methadone and buprenorphine treated patients -- are there differences?

BACKGROUND: Some recent studies have suggested a lower risk of fatal intoxications in drug-dependent patients under buprenorphine compared to methadone treatment. METHODS: Epidemiological reference data for the Munich region suggest that in 2003 approximately 10 % of all substitution patients were treated with buprenorphine, and 87 % with methadone. We studied the proportion of patients under methadone and buprenorphine substitution among drug-related deaths. Data from forensic post-mortem and toxicological analysis were analyzed. RESULTS: Data indicate that in 96 (35 %) of all 272 so-called drug deaths, methadone was involved compared to a single case of buprenorphine, possibly indicating a relatively better risk profile of buprenorphine. DISCUSSION: More prospective studies are necessary to assess the risk of fatal intoxications under different substitution regimens.

Cervical spine: postmortem assessment of accident injuries--comparison of radiographic, MR imaging, anatomic, and pathologic findings.

PURPOSE: To assess the ability of postmortem radiography and magnetic resonance (MR) imaging to depict occult cervical spine injuries as compared with anatomic and pathologic findings. MATERIALS AND METHODS: The cervical spines of 10 adult accident victims underwent radiography and MR imaging, with T1-weighted, fast spin-echo T2-weighted, and four gradient-echo pulse sequences. The frozen specimens were cut into 3-mm-thick slices (sagittal plane) and photographed, and microfocus radiographs were obtained. Imaging findings were compared with the anatomic and pathologic findings. RESULTS: Eight of the 10 specimens had 28 posttraumatic lesions: three fractures (two missed at the initial MR imaging reading), 10 facet joint capsule lesions with bleeding, five soft-tissue and ligament lesions, eight disk lesions, and two spinal cord lesions. Radiography depicted one lesion (4%). Two partial ruptures of the anterior annulus fibrosus were depicted at only MR imaging. Initially, 11 of 28 lesions were detected on MR images; retrospectively, 17 of 28 lesions were correlated with anatomic findings. CONCLUSION: Soft-tissue and intervertebral disk and ligament injuries account for 89% (25 of 28) of posttraumatic cervical spine lesions detected on postmortem images. Occult lesions, including apophyseal joint injuries, were found in clinically noninjured cervical spines. MR imaging was limited in the depiction of discrete lesions when T1-weighted non-fat-saturated, fast spin-echo T2-weighted, and gradient-echo pulse sequences were used.

Sex determination and estimation of stature from the long bones of the arm.

The determination of sex and the estimation of stature from bones play an important role in identifying unknown bodies, parts of bodies or skeletal remains. In medico-legal practice statements on the probable sex of a decomposed body or part of a body are often expected even during autopsy. The present study was, therefore, restricted to few easily accessible dimensions from bones which were prepared only by mechanically removing soft tissues, tendons and ligaments. The specimens came from the Anatomical Institutes in Munich and Cologne from the years 1994-1998 including a total of 143 individuals (64 males and 79 females). The mean age was 79 years (46-108), the mean body height 161cm (134-189). The following measurements were taken: maximum humeral length (mean: 33.4cm in males; 30.7cm in females), vertical humeral head diameter (mean: 5.0cm in males, 4.4cm in females), humeral epicondylar width (mean: 6.6cm in males; 5.8cm in females), maximum ulnar length (mean: 26.5cm in males, 23.8cm in females), proximal ulnar width (mean: 3.4cm in males, 2.9cm in females), distal ulnar width (mean: 2.2cm in males; 1.8cm in females), maximum radial length (mean: 24.6cm in males; 22.0cm in females), radial head diameter (mean: 2.6cm in males, 2.2cm in females) and distal radial width (mean: 3.6cm in males; 3.2cm in females). The differences between the means in males and females were significant (P<0.0005). A discriminant analysis was carried out with good results. A percentage of 94.93% of cases were correctly classified when all measures of the radius were applied jointly, followed by humerus (93.15%) and ulna (90.58%). Applied singly, the humeral head diameter allowed the best distinction (90.41% correctly grouped cases), followed by the radial length (89.13%), the radial head diameter (88.57%) and the humeral epicondylar width (88.49%). The linear regression analysis for quantifying the correlation between the bone lengths and the stature led to unsatifactory results with large 95%-confidence intervals for the coefficients and high standard errors of estimate.

[The physician as Sherlock Holmes. Accident, murder by poisoning or suicide?]. / Der Arzt als Sherlock Holmes. Unfall, Giftmord oder Suizid?

Any case of unclear or atypical clinical presentation must arouse a suspicion of poisoning. Although pathognomonic findings are rare, there may nevertheless be an accumulation of signs and symptoms. These include impairment of consciousness, vertigo, headache, circulatory disorders, cramps/convulsions, vomiting, diarrhea and abdominal pains. Forensic terminology differentiates between outside influence, self-poisoning and accidental poisoning. In the former case, substances are used that are deadly in small amounts, and are unremarkable in appearance, smell and taste. The poisons used by suicides are usually commonly used poisonous substances that are freely available to purchasers. For forensic purposes, it is essential that specimens of blood, urine or stomach contents be obtained for toxicological investigations. Inspection of the corpse must routinely include a search for unusual signs (e.g. traces of powder around the mouth, foam at the mouth and nose, desiccation, unusual postmortem lividity, hair loss, etc.).

The neuropathology of heroin abuse.

A broad spectrum of neuropathologic changes are encountered in the brains of heroin abusers. The main findings are due to infections, either due to bacterial spread from bacterial endocarditis, mycoses, or from HIV-1 infection. Other complications include hypoxic-ischemic changes with cerebral edema, ischemic neuronal damage and neuronal loss, which are assumed to occur under conditions of prolonged heroin-induced respiratory depression, stroke due to, for example, thromboembolism, vasculitis, septic emboli, hypotension, and positional vascular compression. Myelopathy is believed to be the result of an isolated vascular accident within the spinal cord due to an as yet unknown mechanism. A distinct entity, spongiform leukoencephalopathy, has been described mainly after inhalation of pre-heated heroin. A lipophilic toxin-induced process was considered to be due to contaminants and to be induced or enhanced by cerebral hypoxia, but a definite toxin could not be identified. At the cellular level, abnormalities in signal transduction systems and changes of various receptor densities have been reported. The exact etiology of the different neuropathological alterations associated with heroin abuse is still unclear, but may also be related to additional substances used as adulterants.

Melanoma-associated adhesion molecule MUC18/MCAM (CD146) and transcriptional regulator mader in normal human CNS.

The proteins MUC18 and Mader have been identified as markers of tumor progression in melanoma cells. MUC18, also known as MCAM (melanoma cell adhesion molecule) and as CD146 (endothelial antigen), is a cell adhesion molecule belonging to the immunoglobulin superfamily. Mader is a transcriptional regulator shown to negatively regulate EGR-1. As it is known that neoplastic cells of neuroectodermal origin frequently express neuron-specific molecules, we studied whether these melanoma-associated antigens are found in normal CNS tissue. We investigated the expression of MUC18/MCAM and Mader in adult human post mortem CNS tissue by immunohistochemistry, immunoblot and two-dimensional gel electrophoresis. Our results show that Mader is preferentially expressed on neurons and glial cells and that the adhesion protein MUC18/MCAM is mainly expressed on vasculature within the CNS. These observations may have important implications for further studies investigating their possible roles in cell adhesion and proliferation control within the CNS.

Detection of the novel cell adhesion molecule MUC18 in human brain tissue.

The implication of cell adhesion molecules (CAMs) in the mediation of the immune response to inflammatory stimuli has been shown in different neurological syndromes. The neural cell adhesion molecule (NCAM) and the myelin associated glycoprotein (MAG) are functionally important CNS-cell adhesion molecules (CAMs) and members of the immunoglobulin gene superfamily (IgSF). Both CAMs are expressed from the time of neuronal induction and myelin formation and are likely to contribute to the generally adhesive properties of neurons and oligodendrocytes. The present study describes, by means of SDS-PAGE and immunoblotting, a novel CNS antigen which is a glycoprotein detected in post mortem frontal lobe tissue of ten subjects at an M(r) 65 and 113 kD which showed the greatest sequence homology to neuronal IgSF members like NCAM. This expected membrane CAM, with probable functions in CNS cell-cell interactions, had been detected first in primary human melanoma cells, with increasing expression as tumors progress and is expected to be a developmentally regulated CAM in neuroectodermal tissues.

Aortic endothelium in HIV-1 infection: chronic injury, activation, and increased leukocyte adherence.

Clinical and serological studies provide evidence for a pathogenetically relevant vasculopathy in acquired immune deficiency syndrome (AIDS); however, the morphological status of the endothelium under conditions of human immunodeficiency virus (HIV)-1 infection is only sparsely documented. In this study we adapted an en face preparation technique of endothelium for use in immunohistochemistry and investigated the aortic endothelium of pre-AIDS and AIDS patients (n = 32) in comparison with an HIV-negative group (n = 17). The control group showed a regular pattern of evenly distributed aortic endothelial cells, whereas the endothelial cell pattern in the HIV-1-infected patients was clearly disturbed. Simultaneously, the degree of leukocyte adherence on the aortic endothelium increased significantly. These changes were accompanied by an up-regulation of the vascular cell adhesion molecule-1 (VCAM-1) and E-selectin (ELAM-1). The endothelium turnover increased, and one-half of the HIV-1-infected patients exhibited HLA-DR (major histocompatibility complex class II) antigen in the aortic endothelium. Our results provide evidence for a profound and repeated injury with regeneration and activation of the endothelium in HIV-1 infection. Injury as well as activation of the endothelium impairs its normal regulatory properties. This could have consequences for the maintenance of the blood-brain barrier; it might influence the immunologically important interaction of the endothelium with T cells; and it might trigger Kaposi's sarcoma.

Bordetella pertussis infections and sudden unexpected deaths in children.

UNLABELLED: From December 1990 to November 1993 nasopharyngeal specimens were obtained for culture from 50 children (mean 4.9 +/- 3.3 months of age) who had died suddenly. Bordetella pertussis was not isolated. Subsequently, nasopharyngeal specimens for polymerase chain reaction (PCR) analysis were obtained from another 51 victims of sudden death (mean 5.4 +/- 4.4 months of age); nine (18%) were B. pertussis positive. CONCLUSION: Our findings support previous epidemiological studies which noted an association between epidemic pertussis and sudden infant death syndrome. Further PCR studies with both internal and external controls should be performed.

Fibrin degradation products in post mortem brain tissue of schizophrenics: a possible marker for underlying inflammatory processes.

Alterations in protein composition are often present in diseases of the central nervous system (CNS). Inflammatory processes causing these alterations have been suggested by many authors to underlie the cerebral disturbance in some cases of schizophrenia. In a previous study, two disease-associated additional polypeptides P1 and P2 could be detected in the cerebrospinal fluid (CSF) of 60 out of 123 (49%) schizophrenic patients. These polypeptides were identified as cleavage products of the beta-chain of fibrin(ogen), an acute-phase protein which is increased in inflammatory processes. Because investigations of brain tissue might better reflect the disease process than cerebrospinal fluid, we examined 6 post mortem brains (3 schizophrenics, 3 normal controls) for the presence of fibrin(ogen) and its cleavage products by two dimensional gel electrophoresis followed by immunoblotting. We detected fibrin(ogen) and its degradation products P1 and P2 in all schizophrenic brain tissue samples, but not in that from controls. These results are consistent with previous CSF observations and suggest that a CNS inflammatory process may be occurring in a subgroup of schizophrenic patients.

Expression of T cell receptor gamma delta antigens in human brain tissue.

The human gamma delta T cell receptor (TCR) is normally expressed on lymphoid tissue. Since expression of different molecules of the T cell system has been described for human brain cells, we examined the expression of CD4 and TCR gamma delta antigens with a panel of various anti-gamma delta TCR monoclonal antibodies (mAbs) and an anti-CD4 mAb using immunohistochemistry on different regions of frozen human postmortem tissue from five different brains. We could confirm the expression of CD4 antigens. gamma delta TCR expression on brain tissue was found in different regions of the brain by immunohistochemistry. Double staining with anti-gamma delta TCR and antineuronal enolase (NSE) mAbs showed that gamma delta TCR+ cells were not stained by anti-NSE, although they were sometimes located near neurons and showed dendritic forms; they are possibly tissue-resident gamma delta T cells, as described in the skin. Polymerase chain reaction analysis using a highly sensitive primer sequence against the constant-region delta sequence supports, combined with immunohistochemistry findings, the notion that the gamma delta TCR is expressed in human brain.

Expression of human heat-shock protein 70 antigens and gamma/delta T-cell receptor antigens in human central nervous tissue.

The human gamma delta T cell receptor is normally expressed on lymphoid tissue. Because expression of different molecules of the T-cell system has been described on human brain cells, we examined the expression of T-cell receptor gamma delta antigens with a panel of various anti-gamma/delta TCR mAbs using immunohistochemistry on different regions of frozen human postmortem tissue of five different brains. We found expression of gamma/delta TCR antigens on brain tissue in different regions of the brain, probably on neurons. Using mAbs against the 70-kd human heat-shock-protein (hsp 70), immunohistochemistry showed staining of microglia. A polymerase chain reaction analysis using a highly sensitive primer sequence against the constant region delta sequence supports the notion that the gamma/delta TCR is expressed in human brain; however, the sequence cannot be assigned to a specific tissue with this method. Both heat shock proteins and the gamma/delta TCR seem to be involved in autoimmune processes, and their expression on colocalizing structures in human CNS may play a role in triggering neuropsychiatric autoimmune disorders.

[Self-castration with suicide]. / Selbstkastration im Rahmen eines Suizids.

Suicide of a 31 year old man with multiple slashes and stab wounds including complete amputation of penis, scrotum and testicles is reported. Wound patterns in genital self-mutilations are discussed. Despite serious loss of blood the reported survival periods are remarkable; death from bleeding seems to be rare. A review of similar cases shows that self-castrations as well as other self-inflicted genital mutilations are usually associated with psychiatric disorders and transsexuality or hypersexuality.

[Penetrating injuries of the orbital roof caused by the point of an umbrella]. / Perforationsverletzungen des Orbitadachs durch Regenschirmspitze.

Two lethal cases of penetration injury of the orbita are reported. The injuries were caused directly by the point of an umbrella (accident or homicide), leading to canalicular destruction of the frontal lobe of the cerebrum. The mechanism of injury with cerebral involvement was not determinable except by autopsy, and the importance of a thorough clinical examination is therefore emphasized.