A sudden infant death associated with atrial septal aneurysm and abnormality of the connecting site between the inferior vena cava and right atrium.

An atrial septal aneurysm (ASA) is a rare cardiac anomaly characterized by varicose bulgingofthe atrial septum (oval fossa) into the left or right atrium. Pathogenesis and clinical significance of ASA are controversial. We report an autopsy case of a huge undiagnosed ASA with abnormality of the connecting site between the inferior vena cava and the right atrial ostium in a 2-month-oldJapanesefemale who died suddenly and unexpectedly. She was born at 36 weeks 4 days (body weight 3,110 g). No abnormality was detected during pregnancy or delivery. The postnatal growth was normal with no cardiac problem detected at the 1-month checkup. The ASA bulged off in a mass to the left atrium (width, 0.8 cm; excursion ratio, 53%), reaching close to the inflow site of the right pulmonary vein, with dilation of the pulmonary vein. The connecting site between the inferior vena cava and the right atrium was atypically located 1.6 cm away from the atrioventricular groove. Although most cases of ASA in an infant resolve physiologically as the infant grows, the infant in the present case is thought to have had an exceptional pathological ASA, possibly causing supraventricular arrhythmia. The abnormality of the connecting site between the inferior vena cava and the right atrium might have affected the development and continuation of the ASA.

Diagnostic significance of the histopathology of bone marrow macrophages in forensic autopsies.

Forensic pathologists often encounter autopsies that require an assessment of antemortem general conditions (e.g., infection, metabolic disorders). To establish evaluation clues for such cases, we quantitatively examined macrophages and the general pathology of bone marrow in samples from 180 forensic autopsy cases of decedents with various conditions. Hematoxylin-eosin staining, Berlin blue staining, and immunostainings for CD163, CD138, and CD61 were performed. We determined the numbers per field (density) of total macrophages, swollen macrophages, macrophages with hemophagocytosis, and hemosiderin-laden macrophages. Each density was standardized by identifying its ratio to the total number of macrophages. The decedents' background data (cause of death, other pathological findings, postmortem interval, antemortem symptoms, and presence of resuscitation) were extracted. No correlations were found between the postmortem interval and the other decedent data, indicating that these data are not affected by postmortem changes. In the group in which inflammatory disease was the cause of death, there were significant elevations in the ratio of the swollen macrophage density to total macrophages. Significantly higher ratios of the density of swollen and hemophagocytic macrophages were observed in the group in which conditions with a prolonged agonal period were the cause of death. The group with a return of spontaneous circulation to resuscitation showed a significantly higher ratio of macrophage density with hemophagocytosis. This study provides the first statistical analysis focused on bone marrow histopathology in forensic autopsies. The results will be useful for elucidating causes of death and agonal-period conditions.

An autopsy case of early-stage amyotrophic lateral sclerosis with TDP-43 immunoreactive neuronal, but not glial, inclusions.

Phosphorylated transactivation response DNA-binding protein 43 kDa (p-TDP-43)-immunoreactive neuronal and glial cytoplasmic inclusions are a histopathological hallmark of sporadic amyotrophic lateral sclerosis (ALS) and frontotemporal lobar degeneration with TDP-43. We report an autopsy case of lower motor neuron-predominant ALS in a 47-year-old Japanese man who committed suicide 5 months after onset. Histopathologically, neuronal loss was restricted to the anterior horn of the spinal cord, and no obvious neuronal loss was noted in the motor cortex or brainstem motor nuclei. Bunina bodies were found in the spinal anterior horn cells and the facial and hypoglossal nuclei. Immunohistochemically, p-TDP-43-immunoreactive neuronal, but not glial, cytoplasmic inclusions were frequently found in the spinal anterior horn and facial and hypoglossal nuclei, and rarely in the motor cortex. We considered the present case to be an example of lower motor neuron-predominant ALS. p-TDP-43-immunoreactive aggregates in neurons, but not in glial cells, may be an early-stage pathology of ALS.

Fatal Intracranial Aneurysms and Dissections Causing Subarachnoid Hemorrhage: An Epidemiological and Pathological Analysis of 607 Legal Autopsy Cases.

BACKGROUND: There are no detailed reports, in terms of epidemiology and pathology, on intracranial aneurysms and on dissections that were found in unexpected fatal subarachnoid hemorrhage (SAH) cases. In this report we analyzed, based on large-sized medicolegal autopsy cases, the detailed epidemiology and pathological aspects of both lesions. METHODS: We analyzed 607 autopsy cases of unexpected fatal SAHs including 496 aneurysms and 111 dissections. RESULTS: The following results were obtained: (1) Patients who died of dissections were younger than those who died of aneurysms; (2) symptom prevalence rates of aneurysms were 31.9%, appearing to be lower than those in previous studies; (3) a significantly higher prevalence of clinical symptoms was found in patients with dissections (60.5%) than patients with aneurysms; (4) hypertensive cardiomegaly was indicated in more than 80%, while no obvious difference in incidence in hypertensive cardiomegaly was noted between aneurysms and dissections; (5) aneurysms were found to occur much more frequently in the anterior communicating artery (31.9%) and vertebral arteries (7.5%), while dissections were found much more commonly in vertebral arteries (93.7%); and (6) the size of aneurysms was much smaller in general than that previously regarded as a risk factor of rupturing. CONCLUSIONS: These data might help in the prompt intervention in SAH and also in the prevention of lethal SAH in clinical settings.

Sudden death in a child caused by a giant cavernous hemangioma of the anterior mediastinum.

A 4-year-old girl who had been treated for asthma since the age of 2 years had a severe coughing fit and died suddenly. The patient had a history of occasional severe coughing fits, and these fits had been worsening in severity during the week before her death. Prior to death, she was taken to a clinician, and thymic hypertrophy was suspected based on chest X-ray findings. The clinician recommended that she visit a general hospital at a later date; however, she died that night. Postmortem radiology and autopsy revealed a large mass in the anterior mediastinum compressing the heart and airway, and no other findings attributable to sudden death were observed. Therefore, we concluded that the patient's death was attributable to acute respiratory and cardiac circulatory failure secondary to the pressure induced by the mass. Microscopically, the mass showed a cavernous structure composed of cystically dilated, thin-walled large vessels filled with blood. The final diagnosis was a cavernous hemangioma. Hemangiomas are the most common benign vascular anomalies seen in young children; however, mediastinal hemangiomas are rare and can cause life-threatening complications because of their size and location. Therefore, forensic pathologists should include hemangioma as a differential diagnosis in children with anterior mediastinal masses.

Screening Test for Shed Skin Cells by Measuring the Ratio of Human DNA to Staphylococcus epidermidis DNA.

A novel screening method for shed skin cells by detecting Staphylococcus epidermidis (S. epidermidis), which is a resident bacterium on skin, was developed. Staphylococcus epidermidis was detected using real-time PCR. Staphylococcus epidermidis was detected in all 20 human skin surface samples. Although not present in blood and urine samples, S. epidermidis was detected in 6 of 20 saliva samples, and 5 of 18 semen samples. The ratio of human DNA to S. epidermidisDNA was significantly smaller in human skin surface samples than in saliva and semen samples in which S. epidermidis was detected. Therefore, although skin cells could not be identified by detecting only S. epidermidis, they could be distinguished by measuring the S. epidermidis to human DNA ratio. This method could be applied to casework touch samples, which suggests that it is useful for screening whether skin cells and human DNA are present on potential evidentiary touch samples.

An Autopsy Case of a Pregnant Woman With Severe Placental and Fetal Damage From Domestic Violence.

We present an autopsy case of a pregnant woman who was a victim of domestic violence. The deceased showed injuries mainly to her head and abdomen. Postmortem examination revealed 1400 mL of abdominal hemorrhage, ablation of the perimetrium, placental avulsion, and intracranial hematoma. The cause of death was diagnosed as hemorrhagic shock. The uterus contained a fetus of 7 months' gestational age. Fetal autopsy revealed laceration of the lungs, laceration and avulsion of the liver, and 15 mL of hemoperitoneum. Both placental and fetal injuries suggested repeated severe attacks to the abdomen, such as those expected to result from kicking or hitting.

Sudden death of a child from myocardial infarction due to arteritis of the left coronary trunk.

An eight-year-old Japanese boy developed abdominal pain, followed by convulsion and loss of consciousness. He was taken to an emergency room but could not be resuscitated. At autopsy, the left main coronary trunk (LMT) demonstrated an increase in caliber with severe luminal narrowing, and the left anterior descending branch (LAD) subsequent to the LMT showed severe stenosis. Microscopically, the intima of the LMT demonstrated severe fibrosis and infiltration of lymphocytes and histiocytes suggesting vasculitis, and the small lumen was occupied by a fresh thrombus. The LAD showed significant intimal thickening with strong lymphocytic inflammation at the edge of the thickening. The left ventricle showed widespread myocardial infarction in the recovery stage. There were no findings of atherosclerosis, vasculitis or fibrocellular changes in the ascending aorta or intravisceral arteries other than the LMT and the LAD under investigation. The increase in the caliber of the LMT and the limitation of arteritis to the LMT and the subsequent branch suggested Kawasaki disease (KD), but it was atypical that the patient had no clinical history consistent with KD. The present case showed no findings suggesting classical polyarteritis nodosa (cPAN) at the acute or scar stage in the other vessels being investigated, and cPAN in childhood is rare compared to KD. A nonspecific inflammatory reaction (single organ vasculitis, SOV) was also considered as a possible cause, but it is difficult to determine whether the cause of the coronary stenosis in the present case was SOV because the sampling of arteries was insufficient. If forensic pathologists make unusual findings suggesting vasculitis at autopsy, the collection of a sufficient number of vessels of various sizes is warranted.

Evaluation of forensic examination of extremely aged seminal stains.

The results of forensic tests, such as semen identification and short tandem repeat (STR) analysis of extremely aged seminal stains from unsolved sex crimes can provide important evidence. In this study we evaluated whether current forensic methods could be applied to seminal stains that were stored at room temperature for 33-56years (n=2, 33years old; n=1, 41years old; n=1, 44years old; n=1, 56years old). The prostatic acid phosphatase (SM-test reagent), microscopic (Baecchi stain method) and semenogelin (RSID™ Semen Laboratory Kit) tests were performed as discriminative tests for semen. In addition, the mRNA levels of the semen-specific proteins semenogelin 1 (SEMG1) and protamine 2 (PRM2) were investigated. STRs were analyzed using the AmpFlSTR® Identifiler™ PCR Amplification Kit. All samples were positive in the prostatic acid phosphatase and semenogelin tests, and sperm heads were identified in all samples. The staining degree of the aged sperm heads was similar to that of fresh sperm. Although SEMG1 mRNA was not detected in any sample, PRM2 mRNA was detected in three samples. In the STR analysis, all loci were detected in the 33-years-old sample and five loci were detected in the 56-years-old sample. We confirmed that current forensic examinations - including STR analysis - could be applied to extremely aged seminal stains. These results could be useful for forensic practice.

Rupture of abdominal aortic aneurysm associated with long-term steroid therapy--a case report.

We report an autopsy case of bronchial asthma patient with a specific abdominal aortic aneurysm. The aneurysm did not show arteriosclerosis, and a specific saccular morphology was noted above the bifurcation. Histologically, necrosis of the media resembling acute aortic dissociation was observed. However, angiitis was ruled out. In addition, the aneurysm showed a cicatrized, old intimal crack in addition to the rupture site, suggesting repeated failures. The long-term steroid therapy-related fragility of the arterial wall may have been involved in the etiology of the aneurysm.

Usefulness of catheter guide wires for identifying sites of vascular injuries.

We report 2 cases in which catheter guide wires were useful for detection of vascular injury site. Case 1: A woman was died of hemorrhagic shock after being slashed at the extremities, but the vessels were so collapsed that it was not easy to find the injured site. After a wound track on the left forearm was cut open and a guide wire was inserted, the injury site was detected expeditiously at the left radial artery. Case 2: A woman was stabbed and died of hemorrhagic shock. An autopsy revealed 2 stab wounds in the back, one of which made a cut in the left lung. The wound track was cut open, and the injured vessel was revealed. It was too small in diameter to macroscopically determine whether the injured branch arose from, and so a guide wire was introduced from the injured site, and the injured vessel was easily determined to be a branch of the left pulmonary artery. Guide wires have many features, such as elasticity, flexibility, and hydrophilicity, which are considered to be applicable to forensic uses. The guide wire technique is easy, less invasive, highly vasoselective, and reproducible in identifying vascular injury sites.

An infantile case of asphyxia with coincidental myocarditis.

A six-month-old infant was found dead in a small dustbin in an upside-down position. The police investigation showed that there was no criminal environment including negligence. Analysis at the scene suggested death caused by asphyxia (wedging death). Microscopically, however, diffuse lymphocyte infiltration was observed in the interstitial spaces of the myocardium. Common symptoms of infantile myocarditis are generally non-specific, and the predominant neurological problem is a decrease in activity. The records of rectal temperature suggested that the decedent was dead without a high fever. In the present case, there was no obvious relationship between myocarditis and movement of the infant. We conclude that myocarditis was coincidental to the cause of death by asphyxia.

Gas dispersal potential of infant bedding of sudden death cases (II): Mathematical simulation of O2 deprivation around the face of infant mannequin model.

We assessed O(2) gas deprivation potential of bedding that had actually been used by 26 infants diagnosed with sudden unexpected infant death using FiCO(2) time course of baby mannequin model. All cases were the same ones in our poster paper (I). Mathematically, time-FiCO(2) (t) graphs were given as FiCO(2) (t)=C(1-e(Dt)). Here, "C" approximates the maximum FiCO(2) value, while "D" is the velocity to reach maximum FiCO(2). FiO(2) in a potential space around the mannequin's nares was estimated using a formula: FiO(2)=0.21-FiCO(2)/RQ. RQ is the respiratory quotient, and the normal human value is 0.8. The graph pattern of FiO(2) is roughly the inverse of the FiCO(2) time course. Four cases showed the bottom of estimated FiO(2) to be more than 15%, 15 were 15-6%, and the other seven were 6% or less. Considering the minimal tissue stores of O(2), changes in FiO(2) may be affected by both CO(2) production and gas movement around the infant's face. Especially, the latter seven cases may suggest the participation of the role not only of CO(2) accumulation but also of the decrease of O(2) around the face.

Gas dispersal potential of infant bedding of sudden death cases. (I): CO2 accumulation around the face of infant mannequin model.

We assessed CO(2) gas dispersal potential of bedding that had actually been used by 26 infants diagnosed with sudden unexpected infant death using a baby mannequin model. The age of victims ranged from 1 to 12 months. In some cases, the parents alleged that the infant faces were not covered with bedding when they were found. The parent's memories, however, may not have been accurate; therefore, we examined the potential for gas dispersal based on the supposition that the bedding had covered their faces. The mannequin was connected with a respirator set on the tidal volume and respiratory rates matched with the baby's age. Before measuring, CO(2) flow was regulated in 5%+/-0.1% of end-tidal PCO(2). After the model was placed on each bedding condition, measurements were performed at least five times under each respiratory condition. Four cases showed a plateau of FiCO(2) <4.8%, 15 were 4.8-12%, and the other seven were 12% or more, when they reached a plateau. Of course, our model does not take large tissue stores of CO(2) into account. However, our model could show the potential gas dispersal ability of bedding. Especially, the latter seven bedding could have high rebreathing potential if they covered the infant's faces and the probability of environmental asphyxia should be considered.

Development of a spreadsheet for SNPs typing using Microsoft EXCEL.

Single-nucleotide polymorphisms (SNPs) have some characteristics that make them very appropriate for forensic studies and applications. In our institute, SNPs typings were performed by the TaqMan SNP Genotyping Assays using the ABI PRISM 7500 FAST Real-Time PCR System (AppliedBiosystems) and Sequence Detection Software ver.1.4 (AppliedBiosystem). The TaqMan method was desired two positive control (Allele1 and 2) and one negative control to analyze each SNP locus. Therefore, it can be analyzed up to 24 loci of a person on a 96-well-plate at the same time. If SNPs analysis is expected to apply to biometrics authentication, 48 and over loci are required to identify a person. In this study, we designed a spreadsheet package using Microsoft EXCEL, and population data were used from our 120 SNPs population studies. On the spreadsheet, we defined SNP types using 'template files' instead of positive and negative controls. "Template files" consisted of the results of 94 unknown samples and two negative controls of each of 120 SNPs loci we had previously studied. By the use of the files, the spreadsheet could analyze 96 SNPs on a 96-wells-plate simultaneously.

Influence of cause of death and blood ethanol concentration on the coagulability of cadaveric blood.

It is well-known that cadaveric blood tends to retain their fluidity in acute deaths. However, our experience indicated that blood clots are occasionally seen in such cases, especially with antemortem consumption of ethanol. We reviewed autopsy reports from 2001 to 2006 in our division retrospectively. We made evaluations of blood coagulability based on the descriptions in the autopsy reports, and classified them into three categories; "none", "some amount of clot", and "large amount of clot". Out of 782 cases except for putrefactive or charred bodies, 202 cases showed coagulation of heart bloods. Among them, large amount of clots were observed in 140 cases, in which the cause of death included so-called slow deaths such as hypothermia, infections and in-hospital deaths. Additionally, some reputed acute deaths exhibited large amount of clots; fire death (18 cases), drowning (17 cases), other types of asphyxia (5 cases) and cardiac deaths (9 cases). We adopted 0.1 mg/ml of blood ethanol concentration (BEC) as a cut off value, and a correlation of blood coagulability and BEC was tested with chi-square test. With exclusion of slow deaths, the number of cases with blood clot was significantly higher in cases with positive BEC (180 cases) than those with negative BEC (367 cases) (p=0.000085). However, after raising cut off value of BEC (>1.0 mg/ml), the p value was elevated (p=0.00066). Based on this study, we considered that postmortem blood coagulability was influenced not only by simple pharmacodynamic actions of ethanol but also by other factors including coexisting pathological conditions.

Sudden death of a young woman shortly after fleeing from violence.

A woman in her late-teens ran downstairs and out into the street to escape from violence by her boyfriend. She ran approximately 150 m and was suddenly collapsed immediately after stopping to call for help. She underwent cardiopulmonary resuscitation, which was unsuccessful. Autopsy revealed some minor injuries on the face, trunk and extremities. Meanwhile, the left coronary artery was originated from the right sinus of Valsalva, and the orifice had a slit-like appearance. Additionally, the main trunk of the left coronary artery coursed between the aortic sinus and the pulmonary trunk. Microscopically, the heart (240 g) showed small foci of contraction band necrosis and wavy changes. This type of coronary artery anomaly makes up only 0.0375% among all varieties of the anomaly according to a report of the US. However, it has a greater risk of sudden cardiac death during physical exercise. Taking the eyewitness testimony into account, we determined that the 150 m run at full speed, rather than the assault itself, had caused acute coronary insufficiency, leading the death of the decedent.

Expression levels of mRNAs for catecholamine biosynthetic enzymes as markers of acute response to contusion stress during the early postmortem period.

Various stresses can be followed by sudden unexpected deaths, and autopsies sometimes fail to identify pathological findings that determine the cause of death. Pathologists occasionally explain such deaths as being due to overstimulation of sympathoadrenal systems, but postmortem assessment of antemortem sympathoadrenal activity has not been established. An animal model of weight injuries was used to quantify sympathoadrenal response to contusion stress, which is common in forensic fields. A weight was dropped from a given height onto the right dorsal limb of each anesthetized rat, with a control group and three stress groups (n = 4, each): 1000 g-80 cm, 1000 g-40 cm, and 500 g-40 cm. To explore the postmortem changes, we also included ten groups comprised of control and 1000 g-80 cm groups, whose tissues were harvested during 12 hours after euthanasia. Real-time quantitative polymerase-chain reaction was performed to quantify relative expression levels of mRNAs for catecholamine biosynthetic enzymes in the adrenals and the anterocervical ganglia: tyrosine hydroxylase (TH), dopamine beta-hydroxylase (DBH) and phenylethanolamine N-methyltransferase (PNMT). The expression levels of all target mRNAs in the adrenals increased with the intensity of impact (TH, p < 0.0005; DBH and PNMT, p < 0.005), and particularly, TH mRNA level exhibited near-stepwise elevation (p < 0.05). In contrast, no significant differences were detected in the anterocervical ganglia. Moreover, these mRNA levels in the adrenals decreased with increasing postmortem interval length. Thus, TH mRNA level may be a good marker of sympathoadrenal response to contusion stress during the early postmortem period.

Gas dispersal potential of bedding as a cause for sudden infant death.

We assessed the gas dispersal potential of bedding articles used by 14 infants diagnosed with sudden unexpected infant death at autopsy. Of these cases, eight exhibited FiCO(2) values greater than 10% within 2.5 min, six of which were found prone and two supine. The results demonstrated that these eight beddings had a high rebreathing potential if they covered the babies' faces. We did not, however, take into account in our model the large tissue stores of CO(2). As some bicarbonate pools will delay or suppress the increase of FiCO(2), the time-FiCO(2) graphs of this study are not true for living infants. This model, however, demonstrated the potential gas dispersal ability of bedding. The higher the FiCO(2) values, the more dangerous the situation for rebreathing infants. In addition, FiO(2) in the potential space around the model's face can be estimated mathematically using FiCO(2) values. The FiO(2) graph pattern for each bedding item corresponded roughly to the inverse of the FiCO(2) time course. The FiO(2) of the above eight cases decreased by 8.5% within 2.5 min. Recent studies using living infants placed prone to sleep reported that some babies exhibited larger decreases in FiO(2) than increases observed in FiCO(2). While the decrease of FiO(2) in our model is still theoretical, CO(2) accumulation and O(2) deprivation are closely related. If a striking O(2) deficiency occurs in a short period, babies can lose consciousness before an arousal response is evoked and all infants could be influenced by the poor gas dispersal of bedding; the main cause of sudden death in infancy would thus be asphyxia. When the bedding is soft, the potential for trapping CO(2) seems to be high; however, it is impossible to assess it by appearance alone. We sought to provide some objective indices for the assessment of respiratory compromise in relation to bedding using our model. When a baby is found unresponsive with his/her face covered with poor gas dispersal bedding, we should consider the possibility of asphyxia.

Sudden infant death from dilated cardiomyopathy with endocardial fibroelastosis.

A four-month-old female with no previous medical history suddenly collapsed and failed to recover despite 2h of resuscitation. An autopsy showed marked cardiomegaly (88g) with prominent dilatation of the left ventricle and a whitish opacity on the endocardial surface. The ductus arteriosus was patent, but both orifices were severely stenosed. Microscopically, the endocardium showed pronounced thickening with laminar deposition of elastic and collagen fibers. Additionally, there was a mixture of myocardial fibers with a marked "wavy" appearance and a scattering of mild interstitial lymphocytic infiltration. We believe that endocardial thickening in this infant met the diagnostic criteria for endocardial fibroelastosis (EFE). Although it is controversial whether primary EFE is a distinct pathologic entity or an epiphenomenon, we speculated that "dilated cardiomyopathy with EFE" had caused the decedent's death based on the appearance of the myocardial fibers.