Fatal carbon monoxide poisoning after the detonation of explosives in an underground mine: a case report.

An unusual death caused by carbon monoxide poisoning after the detonation of explosives in an underground mine was investigated by the Office of the Medical Investigator of the State of New Mexico. The 50-year-old miner had 18 years of mining experience but no documented safety training. He collapsed approximately 20 minutes after entering the mine and working at the bottom of the single vertical shaft. The tight confines of the mine shaft hindered rescue personnel from reaching him, and the body was not recovered until 2 days later. The autopsy showed severe coronary artery atherosclerosis with remote and resolving myocardial microinfarcts, as well as the characteristic pink lividity of carbon monoxide poisoning, which was confirmed by laboratory analysis. Detailed investigation of the scene revealed no sources of carbon monoxide other than the explosives. The case represents an uncommon cause of death in mining that may have been avoided through the use of proper safety procedures, and illustrates the importance of recognizing the many sources of carbon monoxide.

Child and adolescent suicide deaths in New Mexico, 1990-1994.

The suicide death rate in New Mexico is consistently higher than the national rate. Among adolescents, suicide is the third leading cause of death nationally, but in New Mexico it is the second leading cause of death. This study describes the pattern of adolescent suicide deaths in New Mexico. We conducted a retrospective review of all medical examiner autopsies for adolescent suicides (ages 20 years and younger) in New Mexico from 1990-1994. Records were reviewed for demographics and possible contributing factors such as depression, previous attempts, and alcohol and drug use. We identified 184 suicide deaths among children and adolescents ages 9-20 years for an overall rate of 12.9 per 100,000. Our rates for ages 5-9 years (0.2), 10-14 years (3.8), and 15-19 years (22.3) are over twice the U. S. rates. Suicide deaths resulted primarily from firearms (67%), hanging (16%), poisoning (6%), inhalation (4%), and other methods (7%). Method varied by ethnicity (p = .01) and gender (p = .03); males and non-Hispanic Whites were overrepresented among firearm deaths. Firearm ownership was known in 60 (48%) of the firearm deaths. Of these, 53% of the firearms belonged to a family member, 25% to the decedent, and 22% to a friend. Over one-third of decedents (41%) experienced mental disorders, primarily depressed mood and clinical depression. Previous suicide attempts were noted for 15% of the decedents. Some 50% of the decedents had alcohol or drugs present at the time of death; among American Indians/Alaska Natives, 74% had drugs or alcohol present (p = .003). Targeted interventions are needed to reduce adolescent suicide in New Mexico. We suggest raising awareness about acute and chronic contributing factors to suicide; training physicians to look for behavioral manifestations of depression; and involving physicians, teachers, and youth activity leaders in efforts to limit firearm accessibility, such as advising parents to remove firearms from their households.

Postmortem lipid levels for the analysis of risk factors of sudden death: usefulness of the Ektachem and Monarch analyzers.

Elevated serum cholesterol, triglyceride, and free fatty acid levels have been identified as risk factors for sudden death from cardiovascular disease and increased risk for myocardial ischemia or arrhythmias; therefore, correlation of antemortem and postmortem lipid levels may be useful in establishing the cause, pathophysiology, or familial risk factors of sudden death. In the present study, antemortem (within 72 h) and postmortem (within 24 h) cholesterol, triglyceride, free fatty acid, and albumin levels were analyzed in seven autopsied hospitalized patients from the University of New Mexico Hospital in Albuquerque, New Mexico. The cholesterol, triglyceride, and albumin levels were measured by dry-slide technology on an Ektachem 700 analyzer, and the free fatty acid levels were measured on a Monarch analyzer with a commercially available kit from Wako Chemical. Postmortem cholesterol levels averaged 13% lower than antemortem levels, postmortem triglyceride levels averaged 38% higher than antemortem levels, postmortem free fatty acid levels averaged 23% lower than antemortem levels, and postmortem albumin levels were essentially unchanged (<0.01% higher) from antemortem levels. Whether the antemortem and postmortem differences in lipid levels were the result of postmortem degradation products, a general phenomenon (such as variable enzyme degradation), or an idiosyncracy of the Ektachem or Monarch systems could not be definitely established. These preliminary results suggest that caution should be exercised when interpreting postmortem cholesterol, triglyceride, and free fatty acid levels analyzed on the Ektachem or Monarch systems.

Postmortem cranial MRI and autopsy correlation in suspected child abuse.

We investigated the correlation between postmortem magnetic resonance imaging (MRI) of the head and autopsy findings in suspected child abuse. Postmortem MRI was performed within 24 h of death and before autopsy in 11 children 2 years old or younger whose deaths were unexplained or suspected to be due to child abuse. MRI findings were available to the pathologist at the time of autopsy. In eight cases of death from non-accidental trauma, cerebral edema, contusion, shearing injury, ischemia, and infarction were well demonstrated on MRI. In the three deaths determined not to be due to trauma, there were no false-positive MRI findings. Autopsy was superior in detection of subarachnoid hemorrhage, suture separation, extracranial injuries, and very small subdural hematomas. MRI findings were useful in directing the autopsy and brain-cutting to focal areas of abnormality. Postmortem MRI and autopsy are complementary, and each may disclose abnormalities missed by the other. In half of the eight cases of child abuse examined, the combination of MRI and autopsy added valuable information compared with the results of autopsy alone. Postmortem MRI can be a valuable addition to autopsy findings in the investigation of fatalities potentially due to child abuse.

Hantavirus pulmonary syndrome. Pathogenesis of an emerging infectious disease.

A recent outbreak of a severe pulmonary disease in the southwestern United States was etiologically linked to a previously unrecognized hantavirus. The virus has been isolated from its major reservoir, the deer mouse, Peromyscus maniculatus, and recently named Sin Nombre virus. Clinically, the disease has become known as the hantavirus pulmonary syndrome (HPS). Since May 1993, 44 fatal cases of HPS have been identified through clinicopathological review and immunohistochemical (IHC) testing of tissues from 273 patients who died of an unexplained noncardiogenic pulmonary edema. In 158 cases for which suitable specimens were available, serological testing and/or reverse transcription-polymerase chain reaction (RT-PCR) amplification of extracted RNA was also performed. IHC, serological, and PCR results were concordant for virtually all HPS and non-HPS patients when more than one assay was performed. The prodromal illness of HPS is similar to that of many other viral diseases. Consistent hematological features include thrombocytopenia, hemoconcentration, neutrophilic leukocytosis with a left shift, and reactive lymphocytes. Pulmonary histopathological features were similar in most of the fatal HPS cases (40/44) and consisted of an interstitial pneumonitis with a variable mononuclear cell infiltrate, edema, and focal hyaline membranes. In four cases, however, pulmonary features were significantly different and included diffuse alveolar damage and variable degrees of severe air space disorganization. IHC analysis showed widespread presence of hantaviral antigens in endothelial cells of the microvasculature, particularly in the lung. Hantaviral antigens were also observed within follicular dendritic cells, macrophages, and lymphocytes. Hantaviral inclusions were observed in endothelial cells of lungs by thinsection electron microscopy, and their identity was verified by immunogold labeling. Virus-like particles were seen in pulmonary endothelial cells and macrophages. HPS is a newly recognized, often fatal disease, with a spectrum of microscopic morphological changes, which may be an important cause of severe and fatal illness presenting as adult respiratory distress syndrome.

Hantavirus pulmonary syndrome in the United States: a pathological description of a disease caused by a new agent.

An outbreak of an acute respiratory disease in the southwestern United States has led to the recognition of a new hantaviral illness. This report describes a unique spectrum of antemortem and postmortem pathological findings seen in a case series of nine surviving patients and 13 who died. Clinical, laboratory, and autopsy findings were derived from a consecutive series of individuals confirmed to have hantavirus pulmonary syndrome. Laboratory studies included chemical, hematological, and bone marrow analyses as well as flow cytometric and immunohistochemical phenotyping. Autopsy tissues were examined by routine histological stains, immunohistochemical methods, and transmission electron microscopy. The lung is the primary target organ in this illness. Pulmonary abnormalities include pleural effusions, alveolar edema and fibrin, and an interstitial mononuclear cell infiltrate. Large immunoblast type cells are seen in the lungs, blood, bone marrow, lymph nodes, liver, and spleen. A tetrad of hematological findings includes left-shifted neutrophilic leukocytosis, thrombocytopenia, hemoconcentration in severe cases, and circulating immunoblasts. In contrast to previously described nephropathic hantaviral syndromes, hantavirus pulmonary syndrome is characterized by a unique constellation of pulmonary, hematological, and reticuloendothelial pathological findings. The pulmonary findings are distinguishable from fatal adult respiratory distress syndrome. The data suggest a capillary leak syndrome restricted to the pulmonary circulation. Likewise, the hematological picture is unique and may be valuable in the rapid identification of cases for further diagnostic studies.

The epidemiology of interstitial lung diseases.

Little epidemiologic data are available on the occurrence of interstitial lung diseases (ILDs) in the general population. To describe the prevalence and incidence of ILDs a population-based registry of patients with ILDs was established in Bernalillo County, New Mexico in October 1988. All patients 18 yr of age and older who had a clinical diagnosis of an ILD were identified during the period 10/1/88 through 9/30/90 from physician referrals, hospital discharge diagnoses, histopathology reports, and death certificates. In addition, the prevalence of preclinical or undiagnosed cases was identified by screening lung specimens from 510 autopsy cases. A total of 2,936 referrals were screened; 8.8% were prevalent cases and 6.9% were incident cases. Overall, the prevalence of ILDs was 20% higher in males (80.9 per 100,000) than in females (67.2 per 100,000). Similarly the overall incidence of ILDs was slightly more common in males (31.5 per 100,000/year) than females (26.1 per 100,000/year). The estimated prevalence of preclinical or undiagnosed ILDs among all deaths was 1.8%. The most common incident diagnosed among both sexes were pulmonary fibrosis and idiopathic pulmonary fibrosis, together accounting for 46.2% of all ILD diagnoses in males and 44.2% in females. We conclude that the occurrence of ILDs in the general population may be more common than previous estimates based on selected populations, and these disorders may frequently be unrecognized.

Fire fatalities among New Mexico children.

STUDY OBJECTIVE: To explore the relationship between social conditions and fire mortality rates among children. DESIGN: Retrospective analysis of fire fatalities in children 0 to 14 years old in New Mexico. SETTING: State Office of the Medical Investigator. TYPE OF PARTICIPANTS: All 57 New Mexico children 0 to 14 years old who died from fire-related injuries from 1981 through 1991. INTERVENTIONS: Medical investigator and autopsy records were reviewed and abstracted. Demographic and housing figures were obtained from US Census reports. Data were analyzed by chi 2 or by Fisher's exact test, with Bonferroni correction for multiple comparisons. RESULTS: Two thirds of decedents were male (P = .0014), and three fourths were less than 5 years old (P < .0001). Children living in mobile homes had triple the mortality rate of those in houses or apartments, and children in homes without plumbing (substandard) had more than ten times the mortality rate of those in houses or apartments (P < .0001). Two thirds of the victims in substandard homes were Native American (P < .0001). Errors or negligence of adults occurred in more than half of the deaths. Eighty-two percent of decedents died at the scene; only 11% reached a burn center. CONCLUSION: Substandard homes are associated with an increased fire mortality rate among children. Strategies to prevent childhood fire fatalities should address housing conditions and adult safety practices. Enhanced prehospital or burn unit care is unlikely to greatly affect childhood fire mortality rates.

Rare electrocution due to powerline contact in a hot-air balloon: comparison with fatalities from blunt trauma.

Powerline contact by hot-air balloons is one of the most frequent concurrences in balloon accidents resulting in injury or death. Injuries and deaths are usually a result of blunt trauma from falls. In this report, we describe the aircraft, the circumstances of the accidents and the autopsy data in two powerline contact accidents involving three deaths, one from electrocution and two, from blunt trauma sustained in falls. Appropriate pilot behavior is briefly discussed.

The identification of maternity in an unusual pregnancy-related homicide.

A recent bizarre homicide which culminated in the delivery of a live-born infant necessitated careful determination of true maternal origin. A 23-year-old pregnant woman was abducted, subdued, strangled, and delivered of a term infant by a crude Cesarean section. The infant was stolen and subsequently presented to physicians by a woman posing as the mother. Methods used to help confirm the surviving infant's parentage involved red cell antigen and enzyme system evaluations as well as immunoglobulin allotyping, which ultimately proved to be the most effective serologic test performed. The forensic science investigation of this unusual case also used bite mark analysis and patterned injury interpretation. Immunoglobulin allotyping is specifically discussed as a forensic serology test which is currently available and particularly applicable in cases involving parentage determination.

Child abuse by drowning.

Drowning as a form of subtle fatal child abuse is difficult to distinguish from accidental immersion or from sudden unexpected natural death when the circumstances of immersion are concealed. Homicidal drownings are unwitnessed, usually occurring in the home, and the victims are young, either infants or toddlers. Accidental drownings are more likely to involve toddlers or older children in public areas such as swimming pools, drainage ditches, lakes, and rivers. This is especially true in rural areas. In cities, bathtubs remain a major site of accidental childhood drownings. Perpetrators of deliberate drownings often fit the sociopathologic profile of a child abuser. Because there is often a survival interval between immersion and death, pathologic findings consistent with postimmersion syndrome suggest the cause of death. Foreign material in the lungs, if immersion was other than in clear tap water, and injuries of the face are other positive correlating factors. A thorough investigation of the circumstances and cooperation between the investigating agency and the pathologist are essential to determine the correct manner of death in these cases.

Lethal intrauterine fetal trauma.

Eight cases of lethal intrauterine fetal trauma secondary to motor vehicle accidents are retrospectively studied. In each instance the mother survived, usually sustaining only minor injuries. Some degree of placental abruption or infarction occurred in each case, but fetal abnormalities were more varied. Significant fetal injuries were limited to the head and included two instances of skull fracture associated with cortical lacerations and contusions. Six of the eight fetuses were stillborn, and the other two died during the first postnatal day. At least five of the mothers were unrestrained at the time of the accident, three of whom experienced abdominal impact against the steering wheel but no external abdominal injuries. Although two mothers were wearing seat belts, in only one instance could the seat belt be implicated in contributing to the fetal injury. This study shows that lethal placental or direct fetal injury can occur even though maternal injuries are minor or insignificant. The findings also support current recommendations for use of three-point restraints.

Mesodiverticular band and sudden death in children. A report of two cases.

Meckel's diverticulum is occasionally associated with a fibrous band, which connects the tip of the diverticulum to the mesentery. Beneath this mesodiverticular band, herniated loops of small bowel can incarcerate and infarct. The high mortality rate and the suddenness of death associated with this internal hernia make it important to the forensic pathologist.

Marfan syndrome presenting as aortic rupture in a young athlete: sudden unexpected death?

A 20-year-old man had a spontaneous rupture of the ascending aorta while exercising. The diagnosis of Marfan syndrome, established by the gross and microscopic autopsy findings, was further supported by review of the autopsy report of the father, who had died at age 26 of a nearly identical aortic rupture. To avoid occurrences such as the above, the responsibility of the forensic pathologist should extend beyond the autopsy to appropriate counseling of families in instances where medically treatable hereditary conditions may be present in the survivors.

Incorrect death certification. An invitation to obfuscation.

The physician responsible for signing a death certificate has an obligation to complete the medical part of the form, which includes entering the cause of death. In a review of 384 death certificates signed by house staff and attending physicians at a university hospital over a one-year period, 59% contained errors in cause-of-death entries. The most common error was listing mechanisms rather than causes of death. Since death certificates are used in calculating basic mortality statistics, such a large percentage of error can lead to considerable statistical misinformation.