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.

Discrimination in immunofluorescence between labeled and unlabeled cells by quantitative microfluorometry and computer analysis.

An automated procedure for discrimination in immunofluorescence between antibody-labeled and unlabeled cells has been developed on the basis of microfluorimetric determination of intensity distributions. After smoothing the raw data for irregularities caused by the scoring statistics optimum fit of the negative distribution to the corresponding positive one was achieved. The procedure was tested in a model system by mixing various known proportions of immunofluorescence-negative and -positive plastic beads. In addition, variable mixtures of T-negative CLL cells and normal mononuclear peripheral blood cells were labeled with FITC-conjugated anti-T-antiserum. The expected percentage of T-positive peripheral blood cells agreed satisfactorily with the data measured and computed. Finally, the measured percentage of Ig-positive mononuclear cells from normal peripheral blood was in agreement with the values obtained by other techniques.

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 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.

The detection of petechial haemorrhages of the conjunctivae in dependency on the postmortem interval.

Petechial haemorrhages of the conjunctivae are not specific for lethal throttling or strangulation, but they belong to the important indicators for such mechanisms. In experimental models it is shown that petechial bleedings of the conjunctivae disappear with the occurrence of advanced signs of putrefaction or in cases of fresh-water logging. Therefore, it must be emphasized that the lack of petechial haemorrhages in putrefied or fresh-water-logged corpses is of very restricted meaning for the examination, whether throttling or strangulation has taken place or not, and the autopsy should always be performed in these cases with special regard to the neck.

Alveolar macrophages and the diagnosis of drowning.

In the present study, we examined the number of alveolar macrophages in lung tissue from 17 cases of fresh water drowning, 22 cases of acute death and 6 cases of lung emphysema. When counting only the number of alveolar macrophages per alveolus without consideration of the alveolar size we found no relevant differences between the groups investigated. To exclude any influence of the alveolar size on the results the surface density of the alveolar macrophages and interstitial tissue was estimated and compared in the different groups. In cases of drowning, the lungs showed significantly lower values in both categories. The ratio of 'alveolar macrophages/interstitial tissue' was also reduced in cases of drowning in comparison to the other groups, however, without significant differences. These morphometrical results characterizing the 'emphysema aquosum' with almost 'empty' and dilated alveoli could be explained by a wash-out effect of the drowning fluid leading to a partial removal of the macrophages from the alveoli. This hypothesis was confirmed by the detection of alveolar macrophages in the drowning froth by immunohistochemical analysis. Even though alveolar macrophages were unambiguously identified in advanced putrefied lungs in HE-stained sections as well as by immunohistochemical staining, an estimation of the number of these cells cannot provide further information for the diagnosis of drowning in putrefied corpses due to the autolytic destruction of the lung architecture providing no reliable values.

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.

Drug death autopsies at the Munich Institute of Forensic Medicine (1981-1992).

A total of 638 drug death autopsy cases in southern Bavaria from 1981 to 1992 were analysed, including epidemiological and toxicological investigations. The rate of HIV infections decreased during the last few years. Cocaine does not (yet) play a major role. Suicide rates are high. Heroin intoxications are the most frequent cause of death, mostly in combination with other drugs and alcohol. In 1992 we observed a sharp increase of the number of deaths associated with dihydrocodeine abuse. This seems to be a local phenomenon and has to be explained by uncritical and uncontrolled prescription of large amounts of this opiate by individual physicians.

The immunohistochemical analysis of fibronectin, collagen type III, laminin, and cytokeratin 5 in putrified skin.

Fibronectin, collagen type III, laminin, and cytokeratin 5 were visualized in normal skin and in skin showing early or advanced signs of autolytic decomposition to prove whether the immunohistochemical analysis of these antigens can provide useful information for an age-estimation of skin wounds obtained from putrified corpses. In cases with early signs of decomposition (visible course of veins, greenish discoloration) and without microscopic alterations like relaxation of the epidermal cell layers or destruction of the blood vessel structures, the staining pattern was identical to that found in normal, non-putrefied skin. In skin already showing microscopic alteration of the tissue structure, fibronectin and collagen type III could not be localized unambiguously. The distribution of laminin and cytokeratin 5, however, was well preserved. In advanced putrefied skin no reliable staining results could be obtained for fibronectin, collagen type III, and laminin. Even though cytokeratin 5 was still detectable in remnants of decomposition-resistant skin appendages, no information useful for an age-estimation of skin wounds can be obtained due to the autolytic detachment of the epidermal layers.

Determination of fetal age by immunohistochemical estimation of surfactant-producing alveolar type II cells.

We monitored the immunohistochemically determined amount of surfactant-producing alveolar type II cells in human fetal lung using polyclonal antibodies against apoprotein B and C of human pulmonary surfactant. Lungs of 30 dead-born fetuses without lung affection aged between 15 and 38 weeks of gestation were evaluated and the surface density of surfactant-producing alveolar type II cells was determined by morphometry. In lungs of fetuses with a gestational age less than 22 weeks no relevant number of positively reacting cells could be found. Between the 22nd and 29th week a progressive increase with considerable inter-individual variability was observed. From the 30th week on the number of the type II pneumocytes appeared rather constant without further significant increase. We provide evidence that the immunohistochemical detection of surfactant-producing alveolar type II cells is useful for the determination of the age of unknown and especially fragmented fetuses: The lack of surfactant-producing alveolar type II cells in fetal lungs before the 22nd week allows a rather safe distinction between fetal lungs of higher age from those of lesser age. Between the 22nd and 29th week an age-dependent increase in the number of these cells occurs with wide inter-individual variability allowing only an approximate age determination. In particular, this may be an important piece of information in fragmented fetal corpses. Furthermore, the number of surfactant-producing alveolar type II cells provides additional information on pulmonary maturation and may thus be helpful in the estimation of a theoretical survival chance.

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.

HIV-1- prevalence among drug deaths in major cities of central and northern Europe.

Since 1985, a number of Institutes of Forensic Medicine in Germany have cooperated in a multicenter study, to provide a constant monitoring of HIV-1-prevalence among drug related deaths. In 1990/91, the Institutes in Copenhagen, Stockholm, Vienna and Zürich also participated in this study. HIV-1-prevalence is decreasing in the German cities, whereas the epidemiological development is not uniform in the other major cities. Regional differences are obvious. In 1991, the prevalence rates were as follows: Berlin 15% (n = 220), Hamburg 4% (n = 179), Frankfurt 17% (n = 167), Munich 9% (n = 136), Stockholm 10% (n = 79), Copenhagen 14% (n = 130), Vienna 20% (n = 56), and Zürich 23% (n = 84).

[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.

[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.

[Casuistics of unusual death from loss of blood]. / Zur Kasuistik des ungewöhnlichen Verblutungstodes.

7 cases of unusual natural and unnatural death due to loss of blood are reported. The case reports show the important role of acute and chronic alcohol abuse in this context. They also demonstrate the problems of necropsy caused by the unusual and suspicious situation, in which the corpses are often found; even in cases of natural death sometimes the first aspect arouses the suspicion of a crime.

[Psychopathologic manifestations of oral administration of endemic nightshade plants]. / Psychopathologische Befunde nach oraler Aufnahme von Inhaltsstoffen heimischer Nachtschattengewächse.

Psychopathological findings in two cases of oral poisoning with toxins of "Datura stramonium" (thorn apple) and "Hyoscyamus niger" (insane roof) are reported. Toxicological aspects of voluntary ingestion are discussed as well as the forensic importance of criminal poisoning.

[Incidence of sudden heart arrest in mitral valve prolapse syndrome]. / Zur Häufigkeit eines plötzlichen Herztodes bei Mitralklappenprolaps-Syndrom.

Among 1500 consecutive forensic autopsy cases 4 cases of sudden cardiac death due to a mitral valve prolapse syndrome could be found. Postmortem diagnosis depends on severe macroskopic changes of the valve leaflets. According to literature there is no increased risk of sudden cardiac death in cases of "silent" mitral valve prolapse. Only in 2%-4% of all cases severe mitral regurgitation or leaflet thickening above 5 mm leads to an increased incidence of sudden cardiac death. The 4 presented cases belong to this subgroup.

[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.).