Fatal rupture of hepatic adenomatosis: Autopsy case and review of the literature.

Hepatic adenomatosis is a rare disease consisting of multiple adenomas in otherwise-normal liver parenchyma. Though the discovery of this entity goes back several years, its diagnosis is still challenging in terms of its definition and pathophysiology. Clinically, patients may be completely asymptomatic and the diagnosis is only made incidentally through imaging tests. The discovery could be made when complications occur such as intraperitoneal hemorrhage with hypovolemic shock due to the rupture of an adenoma. We report a fatal case of a ruptured adenoma in a case of hepatic adenomatosis discovered at autopsy. In order to achieve a better view of this disease, we conducted a literature review on this subject describing the pathogenesis, manifestations, and autopsy contribution to addressing this entity.

Fatal falls from great height in Sousse (Tunisia): Study of 141 medicolegal autopsy cases.

INTRODUCTION: Falls from great heights constitute a violent trauma that can lead to death. This represents a suspicious death, leading to initiate legal proceedings with in particular the practice of an autopsy. AIMS: to determine the features of victims of falls from height and relations between medico-legal form of the death, the height of the fall and the nature of traumatic injuries Methods: A retrospective study about 141 cases of death after fall from great height. Data were collected at the Legal Medicine Department of the Farhat Hached University Hospital in Sousse (Tunisia) over a period of 14 years from 2007 to 2020. RESULTS: The average age of the victims was 37±12.8 years with a sex ratio of 6.05. Half of them were day laborers. The majority had no history of psychiatric illness (91.5%). The majority of victims (41.8%) fell from a height of 3 to 6 meters. Regarding injuries, rib fractures (52.4) were predominant, especially on the right side followed by skull fractures (31.2%). A significant difference in the prevalence of rib cage lesions in the groups over 9 meters in height (p<0.05) was found. The lesions of the lower limbs were proportional to the increase in the height of the fall. Deaths were accidental in 80.8% and suicides in 13.5%. CONCLUSION: In cases of high falls, a forensic autopsy is essential to make a complete evaluation of the injuries, to search a correlation between severity of injuries and height of the fall and finally to orientate towards the medico legal form of the fall.

Medical experimentation on prisoners (part 3): the main milestones of the evolving ethical' texts and codes.

Ethical foundations related to the use of human beings in medical research, already existed in the oldest texts. The historical evolution of regulations (in terms of texts and codes) had always drawn its legitimacy and its logic from the historical context. The main aim of these regulations was to satisfy a need to restore moral or physical prejudices, by hoping by means of the law, that these abuses would not be repeated. Although they were the main victims of medical experimentation, prisoners were rarely specifically identified in these legislations. This history note, the third in a series on medical experimentation on prisoners, aims to describe the major founding texts of ethics in medical experimentation, drawing attention to the historical context as well as the issues that shaped these documents.

[Medical experimentation on prisoners (part 4): the dilemma of 'pros' and 'cons'.]

Given the long history of abuse of prisoners in medical experimentation, it is understandable that additional safeguards have been established to protect this social category. However, the debate between the detractors and the supporters of the medical experimentation in the prison environment is still going on. The present history note, the fourth in a series on medical experimentation on prisoners, intended to relate the main arguments of both sides: ie; the detractors and supporters of medical experimentation on prisoners.

Medical experimentation on prisoners (part 1): historical milestones.

The exploitation of prisoners in medical research is an ancient phenomenon. However, the history of the XXth century was marked by major events that reached the peak of horror during the second world war. Although the collective mind has remembered the outrages of the Nazi regime, the truth is that these practices were adopted by the majority of the military powers of that time, and continued after the end of the war. This history note is the first in a series that aims to review the circumstances and implications of these dark moments in the history of medical research in order to pay tribute to the countless victims who paid with their lives for «scientific progress¼ and to understand the reasons for current ethical considerations in biomedical experimentation on persons deprived of liberty.

Death by late presenting of diaphragmatic hernia in an infant: case report and review of the literature.

Background: Congenital diaphragmatic hernia (CDH) is a congenital malformation of the diaphragm, resulting in the herniation of the abdominal organs into the thoracic cavity. If not properly diagnosed before or at birth, CDH represents a life-threatening pathology in infants and a major cause of death. We present a fatal case of congenital diaphragmatic hernia corresponding to Bochdalek hernia, discovered incidentally during a sudden death's autopsy of an infant. To achieve a better view of the range of these anomalies, we also conducted a literature review on this subject describing the pathogenesis, manifestations, diagnosis, and autopsy contribution to addressing these CDH. Case presentation: The case involved a 4-month-old female infant who presented sudden respiratory difficulties after breastfeeding. External examination found marked cyanosis with no evidence of trauma. Upon opening the chest cavity, the stomach, markedly distended, was occupying much of the left pleural cavity. The left lung was compressed and displaced superiorly, and the heart was also compressed and deviated to the right. This mediastinal deviation was due to an ascension of the stomach into the chest cavity through a 2 × 1.5 cm defect in the posterior left hemidiaphragm. Further examination remarked an ecchymotic appearance of the stomach portion entrapped in the hernia defect suggesting recent strangulation of the stomach. The lungs showed atelectasis with signs of pulmonary infection in the histology study. Conclusions: CDH might be considered uncommon and not always mentioned in the list of sudden death in infant causes. Forensic pathologists should know of this malformation in order to apply the best autopsy techniques and thus allow positive feedback to pediatricians considering the possible legal implications.

Imported malaria in adults: about a case of cerebral malaria.

Background: Malaria is the first parasitic infection endemic in the world caused by parasites species of Plasmodium. Cerebral malaria (CM) is a rapidly progressive and severe form of Plasmodium falciparum infection, characterized by a greater accumulation of red blood cells parasitized by Plasmodium falciparum in the brain. The diagnosis of malaria is usually made in living patients from a blood sample taken in the course of a fever on return from an endemic country, whereas CM, often associated with fatal outcomes even in treated subjects, is usually diagnosed at autopsy. Case presentation: We present the case of a 36-year-old man who died a few days after returning from a business trip to the Ivory Coast. As a result of an unclear cause of death, a medicolegal autopsy was ordered. Autopsy findings revealed massive congestion and edema of the brain with no other macroscopic abnormalities at organ gross examination. Histology and laboratory tests were conducted revealing a Plasmodium falciparum infection, with numerous parasitized erythrocytes containing dots of hemozoin pigment (malaria pigment) in all examined brain sections and all other organs. Death was attributed to cerebral malaria with multiple organ failure. Conclusions: This report summarizes several features for the diagnosis of malaria and how postmortem investigations, as well as histology and laboratory diagnosis, may lead to a retrospective diagnosis of a fatal complicated form with cerebral involvement.

[Medical experimentation on prisoners (part 5): ethical considerations].

Medical experimentation on prisoners is one of the most difficult ethical issues because it brings many principles into conflict with the reality of the practice. These ethical principles, which are universal and timeless, are accepted as elementary rights for every human being. However, in a detention setting, these principles are easily lost. Moreover, the scope of this problem goes far beyond the walls of the penitentiary to touch on conflicting issues of scientific publication, social discrimination, and even political decisions sometimes. The present history note, the fifth in a series on medical experimentation on prisoners, intended to discuss the main ethical considerations regarding prisoners, and to highlight the difficulty of their implementation.

Deadly falls into wells: A retrospective study of 72 autopsy cases from Kairouan, Tunisia.

Falls are a traumatic event that represents a major public health problem worldwide. The literature is rich in published studies of falls from heights, but only a few articles have focused on falls into wells. The region of Kairouan, in central Tunisia, is characterized by an arid climate, hence the abundance of wells for watering crops. In this study, 72 cases of deadly falls into wells were retrospectively investigated at the Department of Forensic Medicine in Kairouan over eight years (01/01/2008 to 31/12/2015). A male predominance was found (sex ratio of 2.42), with a mean age of 29 ± 16.1 years. Sixty-five cases (90.3%) were from rural areas, 62.5% had a low level of education, and 50% were unemployed. In our series, the deceased fell from a distance between 3 and 70 meters with an average of 28.3 m. The falls occurred into functional wells in 61.1%, which were filled with water in 51.4%, and were unprotected in 88.9%. Autopsy findings showed bone fractures in 51.4% of cases of which 44.4% were rib fractures. Visceral injuries were identified in 55.6% of cases. The predominant manner of death was suicide (73.2%), and severe polytrauma was the most frequent cause of death (52.8%). This study highlights the need for increased safety measures to keep wells covered and protected in order to prevent these falls.

Influence of weather and air pollution on the occurrence of idiopathic pulmonary embolism in the region of Sousse (Tunisia).

Pulmonary embolism (PE) is the most serious manifestation of thromboembolic conditions. Its incidence varies considerably between countries, suggesting its interaction with the external environment. To analyze the influence of climate and air pollution on the occurrence of idiopathic PE in the region of Sousse (Tunisia). A total of 142 patients with idiopathic PE at two academic hospitals in Sousse (Tunisia) were enrolled in the study over a 7-year period. An analysis of two time series (environmental data and PE cases) was performed. Climatic data were collected from the National Institute of Meteorology. Air pollution data were obtained from the modeling platform of the National Agency for Protection of the Environment. The year 2015 was marked by the occurrence of the highest number of cases (24.6%). A statistically significant decrease in PE risk of 41.9% was observed during the summer with an OR of 0.59 (95% CI [0.36-0.94] and p = 0.026), compared with other seasons. Poisson GLM regression showed a significant increased risk of PE of 3.3% for each 1 °C temperature drop. After multiple binary logistic regression, the elevation of PM10 concentration was independently associated with an increased risk of PE (p < 10-3, OR 79.55, 95% CI [42.28-149.6]). Some environmental parameters may predispose to the onset of idiopathic PE. Understanding their accurate influence may have preventive and curative implications.

Incomplete penetrance for isolated congenital asplenia in humans with mutations in translated and untranslated RPSA exons.

Isolated congenital asplenia (ICA) is the only known human developmental defect exclusively affecting a lymphoid organ. In 2013, we showed that private deleterious mutations in the protein-coding region of RPSA, encoding ribosomal protein SA, caused ICA by haploinsufficiency with complete penetrance. We reported seven heterozygous protein-coding mutations in 8 of the 23 kindreds studied, including 6 of the 8 multiplex kindreds. We have since enrolled 33 new kindreds, 5 of which are multiplex. We describe here 11 new heterozygous ICA-causing RPSA protein-coding mutations, and the first two mutations in the 5'-UTR of this gene, which disrupt mRNA splicing. Overall, 40 of the 73 ICA patients (55%) and 23 of the 56 kindreds (41%) carry mutations located in translated or untranslated exons of RPSA. Eleven of the 43 kindreds affected by sporadic disease (26%) carry RPSA mutations, whereas 12 of the 13 multiplex kindreds (92%) carry RPSA mutations. We also report that 6 of 18 (33%) protein-coding mutations and the two (100%) 5'-UTR mutations display incomplete penetrance. Three mutations were identified in two independent kindreds, due to a hotspot or a founder effect. Finally, RPSA ICA-causing mutations were demonstrated to be de novo in 7 of the 23 probands. Mutations in RPSA exons can affect the translated or untranslated regions and can underlie ICA with complete or incomplete penetrance.

Case of Massive Hydatid Pulmonary Embolism Incidentally Discovered in a 56-Year-Old Woman with Posttraumatic Abdominal Pain.

Hydatid pulmonary embolism rarely occurs. It arises from the rupture of a hydatid heart cyst or the opening of a visceral hydatid cyst into the venous circulation. We report a case with pulmonary hydatidosis resulting in a massive bilateral pulmonary embolism in a 56-year-old woman with history of hepatic echinococcosis. A brief overview of clinical features and radiologic findings is presented.

Epidemiological aspects of child abuse and neglect in Sousse, Tunisia: A 10-year retrospective study.

The aim of our study was to examine epidemiological aspects of child abuse and neglect in Tunisia. We conducted a retrospective and descriptive study over a period of 10 years (January 2006-December 2015), based on the files handled by the Child Protective Services (CPS) agency in the city of Sousse, Tunisia. During the study period, 3736 referrals were received by the CPS agency of Sousse. Of the total, 2212 (59.2%) were screened in and investigated. Of the investigated cases, 317 (14,3%) were substantiated as abuse or neglect. The reports of maltreatment came mostly from parents (37.8%). Neglect was the major type of maltreatment (51.4%) and an association of 2 types of maltreatment was found in 76 cases (24%). Parents were the perpetrators in 221 cases (69.7%). The average age of the victims was 10 years and boys accounted for 56%. In the 257 cases where the marital status of the parents was noted in the files, the parents were divorced in 62 cases (24.1%) and the child lived with a single mother in 35 cases (13.6%). Alcohol addiction was found in 21 parents (6.6%) and one of the parents was incarcerated in 39 cases (12.3%). As for the socio-economic status, it was evaluated in 188 families and was low in 123 cases (65.4%). In the absence of studies related to this scourge in Tunisia, we hope to raise awareness of the abuse and alert those who come into contact with the child on the importance of detecting and reporting early maltreatment and thus to introduce more appropriate care. A comprehensive prevention strategy needs to be established by addressing risk factors, cultural norms conducive to abuse and unwanted pregnancies.

Caregiver-Fabricated Illness in a Child: A Case Report of Three Siblings.

Caregiver-fabricated illness in a child is a form of child maltreatment caused by a caregiver inducing a child's illness, leading to unnecessary and potentially harmful medical procedures and treatments. This condition can result in significant morbidity and mortality. We present the case of three siblings in Tunisia who were poisoned with chloralose by their own mother. The symptoms that the children presented with led to misdiagnoses, which resulted in the death of two of the children. Characteristics of the clinical presentation are articulated, followed by a discussion of the legal measures that apply to the offender and the role of physicians, nurses, and medicolegal experts involved in such a complex medical situation.

Sudden Death Due to Unusual Complication of Takayasu Arteritis: An Autopsy Case.

Takayasu arteritis is an uncommon inflammatory disease with usually a good prognosis. However, sometimes, the evolution can be fatal essentially by a coronary arteries involvement. We present a case of a 19-year-old woman who died suddenly from cardiogenic shock complicating an unknown Takayasu arteritis.At the autopsy, the aorta showed a significant thickening of the wall. The coronary arteries were slightly thickened and did not show any occlusion. Microscopic examination of the aorta showed an abundant granulomatous and a lymphoplasmacytic infiltrate. Microscopic sections of other internal organs showed signs of cardiac hypertrophy and an extensive edema of the lung. Death was attributed to acute heart failure complicating a supravalvular aortic stenosis secondary to unknown Takayasu arteritis.Takayasu arteritis can be life-threatening by an occlusion of the ascending aorta and its major branches, without any coronary arteries involvement.

Suicide and Fire: A 20-Year Study of Self-Immolation Death in Sousse, Tunisia.

Self-immolation is a self-destructive conduct described since antiquity. Its frequency is variable from one country to another and it is a real public health problem in parts of the world. In Tunisia, after the 2011 revolution the problem of self-immolation protest has been highly publicized giving the impression of an increase in this phenomenon. This is a retrospective analysis of all fatal self-immolation cases, collected over a 20-year period (1996-2015) at the Forensic Medicine Department of the Farhat Hached University Hospital, Sousse, Tunisia. A total of 41 cases were collected, of which 23 were men (56%). The mean age was 36.1 years. Prior to 2011, 78.9% of the victims of self-immolation were women and after 2011, 86.4% were men. The rural origin of the victims was found in 56.25% of the cases. History of psychiatric illness was found in four individuals. The self-immolation took place in the victims' homes in 19 cases (46.3%). It came after a conjugal or family conflict in 14 cases (34.1%) and it is of protest character in 8 cases (19.5%). This study confirmed the increasing frequency of self-immolation in Tunisia after the 2011 revolution and noted a change in the victims' profiles.

[Legal redress in relation to physical injury due to post-traumatic anterior pituitary insufficiency]. / Réparation juridique en dommage corporel de l'insuffisance antéhypophysaire post-traumatique.

Post-traumatic anterior pituitary insufficiency (PTAPI) is a rare but established disease caused by ischemic lesions after severe cranial trauma. This case study aims to highlight the criteria for imputability of PTAPI to a cranial trauma as well as the specific principles of legal redress in relation to this disease. We conducted a forensic study of a patient with diagnosed PTAPI followed up in the Division of Endocrinology and Legal Medicine at the University Hospital, Sousse (Tunisia). The patient included in the study was a 45-year old woman with no particular past medical history. (6 gynaecological procedures, 4 parities and 2 abortions) having regular menstrual cycles, without a history of hemorrhagic childbirth, who had been involved in a road accident (pedestrian got hit by a car) causing occipital trauma without initial knowledge loss. She developed hypothyroidism three years after the accident. The hormonal assessment showed the involvement of all the other axes. Neuroradiological examination objectified pituitary gland and pituitary stalk integrity. The definitive diagnosis of PTAPI was made. Medical examination (performed 4 years after the accident) concluded that PTAPI was imputable to the accident. Permanent partial disability rate according to ordinary law has been assessed at 25%. PTAPI diagnosis is made by elimination. The evaluation of physical injury should be based on residual symptoms, on therapeutic constraints and on its impact on daily and professional activity. Patient's evolution under hormone replacement therapy is often favorable, however, complications may occur, hence the necessity to establish these complications in order to preserve the right of the patient to underwent new treatments.

Device-vigilance and environment of the medical practice.

INTRODUCTION: The Device-vigilance (DV) manages incidents or risk of incidents related to the use of medical devices (MD). In Tunisia, absence of a regulatory framework organizing DV is the major obstacle to caregivers' involvement in this system. OBJECTIVE: 1/Compare knowledge, attitudes and practices of our UHC's physicians regarding the establishment of DV system (medical versus surgical) and 2/Detect effect of healthcare's environment on risk's perception linked to the use of MD. METHODS: It is a descriptive cross-sectional and comparative study type knowledge, attitudes and practices; among all physicians of our UHC who are users of MD during their practice. A self-administered pre-established pre-tested questionnaire has been established. Data seizure and analyzing was performed using SPSS software20.0. Test adopted was the X2 (Pearson)(p<0.05) with correction using Yates or exact test Fischer. RESULTS: A statistically significant difference in favor of physicians exercising in medical services is reported for the knowledge of standardized reporting form's existence(p=0.04). Physicians practicing in surgical services report incidences and risk of incidences regarding MD use significantly more than their colleague of medical services. For attitudes, surgical physicians perceive the responsible of the reporting as any caregiver (p=0.007).As for the practices, they are for the presence of MD's organized management in the service of exercise(P<10-4). CONCLUSION: At any healthcare environment, lack of knowledge, inadequacy of the attitudes and readjustment of practices among our physicians must be filled. The promulgation of regulatory texts is necessary in order to promote DV's sector of and to ensure the safety of both patients and caregivers.

Infant acute myocarditis mimicking acute myocardial infarction

Myocarditis is an inflammatory disease of the myocardium with heterogeneous clinical manifestations and progression. In clinical practice, although there are many methods of diagnosis of acute myocarditis, the diagnosis remains an embarrassing dilemma for clinicians. The authors report the case of 9-month-old infant who was brought to the Pediatric Emergency Department with sudden onset dyspnea. Examination disclosed heart failure and resuscitation was undertaken. The electrocardiogram showed an ST segment elevation in the anterolateral leads with a mirror image. Cardiac enzyme tests revealed a significant elevation of troponin and creatine phosphokinase levels. A diagnosis of acute myocardial infarction was made, and heparin therapy was prescribed. The infant died on the third day after admission with cardiogenic shock. The autopsy showed dilatation of the ventricles and massive edema of the lungs. Histological examinations of myocardium samples revealed the presence of a marked lymphocytic infiltrate dissociating myocardiocytes. Death was attributed to acute myocarditis. The authors call attention to the difficulties of differential diagnosis between acute myocarditis and acute myocardial infarction especially in children, and to the important therapeutic implications of a correct diagnosis.

Reckless formalin injection in the eyelid instead of local anesthetic: case report.

Accidental injection of formalin is certainly rare, but it has serious consequences in terms of morbidity and mortality. We report a case of severe ophthalmic damage due to an accidental formalin's injection in the eyelid of a three-year-old child presenting with congenital ptosis's surgical repair of her left eye. This accident has damaged the orbital region and led to upper left eyelid's necrosis, eyeball's deformation and ipsilateral cataract. In terms of our observation, we discussed consequences of this rare type of accident, and its systematic and loco-regional effects. We tried also to explain these manifestations by analyzing the metabolism process of formalin in the human body. Finally, a medico-legal implication of such accident has been illustrated according to the Tunisian law (Penal Code of the Tunisian republic 'PCT').