Diagnostic approaches to acute transfusion reactions.

The erroneous transfusion of ABO-incompatible red cells may lead to life-threatening hemolysis and complement-induced shock, resulting in death in less than 10% of cases (acute hemolytic transfusion reaction, AHTR). Identification of the cause of an erroneous transfusion is accomplished in nearly all incidents merely by checking the identity of the patient, blood sample and blood bag. The erroneous transfusion is confirmed by serological and--in the case of a fatality- immunohistochemical methods. The differential diagnosis should rule out transfusion-related acute lung injury (TRALI), other immunologically triggered causes such as febrile nonhemolytic transfusion reaction (FNHTR) or allergic reactions, but also nonimmunological causes such as bacterial contamination of the blood components, transfusion-associated circulatory overload (TACO) and other rare events such as citrate overload or embolism (by air or debris). In the case of a fatality, evaluation of a patient's medical records, serological and microbiological analyses, autopsy and histology, taken together, clarify questions of causality.

Increase in nerve fibers and loss of mast cells in polycystic and postmenopausal ovaries.

OBJECTIVE: To quantify nerve fibers and mast cells in human ovaries at different functional stages. DESIGN: Retrospective study. SETTING: Research laboratory of the university. SPECIMEN(S): 8 human ovaries in the follicular (cyclic) phase, 7 polycystic ovaries, and postmenopausal ovaries with (n=5) or without (n=7) hyperthecosis. MAIN OUTCOME MEASURE(S): Single- and double immunohistology for the S100 antigen in glial cells of autonomic nerve fibers, for chymase and tryptase in mast cells, and for the common leukocyte antigen on leukocytes. Histometric evaluation was also performed. INTERVENTION(S): None. RESULT(S): Polycystic ovaries contained significantly more S100-positive nerve fibers in the corticomedullary region than did cyclic ovaries (mean +/- SD per 2-mm(2) area, 476 +/- 136 and 224 +/- 133; P<.01). Postmenopausal ovaries with or without hyperthecosis had the highest density of nerve fibers. In cyclic and polycystic ovaries, more tryptase-positive mast cells than chymase-positive mast cells were found in the interstitial cortex and the medulla. In cyclic ovaries, areas with a moderate density of nerve fibers contained many mast cells. Hence, with increasing nerve fiber density in polycystic ovaries, the number of mast cells decreased strikingly compared with cyclic ovaries (p<.001). Almost no mast cells were seen in postmenopausal ovaries with and without hyperthecosis. The number of leukocyte antigen-positive leukocytes was similar in all groups. CONCLUSION(S): The high density of nerve fibers in polycystic and postmenopausal ovaries, together with a conspicuous decrease in mast cells, indicates altered neuroimmune communication.

Diagnostic significance of myofibrillar degeneration of cardiocytes in forensic pathology.

The incidence of myofibrillar degeneration (MFD) was studied in the following different forensic-pathological diagnostic groups of 25 cases each: acute morphine intoxication, acute carbon monoxide intoxication, hanging, strangulation by hand/ligature, drowning, acute hemorrhagic shock, lethal acute brain injury, explainable death of babies or infants and sudden infant death syndrome, together with 18 cases of intoxication with various drugs. The MFD was demonstrated by the Luxol-fast-blue reaction, with two types of phenomena being differentiated, namely cross-band lesions and diffuse staining. All diagnostic groups included cases of MFD of differing degrees. Cross-band lesions were observed in practically all cases of hanging, strangulation and acute hemorrhagic shock. Diffuse stain was noted particularly in cases of drowning and acute brain injury. The diagnostic significance is discussed.

Insulin injection sites: morphology and immunohistochemistry.

In a case of insulin suicide in a nondiabetic woman, insulin was detected in routinely formalin fixed and paraffin embedded subcutaneous injection marks, in spite of a post-morterm interval of 24 days. Around birefringent crystalline material, probably zinc phosphate, immunohistochemistry revealed granular insulin depots as well as an insulin staining along the lipocyte membranes. A cellular reaction of granulocytic character was present, with an uptake of insulin by inflammatory cells.

Inhibition of non-specific leukocyte esterase activity. Absence of monocyte esterase activity due to phosphoric and thiophosphoric acid ester intoxication.

In vitro evaluation of the effect of five insecticidal phosphoric and 11 thiophosphoric acid esters on different, non-specific human leukocytes esterases indicated that most of the organic phosphor compounds studied inhibited the activity of neutral alpha-naphthylacetate esterase, alpha-naphthylbutyryl esterase, and naphthol AS acetate esterase, i.e. the monocyte esterases. The extent of inhibition was dose dependent; the inhibiting dose being identical for the various non-specific esterases. Reactivation with Obidoxim was not successful. Monocyte esterase activity in a human survivor of E 605 intoxication was detectable only after serum acetylcholinesterase had returned to normal levels. The organic phosphor compound studied, however, inhibited neither acid alpha-naphthylacetate esterase nor naphthol AS-D chloroacetate esterase activity.

ABH and Lewis immunohistochemistry of the human eye.

ABH and Lewis antigens are detected by immunohistochemistry exclusively in the anterior cornea epithelium and in the conjunctiva bulbi, but not in the ciliary body, in the retina, or in the vitreous body of the eye. The ABH antigens found in the vitreous humor by the absorption elution technique (Rordorf et al., Forensic Sci. Int. 41, 1989, 111-116) are probably glycosphingolipids, which are not detected by immunohistochemistry. They may come from the plasma of uveal blood vessels, or be produced by local cells.

Axonal injury--a diagnostic tool in forensic neuropathology? A review.

We used beta-amyloid precursor protein (beta-APP) to investigate our own forensic neuropathological case material (n = 252) in light of the current literature on the phenomenon "axonal injury" (AI) to determine the incidence, specificity and biomechanical significance of AI and its significance for determining vitality and survival time. The case material consisted of cases of fatal nonmissile closed-head injury (n = 119), gunshot injury (n = 30), fatal cerebral ischemia/hypoxia (n = 51), brain death caused by mechanical trauma (n = 14) or nonmechanical injury (n = 18), and acute hemorrhagic shock (n = 20). AI was observed in 65% to 100% of cases of closed-head injury, fatal cerebral ischemia/hypoxia, and brain death with a survival time of more than 3 h; AI could not be detected in the cases of acute hemorrhagic shock. A statistically significant difference between traumatically and nontraumatically induced (nondisruptive) AI was not found. There was no statistical evidence of a correlation between AI and the different types of external force, since AI could be demonstrated after both acceleration/deceleration injuries and traumatic impact. Therefore, biomechanical inferences for reconstruction purposes are not possible. On the other hand, beta-APP was found to be a definite marker of vitality. In our material, cases with a posttraumatic interval of under 180 min did not express beta-APP. Moreover, the literature shows that the posttraumatic interval can be determined by other methods for demonstration of AI such as by ubiquitin immunostaining (360 min), silver staining (15-18 h), hematoxylin and eosin staining (about 24 h), or by demonstration of a microglial reaction (about 4 to 10 days) or of a few remaining isolated bulbs, without accompanying fibers, which can be detected after a survival time of up to 17 months.

[Increased ethanol elimination after barium meal--human experimental study with parenteral alcohol administration]. / Beschleunigte Ethanolelimination nach Bariumbreischluck--Humanexperimentelle Studie mit parenteraler Alkoholzufuhr.

The results of human experimental investigations of blood alcohol kinetics in intravenous alcohol administration published in recent years suggest that alterations both of the current ADH activity and of the rate of hepatic blood flow affect the excretion. The effects of a voluminous gastrointestinal load of 500 g of inert BaSO4 definitively free of calories on the elimination kinetics of ethanol are investigated in two groups each comprising five male subjects. The alcohol is administered exclusively parenterally. Peak blood alcohol values between 0.5 and 1.1 per thousand are attained. After a barium meal, the elimination is significantly raised (p less than 0.01; p less than 0.05) in both groups. The rate of increase up to 27 percent of the baseline value (beta 60 min. 0.108; beta 60 max. 0.15 g/kg) is attributed to the raised hepatic blood flow.

[Self-mutilation with a double-blade razor]. / Selbstbeschädigung durch einen Doppelklingen-Rasierapparat.

A 26 year old female simulated an assault by inflicting herself multiple series of skin cut wounds by a double blade razor. The skin lesions produced by this unusual instrument are presented. The overall trauma pattern was characteristic of self-infliction.

[Electrocution accident with three-week survival]. / Stromunfall mit dreiwöchiger Uberlebenszeit.

A 55-year-old man was found unconscious with ventricular fibrillations at his working place near a power press. CPR was successful. After three weeks of intensive care the patient died of ischemic brain damage. The first suspected diagnosis of myocardial infarction was revised when typical current marks were detected on both palms. At the working place the top of a lubricating grease container was found to be energized due to a technical damage: There is a round, multiple-pole plug mounted upon the container top the proper orientation of which is coded by a set of five plastic nipples. All the nipples had been abraded by longlasting mechanical stress, so that the plug could be connected in a variety of possible orientations. In actual fact, the incorrect orientation caused a voltage of up to 240 V to the container top.

[Errors in treatment of soft tissue phlegmon : expert assessment and forensic evaluation]. / Fehler bei der Behandlung von Weichteilphlegmonen: Begutachtung und rechtliche Würdigung.

In ten cases of soft part phlegmons resulting in death (8) and amputation (2) respectively, various types of medical malpractice were evident. The diagnosis was missed, or the disease was correctly diagnosed but underestimated. Typical therapeutic mistakes were the omission of bacteriological investigations and of the proper antibiotical therapy, a delayed hospital admission, or a delayed or insufficient surgical intervention. These errors however could never be proved to have caused the unfavorable outcome in view of the doubtful prognosis of soft part phlegmons even under proper treatment. Thus, evident malpractice never resulted in a condemnation for bodily injury or involuntary manslaughter.

[Cytologic findings as indications: morphologic and immunohistochemical identification of human brain tissue on the clothing of a murderer]. / Zytologischer Befund als Indiz: Morphologische und immunhistochemische Identifizierung von menschlichem Hirngewebe an der Täterkleidung.

A case was described in which a murder was concealed by burning the body. The suspect confessed to committing the crime after being informed that human brain tissue in form of slimy stains as well the same blood group as the victim had been identified on his clothing. Slimy stains (approx. 2 x 3 mm) were identified as brain tissue by sectioning on the cryostat together with the bits of wool fiber. Morphologically, nerve cells were clearly identifiable, particular by demonstrating Nissl's bodies. Application of anti-human serum protein and an anti-human cerebrum serum confirmed this finding and augmented it by confirming that the brain tissue was of human origin. The unusual character of this case and the methods used prompted the authors to publish these findings. The available literature is discussed.

[Cadaver lipid: various origins add to the difficulty of assessing postmortem time]. / Leichenlipid: Unterschiedliche Entstehungsarten erschweren zusätzlich die Abschätzung der Leichenliegezeit.

Establishing the length of time since death is particularly difficult in corpses showing advanced putrefaction. One particular sign of advanced decay is the formation of adipocere, as observed mainly in drowned bodies or following a long period of storage under airtight conditions. During storage in an open, damp environment (e.g. water) the formation of adiopocere becomes visible after approximately 3-6 months and can be found in more extensive form after approximately one year. In this state bodies show evidence of a partly waxlike and partly pasty condition. Continued storage ultimately results, among other things, in further decomposition due to the action of microorganisms from the surrounding area-even if this is chronologically delayed. An exception is provided by the formation of adipocere under air-tight conditions (e.g. wrapped in plastic material or in mass graves). Initially autolysis and heterolysis also occur, involving the release of fatty acids from the lipids produced naturally in the body. As a result of the subsequent hydrogenation of the fats by the action of bacterial enzymes, the unsaturated fatty acids are partially converted into saturated fatty acids. As the fatty acids released in large quantities during adipocere formation clearly have a bactericidal effect, further bacterial decomposition is stopped at this early adipocere stage. Additional microorganisms from outside can no longer infiltrate when this hermetic seal is in place. In addition, the lack of calcium (e.g. from water or moist earth) can be a reason for the fact that further adipocere development, leading to wax-like hardening of the fat, is arrested. The soft parts of the body retain a soft, viscous consistency. Thus the condition of the body can remain constantly preserved over many years and no longer allows a reliable estimate to be made of the period of time since death.

[Fatal sodium azide poisoning in a hospital: a preventable accident]. / Tödliche Natriumazid-Vergiftung im Krankenhaus: ein vermeidbarer Zwischenfall.

A case of fatal sodium azide poisoning is reported. From the hospital staff, a 57 year old patient had obtained 1 g of sodium azide in order to put it as a preservative, in his 24 hour urinal. Probably due to an error, he swallowed the total dose. A cardiovascular collapse was cause of the death after five hours of intensive treatment and reanimation. Azide anions were found in blood (traces, less than 0.5 mg/L), vitreous (10 mg/L) and cerebrospinal fluid (20 mg/L). The use of sodium azide for disinfection of urine samples should be regarded as obsolete. Less toxic substances for disinfection are available. To avoid chemical disinfection, urine samples can be kept at 4-8 degrees C prior to rapid analysis.

[Criteria for differentiating self- or other-inflicted injuries of alleged or real victims]. / Unterscheidungskriterien für Selbst- oder Fremdbeibringung von Verletzungen angeblich oder tatsächlich Uberfallener.

A synoptic study of six cases of self-inflicted sharp force injuries is presented, where young, mostly female people had simulated assaults to gain sympathy or other personal advantage. The morphological distinctives of simulated assault wounds from such of real assault are worked out and the common situative and motivative background is cleared up.

[Catecholamines, myofibrillary degeneration of the heart muscle and cardiac troponin T in various types of agony]. / Katecholamine, Myofibrilläre Degeneration des Herzmuskels und Kardiales Troponin T bei verschiedenen Agonietypen.

The stress of agony (the death struggle) induces a rise in serum catecholamines. High doses of catecholamines cause myofibrillar degeneration (MFD), a form of cardiac injury. Severely damaged cardiac myocytes release troponin T (TnT), a myofibrillar cardiac protein, into the circulation. We studied serum catecholamine levels, MFD and TnT in 119 medico-legal autopsy cases. Catecholamine levels increased with the duration of agony: In the instantaneous death cases, the levels were similar to levels in humans at rest, whereas the levels in prolonged agony were comparable to concentrations found in humans in acute maximal stress. Still, it was not possible to infer the duration of agony from the catecholamine level in an individual case. The exceptionally high dopamine levels found in the group 'resuscitation and/or intensive care before death 'were most likely caused by antemortal treatment with dopamine. Slight MFD was diagnosed in nearly all hearts; its severity was neither related to catecholamine levels nor to duration of agony. TnT, not found in blood of healthy people, was present in nearly all postmortem samples, indicating autolytic effects. Heart blood contained more TnT than femoral blood. We could not detect a relationship between the serum cardiac troponin T level and MFD; but cardiac deaths had significantly higher levels of TnT in heart blood than deaths from other causes. The postulated interrelation between catecholamines, MFD and TnT was not evident from the results.

[Distribution of morphine and morphine glucuronides in body tissue and fluids--postmortem findings in brief survival]. / Verteilung von Morphin und Morphinglucuroniden in Körpergeweben und -flüssigkeiten--Postmortale Befunde bei kurzer Uberlebenszeit.

An intoxication following administration of morphine, tramadol and atracurium in a suicide case is reported. The route of administration and the amount of the particular drug were known from the investigation of the death scene and the findings of the postmortem examination. Tramadol was present in the gastric contents as well as in blood, liver, kidney and brain samples, whereas the drug could not be detected in muscle. All body fluids and tissues investigated contained morphine as well as its 3- and 6-glucuronides with the exception of muscle tissue. The concentrations of morphine and its glucuronide metabolites were determined by LC/MS following solid phase extraction. Interestingly, the concentration of M6G in brain, liver and kidney were close to the concentration of M3G in the particular tissue. This phenomenon might be explained by a preferential hydrolysis of M3G or by a preferential formation of M6G postmortem. Measurement of morphine and M6G in femoral blood and cerebrospinal fluid may be a useful indicator in rapid deaths.

[Fatal incidences during arrest of highly agitated persons]. / Tödliche Zwischenfälle bei der Festnahme höchstgradig erregter Personen.

We report on four cases of sudden circulatory arrest during the physical restraint of extremely excited and repugnant men by the police. Three persons died, and one became apallic. The excited states resulted from acute schizophrenic disorder in one case, from intoxications (ethanol and drugs including cocaine respectively) in two others, and from encephalitis in the fourth case. In only one case one of the police officers was condemned for involuntary mansloughter, responsability was excluded in the remainder. Similar lethal events in "excited delirium" are given in the American literature, the main etiologic factors being acute psychosis and cocaine intoxication. Most of these events occurred, differing from ours, under "hogtying" which is a technique of physical restraint in a prone position with the wrists and ankles bound behind the back. These events are thought to be cardiac in origin and to result from oxygen-consuming motor hyperactivity, excessive catecholamine release, and impaired breathing. Police officers are recommended to restrict all measures of restraint to a mininum in extremely excited persons, and to avoid any compression of the trunk or neck. A continuous monitoring for vital signs is postulated in order to recognize a medical incident as quick as possible.

[Fatal child abuse (caused by physical violence) in Germany during 1 January 1985 to 2 October 1990. Results of a multicenter study]. / Tödliche Kindesmisshandlung (durch physische Gewalteinwirkung) in der Bundesrepublik Deutschland im Zeitraum 1.1.1985 bis 2.10.1990. Ergebnisse einer multizentrischen Studie.

UNLABELLED: No reliable data are available on cases of lethal child abuse (by active force) in the area of Federal Republic of Germany prior to reunification (the former West Germany). In a multicenter study we therefore examined the police and court records for such cases occurring in the period 1 January 1985 to 2 October 1990 in nearly the entire area of Federal Republic of Germany. RESULTS: The study center received information on 58 cases of lethal child abuse. Extrapolated to all institutes of legal medicine, this corresponds to 62 cases in all of West Germany in the period studied. An approximately equal number of unreported cases should be added to this figure. Including unreported cases, at least 20 cases of lethal child abuse occurred per year; thus only one in every two cases ever came to light. Almost two thirds of the victims were younger than one year old. At autopsy 59% exhibited signs of repeated abuse at autopsy. By far the most common cause of death was direct impact from a blunt object, usually to the head. Mostly, the male person to whom the victim relates most closely (father, stepfather, partner of the mother) has killed the child. Twenty-one of the 74 persons charged saw the charges against them dropped or were acquitted due to lack of evidence; 51 received sentences ranging from one year probation to life. In the remaining two cases the outcome of the trial was unknown. Signs of abuse were readily apparent at autopsy in almost all cases. The high number of unreported cases underscores the need to educate medical students and practicing physicians to be on the look-out for signs of abuse and argues for an increase in the rate of autopsy.

[Fatal child neglect in West Germany 1 January 1985 to 2 October 1990. Results of a multicenter study]. / Tödliche Kindesvernachlässigung in der Bundesrepublik Deutschland im Zeitraum 1.1.1985 bis 2.10.1990. Ergebnisse einer multizentrischen Studie.

UNLABELLED: Up to now reliable data were available on cases of lethal child neglect in the area of the Federal Republic of Germany prior to reunification (the former West Germany). In a multicenter study we therefore examined the police and court records for such cases occurring in the period from 1 January 1985 to 2 October 1990 in nearly the entire area of Federal Republic of Germany. RESULTS: The study center received information on 19 cases of lethal child neglect. Extrapolated to all institutes of legal medicine, this corresponds to 20 cases and thus 3.5 cases a year in the whole of West Germany in the period studied. There is to be added a dark-field which cannot be limited more precisely. However, the cases of fatal child neglect might have occurred much more seldom than fatal child abuse caused by use of physical violence. Slightly more than half the victims were younger than 1 year, the oldest one was 7 10/12 years old. Most frequently the children died of starvation and thirst. Mostly the mothers/nursing mothers killed the child alone or together with the victim's father/stepfather. In the majority of the cases there was not a close affection between parents and child. Nearly 30% female/male perpetrators suffered from chronic alcohol abuse. Only 15 (= 56%) of 27 female/male perpetrators were sentenced to imprisonment (period between 7 months on probation and 10 years). Mitigation circumstances existed for nearly half the persons sentenced to imprisonment. It is true that child neglect is a rarer crime, but the experts of legal medicine always have to indicate errors made during the external inspection of the corpse (among others failures to see indications of neglect).