A Retrospective Study of the Investigation of Homicidal Childhood Asphyxial Deaths.

As one of the leading causes of traumatic deaths in newborns, infants, and young children, there is no anatomic or microscopic feature that is pathognomonic for asphyxial deaths. Instead, pathologists rely on investigation information, including confessions and/or witness statements, and potential evidence at the scene. Twenty cases of homicidal newborn, infant, and young children asphyxial deaths were reviewed, which included death and police investigation reports and autopsy reports, as well as histology slides of lung sections. This series of homicidal asphyxial deaths highlight that, in a vast majority of such cases, the final cause and manner of death rulings are dependent on confession by the perpetrator. Furthermore, this series highlights the possible role of histology to help forensic pathologists better certify asphyxial deaths. Finally, this series emphasizes important investigation points and considerations at autopsy during the investigation of asphyxial deaths in newborns, infants, and young children.

Adolescent Russian roulette deaths.

Adolescence, between the ages of 10 and 19 years, is a unique period both physically and emotionally. During this time of life, individuals are known to experiment and engage in risky behavior, sometimes with unforeseen morbidity and mortality. We also see suicide emerge as a manner of death in this age group. The most common method is gunshot wound and sometimes in the form of Russian roulette. Few studies have looked at deaths by Russian roulette, the victims, and scenarios. In particular, no study examines the adolescent victim of Russian roulette. To better understand and classify this entity, adolescent Russian roulette autopsy cases over a 20-year period were examined looking at the victims, scenarios, autopsy findings, cause and manner of death, and the weapons. All victims were males, ages 13 to 19 years, with a Black-to-White ratio of 1:1. No victim had a previous psychiatric history. Toxicology was positive for alcohol and/or marijuana in 50% of the victims. Friends were present when the victim shot himself which occurred in the home the majority of the time. In all but 1 case, premeditation of the game was involved as the victim provided the weapon for the roulette. The cause of death was gunshot wound to the head (6 to the right side, 1 to the mouth, 1 to the forehead), and the manner of death was suicide in 6 cases and accident in 2 cases. A review of the literature discusses the adolescent victim, suicide, and Russian roulette.

Left atrial infarction: a case report and review of the literature.

The majority of cardiac related deaths are due to ischemic heart disease, with the most common clinical scenario being severe coronary artery atherosclerosis resulting in left ventricular myocardial infarction. However, infarction of other cardiac chambers does occur, and often has specific clinical associations. We report a case of a 70-year-old man who suffered from left atrial infarction that resulted in a transmural rupture of his left atrium. The patient had a history of rheumatic heart disease, mitral valve stenosis, and severe atherosclerotic coronary artery disease. Four days before death, he underwent mitral valve replacement and left circumflex coronary artery bypass. Two days later, he developed atrial fibrillation. On the day of death, he had decreased mental status, questionable seizure activity, hematemesis, ventricular tachycardia, and eventually asystole. At autopsy, he had significant hemopericardium with a fibrinous pericarditis and bilateral hemothoraces (total blood volume: 1250 mL). A 0.1 to 0.2 cm left atrial transmural defect was identified. The prosthetic mitral valve was free of vegetations, and completely intact. Similarly, the left circumflex artery bypass graft was completely patent and unremarkable. Severe calcific atherosclerosis was of his native left circumflex and left main coronary arteries. Microscopic examination revealed acute myocardial infarction of the left atrium at the rupture site. The anatomy of atrial circulation as well as the pathology and consequences of atrial infarction are discussed.

Fatal neurotoxic response to neuroleptic medications: case report and review of the literature.

Neuroleptic malignant syndrome (NMS) is a diagnosis of exclusion difficult to make due to a lack of pathognomonic features. Diagnosing NMS by postmortem examination becomes increasingly challenging when possible underlying brain pathology is obscured. The diagnosis is based on clinical history and laboratory findings. Autopsy and histologic findings, if any, usually are reflective of hyperthermia or complications (eg, aspiration pneumonia) of NMS. The authors describe a case of a 36-year-old Hispanic woman with a presumptive diagnosis of pseudoseizures, treated with various combinations of neuroleptic medications over a 6-week period prior to her sudden, unexpected, in-hospital death. Neuroleptic malignant syndrome is likely to have contributed to this patient's death. Confounding factors and medicolegal issues of a postmortem diagnosis of NMS are discussed.

Fatal birth trauma due to an undiagnosed abdominal teratoma: case report and review of the literature.

The fetus is subjected to mechanical forces during labor and delivery, which may result in traumatic injuries. Such injuries include intracranial hemorrhage, spinal cord lesions, cephalhematoma, cranial or peripheral nerve palsies, intraabdominal organ rupture, or bony fractures. Risk for perinatal trauma and mortality is increased in primigravidas, multiple gestations, abnormal presentations, maternal-fetal disproportion, oligohydramnios, forceps or vacuum extractions, and internal version maneuvers. Very-low-birth-weight neonates (<1500 g) are at high risk due to ease of deformity of the cranium. Infants with certain congenital anomalies or pathologic processes that distort normal anatomy are also at increased risk, especially when a prenatal diagnosis is lacking. The authors present a case of a term gestation neonate who sustained a cervical spine dislocation fracture of C5-7, with subtotal transection of the spinal cord and resultant paralysis. The fetus was in vertex presentation, and a manual vaginal delivery was attempted. When the infant lodged in the birth canal following a difficult delivery of the head and arms, its enlarged abdomen was palpated, and the delivery was converted to an emergent cesarean section. The infant lived for 3 days and then expired due to neurologic complications of trauma sustained during the attempted vaginal delivery. Autopsy revealed a previously undiagnosed intraabdominal immature teratoma. The pathology of teratomas, the most common neonatal tumor and occasionally implicated in cases of birth trauma, will be addressed, followed by a review of the literature concerning birth trauma.

Elder neglect and the pathophysiology of aging.

Elder neglect, one of the 6 forms of elder maltreatment, is difficult to diagnose and is underreported both in the scientific literature and to law enforcement. Recognizing fatal neglect is even more challenging especially with concurrent organic disease. Many entities can mimic elder neglect, and many age-related changes can result in pathology that may be confused with maltreatment. We retrospectively reviewed all forensic cases of individuals age sixty-five years and older which were referred for autopsy. Cases of fatal neglect were analyzed as to age, sex, race, cause of death, location of incident, perpetrator, victim-to-perpetrator relationship, and autopsy and ancillary findings. The cases studies totaled 8. The age range was 74 to 94 years. Two were white, 6 black, one male, and 7 female. The causes of death were sepsis due to severe decubitus ulcers and severe dehydration. Five cases occurred in the victim's home, and 3 occurred in an institution (nursing home/care facility). In 5 cases, the perpetrators were family members. The pathophysiology of aging with respect to elder maltreatment is reviewed.

Asphyxia by tracheobronchial thrombus.

Asphyxia secondary to airway obstruction has numerous underlying causes, both acute and chronic. Causes of chronic airway obstruction, such as neoplasms and tracheal scarring, are often clinically apparent well prior to asphyxia. Causes of acute airway obstruction may not be as obvious to clinicians or investigators. These include infections, anaphylactic reactions, status asthmaticus, inhalational injuries, and aspirations, which may result in acute obstruction and sudden death. We report the deaths of 2 individuals, a 43-year-old female and a 78-year-old female, both with adenocarcinoma. The 43-year-old was hospitalized with a stage III, poorly differentiated infiltrating ductal carcinoma of the breast metastatic to the lymph nodes. She was intubated to treat poor respiratory function and acidosis. A bronchoalveolar lavage was consistent with alveolar hemorrhage; no organisms were identified. Blood and "clot" were in her endotracheal tube, so the endotracheal tube was replaced. She became comatose and life support was withdrawn. At autopsy, a large red-gray thrombus obstructed the trachea and extended into the right bronchus. Microscopically, the entire clot was composed of fibrin, red blood cells, and some mucus. Findings of acute respiratory distress syndrome with hyaline membranes were identified. The cause of death was listed as acute respiratory distress syndrome with tracheobronchial thrombus. Experiencing a decline in mental status, the 78-year-old had metastatic adenocarcinoma of unknown primary. She developed sudden respiratory distress and an airway obstruction was discovered. After failure to relieve the obstruction, she decompensated and died. At autopsy, a large, red-gray thrombus obstructed the distal trachea and both bronchi. Microscopically, the thrombus was composed of fibrin, platelets, and red blood cells. The cause of death was asphyxia secondary to airway obstruction by thrombus. We present these 2 unusual cases of asphyxia and review of the literature focusing on asphyxia and the etiology of airway thrombi.

Iatrogenic deaths following treatment for hypertrophic obstructive cardiomyopathy: case reports and an approach to the autopsy and death certification.

Hypertrophic cardiomyopathy (HCM) is a disease process which results in a large, heavy heart, with hypertrophy of the interventricular septum (IVS) and left ventricle. HCM accounts for a significant number of cases of sudden cardiac death each year, most infamously in young athletes. The prevalence of the disease has increased over the past several years due to advances in clinical diagnosis and molecular genetic studies. Over this same period, new forms of treatment also have emerged. One such treatment is alcohol septal ablation (ASA). ASA is a procedure performed by a cardiologist, via cardiac catheterization, by injecting pure ethanol into selected arteries which supply the IVS, resulting in a targeted myocardial infarction. This infarct then retracts and forms a scar, decreasing the outflow obstruction and improving the patient's clinical symptoms.The authors report 2 cases of death following ASA treatment of HCM. The first, a 56-year-old male, had his ASA procedure 10 days prior to death. The second decedent, a 76-year-old female, had her procedure only 30 hours before death. These case reports are followed by a discussion about HCM, including pathology, treatments, and treatment-related pathology, before closing with a discussion about death certification in the cases presented and therapy-related deaths in general.

Sudden death due to asphyxia by esophageal polyp: two case reports and review of asphyxial deaths.

Asphyxia, not an uncommon cause of sudden death, may result from numerous etiologies. Foreign-body aspiration and strangulation are 2 extrinsic causes. Airway obstruction may also be caused by laryngeal edema, asthma, infection, or anaphylaxis. Chronic causes of asphyxia include musculoskeletal diseases (eg, muscular dystrophy, amyotrophic lateral sclerosis), neurologic disorders (eg, myasthenia gravis, multiple sclerosis), respiratory disease (eg, emphysema, chronic bronchitis), or tumors. The manner of death in cases of asphyxiation may be natural, accidental, homicide, or suicide. For the death investigator, determining the cause and manner of death can often be quite challenging. We report here 2 cases of an esophageal fibrovascular polyp causing sudden asphyxial death, review of the literature, and discussion of other differential diagnoses in the case of asphyxial death.

Vertebral artery laceration mimicking elder abuse.

Elder abuse was first described almost 30 years ago. Today, approximately 1 in 25 elders is abused each year in the United States. A newly described form of domestic violence, the incidence of elder abuse will surely increase as the elderly population grows. Physical abuse/inflicted trauma is generally considered the most extreme form of elder mistreatment and includes blunt trauma, sexual assault, traumatic alopecia, and burns. Elder homicide is usually due to gunshot wounds, blunt trauma, stab wounds, or asphyxia. However, the difficult aspect of assessing the possible elder abuse homicide victim is delineating such inflicted trauma from accidental trauma. We report the case of a 94-year-old "demented" male, who reportedly fell out of his wheelchair. He was transported to a local emergency room, where he became unresponsive during examination. He experienced respiratory distress and was pronounced dead shortly thereafter. At autopsy, he had periorbital contusions and a midline abrasion between the eyes, with underlying supraorbital contusion. The skull, brain, and spinal cord were unremarkable for signs of trauma. The major traumatic finding was in the neck region. Neck dissection revealed hemorrhage extending from the base of the skull to the level of T-1 and anteriorly about the soft tissues, strap muscles, and vasculature. The strap muscles were individually examined and were free of hemorrhage. The carotid arteries and jugular veins were unremarkable. The larynx, hyoid, and thyroid were intact, with only surrounding hemorrhage. Further examination revealed a horizontal fracture of the C5 vertebral body and a medial laceration of the left vertebral artery at the C5 level; subarachnoid hemorrhage was absent. What initially appeared to be trauma to the neck, worrisome for strangulation or blunt force trauma, was a large retropharyngeal hematoma from the left vertebral artery laceration. Traumatic rupture of the vertebral artery usually occurs at the C1 and C2 levels, with resultant subarachnoid hemorrhage. This is an especially vulnerable location since it is where the artery turns and then enters the skull. Associated injuries include spinal cord transection or contusion, brachial plexus injury, pharyngoesophageal injury, and vertebral fractures. Retropharyngeal hemorrhage may result from deep neck infection, tumor, and trauma. Hemorrhage associated with trauma often involves flexion of the cervical spine, followed by hyperextension. The accumulation of blood slowly impinges on the pharynx/larynx and vasculature structures. The exact injuries and etiology of the hemorrhage must be determined to distinguish strangulation from blunt force trauma. The presentation of signs and symptoms can be helpful in assessing the decedent; however, in the practice of forensic pathology such a history is more often lacking.

Pathologic findings in malignant hyperthermia: a case report and review of literature.

Malignant hyperthermia (MH) is a rare, potentially lethal disorder of skeletal muscle calcium homeostasis characterized by muscle contracture and life-threatening hypermetabolic crisis following exposure to halogenated anesthetics and depolarizing muscle relaxants. Susceptibility to MH results from mutations in calcium channel proteins that mediate excitation-contraction coupling, with the ryanodine receptor calcium release channel (RyR1) representing the major locus. The mode of inheritance appears to be autosomal dominant with variable penetrance. The authors report the death of a 60-year-old white male with a history of low back pain. He had undergone 2 back surgeries previously, the first occurring 10 years prior to his current presentation. Both previous procedures were done under generalized anesthetic with no complications. Recently, he developed stenosis and presented for fusion of vertebrae L3 and L4. The procedure was performed under general anesthetic including sevoflurane, with no intraoperative complications. The anesthesiologist noted that, near the end of the 2-hour procedure, the decedent's CO2 levels were slightly elevated. After the procedure, the decedent was extubated, the temperature probe which had been recording normal values was removed, and he was rolled from ventral to dorsal position. He immediately became hypotensive and bradycardic. Lifesaving interventions were begun. Subsequently, he went into cardiac arrest, at which time the temperature probe was reinserted into the trachea, where it read a body temperature of 109 degrees F. Malignant hyperthermia protocol was initiated, and interventions continued for over 2 hours, at which time they failed. At autopsy, the abdomen contained 1800 mL of blood, and bilateral hematomas were present in the psoas muscles. The authors present this case of clinically apparent malignant hyperthermia, discuss how to approach such a case, the gross and microscopic findings, ancillary studies, and a review of the literature.

Childhood panhypopituitarism presenting as child abuse: a case report and review of the literature.

Childhood panhypopituitarism may be acquired or congenital. Children with panhypopituitarism can present clinically with diabetes, growth failure, decreased bone density, and morbid obesity. In the forensic setting without the proper history, it can be misdiagnosed as child abuse or neglect. We report a case of a 3-year-old black girl who was admitted to the emergency room with apnea and subsequently died. While at the emergency department, it was discovered that the child had a fractured left hip and was severely growth retarded for age. The coroner wanted to rule out child abuse and/or neglect and requested an autopsy based on the physical findings identified by hospital staff. Significant findings at autopsy included small for age (15th percentile for age), hypoplastic brain/pituitary gland/adrenal gland/thyroid gland, abnormally formed skull with an occipital protuberance, a fractured left hip with decreased bone density, and central adiposity. Subsequent to the autopsy, it was discovered that at 6 weeks of age the child suffered from group B streptococci meningitis that resulted in panhypopituitarism. The panhypopituitarism then resulted in seizure activity, diabetes insipidus, and growth retardation. The authors hope this case report and review of the literature will assist investigators, pathologists, and clinicians in making a distinction between neglect or inflicted injury of child abuse and panhypopituitarism that can present with similar signs and symptoms.