Is That Innocent to Touch the Adipose Tissue?: An Autopsy Case Series of Fat Embolism Syndrome.

ABSTRACT: Although fat embolism in the pulmonary or systemic circulation is usually associated with long bone fractures, it can also occur less frequently during surgical operations, such as liposuction, fat grafting, and joint repair. This study aims to present cases of macro fat embolism resulting in sudden death during the perioperative period. Three cases with a history of sudden death during the perioperative period were included in this study. The surgical operation histories, autopsy findings, and histopathological findings of the cases were evaluated. Fat globules were detected in the medium-sized vessel lumens in the lungs of the cases who died suddenly during surgery. Grade 4 fat embolism was observed in the capillaries, which stained positively with Oil-Red-O in all three cases. Fat embolism syndrome is a rare but life-threatening condition that should be considered in patients with respiratory distress and impaired neurological status in the postoperative period.

[Investigation of viral respiratory tract infection agents by multiplex PCR method in autopsy cases: A five-year study]. / Otopsi olgularinda viral solunum yolu enfeksiyonu etkenlerinin multipleks PCR yöntemi ile arastirilmasi: bes yillik bir çalisma.

Viral respiratory infections are one of the leading causes of morbidity and mortality, especially in children, elderly and immunocompromised patients. The inclusion of post-mortem studies to diagnose the infection causing mortality could be beneficial in specifying new pathogens and determining strategies for treatment and prevention. The aim of this study was to research viral etiology by applying multiplex real-time polymerase chain reaction (Rt-PCR) method in autopsy cases who have been considered to have a respiratory infection and to assess whether the viruses detected are the primary cause of the infection and whether they have any contributory effect on the mortality together with histopathological evidence. In this study, we included a total of 834 cases consisting of sudden death cases from infantile-pediatric age group and autopsy cases from > 18 year age group with suspected respiratory tract infection in our laboratory between January 2013 and May 2017. Of 834 cases, 468 (56.1%) were male and 366 (43.9%) were female, there were 191 (22.9%) cases between 0-1 months, 593 (71.1%) cases between 1 month-18 years, and 50 (6%) cases in the > 18 years age group. In 728 of 834 (87.3%) cases nasopharyngeal/tracheal swab samples and in 106 (12.7%) of them paraffin-embedded lung tissue samples were studied by the use of "FTD Respiratory 21 (Fast-Tract Diagnostics Luxemburg)" kit, with multiplex Rt-PCR method. The post-mortem samples were evaluated for human rhinovirus (HRV), parainfluenza viruses (PIV) (1, 2, 3, 4), influenza virus type A and B (INF-A, INF-B), enterovirus (EV), human bocavirus (HBoV), adenovirus (AdV), human coronavirus (HCoV 229,63,HKU,43), human metapneumovirus A ve B (HMPV-A/B), parechovirus, respiratory syncytial virus (RSV A/B) and Mycoplasma pneumoniae. In our study, at least one respiratory virus was detected by Rt-PCR in 379 (45.4%) of total 834 cases, whereas no viral agent was identified in 455 (54.6%) of the cases. One viral agent was detected in 278 (33.3%), two viral agents were detected in 83 (9.94%) and three viral agents were detected in 18 (2.16%) cases. Overall, the most common viral agent was HRV 110 (13.2%) followed by AdV 39 (4.7%) and RSV A/B 33 (4%). In pediatric cases the rate of positive results for respiratory viruses was 31.8% and in adult group it was 20% (p= 0.032). The most common virus detected among children was HRV and INF-A in adult group. In 101 (12.1%) cases infections caused by two or three agents were diagnosed. Infections with two causative agents were detected as 2.6% (5/191) in 0-1 month age group, 13% (77/593) in 1 month-18 year age group and 2% (1/50) in > 18 age group. The most frequently observed co-infections with double causative agents were HRV and INF-B, HRV and PIV, HRV and HBoV, HRV and AdV combinations. Infections with three causative agents were detected completely among 1 month-18 year age [3% (18/593)] group. In our study, 318 (38.1%) cases had no signs of infection in the postmortem histopathological examination of the lung tissues, while the most common finding was lobular pneumonia/purulent bronchitis in 233 (28%) cases and the second was interstitial pneumonia in 168 (20.1%) cases. When all cases were evaluated in terms of infection, positive results were detected in 469 (56.2%) cases. As a result; postmortem microbiological diagnosis with autopsy and histopathological detection of the patients who are thought to have respiratory tract infection will also determine the infectious agents causing death.

Spontaneous Coronary Artery Dissection: Report of 3 Cases and Literature Review Hormonal, Autoimmune, Morphological Factors.

The number of cases with spontaneous coronary artery dissection (SCAD) is considered to be being underestimated because of a large amount of SCAD leading to sudden death without previous diagnosis. Besides, not only in clinics but also in autopsy practice, correct diagnosis of SCAD is important to prevent forensic malpractice.The article is intended to discuss the pathological findings through the forensic point of view for improving the malpractice expertise in scope of clinicians' timely antemortem diagnosis according to risk factors and in scope of forensic pathologists' the cause of death determination ability according to macroscopical and microscopical findings of the autopsy.In 3 cases reported, the main characteristics were the female sex, pregnancy history and a sudden death without any trauma. However, although there are many women giving birth or using oral contraceptives, only some of them are facing with SCAD. This suggests the possibility of some hereditary factors, whereas hereditary characteristics may be understood in many different ways like hormone-releasing regulating mechanisms as well as immunity, morphology, or any other mechanism. For instance, autoimmunity has been also a hereditary underlying factor for vessel injury considered in presented cases.

Methanol intoxication: pathological changes of central nervous system (17 cases).

The nervous system has increased susceptibility for methanol intoxication. The aim of this study is to investigate various central nervous system lesions of methanol intoxication in 17 cases autopsied in the mortuary department of the Council of Forensic Medicine in Istanbul, Turkey. The reasons of methanol intoxication in the cases was likely the unwitting ingestion of methanol while drinking illegal alcohol. Survival times ranged from several hours to days. In 8 cases (47%), cerebral edema and in 9 cases (53%) at occipital, temporal and parietal cortex, basal ganglia and pons, petechial bleeding was observed. In addition to these findings, hemorrhagic necrosis were observed in thalamus, putamen, and globus pallidus in 5 cases (29.4%) and, in cerebral cortex in another 3 cases (17.6%). In 3 of the cases (17.6%) in which cerebral edema was found, herniation findings accompanied to the situation and in 2 cases (11.7%), pons bleeding was observed. Around the basal ganglia, in 2 of the cases with hemorrhagic necrosis, the situation ended with a ventricular compression. In 7 cases (41%), the associated findings of chronic ischemic changes in cortical neurons, lacunae formation, degeneration of granular cell layer of the cerebellum, and reactive gliosis were considered as the results of chronic alcoholism.

[Assessment of smoking related pathologic changes and MMP-9, TIMP-1 expressions of the lung]. / Akcigerde sigaraya bagli patolojik degisimler, MMP-9 ve TIMP-1 ekspresyonlarinin degerlendirilmesi.

The impact of smoking on the peripheral airways, the determining field of respiratory functions in the lungs, is well known. Fifty two cases were included in the study; autopsy cases of non-cardiopulmonary related deaths with a smoking history, and cases with lung resection, known as smokers. Ten cases without a smoking history and a systemic disease were used as a control group at the histopathological examination. Parenchymal samples were taken from the central and peripheral airways (1st, 2nd, 3rd division) and from each lob. In addition, age, gender, amount and duration of smoking (package/year) were considered and histopathological changes of the lung are evaluated under the light microscope. The relations of all parameters to each other are evaluated and compared with the control group. On the distal airways with small diameter, Respiratory Bronchiolitis (RB) was determined in 14 (26.9%) cases, and Respiratory Bronchiolitis-associated interstitial lung disease (RB-ILD) in 16 (30.7%) cases. Two (3.8%) cases were diagnosed as Desquamative Interstitial Pneumonia (DIP). MMP-9, a matrix metalloproteinase known for its role in the development and repair of obstructive diseases of the lung related to smoking, and TIMP-1, an inhibitor, were used on the lung samples by means of immunohistochemical method. MMP-9 and TIMP-1 expressions of all cases were compared statistically with the existing pathological findings and the control group. MMP-9, TIMP-1 were expressed from the alveolar macrophages, endothelial and epithelial cells. Considering the MMP-9 and TIMP-1 density of alveolar macrophages, no statistically significant differences were found among the RB, RBILD and DIP case groups. However; despite of the significant MMP-9 expression of the DIP cases, TIMP-1 expression could not be determined. Compared to the control group, a more intensive and widespread positive reaction on MMP-9 was found in the alveolar macrophages. In conclusion, although there was no significant relation between the level and duration of smoking and the MMP-9 and TIMP-1 expressions, alveolar macrophages were found to be more important in lung damage related to smoking and the MMP-9 expression from these cells to be more intensive than the control group.

Sudden death due to eosinophilic endomyocardial diseases: three case reports.

Eosinophils are associated with various disorders, such as allergic or hypersensitivity reactions, parasitic diseases, connective tissue diseases, certain neoplastic diseases (Hodgkin's disease, lymphomas, and carcinomas), and various immune deficiency states. Eosinophils can infiltrate any tissue and can cause tissue damage. Heart, has been demonstrated to be the most extensively involved and toxicity of eosinophils is well-established on cardiac tissue. We describe 3 cases with extensive eosinophilic infiltration without endomyocardial fibrosis. All patients died after a short clinical course with rapidly progressive heart failure. Bronchial asthma, hydatid disease and drug reaction were considered as possible etiologies of eosinophilia in case 1 and case 2. Case 3 was considered to fall into the "idiopathic hypereosinophilic syndrome" in which no underlying causes for eosinophilia could be identified.

Sudden death in infancy due to bicuspid aortic valve.

Symptoms of bicuspid aortic valve usually occur in the age group of 50-70 years, but rarely, it can also lead to sudden unexpected death in infancy and early childhood. The autopsy of a 2-month-old baby boy, found dead in his cot, revealed the heart weight as 25 g, and the macroscopic examination showed the circumference of the aortic valve consisting of two leaflets as 8 mm. The thickness of the left ventricle, right ventricle, and septum was measured as 8, 7, and 10 mm, respectively. Microscopically, the heart revealed hypertrophic changes of myocytes. Subendocardial areas displayed necrosis of myocytes, and severe and diffuse ischemic changes characterized by loss of myofibers and vacuolization. Interstitial pneumonia was identified in the lungs. Death occurred as a result of a congenital bicuspid aortic valve obstructing the left ventricular outflow tract complicated by lung infection. As there are only a few reported cases in infancy, and congenital bicuspid aortic valve can lead to sudden unexpected death, this case is presented to the forensic community.

Sudden death due to an unrecognized cardiac hydatid cyst: three medicolegal autopsy cases.

Echinococcosis is a human infection caused by the larval stage of Echinococcocus granulosus. The most common sites of infection are the liver and the lungs. Cardiac hydatid cysts are very rare, even in regions where hydatic cysts are endemic (the Mediterranean, South America, Africa, and Australia). It has been reported that cardiac involvement is seen in about 0.5-3% of human echinococcosis cases. Three cases of cardiac hydatid disease that caused sudden death and which were histopathologically diagnosed are reported. Cardiac echinococcosis is rare, but due to its insidious presentation and affinity to cause sudden death, it is important that it be identified in the histopathological examination.

[Pulmonary and systemic fat embolism as a cause of death in forensic autopsy practice]. / Adli otopsilerde ölüm nedeni olarak akciger ve sistemik yag embolizmi.

BACKGROUND: The aim of this study was to evaluate the possible correlations between the grade of fat embolism and age, gender, severity of trauma and post-traumatic survival time. METHODS: Thirty-one cases with pulmonary and/or systemic fat embolism, auotopsied at the Morgue Department of Council of Forensic Medicine were evaluated retrospectively. RESULTS: Twenty-eight cases (90%) died due to trauma and its complications. Nineteen cases (61%) were injured in motor vehicle-related accidents. Post-traumatic survival time varied between 0-384 hours (61.6+/-86.2 hours). Abbreviated injury scale (AIS) was 8.1+/-3.9 and injury severity score (ISS) was 26.5+/-19.7 SD. Twenty-four (77%) cases were determined as isolated pulmonary fat embolism and 7 (23%) cases as systemic fat embolism on histopathological examination. Possible correlations between the grade of fat embolism and age, gender, severity of trauma and post-traumatic survival time were evaluated statistically with using Chi-square and Spearman's correlation tests. CONCLUSION: There were no correlations between the grade of fat embolism and age, gender, the severity of trauma. Post-traumatic survival time and the severity of trauma had a very weak negative correlation without any statistical significance.

Postmortem diagnosis of cytomegalovirus and accompanying other infection agents by real-time PCR in cases of sudden unexpected death in infancy (SUDI).

As an opportunistic pathogen with high mortality rates, Cytomegalovirus (CMV) may lead to fatal disseminated CMV infection of the premature and newborn; thus necessitating the demonstration of CMV-DNA with clinical history and/or histopathological findings of CMV infection and defining other bacterial and viral infection agents with real-time polymerase chain reaction (RT-PCR) in udden unexpected death in infancy (SUDI) cases as we aimed in this study. 314 (144 female, 170 male) SUDI cases were prospectively investigated from January 2013 to January 2015 in Istanbul Forensic Medicine Institution. The study includes 87 tissue samples of 39 cases for post-mortem histopathological examination of interstitial pneumonia, myocarditis, meningitis, encephalitis, hepatitis, colitis or tubulointerstitial nephritis and/or accompanying chronic sialadenitis. CMV-DNA was found positive in 35 (40.2%) salivary gland, 19 (21.8%) lung, 1 (1.1%) tonsil, and 1 (1.1%) brain tissues. CMV sialadenitis and/or CMV pneumonia associated with other viral and/or bacterial agents were detected in 23 (60%) of 39 infant cases. The demonstration of CMV-DNA would significantly clarify the cause of death and collection of epidemiological data in SUDI cases with clinical history and histopathological findings of CMV infection accompanying chronic CMV sialadenitis. Furthermore, CMV suppresses the immune system, and may predispose to other bacterial and/or viral infections in these cases. Post-mortem molecular investigations are useful in explaining cause of death in SUDI with a suspicion of infection in forensic autopsies.

Maternal death due to non-traumatic fat embolism.

The aim of this report is to document a case of non-traumatic fat embolism (NTFE) and to address the need for considerition of fat embolism in suspicious deaths resulting from respiratory distress in the postpartum period. A 28-years-old woman autopsied at the Morgue Department of the Council of Forensic Medicine is included to the study. This female became unconscious and developed respiratory distress 4 h after delivery, and this was followed by respiratory arrest. External examination revealed resuscitation marks and normal postmortem changes. Light microscopy revealed massive fat embolization involving most of the alveolar capillaries on several sections. Only in one particular area was a bone marrow embolus. Pathological diagnosis of the lung was diffuse pulmonary fat embolism. There was no evidence of other organ involvement with emboli. Other visceral organs showed no striking findings other than mild congestion. The cause of death was considered to be respiratory insufficiency resulting from severe fat embolism of the lungs.

[Widespread mesenteric venous thrombosis and cirrhosis diagnosed with autopsy]. / Otopsi ile tanisi konulan yaygin mezenter ven trombozu ve siroz.

Mesenteric venous thrombosis is a rare disorder with a high mortality rate. Since patients remain asymptomatic, diagnosis of the disease is difficult. Diagnosis can be mainly made with either laparotomy or autopsy. Many factors are considered in the etiology of mesenteric venous thrombosis. Liver cirrhosis and chronic pyelonephritis, which we detected in the autopsy and histologic examination of our case, are considered as two of the factors. In our study, it was aimed to present a case with near-total intestinal necrosis caused by portal vein thrombosis which spread to the lineal vein, pancreatic vein and to the branches of superior mesenteric veins.

[An Autopsy Case of Sudden Death Caused by Cerebral Malaria Infection]. / Serebral Malarya Enfeksiyonuna Bagli Ani Ölümle Sonuçlanan Otopsi Olgusu.

Malaria is a lethal protozoan infection which is generally diagnosed antemortem and rarely diagnosed postmortem in a few cases. A fifty five year old, Turkish citizen male has been referred for autopsy. It has been found that he has gone abroad to work a month ago, however, quitted malaria prophylaxis before the intended end and brought into the emergency department in an unconscious state.Following quinine and clindamycin treatment with the initial diagnosis of cerebral malaria, the case was reported to have died due to his general condition got worsened at the end of the third day of therapy.Histopathological evaluation of postmortem tissues was revealed haphazardly arranged minor bleedings and central vascular necrotic foci in the cerebrum, cerebelum and brain stem; light brown pigment containing cells around vasculature; and pigment containing cells in the spleen and bone marrow. Cerebral malaria has a rapid course and is rare but one of the lethal complications of infections with Plasmodium. Although domestic malaria cases has been decreasing in our country, it should be kept in mind that the malaria infection can be seen in persons travelling abroad to high endemic malarial regions and an appropriate antimalarial prophylaxis should be recommended to those overseas travellers.

Cardiac injuries caused by blunt trauma: an autopsy based assessment of the injury pattern.

Nonpenetrating chest trauma with injury to the heart and aorta has become increasingly common, particularly as a result of rapid deceleration in high-speed vehicular accidents, over the past 2-3 decades. The high mortality rate of cardiac injuries and possible late onset complications make blunt cardiac injuries an important challenging point for legal medicine. One hundred and ninety cases with blunt cardiac injuries in a period of 3 years were analyzed retrospectively in terms of patterns of cardiac injury, survival times, and demographic profiles of the cases in this study.

Suicide among children and adolescents in a province of Turkey.

Despite well-documented increases in completed suicides among children, accurate knowledge of the characteristics of these suicides is very limited. The aim of this study was to investigate general characteristics of suicide among children and adolescents in the province of Istanbul and to evaluate obtained results in the light of the literature. Data were collected from autopsy records of the Morgue Department of Institute of Forensic Medicine, Istanbul. General characteristics of completed suicides among children and adolescents between 2001 and 2005 were retrospectively reviewed. The study included 176 suicides aged 9-19 years. The overwhelming majority of the suicides (92%) were aged 15-19 years. More than half of the suicides (60%) were male. The most frequent means of suicide was hanging (55%) followed by firearms (20%) and jump or descent from height (15%).

Quality assessment of perinatal and infant postmortem examinations in Turkey.

An autopsy examination is important in identifying the cause of death and as a means of auditing clinical and forensic practice; however, especially in perinatal and infantile age groups determining the cause of death leads to some difficulties in autopsy practice. In this study, 15,640 autopsies recorded during the years 2000-2004 in the Mortuary Department of the Council of Forensic Medicine were reviewed. Autopsy findings of 510 cases between 20 completed weeks of gestation and 1 year of age were analyzed retrospectively. The quality of each necropsy report was assessed using a modification of the system gestational age assessment described by Rushton, which objectively scores aspects identified by the Royal College of Pathologists as being part of a necropsy. According to their ages, the cases were subdivided into three groups. Intrauterine deaths were 31% (158 cases), neonatal deaths were 24% (123 cases), and infantile deaths were 45% (229 cases) of all cases. Scores for the quality of the necropsy report were above the minimum acceptable score with 44% in intrauterine, 88% in neonatal and infantile deaths.

Subvalvular aortic stenosis as a cause of sudden death: two case reports.

Sudden death is defined as a death that occurs suddenly, develops during an unpredictable course, and is due to natural or unnatural causes. Although there is no universally standardized definition on how "sudden" a sudden death is, WHO defines sudden death as a death that occurs within 24 hours after the onset of symptoms. The aim of this study is to present 2 rarely reported autopsy cases and to emphasize the importance of systemic autopsy at sudden death. On macroscopic examination, crescent-shaped, thick, fibrous membranes, located 5 mm and 3 mm away from the aortic valves, were detected. Fibrous membranes extended from the ventricular septum to the left ventricular outflow tract, thus apparently narrowing this region. Left ventricular wall and septum were slightly thickened, and there were scattered grayish-white areas of a small diameter. These became more intense in the septum and myocardium of the left ventricle on the anterior plane of the myocardial sections. In both cases, the aortic valves of were thickened and also markedly narrowed on one of them. In this case, the fibrous membrane adhered to the aortic valve and extended to the anterior leaflet of the mitral valve at one side. Both aortic valves comprised 3 leaflets. Other valves and coronary arteries showed no macroscopic pathologic findings. Microscopic examination of both cases demonstrated that the fibrous membrane comprising abundant collagen fibers was situated on the ventricular septum. Hypertrophy, moderate to severe interstitial fibrosis, and focal areas of scarring were observed in the specimens taken from the septal and ventricular myocardium. No abnormality was found on the conduction system examinations. Toxicologic analysis results in blood were negative. Based on the findings, membranous-type (discrete type) subvalvular aortic stenosis, diagnosed during the autopsy, was considered as the cause of sudden death in both cases.