Distinguishing true from pseudo hematoma in the cervical spinal canal using postmortem computed tomography.

Spinal cord injury is difficult to detect directly on postmortem computed tomography (PMCT) and it is usually diagnosed by indirect findings such as a hematoma in the spinal canal. However, we have encountered cases where the hematoma-like high-attenuation area in the cervical spinal canal was visible on PMCT, while no hematoma was observed at autopsy; we called it a "pseudo hematoma in the cervical spinal canal (pseudo-HCSC)." In this retrospective study, we performed statistical analysis to distinguish true from pseudo-HCSC. The cervical spinal canal was dissected in 35 autopsy cases with a hematoma-like high-attenuation area (CT values 60-100 Hounsfield Unit (HU)) in the spinal canal from the first to the fourth cervical vertebrae in axial slices of PMCT images. Of these 22 had a hematoma and 13 did not (pseudo-HCSC). The location and length of the hematoma-like high-attenuation and spinal cord areas were assessed on reconstructed PMCT images, true HCSC cases had longer the posterior hematoma-like area and shorter the spinal cord area in the midline of the spinal canal (P < 0.05). Furthermore, we found that true HCSC cases were more likely to have fractures and gases on PMCT while pseudo-HCSC cases were more likely to have significant facial congestion (P < 0.05). We suggest that pseudo-HCSC on PMCT is related to congestion of the internal vertebral venous plexus. This study raises awareness about the importance of distinguishing true HCSC from pseudo-HCSC in PMCT diagnosis, and it also presents methods for differentiation between these two groups.

Quantitative analysis of respiratory viral distribution in forensic autopsy cases.

Respiratory viruses can cause fatal systemic infections; therefore, post-mortem diagnosis is essential in forensic autopsy cases. However, little is known regarding the distribution of respiratory viruses in the body. In this study, we investigated the anatomical distribution of respiratory viruses in 48 forensic autopsy cases suspected of viral infections at our institute. Fast Track Diagnostics (FTD) Respiratory Pathogens 21 was used as a screening test for 20 respiratory viruses in nasopharyngeal swabs. In cases with positive results for virus detection by the screening test, the detected viruses were quantified in body fluid and organ specimens by virus-specific real-time reverse transcription polymerase chain reaction (RT-PCR) and digital PCR. Viruses were detected in 33 cases, with the viral distribution and load differing among the cases. Since various respiratory viruses were detected from the nasopharyngeal swab and its viral load was higher than those of other body fluid specimens, the nasopharyngeal swab was suggested as a useful specimen for the post-mortem detection of respiratory viruses. Viruses were detected in almost all specimens including the serum in six cases. Considering the viral distribution in the body, pathological findings, and ante-mortem symptoms, these cases were presumed to be systemically infected, having died in the acute infection phase. In conclusion, the anatomical distribution of respiratory viruses can help indicate ante-mortem systemic conditions and the cause of death.

Kinetics and distribution of benzalkonium compounds with different alkyl chain length following intravenous administration in rats.

Benzalkonium chloride is widely used in disinfectants. Several toxicological and fatal cases have been reported; however, little is known about its kinetics and distribution. We investigated the kinetic characteristics and distribution of benzalkonium cation (BZK) based on the length of the alkyl chains C12, C14, and C16. Rats were treated intravenously with BZK solution (dose, 13.9 mg/kg) containing equal amounts of the three homologues. Kinetic parameters in the blood were assessed, and BZK distribution in the blood and tissues was examined both in rapid intravenous (IV) and drip intravenous (DIV) administrations. BZK concentrations were analysed by liquid chromatography-tandem mass spectrometry (LC-MS/MS). BZK with longer alkyl chains showed lower elimination tendencies and remained in the blood for a longer duration. Concentrations of BZK were higher in the heart, lung, spleen, and kidney than those in the blood, and lower in the brain and fat. In both the IV and DIV groups, the lung, liver, spleen, and fat samples showed higher concentrations of the longer alkyl chains (BZK-C12 < -C14 < -C16), and the opposite trend was observed in the kidney (BZK-C16 < -C14 < -C12). Only the heart and muscle samples displayed the homologues in ratios comparable to the original administered solutions. Differences between IV and DIV groups could be identified by comparing concentrations of BZK homologues in the heart, lung, spleen, and kidney samples. We found that the kinetics and distribution of BZK were influenced by the alkyl chain length, and analysing each BZK homologues in blood and tissue samples may provide useful information.

An Autopsy Case of Injuries Caused by Automobile Dragging for a Distance of 3.4 km Without Thoracoabdominal Organ Injuries.

Dragging injuries caused by automobiles involved in an accident are occasionally reported; however, those without injury to the thoracoabdominal organs are rare. We present an autopsy case of a man in his 20s found dead on the road after being dragged by a passenger automobile for a distance of 3.4 km. The accident caused fatal dragging injuries but no thoracoabdominal injuries. The victim appeared to be drunk and was lying on the road in front of the parked automobile. Dragging injuries are a unique type of traffic accident that sometimes result from limited and poor visibility due to darkness, rain, or fog. In particular, lying on the road in a drunken state is a specific risk factor for dragging injuries. The dragging distance, road-surface properties, strength of pressure applied by the underbody of the automobile, and the victim's posture are considered to affect the distribution and degree of dragging injuries. Based on autopsy findings and eyewitness testimonies, we discuss the injury mechanism and attempt to reconstruct the accident.

Pilsicainide Poisoning: An Autopsy Case and Review of Literature.

We describe an autopsy case of fatal poisoning due to accidental overdose of pilsicainide, which is a Vaughan Williams class IC antiarrhythmic drug (a pure sodium channel blocker). A man in his 50s was found dead in his home at approximately noon. He had ischemic heart disease and insomnia, and had previously demonstrated improper prescription drug adherence. The autopsy revealed old coronary artery bypass grafting and mild fibrosis of myocardium, but no acute myocardial infarction was found in microscopic examination. Toxicological analysis also identified a high blood concentration of pilsicainide (femoral vein blood, 14.9 µg/mL), more than 15 times higher than reported therapeutic levels. The blood concentrations of other drugs were at therapeutic levels, and no alcohol was detected. We concluded that the cause of death was pilsicainide poisoning, based on the results of the autopsy and the toxicological examination. This is the first autopsy report of fatal poisoning due to pilsicainide as a single agent.

Nontraumatic Convexal Subarachnoid Hemorrhage Accompanied by Sylvian Hematoma: An Autopsy Case of Ruptured Distal Middle Cerebral Artery Aneurysm.

We describe an autopsy case of nontraumatic convexal subarachnoid hemorrhage (cSAH) accompanied by sylvian hematoma. A woman in her 50s was found dead in her house. On autopsy, massive cSAH accompanied by sylvian hematoma was observed. Because of the absence of subarachnoid hemorrhage (SAH) in the basal cistern, initial suspicion was that of a traumatic SAH. After a detailed investigation, a ruptured cerebral aneurysm of the distal middle cerebral artery was found in the hematoma, and the cSAH in this case was confirmed to be endogenous. Convexal subarachnoid hemorrhages typically result from traumatic injury, whereas endogenous cSAHs are exceedingly rare. Autopsy findings of a sylvian hematoma with SAH may result from endogenous hemorrhage from ruptured aneurysm of the distal middle cerebral artery. Detailed investigation of the hematoma may help identify the culprit lesion and help arrive at the correct postmortem diagnosis.

An experimental study of postmortem decomposition of methomyl in blood.

Methomyl (S-methyl-1-N-[(methylcarbamoyl)oxy]thioacetimidate) is a carbamate pesticide. It has been noted that in some cases of methomyl poisoning, methomyl is either not detected or detected only in low concentrations in the blood of the victims. However, in such cases, methomyl is detected at higher concentrations in the vitreous humor than in the blood. This indicates that methomyl in the blood is possibly decomposed after death. However, the reasons for this phenomenon have been unclear. We have previously reported that methomyl is decomposed to dimethyl disulfide (DMDS) in the livers and kidneys of pigs but not in their blood. In addition, in the field of forensic toxicology, it is known that some compounds are decomposed or produced by internal bacteria in biological samples after death. This indicates that there is a possibility that methomyl in blood may be decomposed by bacteria after death. The aim of this study was therefore to investigate whether methomyl in blood is decomposed by bacteria isolated from human stool. Our findings demonstrated that methomyl was decomposed in human stool homogenates, resulting in the generation of DMDS. In addition, it was observed that three bacterial species isolated from the stool homogenates, Bacillus cereus, Pseudomonas aeruginosa, and Bacillus sp., showed methomyl-decomposing activity. The results therefore indicated that one reason for the difficulty in detecting methomyl in postmortem blood from methomyl-poisoning victims is the decomposition of methomyl by internal bacteria such as B. cereus, P. aeruginosa, and Bacillus sp.

Investigation of an anatomically variant isolated bicuspid pulmonary valve: A case report.

INTRODUCTION: We provide a discussion of the anatomical characteristics of the bicuspid pulmonary valve (BPV) in this paper. We performed an autopsy of an isolated BPV found in the heart of a deceased individual. The deceased was a man in his 60s and had no previous history of cardiovascular disease. The heart weighed 260 g and had mild right ventricular hypertrophy. The pulmonary valve had a fish-mouth-like shape that was convex to the pulmonary trunk and both cusps were thickened and hardened. The anterior and left semilunar cusps of the pulmonary valve were fused. Post-stenotic dilatation was noted. CONCLUSIONS: In comparing the present case with previous reports, we found that, in human BPVs, cusps are fused in at least 2 patterns.

Anaphylactic shock caused by sting of crown-of-thorns starfish (Acanthaster planci).

A 40s-year-old woman with previous history of injury due to contact with crown-of-thorns starfish, Acanthaster planci, was stung on the right middle finger. After immediately losing consciousness, she died 13 h after injury despite intensive medical treatment. Examination of the respiratory system revealed narrowing due to severe edema of the laryngopharynx, as well as alveolar hemorrhage, eosinophilic infiltration, and extensive neutrophil and eosinophil aggregation in the intravascular lumen of the lungs. Examination of the liver revealed severe diffuse hepatocellular necrosis and extremely high levels of liver transaminases, indicating severe liver damage. Based on these findings, we concluded that she had died from anaphylactic shock induced by circulation of crown-of-thorns starfish venom in the bloodstream. Injurious contact with the spine of the crown-of-thorns starfish can cause severe symptoms as well as systematic reactions, including anaphylaxis. To our knowledge, this is the first case of anaphylactic shock or death caused by human contact with the crown-of-thorns starfish reported in the English-language literature. Although rare, anaphylaxis due to injury by marine animals is potentially fatal. Saving lives requires providing education regarding prevention and enabling prompt response to possible anaphylaxis, including preparation of adrenaline for auto-injection.

Detection of imidacloprid in biological fluids in a case of fatal insecticide intoxication.

Here, we describe a high-performance liquid chromatography/photodiode array detector method for the detection of imidacloprid in biological fluids in a case of suicide by ingestion of liquor mixed with Admire® Flowable insecticide (containing 20% imidacloprid). A plastic bottle containing a cloudy liquid (concentration of ethanol in the liquid was 150 mg/ml and that of imidacloprid was 50 mg/ml) was found near the decedent. The biological fluids collected at autopsy were prepared by deproteinization with acetonitrile. Zolpidem was used as an internal standard. The concentrations of imidacloprid in femoral blood and cerebrospinal fluid were 105 and 58.5 µg/ml, respectively. Ethanol was also detected in the samples, with concentrations of 1.0 mg/ml in femoral blood and 1.4 mg/ml in cerebrospinal fluid.

[Cyanamide-ethanol reaction induced shock: report of a case and literature review].

Cyanamide is a known alcohol deterrent, and it may cause severe cyanamide-ethanol reaction if a patient consumes high amounts of alcohol during treatment. We report a rare case of cyanamide-ethanol reaction-induced shock in a 73-year-old man who was taking cyanamide for the treatment of alcohol dependence. The patient complained of acute onset of dyspnea after drinking. On arrival, he was in a state of shock. We immediately started hydration and administered 0.3 mg adrenaline by intramuscular injection. However, the patient's general condition did not improve. We could rescue him only after a high dose of adrenaline was administered by continuous intravascular injection. In general, in the treatment of cyanamide-ethanol reaction-induced shock, adrenaline or noradrenaline should be used instead of dopamine. Some cases of severe cyanamide-ethanol reactions have been recently reported in Japan. We performed a literature review and have discussed these cases in the text.

Peritoneal bleeding due to percutaneous transhepatic gallbladder drainage: An autopsy report.

A 77-year-old man underwent percutaneous transhepatic gallbladder drainage (PTGBD) for acute cholecystitis as a preoperative procedure; however, he suddenly suffered cardiopulmonary arrest 4 h after the PTGBD and died. There were three centesis scars for the PTGBD, and only one pathway from the most dorsal centesis scar reached the gallbladder. Microscopically, the PTGBD pathway crossed and injured the intrahepatic arterial wall, and hepatic parenchymal bleeding extended along the PTGBD pathway to the inferior surface of the liver. Blood flowed to the peritoneal cavity through a small gap between the liver and gallbladder. Consequently, the PTGBD caused lethal bleeding. When the percutaneous transhepatic cholangio drainage/PTGBD pathway runs close to vessels near the liver surface, it might be necessary to deal with the possibility of rapid and lethal peritoneal bleeding.

A transnasal intracranial stab wound by a plastic-covered umbrella tip.

A 48-year-old man died from a transnasal intracranial stab wound caused by an umbrella. The track of the stab passed from the right nostril, through the sphenoid sinus, the left side of the sella turcica and anterior clinoid process, and finally reached the surface of the brain. The stab wound crossed the left internal carotid artery, causing an exsanguination and aspiration of blood into the airway, resulting in death. It is extremely rare that an umbrella tip used during a struggle would stab the nostril of the victim. Transnasal intracranial stab wounds can be overlooked and require sensitive handling.

Morphologic investigation of injury caused by locally applied negative pressure in a rat model.

Although some previous studies have reported patients who developed compartment syndrome or died because of locally applied negative pressure, no detailed investigation of pathologic changes caused by negative pressure-induced injury has been reported in the literature. The main purpose of this study was to examine the morphologic characteristics of injury caused by local negative pressure and correlate these with systemic changes. A total of 30 male Wister rats were used. Animals were randomly assigned to 6 groups. Negative pressure was applied to the right hindlimb of each animal in each group for periods of 0 (sham-operated), 30, 60, 90, 120, or 180 min using a vacuum pump. Macroscopic and microscopic changes induced by local negative pressure were already observed after 30 min and were exacerbated with time. The proportion of muscle degeneration was highest in the deep tissues, irrespective of exposure time. The observed increase in the weight of the injured hindlimb at 180 min was caused by an approximately 30% fluid shift to the hindlimb, demonstrating that the application of negative pressure to the hindlimb of rats can induce hypovolemic shock. We here reveal the morphologic changes induced by local negative pressure and discuss possible mechanisms of negative pressure-induced injury.

[Survey of analytical work done for drugs at the emergency and critical care centers equipped with high-performance instruments provided by the Ministry of Health and Welfare (at present: Ministry of Health, Labour and Welfare) in fiscal 1998].

A questionnaire was sent to 73 emergency and critical care centers where high-performance instruments for analyzing drugs and chemicals were provided by the Ministry of Health and Welfare (currently Ministry of Health, Labour and Welfare) in fiscal 1998. 52 centers (71.2%) responded to the questionnaire. Among these, the instruments have been in operation at 36 centers. This means that analytical work has been performed in at least 49.3% (36/73) of facilities with the instruments. A positive correlation was observed between the annual number of patients tested for drugs and chemicals and analytical work hours at the 36 facilities. The results indicated that 150 cases may be tested for drugs and chemicals in a year on the condition that 100 hours a month of analytical work are secured, and 200 or more cases may be tested if 200 hours a month are secured. As for the running costs required for the operation of the instruments, the instrument maintenance and repair cost was estimated at 2 million yen a year, and it was calculated that 100 cases could be handled with a maximum annual supply expense of 1 million yen and 150 cases could be handled with a maximum annual supply expense of 2 million yen. These results suggest that the instrument running cost would be fully covered at nationwide emergency and critical care centers if the additional 5,000 NHI points (1 point = 10 yen) for hospital admission, which is approved for advanced emergency and critical care centers, were applicable to all facilities. Among the 36 facilities, the implementation of analysis varied for each of the 15 toxic substances recommended for analysis by the Japanese Society for Clinical Toxicology. Further research will be necessary to investigate and assess the frequency of analysis requests and combination of simple qualitative and instrumental analyses for each of the 15 substances, in order to evaluate the approach to the 15 substances in analytical work.

An autopsy case of suction injury.

The right upper extremity of a 38-year-old man was entrapped in an underwater intake of a water duct of a dam reservoir, and he died despite being promptly rescued. His right upper extremity was swollen and exhibited purplish-red discolourations. The skin had numerous blisters and increased tension. Severe subcutaneous and muscle bleeding were observed in the right upper extremity. The circumference and volume of the right upper extremity were approximately 1.2 and 1.4 times, respectively, that the circumference and volume of the left upper extremity. The increase in weight of the right extremity was calculated to be approximately 2.1 kg; this finding indicates a severe decrease in the victim's central blood volume. Furthermore, it is possible that much more than 2.1 kg of blood accumulated in the upper extremity upon exposure to vacuum pressure. We conclude that the victim died of circulatory collapse that was attributable to haemorrhage and re-distribution of blood as a result of vacuum pressure on the right upper extremity. Thus, we have examined the cause of death and the effects of vacuum pressure on the human body.

Fatal propeller injuries: three autopsy case reports.

Most propeller injuries occur at water recreational facilities such as those with provision for water skiing, boat racing, skin and scuba diving. Propeller injuries resulting from nautical accidents can be fatal. The sharp blades of propellers rotating at high speeds cause multiple and serious injuries such as deep laceration, chop wounds, bone fractures and mutilation of extremities. We present the autopsy reports of three people who died after colliding with boat propellers.

Characteristic features of injuries due to shark attacks: a review of 12 cases.

Shark attacks on humans might not occur as often as is believed and the characteristic features of shark injuries on corpses have not been extensively reviewed. We describe the characteristic features of shark injuries on 12 corpses. The analysis of these injuries might reveal the motivation behind the attacks and/or the shark species involved in the attack. Gouge marks on the bones are evidence of a shark attack, even if the corpse is decomposed. Severance of the body part at the joints without a fracture was found to be a characteristic feature of shark injuries.

Complete decapitation of a motorcycle driver due to a roadblock chain.

An 18-year-old male driving an off-road motorcycle died from complete decapitation when his motorcycle tore a roadblock chain from its attachment. The decapitation injuries of the head and the torso corresponded perfectly, without apparent loss of tissue. The severance plane passed horizontally through the upper cervical region and C4, which sustained a comminuted fracture. The sharply delineated severance edge had a band-like abrasion. The decapitation resulted from the rotational movement of the unstrung chain, which struck and strangled the driver's neck. We were able to explain the movement of the chain and the decapitation mechanism. This case emphasizes the importance of discussing dynamics with experts to clarify a causal mechanism.