[Case report: death of a 2-year-old girl with postmortem diagnosis of a rare coronary artery vasculitis typical for Kawasaki syndrome]. / Fallbericht: Tod eines 2-jährigen Mädchens bei postmortaler Diagnose einer seltenen, Kawasaki-Syndrom-typischen Koronararterienvaskulitis.

Coronary artery autoimmune vasculitis (Kawasaki syndrome) is at least in Germany a very rare condition, that typically manifests in childhood. The symptoms are often unspecific and complications with vascular aneurysms, thrombosis and myocardial infarction can occur. Multiple cases of Kawasaki-like symptoms in children with positive SARS-CoV­2 test results have been reported during the course of the COVID-19 pandemic the past year.This case study reports on a 2-year-old child who had fever over 6 days and after a temporary improvement, died within 1 day (pre-COVID19 era).The autopsy showed autoimmune vasculitis of the right and left main coronary artery consistent with Kawasaki syndrome with aneurysm formation, acute thrombosis and myocardial infarction.In the case of macroscopically conspicuous dilated and/or thrombosed coronary arteries and/or myocardial infarction in children, a Kawasaki syndrome should be excluded in addition to other differential diagnoses.

Gene variants associated with obstructive sleep apnea (OSA) in relation to sudden infant death syndrome (SIDS).

BACKGROUND: Both obstructive sleep apnea (OSA) and (at least a fraction of) sudden infant death syndrome (SIDS) are associated with impaired respiration. For OSA, an association with several gene variants was identified. Therefore, our hypothesis is that these polymorphisms might be of relevance in SIDS as well. METHODS: Twenty-four single nucleotide polymorphisms (SNPs) in 21 candidate genes connected to OSA, were genotyped in a total of 282 SIDS cases and 374 controls. Additionally, subgroups based on factors codetermining the SIDS risk (age, sex, season, and prone position) were established and compared as well. RESULTS: Two of the analyzed SNPs showed nominally significant differences between SIDS and control groups: rs1042714 in ADRB2 (adrenoceptor beta 2) and rs1800541 in EDN1 (endothelin 1). In the subgroup analyses, 10 further SNPs gave significant results. Nevertheless, these associations did not survive adjustment for multiple testing. CONCLUSIONS: Our results suggest that there might be a link between SIDS and OSA and its resulting respiratory and cardiovascular problems, albeit this predisposition might be dependent on the combination with other, hitherto unknown gene variants. These findings may encourage replication studies to get a better understanding of this connection.

Three-dimensional templating in hip arthroplasty: the basis for template-directed instrumentation?

INTRODUCTION: Computed tomography-based three-dimensional models may allow the accurate determination of the center of rotation, lateral and anterior femoral offsets, and the required implant size in total hip arthroplasty. In this cadaver study, the accuracy of anatomical reconstruction was evaluated using a three-dimensional planning tool. MATERIALS AND METHODS: A total of eight hip arthroplasties were performed on four bilateral specimens. Based on a computed tomography scan, the position and size of the prosthesis were templated with respect to the anatomical conditions. RESULTS: On average, all parameters were reconstructed to an accuracy of 4.5 mm and lie within the limits recommended in the literature. All prostheses were implanted with the templated size. CONCLUSIONS: The exact anatomy of the patient and the required size and position of the prosthesis were precisely analyzed using a templating software. Based on the present findings, the development of template-directed instrumentation is conceivable using this method. However, further technical features (e.g., navigation or robot-assisted surgery) are required for improved precision for implant positioning.

Multimodal Elimination for Intoxication with a Lethal Dose of Organic Mercury.

We here report on a case of massive organic mercury intoxication in a 40-year-old man that resulted in progressive multiorgan failure. We treated the patient intravenously and enterally with the chelating agent (RS)-2,3-bis(sulfanyl) propane-1-sulfonic acid (DMPS) in addition to hemodialysis. The patient was treated for 6 weeks and could successfully be weaned from mechanical ventilation and hemodialysis. He awoke and was sent to rehabilitation, but unfortunately died 7 months later from refractory status epilepticus. Autopsy revealed severe brain atrophy consistent with organ damage from massive mercury intoxication. The present case illustrates that bimodal DMPS application is sufficient for detoxification from lethal mercury levels, with an associated chance for weaning of organ support and survival to discharge. The case further reminds us of intoxication as a cause of multiorgan dysfunction. We propose to immediately initiate combined parenteral and enteral detoxification in cases of methyl mercury intoxication, especially in cases of high doses.

Femoral interference screw fixation of hamstring and quadriceps tendons for ACL reconstruction.

PURPOSE: This cadaveric study compares the biomechanical properties of femoral graft fixation in ACL reconstruction of either quadriceps or hamstring tendon grafts with four different interference screws. The hypothesis was that quadriceps tendon grafts provide at least equal results concerning gap formation during cyclic loading and ultimate failure load compared to hamstring tendon grafts with four different interference screws. METHODS: Eighty porcine femora underwent interference screw fixation of human tendon grafts for ACL reconstruction. Either quadriceps (Q) or hamstring (H) tendon grafts and four different bioabsorbable interference (Wolf (W), Storz (S), Mitek (M), Arthrex (A)) screws were used, resulting in 8 groups with 10 specimens per groups (WQ, WH, SQ, SH, MQ, MH, AQ, AH). Biomechanical analysis included pretensioning the constructs with 60 N for 30 s, then cyclic loading of 500 cycles between 60 and 250 N at 1 Hz in a servohydraulic testing machine, with measurement of elongation and stiffness including video measurements. After this, ultimate failure load and failure mode analysis were performed. RESULTS: No statistically significant difference could be noted between the groups regarding gap formation during cyclic loading [Cycles 21-500 (mm): WQ 3.6 ± 0.8, WH 3.9 ± 1.4, SQ 3.6 ± 0.8, SH 3.3 ± 1.5, MQ 4.3 ± 0.8, MH 4.6 ± 1.0, AQ 4.8 ± 0.8, AH 4.3 ± 1.5, n.s.], stiffness during cyclic loading [Cycles 21-500 (N/mm): WQ 72.9 ± 16.9, WH 71.6 ± 20.7, SQ 69.5 ± 23.9, SH 77.4 ± 25.1, MQ 59.6 ± 11.2, MH 48.4 ± 15.4, AQ 48.8 ± 12.7, AH 51.9 ± 22.2, n.s.], and ultimate failure load [(N): WQ 474.4 ± 88.0, WH 579.3 ± 124.2, SQ 493.9 ± 105.2, SH 576.0 ± 90.4, MQ 478.6 ± 59.0, MH 543.9 ± 119.7, AQ 480.2 ± 93.8, AH 497.8 ± 74.2, n.s.]. CONCLUSIONS: Quadriceps tendon grafts yield comparable biomechanical results for femoral interference screw fixation in ACL reconstruction compared to hamstring tendon grafts. From a clinical perspective, quadriceps tendon grafts should therefore be considered as a good option in ACL reconstruction in the future.

Xanthochromia of the skull bone associated with HbA1c.

The color of the surface of 105 skull bones (part of the parietal bone) was determined using a portable spectral colorimeter (spectro color(®)). By this means it was possible to characterize the color objectively according to the L*a*b* color system defined by the "International Commission de l'Eclairage" (CIE). Biochemical markers of carbohydrate metabolism, HbA1c from venous blood, and glucose/lactate concentrations from vitreous humor, were also determined, for assessment of the ante-mortem plasma glucose concentration using Traub's sum formula. As biochemical markers for lipid metabolism disorder, cholesterol, triglycerides, high density lipoprotein (HDL), low density lipoprotein (LDL) and very low density lipoprotein (VLDL) were all determined from venous blood. There is a significant correlation of bone yellowing with HbA1c (p<0.001) and age (p<0.001). The literature asserts a significant correlation between diabetic condition and yellowing of the skull bone. Despite efforts to find the substance responsible for the yellowing of the bone in chronic metabolism disorder, no significant correlation was found between bone color and lipoproteins/bone extracted lipid acids.

Inference of biogeographical ancestry across central regions of Eurasia.

The inference of biogeographical ancestry (BGA) can provide useful information for forensic investigators when there are no suspects to be compared with DNA collected at the crime scene or when no DNA database matches exist. Although public databases are increasing in size and population scope, there is a lack of information regarding genetic variation in Eurasian populations, especially in central regions such as the Middle East. Inhabitants of these regions show a high degree of genetic admixture, characterized by an allele frequency cline running from NW Europe to East Asia. Although a proper differentiation has been established between the cline extremes of western Europe and South Asia, populations geographically located in between, i.e, Middle East and Mediterranean populations, require more detailed study in order to characterize their genetic background as well as to further understand their demographic histories. To initiate these studies, three ancestry informative SNP (AI-SNP) multiplex panels: the SNPforID 34-plex, Eurasiaplex and a novel 33-plex assay were used to describe the ancestry patterns of a total of 24 populations ranging across the longitudinal axis from NW Europe to East Asia. Different ancestry inference approaches, including STRUCTURE, PCA, DAPC and Snipper Bayes analysis, were applied to determine relationships among populations. The structure results show differentiation between continental groups and a NW to SE allele frequency cline running across Eurasian populations. This study adds useful population data that could be used as reference genotypes for future ancestry investigations in forensic cases. The 33-plex assay also includes pigmentation predictive SNPs, but this study primarily focused on Eurasian population differentiation using 33-plex and its combination with the other two AI-SNP sets.

[Induratio penis plastica and the capability of vaginal penetration in the context of forensic evaluation]. / Induratio Penis Plastica und Vaginale Penetrationsfähigkeit im Kontext der Forensischen Begutachtung.

The so-called Induratio penis plastica (IPP), also known as Peyronie Disease or Morbus Peyronie, is the most common cause for deviation of the male penis. In most cases, the deviation is directed to the dorsal side. In face of a lawsuit related to a sexual offence, the opponent might argue that, due to an existing IPP, he is generally unable to insert his penis into a female's vagina. The aim of the present study was to examine the clinical files of thirty (30) consecutive patients who presented with IPP. Particular attention was given to the individual degree of penile deviation and the ability of the subjects to conduct vaginal intercourse. Subjects who had a dorsal penile deviation of 800 to 900, or a lateral deviation of 600, were unable to commence vaginal coitus. In contrast, three (3) subjects who presented with a ventral deviation of 30° to 40° had no difficulties in performing vaginal penetration. The medicolegal aspects of these findings are being discussed.

Mitochondrial deoxyribonucleic acid may play a role in a subset of sudden infant death syndrome cases.

AIM: It has been suggested that progressive adenosine triphosphate (ATP) depletion could play a key role in sudden infant death syndrome (SIDS). Because mitochondrial deoxyribonucleic acid (mtDNA) codes for a subset of essential genes for oxidative phosphorylation, we investigated 22 mtDNA polymorphisms in a large sample of Caucasian SIDS cases. METHODS: A total of 774 samples were analysed, 365 from infant SIDS cases (mean age 131 days) and 409 from controls. These were investigated for the presence of 22 haplogroup-specific single nucleotide polymorphisms (SNPs), using a SNaPshot assay, a mini-sequencing assay that combines polymerase chain reaction (PCR) and sequencing. RESULTS: No significant differences in assigned haplogroups could be detected between the groups. With regard to gender and age, we found significant correlations for SNP positions 3010, 8251, 13 708, 14 470, 15 904 and 16 519. The most prominent result was the A allele in SNP 14 470 in male SIDS cases (p = 0.01). CONCLUSION: This is the largest study on mtDNA polymorphisms in SIDS to date, and our results indicate that mtDNA may play a role in a subset of SIDS cases. In order to complement these significant results, it is important to consider nuclear gene coding for mitochondrial proteins in future studies.

A case of instantaneous rigor?

The question of whether instantaneous rigor mortis (IR), the hypothetic sudden occurrence of stiffening of the muscles upon death, actually exists has been controversially debated over the last 150 years. While modern German forensic literature rejects this concept, the contemporary British literature is more willing to embrace it. We present the case of a young woman who suffered from diabetes and who was found dead in an upright standing position with back and shoulders leaned against a punchbag and a cupboard. Rigor mortis was fully established, livor mortis was strong and according to the position the body was found in. After autopsy and toxicological analysis, it was stated that death most probably occurred due to a ketoacidotic coma with markedly increased values of glucose and lactate in the cerebrospinal fluid as well as acetone in blood and urine. Whereas the position of the body is most unusual, a detailed analysis revealed that it is a stable position even without rigor mortis. Therefore, this case does not further support the controversial concept of IR.

Serum procalcitonin levels in the postmortem diagnosis of sepsis.

Procalcitonin is regarded as a valuable marker for sepsis in living persons and even in post-mortem investigations. At the Institute of Legal Medicine, 25 autopsy cases with suspected bacterial infectious diseases or sepsis were examined using the semi-quantitative PCT-Q(®)-test (B.R.A.H.M.S., Germany) in 2010 and 2011. As controls, 75 cadavers were used for which there was no suspicion of a bacterial infectious disease or sepsis. Femoral blood was cultured from the cases and from controls, and samples from the brain, heart, lungs, liver, spleen and kidneys were examined histologically for findings seen in sepsis. Twelve cases in the sepsis/infectious disease group (48%) were classifiable as sepsis following synopsis of PCT levels, autopsy results, and histopathological and microbiological findings. This study shows that the semi-quantitative PCT-Q(®)-test is a useful supplementary marker in routine autopsy investigations, capable of classifying death as due to sepsis.

[Death on the operating table and death in the early post-operative period : recommendations of forensic pathologists]. / Mors in tabula und früh-postoperativer Tod : Empfehlungen des Rechtsmediziners.

Death during an operation represents a severe event for physicians and family of the deceased. A further difficulty arises when certifying the cause and manner of death because medical staff are often afraid that they will incriminate themselves when declaring an unnatural death or an unclear manner of death but are also afraid to issue a false statement by declaring a natural death. In such cases of mors in tabula it is recommended to declare an unclear manner of death because this leads to police investigations and in the majority of the cases to exoneration of the medical staff.

Marfan syndrome: clinical consequences resulting from a medicolegal autopsy of a case of sudden death due to aortic rupture.

To investigate the sudden death of a 31-year-old man, a medicolegal autopsy was performed. Major findings were a dilated aortic root with a longitudinal rupture of the intima and dissection of aorta and right coronary artery and consequent tamponade of the pericardial sac. Moreover, arachnodactyly and other skeletal deformities in combination with the histological finding of a pseudocystic medionecrosis of the aortic wall were noted. By sequencing of the FBN1 gene, a mutation (1622G>A) leading to the diagnosis of Marfan syndrome was found. Genetic counseling was recommended to the relatives who reported that the father of the deceased had died at the same age from aortic rupture. While fortunately the child of the deceased lacked this mutation, it was found in his younger sister. The results of the autopsy thus enabled early diagnosis and beginning of treatment in the sister and thus a considerable statistical increase in lifespan. With this report, we want to show that medicolegal autopsies can also have medical consequences for relatives. We argue that in all sudden and unexpected deaths in young persons up to 35 years an autopsy should be performed, not only to detect unnatural causes of death but also to identify heritable diseases and thus aid the relatives.

DNA polymorphisms in the tyrosine hydroxylase and GNB3 genes: association with unexpected death from acute myocardial infarction and increased heart weight.

Sudden and unexpected death from myocardial infarction (MI) is one of the most commonly observed findings in forensic medicine. To investigate the biochemical and genetic background of this disease we investigated the genotypes for two polymorphisms associated with hypertension: TH01, a tetrameric microsatellite in the tyrosine hydroxylase gene and the single nucleotide polymorphism C825T in the GNB3 gene in 116 sudden deaths from MI (78 males, 38 females) and in a control group of 137 deaths from natural causes other than MI (52 males, 85 females). For TH01 no correlation with the prevalence of MI was found. For C825T, results were different. While for the male individuals allelic frequencies and genotype distributions were similar in both groups, T-homozygosity was significantly more common in female fatalities from MI than in the female control group (24% versus 7%; Relative Risk 2.29). Nevertheless, neither for TH01 nor for C825T an association with heart weight was found. Thus our results demonstrate that the C825T polymorphism may play a role in the development of myocardial infarctions, at least in females. They also demonstrate that the genetic component in complex diseases like MI may depend on the gender of the patients. As the influence of this polymorphism on arterial blood pressure appears to be relatively small, and G-proteins are involved in numerous intracellular signal cascades it can be speculated that T-homozygosity at this locus might influence the incidence or mortality of cardiovascular disease via hitherto unknown mechanisms.

Sudden cardiac death in hereditary hemochromatosis: an underestimated cause of death?

Hereditary hemochromatosis (HH) is a frequent autosomal recessive disease which causes iron-overload of various organs. Of all northern European affected individuals, 90-95% show 1 of 3 known point mutations in the HFE gene. Symptoms and organs involved can vary considerably: Only a small fraction of the 200,000-400,000 persons affected in Germany develop the classical picture of liver cirrhosis and/or pancreatic fibrosis. Nevertheless, the life expectancy of persons with moderate or even subclinical symptoms is reduced, in many cases due to myocardial damage leading to cardiomyopathy with greatly increased risk of sudden cardiac death. Although the high prevalence of HH suggests that sudden cardiac death due to cardiac HH is a relatively common cause of death, the forensic literature lacks such reports. We present the case of sudden cardiac death in a young man with histological findings of massive cardial hemochromatosis which is characterized by the fact that none of the three known mutations for HH were found. This case demonstrates that genetic screening alone might not be sufficient to identify all persons at risk to developing HH.

Persisting fetal microchimerism does not interfere with forensic Y-chromosome typing.

Forensic Y-chromosome typing applies Y-chromosomal polymorphisms to the analysis of male/female mixed stains such as vaginal swabs in rape cases. The sensitivity of this approach exceeds that of cytological techniques combined with autosomal DNA typing. Y-chromosome typing is based on the assumption that Y-chromosomal DNA found in tissue or secretions of women must originate from a male individual, usually the perpetrator. Nevertheless, it was shown recently that fetal cells can migrate into the female body during pregnancy and can persist for decades ("persisting fetal microchimerism"). The body of a woman after a pregnancy with a male embryo can thus display a small fraction of fetal cells with Y-chromosomes. Using high sensitivity PCR protocols (reamplification with nested primers and up to 60 PCR cycles) fetal cells were previously identified in a number of maternal tissues including skin, blood, muscle and solid organs. It is, however, not clear at present, whether these cells can occur in vaginal secretions, and whether they are capable of producing false positive results in forensic Y-chromosome typing. To evaluate these questions, 66 blood samples of women with at least one son and nine vaginal swabs of women without sexual intercourse in the last 2 weeks were amplified for a stretch of the SRY gene. Eight thyroid gland tissues with already established male fetal microchimerism were used as positive control samples. Blood samples of 10 young girls without history of pregnancy were used as negative controls. Using a PCR with 10 ng of extracted DNA and 30 PCR cycles ("routine sensitivity assay") none of the samples yielded positive results. However, in a PCR with 200 ng of extracted DNA and 45 PCR cycles ("high sensibility assay"), 14% of the blood samples of mothers and 33% of the vaginal swabs amplified for SRY. Our results thus show that increasing the sensitivity of the PCR method and the amount of template DNA produce positive results while protocols used for routine Y-chromosomal typing with small amounts of DNA (approximately 10 ng of DNA) and with a limited number of PCR cycles (approximately 30) can clearly eliminate this peril.

Fatal truck-bicycle accident involving dragging for 45 km.

Vehicle-bicycle accidents with subsequent dragging of the rider over long distances are extremely rare. The case reported here is that of a 16-year-old mentally retarded bike rider who was run over by a truck whose driver failed to notice the accident. The legs of the victim became trapped by the rear axle of the trailer and the body was dragged over 45 km before being discovered under the parked truck. The autopsy revealed that the boy had died from the initial impact and not from the dragging injuries which had caused extensive mutilation. The reports of the technical expert and the forensic pathologist led the prosecutor to drop the case against the truck driver for manslaughter.

D1S1171: a new highly variable short tandem repeat polymorphism.

This study reports the evaluation of the STR locus D1S1171 (GDB: 312934) for forensic purposes, which was investigated by PCR amplification and native polyacrylamide gel electrophoresis in 141 unrelated Austrians. No deviations from Hardy-Weinberg expectations were observed. The mean exclusion chance (MEC) was 0.677, the discriminating power (DP) was 0.951 and the observed heterozygosity rate was 0.853. An allelic ladder consisting of 10 sequenced alleles (96-132 bp) was constructed. Sequence analysis revealed a GAAA repeat motif. According to the number of tetranucleotide repeats the smallest allele was designated 9 and the largest allele 18.

Evidence of fetal microchimerism in Hashimoto's thyroiditis.

Fetal microchimerism, the engraftment of fetal progenitor cells into maternal tissues, has been implicated in the etiology of autoimmune diseases. We used PCR analysis to determine whether microchimerism occurred in the thyroid glands of female patients suffering from Hashimoto's disease and thus may be involved in its etiology. PCR amplification was performed from thyroid gland specimens using primers unique to a Y-chromosomal sequence (SRY gene) and primers for a sequence that is Y/X-chromosomal homologous except for a 6-bp deletion in the X-chromosomal sequence (amelogenin). Microchimerism was detected in 8 of 17 Hashimoto patients, but in only 1 of 25 controls (nodular goiters). Both groups were of similar age and had comparable numbers of pregnancies and numbers of sons. All individuals with microchimerism had given birth to at least 1 son. Our results show that microchimerism is significantly more common in Hashimoto patients than in patients suffering from nodular goiter. We therefore suggest that microchimerism might play a role in the development of Hashimoto's disease, although we cannot completely eliminate the hypothesis that microchimerism is just an "innocent bystander" in a process triggered by other mechanisms.

Significant differences between Yemenite and Egyptian STR profiles and the influence on frequency estimations in Arabs.

A population genetic study was performed on Yemenites using the set of nine short tandem repeat loci (STRs) D3S1358, VWA, FGA, D8S1179, D21S11, D18S51, D5S818, D13S317 and D7S820. Analysis of the data revealed that all loci were in Hardy-Weinberg equilibrium and evidence of linkage equilibrium was found for only 1 out of 36 locus pairs. At seven loci the allelic distributions found in the Yemenite sample were significantly different from those found for an Arab population sample from Egypt. Nevertheless, we assume that the Yemenite database can be used for Arabs of unknown or foreign (non-Yemenite) origin in the absence of population-specific databases without exerting a significant bias on the biostatistical interpretation. In an experimental set-up (ethnic profile frequency ratio test), the impact of calculating multi-locus profile frequencies for foreign Arab individuals (Egyptians) using the Yemenite database instead of a region-specific one was negligible.