A lethal case of massive hemorrhage after percutaneous liver biopsy in a patient with thrombasthenia.

Percutaneous needle liver biopsy is an important procedure in the diagnosis of and assessment of the severity of liver diseases. Although liver biopsy is considered to be a relatively safe procedure, there are occasional cases of death due to massive bleeding after liver biopsy. Thrombasthenia is a disease in which bleeding occurs in the mucosa and skin due to platelet dysfunction. A 60-year-old female was admitted for a liver biopsy for further investigation after an abnormal liver function test. She was diagnosed with thrombasthenia and was being treated with oral tranexamic acid and carbazochrome. Blood tests showed little decrease of platelet count and no abnormalities of blood coagulability. Approximately ten hours after the liver biopsy, the patient complained of nausea and lightheadedness, followed by decreased blood pressure and decreased consciousness. An emergent abdominal CT scan showed a large amount of blood in the abdominal cavity. The patient died despite multidisciplinary treatment, and a forensic autopsy was performed. At internal examination, approximately 2,620 mL of dark red blood was accumulated in the abdominal cavity. A puncture wound led 1.8 cm into the liver from the surface of the liver, and no major vascular damage was observed. The cause of death was considered to be blood loss due to bleeding from the puncture wound. Even if the platelet count is normal, such as in a case of thrombasthenia, the risk of bleeding should not be underestimated. Careful attention should be paid when performing liver biopsy in a patient with risk factors.

Sudden Death in an Adult Due to Nontraumatic Diaphragmatic Hernia.

Sudden death due to diaphragmatic hernia in an adult is exceptionally rare. A 43-year-old man was found dead by his cohabiting mother, lying supine on the floor in his house. He had complained of epigastric discomfort for 1 month, and respiratory symptoms occurred 1 day before his death. He had no history of trauma. Postmortem computed tomography scan revealed the enlarged fluid-filled stomach herniated into the left pleural cavity, compressing the left lung with a mediastinal shift to the right. At autopsy, the left pleural cavity was occupied by herniated abdominal contents with mediastinal shift. The herniation of the stomach, the whole spleen, a portion of the colon, and omentum into the left pleural cavity had occurred through a smooth oval 9 × 5-cm defect in the posterolateral part of the light diaphragm. The stomach was markedly distended and contained 1600 mL of yellowish brown liquid with food residue. Ischemic changes of the herniated organs were not observed. Death was attributed to respiratory failure from abdominal viscera herniation into the left pleural cavity.

Simultaneous time course analysis of multiple markers based on DNA microarray in incised wound in skeletal muscle for wound aging.

Assessment of incised wound age in skeletal muscles is important because fatal injuries are often complicated with muscle involvement. Transcriptome of injured skeletal muscle along with histopathological and immunohistochemistry staining, were analyzed to explore the biological effect of incised injuries using a mouse incised injury model. An incisional wound was made at the biceps femoris muscle of anesthetized mice, and the muscles were sampled at 6, 12, 24, 36 and 48h post-injury. DNA microarray analysis using RNA extracted from the muscle samples of 12h post-injury identified 3,655 upregulated and 3,583 downregulated genes. Referring to the results of the gene ontology and gene expression pathway analysis, time course expression of five cytokines, namely chemokine (C-C motif) ligand 4 (CCL4), chemokine (C-X-C motif) ligand 5 (CXCL5), interleukin-1 beta (IL-1ß), interleukin- 6 (IL-6) and interleukin-7 (IL-7), were analyzed by quantative reverse transcription PCR (qRT-PCR). CXCL5 was the most upregulated gene throughout the post-injury period with higher expression from 6 through 36h post injury. Upregulation of CCL4 and IL-1ß was also persisted until 36h post injury. IL-6 mRNA was highly and rapidly expressed at 6h post-injury followed by significant decrease at 12h. Unlike other four cytokines, IL-7 showed slow and steady increasing over time until 48h post-injury. Immunohistochemical staining of post-injury samples showed gradual mild increase of staining intensity proportional to increasing time points especially around the wound edges. The present study highlights the unique dynamics of each cytokine and reflects their roles in the process of muscle wound healing, and suggests the potential of them as a tool for forensic wound age estimation.

A fatal case of acute hepatitis B developed in a toluene abuser.

Liver dysfunction involving toluene intoxicity includes elevation of transaminase level and delayed complications of liver failure, but its effect on hepatitis B virus (HBV) infection is as yet unknown. Here, we report a case of fulminant hepatitis B developed in a toluene abuser. A 23-year-old female toluene abuser was admitted to a local clinic because of nausea, vomiting, and dizziness, and a mild elevation of serum transaminase level was identified. She was treated as an outpatient, but continued toluene inhalation during follow-up. Five days later, she was found in a drowsy state of consciousness and taken to the emergency unit of our institution. Laboratory findings showed an alanine aminotransferase level of 4,659 IU, a remarkably prolonged prothrombin time, and she was diagnosed with fulminant hepatitis B. Intensive care was carried out, but she died the next day. Molecular analysis revealed that the HBV isolate was classified as genotype C, and nucleotide positions that are prone to fulminant hepatitis were A at 1,762 and G at 1,764 in the core promoter region, and G at 1,896 in codon 28 in the precore region. The long-term toluene inhalation could have contributed to drastic clinical course of acute hepatitis B in this patient.

Two fatal cases of child abuse in which neighbors were unaware of the victims' disappearance for a long period.

We describe two fatal cases of child abuse in which neighbors were unaware of the victims' disappearance for 1.5 months and 1 year, respectively. Recently, there have been fatal child abuse cases in which neighbors have been aware of the signs of the abuse but not notified the Child Care Authorities. Lack of concern about child welfare in the community is the greatest obstacle to protecting children at risk of abuse. The most effective means of preventing child abuse is to educate the community about how to recognize the signs of abuse and to inform the authorities. We emphasize that the community has an obligation to protect children against crime, including child abuse. The roles of the Social Services in preventing child abuse have been extended. Forensic pathologists are required to play a key role in child abuse prevention, and in Japan their activity should be extended to the administrative field.

Estimation of caloric deficit in a fatal case of starvation resulting from child neglect.

We report the case of a 3-year-20-day-old girl who died of starvation as a result of severe neglect. Her body weight had been 12 kg 70 days before her death, but was only 5 kg at the time of autopsy. From information supplied by her parents to police, we calculated her daily caloric intake and estimated the factors for physical activity. The daily recommended dietary allowance for the victim was calculated from 700 kcal/ day x the appropriate factor for physical activity. In the absence of enough food, body fat (7.2 kcal/g body fat) and protein (4 kcal/g protein) would have been used to compensate until death. The calculated body weight at the time of death was around 5 kg. The statements of the parents therefore appear to be true.

Cytoplasmic vacuolation in cultured rat astrocytes induced by an organophosphorus agent requires extracellular signal-regulated kinase activation.

There are various toxic chemicals that cause cell death. However, in certain cases deleterious agents elicit various cellular responses prior to cell death. To determine the cellular mechanisms by which such cellular responses are induced is important, but sufficient attention has not been paid to this issue to date. In this study, we showed the characteristic effects of an organophosphorus (OP) agent, bis(pinacolyl methyl)phosphonate (BPMP), which we synthesized for the study of OP nerve agents, on cultured rat astrocytes. Morphologically, BPMP induced cytoplasmic vacuolation and stellation in the rat astrocytes. Cytoplasmic vacuolation is a cell pathological change observed, for example, in vacuolar degeneration, and stellation has been reported in astrocytic reactions against various stimuli. By pretreatment with cycloheximide, a protein synthesis inhibitor, stellation was inhibited, although vacuolation was not. Cell staining with a mitochondrion-selective dye indicated that the vacuolation probably occurs in the mitochondria that are swollen and vacuolatred in the center. Interestingly, the extracellular signal-regulated kinase (ERK) cascade inhibitor inhibited vacuolation and, to some extent, stellation. These results suggest that the ERK signaling cascade is important for the induction of mitochondrial vacuolation. We expect that a detailed study of these astrocytic reactions will provide us new perspectives regarding the variation and pathological significance of cell morphological changes, such as vacuolar degeneration, and also the mechanisms underlying various neurological disorders.

Y-chromosomal short tandem repeats haplotyping from vaginal swabs using a chelating resin-based DNA extraction method and a dual-round polymerase chain reaction.

Reported are 2 autopsy cases in which Y-chromosomal microsatellite short tandem repeats DYS19, DYS389I and II, DYS390, and DYS393 could be haplotyped with vaginal swabs by using a Chelex 100-based DNA extraction method and dual-round polymerase chain reaction. The extraction of DNA from vaginal swabs by using this method was as efficient or more efficient than using proteinase K and phenol-chloroform extraction or the alkaline lysis methods. Y-chromosomal microsatellite short tandem repeats haplotyping based on the dual-round polymerase chain reaction method provided genotypes from all the loci determined. Although amplification of Y-chromosomal microsatellite short tandem repeats loci is not directly involved in the existence of spermatozoa, it is considerably advantageous for male individualization from body fluid mixture stains in criminal cases.

An autopsy case of poisoning by massive absorption of cresol a short time before death.

A 65-year-old male patient who was hospitalized with schizophrenia died about 15 min later after ingestion of a large volume of saponated cresol solution in a mental hospital. Fatal levels of free p- and m-cresol in the heart blood were detected at 458.8 and 957.3 microg/ml, respectively, which far exceeded the fatal levels determined previously. The levels in the heart muscle, liver and spleen tissues were also extremely high, and there was 250 ml of cresol-odor-emitting fluid in the stomach. The levels of glucuronic-acid-conjugated p- and m-cresols in the heart blood were 38.2 and 85.6 microg/ml, respectively. Although the high levels of cresols in the heart blood may be due to diffusion from the stomach contents, it is surmised that the essential levels of free and conjugated forms in blood were at least 99 and 240 microg/ml, respectively, considering the results of postmortem examinations and some case reports. It was concluded that about 340 microg/ml of the total cresols was absorbed in a very short period following oral ingestion of saponated cresol solution in this case.

Y-STR haplotype data and allele frequency of the DXS10011 locus in a Japanese population sample.

The distribution of allele frequency of X-chromosomal STR, DXS10011, from 99 unrelated Japanese, 72 male and 27 female, were determined by PCR amplification and PAGE. At the same time, haplotype frequencies of five Y-chromosomal STR loci, DYS19, DYS389I, DYS389II, DYS390 and DYS393 from male samples were determined.

Mitochondrial sequence haplotype in the Japanese population.

Sequence polymorphysms of the mitochondrial DNA (mtDNA) control region, hypervariable regions I and II, from 50 unrelated Japanese were determined by PCR amplification and cycle sequencing.