Petechial bleedings in sudden infant death.

The autopsy reports of 484 cases of deceased infants (201 females, 283 males) were analysed retrospectively for the existence of external and internal petechial bleedings (PET). The cases were divided into five groups on the basis of the cause of death (sudden infant death syndrome, sepsis, airway infections, asphyxia and trauma). Internal PET (pleural, pericardial, epicardial, thymic and peritoneal) were observed in each group with a lower prevalence in cases of trauma. The highest prevalence of external (cutaneous and conjunctival) PET was detected in cases of asphyxia (38% and 31%, respectively). However, even if with low prevalence, such bleedings were detected in every group. Factors like sex, age, cardiopulmonary resuscitation and its duration did not influence the presence of PET. The detection of external PET at autopsy is a suspicious finding that suggests asphyxia. Because of the possible natural origin of these bleedings, the medicolegal investigation has to be as complete as possible and has to include histology as mandatory.

[Sudden death of twins: botulism because of contamination by pap vegetables]. / Plötzlicher Tod bei Zwillingen: Botulismus durch Kontamination von Gemüsebrei.

Botulism is caused by the blockage of the neural transmission in the cholinergic synapses by botulinum neurotoxin (BoNT) which is produced by Clostridium botulinum or other Clostridia. The classic form of botulism occurs after the ingestion of food contaminated by BoNT. The course of the infection can be asymptomatic, mild with subtle paralysis ("failure to thrive") oder severe with generalized paralysis ("floppy infant"). Infected infants can also die sudden and unexpectedly. These deaths often are attributed to Sudden Infant Death Syndrome (SIDS), unless a thorough postmortem examination reveals Botulism. The rate of fatal Botulism falsely attributed to SIDS is not known, because it is difficult in most cases to show the causal relationship between contamination, disease and death. We report the sudden and unexpected simultaneous death of twins of 22 months which could be attributed to Botulism. Contamination of food, colonization of the gut by Clostridia and infection with specific pathomorphological changes could be proven. The initial suspicion of infanticide could be excluded. lt could be shown, that Botulism is a potential cause of simultaneous unexpected deaths in twins.

Experiences with a compound method for estimating the time since death. I. Rectal temperature nomogram for time since death.

The temperature-based nomogram method for estimation of the time period since death was used at the scene of death as the primary method within a compound method in 72 consecutive cases. The situation and cooling conditions inspected and evaluated by the forensic pathologist at the scene are described as far as necessary to enable handling of the method. A comparison of the estimated period since death with the period determined by the police investigations demonstrates the reliability of the method. There were no contradictions in any of the 60 cases between the period of death estimated by this method and that determined by the police investigations. The criminal investigations were effectively supported in the earliest stages in 11 cases despite the fact that the period estimated was of considerable duration.

Experiences with a compound method for estimating the time since death. II. Integration of non-temperature-based methods.

The period since death was estimated at the scene in 72 consecutive cases using the temperature-based nomogram method as the primary method and supplemented by examination of criteria such as lividity, rigor mortis, mechanical and electrical excitability of skeletal muscle and chemical excitability of the iris. A case-oriented, computer-assisted selection of the non-temperature-based methods and integration of the results into a common result of the compound method was made following a special logistic. The limits of the period since death as estimated by the nomogram were improved in 49 cases by including the non-temperature-based methods and also provided results in 4 cases where the temperature method could not be used. In a further 6 cases the non-temperature-based methods confirmed the limits estimated by the temperature method but in 14 cases a useful result could not be obtained. In only one of the cases investigated was the upper limit of the period since death, as estimated by the criterion re-establishment of rigor (8 h post-mortem), in contradiction with the period determined by the police investigations (9.4 h post-mortem).

Reaction patterns in selected lymphatic tissues associated with sudden infant death (SID).

In 50 cases of sudden infant death cervical, paratracheal and lung hilar lymph nodes, the thymus and the spleen were investigated by histology and immunohistochemistry (CD 20, 21, 45RO). The cases were divided into 3 groups based on autopsy findings including extensive histology: A --without pathological changes (N = 12), B --with minimal to intermediate inflammation (N = 23) and C --with severe inflammation (N = 15). In accordance with previous results the frequency of "pathological" lymph node changes, such as paracortical lymphoid hyperplasia and variegated hyperplasia of the pulp increased from group A to group C. The B-cell antigens reacted accordingly. A pronounced lymphodepletation of the thymus as a sign of a long lasting stimulation of the T-cell system was also observed increasingly from group A to C. In summary, in none of the cases results obtained were indicative of a defect of the T- or B-cell system. The results in group A seem to indicate that changes in the reaction pattern of the lymphoid tissues could be a more sensitive method of detection of early stages of inflammation than local histology.

Morphology, immunohistochemistry and morphometry of pancreatic islets in cases of sudden infant death syndrome (SIDS).

The pancreatic islets from 112 infants (66 males and 46 females) who died of SIDS during the years 1990-1992 have been studied. The control group consisted of endocrine pancreas tissue from 19 infants who died of a clear cause of death (pneumonia, drowning, sepsis, etc.). The mean age of the SIDS group was 5.1 months. We found histologically normally developed organs in all the SIDS cases. By evaluating the relative endocrine cell area of the pancreas by immunohistochemical investigations, A-cells were found to make up 10-30%, B-cells 30-60%, D-cells 10-30% and pancreatic polypeptide cells less than 10% in the SIDS group and in the controls with a small increase in glucagon and insulin cells among SIDS cases. The morphometric evaluation revealed that cell enlargement and cytoplasm shrinking occurred slightly more often in the SIDS group than in the control group. The diameter of the islets was normal and the maximal volume was not enlarged. The results did not show significant differences so that a relationship between alterations of the endocrine pancreas and sudden infant death syndrome could not be demonstrated.

Morphology, immunohistochemistry and morphometry of the thyroid gland in cases of sudden infant death syndrome (SIDS).

The thyroid glands of 107 SIDS victims (sudden infant death syndrome) have been studied. Controls consisted of 20 thyroid glands from infants who died of other causes (accidents, pneumonia etc.). The thyroid glands were investigated histologically, immunohistologically and morphometrically. Immunohistochemistry (S-100 protein and calcitonin) and morphometry showed no significant results. Histologically, hyperemia (severe: 34 cases = 31.8%; mild: 23 cases = 21.5%), and fibrosis (45 cases = 42.1%; mild: 26 cases = 24.3%) were found. A large number of cases showed depleted follicles (87 cases = 81.3%), little colloid (little: 37 cases = 34.6%; none: 9 cases = 8.4%) and desquamation (severe: 21 cases = 19.6%; abundant: 20 cases = 18.7%). Only fibrosis and depleted follicles were found more often in SIDS than in the controls (conditional logistic regression: rise of incidence for SIDS 2.9 times, P = 0.028, and 1.2 times, P = 0.051, respectively), a commoner occurrence of hyperemia in SIDS was of limited significance (P = 0.105). The alterations found can be taken as stress reactions to current or recurrent hypoxemia and the mild fibrosis indicates recurrent hypoxemia. All alterations indicate that the victims had previously suffered near death episodes. Even though the glands were handled with care, artefacts and autolysis must be taken into consideration. Neither the histological, immunohistological nor morphometrical studies of the thyroid gland gave an explanation as to the cause of death or showed any changes providing explicit help in diagnosing SIDS.

[Fatality in diabetic coma during foreign travel]. / Todesfall im Coma diabeticum bei Auslandsaufenthalt.

The case history and the autopsy findings of a 44-year-old women who died shortly after her flight to Khartoum (Sudan) in a hospital is presented. The clinical diagnosis in Africa was "shock caused by gastroenteritis". The body was embalmed thoroughly and brought back to Germany. The autopsy was performed just prior to the cremation (according to "section 3 Abs. 2 Nr. 2 Feuerbestattungsgesetz"). Morphological findings (nodular glomerulosclerosis and glycogen nephrosis with Armanni-Ebstein-cells) and postmortem biochemical analyses of vitreous humour led to the diagnosis of a hyperglycaemic coma. The fatal course might have been prevented by sufficient health information to the patient (who suffered from type 1 diabetes); the diagnostic errors in the hospital could have easily been avoided by careful anamnesis and diagnostic procedures.

[Acute and chronic effect of alcohol--a long-term problem in forensic medicine autopsies]. / Der akute und chronische Alkoholeinfluss--ein Dauerproblem im rechtsmedizinischen Sektionsgut.

Influence of the acute and chronic alcohol influence in connection with the sudden unexpected death is very high. Between 1986 and 1990 in 949 death cases out of 2402 autopsies carried out in the Institute for Forensic Medicine in Essen the death could be related either to chronic alcohol abuses or to an acute alcoholisation. The influence of alcohol in the various kinds of death is described.

[Sonography for intracorporeal drug smuggling]. / Sonographie bei intrakorporalem Drogenschmuggel.

To evaluate the place of ultrasonography in the detection of intracorporeal drug packets (body-packs) ten volunteers were examined by ultrasound after having swallowed four body-packs each. Diagnostic criteria had first been established by ultrasound imaging of body-packs in a water bath. The body-packs contained finger-stalls, 1.5-1.8 cm in diameter, filled with hard-pressed glucose. The criterion for identification in the water-bath was shown to be a sickle-shaped echo with a dorsal echo deficit. This sign identified 23 of the 40 body-packs in eight of the ten subjects. Within the first three hours of ingestion 22 body-packs were demonstrated in eight of the subjects; after 17 hours nine body-packs were identified in the stomach of four subjects. In only one subject was it possible to identify (two) body-packs in the region of the small-large intestine. In practice, intracorporeal drug smugglers will almost always have the body-packs in the stomach at the time of likely examination. Extensive ultrasound screening of suspected smugglers is, therefore, recommended.

Long-term prognosis of chronic idiopathic membranous glomerulonephritis. An analysis of 334 cases with particular regard to tubulo-interstitial changes.

A retrospective long-term study (average follow-up time 5.2 years) of 334 patients with idiopathic membranous glomerulonephritis (MGN) was carried out with the following results: 1) MGN was found to have a relatively good prognosis when all cases were considered together: 5-year kidney survival rate (KSR) -88%, and 10-year KSR -77%. 2) Univariate survivorship analysis showed the following morphological and clinical parameters to be associated with an increased risk of terminal renal insufficiency or death from renal disease: a) tubulo-interstitial changes; b) glomerular stage III as opposed to stages I and II; c) elevation of serum creatinine concentration at the time of the biopsy; d) arterial hypertension at the time of the biopsy. 3) Multivariate analysis showed that only tubulo-interstitial changes (interstitial fibrosis and/or acute renal failure) found at the time of the biopsy and their clinical correlate, serum creatinine concentration, were significant and therefore of definite prognostic importance. 4) Unsystematic therapy with steroids and/or cytostatic agents does not improve the long-term prognosis of MGN. 5) The cause of disease in the tubulo-interstitial system in MGN is discussed. Interstitial fibrosis is considered to develop possibly as a consequence of unresorbed interstitial edema which can develop during an episode of acute renal failure. Coexisting T-cell-mediated disease in the region of the intertubular capillaries is also considered as a possible factor in the development of interstitial fibrosis.

[Suicide with a supposedly safe plant growth regulator]. / Selbsttötung mit einem als unschädlich geltenden Pflanzenwachstumsregler.

The suicide of a young man with the plant growth regulator Cycocel (chlorocholine chloride and choline chloride) is reported. Morphological and toxicological findings are presented. According to the manufacturers this product is harmless. So far cautionary labelling is not required. A discussion is given on whether such active substances should be subject to stricter controls.

[Body-packing: detection of incorporated drug packets using ultrasound technics]. / Body-Packing: Nachweis inkorporierter Drogenpäckchen mittels Ultraschalltechnik.

According to the Federal Criminal Office the number of undetected cases of intracorporal drug smuggling is startlingly high. To enable the investigating authorities to carry out searches of suspicious persons in the airport, a safe, comparatively cheap and simple procedure is required. Using nine volunteers the detection of swallowed packets is demonstrated by means of ultrasound techniques. The advantages and disadvantages of this method, as well as the value of the radiological pictorial methods (conventional X-rax check, digital radiography, 2-spectrum-radiography and X-ray computer tomography) which we have already tested, are presented.

[Body packing: the value of modern imaging procedures in the detection of intracorporeal transport media]. / Body-Packing: Wertigkeit moderner bildgebender Verfahren zum Nachweis inkorporierter Transportmedien.

The necessity of rapid objective appraisal of the suspicion of intracorporeal drug smuggling (body-packing) by effective methods of investigation in the course of the first criminal investigation department measures raises the questions of suitable and admissible methods. The proportion of undetected crimes in intracorporeal narcotic smuggling must be rated as very high according to the data of the Federal Criminal Investigation Department. In the present paper, the suitability of various imaging techniques for drug detection are reported in terms of their risk, practicability and costs. For this purpose, the value of digital radiography, two-spectra radiography and X-ray computer tomography as compared to conventional X-ray investigations is examined in human experiments. A reality-oriented narcotics dummy (glucose pressed hard in preservative) was developed and administered to nine volunteers per os with a variable initial alimentary situation. Four radiograms were taken at fixed times up to 12 hours after administration with each imaging technique. The highest rate of detection was attained with computer tomography. In contrast to the other methods, more than 90% of the body packs could be identified here. Nevertheless, an application in criminal investigation practice cannot be recommended owing to various disadvantages. The recovery rate of the remaining methods is between 20% and 25%.

[Acute renal failure--clinical aspects and morphology]. / Akutes Nierenversagen--Klinik und Morphologie.

This study reports the pathological-anatomical diagnoses in 180 cases in which a diagnosis of acute renal failure (ARF) had been made on clinical grounds. The clinical and pathological diagnoses were in agreement in 43.3% of the cases. In 56.7%, the pathological-anatomical diagnosis differed from the clinical diagnosis. Glomerulonephritis (GN) was particularly often concealed behind ARF, in particular rapidly progressive GN, but also acute interstitial nephritis or hemolyticuremic syndrome. In addition, the clinical diagnoses in cases with a pathological-anatomical diagnosis of ARF are presented. Finally, the clinical diagnoses made in cases with a pathological-anatomical diagnosis of GN with ARF are reported. It is thus shown that the pathologist is in a position to distinguish GN with true compensated retention from GN with transient ARF simulating compensated retention.

[Criteria for differentiating self- or other-inflicted injuries of alleged or real victims]. / Unterscheidungskriterien für Selbst- oder Fremdbeibringung von Verletzungen angeblich oder tatsächlich Uberfallener.

A synoptic study of six cases of self-inflicted sharp force injuries is presented, where young, mostly female people had simulated assaults to gain sympathy or other personal advantage. The morphological distinctives of simulated assault wounds from such of real assault are worked out and the common situative and motivative background is cleared up.