Urea, Uric Acid, and Creatinine in Postmortem Blood, Vitreous Humor, and Synovial Fluid: A Comparative and Correlation Study.

Urea, uric acid, and creatinine have been demonstrated to be relatively stable in postmortem blood (BL), thus being useful for diagnostic purposes. However, no studies have explored their levels in BL, vitreous humor (VH), and synovial fluid (SF) concurrently. Therefore, we measured and compared their levels in these fluids. We also determined the effects of various factors on their levels. The results indicated that BL urea, uric acid, and creatinine levels were significantly higher than VH and SF levels. VH and SF urea levels and SF creatinine levels had a strong correlation with BL urea and creatinine levels, respectively. BL creatinine levels were higher in men than in women. BL and SF creatinine levels were negatively correlated with age. SF uric acid and BL, VH, and SF creatinine levels exhibited a positive correlation with weight. Only VH creatinine levels were positively correlated with body mass index. None of urea, uric acid, and creatinine levels were correlated with postmortem interval.

Comparative and Correlation Studies of Biochemical Substances in Vitreous Humor and Synovial Fluid.

Vitreous humor (VH) and synovial fluid (SF) become optional postmortem samples for biochemistry investigation. However, few studies have explored SF as a potential source, and there is still controversy whether the biochemical concentrations in bilateral VH are the same. We explored the concentrations of biochemical substances in both VH and SF, and compared between both sides and between the fluids. We also correlated the biochemical concentrations in both fluids. All samples were centrifuged after collection and the supernatant fluids were used for the analysis. The results indicated no significant difference in the constituent concentrations between the fluids from both sides (p > 0.05). Sodium, potassium, chloride, and magnesium concentrations were significantly higher in the VH, but in vice versa for glucose, uric acid, and creatinine concentrations (p < 0.001). Sodium, potassium, glucose, lactate, urea, uric acid, and creatinine concentrations between both fluids showed significant correlation (p < 0.05), but not chloride and magnesium concentrations.

Fatal Massive Pulmonary Embolism Following a Minor Ankle Injury as a Rare Cause of Sudden Unexpected Death: A Case Report.

Venous thromboembolism is a condition that includes both deep vein thrombosis and pulmonary thromboembolism. Pulmonary thromboembolism is a condition that is familiar to forensic pathologists for its common cause of sudden unexpected death. Fatal pulmonary thromboembolism following deep vein thrombosis has been previously reported as a consequence of major ankle injury but not following minor ankle injury. Here, I report the case of sudden unexpected death in a 54-year-old female without known underlying risk factors for venous thromboembolism, except for a history of minor injury at her left ankle, which possibly caused local vascular wall damage with subsequent deep vein thrombosis and eventual massive pulmonary thromboembolism.

Sudden Unexplained Nocturnal Death Syndrome: Epidemiological and Morphological Characteristics in Thai Autopsy Cases.

With limited knowledge on epidemiological and morphological characteristics of sudden unexplained nocturnal death syndrome (SUNDS), this study was aimed to identify such data in Thai SUNDS autopsy cases. All the cases were men and nondrug abusers aged 20-49 years old. Most cases were originated in the Northeastern region of Thailand. Half of them were found dead from midnight to 6 a.m., with a peak time at 2 a.m. The death rate was relatively higher in May and June. Most SUNDS cases were blue-collar workers (93.2%) and nonsmokers (60%), with a normal BMI (72.1%). Approximately one-fifth of the cases had detectable blood alcohol concentrations. Symptoms before death were respiratory difficulty, seizures, and urinary incontinence. Their mean heart weight was 329.8 ± 35.1 g. Their lungs (88.6%) had some degree of congestion. Acute pancreatitis was not found in these SUNDS cases, and approximately half (40.9%) of the cases had their gastric content <100 mL.

Septic Cavernous Sinus Thrombosis Following a Minor Head Injury: A Rare Cause of Medico-Legal Death.

Septic cavernous sinus thrombosis (SCST) is an uncommon consequence of head and face infection, but a rare complication after craniofacial fracture. In this case, SCST developed in a 13-year-old girl following a minor fall during volleyball, with impact and resulting abrasive contusion of the left forehead. She developed watery rhinorrhea, progressive headache, fever, nausea, vomiting, and left proptosis with blurred vision, and was admitted to hospital 3 days after injury. Drowsiness, high-grade fever, severe headache, left ocular pain with marked periorbital swelling, and paralysis of extraocular eye movements developed. Computed tomography scan identified left sphenoid and ethmoid sinusitis, a posterior clinoid fracture, and septic cavernous sinus thrombosis. She died after 10 days of in-hospital antibiotic therapy. Death was due to Staphylococcus aureus sepsis with septic pulmonary thromboemboli due to suppurative meningitis and cerebral infarction, due to SCST following apparently minor blunt head injury from an accidental fall.

Fatal Acute Hemorrhagic Bowel Infarction Caused by Mesenteric Venous Thrombosis.

Acute mesenteric venous thrombosis (MVT) is a rare, but life-threatening medical phenomenon. MVT is normally characterized by insidious onset, with nonspecific signs and symptoms. A high index of clinical suspicion is required for diagnosis, and emergency surgery is necessary to optimize the chances of patient survival, especially in the people aged more than 70 years. Surprisingly, based on my review of the literature, no fatal acute MVT case has been reported in the forensic literature. All reported such cases have been documented in medical literature, and most of them have been associated with underlying risk factors for venous thrombosis, such as hypercoagulable state, certain cancers, and stasis of the blood flow. Here, I report the case of a sudden unexpected death due to extensive intestinal ischemia and infarction with massive abdominal hemorrhage caused by acute MVT in a 72-year-old man without known underlying risk factors.

Ascending Aortic Rupture through a Penetrating Atherosclerotic Ulcer: A Rare Cause of Sudden Unexpected Death.

Spontaneous rupture of the aorta through an atherosclerotic lesion without preexisting aortic aneurysm, dissection, or history of trauma is very rare. Without prompt aortic repair, all cases result in sudden death with a definitive diagnosis made only intraoperatively or during autopsy. The phenomenon has been uniformly found in individuals with hypertension. The author reports a sudden unexpected death caused by spontaneous rupture of the ascending aorta in a 57-year-old man with a history of hypertension. The ascending aortic wall showed a longitudinal intimal tear measuring approximately 1 cm in length and rupture of the ascending aorta through an atherosclerotic ulcer, leading to massive hemopericardium and eventual death. Chronic hypertension and a penetrating atherosclerotic ulcer of the ascending aorta were the apparent underlying etiologies of the aortic rupture in the present case. This case illustrates not only the association between a rupture and a penetrating atherosclerotic ulcer with a silent death, but also raises awareness of possible such deaths.

Left Ventricular Aneurysm: Sudden Unexpected Deaths in a 29-Year-Old Man.

Left ventricular aneurysm (LVA) is an abnormal dilated heart structure, either congenital or acquired. LVA is a rare cardiac condition with no symptoms in most cases, thus occasionally diagnosed during investigations of other diseases. Its association with certain cardiac complications and sudden cardiac deaths has been reported. However, its role as a cause of sudden unexpected death is rare. The author reported a sudden cardiac death in a 29-year-old man with LVA. Without a significant coronary artery disease and known etiologies of LVA, such an abnormal heart structure in the present case was considered congenital LVA. As no other possible mechanisms of death could be identified other than LVA with its associated pathologic lesions, mural thrombi, and dilated cardiomegaly, his death was attributable to fatal cardiac arrhythmia (most commonly ventricular tachycardia) secondary to LVA.

Fatal Self-Poisoning With Massive Propranolol Ingestion in a Young Male Physician.

Suicidal intoxication from massive propranolol ingestion is rare. Surprisingly, no reported cases have involved physicians. The author herein reports a case of self-poisoning death due to ingestion of propranolol by a young male physician. A 31-year-old man with major depressive disorder was found dead in his dormitory room. Fifteen empty packages, each having contained ten 40-mg propranolol tablets, were found without any tablets leftover in his room. A suicide note was also found in his room. He was thus alleged to have ingested 6 g of propranolol for self-poisoning. Autopsy findings revealed approximately 150 mL of pink fluid with some partially dissolved pink tablets in the stomach. No anatomic cause of death was found, except for mild dilatation of cerebral ventricles. Toxicologic analysis revealed propranolol in his blood and gastric contents. The cause of death was attributed to acute cardiac arrest due to severe acute propranolol intoxication from self-poisoning caused by major depressive disorder possibly secondary to organic brain syndrome.

Relative studies between hair index, hair area, and medullary index with age and sex in Thai scalp hair.

Human scalp hair is one of the most common trace materials found at violent crime scenes. Accordingly, scalp hair is critical evidential material in forensic investigations for identifying relations and persons, which could result in solving cases. Knowledge about micro-morphological variations of scalp hair in the Thai population, however, is scarce, and information on age changes and sex differences with respect to these traits is limited. The present study was thus undertaken to explore three micro-morphological parameters of Thai scalp hair-hair index (HI), hair area (HA), medullary index (MI)-relative to age and sex differences. Scalp hair samples were collected from 340 unrelated Thai cadavers (170 male, 170 female) of all ages, which were divided into seventeen age groups, 5-year-old interval per group beginning with 0-5years and ending up with ≥80 years. Approximately 30 hair strands at the posterior vertex region of the scalp were cut with scissors as close to the scalp as possible. The hair samples were subsequently used to make permanent slides, and the mounted hairs were examined for microscopic cross-sectional characteristics. The authors found that the HI and MI were similar in the male and female cadavers and did not significantly differ (p>0.05) according to age. In contrast, the HA was significantly different between the male and female cadavers at 50-69years of age (p<0.05). There were other differences according to age as well. That is, the HA increased abruptly during their early twenties and then decreased gradually until ≥80 years of age. Thus, Thai scalp hair shows some age and sex variations that are reflected in the HA and might be useful for forensic, medical, and anthropological investigations.

Severe acute hemorrhagic pancreatitis secondary to cholelithiasis as a rare cause of sudden unexpected death in medico-legal case: A case report.

INTRODUCTION: Acute pancreatitis (AP) is an uncommon disease with a wide clinical course varying from mild and self-limiting to severe with eventual death. However, death caused by AP is rare. Most cases of AP reported in the English-language literature are based on clinical data; few are medico-legal studies. CASE PRESENTATION: The author recently experienced a case of sudden unexpected death in a young man caused by extensive severe hemorrhagic AP secondary to cholelithiasis, not chronic alcoholism, which is a much more prominent etiology of AP in medico-legal perspectives. The deceased had complained of dizziness, nausea, and fatigue without significant abdominal pain for about 1 week and received some home medications for symptomatic treatment including an antibiotic drug from a clinic just 2 days prior to his death. He had complained of lower extremity weakness, intense thirst, and subsequently collapsed and was brought to a nearby hospital where he was pronounced dead shortly after his admission following unsuccessful advanced cardiopulmonary resuscitation attempts. CONCLUSION: This case is herein reported with an extensive review of the pertinent literature to highlight the findings of the case and raise awareness within the medico-legal profession and also the medical profession.

Inferior Vena Cava Tumor Thrombosis Secondary to Metastatic Uterine Cancer: A Rare Cause of Sudden Unexpected Death.

Pulmonary tumor thromboembolus (PTTE) secondary to uterine cancer is a rare cause of sudden unexpected deaths in the elderly population. Additionally, tumor extension to the inferior vena cava (IVC) makes it rarer. No such cases have been previously reported in the forensic literature. We report this phenomenon in a previously healthy 70-year-old woman with no other known risk factors for the development of deep vein thrombosis. The deceased was found dead while watching television with her relatives. Autopsy examination revealed that her death was attributed to a saddle embolus lodged in the main pulmonary arteries. A uterine tumor was discovered, and microscopic examination revealed low-grade endometrial stromal sarcoma with angiolymphatic invasion. The tumor cells were also found in the embolus and the remnant thrombosis attached to the inner wall of the IVC. This case demonstrates a sudden unexpected death caused by acute PTTE following seeding of uterine cancer into the IVC and raises awareness of such events.

The Stability of Prostate-Specific Antigen in Semen Under Various Temperatures.

Prostate-specific antigen (PSA) is most commonly used for identifying semen, especially in the absence of sperm. However, PSA concentration varies according to storage temperature and duration, and little is known about its stability in semen. This study was therefore aimed to determine the stability under five different temperatures: -80, -20, 4, 25, and 37°C; and nine different durations: 1, 2, 3, 5, 7, 14, 30, 90, and 180 days. All samples were stored at -80°C after being secreted from the volunteers' body until analyzed. Results showed that the PSA concentration declined significantly over time under all temperatures studied except -80°C. At -20 and 4°C, PSA was still detectable on Day 180 with 50% and 70% decrease from its original concentration, respectively. At 25 and 37°C, PSA was detected up to Day 7 and 3, respectively. This information might assist forensic scientists understand more about PSA nature and integrate it into their works.

The study on telomere length for age estimation in a Thai population.

Age is one of the key parameters in establishing a physical characteristic profile of an individual. For biological evidence left in crime scenes such as blood, saliva, hair, etc, the evidence owner's age can be determined only by DNA extracted from these materials. Previous researches have found that there are certain DNA regions with specialized characteristic and function called telomere being able to predict age. The present study was to determine the correlation between telomere length and age as well as the effect of sex on the correlation and to create linear regression equation for age estimation in Thai population for forensic purposes. Blood samples obtained from unrelated healthy Thai fresh cadavers without anatomical organ abnormalities were used in this study. All cadaver subjects underwent the postmortem examination in jurisdiction of the Department of Forensic Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, and Institute of Forensic Medicine, Police General Hospital. Fifty blood samples from both sexes of all ages divided into 6 groups for equal age distribution (0-11, 12-23, 24-35, 36-47, 48-59, and 60 years old and older) were collected for a total of 100 samples. The extracted genomic DNA samples were then subjected to telomere length estimation by terminal restriction fragment (TRF) assay. The results showed that the mean TRF length was inversely correlated with age (r = -0.625), and sex did not have a statistically significant influence on the association between age and mean TRF length (P > 0.05). The obtained linear regression equation was y = 113.538 ± 9.604 - 0.012 × (R = 0.391; P < 0.001). However, the correlation was too low to be used for age estimation with high certainty and a possible reason for this in part would be the postmortem DNA degradation at some level, even using fresh cadaver blood, and other biological factors such as ethnicity and DNA sources. Roughly, those individuals who had a mean TRF length longer than 6.3 kilobase (kb), between 5.5 and 6.3 kb, and shorter than 5.5 kb aged younger than 28 years, 30 to 44 years, and older than 46 years, respectively (P < 0.01). As a preliminary study, this study highlighted that telomere length could act as a useful biomarker of aging in human population and might be used for rough age estimation in a Thai population. However, further studies with a larger sample size and/or in living human bloods as well as other cell types are recommended to support the results of this study.

Spontaneous rupture of acute ascending aortic dissection in a young pregnant woman: a sudden unexpected death.

Acute aortic dissection (AAD) in pregnancy is a rare phenomenon. Usually, it occurs during the third trimester, resulting in a catastrophic outcome for both mother and fetus and thus requiring a high level of clinical suspicion and a prompt multidisciplinary approach. There have been numerous such reports published in clinical literatures, yet there is little documentation in forensic literatures. Nearly all the reported cases have been associated with underlying risk factors for aortic pathology, predominantly connective tissue disorders. The author reports a sudden unexpected death due to a ruptured AAD in a 32-year-old pregnant woman with no cardiovascular risk factors at 37 weeks' gestational age. The ascending aortic wall showed a longitudinal intimal tear measured 0.6 cm in length and a longitudinal external tear measured 6 cm in length. Pre-eclampsia superimposed on chronic hypertension was solely possible cause of ruptured AAD in this case. The present case not only illustrates the association of AAD and pregnancy with a resultant fetal-maternal death but also raises awareness of possible such cases.

Systemic thromboembolism after deep vein thrombosis caused by uterine myomas.

A systemic thrombus embolization after deep vein thrombosis (DVT) caused by uterine myomas is very rare. The authors recently had experienced this association in a single 46-year-old Thai woman with previous healthy history and no other known risk factors for development of DVT. On arrival at a nearby small hospital, the deceased had presented with an abrupt onset of right hemiparesis, and 34 hours after admission to the hospital, she suddenly developed a cardiopulmonary collapse and was pronounced dead. Autopsy examination revealed that her death was attributed to massive pulmonary thromboembolism with systemic embolization through coexistent patent foramen ovale after DVT of her bilateral lower extremities caused by uterine myomas.

Hair follicle counts in Thai population: a study on the vertex scalp area.

OBJECTIVE: To assess the normal value of the hair follicle counts in a 4-mm punch biopsy on the vertex scalp area from the Thai population. To compare the hair follicle count in the present study with those in previous described reports. MATERIAL AND METHOD: Twenty autopsy patients of clinically normal scalp were obtained for study from the Department of Forensic Medicine, Siriraj Hospital, Mahidol University. A 4-mm punch biopsy was performed on each patient on the vertex area of the scalp and, subsequently, horizontally bisected at the level of 1 mm below the skin surface and studied by hematoxylin-eosin staining. The total number of hair follicles, the phase of each hair follicle in a normal hair cycle, the number of terminal hairs, intermediate hairs, vellus hairs, and hair follicular unit were also included in this study and compared to those in previously described reports. RESULTS: Of our 20 studied cases, the mean numbers of total hair follicle counts, terminal, intermediate, and vellus hair follicles were 28.3 +/- 9.2, 16.5 +/- 8.4, 5.0 +/- 4.6, and 6.9 +/- 7.0 respectively. The density of hair follicles in our study was statistically less than those found in Caucasians (p-value = 0.002) but more than those in African-Americans (p-value = 0.004) and in Koreans (p-value < 0.001). CONCLUSION: Data collected from previous publications provided only the number of hair follicles in other ethnic groups, but not from the Thai population. The number of hair follicles described in those studies may be unreliable and invalid in the interpretation of scalp biopsies in alopecia Thai patients. They may lead to a misdiagnosis of the disease. The density of hair follicles in Caucasians, African-Americans, Koreans, and Thai population were authentically different according to their ethnic backgrounds. This is important because the number of hair follicles should be considered when a pathologist evaluates the scalp biopsy specimens of alopecia patients.

A fatal heroin addict with myocardial lesion.

This is a histological report of a myocardial lesion of a 44-year-old white man who was found dead in a hotel with circumstances strongly suggestive of heroin intoxication. Based on. autopsy findings and toxicologic analysis, the present case was an instance of straight forward heroin overdose in snorter. The most striking pathologic finding of the heart was a few patches of marked dark mottling appearance in the left ventricle and ventricular septum. Histological appearance of the lesions revealed marked congestion with intramyocardial extravasation of blood. Since the deceased had patent coronary arteries without evidence of atheroma, the lesions were thought to be the results ofcoronary artery spasm. There has also been substantial evidence in the previous reports to believe that the condition is secondary to heroin-induced coronary artery spasm. However its actual underlying mechanism remains unclear.

Cloning of CYP2J2 gene and identification of functional polymorphisms.

CYP2J2 is abundant in cardiovascular tissue and active in the metabolism of arachidonic acid to eicosanoids that possess potent anti-inflammatory, vasodilatory, and fibrinolytic properties. We cloned and sequenced the entire CYP2J2 gene (approximately 40.3 kb), which contains nine exons and eight introns. We then sequenced the CYP2J2 exons and intron-exon boundaries in 72 healthy persons representing African, Asian, and European/white populations as part of the National Institutes of Health/National Institute of Environmental Health Sciences Environmental Genome Single Nucleotide Polymorphism Program. A variety of polymorphisms were found, four of which resulted in coding changes (Arg158Cys, Ile192Asn, Asp342Asn, and Asn404Tyr). A fifth variant (Thr143Ala) was identified by screening a human heart cDNA library. All five variant cDNAs of CYP2J2 were generated by site-directed mutagenesis and expressed in Sf9 insect cells by using a baculovirus system. The recombinant wild-type and variant CYP2J2 proteins immunoreacted with peptide-based antibodies to CYP2J2 and displayed typical cytochrome P450 (P450) CO-difference spectra; however, the Asn404Tyr and Ile192Asn variants also had prominent spectral peaks at 420 nm. The ability of these variants to metabolize arachidonic acid and linoleic acid was compared with that of wild-type CYP2J2. Three variants (Asn404Tyr, Arg158Cys, and Thr143Ala) showed significantly reduced metabolism of both arachidonic acid and linoleic acid. The Ile192Asn variant showed significantly reduced activity toward arachidonic acid only. The Asp342Asn variant showed similar metabolism to wild-type CYP2J2 for both endogenous substrates. Based on these data, we conclude that allelic variants of the human CYP2J2 gene exist and that some of these variants result in a P450 protein that has reduced catalytic function. Insofar as CYP2J2 products have effects in the cardiovascular system, we speculate that these variants may be functionally relevant.