Unravelling the enigma: Autopsy challenges in alleged snakebite deaths.

Snakebites account for a substantial public health burden in India, contributing to 80 % of global snakebite fatalities. This case series explores the intricacies of two alleged neurotoxic snakebite deaths, delving into the complexities of diagnosing neurotoxic snakebite deaths in India through meticulous medico-legal autopsies. Despite initial suspicions and circumstantial evidence suggesting snakebite involvement, the autopsies revealed surprising causes of death. The article discusses challenges in accurately attributing deaths to snakebites, and the potential for false claims, and underscores the crucial role of Forensic pathologists in dispelling enigmas. Forensic pathologists are urged to maintain an unbiased approach, allowing postmortem findings to guide conclusions amidst deliberate attempts to mislead. The cases described highlight that ruling out snake bites in cases with positive history is as challenging as opining a case of neurotoxic snake bite as they are mainly the diagnosis of exclusion in autopsy.

Use of innovative sample dryer for effective sample drying in forensic investigations: An experimental study.

BACK GROUND: The sample collection and preservation before transportation to a Forensic Science Laboratory in a medicolegal case in India is a crucial step in establishing a link between accused, victim, crime scene and the weapon. This paper discusses pioneering advancement in health technology-a state-of-the-art sample dryer developed to preserve biological samples during Forensic investigations. This unique design has been officially registered with the design office in India as a copy right. AIMS AND OBJECTIVES: The primary goal of the sample dryer is to augment the preservation of biological evidence by removing moisture content through air drying before packaging, sealing and its transportation to a Forensic Science Laboratory. MATERIAL AND METHODS: The process of air drying of biological samples by variety of experiments conducted in sample's dryer designed for the purpose which employs a range of air movement techniques including horizontal, vertical, and circular laminar flows to swiftly extract moisture from the samples. The drying duration for each experimental sample was documented upon manual confirmation of complete drying. RESULTS: The results were extraordinary, showcasing that the sample's dryer reduced the drying time drastically by up to 27 times lesser in comparison to conventional methods for identical samples. The diverse airflow patterns generated by the sample dryer unequivocally demonstrated it's utility in achieving superior sample preservation through efficient air drying. CONCLUSION: Given the exceptional outcomes observed in the experimental phase, the authors strongly advocate for the widespread adoption of this innovative sample's dryer equipment to ensure effective air drying of biological samples and their efficient sample preservation to enable successful forensic analysis as expected.

Histological Changes in Adrenal Glands in Suicidal and Sudden Death Cases: A Postmortem Study.

Introduction Various studies have linked suicidal behavior, stress, affective disorders, and dysregulation of the hypothalamic-pituitary-adrenal (HPA) axis resulting from chronic stress. Chronic stress has been shown to cause enlargement of the adrenal glands, altering their function and potentially leading to suicidal behaviors in individuals with depression. This study aimed to compare the histological changes in the adrenal glands of individuals who died by suicide with those who experienced sudden death. Suicide victims are exposed to chronic stress, while individuals with sudden deaths face acute stress related to the act of dying. Methods This analytical study, approved by the Institutional Ethics Committee (IEC), was conducted in the Department of Forensic Medicine and Toxicology at Gandhi Medical College, Bhopal. The study included 100 confirmed cases of suicide, irrespective of gender, aged 15-60 years, with notable autopsy findings, relevant history, no signs of decomposition, and varying survival periods (including immediate deaths within 24 hours). Additionally, 20 controls were selected, involving individuals who died suddenly from causes other than suicide within 24 hours of the incident. Informed consent was obtained using a prescribed proforma from relatives and the police. Histological examination slides of the adrenals were prepared and analyzed. Data were collected and statistically analyzed using GraphPad software and Epi Info 7. Results Capsular hemorrhage was observed in 98% of suicide cases and 40% of controls. Nodulation was present in 48% of suicidal cases and 20% of controls. Zonal extension of zona fasciculata was specific to chronic stress in suicidal cases. In 25% of suicidal cases, a prominent extension of the medulla was noted. Irregular thinning of zona glomerulosa with shrunken cells and increased nuclear density in 88% of cases were considered specific to chronic stress conditions and suicide, not observed in controls. Lipid depletion was observed in all suicidal cases, with diffuse depletion in 47% and focal depletion in 53% of cases. In contrast, 45% of those exposed to the acute stress of dying showed focal depletion, with none exhibiting diffuse depletion. Suicidal cases displayed dilated prominent sinusoids in all three zones and the adrenal medulla (98-99%), absent in controls. Adrenal hemorrhage and necrosis were specific to chronic stress conditions, with 7%, 8%, 32%, and 16% of cases showing hemorrhage in all three zones and adrenal medulla, respectively, and none in controls. Conclusion Histological changes observed in acute stress conditions included focal lipid depletion, capsular hemorrhage, nodular hyperplasia, and hemorrhage and necrosis with edema. However, the proportion and severity of these changes were lower than those observed in the suicidal group, suggesting that these findings may be considered non-specific for differentiating between acute and chronic stress.

The psychological autopsy: An overview of its utility and methodology.

Objectives: The objective of this study is to provide an overview of the psychological autopsy (PA) research method, including its methodology, uses, limitations, and ethical considerations. Materials and Methods: The study conducted a PA investigation on 35 cases of suicide. Information was collected from multiple sources and reliable informants, including family members, friends, medical and mental health professionals, and other relevant individuals. Qualitative and quantitative research methods were used to analyze the collected information. Results: The results indicated that several factors were associated with suicide, including mental health problems, life stressors, interpersonal conflicts, substance abuse, and history of previous suicide attempts. The findings have important implications for suicide prevention strategies, emphasizing the significance of addressing mental health issues and providing social support. Conclusion: The PA is a valuable research method for investigating and understanding suicide. Despite challenges such as recall biases and methodological limitations, it provides insights into the psychological factors associated with suicide and informs suicide prevention strategies. However, conducting psychological autopsies requires careful consideration of ethical issues. Further research is needed to replicate and extend the findings of this study.

Hypoplastic coronary artery disease, as a cause of sudden death.

Hypoplastic coronary artery disease (HCAD) is a rare coronary artery anomaly that may be the cause of sudden death. It can involve a single or all coronary arteries. This anomaly may cause circulatory insufficiency leading to myocardial infarction. HCAD has no symptoms or may exhibit cardiovascular signs like syncope, dyspnea, chest discomfort, or dizziness. It is often diagnosed at autopsy, and early diagnosis is made with a coronary angiogram. We report HCAD as the cause of the sudden death of a 25-year-old female with a history of loss of consciousness following exertion. On autopsy, all the coronary arteries' lumen was narrowed with thin vessel walls. Histopathological examination shows an underdeveloped and missing muscular layer of the left anterior descending and circumflex coronary arteries' vascular wall. Many cases of HCAD diagnosed by radiographic imaging in living patients have been reported in the literature, but a structural anomaly of coronaries leading to HCAD has not been reported. We report a case of HCAD describing the histopathological examination findings of the vascular wall of coronary vessels illustrating the structural difference.

Gross Changes in Adrenal Glands in Suicidal and Sudden Death Cases: A Postmortem Study.

Introduction Chronic stress breaches the normal homeostasis of the hypothalamic-pituitary-adrenal axis, leads to chronic adrenal fatigue, and causes hypertrophy and hyperplasia of the adrenal gland. The current study was carried out with the aim of observing the difference in gross morphological changes in the adrenals of people dying by suicide and from sudden death, as persons committing suicide are exposed to chronic stress (depression), while those dying suddenly are exposed to the acute stress of dying. Materials and methods The present analytical study was carried out in the Department of Forensic Medicine and Toxicology, Gandhi Medical College, Bhopal, India, after approval from the Institutional Ethics Committee (IEC). A total of 100 established cases of suicide with prominent autopsy findings and relevant history without signs of decomposition, aged 15-60 years, irrespective of gender, and a variable survival period (immediate death to within 24 hours) were selected. A total of 20 controls included those who died suddenly from an act other than suicide within 24 hours of the incident. Due consent was obtained from the relatives and police in the prescribed proforma. Kidneys, along with peri-renal fat and adrenal glands on both sides, were carefully removed and examined. Results  A total of 25% of suicide victims reported a history of chronic stress, 13% self-destructive behavior, 3% untreated depression, and 8% reported financial or marital difficulties. The right adrenal gland was found to be heavier than the left in the control group. In addition, both left and right adrenal glands weighed more in males. Among the suicidal cases, the weight of the left adrenal gland was greater than that of the right, and the weight of the gland in males was higher than that in females. The difference in adrenal gland weight among males was significant in both case and control groups (combined p-value = 0.0001) but was insignificant in females, probably due to their disproportionate ratio in both groups. There was no significant relationship between adrenal gland weight and individual age or weight. However, adrenal gland weight in both groups was significantly associated with the height of the individual (p-value = 0.001 in the study group and < 0.05 in the control group). The difference in adrenal gland volume between the suicidal and control groups was not significant, indicating that the increase in size is not a differentiating criterion for acute and chronic stress. The relative adrenal gland weight was significantly higher in the suicidal group. Conclusion The external appearance of the adrenal gland may be regarded as a normal response to stress in relation to the mode of death. The left adrenal gland is more likely to show an increase in weight in response to chronic stress. The weight of the adrenal gland in both groups is significantly associated with the height of the deceased. Relative adrenal weight can be considered as specific for suicidal cases exposed to chronic stress. However, the volume of the adrenal gland may be considered an unreliable criterion in the differentiation of chronic stress from acute stress.

Hypoplastic coronary artery disease, as a cause of sudden death

ABSTRACT Hypoplastic coronary artery disease (HCAD) is a rare coronary artery anomaly that may be the cause of sudden death. It can involve a single or all coronary arteries. This anomaly may cause circulatory insufficiency leading to myocardial infarction. HCAD has no symptoms or may exhibit cardiovascular signs like syncope, dyspnea, chest discomfort, or dizziness. It is often diagnosed at autopsy, and early diagnosis is made with a coronary angiogram. We report HCAD as the cause of the sudden death of a 25-year-old female with a history of loss of consciousness following exertion. On autopsy, all the coronary arteries' lumen was narrowed with thin vessel walls. Histopathological examination shows an underdeveloped and missing muscular layer of the left anterior descending and circumflex coronary arteries' vascular wall. Many cases of HCAD diagnosed by radiographic imaging in living patients have been reported in the literature, but a structural anomaly of coronaries leading to HCAD has not been reported. We report a case of HCAD describing the histopathological examination findings of the vascular wall of coronary vessels illustrating the structural difference.

Stimulated Reporting of Adverse Events Following Immunization with COVID-19 Vaccines.

In India, up until December 2021, Covishield and Covaxin vaccines against COVID-19 were being used for mass vaccination programs. In view of the urgency of fighting the ongoing pandemic, many vaccines have been granted emergency use approval while phase 2/3 clinical trials were still underway. Even for vaccines that have completed phase 3 trials, safety data may not be comprehensive. This retrospective observational study was conducted at a designated Regional Training Centre for Pharmacovigilance cum Adverse Drug Reaction Monitoring Centre (AMC) under the Pharmacovigilance Programme of India. The data sources were stimulated spontaneous reports of Adverse Events Following Immunization (AEFI) due to the COVID-19 vaccines from 10 January to 31 December 2021. A total of 51,010 COVID vaccine doses were administered during the study period. There were 330 AEFI reported (AEFI rate: 0.65%). Six AEFI were serious events among which three were Adverse Events of Special Interest. The majority of the AEFI were systemic, reported after the first dose, and with an onset between 1 and 24 h after vaccination. On comparing Covishield and Covaxin, there were no statistically significant differences in the AEFI reported with either vaccine in terms of gender, seriousness, lag period, duration, recovery, causality, treatment received for AEFI, presence of co-morbidity, or history of COVID-19 infection. Overall, the rates of AEFI was uncommon, and serious AEFI were rare with both Covishield and Covaxin, with a higher rate after the first dose. Whether immunological tolerance or allayed anxiety was responsible for the lower AEFI risk with the second dose remains to be investigated.

Organ Involvement in COVID-19: A Molecular Investigation of Autopsied Patients.

Precise reasons for severe manifestation of SARS-CoV-2 remain unanswered, and efforts have been focused on respiratory system management. Demonstration of unequivocal presence of SARS-CoV-2 in vital body organs by cadaver autopsy was the only way to prove multi-organ involvement. Hence, the primary objective of the study was to determine presence of the SARS-CoV-2 in various organs of patients succumbing to SARS-CoV-2 infection. A total of 246 samples from different organs of 21 patients who died due to severe COVID-19 illness were investigated by qRT-PCR, and SARS-CoV-2 was detected in 181 (73.57%) samples and highest positivity of SARS-CoV-2 being (expectedly) found in nasopharynx (90.4%) followed by bilateral lungs (87.30%), peritoneal fluid (80%), pancreas (72.72%), bilateral kidneys (68.42%), liver (65%) and even in brain (47.2%). The deceased patients were categorized to three subgroups based upon the extent of organs in which SARS-CoV-2 was detected by qRT-PCR (high intensity ≥80%, intermediate intensity = 65-80% and low intensity ≤65% organs involvement). It was conclusively established that SARS-CoV-2 has the property of invasion beyond lungs and even crosses the blood-brain barrier, resulting in multi-system disease; this is probably the reason behind cytokine storm, though it is not clear whether organ damage is due to direct injury caused by the virus or result of inflammatory assault. Significant inverse correlation was found between the Ct value of lung samples and number of organs involved, implying that higher viral load in lungs is directly proportionate to involvement of extrapulmonary organs and patients with higher viral load in respiratory secretions should be monitored more closely for any warning signs and the treatment strategies should also address involvement of other organs for better outcome, because lungs, though the primary site of infection, are not the only organ system responsible for pathogenesis of systemic illness.

Clinical, Virological, and Pathological Profile of Patients Who Died of COVID-19: An Autopsy-Based Study From India.

Background and objective Ever since its emergence in December 2019, coronavirus disease 2019 (COVID-19) has affected more than 220 million people worldwide, resulting in more than 45 million deaths. The present autopsy-based study was undertaken to understand the pathophysiology of the disease and correlate the histopathological and virological findings with the antemortem clinical and biochemical determinants. Methods In this prospective observational study, autopsies were carried out on 21 reverse transcription-polymerase chain reaction (RT-PCR)-proven COVID-19 patients who had died of the disease. The histopathological findings of tissue samples from lungs, liver, and kidneys collected during the autopsy were graded based on their presence or absence; if present, they were graded as either focal or diffuse. The findings were correlated with antemortem clinical and biochemical findings. Postmortem tissue RT-PCR analysis was conducted, and findings were compared with postmortem histopathological findings. Results There was multisystem involvement with the COVID-19 cases. The involvement of lungs was observed in most of the cases (90.4%). The presence of viral RNA was observed in all the organs including the liver (57.1%) and kidney (66.6%). An association was observed between antemortem biochemical parameters [aspartate aminotransferase (AST), alanine aminotransferase (ALT)] and the histopathological features in the liver. No correlation between the Sequential Organ Failure Assessment (SOFA) score recorded clinically and lung histopathology was observed; nor was there any correlation between blood urea-creatinine levels and kidney histopathology. Conclusions Our study shows that COVID-19 is a multisystemic disease and the mortality associated with it is likely to be multifactorial. Despite the presence of amplifiable severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in various organs, no association could be established between the clinical and histopathology findings. Neither the duration of hospitalization nor the duration of mechanical ventilation showed any correlation with the severity of histopathological findings in the lungs at autopsy.

COVID-19 Autopsy in India: Protocols, Procedures, and Experiences.

BACKGROUND: Coronavirus disease 2019 (COVID-19) has besieged mankind because of its novelty, causing a global health crisis. The autopsy-based studies provide a crucial role in understanding the pathophysiology and the behavior of the disease. But there is a paucity of such studies in the world especially so from developing nations. Conducting a complete autopsy on infectious bodies like COVID-19 requires conducive infrastructural setup and protocols suited to the needs, and precautions are to be taken meticulously. METHODS: A complete pathological autopsy was conducted on a known case of a COVID-19-hospitalized patient, who died in our institution, with the aim to look for histopathological changes in each organ and to compare these findings with clinical findings such as duration of hospitalization, mechanical ventilation, comorbidities, biochemical parameters, and the result of real-time polymerase chain reaction (RT-PCR) of the tissues. The complete autopsy was performed after obtaining consent from the family, and the study was approved by the Institutional Ethics Committee. Histopathological examination (HPE) and RT-PCR were conducted on the tissue collected during autopsy. Clinical and biomedical data were collected and correlated. RESULT:  The written informed consent from the family could be obtained in only 15.3% of cases, which was a limiting factor. The post-mortem interval ranged from 3.5 to 19.5 hours. The gross findings revealed pathologic features of viral infection as well as existing comorbidities in all the organs. The development of protocols and new innovations to limit the spread of infection, taking into consideration the limited facilities, which are described in this article, resulted in the successful completion of all the autopsies with a good sample collection, and nobody in the autopsy team was tested positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). CONCLUSIONS:  The experience gained from these 21 COVID-19 autopsies helps to outline the basic or minimal requirements for conducting autopsies in highly infectious cases even in not-so-ideal conditions and also provides guidelines to be used while conducting such autopsies, especially in developing countries.

An unusual case of impalement injury.

Impalement injuries result when a hard elongated object penetrates the body cavity or any body part and remains in place. A rare and unusual case of impalement by a bamboo stick in the thoracic cavity through the oropharynx is described. Injury resulted when a man tried to pole-vault with a bamboo stick, which slipped and entered his mouth. Impalement injury through the natural orifice of the oropharynx is discussed, along with the mechanism of the trauma and subsequent death.

Carotid sheath haematoma: a case report.

Carotid sheath haematoma is a rare finding, sometimes the only injury found in cases of manual strangulation without any associated external or internal injury to the neck. One such rare case is reported in an 8 year old female victim where presence of carotid sheath haematoma not only helped to ascertain the cause of death but also helped in the reconstruction of mechanism of infliction of force on the neck.

Spontaneous ignition in case of celphos poisoning.

Celphos (aluminum phosphide) poisoning is the most common cause of poisoning in India. The mechanism of action, acute and chronic effect on human body, its symptoms and signs, and the line of treatment are well documented and research is still going on to find a suitable antidote. "Spontaneous ignition" is a rare but interesting finding in case of aluminum phosphide poisoning. We present the autopsy findings in this case report along with the probable factors that led to occurrence of such finding.

Estimation of time since death from CSF electrolyte concentration in Bhopal region of central India.

Estimation of time since death from sodium and potassium ion concentration levels in CSF (cerebrospinal fluid) was carried out in 100 medico legal autopsies with known time of death in the department of Forensic medicine, Gandhi Medical College in Bhopal region of Central India. CSF was aspirated from lateral ventricles after opening the skull and dura, and concentration of these ions were estimated by flame photometry. Results revealed a significant correlation of sodium and potassium ions in CSF up to 25 h of time since death, with average per hour rise of 1.21 meq/h for potassium and fall of 1.115 meq/h for sodium ions. A useful relationship between sodium potassium ion ratio and PMI (post-mortem interval) was also elicited. The study concludes that changes in CSF electrolyte is a significant parameter to estimate time since death.

4. Cerebral venous thrombosis in pregnancy: a case report.

Sudden unexpected death in many instances comes with stimulating or interesting findings, often in contrast to the history provided. Two cases of sudden death in pregnant females with central venous thrombosis are described, because of their rarity. The incidence, etiological factors, predisposing conditions and the ethical and legal questions arising from such deaths are discussed.