Pulmonary capillaritis as a cause of lethal diffuse alveolar hemorrhage.

Lethal pulmonary hemoptysis is a common finding in forensic medicine. Since hemoptysis does not necessarily occur before death and its previous symptoms are usually unspecific, indicative signs or findings at the site of a corpse may be completely absent. If lethal acute alveolar hemorrhage is found in the post-mortem examination, a differential diagnosis should be made for traumatic, substance-related, infectious, or organic causes. Cocaine-associated pulmonary hemorrhage and drug reactions are in the foreground. For organic causes, autoimmune diseases should be considered in addition to cardiac, haematological, and infectious causes. The following two cases show similarities both in the sudden, unexpected deaths and the anamnesis of the two deceased women. One of the deceased received a Corona vaccination a few months earlier. In each case, the post-mortem examination revealed an acute diffuse pulmonary hemorrhage caused by acute inflammation of the lung capillaries. This case presentation demonstrates the necessity of a complete autopsy including toxicological and histological analyses. The documentation and publication of rare causes of death are essential for medical research and practice in order to critically consider and discuss the possibility of to date unknown associations in similar cases.

A standard protocol for the analysis of postmortem muscle protein degradation: process optimization and considerations for the application in forensic PMI estimation.

The analysis of postmortem protein degradation has become of large interest for the estimation of the postmortem interval (PMI). Although several techniques have been published in recent years, protein degradation-based techniques still largely did not exceed basic research stages. Reasons include impractical and complex sampling procedures, as well as highly variable protocols in the literature, making it difficult to compare results. Following a three-step procedure, this study aimed to establish an easily replicable standardized procedure for sampling and processing, and further investigated the reliability and limitations for routine application. Initially, sampling and processing were optimized using a rat animal model. In a second step, the possible influences of sample handling and storage on postmortem protein degradation dynamics were assessed on a specifically developed human extracorporeal degradation model. Finally, the practical application was simulated by the collection of tissue in three European forensic institutes and an international transfer to our forensic laboratory, where the samples were processed and analyzed according to the established protocol.

Morphology of direct and indirect rib fractures.

Rib fractures are a common finding in legal medicine and information on the impact mechanism is relevant for trauma reconstruction. This study focuses on morphological characteristics of rib fractures resulting from direct or indirect force. Fresh human ribs (n = 312) were divided into two groups and broken through local force (direct) and bending (indirect) in anterolateral areas. The ribs were macerated, visually investigated and the results statistically analysed. The indirect fractures showed a significant larger lateral offset of the internal and external fracture ends while the fracture ends of the direct fractures were more often straight, in line. Also, the morphology of the inner and outer fracture edges was significantly related to fracture type. Direct fractures mostly had rough and jagged inner edges (tension side) and straight, smooth outer edges (compression side), whereas indirect fractures more often showed the characteristics vice versa. The results were more convincing in combination and in ribs from persons aged ≤ 75 years at death. In summary, the direct and indirect rib fractures showed significantly different characteristics regarding orientation and offset of the fracture lines and roughness of the inner and outer fracture edges, which can be helpful to distinguish the traumatizing impact mechanisms in forensic autopsy routine.

Compound elevated fracture-reconstruction of an unusual skull injury.

Our institute of Legal Medicine was asked to examine a 27-year-old patient admitted to the neurosurgical department after a non-fatal accident (non-observed fall from height) at a construction site. Forensic advice was needed because of unexplainable injuries. By example of this case of a near-to-impalement, we would like to highlight an unusual, clinically frequently forgotten, and forensically thus far not discussed type of skull fracture with outward dislocation of bone fragment(s). These so-called compound elevated fractures of the skull are described occasionally in, mainly neurosurgical, case reports. Knowing its entity and its pathomechanism may be of forensic interest, particularly in order of reconstruction purpose. This article provides a brief review of the literature with special regard to the pathomechanism. In addition, it demonstrates the possible pitfall of computed tomography, or more specifically, the 3D reconstruction. To our knowledge, this is the first forensic report describing this kind of fracture.

Gross and histopathological pulmonary findings in a COVID-19 associated death during self-isolation.

Forensic investigations generally contain extensive morphological examinations to accurately diagnose the cause of death. Thus, the appearance of a new disease often creates emerging challenges in morphological examinations due to the lack of available data from autopsy- or biopsy-based research. Since late December 2019, an outbreak of a novel seventh coronavirus disease has been reported in China caused by "severe acute respiratory syndrome coronavirus 2" (SARS-CoV-2). On March 11, 2020, the new clinical condition COVID-19 (Corona-Virus-Disease-19) was declared a pandemic by the World Health Organization (WHO). Patients with COVID-19 mainly have a mild disease course, but severe disease onset might result in death due to proceeded lung injury with massive alveolar damage and progressive respiratory failure. However, the detailed mechanisms that cause organ injury still remain unclear. We investigated the morphological findings of a COVID-19 patient who died during self-isolation. Pathologic examination revealed massive bilateral alveolar damage, indicating early-phase "acute respiratory distress syndrome" (ARDS). This case emphasizes the possibility of a rapid severe disease onset in previously mild clinical condition and highlights the necessity of a complete autopsy to gain a better understanding of the pathophysiological changes in SARS-CoV-2 infections.

Systematic Evaluation of Radiation Dose Reduction in CT Studies of Body Packers: Accuracy Down to Submillisievert Levels.

OBJECTIVE: The objective of this study was to systematically evaluate the accuracy of abdominal CT performed at different radiation dose levels for the detection of body packs in human cadavers, in comparison with the accuracy of abdominal radiography. MATERIALS AND METHODS: In this study, differing numbers of body packs (range, 0-20) were placed in the alimentary tract of human cadavers and then underwent imaging with abdominal radiography and with CT performed at different radiation dose levels (ranging from the standard abdominal CT dose to the technical minimum dose). Depiction of body packs on abdominal radiographs and on each CT scan was assessed by two independent blinded radiologists, and the accuracy of detection of body packs was calculated. The radiation dose associated with abdominal radiography was measured, and the effective radiation dose associated with CT was estimated. RESULTS: The mean (± SD) effective radiation dose for abdominal radiography was 1.4 ± 0.3 mSv, whereas the mean effective dose of CT ranged from 0.1 to 9.6 mSv. Interobserver agreement for body pack detection was moderate (κ = 0.51) for abdominal radiography and good (κ = 0.72-0.85) for CT. In a per-body pack analysis, abdominal radiography depicted 42% of the body packs with a sensitivity of 71% and a specificity of 100%. When performed at radiation dose levels of 0.6 mSv or greater, CT correctly detected all body packs. In per-person analysis, the sensitivity and specificity of CT for the correct detection of at least one body pack per cadaver was 100% for all radiation dose levels. CONCLUSION: CT performed at a dose of 0.6 mSv can be used for the detection of body packs. With a sensitivity and specificity of 100%, CT is superior to abdominal radiography in terms of reliability, associated radiation dose, and accuracy of detection.

Dual-energy CT behavior of heroin, cocaine, and typical adulterants.

PURPOSE: To investigate the dual-energy CT behavior of cocaine and heroin and of typical adulterants, and to evaluate the elemental composition of pure cocaine and heroin compared with cocaine and heroin in bodypacks. METHODS: Pure heroin and pure synthetic cocaine samples, eight different adulterants, and in each case ten different bodypacks containing cocaine or heroin, were imaged at 80, 100, 120, and 140 kVp in a dual source CT system at two different degrees of compression. Two radiologists, blinded to the samples, measured the attenuation. The dual-energy index (DEI) was calculated. We performed atomic mass spectrometry for the elemental analysis of pure cocaine, pure heroin, and heroin and cocaine in bodypacks, and 140 kVp in a dual-source CT system. RESULTS: Inter- and intra-observer agreement for attenuation measurements was good (r = 0.61-0.72; p < 0.01). The cocaine bodypacks had a positive DEI of 0.029, while the pure drugs and the heroin bodypacks had a negative DEI (-0.051 to -0.027). Levamisole was the only substance which expressed a positive DEI of 0.011, while the remaining adulterants had negative DEIs ranging between -0.015 and -0.215. Atomic mass spectrometry revealed a concentration of tin in the cocaine bodypack that was 67 times higher than in the pure synthetic cocaine sample. CONCLUSIONS: The different DEIs of bodypacks containing cocaine and heroin allow them to be distinguished with dual-energy CT. Although the material properties of pure cocaine, pure heroin, or common drug extenders do not explain the differences in DEI, tin contamination during illicit natural cocaine production may be a possible explanation.

[Analysis with the Combur-Test--special aspects in forensic trace examination]. / Analysen mit dem Combur-test--Besonderheiten in der forensischen Spurenuntersuchung.

The Combur Test is a ready-made and easy-to-use pretest for blood. It is based on the oxidation of tetramethylbenzidine (TMB), which is catalysed by haemoglobin and its derivatives. Despite its high sensitivity, there are many known substances which are responsible for false positive and false negative test results. On the basis of experiments of our own, case reports and the pertinent literature special aspects of the application of the Combur Test in the forensic routine case work are discussed.

Method to predict the chance of developing a male profile out of mixtures of male and female DNA.

In forensic examination it is a standard to take vaginal swabs from victims of sexual assault for further molecular genetic analysis. Laboratories then are usually confronted with mixtures of lots of female and only a small amount of male DNA. Nowadays it is possible to work with specific Y chromosomal markers after DNA extraction by differential lysis. The determined ratio of autosomal DNA and Y chromosomal DNA can be used to identify the possibility of generating a male profile in these samples.

[Semen analysis using methods of molecular genetics--a case report]. / Anwendung des molekulargenetischen Spermanachweises--ein Fallbeispiel.

The presented case report describes the exclusion of the suspect of a sexual offence by means of methods of molecular genetics. Pretests for prostate-specific antigen performed at the beginning of the investigation and cytological sperm tests were negative. Nevertheless, by combining the methods of differential lysis and DNA quantification a small number of spermatozoa could be demonstrated in the trace evidence. Subsequently, the profile of the woman's boyfriend, with whom she had had unprotected vaginal intercourse two days before the incident, could be detected in the fraction of the hard lysis.

Forensic and psychiatric aspects of joint suicide with carbon monoxide.

A case of joint suicide of a young woman and man who became acquainted in a suicide web forum and used this platform to make an appointment to commit suicide together is described. During their investigation, police were able to reconstruct the events by analysing the computer of the deceased women which was also found with the bodies. An indoor charcoal burning unit was used to release carbon monoxide as the method of suicide.

[Reconstruction of sexual offences--forensic aspects of sperm traces]. / Tatrekonstruktion bei Sexualdelikten--forensische Aspekte von Spermaspuren.

The investigation of sexual offences is a real challenge, as the injuries are often unspecific or faint and may sometimes be missing completely. Evidence recovery and analysis as well as the statements of the victims and suspects are therefore of vital importance. In both presented cases, the results of trace evidence analysis were basically consistent with a sexual assault, but the victims' statements regarding the course of events and the pattern of traces showed severe discrepancies.

Emergence of dendritic cells in the myocardium after acute myocardial infarction - implications for inflammatory myocardial damage.

Dendritic cells (DC) are crucial for T cell mediated immune responses. Recently, we observed a significant decrease in circulating myeloid DC precursors in patients with acute myocardial infarction (AMI). The aim of the present study was to investigate whether myeloid DC are present in infarcted myocardium. Myocardial specimens of 10 patients with AMI and 7 accident victims (controls) were collected after autopsy. In immunostainings the presence of DC (CD209(+), fascin(+)), T cells (CD3(+)), macrophages (CD68(+)), and HLA-DR expression was analyzed. Significantly higher numbers of CD209(+)-DC (97 vs. 44 cells/0.25 mm(2), p=0.03), fascin(+)-DC (54 vs. 8 cells/0.25 mm(2), p=0.02), T cells (27 vs. 6 cells/0.25 mm(2), p=0.02), and macrophages (44 vs. 6 cells/0.25 mm(2), p=0.01) associated with high HLA-DR expression were detected in infarcted myocardium. Frequent colocalizations of DC and T cells were observed. In occluded coronary arteries numerous DC, T cells, macrophages and high HLA-DR expression were found. We show that DC are present in infarcted myocardium after AMI. High HLA-DR expression and the colocalization with T cells suggest that they might trigger an immune response leading to further myocardial damage.

[Reproach of malpractice - legal procedure and possible consequences]. / Der Behandlungsfehlervorwurf - juristisches Prozedere und mögliche Konsequenzen.

Legal liability proceedings against doctors have increased considerably within the last few years. These discussions frequently start with communication problems between doctors and patients. Patients should be informed openly about unwanted incidents; this does not mean recognition of a liability obligation. Many proceedings do not get to courts when an agreement can be obtained after an independent expertise. In addition to a criminal proceeding a civil law liability can follow on proved malpractice. The important steps of legal proceeding and their consequences are represented.

[Sudden death in infancy]. / Der plötzliche Tod im Kindesalter.

In industrial countries, sudden infant death syndrome (SIDS) poses the most common mode of deaths occurring in the postneonatal period. During the last years the incidence has decreased and is currently less than 0.5 per 1000 live births. The cause of SIDS is still unknown. One theory claims that SIDS is due to suffocation caused by failure of central respiratory control, CO(2) rebreathing or airways obstruction. Further pathological factors including hyperthermia as well as impairment of the sleeping- and waking centre are in discussion. The most important risk factors include lying prone, heat exposure of the child, premature delivery, maternal age less than 18 years, smoking and drug abuse during pregnancy and the absence of breast feeding. SIDS is not an entity but a descriptive term for sudden and unexpected deaths in infancy without adequate cause of death being established by methods currently used. SIDS in forensic medicine is not only important because of its relative frequency, but also because of the differential diagnoses which have to be considered in each case. Therefore other natural and unnatural causes of death have to be explored by autopsy and careful postmortal examination (histological, toxicological, microbiological and virological analysis), taking into account circumstances at the death scene and medical history of the infant.

Expression of the carbohydrate tumour marker SLeX, SLeA (CA19-9), LeY and Thomsen-Friedenreich (TF) antigen on normal squamous epithelial tissue of the penis and vagina.

BACKGROUND: Sialyl Lewis x (SLeX), sialyl Lewis a (SLeA), Lewis Y (LeY) and the Thomsen-Friedenreich (TF) antigen are carbohydrate motifs that mediate the adhesion between tumour cells and the endothelium. These antigens are usually not expressed in non-malignant tissue. Overexpression of SLeX and SLeA is combined with poor prognosis and malignant relapse. In this study, we analysed the combined expression of SLeX, SLeA, LeY and TF in normal squamous epithelium tissue of the penis shaft, glans and foreskin and in addition of the vagina and vulva. MATERIALS AND METHODS: Paraffin-embedded slides of vaginal tissue (8), vulva tissue (8) and penis shaft (8) and glans tissue (8) were fixed and incubated with monoclonal antibodies against SLeX (IgM), SLeA (IgM), LeY (IgM) and TF (IgM). Staining reaction was performed with ABC reagent. The intensity of immunohistochemical reaction on images of the slides was analyzed using a semiquantitative score. RESULTS: Strong focal expression of both sialyl Lewis antigens was found in the uretra of the penis shaft and on epithelial tissue of the glans, and permanent moderate expression of SLeX and SLeA in squamous epithelial tissue of the vagina. Moderate expression of TF was observed in male squamous epithelial tissues of the glans and foreskin and faint expression of TF was found in vulval epithelial tissue. Faint expression of Le Y was observed in female vulval epithelial tissue. CONCLUSION: Expression of SLeX, SLeA, LeY and especially of the TF antigen in normal non malignant epithelial tissue is surprising and can be explained by the function of this tissue in human reproduction. In addition, moderate TF expression seems to be restricted to epithelial tissue of the penis glans and foreskin.

Age determination of brain contusions.

In 104 individuals who had sustained traumatic brain injury, the course of traumatically induced morphological changes was investigated immunohistochemically during the first 30 weeks after the trauma. Regarding the inflammatory cell reaction in human cortical contusions, CD15-labeled granulocytes were detectable within 10 minutes following brain injury, whereas significantly increased numbers of nuclear leukocytes occurred after a postinfliction interval of at least 1.1 days (leukocyte common antigen), 2 days (CD3), or 3.7 days (UCHL-1), respectively. A positive nuclear staining for the proliferation marker MIB-1 by cerebral macrophages could be observed as early as 3 days after the injury and regularly in cases with a survival between 7 and 11 days. Injury-induced glial staining reactions could be demonstrated, at the earliest, after a postinfliction interval of 3 hours for α1-antichymotrypsin, 22 hours for vimentin, 1 day for glial fibrillary acidic protein, and 7 days for tenascin. Regarding the vascular response to brain injury, a significantly increased immunoreactivity could be detected in cortical contusions with a wound age of at least 3 hours for factor VIII, 1.6 days for tenascin, and 6.8 days for thrombomodulin, whereas the immunostaining for laminin and type IV collagen was regularly whereas the immunostaining for laminin and type IV collagen was regularly positive even in the vascular endothelium of ininjured brain tissue.

Contact-free isolation of sperm and epithelial cells by laser microdissection and pressure catapulting.

With the PALM MicroBeam system, precise laser microdissection of single cells from cell smears or tissue preparations is possible. Furthermore, this system uses a contact-free and therefore contamination-free laser pressure catapulting technique in which high energy generated by a focused laser pulse catapults single dissected cells into a collecting vessel. In this study, this technique was tested for forensic purposes with smear preparations from postcoital vaginal swabs, sperm swabs, and buccal cell swabs on different types of microscopic slides. Apart from super-frosted slides, cutting and catapulting of selected cells was possible in all cases. Subsequent polymerase chain reaction was performed using the genRES MPX-2 Amplification Kit. In the case of sperm cells stained with hematoxylin and eosin, fragments larger than approximately 200 bp could not be detected. Partial genetic profiles were obtained for DNA amounts originating from only two cell equivalents. Complete profiles, however, were observed with all preparations of a minimum of 10 epithelial cells, demonstrating a potential benefit of this technique for the contamination-free forensic analysis of extremely small specimens or mixed stains.

Influence of lung fixation technique on the state of alveolar expansion-a histomorphometrical study.

Lungs removed at necropsy normally collapse due to the loss of negative pleural pressure leading to a quite unnatural appearance of both gross and histological specimens. In order to demonstrate the influence of post-mortem lung retraction on the degree of alveolar expansion, a histomorphometrical analysis was performed in lungs from a 9-month-old healthy infant. Tissue specimens from the right lung were obtained at autopsy and routinely fixed after retraction ('routinely fixed lung'), whereas the left lung was fixed in situ before opening the thoracic cage ('in situ fixed lung'). The size of the alveoli as well as the thickness of the alveolar walls were measured using an automatic image processing and analysis system (Leica QWIN) in both lungs. The mean alveolar size was 8.7 x 10(3) microm(2) in the routinely fixed lung (alveoli, n=1.1576) and 10.9 x 10(3) microm(2) in the in situ fixed lung (alveoli, n = 841). In contrast, the diameter of the alveolar walls showed no significant difference in both lungs. The average thickness of the alveolar walls was 7.9 microm (measuring sites, n = 1.190) in the routinely fixed lung and 8.1 microm in the in situ fixed lung (measuring sites, n = 1.027), respectively. The results provide evidence of significantly reduced aeration in the retracted and routinely fixed lung which could be of special forensic interest in cases of suspicious infanticide, stillbirth or infant death by drowning or suffocation.

Clostridium fallax associated with sudden death in a 16-year-old boy.

Clostridial myonecrosis or gas gangrene occurs most frequently in contaminated wounds following trauma or surgery. It is caused by a wide variety of Clostridium species, the most common being Clostridium perfringens. Spontaneous, non-traumatic clostridial myonecrosis is uncommon and is usually associated with gastrointestinal and haematological malignancy, diabetes mellitus and peripheral vascular disease. The case of a previously healthy 16-year-old boy with acute onset of gastrointestinal symptoms, who died of bacterial sepsis without apparent preceding trauma, is presented here. Clostridium fallax was identified as the most probable causative agent. As far as is known, this is the first report of fatal sepsis in humans due to C. fallax, which has been described only rarely as a cause of gas oedema in animals.