Evaluation of screening for drug use using postmortem prolactin levels in serum and cerebrospinal fluid.

Prolactin (PRL) levels can usually be controlled by PRL-inhibiting psychiatric drugs that include anti-dopamine agents. However, the use of dopamine (DA) antagonists may lead to hyperprolactinemia under certain clinical conditions. The aim of this study was to investigate postmortem PRL levels as potential markers of drug abuse, especially that of DA antagonists, in autopsy cases. We examined 121 autopsy cases, excluding cases involving acute hypoxia/ischemia, such as asphyxia, because PRL concentrations are reportedly increased under acute hypoxic conditions. Detected drugs were classified as either DA antagonists, stimulants, psychotropic drugs other than DA antagonists, or other non-psychotropic drugs, and many cases had no detected drugs. Samples comprised blood collected from the right heart chamber and cerebrospinal fluid (CSF). PRL protein level was measured by chemiluminescent immunoassay, and PRL gene expression in the anterior pituitary of autopsy cases was analyzed by reverse transcription-polymerase chain reaction. The PRL-positive cell ratio in the anterior pituitary gland was also measured by immunohistochemical analysis. The results indicated that PRL levels in the serum and CSF were higher in DA antagonist cases than in other cases. PRL levels in the serum and CSF also correlated with the PRL gene expression in cases with abuse of DA antagonists. However, no significant difference in the PRL-positive cell ratio in the anterior pituitary gland was evident between any of the classes of drug-detected and drug-undetected cases. These results suggest that postmortem measurements of PRL transcription levels may be useful for diagnosing cases of DA antagonist use.

Intranuclear ubiquitin immunoreactivity of the pigmented neurons of the substantia nigra in fatal acute mechanical asphyxiation and drowning.

To evaluate the significance of immunohistochemical staining of ubiquitin (heat shock protein) in the midbrain for the medico-legal diagnosis of fatal asphyxiation and drowning, we investigated forensic autopsy cases of fatal mechanical asphyxia (n = 18), manual/ligature strangulation (n = 9), hanging (n = 4), aspiration/choking (n = 5) and drowning (n = 16). These were compared to control groups (n = 30) consisting of fatalities from brainstem injury (n = 12) and acute myocardial infarction (n = 18). Ubiquitin was clearly demonstrated in the nuclei of pigmented substantia nigra neurons, showing two intranuclear staining patterns: a type of inclusion (possibly Marinesco bodies) and a diffuse staining. The diffuse staining was significantly more frequently observed in cases of drowning. The percentage of total ubiquitin positive neurons was frequently higher in strangulation (5.1-28.4%, mean 17.0%), aspiration/choking (5.3-32.0%, mean 17.6%) and drowning (7.0-34.1%, mean 19.8%), but relatively low in hanging (5.1-12.7%, mean 8.6%), brainstem injury (0-10.4%, mean 5.0%) and acute myocardial infarction (1.5-16.9%, mean 8.3%). These observations suggest that intranuclear ubiquitin immunoreactivity of the pigmented substantia nigra neurons in the midbrain was induced by a fatal severe stress on the central nervous system in asphyxiation and drowning.

Intranuclear ubiquitin immunoreactivity in the pigmented neurons of the substantia nigra in fire fatalities.

To evaluate the significance of immunohistochemical staining of ubiquitin (heat shock protein) in the midbrain for medico-legal investigation of death in fires, we examined forensic autopsy cases of fire fatalities (n = 35) in comparison with controls (n = 27; brain stem injury, acute myocardial infarction and carbon monoxide poisoning other than fire fatality). There were two intranuclear staining patterns in the nuclei of pigmented substantia nigra neurons: a type of inclusion (possible Marinesco bodies) and a diffuse staining. Percentage of nuclear ubiquitin positivity (Ub-positive %) in fire fatalities (2.7-44.7%; mean, 18.5%) was significantly higher than in brain stem injury (n = 9; 0-10.4%; mean, 4.5%) and myocardial infarction (n = 14; 1.5-14.6%; mean, 6.9%), independently of blood carboxyhemoglobin (COHb) levels. Age-dependent increase in Ub-positive % was observed in lower COHb (< 60%) cases. The intranuclear diffuse ubiquitin staining was not observed in cases of high blood cyanide level (> 1.0 microg/ml). These observations showed that intranuclear ubiquitin immunoreactivity of the pigmented substantia nigra neurons in the midbrain was induced by severe stress in fires.

Immunohistochemical investigation of pulmonary surfactant-associated protein A in fatal poisoning.

To evaluate the immunohistochemical distribution of pulmonary surfactant-associated protein A (SP-A) in fatal poisoning in relation to the effects of drugs and poisons on respiratory function, 42 forensic autopsy cases were examined by scoring the staining intensity. The highest scores of SP-A staining, with dense granular deposits (aggregates) in the intra-alveolar space, were observed in fatalities from pancuronium bromide (muscle relaxant) injection and petroleum (butane) gas inhalation. Poisoning with organophosphate pesticides and arsenic (ingestion) showed a second grade SP-A score. However, The SP-A scores were relatively low in ethanol and sedative-hypnotic intoxication. Carbon monoxide intoxication showed a varied degree of SP-A score, and the aggregated SP-A score tended to be higher in cases of lower blood carboxyhemoglobin concentration. A varied SP-A score was also observed in methamphetamine fatalities, in which the score was relatively low in cases with a higher serum drug level. Increase of SP-A was not always associated with the intra-alveolar effusion or hemorrhages. The above-described observations suggested that the immunohistochemical score of SP-A may be a possible indication for intensity and duration of drug/poison-dependent respiratory distress.

Fatal traumatic rupture of an aortic aneurysm of the sinus of Valsalva: an autopsy case.

This report describes an autopsy case of a rare type of aortic sinus of Valsalva aneurysm, which caused fatal rupture from a blunt chest impact. A 51-year-old male was hit in the chest with a fist, lost consciousness after about 15min and died after approximately 7h. The postmortem examination revealed a large saccular aneurysm of the right coronary sinus bulging on the right atrium, which had a full laceration causing pericardial hematoma (cardiac tamponade). A related chest wall injury was observed in the right outer mammary region. A rare type of bulging onto the right atrium and subsequent sclerosis of the right coronary artery appeared to have greatly contributed to the fatal rupture.

Post-mortem urinary myoglobin levels with reference to the causes of death.

To evaluate pathophysiological significance of post-mortem urinary myoglobin levels in determining the cause of death, we investigated 210 forensic autopsy cases, partially in comparison with serum levels. Post-mortem serum myoglobin levels were extraordinary high in most cases possibly due to post-mortem change. Urinary myoglobin levels did not correlate with the serum levels, showing possible post-mortem elevation in cases of a prolonged post-mortem period over 48h. A high (>1000 ng/ml), moderate (100-1000 ng/ml), slight (50-100 ng/ml) and not significant (<50 ng/ml) elevation of urinary myoglobin were observed in 26, 43, 31 and 110 cases, respectively. Half the highly elevated cases were those with a survival time over 24h. In cases of minor muscle injury such as head trauma, elevation of urinary myoglobin level was closely related to longer survival. In acute/subacute deaths with a post-mortem interval within 48h, a significant difference was observed in relation to the blood carboxyhemoglobin (COHb) levels of fire victims: myoglobinuria over 100 ng/ml was more frequently and markedly observed in cases with COHb below 60% than over 60%, suggesting muscle damage in fatal burns. Similar elevation was observed in heat stroke victims, and also in some cases of acute and subacute death from polytrauma, asphyxiation, drowning, electricity and spontaneous cerebral bleeding, but not in myocardial infarction. Thus, it was suggested that high post-mortem urinary myoglobin levels in acute and subacute death cases may be a possible indicator of antemortem massive skeletal muscle damage as well as exertional muscle hyperactivity or convulsive disorders associated with hypoxia.

Immunohistochemical investigation of pulmonary surfactant-associated protein A in fire victims.

To evaluate the forensic pathological significance of the immunohistochemical distribution of pulmonary surfactant-associated protein A (SP-A) in determining the cause of death in fires, 57 fire victims were examined by scoring the staining intensity. The highest SP-A score with dense granular deposits (aggregates) in the intra-alveolar space was frequently observed in cases with a lower blood carboxyhemoglobin (COHb) level (<60%). The SP-A score was relatively low in carbon monoxide intoxication due to causes other than fires. High SP-A scores showed a relation to the serum level and in part related to the bloody exudate in the lower airway. These observations suggested that the increase in SP-A in fire victims may be mainly related to pulmonary alveolar injury due to the inhalation of hot air and/or irritant gases rather than hypoxia.

Child and elderly victims in forensic autopsy during a recent 5 year period in the southern half of Osaka city and surrounding areas.

To outline the recent features of child and elderly victims from the medico-legal perspective with special reference to abuse and neglect, a retrospective investigation of forensic autopsy cases over a 5 year period (1994-1998) in the southern half of Osaka city and surrounding areas (a population of 1.57 million) was undertaken. Among 646 autopsy cases, there were 53 child cases (under the age of 15 years, about 80% below 6) and 121 elderly cases (65 years old and above). Nearly half of the child deaths and more than half of the elderly deaths were described as accidental. Fire and traffic victims were much more frequent in the elderly. Child victims included those of neonaticide/infanticide (n=6), physical abuse (n=10), unintentional fatal infliction (n=2), neglect (n=2), mutual suicide (n=2), suicide (n=1) and murder (n=3). Child abuse and neglect were domestic maltreatment by the parents. In this series, there was a comparable number of fatalities due to maltreatment in the elderly (n=13) and in children, and non-domestic violence was more frequent in the elderly than domestic violence. Elderly females tended to be battered by their sons or grandsons in domestic violence cases, whereas males were predominantly attacked by younger males in non-domestic violence. The other elderly victims included those of self-neglect (n=2), murder (n=7) and suicide (n=9). Non-domestic homicide of the elderly occurred mainly in the center of the city, whereas domestic maltreatment of children and the elderly was sporadic, although somewhat more frequent in the peripheral zone of the city and the surrounding areas. The above profile of child and elderly abuse suggests a substantial influence of social and familial backgrounds.

Automated determination of carboxyhemoglobin contents in autopsy materials using head-space gas chromatography/mass spectrometry.

To establish a method for the routine analysis of carboxyhemoglobin (COHb) in autopsy materials including those which have undergone postmortem changes, e.g. thermo-coagulation, putrifaction and contamination, an automated head-space gas chromatography/mass spectrometry (GC/MS) analysis was utilized. The procedure consisted of preparation of the sample in a vial and a carbon monoxide (CO) saturated sample, for estimation of hemoglobin content, in another vial, the addition of n-octanol, potassium ferricyanide and an internal standard (t-butanol), GC separation and determination of CO using a GC/MS system equipped with an automated head-space gas sampler. The method was practical not only with the blood and bone marrow aspirates to confirm the findings on the CO-oximeter system, but also with the thermo-coagulated and putrified blood.

Methamphetamine-related fatalities in forensic autopsy during 5 years in the southern half of Osaka city and surrounding areas.

To outline the recent features of methamphetamine-related fatalities from the medico-legal point of view, a retrospective investigation of forensic autopsy cases involving methamphetamine during a 5-year period (1994-1998) in the southern half of Osaka city and surrounding areas (about 1.57 million population) was undertaken. Among 646 autopsy cases, methamphetamine was detected in 15 victims (nine males, six females; 16-71 years of age; most frequently in males in their thirties). Primary scenes of fatal events were concentrated in the middle of the city. About half of them were transferred from emergency medical centers (survival time, up to 30 h). The cause and manner of death were: methamphetamine poisoning (n=4), homicide (n=4), accidental falls and aspiration from drug abuse (n=4), fire death (n=1), myocardial infarction (n=1), and cerebral hemorrhage (n=1) under drug influence. Usually injection scars and fresh puncture sites were found. Blood methamphetamine concentrations were 2.29-17.05 micromol/dl in the fatal poisoning, 0. 44-3.80 micromol/dl in deaths from other extrinsic causes (trauma), and 1.35-2.17 micromol/dl in cardio- and cerebrovascular strokes. Common complications were cardiomyopathy, cerebral perivasculitis and liver cirrhosis/interstitial hepatitis. Fatal and nonfatal methamphetamine poisonings are separately dealt with by the administrative medical examiner's office and in emergency medical centers. Tightly cooperative approaches of clinical and medico-legal experts are required for the effective social and medical management of drug abuse.

A case of serial homicide by injection of succinylcholine.

The abstract of this paper was presented at the 14th Meeting of the International Association of Forensic Sciences, Tokyo in 1996. We report a bizarre criminal case of suspected serial homicide by injection of a muscle relaxant (succinylcholine). Five victims were found buried in a rural area. In two victims showing moderate decomposition (about three months after death), intense pulmonary oedema with pleural effusion was observed. Evidence of a puncture site was found in one of the victims. Succinylcholine could not be detected in the victims, but was identified in a syringe found near the corpses. The 40-mg ampule dose of succinylcholine administered intramuscularly to the victims, possibly causing prolonged apnea, was considered to be at least around the minimum lethal dose, although the combined effect of the sedation with hypnotics also used was not negligible.

Sudden infant death attributed to peracute pulmonary infection: two autopsy cases.

This report describes two autopsy cases of sudden infant death attributed to peracute pulmonary infection in which possible causative microorganisms could be identified despite only minor pathological findings. Both babies were 5-month-old boys, who had no symptomatic disorders and were found dead in bed. Their main macropathology was inflated heavy lungs with patchy bleedings. One case showed a pulmonary histopathological finding suggestive of viral infection, and adenovirus DNA was detected from the intrabronchial fluid. In the second case, pulmonary histopathology was a feature of early inflammatory reaction involving focal necrosis with some neutrophil infiltration and many intra-alveolar macrophages containing gram-positive cocci, and Staphylococcus aureus was identified in venous blood culture. These findings significantly support the presence of pathogenic microorganisms in sudden infant death.

Dental identification in routine forensic casework: clinical and postmortem investigations.

The aim of this study was to examine the factors which may disturb dental identification of unknown human remains and the practical value of dental evidence in routine forensic casework, including the changes due to dental treatment and postmortem interference. In the investigation of changes due to dental treatment on 696 patients' dental history at two clinics, increase of the number of dental restorations was the greatest in the initial 1-2 years. This finding suggests that dental treatments performed in early period after initial examination contributes more to forensic dental identification than those performed afterwards. The lower anterior teeth (incisors and canines) remained relatively unchanged for years compared with other teeth. The molars appeared to be more frequently restored at a relatively younger age and more frequently missing in the elderly. The investigation of 260 unknown remains in 971 forensic autopsy cases during a period of seven years (1992-1998) at our institute indicated the particular usefulness of dental evidence in cases where the candidates were identified from some other evidence, and usually in cases having a postmortem period corresponding to the obligatory preservation term for the clinical dental records and radiographic films. There were non-identity in the status of dental treatments between ante-mortem dental findings due to additional treatments received after the last day of examination recorded in the corresponding clinical dental records. Postmortem damage from decomposition and fire was more frequently observed in the anterior teeth. These observations indicate that precise documentation of dental evidence including postmortem deterioration and the establishment of a well-organized dental database of missing persons together with a suitable screening system is required to more effectively utilize dental evidence in routine forensic casework.

Significance of DNA analysis for determination of ABO blood groups from hair and nail of decomposed human remains: a comparison with phenotyping by the absorption-elution method.

Seventy samples from 35 decomposed human remains were investigated for ABO histo-blood group phenotypes and genotypes by the absorption-elution method and PCR-RFLP, respectively. Phenotypes could be determined by the absorption-elution method in all cases except for some failures to detect A and H antigens from scalp hair. Genotyping was also usually successfully performed using nails when intact samples were available. The findings using hairs appeared to depend on the postmortem interval. In this series, an inconsistency between ABO phenotyping and genotyping was observed in two cases, suggesting postmortem antigenic alteration in hair and nail. These findings suggested the usefulness of serial examinations by phenotyping and genotyping for reliable ABO blood grouping of badly decomposed remains.

Decapitation in suicidal hanging--a case report with a review of the literature.

We report a case of self-decapitation by suicidal hanging from a river bridge and discuss the decapitation mechanism, reviewing the literature. The torso and the head of the victim, respectively, were found apart in a river approximately 100 m and 600 m, respectively, downstream from the bridge in two days. Morphological, serological and DNA analyses confirmed their identity. Torn ligaments between the atlas and axis accompanied by fractures in the axis at the partes interarticulares were indicative of a traction force combined with anteroflexion of the head by falling from a height, and the radial pressure due to a strong, single twisted nylon rope with a slip knot was considered to have contributed considerably to the subsequent skin laceration with wavy marginal abrasions. In the reviewed literature, cervical spine fractures were described only in two of six cases, suggesting head movement at the time of decapitation.

Wounding dynamics in distorted bitemarks: two case reports.

An essential factor involved in distortion of bitemarks on the skin is the dynamics of biting related to the location on the body. This study describes the comparison between the identification of bitemarks left on different regions of the victims' bodies in two homicide cases. The findings indicated that a stepwise dynamic comparison of serial adjacent marks with a part of the dentition in consideration of movement of the jaws and distortion of the skin was useful in identifying matching points. The identification process indicated possible wounding dynamics of biting.

A sudden death due to cardiac conduction system injury from a blunt chest impact.

We report a case of sudden death due to cardiac conduction system injury from a blunt chest impact. A 20 year old male, kicked in the precordial region, lost consciousness, and was confirmed dead on arrival at a hospital emergency care unit. According to his friends, they played a golf competition accompanied with a physical punishment. The victim, losing the game, allowed the winner to give him several kicks in the chest. Although well prepared against each kick, he fell down instantaneously after the final impact, and death was confirmed at a hospital. There was no apparent sign of injury on the body surface. At autopsy, there was no evident subcutaneous or intramuscular hemorrhages, rib or sternum fracture. Subendocardial hemorrhage in the region of the atrioventricular node and a contusion extending from the posterior wall of the left ventricle to the upper ventricular septum were observed. Histological examination revealed injury of atrioventricular node and His' bundle. Although the cardiac injury including contusion of the myocardium itself was not so extensive, it was considered that arrhythmia was induced by the cardiac conduction system failure, which was considered to be the cause of death.

Pulmonary embolism: a case of sudden unexpected death in a psychiatric hospital.

We report a case of suspected fatal physical abuse in which the cause of death was proved to be pulmonary embolism. A patient with mental retardation presenting aggressive behavior was admitted to a psychiatric hospital and was treated with major tranquilizers. She suddenly died subsequent to an angina-like attack. For several days before her death, she had been confined to her bed because of very low physical and mental activity. Bruises and abrasions were observed on the extremities, suggesting the recent restraints. There was no positive evidence of physical abuse. At autopsy, the cause of death was elucidated to be pulmonary embolism originating from thrombi in the left popliteal vein. This case indicates the risk of pulmonary embolism in immobilized patients in psychiatric hospitals.

Sudden death following psychiatric electroconvulsive therapy: a case report.

We report a case of sudden death following psychiatric electroconvulsive therapy (ECT). A schizophrenic patient with manic excitement (39-year-old male) in a mental hospital died while vomiting immediately after ECT. The cause of death was diagnosed as asphyxia due to aspiration of vomitus (choking). It is now considered that ECT is an effective treatment for a range of psychiatric disorders and the benefit-risk ratio is equal to or greater than that of psychoactive drugs. Recently, however, there have been 2 other forensic autopsy reports of death due to ECT in Japan. These cases suggest that more effort and careful management are necessary to prevent the accidental deaths.

Detection of bromisovalum from the bone marrow of skeletonized human remains: a case report with a comparison between gas chromatography/mass spectrometry (GC/MS) and high-performance liquid chromatography/mass spectrometry (LC/MS).

We report a case of totally skeletonized human remains in which a considerable amount of a hypnotic, bromisovalum (bromovalerylurea), was detected from the bone marrow. The unknown skeletal remains were found in a bush, together with empty vials of bromisovalum and a water bottle. The body was identified as a 46-year-old male, who had died about seven months previously. There was no evidence of trauma. The dried bone marrow of both femurs was separately collected and toxicologically analysed by gas chromatography/mass spectrometry (GC/MS) and a high-performance liquid chromatography/mass spectrometry (LC/MS). Bromisovalum was identified from the femurs. The concentration along with the circumstantial evidence suggested possible contribution of bromisovalum to the fatality. However, a considerable quantitative difference was observed between the left and right femur, showing significant post-mortem interference to toxicological evidence. The result showed that multiple sampling at least would be required for quantitative evaluation of post-mortem toxicological evidence. Moreover, the diagnostic value should also be considered with caution in relation to the load to bone marrow ratio of each drug concentration.