[Fatal therapeutic event after an injection of chlorpromazine]. / Fatalni terapijski zades posle injekcije hlorpromazina.

Accidental deaths after parenteral use of medicaments are usually very rare. The most common cause of death is allergic reaction. In literature, the most menacing medicaments are antibiotics. Taking into account that macroscopic and microscopic autopsy findings are uncharacteristic and poor clinical features and circumstances are more or less characteristic and objective, and that the establishing of cause and mode of death could be a problem for dissectors. Later, in forensic expertise, the questions about medical malpractice could arise. In this paper the authors report on the case of a male, aged 46, a chronic psychiatric patient with schizophrenia, treated by neuroleptics, who died about half an hour after intramuscular injection of chlorpromazine. On the basis of the autopsy, microscopical and toxicological findings, clinical features and circumstances, as well as exclusion of other possible violent and morbid causes of death, it was established that the unexpected and sudden death was caused by anaphylactic allergic reaction due to injected medicament--chlorpromazine.

[Post-traumatic pulmonary and systemic fat embolism in forensic practice. Prospective histological study]. / Posttraumska plucna i sistemska masna embolija u forenzijskoj praksi. Prospektivna histologijska studija.

INTRODUCTION: The more or less subclinical presence of fat emboli in the lungs and other vital organs, without ischaemic changes in them, whose presence could be postmortem established only by microscopic examination, is termed in forensic medicine systemic fat embolism. On the other hand, Fat Embolism Syndrome (FES) is a clinical manifestation of the presence and influence of fat emboli in organs, with clearly defined neurological, respiratory and cutaneous signs and various symptoms, grouped in the so called major and minor signs [8-11]. PURPOSE: The purpose of this paper is to establish the frequency of post-traumatic occurrence of fat emboli in capillaries of the lungs and other organs in cases where the cause of death was not related to pulmonary or systemic fat embolism, but where the typical fat depot injury was established. MATERIAL AND METHOD: A prospective autopsy histological study was carried out. The sample included 56 cases. The clinical and autopsy data were analyzed and compared in order to establish the value of injury Severity Score--ISS. Histological samples of all vital organs were stained by special technique (Sudan III) and the findings in the lungs and kidneys were graded according to Sevitt's criteria [12]. All data were statistically analyzed (chi 2 test, ANOVA). RESULTS AND DISCUSSION: The sample included 38 males (average age 53.10 years) and 18 females (average age 54.84 years). The older (ANOVA; p = 0.0017) males (chi 2 = 7.14; p < 0.01), injured as pedestrians (ANOVA, p-->0) were statistically significantly more represented. The most common determined causes of death were: cerebral contusions (30), exsanguination (22), respiratory disorders (9), combustion (6), spinal cord contusions (1), and others (complication of injuries, such as inflammations or sepsis--4). These causes were singular or competitive plural. The average value of ISS was 34.59 (SD = 13.16) and that of outliving period 3.70 days (SD = 5.88). The distribution of outliving period was log-normal. Pulmonary fat embolism was established in all cases: in 14 cases pulmonary fat embolism of the first degree; in 16 of the second grade and in 26 of the third degree. Pulmonary fat embolism of the third degree could be the precipitate singular or concurrent cause of death. The presence of fat emboli in glomeruli was established in 39 cases: in 30 cases the kidney fat embolism of the first degree was established, in 6 of the second degree and in 3 cases of the third degree. In 11 cases the presence of fat globules in brain capillaries was established and in 3 cases in the capillaries of other organs (heart, liver, spleen). By analyzing the clinical and autopsy data, as well as microscopic findings, we concluded that in four cases the cause of death was associated with systemic fat embolism, what previously had been missed. CONCLUSION: In all our sample cases pulmonary fat embolism was verified, and in a great number of them systemic fat embolism. According to medicolegal principles, pulmonary and systemic fat embolism that develop a few hours after trauma can be considered as a consequence of typical body fat depot injury. The later developed FES could be considered as the complication of such an injury. Pulmonary and systemic fat embolism could complicate the basic trauma, e.g. craniocerebral, abdominal or thoracic, and could be considered as the precipitating cause of death. Because of non-specific and non-characteristic macroscopic autopsy findings, pulmonary and systemic fat embolism could be missed as the cause of death.

[Post-traumatic systemic fat embolism syndrome. Retrospective autopsy study]. / Posttraumski sindrom sistemske masne embolije. Retrospectivna autopsijska studija.

INTRODUCTION: The obstruction of blood vessels or heart chambers with fat globules, reached by circulation, is fat embolism [1, 2]. Clinical manifestation of the presence of fat emboli in vital organs is Fat Embolism Syndrome (FES). This syndrome is characterized by neurologic, respiratory and cutaneous signs and different symptoms [5-8], grouped in major and minor signs by Gurd and Wilson. PURPOSE: The purpose of this paper is to analyze and compare the autopsy findings and clinical data in cases where FES is emphasized as the single or concurrent cause of death after performed autopsy. MATERIAL AND METHOD: This retrospective study includes the autopsy material of the Institute of Forensic Medicine in Belgrade, over the period 1985-1998 when FES is pointed out as a cause of death. The severity of trauma for each case was determinated by Injury Severity Score (ISS). The microscopical findings, which are incorporated in autopsy reports, were separately analyzed. The sample was statistically prepared (chi 2 test, ANOVA). RESULTS: The sample included 56 patients: 43 males (average age 51.65 years) and 13 females (average age 65.07 years). The proportion of men was more significant (chi 2 test = 8.98; p < 0.01) as well as the persons aged 60-80 years (ANOVA, p = 0.0017). In our sample there were more pedestrians (32 patients) (Anova, p-->0) than other injured persons. Fractures of the femur, tibia and/or pelvic bones were typical injuries in each examined patient. The authors combined the clinical and autopsy data in order to get the ISS value. The mean ISS value was 20.65 (SD = 7.47). The mean value of the surviving period was 5.8 days (SD = 3.6). The sample distribution of surviving period was normal (Gauss distribution). The latent period from injury to the onset of the first major FES signs was about 24 hours (32 patients had one of the major FES signs during the first 24 hours after admission; 8 patients after 24-48 hours and 10 after 48 hours after admission). Six patients who were admitted in deep coma were not analyzed. DISCUSSION: The most common first major FES sign refers to the sudden onset and rapid progressive qualitative or/and quantitative disturbance of conciousness (deep coma developed after a short period, without obvious causes) in 40 cases. In six patients ophthalmological characteristic retinal blood vessels changes were found: they pointed to FES. The second major FES sign was respiratory disturbance alone (manifested at first as chest pain and spitting of blood, and later as disturbances in artery blood gas analysis), or in combination with disturbed conciousness--in 15 cases The characteristic later developed cutaneous chest and axillary rush as the only specific FES sign was established in 11 cases (surviving period was from 5 to 12 days), but clinically only in one case. In addition to objective difficulties, in most cases, one of the minor FES signs was established: in 22 cases haematological disturbances (i. g. low value of haematocrit, haemoglobin, number of platelets or/and coagulation factors); in 13 cases hyperpirexia, and other minor FES signs only occasionally. The postmortem diagnosis of FES could be established only microscopically (Sudan III staining). Bronchopneumonia (24 cases), hyaline membranes (7 cases), as well as lung oedema and alveolar haemorrhages (in almost two thirds of the sample) were the most common microscopical findings in the lung as complications of FES. The most characteristic postmortem brain findings in FES are dotted perivascular haemorrhages, mostly in the white matter. These changes were not established in 7 cases (surviving period was 1 to 2 days), but the especially stained sections pointed to FES as the cause of death. In addition to various chronic pathological changes, only intestinal haemorrhages and/or oedema of solid organs could be established microscopically. CONCLUSION: In the analyzed sample of 56 patients who died of FES, FES was clinically established onl

[Multidisciplinary investigations in dead persons suspicious of AIDS]. / Multidisciplinarna istrazivanja kod osoba umrilih pod sumnjom na ejds (AIDS).

The background of AIDS is the deregulation of the cellular immune system caused by HIV infection. AIDS has proved to be entirely different from any previous known diseases. It affects practically all the tissues and organs of the human body. Clinical and autopsy diagnoses are confronted with an incomparable diversity of inflammatory, vascular, degenerative and neoplastic changes. Thanks to clinical and pathological researshes, the medical knowledge of AIDS has rapidly progressed. The Institute of Forensic Medicine is, for now, the unique medical institution organized to perform obligatory autopsies of drug-addicts, to detect the other cases suspect of HIV infection or some AIDS indicative diseases. The aim of this study is to establish the basis for multidisciplinary investigations of AIDS and to solve very important problems such as: a) to accept the diagnostic criteria for correct diagnosis of AIDS, with or without laboratory evidence of HIV infection; b) to recognize the early stadium of clinico-pathological entities associated with HIV infection; c) to improve the "indicator" of AIDS disease for daily medical practice.