Cambios histopatológicos en la necrosis miocárdica mediante la expresión de fibronectina / Histopathological changes in myocardial necrosis through fibronectin expression

El objetivo principal del estudio ha sido la aplicación de técnicas inmunohistoquímicas para poder efectuar el diagnóstico de la isquemia miocárdica en fases precoces con un margen mayor de seguridad. Se han seleccionado casos de muerte súbita de origen cardíaco en sujetos adultos, y se ha realizado una valoración descriptiva y semicuantitativa de los hallazgos. El diagnóstico histopatológico mediante la utilización de fibronectina por procedimientos inmunohistoquímicos ha demostrado una sensibilidad muy superior a la de las tinciones habituales. Los resultados altamente satisfactorios y la simplificación al máximo de la técnica pueden contribuir a su implantación en los laboratorios forenses y a que sea aplicada en un número importante de casos judiciales (AU)

The main objective of the study was the application of immunohistochemical techniques in the diagnosis of myocardial ischemia in the early stages with a greater margin of assuredness. We have selected cases of sudden cardiac death in adults, making a descriptive and semiquantitative assessment of the findings. Histopathological diagnosis by inmunohistochemical techniques using fibronectin antibodies has shown higher sensitivity than routine techniques. The satisfactory results as well as well as the simplification of the technique contributes to its implementation in forensic laboratories and application in an important number of forensic cases (AU)

Hemorragia pulmonar masiva presentada como muerte súbita neonatal / Massive pulmonary haemorrhage presented as sudden neonatal death

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Enclavamiento torácico mortal durante un accidente de tráfico / Fatal thoracic impalement during a traffic accident

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Intoxicación Suicida por paracetamol / Suicidal poisoning with paracetamol

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Muerte súbita en un joven con Síndrome de Marfan / Sudden death in a young man with Marfan´s Syndrome

El síndrome de Marfan es un trastorno del tejido conectivo con grados de expresión clínica variable. Las manifestaciones clínicas más importantes de este síndrome suelen localizarse a nivel ocular, esquelético y cardiovascular, siendo estas últimas las que con mayor frecuencia conducen a la muerte. Las complicaciones cardiovasculares se presentan principalmente a nivel valvular y aórtico; en concreto a este último nivel es común observar áreas de degeneración quística de la capa media de la aorta (medionecrosis quística), caracterizada por la presencia de apoptosis y por la pérdida de células musculares lisas. Aunque el sustrato biológico específico es desconocido, se ha atribuido a la existencia de un aumento en la síntesis de ácido hialurónico, un aumento en la solubilidad del colágeno y de la elastina, alteraciones en la cantidad relativa de colágeno tipo I y III y más recientemente la presencia de cadenas de colágeno-alfa2. El interés de este cuadro en Patología forense radica en su posible presentación en forma de muerte súbita sin ningún tipo de clínica previa. Resulta por tanto fundamental identificar cuidadosamente todos los hallazgos necrópsicos para poder relacionarlos con este síndrome. La cuestión posee además un interés epidemiológico al objeto de comunicar a la familia del fallecido aquella información que sea de importancia médica para otros miembros de la misma. Exponemos un caso de estas características en un varón joven, sin patología previa conocida que falleció súbitamente a la salida de una discoteca. El estudio necrópsico reveló una disección aórtica en su porción extrapericárdica como causa responsable de la muerte. El caso se ilustra además con el correspondiente estudio histopatológico específico

Marfan´s syndrome is a disorder of the connective tissue with a variable clinical expression. Clinically the most important manifestations are the ocular, skeletal and cardiovascular ones, which frequently lead to death. Cardiovascular complications involve mainly the valves and the aorta, in fact at this level is common finding cystic medial degeneration areas, characterized by apoptosis and by the loss of vascular smooth muscle cells. Although the specific biological defect is unknown, it has been thought to be an increase of the hialuronic acid synthesis, an increase of the collagen and elastine solubility, the alteration in the ratio collagen type-1 and type-3 and more recently, the presence of collagen-alpha2 chains. The interest of this syndrome in forensic pathology is that it can be present as a sudden death without any previous manifestation, being very important to identify carefully all the autopsy findings to relate them with this syndrome. It has also an epidemiologic interest with the aim of communicating the information that may be of medical importance to other family´s members. We report a case with these characteristics in a young man without previous symptoms who died suddenly at the disco´s exit. The macroscopic examination showed aortic dissection in the extrapericardical portion, considered as cause of the death. The case is also illustrated with the specific histopathologic study

Gastric mucosa lesions in drowning: its usefulness in forensic pathology.

In a retrospective study of 52 autopsy cases of drowning fatalities, death circumstances, macroscopical and histological findings of the stomach mucosa were carefully studied. Results were compared with a control group, composed by 80 cases of different kinds of asphyxia (hanging, chocking and suffocation), skull injuries, sudden cardiac death and poisonings. The spectrum of gastric lesions observed during autopsy in drowning group, are presented. Stomach mucosa tears were found in 21.1% of the cases of drowning, preferably on fundus (54.5%). The control group does not show similar lesions. The physiopathological mechanism of its production, are also discussed. On sight of these results, it is concluded that the macro and microscopical examination of the stomach could be useful as an adjunct procedure for drowning diagnosis. The presence of gastric mucosa lesions has an intravital significance and could be correlated with other anatomical or histological signs of drowning for the diagnosis. In every case, necropsic examination must be carried out as soon as possible in order to avoid putrefactive artifacts.

Proteínas estructurales y mediadores de la inflamación: marcadores para el diagnóstico postmortem de la isquemia miocárdica (estudio inmunohistoquímico) / Structural proteins and mediators of inflammation: markers for the diagnostic postmortem of myocardial ischemia (inmunohistochemical study

El diagnóstico histopatológico post-mortem del infarto de miocardio presenta múltiples problemas en material humano procedente de autopsias. Hasta el presente momento, el problema no ha podido ser resuelto con el uso de las técnicas histológicas convencionales (hematoxilina-eosina, tricrómico de Masson y técnicas histoquímicas). Otra desventaja de este último método es que solo son aplicables sobre tejido fresco. En este estudio, se han recopilado muestras pertenecientes a 50 corazones, procedentes de autopsias de individuos fallecidos por muerte súbita de origen cardíaco. Además, se incluyeron seis casos de infarto de miocardio macroscópico (controles positivos) y ocho casos de muertes rápidas de origen no cardíaco (controles negativos). Se ha investigado la expresión de actina, desmina, mioglobina y factores de Complemento (C5b-9) mediante el método del Complejo avidita-biotina-peroxidasa y su posible utilidad en el diagnóstico postmorten de las muertes cardíacas. Los resultados del estudio, muestran que el método inmunohistoquímico sobre tejido fijado en formol e incluido en parafina es útil para el diagnóstico postmortem de la isquemia miocárdica (AU)

Postmortem histopathological diagnosis of myocardial infarction has many problems in human material coming from autopsy. Until the present moment, this matter hasn’t been resolved by conventional histological procedures (hematoxilin-eosin, Masson´s trichrome and histochemical techniques). Another disadvantage of the enzyme-histohemical technique is that it is only applicable to un-fixed specimens. In this study, 50 myocardial tissue specimens were taken at autopsy from victims who died of sudden cardiac death. In addition, six cases of macroscopic myocardial infarction (positive controls) and 8 cases of rapid and non-cardiac causes of death (negative controls) were included in the study. The expression of actin, desmin, myoglobin and Complement factor (C5b-9) by avidin-biotin-peroxidase complex method, and its possible utility in post-mortem diagnosis of human heart failure, were studied. Results of our study, show that the inmunohistochemical method using formalin-fixed, paraffin-embebed tissue is valuable for post-mortem detection of myocardial ischemia (AU)

Proteínas estructurales y mediadores de la inflamación: marcadores para el diagnóstico postmortem de la isquemia miocárdica (estudio inmunohistoquímico) / Structural proteins and mediators of inflammation: markers for the diagnostic postmortem of myocardial ischemia (inmunohistochemical study)

El diagnóstico histopatológico post-mortem del infarto de miocardio presenta múltiples problemas en material humano procedente de autopsias. Hasta el presente momento, el problema no ha podido ser resuelto con el uso de las técnicas histológicas convencionales (hematoxilina-eosina, tricrómico de Masson y técnicas histoquímicas).Otra desventaja de este último método es que solo son aplicables sobre tejido fresco.En este estudio, se han recopilado muestras pertenecientes a 50 corazones, procedentes de autopsias de individuos fallecidos por muerte súbita de origen cardíaco. Además, se incluyeron seis casos de infarto de miocardio macroscópico (controles positivos) y ocho casos de muertes rápidas de origen no cardíaco (controles negativos). Se ha investigado la expresión de actina, desmina, mioglobina y factores de Complemento (C5b-9) mediante el método del Complejo avidita-biotina-peroxidasa y su posible utilidad en el diagnóstico postmorten de las muertes cardíacas.Los resultados del estudio, muestran que el método inmunohistoquímico sobre tejido fijado en formol e incluido en parafina es útil para el diagnóstico postmortem de la isquemia miocárdica (AU)

Intoxicación suicida por paracetamol / Suicidal poisoning with paracetamol

La intoxicación por paracetamol es un hecho verdaderamente infrecuente, debido sobre todo al elevado rango terapéutico que posee. Los efectos letales de su ingestión a menudo son el resultado de las complicaciones que originan, aunque por efecto directo del fármaco (intoxicación aguda) se producen tanto en suicidios como a causa de sobredosis en búsqueda de analgesia (intoxicación medicamentosa accidental). El presente artículo expone el caso de una mujer joven con antecedentes psiquiátricos, que fallece tras la ingestión de una elevada dosis de esta substancia. La ausencia de información previa, la rareza del método elegido y la inespecificidad del cuadro clínico, complicaron inicialmente la resolución del caso. Los hallazgos necrópsicos, así como el conocimiento de sus antecedentes psiquiátricos y la ulterior investigación policial, fueron claves para aclarar el origen y la etiología médico legal de la intoxicación (AU)

Delayed presentation of carotid dissection, cerebral ischemia, and infarction following blunt trauma: two cases.

Carotid artery dissection followed by cerebral infarction as a result of blunt trauma can occur in a number of forensically relevant situations. We describe two such cases. In the first case, a 19-year-old female was involved in a road traffic accident, when her car crashed into the rear of another car. Initially, the young woman presented a minor head injury without loss of consciousness and minor bruising to the left side of the neck. After 48 h, she had developed confusion, speech difficulties, right facial nerve paralysis, and right hemiplegia. CT scan and carotid angiography showed cerebral ischemia with infarction in the territory of the middle left cerebral artery and complete dissection of the left carotid artery. In the second case, a 33-year-old male with depression attempted to hang himself. The rope gave way and he fell down. He had also taken a paracetamol, and a non-steroidal anti-inflammatory drug overdose. He did not lose consciousness but appeared withdrawn and depressed. Approximately 6 h later, his conscious state deteriorated. A CT scan revealed thrombosis of the left internal carotid artery, extending to the middle cerebral artery. The patient died. Both cases reinforce the need for full neurological assessment and review of any individual subject to blunt trauma to the neck, whether accidental or deliberate or where the history is incomplete. In the forensic setting, in particular, RTAs, suspension by the neck, strangulation, and garotting are all instances when examination and assessment must be thorough--and clear advice given--in the absence of any immediate signs or symptoms--that any new symptoms or signs require immediate and thorough neurological investigation. There should be low threshold for prolonged neurological observation or further neurovascular investigations such as ultrasound, CT or MRI scan or angiography, to minimize the risk of developing potentially fatal or incapacitating sequelae.

Suicidal deaths using fireworks.

The use of commercial explosives is an unusual method of commiting suicide, and only a few cases have been described in the medicolegal literature. In this paper, two cases of suicide are considered that reflect backgrounds of financial problems and psychological illnesses, respectively. Both individuals comitted suicide by detonating an explosive (fireworks). In the first case putting the explosive on his head and in the second case into his mouth. In both cases the cause of death was the destruction of the central nervous system. The following cases emphasize the importance of the forensic pathologist in the recognition of the scene, as well as the systematical collection of trace evidence of the explosion for their subsequent study in the laboratory and their correlation with the autopsy findings.

Suicidio por arma de fuego: hallazgos típicos y atípicos / Suicide by gunshot: typical and atypical findings

El presente artículo examina, desde el punto de vista forense, 32 casos de suicidio por armas de fuego, considerando diferentes parámetros. Mientras que el 78.1 por ciento de las víctimas fueron varones, las mujeres constituyeron solo un 21.9 por ciento de los casos. La mayoría de los suicidios fueron realizados en el domicilio o en sus proximidades. En el 65.6 por ciento de los casos existían antecedentes médicos (alcoholismo o drogadicción) y en el 59.3 por ciento episodios depresivos. En 7 casos se encontraron notas manuscritas anunciando sus intenciones. En 3 casos se apreció más de un disparo. La investigación toxicológica fue positiva en el 84.3 por ciento de los casos. Se describen ciertos problemas encontrados en la investigación, algunos resultados analíticos sorprendentes y casos de ejecución bizarra. Se señala la necesidad de establecer un procedimien-to de examen de las lesiones lo más comprensivo y sistematizado posible (AU)

Surprising drifting of bodies along the coast of Portugal and Spain.

Ocean currents are extremely important as agents affecting the scene of death, because they may transport bodies long distances. Under these circumstances, considerable difficulty is involved when conducting the search for a missing person. Furthermore, when the victim's body is found on the shore of a foreign country, additional complications arise regarding identification. In the medicolegal literature, this issue has rarely been evaluated from a forensic point of view. In this paper, we present the medicolegal investigations performed at the Santiago de Compostela Department of Forensic Medicine and Pathology (Ministry of Justice, Spain) and nine cases of identification of bodies which had drifted a considerable distance from the scene of death. The two bodies were considered to be the victims who committed suicide at the sea side, and the other seven bodies were identified as the victims of the bus accident in the Duero River, Portugal. When the distance and speed of the drifting bodies of the former two were compared to those of the latter seven bodies, it was surprising that the seven victims of the bus accident were found as clustered at the coast of Spain and some of them were pushed by the currents as much as 380 km in only 60 h. Such phenomena has never been reported, and the discovery of the majority of the corpses has had international far-reaching consequences. The identification of the victims was successfully carried out by dentistry, by DNA and in most cases, especially in those related to the bus accident in Portugal, by digital photography sent by electronic mail to the victim's home country. Attention is also given to a possible explanation related to the buoyancy and displacement of the bodies.

Suicidal hanging within an automobile.

Accidental asphyxia related to cars has been described in different reports, but suicidal hanging in an automobile is very unusual. Two cases of suicidal hanging inside an automobile are described, illustrating an unusual form of hanging. In one case, the deceased used his belt as a ligature, and the point of attachment was the window of the car. The second victim used the safety belt of the passenger seat. In both cases, the automobile engine was turned off, all the windows were closed, and the door locks were blocked. The medicolegal cause of hanging was based on the scene of the investigation, police and witness reports, social history, autopsy findings, and toxicologic examinations.

Enclavamiento torácico mortal durante un accidente de tráfico / Fatal thoracic impalement during a traffic accident

El enclavamiento durante los accidentes de circulación es un hecho extremadamente infrecuente. El presente artículo describe un caso que tiene lugar después de que un camión se sale de la calzada y choca contra una vivienda que se encontraba deshabitada. El pasajero que ocupaba el asiento del acompañante sufrió lesiones de escasa consideración, mientras que el conductor falleció al ser enclavado por una tabla, que se desprendió de la techumbre y atravesó su tórax. Se detalla fundamentalmente la morfología de las lesiones. El caso es representativo de un tipo de lesión muy poco frecuente en el contexto de los accidentes de tráfico y por ello posee importancia médicolegal, especialmente cuando surgen controversias acerca de la posición original que ocupaban los pasajeros en el interior del vehículo, en particular el conductor.El cuidadoso examen de la escena de los hechos, de las ropas de la víctima y los resultados de la autopsia, fueron igualmente importantes para llegar a una conclusión válida (AU)

Muerte súbita debida a puente arterial coronario / Unexpected death due to myocardial coronary bridging

Una gran parte de las muertes naturales tienen lugar bajo la forma de una muerte súbita. Este tipo de fallecimientos representan una considerable perturbación económica y emocional para la sociedad y la familia, especialmente cuando afectan a personas jóvenes. En el presente caso se describen las circuns-tancias de la muerte, y los hallazgos macro y microscópicos en un caso de puente coronario intra-miocárdico, presente en un joven de 27 años, que fallece súbitamente mientras realizaba un vigoroso ejercicio físico (cortando árboles). Se practicó una autopsia médicolegal completa, encontrándose como hallazgo principal un puente arterial coronario. Se describen las circunstancias de la muerte, los hallazgos macro y microscópicos, incluyendo la inmunohistoquímica. Se discute la localización y el significado fisiopatológico de este hallazgo (AU)

Unexpected sudden death resulting from anomalous origin of the left coronary artery from the right sinus of Valsalva.

Sudden death accounts for a large proportion of nontraumatic deaths. These deaths represent a considerable financial and emotional burden to the community, especially when they occur in younger age groups. One case of a 14-year-old man, who suddenly collapsed and died while playing soccer at school is shown. A complete medicolegal autopsy was performed, including toxicological analysis and microscopic examinations. During the necropsy, an study anomalous origin of the left coronary artery originating from the right Valsalva's sinus was noted. The present article discusses the possible relationship between this finding and sudden death.

A fatal case of suicidal pentoxifylline intoxication.

Pentoxifylline is a xanthine derivative used in the treatment of peripheral vascular disease. It is considered to be a safe drug and to the best of our knowledge there are no reports in the medical literature of cases of fatal poisoning. There is only one previous report of a young woman who tried to commit suicide by taking a large amount of the drug but recovered. We report the case of a 54-year-old man who took a massive dose of pentoxifylline and died after 24 h from refractory shock. The blood levels of pentoxifylline were as high as 32.5 micrograms/ml where the average therapeutic level is 1.3 micrograms/ml.

An unusual case of death by lighting.

Lightning-related deaths are relatively uncommon, especially indoors. Some cases, involving unusual circumstances, may be of medicolegal relevance. We report a highly infrequent case of fulguration occurring inside a house in a country area. The deceased, a 55-year-old man, was struck by lightning while he was in his bed. Scene investigation and autopsy findings were equally important in finding out the cause of death. We think that the present case is of interest to forensic pathologists because what occurred might be difficult to clarify.