The Future Is Now: Unraveling the Expanding Potential of Human (Necro)Microbiome in Forensic Investigations.

The relevance of postmortem microbiological examinations has been controversial for decades, but the boom in advanced sequencing techniques over the last decade is increasingly demonstrating their usefulness, namely for the estimation of the postmortem interval. This comprehensive review aims to present the current knowledge about the human postmortem microbiome (the necrobiome), highlighting the main factors influencing this complex process and discussing the principal applications in the field of forensic sciences. Several limitations still hindering the implementation of forensic microbiology, such as small-scale studies, the lack of a universal/harmonized workflow for DNA extraction and sequencing technology, variability in the human microbiome, and limited access to human cadavers, are discussed. Future research in the field should focus on identifying stable biomarkers within the dominant Bacillota and Pseudomonadota phyla, which are prevalent during postmortem periods and for which standardization, method consolidation, and establishment of a forensic microbial bank are crucial for consistency and comparability. Given the complexity of identifying unique postmortem microbial signatures for robust databases, a promising future approach may involve deepening our understanding of specific bacterial species/strains that can serve as reliable postmortem interval indicators during the process of body decomposition. Microorganisms might have the potential to complement routine forensic tests in judicial processes, requiring robust investigations and machine-learning models to bridge knowledge gaps and adhere to Locard's principle of trace evidence.

Positive airway pressure longer than 24 h is associated with histopathological volutrauma in severe COVID-19 pneumonia-an ESGFOR based narrative case-control review.

Background and Objective: A thorough understanding of the pathogenic mechanisms elicited by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) still requires further research. Until recently, only a restricted number of autopsies have been performed, therefore limiting the accurate knowledge of the lung injury associated with SARS-CoV-2. A multidisciplinary European Society of Clinical Microbiology and Infectious Diseases (ESCMID) Study Group of Forensic and Post-mortem Microbiology-ESGFOR team conducted a non-systematic narrative literature review among coronavirus 2019 disease (COVID-19) pneumonia cases assessing the histopathological (HP) effects of positive airways pressure. HP lung features were recorded and compared between mechanically ventilated (>24 hours) and control (ventilation <24 hours) patients. A logistic regression analysis was performed to identify associations between mechanical ventilation (MV) and HP findings. Methods: A PubMed and MEDLINE search was conducted in order to identify studies published between March 1st 2020 and June 30th 2021. Key Content and Findings: Seventy patients (median age: 69 years) from 24 studies were analysed, among whom 38 (54.2%) underwent MV longer than 24 hours. Overall, main HP features were: diffuse alveolar damage (DAD) in 53 (75.7%), fibrosis (interstitial/intra-alveolar) in 43 (61.4%), vascular damage-including thrombosis/emboli- in 41 (58.5%), and endotheliitis in only 8 (11.4%) patients. Association of DAD, fibrosis and vascular damage was detected in 30 (42.8%) patients. Multivariate analysis, adjusted by age and gender, identified MV >24 hours as an independent variable associated with DAD (OR =5.40, 95% CI: 1.48-19.62), fibrosis (OR =3.88, 95% CI: 1.25-12.08), vascular damage (OR =5.49, 95% CI: 1.78-16.95) and association of DAD plus fibrosis plus vascular damage (OR =6.99, 95% CI: 2.04-23.97). Conclusions: We identified that patients mechanically ventilated >24 hours had a significantly higher rate of pulmonary injury on histopathology independently of age and gender. Our findings emphasize the importance of maintaining a protective ventilator strategy when subjects with COVID-19 pneumonia undergo intubation.

Forensic evaluation of two nucleic acid extraction systems and validation of a RT-qPCR protocol for identification of SARS-CoV-2 in post-mortem nasopharyngeal swabs.

The COVID-19 outbreak has represented a challenge for the international scientific community and particularly for forensic sciences. The lack of Coronavirus post-mortem testing led the National Institute of Toxicology and Forensic Sciences (INTCF) from Spain to verify the performance and utility of a quantitative reverse transcription PCR (RT-qPCR) clinical diagnosis protocol for SARS-CoV-2 detection (TaqPath™ COVID-19 CE-IVD RT-PCR Kit), to shed light on the cause of death (COD) in potentially COVID-19 cases in judicial autopsies. Two different RNA extraction methods were also tested (EZ1® DSP Virus Kit on the EZ1® Advanced XL robot versus MagMAX™ Viral/Pathogen Nucleic Acid Isolation Kit) regarding extraction efficiency, precision and contamination. RT-qPCR was evaluated for precision, specificity, limit of detection and concordance. Both the automated and the manual RNA extraction procedures showed good efficiency, but the automated virus extraction by bio-robot produced more reproducible results than the manual extraction. The SARS-CoV-2 RT-qPCR assay showed high sensitivity with a detection limit up to 10 copies/reaction and high specificity, as no cross-reactivity was detected between any of the 12 different RNA viruses tested, including three types of coronaviruses (SARS-CoV, NL63 and 229E). Reproducibility and repeatability of the studied method as well as concordance with other SARS-CoV-2 molecular detection protocols were also demonstrated.

Microbiology in minimally invasive autopsy: best techniques to detect infection. ESGFOR (ESCMID study group of forensic and post-mortem microbiology) guidelines.

This manuscript aims to: 1) provide specific guidelines on PMM techniques in the setting of minimally invasive autopsy (MIA), both for pathologists collecting samples and for microbiologists advising pathologists and interpreting the results and 2) introduce standardization in PMM sampling at MIA. Post-mortem microbiology (PMM) is crucial to identify the causative organism in deaths due to infection. MIA including the use of post-mortem (PM) computed tomography (CT) and PM magnetic resonance imaging (MRI), is increasingly carried out as a complement or replacement for the traditional PM. In this setting, mirroring the traditional autopsy, PMM aims to: detect infectious organisms causing sudden unexpected deaths; confirm clinically suspected but unproven infection; evaluate the efficacy of antimicrobial therapy; identify emergent pathogens; and recognize medical diagnostic errors. Meaningful interpretation of PMM results requires careful evaluation in the context of the clinical history, macroscopic and microscopic findings. These guidelines were developed by a multidisciplinary team with experts in various fields of microbiology and pathology on behalf of the ESGFOR (ESCMID - European Society of Clinical Microbiology and Infectious Diseases - Study Group of Forensic and Post-mortem Microbiology, in collaboration with the ESP -European Society of Pathology-) based on a literature search and the author's expertise. Microbiological sampling methods for MIA are presented for various scenarios: adults, children, developed and developing countries. Concordance between MIA and conventional invasive autopsy is substantial for children and adults and moderate for neonates and maternal deaths. Networking and closer collaboration among microbiologists and pathologists is vital to maximize the yield of PMM in MIA.

COVID-19 y estudios microbiológicos post mortem / COVID-19 and post-mortem microbiological studies

En este artículo se revisan los aspectos microbiológicos de la infección COVID-19 y se presentan las recomendaciones sobre los análisis que deben realizarse en casos forenses. En primer lugar se analizan las características taxonómicas del virus, su relación con la familia Coronaviridae y su estructura genética. Se presentan brevemente las características clínicas y patológicas de la infección COVID-19, así como las coinfecciones que pueden asociarse a este virus. En el diagnóstico de laboratorio se describen la PCR -técnica de elección en la fase aguda de la infección-, los estudios antigénicos y los estudios serológicos. Finalmente se detallan los principales objetivos para los estudios microbiológicos en fallecidos en relación con la pandemia COVID-19 y se describen los principales análisis microbiológicos post mortem a realizar en fallecidos en el ámbito forense. Los estudios microbiológicos deben estar dirigidos tanto a la detección del SARS-CoV-2 como a la de las coinfecciones, que también podrían contribuir a la causa de muerte

We review the microbiological aspects of COVID-19 infection and present the microbiological studies that should be performed in forensic cases. We describe the taxonomic characteristics of the virus, its relationship with the Coronaviridae family and its genetic structure. We briefly present the clinical and pathological characteristics of COVID-19 infection, as well as the co-infections that could be associated with this virus. In the laboratory, PCR is a first-choice technique in the acute phase of the infection, together with antigen and serological studies. Finally, we describe the main objectives of microbiological studies in the deceased in relation to the COVID-19 pandemic, as well as the main post-mortem microbiological analysis to be carried out in the medico-legal context. The microbiological analysis should aim to detect both SARS-CoV-2 and coinfections, which may also contribute to the cause of death

Whole-genome sequencing of Neisseria gonorrhoeae in a forensic transmission case.

Molecular epidemiology and phylogenetic analyses are frequently used in the investigation of viral transmission cases in forensic contexts. Here, we present the methods and results of the analysis of a bacterial transmission episode in an alleged child abuse case using complete genome sequences obtained by high-throughput sequencing (HTS) methods. We obtained genomes of Neisseria gonorrhoeae from the victim, the suspect, and 29 unrelated controls. The analysis of the genomes revealed that the victim and suspect isolates had identical sequences in both the bacterial chromosome and the single plasmid present in them. One of the local controls was very similar (differing in only 2 SNPs) to the case sequences, but the remaining controls were very divergent. Additional cases of identity and very high similarity among controls were observed occasionally, pointing at recent transmission cases. These results were more discriminative than the previous molecular epidemiology analyses performed at the hospital's Microbiology Service, as Multi-Locus Sequence Typing (MLST) could not distinguish between the suspect/victim and the controls isolates, and Pulse Field Gel Electrophoresis (PFGE) was not able to distinguish between the suspect/victim and one of the local controls. These results lead us to conclude that complete bacterial genome sequences obtained with HTS technologies may be a valuable tool for establishing recent transmission cases and, although more studies are needed, they have a great potential for being used in forensic analyses.

Postmortem microbiology sampling following death in hospital: an ESGFOR task force consensus statement.

Postmortem microbiology (PMM) is a valuable tool in the identification of the cause of death and of factors contributory to death where death has been caused by infection. The value of PMM is dependent on careful autopsy planning, appropriate sampling, minimisation of postmortem bacterial translocation and avoidance of sample contamination. Interpretation of PMM results requires careful consideration in light of the clinical history, macroscopic findings and the histological appearances of the tissues. This consensus statement aims to highlight the importance of PMM in the hospital setting and to give microbiological and pathological advice on sampling in deaths occurring in hospital.

Importancia de la autopsia forense en el diagnóstico del shock séptico: a propósito de un caso / Importance of the forensic autopsy in the diagnosis of septic shock: a case report

El shock séptico en ocasiones se inicia con síntomas inespecíficos que dificultan el diagnóstico clínico y por tanto el tratamiento adecuado. Cuando la evolución es fulminante y el resultado es fatal, el único diagnóstico etiológico posible es el post mortem. Las muertes súbitas e inesperadas en los niños y adultos jóvenes son objeto con frecuencia de las autopsias forenses. Algunas muertes súbitas tienen origen infeccioso, lo que obliga a realizar análisis complementarios, incluidos los microbiológicos, para establecer la causa de la muerte. Se presenta el caso de un varón de 19 meses de edad que, tras sufrir un cuadro banal de una herida en el pie, evolucionó hasta shock séptico y fallecimiento como consecuencia de una sepsis por Streptococcus pyogenes, como se demostró en los estudios post mortem (AU)

Septic shock sometimes starts with unspecific symptoms that hamper the clinical diagnosis and, therefore an appropriate treatment. When the septic shock follows a fulminating course with a fatal outcome, the etiological diagnosis has to be conducted post-mortem. Sudden unexpected deaths in children and young adults are frequently the object of medico-legal autopsies. Some sudden unexpected deaths have an infectious origin, which requires further analyses, including microbiology, to establish the cause of death. Here, the case of a fatal septic shock in a 19-month old male infant is presented. After a mild foot injury, an infection by Streptococcus pyogenes progressed to septic shock with a fatal outcome as post-mortem studies demonstrated (AU)

Sugerencias sobre el análisis molecular microbiológico post mórtem. Respuesta de los autores / Suggestions on post-mortem microbiological molecular analysis. Authors reply

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Análisis microbiológico post mórtem / Post-mortem microbiology analysis

La microbiología post mórtem tiene interés en la autopsia clínica y en la médico-legal o forense. En ambas permite confirmar una infección sospechada, aplicándose además en la primera al estudio de donaciones, y en la segunda principalmente a las muertes inesperadas y súbitas. La aplicación de protocolos de recogida de muestras de autopsia minimiza la posibilidad de contaminación, facilitando la interpretación de resultados. El establecimiento de criterios de interpretación específicos para cultivos post mórtem, la aplicación de técnicas moleculares de laboratorio, y su fusión con la biología molecular y la histopatología han permitido que la microbiología post mórtem adquiera un rol protagonista en la autopsia, abriéndose a una nueva dimensión científica. La creación de equipos multidisciplinares que incluyan microbiólogos, forenses y patólogos permitirá una mejora en los servicios que ofrece a la comunidad en aras de una visión integral de la salud que contribuya a la prevención de las enfermedades infecciosas (AU)

Post-mortem microbiology is useful in both clinical and forensic autopsies, and allows a suspected infection to be confirmed. Indeed, it is routinely applied to donor studies in the clinical setting, as well asin sudden and unexpected death in the forensic field. Implementation of specific sampling techniques in autopsy can minimize the possibility of contamination, making interpretation of the results easier. Specific interpretation criteria for post-mortem cultures, the use of molecular diagnosis, and its fusion with molecular biology and histopathology have led to post-mortem microbiology playing a major role in autopsy. Multidisciplinary work involving microbiologists, pathologists, and forensic physicians will help to improve the achievements of post-mortem microbiology, prevent infectious diseases, and contribute to a healthier population (AU)

[Post-mortem microbiology analysis]. / Análisis microbiológico post mórtem.

Post-mortem microbiology is useful in both clinical and forensic autopsies, and allows a suspected infection to be confirmed. Indeed, it is routinely applied to donor studies in the clinical setting, as well as in sudden and unexpected death in the forensic field. Implementation of specific sampling techniques in autopsy can minimize the possibility of contamination, making interpretation of the results easier. Specific interpretation criteria for post-mortem cultures, the use of molecular diagnosis, and its fusion with molecular biology and histopathology have led to post-mortem microbiology playing a major role in autopsy. Multidisciplinary work involving microbiologists, pathologists, and forensic physicians will help to improve the achievements of post-mortem microbiology, prevent infectious diseases, and contribute to a healthier population.

Clinicopathological features of sudden unexpected infectious death: population-based study in children and young adults.

INTRODUCTION AND OBJECTIVES: Infectious diseases are one of the major causes of sudden death, but data of sudden unexpected death from infectious diseases (SUDID) are sparse in children and young people. The aim of this study is to analyse their epidemiological, clinical, pathological and microbiological characteristics. METHODS: Population observational study of all deaths due to infectious diseases in people aged 0-34 years in Biscay between 1991 and 2010. The data of Mortality Register and Forensic Pathology Service were analysed. The SUDID cases in which a forensic autopsy was performed were identified. RESULTS: There were 56 SUDID cases (16% of the all sudden deaths). Myocarditis (n=20) and acute bacterial bronchopneumonia/pneumonia (n=18) were the most frequent causes, followed by meningococcemia (n=5) and viral pneumonia (n=4). A chronic co-morbid condition (mainly drug abuse in young people and moderate low birth weight in infants) was recorded in one-third and prodromal symptoms in two-thirds. Seventeen young people had consumed illegal drugs and/or methadone. In 17 of the 23 autopsies where microbiological analyses were performed, the organism responsible was identified. The incidence of SUDID was 0.6/100000 inhabitants/year, representing 5% of all deaths from infectious diseases. SUDID rate was 1.87 times higher in males than in females. The highest incidence occurred in infants (3.7). CONCLUSIONS: SUDID is infrequent, but it represents a significant proportion of all sudden deaths in children and young people. The relationship between methadone and bronchopneumonia is noticeable. This article stresses the importance of microbiological analyses in SUDID. Investigation based on forensic pathology provides useful epidemiologic, clinico-pathological and microbiological information for prevention of infectious diseases.

Outbreak of invasive group A streptococcal disease among children attending a day-care center.

BACKGROUND: Most cases of invasive group A streptococcal (GAS) disease arise sporadically in the community, but outbreaks of severe invasive GAS infections have been reported in closed environments, such as military populations, family communities and hospitals. An outbreak of invasive GAS disease involving 3 cases of streptococcal toxic shock syndrome (TSS), one with a fatal course, occurred among children attending a day-care center located in Cantabria, Northern Spain. OBJECTIVE: To determine the characteristics of GAS isolates obtained from the outbreak environment. METHODS: GAS isolates obtained from children attending the same day-care facility, staff members, and family contacts were assayed for emm typing, pulse-field gel electrophoresis (PFGE), and toxin-gene content. One isolate obtained from the fatal case was also characterized by multilocus sequence typing. Antimicrobial susceptibility testing was done. Strains from patients unrelated to the outbreak were included for comparison. RESULTS: All GAS isolates from children attending the day-care center, including those from streptococcal TSS cases, shared the same emm type 4, genomic pattern by PFGE (A) and toxin-gene profile. Neither the emm type nor the PFGE pattern or toxin gene profile of the outbreak-associated strains were encountered among GAS isolated from household or staff contacts. CONCLUSIONS: A clone of GAS belonging to emm type 4 and characterized by a specific PFGE pattern and toxin-gene profile was responsible for a community outbreak of streptococcal TSS disease in a child day-care center in Spain. This is the first day-care outbreak reported in our country.

Detection of human herpesvirus-6, Epstein-Barr virus and cytomegalovirus in formalin-fixed tissues from sudden infant death: a study with quantitative real-time PCR.

BACKGROUND: The role of viruses in the context of sudden infant death in early childhood is still unclear, although there are many findings pointing to a viral infection possibly leading to death. OBJECTIVES: To analyse the prevalence and viral loads of human herpesvirus-6 (HHV-6), Epstein-Barr virus (EBV), and cytomegalovirus (CMV), three viruses that have been previously detected in some cases of sudden death in infants, in tissues from sudden infant death syndrome (SIDS) patients and controls. MATERIALS AND METHODS: Thirty-nine formalin-fixed paraffin-embedded tissue sections of eleven consecutive cases of SIDS, and thirty-nine formalin-fixed paraffin-embedded tissue sections of nine control cases were analysed by a specific quantitative real-time PCR for the detection of HHV-6, EBV, and CMV. RESULTS: The comparison of the whole viral DNA prevalence in cases and tissue sections between SIDS and controls showed a statistical significance (72.7% vs. 22.2%, p=0.025; 41.1% vs. 10.3%, p=0.001, respectively); in particular, we found a statistical significant difference for the EBV DNA prevalence among cases (p=0.042) and tissues (p=0.048), and a statistical significant difference for the HHV-6 DNA prevalence among cases (p=0.017). CONCLUSIONS: This is one of the first studies using quantitative real-time PCR for virus detection in cases of SIDS, and the results suggest that some herpesvirus infections, and particularly those caused by EBV and HHV-6 could be related with some cases of SIDS. Further studies will be necessary to understand the real significance of these findings in the context of SIDS.

[Outbreak of streptococcal toxic shock syndrome in a day care center in Cantabria, Spain, 2006]. / Brote de síndrome de shock tóxico estreptocócico en una guardería de Cantabria en 2006.

BACKGROUND: Beta hemolytic group A streptococcus only exceptionally produces aggressive disease with high lethality. Even more uncommon is the occurrence of an outbreak. In Spain, no outbreak in child care center has been previously described. METHODS: Descriptive study of an outbreak of streptococcal toxic shock syndrome (3 cases, one lethal) in a child care center, which motivated the health care intervention with chemoprophylaxis, the closure of the child care center and the study of contacts. We analyzed the determinants of infection in the invasive and non-invasive cases, and the results of the pharyngeal culture of contacts. RESULTS: We identified 3 invasive and 14 non-invasive cases between 40 children attending the child care center (attack rate 42.5%). We studied 19 possible determinants of the infection, finding only an association with being over the age of 24 months and the assistance to the handouts classroom (that of the oldest children). It was not associated with chickenpox. All children attending the child care center, its staff (4 women) and 258 contacts were microbiologically investigated. In 12 children the emm 4 strain was isolated, including 2 of 3 cases with invasive disease. In 13 of 258 contacts other strains of beta hemolytic group A streptococcus were isolated, but in none of them the strain responsible of the outbreak was found. Azytromicin chemoprophylaxis was implemented for all children and contacts, and in those with a positive isolation, the culture was repeated until negative. CONCLUSIONS: The invasive strain circulated only in the child care center. Azytromicin chemoprophylaxis eradicated effectively the infection.

Brote de síndrome de shock tóxico estreptocócico en una guardería de Cantabria en 2006 / Outbreak of streptococcal toxic shock syndrome in a day care center in Cantabria, Spain, 2006

Fundamento: Las infecciones por estreptococo beta-hemolítico grupo A (EGA) sólo excepcionalmente son agresivas y con letalidad alta. Más infrecuente aún es la ocurrencia de un brote. El objetivo de este estudio es la descripción de un brote epidémico por estreptococo beta-hemolítico grupo A en una guardería de Cantabria. Métodos: Estudio descriptivo de un brote de síndrome de shock tóxico estreptocócico (3 casos, uno letal) en una guardería, que motivó una intervención de salud pública con quimioprofilaxis, cierre de la guardería y estudio de los contactos. Se analizan los determinantes de la infección en los casos invasivos y no invasivos, y los resultados de los cultivos faríngeos de los contactos. Resultados: Se identificaron 3 casos invasivos y 14 no invasivos entre los 40 niños de la guardería (tasa de ataque 42,5%). Se estudiaron 19 posibles determinantes de la infección, asociándose sólo la edad mayor de 24 meses y la asistencia al aula de fichas (la de los niños más mayores). No se asoció a la varicela. Se investigaron microbiológicamente todos los niños de la guardería y su personal (4 cuidadoras) y 258 personas de contacto. En 12 de los niños se aisló el estreptococo emm 4, incluyendo 2 de los 3 casos con enfermedad invasiva. En 13 de los 258 contactos se aislaron otras cepas de estreptococo, pero en ninguno la causante del brote. Se hizo quimioprofilaxis con azitromicina a todos los niños y contactos, y a los positivos se les repitió el tratamiento hasta su negativización. Conclusiones: La cepa invasiva circuló sólo en la guardería. La quimioprofilaxis erradicó efectivamente la infección (AU)

Background: Beta hemolytic group A streptococcus only exceptionally produces aggressive disease with high lethality. Even more uncommon is the occurrence of an outbreak. In Spain, no outbreak in child care center has been previously described. Methods: Descriptive study of an outbreak of streptococcal toxic shock syndrome (3 cases, one lethal) in a child care center, which motivated the health care intervention with chemoprophylaxis, the closure of the child care center and the study of contacts. We analyzed the determinants of infection in the invasive and non-invasive cases, and the results of the pharyngeal culture of contacts. Results: We identified 3 invasive and 14 non-invasive cases between 40 children attending the child care center (attack rate 42.5%). We studied 19 possible determinants of the infection, finding only an association with being over the age of 24 months and the assistance to the handouts classroom (that of the oldest children). It was not associated with chickenpox. All children attending the child care center, its staff (4 women) and 258 contacts were microbiologically investigated. In 12 children the emm 4 strain was isolated, including 2 of 3 cases with invasive disease. In 13 of 258 contacts other strains of beta hemolytic group A streptococcus were isolated, but in none of them the strain responsible of the outbreak was found. Azytromicin chemoprophylaxis was implemented for all children and contacts, and in those with a positive isolation, the culture was repeated until negative. Conclusions: The invasive strain circulated only in the child care center. Azytromicin chemoprophylaxis eradicated effectively the infection (AU)

Real-time polymerase chain reaction detection of Neisseria meningitidis in formalin-fixed tissues from sudden deaths.

Accurate identification of meningococcal sudden deaths is needed to avoid underestimation of the true incidence of the disease. This study analyzed the usefulness of a real-time polymerase chain reaction (PCR) protocol using MGB (3'-minor groove binder) probes to detect Neisseria meningitidis in formalin-fixed paraffin-embedded tissues from sudden deaths where a meningococcal fulminating infection was suspected. The protocol included detection of meningococcal DNA (ctrA gene), multiplex B/C PCR serogrouping (siaD gene), and rapid confirmation of PCR products by microcapillary electrophoresis. Sixty-nine tissues from 15 culture-confirmed meningococcal sudden deaths were analyzed (positive cases). Validation studies were performed. In each positive case, both the ctrA and the B/C siaD genes were detected. The ctrA was detected in 81.2% of the samples, whereas the serogroup (B or C) was identified in 44.9% of them. Therefore, this protocol may improve nonculture diagnosis and case ascertainment in meningococcal disease deaths, particularly when formalin-fixed tissues are the only available specimen.

Muerte súbita por meningitis bacteriana y choque séptico: aportaciones del diagnóstico del estudio necrópsico / Sudden death by bacterial meningitis and septic shock: contribution of the post-mortem diagnosis

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