Frontal sinus pattern analysis for human identification using non-contrast computed tomography images: A Sri Lankan experience.

Objective: Morphometry of frontal sinuses has been studied extensively in many countries. However, these findings cannot be generalized due to genetic and environmental factors affecting the skeletal structure. The main aim of this study was to morphometrically analyze the frontal sinuses in patients who underwent non-contrast computed tomography (NCCT) skull imaging at Teaching Hospital Peradeniya and to assess its association with age and sex. Methods: This retrospective study included 300 NCCT skull images obtained by a multi-slice computed tomography(MSCT) scanner at the Teaching Hospital Peradeniya. This age- and sex-matched sample was selected using consecutive sampling and consists of seven age groups (20-29, 30-39, 40-49, 50-59, 60-69, 70-79, and 80-89). Right and left frontal sinus values (length, height, width of each sinus, and total width) were measured using the RadiaAnt DICOM Viewer 2020.2.3 software, and age and sex were obtained from the CT images. The association among the variables was analyzed using the t-test and binary logistic regression model. Results: In our study sample, 59% (n = 177) were male and the mean age was 57.94 years. The means of left side sinus values were larger than right sinus values, which was statistically significant. A statistically significant association was seen between frontal sinus parameters and sex; those of males were higher than that of females. No significant association between the sinus size and age was observed. Conclusion: Morphometric analysis of frontal sinuses using NCCT images is useful for the sex differentiation of unknown bodies for medico-legal purposes. Furthermore, the mean sinus values specific to the current study population will also be helpful in ethnic differentiation.

Self-induced hemopericardium using a syringe needle: A rare method of suicide.

This communication highlights a rare case of suicide by self-induced hemopericardium caused by a penetrating syringe needle. A 20-year-old male, diagnosed with ulcerative colitis, severe depression and hypochondriasis, was found dead at home. There was a 23-gauge 3 cm long syringe needle, connected to a 3 cc barrel, penetrating the left side of the chest. Autopsy revealed 3 fresh puncture marks on the left side of the anterior chest with subcutaneous hemorrhage underlying the puncture marks. The needle had penetrated through the 4th intercoastal space and entered the pericardial cavity causing superficial lacerations to the anterior wall of the heart. There were two anterior pericardial perforations. A hemopericardium of 235 ml was noted. Interventricular septal branches arising from the lower half of the left anterior descending artery were lacerated. Microscopy revealed multiple fresh hemorrhages into the myocardium at the site of myocardial injuries. Toxicological analysis of blood, urine and swabs from the syringe barrel was negative. The cause of death was given as hemopericardium due to laceration of the interventricular septal branches of the left anterior descending artery due to penetration by a 23-gauge syringe needle. The circumstance was concluded as suicidal. Suicide by stab to the chest using a 23-gauge syringe needle, resulting in hemopericardium where the source of blood was the coronary artery, has not been reported in the medical literature. A forensic pathologist must be vigilant and cautious in the interpretation of similar findings especially when cardiopulmonary resuscitation and/or therapeutic intracardiac injections have been administered.

Trap gun: an unusual firearm, aimed at wild animals but causing a silent epidemic of human fatalities.

Among a variety of uncommon firearms of different origin used worldwide, the trap gun used in Sri Lanka is underreported. This is an illegal, locally made, smooth-bore, long-barreled, muzzle-loading firearm with a victim-activated simple trigger mechanism. It is mainly used to protect crops and livestock from the potential harm by wild animals. Trap gun is mounted horizontally on pegs of sticks fixed to the ground. Miscellaneous metal pieces are used as ammunition. A small metal container filled with powdered matchstick heads/firecrackers covered by the striker surface of the matchstick box is used as the percussion cap. A metal hammer is set to hit the percussion cap. Through a lever mechanism, the hammer is kept under tension. The lever mechanism is connected to a trigger cord, which runs across the animal path. The first passerby, a human being or a wild animal, who accidentally trips the trigger cord and activates the trigger mechanism is critically injured. This characteristically damages the lower limbs of the human being. This communication highlights a death due to trap gun injury. The injury pattern caused by trap gun could overlap with that of shotgun and rifled firearm. A meticulous autopsy could sort it out.

Over-a-century-old death investigation system in Sri Lanka: an appraisal for reforms.

Although the death investigation systems in the world are divergent, the prime objective of each system is to certify the cause of death and manner of unnatural and unexplained deaths. In addition, it provides evidence for the purpose of fair administration of justice and data for health sector regulation. Many jurisdictions recently underwent considerable review and made changes to their death investigation systems in accordance with modern innovation in medicine and science. This enhanced the quality of justice in those countries. The death investigation system in Sri Lanka was originally established in 1883 and is a modified model of the British coroners system. However, the system has not undergone significant revisions since then and is confined to an informal traditional framework. The scope of this article was to review the death investigation system in Sri Lanka with a view to amend it in accordance with the current global trends.

The role of the Armanni-Ebstein lesion, hepatic steatosis, biochemical analysis and second generation anti-psychotic drugs in fatal diabetic ketoacidosis.

Diabetic ketoacidosis (DKA) is an acute severe complication of diabetes and characterized by a complex disordered metabolic state due to an absolute or relative insulin deficiency, leads to hyperglycaemia, ketoacidosis and ketonuria. DKA can cause sudden unexpected death and often yields minimal and/or subtle autopsy findings or a negative autopsy and the diagnosis mainly depends upon biochemical analysis of body fluids. This communication highlights the role of Armanni-Ebstein lesion, hepatic steatosis, biochemical analysis and second generation anti-psychotic drugs in 25 adult cases of fatal diabetic ketoacidosis. The study recognises and reconfirms that fatal DKA occurs in both type I and II diabetes. The macroscopic autopsy features observed in this study are non-specific and do not guide the pathologist towards the diagnosis of fatal DKA. Once other possibilities have been excluded, the Armanni-Ebstein lesion alone or the combination of hepatic steatosis and Armanni-Ebstein lesion in an otherwise negative autopsy of a sudden unexpected death should raise the suspicion of DKA as the cause of death and indicate biochemical analysis of body fluids. Our findings also remind forensic pathologists to search for fatal DKA in sudden unexpected death with a negative autopsy, where there is a history of second generation anti-psychotic treatment.

A death following hemopericardium due to rupture of a right ventricular aneurysm due to a congenital ventricular septal defect.

Right ventricular aneurysm (RVA) is a rare clinicopathological entity. Although it occurs as a consequence of a variety of conditions, congenital ventricular septal defect (VSD) as an etiology for the RVA has not been previously reported. A 42-year-old man without a significant family or past medical history was found dead in bed. At autopsy, the internal examination revealed a hemopericardium of 280 mL. There was a 1.5 cm diameter ruptured aneurysm of the free wall of the right ventricle. A VSD was present in the lower part of the muscular interventricular septum. The RVA was directly facing to the VSD without any obstruction in between. Microscopically the wall of the aneurysm consisted only of a thin layer of fibrous tissue transmurally with minimal interspersed cardiomyocytes. Cause of death was concluded as hemopericardium following rupture of RVA caused by a congenital VSD.

Pericardium: an exceedingly rare site for a primary biphasic synovial sarcoma.

Pericardial neoplasms are rare. Among pericardial neoplasms, metastatic spread is more common and primary synovial sarcomas of the pericardium are exceedingly rare. A 61-year-old man was found dead in bed. Autopsy revealed the cause of death as atherosclerotic and hypertensive heart disease. There was a pericardial soft tissue mass lying predominantly over the left atrium. The cut surface was bulging out and grayish white in color with cystic changes. Microscopy showed spindle cells in densely cellular fascicles surrounding the epithelial cells. The epithelial cells were cuboidal and formed glandular structures and cleft-like spaces. Immunohistochemistry demonstrated cytokeratin and vimentin positivity in the spindled areas. Molecular analysis confirmed the diagnosis. Synovial sarcoma may be mistaken for other common neoplasms occurring in the pericardium due to its rarity. In all cases of pericardial tumors, a diligent search for synovial sarcoma by way of histological analysis including, immunohistochemistry and molecular analysis is indicated.

Fatal subarachnoid hemorrhage following traumatic rupture of the internal carotid artery.

Traumatic subarachnoid hemorrhage (TSAH) is a life-threatening intracranial bleed often associated with violent assault or motor vehicle accidents. The vast majority of TSAH is associated with rupture of the vertebral artery, although rare cases of traumatic aneurysm of the internal carotid artery (ICA) have been reported. A 27-year-old man was found bleeding and unresponsive following a violent altercation in which he received repeated blows to the head and neck. CT scan showed acute SAH, and death ensued within 24 h. Autopsy revealed generalized bruising of the face, a complete midline mandibular fracture, and massive basal SAH resulting from traumatic rupture of the right terminal internal carotid artery at the origin of the middle cerebral artery. Anterior and posterior neck dissection revealed focal hemorrhage associated with the right neural arch of the first cervical vertebra (C1). Autopsy findings were consistent with TSAH resulting from rupture of the ICA following blunt force trauma to the head. The rupture site in TSAH can be difficult to locate, and injury to the ICA may be overlooked if not routinely examined. Dissection of the neck and skull base is required to ensure accurate identification of the site of vascular injury.

"Excited delirium syndrome": is it a cause of death?

Excited delirium syndrome (EDS) has become a controversial and vexing forensic issue due to its association with restraint and sudden unexpected death. Although some authorities and jurisdictions recognised EDS as a cause of death there is no consensus among the medical community in this regard. The overlapping nature of the spectrum of antemortem behaviours and signs with many natural disease processes complicates this issue further. We describe two deaths which initially presented as EDS-like behaviour during restraint. In the first case, the deceased was travelling on a long distance flight when he died while in the custody of air cabin crew. The autopsy revealed the cause of death as air travel-related pulmonary thromboembolism. Acute alcoholic intoxication, nicotine withdrawal, hypoxia due to acute pulmonary thromboembolism, and hypobaric environment in the air plane cabin appeared as the potential reasons for EDS-like behaviour. In the second case, the deceased died while in the custody of immigration officials. At autopsy the cause of death turned out to be tense pericardial effusion due to fibrinous pericarditis. In this case, hypoperfusion of the brain following systemic hypotension as a result of cardiac tamponade associated with pericardial effusion likely led to the EDS-like behaviour. Clinicopathologic correlation in these two cases would strongly suggest EDS as the cause of death, had the decedents not had fatal anatomical causes of death. This alerts the forensic pathologist that not all the individuals dying with signs and symptoms of EDS during restraint are accounted for EDS as the immediate cause of death.

Practice of clinical forensic medicine in Sri Lanka: does it need a new era?

Clinical forensic medicine is a sub-specialty of forensic medicine and is intimately associated with the justice system of a country. Practice of clinical forensic medicine is evolving, but deviates from one jurisdiction to another. Most English-speaking countries practice clinical forensic medicine and forensic pathology separately while most non-English-speaking countries practice forensic medicine which includes clinical forensic medicine and forensic pathology. Unlike the practice of forensic pathology, several countries have informal arrangements to deal with forensic patients and there are no international standards of practice or training in this discipline. Besides, this is rarely a topic of discussion. In the adversarial justice system in Sri Lanka, the designated Government Medical Officers practice both clinical forensic medicine and forensic pathology. Practice of clinical forensic medicine, and its teaching and training in Sri Lanka depicts unique features. However, this system has not undergone a significant revision for many decades. In this communication, the existing legal framework, current procedure of practice, examination for drunkenness, investigations, structure of referrals, reports, subsequent legal procedures, undergraduate, in-service, and postgraduate training are discussed with suggestions for reforms.

Fatal pediatric head injury due to toppled television: does the injury pattern overlap with abusive head trauma?

Pediatric head injuries can occur from abusive head trauma (AHT) or accidents. Accidental pediatric head injuries caused by cathode-ray tube televisions (CRTT) toppling have become a 'silent epidemic'. Differentiation between a fatal case of AHT and CRTT toppling could be vexing when the historical and scene evidence are subtle. A 2-year-old girl was found unresponsive in her house and could not be resuscitated. A 27" CRTT was found fallen from its stand onto the floor at the scene. The siblings report that the deceased was climbing on the television stand when it toppled. Autopsy revealed a spectrum of head injuries including, contusions, fractures, bilateral acute subdural hemorrhages, subarachnoid hemorrhages, brain contusion-lacerations and corpus callosal hemorrhages. Microscopy of the eyes revealed bilateral acute retinal hemorrhages. The cause of death was given as crushing injuries of head and brain. The skull fracture pattern is compatible with an accident causing crush injury due to the toppled CRTT rather than AHT. The injury pattern reconfirms that the head is the most vulnerable site in case of CRTT tipover. Although there may be an overlap between the injury pattern in AHT and in CRTT tipover cases, a careful evaluation of the history and scene and autopsy findings such as the crushing nature of the skull fractures and distribution of injury, can solve this problem.

Left-sided ventricular cardiomyopathy with minimal right ventricular involvement.

Left-sided ventricular arrhythmogenic cardiomyopathy is rare and represents a rather different expression of the arrhythmogenic right ventricular (RV) cardiomyopathy (ARVC). Among sudden cardiac deaths, ARVC plays a significant role. ARVC is considered as a cardiomyopathy of unknown aetiology that primarily involves the right ventricle (RV) and is characterized by progressive replacement of myocytes by fibro-fatty tissue, complicating a spectrum of arrhythmias. Predominant ARVC with left ventricular (LV) involvement is also reported. The LV variant of arrhythmogenic cardiomyopathy with minimal or no RV involvement is rare. A 31-year-old previously healthy young man, without a significant family history, was found dead in bed. Autopsy revealed an enlarged heart and asymmetrical LV hypertrophy with widely patent coronary arteries. LV myocardium demonstrated evidence of prominent epicardial fibro-fatty tissue that is predominantly fatty in nature and infiltrates into the myocardium. Microscopy of the LV free wall showed fibro-fatty tissue infiltration into the epicardial aspect of the LV that extends well into the mid-myocardium. A moderate to marked degree of interstitial fibrous tissue deposition was noted about adipocytes and cardiomyocytes. There was no evidence of chronic ischaemic changes or of significant myofibre disarray. The RV showed minimal fibro-fatty infiltration with normal myocytes. This report highlights a rare case which confirms previous observations that the LV variant of arrhythmogenic cardiomyopathy could occur with minimal or no involvement of the RV. Further studies are required in this context to elicit the spectrum and the exact nature of this disease.

Attempted suicidal hanging: an uncomplicated recovery.

Although hanging is common across the world, survival after attempted hanging is very rare with death usually occurring within minutes or over the first 24 hours. If the person survives the initial event, later he/she may die because of the severity of the initial hypoxic and ischemic brain damage. Survival from hanging is often associated with various complications including a large variety of neurological consequences. This case report highlights a rare case of survival in attempted hanging of a 35-year-old man, with previous suicide ideation. Within 15 minutes of the incident, he was brought to a tertiary care hospital. On admission, he was unconscious and the Glasgow Coma Scale was 4 with tachycardia, weak pulse, bradypnea, and shallow breathing. With vigorous and prompt resuscitation methods, he gradually recovered without any residual neurological outcome. Prognostically good results could be achieved, if such victims are vigorously and promptly resuscitated, irrespective of their initial presentation.

Strychnine in amoxicillin capsules: a means of homicide.

Fatal strychnine poisoning is uncommon. It is no longer used as a therapeutic drug and its availability to the public is controlled by legislations in various jurisdictions, but it is still in use as a rodenticide and an adulterant in street drugs. Homicide by strychnine is extremely rare. As the autopsy findings are subtle, strychnine poisoning could easily be overlooked and a homicide may go undetected. This communication highlights an unusual case of homicide by strychnine. It is important that in deaths where there are no gross autopsy findings, sudden death in particular, that routine toxicology be performed, in which strychnine is likely to be detected.

Accidental hanging: a novel mobile suspension apparatus partially hidden inside the clothes.

Accidental hanging is uncommon. An immobile/fixed and exposed suspension apparatus is seen in almost all cases of hanging. A 50-year-old man, who was drunk, was trying to steal an iron rod by hiding it under his clothing. To secure hiding, he attached it to his body by a loose ligature around the neck, the waist belt of the sarong, and another band around the waist and by his underwear. Sometime later, because of ethanol intoxication, he fell asleep in the sitting position. While he was sitting on the floor, the iron rod was lifted up accidentally, and its upper end was wedged against the wall behind the victim, and the lower end was fixed against the floor. When he fell asleep, the weight of the tilted head acted as the constricting force compressing the neck by the ligature that was used to attach the iron rod to the neck. The cause of death was concluded as hanging in a man with ethanol intoxication. This case highlights a novel mobile suspension apparatus partially hidden inside the clothes, in a case of accidental hanging. A similar case has not been reported in the forensic literature.

Alcoholism and the Armanni-Ebstein lesion.

The Armanni-Ebstein lesion is a histological change in the kidney consisting of sub-nuclear vacuolation of the proximal tubules. It has been most associated with diabetic ketoacidosis. The vacuoles have been reported to contain glycogen. More recent studies show them to contain fat. Recent papers have associated the Armanni-Ebstein lesion with non-diabetic ketoacidosis. We present 11 cases of alcoholic ketoacidosis where the Armanni-Ebstein lesion was identified. None had a history of diabetes mellitus and none showed any changes of diabetic nephropathy. All 11 cases had raised acetone levels (3-67 mg/100 mL (mean 17.9 mg/100 mL and median value of 16 mg/100 mL). In addition a case of isopropanol poisoning was found to have the Armanni-Ebstein lesion. Isopropanol is converted to acetone but is not associated with acidosis. These results indicate that the Armanni-Ebstein lesion is not specific to diabetes mellitus.

Sudden unexpected death in epilepsy: a retrospective analysis of 24 adult cases.

Sudden unexpected death in epilepsy is a common form of seizure-related death but is poorly appreciated by the medical profession. A number of risk factors have been identified in this context including male gender, young adult age group (20-40 years), poor compliance with antiepileptic drugs, polytherapy, and presence of neuropathological lesions. In addition it has been noted that most of the victims sustained an unwitnessed collapse at home. In this paper, we describe a retrospective review of 24 adult cases of sudden unexpected death in epilepsy. The study recognizes two risk factors; poor compliance with anti-epileptic monotherapy and an age between 20 and 29 years. All the victims were found dead at home and only one had a witnessed collapse. Our study shows a variety of neuropathological findings as the etiology. The completeness of the autopsy findings for all the cases is a strength compared to some of the other studies.

Accidental hanging by a T-shirt collar in a man with morphine intoxication: an unusual case.

Accidental hanging is rare across all age groups, and it is even rarer in the adult population except in autoerotic asphyxia. Few cases have been reported in the literature, which describe unusual patterns of accidental hanging. This article focuses on an unusual pattern of accidental hanging of a 25-year-old man, who was in a state of morphine-induced central nervous system depression and found dead in a sitting position with the collar of his T-shirt hanging off a jutting-out root of a tree. The hanged collar acted as a ligature compressing the neck.

Death due to hemorrhagic shock after delayed rupture of spleen: a rare phenomenon.

Delayed splenic rupture after blunt trauma is rare and contributes to a significant mortality rate. As this is accompanied by a period of clinical quiescence, a close clinical vigilance is required for early diagnosis and surgical intervention. A case report on death because of delayed rupture of healthy spleen after blunt trauma is presented. The pathophysiology of delayed rupture and importance of early detection are discussed. The case presented is the first known case of death due to delayed splenic rupture in Sri Lanka.

Mechanisms of delayed splenic rupture: a new hypothesis.

A 46-year-old man was assaulted with a club to the face, chest and abdomen. On admission there were no signs of circulatory shock. The abdominal examination was unremarkable. During his stay in hospital he had light diets. He was managed symptomatically and discharged 5 days after the incident. Two hours after discharge he was admitted again with a complain of severe abdominal pain. Immediately after a heavy diet, he experienced this abdominal pain. On admission, he was pale with features of circulatory shock. There was a marked tenderness with rigidity and guarding on abdominal palpation. Without a proper diagnosis he was pronounced dead 13 h after admission. Autopsy revealed a haemoperitoneum. A haematoma was seen overlying a splenic laceration on the gastric area of the visceral surface. The body of the empty stomach was in contact with this haematoma. Histological examination confirmed the perisplenic haematoma of otherwise normal spleen. The pressure exerted by full stomach after heavy solid meals may disturb perisplenic haematoma overlying a laceration on the gastric surface of the spleen causing delayed splenic rupture leading to sudden fatal intraperitoneal haemorrhage.