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. 2017 Nov 1;7(1 Suppl):S-72–S-146. doi: 10.1177/192536211700701S02

Poster Presentations

PMCID: PMC6474428
Acad Forensic Pathol. 7(1 Suppl):S-72–S-146.

Detection of Methanol in a Subdural Hematoma after Embalming

BE Criss 1., RH Powers 2., RG Topmiller 3., DE Dean 3.

Abstract

Analyses of subdural hematomata have been traditionally used to determine the ante mortem level of drugs and/or ethanol based on the assumption that the sequestered nature of materials within the hematoma makes them less subject to metabolism or degradation than in the freely circulating blood. Results derived from hematomata are presumed to more closely resemble the drug or alcohol concentration at the time of injury than those determined from postmortem blood. In a cautionary note, we report the case of an 87-year-old woman whose death was not reported to the coroner's office until after her body had been embalmed. The gross autopsy examination documented significant hypertension as well as a traumatic brain injury with a subdural hematoma causing a mass effect. Testing of the subdural clot revealed methanol (51.8 mg%), without additional analytes. There was no indication that the decedent had been poisoned with methanol. We postulate that methanol diffused into the clot after introduction with the embalming solution (consisting only of methanol and formaldehyde; no ethanol, isopropanol or acetone was contained in the preparation used). These findings suggest two cautions should be exercised regarding postmortem hematoma findings. First, methanol can be present in such postmortem samples in the absence of other low molecular weight alcohols (LMWAs) and acetone, and yet not represent a methanol poisoning; secondly, that the interior of hematomata are not necessarily “protected space” from the postmortem diffusion of at least methanol, and potentially other LMWAs. A search of the English literature for cases of subdural hematomata in embalmed decedents failed to reveal any previously published reports with analogous results. Therefore, to our knowledge, this is the first case of the detection of methanol in a postmortem, previously embalmed subdural hematoma.

Acad Forensic Pathol. 7(1 Suppl):S-72–S-146.

Public Transportation Deaths in Chicago from 2014 to 2016

MD Eckhardt 1., E Eason 1.

Abstract

Public transportation is a vital service in Chicago with millions of people utilizing it every day. There are 2 main modes of transportation serving Chicago including the elevated or “L” train which runs throughout Chicago and the public bus. This study will seek to examine deaths that occurred on the Chicago Transit Authority (CTA) from 2014 to 2016, analyzing them by both type of death and mode of transportation on which the death occurred.

A search of the Cook County Medical Examiner's Office database from 2014 to 2016 was done to find deaths whose circumstances were related to the CTA. There were 37 deaths related to public transportation that occurred in Chicago between 2014 and 2016 that were investigated by the Cook County Medical Examiner's office in which the decedent died while on the mode of transportation. Of these, 6 were female and 31 were male. The age range was 21 to 82 and the racial demographics showed 22 of the decedents were black and 15 were white.

Twenty-three of these deaths were certified as Accident due to drug overdose, with 13 found on the “L” train and 9 found on the bus. A breakdown of the drugs taken demonstrated fentanyl and fentayl analogues, either alone or in combination was involved in the majority of cases (72%) and ethanol was involved in 7 of the cases. Interestingly, 9 of the 13 who were found dead on the train were found on the Blue line, which is a 24-hour train with service to O'Hare airport, and 8 of those 10 were found at O'Hare airport, the last stop on the line, between the late evening to early morning. A closer look at these cases showed the decedents were all male and overwhelmingly white (7/8). In a few of these cases, the decedent was either known or speculated to be homeless, which would make the blue line a more common line owing to the fact that it is a 24-hour line.

Fourteen of the cases were certified as Natural, with a cardiac cause in 13 of these cases and one case of acute asthma exacerbation.

Finally, there was one homicide of a 25-year-old black female who was stabbed to death by her boyfriend on the Red line.

This study will provide a detailed analysis of these cases and act as a resource for CTA related research in the future.

Acad Forensic Pathol. 7(1 Suppl):S-72–S-146.

Fatal Bioprosthetic Root Fungal Endocarditis in a 14-Year-Old Girl

JD Berg 1., R Rabah 2., K Snell 1.

Abstract

Prosthetic valve and aortic root endocarditis (PVE) is associated with high mortality and morbidity and may occur in the perioperative period or later as a consequence of secondary hematogenous seeding from a distant infectious focus. Causative organisms include streptococci, staphylococci and enterococci, thus antibiotics prophylaxis is recommended for these patients during dental procedures and other surgeries with increased infection risk. Fungal PVE is less common, with candida and aspergillus being the most frequently identified organisms. We present the case of a 14-year-old girl with a complicated past medical history of truncus arteriosus and coarctation of the aorta status post multiple cardiac operations, the most recent surgery was 5 months prior to death and included redo neo-aortic root and ascending aorta replacement with 25 millimeter Medtronic Freestyle bioprosthetic root, modified Konno procedure and replacement of right ventricle to pulmonary artery conduit with 25 millimeter pulmonary allograft with Gore-Tex proximal extension. She had been in her normal state of health until experiencing intermittent low grade fevers, nausea, and respiratory difficulty for a 1 week duration that had necessitated the patient stay home from school. On the final day of life, the patient had increased respiratory difficulty and was taken to the hospital. In route, the patient lost consciousness and was found to be in asystole upon presentation to the emergency department. At postmortem examination the heart was enlarged with left ventricular hypertrophy and dilation. The aortic bioprosthesis appeared dusky with loosely adherent vegetation partially occluding the coronary ostia composed of numerous septated hyphae. The fungal growth was limited to the bioprosthetic root and valve without invasion of surrounding tissue or extension to the native aorta, left ventricular outflow tract tissue, other valves or the right ventricular conduit. The left ventricle demonstrated hypertrophic changes, patchy necrosis with neutrophilic inflammation consistent with acute myocardial infarction and additional areas of fibrosis indicative of previous older infarcts. GMS stain highlighted rare fungal elements in small coronary arteries, pancreas, adrenal gland, and peripheral pulmonary vessels consistent with fungal sepsis. The exact type of fungus can't be further determined since the postmortem iliac blood cultures were negative. The morphologic findings were not characteristic for candida or aspirgillosis. Fungal endocarditis is a very rare but possibly late complication of prosthetic valve surgery and must be in the postmortem differential so as to ensure proper collection of culture specimens.

Acad Forensic Pathol. 7(1 Suppl):S-72–S-146.

Peculiar Patterns of High-Voltage Electrocutions

AR Perkins 1., SS Rivers 2., L Chrostowski 2.

Abstract

Electrocution is an uncommon cause of death in the United States; but still remains a leading occupational hazard, particularly among those working in the construction industry. Both low and high voltage current exposure, defined as less than and greater than 600 Volts, respectively, can lead to an individual's death. Unlike those seen in low-voltage electrocutions, where external wounds may be minimal to absent, injury patterns in high-voltage electrocutions are often severe, presenting little diagnostic challenge to the experienced forensic pathologist. Entrance and exit site wounds (commonly on the hands and feet, respectively), multiple and confluent third-degree burns, along with limb amputations are frequently noted on external examination. Despite the majority of cases showing these changes, atypical patterns of injury or a complete lack thereof, can be seen. We present multiple cases of high-voltage electrocution deaths that demonstrate atypical patterns of injury and/or distracting additional injuries on examination including scalding pattern burns, unusual entrance and exit wounds, and cases that lacked external evidence of electrocution. It is important when approaching a case where electrocution is apart of the differential for the cause of death, that while high-voltage electrocutions often demonstrate signature and severe injury patterns, to be aware that an individual may exhibit uncharacteristic wounds or lack injuries. These atypical presentations, while uncommon, do not exclude electrocution as the cause of death, especially when the scene and investigation are supportive.

Acad Forensic Pathol. 7(1 Suppl):S-72–S-146.

Death Due to Chikungunya - Forensic Case Report

W Xing 1., S Souccar 2.

Abstract

Chikungunya should be highly suspicious in patients who have history traveling from affected areas particularly if they are elderly, neonates or have other co-morbidity. Mosquito born illnesses, such as Chikungunya must be ruled out when establishing the cause of death as it may resemble other viral infections. While Chikungunya can rarely cause death in the United States, it may easily be mistaken for other illnesses. History along with a clinical presentation of the patient are a crucial part while arriving at an accurate diagnosis. Autopsy and microscopic tissue examination can be unequivocal in their findings. Therefore appropriate testing must be done when establishing the cause of death. SERO and WHO have proposed specific criteria and testing to establish the diagnosis of Chikungunya and should be followed when noted travel from affected areas is in place. There are laboratory testings for confirmation of diagnoses, such as Viral Isolation and ELISA, however RT-PCR is an efficient and quick way to check. Here is a case of a 63-year-old man with other risk factors that was misdiagnosed; the initial laboratory testing of IgG antibodies was negative. Initial forensic examination and finding showed that the cause of death was still pneumonia and septic shock. The Pathologist at the coroner's office then requested RT-PCR testing on a blood sample, which returned positive and the cause of death was attributed to Chikungunya, proving that the similarities between it and other symptoms can cause it to be overlooked as a cause of death.

Acad Forensic Pathol. 7(1 Suppl):S-72–S-146.

Sudden Cardiac Death While Scuba Diving: Hypertrophic Cardiomyopathy and the Importance of Histologic Evaluation in Cases with Subtle or Absent Cardiac Hypertrophy

LM Schuppener 1., RF Corliss 1.

Abstract

Background:

Hypertrophic cardiomyopathy (HCM) is an autosomal dominant genetic disease that carries an increased risk of sudden cardiac death. The diagnosis of HCM is often initially based on the gross finding of prominent asymmetric septal hypertrophy; however, cases of HCM without asymmetric septal or even prominent ventricular hypertrophy have been described, constituting the “non-hypertrophic variant.” In cases with minimal or absent gross cardiac hypertrophy, the histologic findings of myocyte disarray, interstitial fibrosis, and vascular abnormalities may be the only diagnostic feature identified through routine autopsy. As with other hereditary arrhythmia syndromes, diagnosis of HCM in sudden unexpected deaths has significant implications to relatives of affected individuals.

Methods:

An autopsy and a review of the literature were performed.

Case Report:

A 54-year-old man without known medical history was recovered unresponsive in 11 feet of water while scuba diving. Investigation revealed functional diving equipment with air remaining. No significant trauma was identified externally. On internal examination, the sphenoid sinus, lungs and stomach were without significant fluid accumulation. The 420 g heart had several remote infarcts and mild asymmetric septal hypertrophy (2.3 cm interventricular septum) with 1.9 and 0.6 cm left and right ventricles, respectively. Histologic sections showed florid myocyte disarray within the anterior and posterior septum, left and right ventricular hypertrophy, and interstitial fibrosis with prominent regional intramural vasculopathy. Blood and urine were negative for drugs and alcohol. Other findings at autopsy included moderate coronary atherosclerosis with up to 50% stenosis, hepatomegaly, and a benign renal papillary adenoma.

Results:

The cause of death was ruled fresh water drowning while scuba diving, associated with previously undiagnosed HCM. No genetic testing was performed on the deceased; however, due to the genetic nature of HCM, his only first degree relative (sister) was contacted and it was recommended that she be screened for HCM. An echocardiogram was performed and was within normal limits. A CT scan and genetic testing were offered but declined. The deceased had no children and no other relatives were tested.

Discussion:

A diagnosis of HCM should be considered in cases of suspected sudden cardiac death, and may present with subtle or absent ventricular or septal hypertrophy. Histologic evaluation of the heart is needed in these cases to initially identify HCM. If HCM is diagnosed at autopsy, first-degree relatives of the deceased should be notified and offered genetic counseling and screening to mitigate the chances of sudden cardiac death in affected family members.

Acad Forensic Pathol. 7(1 Suppl):S-72–S-146.

Farm Machine Related Deaths in Alberta from 2000 - 2015

JA Andrews 1., E Brooks-Lim 2.

Abstract

Alberta is a landlocked Canadian province bordered by the Rocky Mountains on the west, expansive prairies to the east as well as south, and the Canadian arctic to the north. Over the past 100 years, there was a trend for Alberta farms to amalgamate resulting in a single owner maintaining a larger breadth of land. Consequently, large machinery plays integral to a single owner cultivating on average more than 1,000 acres of land. As with other industries, such as manufacturing, the presence of heavy machinery introduces further risk of morbidity and mortality. In a detailed retrospective analysis, this poster will examine the demographics, characteristics, and trends of machine related farm deaths in Alberta from 2000 to 2015.

Initial data for agricultural related deaths were obtained through the Alberta Office of the Chief Medical Examiner. Inclusion criteria: death directly related to farm accident; involved farm machinery; any age or gender; and death occurred either during work or recreational activities. Exclusion criteria included: homicide or suicide manners of death; and death occurred on or around a machine but was not related to the machine. We collected multiple data points surrounding demographics, circumstances of death, machinery involved, and mechanism of death.

A total of 308 accidental farm deaths occurred in Alberta during the examined period of which machine related accidents resulted in 54% of deaths and non-machine accidents accounted for the other 46% of deaths. For machine related deaths a total of 28 deaths occurred in individuals less than 18 years old (17%); 86 deaths occurred in individuals between the age 18 to 64 (52%); and 52 deaths occurred in individuals over the age of 65 (31%). The vast majority of individuals killed by machines were the farm owner or family member (84%). Tractors were the deadliest object on the farm (47 deaths), followed by off road vehicles (22 deaths). Deaths related to machines most commonly involved being pinned/struck (33%), vehicle rollover (22%), runover (17%), and entangled in machinery (13%).

During the sixteen-year period examined, the majority of agricultural deaths were farm family members and involved a piece of machinery. In addition, the clear majority of deaths occurred in males, in sunlight hours, during work related activities. Overall, this data provides a more complete view of farm machine related deaths and will assist in future efforts to reduce agricultural related deaths.

Acad Forensic Pathol. 7(1 Suppl):S-72–S-146.

Death Related to Fistulas Involving the Gastrointestinal and Cardiovascular Systems

AJ Medwick 1., JA Prahlow 1.

Abstract

Gastrointestinal tract fistulas are relatively uncommon and can be congenital or acquired. Fistulas may communicate with a variety of anatomic locations, including body cavities, the skin, and other organ systems. Acquired fistulas which communicate with the cardiovascular system are of particular concern, as they may be associated with significant morbidity and mortality. This study reports on 3 cases of acquired, post-surgical fistula formation involving the gastrointestinal and cardiovascular systems.

Case 1: A 57-year-old man experienced sudden cardiac death shortly after having a permanent pacemaker placed for atrial fibrillation. Approximately 2 years earlier, he underwent surgical resection of his esophagus for cancer, and he had a diaphragmatic hernia repair several weeks before death. He also had hypertensive and atherosclerotic cardiovascular disease and emphysema. At autopsy, the cause of death was determined to be upper gastrointestinal tract hemorrhage due to a gastro-left atrial fistula which developed as a complication following surgeries for esophageal cancer.

Case 2: A 67-year-old female with severe chronic obstructive pulmonary disease (COPD), as well as a thoracic aortic aneurysm for which she had undergone aortic reconstruction with graft placement, presented to the hospital with massive hematemesis with associated breathing difficulties. Prior to dying, an upper endoscopy revealed a probable esophageal fistula thought to be communicating with the respiratory system. At autopsy, the fistula was found to be communicating with the aorta.

Case 3: A 51-year-old woman was found unresponsive at home. All resuscitative efforts were unsuccessful. The case was referred for medicolegal autopsy. She had a past history of COPD, gastric bypass surgery, and relatively recent bacterial pericarditis, which required drainage and antibiotic therapy. Autopsy revealed the presence of a gastric fistula involving and traversing the left hemidiaphram to involve the posterior wall of the left ventricle of the heart. Approximately 500-1000 mL of dark blood intermixed with gastrointestinal contents was present within the stomach and proximal small intestines, but no fresh-appearing hemorrhage was evident.

Postoperative gastrointestinal-cardiovascular fistulas are relatively rare, but can result in significant morbidity and mortality. They may develop following gastrointestinal tract or cardiovascular surgery. Clinicians are advised to be aware of these rare, but often fatal, post-operative complications. The cases serve to remind investigators of the importance of obtaining pertinent detailed medical/surgical history as a part of an adequate death investigation. Forensic pathologists are reminded that proper dissection techniques and photographic documentation are essential when confronted with such cases.

Acad Forensic Pathol. 7(1 Suppl):S-72–S-146.

Sarcoidosis Deaths in Wayne County, Michigan: A 20-year Retrospective Study

M Webb 1., KS Conway 1., MK Ishikawa 1., FJ Diaz 2.

Abstract

Sarcoidosis is a disease of unknown etiology characterized by the formation of non-caseating granulomas in various organ systems. This paper reviews 84 cases of natural death in decedents with sarcoidosis between the years 1996 and 2017 and autopsied at the Office of the Wayne County Medical Examiner in Detroit, Michigan. Each case was reviewed based on information available in autopsy reports. The median age of decedents was 44 years (29 – 59 years of age). Blacks comprised 95% of the cohort, and 52% were female. Sarcoidosis or direct sequelae of sarcoidosis were the cause of death in 79% of cases. 29% of patients had a documented history of sarcoidosis. 70% of patients had evidence of systemic sarcoidosis. The most common sites of involvement were lungs or hilar lymph nodes (92%), heart (45%), liver (39%), and spleen (30%). Only pulmonary and cardiac disease had significant rates of isolated involvement, with 26% of decedents having isolated pulmonary disease and 4% of decedents having isolated cardiac disease. Decedents with cardiac involvement, when compared with decedents without cardiac involvement, were more likely to have no documented history of sarcoidosis (87% vs. 59%, p=0.004), more likely to have died of a sarcoidosis-related cause (97% vs. 65%, p<0.001), and died at a younger mean age (41 years vs. 46 years, p=0.001). Our findings suggest that sarcoidosis is significantly under diagnosed among our affected demographic and cardiac involvement is a uniquely poor prognostic factor.

Acad Forensic Pathol. 7(1 Suppl):S-72–S-146.

Spontaneous Hepatic Rupture in a Pregnant Woman with Preeclampsia: An Autopsy Case

J Park 1., J Na 2., Y Oh 1., Y Lee 1., S Oh 1., H Kim 1.

Abstract

Spontaneous hepatic rupture which is a complication of hypertension in pregnancy is rare, but it shows high maternal and perinatal mortality. It is frequently associated with the thirties, multipara, severe preeclampsia or HELLP syndrome (clinical syndrome with hemolytic anemia, hepatic enzyme increase, thrombocytopenia). The authors experienced an autopsy case that twin pregnant 42-year-old woman at 36 weeks gestational age suffered sudden developing and rapid progressing hypertension in pregnancy and she died because of spontaneous hepatic rupture despite emergent operation.

She took sudden abdominal pain of right upper quadrant (RUQ) after waking up in early morning. She had history of stillbirth in 23 gestational week 2 years ago and was being treated with insulin for diabetes diagnosed afterwards. Her weight (102 kg and 109 kg), blood pressure (156/91 mmHg and 157/96 mmHg) and her urine protein (+/- and 4+) measured in regular check-up at 2 weeks and 1 day before the onset of the symptom and preeclampsia was suspected. When she visited ER with the abdominal pain, her BP was 110/70 mmHg. After conducting blood and urine analysis, emergent caesarean section was performed. She gave birth to one live baby and one stillborn baby, and surgery was performed in hepatic capsular rupture with hemoperitoneum found during the surgery. After surgery, sudden cardiac arrest occurred. Emergency measures such as cardiopulmonary resuscitation (CPR) were conducted, but she did not recover and expired. According to guardian of the deceased, the deceased did not have history of even the slightest trauma in her whole body, especially including abdomen.

Autopsy revealed that capsule in right lobe of liver adjacent to diaphragm was torn in various directions and massive coagulated blood was found between liver capsule and parenchyma. After resection of liver, there was no specific finding like bleeding in parenchyma and histological examination of liver parenchyma revealed multifocal necrosis. It also revealed that hypovolemic signs such as weak postmortem lividity, and palor of skin, conjunctiva and solid organs.

It is our opinion that close examination of the trunk and liver for classification of cause of rupture, and investigation of past medical history such as preeclampsia are needed during postmortem examination in all cases of pregnant women with hepatic rupture or her fetus. To our best of knowledge, this fatal complication of pregnant women is not yet presented with postmortem examination in Korea so the authors report to share the knowledge with our case.

Acad Forensic Pathol. 7(1 Suppl):S-72–S-146.

Unknown Cause of Recurrent Metabolic Acidosis Diagnosed by Autopsy

MH Schild 1., LA Havrilla 1., WT Harrison 1., TA Sporn 1.

Abstract

Early diagnosis and treatment of ethylene glycol poisoning can prevent considerable morbidity and mortality. Sequelae of ingestion include central nervous system depression, cardiopulmonary compromise, and renal insufficiency. Ethylene glycol itself is not toxic; however, its organic acid metabolites cause considerable metabolic derangement and organ damage. Laboratory findings include an increased anion gap metabolic acidosis, increased osmol gap, calcium oxalate crystalluria, and detectable ethylene glycol in the serum. Administration of ethanol or fomepizole, sodium bicarbonate, and hemodialysis are mainstays of treatment.

We present a 38 year old female with a history of alcohol abuse, prescription drug abuse, seizures, and chronic kidney disease who was admitted multiple times for lactic acidosis, acute kidney failure, and altered mental status. Laboratory values revealed a high anion gap metabolic acidosis, an elevated lactic acid, and a normal osmol gap. Extensive toxicology workups did not detect ethanol, methanol, isopropyl alcohol, ethylene glycol, heavy metals or volatile gases. Her prescription Depakote levels were low, thiamine was elevated, and cyanide and metformin levels were within normal limits. She was treated empirically for beta-blocker and cyanide toxicity without improvement and was placed on hemodialysis for kidney failure, subsequently passing away. The differential diagnosis at the time of death included unknown toxicity, unspecified metabolic disorder, and unspecified mitochondrial disorder. The family was concerned about a possible genetic mitochondrial disorder causing the patients recurrent lactic acidosis and consented for an autopsy. Autopsy findings included microscopic intravascular and perivascular dumbbell shaped crystals, consistent with calcium oxalate monohydrate crystals, confirming the diagnosis of ethylene glycol toxicity. This case demonstrates the difficulties in identifying ethylene glycol toxicity clinically and the importance of autopsy in this diagnosis. A normal osmol gap does not exclude ethylene glycol poisoning. Ethylene glycol and its first metabolite, glycoaldehyde, contribute to a high osmol gap, however, the later metabolites, glycolic acid and glyoxylic acid do not. Therefore, the osmol gap is raised in the initial stages of ethylene glycol toxicity, but decreases later while the anion gap increases. Ethylene glycol has a half-life of is 2.5-8 hours and positive ethylene glycol toxicology results depend on the time of ingestion. Measurement of glycolate may help the diagnosis following metabolism of ethylene glycol, however, this analysis is not readily available in most hospital laboratories. Furthermore, metabolites of ethylene glycol can cross-react with the most common lactic acid assays, leading to falsely elevated serum lactate levels.

Acad Forensic Pathol. 7(1 Suppl):S-72–S-146.

The Fungus among Us: A Fatal Case of Invasive Aspergillosis in a Non-Transplant Patient

S Reed 1., K Jasnosz 1.

Abstract

Invasive aspergillosis is a life-threatening infection with a striking mortality rate that varies according to anatomic site of involvement. The overall case fatality rate (CFR) for invasive aspergillosis has been estimated at 58%; central nervous system involvement is nearly uniformly fatal with a CFR of 99%. The most commonly affected patients include those with hematologic malignancies, solid organ transplants, and profound immune compromise such as HIV/AIDS, with a much smaller percentage of cases (around 1-2%) seen in patients with chronic obstructive pulmonary disease (COPD).

This was a 65 year old Caucasian female with a medical history of oxygen-dependent COPD and acute on chronic respiratory failure. She had recently been diagnosed with influenza pneumonia, which exacerbated her respiratory failure such that she required a tracheostomy and placement in a long-term care facility. Approximately one month later, she developed cavitary lung lesions that were suspicious for tuberculosis. Her condition was declining despite treatment with multiple antimicrobial agents, and she was transferred to our facility for advanced care. She developed mental status changes, sepsis and multiorgan failure. Despite increased ventilator, hemodynamic and dialysis support, she unfortunately passed away.

An unlimited autopsy revealed extensive bilateral pulmonary aspergillosis, including a 6 cm fungal abscess of the right upper lung lobe, multiple associated pulmonary infarcts, fungal pleuritis, and diffuse organizing pneumonia. The patient's brain had several hemorrhagic infarcts in the left frontal lobe and thalamus, with associated fungal hyphae and mycotic vasculitis. Lung tissue cultures grew Aspergillus fumigatus. The cause of death was overwhelming pulmonary aspergillosis with spread to the central nervous system.

Considerations for disseminated aspergillosis are appropriate in, but not limited to, a specific patient population, namely those status post solid organ or bone marrow transplant. This was an unusual case of aggressively invasive aspergillosis with a considerable organism burden in a non-transplant patient. This patient was immunocompromised from the standpoint of having long-standing respiratory disease, necessitating inhaled corticosteroids and eventually tracheostomy. Her cavitary lung lesions initially raised concern for tuberculosis, rather than disseminated aspergillosis, given her residence in a long-term care facility. The source of the fungal infection was unclear. This case illustrates the importance for an expanded differential in an immunocompromised patient.

Acad Forensic Pathol. 7(1 Suppl):S-72–S-146.

Sudden Cardiac Death in the Young: A Case-Based Discussion

SC Thomas 1., S Strauch Rivers 2., J Dierksen 1., L Chrostowski 2., C Dominguez 1.

Abstract

Sudden cardiac death in the young (SCDY) accounts for approximately 1-2% of all sudden deaths within the United States. The most common etiologies implicated include cardiomyopathy, coronary artery anomaly, obstructive coronary disease, myocarditis, valvular disease, channelopathy and aortic disease leading to dissection or rupture. Sudden cardiac death can be defined as an out-of-hospital death caused by any cardiac condition that occurs within one hour of symptom onset, however other definitions based on longer time frames and circumstances exist.

We present three cases of SCDY, occurring within the past year at our institution. The first case involves a 21-year old young woman, admitted to the hospital for peripheral edema and abdominal pain. She suffered a seizure while showering, with subsequent cardiorespiratory arrest. Her medical history was significant for a recently treated Helicobacter pylori infection three weeks prior. Autopsy revealed pale, firm myocardium with amyloid deposition seen microscopically. The second case was a 3-year old boy, with a 1-day history of nausea, vomiting and abdominal pain who had a cardiac arrest following a seizure-like episode. Autopsy showed an enlarged heart, incidental intestinal intussusception, and negative viral studies. Microscopically, the heart had a diffuse lymphocytic infiltrate, consistent with myocarditis. The last case depicts a 2-year old previously healthy boy noted to stop breathing while sleeping at night. His medical history was significant only for nebulizer usage when sick. Significant autopsy findings revealed pearly white endocardial lining within the left ventricle, extending to the aortic valve, with no associated outflow obstructions or other congenital abnormalities identified. Endocardial fibroelastosis, diffuse type was diagnosed following microscopic analysis.

The diagnostic process of these infrequently seen cardiac-related deaths in the young may initially present with difficulty. Cardiac amyloidosis is scarcely reported in the young without a known inherited disorder or hematologic malignancy. Our patient's associated H. pylori infection may have contributed, as it is a well-known chronic inflammatory process. Endocardial fibroelastosis can be seen in a variety of congenital and acquired cardiac-related conditions, which creates a diagnostic predicament when no discrete underlying cause is found, as in our case. Lymphocytic myocarditis, although uncommon, is not rare and is usually associated with a viral agent; however no identifiable viral agent has been discovered in our case thus far. Each case, our thought process and the steps leading toward our understanding of the causes of death will be discussed.

Acad Forensic Pathol. 7(1 Suppl):S-72–S-146.

Healed Fracture of Superior Horn of Thyroid Cartilage in Autoerotic Asphyxia: An Indication of Prior Activity? A Case Report Utilizing 3D Scanning and Printing of the Larynx

M Eckhardt 1., KJ Moore 2., K Shah 3., M Bois 3., JJ Maleszewski 3., PT Lin 3.

Abstract

We report a case of autoerotic asphyxia in an adult man with no known prior history of autoerotic activity. However, the presence of a healed fracture of the superior horn of the thyroid cartilage is suggestive of prior autoerotic asphyxia activity. 3D scanning technology coupled with 3D printing of the larynx was used to permanently document the laryngeal findings.

The decedent is a 45 year-old man who was found on the floor of his bedroom with a belt ligature around the neck. The belt was thought to have been suspended from the door frame. A nearby towel and barbell weight may have been components of an “escape mechanism”. Another rope ligature was loosely wrapped around the decedent's wrists, scrotum and penis. Nearby items include a cell phone, computer with monitor and a mirror. There was no history of depression or suicidal ideation.

Autopsy was notable for the presence of fixed lividity of the lower extremities in a “stocking-pattern” and an incomplete ligature furrow around the neck. There were no conjunctival or facial petechial hemorrhages, hemorrhages of the strap muscles of the neck, or recent laryngeal or hyoid fractures. However, there was a healed fracture of the right superior horn of the thyroid cartilage.

Autoerotic asphyxia is a means of sexual gratification in which the person employs a mechanism to induce hypoxia and heighten arousal during solo sexual activity. Death occurs in this setting when there is loss of consciousness, thus preventing the person from ceasing the asphyxia. In many cases there is an escape mechanism that should allow the asphyxia to stop after loss of consciousness and for whatever reason this fails.

The majority of autoerotic asphyxia deaths occur in young males. The scene is usually a private location and commonly has an element of fetishism (ex. pornography, bondage, cross-dressing). Autopsy findings are nonspecific and similar to classic asphyxia deaths including petechiae and visceral congestion. Thyroid cartilage fracture and vertebral fractures can occur but are less common.

3D scanning and printing technologies are advancing rapidly and have numerous potential uses in forensic pathology, such as the creation of 3D images that can be manipulated on a computer screen or physical models that can be handled in court to facilitate understanding of complex anatomical specimens. This technology also allows permanent documentation of specimens in their original state, prior to dissection and histologic sampling, allowing other experts to perform independent evaluations.

Acad Forensic Pathol. 7(1 Suppl):S-72–S-146.

Fat Embolism Syndrome in a Patient with Duchenne Muscular Dystrophy following Minor Trauma: A Case Report

TJ Danielsen 1., J Barnard 1.

Abstract

Introduction:

Duchenne muscular dystrophy (DMD) is an X-linked recessive disorder caused by a mutation encoding the dystrophin protein on the short arm of the X chromosome. Dystrophin is an integral structural protein required for skeletal muscle contraction. DMD affects approximately 1 in 5000 live male births and results in progressive skeletal muscle degeneration and fatty replacement. Fat embolism syndrome (FES) is the systemic manifestation of fat droplets impairing microcirculatory blood flow and often results in pulmonary and neurological symptoms. Although typically occurring in the setting of a long bone fracture, orthopedic surgery, or a cosmetic procedure, such as liposuction, FES has also been documented in patients with DMD following only minor trauma. Patients with DMD are particularly vulnerable to traumatic injuries, ranging from minor trauma to bone fracture, due to their progressive weakness and invariable immobility. Due to the fatty replacement of skeletal muscle in these patients, soft tissue trauma can potentially cause FES.

Case Report:

We present the case of an 18-year-old male with a clinical history of DMD who experienced a short fall from a broken wheelchair lift. He fell approximately two feet and sustained minor trauma to his posterior trunk that was characterized as focal redness. He presented to the hospital neurologically altered and in respiratory distress shortly thereafter. His condition worsened and he was transferred to the intensive care unit (ICU). He continued to deteriorate and he was pronounced dead hours following the fall. The presentation and clinical course raised the suspicion of FES. At autopsy, the gross examination showed no contusions or significant injury over the posterior trunk. The autopsy also revealed diffuse and extensive fatty replacement of the skeletal musculature and biventricular dilation of the heart. Microscopic examination provided confirmation of fat emboli in the lungs, kidneys, brain, and heart.

Acad Forensic Pathol. 7(1 Suppl):S-72–S-146.

Fatal Achalasia: A Case of Sudden Death and a Review of the Literature

AM Laib 1., I Scordi-Bello 2.

Abstract

In forensic pathology, esophageal disease is rarely determined to be the cause of sudden death at autopsy. When encountered, the most common fatal esophageal conditions include hemorrhagic lesions such as esophageal varices, infectious ulcers, and perforating Barrett's esophagus. Achalasia is a rare esophageal dysmotility disorder with impaired peristalsis and incomplete relaxation of the lower esophageal sphincter, which can result in the development of megaesophagus (width >7-8cm). While there have been over 40 reported cases of acute respiratory distress as a complication of megaesophagus, only a small number of those cases experienced cardiac or respiratory arrest, usually with a non-fatal outcome due to successful resuscitation.

We report the case of a 41-year-old male with no known history of esophageal disease who was found deceased by his wife after spending the night asleep on the sofa. He had occasional heartburn but reported no discomfort or distress prior to falling asleep. He had consumed alcoholic beverages but was not felt to be intoxicated. At autopsy, the face was plethoric but there was no evidence of petechiae. The esophagus contained a large bolus of partially-masticated food and was markedly dilated, with a maximum width of 17cm, tapering to a narrowed gastroesophageal junction measuring 2cm. The stomach contained approximately 1000cc of partially digested food. There was no evidence of vomitus or food particles within the upper or lower airways. The trachea and surrounding thoracic structures were significantly compressed by the megaesophagus. White frothy foam was found within the trachea and bronchi, and the lungs were markedly congested and edematous. Microscopic examination revealed chronic inflammation and muscular hypertrophy of the esophagus. Cause of death was determined to be complications of achalasia. Manner of death was natural.

Achalasia occurs in <10 per 100,000 individuals in the United States, has an unknown etiology and appears to result from denervation of smooth muscle with degeneration of the vagus nerve and ganglion cells. Achalasia can have an indolent asymptomatic course, but most often presents with symptoms of dysphagia, dyspepsia, regurgitation and weight loss. Respiratory compromise is a rarely reported complication. Literature review reveals five reported cases of fatal outcomes attributed to achalasia, and only two reported cases with no significant contributing factors such as aspiration or ischemic heart disease. Excluding aspiration and ulceration/perforation, possible mechanisms of death with megaesophagus include: arrhythmias secondary to valsava maneuver; compression of the trachea, cardiovascular structures or vagal nerve; or a combination of these factors.

Acad Forensic Pathol. 7(1 Suppl):S-72–S-146.

Opioid Associated Deaths in South Carolina: A Retrospective Review

DC Butler 1., NI Batalis 1.

Abstract

Objective:

Rising rates of opioid abuse in the United States have generated an overdose epidemic. Particularly in the last few years, many offices across the country have seen a shift from prescription opioid overdoses to heroin, illicitly produced fentanyl, and now various fentanyl analog related deaths. Given this national trend, a retrospective review was performed to better characterize the incidence of heroin, fentanyl, and fentanyl analog associated deaths in South Carolina.

Methods:

Autopsy records from the Medical University of South Carolina's forensic pathology practice, which serves roughly a third of the state, were reviewed from 2013-2016 to identify cases in which heroin, fentanyl, and/or fentanyl analogs were detected. These cases were then queried to determine the following: drug concentration; presence of any other drugs; whether natural disease was considered as a contributing factor; the manner of death; and if heroin, fentanyl, and/or fentanyl analogs were determined to be the cause of death.

Results:

A total of 3,350 autopsy reports were reviewed. In 2013, the incidence of both heroin and fentanyl was relatively rare (2.2% and 1.5%, respectively), but increased somewhat steadily throughout the ensuing years. Between 2013 and 2016, the incidence of fentanyl climbed from 1.5% to 5.1% and appears to be rising, while heroin rose from 2.2% to 4.5% and appears to have leveled off. Combined, heroin and fentanyl accounted for 2.6% of total deaths in 2013 but increased to 7.6% in 2016, with more substantial increases in 2014 and 2015. With rare exception, when heroin was detected it was attributed as the cause of death or as a contributory cause of death. The same was not true for fentanyl, particularly in 2013. However, the concurrent presence of fentanyl and fentanyl being attributed as a cause of death rose from 30% in 2013 to 48-75% between 2014 and 2016. Indications of therapeutic fentanyl use have also steadily decreased from 90% in 2013 to 37% in 2016. Fentanyl analogs were rarely encountered, although a dramatic increase of 11 cases was seen in 2016, including two cases of the novel analog acrylfentanyl.

Conclusion:

Between 2013 and 2016, opioid related deaths have steadily increased in South Carolina, including a major rise in fentanyl associated death, though this increase in incidence seems to lag behind larger jurisdictions such as those found in the Midwest and Northeast.

Acad Forensic Pathol. 7(1 Suppl):S-72–S-146.

Migraine, Methamphetamine and Myocardial Infarction Highlight Potential Bias in a Case of Thrombotic Microangiopathy

MR Lawless 1., E Linde 2.

Abstract

Thrombotic microangiopathy (TMA) is a pathologic finding seen in several hereditary and acquired conditions, including thrombotic thrombocytopenic purpura (TTP) and hemolytic uremic syndrome, which result in microangiopathic hemolytic anemia and thrombocytopenia. The clinical presentation of TMA can range from nonspecific fatigue and headache, to fever, renal failure, stoke and purpura.

We report a fatal case of a TMA in a 31-year-old woman with a history of hypertension, which was presented to the Coroner's service as a possible methamphetamine overdose. Initially, she presented to a local hospital with headache, fatigue, and weakness. She was managed conservatively for a migraine headache and released upon symptom resolution. Three days later, she was found unresponsive at her residence by her boyfriend and was transported to a local hospital. No pill bottles or illicit substances were found near her. Naloxone administration failed to improve her symptoms. Physical examination revealed agonal breathing and punctate ecchymosis of the left upper extremity. Admission labs demonstrated an elevated creatinine, troponin, and markedly elevated CHF peptide, as well as mildly prolonged prothrombin time and partial thromboplastin time. Further workup was precluded when her pulse was lost during chest x-ray. Resuscitation efforts were unsuccessful. A complete blood count was not performed at either admission.

At autopsy, a large transmural myocardial infarction (MI) involving the posterior left ventricle was grossly identified despite widely patent coronary arteries. Microscopic examination identified additional multifocal areas of infarction without a specific distribution that were hours to weeks old. Numerous occlusive thrombi were seen within the cardiac microvasculature. Histologic features of TMA in the background of acute kidney injury were also seen within the section of the kidney. Postmortem toxicology was non-contributory. While TTP is suspected, a definitive etiology of her TMA cannot be established due to a lack of clinical history and confirmatory testing.

This case highlights an uncommon presentation (MI) of an uncommon disease (TMA). Moreover, this case demonstrates that medical and social histories may inappropriately bias practitioners and forensic pathologists in their decision making and death investigation. In this regard, non-specific findings did not prompt additional laboratory investigation, and an MI without coronary disease with a history of possible methamphetamine use suggested a drug-related death. Overall, this case reminds professionals to remain vigilant in both clinical assessment and death investigation.

Acad Forensic Pathol. 7(1 Suppl):S-72–S-146.

Case Report: Postmortem Hypopyon Associated with Neisseria Meningitidis Meningitis

WA Ennis 1., T Luckasevic 1., K Williams 1.

Abstract

A hypopyon is an accumulation of leukocytic exudate in the anterior chamber of the eye. It may be visualized without the aid of an ophthalmoscope as a white, dependent fluid collection anterior to the iris. Rarely, hypopyon has been found to be associated with Meningococcal Meningitis in the living. We describe a case in which bilateral hypopyon is observed in a decedent with purulent meningitis, pericardial effusion, and lobar pneumonia. The decedent was found with early decomposition changes in a left lateral position. The left lateral aspects of the irides were partially obscured by pus. Leptomeningeal and lung cultures, but not pericardial fluid, were positive for Neisseria meningitidis group B. Recognizing hypopyon as potentially associated with Neisseria meningitidis infection may prevent exposure to autopsy staff.

Acad Forensic Pathol. 7(1 Suppl):S-72–S-146.

Homicide Due to Positional Asphyxia

C Dominguez 1., A Perkins 1., A Duque 2., V Bravo 2.

Abstract

Homicide via positional asphyxia is rarely described in the forensic literature. The mechanism of death by positional asphyxia is due to the restriction of the individual's normal respiratory movements. This causes a reduction in tissue oxygenation of the internal organs, most importantly of the heart and brain. While negative findings are common in other types of asphyxia, gross evidence is frequently noted in victims of these homicides.

We present a case of a 27-year-old male found folded and bound in a suitcase in Medellin, Colombia, after being reported missing for two days. Transparent tape was used to cover the decedent's face and to bind his hands and feet. On external examination, the decedent had congested facies, multiple petechiae, conjunctival hemorrhages, a hematoma within the right periorbital region, and ecchymoses on the wrists and legs. The internal examination revealed cerebral congestion along with pressure striea. Histological findings included pulmonary edema, marked vascular ectasia, and focal hemorrhages in the gastric mucosa and submucosa without inflammatory infiltrates or necrosis. The blood alcohol level and toxicology screen of the urine for narcotic drugs and depressants of the central nervous system were both negative.

Although not exclusive to positional asphyxia, these autopsy findings may represent distinctive patterns characteristic of this unique and uncommon type of death.

Acad Forensic Pathol. 7(1 Suppl):S-72–S-146.

Abduction, Interrogation, and Violence: A Series of Torture Cases from Medellín, Colombia

C Dominguez 1., E Baardsen 1., A Perkins 1., ME Botero 2., E Parrado 2., V Bravo 2.

Abstract

Medellín, Colombia, located in the Aburrá Valley, is the second largest city in Colombia, with an estimated population of 2.44 million. It was once known as the most dangerous city in the world following an urban war initiated by drug cartels in the late 1980s. After the deaths of key cartel figures, crime rates, although still relatively high, gradually declined throughout the 1990s. Between 2003 and 2006, urban militias and paramilitary groups were demobilized by the Colombian government. Despite the 95% decrease in annual homicides since the late 1980s, the average homicide rate remains 2.5 times higher than the average in all other Colombian cities and 20 times that of the United States. In 2009, there was an average of nine homicides per day. Although now less commonly seen in the Medellín medical examiner's office, cases of torture continue to constitute a percentage of these homicides.

Torture is defined as the deliberate infliction of severe physical and/or psychological harm on an individual by a perpetrator who acts on behalf of a group or individual. Torture can include a variety of forms including falanga, prolonged suspension, electric shock injuries, repeated blunt force impacts, and sexual assault. Often torture is performed to obtain information, coerce a confession, force collaboration, discipline individuals, and/or to spread terror in the community. We present four cases in which the decedent died as the result of torture: a 27-year-old man found covered with blankets in a taxi with a plastic bag tied around his head, strangled with immobilization signs of the hands and feet; a 26-year-old man found handcuffed in an apartment with chop wounds to the head, thorax and extremities; a 27-year-old man thrown from a moving vehicle with his feet bound by zip ties and head covered in plastic wrap; and a 30-year-old man found in a ditch, naked with ligatures at his neck and hands and signs of sexual assault. These cases demonstrate some of the peculiar scenes, various manners in which injuries are inflicted, and the characteristic autopsy findings commonly seen in these types of homicides. The aim of this work is to increase the forensic pathologist's understanding of the causes and mechanisms of torture deaths, highlight key components necessary to the autopsy report, and improve the medical documentation of torture.

Acad Forensic Pathol. 7(1 Suppl):S-72–S-146.

Intentional and Forced Lethal Ingestion: A Comparison of Two Acute Cyanide Poisoning Cases in Colombia

C Dominguez 1., S Thomas 1., S Grewe 1., ME Botero 2., E Parrado 2., V Bravo 2.

Abstract

Cyanide is a lethal toxin that can rapidly cause death after an exposure. Exposure to cyanide can occur from multiple sources including cigarettes, diet, pesticides, medications such as sodium nitroprusside, and occupational exposures such as mining, rubber manufacturing, and metal working. The most common source of cyanide exposure is fires because it can be given off during combustion. This toxin can be absorbed through the skin, gastrointestinal tract, and lungs. It works by inhibiting cellular aerobic metabolism by interfering with oxidative phosphorylation causing tissue hypoxia. Cyanide poisoning is uncommon, and can be accidental or it can be intentional as a means of suicide or homicide. Autopsy findings of acute and chronic cyanide ingestion are often variable and nonspecific, highlighting the importance of an initial suspicion since routine cyanide testing is not commonly performed at autopsy. Given the rarity of this diagnosis, we present two cases from Colombia in which cyanide ingestion proved to have a fatal outcome.

In the first case a 44-year-old man, was found dead by coworkers at his office, where he reportedly was last seen crushing unknown white pills. Autopsy findings showed cherry red liver mortis, pulmonary edema, conjunctival petechiae and markedly congested, dull gastrointestinal mucosa. The gastric content consisted of black, dark fluid with a characteristic “bitter almond” odor. A rapid cyanide test was positive and additional studies were confirmatory. The manner of death was ruled a suicide.

The second case involves a 25-year-old man last seen with a woman near a lake. During the scene investigation, the man was found deceased near a bottle containing clear liquid. The autopsy revealed cherry red livor mortis, pulmonary edema and eroded, severely congested gastric mucosa. A rapid cyanide test on the stomach contents and bottle found at the scene was positive, with concordant confirmatory testing. A thorough case investigation revealed the woman forced the decedent to drink the bottled liquid. The manner of death was ruled a homicide.

Homicidal, forced ingestion of cyanide has been rarely reported, which illustrates the importance of a thorough case investigation. Deriving a manner of death may largely depend on circumstances not physically present at a death scene. In Colombia, cyanide is a major component of jewelry cleaning solutions, which are easily accessible to the public. It is important for pathologists to keep cyanide poisoning in the differential for both homicides and suicides, with an awareness of chemical products that harbor it.

Acad Forensic Pathol. 7(1 Suppl):S-72–S-146.

Vascular Projectile Embolization

J Chao 1., JJ Barnard 2., J deJong 1., JA Prahlow 1.

Abstract

Deaths related to firearms are common within the United States, with most cases having conspicuous projectile wounds found at autopsy. Individual gunshot wounds may be perforating or penetrating. In most cases with penetrating wounds, projectiles are relatively easily found via radiography and by following the pathway on internal examination. When a projectile is not detected in the expected region, intravascular embolization of the projectile should be suspected. The authors present three unusual cases of intravascular projectile embolization.

Case 1: The charred remains of a 10-year-old male were found within a burning trailer. Multiple shotgun slug fragments were identified within the child's head, confirming that the child had been killed prior to the fire. A single slug fragment was identified within the neck region on x-ray. At autopsy, this fragment was found within an intact jugular vein.

Case 2: A 16-year-old male sustained a gunshot wound of the back. He was alert and oriented, but was taken to the Emergency Department for evaluation. A chest x-ray was negative, but a bullet was identified in his lower trunk region on pelvic/abdominal x-ray. An exploratory laparotomy was undertaken, but was negative. Clinicians presumed that the bullet had remained behind the visceral organs, in the lower back/buttock region. He was discharged to home. Approximately 1-month later, he suddenly collapsed at home. Despite resuscitation attempts, he was pronounced dead. At autopsy, a massive hemothorax was found to have originated from a large subpleural, periaortic hematoma, related to a gunshot defect of the aorta. The projectile was found within the left internal iliac artery.

Case 3: The decomposing body of a 21-year-old male was found face down in water in a drainage ditch. He had sustained multiple gunshot wounds in a drug-related confrontation. At autopsy, a gunshot wound of the central chest traversed the heart before ending within the inferior vena cava. The bullet was not easily identifiable. Further examination revealed that the small-caliber bullet had embolized in a retrograde direction in to a tributary of a hepatic vein, within the liver.

Intravascular bullet/projectile embolization is well-described within the clinical and forensic literature. Embolization may be arterial or venous, as well as antegrade versus retrograde. Typically, such emboli involve small caliber bullets or shot pellets. The authors present 3 unusual cases of projectile emboli at autopsy, one involving shotgun slug fragment embolization, one where death was delayed, and one with retrograde embolization into the liver.

Acad Forensic Pathol. 7(1 Suppl):S-72–S-146.

The Autopsy: An Assessment of Utility at One Institution

CR Miller 1., RD Johnston 1., BH Blake 1., JF Aronson 1.

Abstract

Introduction:

We are investigating the ability of the autopsy at our institution to elucidate previously unrecognized major or minor diagnoses. Autopsy rates in hospitals have decreased from 40-60% of all hospital deaths before 1970 to 5% in the 21st century, in spite of the fact that hospital autopsies frequently reveal errors made in suspected cause of death and errors made which could have affected the patient's clinical outcome.

Materials and Methods:

At our institution, we perform approximately 300 autopsies per year. A representative sampling of 68 of these 300 cases from 2016-2017 was examined via a worksheet (adapted from Dr. Alex Williamson's version, Hofstra School of Medicine) completed by the attending physician and resident who performed each case.

Results:

Approximately a quarter (23.5%; n = 16) of our cases are in-hospital deaths. The remainder are categorized as Texas Department of Corrections (TDC) outside-hospital deaths, medical examiner (ME) cases, and private autopsies. Of these 68 total queried cases, 76.5% (52/68) were categorized as having the diagnosis established by autopsy (with 62.5% (10/16) in hospital cases and 80.7% (42/52) in non-hospital cases), and 83.8% (57/68) were categorized as having major clinical diagnoses confirmed by autopsy (87.5% (14/16) in hospital cases and 82.7% (43/52) in non-hospital cases). In 26.5% (18/68) of all cases, one or more major unsuspected diagnoses were identified at autopsy (43.8% (7/16) in hospital cases and 21.1% (11/52) in non-hospital cases). In 52.9% (36/68) of all cases, autopsy established the cause of death, and in 47.1% (32/68) of cases the autopsy confirmed the clinically suspected cause of death. These categories are broken down to 62.5% (10/16) and 56.3% (9/16) in hospital cases, respectively, and 50.0 (26/52) and 44.2 (23.52) in non-hospital cases, respectively. The differences in rates of discrepant findings between in-hospital and non-hospital cases was not significant across the board.

Conclusion:

Conclusions regarding differences between in-hospital and non-hospital deaths are limited by low sample numbers for this ongoing study. Regardless, overall percentages of cases where major diagnoses (including the cause of death) were established at autopsy were high. The autopsy is vital in identifying clinicopathologic discrepancies, and the significance of identifying these discrepancies can have far reaching effects on patient care and management. The reporting of these ante- and post-mortem diagnostic discrepancies will help our institution (and hopefully others) reduce future medical errors and improve patient safety, thus “closing the quality loop”.

Acad Forensic Pathol. 7(1 Suppl):S-72–S-146.

Death following Bilateral Spontaneous Renal Artery Dissection Associated with Fibromuscular Dysplasia: Case Report and Review of the Literature

AL Lukefahr 1., B Parks 1.

Abstract

Spontaneous renal artery dissection (SRAD) is a rare entity, usually occurring in men in the fourth to sixth decade of life. Conditions associated with the development of SRAD include fibromuscular dysplasia, connective tissue disorders, severe hypertension, and extreme physical exertion. Bilateral dissection is seen in 10-15% of cases of SRAD. Here we report a case of a 20-year-old man who developed bilateral renal artery dissection associated with a left kidney infarct. Past medical history was significant for premature birth (34 weeks gestation), left renal malrotation, elevated left hemidiaphragm, and stomach volvulus status-post repair. Following presentation to a local emergency department for left flank pain, he was noted to have partial occlusions of the proximal and distal left renal artery branches associated with infarcts of the left kidney. Following administration of Lovenox for presumed renal arterial thrombus, he became unresponsive and developed anemia (hemoglobin 3.3 g/dL), hypotension, and a distended abdomen. Following surgical intervention to evacuate a retroperitoneal hematoma, he developed asystole. Autopsy identified hemorrhage of an unidentified retroperitoneal vascular source. Gross examination revealed what appeared to be bilateral renal artery thromboses; however, microscopic evaluation of the vasculature revealed fibromuscular dysplasia, not further classifiable, involving both renal arteries and infrarenal aorta, with medial dissection and pseudo-aneurysm formation involving both renal arteries. Cause of death was attributed to hemorrhage, likely secondary to clinical anticoagulation. In addition, a literature search was performed on the Medline-PubMed and Web of Science databases using the keywords bilateral, renal, artery, and dissection. An overview of the results is discussed, with an emphasis on the demographics and suspected etiologies of reported cases. This case highlights the importance of careful microscopic analysis of renal arteries at autopsy in the case of suspected renal artery thrombus or dissection. Failure of the forensic pathologist to recognize the presence of fibromuscular dysplasia may have significant implications for determining cause and manner of death (given that blunt abdominal trauma is also a cause for renal artery dissection) and for surviving family members, who may have also inherited a condition which carries a high risk for arterial dissections.

Acad Forensic Pathol. 7(1 Suppl):S-72–S-146.

Correlation or Causation? The Role of Benzodiazepines in Combined Drug Deaths with Opioids

BC Hoelscher 1., CC Stacy 1., DJ Duff 1.

Abstract

This study reviews the literature to examine the evidence for a causative role of benzodiazepines in combined drug deaths with opioids. Despite an increase in the number of deaths in which opioids and benzodiazepines are both detected by postmortem toxicology, questions still remain regarding this combination and whether benzodiazepines actually contribute to death in many of these cases. In multiple drug overdoses involving opioids and benzodiazepines, it may be difficult to determine if death is caused by the opioid(s), the benzodiazepine(s), or a combination. Opioids are strong respiratory depressants, whereas benzodiazepines are weaker respiratory depressants. Deaths caused solely by benzodiazepines are rare. It is said that the two drug classes have a synergistic respiratory depressant effect, but the exact mechanism has not been determined. In 2016, the FDA began requiring boxed warning labels on opioids and benzodiazepines indicating serious risks from combined use based on a review of data showing increased emergency department visits as well as overdose deaths in which both classes of drugs are detected. There is abundant literature describing an increase in the number of deaths in which opioids and benzodiazepines are involved. But has the causative role of benzodiazepines been proven, or could this just be a correlation because opioid users also tend to use benzodiazepines? It is recommended to list the generic name of each drug thought to be a causative factor in the death on the death certificate, but the criteria for making this determination are not clear. In certifying drug deaths in these types of cases, some pathologists list every respiratory depressant drug detected, whereas others consider the blood levels of individual drugs, sometimes excluding benzodiazepines found at therapeutic levels. The available literature regarding specific lethal concentrations in these combined intoxications is scarce. One might expect for opioid concentrations to be lower in combined intoxication deaths also involving benzodiazepines compared to opioids alone, but this is not consistently demonstrated in the literature.

Acad Forensic Pathol. 7(1 Suppl):S-72–S-146.

A New Speedball: Methamphetamine and Tapentadol

CR Cunningham 1., CC Stacy 1., DJ Duff 1.

Abstract

Tapentadol is a centrally acting μ-opioid receptor agonist and norepinephrine reuptake inhibitor that is used for moderate to severe pain. In the literature, there are few reports of fatal intoxications involving tapentadol. We report a case of a fatality due to the combined toxicity of methamphetamine and tapentadol. The patient was a 51 year old female with a medical history of hypertension, diabetes mellitus, and coronary artery disease. An autopsy revealed pulmonary congestion (combined lung weight 980 g), chronic hepatitis with bridging fibrosis, a 4.6 cm adrenal cortical adenoma, left ventricular hypertrophy with a heart weight of 390 g, and severe coronary artery atherosclerosis with up to 80% stenosis of the right coronary artery. Postmortem blood was positive for methamphetamine (2.2 mg/L), tapentadol (1.1 mg/L), diazepam (0.057 mg/L) and nordiazepam (0.025 mg/L). The cause of death was determined to be methamphetamine and tapentadol intoxication with arteriosclerotic and hypertensive heart disease and diabetes mellitus as contributing factors.

Acad Forensic Pathol. 7(1 Suppl):S-72–S-146.

Homicides Disguised as Staged Suicides

SP Prahlow 1., SD Cohle 2., JA Prahlow 3.

Abstract

Deaths related to homicidal and suicidal gunshot wounds are common in the United States. In most instances, investigation allows for relatively easy differentiation between homicides and suicides. Occasionally, however, such differentiation proves to be difficult, with the manner of death (MOD) in some cases ultimately being certified as “undetermined.” A number of investigative and autopsy findings help to differentiate a suicidal gunshot wound case from a homicidal case. This report describes multiple deaths related to contact gunshot wounds of the head where initial investigation suggested that the deaths represented suicides; however, based on scene and autopsy findings, along with subsequent investigative information, each case was appropriately ruled as a homicide.

Case 1: An 18-year-old male was found dead on the floor of his secured apartment, with a small-caliber, semi-automatic handgun near his body, and a blanket partially covering his hands and face. His sister had come to check on him after hearing rumors that he was dead. A letter written to his girlfriend was found elsewhere in the apartment. In it, the decedent asked her for forgiveness. Subsequent body examination revealed that the decedent's hands were clasped together, in a “folded hands” position. There was a penetrating contact gunshot wound of the right temple, with the bullet path traversing the right temporoparietal and left temporal cerebrum. Subsequent police investigation revealed that the decedent had been involved with dealing drugs, and another dealer shot him in the head while he was resting on the floor.

Case 2: A 40-year-old woman was found dead in bed by her husband after he heard a gunshot. Initial investigation suggested that the case represented a suicide. The woman had suffered from depression since being kicked in the head by a horse approximately 14 months previously. Autopsy revealed two contact perforating gunshot wounds of the head. Blood spatter evidence on the husband's clothing suggested that the husband was in the vicinity of his wife at the time of gunfire. In addition, a letter written by the woman was discovered which contradicted the horse kick claim, accusing the husband of having assaulted her. The husband was subsequently charged and convicted of murder.

The cases are presented, along with a discussion regarding important aspects of the investigation and autopsy which led to the proper MOD certification of each death.

Acad Forensic Pathol. 7(1 Suppl):S-72–S-146.

Opiates and the Possible Link to Suicide

AL Lytle 1.

Abstract

Purpose:

This research examines toxicology findings for opiates/opioids in individuals with the manner of death ruled as suicide in New Hampshire to test the hypothesis that a significant number of these individuals were opiate/opioid dependent.

Methods:

Toxicology reports on all suicide deaths were examined for opiates/opioids from January 1, 2014 through December 31, 2016. Each case report for individuals positive for opiates/opioids was examined for evidence of abuse and dependence. The criteria for dependence was determined by reporting family member or physician.

Results:

There were 711 suicides in New Hampshire from January 1, 2014 through December 31, 2016. Of these, 176 (25%) had opiates/opioids present in their toxicology. Of these, 127 (72 %) had historical evidence of opiate/opioid dependence reported. These findings prove to be statistically significant when a standard t-test was performed (p<0.05).

Conclusion:

Few studies have attempted to determine a relationship between suicide and opiate/opioid abuse and dependence. The results of this research validate a need for more studies in order to correlate a possible link between the effects of opiate/opioid abuse and suicide.

Acad Forensic Pathol. 7(1 Suppl):S-72–S-146.

A Dry Heat? … It's OK We Have Shower to Shower Bath Powder to Conceal the Decomposition Odors and Expedite the Mummification Process

HL Reinhard 1., AS Spencer 1., WK Ross 1.

Abstract

Mummification is the result of extreme postmortem desiccation. Dehydration of the body tissues inhibits bacterial decay and prevents putrefaction of the skin and internal organs. Mummification is most commonly seen in warm, arid, and windy conditions. Throughout the centuries, numerous chemicals and other factors such as lime, lye, salt, heavy metals and bat guano have been shown to contribute to the mummification process and long-term preservation. To date, mummification via the components found in bath powder such as cornstarch, talc, and sodium bicarbonate has not been well described in the literature.

We report the case of a mummified 51- year-old female who died of acute promethazine toxicity and remained in an inhabited apartment for approximately one month post mortem. The decedent was found lying in bed covered with a blanket in a stage of mummification. Shower to Shower bath powder was used by her roommate to conceal the decomposition odors and fluids and assist the mummification process. The bath powder used was composed of Zea Mays cornstarch, talc, sodium bicarbonate, tricalcium phosphate, fragrance, and maltodextrin.

Postmortem examination revealed generalized marbling and extensive drying throughout the entire body particularly of the hands and the feet with contraction of the nose and lips. No offensive odor was appreciated. White powder was identified around the nose, ears, in and around the oral cavity, and within the trachea. Decomposition within the body cavity was present but limited, given the one month postmortem interval.

This case demonstrates the pathological and decompositional changes found following mummification with cornstarch, talc, and sodium bicarbonate after one month postmortem. It is hypothesized that the corn starch binds the glycerol associated with adipocere formation and ultimately results in desiccation of the tissues. Documentation of these changes will allow for future recognition of the specific mummification process and better estimation of the postmortem interval.

Acad Forensic Pathol. 7(1 Suppl):S-72–S-146.

Fatality While Bear Hunting: A Homicide or an Accident?

A Spagnolia 1., WL Kemp 1., M Sens 1.

Abstract

Introduction:

When a hunter intentionally fires a weapon and the projectile strikes another human, the manner of death is often certified as homicide, as the intent of the individual firing the weapon is often unknown and the possibility of a hunting “accident” actually representing a concealed intentional homicide must always be considered. However, in some circumstances, such as a documented ricochet, the manner of death may be certified as accident. Other circumstances may also merit an accidental manner of death.

Materials and Methods:

The decedent was a 39-year-old male who was hunting with a friend when one of the two men shot a bear, which subsequently entered a brushy area. The two men waited, assuming to allow the wounded animal to die, and then entered the brush after it. The bear was only wounded and proceeded to attack the two men. While the decedent was being mauled, his partner shot and killed the bear. The decedent was brought in for autopsy to determine his cause of death. In the left thigh were numerous puncture wounds, consistent with the bear's teeth, none having injured a major artery; however, on the lateral surface of the left arm was an entrance-type gunshot wound with an irregular, up to 4.0 cm wide, marginal abrasion. The projectile had perforated both pleural cavities and was recovered near the right humeral head. Perforation of the pulmonary artery, the aorta, and other vasculature led to a measured total blood loss of 3300 mL. An autopsy of the bear by a veterinarian revealed a perforating gunshot wound. In addition, on the projectile recovered from the decedent, both human and bear blood was identified.

Discussion:

According to the National Association of Medical Examiner's Guide for Manner of Death Classification, if a hunter intentionally fires a weapon and kills a human, the manner of death may be classified as homicide; however, if a weapon is discharged, and the projectile strikes an object, ricochets and kills a human, the manner of death may be classified as accident. In the death reported, the scenario does not fit either of the above situations; however, given that 1) the decedent's friend fired a projectile with an intent to hit the bear that was mauling his partner and 2) that the projectile perforating the bear and entering his partner was unintended, the manner of death was certified as accident.

Acad Forensic Pathol. 7(1 Suppl):S-72–S-146.

Islet Cell Hyperplasia: A Potential Marker for Androgenic Steroid Use in Bodybuilders

J Weinand 1., WL Kemp 1., M Sens 1.

Abstract

Introduction:

The use of androgenic steroids has been associated with certain pathologic changes, most commonly hypertrophy and fibrosis of the heart. Although islet cell hyperplasia of the pancreas has not apparently been well-described in bodybuilders using androgenic steroids, it has been described in a group of patients who were prescribed androgenic steroids for the treatment of aplastic anemia occurring in association with Fanconi's anemia.

Methods and Results:

A 39-year-old male stepped in front of a train and sustained multiple blunt force injuries. At autopsy, he was noted to be very muscular and was found to be a professional bodybuilder at a local gym. As per office protocol, histologic examination of the organs was performed and the section of pancreas revealed marked islet cell hyperplasia. Using ImageJ, the area of the islets in photomicrographs of the decedent and seven control specimens from other autopsies was determined. The area of 16 islets sampled from the decedent ranged from 8302 μm to 668,594 μm, with a mean of 175,591 μm. In the seven control cases from 3-10 islets were photographically sampled per decedent, with a range of area from 3885 μm to 296,044 μm, and a mean of 33,532 μm (comment: one individual had two islets of >200,000 μm in area).

Discussion:

While the effects of androgenic steroids on the body are described in the literature, its effects on the heart are most often the focus. A PubMed search using the terms, “bodybuilder” and “islet cell hyperplasia” revealed no apparent articles addressing this histologic finding in association with illicit use of androgens. However, hypertrophy and hyperplasia of the pancreatic islets has been described in patients with aplastic anemia treated with androgenic steroids. Islet cell hyperplasia has also been described in patients with insulinomas, gastrinomas, high circulating levels of gastrin, and chronic pancreatitis. Nesidioblastosis, a cause of diffuse islet cell hyperplasia in children, is very rare in adults. An islet size of greater than 250 μm in diameter (approximately 49,000 μm in area) is considered hyperplastic, and if carefully screened for, reportedly up to 10% of adults can have islet cell hyperplasia. Based upon the report of islet cell hyperplasia associated with androgenic steroid therapy in patients with aplastic anemia, this case report, illustrating islet cell hyperplasia in a bodybuilder, suggests that islet cell hyperplasia may be a marker indicating the use of androgenic steroids.

Acad Forensic Pathol. 7(1 Suppl):S-72–S-146.

Acute Subdural Hemorrhage Associated with Both Metastatic Adenocarcinoma of the Dura and Minor Head Trauma: A Case Report and Review of the Literature

J Julson 1., WL Kemp 1., M Sens 1.

Abstract

Introduction:

Reportedly, 8-9% of individuals with metastatic neoplasms will have dural metastases identified at autopsy; however, between 1904-2003, only 198 cases of dural metastases were reported in the literature. The mechanism for the metastases may be 1) hematogenous spread, 2) direct invasion from metastases in the cranium, or 3) rarely, through direct extension from a cerebral metastasis. Tumors of the prostate, breast or lung often extend into the dura directly from bony metastases. Occasionally, dural metastases are associated with a subdural hemorrhage, with only about 55 cases reported in the literature. Head trauma also causes subdural hemorrhages. This case report describes an acute subdural hemorrhage occurring in association with both recent minor head trauma and dural metastatic adenocarcinoma.

Materials and Methods:

While incarcerated, a 44-year-old male with a history of diabetes mellitus and hepatitis C was witnessed to strike his head hard against the floor. Although he was active in the interim, three days later he was found unresponsive in his cell and transported to the hospital where a CT scan revealed a surgically un-manageable acute subdural hemorrhage. He subsequently died and an autopsy was performed. The bridge of his nose had a 2.0 cm crusted abrasion and scene investigation revealed scattered smears of blood and blood soaked towels, with medical personnel estimating a blood loss of 500 mL. Autopsy revealed an acute subdural hemorrhage grossly and metastatic adenocarcinoma in the dura mater, pituitary gland, lungs and lymph nodes microscopically. No primary source for the neoplasm was identified.

Discussion:

The mechanisms proposed for the development of a subdural hemorrhage in the background of dural metastases are rupture of blood vessels that were formed by neo-vascularization of the hemorrhage, obstruction of dural venous vessels leading to dilation and rupture, or, a pre-existing subdural hemorrhage may serve as a medium for the deposition of blood-borne metastases. In addition to 1) the presentation of a condition rarely reported in the medical literature (i.e., dural metastases associated with a subdural hemorrhage) and 2) the first apparent report of a subdural hemorrhage in an individual with both dural metastases and well-documented recent minor head trauma, this report illustrates that histologic examination of the dura mater and a subdural hemorrhage can, in addition to help determine the age of the subdural hemorrhage, also potentially help identify an underlying causative or contributory etiology for the subdural hemorrhage.

Acad Forensic Pathol. 7(1 Suppl):S-72–S-146.

An Unusual Case of Sudden Death Due to Subarachnoid Hemorrhage

SM Maines 1., S Crook 1., K Shah 1.

Abstract

The concept of “cognitive bias” has become a hot topic in the forensic science community in recent years. What some call bias, pathologists consider an essential part of the job. Forensic pathologists are physicians who must correlate anatomic findings with clinical history and scene investigation to arrive at a complete and accurate cause and manner of death. We present a case that highlights the intersection of art and science that defines the field of forensic pathology and necessitates its practice by a physician.

A previously healthy 56 year old Asian male who presented to the hospital with easy bruising, mucosal bleeding, and melena was found to be severely pancytopenic with bone marrow findings consistent with aplastic anemia. Parvovirus PCR was positive; other causes were ruled out. The patient completed two doses of a 5-day IVIG treatment plan before being found on the floor near his hospital bed. A head CT showed subarachnoid hemorrhage, cerebral edema, and transtentorial cerebellar tonsillar herniation. At autopsy, there was no evidence of injury to the scalp or calvarium. Intracranial findings were consistent with CT results.

Parvovirus B19 is a common infectious disease that is known to induce aplastic crisis in patients with hemolytic anemia. In healthy subjects, the virus typically causes the symptoms described of Fifth's disease and occasionally a mild, transient pancytopenia. Only rare case reports have described severe aplastic anemia in otherwise healthy individuals. While most subarachnoid hemorrhages are a result of a ruptured berry aneurysm or trauma, this unusual case highlights the importance for medical examiners to maintain a broad differential diagnosis and obtain thorough clinical and social history. Without these considerations, the more rare underlying causes may be missed, affecting families, epidemiologic statistics, and potentially legal proceedings. What qualifies forensic pathologists as physicians is their ability to integrate both physical findings and pertinent clinical and social history In this case, we identify a clear example of the importance of that integration and its necessity for excellent job performance.

Acad Forensic Pathol. 7(1 Suppl):S-72–S-146.

Get Rich or Die Trying: A Case of Traumatic (Compression) Asphyxia

CT Allard 1., SL Stauffer 1.

Abstract

With the creation of the Mining Safety and Health Administration (MSHA), mining related fatalities have fallen to record lows with only 26 total deaths reported in 2015. Of these very rare deaths, approximately 31% were in the stone, sand, and gravel mine sector with asphyxia, strangulation, and drowning accounting for the majority of deaths.

We present a case of a 52-year-old man found deceased at a limestone mine where he was employed. Per investigative reports, while at work the decedent ventured into a closed and unstable area of the mine searching for crystals (that he likely intended to sell) when a rockfall occurred and trapped him under approximately 500 tons of dirt and stone material. Several hours passed before his body was recovered via the use of a backhoe. Time of death was pronounced at 0330 the following morning.

Autopsy examination revealed florid, confluent petechiae of the head (including the conjunctivae and oral mucosa), neck, upper chest, and axillae. There was also prominent congestion of the sclerae. Minor cutaneous blunt force injuries were present on the torso and extremities, and there were multiple right-sided rib fractures. There were no other significant internal injuries of the head, neck, or torso, and no earthen material was present in the airways.

Other injuries found at autopsy were an open fracture of the right tibia and fibula, palpable fractures of the right knee, dislocation of the left knee, palpable instability of the left ankle, and dry abrasions and gaping, open, non-hemorrhagic lacerations of the lower extremities. The appearance and locations of these extremity injures suggested that they were produced postmortem during the recovery efforts, and were likely made by the backhoe.

In addition, several large clear crystals were found within the body bag and in the decedent's clothing pockets, along with a business card for a crystal selling establishment.

This constellation of findings is compatible with death due to traumatic (compression) asphyxia, with overlying postmortem injuries. This case not only highlights a rare circumstance of death that a forensic pathologist may encounter, but it also demonstrates the contrast between antemortem and postmortem injuries in an individual for which heavy machinery is used for body recovery.

Acad Forensic Pathol. 7(1 Suppl):S-72–S-146.

Large-Scale Computed Tomography Database with Associated Lifestyle and Health Data

S Daneshvari Berry 1., HJ Edgar 2.

Abstract

Research is often constrained by a lack of appropriate data for hypothesis testing. For example, various gas collections can be present in a decedent, many of which could have profound forensic implications. How frequently gas embolism plays a role in the pathophysiology of death is not clearly understood. Additionally, gas collections are important indicators of decomposition, which can be modified by or partially obscure pre-existing injury or infection. How frequent are traumatic pneumothoraces and tension physiology in cases of multiple blunt force traumas? This and many other research questions require a large, diverse full-body Computed Tomography (CT) data set that currently does not exist.

The Office of the Medical Investigator (OMI) is a centralized medical examiner office for the state of New Mexico. Any individual who dies of unknown or suspicious causes is routed to the OMI. This includes not only deaths from homicide and suicide, but a large proportion of natural and accidental deaths as well. In 2010 35% of deaths in New Mexico were autopsied. The racial and ethnic diversity of the state is reflected in the OMI sample.

In 2010, the Center for Forensic Imaging at the OMI received a large National Institute of Justice grant to determine if the traditional autopsy could be supplemented or supplanted by CT. As a result, every decedent that underwent an autopsy also received a full-body, high resolution CT scan. After the grant ended, the OMI continued to scan every decedent. This has resulted in 11,000 scans with little associated data.

In order to make these CT images retrievable to researchers as well as to answer research questions, a Delphi method survey was conducted. This resulted in 59 metadata variables to associate with the images making them useful in forensics, anthropology, medicine, and dentistry. In 2016 the National Institute of Justice awarded a grant to construct a free access Decedent Database available to bona fide researchers. Lifestyle and health metadata will be collected from both the medical examiner's database as well as interviews with the next of kin. The metadata on all 11,000 decedents will be available online, and images will be sent on portable drives via postal mail. The database will have the potential to answer many currently unanswerable questions.

The database is currently under development and will be available to researchers by the end of 2018.

Acad Forensic Pathol. 7(1 Suppl):S-72–S-146.

Severe Lung Injury Associated with A/H1N1pdm09 Infection in the Post-Pandemic Season

K Hayashi 1., N Nakajima 2., S Iwatate 3., K Asakura 1., A Hamamatsu 1.

Abstract

Background:

The A/H1N1pdm09 virus (A/H1N1pdm09) was first reported as a novel influenza virus in Mexico in March 2009, and it rapidly spread worldwide from human to human. In the pandemic season (from June 2009 to August 2010), several fatal cases were complicated with viral pneumonia, which subsequently developed into acute respiratory distress syndrome (ARDS), leading to patient death due to respiratory failure. A/H1N1pdm09 continues to circulate as a seasonal influenza virus in the post-pandemic period. Seasonal influenza-associated pneumonia is generally secondary bacterial pneumonia, and pathologically, it rarely develops into primary viral pneumonia. The number of the cases has decreased in the post-pandemic season. However, between the winter of 2015 and the spring of 2016, 14 cases were positive for A/H1N1pdm09 virus and more than half of the cases in Tokyo Medical Examiner's Office had ARDS. We would like to know if the cause of ARDS was linked to the host or the virus. For example, does A/H1N1pdm09 have high alveolar epithelial infectivity?

Methods:

To elucidate the pathogenic mechanism of A/H1N1pdm09 infection-associated lung injury and ARDS in the post-pandemic season, we examined 34 A/H1N1pdm09 positive autopsy cases from 2009 to 2016 and examined lung tissues using molecular, biological, and pathological methods.

Results:

Among 34 cases (23 males and 11 females, mean age 46 years), nearly 41% were psychiatric patients and 38% were obese individuals (BMI > 30). Thirteen cases (38%) demonstrated diffuse alveolar damage. Only a few A/H1N1pdm09 antigen-positive cells were detected in lung sections, some of which were alveolar epithelial cells, and the copy number of A/H1N1pdm09 RNA was low. In all cases, the receptor binding site sequence of hemagglutinin in A/H1N1pdm09 had a preference for alpha-2,6 linked sialic acids, suggesting low infectivity in alveolar epithelial cells.

Discussion/Conclusions:

Even in post-pandemic seasons, the A/H1N1pdm09 virus has more potential to induce severe lung injury than other influenza viruses. Furthermore, an overactive immune response is likely in psychiatric or obese host.

Acad Forensic Pathol. 7(1 Suppl):S-72–S-146.

LlfeLink of Georgia's Coroner Referral Program

CM Gammill 1., C Borderieux 1.

Abstract

In 154 of 159 counties in Georgia, the responsibility for death investigations falls under the jurisdiction of the elected Coroner. In most of those counties, the Georgia Bureau of Investigation Medical Examiner provides autopsy and other forensic services to aid in their investigation. There are approximately 400 Coroner or Deputy Coroners in Georgia. There is no requirement that Coroners have any medical or death investigation training prior to being elected as Coroner.

Georgia law requires hospitals to have agreements with an Organ Procurement Organization (OPO), a tissue bank, and an eye bank, requiring cooperation between those groups. However, participation of Coroners is not mandated. The law does state that a medical examiner and procurement organization shall cooperate to maximize the opportunity to recover anatomical gifts.

In 2012, the Coroner and Medical Examiner Liaisons at LifeLink of Georgia began to look for ways to increase opportunities for tissue recoveries. Having relationships with medical examiners, which included direct referrals, we found many potential donors were ruled ineligible due to lack of timely notifications, and decedents were often not seen by a medical examiner or hospital, but had direct funeral home disposition after Coroner involvement. Based on this information, the Coroner Referral Program began in 2013.

Implementation of the Program began with training for LifeLink of Georgia staff who may have contact with coroners, to include communications personnel, Family Care Coordinators, Medical Screeners, Recovery Technicians, and Quality Review Coordinators. The training included discussions of the Coroners authority and responsibilities, and how we could assist them during their death investigation.

Training for the Coroners regarding the Coroner Referral Program was centered on providing information regarding the benefits of organ and tissue donation to the families of organ and tissue donors, and benefits of organ and tissue donation to the broader community. We included donor families discussing their experiences and how donating helped them through their grieving process. LifeLink of Georgia has produced videos of Coroners who lost family members who were waiting on lifesaving organs, and Coroners and donor families who were involved in making referrals. We also provided training about referral processes, including information collection, timeliness, and the referral call.

After the first year of training in 2013, Coroners had made 71 referrals. In 2014, referrals increased to 203, 2015 saw 322 referrals, and in 2016, 255 referrals came from Coroners. Coroners from 69 counties have made referrals.

Acad Forensic Pathol. 7(1 Suppl):S-72–S-146.

Dehiscence and Exsanguination of a Healing Surgical Chest Incision Mimicking Traumatic Injury in a Non-Decomposed Person

J McLemore 1., S Sweede 2.

Abstract

A man in his 6th decade with numerous co-morbidities including substance/alcohol abuse, diabetes, and generalized atherosclerosis, was found in his secured residence, prone on his bed. The mattress had been soaked through with his blood. Initial inspection of his body by the county medical examiner revealed an open defect on the midline of his upper chest, worrisome for a firearm or sharp force injury. Further visualization of the wound was suboptimal because of the decedent's chest hair and blood. The medical examiner was reluctant to clean or shave around the defect for fear of contaminating potential evidence in a homicide. No firearms were found in the apartment, and no knives were near the body. The decedent's medical history was significant for coronary artery by-pass graft surgery and mitral valve replacement three months prior to death. He had seen his primary care provider about 1 week prior to being found dead although no mention of the condition of his surgical site was found in the medical records. Because initial examination of the body at the scene was concerning for a possible homicide, an autopsy was conducted. After shaving and cleaning of the chest at autopsy, findings revealed a 3/4 inch round defect, at the superior edge of a poorly healing surgical incision. Reflecting the tissue of the chest revealed a sternum that had been pulling apart with adjacent small soft tissue abscesses, loose sutures and disrupted sternotomy wires. The pericardial sac was fibrotic but intact; no major vessels were disrupted. The source of the bleeding was not definitively found; however, the left internal mammary artery (IMA) graft, which had been documented in the surgical records as being grafted to the left anterior descending coronary artery, was lost in the inflamed substernal soft tissue. Disruption of the IMA graft was the presumed source of the bleeding. A point-of-care urine drug screen was positive for cocaine. Inspection of his medications at his residence indicated that he had not taken his antibiotic that was prescribed after his surgery.

Risk factors for postoperative dehiscence of sternotomy surgical sites include but are not limited to malnutrition, tobacco, alcohol and drug addictions. Dehiscence of surgical wounds has been known to mimic antemortem trauma in decomposed bodies; however, this same mimic in non-decomposed bodies has not been previously reported.

Acad Forensic Pathol. 7(1 Suppl):S-72–S-146.

Controversial Conclusions: Manner of Death Determination in Fatal Train Collisions

C Pryor 1., AL Falzon 2., CH Revercomb 1., K Rogers 3.

Abstract

In traumatic fatalities resulting from a train collision, the cause of death is often evident to the forensic pathologist, through a review of the significant injuries sustained. Determination of the manner of death, however, can prove difficult. Fatal pedestrian collisions become controversial, particularly when the strike was not witnessed and when no previous suicidal ideation or behaviors are documented. Ramifications of the manner of death ruling are far reaching, impacting criminal investigation, allocation of insurance benefits as well as the family grieving process. Behavior preceding the incident, presence of a suicide note, previous ideations/attempts, and recent stressors are all important considerations in the pathologists’ manner of death determination. Toxicology results are also important as they can be indicative of a level of incapacitation as opposed to rational intent. Available investigative data for all traumatic train related fatalities in the state of New Jersey from January 1, 2011 through December 31, 2015 were reviewed. The 142 traumatic train-related fatalities included 134 pedestrians and 8 individuals who were inside a motor vehicle that was struck by a train, including 5 drivers and 3 passengers. At least one train vs. motor vehicle incident resulted in multiple fatalities. The manners of death included suicide (n=91), accident (n=45) and undetermined (n=6). A demographic review highlighted patterns among gender, race, marital status and age. The highest incidence of fatal train interactions was in the age group of 18-29 year olds, 25% of the incidents. The decedents were majority male, with 114 fatalities, of which, 63% were ruled suicide, 32% accident, and 5% undetermined. The 28 female decedents included 68% suicides and 32% accidents. In all six cases ruled undetermined, there were no notes or reported prior indications of suicidal intent. Toxicology findings in five of the six cases indicated recent use of alcohol, non-prescribed drugs, or both. Cases where the determined manner of death was suicide were, in some cases, met with familial remonstration. In at least one of these cases, familial opposition prompted amendment of the manner of death from suicide to accident.

Acad Forensic Pathol. 7(1 Suppl):S-72–S-146.

Drug Immunoassay Testing of Vitreous Fluid as a Surrogate for Urine Testing

L Tormos 1., S Presnell 1.

Abstract

Standard immunoassay testing kits are fast and relatively inexpensive screens for drugs of abuse. Status DS is a one-step assay that provides results in as little as five minutes. The manufacturer's validation testing shows a 97-99% correlation to gas chromatography-mass spectrometry (GC/MS). The test menu includes:

  • •

    Tricyclic Antidepressants (TCA)

  • •

    Opiates (OPI)

  • •

    Methadone (MTD)

  • •

    Phencyclidine (PCP)

  • •

    Amphetamine (AMP)

  • •

    Barbiturates (BAR)

  • •

    Methamphetamine (MET)

  • •

    Benzodiazepines (BZO)

  • •

    Marijuana (THC)

  • •

    Cocaine (COC)

Positive results may help guide the death investigation and negative screens may allow completion of cause of death statements in cases where there is sufficient anatomical disease. However, not all decedents have urine at the time of postmortem examination. Use of vitreous fluid as a surrogate is technically limited by viscosity of the fluid and suitability as a sample.

Study:

Hyaluronidase is an enzyme that digests hyaluronic acid, decreasing vitreous viscosity. Sonication applies sound energy to agitate particles in a sample and disrupt biological material. A prospective study was designed to screen untreated, hyaluronidase treated vitreous fluid (HVF), and sonicated vitreous fluid (SVF) in autopsy cases where the cause of death was suspected to be associated with drug use. To qualify for the study, urine and vitreous fluid had to be available for collection. The results were then compared to the blood and urine drug concentrations analyzed at reference laboratories.

Results:

The following drugs were detected in urine at the time of autopsy: OPI, AMP, MET, BZO, THC, COC, MTD, and TCA. Urine results correlated well with the presence of drugs in blood; false positive opiate results correlated with the presence of fentanyl or derivatives. In comparison, OPI, MET, BZO, MTD and COC were confirmed in HVF. Untreated vitreous and HVF failed to identify THC (5 cases), AMP (3 cases), BZO (5 cases), OPI (4 cases), MET (1 case), TCA (1 case). Vitreous fluid and HVF had comparable results, although hyaluronidase treatment evidenced opiates in 3 cases, and benzodiazepines and methadone in 1 case each. Sonication had no benefit, and some positive samples turned negative after sonication.

Conclusions:

Vitreous fluid is not a good surrogate for immunoassay testing. Hyaluronidase treated vitreous fluid may provide the next best alternative fluid for testing when urine is not available. Sonication is not recommended, and is also more technically difficult.

Acad Forensic Pathol. 7(1 Suppl):S-72–S-146.

3,4-Methylenedioxymethamphetamine (MDMA, Ecstasy) Intoxication in a Young Adult with Giant Coronary Aneurysms from Kawasaki Disease

R Eigsti 1., F Dennis 1., M Nashelsky 1.

Abstract

Kawasaki disease is an acute vasculitis of unknown etiology that usually occurs in children less than 5 years old. The disease commonly presents as an acute febrile syndrome with conjunctivitis, polymorphous skin rash, cervical lymphadenopathy, oral mucositis, and skin desquamation. Coronary artery aneurysms due to arteritis are the most common cardiac complication and develop within 8 to 12 days of disease onset. Aneurysms develop in 5% of treated patients and 20% of untreated patients. Over time, these aneurysms may spontaneously regress, remain the same size, expand, or rupture. Chronic aneurysms are associated with an increased risk of developing luminal thrombosis and myocardial injury. Coronary angiogram and intravascular ultrasound are used to characterize the aneurysms. Patients are often followed with serial echocardiography.

We present a case of an 18-year-old male with a past medical history of Kawasaki disease complicated by giant aneurysms of the right and left coronary arteries. Serial echocardiographic studies and treadmill EKG stress tests as recent as 1.5 years before death revealed excellent cardiac function with no evidence of dyskinesis and a normal cardiovascular response to exercise. The decedent sustained a witnessed collapse after ingesting MDMA and ethanol. He was transported to the emergency department and pronounced dead after unsuccessful resuscitative efforts.

Autopsy revealed large aneurysms of all three main epicardial coronary arteries. The maximum arterial diameter was 2.0 cm. The aneurysmal areas had extensive foci of severe stenosis by fibrocalcific plaques, with areas of pinpoint luminal narrowing. These findings were highly consistent with the history of Kawasaki disease. The heart also had left ventricular hypertrophy and mild bi-atrial and biventricular dilatation. Microscopic examination revealed variable myocyte hypertrophy ranging from mild to severe. These findings are related to the coronary artery disease. There were remote microinfarcts in the anterior and posterior left ventricle and a recent, healing microinfarct was in the posterior left ventricle.

This case illustrates the residual, lasting effects of cardiac disease due to Kawasaki disease in the setting of illicit stimulant use. MDMA is an amphetamine derivative and produces sympathetic activation. Drug induced sympathetic activation can cause cardiovascular effects including tachycardia, vasoconstriction, blood pressure alterations, dysrhythmias, and coronary artery spasm. It is likely that Kawasaki disease-related structural abnormalities of the heart yielded.

Acad Forensic Pathol. 7(1 Suppl):S-72–S-146.

Unsafe Sleep Environments: A Florida Case Series Illustrating the Dangers of Bed Sharing, Soft Bedding, and Prone Positioning

EM Baardsen 1., AR Perkins 1., SR Rivers 2., K Devers 2.

Abstract

Sudden unexpected infant death (SUID) is defined as the death of an infant (less than 1 year of age) that is sudden, unexpected, and without an obvious cause prior to investigation. The Centers for Disease Control and Prevention (CDC) reported that approximately 3,700 sudden unexpected infant deaths occurred in the United States in 2015. These deaths were divided into three commonly reported types: sudden infant death syndrome (SIDS), unknown cause, and accidental suffocation and strangulation in bed. Possible causes of the latter include suffocation by soft bedding, overlay by caregivers, wedging/entrapment, and strangulation. Bed sharing and overlay represent the greatest risk to infants up to four months old. Infants between four and twelve months of age are capable of rolling, putting them at increased risk of suffocation/strangulation and wedging/entrapment. It can be difficult to distinguish SIDS from suffocation/strangulation because the event is often unwitnessed and livor patterns can alter after prolonged medical attempts of resuscitation. We present a series of 18 cases from Hillsborough County, Florida, that occurred between 2014 and 2016 that demonstrate a variety of dangerous sleep environments that ultimately resulted in the sudden unexpected accidental death of children less than one year of age. These cases reflect various unsafe practices, including prone positioning, the use of soft bedding, and bed sharing. Several of the cases depict a combination of these practices. When approaching cases of sudden unexpected infant death, it is crucial to examine the scene thoroughly, consider details provided by caregiver reenactments when available, and thoroughly examine the child for characteristic signs and markings, before making the final determination that the death was the result of accidental suffocation and strangulation in bed.

Acad Forensic Pathol. 7(1 Suppl):S-72–S-146.

A Review of 5 Unusual Gunshot Wound Suicides Reflects the Importance of Proper Death Investigation in Determining Manner of Death

JM Wright 1., M Kessler 1.

Abstract

Our office has investigated multiple instances of suicides involving multiple gunshot wounds. We discuss five cases examined between November 2016- April 2017. All cases were initially reported as a single gunshot wound by law enforcement or a medical professional. However, in all cases autopsy findings revealed multiple gunshot wounds and it was essential to correlate findings with scene and police investigation. These cases highlight the importance of proper scene investigation performed by trained professionals in death investigation. Case one, reported by hospital staff, was a 61-year-old male with a gunshot wound to the right temple with soot and stippling and a gunshot graze wound located on the forehead with stippling. Police observed three bullet holes located to a closet door and door trim. The second case, reported by police, was a 75-year-old male found in his vehicle with a handgun. The decedent had a contact gunshot wound to the posterior head and a gunshot wound to the chin which did not injury any vital structures. The third case, reported by police, was a 66-year-old male found to have gunshot wounds to the head, upper and lower abdomen, right hand and forearm. The fourth case, reported by police, was a 78-year-old male with an extensive medical history. The decedent had a near contact gunshot wound to the upper abdomen and an intraoral gunshot wound. The last case, reported by police, was a 26-year-old male who had an intraoral gunshot wound. This case involved, two adjacent bullet holes located in the wall behind the decedent's head, two spent casings and one gunshot wound path. Two out of the five cases involved a clinical diagnosis of depression or anxiety. One case showed recent ideations with no diagnosis of depression or anxiety however, a history of paranoia and obsessive-compulsive tendencies were appreciated. Two of the five cases left a suicide note. Toxicology was performed on three out of five cases, which resulted in one positive for Ketamine, one with negative results and one currently pending. In conclusion, correlation of scene investigation, autopsy findings, review of records and toxicology results are critical to determine proper manner of death. In addition, these cases illustrate the importance of scene investigation performed not only by law enforcement but by a properly trained death investigator and also reflect the importance of an autopsy performed by a certified forensic pathologist.

Acad Forensic Pathol. 7(1 Suppl):S-72–S-146.

Evidence at Scene Investigation in Drug-Related Deaths Varies by Neighborhood and Discovering Party

C Liverman 1., E Moffatt 2.

Abstract

Drug-related accidental deaths comprise an increasing proportion of forensic autopsy cases in many jurisdictions. In many such cases, physical findings at autopsy are minimal, and evidence from the scene investigation is critical for formulating a differential diagnosis and determining the need for toxicology studies. Few studies in the literature have examined the factors that influence the evidence found at drug overdose scenes. To approach this question, we queried the database of the City and County of San Francisco Office of the Chief Medical Examiner for all cases of drug-related accidental death during the years 2015 and 2016. A total of 322 cases were analyzed, after exclusion of cases without scene investigations (hospital deaths). For each case, investigator history was reviewed for evidence of drug use at the scene, including paraphernalia, as well as drug type and the party discovering the body. Additional data from the autopsy record were recorded, including location and final cause of death.

Overall, scene investigation revealed the presence of drugs in 48% of drug-related deaths and evidence of drug use in 72% of cases. The proportion of cases with drug evidence varied by neighborhood, with evidence present in 81% of cases in the area of greatest drug death density (San Francisco's Tenderloin district) compared to 65% of cases outside this area (p<0.01, Fisher's exact test). No significant difference in presence of drugs was found between neighborhoods. When the data were analyzed according to party finding the body, drugs were present in 43% of cases discovered by family or friends of the decedent, 46% of cases found by a stranger and 80% of cases found by law enforcement/EMS. (p=0.07, police v. acquaintances, Fisher's exact test). For cases outside the Tenderloin district, a similar relationship was seen, with drugs more likely to be discovered in cases found by police/EMS compared to those discovered by either acquaintances or strangers (p<0.02, Fisher's exact test).

The findings show that sensitivity of scene investigation in drug-related deaths varies by neighborhood, with a greater likelihood of discovering drug evidence in neighborhoods with endemic drug use than in areas with higher socioeconomic status. Secondly, scenes in which the police or EMS are first to the scene are more likely to have drugs present, suggesting that drugs are removed from the scene by acquaintances or strangers prior to investigation in some cases, particularly in higher socioeconomic status areas.

Acad Forensic Pathol. 7(1 Suppl):S-72–S-146.

Characterization of Gabapentin-Related Deaths in West Virginia

MA Abate 1., GS Smith 2., Z Dai 2., AR Mock 3., JC Kraner 3., JA Kaplan 3., S Falsafi 4.

Abstract

Gabapentin has been identified in many West Virginia (WV) deaths, and increases in gabapentin misuse and abuse have been reported in recent literature. However relatively little information is known regarding gabapentin and its role in drug-related deaths. Our forensic drug database (FDD) was used to analyze information from all WV drug-related deaths, with complete data currently present for 2005 – 2014 and about 10 months each for 2015 and 2016. Decedent data include death certificate information, toxicology findings, medical history, and key autopsy findings. Of 7,356 total drug-related deaths, gabapentin was identified as a contributing cause in 398 cases (5.4%) (manner accidental in 89.5%). However, 46.0% (183) of all gabapentin deaths occurred during 2015-16, which represents 12.8% of all drug deaths during this period (N = 1428). Significant differences between gabapentin (G) and non-gabapentin-related (NG) deaths include: 1) slightly older mean G age (45 G vs.41 NG), 2), greater percentage of females in G deaths (48.5% G vs. 33% NG), 3) greater mean number of drugs involved (4.7 G vs. 2.7 NG), 4) greater number of deaths with at least 1 concurrent opioid present (89% G vs. 79% NG), 5) greater number of deaths with at least 1 concurrent benzodiazepine present (70% G vs. 49% NG), and 6) less alcohol involvement (11% G vs. 25% NG). Significant differences were also found in the concurrent drugs present in G and NG deaths. During 2005-14, alprazolam, oxycodone, hydrocodone, and diazepam were among the five drugs most frequently identified in both G and NG deaths, along with clonazepam (G deaths) and ethanol (NG deaths). The top five drugs present in G deaths during 2015-16 were the same as 2005-14 (although frequencies varied). However, fentanyl and heroin were the most frequently identified concurrent drugs in NG deaths during 2015-16 (∼ 32% of cases each). Significantly greater percentages of G decedents had a documented history (medical, other records) of drug and/or alcohol abuse as well as existing cardiovascular, psychiatric, pulmonary, or hepatic disorders compared to NG decedents. Analysis of gabapentin blood concentrations found that 40% were above the usual therapeutic maximum (20 mcg/ml), and a potential therapeutic indication for use was identified in only 28% of cases. Gabapentin overuse/abuse may contribute to many drug-related deaths with significant differences found compared to those deaths not involving gabapentin. However, gabapentin's contribution to toxicity relative to the other detected drugs in these deaths remains uncertain.

Acad Forensic Pathol. 7(1 Suppl):S-72–S-146.

Autopsy Case of Nephronophthisis and Fat Overload Syndrome

R Baldzizhar 1., P Katzman 1.

Abstract

Background:

Nephronophthisis is an autosomal recessive, genetically heterogenic renal disease with identified mutations in a number of genes that encode proteins involved in the function of primary cilia. The infantile form is characterized by mutations in the NPHP2 gene, which leads to end stage renal disease. Extrarenal manifestations may include bone anomalies, hepatosplenomegaly and portal fibrosis, situs inversus, septal cardiac defects.

Methods:

Patient was a 22 month old female with a past medical history of failure to thrive, chronic kidney disease, nephrogenic diabetes insipidus, G-tube dependence, and chronic liver disease of unclear etiology. Two liver biopsies were most consistent with acute hepatitis and a renal biopsy showed chronic tubulointerstitial nephritis, secondary focal segmental glomerulosclerosis, proliferative arteriolosclerosis, and microscopic renal dysplasia. She was re-admitted with acute worsening of hyperbilirubinemia and transaminitis with electrolyte disturbance. On day 10 of her hospital stay patient inadvertently received IV lipid infusion over 2 hours rather than the typical 20 hours and subsequently developed respiratory distress, increasing abdominal ascites, and bleeding from mucous membranes and intravenous lines sites. Patient was resuscitated with blood products and became more alert with improved respiratory status. Later she had sudden decompensation, received cardiopulmonary resuscitation, more blood products, electrolyte replacement, and abdominal paracentesis. Unfortunately the patient was unable to be resuscitated and died.

Results:

Autopsy gross findings included anasarca, multiple small abdominal and parietal petechial hemorrhages. Serosanguineous fluid was found in the pleural cavities and abdominal cavity. Microscopic findings confirmed diagnosis of macronodular liver cirrhosis accompanied by marked cholestasis and bile duct proliferation with intervening areas of parenchymal hemorrhagic necrosis. Pancreas showed acute pancreatitis. Kidneys had bilateral patchy chronic interstitial nephritis with interstitial fibrosis and cortical necrosis with atrophic tubules with dilatation, variably thickened basement membranes, and calcifications, and immature glomeruli.

Conclusion:

This case represents an interesting combination of a rare inherited disease and a rare potentially fatal treatment complication. By whole exome sequencing this patient had a novel (non-inherited) STAT3 mutation that was not described in patients with nephronophthisis. The fat overload syndrome described after rapid infusion of lipids can also be accompanied by hepatosplenomegaly, respiratory distress, and spontaneous hemorrhage associated with anemia, leukopenia, thrombocytopenia and coagulopathy. It is not clear in this case to what extent the two diseases overlapped to cause the patient's death. However, given this patient's pre-existing nephronophthisis with declining status, the fat overload syndrome may have been the factor leading to death.

Acad Forensic Pathol. 7(1 Suppl):S-72–S-146.

Nonterrorist-Related Suicide Due to Explosion: A Case Report and Review of the Literature

SM Crook 1., S Maines 1., L Lippincott 2.

Abstract

Historically, explosion-related deaths were primarily accidental (particularly within the workplace) or homicidal in nature. In the late 20th century, terrorist acts in the form of “suicide bombings” became notable and frequent occurrences reported in the media. A rare, but important, subset of explosion-related deaths occur in the form of nonterrorist suicides and require special attention. We report the case of a 49 year old male who was found deceased in his bathroom with massive craniofacial injuries. Neighbors stated he had been acting paranoid recently and was seen shooting a gun outside his home earlier that day. At the scene, an air rifle was found at the victim's feet and wires were found in his hands and on the bathroom floor. According to scene investigators, the wires were consistent with those used to detonate blasting caps. No explosive devices were found at the scene or in the house. Radiographs of the body revealed very rare radiopaque foreign particulate matter in the head. At autopsy, extensive injuries to the mid craniofacial region were identified and included comminuted fractures of the facial bones and basilar skull, lacerations of bilateral frontal cerebral lobes, and subdural and subarachnoid hemorrhages. A tooth and small fragment of irregular copper-colored metal were recovered from the lacerated frontal lobe tissue. Contusions and abrasions of the upper extremities were the only other injuries noted. Toxicologic analysis of postmortem blood was positive for methamphetamine, alprazolam, and hydrocodone. The cause of death was determined to be blunt force injuries sustained from a self-inflicted blasting cap explosion.

Nonterrorist-related suicides by explosives are rare. This case highlights the importance of a comprehensive scene investigation and thorough postmortem examination in explosion-related deaths. In this case, the explosive itself was destroyed, leaving a paucity of physical evidence of the device both at the scene and within the body. Therefore, it is important for medical examiners to have a working knowledge of the variety of explosive devices used and to recognize injury patterns consistent with explosion-related deaths. In addition, it is imperative to rule out other causes of death that may be masked by an explosion, such as gunshot and stab wounds. We will discuss the types of explosives used and the injury patterns seen as it relates to manner of death.

Acad Forensic Pathol. 7(1 Suppl):S-72–S-146.

Persistent Left Superior Vena Cava as Part of a Wound Path in a Fatal Stabbing

SL Stauffer 1., LW Jackson 2.

Abstract

Persistent left superior vena cava (PLSVC) is a rare but often asymptomatic venous anomaly in the thorax, with case reports and reviews indicating its presence in 0.4% of the general population. A right superior vena cava is also identified in approximately 90% of these cases. An isolated PLSVC (i.e. present in the absence of a right superior vena cava) is rarer still, present in only 0.04% of the population, and can be associated with increased susceptibility for arrhythmias.

We present a case of a pregnant 23-year-old woman who died due to multiple sharp force injuries inflicted by another individual. Agonal breathing and the pregnancy were noted by first responders at the incident scene, therefore the woman was transported via ambulance to a local hospital. A left thoracotomy was performed in the emergency department simultaneous with an emergent caesarian section. The operating physician identified an actively bleeding large caliber blood vessel adjacent to the heart (believed at the time to be the left pulmonary artery) and sutured the defect. Despite the emergent surgical intervention, both the woman and baby died shortly thereafter.

The autopsy examination revealed many incisions and stab wounds on the mother's face, neck, torso, and extremities. Internally, an emergently placed suture was noted in an anomalous large caliber left-sided thoracic vessel. Further examination of the cardiopulmonary vasculature revealed that this sutured vessel was a PLSVC that drained directly into a markedly dilated coronary sinus. There was absence of a right superior vena cava. The PLSVC was a component of the fatal wound path of a stab wound of the mother's chest, that perforated the left shoulder, left upper lung lobe, pericardium, left superior vena cava, and penetrated the left atrium.

While PLSVC is generally considered to be an anatomic variant with little clinical consequence when the right superior vena cava is preserved, its occurrence with concomitant absence of a right superior vena cava it may lead to susceptibility for arrhythmias. Though any injury to major cardiac vessels poses a threat to survival, the presence of a PLSVC in this decedent was particularly significant as it was injured during the stabbing and presented an unexpected challenge to the treating surgical team during resuscitative efforts. Our report underlines the importance of careful examination of the anatomy involved in a wound path, as well as awareness by the treating physicians and pathologists of anatomic variants that may be encountered.

Acad Forensic Pathol. 7(1 Suppl):S-72–S-146.

Suicide by Fire: A Case Report and Review of the Literature

PD Pittman 1., M Aurelius 2.

Abstract

Suicide by fire, self-burning, or self-combustion is a highly aggressive and dramatic method of suicide, that entails pouring flammable materials onto oneself and igniting it with the intention of severely hurting or killing oneself. Historically, this act has had powerful cultural meaning and political impact across the world, most notably in eastern, African and Asian countries, where this act accounts for more than 70% of all suicides. In westernized countries, such as the United States, successful completion of suicide by fire is exceedingly rare, accounting for approximately 1% of all reported suicides. This low rate of success is often attributed to increased sophistication and treatment of severe burns, thus leading to less successful attempts and a greater length of survival with marked morbidity. Those at greatest risk for suicide by self-burning are individuals between the ages of 30 and 59, and those with a past medical history of substance abuse/dependence disorders and/or a psychiatric disorder such as psychosis or major depressive disorder. Additionally, victims of suicide by burning are significantly more likely to be female when compared to all victims of suicide by all methods. Forensically, it is critical to meticulously differentiate manner of death for any suspected case of suicide by self-burning from accidental burns and homicide, as evidence and witness accounts may be limited.

This is a case of a 53 year old white female with a lengthy medical history of bipolar disorder, depression and domestic violence who was found deceased and fully charred in her residence after it was entirely engulfed by flames. According to witnesses the decedent had been acting erratically the day of the fire, had been burning candles in her bedroom, and was using social media to make suicidal threats and post cryptic messages stating “fire is the gateway to the underworld”. A complete forensic autopsy was performed, and formalin fixed paraffin embedded sections were submitted for histologic examination. Herein we will focus on the medical findings, autopsy findings and death investigation that favor this case to be a suicide by self-burning. This case emphasizes the importance of death scene investigation-including investigating social media sites when looking for intent-toxicological evaluation.

Acad Forensic Pathol. 7(1 Suppl):S-72–S-146.

Turner Syndrome is Another Risk Factor for Aortic Dissection

A Edgecombe 1.

Abstract

A 34-year-old female was at church when she developed chest pain, diaphoresis, nausea and vomiting. She attended the Emergency Room where blood work and chest x-ray demonstrated non-specific findings. An ECG showed prolonged QT. She was later discovered unresponsive in the waiting room. Her medical history was significant for Turner syndrome, obesity and hypertension. An echocardiogram performed one month prior showed a mildly dilated and hypertrophied left ventricle. At autopsy, she had a height of 156 cm and weighed 137 kg with a body mass index of 56.3 kg/m2. There was a DeBakey type I aortic dissection with hemopericardium and bilateral hemothoraces. Hypertensive heart disease was also noted with cardiomegaly (520 g) and concentric left ventricle hypertrophy.

Turner syndrome occurs sporadically in 1/2000 live female births when there is a partially or completely missing X chromosome. Clinical features include short stature, high arched palate, short webbed neck, broad chest with widely spaced nipples, lymphedema of the hands and feet, skeletal malformations and premature ovarian failure. Abnormal cardiovascular development is seen in 50% of cases including bicuspid aortic valve, aortic coarctation, aortic dilatation, atrial and ventricular septal defects and pulmonary venous abnormalities. There is a 100 to 200-fold increased risk of aortic dissection. The median age of dissection is 30-35 years, but it is described in those less than 20 years. Most who develop aortic dissection have aortic valve disease, coarctation and/or hypertension. Pregnancy increases the risk. The underlying genetic or vascular abnormality is not known. Those with Turner syndrome also have increased risk of premature hypertension and coronary artery disease. Other associated features include renal anomalies (horseshoe kidney), ocular disease, hearing loss, osteoporosis, fractures, diabetes, Hashimoto's thyroiditis and Celiac disease.

In the presented case, a clinical diagnosis of aortic dissection was not considered. Many teachings/textbooks neglect to include Turner syndrome as a risk factor for aortic dissection. Physicians should be aware of the vastly increased risk of cardiovascular disease with Turner syndrome, especially aortic dissection.

Acad Forensic Pathol. 7(1 Suppl):S-72–S-146.

Toxicology Reports – Do They Stand on Their Own, Or Fall Flat on Their Asp?

L Labay 1., R Middleberg 1., M Rieders 1.

Abstract

Forensic toxicological testing is an integral component of death investigation. Simplistically, specimens are collected at autopsy and transported to the laboratory for analysis; upon completion of work, a report detailing the findings is issued. As important as laboratories are in the death investigation process, however, the procedures that relate to the administrative and quality assurance practices that happen “behind the scenes” remain largely unknown by those using the services. In fact, many are unaware of the role they play in the ultimate utility of toxicological analyses and findings. The factors that influence toxicological findings, and ultimately interpretation of results, can be classified as pre-analytical and analytical factors. Pre-analytical factors run the gamut from sample collection techniques to proper preservatives in collection vessels to specimen storage. Analytical factors are generally related to the laboratory and include accreditation, proficiency testing participation, analyst training and qualification, specimen storage and discard, and security of data and records retention. The purpose of this submission is to underscore, discuss and demystify both pre-analytical and analytical processes that can drastically affect specimen integrity and utility, analyses and interpretation of findings. A comprehensive checklist will be provided as a handout which can be used to ensure that no important aspect related to toxicological testing is overlooked.

Acad Forensic Pathol. 7(1 Suppl):S-72–S-146.

Death of a Student Related to Occupational Exposure of Fentanyl

L Labay 1., C Catanese 2., J Gropper 3.

Abstract

Fentanyl is a potent synthetic opioid that is used as a surgical anesthetic and to alleviate symptoms associated with chronic or postoperative pain. The drug exhibits similar pharmacological and toxicological actions including analgesia, euphoria, respiratory depression and physiological dependence as other opiate-related drugs. Therapeutic misuse and abuse of fentanyl is extremely dangerous because of the low concentrations necessary to induce respiratory depression. During various periods of time, clusters of fentanyl-related deaths have been reported and more recently deaths have been attributed to illicitly manufactured fentanyl or its analogues.

A case is reported of a 22-year old male pharmacy student who died in hospital one-week after being occupationally exposed to fentanyl while working at a compounding pharmacy. On the fourth day of his internship he was found collapsed approximately 10 minutes after being last observed. He was unconscious and not breathing; resuscitative efforts were made. The medical diagnosis was acute anoxic brain injury with complex seizures. His family reported they observed flinching whenever his toes were touched, balling up of the fists upon receiving injections, occasional tears and some eye movement beneath the eyelids. Significant pathology findings included pulmonary congestion and edema. Toxicological testing of a blood sample collected at hospital admission showed the presence of fentanyl at 0.21 ng/mL. Cause of death was attributed to transdermal fentanyl exposure. Proper training, supervision and handling of any samples that may contain fentanyl or fentanyl analogue(s) is essential. In addition to the use of personal protective equipment it has now become necessary for co-workers to recognize the signs and symptoms associated with opioid overdose, have access to naloxone and possess the skills to administer it. The purpose of this presentation is to underscore the need to appropriately train all staff, especially those who are inexperienced with laboratory safety practices and may not appreciate the potency of fentanyl and other related substances.

Acad Forensic Pathol. 7(1 Suppl):S-72–S-146.

Intravaginal Stuffing of Methamphetamine Resulting in Accidental Overdose

DC Peterson 1., LJ Haldiman 1., BR Pietak 1., CC Frazee 2., U Garg 2.

Abstract

“Body packing” and “body stuffing” are two well-known methods of concealing illicit drugs. Body packing is defined as the act of swallowing packets containing illegal drugs for the purpose of smuggling in contrast to body stuffing, which is the swallowing of relatively small amounts of loosely wrapped drug due to fear of arrest. Generally, the packaged drugs are orally ingested. Because body stuffing is usually hastily done when there is threat of arrest, the drugs may be poorly packaged leading to leakage and accidental overdose. Intravaginal body stuffing is infrequently seen but can have similar dire consequences if the drugs are poorly packaged. In fact, drugs absorbed through the vagina may lead to higher concentrations as they do not pass through the liver and undergo first pass metabolism.

The deceased was a 28-year-old female with a history of celiac disease, stage IV chronic kidney disease, and previous drug abuse, specifically methamphetamine. She was found dead in her secured residence. At autopsy, a clear ziplock-style plastic bag was recovered from her vagina containing approximately 12 mL of yellow-tinged liquid and clear crystal-type material. Toxicological analysis of blood from the ascending portion of the aorta revealed methamphetamine concentration of 50,000 ng/mL and amphetamine concentration of 2,800 ng/mL, greatly exceeding the toxic levels. In a series of 13 adult deaths attributed to methamphetamine overdose, the average postmortem blood methamphetamine concentration was just 1,000 ng/mL, fifty times less than that found in the deceased. It is important to point out that toxicological analysis in this case was performed on heart blood, and methamphetamine has been found to undergo postmortem redistribution. Methamphetamine heart/femoral blood concentration ratios averaged 2.1 (1.2 – 5.0) in a series of 20 deaths or 1.9 in a series of 5 cases (range 1.0 – 3.8).

Intravaginal body stuffing is a rarely seen method of concealing illicit drugs. Accidental overdose secondary to poor packaging of the illicit drugs “stuffed” in the vaginal canal can occur. This case demonstrates vaginal drug absorption resulting in fatal concentrations of methamphetamine. It is not clear why the deceased in this case was body stuffing. However, scene investigation revealed partially packed bags in her apartment. She had recently spoken with her mother about possibly traveling several hours to visit a relative.

Acad Forensic Pathol. 7(1 Suppl):S-72–S-146.

Intimate and Familial Murder: Examining Trends in Domestic Violence Homicides in Oklahoma from 2010-2014

AL Wiens 1., A LaMothe 2., R Thrasher 2., J Lanter 1.

Abstract

Domestic violence homicides have been subject to research for many decades; however, the literature is lacking thorough analysis of domestic violence in relationships other than those of intimate (dating/marital) partners which includes relationships such as parents, siblings, or roommates. This study focuses on trends and characteristics of domestic violence homicides that occurred in Oklahoma from January, 2010, through December, 2014. The electronic database of the Office of the Chief Medical Examiner was culled for data. During the 5-year timeframe examined, 1,318 cases were classified as homicide, and 368 cases (28%) met the designation of domestic violence homicide as defined by Title 22 of the Oklahoma State Statutes in the Protection from Domestic Abuse Act. Data collected for each case included demographics of the decedent and offender, relationship between decedent and offender, cause of death, and number of injuries to the decedent. Collected variables were statistically analyzed to test significant associations. Firearm injuries accounted for 48% of domestic violence homicides; blunt force trauma was the second most common cause of death at 23% of cases. Current dating/marital partners were the most common offenders (142 cases), followed by parent of the decedent (49 cases), child of the decedent (46 cases), and other family members (47 cases). Ages of decedents ranged from infancy (0 years) to 91 years old; 48% of decedents were male and 52% were female. Female decedents were more likely than male decedents to die of mechanisms such as asphyxia, drowning, thermal injuries, or combined mechanisms. The most common type of domestic violence homicide was between an offender and decedent of opposite genders who were of the same race. Male offenders were more likely than female offenders to be family members of the decedent. In contrast to published national data stating fathers are the most common offenders when the decedent is a child under age 5 years, our study found that female offenders were more likely than male offenders to kill their children. Greater than 10 injuries were most commonly seen when the offender was the ex-partner (dating and/or marital) of the decedent, the parent of the decedent, or the dating/marital partner of the decedent's parent. Our findings differ from national data in several areas, and this study illustrates the prevalence of family member domestic violence homicides despite their relative exclusion from published literature on domestic violence which tends to focus on intimate partner relationships.

Acad Forensic Pathol. 7(1 Suppl):S-72–S-146.

Suicide by Chop Saw

ER Amoresano 1., S Shapiro 2.

Abstract

Suicide by power saw is exceedingly rare and there are only a few case reports in the forensic literature describing the use of band, circular, or chain saws. The use of chop saws in suicide, however, has not been described. Presented here are three cases of suicide committed using chop saws. All three of the decedents were men between the ages of 65 and 80 with a documented history of depression. While one case exhibits the injury pattern seen in the vast majority of power saw suicides, namely a single large cutting wound to the head or neck, the other two cases involve the complete amputation of an upper extremity - a finding reported in only one other power saw suicide case. The death investigation and pertinent autopsy findings are summarized and compared to the literature regarding suicide by other power saws.

Acad Forensic Pathol. 7(1 Suppl):S-72–S-146.

Hymen Absence in Prepubertal Girls and Chronic Sexual Abuse: Review of the Literature and a Case Report

G di vella 1., M D'Amato 2., SM Curti 3., F Lupariello 3., E Coppo 4., A Urbino 4., C Petetta 3.

Abstract

Absence of hymenal tissue is not a documented congenital anatomical variation. This finding in prepubertal females has been interpreted as a sure sign of blunt force or penetrating trauma. Because of the rarity of complete absence of the hymen, this presentation will present a review of the literature and describe a definitive case. A review of the literature on child abuse was conducted using the Medline electronic database with the following algorithm: (“Child Abuse”[MeSH]) AND “Hymen”[MeSH]. The search strategy yielded 73 potentially relevant articles. Searching for case reports on the absence or loss of hymenal tissue, none of the articles met the research criteria: 32 were excluded on the basis of the title, 26 after reading the abstract, and 10 after reading the entire article. Six of the abstracts or articles were not available for review. Among the 1792 cases observed in the “Ospedale Infantile Regina Margherita” (Turin) unit dedicated to the evaluation of suspected abused or mistreated children (“Bambi”), only one case was characterized with a complete absence of hymenal tissue. This data encompassed a time period from February 2002 to July 2016. A 5-years-old girl was hospitalized in the Child and Adolescent Psychiatry Unit due to episodes of chest pain, seizure activity, aphasia, hypotonia and no response to stimuli. During the last two years she had vaginal loss and hyperemia, abdominal pain, headache and cystitis. After her spontaneously talking about repeated touching by her “bad uncles,” the little girl was examined by specialized unit staff. The genital area inspection was conducted in the supine and the knee-chest position with colposcopy. The medical examiner observed normal prepubertal external genitalia, no vulvar hyperemia and total absence of hymenal tissue. Despite the fact that, in most cases of suspected sexual abuse, the child has no physical signs, in a limited number of cases those signs are present. While the child's tale remains the most important evidence in case of suspected sexual abuse, physical findings resulting from sexual abuse, when present, are fundamental in the legal arenas. A defect in the posterior half of the hymen wider than a transection is consistent as a diagnostic sign of penetrating trauma and/or sexual contact, so this finding, combined by a corroborated story of the child, is interpretable as sexual abuse due to repeated introduction of blunt instruments into the vagina.

Acad Forensic Pathol. 7(1 Suppl):S-72–S-146.

Two Cases of Deaths by Boiling in Japanese-Style Bathtubs

S Iwadate 1., K Iwadate 2., K Hayashi 3.

Abstract

The so-called bathtub deaths are one of the most common manners of unexpected deaths among Japanese elderly persons. The annual number of fatalities is reported to be approximately 15,000. The cause of many such deaths is drowning resulting from the loss of consciousness while a person is soaking in a bathtub. In some cases, the person dies of stroke or heart attack immediately before falling under the water. In Japanese-style bathtubs without thermostatic controls, these death cases sometimes involve postmortem burn injuries due to the boiling water in the tub. However, death due to burns caused by boiling hot water in a bathtub is rare. We demonstrate two cases of bathtub deaths in which the persons were suspected to have been boiled alive, and compared these with a case of death due to the onset of subarachnoid hemorrhage while the person was soaking in a bathtub in which the body was boiled postmortem.

Acad Forensic Pathol. 7(1 Suppl):S-72–S-146.

When Spirituality Leads to Death: Case of Ascetic Fasting and Autopsy Findings

G Di Vella 1., M D'Amato 2., F Lupariello 1., C Petetta 1., S Curti 1.

Abstract

A 62 year-old-male teacher, not suffering from chronic diseases, underwent periodically prolonged fasting to perform “purification cycles.” The last of these fasts was initiated about three weeks before his death. His companion also fasted, but had ceased due to weakening. The teacher had endured more prolonged fasting in the past, so no one had been alarmed, despite his progressive, debilitating condition. However, this time, the man experienced a sudden respiratory crisis and loss of consciousness, and despite resuscitation attempts, he succumbed. Inside the house, the authorities found many notes posted on the doors and walls, with inscriptions in French invoking deities, probably of Christian inspiration. There were also writings regarding the fact that the man's body could reborn only if he had entrusted it to rituals performed by hands of women. The man had never been diagnosed with any psychiatric illness, despite the facts that neighbors were aware of his eating habits and he claimed to have paranormal powers in association with his partner. The external examination showed severe cachexia (weight 39.4 kg, height 178 cm, body mass index 12.43 kg/m2), diffuse muscle atrophy, thin skin, sunken eyes, sharp orbital margins and nose tip, sunken supraclavicular fossae and intercostal spaces, prominent ribs, and abdominal concavity extending from the costal margins to the iliac bones. The internal findings consisted of almost absent adipose tissue of the abdominal wall, reduced internal fat stores (omentum, mesentery, perirenal, subepicardial), and decreased weight of all organs with exception of the brain. The gastrointestinal tract was thin with translucent walls, and the stomach and small bowel were empty. The gallbladder was distended and filled with fluid bile. According to the literature, the macroscopic and histopathologic findings confirmed the prolonged fasting. The characteristics included brain edema, interstitial edema in heart tissue, heart myofibril fragmentation, congestion and steatosis in liver parenchyma, necrosis in gastric and intestinal mucosa, and reduced glycogen inthe liver andmuscle storage. Toxicological tests for the presence of alcohol and drugs in body fluids were negative. The medical examiner attributed the death to a sudden onset of a ventricular arrhythmia. In fact, according to the literature, anorexic patients show a prolongation of the Q-T interval which can result in a ventricular tachyarrhythmia. This risk becomes high when weight loss falls below 35% of the ideal, a finding in this subject's case.

Acad Forensic Pathol. 7(1 Suppl):S-72–S-146.

Pharmaceutical Tablet Excipients in a Placenta: Sign of Intravenous Abuse or Contamination?

DK Arboe 1., RJ Miller 1., C Niblo 1., J Sawady 2., JF Tomashefski 2.

Abstract

Prescription drug abuse is a rising trend due in part to their relative ease of procurement. Injection of crushed tablets is used to increase the intoxication effect with a more immediate onset. In addition to the active ingredient(s), tablets contain a variety of excipients such as crospovidone, talc, starch and microcrystalline cellulose. Associated pulmonary complications of injected tablets include dyspnea, hypoxemia, and pulmonary hypertension due to the filtration of the particles by the smaller vasculature of the lungs. The appearance of these foreign bodies has been well-documented in the lungs and less so in other organs due to the size of the excipient and the associated inability to exit pulmonary circulation. To our knowledge, placental tissue with tablet excipients has not been described in the literature.

We present a placenta from a case of intrauterine fetal demise that fell under the jurisdiction of the Oklahoma Office of the Chief Medical Examiner due to maternal incarceration and drug use. Additional maternal history included advanced maternal age (36 years old), multiparity, and previous abortions. The fetus was determined to be nonviable at 14 weeks gestational age and was delivered vaginally via induction at 17 weeks gestation age. Histologically, the first trimester placenta showed foreign bodies morphologically consistent with crospovidone (a disintegrant) and microcrystalline cellulose (a disintegrant and diluent) concentrated in what appeared to be vascular spaces without an associated cellular reaction. They were most prominent in the umbilical cord and membranes with additional rare foci in the chorionic plate and maternal sinusoids. Vascular immunohistochemical staining (CD 34) performed at MetroHealth Medical Center (Cleveland, OH) did not show an endothelial lining where the material was located. Among many theories relating to how tablet excipient foreign bodies became embedded within the placental tissue, the one primarily agreed upon is that placental surface contamination likely occurred during delivery from the presence of dissolved labor induction tablet(s) in the vaginal canal. Had the excipients been present in vascular spaces, the size of the particles would require the presence of a right to left vascular shunt that bypasses the lung vasculature. Given this mother had no known cardiac history, clinical knowledge of the placental findings would be paramount for her primary care physician(s). Given such clinical implications, etiologic consideration for histologically observed foreign bodies is not only important for forensic pathologists, but also for other surgical pathologists and our clinical colleagues.

Acad Forensic Pathol. 7(1 Suppl):S-72–S-146.

A 6-Year-Old Child Dead in a Locked Car: A Case Report

L Andrello 1., SD Visonà 2., M Pinorini 3., E Grata 3., L Morini 2., AM Osculati 2.

Abstract

The authors present a case of a 6-year-old girl who was accidentally entrapped inside a vehicle.

On 21st of July 2015 a 6-year-old, healthy girl was forgotten by her mother in their locked car, which was parked under the blazing sun with the windows all closed. The child was found dead in the car at 8 pm, after about five hours (the time she remained in the car is not precisely known). A crime scene investigation was carried out at 9 pm and then the rectal temperature was measured at 10pm, pointing out 107.6° F (42°C); the environmental temperature, in the car with the doors opened, was 82.82°F (29.9°C). The police investigations revealed that it was not possible to open the doors or the car windows from inside the car, as it was locked by remote key.

Postmortem TC did not point out any significant findings. A forensic autopsy was performed, followed by histologic examinations and toxicology. The internal examination revealed pleural and pericardial petechiae, massive generalized congestion and gastric material into the upper and lower airways. The histology confirmed the macroscopic findings; toxicology was negative for exogenous substances. A postmortem blood-gas analysis performed during the autopsy revealed a pO2 of 6.85 kPa, a HbO2 of 41.8%, satO2 of 42,6%.

On the basis of the results of the autopsy, as well as the histology and the toxicological data, the cause of death was identified as an heat stroke.

In the present case, the car became an oven as left in a sunny area at high temperatures. A car parked in direct sunlight can reach 131°F (55 °C) to 171°F (77.1° C) in 15 minutes.

The literature reported that in 2003, 42 children died, of heat stroke, as a result of being left inside a vehicle.

Leaving children unattended in or around vehicles is a serious problem. Leaving children in cars without knowing the consequences can be regarded as ignorance, but has to be considered child neglect in medicolegal terms.

This report underlines the need to increase the public awareness that vehicles are lethal to children, as some vehicles cannot be opened from inside if locked by remote key. Every effort should be made to make compulsory by law the equipment of devices to detect a person into cars at the moment of the locking; such precaution can save children.

Acad Forensic Pathol. 7(1 Suppl):S-72–S-146.

Sudden Death in Pregnancy: A Fatal Case of Acute Chorioamnionitis

AM Wilson 1.

Abstract

Maternal deaths, as defined by the World Health Organization (WHO) as “the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes,” are increasing in the United States. Maternal deaths may present to the Medical Examiner as sudden unexpected death. The differential diagnosis is broad and may include causes resulting from injury, violence or drug use. Natural conditions include cardiovascular disease, cardiomyopathy, pulmonary thromboemboli, hemorrhage, or infection. Although infection is not as frequent as it was decades ago, it remains an important factor in maternal morbidity and mortality. Acute chorioamnionitis is an extremely rare cause of sudden maternal death.

This is a case of 30-year-old Caucasian female who presented to the emergency department with complaints of severe abdominal pain and lower back pain. She was gravida 2, para 0 and at 32 weeks gestation. Prenatal history is unknown. She reported no significant prior medical history. She reported leaking fluid from her vagina for the prior 4 days associated with chills for at least 2 days. Upon arrival in the emergency department, she was tachycardic, febrile and had chills. Fetal heart rate monitoring showed non-reassuring fetal heart tones and she was taken for an emergent Cesarean section. A live-born infant was delivered without complications. Purulent fluid was noted in the uterus and cultures were taken. Immediately following delivery, she experienced refractory hypotension, pulseless electrical activity, cardiac arrest and death. A full autopsy was performed. The placenta was examined.

The autopsy demonstrated post-surgical changes of the uterus and pelvis. The uterus showed myometritis and septic emboli. The visceral organs displayed diffuse intravascular thrombi. The placenta revealed tri-vessel necrotizing acute vasculitis/funisitis of the umbilical cord. Special stains were positive for bacteria. The placenta disc showed acute necrotizing chorioamnionitis and acute chorionic plate vasculitis with multifocal vascular thrombosis. The uterine cultures were positive for Streptococcus anginosus, a rare case of acute chorioamnionitis. Toxicology was noncontributory.

This case illustrates acute chorioamnionitis associated with disseminated intravascular coagulopathy (DIC) and hemodynamic collapse resulting in maternal death. This case is presented to promote recognition of the increasing rate of maternal deaths and acute chorioamnionitis as a cause of sudden maternal death, along with its associated autopsy and placental findings.

Acad Forensic Pathol. 7(1 Suppl):S-72–S-146.

A Suicide Involving Multiple Gunshot Wounds: Importance of Correlation of Thorough Scene Investigation and Autopsy Findings in Determining Manner of Death

PP Beckham 1., M Kessler 1.

Abstract

Single gunshot wound suicides are a common type of case in any medical examiner's office. We discuss a case in which the importance of scene investigation and correlation to autopsy findings are essential. Police initially reported the apparent suicide of a 67-year-old White male, found deceased in a recliner at home, from what appeared to be a single, perforating gunshot wound of the head. The decedent lived in hoarder conditions and had been depressed over having to clean and sell his home. At autopsy, the decedent was found to have five gunshot wound paths to include a wound of the head, two of the abdomen, one of the right thumb, and one of the right forearm, each with distinctive patterns of close/contact range gun fire. The injuries of the abdomen and extremity would not have been initially fatal. Police re-evaluated the scene. A black .357 revolver was discovered on an adjacent couch with one spent casing, and was partially under a blanket, as if tossed. A silver .357 revolver with blood on it was at the decedent's hip. This revolver had two spent casings, and the cylinder was rotated in a direction counter to the rotational mechanism with one of the spent casings in the active chamber, thus indicating the gun was loaded one bullet at a time. A box of Remington .357 Magnum ammunition was located next to the decedent with blood on the inside and outside. From comparison of scene findings to autopsy findings, it is postulated that the decedent attempted to use the revolver found on the couch, shot himself once in the abdomen and when the result was a nonfatal, painful injury, he tossed it onto the couch. The decedent then loaded one round into the other revolver, as he is doing this it fired, creating the superficial wound paths of his upper abdomen, right thumb, and right forearm. Distinctive patterns of soot and stippling and precise locations of the wounds, made it probable that these three wound paths are the result of a single bullet trajectory. The decedent loaded another round, this time, inflicting a contact gunshot wound to the head, which after exiting, struck the ceiling and dropped plaster onto the final scene including onto the gun on the couch. This is a case in which a complete scene review and comparison of autopsy findings are vital in determining manner of death.

Acad Forensic Pathol. 7(1 Suppl):S-72–S-146.

All Tied Up: How a Good Death Investigation Turned a Possible Homicide into an Unusual Natural Death

A Spencer 1., H Reinhard 1., WK Ross 1.

Abstract

In the post-Fifty Shades of Grey era, paraphilias have increasingly become represented in the mainstream media. This, along with the infinite accessibility of the internet, creates an environment in which more people are exposed to these ever creative and, sometimes unusual, sexual practices. Then when the unexpected happens, these situations can pose very unique challenges for death investigators.

We present the case of a 69 year old male who was found deceased in his residence by police. All doors and windows were locked and undisturbed. The decedents valuables were also undisturbed. The body was prone, laying across the bed in the bedroom. The body exhibited long blonde hair and was dressed in women's attire. The decedent appeared tightly and elaborately bound around the torso, but loosely around the legs and ankles and wrists behind the back. The decedent was blindfolded and gagged. A plastic pump apparatus and remote control were found in the hands. A serrated knife was found on the floor at the decedent's feet and 2 pairs of scissors were adjacent to the body. These scene findings were concerning for a possible homicidal or accidental death.

At autopsy, removal of the wig and clothes confirmed the decedent to be the male homeowner. Externally, the body showed signs of advanced decomposition. No injuries were identified. The oropharynx was unobstructed. The pump apparatus was inserted into the rectum and contained a vibrating toy that was connected to the remote. A pet collar was fastened around the genitals along with a condom containing another vibrating toy.

Internal examination revealed cardiomegaly, dilated cardiomyopathy, and atherosclerosis occluding the left anterior descending coronary artery by 40%. The remainder of the LAD's lumen was entirely occluded by an adherent blood clot.

The unique circumstances of this case made it crucial to rule out a homicidal or accidental death. Taken together, scene and autopsy findings ruled out these possibilities. The tight intricate bindings on the torso resulted from decompositional bloating and represented self-bondage. The knife and scissors found with the body likely represented “fail safes” to escape the bindings if necessary. The blood clot in the LAD likely caused a devastating acute ischemic event, consistent with acute coronary syndrome and a natural cause of death.

This case illustrates the importance of a thorough and collaborative death investigation. In the face of increasingly complex cases, both scene and autopsy findings are critical to a successful investigation.

Acad Forensic Pathol. 7(1 Suppl):S-72–S-146.

The Role of Mitragynine in Two Postmortem Investigations

MA Frank 1., D Papsun 2., K Graf 2., B Logan 2.

Abstract

Mitragynine, the primary active alkaloid of the plant Kratom, is increasingly seen in postmortem investigations; however, the role of mitragynine in death is far from understood. Mitragynine has divergent pharmacological activity with both stimulant and opioid effects at different doses, and has garnered attention as a natural alternative for pain management. The toxicity of mitragynine is debated in the scientific community, as advocates highlight its long history of use in Southeast Asia, while opponents denote increasing adverse events associated with its use in the West. Quantitative reports of mitragynine in biological specimens from forensic investigations in the literature are sparse; therefore, the intention of this report is to detail mitragynine findings in two fatalities from Colorado.

Case 1 is a 30-year-old male with a known history of substance abuse and recent onset of seizures, who was found deceased in a state of decomposition on the living room floor of his apartment. Drug paraphernalia was found at the scene, including a plastic baggie containing a green powdered substance, empty capsules, and a pill organizer containing capsules of green powder. Toxicology results confirmed mitragynine in postmortem iliofemoral blood (23 ng/mL). The cause of death was ruled as acute mitragynine intoxication, with nontraumatic seizures of undetermined etiology and cardiomegaly contributing; manner was accident.

Case 2 is a 28-year-old male found deceased lying in bed in his residence. Scene investigation revealed several recreational marijuana products, bags containing green powders inscribed “THAI” and “GREEN MAENG DA”, and an unlabeled plastic bag containing a white powder. Autopsy findings include pulmonary and cerebral edema, urinary retention, and severe constipation. Toxicology results confirmed furanyl fentanyl (140 ng/mL) and mitragynine (1400 ng/mL) in postmortem iliofemoral blood. The cause of death was ruled as the combined toxic effects of furanyl fentanyl and mitragynine, with a manner of accident.

Concentrations of novel substances such as mitragynine are largely undefined as to what constitutes a desired effect, therapeutic use, or toxicity. Case studies are needed for accurate interpretation of these findings in forensic investigations. Due to the current public debate regarding the safety profile of mitragynine, it is necessary to quantitate this substance in biological specimens, as well as put the finding into the appropriate context for the case. Determining the significance of mitragynine detected in postmortem investigations continues to challenge toxicologists and medical examiners, as these investigations are confounded by variables such as polysubstance abuse and underlying pathology.

Acad Forensic Pathol. 7(1 Suppl):S-72–S-146.

Causes of Mesenteric Ischemia at Autopsy: the Importance of Histologic Examination

N Alemar Hernandez 1., KM Thomas 1., A Rapkiewicz 1.

Abstract

Background:

Acute mesenteric ischemia refers to the sudden reduction in intestinal blood flow. Acute mesenteric ischemia is a medical emergency that can be catastrophic and despite surgical intervention has a mortality rate of up to 47%.

The most common causes of mesenteric arterial occlusion are thrombosis and thromboembolism, but there are other etiologies such as atherosclerosis, hypotension, hypercoagulability, vessel compression and, less common, vasculitis. We herein report five autopsy cases with mesenteric ischemia.

Materials and Methods:

The New York University Langone Medical Center and the Bellevue Hospital computer databases were queried for all deaths relating to mesenteric ischemia from the period 2000-2017.

Results:

Mesenteric ischemia was identified as a contributing cause of death in 5 cases. The cohort includes men and women who range in age from 53 to 83 years. The immediate cause of death was septic shock (3), multiorgan failure due to cholesterol atheroembolism and pulmonary thromboembolism. All cases underwent a dissection of the mesenteric vasculature. The etiology of the mesenteric ischemia was considered arterial in origin in all five cases. All of the cases showed involvement of the large intestines, whereas only the arterial thrombosis and thromboembolism cases showed concomitant involvement of the small intestines. The cases with arterial thrombosis had continuous involvement of small bowel in the geographic distribution of the superior mesenteric artery. The case with atherosclerosis also had continuous involvement of bowel in the geographic distribution of the superior and inferior mesenteric arteries. The cases of vasculitis and arterial thromboembolism had multifocal involvement of the bowel in a non-vascular pattern.

Conclusion:

Acute mesenteric ischemia often results in fatal outcomes as the clinical presentation if often non-specific. Therefore, proper documentation and dissection in cases where mesenteric ischemia and infarction is suspected or discovered at the time of autopsy is imperative to determining the etiology. The mesenteric vasculature should be dissected followed by histologic sections. The supplementation of microscopic examination of the vasculature will reveal the uncommon causes of mesenteric ischemia.

Arterial thrombosis is most often due to atherosclerosis and tends to occur in areas of severe narrowing, the superior mesenteric artery at its origin, superimposed on an atherosclerotic plaque. The most common vasculitis associated with mesenteric ischemia is polyarteritis nodosa. Arterial thrombosis and atherosclerosis are usually associated with more extensive bowel involvement than atheroembolism, as well as involvement of watershed areas. Atheroembolism and vasculitis more commonly present with segmental or multifocal involvement of bowel.

Acad Forensic Pathol. 7(1 Suppl):S-72–S-146.

Cirrhosis and Emphysematous Change in a 12 Month-old Male Infant

DS Bumgarner 1., D Borys 1.

Abstract

A preterm, male infant, born at 24 and 5/7 weeks gestation, with history of necrotizing enterocolitis and respiratory distress syndrome, expired at 1 year old of acute bronchopneumonia. The patient required mechanical ventilation and total parenteral nutrition for most of his life. The patient also had a history of elevated alkaline phosphatase, hypertriglyceridemia, transaminitis, and hyperbilirubinemia. Autopsy was performed at the request of the parents. Gross findings included hepatomegaly and pulmonary congestion. Histologic examination revealed cirrhotic liver with prominent bile duct proliferation and plugging. Emphysematous change with hypertrophy of bronchiolar smooth muscle was identified in the lungs. Given the unusual hepatic and pulmonary findings in a 1 year old, the diagnosis of alpha1-antitrypsin (A1AT) deficiency was considered. Immunohistochemical stains for A1AT revealed extensive deposits of A1 AT in the liver. Periodic acid–Schiff-diastase stain, however, revealed diastase-sensitive intrahepatic glycogen. The lungs displayed extensive A1AT staining. An A1AT deficiency presents with diastase-resistant intrahepatic glycogen deposits and markedly decreased A1AT staining in pulmonary sections. Given these findings, A1AT deficiency was ruled out. A search of the literature revealed that prolonged parenteral feeding may induce cirrhosis and hepatic/biliary derangements, including those seen in this patient. Prolonged ventilator dependence may also lead to emphysematous change and hypertrophy of bronchiolar smooth muscle. Thus, the unusual pulmonary and hepatic findings were consistent with prolonged parenteral feedings and mechanical ventilation. This case demonstrates A1AT deficiency may mimic the histologic changes seen in critically ill patients dependent on intravenous nutrition and mechanical ventilation.

Acad Forensic Pathol. 7(1 Suppl):S-72–S-146.

Not Another Drug Overdose

ME Pietrangelo 1., W Kupsky 2.

Abstract

Introduction:

Alexander disease is a rare, progressive, usually fatal neurologic disease in the leukodystrophy family, first described in 1949 by Dr. W. S. Alexander. Historically there were three forms based on age of onset. Currently two forms are described. Common to all types are abnormal aggregates of Rosenthal fibers in the brain and spinal cord, caused in 95% of cases by a mutation in astrocyte glial fibrillary protein (GFAP).

Methods:

This is a case report of a 26 year old male found unresponsive in the shower by his father. After resuscitation he was found to have suffered anoxic brain injury. The working diagnosis of his treatment team was prolonged QT syndrome due to psychiatric medication. Of concern to the medical examiner's office was a recreational drug overdose, due to the frequency of overdoses occurring in his local demographic. He underwent autopsy.

Results:

Autopsy was unremarkable except for cerebral and cerebellar edema with tonsillar and uncal notching consistent with anoxic brain injury. Toxicology was unremarkable. Microscopic sections of autopsy tissue were unremarkable except for the brain. Sections of the hippocampus, pons, medulla, cerebellum and proximal cervical spinal cord showed widespread Rosenthal fibers and eosinophilic granular bodies with gliosis, consistent with later onset Alexander disease.

Discussion:

These unexpected findings demonstrate that seemingly routine cases may prove to be quite the opposite. This case emphasizes the importance of a complete death investigation including medical record review, a full autopsy, toxicology and microscopy to accurately determine the cause and manner of death.

Acad Forensic Pathol. 7(1 Suppl):S-72–S-146.

Hemopericardium Complicating Pacemaker Implantation

K Obenson 1., R Belliveau 2.

Abstract

Introduction:

The implantation of pacemakers and cardioverter-defibrillators has become routine and most implantation procedures are completed uneventfully. Under exceptional circumstances the procedure may be complicated by a fatal outcome.

Case Presentation:

The decedent, a 77 year old male status-post stent placement for stenotic coronary artery disease, was admitted a day after placement of an implantable cardioverter-defibrillator for syncope and heart block. His medical history was also significant for aortic valve stenosis with an ejection fraction of 56. He suffered a sudden cardiovascular collapse during a CT scan which showed an accumulation of blood in the pericardial sac.

Autopsy examination was significant for hemopericardium of 300 to 400 cc of both liquid and clotted blood. Pre-dissection conventional radiograph of the explanted heart confirmed pacemaker lead insertion into the right atrium and right ventricle. Stents were observed in the right coronary artery and left anterior descending coronary artery. There was no gross evidence of acute myocardial infarction or ventricular rupture. A small hemorrhagic focus measuring approximately 5 mm in diameter, was observed on the right ventricular border of the heart approximately 2 cm from the apex. Section through this area showed a transmural hemorrhagic needle track through which the lead partially protruded. The ventricular myocardium in in this area was approximately 1 mm thick. The right atrial lead retained its placement position. There was substantial aortic valve stenosis and calcification. Cross section of the stented coronary arteries showed no thrombi. Histologic sections of the right ventricle confirmed gross impression of acute hemorrhage. No recent ischemic changes were observed in any of the other myocardial sections. There was no evidence of underlying cardiomyopathy. The implanted device was interrogated by the electrocardiology unit and the results reviewed with the cardiac electrophysiologist. No malfunction was detected. The immediate cause of death was classified as hemopericardium and cardiovascular collapse due to ventricular perforation complicating pacemaker insertion. Underlying contributory factors included ischemic coronary artery disease and aortic stenosis.

Conclusion:

Death due to pacemaker lead insertion is a rare but important consequence of the procedure and should not automatically be considered de facto evidence of medical negligence. The extremely thin right ventricular muscle wall likely increased the risk of perforation. This was the first known fatality in our center.

Acad Forensic Pathol. 7(1 Suppl):S-72–S-146.

Rapid Screening for Drugs of Abuse Using Different Bodily Fluids Using a Workplace Urinary Preliminary Screening Test

E Moffatt 1., M Hunter 1., A Hart 1., H Narula 1.

Abstract

The Alere iCup is a urine toxicology point of care screen developed for workplace drug preliminary screening and screens for 14 classes of drugs, including morphine, oxycodone and propoxyphene. The test results are easily read by a horizontal line for “positive” and a blank are for “negative” within five minutes. The amount of urine needed is approximately 30 milliliters (but smaller amounts can be used).

The recommended fluid is urine. We have also used cerebral spinal fluid and serum with results corroborated with toxicology lab testing. In general, vitreous fluid is not of sufficient volume and pleural fluid can give variable results. We have tested approximately 40 cases so far with no frank contradictions between the “cup” result and our in-house toxicology results. Testing with more cases is ongoing.

In our experience, if the “cup test” is negative, then the actual toxicology testing done by our in house lab is also negative. Additionally, the urine can still be sent for GC-MS testing, by pouring it out of the test cup and into a red top and sending to the toxicology lab. Serum can be used, but obtaining enough serum (approximately 10 milliliters) by centrifugation can be time consuming. The Alere iCup also works on fluids which are early to mildly moderately decomposed; the cloudiness and red color of the urine does not seem to affect the test results.

Drawbacks of this screen include inability to test for fentanyl or ethanol. Also, some opiate deaths occur so quickly that the offending drug is not yet in the urine (necessitating the use of another fluid such as cerebral spinal fluid for a trusted result). The strength of this test is to rapidly screen for several classes of drug with reliability of a negative result and more accurately inform the need for an autopsy and/or further toxicology testing.

Acad Forensic Pathol. 7(1 Suppl):S-72–S-146.

Drug-Related Hypersensitivity Reactions and the Autopsy

NJ Barna 1., A Rapkiewicz 1.

Abstract

Background:

Adverse drug reactions are important causes of morbidity and mortality with cutaneous eruptions being among the most common manifestations encountered in the United States. Drug-related hypersensitivity reactions are classified as a spectrum of disorders that encompass drug related eosinophilia with systemic symptoms (DRESS), toxic epidermal necrolysis (TEN) and Stevens-Johnson Syndrome (SJS). We herein report four deaths in the setting of drug-related hypersensitivity reactions.

Materials and Methods:

The New York University Medical Center and Bellevue Hospital pathology database was queried for all deaths related to DRESS, TEN or SJS from the period of 2000 – 2017.

Results:

DRESS or SJS were found as a contributing cause of death in 4 cases. The cohort included three females and one male with an age range of 50 – 65 years. An inciting medication was clinically identified in three cases with allopurinol implicated in three cases. Two cases had successful clinical abatement of skin findings and thus no macroscopic post-mortem skin changes were identified; however, all four cases had microscopic findings indicative of various stages of damage. Microscopic skin findings ranged from minimal interface vacuolar change in an example of resolving DRESS to patchy epidermal necrolysis in SJS. Complications of drug reactions and associated treatment seen in this series were often clinically unrecognized and included disseminated cytomegalovirus (CMV) infection, necrotizing eosinophilic myocarditis and fulminant liver necrosis.

Conclusion:

Autopsies for cases of drug-related hypersensitivity reactions present a unique challenge in that a diverse array of complications may result in the setting of such disease. Gross skin findings should be fully documented with attention to body surface area involvement and areas of post-mortem artifact such as skin slippage must be avoided during sampling. Skin lesions of DRESS can be temporally heterogeneous; therefore, areas of both resolving and new eruptions should be sampled. Cases of DRESS may have greater mucous membrane involvement than is appreciated clinically while not qualifying as SJS/TEN. Viral reactivation may occur as a direct effect of drug hypersensitivity or in the setting of aggressive pre-mortem immunosuppressant administration; thus, there should be careful microscopic evaluation for viral pathology as well as a low threshold for ancillary testing. Liver failure is a common complication in drug-related hypersensitivity disorders and may be recognized in the pre-mortem period; however, autolysis may preclude definitive microscopic characterization of necrosis at autopsy.

Acad Forensic Pathol. 7(1 Suppl):S-72–S-146.

Type IV Glycogen Storage Disorder (Andersen Disease) in an 8 Week Old Infant

BJ Murie 1., J Newell 1.

Abstract

Glycogen storage disorders are a rare group of genetic conditions which affect the manner in which glycogen is structured and stored in various organs. Type IV Glycogen storage disorder (Andersen Disease) affects glycogen branching enzyme, which leads to alteration of the molecular structure of glycogen, resulting in poor utilization of energy stores and failure to thrive in infancy. This rare condition is generally life threatening, as liver failure may ensue, and death often occurs within the first few years of life.

We report the case of an 8 week old male, born at 33 weeks gestation for decreased fetal movement and polyhydramnios, who suffered diminished cardiac function, atelectasis, and hypoxic encephalopathy during hospitalization. Prior to death, a muscle biopsy was performed which showed polyglucosan bodies consistent with a glycogen storage disorder, and was confirmed by genetic analysis which showed a mutation in the GBE1 gene. He continued to require aggressive medical management, and the family chose to withdraw care, given the poor prognosis.

Findings at autopsy showed a non-dysmorphic male infant with no gross pathologic abnormality seen in the organs. Microscopic examination of the tissues showed extensive involvement of multiple organs by intracellular polyglucosan bodies, compatible with Andersen Disease. Polyglucosan bodies are seen as spheroid pale blue predominantly cytoplasmic inclusions highlighted by Periodic Acid Schiff (PAS) staining. The organs involved included the heart, liver, and skeletal muscle.

Taken together, the genetic studies and autopsy findings confirmed the diagnosis of Andersen Disease, and the cause of death was believed to be complications associated with this disease process. This was a case in which more findings were seen microscopically than macroscopically, illustrating a possible diagnostic challenge. Although rare, such genetic disorders should be considered in the differential diagnosis in the death of infants.

Acad Forensic Pathol. 7(1 Suppl):S-72–S-146.

Dismemberment by Chainsaw: A Case Report

AL Wiens 1., AK Berg 1., CJ Zambrano 1.

Abstract

Postmortem efforts to conceal a homicide may include various scenarios such as clandestine burial, dumping the body into a waterway or off a roadway, burning of remains, or dismemberment. Dismemberment involves the use of a tool to divide or section the remains to aid in their transport, dispersal, and/or concealment. Over the past 42 years, the Oklahoma Office of the Chief Medical Examiner has investigated 16 dismemberment cases. Eleven of these cases displayed evidence of cut and/or saw marks; chop marks were noted in three cases; in one case, the method of dismemberment was undetermined. We present a unique case of dismemberment involving a chainsaw, the only such case in the state's series. Following dismemberment, the fragmented human remains were dumped at a city waste site where they were discovered approximately five weeks after disposal. The remains were differentially preserved, displaying a mixture of skeletonized and partially-skeletonized elements. Portions of the limbs were enclosed in a duffel bag and had identifiable tattoos which aided in tentative identification of the individual. Anthropological examination of the skeletal remains revealed very large false start kerf marks from the chainsaw, a unique bisection of the vertebral column in the sagittal plane, thermal modification, and evidence of two gunshot wounds. Positive identification was established by fingerprint comparison. The police investigation and suspect confessions support the findings of two gunshot wounds and postmortem dismemberment with a chainsaw. To this date, the instruments and site of dismemberment have not been located.

Acad Forensic Pathol. 7(1 Suppl):S-72–S-146.

Malignant Asphyxia Due to Laryngeal Adenosquamous Carcinoma: A Case Report

KL Palmer 1., MD Gosse 1., DJ Pelletier 1., RA Robinson 1., SL Stauffer 1.

Abstract

Adenosquamous carcinoma of the head and neck is a rare and aggressive epithelial neoplasm that has features of both adenocarcinoma and squamous cell carcinoma. Central airway obstruction leading to asphyxia and sudden death has been reported in a number of malignancies; however, no such cases due to laryngeal adenosquamous carcinoma have been reported. We present a case of a 57-year-old male with a six month history of cough, shortness of breath, and hoarseness who presented to his doctor with a worsening cough. He was given an oral corticosteroid and a consultation with otolaryngology was scheduled for the following week to evaluate need for diagnostic laryngoscopy. The following morning the patient was found unresponsive in his home. Despite resuscitation efforts, the patient was pronounced dead shortly thereafter. At autopsy, a 6 × 5.5 × 3 cm laryngeal mass causing near complete airway obstruction was identified. The mass extensively involved the supraglottic and glottic regions bilaterally, as well as the left submandibular gland, pre-epiglottic space, and true and false vocal cords. Histologic examination of the tumor revealed widely invasive adenosquamous carcinoma. The cause of death was determined to be asphyxia due to internal airway obstruction by laryngeal adenosquamous carcinoma. Adenosquamous carcinoma is a rare malignancy displaying distinct areas of glandular and squamous differentiation, with at least 10% of each component required for the diagnosis. This tumor most commonly occurs in areas where adenocarcinoma is common, such as the lung, pancreas, stomach, intestines, and breast. Less commonly, it may arise in areas where squamous cell carcinoma is more commonly encountered, such as the uterine cervix and larynx. Fewer than 100 cases of laryngeal adenosquamous carcinoma have been reported in the literature. Airway obstruction secondary to malignancy may result from tumors that arise from the airway itself, direct invasion of the airway, external compression by a paratracheal tumor, or tumor fragmentation with airway impaction. Sudden death caused by malignant airway obstruction is a rare phenomenon, and this report highlights the importance of examination of the respiratory system for unrecognized malignancies.

Acad Forensic Pathol. 7(1 Suppl):S-72–S-146.

Mixed Drug Intoxication in a Patient with Tracheobronchopathia Osteochondroplastica (TPO)

N Dhungana 1., RL Eigsti 1., RA Robinson 1., SL Stauffer 1.

Abstract

Tracheobronchopathia osteochondroplastica (TPO) is an extremely rare benign disorder characterized by growth of osteocartilaginous submucosal nodules that project into the tracheal lumen. This abnormal tissue growth is asymptomatic in most individuals, but in some it can produce non-specific symptoms such as chronic cough, hoarseness, dyspnea, and hemoptysis. In some individuals with moderate to severe disease, it can lead to airway stenosis and significant respiratory compromise requiring surgical resection and/or placement of a tracheostomy.

We present a case of a 48-year-old woman with a past medical history of TPO status post tracheostomy placement, as well as Crohn's disease, depression, and a reported possible suicide attempt. The decedent was last known to be alive the evening before her death when she had sent text messages of apparent suicidal intent to her sister and her husband. She was found deceased in her bed by her husband approximately 6.5 hours afterword, with her tracheostomy tube attached to her neck via a strap, but the end of the tube outside of the stoma. Of note, the decedent had recently filled a prescription for hydrocodone and a pill count done at the scene revealed that 54 of the hydrocodone pills were unaccounted for.

Autopsy examination revealed a stoma in the anterior midline neck with surrounding exophytic red granulation tissue formation and adjacent redundant skin and soft tissue. There was obstruction of the larynx (above the level of the tracheostomy) by submucosal osteocartilaginous nodules. Histological sections of the larynx showed heterotopic bone and cartilage formation. Postmortem toxicology examination of femoral blood was positive for opioids and benzodiazepines, including hydrocodone (135 ng/mL). The cause of death was attributed to mixed drug (alprazolam, hydrocodone) intoxication. Obstruction of the laryngeal airway by heterotopic ossification of the larynx (tracheobronchopathia osteochondroplastica) was noted to be a contributing significant condition, as it likely contributed to the degree of respiratory compromise in this decedent. The manner of death was classified as suicide.

This case demonstrates the appearance of a very rare benign condition that can lead to significant anatomic alteration of the airway and respiratory compromise in the setting of a mixed drug intoxication.

Articles from Academic Forensic Pathology are provided here courtesy of SAGE Publications

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