Minimizing aerosol bone dust during autopsies Abstract When sawing bone for medical or medico-legal procedures, fine, airborne dust is produced (aerosols) that can pose a health hazard when inhaled. The aim of this study was to determine the influence of saw blade frequency and contact load, bone condition, test environment, and saw blade type, on the production of aerosol particles. A custom test setup was designed, manufactured and used in 8 bone sawing experiments, using a particle counter to determine the production of aerosol particles while varying the 5 chosen parameters. The number of counted particles was highest with higher saw blade frequencies, lower saw blade contact loads, in dry completely skeletonized bone compared to fresh bone, and using an electrical oscillating saw compared to hand-sawing. Under all conditions, the high amount of aerosol counted posed potential health risks. The ventilation system that we tested was adequate in removing the produced particles, but these high-tech systems are not always available in developing countries or emergency situations. The production of aerosols can be reduced by optimizing the sawing parameters. However, even the lowest number of aerosol particles counted during the current study was high enough to cause potential health risks to practitioners. Safety precautions should be taken, such as external ventilation, proper breathing gear, and adequate protocols, to truly minimize the risk in all bone sawing scenarios.

The forensic significance of pseudomesotheliomatous adenocarcinoma of the lung Abstract Pseudomesotheliomatous carcinomas (PMC) are rare tumors that clinically, macroscopically, and sometimes histologically resemble malignant pleural mesotheliomas. We report a case of a 91 year woman who was found to have diffuse nodular pleural thickening and a lung mass during a workup for persistent cough. She declined rapidly and died before a histologic diagnosis could be made. Postmortem examination revealed a tumor that diffusely involved the pleural surface with local extension into the chest wall, pericardium, and diaphragm along with a concurrent lung mass. Histologic examination showed poorly-differentiated cells predominantly arranged in sheets, cords, and nests with focal glandular differentiation. An immunohistochemical panel of calretinin, WT1, BEREP4, MOC31, and TTF1 confirmed the diagnosis of primary lung adenocarcinoma. The macroscopic, histologic, and immunohistochemical features used to distinguish metastatic and primary lung adenocarcinoma from epithelioid malignant mesothelioma are discussed. The distinction of malignant mesothelioma from pseudomesotheliomatous carcinoma is important for medicolegal reasons regarding asbestos related compensation claims.

Death due to external compression of the trachea in a patient with multinodular hemorrhagic goiter Abstract In this paper we describe the case of an 81-year-old Caucasian female (142 cm tall, weighing 45 kg) who suffered from a multinodular goiter for approximately 40 years. Following the onset of a clinical condition characterized by acute respiratory failure, she was transported to the emergency room by ambulance, where she died within a few hours after admission. A recent cardiac examination showed the absence of risk factors for cardiovascular disease, sinus tachycardia with a heart rate of 131 bpm, negative objectivity for signs of cardiocirculatory failure, a blood pressure of 120/80 mmHg and modest exertional dyspnea. A recent hemochemical laboratory analysis showed a TSH value of 0.01microUI/mL, FT3 value of 4.76 pg/mL and FT4 value of 2.33 ng/mL, pointing to a pattern of hyperthyroidism, attributable to Basedow’s goiter. Autopsy showed some peculiarities, and we came across two extremely rare findings; the thyroid gland had reached a very large size in relation to the patient’s body mass (1510 g, in a patient of 142 cm and 45 kg), and the death of the patient was due to the development of a massive intra-thyroid hemorrhage that had caused acute external compression of the trachea. To the best of our knowledge this very rare event has not previously been reported in the international scientific literature.

Differentiation between perimortem trauma and heat-induced damage: the use of perimortem traits on burnt long bones Abstract Burnt human remains present a difficult interpretative dilemma to forensic pathologists and anthropologists. Distinguishing postmortem damage in long bones as a result of fire damage from perimortem fractures is an important challenge in trauma analysis. During our case investigation of a burnt body from a fiery car crash, distinct perimortem traits on long bone fractures were still distinguishable along the charred areas. Next to timing of fractures and shortening the perimortem time gap suggesting that the fractures occurred when soft tissue was still present, the traits make it possible to distinguish blunt trauma caused by the accident from heat-induced bone damage. Applying this specific perimortem pattern could be an additional macroscopic tool to interpret blunt force trauma more accurately in the analysis of burnt remains.

A fatal case of bowel obstruction caused by non-steroidal anti-inflammatory drug enteropathy Abstract We report the case of a 34-year-old woman who died after presenting to hospital with a 2-month history of vomiting, abdominal pain and diarrhea. Subsequent inquiries revealed that she had a history of non-steroidal anti-inflammatory drug (NSAID) abuse, and the autopsy revealed stricture formation consistent with being caused by NSAID enteropathy.

Genetic testing in sudden infant death – a wolf in sheep’s clothing?

“Nutrition or no nutrition?”: Chylothorax or leakage of total parenteral nutrition? Abstract Total parenteral nutrition (TPN) using a central line is an invasive and widely used procedure associated with several complications. Pleural effusion secondary to the leakage of alimentation into the pleural cavity is a rare but encountered complication of central-line TPN administration. This case study focuses on a postmortem examination of an 84-year-old woman, hospitalized due to malnutrition and dysphagia. The left internal jugular vein was cannulated, with no post-procedural x-ray check-up of the catheter tip position. An autopsy revealed 800 ml of milky-white fluid in the left pleural cavity, raising the issue of whether the pleural effusion was of chylous or TPN origin. The aim of this case study was to describe the postmortem diagnostic approach of the fluid analysis. Suspecting chylothorax, we first analyzed the triglyceride (TG) levels in the fluid, which, according to the literature, is the best parameter to detect chyle when lipoprotein electrophoresis (chylomicron %) is unavailable. Biochemistry showed increased levels of TG, which can be found in both chylous and TPN fluid. We then added glucose and potassium to the biochemical analysis, again showing increased levels at 46 mmol/L and 22 mmol/L, respectively. We had no information about the given TPN, and thus, comparing the final chemical results with the TPN composition was impossible. The presence of increased levels of triglycerides, glucose, and potassium in the white fluid more strongly resembled a standard TPN than chyle. Hence, by using these three measurements, we concluded that the milky-white fluid was a leakage of TPN.

Lethal manifestations of angioedema Abstract An 86-year-old woman with a history of angioedema was found dead at her home address. She had recently complained of a swollen tongue. At autopsy the tongue was grossly edematous, protruding from the mouth. There was also marked edema of the tonsillar fossae, epiglottis and glottic inlet, causing critical obstruction. Histology of the tongue and upper airway demonstrated marked submucosal edema. Death was attributed to upper airway obstruction due to angioedema of the tongue, oropharynx and glottic inlet. Angioedema is characterized by localized non-pitting edema of the deep dermis and subcutaneous/submucosal tissues. It may be acute or chronic, acquired or inherited. Sudden death may result from critical airway occlusion, although both stroke and ischemic heart disease are known to occur. Post mortem genetic testing for hereditary variants can be conducted for SERPING1 gene and F12 gene/THR328 mutations.

Rapid detection of pathogenic virus genome sequence from throat and nasal swab samples using an exhaustive gene amplification method Abstract Rapid identification of pathogenic agents is important in response to the emergence of biocrime and bioterrorism, to facilitate appropriate confinement and treatment. As the rapid determination system of viral genome sequences (RDV method) using exhaustive gene amplification is useful for rapid identification, we examined whether this method could be applied to forensic samples. To detect pathogenic virus in a cat with suspected viral infections, fluid swab samples were applied to the RDV method. The following steps were performed: viral propagation, extraction of the viral genome, amplification of the first library, fragmentation of the library, amplification of the second library using non-specific primer sets, and direct sequencing of the amplicon. To confirm the viruses detected by this method, we performed conventional PCR using virus-specific primers. We detected pathogenic virus genome sequences from the swab samples and confirmed infection with these viruses. In addition, we directly detected a viral genome sequence from the nasal swab sample without the viral propagation step. The RDV method is infrequently used in forensic analysis. This method is practicable with equipment existing in a normal laboratory and is useful for rapid detection and identification of pathogenic viruses in forensic samples. This method would also be applicable to the detection of bacteria and fungi.

Aortopulmonary fistula related death – forensic implications Abstract A 79-year-old man with a history of arterial hypertension, insulin-dependent diabetes mellitus, renal insufficiency and thoracic endovascular aortic repair (TEVAR) was brought to the emergency department, following an episode of oliguria and urine retention. During chest X-ray he suddenly collapsed and died. Autopsy revealed a large atherosclerotic saccular thoracic aortic aneurysm whose right lateral wall firmly adhered to the right lung. There was more than 2.5 l of blood with fibrin deposits in the right part of the thoracic cavity. The right bronchus contained a cast of blood; blood was also present in the trachea and the distal airways of the right lung. Further dissection revealed that the aneurysm had eroded the tissue surrounding it and made a fistulous canal into the lower lobe of the right lung, causing the lung to fill with fluid blood. The cause of death was hemorrhage from the aortopulmonary fistula caused by pressure necrosis from the thoracic aortic aneurysm.