American Journal of Forensic Medicine and Pathology最新文献

Abstract: Calciphylaxis, or calcific uremic arteriolopathy, is a rare condition with a poorly understood pathophysiology. It is often associated with diseases that cause abnormalities in calcium metabolism, such as end-stage renal disease (ESRD) and hyperparathyroidism. While it most often affects the skin, involvement of extracutaneous organs, called systemic calciphylaxis, has been reported.Interestingly, other risk factors have now been identified with the development of calciphylaxis including recent infections, corticosteroid or warfarin use as well as diabetes mellitus, autoimmune diseases, and protein C or S deficiency.We present a 48-year-old female patient with a history of human immunodeficiency virus infection, and recent hospitalizations for acute pancreatitis and COVID-19 who presents with nonspecific abdominal pain, weakness, and mild erythematous skin lesions. Subsequently, the patient developed acute vision loss, severe hypertension, and acute kidney injury with significantly worsening skin lesions. Ultimately, the patient deteriorated rapidly and succumbed. At autopsy, cutaneous calciphylaxis was confirmed, affecting over 50% of body surface area as well as widespread organ involvement by visceral calciphylaxis, most strikingly in the heart and lungs. This case highlights the importance of considering COVID-19 and other nonuremic risk factors as being a trigger for developing catastrophic systemic calciphylaxis.

Abstract: Both obesity and opioid abuse are increasing in numbers globally. As these entities may be associated with significant respiratory compromise, it was hypothesized that synergism may occur and that as a result of this obese individuals may be more sensitive to the effects of opiates, that is, that deaths may occur at lower blood levels. To investigate this possibility, case files at Forensic Science SA, Adelaide Australia, were reviewed for all cases that occurred between 2000 and 2019 where deaths had been attributed to heroin or morphine toxicity. There were 259 cases (66 females, 193 males; age range: 18-91; average: 41.5). The average body mass index (BMI) was 26.8 (females, 26.1; males, 27.0). The total number of obese (BMI ≥ 30 < 40) decedents was 50, and the total number of morbidly obese (BMI ≥ 40) decedents was 17. No significant association was found in the obese or morbidly obese between BMI and postmortem drug levels of <0.01, ≥0.1 < 0.3, ≥0.3, <0.4, or ≥0.4 mg/L (P = 0.30, Fisher exact test). The lack of association between fatal postmortem opiate levels and BMI suggests that the negative respiratory effects of opioids and a high BMI may in some way be compensated for by as yet unidentified metabolic/pharmacokinetic factors in obesity.

Abstract: Cervical facet joint neurotomy, also known as cervical radiofrequency ablation (RFA) or cervical facet rhizotomy, is a medical procedure aimed at alleviating chronic neck pain caused by issues related to the cervical facet joints through ablation of neurons ( J Pain Res 2021;14:2807-2831). Although generally safe, adverse events can occur. Infection is a rare consequence of this procedure. Most injection-site infections related to cervical RFA occur spontaneously and resolve with oral antibiotics without sequelae ( World Neurosurg 2018;111:e644-e648). We report a case in which a cervical RFA injection resulted in the development of necrotizing fasciitis and ultimately death. To our knowledge, this has not been previously reported and is the first documented fatality due to infectious sequelae of a cervical RFA procedure.

Abstract: This case report characterizes a unique way in which suicide was accomplished through ingestion of chemicals typically used to create acrylic fingernails that resulted in death. Ethyl methacrylate and acrylic powder are commonly combined to form acrylic nails in nail salons. The process of applying acrylic nails utilizes each substance by mixing both before it typically solidifies within seconds of combining the two compounds. Ingestion of these compounds has not been previously described within the medical literature. The decedent was a nail technician at a local salon. He was found unresponsive in his yard which led to a 911 call. At the scene, a mostly empty 16-oz bottle of ethyl methacrylate, a chemical used at the salon where he worked, was found. At autopsy, the decedent's body had a strong chemical odor consistent with odors present at nail salons. Significant gastrointestinal tract damage was seen including discoloration within the esophagus, and the stomach contained a molded, hardened nail compound. The cause of death was ruled as complications of nail acrylic powder and liquid ethyl methacrylate ingestion. This case shows the unusual findings seen at autopsy from a decedent who committed suicide by ingestion of ethyl methacrylate with acrylic powder.

Abstract: Self-inflicted penetrating brain injuries with drills have been reported but are uncommon and typically involve the use of conventional drill bits. We report an unusual case of a 56-year-old man with a history of psychiatric illness who completed suicide using an electric drill and spade-type drill bit. Multiple superficial scalp and deeper bony injuries were sustained, although without breach of the dura, and death was not from brain injury, but secondary to venous air embolism related to entrainment of air into diploic vessels.

Abstract: Ethylene glycol (EG) is a widely available chemical and a well-known toxin in forensic pathology, which can lead to severe metabolic acidosis and death. Its metabolism in the body leads to formation of calcium oxalate (CO) crystals, which can precipitate in the kidney leading to renal failure. Although the identification of CO crystals in the kidney is widely known, the deposition of CO crystals in other organs has only occasionally been reported and seldom studied. This report examines 18 deaths due to EG toxicity for the presence of CO crystals in various organs. CO crystals were identified most often in the kidneys, followed by the brain and lungs. It is hypothesized that crystal deposition in these other organs may contribute to the toxicity of EG.

Abstract: Caseous calcification of the mitral annulus (CCMA) is a rare variant of mitral annular calcification (MAC) usually described as an antemortem finding. We report a case of sudden cardiac arrest in a 39-year-old male with end-stage renal disease undergoing hemodialysis with a history of Fabry disease by kidney biopsy. Autopsy revealed significant circumferential annular calcification in both mitral and aortic valves with a caseous gross appearance. Histologically, these areas consisted of amorphous basophilic material accompanied by a surrounding granulomatous-appearing infiltrate. Von Kossa staining on non-decalcified tissue revealed strong positive staining, confirming CCMA diagnosis. While identifiable, the atrioventricular node was displaced and distorted by caseous deposits. Toluidine blue staining of myocardium showed osmophilic accumulations, and electron microscopy (EM) showed myeloid/zebra bodies, consistent with Fabry disease. We posit that Fabry disease leads to end-stage kidney disease, altering calcium phosphate metabolism, a proposed mechanism for CCMA. This case highlights the multifactorial nature of sudden cardiac death in decedents with various structural cardiac changes and potential renal-disease-induced electrolyte imbalances. We aim to bring awareness to this rare entity, its potential role in a sudden cardiac death, and to highlight the need to use non-decalcified tissue when staining for calcium to establish the diagnosis.