American Journal of Forensic Medicine and Pathology最新文献

Abstract: Necrotizing wound infections are potentially lethal complications of surgeries, including cesarean deliveries. A 32-year-old female with obesity and hidradenitis suppurativa (HS) underwent uncomplicated cesarean section. Four days later, she developed abdominal pain and imaging showed ascites; she was treated with antibiotics. She progressed to septic shock and expired the following day from cardiopulmonary arrest. Hospital blood cultures grew no microorganisms. Autopsy revealed soft tissue purulence around the incision and copious purulent ascites without evidence of tubo-ovarian abscess, retained products of conception, or emboli. Microscopic examination of the tissues demonstrated inflammatory debris with neutrophils and gram-positive cocciform bacteria. Postmortem bacterial cultures had no growth. Paraffin blocks submitted to the Centers for Disease Control Infectious Disease Pathology Branch revealed Streptococcus pyogenes . Historically, group A streptococcus (GAS) was a major cause of peripartum mortality, and the prevalence of puerperal sepsis-associated deaths declined with antibiotic usage. Although the rates of mortality have remained stable in the United States, GAS has made a resurgence over recent decades. Additionally, there is some evidence in the literature of cutaneous bacterial biofilms associated with HS. Theoretically, this could have increased the risk of perioperative infection due to colonization or secondary infection of HS lesions.

Abstract: Forensic investigation of intrauterine and perinatal deaths can be challenging, given their relative infrequency and the possible involvement of maternal substance use, trauma, and socioeconomic factors. Intrauterine and perinatal deaths investigated by the Cuyahoga County Medical Examiner's Officer between 2013-2023 were reviewed. One hundred twenty-eight cases were identified (83 stillborn and 45 live births). The predominant indications for referral were concern for maternal substance use (57.8%) or trauma (35.2%). Gestational ages ranged from 11.5 to 42.5 weeks; 36.7% were <22 weeks, and only 10.2% were full term (>37 weeks). The maternal age range was 16-41 years, with most (65.2%) between 20-34 years. Not all case files included obstetric history or home address; of those which did, 53.0% received no prenatal care and 81.7% came from zip codes in the bottom quartile of household incomes. Causes of death included acute and/or chronic maternal substance use (28.9%), chorioamnionitis (21.9%), and abruption (19.5%). Manners of death (when applicable) included natural (53.3%), accident (26.7%), homicide (8.9%), and undetermined/unassigned (11.1%). Potentially confounding socioeconomic factors were identified in most cases. This demonstrates the importance of considering these factors and exercising caution when assigning specific causes and manners to intrauterine and perinatal deaths.

Abstract: Iatrogenic infections of cadaveric bone grafts have led to 2 outbreaks of Mycobacterium tuberculosis (Mtb) infection in the United States that have resulted in multiple fatalities. We report a case of one of the bone graft recipients from the 2023 outbreak. A 57-year-old immunocompromised female with a history of renal failure status post 3 kidney transplants underwent a laminectomy with a cadaveric bone graft due to spinal stenosis. She was later hospitalized with diffuse lymphadenopathy and surgical site purulent ulceration. The workup included positive cultures for Mtb. Despite appropriate therapy, the patient died in the hospital. Autopsy findings included purulent discharge from the surgical site, medullary abscesses of one of the transplanted kidneys, diffuse pinpoint areas of softening in the liver, and lung congestion. Histology of the liver and right lung demonstrated loose granulomas with abundant acid-fast organisms. The kidney abscesses were due to Candida species infection. Overall, findings were consistent with disseminated Mtb infection. Additional investigation found similar infections in recipients of the same bone graft source. We compare the Mtb outbreaks to similar outbreaks, including cases of fungal meningitis due to steroid injections, and discuss our approach and strategy in cases of iatrogenic infection.

Abstract: Deaths by homemade suicide machines naturally capture public attention given the sensationalism of the subject matter and the complexity of the mechanisms involved. In this case, a self-made apparatus designed to administer a fatal dose of fentanyl, leading to an intentional acute toxicity, was used. As detailed in his 19-page manifesto discovered posthumously, the decedent engineered this device with the express purpose of testing the Many-Worlds Interpretation of quantum mechanics. This interpretation posits that for every time one outcome is observed, there are "parallel universes" in which a different outcome becomes reality; these "parallel universes" are collectively called the "multiverse." By programming his homemade device to kill the versions of himself in the "parallel universes" where he did not achieve a desired outcome-that is, having the winning numbers of a Powerball lottery drawing-the decedent sought to experience a reality where he did win the lottery, which would somehow through his convoluted logic thereby prove the existence of the "multiverse."Initially, the bizarre details of the scene led investigators to consider possibilities like intentional electrocution or even homicide executed by remote means. Thorough death scene and background investigation was critical to determine that it was an elaborate act of suicide.

Abstract: In postmortem forensic investigations, where the bladder is voided or dehydrated prior to autopsy, it is possible to wash the bladder with saline to collect the resulting "bladder wash" and any residual urine for toxicological analysis. Although this method is not yet commonplace or standard, a recent study has demonstrated that bladder wash is an effective alternative specimen in postmortem forensic toxicology. The current study aimed to assess forensic pathologists' opinions on the use of bladder wash samples both before and after reviewing bladder wash toxicological data. An online survey was distributed to forensic pathologists from NAME, and responses were analyzed to identify any shifts in perceptions after data presentation. The findings revealed that most forensic pathologists recognized the benefits of bladder wash collection and analysis as well as its usefulness in determining the cause and manner of death, with noticeable changes in perspective following exposure to supporting data. This study highlights the potential value of standardizing the easy and accessible collection of bladder wash for postmortem toxicological analysis, thereby providing forensic pathologists with invaluable information when other biological specimens are unavailable.

Abstract: This article is intended as a brief review on the glucagon-like peptide-1 (GLP-1) agonist Semaglutide (Ozempic®, Rybelsus®, Wegovy®), an antidiabetic medication that has gained significant popularity in the United States for its role in long-term weight-loss management. While current research on GLP-1 agonists, including semaglutide, focuses primarily on their therapeutic effects in managing diabetes and obesity, information regarding their forensic and medicolegal significance is limited. Concerns related to GLP-1 agonists may arise due to their pharmacokinetics, potential drug-drug interactions, and side effects including hypoglycemia, which can be relevant in cases involving human performance, such as impaired driving, or in unexpected fatalities. Semaglutide additionally presents analytical challenges due to its large, highly charged molecular structure and potentially limited stability in whole blood, which may complicate its detection and quantification in forensic laboratories using common instrumentation. The development of robust analytical methods will be essential to account for its pharmacological effects and to address its potential role in intoxications or unexplained fatalities, especially in the context of misuse or off-label use for weight loss. A strong case can be made for the necessity of further research into the detection, quantification, and interpretation of semaglutide concentrations in forensic toxicology casework.

Abstract: Dermoid cysts are benign developmental anomalies that are typically cutaneous and occur along lines of embryonic closure. Rarely, intraosseous dermoid cysts can occur in the pediatric population. This report presents an incidental finding of an intraosseous dermoid cyst found during autopsy in the frontal bone of a 3-year-old female patient who died by drowning. The cyst measured 1.2 × 0.7 × 0.6 cm and was located along the sagittal suture. Histopathologic examination of the cyst revealed keratinized stratified squamous epithelium alongside sebaceous glands and hair follicles, confirming the diagnosis of dermoid cyst. Premature closure of all cranial sutures, or craniosynostosis, was also noted. This unique combination of findings may indicate an etiological connection, which may warrant further research. Furthermore, this report provides rare photographs while most intraosseous dermoid cysts are only captured via radiography. From a forensic pathology perspective, incidental findings like these can provide critical insights into congenital anomalies that may impact the family, future research, or medicolegal conclusions, highlighting the broader relevance of thorough autopsies. Moreover, incidental findings such as this case contribute to the growing need for forensic guidelines on how to manage and document unexpected discoveries during investigations.