Ann Sophie Schröder

Planned complex suicide by penetrating captive-bolt gunshot and hanging: Case study and review of the literature

Captive-bolt guns or slaughterers guns are devices widely used in meat industry and private farmer households for slaughtering animal stocks. They consist of a simple cylindrical metal tube (barrel) with a metal bolt placed in their centre (around 9-15cm long and 1-1.5cm wide). The bolt is actuated by a trigger pull and is propelled forward by compressed air or by the discharge of a blank powder gun cartridge. Violent deaths inflicted by captive-bolt guns are rarely encountered in forensic practice and are predominantly suicidal events. We report an unusual complex suicide by hanging and self-shooting with a slaughterers gun in a 21-year-old boy. The victim after putting a ceiling fixed rope around his neck shot himself in the head (occipital region) with a Kerner captive-bolt gun. He used two mirrors (a cosmetic mirror and a man-sized one) in order to properly visualize his back and to target the occipital region of his head. Radiological data (computed tomography with three dimensional reconstruction) and autopsy findings are discussed according to the clinical and forensic literature. A brief review on planned complex suicides is also given.

Virus NAT for HIV, HBV, and HCV in Post-Mortal Blood Specimens over 48 h after Death of Infected Patients – First Results

Objective: According to EU regulations (EU directive 2006/17/EC), blood specimens for virologic testing in the context of post-mortal tissue donation must be taken not later than 24 h post mortem. Methods: To verify validity of NAT in blood specimens collected later, viral nucleic acid concentrations were monitored in blood samples of deceased persons infected with HIV (n = 7), HBV (n = 5), and HCV (n = 17) taken upon admission and at 12 h, 24 h, 36 h and 48 h post mortem. HIV and HCV RNA were quantified using Cobas TaqMan (Roche), HBV DNA was measured by in-house PCR. Results: A more than 10-fold decrease of viral load in samples taken 36 h or 48 h post mortem was seen in one HIV-infected patient only. For all other patients tested the decrease of viral load in 36hour or 48-hour post-mortal samples was less pronounced. Specimens of 3 HIV- and 2 HBV-infected patients taken 24 h post mortem or later were even found to have increased concentrations (>10-fold), possibly due to post-mortem liberation of virus from particular cells or tissues. Conclusion: Our preliminary data indicate that the time point of blood collection for HIV, HBV and HCV testing by PCR may be extended to 36 h or even 48 h post mortem and thus improve availability of tissue donations.

Post-mortem development of conjunctival petechiae following temporary prone position

Conjunctival petechiae are an important diagnostic finding in external examination of forensic cases, being a sign of possible mechanical compression of the neck and jugular veins (e.g. choking, strangulation). Nevertheless, it is well known, that strong congestion of the conjunctival blood vessels might lead to the development of petechiae in the perimortal and early post mortem period, e.g. due to a head down position of the body. By now it remains unclear, whether a short term horizontal prone position of a body can lead to the development of conjunctival petechiae in the early post mortem period, a situation that might occur in everyday forensic casework. Therefore, we investigated the occurrence of conjunctival petechiae in 20 deceased at <12 h after death following a prone position of 2 h. Petechiae developed in 8 cases. Therefore, our results for the first time give evidence that conjunctival petechiae can be observed after a short-term horizontal prone position of a body in the early post mortem period, influencing the assessment of future forensic cases. Furthermore, statistical analysis revealed significant correlations with the examination method used to ectropionise the eyelids (forceps vs. cotton swab) and preceding resuscitation attempts. The latter observations should be considered in future research on the phenomenon.

Fatal air embolism in hospital confirmed by autopsy and postmortem computed tomography

Vascular air embolism is caused by penetration of air into veins or arteries through a surgical wound or other connection between the external and internal aspects of the body. Vascular air embolism has various causes, and iatrogenic air embolisms are the most frequently described. We report a case of fatal air embolism in an 83-year-old woman who was admitted to hospital. At the time of the incident, she was alone in her ward receiving an intravenous infusion of antibiotics via a peripheral line in her right forearm. She was also inhaling air through a mask, which was connected via a tubing system to a compressed air connection in the wall behind her bed. Autopsy and postmortem computed tomography (PMCT) findings are presented. The case illustrates the high diagnostic value of PMCT, which is an effective procedure for detecting the presence of air or gas.

Fatal pneumoperitoneum following endoscopic retrograde cholangiopancreatography confirmed by post-mortem computed tomography

We present the case of an 80-year-old female who died in intensive care after unsuccessful resuscitation within 4 h after endoscopic retrograde cholangiopancreatography (ERCP).The patient was scheduled for an ERCP because of intermittent abdominal pain, hyperbilirubinemia, elevated liver enzymes, and dilated intrahepatic ducts diagnosed by abdominal contrast computed tomography. She had several comorbidities and her clinical history included dementia, breast cancer, diabetes mellitus, and chronic renal insufficiency. The patient remained stable and no complications were noted by the physicians throughout the ERCP with sphincterotomy for the removal of bile stones (up to 15 mm diameter) from the intrahepatic ducts. The procedure lasted for approximately 20 min. Immediately after the intervention, she developed dyspnea, tachycardia, and peripheral cyanosis and physical examination showed abdominal distension. The patient deteriorated rapidly and died within 4 h despite extensive resuscitation attempts. Radiological imaging and exploratory surgery were not performed in the hospital. A medicolegal autopsy and whole-body post-mortem computed tomography (PMCT, 4-rowmultidetector CT; PhilipsMX 8000; scanning parameters:mAs: 280; kVp: 120; slice thickness: 3.2/1.6 mm) were performed 3 days after death, at which time, the body showed no putrefaction. External examination revealed firm abdominal distension in an obese female (body mass index, 39 kg/m) (Fig. 1). Petechial hemorrhages were observed on the facial skin, eyelids, and conjunctivae (Fig. 2). PMCT demonstrated massive pneumoperitoneum and extreme elevation of the diaphragm (Fig. 3) and a total volume of approximately 11L of intraperitoneal air was calculated using volume rendering (standard DICOM viewer OsiriX v. 3.7.1, 32-bit, OsiriX Foundation, Geneve, Switzerland, http://www.osirixviewer.com). Before dissection, an intraperitoneal pressure of 27 mm Hg was measured using a manometer. The pneumoperitoneum was confirmed by autopsy. Opening of the abdominal wall resulted in the release of an inodorous gas and spontaneous regression of the abdominal wall. As demonstrated by the autopsy, the pneumoperitoneum resulted from an anterior duodenal wall perforation of 1.5 9 1.5 cm that was located 2.5 cm from the major duodenal papilla (Figs. 4, 5). Mild hemorrhage was noted around the perforation and no signs of inflammation or other internal organ injury were seen. Three gall stones were found: one in the ampulla (diameter, 14 mm) and two in the duodenum (diameter, 10 mm). The external bile duct was dilated to 3.2 cm. All of the findings, including forensic investigations, verified that death was due to respiratory failure caused by upper abdominal congestion from a tension pneumoperitoneum resulting from duodenal wall perforation during ERCP.

Sudden death from acute epiglottitis in a toddler

The bacterium Haemophilus influenzae type b (Hib) can cause severe and life-threatening infections such as epiglottitis and meningitis. The course of the disease can be very rapid, resulting in sudden death. The incidence of Hib-induced epiglottitis in children has declined since the introduction of vaccinations in countries where such vaccinations are routinely administered. We herein present a case involving a 2.5-year-old boy who died suddenly at home. He had developed acute-onset throat and abdominal pain and a high fever. Despite an emergency cricothyrotomy due to a complicated intubation because of a massively swollen epiglottis, the efforts to resuscitate the child were unsuccessful. He was a previously healthy toddler, but he had not yet been vaccinated. Microbiologic analysis revealed the pathogenic bacterium Hib. The main autopsy finding was acute epiglottitis with swelling and cherry-red coloring of the epiglottis. Postmortem cultures of the cerebrospinal fluid and heart blood also revealed Hib as the pathogenic agent. Acute pneumonia was also diagnosed microscopically. The present report describes a rare case of Hib-induced acute epiglottitis and presents the key findings of forensic investigations in this type of disease.

The use of HIV post-exposure prophylaxis in forensic medicine following incidents of sexual violence in Hamburg, Germany: a retrospective study

In Hamburg, Germany, the initiation of HIV post-exposure prophylaxis (HIV PEP) in cases of sexual violence is often carried out by forensic medical specialists (FMS) using the city’s unique Hamburg Model. FMS-provided three-day HIV PEP starter packs include a combination of raltegravir and emtricitabine/tenofovir. This study aimed to investigate the practice of offering HIV PEP, reasons for discontinuing treatment, patient compliance, and whether or not potential perpetrators were tested for HIV. We conducted a retrospective study of forensic clinical examinations carried out by the Hamburg Department of Legal Medicine following incidents of sexual violence from 2009 to 2016. One thousand two hundred eighteen incidents of sexual violence were reviewed. In 18% of these cases, HIV PEP was initially prescribed by the FMS. HIV PEP indication depended on the examination occurring within 24 h after the incident, no/unknown condom use, the occurrence of ejaculation, the presence of any injury, and the perpetrator being from population at high risk for HIV. Half of the HIV PEP recipients returned for a reevaluation of the HIV PEP indication by an infectious disease specialist, and just 16% completed the full month of treatment. Only 131 potential perpetrators were tested for HIV, with one found to be HIV positive. No HIV seroconversion was registered among the study sample. Provision of HIV PEP by an FMS after sexual assault ensures appropriate and prompt care for victims. However, patient compliance and completion rates are low. HIV testing of perpetrators must be carried out much more rigorously.

Todesfeststellung und Leichenschau – Todeszeichen erkennen und richtig deuten

Die Todesfeststellung steht am Beginn jeder arztlichen Leichenschau. Unter Berucksichtigung sicherer Todeszeichen ist eine zweifelsfreie Einschatzung schnell und einfach moglich. Sind keine sicheren Todeszeichen vorhanden, ist zu reanimieren. Sichere Todeszeichen sind Totenflecke, Totenstarre, Faulnis sowie nicht mit dem Leben zu vereinbarende Verletzungen. Grundkenntnisse uber postmortale Veranderungen ermoglichen eine grobe Todeszeitbestimmung und konnen ggf. Hinweise auf die Todesursache geben.

Todesfeststellung und Leichenschau – Keine Angst vor der Leichenschau!

Die Leichenschau ist die letzte arztliche Tatigkeit am Patienten. Mit ihr erfolgt eine Einschatzung, ob die Umstande eines Todesfalles weiter untersucht werden sollten oder nicht. Primare Aufgabe des leichenschauenden Arztes ist die Feststellung des Todes. Dazu kommen Angaben zur Todeszeit, der Todesursache und der Todesart auf der Todesbescheinigung. Bei Anhaltspunkten fur einen nicht naturlichen oder ungeklarten Tod ist die Polizei zu rufen. Ein standardisiertes Vorgehen hilft bei der Leichenschau.

Sudden death due to pulmonary embolism in a patient with cardiac sarcoidosis

We present a case of a 41-year-old Caucasian woman who collapsed suddenly. An ambulance was called immediately and resuscitation was attempted without success. The clinical history included low blood pressure and hypermenorrhea. During the weeks prior to her collapse she suffered from a mild cold. One week prior to her death she fainted and hit her head but further treatment was not needed. She had no previous cardiac history and had not been diagnosed with sarcoidosis, nor had any known family member. An autopsy showed pulmonary embolism of the large and intermediate arteries of the right lung and of the small arteries of the left lung. This finding was accompanied by heart failure with effusions of 200 ml in the left pleural cavity and 50 ml in the right, pulmonary edema, cerebral edema, and ‘‘shock’’ kidneys. The heart weighed 340 g (body weight 83 kg). Macroscopically, it presented distinct, focally dense lesions, with a pale to red-brown color and red centers (Fig. 1). The lesions extended over the posterior and lateral part of the heart, as well as the anterior parts of the left ventricle. The most severely affected area was within the myocardium, with a gradient towards the spotted endocardium of the left ventricle and the anterior papillary muscle. An examination of the ventricles showed no sign of mural thrombosis. Coronary artery sclerosis was not present. The macroscopic appearance of the lung and lymph nodes provided no evidence of pathological changes. Approximately one-third of the left kidney had lesions of a similar appearance to those in the heart (Fig. 2). Additional deep vein dissection identified an adherent thrombus in the left popliteal vein with superficial coverage by fresh thrombotic material. Histological examination of the heart revealed widespread scarring with degeneration of the myocytes. Those areas were accompanied by massive aggregates of lymphocytes neighboring non-caseating epithelioid granulomas. Giant cells partially containing asteroid bodies could be detected (Fig. 3). The left kidney showed identical findings, with granulomas, scarring and displacement of parenchyma (Fig. 4). We verified the diagnosis of pulmonary sarcoidosis with extrapulmonary manifestation in the heart and kidneys using the following criteria: noncaseating epithelioid granuloma with asteroid bodies in the endocardium, granulomas in the pericardium and granulomas in the lung, lymph nodes and kidneys.