Francesca Cittadini

Potassium concentration differences in the vitreous humour from the two eyes revisited by microanalysis with capillary electrophoresis

This paper presents a study of the variability of potassium concentrations in the vitreous humour of the two eyes of the same body at identical postmortem interval. The study was carried out by collecting microsample amounts (50 microl) of vitreous humour and by using an original method of capillary electrophoresis with indirect detection. The electrophoretic separations were carried out in a pH 4.5 running buffer composed of 5 mmol/l imidazole, 5 mmol/l 18-crown-6 ether and 6 mmol/l alpha-hydroxybutyric acid. Detection was by indirect UVabsorption at 214 nm. Vitreous humour samples were collected from 57 medico-legal autopsies or external examinations of cases of sudden natural or violent deaths. All samples prior to analysis were diluted 1:20 with a 40 microg/ml aqueous solution of barium, the used internal standard, and finally injected by nitrogen pressure. The mean concentrations of potassium measured in the two eyes of all the cases included in the present study ranged from 4.1 to 23.5 mmol/l with the postmortem interval values varying from 7 to 144 h. A highly significant (P<0.0001) linear correlation was found between these two parameters as described by the equation: y=0.1698x+2.3587, r=0.89. The intra-eye variability of potassium concentrations was low with an average RSD of 3.89% (+/- 1.83 SD) (48 eyes, five samples per eye). No statistically significant difference was found between the potassium concentrations in the two eyes of the same subject in a group of 24 cases, excepting a single case.

Computed tomography (CT) virtual autopsy and classical autopsy discrepancies: Radiologist's error or a demonstration of post-mortem multi-detector computed tomography (MDCT) limitation?

Modern imaging technologies, such as computed tomography (CT) techniques, represent a great challenge in forensic pathology. The field of forensics has experienced a rapid increase in the use of these new techniques to support investigations on critical cases, as indicated by the implementation of CT scanning by different forensic institutions worldwide. Advances in CT imaging techniques over the past few decades have finally led some authors to propose that virtual autopsy, a radiological method applied to post-mortem analysis, is a reliable alternative to traditional autopsy, at least in certain cases. The authors investigate the occurrence and the causes of errors and mistakes in diagnostic imaging applied to virtual autopsy. A case of suicide by a gunshot wound was submitted to full-body CT scanning before autopsy. We compared the first examination of sectional images with the autopsy findings and found a preliminary misdiagnosis in detecting a peritoneal lesion by gunshot wound that was due to radiologists error. Then we discuss a new emerging issue related to the risk of diagnostic failure in virtual autopsy due to radiologists error that is similar to what occurs in clinical radiology practice.

Capillary zone electrophoresis of potassium in human vitreous humour: validation of a new method

The analysis of potassium in the vitreous humour has long been regarded as an important tool in medicolegal and forensic toxicological investigation, particularly for the determination of the post-mortem interval. The present work was aimed at the optimisation and validation of a reliable, simple and fast capillary electrophoresis method for potassium analysis in the human vitreous humour with indirect UV detection at a wavelength of 214 nm. Electrophoretic separations were carried out in a running buffer comprising 5 mM imidazole, 5 mM 18-crown-6 ether and 6 mM D,L alpha-hydroxybutyric acid (HIBA), adjusted to pH 4.5. Constant voltage runs were carried out by applying a voltage of 500 V/cm at 25 degrees C. The samples were injected in the hydrodynamic mode at the anodic end of the capillary (0.5 p.s.i. for 10 s; 1 p.s.i. = 6894.76 Pa). The method showed good linearity in the concentration range from 6.5 mM to 16.25 microM, with an r2 value of 0.9994. The limit of detection, based on a signal-to-noise ratio of three, was 9.0 microM. Absolute intra-day RSDs of migration times were <0.40%, while the day-to-day values were < or =1.72%. Absolute peak area reproducibility was always better than 2.50%. A comparison of capillary electrophoresis with flame photometry on twelve real autopsy samples showed an excellent correlation with an r2 value of 0.9333. A preliminary application to real cases (20 subjects) was carried out plotting vitreous humour potassium vs. post-mortem interval with a resulting r2 of 0.904 and a Y-intercept of 4.75 mM, in agreement with the existing literature.

Unattended fatal hemorrhage caused by spontaneous rupture of a varicose vein.

To the Editor: With great interest we read the article by Racette and Sauvageau, recently published on the Journal, reporting 2 very unusual cases of fatal bleeding caused by a sudden rupture of varicose veins in the legs. Recently, we experienced a similar case concerning a 82-year-old man who was found dead, lying on the bedroom floor of his home, surrounded by a large quantity of blood. On external examination, no traumatic lesions were observed and dried blood was smeared on the back of his hands, thighs, and legs. A superficial ulcer, measuring 5 mm was noted on the medial surface of left ankle, 3 cm above the medial malleolus (Fig. 1). On one side of this ulcer, a small hole communicating with the lumen of a superficial varicose vein was observed. Necroscopy revealed blue blebby lesions, cutaneous pigmentation with trophic changes, and teleangiectasias on the surface of both legs, compatible with chronic venous disease. No other significant source of bleeding was evidenced. The autopsy revealed pronounced pallor of all the internal organs but there were no signs of recent myocardial infarction or other significant pathology. Death was caused by a hypovolemic shock because of hemorrhage, as a consequence of the rupture of the varicose vein. Fatal hemorrhage from a varicose vein without sign of trauma is a rare event, indeed, in literature, only 30 cases have been reported. According to Racette and Sauvageau, in our case the spontaneous bleeding from a varicose vein was provoked by an acute perforative ulcer of small dimensions. Varicose veins are a common chronic condition known to man since antiquity and with a worldwide distribution. Aching, itching, heaviness, tired legs, cramping, swelling, or nighttime restless legs are the symptoms associated with venous disease. Ulceration and hemorrhage are well-known complications of chronic venous disease generally considered nonlethal. Compression is the mainstay of venous ulcer management. Patients should be warned to remove the compression if they notice any side effects (such as numbness, tingling, pain, and dusky toes) and seek advice. Interestingly, almost all cases of hemorrhage from a varicose vein reported throughout literature regard elderly patient, single at the time of death. Recognition of the risk of massive hemorrhage may enable preventive treatment to be undertaken before resulting in eventual loss of consciousness and an unattended death. Although chronic venous disease is generally claimed nonlethal, the forensic pathologist should consider the hemorrhage from varicose veins a cause of sudden natural death.

Erratum to: Genetic and toxicologic investigation of Sudden Cardiac Death in a patient with Arrhythmogenic Right Ventricular Cardiomyopathy (ARVC) under cocaine and alcohol effects

Cocaine and alcohol toxicity is well known, especially when simultaneously abused. These drugs perform both acute and chronic harmfulness, with significant cardiac events such as ventricular arrhythmias, tachycardia, systemic hypertension, acute myocardial infarction, ventricular hypertrophy, and acute coronary syndrome. The present report refers about a patient who died after a documented episode of psychomotor agitation followed by cardiac arrest. At the autopsy investigation, arrhythmogenic right ventricular cardiomyopathy (ARVC) was diagnosed and confirmed by postmortem molecular analysis revealing a mutation in the DSG2 gene. Postmortem toxicological analysis demonstrated a recent intake of cocaine, and the death was attributed to cardiac arrhythmias. The detection of cocaine and cocaethylene in hair samples proved chronic simultaneous intake of cocaine and alcohol at least in the last month. The authors discuss the role of these drugs and genetic predisposition of the ARVC in causing the death of the patient.

Decapitation Due to Car Accident

The occurrence of complete decapitation as a consequence of car accident is an extremely rare event. This fatality is generally seen in pedestrians run over by trains and also in motorcyclists who impact against the tailboard of trucks. Moreover, complete transection of pedestrians and occupants of cars has been described in road accidents especially in case of vehicles traveling at a high speed. We present a case of decapitation with complete degloving injury of the neck in a patient involved in a traffic accident, and we briefly discuss the possible mechanisms producing this injury.

Sudden cardiac death associated with a coronary artery anomaly considered benign

Separate origin of the left anterior descending and circumflex coronary artery from the left sinus of Valsalva is one of the most frequent benign coronary artery anomalies. We hereby report, for the first time, a case of sudden death in a young man with this anomaly. The clinicopathologic findings and the possible pathogenetic mechanisms are discussed.

Sudden cardiac death due to an anomalous posterior papillary muscle

Anomalies of the mitral subvalvular apparatus can include differing types of papillary muscles and chordae tendinae. Direct insertion of the anomalous papillary muscle or chordae tendinea into the anterior mitral leaflet and fusion to the ventricular septum are common findings related to these anomalies. Anomalous papillary muscles or chordae, especially those that insert directly into the mitral leaflets, play a role in obstructing left ventricular outflow by restricting the mobility of the leaflets and/or tethering them toward the septum, thus narrowing the left ventricular outflow tract (LVOT). The incidence of mitral valve anomalies associated with LVOT is probably underestimated. This topic is frequently studied, however, especially in the pediatric cardiac surgery milieu, because LVOT obstruction could have a surgical solution. We report a case of an 18-year-old woman affected by epilepsy since 5 months of age who was found dead in her bedroom. An uncommon anomalous papillary muscle/chordae was the main autopsy finding. This malformation causes direct continuity between an accessory papillary muscle and a mitral leaflet, resulting in a long rigid area that can cause dynamic late-systolic intraleft-ventricular obstruction. In our case, in the absence of any other pathologic findings or major structural abnormalities, we speculate that a malignant cardiac arrhythmia provoked by the accessory papillary muscle could be the cause of death.

Virtual autopsy with multidetector computed tomography of three cases of charred bodies.

Herein, we report a comparison of multidetector computed tomography (MDCT) and autopsy in the evaluation of three cases of charred human bodies. Interestingly, MDCT identified several findings useful for forensic purposes, including traumatic injuries not related to the fire, relevant vital reaction signs and detection of foreign bodies. Our results, in addition to data gathered in previous studies, indicate that MDCT is an excellent tool for imaging in postmortem investigations and that it has great potential for the forensic documentation and examination of charred bodies.

The usefulness of biomarkers of alcohol abuse in hair and serum carbohydrate-deficient transferrin: a case report.

The detection of carbohydrate-deficient transferrin (CDT) in serum is widely accepted to identify chronic alcohol consumption over the previous two weeks, but minor ethanol metabolites detected in hair often complete the information obtained. In particular, ethylglucuronide and cocaethylene (a marker of simultaneous intake of cocaine and alcohol) allow correct interpretation of data obtained in forensic cases. We refer to a negative CDT value obtained from a serum sample collected during hospitalization of a man admitted for cardiac arrest who died about 14 h later. Clinical analysis performed on admission showed a high ethanol level and a positive urinary screening for cocaine. The toxicological analyses of post-mortem samples found cocaine metabolites in his urine and blood. The negative CDT level suggested the ethanol concentration at admission to be an acute episode. Cocaine and cocaethylene well above the cut-off suggested by the literature were found in hair analyzed for the entire length (about 1 cm). Ethylglucuronide detected on the same hair sample confirmed chronic abuse of ethanol in the previous month, at least. The present report suggests caution in the interpretation of biomarkers of alcohol abuse, encouraging the detection of more than one marker to avoid misinterpretation.