Gert Saayman

Lightning medicine in South Africa

South Africa has a rich history of lightning research; however, research on the clinical and pathological effects and features of lightning-related injury (keraunomedicine or lightning medicine) remains neglected locally. By providing an overview of keraunomedicine and focussing on South African perspectives, we hope to raise awareness and propose that a concerted and co-ordinated attempt be made to report and collate data regarding lightning strike victims in South Africa.

Subendocardial Fibrosis in Left Ventricular Hypertrabeculation-Cause or Consequence?

Left ventricular noncompaction has been classified as a primary cardiomyopathy with a genetic origin. This condition is morphologically characterized by a thickened, two-layered myocardium with numerous prominent trabeculations and deep, intertrabecular recesses. Recently, it has become clear that these pathological characteristics extend across a continuum with left ventricular hypertrabeculation at one end of the spectrum. The histological findings include areas of interstitial fibrosis. We present a case of left ventricular hypertrabeculation which presented as sudden infant death syndrome. Histologically areas of subendocardial fibrosis was prominent and we propose that this entity may be a hidden cause of arrhythmic death in some infants presenting as sudden infant death syndrome., with areas of subendocardial fibrosis as possible arrhythmogenic foci.

A retrospective analysis of alcohol in medico-legal autopsied deaths in Pretoria over a 1 year period

The misuse of alcohol has a particularly detrimental effect and is one of the most significant public health problems in South Africa and it also has an impact on the criminal justice system with evidence of association between high levels of alcohol and risk-taking behaviour, committing crimes, or being a victim of crime. A global trend has been set worldwide with alcohol being one of the most common drugs found in post mortem specimens and especially with regard to cases admitted for medico-legal autopsies. The influence of alcohol on the cause of death is either a contributory or an underlying factor in a substantial number of violent deaths. We retrospectively reviewed 1455 cases, in which alcohol was taken, of 2344 medico-legal autopsies done in 2009. We found that 47% of the cases tested positive for alcohol, with the reported blood alcohol concentrations varying from 0.01 to 0.95g per 100ml (mean=0.16±0.11g per 100ml) with the highest proportion being in the 0.10-0.19g per 100ml range. A breakdown of the results showed that road traffic accidents, assaults and firearm-related deaths predominated the alcohol-positive cases. The results showed that there was a definite correlation between alcohol consumption and the incidence of other that natural deaths.

The incidence, pathology of trauma and victim profiles of homicidal deaths in Pretoria, South Africa (2007–2008)

This study aimed to establish the incidence of homicide, associated pathology of trauma and victim profiles in cases admitted to or managed as homicidal deaths at the Pretoria Medico-Legal Laboratory (PMLL) over the period of 2007–2008. A total of 1088 cases were reviewed. Homicides accounted for 22.7% of all cases admitted to the PMLL. The majority of homicide victims were male individuals (87.0%). The most common cause of death was gunshot wounds (42.6%), followed by blunt force trauma (25.1%). Homicides are most likely to occur at the victims place of residence (28.5%) and only 37.4% of victims survive long enough to receive hospital care. The results of this study seem to concur with international findings for the most part, with a few interesting deviations. Highlighting at-risk groups, as well as dangerous locations and incident times, creates the potential to decrease the occurrence of unnecessary deaths by generating an awareness of the trends.

Deaths from bee stings: a report of three cases from Pretoria, South Africa

In South Africa bee stings are most commonly caused by either Apis mellifera capensis or A. mellifera scutellata, indigenous species which are notoriously aggressive when compared to European honey bees. According to Statistics South Africa, 109 deaths were documented for the period 2001–2011 as having been caused by hornets, wasps, and bees (ICD10—X26). This appears to be a small number but, as was reported in Australia, these statistics might be inaccurate due to either over- or underreporting of cases. We report 3 cases of fatalities due to bee stings, including one with postmortem features of diffuse intravascular coagulopathy. A brief overview of the venom of the honey bee, reactions following a bee sting and possible mechanisms of death are presented. Confirming the diagnosis in these cases may be very problematic for the forensic pathologist, as in many cases minimal history is available and both external and internal examination could fail to reveal any specific signs of bee sting or other obvious morphologic abnormalities. Thus, there is a need for reliable confirmatory or supportive diagnostic tests.

Fatal head injuries in children under the age of 5 years in Pretoria

AbstractThe incidence of fatal injuries in children has been reported to be highest among children aged 1 to 4 years. Major causes of head injury include road traffic accidents, falls, and intentional or inflicted injury (such as nonaccidental injury syndrome). This study reviewed the profile of children (under 5 years of age) who had been admitted to a large urban medicolegal mortuary (in Pretoria, the capital city of South Africa), after having suffered fatal head injuries. This study was conducted over a 5-year period (from January 2004 through December 2008), and a total of 107 cases were identified for inclusion. These cases constituted nearly a fifth of admissions in this age group. The male-to-female ratio was 56%:44%, and the peak age of injury was less than 1 year. Most head injuries were sustained in road traffic accidents (70%) followed by falls (10%) and other types of blunt force injuries (9%). Only 1 case of nonaccidental injury syndrome (child abuse) was found. The great majority of deaths were deemed to have been accidental in nature (91%) with 6 (6%) homicides. Urgent review pertaining to the use of child restraint devices and the safety of pedestrians is required, and the institution of childhood injury registers could aid in reducing childhood fatalities in South Africa.

Bone marrow embolism to the lung in electrocution : two case reports

Bone marrow embolism in electrocution was first described in the literature by Rappaport et al (Am J Pathol. 1951;27(3):407-433) in 1951. Two case studies demonstrating this phenomenon are reported here, one involving high-voltage exposure with associated skeletal injuries and the other involving domestic current and without evidence of skeletal injury. Both cases demonstrated bone marrow embolism on histologic examination of the lungs. The purposes of this article are to reiterate the existence of this unusual phenomenon and to consider possible pathogenetic mechanisms.

Case report : lightning-induced pneumomediastinum

Abstract We present the case of a 41-year-old woman who was fatally injured during a witnessed lightning strike event and in whom autopsy revealed the unusual keraunopathological finding of overt pneumomediastinum. The possible pathophysiological mechanism(s) of causation of this phenomenon are discussed, with specific reference also to the “Macklin” effect and the role of blast overpressures associated with lightning strike. It is suggested that the latter may lead to sudden alveolar rupture, with subsequent rapid tracking of air along bronchovascular sheaths in a centripetal manner toward the hilum of the lung and thus into the mediastinum. A review of the blast literature suggests that this victim would have been exposed to a blast pressure wave of approximately 29-psi (200 kPa) to 72-psi (500 kPa) magnitude.

Death at the wheel due to tuberculosis of the myocardium : a case report

According to the World Health Organization, an estimated 9 million people contracted tuberculosis (TB) with approximately 25% of TB cases being from Africa. TB was reported as the number one cause of natural death for the period 2011-2013 in South Africa. The first reported case of myocardial TB was in 1664 by Maurocordat and the first reported case of sudden cardiac death due to TB was made in 1977. We present a case report of myocardial TB in an apparently healthy, 35-year-old male who died suddenly while driving his car. The problems associated with the diagnosis of TB of the myocardium and an overview of the relevant literature is provided.

Disk battery ingestion: a rare cause of perforation of the brachiocephalic artery.

A previously healthy 2 year old female toddler was brought to the emergency department with a history of severe hematemesis. Posterior-anterior (PA) and lateral chest radiographs demonstrated a round radio-opaque object (approximately the size of a US quarter coin) in the esophagus (Fig. 1). A pediatric surgeon was consulted for endoscopic removal of the foreign body, but the child’s condition deteriorated rapidly and despite full resuscitative efforts, the child died before the foreign object could be removed. Lodox Statscan performed prior to commencement of the autopsy confirmed the presence of the foreign object in the esophagus. Externally, signs of resuscitation efforts were found, as well as pallor of the mucosal surfaces. Dissection revealed a right sided hemothorax of approximately 25 ml, with no rib fractures. There was a perforating defect of the posterior wall of the esophagus, measuring 20 mm 9 5 mm, with a disk battery (model CR2032) wedged in situ within the defect, with surrounding superficial mucosal sloughing and signs of reactive induration and inflammation (Fig. 2). The perforating defect extended to involve the subjacent brachiocephalic artery (innominate artery), immediately distal to the point of origin from the aortic arch (Fig. 3). The disk battery measured 20 mm in diameter and 3.2 mm thick (Fig. 4). Further dissection revealed the presence of blood in the stomach, duodenum, and jejunum. Histological examination of the esophagus showed transmural infiltrate of predominantly chronic inflammatory cells with minimal neutrophils and eosinophils (Fig. 5). Sections from the brachiocephalic artery showed a florid acute inflammatory reaction with numerous neutrophils and eosinophils and with minimal lymphocytes in the adventitial layers. Based on the overall history and findings, we concluded that the battery had been ingested approximately 2 weeks prior to the child’s death, lodged within the esophageal lumen where it subsequently eroded the mucosa and posterior wall and later into the brachiocephalic artery. The corrosive effect led to intermittent hemorrhage into the gastrointestinal tract and the subsequent severe pre-terminal hematemesis. We could not trace any previous published reports of esophageal perforation with associated brachiocephalic artery injury and severe hemorrhage as a result of ingestion of a disk/button battery.