Lorraine du Toit-Prinsloo

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.

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.

Long QT syndrome and sudden unexpected infant death

Long QT syndrome (LQTS) is an inheritable primary electric disease of the heart characterised by abnormally long QT intervals and a propensity to develop atrial and ventricular tachyarrhythmias. It is caused by an inherited channelopathy responsible for sudden cardiac death in individuals with structurally normal hearts. Long QT syndrome can present early in life, and some studies suggest that it may be associated with up to 20% of sudden unexplained infant death (SUID), particularly when associated with external stressors such as asphyxia, which is commonly seen in many infant death scenes. With an understanding of the genetic defects, it has now been possible to retrospectively analyse samples from infants who have presented to forensic pathology services with a history of unexplained sudden death, which may, in turn, enable the implementation of preventative treatment for siblings previously not known to have pathogenic genetic variations. In this viewpoint article, we will discuss SUID, LQTS and postmortem genetic analysis.

Massive hemoptysis due to primary mucoepidermoid carcinoma of the lung in a 12-year-old.

Case Report A12-year-old African male patient presented with a history of progressive weight loss of several months duration and a complaint of persistent hemoptysis. Radiological examination (chest X-ray and computerized tomographic scan) confirmed the presence of a mass in the lower lobe of the right lung. Following hospitalization, the hemoptysis intensified and the patient was anesthetized for endobronchial examination and biopsy in order to establish the nature and extent of the pulmonary mass. Shortly after intubation, severe rapid intraparenchymal hemorrhage of the right lung occurred which led to sudden cardiac arrest. The patient was successfully resuscitated and was then admitted to the intensive care unit whilst still intubated. The endobronchosopic examination and biopsy procedure were abandoned and the right lung mass remained undiagnosed. A brain CT-scan performed shortly thereafter confirmed that hypoxic damage was present. The patient showed no improvement and finally succumbed one month later.

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.

Feasibility of analysis of the SCN5A gene in paraffin embedded samples in sudden infant death cases at the Pretoria Medico-Legal Laboratory, South Africa

To determine variations in the SCN5A gene linked to inherited cardiac arrhythmogenic disorders in sudden, unexplained infant death (SUID) cases examined at the Pretoria Medico-Legal Laboratory, South Africa. A retrospective study was conducted on SUID cases and controls, analyzing DNA extracted from archived formalin-fixed, paraffin-embedded (FFPE) myocardial tissue samples as well as blood samples. A total of 48 FFPE tissue samples (cases), 10 control FFPE tissue samples and nine control blood samples were included. DNA extracted from all samples was used to test for variations in the SCN5A gene by using high resolution melt (HRM) real-time PCR and sequencing. Genetic analysis showed 31 different single nucleotide variants in the entire study population (n = 67). Five previously reported variants of known pathogenic significance, and 14 variants of benign clinical significance, were identified. The study found 12 different variants in the cases that were not published in any database or literature and were considered novel. Of these novel variants, two were predicted as “probably damaging” with a high level of certainty (found in four case samples), one (identified in another case sample) was predicted to be “possibly damaging” with a 50% chance of being disease-causing, and nine were predicted to be benign. This study shows the significant added value of using genetic testing in determining the cause of death in South African SUID cases. Considering the high heritability of these arrhythmic disorders, post mortem genetic testing could play an important role in the understanding of the pathogenesis thereof and could also aid in the diagnosis and treatment of family members at risk, ultimately preventing similar future cases.

Self-inflicted explosive death by intra-oral detonation of a firecracker: a case report

Self-inflicted explosive deaths due to detonation of fireworks are rare. In this case report, a peculiar case of an elderly male who discharged a firecracker inside his mouth, resulting in fatal blast induced craniofacial injuries, is described. There is paucity of published data describing fireworks-related suicidal and/or non-suicidal deaths. Even scantier data is present specifically describing fireworks-related blast induced neurotrauma and the mechanism(s) of injury involved in such cases. This case report emphasizes the severe damage that a commercially available explosive, the so-called “Gorilla Bomb”, can cause, and raises questions about the relative ease of its acquisition.

Osseus metaplasia in chronic renal allograft rejection

The formation of heterotopic bone tissue outside the skeleton, known as osseous metaplasia, is a well-known phenomenon, but only a handful of cases describe this in renal allografts. We report the case of a 26-year-old female who was admitted to hospital for repair of an arteriovenous fistula of the right arm. Following her demise, the incidental finding of osseous metaplasia in the allograft kidney was made at autopsy. The pathophysiology, histology and possible clinical significance of the lesion are described.