Lucia Tattoli

Nasal ciliary motility: a new tool in estimating the time of death

Determination of time since death is one of the most difficult and crucial issue in forensic medicine. Apart from body cooling, which is commonly used in the early postmortem interval (PMI), supravital reactions are the most interesting postmortem changes for time of death estimation. Nasal ciliary motility has been occasionally observed in postmortem period although no studies have focused on this phenomenon for forensic purposes. We aimed to evaluate the diagnostic usefulness of ciliary motility as a potential tool in estimating the time of death. Specimens of ciliated epithelium from 100 consecutive cadavers were obtained by scraping the nasal mucosa at three different postmortem intervals. The samples were then smeared on a slide, and an in vitro evaluation of ciliary movement was analyzed by phase-contrast microscopy. A postmortem nasal ciliary motility was observed, and a statistically significant relationship between decreasing ciliary movements and increasing postmortem interval was detected even in presence of putrefactive changes of nasal ultrastructure integrity. Some peculiar causes of death seem to influence ciliary motility in the early PMI, while no significant correlations with sex or age were observed. According to the results of this study, postmortem evaluation of nasal ciliary motility may be a bona fide and a feasible option for estimating the time of death.

Occupational asphyxiation by unknown compound(s): environmental and toxicological approach.

During a routine truck-tank washing operation, five healthy workers were found motionless inside an empty tanker. Four of them died inside the tanker while the fifth died the following day in hospital. Since the true nature of the fatal compound(s) were not known, a rigorous environmental and toxicological approach supported by autopsy findings was essential to clarify the cause of death. Environmental results indicated that H(2)S fumes arising from the liquid sulfur previously shipped were responsible for the serial deaths, also confirmed by a simulation performed on two similar truck-tanks. These environmental findings were supported by toxicological analyses through the measurement of thiosulfate, one of the main H(2)S metabolites. Abnormal thiosulfate concentrations from 1.1 to 186.2 mg/kg were revealed in all post-mortem biological samples (blood, lung, liver, kidney, brain and fat). Finally, the cluster analysis performed on thiosulfate body distribution contributed to establishing the time of death according to the accident scene reconstruction. This report presents valuable findings in correctly identifying the cause of death in gas asphyxiation cases by unknown compound(s).

Postmortem bone marrow analysis in forensic science: Study of 73 cases and review of the literature

In forensic sciences, bone marrow (BM) is an alternative matrix in postmortem toxicology because of its good resistance to autolysis and contaminations. Nevertheless, few studies have been focused on postmortem BM morphological changes after pathological stimuli. We examined 73 BM samples from forensic autopsies; causes of death were both natural and traumatic. BM samples were collected from the sternum by needle aspiration and biopsy; in selected cases, immunohistochemistry was performed. Few autolytic changes were found; BM cellularity decreased with increasing age and postmortem interval. Notable cell changes were detected in 45 cases (61.64%): neoplastic (n=4), and non-neoplastic BM findings (n=41), including multiorgan failure/sepsis (n=26), myelodisplastic-like conditions (n=11), and anaphylactic reactions (n=4). The results showed that BM cellularity supported circumstantial and autopsy findings, suggesting that BM samples could be a useful tool in forensic science applications.

Complete Cardiac Rupture Associated with Closed Chest Cardiac Massage: Case Report and Review of the Literature†

Chest skeletal injuries are the most frequent complications of external chest massage (ECM) during cardiopulmonary resuscitation, but heart and great vessels lacerations that are indeed very rare. We report the case of a 35‐year‐old workman who collapsed and underwent ECM by his co‐workers for almost 30 min. At autopsy, no external injuries, fractures or bruises of the ribs or sternum, were observed. A hemopericardium with a rupture of the heart was found, with no signs of pre‐existent cardiac disease. Bruises of thoracic aortic wall, lung petechiae, a contusion of the liver, and bruises of lumbar muscles were found. The cause of death was due to sudden cardiac death with an extensive cardiac rupture. This is an unusual report of massive heart damage without any skeletal or muscle chest injuries, secondary to cardiopulmonary resuscitation. This kind of cardiac lesions may be considered when thoracic–abdominal trauma, or medical history, is unclear.

Remarkable findings in suicidal hanging

hanging by a tie that was fixed to the upper hinge of a door. His feet were touching the ground. It was known that he had tried to commit suicide before. At medico-legal autopsy a single furrow was found on the neck with a ligature knot behind the left mandibular angle. Dissection of the neck’s soft tissue in layers revealed bilateral fresh hemorrhages in the pharyngeal tonsils with macroscopic delineation of gland follicles (Fig. 1). Fractures of both superior horns of the thyroid cartilage, superficial hemorrhage in the tongue’s base, and petechiae of the facial skin and conjunctivae were also present. Except for brain swelling, pulmonary edema, and severe generalized atherosclerosis, no other findings were observed. Toxicological investigations were negative. The cause of death was declared as hanging and the manner of death was ruled suicide. Case 2 A 74-year-old man was found hanging from the railing of a bridge, freely suspended by a hemp rope with an estimated drop of 3.5‐4 m. The deceased was 160 cm tall and weighed 77 kg. The 1 cm thick rope compressed the neck with a knot on the anterior area of the neck forming a loop that ran above the laryngeal protuberance. The loop ended in a fixed ligature knot behind the left ear. At external examination, dried saliva was found coming out of the right corner of the mouth, draining down over the chin. Autopsy revealed bilateral symmetrical hemorrhages at the sternal insertion of the periosteal-clavicular origin of the sternocleidomastoid muscles, and a complete laceration of all tissue layers between the cricoid cartilage and the hyoid bone that crossed the upper part of the thyroid cartilage and exposed the laryngeal mucosa. The trachea contained a small amount of fine froth with no signs of blood aspiration. A full-thickness transverse laceration, as well as superficial tears in the intima of the right common carotid artery, were also seen proximal to the bifurcation (Fig. 2). Hemorrhages (‘‘Simon’s bleedings’’) beneath the anterior longitudinal ligament of the thoracic and lumbar spine were also present. Toxicological analysis was unremarkable.

An unusual mechanism for patterned bruising in a fatal fall from a building

A 90-year-old man was found dead lying on the ground in front of a building. He had committed suicide by jumping from the 5th floor (approximately 15 m height) of the building where he had lived in his apartment. His medical records revealed that the man had suffered from dementia with a history of psychiatric disorders and suicidal tendencies. A suicide note was found in his apartment. External examination of the body revealed blunt force injuries on the skin (abrasions and hematomas) of the thorax and on the limbs. Of note, an unusual finding was that of patterned bruising of the right forearm with parallel linear stripes along the posterior surface of the arm overlying the right radius and ulna (Fig. 1). At autopsy, multiple fractures of the thoracic cage including the sternum, the ribs and the thoracic spine, were found. Complete transmural tears of the heart were also observed together with extensive contusions and tears of both lungs and the liver. In addition, there were comminuted fractures of the lower limbs. Toxicological examination was negative. Death was attributed to multiple trauma. The manner of death was ruled as a suicide. Discussion

Fatal fulminant hepatitis following administration of clarithromycin in a patient chronically treated with antipsycotic drugs.

Background: Clarithromycin is a widely used antibiotic, especially prescribed for the treatment of respiratory tract infections, The drug is generally well tolerated. It is described as a very rare cause of fulminant liver failure. Case presentation: Herein we report a case of fatal fulminant hepatitis in a young patient. In his past history the patient presented documented episodes of hypertransaminasemia. Conclusions: This case confirms that clarithromycin although very rarely, can be a cause of fulminant hepatitis, especially in patients with pre-existing liver damage. Although the presumption that clarithromycin hepatotoxicity is dose related is reasonable, an immune-toxicologic hypothesis cannot be excluded.

Multiple stab wounds: understanding the manner of death through the psychological autopsy

A 48-year-old physical therapist with no history of psychiatric disorders or suicidal tendencies was found dead by his relatives inside his apartment. Multiple stab wounds were present on the chest and the abdomen. Several more superficial cuts were also seen on the neck and the left wrist. At the death scene, there was a large pool of blood in the room, with secondary droplets and stains; a kitchen knife was found beside the body, and a suicide note on a table. Especially the number of wounds raised strong suspicion of a homicide in the first instance but some circumstances (the farewell letter, the absence of clothing injuries, no signs of third-party involvement) and autopsy findings (absence of defense or blunt injuries, the localization of the wounds, the presence of hesitation marks) pointed toward a suicide etiology. Because of the many stab injuries and the lack of a psychiatric history, further forensic investigations were required including a so-called psychological autopsy. This case report highlights that only a comprehensive interpretation of all the elements (circumstances, the scene of death, autopsy findings, and psychological autopsy) can lead to the correct solution of atypical cases of suicide.

Could the Shroud of Turin be an effect of post-mortem changes?

Case reportA 71-year-old man was found dead in his locked apartmentin a prone position on the floor of the hallway. Theputrefied body was lying with the right side of his face onthe floor. The upper limbs were both flexed at the elbows:the right one was underneath the chest, the left one waslying on the ground. The decedent was wearing underwearand socks.Medical records revealed that the man had suffered fromhypertension, diabetes, and stomach problems. Thedeceased had not been seen for some weeks by otherpersons.When the body was removed for examination, a widereddish-brown stain (Fig. 1) that corresponded to putre-factive body fluid and depicted the exact shape and positionof the body, in particular defining the position of the flexedupper limbs clearly, with the right arm close to the neck,was noticed on the carpeted floor. The underwear he hadbeen wearing at the time of death was also recognizable bya lighter colored area of putrefaction staining on the carpet,as was the abdominal region, according to the differentputrefactive discoloration of the skin surface.At medico-legal autopsy, external examination con-firmed severe putrefaction of the 168 cm, 51 kg body.Some maggots were present and a dirty greenish-brownishdiscoloration of the entire body was observed. The skin ofthe hands was dried and there was skin slippage in someareas. There was no evidence of external injury. Autopsyshowed multiple micro hemorrhages of the gastric mucosa,and moderate senile calcific valvular heart disease was alsofound. No remarkable pathological findings were noticed inthe other internal organs. The cause of death remainedunclear after autopsy but toxicological investigationsindicated the possibility of diabetic coma (acetone 68 mg/kg in the muscle).DiscussionThe interpretation of post-mortem changes can be a chal-lenge for the forensic pathologist, since the value ofexternal examination and autopsy is reduced as the state ofputrefaction advances [1, 2]. The process of putrefaction istemperature dependent and is enhanced by autolysis-induced breakdown products of tissue which favor bacterialspread throughout the whole body [3]. In later stages, thebody begins to swell due to the production of gas bybacteria, and the outer layers of the skin slip off the body.Also, a purge of putrid, blood-stained hemolytic fluid fromnose, mouth, anus, and vagina occurs due to the increase ofputrefaction gas pressure within the thorax and peritonealcavity. In even later stages, the liquefaction of the tissuesis complete and is followed by the drying of surfacetissues [4].Sometimes purging and leaking of putrefactive fluidcan extensively stain the material on which the decedent

Examples of tramline bruises in clinical forensic medicine

A 9-year-old deaf boy was brought to our institute by a social worker. He reported that a woman who worked in the children’s home where he lived had beaten him with a wooden stick the day before. He added that this was the third time that it had happened. When the woman was questioned about the events, she denied the physical abuse and claimed that the injuries had been caused by playing with other children. Physical examination of the boy revealed several injuries on his upper body; notably, six tramline bruises were present on his right arm (Fig. 1a, b), and six tramline bruises were present on his left forearm (Fig.1c). The injuries were 4.0 cm long and 1.2 cm wide. According to our expert report, the morphology and location of the injuries as well as the clustering of injuries was proof that these injuries were abuse-related (intentional). An accidental origin of the injuries was excluded.