Martin Janík

Comments on Tongue protrusion as an indicator of vital burning.

Dear Editors:We have read with great interest an excellent article aboutevaluationofanew diagnosticsign: “Tongueprotrusionasanindicator of vital burning” [1]. In this letter, we would like tocommentonthenewautopticindicatordiscussedinthearticleand contribute our recent observations and suggestions.A number of key questions must be answered whenassessing cases of severely burned bodies, including causeofdeath,mannerofdeath,identityofthevictim,thereasonthevictim was in the fire, and vitality of trauma. Clarification ofthe last question is crucial because answers to the remainingquestionsmoreorlessdependonwhetherburningwasvitalornot. Before any cause and manner of death offire victims canbe formulated, it should be borne in mind that a variety ofartifactsmaybecausedbyextremeheat,includingsplittingofthe skin; heat fracturing of the long bones and the skull; fireepidural hematomas; and the so-called pugilistic attitude with“boxer” appearance of the arms, i.e., contraction of themuscles and flexion of the joints of the extremities [2].Vital burning may be confirmed by various macroscopicfindings and histological and immunohistochemical evidenceas well as by laboratory tests revealing, for example,carboxyhemoglobin or hydrogen cyanide levels in a bloodsample. The craw sign and partial burning of eyelashesrevealed on external examination are considered to be themostreliablefindings,andinformationonthevitalityofburnscan be indicated on internal examination by the presence ofsoot in airways and/or in esophagus and stomach. Thermaldamage to the respiratory tract epithelium may also confirmthe vitality of burns [3].Until now, tongue protrusion in burning fatalities has beenunderstood as a characteristic finding in fire deaths, but itssignificanceasanindicatorhas,unfortunately,beenuncertain.There has been no evidence-based proof in the literatureverifying its roleinascertainingvitalityinfiredeaths. Severaltextbooks and review articles have characterized tongueprotrusion in fire deaths as an artifact, and an internationallyrecognized book of forensic histopathology has portrayedcomb-like heat damage of lingual mucosa (heat blisters) withincorporatedsootparticles as accompanyingthe protrusionofthe tongue [4]. However, these histopathological findingsalone do not prove that the victim was alive at the time ofthefiresoutbreak.AstudybyBernitzetal.[1]suggestedthattongue protrusion is a valuable finding that might beconsidered a vital sign characteristic of death in fire, butfurther prospective studies of this phenomenon in relation tofiredeathsareneeded.Manyquestionsmuststillbeanswered,including: Is tongue protrusion really a vital sign or does thetongueprotrudefromtheoralcavitybecauseofcontractionofthe facial skin resulting from the heat of the fire and is thevitality of this phenomenon therefore disputable evidence?Does the absence of tongue protrusion suggest non-vitalburning? What is the underlying mechanism responsible fortongue protrusion? Is the tongue protrusion related to aparticular mechanism of death in fire?Recently, we encountered a case of the self-immolation of a45-year-old male who was found dead in sitting position at hisapartment.Thedeceasedsburnswereundoubtedlyvital,aswefound soot in airways and an increased carboxyhemoglobinlevel in his blood. On external examination, there was typicaltongue protrusion with locking of the tongue between teethfronts. Surprisingly, dissection of the tongue revealed three

Circular saw-related fatalities: A rare case report, review of the literature, and forensic implications

Fatalities attributed to powered circular saws appear to be vanishingly rare events with highly wounding and rapidly incapacitating effects. When they do occur, they are mainly self-inflicted in nature. We report the suicide committed by a 79-year-old man using a self-made circular table saw. Autopsy confirmed that the man received multiple heterogeneously distributed saw-type impacts to the head and neck resulting in complete amputation of the upper skull and partial beheading. Homemade or modified commercial sawing instruments and the resultant injuries pose a number of forensic challenges starting from the death scene investigation, continuing with technical examinations, and concluding with determining the manner of death. As with all deaths due to sharp force injuries, fatalities involving power tools such as chainsaws, circular, and band saws warrant a high degree of suspicion of criminal activity and require diligence during all phases of the death investigation.

Non-traumatic and spontaneous hemothorax in the setting of forensic medical examination: A systematic literature survey

Spontaneous hemothorax is a well-known yet seldom-reported entity in forensic literature. While trauma-related hemothorax is frequently encountered in a medicolegal setting, non-traumatic and spontaneous hemothorax are relatively uncommon entities. The wide range of causes that can trigger fatal intrathoracic bleeding include thoracic aortic dissection, followed by vascular malformations, various oncological diseases, and connective tissue abnormalities. In rare instances, extramedullary hematopoiesis, ectopic pregnancy, congenital heart defects, amyloidosis, or parasitic diseases may constitute a source of bleeding. This etiological heterogeneity may, as a result, cause diagnostic difficulties during post-mortem elucidation of hemothorax. It should be borne in mind that hemothorax after low-energy trauma does not exclusively indicate traumatic hemorrhage, hence, the non-traumatic origin of bleeding must be taken into consideration. In this paper, we present a systematic review of the relevant literature enriched by the results of our observations to investigate the etiologies and recommendations for the post-mortem diagnosis of spontaneous hemothorax in an attempt to better delineate the possible medicolegal considerations. It is important that forensic pathologist as well as clinicians are aware of the diseases that could potentially give rise to fatal hemothorax.

Carbon monoxide-related fatalities: A 60-year single institution experience

OBJECTIVE Though carbon monoxide (CO) poisonings account currently for a relatively small percentage of total non-natural deaths in Europe, they represent a serious public health burden and significant component of avoidable mortality in many countries. Our aim was to investigate long-term trends and to determine epidemiologic characteristics of the CO-related deaths in the Czech Republic, recorded at the Department of Forensic Medicine in Hradec Králové. METHODS This was an autopsy-based single-centre retrospective cohort study of all fatalities caused by CO poisoning over six decades (1947-2006). All data were numerically evaluated and processed using NCSS 10 Statistical Software. Statistical significance was defined as a p-value less than 0.05. RESULTS A total of 1233 CO-related deaths were identified for inclusion in the study. The manner of death was ranked in order as follows: 45% accidental poisoning, 40% suicidal poisoning, 1% homicidal poisoning, 14% remained undetermined. There were slightly more male victims (59%) than female, and the mean age overall was 48 years. The majority of CO-related fatalities were attributed to coal gas inhalation, with the remainder being from inhaled motor vehicle exhaust fumes, inhaled fire smoke, and other combustion sources such as charcoal, gas and wood-burning appliances. The mean blood carboxyhemoglobin (COHb) level was 66%. A positive blood ethanol concentration was measured in 455 (37%) cases examined. Non-intentional poisonings were highly correlated with the winter months. CONCLUSION This study shows that the prevalence of CO-related deaths has decreased significantly in the Czech Republic following the widespread detoxification of the domestic gas in the 1990-1995. Our findings suggest that acute ethanol use, poorer socioeconomic position, and inadequate education status about the danger of CO are associated with an increased risk of fatal CO poisoning. Finally, our results demonstrate the continued value of the autopsy in monitoring global public health security issues and socioeconomic situation. Further similar large-scale studies in different populations are needed to improve the targeting of interventions to the groups with the highest level of risk, and to understand the sources of variation in CO-related mortality.

Agenesis of the Superior Cornua of the Thyroid Cartilage: A Rare Variant of Medicolegal Importance

AbstractIt is important that forensic pathologists are familiar with variations in the size and shape of the laryngohyoid complex when interpreting injuries and pathology of the head and neck region. Accurate postmortem examination of the laryngohyoid structures may be difficult if anatomical variation in these structures is present. Agenesis of the upper horns of the thyroid cartilage has medicolegal significance because it may be mistaken for a fracture or other trauma-related conditions. We present 3 cases with different forms of agenesis of the superior cornu of the thyroid cartilage, namely, right unilateral, left unilateral, and bilateral agenesis.

Tricuspid valve endocarditis complicated by septic pulmonary embolism in an intravenous drug user

Case reportA 32-year-old woman collapsed suddenly in the early hoursof the morning after visiting the toilet. Her partner made anemergency call immediately and started telephone-assistedcardiopulmonary resuscitation. Subsequent professionalresuscitation efforts were unsuccessful, and the woman waspronounced dead at the scene. She was known to be a long-term intravenous drug (IVD) user. A medicolegal autopsywas requested considering the woman’s young age and herspecific history of IVD abuse.Autopsy revealed the body of a poorly nourished Cau-casian woman, 162 cm in height and 55 kg in weight. Onexternal examination, there were prominent areas ofdepigmentation of the skin in the bilateral groin area, theanterior part of the right thigh, and the left cubital fossa.Fresh subcutaneous hemorrhages were seen on the anteriorpart of the right thigh with fresh puncture marks. Externalexamination also revealed multiple petechial hemorrhageson the right lower leg. Other external findings wereunremarkable.Dissection of the heart (weight, 280 g; dimensions13 9 10 9 4 cm) showed almost complete destruction ofthe anterior and septal cusps of the tricuspid valve (Fig. 1).The edges of the ulcerated cusps contained yellowishgranular vegetations. A smaller shaggy vegetation was alsopresent on the atrial aspect of the posterior cusp of thetricuspid valve, but the degree of destruction of the pos-terior cusp was not as severe as that of the anterior andseptal cusps. The leaflets of the tricuspid valve wereedematous and slightly coarse. A yellowish mass with aslightly granular surface was wedged into both branches ofthe pulmonary artery, causing complete obstruction(Fig. 2). The cardiac muscle was grossly normal. Therewas no septal defect. No pathological change was seen inthe coronary arteries.Further findings included septic changes of the spleen(weight, 460 g), congestion of the internal organs, and lungand brain edema.Histological examination of the lesions on the tricuspidvalve and the mass from the pulmonary artery revealed anorganizing thrombus with numerous colonies of bacteria,focal areas of acute inflammation, and microabscess forma-tion (Fig. 3a). Gram staining displayed gram-positive coc-cobacilli (Staphylococcus aureus). Histological examinationof the heart showed dispersed occlusions of small intramyo-cardial arteries bythrombicontaininglarge numbersofgram-positive bacteria with acute inflammation of adjacent areas ofmyocardium (Fig. 3b). There were no signs of nuclear atypiain the cardiomyocytes. Focal microabscesses containinggram-positive bacteria, karyorrhectic debris, and polymor-phonuclear cells surrounded small vessels in both lungs(Fig. 3c). Histologically proven focal and segmental septicglomerular infarcts were present in both kidneys (Fig. 3d).

Lipomatous hypertrophy of the interatrial septum: a possibly neglected cause of sudden cardiac death

An 89-year-old woman was found dead in the corridor of her apartment. A forensic autopsy was requested because her death was sudden and unexpected with an uncertain cause. The woman’s significant past medical history included chronic venous insufficiency of the lower limbs and ischemic heart disease. External examination showed small abrasions of the forehead and chronic ulcers on the lower limbs. Internal examination revealed moderate generalized atherosclerosis, dilation of both cardiac ventricles, congestion of internal organs, and pulmonary edema. Sectioning the heart (weight 570 g, dimensions 14 9 14 9 4 cm) revealed an unencapsulated fatty accumulation within the cardiac interatrial septum with particular sparing of the fossa ovalis (Fig. 1). The interatrial septum was up to 2.5 cm thick. The mass was firm and yellow to brown in color. It had an appearance different to epicardial fat (Figs. 1, 2). The coronary arteries were calcified, but there was no significant stenosis or thrombotic occlusion. There was also no gross myocardial fibrosis or necrosis. Additional autopsy findings included a small leiomyoma on the anterior wall of the uterus and a cyst (4 cm diameter) with clear content on the posterior aspect of the right kidney. Histological examination of the cardiac interatrial septum revealed mature fat with an admixture of brown fat, fibrous tissue, entrapped myocardial fibers, and hypertrophied myocytes with atypical nuclei (Fig. 3). Postmortem toxicological analysis was negative for drugs and alcohol. Death was attributed to a fatal cardiac arrhythmia caused by the fatty accumulation in the cardiac interatrial septum.

A planned complex suicide by gunshot and vehicular crash

Complex suicide is usually defined as the application of more than one killing mechanism to ensure a fatal outcome. Herein we report an unusual case of a planned complex suicide of a 20 year old-male combining gunshot with coincidental intentional vehicular crash. The case was initially assumed to be a simple traffic accident until a rimfire pistol was found in close proximity to the deceased as well as gunshot wound of the head. This paper demonstrates the importance of careful inspection of the death scene, as well as the complex performance of autopsy examination to explain the manner of death and distinguish accidental deaths from suicides in such cases. Nevertheless, this assessment might by very difficult or even impossible. It has to be assumed that a high number of suicides in road traffic remain undetected.

Letter to the editors regarding the article entitled: “paradoxical undressing associated with subarachnoid hemorrhage in a non-hypothermia case?”

We read with great interest the recently published article by Descloux and colleagues describing suspected paradoxical undressing in a non-hypothermia fatality [1]. In this article, the authors reported a case of aneurysm-related spontaneous subarachnoid hemorrhage and concluded that the paradoxical undressing might be related to hemorrhage-induced dysregulation of the hypothalamic temperature-regulating centers. They postulate that hypothalamic injury associated with subarachnoid hemorrhage might induce—owing to a local inflammatory response and pyretic cytokines activity—fever with a feeling of warmth. As we have recently had a quite similar experience, we would like to share the findings of our case, which brings additional evidence of bizarre behavioral features including non-hypothermic undressing described in Descloux and colleagues’ article. Our case concerns a 65-year-old woman who was found dead and completely naked in the prone sleeping-like position in the basement area of her home (Fig.1a). Examination of the scene revealed scattered blood traces consistent with pools of blood originated from the remote position, below the entrance stairs leading to the basement. The floor around the body was littered with torn sheets of newspapers, items of the woman’s clothing, and black soil. There was an overturned flowerpot with black soil not far from the body in the basement’s front room. Upon evaluation of the body, multiple stigmata of blunt force trauma were identified, encompassed the following: a partial-thickness laceration in the left occipital region of the scalp, pronounced periorbital hematomas, and several minor hematomas and abrasions on the face. In addition, medium-sized contusions were identified on the left shoulder, the wrists, the left breast, and the right thigh. Numerous small-sized hematomas and abrasions were also present on the hands, elbows, and knees. Overall, the first impressions of the scene and the body highly suggested an intervention by a third party, forced entry, or a struggle. An urgent autopsy was performed to show left-sided skull base fracture involving the occipital bone, the petrous portion of the temporal bone, and the orbital plate. Examination of the brain showed acute subdural hematoma overlying cerebral convexities that frontally pooled on the brain base (Fig.1b), contrecoup extensive hemorrhagic contusions of the frontal and temporal lobes, and patchy subarachnoid hemorrhages with abundant blood filling the cerebral ventricles. Additional significant findings included severe cerebral atherosclerosis, approximately 1700 mL of semi-liquid black soil within the stomach (Fig.1c), and mildly aspirated gastric material into the upper respiratory tract. There were no autopsy signs related to hypothermia. Postmortem laboratory investigations including routine toxicology assays were diagnostically unrevealing. Based on the above and the extensive police investigation, it was concluded that all findings were consistent with an accidental fall from the basement’s entrance stairs, resulting in severe craniocerebral injury. In a debilitated state, it seems that the woman made repeated uncoordinated movements, crawled, and wandered within the basement area, leading to multiple self-inflicted blunt force injuries. Additionally, undressing actions coupled with a bizarre eating behavior * Martin Janík janik.mato@gmail.com

An atypical impaling injury of the iliofemoral region

A 46-year-old man with a history of chronic alcoholismwas found at his home address dead lying next to barrelsfilled with flammable liquids and an iron picket fence witha gate into a nearby a forest area (Fig. 1). Examination ofthe scene revealed blood traces with pubic hair coveringthe surface of some of the iron spikes of the gate (Fig. 2).An emergency doctor evaluated the decedent and describeda bizarre tear-like wound of the right femoral region.Because of the unclear cause-of-death determination, thebody was referred for a medico-legal autopsy evaluation.External examination of the adequately nourished,174 cm, 80 kg adult male showed an apparent, channel-like tissue defect of the right femoral region with evidenceof multiple blunt impacts, as well as superficial sharp forcewounds, over the entire anterior surface of the body(Fig. 3). On the right anteromedial aspect of the proximalportion of the femoral region there was an extensive(20 9 20 9 13 cm), obliquely oriented, and irregularlyshaped laceration (Fig. 4a). The wound path penetrated andtransected the quadriceps femoris muscle, the right femoralartery, and vein and entered the right inguinal region(Fig. 4b). The wound track then ascended through theretroperitoneal space and pierced the right psoas majormuscle. There was pronounced hemorrhage into the softtissues along the wound channel and around the pubicregion (Fig. 4c). In addition, four cm to the left of theabove laceration, another obliquely oriented skin perfora-tion was discovered measuring three cm in its largestdimension, that communicated with the impaling wound.The anorectal area was free of injuries. As indicated,multiple abrasions, contusions, and sharp force woundswere also found: on the ventral aspect of the upperextremities there were multiple, small, irregularly shapedcutaneous abrasions, and one deep cutaneous laceration inthe left cubital fossa; on the anterior aspect of the thoraxthere were two oval contusions and multiple longitudinalabrasions. External examination of the lower extremitiesalso disclosed multiple abrasions, contusions, and superfi-cial incised wounds. Internal examination did not show anyother injuries except those described. Toxicological eval-uation of blood revealed a blood alcohol level of 220 mg/dL. Further toxicological investigations of the blood andurine were negative.The cause of death was extensive external blood losscaused by transection of the right femoral artery and veinas a result of an atypical impaling injury.It appeared that the decedent, under the influence ofalcohol, tried to climb over the picket fence and wasaccidentally impaled through the right femoral region.Thus, the manner of death was classified as accidental. Weassume that repeated falls prior to the fatal event and theuncoordinated movements and striking of the body againstthe fence while impaled was a plausible explanation for themultiple blunt force injuries on the anterior aspect of thebody.DiscussionRare injuries, such as impalements are sometimesencountered at autopsy. Impaling injuries usually result