Michael Philip Burke

Comparison of antiepileptic drug levels in sudden unexpected deaths in epilepsy with deaths from other causes

Summary: Purpose: (a) To compare postmortem antiepileptic drug (AED) levels in patients with sudden unexpected death in epilepsy (SUDEP) with those in a control group of subjects with epilepsy. If SUDEP patients more frequently had undetectable or subtherapeutic AED levels, this would suggest that compliance with AED treatment is poorer in this group and that poor compliance is a risk factor for SUDEP. (b) To determine whether a particular AED was detected more commonly in the SUDEP group, suggesting that this AED is associated with a higher risk of SUDEP.

NONTRAUMATIC CLOSTRIDIAL MYONECROSIS

We describe three cases of nontraumatic clostridial myonecrosis seen at the Victorian Institute of Forensic Medicine. Nontraumatic clostridial myonecrosis is an uncommon and often fatal condition that requires immediate institution of appropriate medical and surgical therapy. It is most commonly caused by Clostridium perfringens and Clostridium septicum and is associated with gastrointestinal and hematologic malignancies, diabetes mellitus, and peripheral vascular disease. The clinical features include a rapidly evolving acute illness with severe pain, marked tachycardia, and brawny discoloration of the skin with bullae formation and crepitus, followed by hypotension and acute renal failure. Features at autopsy include reddish brown skin discoloration with bullae formation and necrotic skeletal muscle. Radiographs may be of use prior to the postmortem in detecting gas within the soft tissues. Gram stain and microbiologic culture are important in establishing a definitive diagnosis; although the major factors in suggesting the diagnosis are the recognition of the typical clinical history and macroscopic autopsy findings.

Fulminant Heart Failure Due to Selenium Deficiency Cardiomyopathy (Keshan Disease)

Selenium deficiency is a rare cause of cardiomyopathy that may be encountered by the forensic pathologist. Selenium deficiency is associated with a cardiomyopathy, myopathy and osteoarthropathy. In Asia and Africa, dietary selenium deficiency is associated with a cardiomyopathy known as Keshan disease and an osteoarthropathy called Kashin-Beck disease. Chronic selenium deficiency may also occur in individuals with malabsorption and long term selenium-deficient parenteral nutrition. Selenium deficiency causes myopathy as a result of the depletion of selenium-associated enzymes which protect cell membranes from damage by free radicals. We present a case of fulminant heart failure in a middle aged woman with a complex medical and surgical history including documented malabsorption and selenium deficiency. Pathological examination of the heart showed features consistent with Keshan disease.

INVOLVEMENT OF CODEINE IN DRUG-RELATED DEATHS

The incidence and role of codeine in drug-related deaths in Victoria was investigated over a 5-year period. There were a total of 107 cases involving codeine, representing 8.8% of all drug-related deaths in this period in Victoria. There were only six fatalities in which codeine was considered the major poison. The mean (+/- SD) concentration of codeine in femoral blood was 4.0 +/- 2.3 mg/L (range, 2.1-8.0 mg/L). The mean concentration of free codeine was 1.3 +/- 0.9 mg/L (range, 0.4-2.8 mg/L). The remaining 101 cases involved a combination of codeine and other drugs. The mean total codeine blood concentration was 1.8 +/- 3.3 mg/L (range, 0.04-26 mg/L), which was significantly lower than in those cases where codeine was the major poison (p < 0.002). The mean concentration of free codeine was 0.82 +/- 4.9 mg/L (range, 0.02-9.0 mg/L), which was not significantly different (p > 0.05) from the six codeine-only cases. The most common drugs found in this group, other than codeine, were acetaminophen (62%), diazepam (46%), salicylate (20%), and ethanol (25%). The association of other psychoactive drugs in these deaths made the contribution of codeine difficult to assess. Free codeine concentrations > 0.4 mg/L and total codeine concentrations > 2.0 mg/L may be sufficient to cause death in the absence of any other contributing factors.

Vertebral artery trauma

Vertebral artery trauma is not commonly seen by forensic pathologists. The experience of vertebral artery trauma at the Victorian Institute of Forensic Medicine (30 cases) is summarized and reviewed in the light of the literature. Causes of vertebral artery trauma are discussed. In case 1, the history and timing of the injury raise the question as to whether the vertebral artery dissection occurred before the episode of trauma, that is, was spontaneous or resulted from trauma. Moreover, underlying vertebral artery disease was present, raising the question as to how much trauma was needed to cause vertebral artery dissection. In case 2, despite the history of head/neck trauma, a neurosurgeon considered the subarachnoid hemorrhage was spontaneous, due most likely to ruptured saccular aneurysm or arteriovenous malformation. In case 3, the vertebral artery rupture was not diagnosed in the setting of multiple injuries. Case 4 is an example of prolonged survival with delayed onset of symptoms following vertebral artery trauma. Case 5 is an example of the not uncommon scenario of homicidal vertebral artery trauma accounting for basal subarachnoid hemorrhage, rapid collapse and death. Cases 1 and 4 indicate that relatively normal activity may be possible following vertebral artery trauma in some cases (at least for a time). Cases 1 and 4 are also examples of intracranial vertebral artery dissection.

Suicide Using Multiple Crossbow Arrows

We report the case of 44-year-old man who committed suicide using multiple crossbow arrows. The first arrow that he fired went between the left eye and nose and passed into a frontal lobe of the brain with no exit wound. He fired a second arrow that entered the palate and went through the brain but did not exit the skull. To the best of our knowledge, no cases of suicide using multiple crossbow arrows have previously been reported.

Postmortem extravasation of blood potentially simulating antemortem bruising

A case of florid postmortem extravasation of blood, potentially simulating antemortem bruising, is presented. A 98-year-old woman died in hospital, the cause of death being certified as congestive cardiac failure. After burial, it was apparent that the grave had been disturbed by crowbars and shovels. Exhumation was performed and autopsy revealed considerable apparent facial bruising as well as lacerations and fractures. There was no documentation by the medical or nursing staff of any injuries to the deceased preceding death. There was also no documentation of injury by the funeral directors. Subsequently, two men admitted to removing the body from the grave and mutilating it. Thus, what was apparently facial bruising was, in fact, postmortem extravasation of blood simulating antemortem bruising. The degree of extravasation was considered to be related to the severity of the injuries, loose subcutaneous tissues of the head and neck, and dependent position of the body upon return to the grave. This case demonstrates the degree of postmortem extravasation of blood that may occur in particular circumstances and may simulate antemortem bruising. In other circumstances, the postmortem extravasation of blood may well have led investigators to pursue inquiries regarding homicide.

Death due to intravenous leiomyomatosis extending to the right pulmonary artery

Sir, Intravenous leiomyomatosis is a rare benign uterine proliferation of smooth muscle involving myometrial veins that may extend into the inferior vena cava and right side of the heart. It may be a cause of significant morbidity and even mortality. A recent review of the literature revealed a total of 16 cases with intracaval and intracardiac extension. We present the case of a 47-yearold woman who presented with collapse, was considered clinically to have a pulmonary thromboembolus, for which she was anticoagulated, and who subsequently had a cardiac arrest and died. Intravenous leiomyomatosis extending into the right pulmonary artery was found at autopsy. The clinical and pathological features of intravenous leiomyomatosis are discussed. A 47-year-old woman was seen at a major teaching hospital with an episode of collapse in which she lost consciousness for approximately 5 min. The episode was diagnosed as a vasovagal incident and she was discharged. She re-presented to a different teaching hospital some 7 days later with a history of daily collapses associated with palpitations, tightness in the chest and throat, and acute shortness of breath. A ventilation perfusion scan suggested a pulmonary thromboembolus. The patient suffered a cardiac arrest with electromechanical dissociation whilst being prepared for an echocardiogram. Resuscitative measures were successful, and she was treated with anticoagulation therapy and thrombolysis and had an inferior vena caval filter inserted. An echocardiogram showed extensive thrombus within the inferior vena cava, right atrium and ventricle, and right ventricular outflow tract. A second cardiac arrest occurred from which she could not be resuscitated. The post-mortem examination revealed an encapsulated, cylindrical mass within the left common iliac vein extending through the inferior vena cava, right atrium, right ventricle and into the right pulmonary artery (Fig. 1, 2). No thrombus was seen within the deep calf veins. Within the uterus was a circumscribed mucoid tumour measuring 10 cm in maximum extent with a whorled trabecular cut surface. No necrosis or haemorrhage was seen in the tumour. The mass within the iliac vein was tracked back to myometrial veins in the region of the uterine tumour. The rest of the autopsy was normal. The provisional autopsy differential diagnosis was of a uterine leiomyosarcoma with extension into the myometrial and pelvic veins, inferior vena cava, right heart and pulmonary artery, or uterine leiomyosarcoma, with associated thrombosis of myometrial veins extending to pelvic veins and right pulmonary artery. Histological examination of the intravascular mass and the uterine tumour showed fasicles of bland spindle cells with features of smooth muscle and no evidence of atypia, mitoses or necrosis (Fig. 3). The spindle cells of both the intravascular mass and the uterine tumour stained strongly and diffusely for desmin and actin (Fig. 4). The features were consistent with intravenous leiomyomatosis. True intravenous leiomyomatosis, by definition, is seen outside the borders of a leiomyoma. Vascular invasion within a leiomyoma (leiomyoma with vascular intrusion)

Management of medicolegal natural deaths from hemopericardium or hemothorax using postmortem CT scanning

At the Victorian Institute of Forensic Medicine the forensic pathologist provides expert medical advice to the Coroner. Cases of natural death from hemopericardium and hemothorax are reasonably common in the forensic setting and are readily identifiable on postmortem CT (PMCT) scanning. The management of these cases raises interesting and challenging issues for the forensic pathologist. We present three cases in which PMCT angiography was useful in the management of each individual case and illustrate the potential of the technique in medico-legal death investigation.

Forensic pathology of fractures and mechanisms of injury : postmortem CT scanning

Introduction of Computed Tomography (CT) into Routine Forensic Pathology Practice Introduction The Victorian Model The Introduction of Postmortem CT Current Victorian Institute of Forensic Medicine (VIFM) System Decision-Making Process Cause of Death Family Contact Program CT in Trauma CT in Tissue Donation Errors in CT Diagnosis by Forensic Pathologists Proficiency Standard of Forensic Pathologists in Analysis of CT Images CT Education for Forensic Pathologists Deficiencies of CT in Routine Forensic Practice Audit Practical Issues in the Use of CT in Routine Forensic Practice Illustrative Case Studies Classification of Injuries Introduction Types of Skin Injury Other Skin and Soft Tissue Injuries Inflammation and Artifacts Postmortem Insect Predation The Forensic Importance of Skin Injuries Case Study Fractures Anatomy of Bone Fractures Pediatric Fractures Case Study Computed Tomography Introduction Basic Principles of CT Evolution of CT Scanning Reconstruction in CT Scanning The Detection of Foreign Materials by MDCT Practical Issues in CT Scanning Artifacts in CT Scanning Fracture Diagnosis Pediatric Fractures and CT Practical Guidelines for Forensic Pathologists Reading CT Scans Common Fracture Complications Seen on CT Head: Skull, Face, and Hyoid Bone Skull Facial Fractures Spine Vertebral Column Cervical Spine Thoracolumbar Spine Anatomy The Concept of the Three Spinal Columns Cervicothoracic Junction Thoracolumbar Spine Etiology Mechanism CT Diagnosis of Thoracolumbar Fractures Forensic Issues in Thoracolumbar Fractures References Chest Ribs Sternum Scapula Clavicle Upper Limbs Humerus Ulna Radius Carpal Bones Metacarpals and Phalanges Shoulder Dislocation Elbow Fracture Dislocation Wrist Fracture Dislocation Forensic Aspects of Upper Limb Injury Pelvis Anatomy Etiology Avulsion Fractures Pediatric Pelvic Fractures CT Diagnosis of Pelvic Fractures Forensic Aspects of Pelvic Fractures Case Study 1 Case Study 2 Case Study 3 Lower Limbs Femur Patella Tibia Fibula Forensic Issues in Fractures to the Lower Leg Fractures Involving the Foot Joint Injury to the Lower Leg The Use of CT in Difficult Forensic Cases Decomposed and Burnt Remains Falls Child Abuse Transportation Incidents Concluding Remarks Index