Saskia S. Guddat

Age‐dependent histoarchitectural changes in human lymph nodes: an underestimated process with clinical relevance?

Experimental evidence indicates that lymph nodes in humans undergo alterations during ageing. This is clinically important because of the crucial role of these organs in the immune system and their lymph reabsorption and drainage function. Although some age‐related changes in lymph node histoarchitecture have been described, they are seldom taken into account in traditional depictions of lymph nodes. Recently introduced clinical procedures, such as intranodal vaccination or lymph node transplantation, have demonstrated the need for an accurate knowledge of these degenerative processes. In this study, superficial inguinal lymph nodes were obtained from 41 deceased patients between 17 and 98 years old. To minimize immunological influences, such as chronic diseases, specimens were only obtained from forensic pathology autopsies. An immunohistochemical analysis was carried out, on the basis of which lymph node degeneration was scored according to the numbers of lymphocytes and high endothelial venules, and degree of fibrosis and lipomatosis. We observed an age‐dependent tendency towards the replacement of areas populated with diverse immune cells by connective tissue. Paradoxically, these changes were also detected in some of the nodes from younger age groups. In conclusion, lymph nodes can display degenerative changes that are mainly age‐related and often diverge from the common description found in textbooks. These alterations should be taken into account when dealing with lymph nodes diagnostically and therapeutically in clinical practice.

C-28/I2 and T/C-28a2 chondrocytes as well as human primary articular chondrocytes express sex hormone and insulin receptors--Useful cells in study of cartilage metabolism.

Sex hormones and insulin have been implicated in articular cartilage metabolism. To supplement previous findings on the regulation of matrix synthesis with 17β-estradiol and insulin and to find a possible model to study cartilage metabolism in vitro, we evaluated the expression of estrogen receptors α and β (ERα, ERβ), androgen receptor (AR) and insulin receptor (IR), in immortalized C-28/I2 and T/C-28a2 chondrocytes and in human primary articular cartilage cells. Chondrocytes were treated with increasing concentrations of 17β-estradiol, dihydrotestosterone or insulin and analyzed by means of RT-PCR and Western blotting. Both cell lines as well as human articular chondrocytes expressed ER α and β, AR and IR at mRNA and protein levels. In immortalized C-28/I2 chondrocytes, we showed that increasing concentrations of 17β-estradiol diminished the 95kDa band of IR. Since 17β-estradiol suppresses insulin-induced proline incorporation and type II collagen synthesis, as we have previously demonstrated, our findings give the first clue that 17β-estradiol may have negative effects on cartilage anabolism triggered by insulin during hormonal imbalance. Compared to chondrocytes cultured without hormones, immunostaining for ERα/β, AR and IR was decreased in both cell lines after incubation of cells with the receptor-specific hormones. It can be assumed that C-28/I2 and T/C-28a2 chondrocytes interact with the respective hormones. Our findings provide a reproducible model for investigating sex hormone and insulin receptors, which are present in low concentrations in articular chondrocytes, in the tissue-specific context of cartilage metabolism.

Megaesophagus and Possible Mechanisms of Sudden Death

Abstract:  Achalasia is a neurodegenerative condition characterized by esophageal dysmotility and megaesophagus. Two cases are reported that demonstrate unexpected deaths associated with previously unsuspected achalasia. Case 1: A 66‐year‐old woman was found dead at her home. At autopsy significant stenosing coronary artery atherosclerosis was found with cardiac failure. In addition, a striking finding was narrowing of the distal esophagus with marked proximal dilatation. The esophagus was completely filled with a large amount of soft masticated food and was bulging anteriorly, compressing the left atrium. Death was attributed to ischemic heart disease complicated by previously unsuspected achalasia. Case 2: An 84‐year‐old man collapsed and suffered a respiratory arrest while eating. Internal examination revealed narrowing of the cardioesophageal junction with marked proximal dilatation of the esophagus that contained approximately 50 mL of soft semi‐fluid masticated yellow food paste. Fragments of yellow masticated food remnants were present in upper and lower airways but not within the stomach. There was a history of dementia with symmetrical cerebral ventricular dilatation found at autopsy. Death was attributed to food asphyxia complicating previously unsuspected achalasia with dementia. Megaesophagus may, therefore, be a significant finding at autopsy that may either be a primary cause of unexpected death or else may exacerbate or compound the effects of pre‐existing underlying disease.

Multiple injuries in suicide simulating homicide: Report of three cases

Multiple inflicted injuries in traumatic deaths usually indicate homicide. Three cases are reported where homicide was initially suspected due to findings at the death scene and the apparent nature of the injuries however, after investigation, involvement of any other individuals in the deaths could be excluded. Case 1: A 52-year-old male was found with multiple stab wounds. At autopsy, 36 stab wounds were identified, the majority of which were superficial. Only two stab wounds had penetrated deeply. Case 2: A 19-year-old female was found with three gunshot entry wounds to the right temple and a .22 calibre automatic rifle resting across her lap. Case 3: A 47-year-old female was found with numerous haematomas and three deep head wounds in keeping with trauma from impact with a blunt object. A high level of clozapine was detected on toxicological analysis of blood and a history of schizophrenia was reported. Although multiple self-inflicted wounds are most often caused by sharp objects such as knives, on occasion multiple gunshot wounds and rarely, blunt trauma may also be encountered. Careful integration of scene and autopsy findings may be required to avoid misinterpretation of the circumstances and manner of death.

Fatal spontaneous subdural bleeding due to neonatal giant cell hepatitis: a rare differential diagnosis of shaken baby syndrome

A 7-week-old girl showed vomiting after feeding, facial pallor, loss of muscle tone and respiratory depression. An emergency doctor performed successful resuscitation and after arrival in hospital, cranial ultrasound showed left-sided subdural hemorrhage, cerebral edema with a shift of the midline, and a decrease in cerebral perfusion. Ophthalmologic examination showed retinal hemorrhage. In view of this, the doctors suspected shaken baby syndrome and approached the parents with their suspicions, but they denied any shaking or trauma. Despite surgery for the subdural hemorrhage the girl died a few hours later with a severe coagulopathy. Autopsy verified subdural hemorrhage, cerebral edema and retinal hemorrhage, but also revealed intact bridging veins and a lack of optic nerve sheath hemorrhage, therefore shaken baby syndrome could not be proven by autopsy. Histological examination showed severe neonatal giant cell hepatitis as the cause of the severe coagulopathy and the associated spontaneous subdural bleeding. Neonatal giant cell hepatitis may be responsible for unexpected deaths in infancy and, although rarely associated with subdural bleeding, must be considered as a potential differential diagnosis of shaken baby syndrome.

Abschiedsbrief auf dem Körper nach genitaler Selbstbeschädigung

ZusammenfassungDer Suizid eines 29-jährigen Mannes, der sich atypisch erhängte, nachdem er sich zuvor selbst partiell zirkumzidiert hatte, wird beschrieben. Dieser stand vermutlich im Zusammenhang mit der bei dem Suizidenten langjährig bestehenden, aktuell akut exazerbierten hebephrenen Schizophrenie mit halluzinatorisch-wahnhaften Symptomen. Im Rahmen der Obduktion fielen neben den Befunden des atypischen Erhängens auf den gesamten Körper mit Filzstift aufgemalte, teils auch oberflächlich eingeritzte abschiedsähnliche Zeilen und Satzfragmente auf. Die Suizidalität wurde hier in wahnhafter Form thematisiert. Dies wurde von rechtsmedizinischer Seite in engem zeitlichen Zusammenhang mit dem Tod gesehen. Die außergewöhnlichen Befunde werden in Ergänzung zum Schrifttum vorgestellt und diskutiert.AbstractThe case of suicide of a 29-year-old schizophrenic male who hanged himself in an atypical manner following partial circumcision is described and discussed. This was probably in the context of a long-lasting but currently acute exacerbated hebephrenic schizophrenia with hallucinatory-delusional symptoms. At autopsy, apart from the signs of atypical hanging, sentences and fragments of sentences resembling those of a suicide note were found written with a felt-tip pen and also superficially scratched on the skin over the entire body. The sentences were on the subject of suicide in a delusional form and were thus considered as having been written in close chronological connection with death. The unusual findings are presented and discussed as a supplement to the current literature.

Calcified myocardial necrosis in pediatric patients after cardiopulmonary resuscitation

We report three autopsy cases of wide-spread myocardial necrosis with calcification in pediatric patients after temporary generalized hypoxia and initially successful cardiopulmonary resuscitation, but subsequent in-hospital death. Autopsy and histological workup in all three cases showed multiple circumscribed calcified and necrotic areas in progressive stages of organization within the myocardium. We conclude that these macro- and microscopic autopsy features appear to be related to reperfusion injuries in children as a consequence of hypoxic-ischemic changes occurring in the peri- and postresuscitation period.

Vertebral column kyphoscoliosis and unexpected death

A case of spontaneous gastric perforation is reported in a 75-year-old woman due to massive hemorrhaging from a benign gastric ulcer. Blood was prevented from leaving the stomach due to posterior displacement and rotation of the stomach associated with marked underlying vertebral column kyphoscoliosis. Significant deformity of the spine had caused malpositioning of the stomach as a result of the abnormal shape of the peritoneal and chest cavities. This in turn had led to mechanical obstruction and prevented egress of blood arising from a bleeding arteriole in the base of a chronic gastric ulcer. Rapid distension had resulted from the inability to spontaneously decompress the stomach, which in turn had led to rupture.

Verbluten in den Magen-Darm-Trakt aus einer Aortenprothese

ZusammenfassungIn der rechtsmedizinischen Sektionspraxis findet sich Verbluten als Todesursache in 5–10% der Fälle. Im vorliegenden Fall wurde ein signifikanter Blutverlust in den Magen und in das Duodenum festgestellt. Das Blut im Duodenum und sich anschließenden Dünndarmanteilen war geronnen und glich einem Ausgusspräparat der Darmschleimhaut, sodass von einer Sickerblutung ausgegangen wurde. Bei der Suche nach der Blutungsquelle fand sich ein intraduodenaler Verlauf eines aortobifemoralen Bypasses bei arteriosklerotisch bedingtem Verschluss beider Beckenschlagadern. Das Material des Bypasses war aufgrund der Einwirkung der Verdauungssäfte verfärbt und stark brüchig; als Blutungsquelle fand sich ein Einriss der Gefäßprothese. Da sich am Übergang der Prothese zur Darmschleimhaut Nahtmaterial befand, wurde zunächst von einem ärztlichen Kunstfehler ausgegangen. Bei dem intraduodenalen Verlauf des Bypasses handelte es sich jedoch um eine aortoenterale Fistel, eine seltene, jedoch ernste Komplikation der Aortenchirurgie.AbstractIn 5–10% of medico-legal autopsies exsanguination is the actual cause of death. In the case reported here, a significant loss of blood into the stomach and duodenum occurred. The blood in the duodenum and the adjacent parts of the small intestine was coagulated and gave the impression of the relief of the intestinal mucosa and therefore it was assumed that the blood had originated from a slowly bleeding source. While looking for the source of bleeding, an intraduodenal course of an aortobifemoral bypass with arteriosclerotic occlusion of both pelvic arteries was found. The material of the bypass was discolored and extremely fragile due to exposure to the digestive juices and a tear in the material was found as the source of bleeding. As suture material was found at the transition of the prosthesis with the intestinal mucosa, medical malpractice was initially suspected, but the intraduodenal course of the bypass was found to be due to an aortoenteric fistula, a rare but severe complication of aortic surgery.

Tödliche Kohlenmonoxidintoxikation bei einem Schwarzafrikaner

ZusammenfassungDie Inhalation von Kohlenmonoxid (CO) wird nicht wahrgenommen, da es sich hierbei um ein farb- und geruchsloses Gas handelt. Daher werden neben CO-Intoxikationen aus suizidalem Anlass auch häufig akzidentielle Vorfälle beobachtet. Durch die hohe Hämoglobin- (Hb-)Affinität des CO kann es, bei ausreichender Gaskonzentration in der Luft, innerhalb weniger Minuten zum inneren Ersticken kommen. Daher ist das Erkennen einer CO-Intoxikation bei der äußeren Leichenschau anhand der klassischen Merkmale wie kirschrote Leichenflecke, hellrosa imponierende Augenbindehäute und Fingernagelbetten und einer verzögerten Lösung der Totenstarre sehr wichtig, um einen adäquaten Selbstschutz (Öffnen von Fenstern, Verlassen des Fundorts) und Fremdschutz (Evakuierung anderer Bewohner, Detektion der CO-Emissionsquelle) einleiten zu können. Berichtet wird von einem jungen Schwarzafrikaner, der während eines Besuches bei seinem Bruder einen epileptischen Anfall erlitt. Als für den Krampfanfall ursächlich wurde im Krankenhaus ein Hypophysenadenom diagnostiziert. Zwei Tage nach der Entlassung aus dem Krankenhaus wurde der Mann tot aufgefunden. Bei dem Toten fehlten die klassischen äußeren Merkmale der CO-Intoxikation bzw. wurden erst im Vergleich mit einem anderen toten Schwarzafrikaner augenfällig. So wurde die todesursächliche CO-Intoxikation erst während der Obduktion erkannt.AbstractInhalation of carbon monoxide (CO) is not perceptible because CO is a colourless and odourless gas. Therefore, not only suicides but also accidental CO intoxication can often be observed. Due to its high affinity to haemoglobin, CO can lead to internal asphyxia within a few minutes depending on the concentration in air. Therefore, it is very important to recognise a CO intoxication on the basis of the typical criteria seen at external examination of a body, such as cherry-red livor mortis, light pink conjunctivae and fingernails in order to initiate adequate self-protection (opening of windows, leaving death scene) and protection of others (evacuation of other occupants, detection of the CO source of emission). The present case report concerns a young African male who had an epileptic seizure during a visit to his brother. In hospital, a pituitary adenoma was diagnosed as the cause of the seizure. The young man was found dead 2 days after leaving hospital. He lacked the typical external criteria or they first became obvious after comparison to another dead black African and the lethal CO intoxication was first recognised only at autopsy.