Academic Forensic Pathology

Pathologists are faced with a variety of problems when considering placental tissue in cases of stillbirth. It is recognized that there are changes which occur following fetal demise and which can complicate the assessment and may coexist with other morphological changes. It is recognized that up to 25% of stillbirths may have a recognizable abnormality causing fetal demise. A systematic review of placental tissue allows many of these disorders to be identified. This review considers macroscopic and microscopic features of placental pathology in stillbirth together with clinicopathological correlation. Stillbirth definitions, general aspects of macroscopic assessment of placentas, placental changes after fetal demise, and some recognizable causes of fetal demise are considered.

Melatonin is an endogenous hormone that regulates sleep patterns. It is available in varying formulations and dosages and is marketed as a natural substance that can alleviate insomnia. Recent news reports indicate that melatonin has been administered without appropriate authorization in daycare settings. Even though lethal outcomes have not been solely attributed to exogenous melatonin overdose, it has been relevant to select police and postmortem investigations.

A quantitative liquid chromatography-tandem mass spectrometry (LC-MS/MS) assay was developed for the analysis of biological specimens. Results of 22 positive blood samples were evaluated based upon gender, age, and melatonin concentration from cases submitted by clinical, police, and death investigation agencies. Two cases are described. In Case 1, a 9-month-old was found unresponsive after cosleeping with a sibling. Allegations included exposure to an unspecified pesticide and dextromethorphan, and consumption of half a cigarette. There was admitted use of melatonin. Melatonin was quantified in blood and gastric fluid at concentrations of 13 ng/mL and 1200 ng/mL, respectively. In Case 2, a 13-month-old was found nonresponsive in a shared room. Melatonin was found within some of the sippy cups. The infant was extremely warm to the touch. Resuscitative efforts were unsuccessful and death was pronounce3d. Analysis showed a result of 210 ng/mL in blood.

The presented quantitative LC-MS/MS method can successfully be applied to evaluate exposure to exogenous melatonin. Toxicology testing can assist in the investigation of these case types by substantiating the purposeful administration of melatonin.

Acute subdural hemorrhage is typically associated with a history of head trauma, and as such it is a finding with significant potential medicolegal consequences. In this article, 37 adult and post-infantile pediatric sudden death autopsy cases with small volume (“thin film” or “smear”) acute subdural hemorrhage are presented—in which there is either no further evidence of head trauma or only features of minor head injury. The possible underlying pathophysiological mechanisms are explored, and it is concluded that a common thread in many of these cases is likely to have been cranial venous hypertension at around the time of death. These findings may have implications in instances where small volume subdural hemorrhage is identified in the absence of other evidence of significant head injury.

There has been a growing opioid crisis in the United States and Canada. The aim of this study was to analyze trends in opioid-related deaths from the Eastern Ontario Regional Forensic Pathology Unit so that prevention strategies for these deaths can be developed. The analyses included examining the opioids involved and demographic characteristics of the individuals in these deaths so that possible risk factors for opioid-related deaths could be identified.

A retrospective cross-sectional analysis of the full autopsy and toxicology data between 2011 and 2016 was conducted. Trends regarding the opioids involved in the death, all opioids reported in the toxicology reports and certain nonopioid drugs reported in the toxicology reports were examined. The distribution of opioid-related death by age-group and manner of death was also conducted.

Two hundred seventy-four opioid-related deaths met the inclusion criteria and were examined. The majority of individuals overdosing were male. The most frequent age range for opioid-related deaths was 45 to 54 years with increasing deaths among individuals aged 55 years and older over the period studied. Fentanyl was responsible for most deaths overall when single or multiple opioids were involved. However, hydromorphone involvement was the only opioid to have a statistically significant increase over the time period. Analysis of nonopioid-related drugs revealed extensive use of antidepressants, benzodiazepines, and their metabolites. Accident was the most common manner of death throughout all age groups except for those aged 65 years or older, where suicide was most common.

Cor pulmonale (right heart failure) due to microscopic pulmonary tumor emboli (MPTE) can arise from a variety of malignancies including breast, lung, and liver and carries significant morbidity and mortality. Tumor cell aggregates spread hematogenously to the lungs and occlude small pulmonary vessels leading to pulmonary hypertension through either a mechanical process or inducing vascular remodeling as a downstream result of interactions between the embolus and the vessel wall. Its presentation includes unexplained dyspnea, hypoxemia, tachycardia, pulmonary hypertension, right heart failure, and in some cases sudden death. The symptoms may suggest the more common entity of pulmonary thromboembolism, particularly in the setting of previously known metastatic cancer; however, computed tomography scans may appear normal and ventilation-perfusion scans which are the preferable diagnostic modality are not always ordered. In most cases of MPTE, the presentation reflects metastasis of an already known and advanced tumor, but, in rare cases, it may be the primary manifestation of an occult malignancy. We present here 2 unique cases of MPTE in women with occult cervical cancer. In both cases, the malignancy was discovered and diagnosed at autopsy. Microscopic pulmonary tumor emboli can be easily overlooked, and therefore, forensic pathologists and other death investigators should be aware of it and trained to at least consider the possibility in appropriate situations. Thorough microscopic examination of apparently normal tissues may be necessary, particularly in cases of unexplained right heart failure and sudden death, even if the decedent has few or no identifiable risk factors for cancer.

Carbon dioxide (CO₂) therapy is the subcutaneous or transcutaneous administration of CO₂ for therapeutic purposes. Carbon dioxide therapy is used for localized lipolysis, to treat chronic skin conditions, and is a safe treatment. Full-body CO₂ baths are offered in European spa centers, in which the clients are placed into full body bags infused with CO₂ at an optimal concentration range between 1000 and 1400 mg/L (516 000-722 500 ppm). Commercially manufactured, air-tight bags and accompanying apparatus designed to provide CO₂ baths can be purchased for home use. Few human CO₂-related deaths have been reported. They have been mostly accidental, consisting of persons trapped in a closed environment in the presence of “dry ice” or solid CO₂. There have been no reported deaths of a human undergoing a CO₂ therapy at home. We present a case of a middle-aged male found at home completely inside an air-sealed bag wrapped tightly around his body. The bag was connected to a working pump and a CO₂ gas tank. The pump was connected through an inflow and outflow circuit to the bag. The inflow tubing for CO₂ gas delivery was partially disrupted, while the outflow tubing was intact. The autopsy and toxicology were unremarkable. The cause of death was determined to be asphyxia by vitiated atmosphere as evident by the displacement of oxygen by CO₂ and low pressure created inside a “CO₂ therapy bath.” The manner of death was accidental.

Sarcoidosis is a noncaseating granulomatous disease of unknown etiology. The incidence is 11 per 100 000 white individuals and 34 per 100 000 black individuals. Cardiac involvement is seen in 2% to 5% of patients with systemic sarcoidosis and is often clinically undetected. This may be due to relative rarity of cardiac involvement, variability in presentation, or that there are no good clinical criteria for the diagnosis of cardiac sarcoidosis. Patients may be totally asymptomatic or have heart block, myocardial infarctions, heart failure, or sudden cardiac death, which may be due to involvement of the conduction system by sarcoidosis. We present a case of a 54-year-old black male with hypertension and hyperlipidemia. Prior to his death, he was witnessed to suddenly stand up, grab his chest, and collapse. His clinical cause of death was hypertensive and atherosclerotic cardiovascular disease. A retrospective review of autopsy cases over the last 23 years (1995-2018) at our institution (n = 6900) was undertaken. This case illustrates a rare disease and highlights the importance of complete autopsy even in patients who might otherwise be signed out as an external exam or records review only.

Takayasu arteritis (TA) is a rare idiopathic vasculitis of large blood vessels. Prevalence is highest in Japan, with predominance in young females. Classic signs and symptoms include limb claudication, decreased/absent distal pulses, vascular bruits, and blood pressure discrepancy between arms. Without treatment, progression leads to mural fibrosis, stenosis, hypertension, thrombus formation, and ischemic changes of surrounding tissue. Takayasu arteritis is usually a clinical and radiographic diagnosis and has a low mortality rate with effective treatment. Here, we present an unexpected case of TA in a 19-year-old black male diagnosed at autopsy. No suggestion of vasculitis was noted during antemortem workup. Takayasu arteritis may be encountered in the forensic setting in cases of sudden death in a young person, especially in the context of an atypical demographic.

Vitamin C (ascorbic acid) has long been known to have antioxidant properties, with associated claims that it can boost the immune system, fight off infection, and help in the treatment of cancer. Similar to many other over-the-counter and herbal medicines, vitamin C can cause potential side effects with significant morbidity and rarely mortality. We discuss a case of an elderly woman with metastatic adenocarcinoma of the lung that was treated with several rounds of allopathic chemotherapy; however, treatment was stopped because of worsening quality of life and disease progression. She was treated with 10 courses of intravenous high-dose vitamin C at a local homeopathic medical center as an alternative treatment method. Five days after the last vitamin C administration, she was admitted to an allopathic hospital due to acute renal failure and oliguria culminating in a myocardial infarct due to underlying atherosclerotic disease. Workup revealed dehydration secondary to poor oral intake and acute renal failure which was clinically concerning for calcium oxalate– induced kidney injury. At the time of autopsy, in addition to her widely metastatic adenocarcinoma and myocardial damage, hyperoxalosis of the kidney with acute kidney injury was present. Hyperoxalosis of the kidney is a documented phenomenon related to administration of intravenous and oral vitamin C at superphysiologic doses as recommended by some natural and homeopathic practitioners and is, therefore, a significant complication of treatment. This case highlights the renal complications of supertherapeutic vitamin C administration and the associated morbidity which can contribute to death.

Acute intravascular hemolysis is a rare and often lethal complication of Clostridium perfringens septicemia.Clostridium perfringens is an anaerobic, gram-positive spore-forming rod which is commonly implicated in cases of food poisoning, gas gangrene, and severe hemolytic anemia in humans via the alpha-toxin (phospholipase C). We report an interesting and rare case of a 72-year-old woman who developed massive intravascular hemolysis secondary to C perfringens bacteremia in the setting of poorly differentiated high-grade endometrial malignancy.