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To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.forsciint.2008.03.021 Byline: E. Turillazzi (a), P. Greco (b), M. Neri (a), C. Pomara (a), I. Riezzo (a), V. Fineschi (a) Keywords: Latex allergy; Caesarean section; Fatal case; Anaphylactic shock; Tryptase; IgE test Abstract: The true incidence of anaphylactic latex reactions and their associated morbidity and mortality remain poorly defined. It is noteworthy that a number of groups of individuals are at risk for anaphylactic reactions to latex during surgical and medical procedures; one of these groups is represented by the obstetric and gynaecologic population. A case of unrecognized first anaphylactic reaction to latex in a pregnant woman patient who underwent a caesarean section is presented. The diagnosis of latex allergy was missed and the following day the woman underwent a surgical re-exploration complicated by fatal cardiovascular arrest. At post-mortem examination, pulmonary mast cells in the bronchial walls and capillary septa were identified and a great number of degranulating mast cells with tryptase-positive material outside the cells was documented. A post-mortem latex-specific IgE test showed a high titre (14.00U/I). Latex-induced fatal anaphylactic shock was recorded as the cause of death. This case highlights some of the practical difficulties in the initial diagnosis and subsequent investigation of fatal anaphylactic reaction during anaesthesia. Anaphylaxis is often misdiagnosed because many other pathologic conditions may present identical clinical manifestations, so anaphylactic shock must be differentiated from other causes of circulatory collapse. Although latex allergy usually has a delayed onset after the start of the surgery and most often a slow onset too, it should be always suspected if circulatory collapse and respiratory failure occur during surgery, even if the patient does not belong to a risk group; in the presence of identified risk factors for latex allergy a well-founded suspicion must be stronger, leading to an immediate discontinuation of the potential trigger. Author Affiliation: (a) Department of Forensic Pathology, University of Foggia, Ospedale Colonnello D'Avanzo, Via degli Aviatori 1, 71100 Foggia, Italy (b) Department of Obstetrics and Gynaecology, University of Foggia, Ospedali Riuniti, Via L. Pinto 1, 71100 Foggia, Italy Article History: Received 8 August 2007; Revised 29 February 2008; Accepted 19 March 2008

Dogs are commonly used to detect explosives, narcotics, and other illegal materials. In the forensic setting, cadaver dogs are trained to detect and locate concealed human remains or fluids due to the high sensitivity and selectivity of the canine olfactory system and the relative ease with which dogs can be trained and handled. The need for international and scientifically validated standards has long been outlined by the literature. It is important, therefore, to establish the reliability of the handler/dog team. Our study aimed to detect the real effectiveness of dogs trained to locate human cadaveric blood in very low concentrations, through an optimized and rigorously controlled design which would rule out any possible sources of bias. The study was designed to determine the dogs' olfactory sensitivity to human cadaveric blood and how this capacity might change as the dilution of blood increases from pure blood to very low concentrations. The further step was to examine the dogs' ability to discriminate among target (human cadaveric blood) and non-target (confounding substances) odors (discriminative capability). Our results revealed that well trained dogs were able to detect human cadaveric blood samples even when very low concentrations of blood were stored in the tubes, showing high levels of olfactory sensitivity and to discriminate the target odor even when the non-target odor was orders of magnitude higher in concentrations. Although our results are based only on two dogs, the procedure we used may provide a comprehensive answer to the need for a scientifically unassailable tool for quantifying and objectifying the performance of well-trained specific search dogs in detecting human cadaveric blood traces., (Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.)

The aim of the paper was to perform a chronological assessment of the phenomenon of delayed rupture of the spleen, to assess the phenomenological order about the sub-capsular hematoma transformation to determine the causal relationship with trauma as hypothetical cause of death. 80 cases of blunt trauma with splenic capsular hematoma and subsequent rupture of the spleen were evaluated: 38 had an acute rupture of the spleen, 42 presented a break in days or weeks after the traumatic injury. Time between the traumatic event and delayed rupture of the spleen is within a range of time from one day to more than one month. Data recorded included age, sex, type of trauma, injury severity score, grade of splenic injury, associated intra-abdominal injuries, pathologic specimen evaluation. Immunohistochemical investigation of perisplenic hematoma or laceration was performed utilizing polyclonal antibodies anti-fibrinogen, CD61 and CD68, and showed structural chronological differences of sub-capsular hematoma. Expression of modification and organization of erythrocytes, fibrinogen, platelets and macrophages provides an informative picture of the progression of reparative phenomena associated with sub-capsular hematoma and subsequent delayed splenic rupture. Sub-capsular splenic hematoma dating, which we divided into 4 phases, is representing a task in both clinical practice and forensic pathology., (Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.)

The identification of gunshot residues (GSRs) on human body in firearm related fatalities may be essential for the evaluation of gunshot wounds and for the analysis of the shooting distance. The present study introduces the elemental analysis of the GSRs by inductively coupled plasma atomic emission spectrometer analysis (ICP-AES) performed on skin samples. ICP-AES was used to increase the accuracy of the analysis in gunshots fired from long and medium distance. In this experimental study, a series of 50 test shots have been performed in an open space with lateral wind protection. As target we used pig skin cut into 20 cm × 20 cm squares. The firing distances were 0.2, 5, 50, 100 and 150 cm. To exclude environmental contamination, each skin sample was carefully washed with deionized water and dried at room temperature in a closed box before the shooting test. We choose 9×21 and the 7.65 mm calibers handguns, loaded with different ammunitions. At ICP-AES analysis a clearly decreasing trend in the quantity and the concentration of the different elements of GSR by increasing the firing distance for both the guns used in the test was evident for every portion of skin samples analyzed. The analytical results obtained by ICP-AES confirmed very high concentrations of Pb, Sb, and Ba in the close-range shots and low concentrations of these particles in the intermediate and distant shots. In particular, the concentration of Sb, Ba, and Pb was significantly different from loose values when the firing distance was 100-150 cm for both the 9×21 and the 7.65 mm calibers., (Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.)

The accuracy of antemortem diagnosis of pulmonary embolism is within the range of just 10-30%, so representing one of the most frequent missed diagnosis in sudden, unexpected death. We describe 43 fatal cases of pulmonary embolism as confirmed by post-mortem examination. The aim of our study was to verify the systematic search for the most common genetic thrombophilias (Factor V Leiden (G1691A) and FII (G20210A) gene variants) and dating the thrombus. As a whole, 41 patients (95.3%) had at least one risk factor. Pre-existing symptoms are described just before fatal embolism in 18 (41.9%) out 43 patients. In 18 out of 43 (41.9%) it was not possible to find the thrombotic site. In 24 out of the remaining 25 cases the involvement of the deep veins of one leg was shown; in 1 case the thrombus was localised in the inferior caval vein. 10 (41.7%) were iliac vein thromboses, 7 (29.1%) femoral, 2 (8.3%) popliteal, 3 (12.6%) posterior-tibial, 1 (4.1%) anterior-tibial and 1 (4.1%) peroneal vein thromboses. In our cohort of patients, 4 (10%) out of 40 cases carried the 20210A prothrombin gene variant in heterozygosis. One (2.5%) out of 40 carried the Factor V Leiden (G1691A) gene variant in heterozygosis. Patients carrying these gene variants in homozygosis or carrying both were not present in our case-series. We strongly underline the relevance of a complete methodological approach, integrating clinical data by means of autopsy findings and histological study. On the contrary, investigating common inherited thrombophilia is not warranted., (Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.)

Neurosarcoidosis carries a mortality of 10%, over twice that of sarcoidosis overall, although it has been rarely reported as a cause of sudden death. The current evidence suggests that sarcoidosis results from an enhanced immune reaction to a variety of antigens, non-self or self which causes CD4 (helper-inducer) T-cell accumulation with a ratio of helper-inducer T cells to suppressor-cytotoxic T cells usually high in affected organs, activation and release of inflammatory cytokines, and formation of granulomatous lesions. Numerous cytokines and other mediators are produced by both activated macrophages and T lymphocytes bearing the CD4-helper phenotype during the granuloma responses. A number of data suggest that interferon-gamma (IFN-gamma) and cytokines such as TNF-α, IL-2, and IL-18 play a critical role in the formation of granulomas. In this article, we describe the clinical and pathological characteristics of a patient who suddenly died due to acute respiratory failure. Neurosarcoidosis with massive and extensive involvement of the brainstem was established as the cause of death. Western blot analysis in the patient demonstrated the TNF-α presence as a 51-kDa protein in the brain tissue. The immunohistochemical analysis showed a poor positiveness for CD4 in all samples around the granulomas, as well as moderate positiveness for CD8, CD15, and CD20; CD45 and CD68 showed a strong positiveness in all the brain samples. Histological findings, immunohistochemical analysis, and proteomic studies addressed the diagnosis of neurosarcoidosis with involvement of the nucleus of the solitary tract in the brainstem and central hypoventilation as the cause of death., (Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.)

Stress-induced cardiomyopathy (SICM) is characterized by transient systolic dysfunction of the apical and/or midventricular myocardial segments in the absence of obstructive coronary artery disease and is unique in that it can manifest itself after acute emotional stress. Excessive amounts of catecholamines released from sympathetic nerve endings as well as from the adrenal medulla under stressful conditions are considered to produce intracellular Ca(2+) overload and cardiac dysfunction through the β(1)-adrenoceptor signal transduction pathway. We describe the clinical and pathomorphological findings in two stress-induced cardiomyopathy fatal cases. Levels of catecholamines and their metabolites in urine samples were assessed too. Morphological patterns seen in SICM result from the complex interplay between sympathetic innervations, β-receptor density and function and catecholamine sensitivity., (Copyright © 2010 Elsevier Ireland Ltd. All rights reserved.)

Fat embolization following major trauma is reported to be a quite common event, while the clinical fat embolism syndrome (FES) seems to be a much rarer event. Fat embolism occurs in 2 up to 23% of patients with isolated femoral shaft fractures. This complication appears to be related not only to the fracture, but also to the timing of stabilization. Sometimes it may be impossible to perform histochemical reactions on frozen sections to detect fat emboli thus confirming diagnosis or suspicion of FES. The finding of fibrinogen and platelets around the apparently empty spaces in the blood vessels has been proposed as an evidence for vital reaction due to either a vital cellular reaction or a flotation mechanism, thus supporting an intravital fat embolism. We report a fatal case due to fat embolism syndrome in a young man hospitalized for a right femoral neck fracture, treated with orthopaedic surgery and subjected to an intra-surgery transesophageal echocardiography that revealed embolization of numerous highly echogenic bodies. Four hours after the onset of clinical symptoms the man died from respiratory failure. The autopsy confirmed the clinical diagnosis of fat embolism syndrome. The histological examination revealed a large amount of fat globules in cerebral and pulmonary arteries and in glomerular capillaries, as well as fibrin and platelet deposition confirmed by the positive results by Sudan III staining for lipids and immunohistochemistry with anti-CD61 and anti-fibrinogen antibodies. The quantitative classification of fat embolism was grade 3 of Sevitt's classification or grade 4 of Fineschi's quantification, according to the current quantitative microscopic methods used for grading fat embolism in pulmonary tissue., (Copyright © 2010 Elsevier Ireland Ltd. All rights reserved.)

In most deaths caused by explosive, the victim's body becomes a depot for fragments of explosive materials, so contributing to the collection of trace evidence which may provide clues about the specific type of device used with explosion. Improvised explosive devices are used which contain "homemade" explosives rather than high explosives because of the relative ease with which such components can be procured. Many methods such as chromatography-mass spectrometry, scanning electron microscopy, stereomicroscopy, capillary electrophoresis are available for use in the identification of explosive residues on objects and bomb fragments. Identification and reconstruction of the distribution of explosive residues on the decedent's body may give additional hints in assessing the position of the victim in relation to the device. Traditionally these residues are retrieved by swabbing the body and clothing during the early phase, at autopsy. Gas chromatography-mass spectrometry and other analytical methods may be used to analyze the material swabbed from the victim body. The histological examination of explosive residues on skin samples collected during the autopsy may reveal significant details. The information about type, quantity and particularly about anatomical distribution of explosive residues obtained utilizing confocal laser scanning microscope (CLSM) together with inductively coupled plasma atomic emission spectrometer (ICP-AES), may provide very significant evidence in the clarification and reconstruction of the explosive-related events., (Copyright 2009 Elsevier Ireland Ltd. All rights reserved.)

Emotional, physiological and physical stress is associated with increased rates of cerebrovascular events and sudden deaths. The pathophysiology of stress-induced cardiomyopathy is not well understood. Proposed mechanisms for catecholamine-mediated stunning in stress cardiomyopathy include epicardial vasospasm, microvascular dysfunction, hyperdynamic contractility with midventricular or outflow tract obstruction, and direct effects of catecholamines on cardiomyocytes. Studies show evidence of significant heritable influences on individual responses to adrenergic stimulation. Data from such studies may be of help for a more accurate comprehension of clinical and morphological alterations of the heart. Irrespective of the cause, patients with the classic stress-induced cardiomyopathy morphology deserve special attention because this extensive distribution of wall motion abnormalities has implications for potential associated complications. Cardiac response may be significantly coupled to genetic differences at candidate loci that encode components of catecholamine biosynthesis, storage, and metabolic pathway. Given the role of the sympathetic nervous system in responses to acute stress, it is reasonable to explore whether genetically determined alterations in catecholamine system functions contribute to acute and chronic cardiovascular disorders such as stress-induced cardiomyopathy., (2009 Elsevier Ireland Ltd. All rights reserved.)

A rare case of cardiac failure due to hypertensive crisis in pheochromocytoma in a 25-year-old young man is presented. In the Emergency Department the patient complained of persisting headache and vomiting; he was distressed but fully alert, his heart rate was 110 b/min and blood pressure 180/80 mmHg. Few hours after admission, the clinical course suddenly got worse with signs and symptoms of fatal cardiac shock (dyspnoea, cyanosis, pulmonary oedema, hypocontractility of left ventricle). Autopsy revealed a large tumour of the left adrenal gland. Histological examination confirmed macroscopic suspicion of pheochromocytoma. Catecholamine serum levels were analysed by high pressure liquid chromatography (HPLC) with electrochemical detection. The urine contained 35 microg/24 h norepinephrine and 184 microg/24 h epinephrine (normal range < or = 64 and < or = 36 microg/24 h respectively). These laboratory findings impressively demonstrate that the tumour was active, secreting high levels of epinephrine. Cardiac failure due to an acute catecholamine-related hypertensive crisis was established as the cause of death.

The histological age determination of venous thromboses in fatal pulmonary embolism cases is an important task of forensic medicine and requires thorough knowledge of the general and specific pathology of pulmonary thromboembolism (PTE). The aim of our investigation was to carry out a chronological evaluation of the deep venous thrombosis (DVT) phenomenon, to assess the chronological transformation of the thrombus and to determine the causal relationship with PTE as cause of death. The clinical data and the autopsy records of the 2843 autopsies performed over the period 1 November 1998 to 31 December 2007 were retrospectively evaluated, and 140 cases in which PTE was pointed out as cause of death were selected. The dissection of the deep veins of the legs has been performed systematically to search for the starting point of venous embolism. 4.5% of pulmonary embolisms originated in the in iliac veins, 20.7% in the femoral veins, and 74.8% in the deep crural veins. In the venous sites of thrombosis, the histological assessment has been performed in conjunction with the surrounding vascular wall of uncut blood vessel with at least three to six different transverse incisions. Histological assessment of the embolus samples was also performed in conjunction with the venous sites of thrombosis. In our selected 140 cases of PTE, the DVT was classified as phase 1 in 48 cases (34.29%), as phase 2 in 70 cases (50%), and 22 cases (15.71%) were evaluated as older than 2 months (phase 3). The observed transformation of the thrombus by organization is suitable for a forensically utilizable age determination. However, only three chronological stages can be distinguished with any degree of certainty using immunohistochemistry and CLSM.

We present an uncommon case of sudden cardiac death in a 34-year-old white woman. She was found lifeless at home by her parents. Three months before death she was recovered at the Emergency Room for chest pain, palpitation and loss of consciousness. Subsequent cardiological evaluation with ECG showed sinusal rhythm, QRS deviation to the left, QS aspect, asymmetric and rounded T waves and slight length of QT. During hospitalization she presented some episodes of supraventricular paroxysmal tachycardia and non-sustained ventricular tachycardia. No echocardiography alterations were found. An anti-arrhythmic treatment was prescribed. Autopsy revealed some fibrotic scarring in the myocardium of left ventricle. The histological examination of the heart revealed diffuse and extensive fibrosis with non-caseating sarcoid granulomas. The lungs, kidneys and lymph node also showed the same non-caseating granulomas. The diagnosis of sarcoidosis with massive and extensive cardiac involvement was established as cause of death.

The association between sudden infant death syndrome and immunization is frequently discussed. Serious adverse events following vaccination have generally been defined as those adverse events that result in permanent disability, hospitalization or prolongation of hospitalization, life threatening illness, congenital anomaly or death. They are generally referred to the inherent properties of the vaccine (vaccine reaction) or some error in the immunization process (programme error). The event could also be totally unrelated but only temporally linked to immunization (coincidental event). A fatal case of a 3-month-old female infant, who died within 24 h of vaccination with hexavalent vaccine is presented. Clinical data, post-mortem findings (acute pulmonary oedema, acute pulmonary emphysema), quali-quantitative data collected from immunohistochemical staining (degranulating mast cells) and laboratory analysis with a high level of beta-tryptase in serum, 43.3 microg/l, allows us to conclude that acute respiratory failure likely due to post hexavalent immunization-related shock was the cause of death.

Acute interstitial pneumonitis (AIP), also known as Hamman-Rich syndrome, is a distinct type of idiopathic interstitial pneumonia affecting patients of both genders without pre-existing lung diseases. We describe the case of a fulminant form of AIP and discuss the pathophysiological mechanisms of AIP with reference to the histological pattern. A 15-year-previously-healthy male boy presented to the Hospital with a 6-day history of malaise, fever and cough. The clinical prodromes were followed by the acute onset of increasing shortness of breath rapidly progressing in acute respiratory failure. Chest X-ray demonstrated bilateral diffuse airspace opacification; the high resolution CT confirmed the presence of bilateral, symmetric diffuse ground-glass attenuation. The patient was admitted to the intensive care unit, but died after few hours. An autopsy was performed within 24h. The histological examination of lung specimens showed a pattern of diffuse alveolar damage. immunohistochemical, microbiological and toxicological tests were also carried out. The clinical presentation, the histological findings and the exclusion of infective, traumatic, toxic and metabolic causes of acute respiratory distress syndrome (ARDS) allowed us to conclude that the boy was affected by AIP. In conclusion, AIP is a diagnosis of exclusion. It has a mortality rate ranging about 50%, despite mechanical ventilation. In fatal cases of AIP diagnosis can be based on clinical presentation, radiological, histological and microbiological findings and can be further confirmed by immunohistochemical analysis.