Abstract Pheochromocytomas are chromaffin-cell derived neuroendocrine tumors of the adrenal medulla with the ability to synthesize and secrete excessive catecholamines. Common manifestations include paroxysmal or sustained hypertension, headache, sweating, and palpitations. Other less common manifestations have been described and can be life threatening, including cardiovascular shock, myocardial infarction, arrhythmias, and cardiomyopathy. We report a case of a 31-year-old postpartum female with no significant past medical history who presented with headache and died suddenly in an emergency room. Autopsy revealed a pheochromocytoma of the right adrenal gland with significantly elevated metanephrine levels and acute myocardial toxicity. Sudden excessive catecholamine release can cause cardiovascular complications and be rapidly fatal without significant elevation of blood pressure. A review of catecholamine-induced cardiotoxicity will follow. Awareness of this association by the forensic pathologist is vital in order to properly classify the death and apprise relatives of the potential utility of genetic screening. Acad Forensic Pathol. 6(1 Suppl):S-66–S-119. Molecular Diagnoses of Cardiovascular Diseases Using a Multigene Panel on Sudden Cardiac Deaths [29]S Park S Park ^1. National Forensic Service, Seoul, Korea, Republic of; Find articles by [30]S Park ^1., [31]S Cho S Cho ^2. Seoul National University College of Medicine, Seoul, Korea, Republic of Find articles by [32]S Cho ^2., [33]B Choi B Choi ^1. National Forensic Service, Seoul, Korea, Republic of; Find articles by [34]B Choi ^1., [35]J Park J Park ^1. National Forensic Service, Seoul, Korea, Republic of; Find articles by [36]J Park ^1., [37]M Kim M Kim ^1. National Forensic Service, Seoul, Korea, Republic of; Find articles by [38]M Kim ^1., [39]Y Kwon Y Kwon ^1. National Forensic Service, Seoul, Korea, Republic of; Find articles by [40]Y Kwon ^1., [41]D Kim D Kim ^1. National Forensic Service, Seoul, Korea, Republic of; Find articles by [42]D Kim ^1., [43]K Kim K Kim ^1. National Forensic Service, Seoul, Korea, Republic of; Find articles by [44]K Kim ^1., [45]M Kim M Kim ^2. Seoul National University College of Medicine, Seoul, Korea, Republic of Find articles by [46]M Kim ^2., [47]M Seong M Seong ^2. Seoul National University College of Medicine, Seoul, Korea, Republic of Find articles by [48]M Seong ^2., [49]S Lee S Lee ^2. Seoul National University College of Medicine, Seoul, Korea, Republic of Find articles by [50]S Lee ^2. * (BUTTON) Author information * (BUTTON) Copyright and License information ^1. National Forensic Service, Seoul, Korea, Republic of; ^2. Seoul National University College of Medicine, Seoul, Korea, Republic of [51]PMC Copyright notice Abstract Background: Sudden cardiac deaths are commonly encountered while forensic practice. A significant proportion of them are revealed to be negative autopsy, especially in Asian young adults, including Koreans. Molecular autopsy including postmortem genetic testing can be considered for these subjects. Material and methods: We retrieved ten cases of sudden cardiac death revealing negative autopsy, and performed molecular genetic testing using a multigene panel of 98 genes related to the heart (hereditary heart disease, channelopathy, cardiomyopathy and etc.) Results: 19 variants were identified in 12 genes amongst 98 genes and 18 variants were heterozygote and the other variant was homozygote. Discussion: All variants identified in our cases were not the pathogenic mutation and their clinical significance was unknown. One variant (MYH7:c.77C>T, p.Ala26Val, heterozygote) identified in one of our case was reported to be found in the linage of hypertrophic cardiomyopathy family. Another variant (c.5963T>G, p. Leu1988Arg, heterozygote) could be considered as a single nucleotide polymorphism related to long QT syndrome, but its allele frequency is known to be more than 1%. These features are not conclusive for confirmation of the pathogenic mutation. Conclusion: Although our results are not conclusive and further research would be necessary, molecular autopsy could give us features of related genes in sudden cardiac deaths with negative autopsy. Acad Forensic Pathol. 6(1 Suppl):S-66–S-119. Association of Waist-Hip Ratio to Sudden Cardiac Death and Severe Coronary Atherosclerosis in Medicolegal Autopsies [52]L Kocovski L Kocovski ^1. McMaster University, Hamilton, Ontario, Canada; Find articles by [53]L Kocovski ^1., [54]D Lee D Lee ^1. McMaster University, Hamilton, Ontario, Canada; Find articles by [55]D Lee ^1., [56]S Parpia S Parpia ^1. McMaster University, Hamilton, Ontario, Canada; Find articles by [57]S Parpia ^1., [58]J Fernandes J Fernandes ^2. Hamilton Regional Forensic Pathology Unit, Hamilton, Ontario, Canada Find articles by [59]J Fernandes ^2., [60]V Nair V Nair ^1. McMaster University, Hamilton, Ontario, Canada; Find articles by [61]V Nair ^1. * (BUTTON) Author information * (BUTTON) Copyright and License information ^1. McMaster University, Hamilton, Ontario, Canada; ^2. Hamilton Regional Forensic Pathology Unit, Hamilton, Ontario, Canada [62]PMC Copyright notice Abstract Various modifiable and non-modifiable risk factors, such as abdominal obesity, are known to affect the development of atherosclerotic cardiovascular disease and subsequent sudden cardiac death (SCD). There are various anthropometric measurements to assess central adiposity. The waist-hip ratio (WHR, i.e. waist circumference divided by hip circumference) is a surrogate marker of visceral obesity that has been shown in various studies to be a better predictor of cardiovascular risk than the body mass index (BMI), a measurement of generalized obesity. Objectives: To determine whether there is any association of increased WHR with SCD or severe coronary atherosclerosis (SCA, coronary artery diameter stenosis ≥ 75%). Methods: WHR measurements were determined prospectively on all medicolegal autopsies performed at the Hamilton Regional Forensic Pathology Unit during one year. The complete case reports were reviewed and known cardiovascular risk factors (diabetes mellitus, hypertension, hyperlipidemia, cigarette smoking) were examined in addition to measurements of WHR, BMI and heart weight. Logistic modeling was performed to determine any association between the cardiovascular disease risk factors, WHR, BMI, heart weight, and SCD or SCA. Results: 203 cases had complete data and satisfied inclusion criteria (age > 18 years, complete remains, none/minimal decomposition). There were 62 (30%) females and 141 (70%) males with a mean age of 52 years. SCD occurred in 46 (23%) individuals. WHR was not shown to be statistically significantly associated with either SCD [odds ratio (OR) = 1.1; 95% confidence interval (CI) = 0.7 to 1.8; p = 0.68] or SCA (OR = 1.4; 95% CI = 0.9 to 2.2; p = 0.14). BMI was shown to be significantly associated with SCA (p < 0.001), and heart weight was shown to be significantly associated with both SCD and SCA (p < 0.001, both). Conclusion: WHR, as a surrogate marker of central obesity and increased risk of atherosclerotic cardiovascular disease, has been shown not to be statistically significantly associated with either SCD or SCA in postmortem cases. Acad Forensic Pathol. 6(1 Suppl):S-66–S-119. Left-Dominant Arrhythmogenic Cardiomyopathy [63]L Lopez-Morell L Lopez-Morell ^1. Brody School of Medicine at East Carolina University, Greenville, North Carolina Find articles by [64]L Lopez-Morell ^1., [65]KL Kelly KL Kelly ^1. Brody School of Medicine at East Carolina University, Greenville, North Carolina Find articles by [66]KL Kelly ^1. * (BUTTON) Author information * (BUTTON) Copyright and License information ^1. Brody School of Medicine at East Carolina University, Greenville, North Carolina [67]PMC Copyright notice Abstract Introduction: Arrhythmogenic right ventricular cardiomyopathy/dysplasia (ARVC/D) is now a well-recognized entity that can cause sudden death. The literature to date reports the estimated prevalence of ARVC/D ranging from 1 in 2,000 to 1 in 5,000, with a male to female ratio of 3:1. Most commonly, ARVC/D has an autosomal dominant inheritance pattern with reduced penetrance and variable expression, with 12 linked genes involving various elements of the cardiac desmosome. Grossly at autopsy, the right ventricle may be paper thin and semi-translucent or the wall may be thickened by mature fat. Histologically, ARVC/D shows transmural fatty infiltration of the right ventricle with patchy fibrosis and chronic inflammatory cells. Similar findings in the ventricular septum and/or left ventricle have been assumed to be due to involvement by ARVC/D. Isolated histologic changes of subepicardial or intra-mural prominent fatty infiltration with fibrosis may be mis-diagnosed as a healed myocardial infarct or healed myocarditis by forensic pathologists. If the fatty infiltration with fibrosis is not in the area of a specific coronary artery distribution, it is unlikely due to a myocardial infarct. These isolated histologic finding are now interpreted as a subtype of ARVC/D, and has been dubbed left-dominant arrhythmogenic cardiomyopathy (LDAC) (also known as left-sided ARVC or arrhythmogenic left ventricular cardiomyopathy). Recognition of this entity is essential for accurately determining cause of death and for families of the deceased who can seek screening, genetic counseling, and treatment for this often fatal and progressive disease. Case Reports: We present two cases of sudden cardiac death caused by left dominant arrhythmogenic cardiomyopathy. Both cases showed foci of myocyte replacement by mature adipose tissue admixed with dense fibrosis limited to the left ventricle. The first case was a 61 year old man found dead in bed with a medical history of hypertension and seizure disorder. The second case was a 33 year old woman who woke with cough and died suddenly. Her medical history included morbid obesity and hypertension. Conclusion: Left-dominant arrhythmogenic cardiomyopathy is an autosomal dominant disease process with a 50 percent probability of inheritance. A careful family history should be taken in these cases, focusing on unexplained premature deaths, arrhythmia symptoms and conduction system disease. This entity must be recognized by the forensic pathologist investigating sudden, unexpected death in order to collect the appropriate specimens for genetic testing and notify the family in order for first-degree relatives to be appropriately evaluated. Acad Forensic Pathol. 6(1 Suppl):S-66–S-119. Analysis of Sudden Cardiac Deaths of Young Adults in Forensic Autopsy Cases [68]T Ren T Ren ^1. Institute of forensic science of Tianjin Public Security Bureau, Tianjin, China Find articles by [69]T Ren ^1. * (BUTTON) Author information * (BUTTON) Copyright and License information ^1. Institute of forensic science of Tianjin Public Security Bureau, Tianjin, China [70]PMC Copyright notice Abstract The World Health Organization (WHO) defines sudden cardiac death (SCD) as death due to cardiac causes within 1 hour of the onset of symptoms in a person with known or unknown cardiovascular disease. It is estimated that more than 7 million lives per year are lost to SCD worldwide. The objectives of the study are to (1) analyze the cause and risk factors SCD and (2) to improve the level of awareness of SCD and emergency treatment. This is a retrospective review of forensic autopsy cases from Tianjin Public Security Bureau (TPSB). This study focused on the clinical history, death scene presentation, and autopsy findings of SCD. A total of 11 SCD cases were identified by our review. Of the 11 cases, 10 were male and 1 female. The age ranged from 18 years to 38 years. Nine of the 11 individuals had significant medical history. One person had recent cold symptom. And the other person had occasional palpitations syncope in the past six months. Three of the individuals suddenly collapsed during altercation. The causes of SCD included myocarditis (N=4), rheumatic heart disease (N=2), atherosclerotic cardiovascular disease (N=1), hypertrophic cardiomyopathy (N=1), dilated cardiomyopathy (N=1), cardiac arrhythmia associated with lesions in the conduction system (N=2). In China, the number of SCD has increased in the recent years, especially in the young adults’ population. The cause of sudden death in young adults with non-coronary heart disease, such as myocarditis and cardiomyopathy is a big concern. The detailed scene investigation findings and postmortem examination finding of SCD in young adults are presented. Key words: sudden cardiac death, young adult, myocarditis, cardiomyopathy, and forensic autopsy Acad Forensic Pathol. 6(1 Suppl):S-66–S-119. A Tale of Two Brothers: Two Cases of Adrenomyeloneuropathy [71]CS Beisser CS Beisser ^1. Lucas County Coroner's Office, Toledo, Ohio; Find articles by [72]CS Beisser ^1., [73]RE Mrak RE Mrak ^2. University of Toledo College of Medicine and Life Sciences, Toledo, Ohio Find articles by [74]RE Mrak ^2. * (BUTTON) Author information * (BUTTON) Copyright and License information ^1. Lucas County Coroner's Office, Toledo, Ohio; ^2. University of Toledo College of Medicine and Life Sciences, Toledo, Ohio [75]PMC Copyright notice Abstract Adrenomyeloneuropathy (AMN) is the adult variant of adrenoleukodystrophy. It is X-linked and about 50% of female carriers will manifest some symptoms. Clinically, it presents with ataxia, adrenal insufficiency, visual defects, bowel and bladder dysfunction, and seizures. The testes are also affected. The apparent biochemical abnormality is decreased activity of VLCF acyl-CoA synthetase, which causes increased levels of very long chain fatty acids (VLCFA). This eventually causes a lipotoxicity-induced demyelination. The disease progresses slowly to spastic paraparesis, disability, and death. We present two cases of brothers, both of whom had been diagnosed with AMN prior to death and who died within two months of each other. The first died from injuries resulting from a traffic collision. He was not at fault and a witness noticed no problems with his driving. However, the family was surprised that he could drive. The second was found dead at home after the family had not heard from him for 24 hours. He was not able to care for himself and needed a walker to ambulate. He had not seen a doctor for 20 years, according to the family. Of interest, a third brother had previously committed suicide because he did not want to live with his AMN. The cause of death in the first case was certified as multiple blunt trauma, with no contribution of the AMN. The manner was accident. The cause of the death in the second case was certified as AMN. The manner was natural. Acad Forensic Pathol. 6(1 Suppl):S-66–S-119. Pulmonary Tumor Microemboli Mimicking Acute Pulmonary Embolism as a Cause of Sudden Death [76]ME Quinn ME Quinn ^1. University of Colorado School of Medicine, Aurora, Colorado; Find articles by [77]ME Quinn ^1., [78]KC Lear-Kaul KC Lear-Kaul ^2. Arapahoe County Coroner's Office, Centennial, Colorado Find articles by [79]KC Lear-Kaul ^2. * (BUTTON) Author information * (BUTTON) Copyright and License information ^1. University of Colorado School of Medicine, Aurora, Colorado; ^2. Arapahoe County Coroner's Office, Centennial, Colorado [80]PMC Copyright notice Abstract Pulmonary tumor microemboli, while not uncommon in patients with solid tumors, is a diagnosis rarely made antemortem. Clinically, patients may present with dyspnea, cough, chest or abdominal pain, symptoms of right heart failure, hypoxemia, and fulminant respiratory failure, all of which can mimic other intrathoracic processes. There is often no radiologic evidence. Tumor microemboli are distinct from tumor macroemboli, which would be expected to present like massive pulmonary thromboemboli. Microemboli, on the other hand, more closely mimic infection or interstitial lung disease, with diagnosis typically made at autopsy. Physiologically, pulmonary tumor microemboli may result in pulmonary hypertension, right ventricular failure and acute cor pulmonale via acute or chronic occlusion of small arteries and arterioles. Herein we discuss a 66-year-old man with a history of diabetes and obstructive sleep apnea who originally presented to a local emergency department with altered mental status. Workup in the emergency department including abdominal ultrasound and liver function tests indicated hepatic encephalopathy due to previously undiagnosed cirrhosis. During his initial evaluation he was also diagnosed with acute respiratory failure and placed on 15 L of oxygen. The patient developed worsening hypoxemia, tachypnea and tachycardia, ultimately progressing to bradycardic arrest unresponsive to medical and electrical cardioversion. Due to the clinical suspicion of pulmonary thromboembolism, tissue plasminogen activator (TPA) was administered; however he ultimately expired despite aggressive resuscitation. Autopsy examination was performed to clarify the etiology of his sudden cardiac arrest. Hepatic cirrhosis was confirmed, and he was found to have a previously undiagnosed intrahepatic cholangio-carcinoma with hemorrhagic tumor nodules diffusely involving the liver. The lungs were markedly edematous with a combined weight of 2550 grams; no gross evidence of neoplasia or large arterial emboli were present. Microscopically, the pulmonary small arteries and arterioles contained occlusive aggregates of tumor cells. No additional metastatic lesions were identified. The forensic pathologist must be aware of tumor embolism as a possible cause of sudden death, and should consider autopsy in the setting of respiratory failure or when given a history suggestive of massive pulmonary embolism to rule out tumor macro- or microembolism, with or without a known underlying malignancy. Acad Forensic Pathol. 6(1 Suppl):S-66–S-119. Acute Pancreatitis from Obstructive Cholelithiasis Presenting as Sudden, Unexpected Death: A Case Report and Review of the Literature [81]LA Havrilla LA Havrilla ^1. Duke University Hospital, Durham, North Carolina; Find articles by [82]LA Havrilla ^1., [83]W Harrison W Harrison ^1. Duke University Hospital, Durham, North Carolina; Find articles by [84]W Harrison ^1., [85]M Aurelius M Aurelius ^2. North Carolina Office of the Chief Medical Examiner, Raleigh, North Carolina Find articles by [86]M Aurelius ^2. * (BUTTON) Author information * (BUTTON) Copyright and License information ^1. Duke University Hospital, Durham, North Carolina; ^2. North Carolina Office of the Chief Medical Examiner, Raleigh, North Carolina [87]PMC Copyright notice Abstract Acute pancreatitis is a fairly common medical condition ranging from mild and self-limiting to severe and even fatal. It can be induced by a variety of situations that all ultimately lead to inflammation, release of pancreatic enzymes, and auto digestion of the pancreas. The two most common causes of acute pancreatitis are long-term alcohol use and gallstones, totaling approximately 70-80% of cases. Gallstones may become lodged in the cystic duct or common bile duct creating obstruction. Other causes include idiopathic, hypercholesterolemia, endoscopic retrograde cholangiopancreatography (ERCP), and a variety of medications. Symptoms include nausea, vomiting, and abdominal pain, which may radiate to the back. Complications include pseudocysts, peritonitis, abscess formation, sepsis, multisystem organ failure and death. The mortality rate ranges from 10-30% depending on the etiology, severity, and co-existing factors. Postmortem studies of fatal acute pancreatitis in the medicolegal autopsy population are sparse. Acute pancreatitis from obstructive cholelithiasis diagnosed at autopsy presenting as sudden death is rarely reported in the medical literature. We report a case of a 29-year-old White non-Hispanic man who had a two-day history of worsening nausea, vomiting and diarrhea prior to being found dead in bed. The decedent had no other significant past medical history and no history of drug or alcohol use. Significant findings at autopsy included fat necrosis most concentrated around the pancreas with the pancreas demonstrating acute hemorrhagic necrotizing pancreatitis. The gallbladder contained greater than 20 yellow stones and an obstructive stone was found within the cystic duct. In cases of sudden, unexpected death with a recent history of nonspecific gastrointestinal symptoms, acute pancreatitis must be on the differential diagnosis. When acute pancreatitis is suspected, the gallbladder, pancreas and proximal duodenum should be removed en bloc and the gallbladder, cystic duct and common bile duct should be carefully examined for obstructive stones. The obstruction may be transient or persistent. The typical location for biliary stone disease resulting in pancreatitis is at the sphincter of Oddi. However, even if no gallstones are impacted causing obstruction at the time of autopsy, gallstone pancreatitis cannot be excluded because a small stone that may have passed could have caused a brief harmful obstruction at one point it time. This case illustrates the importance of obtaining a thorough medical history and altering dissection and evisceration techniques to identify the etiology of acute pancreatitis in patients with nonspecific gastrointestinal symptoms presenting with sudden, unexpected death. Acad Forensic Pathol. 6(1 Suppl):S-66–S-119. Undiagnosed Pheochromocytoma Simulating Malignant Hyperthermia [88]NS Ramani NS Ramani ^1. SUNY Upstate Medical University, Syracuse, New York Find articles by [89]NS Ramani ^1., [90]R Stoppacher R Stoppacher ^1. SUNY Upstate Medical University, Syracuse, New York Find articles by [91]R Stoppacher ^1., [92]K Clark K Clark ^1. SUNY Upstate Medical University, Syracuse, New York Find articles by [93]K Clark ^1., [94]C Catanese C Catanese ^1. SUNY Upstate Medical University, Syracuse, New York Find articles by [95]C Catanese ^1. * (BUTTON) Author information * (BUTTON) Copyright and License information ^1. SUNY Upstate Medical University, Syracuse, New York [96]PMC Copyright notice Abstract Introduction: Pheochromocytomas are rare catecholamine-producing neuroendocrine tumors arising from chromaffin cells of the adrenal medulla or extraadrenal paraganglia. It is surgically curable, and can be lethal if remain undiagnosed. Autopsy studies have indicated that a significant proportion of pheochromocytomas remain undiagnosed during life. We report a patient diagnosed with malignant hyperthermia earlier, but later found to have pheochromocytoma on autopsy. Case report: Following a pre-procedural pain block for elective right shoulder arthroscopy, 53 year-old hypertensive Caucasian male complained of chest pain which resolved in 15 minutes. EKG was normal. During induction in the operating room, he had increased blood pressure. Post-operatively, he developed pulmonary edema. His blood pressures dropped from 220s to 80s. He later developed malignant hyperthermia and died following unsuccessful attempts to stabilize him. Autopsy: Autopsy revealed a 10 × 8 × 7.5 cm mahogany colored, circumscribed right adrenal encapsulated tumor weighing 530 grams. It was necrotic, hemorrhagic and cystic along the cut surface. Relicts of yellow-orange adrenal cortex were visible at the margin of the tumor, indicating that tumor clearly originated from the underlying adrenal gland. The left adrenal gland was unremarkable. H and E sections of the adrenal tumor showed hyper-cellularity with focal hemorrhage. Cells showed zellballen i.e. alveolar pattern in vascular network, with finely granular basophilic cytoplasm and round to oval nuclei. They were slightly pleomorphic with rare mitoses. The immunohistochemical stains highlights synaptophysin and chromogranin in the tumor cells, confirming the diagnosis of pheochromocytoma. 24 hours urine sample collected before his death, showed >22727 microgram/gram CRT metanephrines and normetanephrines. Overall, findings were impressive for a hyperactive tumor secreting high levels of catecholamines. The cause of death was established as the complications of pheochromocytoma during general anesthesia for shoulder arthroscopy and the manner of death was natural. Conclusion: Hypermetabolic response during anesthesia and surgery is unusual and can be from several etiologies such as thyroid storm, malignant hyperthermia and pheochromocytoma. This case illustrates how pheochromocytoma can mimic malignant hyperthermia, and it should always be considered and managed appropriately in such scenarios to avoid untoward consequences. Pathologist should also be aware of this when conducting autopsy in cases with prior clinical diagnosis of malignant hyperthermia. Acad Forensic Pathol. 6(1 Suppl):S-66–S-119. Simultaneous Sudden Death of Two Siblings during Sleep While in Police Custody: A Report of Two Cases [97]G Qian G Qian ^1. Office of Chief Medical Examiner, Baltimore, Maryland Find articles by [98]G Qian ^1., [99]Z Yang Z Yang ^1. Office of Chief Medical Examiner, Baltimore, Maryland Find articles by [100]Z Yang ^1. * (BUTTON) Author information * (BUTTON) Copyright and License information ^1. Office of Chief Medical Examiner, Baltimore, Maryland [101]PMC Copyright notice Abstract Sudden Adult Death Syndrome (SADS) refers to sudden unexpected death of young adults and the cause of death is unexplained after thorough death scene investigation and complete autopsy examination. Since it was first noted among Hmong refugees in the US in 1977, there have been many reports worldwide. Here, we present two rare cases in which two brothers died in different cells during sleep while they were at the detection center. One was a 47-year-old and the other was a 33-year-old. According to the report from the on duty officer, the two brothers woke up and went to the bathroom around 2 - 3 a.m. Then they went back to their separate cells with other inmates. The next morning, the older brother was found unconsciousness by his inmate. Resuscitation was performed at scene and he was pronounced dead on his way to the hospital. Three hours later, the younger brother was found unresponsive in bed. He was pronounced dead at scene. Because both brothers died while in police custody and they died almost simultaneously, their family strongly suspected foul play. Autopsies were conducted the next day. External examination revealed that both men were well developed and well nourished males. There was no evidence of recent injury. Internal examination revealed scattered petechiae on the surface of the heart and lungs. No other significant findings by gross examination. Histological examination of the older brother showed 75 - 90% atherosclerotic stenosis of the proximal and distal left anterior descending coronary artery. His heart weighed 415 grams. The younger brother had about 25% atherosclerotic stenosis of the proximal and distal left anterior descending coronary artery. His heart weighed 470 grams. Postmortem toxicological analysis was negative for alcohol and drugs. The cause of death of the 47-year-old brother was atherosclerotic cardiovascular disease coronary heart disease. The cause of death of the younger brother was certified as SDAS. Further investigation revealed that neither brother had any reported medical condition. However, according to the family, one of their brothers was found dead during sleep several years ago. The importance of thorough death scene investigation findings and review of medical and family history will be discussed. In addition, possible contributing factors, such as genetic component and the psychological impact in police custody will be addressed. Acad Forensic Pathol. 6(1 Suppl):S-66–S-119. Unusual Brain “Abscesses” in an IV Drug Abuser [102]S Maines S Maines ^1. University of Kentucky, Lexington, Kentucky Find articles by [103]S Maines ^1., [104]K Song K Song ^1. University of Kentucky, Lexington, Kentucky Find articles by [105]K Song ^1., [106]B Frost B Frost ^1. University of Kentucky, Lexington, Kentucky Find articles by [107]B Frost ^1., [108]S Crook S Crook ^1. University of Kentucky, Lexington, Kentucky Find articles by [109]S Crook ^1., [110]D Richards D Richards ^1. University of Kentucky, Lexington, Kentucky Find articles by [111]D Richards ^1. * (BUTTON) Author information * (BUTTON) Copyright and License information ^1. University of Kentucky, Lexington, Kentucky [112]PMC Copyright notice Abstract Drug overdose, infection, trauma, and AIDS-related complications are the most common causes of death worldwide among people who use intravenous drugs. We report a case of a 41-year old woman who expired shortly after presentation to the emergency department. Her family reported several days of fatigue and altered mental status; however, these symptoms were attributed to a history of intravenous drug use and a seizure disorder. Physical exam revealed an enlarged right inguinal lymph node and fixed and dilated pupils with a Glasgow Coma Scale score of 3. Imaging showed uncal herniation, cerebral edema, and multiple ring-enhancing lesions. Initial differentials included septic emboli with abscess formation, toxoplasmosis (HIV-related infection), and lymphoma. Care was withdrawn due to poor prognosis, and the family requested an autopsy. To our surprise, what were clinically thought to be inguinal and brain “abscesses” were positive for S-100 and Melan-A and only focally positive for cytokeratin AE1/AE3, consistent with metastatic melanoma (despite unknown primary). This case highlights the importance of complete autopsies in cases that may seem to be clearly due to drug overdose or complications of drug abuse. Acad Forensic Pathol. 6(1 Suppl):S-66–S-119. Zebras Make Hoofbeats, Too: A Fatal Case of Occult Budd-Chiari Syndrome [113]S Reed S Reed ^1. Allegheny General Hospital, Pittsburgh, Pennsylvania Find articles by [114]S Reed ^1., [115]F Bilimoria F Bilimoria ^1. Allegheny General Hospital, Pittsburgh, Pennsylvania Find articles by [116]F Bilimoria ^1., [117]A Balog A Balog ^1. Allegheny General Hospital, Pittsburgh, Pennsylvania Find articles by [118]A Balog ^1., [119]M Bunker M Bunker ^1. Allegheny General Hospital, Pittsburgh, Pennsylvania Find articles by [120]M Bunker ^1. * (BUTTON) Author information * (BUTTON) Copyright and License information ^1. Allegheny General Hospital, Pittsburgh, Pennsylvania [121]PMC Copyright notice Abstract Budd-Chiari syndrome (BCS), or hepatic venous outflow obstruction, is a rare complication of the myeloproliferative neoplasms (MPN), including polycythemia vera. Often the onset of BCS is clinically silent, with the development of symptoms such as fever, abdominal pain and lower limb edema heralding a poor patient outcome. We present a case of Budd-Chiari syndrome that was identified on autopsy. The patient, a 66-year old obese Caucasian female with a history of polycythemia vera, presented to an outside hospital with complaints of right upper quadrant pain, fever, nausea and vomiting concerning for acute cholecystitis. Laboratory workup showed elevated bilirubin and transaminases, and she subsequently underwent emergent cholecystectomy. Her post-operative recovery was complicated by progressive renal and liver failure of unclear etiology, thus she was transferred to our center for continued care. Her clinical picture was suspicious for a bile leak, though none could be identified by endoscopic retrograde cholangiopancreatography (ERCP). Her body habitus precluded imaging studies from appropriately visualizing the hepatic vasculature. The patient had a prolonged clinical course of worsening liver and renal failure, eventually progressing to encephalopathy and respiratory failure. Comfort care was initiated, and the patient unfortunately expired. A limited autopsy demonstrated an obese Caucasian female with marked anasarca. Internal examination revealed hepatosplenomegaly with extensive bilateral occlusion of the hepatic veins, as well as multiple bilateral pulmonary emboli. The lungs and spleen demonstrated numerous gross infarcts. Histological examination of the hepatic veins demonstrated extensive organized thrombosis and massive perivenular necrosis with associated hemorrhage. The cause of death was attributed to multiorgan failure secondary to hepatic vein occlusion and subsequent necrosis, consistent with Budd-Chiari syndrome. In retrospect, the patient's symptomatology prior to her cholecystectomy was suggestive of acute hepatic vein occlusion, but could easily be interpreted as acute cholecystitis. The patient's body habitus and worsening renal function limited the utility of imaging studies to identify a hepatic vein obstruction. We present this case to demonstrate the importance of an expanded differential diagnosis despite a seemingly common clinical presentation. While primary Budd-Chiari syndrome is rare, it should be considered in any patient with persistent, unexplained hepatopathy and a history of a myeloproliferative neoplasm. Acad Forensic Pathol. 6(1 Suppl):S-66–S-119. Causes of Sudden Death in Schizophrenia Patients: A Forensic Autopsy Population Study [122]D Sun D Sun ^1. EastChina University of Political Science and Law, Shanghai, China; Find articles by [123]D Sun ^1., [124]L Li L Li ^2. Fudan University Medical College, Shanghai, China; Find articles by [125]L Li ^2., [126]X Zhang X Zhang ^3. Office of the Chief Medical Examiner, Baltimore, Maryland; Find articles by [127]X Zhang ^3., [128]D Fowler D Fowler ^3. Office of the Chief Medical Examiner, Baltimore, Maryland; Find articles by [129]D Fowler ^3., [130]L Li L Li ^4. US-China Forensic Research Center, Baltimore, Maryland; Find articles by [131]L Li ^4., [132]D Sun D Sun ^1. EastChina University of Political Science and Law, Shanghai, China; Find articles by [133]D Sun ^1., [134]N Liu N Liu ^5. Institute of Forensic Science, Ministry of Justice., Shanghai, China Find articles by [135]N Liu ^5. * (BUTTON) Author information * (BUTTON) Copyright and License information ^1. EastChina University of Political Science and Law, Shanghai, China; ^2. Fudan University Medical College, Shanghai, China; ^3. Office of the Chief Medical Examiner, Baltimore, Maryland; ^4. US-China Forensic Research Center, Baltimore, Maryland; ^5. Institute of Forensic Science, Ministry of Justice., Shanghai, China [136]PMC Copyright notice Abstract Schizophrenia is a detrimental psychiatric disorder, with an increased mortality from natural and non-natural causes and a much shorter life expectancy than in the general population. Subjects and methods: this study was a retrospective review of autopsy cases of all the individuals with medical history of schizophrenia investigated by the Office of the Chief Medical Examiner (OCME), in the State of Maryland over a 5-year period from 2008 to 2012. The cases were analyzed as to the general characteristic of the individuals (age, gender, and race); medical history; death scene investigation findings; autopsy and postmortem toxicological findings; and cause and manner of death. Result: from 2008 to 2012, a total of 391 schizophrenia patients were autopsied at the OCME because they died suddenly and unexpectedly. Their age ranged from 15 to 100 years with the mean age of 52 years. Of the 391 deaths, 191 (48.8%) were white, 185(47.3%) were African American, and 15(3.9%) were either Hispanic or Asian. The male and female ratio was 1.5:1. The majority of the deaths (251, 64.2%) were caused by natural diseases, 47 deaths (12.0%) were accidents, 45 deaths (11.5%) were suicides (11.5%), and 10 deaths (9.7%) were homicides. The manner of death remained undetermined in 38 cases (9.7%). Of the 251 natural deaths, 198 cases were due to cardiovascular diseases (50.6%). Atherosclerotic cardiovascular disease (ASCVD), hypertensive atherosclerotic cardiovascular disease (HASCVD) and hypertensive cardiovascular disease (HCVD) were the primary diagnoses of cardiac deaths (169 in total, 85.4%). Cause of death was listed as cardiac arrhythmia in 11 cases. This diagnosis was made based on postmortem scene investigation (sudden death with no evidence of suspicious), review of medical history (no history of any other medical diseases), complete autopsy with no identifiable macroscopic and microscopic abnormal findings, and negative toxicological tests. Of the 11 cardiac arrhythmia deaths, 7 patients were less than 40 years of age. Drug intoxication was the second most common cause of death in our study group (50 cases, 12.8%). In conclusion, the study shows high fatality caused by cardiovascular diseases and drug intoxication among schizophrenia patients, which calls attention of the medical community to closely monitor the high risk factors of sudden death among schizophrenia patients. Acad Forensic Pathol. 6(1 Suppl):S-66–S-119. Sudden Death Due to Pulmonary Thromboembolism While in Police Custody: A Report of Three Autopsy Cases [137]N Liu N Liu ^1. Institute of Forensic Science, Ministry of Justice, P. R. China, Shanghai, China; Find articles by [138]N Liu ^1., [139]Y Chen Y Chen ^1. Institute of Forensic Science, Ministry of Justice, P. R. China, Shanghai, China; Find articles by [140]Y Chen ^1., [141]Z Qin Z Qin ^1. Institute of Forensic Science, Ministry of Justice, P. R. China, Shanghai, China; Find articles by [142]Z Qin ^1., [143]L Li L Li ^2. China University of Political Science and Law, Beijing, China Find articles by [144]L Li ^2. * (BUTTON) Author information * (BUTTON) Copyright and License information ^1. Institute of Forensic Science, Ministry of Justice, P. R. China, Shanghai, China; ^2. China University of Political Science and Law, Beijing, China [145]PMC Copyright notice Abstract Pulmonary embolism (PE) is a potentially life threatening complication of deep vein thrombosis (DVT) and can lead to sudden death. There are many risk factors for development of DVT. People who have a history of recent prolonged sitting (as with air travel) or bedrest are known at risk for developing DVT and PE. Sudden death from PE secondary to prolonged restrain in police custody are rarely reported in the literature of forensic sciences. We present three cases of sudden death due to PE while they were in police custody. Case 1 was a 42-year-old man who was arrested for theft. Reportedly, he was very combative during interrogation so that he was restrained in sitting position for four days in a local police station. His physical activities were limited to eating, drinking, sleeping in a restrained position, and going to bathroom. On the day 4, he suddenly collapsed. He was transported to a local hospital and was pronounced dead after 3 hours of resuscitation. Case 2 was a 43-year-old woman who was arrested for suspicion of economic crime. During inquisition, she was shackled in sitting position on a chair for about 20 hours. The subject was quiet almost of time. Reportedly, she was restrained in the sitting position during the entire interrogation without any physical movement except for drinking very little water. She suddenly collapsed when she got up to go bathroom. She was pronounced dead after about 2 hours of resuscitation. Case 3 was a 48-year-old man who was found pale with abnormal breathing after 26 hours of restraint in a local police station. He died on arrival in a local hospital. Postmortem examination revealed that all the three decedents died of pulmonary embolism due to deep vein thrombosis. No other significant natural diseases were found at autopsy. No drug or alcohol were detected. The detailed scene investigation findings will be presented and risk factors for sudden death during restrain in police custody will also be discussed. Acad Forensic Pathol. 6(1 Suppl):S-66–S-119. Genomic Analysis of Oxygen-glucose Derprivation in Primary Culture Cortical Neurons [146]M He M He ^1. Department of Forensic Medicine, School of Basic Medical Sciences, Fudan University, Shanghai, China Find articles by [147]M He ^1., [148]Y Shen Y Shen ^1. Department of Forensic Medicine, School of Basic Medical Sciences, Fudan University, Shanghai, China Find articles by [149]Y Shen ^1., [150]B Li B Li ^1. Department of Forensic Medicine, School of Basic Medical Sciences, Fudan University, Shanghai, China Find articles by [151]B Li ^1. * (BUTTON) Author information * (BUTTON) Copyright and License information ^1. Department of Forensic Medicine, School of Basic Medical Sciences, Fudan University, Shanghai, China [152]PMC Copyright notice Abstract Cerebral ischemia-reperfusion injury (IRI) is a common clinical pathological process, and it is a key step in causing further ischemic organ damage. Understanding endogenous mechanisms of neuroprotection may have important clinical applications. However, the mechanism responsible for the cortical neurons to global ischemia remain are still not fully understood. To identify genes and pathways that are dysregulated as a consequence of cerebral ischemia, we investigated mRNA expression differences in mouse primary culture cortical neurons with oxygen-glucose deprivation (OGD) versus normal controls by differential RNA-seq analysis. Here we describe the RNA-seq data derived for two biological replicates of mouse primary culture cortical neurons with or without OGD, and present the bioinformatics pipeline used to test for differential gene expression and pathway enrichment analysis. A total of 7744 genes showed significant differential expression after OGD and were enriched for genes associated with neuroactive ligand-receptor interaction, calcium signaling and axon guidance. There was additional enrichment for genes involved in MAPK signaling, long-term potentiation (LTP), focal adhesion and ECM-receptor interaction. These findings improve the biological understanding of how the cortical neuron behaves after ischemia, and also illustrate some possible underlying molecular mechanisms of cerebral ischemia. Acad Forensic Pathol. 6(1 Suppl):S-66–S-119. Intracerebral Glioneuronal Heterotopia: A Case Report of Sudden Death in a Young Adult Epileptic Patient [153]C Dominguez C Dominguez ^1. University of South Florida, Brandon, Florida; Find articles by [154]C Dominguez ^1., [155]A Perkins A Perkins ^2. University of South Florida, Tampa, Florida; Find articles by [156]A Perkins ^2., [157]L Chrostowski L Chrostowski ^3. Medical Examiner Department Hillsborough County, Tampa, Florida Find articles by [158]L Chrostowski ^3. * (BUTTON) Author information * (BUTTON) Copyright and License information ^1. University of South Florida, Brandon, Florida; ^2. University of South Florida, Tampa, Florida; ^3. Medical Examiner Department Hillsborough County, Tampa, Florida [159]PMC Copyright notice Abstract Context: Heterotopias of the brain and brainstem are a group of disorders that results from a failure of normal neuroblast migration during embryological development, thus leading to cytologically normal neurons and glial cells in abnormal locations1. The symptoms are variable depending on the location of the heterotopic tissue and may range from an asymptomatic course to severe epilepsy or mental retardation. Design: Here we report a case of intracerebral glioneuronal heterotopia that presented as sudden death in a young adult in order to highlight the importance of neuropathological examination of the brains in patients with a history of epilepsy. Results: A 35-year-old man with a history of epilepsy since the age of 16 was found prone in his bed, cold to the touch, with rigor mortis and fixed lividity, by his family members doing a wellness check. The autopsy examination negative for evidence of trauma and toxicologic tests did not detect any substances of forensic significance. In the neuropathologic gross examination, the brain was non-edematous and without herniations. Areas consistent with heterotopic grey matter were observed extending from the ependyma of the lateral ventricle, within the cortical grey matter, and within the periventricular white matter. Microscopically, these areas showed subependymal gliosis with Rosenthal fibers-like structures and multiple corpora amylacea. Additionally, there were clusters of neurons within the white matter, including motor neurons, which lacked organization and were accompanied by gliosis and ectatic vessels, consistent with glioneuronal heterotopy. The remainder of the autopsy examination revealed no other abnormalities. Conclusions: Intracerebral glioneuronal heterotopy may be present in patients with a history of epilepsy. Consideration of this entity as a part of the differential diagnoses in cases of sudden unexpected death in patients with epilepsy with or without evidence of a seizure may be helpful for accurate determination of the cause and manner of death. Acad Forensic Pathol. 6(1 Suppl):S-66–S-119. A Case of Previously Unsuspected Huntington's Disease Diagnosed at Autopsy [160]CR Miller CR Miller ^1. The University of Texas Medical Branch, Galveston, Texas Find articles by [161]CR Miller ^1., [162]NC Mambo NC Mambo ^1. The University of Texas Medical Branch, Galveston, Texas Find articles by [163]NC Mambo ^1., [164]GA Campbell GA Campbell ^1. The University of Texas Medical Branch, Galveston, Texas Find articles by [165]GA Campbell ^1. * (BUTTON) Author information * (BUTTON) Copyright and License information ^1. The University of Texas Medical Branch, Galveston, Texas [166]PMC Copyright notice Abstract Huntington's disease (HD) is a neurodegenerative disorder with a worldwide prevalence of 5 – 10 per 100,000. It is characterized by choreiform movements, behavioral disturbances, and eventual mental decline. Symptoms usually present between 30 and 50 years of age, and the diagnosis is made based on the combination of clinical symptoms, family history, and genetic testing. The inheritance pattern is autosomal dominant and the disease is caused by an elongation of the CAG repeat in the Huntingtin gene. There are several reports of diagnoses of Huntington's disease confirmed at autopsy in the literature, but to our knowledge there are no reports in the literature of new diagnoses of Huntington's disease being made at autopsy. We present a case of a 28-year-old male who at autopsy macroscopically showed bilateral lateral ventricle dilation and atrophy bilaterally of the head of the caudate nuclei, and microscopically showed bilateral severe neuronal loss and gliosis of the caudate and putamen nuclei. Genetic testing for the number of CAG repeats us being undertaken. Acad Forensic Pathol. 6(1 Suppl):S-66–S-119. Shaken but Not Forgotten [167]A Gupta A Gupta ^1. University of Michigan, Ann Arbor, Michigan Find articles by [168]A Gupta ^1., [169]J Lozano J Lozano ^1. University of Michigan, Ann Arbor, Michigan Find articles by [170]J Lozano ^1., [171]K Kesha K Kesha ^1. University of Michigan, Ann Arbor, Michigan Find articles by [172]K Kesha ^1., [173]A Lieberman A Lieberman ^1. University of Michigan, Ann Arbor, Michigan Find articles by [174]A Lieberman ^1., [175]JM Jentzen JM Jentzen ^1. University of Michigan, Ann Arbor, Michigan Find articles by [176]JM Jentzen ^1. * (BUTTON) Author information * (BUTTON) Copyright and License information ^1. University of Michigan, Ann Arbor, Michigan [177]PMC Copyright notice Abstract We present neuropathological findings of a 32-year-old man of being shaken during his infancy and had survived 31 years after suffering the traumatic abusive head injuries. He had neurological deficits and Gross examination of brain was remarkable for a small area of intraparenchymal bleed into the right frontal lobe. The hemorrhagic areas show subacute –chronic infarction with macrophages, neovascularization, loss of neurons and gliosis, and were consistent with history of hypotensive episodes due to septicemia due to lung infection. White and gray matter and deep brain nuclei were unremarkable on gross examination and routine histological stains. Sections of corpus callosum genu and splenium were stained with Bielschowsky (sliver stain), Luxol fast blue, beta amyloid, phosphorylated Tau and neurofilaments stains to rule out diffuse axonal injury. Bielschowsky stain showed preservation of axonal cytoskeleton. Luxol fast blue was unremarkable for demyelination. Beta amyloid and Tau stains were negative for beta amyloid and Tau deposits, respectively. Phosphorylated neurofilaments staining showed relative loss of expression in the corpus callosum highlighting the persistent cytoskeletal abnormalities that have been attributed to diffuse axonal injury. Traumatic injuries have been demonstrated to result in reductions in the inter filament spacing post injury, either due to altered phosphorylation or proteolysis of the side arms (NF compaction) (Siedler). NF compaction leads to decreased immunoreactivity to the neurofilaments stain, and can been seen as early as 6hrs (Ann Mae DiLeonardi). Our case showed loss of neurofilaments even after a prolong survival of 32 years, suggestive of a far longer time-course of changes following injury. In acute and subacute setting of diffuse axonal injury β- Amyloid precursor protein (APP) accumulate in the axonal swelling and terminal bulbs and APP is enzymatically cleaved to generate Aβ peptides. Geddes et.al showed axonal bulbs consistently lose positive β-APP labeling after about a week, and no labeling may be obtained if a nerve fiber was injured more than 30 days before death. In our case, immunohistochemical stains do not highlight the accumulation of Aβ peptides. We purpose use of neurofilaments immunohistochemical stain as a marker for ongoing axonal injuries in traumatic head injury cases with prolong survival. Acad Forensic Pathol. 6(1 Suppl):S-66–S-119. Primary Cardiac Tumors in Infancy: A Case Report [178]C Dominguez C Dominguez ^1. University of South Florida/Instituto Nacional de Medicina Legal y Ciencias Forenses, Brandon, Florida; Find articles by [179]C Dominguez ^1., [180]V Bravo V Bravo ^2. Instituto Nacional de Medicina Legal y Ciencias Forenses, Medellin, Colombia; Find articles by [181]V Bravo ^2., [182]A Duque A Duque ^2. Instituto Nacional de Medicina Legal y Ciencias Forenses, Medellin, Colombia; Find articles by [183]A Duque ^2., [184]AR Perkins AR Perkins ^3. University of South Florida, Tampa, Florida Find articles by [185]AR Perkins ^3. * (BUTTON) Author information * (BUTTON) Copyright and License information ^1. University of South Florida/Instituto Nacional de Medicina Legal y Ciencias Forenses, Brandon, Florida; ^2. Instituto Nacional de Medicina Legal y Ciencias Forenses, Medellin, Colombia; ^3. University of South Florida, Tampa, Florida [186]PMC Copyright notice Abstract Primary cardiac tumors leading to sudden death in infancy are rare. Here, we describe a case of a primary cardiac fibroma that first presented as sudden death in an infant. An 8.36-month-old male infant, without any previous medical history, died suddenly in the city of Medellin-Antioquia, Colombia. The family stated that approximately 15 minutes after he received a bottle-feeding, the baby became cyanotic and subsequently lost consciousness. He was taken to the hospital immediately; however, he arrived lifeless. The forensic autopsy revealed a well developed infant with central and peripheral cyanosis, without signs of trauma. The internal examination revealed a single cardiac tumor in the anterior region of the left ventricle. The mass was white and whorled; microscopic findings were compatible with fibroma. The manner of death was natural due to cardiogenic shock and the cause of dead was determined as a primary cardiac tumor. Fibromas are the second most frequent primary tumor in the pediatric population, they can cause multiple symptoms including outflow obstruction, arrhythmias, syncopal episodes and sudden death. Grossly they are solitary, well-circumscribed intramural lesions, that are homogenous white in color. These tumors originate from fibroblasts of the connective tissue and the majority are located in the free wall of the left ventricle or the intraventricular septum. Histological examination shows an unecapsulated neoplasm comprised of fusiform cells without atypia that infiltrate and displace the normal underlying myocardium. There may be areas of calcification and occasional foci of necrosis or areas of cystic degeneration due to it's large growth. Consideration of this entity, information about the pre and postnatal history, along with the circumstances of the death, and autopsy findings are important for the accurate determination of the cause and manner of death. Also it is important to determine the prevalence of this entity in our population. Acad Forensic Pathol. 6(1 Suppl):S-66–S-119. Pericardial Tamponade in a 2-Month Old Infant [187]CC Stacy CC Stacy ^1. University of Missouri, School of Medicine, Columbia, Missouri; Find articles by [188]CC Stacy ^1., [189]D Duff D Duff ^2. University of Missouri Columbia, School of Medicine, Columbia, Missouri Find articles by [190]D Duff ^2. * (BUTTON) Author information * (BUTTON) Copyright and License information ^1. University of Missouri, School of Medicine, Columbia, Missouri; ^2. University of Missouri Columbia, School of Medicine, Columbia, Missouri [191]PMC Copyright notice Abstract This is the case report of the sudden unexpected death of a two-month old infant male due to an acute pericardial tamponade due to a ruptured coronary artery aneurysm due to Kawasaki's disease. The infant was a term delivery with no issues with pregnancy, delivery or neonatal period. He was previously healthy except for recent congestion diagnosed as bronchitis. The mother was breast feeding when the infant suddenly became unresponsive and could not be resusciated. A complete autopsy and infant death workup was performed including high resolution x-rays, metabolic screen, cultures (bacterial and viral) and toxicology. There was no evidence of injury. Cultures, metabolic screen and toxicology were negative. On autopsy 125 cubic centimeters of partly clotted blood was present in the pericardium. The coronary arteries were dilated and partly thrombosed and there were tears of the right and left coronary arteries. On histology there was fibrinous degeneration and lympho-histocytic infiltrates of the coronary artery walls. A similar vascular degeneration was present within vessels of the kidneys. The brain was examined by a neuropathologist and there were no findings except for ischemic changes. The diagnosis of Kawasaki's vasculitis was made. This is the leading cause of acquired heart disease of children. This disease occasionally first presents to the medical examiner's office as an sudden unexpected infant death. Acad Forensic Pathol. 6(1 Suppl):S-66–S-119. A Complex Case of Loeys-Dietz Syndrome: An Autopsy Report and Review of the Literature [192]TN Caza TN Caza ^1. SUNY Upstate Medical University, Syracuse, New York; Find articles by [193]TN Caza ^1., [194]A Mercedes A Mercedes ^2. University of Nevada School of Medicine, Las Vegas, Nevada Find articles by [195]A Mercedes ^2., [196]R Stoppacher R Stoppacher ^1. SUNY Upstate Medical University, Syracuse, New York; Find articles by [197]R Stoppacher ^1., [198]C Catanese C Catanese ^1. SUNY Upstate Medical University, Syracuse, New York; Find articles by [199]C Catanese ^1. * (BUTTON) Author information * (BUTTON) Copyright and License information ^1. SUNY Upstate Medical University, Syracuse, New York; ^2. University of Nevada School of Medicine, Las Vegas, Nevada [200]PMC Copyright notice Abstract Loeys-Dietz syndrome, a rare autosomal dominant genetic disorder characterized by germline mutations in the transforming growth factor beta (TGFβ) signaling pathway, is an inherited cause of predisposition to aneurysm formation in children. The underlying connective tissue disease results in dilation and weakening of arterial walls that can lead to aneurysmal rupture, dissection, and sudden cardiac death. In affected individuals, aortic surgery is often required early to prevent rupture or dissection of life-threatening aneurysms, with the timing and technique utilized dependent on the age of the patient, absolute dimension of the aorta, rate of progression of dilatation, genotype, and aortic valve function. A common route of aortic stabilization is via the Bental procedure, where the aortic root is replaced with a porcine aortic valve attached to a Carpentier-Edwards conduit with a second conduit at the transverse arch anastomosed to the native transverse arch. While aortic root stabilization can prevent dissection, there is a risk of graft dehiscence in a growing child, as well as a nidus for infection due to the presence of synthetic material. We identified both of these therapy-related complications in an autopsy of a young girl with Loeys-Dietz syndrome. We present a case of a 6-year old child with Loeys-Dietz syndrome who developed an annular aortic valve abscess and ascending septic dissection of the aorta due to Staphylococcus aureus valve endocarditis. A porcine aortic valve of a Bentall graft was identified as the source of infection. Porcine prosthetic valves increase the risk of infectious endocarditis, aortic stenosis, and sudden death. Endocarditis of porcine valves usually affects the cusps, with annular infection being uncommon, where both vegetations and annular abscess were identified in the decedent. Aortic valve endocarditis led to aortic insufficiency and stenosis with partial dehiscence of the graft material. The increased pressures within the aortic root caused further dilatation, surrounding the graft, leading to dissection of the aorta, hemodynamic decompensation and death. Within this case, multiple complications from Loeys-Dietz syndrome were seen in a single patient, including prosthetic valve infection, aortic root aneurysm and dissection, and septic emboli. Loeys-Dietz syndrome should be considered in the differential diagnosis, along with Marfan's and vascular Ehlers-Danlos’ syndrome, when an aortic root aneurysm or dissection is seen in a child. Screening of family members should also be considered, due to the autosomal dominant inheritance of this disorder. Acad Forensic Pathol. 6(1 Suppl):S-66–S-119. Fatal Rotavirus Infection in a Four-Year Old with Unsuspected Autoimmune Adrenal Insufficiency [201]A Krywanczyk A Krywanczyk ^1. University of Vermont Medical Center, Burlington, Vermont; Find articles by [202]A Krywanczyk ^1., [203]EA Bundock EA Bundock ^2. Vermont Office of the Chief Medical Examiner, Burlington, Vermont Find articles by [204]EA Bundock ^2. * (BUTTON) Author information * (BUTTON) Copyright and License information ^1. University of Vermont Medical Center, Burlington, Vermont; ^2. Vermont Office of the Chief Medical Examiner, Burlington, Vermont [205]PMC Copyright notice Abstract The diagnosis of adrenal insufficiency is often delayed, as the presenting symptoms of fatigue, abdominal pain, and anorexia are vague and nonspecific. However, timely diagnosis and treatment with replacement steroids are needed to prevent fatal adrenal crisis. While the most common cause of primary adrenal insufficiency in childhood is congenital adrenal hyperplasia, a significant minority (up to 15%) is caused by autoimmune destruction of the gland. We present a case of a four year old, previously healthy child who had a one day history of nausea and vomiting, and was found unresponsive by her caretaker. Despite emergency rescue and transport to the hospital, she was pronounced dead. At autopsy, the adrenal glands were atrophied. Histologic examination revealed lymphocytic infiltration of the bilateral adrenal glands, consistent with autoimmune adrenal insufficiency. PCR detection was positive for rotavirus. The cause of death was determined to be adrenal crisis in the setting of rotavirus gastroenteritis due to adrenal insufficiency (Addison's Disease). Acad Forensic Pathol. 6(1 Suppl):S-66–S-119. Secondary Pseudohypoaldosteronism Presenting as Sleep-Related Sudden Unexpected Infant Death [206]ME Quinn ME Quinn ^1. University of Colorado School of Medicine, Aurora, Colorado; Find articles by [207]ME Quinn ^1., [208]KC Lear-Kaul KC Lear-Kaul ^2. Arapahoe County Coroner's Office, Centennial, Colorado Find articles by [209]KC Lear-Kaul ^2. * (BUTTON) Author information * (BUTTON) Copyright and License information ^1. University of Colorado School of Medicine, Aurora, Colorado; ^2. Arapahoe County Coroner's Office, Centennial, Colorado [210]PMC Copyright notice Abstract We present a case of a 2-month old formula-fed male infant who was placed to sleep supine and found unresponsive approximately 2 hours later. He was transported to a local emergency department where he was pronounced dead. His history was significant for premature birth at 30 weeks due to severe maternal preeclampsia with intrauterine growth restriction. He was discharged from the NICU eight days prior to his death. Autopsy examination revealed a small-for-age infant with no gross pathologic findings. The adrenal glands were grossly and microscopically unremarkable. Histology revealed acute pyelonephritis. Vitreous electrolyte analysis demonstrated markedly decreased sodium (91 mmol/l) and chloride (81 mmol/l) with mild potassium elevation (10 mmol/l), consistent with antemortem hyponatremia. Postmortem metabolic screening for congenital adrenal hyperplasia (CAH 17-OHP) was negative. Severe hyponatremia and hyperkalemia due to salt-wasting with resultant dehydration is life-threatening in the neonatal period. The differential for hyponatremia in infants includes natural causes such as vomiting and diarrhea, salt-wasting nephropathies, and endocrine dysfunctions, as well as external etiologies including water intoxication from diluted infant formula. Endocrine etiologies include primary aldosterone resistance as a result of congenital adrenal hyperplasia (CAH), adrenal hypoplasia (AHC), aldosterone synthase deficiency, or secondary aldosterone resistance (pseudohypoaldosteronism). The underlying pathophysiology of aldosterone resistance (AR) or pseudohypoaldosteronism (PHA) is unresponsiveness of the renal tubules to aldosterone. Patients present with hyponatremia, hyperkalemia, and metabolic acidosis in the setting of elevated plasma aldosterone and renin. Primary AR encompasses a group of congenital disorders of the renal tubular epithelium resulting in mineralocorticoid resistance causing insufficient potassium and hydrogen secretion. Secondary AR, on the other hand, can occur as a result of genitourinary problems due to or resulting in obstruction, infection, or inflammation, to include obstructive uropathy, pyelonephritis, tubulointerstitial nephritis, and drug effects. Renal inflammation is presumed to result in transient decreased responsiveness to aldosterone. This case underscores the importance of vitreous electrolyte analysis in sudden unexpected infant deaths. The forensic pathologist must be aware of the possibility of congenital adrenal disorders in a baby who develops a salt-losing crisis in the first few weeks of life, or with decreased sodium and increased potassium on post-mortem vitreous analysis. In addition to congenital disorders, causes of secondary AR must be ruled out. Structural anomalies of the genitourinary tract may be significant contributors. A careful and detailed history is also needed from the infant's caretaker to exclude external sources such as water intoxication. Acad Forensic Pathol. 6(1 Suppl):S-66–S-119. Rat Bite Fever with Streptobacillus moniliformis Meningitis and Myocarditis Resulting in the Death of a 7-Month Old Infant [211]HL Reinhard HL Reinhard ^1. Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania; Find articles by [212]HL Reinhard ^1., [213]A Spencer A Spencer ^1. Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania; Find articles by [214]A Spencer ^1., [215]WK Ross WK Ross ^1. Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania; Find articles by [216]WK Ross ^1., [217]T Reinhard T Reinhard ^2. Dauphin County Coroner's Office, Harrisburg, Pennsylvania Find articles by [218]T Reinhard ^2. * (BUTTON) Author information * (BUTTON) Copyright and License information ^1. Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania; ^2. Dauphin County Coroner's Office, Harrisburg, Pennsylvania [219]PMC Copyright notice Abstract Rat bite fever is a rare, systemic illness most commonly caused by Streptobacillus moniliformis in North America and Spirillum minus in Asia. The most common method of transmission is direct inoculation via a rodent or consuming contaminated food or water. The illness is characterized by relapsing fever, myalgias, and migratory arthralgias followed by a maculopapular rash on the extremities. The most serious complications of rat bite fever include bronchopneumonia, endocarditis, and meningitis. Although rat bite fever is easily treatable with antibiotics, when left untreated it can be a rapidly fatal illness. We report the case of a previously healthy 7-month-old male who was bitten on the finger by a rat, which the family raised for their pet snakes. The infant presented to the emergency department with a fever and skin rash the day of the bite. At that time, he was diagnosed with a viral exanthem and sent home. Two days later, the infant returned to the emergency department with lethargy and jaundice. During his transfer to a larger medical facility, the infant went into cardiac arrest and eventually expired despite resuscitative efforts. Post-mortem examination revealed an erythematous lesion on the upper outer region of the right arm, scleral icterus, cerebral edema with a brown fluid collection over the left temporal pole, bilateral ventricular dilation of the heart, and pulmonary edema with congestion. There were no overt bite marks appreciated on his fingers. Histopathological examination demonstrated meningitis and encephalitis of the brain, focal thromboemboli and congestive changes in the lungs, and the heart showed evidence of myocarditis. PCR testing of the brain tissue was positive for S. moniliformis. After forensic causation analysis, the cause of death was determined to be complications of meningitis and myocarditis by S. moniliformis. Although rat bite fever is a rare illness, it should remain as a differential diagnosis when there are pet rats in the house and in areas of poverty or poor sanitation. Acad Forensic Pathol. 6(1 Suppl):S-66–S-119. Cerebral Toxoplasmosis: A Case Report with Correlation of Radiographic Imaging, Surgical Pathology, and Autopsy Findings [220]WT Harrison WT Harrison ^1. Duke University Medical Center, Durham, North Carolina; Find articles by [221]WT Harrison ^1., [222]CM Hulette CM Hulette ^1. Duke University Medical Center, Durham, North Carolina; Find articles by [223]CM Hulette ^1., [224]L Havrilla L Havrilla ^1. Duke University Medical Center, Durham, North Carolina; Find articles by [225]L Havrilla ^1., [226]M Aurelius M Aurelius ^2. North Carolina Office of the Chief Medical Examiner, Raleigh, North Carolina Find articles by [227]M Aurelius ^2. * (BUTTON) Author information * (BUTTON) Copyright and License information ^1. Duke University Medical Center, Durham, North Carolina; ^2. North Carolina Office of the Chief Medical Examiner, Raleigh, North Carolina [228]PMC Copyright notice Abstract Toxoplasmosis is caused by infection with the protozoa Toxoplasma gondii that is transmitted by consumption of infectious oocysts in cat feces, consumption of tissue cysts in meat, and transplacental transfer of tachyzoites from mother to fetus. Cerebral toxoplasmosis is a potentially fatal disease that most commonly occurs in immunocompromised individuals, such as transplant patients and those infected with human immunodeficiency virus (HIV). If left untreated, the consequences can be catastrophic; however, accurate clinical diagnosis can be difficult as the imaging findings can overlap with lymphoma or metastatic disease. We present the case of a 77-year-old woman with a recent history of diffuse large B-cell lymphoma, now in remission, and remote ductal carcinoma in-situ of the the left breast, who presented with worsening right sided weakness. Repeat magnetic resonance imaging (MRI) scans of the head were notable for multiple enhancing lesions throughout both cerebral hemispheres concerning for multifocal metastatic disease. A biopsy was performed and the histologic sections demonstrated a dense T-cell lymphocytic infiltrate consistent with encephalitis/vasculitis. No organisms were identified. Unfortunately, her neurological status rapidly declined and she died. The family requested and consented for an autopsy, which revealed multiple necrotic lesions in the brain. Microscopic examination with immunohistochemical staining for Toxoplasma gondii demonstrated numerous cysts and tachyzoites. The heart also demonstrated patchy myocarditis with rare toxoplasma cysts. Heightened awareness of the occurrence of cerebral toxoplasmosis is needed among practicing autopsy pathologists and medical examiners, as imaging can be non-specific and surgical biopsies non-contributory. This case emphasizes the importance of consented hospital autopsy cases for quality improvement by uncovering previously undiagnosed major findings that may affect patient outcome or treatment. Acad Forensic Pathol. 6(1 Suppl):S-66–S-119. Rapidly Fatal Bacillus cereus Sepsis in a Neutropenic Pediatric Oncology Patient [229]DS Bumgarner DS Bumgarner ^1. Loyola University Medical Center, Maywood, Illinois Find articles by [230]DS Bumgarner ^1. * (BUTTON) Author information * (BUTTON) Copyright and License information ^1. Loyola University Medical Center, Maywood, Illinois [231]PMC Copyright notice Abstract We present the case of a 15-year-old male with history of chemotherapy related neutropenia who presented to Lurie Children's Hospital Emergency Department (ED) with abdominal pain and intractable vomiting. He had been discharged from the same institution five days earlier after multiple rounds of chemotherapy related to a recent diagnosis of Acute Myeloid Leukemia (AML). Aside from neutropenia, the patient was in relative good health, with a recent bone marrow biopsy free of residual disease. After several uneventful days at home, the patient went to a local Thai restaurant with a family member. Within 12 hours of food consumption, the patient developed abdominal pain and vomiting. He was taken to the Lurie Children's ED where he rapidly decompensated with profound hypotension and bilateral pulmonary edema. Blood cultures were drawn and revealed Bacillus cereus infection. Labs revealed profound neutropenia, thrombocytopenia, and elevated hepatic enzymes. The patient ultimately died 24 hours after the relevant meal. The family requested a below the neck autopsy. Gross findings included multiple ulcerations of the proximal duodenal mucosa and congested, edematous bilateral lungs. Histology revealed the unique finding of zonal coagulative necrosis throughout the liver. The necrosis was not associated with acute or chronic inflammation. Within the necrotic zones were multiple aggregates of gram positive bacilli compatible with B. cereus. B. cereus emetic gastroenteritis is usually a self limiting disease with symptoms consisting of abdominal pain, nausea, and vomiting. Symptoms are initiated by a heat-stable enterotoxin produced by the spore-forming organism. Morphologically, B. cereus is a rod-shaped, gram positive bacterium which displays gray, opaque colonies on sheep agar plates. Immunocompetent patients usually display a 1 to 6 hour incubation period followed by a symptomatic period of approximately 9 to 12 hours. A review of the literature revealed several case reports and studies which suggest neutropenic patients with underlying hematologic malignancies are more susceptible to sepsis caused by B. cereus than other populations. AML, the underlying malignancy in this case, is the most common form of leukemia seen in cases of B. cereus sepsis. Autopsy findings also mirror those found in this case, with zonal liver coagulative necrosis and bacterial infiltration present with little accompanying inflammation. Given our findings and those present in the literature, we suspect the patient consumed food contaminated by B. cereus which was able to translocate through the chemotherapy damaged intestinal mucosa leading to clinical sepsis and the histological abnormalities of the liver. Acad Forensic Pathol. 6(1 Suppl):S-66–S-119. “When Opportunity Knocks”: A Case Report of Numerous Opportunistic Pathogens as a Source of Sepsis in a Patient with Extensive Metastatic Cancer [232]F Bilimoria F Bilimoria ^1. Allegheny Health Network, Pittsburgh, Pennsylvania Find articles by [233]F Bilimoria ^1., [234]S Reed S Reed ^1. Allegheny Health Network, Pittsburgh, Pennsylvania Find articles by [235]S Reed ^1., [236]E Lynch E Lynch ^1. Allegheny Health Network, Pittsburgh, Pennsylvania Find articles by [237]E Lynch ^1., [238]JF Silverman JF Silverman ^1. Allegheny Health Network, Pittsburgh, Pennsylvania Find articles by [239]JF Silverman ^1. * (BUTTON) Author information * (BUTTON) Copyright and License information ^1. Allegheny Health Network, Pittsburgh, Pennsylvania [240]PMC Copyright notice Abstract Multiple processes can occur in a patient with an uncontrolled tumor growth that can cause the patient to present appearing immunocompromised. At the molecular level, tumor cells are capable of secreting cytokines that directly affect the immune system. Vascular Endothelial Growth Factor in particular has been identified as a cytokine secreted that inhibits dendritic cell maturation, alters T:B cell ratios, and promotes angiogenesis to support tumor growth. Here we present a 78-year Caucasian male with an extensive medical and surgical history who presented to the hospital due to an inability to tolerate oral intake due to gastric outlet obstruction. The patient's course of illness started approximately 4 months earlier with multiple admissions to outside hospitals for his symptoms. Multiple pancreatic duct brushing were attempted due to concerns of pancreatic cancer; however all cytology specimens were negative for carcinoma. During his time admitted, the patient was transferred multiple times to the intensive care unit due to recurring septic shock, however no source of sepsis was ever identified. After one month with progressively worsening symptoms, the patient's family withdrew aggressive treatment and he passed away. Post-mortem examination showed the patient's entire biliary tract to be firm, thickened and dilated. Histological examination showed malignant cells consistent with gallbladder adenocarcinoma, pancreatobiliary type. Metastasis to neighboring organs, lymph nodes, and the urinary bladder was identified. Multiple opportunistic infections were identified that were not documented prior to the patient's death. Mucormycosis was identified in the alveolar space, the bronchial artery walls, and within the arterial lumen in the right upper lung lobe; and in the mucosa, submucosal artery walls, and the within the arterial lumen of the stomach. Cytomegalovirus infected cells were identified in the middle right and lower lung lobes, and in the sampled lymph nodes. Bacterial colonies were identified in the lower lung lobes, the intra-hepatic biliary ducts, and within the pseudomembranous ileocolitis. This case demonstrates how disruptive malignant cells can be to a patient's immune system. In this reported case, the patient's immune system was so compromised from an uncontrolled malignancy that it mimicked the findings in untreated immunocompromised patients with multiple opportunistic pathogens being identified post-mortem. Acad Forensic Pathol. 6(1 Suppl):S-66–S-119. A Preliminary Study on Postmortem Interval Estimation by HILIC-MS Based Metabolomics Approach of Postmortem Myocardium [241]T Du T Du ^1. School of Basic Medical Sciences, Fudan University, Shanghai, China; Find articles by [242]T Du ^1., [243]y Shen y Shen ^1. School of Basic Medical Sciences, Fudan University, Shanghai, China; Find articles by [244]y Shen ^1., [245]Z Zhao Z Zhao ^1. School of Basic Medical Sciences, Fudan University, Shanghai, China; Find articles by [246]Z Zhao ^1., [247]J Xie J Xie ^1. School of Basic Medical Sciences, Fudan University, Shanghai, China; Find articles by [248]J Xie ^1., [249]A Xue A Xue ^1. School of Basic Medical Sciences, Fudan University, Shanghai, China; Find articles by [250]A Xue ^1., [251]K Ma K Ma ^2. Criminal Science and Technology Institute, Shanghai Public Security Bureau, Shanghai, China Find articles by [252]K Ma ^2., [253]Z Lin Z Lin ^1. School of Basic Medical Sciences, Fudan University, Shanghai, China; Find articles by [254]Z Lin ^1., [255]Y Wu Y Wu ^1. School of Basic Medical Sciences, Fudan University, Shanghai, China; Find articles by [256]Y Wu ^1., [257]Y Xie Y Xie ^1. School of Basic Medical Sciences, Fudan University, Shanghai, China; Find articles by [258]Y Xie ^1., [259]X Ye X Ye ^1. School of Basic Medical Sciences, Fudan University, Shanghai, China; Find articles by [260]X Ye ^1. * (BUTTON) Author information * (BUTTON) Copyright and License information ^1. School of Basic Medical Sciences, Fudan University, Shanghai, China; ^2. Criminal Science and Technology Institute, Shanghai Public Security Bureau, Shanghai, China [261]PMC Copyright notice Abstract Estimation of postmortem interval (PMI) is one important challenge in forensic pathology. It is difficult to obtain the true PMI because there are a set of factors that interfere with the estimation of PMI. Several methods have been used for the measurement of PMI and new approaches are also developed including some new methods and new materials. In this study, we used metabolomics technology to detect PMI-related metabolites. Metabolomics broadly aims to measure the systemic metabolic changes over time in multicellular systems and can be defined as the comprehensive analytical approach for the study of all low molecular weight biochemical, including sugars, amino acids, organic acids, nucleotides, and lipids from biological specimens, and Metabolomics allows the analysis of hundreds of metabolites from complex biological samples with a high throughput, providing information regarding the metabolism of the organism, and is considered to be an unbiased and nontargeted approach. Myocardium was collected through a realistic natural conditions animal model (0,24,48,72,96, and 120h; n=6), and combined HILIC-MS based on metabolomics was performed. Our results showed that the trend in PLS-DA was related to PMI and identified 251 metabolites that had more dependence on PMI. We found only eight qualitative kinds of metabolites by comparing the network database, although all of these metabolites might be suitable candidates for the estimation of PMI. The changes of concentrations of metabolites vary after death. We try to use a set of multiple parameters, which will increase the accuracy and stability of the estimation. In addition, we expect that HILIC-MS based metabolomics model can be sensitive enough to study death time with small amount of tissues, and help in understanding changes in endogenous metabolites with forensic investigations. All in all, we suggest that metabolomics of myocardium (even other tissues) can be used in the study of PMI by HILIC-MS in the future. Acad Forensic Pathol. 6(1 Suppl):S-66–S-119. Correlation between Postmortem Interval and Degradation of 18S rRNA and Beta-Actin RNA in Liver after Death under the Condition of Variant Temperature [262]D Zhao D Zhao ^1. China University of Political Science and Law, Beijing, China Find articles by [263]D Zhao ^1., [264]T Yang T Yang ^1. China University of Political Science and Law, Beijing, China Find articles by [265]T Yang ^1. * (BUTTON) Author information * (BUTTON) Copyright and License information ^1. China University of Political Science and Law, Beijing, China [266]PMC Copyright notice Abstract Postmortem interval (PMI) is the interval between the time when the dead body was examined and the time when the death occurred. The high error rate of the current methods for PMI estimation can not meet the needs of forensic casework in many occasions, so the forensic scholars have always been full of expectation for better new methods for PMI estimation. DNA and RNA degradation happens along with tissue autolysis after the death of the body until complete decomposition. To investigate the relationship between Ct values of mice liver and PMI under various ambient temperatures, mice were stored at 10°C,15°C,20°C,25°C, and 30°C after execution, and total RNA was extracted from mice liver every 6 hours (PMI 6h to 72h). The levels of 18S rRNA and beta-actin RNA were examined using real-time PCR. The results were expressed by cycle threshold (Ct) values to explore relationship between PMI and Ct values, and the Interpolation functions were established to estimate PMI. In each group, Ct values increased along with extended PMI. The three-variable quintic surface equations were obtained after interpolation analysis on temperature range from 10°C to 30°C. The rule of Ct value changes at ambient temperature complied with three-variable quintic surface equation distribution. The three-variable quintic surface equation for 18S rRNA was [MATH: f(x,y)=−426.9+ 30.82x+44.48y−1.2 97x2−1.837xy−1.388y2< mo>+0.03438x3+0.03817x2y+0.03867xy2< /mn>+0.02877y3< mo>−0.0006129x4−< mn>3.897e−07< msup>x3y− 0.001223x2y2+0.0002566x< /mi>y3−0.0005374 y4+3.606e−06x5< mo>−2.846e−06x4y+1.009e− 05x3y2−3.439e− 06x2y3−2.556e −07xy4 +2.664e−06y5(R2=0 .9994). :MATH] The three-variable quintic surface equation for beta-actin RNA was [MATH: f(x ,y)=−104 .7−0.8324x+0.2868 y+0.03114x2+< /mo>0.4716xy+0.4078< mi>y2−0.0004598x< mn>3−0.01113< mi>x2y−0.03162xy2−0.009044 y3+3.831e−06x4+ 0.0001181x3y+ 0.0005082x2y2+0.0004224xy3+9.099< mi>e−05y4 +5.105e−08x5−7. 57e−07< mi>x4y−1.092e −06x3y2−5.766 e−06x 2y3+1.805e−07 xy4−5.294e−07y 5(R2< /msup>−0.9963). :MATH] Based on this study, measurement of interpolation function may be applicable for PMI estimation at ambient temperature. Acad Forensic Pathol. 6(1 Suppl):S-66–S-119. Interpolation Analysis: A New Method in Estimating the Time of Death at Ambient Temperature [267]J Zhuqing J Zhuqing ^1. Key Laboratory of Evidence Science, China University of Political Science and Law, Beijing, China; Find articles by [268]J Zhuqing ^1., [269]Y Meng Y Meng ^1. Key Laboratory of Evidence Science, China University of Political Science and Law, Beijing, China; Find articles by [270]Y Meng ^1., [271]Z Dong Z Dong ^1. Key Laboratory of Evidence Science, China University of Political Science and Law, Beijing, China; Find articles by [272]Z Dong ^1., [273]Z Xiang Z Xiang ^2. The Chief Office of Medical Examiner, Baltimore, Maryland Find articles by [274]Z Xiang ^2., [275]L Ling L Ling ^2. The Chief Office of Medical Examiner, Baltimore, Maryland Find articles by [276]L Ling ^2., [277]Y Tiantong Y Tiantong ^1. Key Laboratory of Evidence Science, China University of Political Science and Law, Beijing, China; Find articles by [278]Y Tiantong ^1. * (BUTTON) Author information * (BUTTON) Copyright and License information ^1. Key Laboratory of Evidence Science, China University of Political Science and Law, Beijing, China; ^2. The Chief Office of Medical Examiner, Baltimore, Maryland [279]PMC Copyright notice Abstract Objective: Determination of postmortem interval (PMI) is one of the most difficult and important work in forensic practice. Historically, there have been numerous models proposed to estimate time of death. However, medico-legal experts failed to achieve a breakthrough in the determination of the time of death, due to all postmortem changes are strongly influenced by unpredictable endogenous and environmental factors. Accumulated evidence indicates that ambient temperature is one of the main influencing factors. In this study, we applied mathematical method of interpolation function fitting to establish a three-dimensional surface equation of ATP postmortem changes. These mathematical methods are imposed to avoid or minimize the effects of ambient temperature variations. Methods: Blood specimens were obtained from 48 volunteers. These specimens were stored at 10°C, 15°C, 20°C, 25°C, 30°C, and 35°C temperature respectively. At different time points, ATP concentrations in the blood samples were measured using an ATP fluorescence rapid detector, and then displayed on the detector screen in the form of relative light units (RLU). Relationship between PMI and ATP degradation levels was investigated statistically by SPSS 17.0 and MATLAB 10.0 software. Statistical analysis, curve-fitting, interpolation analysis and surface-fitting were performed. Results: The result showed blood ATP concentration decreased after sampling and the change rate of ATP concentrations were different at different temperature. The blood ATP concentration decreased more rapidly at higher temperature when compared to the lower temperature. However, there were a strong negative correlation between the blood ATP level at the same temperature and PMI. We obtained six regression equations (R^2=0.976-0.990) with RLU values at PMIs of 228 h (10°C), 156 h (15°C), 116 h (20°C), 84 h (25 °C), 64 h (30°C) and 56 h (35°C). The changing rate of ATP concentration at different temperature at different PMI can be described by three-variable fourth degree equation. The interpolation function (R^2=0.959) was established with PMI as the dependent variable (z), RLU value as independent variable (x) and temperature as independent variable (y). Conclusion: We developed a mathematical model to estimate the PMI by introducing temperature variable, and widened the estimation from a two-dimensional surface to three-dimensional space. The theoretical and experimental investigations lay a solid foundation for potential application and exploratory studies, with the ultimate goal of increasing the accuracy of PMI estimation. Acad Forensic Pathol. 6(1 Suppl):S-66–S-119. Postmortem Bacteriology and Postmortem Interval: Useful or Not? [280]RJ Asch-Kendrick RJ Asch-Kendrick ^1. Johns Hopkins Hospital, Baltimore, Maryland; Find articles by [281]RJ Asch-Kendrick ^1., [282]J Camacho J Camacho ^1. Johns Hopkins Hospital, Baltimore, Maryland; Find articles by [283]J Camacho ^1., [284]S Riedel S Riedel ^2. Beth Israel Deaconess Medical Center, Boston, Massachusetts Find articles by [285]S Riedel ^2., [286]JE Hooper JE Hooper ^1. Johns Hopkins Hospital, Baltimore, Maryland; Find articles by [287]JE Hooper ^1. * (BUTTON) Author information * (BUTTON) Copyright and License information ^1. Johns Hopkins Hospital, Baltimore, Maryland; ^2. Beth Israel Deaconess Medical Center, Boston, Massachusetts [288]PMC Copyright notice Abstract Background: The utility of postmortem microbiology is an unsettled topic with contradictory literature. Many researchers postulate that positive autopsy cultures do not reflect clinical reality but are a result of agonal spread, transmigration of bacteria from the bowel, or external contamination at the time of collection. Our goal was to quantify and assess validity and reliability of pre and postmortem cultures over a defined time period in a major academic center. Design: We performed a retrospective review of postmortem cultures from a large academic medical center. Our autopsy database was searched from 2001 through 2014. Premortem culture results were also obtained from within 31 days prior to death. Our population included all live-born autopsies (no intrauterine fetal demise). Data collected included age, gender, race, postmortem interval, cause of death, major diseases, types and results of pre and postmortem blood and tissue cultures. Results: Two hundred and twenty-five cases were identified. Of these cases, 104 (80 adult and 20 pediatric) had premortem cultures performed. Of the cases with both pre and postmortem cultures, 32 showed positive pre and postmortem cultures, and 72 showed negative premortem cultures and positive postmortem cultures. The pediatric population had lower rates of conversion from negative premortem cultures to positive postmortem cultures. Our mean postmortem interval was 24.1 hours. When conversion rates were compared between short postmortem intervals, defined as less than 24.1 hours, and long postmortem intervals, defined as greater than 24 hours, the results were quite similar. Conclusion: Our results indicate that an extended postmortem interval does not alter the percentages of positive postmortem cultures, particularly in relationship to premortem results. This finding mitigates against the common argument that positive postmortem culture results are created by transmigration of bacteria from degenerating bowel. Thus, postmortem cultures may have greater validity than previously considered. It may also be more likely that false positive results are created by contamination during collection. Informed by the results of the retrospective analysis, the second phase of this study will include prospective blood and tissue culture of patients with and without proven premortem sepsis including evaluation of soft tissue and bowel sites. Also, physical tools and the autopsy environment will be cultured to analyze them as possible influences on postmortem culture results. A standard for postmortem collection in hospital and forensic cases is long overdue and our future studies hope to elaborate on the optimal methods for avoiding contamination. Acad Forensic Pathol. 6(1 Suppl):S-66–S-119. Rabbit Plasma-Based Postmortem Interval Determination with Attenuated Total Reflectance-Fourier Transform Infrared Spectroscopy in Combination with Chemometrics [289]J Zhang J Zhang ^1. Xi'an Jiaotong University, Xi'an, China Find articles by [290]J Zhang ^1., [291]Z Wang Z Wang ^1. Xi'an Jiaotong University, Xi'an, China Find articles by [292]Z Wang ^1. * (BUTTON) Author information * (BUTTON) Copyright and License information ^1. Xi'an Jiaotong University, Xi'an, China [293]PMC Copyright notice Abstract Postmortem interval (PMI) determination is one of the most challenging tasks in forensic medicine due to a lack of accurate and reliable methods. It is especially difficult for late PMI determination. Although many attempts with various types of body fluids based on chemical methods have been made to solve this problem, few investigations are focused on blood samples. In this study, we employed an attenuated total reflection (ATR)-Fourier transform infrared (FTIR) spectroscopy coupled with principle component analysis (PCA) to monitor biochemical changes in rabbit plasma of increasing PMI. Partial least square-discrimination analysis (PLS-DA) was used based on the spectral data for PMI prediction in an independent sample set. Our results revealed that postmortem chemical changes in different compositions of the plasma was time-dependent and various components including proteins, lipids and nucleic acids contributed to the discrimination of the samples from different time points. A satisfactory prediction within 48h postmortem was performed by the combined PLS-DA model with a good fitting between actual and predicted PMI of 0.98 and with error of ±3.03 h. In consideration of the simplicity and portability of ATR-FTIR, our study demonstrates the great potential of this technique as an alternative method to rapidly determine the time of death with body fluids at a crime scene. Acad Forensic Pathol. 6(1 Suppl):S-66–S-119. Gunshot Wound to the Head: Is it Suicide? [294]A Covach A Covach ^1. University of Wisconsin Hospital and Clinics, Madison, Wisconsin Find articles by [295]A Covach ^1., [296]R Corliss R Corliss ^1. University of Wisconsin Hospital and Clinics, Madison, Wisconsin Find articles by [297]R Corliss ^1. * (BUTTON) Author information * (BUTTON) Copyright and License information ^1. University of Wisconsin Hospital and Clinics, Madison, Wisconsin [298]PMC Copyright notice Abstract Background: In 2013, suicide was the tenth leading cause of death in the United States, accounting for 1.7% of deaths overall. This number is disproportionately represented in a medical examiner office's case load, with up to 10% of cases being classified as suicide in some offices. Firearm use accounts for a reported 32.3% of suicides in women and 56.9% of suicides in men. We present a case of an apparent firearm suicide by a right handed woman. The intermediate range gunshot wound was to the left temple, and the weapon was atypically positioned partially in the left hand. The body was discovered and reported to the local 911 dispatcher by her husband. Scene investigation did not reveal a suicide note. Methods: Autopsy was performed in the usual manner, with a review of the literature. Results: The cause of death was a gunshot wound to the left frontotemporal scalp, with a circular stippling pattern measuring 1.4 cm in diameter surrounding the entrance wound defect. The projectile traveled through the frontal lobes of the brain and was recovered from the right temporal epidural space. Recovered from the scene was a Lorcin L-22 .22 caliber semiautomatic pistol. Blood toxicology was negative for alcohol and illicit drugs. Discussion: Most suicide gunshot wounds to the head are contact range, however, a small percentage of cases classified as suicides (1.9%) are intermediate range. The site in this case is typical for suicide with 74% of firearm entrance wounds being in the temple. The finding of a right handed woman with a left sided entrance wound does raise the suspicion for potential homicide, although suicide with the non-dominant hand has been reported in up to 7.4% of cases. Of greatest concern in this case is the highly atypical positioning of the weapon in the non-dominant hand, with the index finger through the trigger guard, from the right side of the pistol. The presence of a suicide note would have been supportive of suicide, but these are only present in about 25% of cases. Location of the wound(s), number of shots, range, gender, familiarity with and access to firearms, motive, position of the firearm, and social circumstances of each individual case should all be considered when determining the manner of death of an apparent firearm suicide. Following complete investigation and correlation with autopsy findings, this case was signed out as manner undetermined. Acad Forensic Pathol. 6(1 Suppl):S-66–S-119. Keyhole Lesions of the Skull: A Series of Three Cases and a Review of the Literature [299]BJ Platt BJ Platt ^1. Office of the Chief Medical Examiner, Commonwealth of Virginia, Norfolk, Virginia Find articles by [300]BJ Platt ^1., [301]WM Gunther WM Gunther ^1. Office of the Chief Medical Examiner, Commonwealth of Virginia, Norfolk, Virginia Find articles by [302]WM Gunther ^1. * (BUTTON) Author information * (BUTTON) Copyright and License information ^1. Office of the Chief Medical Examiner, Commonwealth of Virginia, Norfolk, Virginia [303]PMC Copyright notice Abstract We describe a case series of three gunshot wounds to the head with keyhole features. The first case involves a 26-year old female with a hard contact gunshot wound from a .38 caliber handgun to the forehead with keyhole features of the frontal bone. The second case involves a 70-year old female with a hard contact gunshot wound to the head from a .22 caliber revolver with keyhole features of the frontal bone. The third case involves a 30-year old male with a distant gunshot wound of the occipital bone from a handgun of unknown caliber, with keyhole features of the left posterior parietal bone. The keyhole gunshot wound, in flat or rounded bones derived from intramembranous ossification such as the skull plates, is classically described as consisting of a rounded portion with internal beveling on the inner table coupled with a triangular portion with external beveling on the outer table as a result of the bullet striking at a tangential angle. Various hypotheses have been described to account for the juxtaposed features of the keyhole lesion: a combination of entrance and exit wounds due to the tangential angle of the gunshot and the competing vertical and tangential force vectors, fragmentation of the bullet upon impact with a bullet fragment exiting and creating the triangular portion of external beveling, gases from the barrel expanding and separating the portions of the fractured skull creating the external beveling, and a sequence of radial and concentric fractures which create intersecting fracture lines that result in a loose chip that exposes external beveling. This case series compares the characteristics of these wounds to the available literature regarding keyhole gunshot wound injuries to the skull. Features of these cases most closely correspond to the tangential angle and bullet fragmentation hypotheses. Scene investigation in one of these cases, correlated with autopsy findings, supported the bullet fragmentation hypothesis. Acad Forensic Pathol. 6(1 Suppl):S-66–S-119. Embolization of Fragmenting “Trocar” Ammunition [304]CR Cunningham CR Cunningham ^1. University of Missouri School of Medicine, Columbia, Missouri Find articles by [305]CR Cunningham ^1., [306]CC Stacy CC Stacy ^1. University of Missouri School of Medicine, Columbia, Missouri Find articles by [307]CC Stacy ^1., [308]DJ Duff DJ Duff ^1. University of Missouri School of Medicine, Columbia, Missouri Find articles by [309]DJ Duff ^1. * (BUTTON) Author information * (BUTTON) Copyright and License information ^1. University of Missouri School of Medicine, Columbia, Missouri [310]PMC Copyright notice Abstract We describe a case of a gunshot wound with fragmenting ammunition consisting of eight relatively lightweight petals or “trocars” and a heavier bullet base. There was a single thoracoabdominal gunshot wound with an entrance wound of the right back. The bullet base traveled through the right kidney and right liver, coming to rest near the right 5th rib. The direction of the shot was forward, leftward and upward. As designed, the petals separated from the bullet base, and there were associated injuries of the right middle and lower lobes of the lung and the left atrium of the heart. Associated with the wounds, there was partial collapse of the right lung, right hemothorax (1,400 ml) and hemoperitoneum (100 ml). Bullet fragments were recovered in the soft tissue near the right kidney, in the right hemidiaphragm, pelvic soft tissue, the right middle lobe of lung and near the small bowel. There were also two bullet fragment emboli, one in the proximal right forearm and one in the right lower leg. These were not identified initially with radiographs of the chest and abdomen. Once the likely type of ammunition was determined, additional radiographs were performed in search of emboli. One embolus may have originated from the perforation of the left atrium. The precise origin of the other embolus was not found. This case describes the wound characteristics of a single round of fragmenting “trocar” ammunition and is a unique example of bullet fragment embolization. Acad Forensic Pathol. 6(1 Suppl):S-66–S-119. Digital Forensic Evidence Cracking Ingenious Murder Cover Up [311]M Chauhan M Chauhan ^1. Maulana Azad Medical College & Associated Hospitals, New Delhi-02., New Delhi-02, India Find articles by [312]M Chauhan ^1., [313]M Pradhan M Pradhan ^1. Maulana Azad Medical College & Associated Hospitals, New Delhi-02., New Delhi-02, India Find articles by [314]M Pradhan ^1., [315]A Aggrawal A Aggrawal ^1. Maulana Azad Medical College & Associated Hospitals, New Delhi-02., New Delhi-02, India Find articles by [316]A Aggrawal ^1. * (BUTTON) Author information * (BUTTON) Copyright and License information ^1. Maulana Azad Medical College & Associated Hospitals, New Delhi-02., New Delhi-02, India [317]PMC Copyright notice Abstract The increasing computational power of the mobile devices has been highly instrumental in the recent past. The information stored in mobile devices can ascertain the movement and location of an individual alongside his contact and communications with others. There are some unique considerations about mobile phones and associated devices if found as a source of evidence. A major advantage of mobile devices from a forensic perspective is that even deleted information can be recovered from mobile devices in criminal investigations. This is due to the utilization of Flash memory chips in which stored information can be erased block-by-block and mobile devices generally wait until a block is full before erasing data. Data associated with mobile phones is found in a number of locations viz: embedded memory, attached removable memory (Storage Device SD Card) and the Subscriber Identity Module (SIM) card. Mobile devices use radio waves to communicate over networks with various frequencies and follow standard communication protocols, the two most common being GSM and CDMA. GSM devices use SIM (Subscriber Identity Module) cards available in different shapes and sizes and comprise of a microprocessor with a unique Integrated Circuit Card Identifier (ICCID) containing the mobile country code (MCC), mobile network code (MNC) and a serial number. A SIM card may also contain a Location Area Identity (LAI) and Temporary Mobile Subscriber Identity (TMSI) which generally change each time a device moves to a new location within the network [1]. Here is reported an unusual case of homicide of an unidentified female who had been strangled, body tied up and disposed in an ingenious manner of body sacking. In this case the recovery of SIM and memory card under the victim's undergarments at autopsy played a key role in the identification of the victim, assailant and motive of homicide. The SIM card handed over to the investigative authority tracked the suspect by the IMSI method of phone tapping and proved to be exclusively important by temporal, relational and functional analysis. The accused was found out to be the live in partner of the already married woman who had left her husband and children 4-5 years back. The objective of this article is to emphasize the importance of digital evidence if found at autopsy. After this presentation, the attendees will learn about the basic mechanism of the mobile phones as an aid in solving crimes. 1) Casey E. Digital evidence and computer crime: forensic science, computers, and the Internet. 3rd ed. Waltham (MA): Academic Press; c2011. Chapter 20, Digital evidence on mobile devices[cited 2016 Sep 7]. Available from: [318]http://booksite.elsevier.com/9780123742681/Chapter_20_Final.pdf. Acad Forensic Pathol. 6(1 Suppl):S-66–S-119. The Role of Computerized Tomography with 3D Reconstruction and Volume Rendering: A Prospective Study of all Lightning and Electrocution Deaths Presenting to the Medico-Legal Laboratory of Pretoria (2013–2016) [319]R Blumenthal R Blumenthal ^1 University of Pretoria, Pretoria, South Africa Find articles by [320]R Blumenthal ^1, [321]NK Morris NK Morris ^1 University of Pretoria, Pretoria, South Africa Find articles by [322]NK Morris ^1, [323]E Van Der Walt E Van Der Walt ^1 University of Pretoria, Pretoria, South Africa Find articles by [324]E Van Der Walt ^1, [325]ZI Lockhat ZI Lockhat ^1 University of Pretoria, Pretoria, South Africa Find articles by [326]ZI Lockhat ^1 * (BUTTON) Author information * (BUTTON) Copyright and License information ^1 University of Pretoria, Pretoria, South Africa [327]PMC Copyright notice Abstract The purpose of this study was to determine what value non-invasive virtual autopsy plays in lightning and electrocution cases. This was a joint study between the Department of Forensic Medicine, University of Pretoria and the Department of Radiology, University of Pretoria. We conducted a prospective study on all lightning- and electrocution deaths presenting to the Medico-Legal Laboratory of Pretoria from 1st June 2013 to 1st June 2016. All cases submitted for forensic examination had whole body computerized tomography with 3D reconstruction and volume rendering prior to medico-legal autopsy examination. All data was treated confidentially. This three-year prospective study was approved by the University of Pretoria's Ethics and Integrity Committee. A summary of the main findings for all low-voltage (<1000 V), high-voltage (>1000 V) and lightning cases will be discussed in the presentation. Acad Forensic Pathol. 6(1 Suppl):S-66–S-119. Rupture of the Left Ventricle Due to Blunt Trauma without Concomitant Injury: A Case Report [328]H Dong H Dong ^1. Tongji Medical College of Huazhong University of Science and Technology, Wuhan, China; Find articles by [329]H Dong ^1., [330]J Mu J Mu ^2. Hebei North University, Zhangjiakou, China Find articles by [331]J Mu ^2., [332]W Lin W Lin ^1. Tongji Medical College of Huazhong University of Science and Technology, Wuhan, China; Find articles by [333]W Lin ^1. * (BUTTON) Author information * (BUTTON) Copyright and License information ^1. Tongji Medical College of Huazhong University of Science and Technology, Wuhan, China; ^2. Hebei North University, Zhangjiakou, China [334]PMC Copyright notice Abstract The heart is relatively well protected within the thoracic cavity from all sides. It is rare that blunt trauma could lead to an isolated cardiac rupture without concomitant injury. Moreover, the heart is primarily ruptured on the thin-walled right ventricle and the atria. The left ventricle is least likely to suffer a rupture but has the highest lethality. Here we present a case of isolated left ventricular rupture due to blunt trauma. A 44-year-old female decedent was autopsied which showed about 250 ml blood and clot in the pericardial cavity and three parallel transmural rupture along the left edge of the ventricle. There was no obvious injury to the chest wall or thoracic viscera. Histological examination revealed no underlying cardiac pathology except myocardial interstitium bleeding. The other parts of the body and organs were unremarkable. The case investigation indicated that the decedent collapsed immediately after the suspect, her lover, swung his elbow to her chest and promptly died, although the suspect thought she played dead for a certain time. We describe and discuss the causality between blunt trauma and cardiac rupture. This case report highlights the need for forensic pathologists to recognize that cardiac rupture may be caused by blunt chest trauma, even without fracture of the thorax bone and visible external injury. Also the forensic pathologist should pay attention to the possible involvement of cardiac resuscitation in the heart rupture. Acad Forensic Pathol. 6(1 Suppl):S-66–S-119. Forensic Analysis of Sudden Death due to Vagal Inhibition: A Case Report with Literature Review [335]Z Yang Z Yang ^1. Institute of Forensic Science PSB Tianjin, Tianjin, China; Find articles by [336]Z Yang ^1., [337]G Qian G Qian ^2. Institute of Criminal Science and Technology Jinhua City PSB, Jinhua, China Find articles by [338]G Qian ^2. * (BUTTON) Author information * (BUTTON) Copyright and License information ^1. Institute of Forensic Science PSB Tianjin, Tianjin, China; ^2. Institute of Criminal Science and Technology Jinhua City PSB, Jinhua, China [339]PMC Copyright notice Abstract Sudden death due to vagal inhibition is a condition that occurs within seconds or a minute or two due to minor trauma or relatively simple and harmless peripheral stimulation. The common causes of vagal inhibition include pressure on the neck particularly on the carotid sinuses, unexpected blows to the larynx, chest, abdomen and genital organs, or sudden immersion of body in cold water. We reported a case of a 25-year-old man was fighting with another young man at a parking lot. According to the witnesses, the two men were wrestling and holding each other in the neck area, and suddenly both fell onto the ground while they were fighting. The other man got up, but the victim was found unconsciously with rapid breath. Resuscitation was performed at scene but unsuccessful. He was pronounced dead at scene. Autopsy was performed the next day. External examination revealed that a 25-year-old, well developed and well-nourished male. There were two abrasions (1.2× 0.3c and 0.3×0.1cm) on the right forehead, a 1×0.3cm abrasion with blood clot on right superciliary ridge, a 1×0.5cm scattered abrasion in the middle of eyebrows, and a 0.5×0.5cm abrasion in the middle of upper lip. Internal examination revealed no evidence of injury to the internal organs. There was no soft tissue hemorrhage in the neck. There were scatted petechiae on the surface of the heart. Histological study showed no significant pathological changes of the internal organs. Postmortem toxicological analysis was negative for alcohol and drugs. Because there was no evidence of injury or natural diseases identified at autopsy, the cause of death was classified as “undetermined”. But sudden cardiac death due to vagal inhibition was likely the mechanism of his death. The sudden death due to vagal inhibition will be discussed and the literature will reviewed. Key words: Sudden Death, Vagal Inhibition, Forensic Autopsy, Death Scene Investigation. Acad Forensic Pathol. 6(1 Suppl):S-66–S-119. “Don't Try to Stop Me:” An Unusual Suicide by Circular Saw [340]F Bilimoria F Bilimoria ^1. Allegheny General Hospital, Pittsburgh, Pennsylvania; Find articles by [341]F Bilimoria ^1., [342]S Reed S Reed ^1. Allegheny General Hospital, Pittsburgh, Pennsylvania; Find articles by [343]S Reed ^1., [344]T Luckasevic T Luckasevic ^2. Allegheny County Medical Examiner's Office, Pittsburgh, Pennsylvania Find articles by [345]T Luckasevic ^2. * (BUTTON) Author information * (BUTTON) Copyright and License information ^1. Allegheny General Hospital, Pittsburgh, Pennsylvania; ^2. Allegheny County Medical Examiner's Office, Pittsburgh, Pennsylvania [346]PMC Copyright notice Abstract Suicide by sharp force trauma represents a minority of cases within the forensic literature, accounting for approximately 1.6 – 3% of completed suicides, and typically involving a stabbing methodology. The use of power tools such as chainsaws, band- or circular saws represents an especially rare occurrence, with only a handful of case reports existing in the literature. The majority of these cases demonstrate injury to the anterior neck and vital vasculature, with associated hesitation or rehearsal marks in close proximity to the fatal wound. Here we report a rare case of suicide by circular saw enacted by a 50-year old Caucasian male, involving an unusual hesitation wound at the lateral orbit, far removed from the fatal wound to the right anterior neck. The decedent experienced a brief period of post-injury survival, during which time he was able to verbally and physically threaten a responding police officer before succumbing to his injuries. Post-mortem examination demonstrated sharp force injury to the right lateral temporal and periorbital regions with associated orbital fracture, in addition to multiple sharp force injuries to the right lateral neck, lacerating the right sternocleidomastoid and omohyoid muscles, and transecting right jugular vein and right carotid artery. A superficial laceration to the left thumb was also identified. Post-mortem toxicology revealed a blood ethanol level of 0.221%. The cause of death was determined to be exsanguination, with the manner of death being suicide. This case demonstrates a rare instance of a violent suicide by circular saw involving a brief period of post-injury survival wherein the decedent could possibly pose a threat to responding officers, thus emphasizing the importance of maintaining personal safety of first responders. Acad Forensic Pathol. 6(1 Suppl):S-66–S-119. Traumatic Dissection of the Portal Vein: An Unusual Cause of Delayed Death Due to Blunt Force Abdominal Injury [347]A Drobysheva A Drobysheva ^1. University of Texas Southwestern Medical Center, Dallas, Texas; Find articles by [348]A Drobysheva ^1., [349]C Schoppe C Schoppe ^2. Southwestern Institute of Forensic Sciences, Dallas, Texas; Find articles by [350]C Schoppe ^2. * (BUTTON) Author information * (BUTTON) Copyright and License information ^1. University of Texas Southwestern Medical Center, Dallas, Texas; ^2. Southwestern Institute of Forensic Sciences, Dallas, Texas; [351]PMC Copyright notice Abstract Introduction: In the clinical setting injuries to abdominal visceral vessels resulting from blunt force trauma are uncommon, with an incidence of 5-10% of all abdominal vascular injuries. Abdominal trauma is a rare cause of portal vein thrombosis, and it is associated with lacerations of the liver or chronic liver disease. Here we report a case of a traumatic dissection of an arterialized portal vein with delayed death due to venous thrombosis. Case report: The deceased is a 61-year old male with a history of end stage cirrhosis due to Hepatitis C and chronic ethanolism. While walking alongside railroad tracks, the decedent was struck by a moving passenger train. He was transported to the hospital and diagnosed with multiple injuries including a subdural hematoma, right-sided rib and long bone fractures, liver lacerations, and transections of the small and large bowel. He was treated surgically and showed continued clinical improvement at which point he was extubated on post-injury day 9. His liver function was chronically decreased, but remained stable. Shortly after extubation, the decedent developed acute liver failure and died several hours later. Salient autopsy findings revealed end stage hepatic cirrhosis and organizing liver lacerations. Examination of the hepatic vessels showed a thickened and fibrotic portal vein with thrombotic occlusion. Hemorrhage was grossly evident within the thickened vessel wall. Microscopic sections of the portal vein showed arterialization and fibrosis of the vessel wall with an organizing dissection, which was confirmed with elastic and trichrome stains. The vessel lumen was filled with antemortem thrombus, characterized by layering of cellular elements into the lines of Zhan. Discussion: In the absence of a transjugular intrahepatic portosystemic shunt procedure, the most likely explanation for the autopsy findings is that longstanding portal hypertension or a silent arteriovenous shunt initiated portal vein remodelling and arterialization. The structural changes in the portal vein allowed for dissection during the traumatic incident. The histologic appearance of the portal vein thrombus was consistent with the timing of the decedent's acute decompensation, thus providing an explanation for the abrupt hepatic failure and death. Blunt force injuries to the abdominal vasculature are uncommon in the clinical setting, as the energy required to damage the vessels is great and is typically associated with other non-survivable injuries. In this case, however, pre-existing liver disease allowed for traumatic dissection and thrombosis of the arterialized portal vein resulting in delayed death following seemingly survivable blunt force trauma. Acad Forensic Pathol. 6(1 Suppl):S-66–S-119. Fatal Dragging Deaths with Soft Tissue and Bone Friction/Grinding/Dragging Injuries [352]SP Prahlow SP Prahlow ^1. Valparaiso University (recent graduate…current pre-med student), Tallahassee, Florida; Find articles by [353]SP Prahlow ^1., [354]JA Prahlow JA Prahlow ^2. Western Michigan University Homer Stryker MD School of Medicine, Kalamazoo, Michigan Find articles by [355]JA Prahlow ^2. * (BUTTON) Author information * (BUTTON) Copyright and License information ^1. Valparaiso University (recent graduate…current pre-med student), Tallahassee, Florida; ^2. Western Michigan University Homer Stryker MD School of Medicine, Kalamazoo, Michigan [356]PMC Copyright notice Abstract Vehicle versus pedestrian (and vehicle versus bicyclist) collisions frequently result in skin injuries that can be described as “friction abrasions.” These injuries are often related to the victim making contact with a hard road surface. When the victim is actually overrun by a motor vehicle, the skin trauma may be related to contact with the roadway, the undersurface of the vehicle, or both. In such instances, the cutaneous injuries are typically severe, sometimes with associated underlying soft or even bony injuries. If a victim is actually dragged underneath the vehicle for a substantial distance, relatively characteristic “friction/grinding” injuries can be produced, involving skin, soft tissue, and bone. Death is a frequent outcome, and there are often many lethal injuries identified at autopsy, making the determination of whether or not the victim was conscious while being dragged under the vehicle difficult, if not impossible. In this report, two cases of dragging deaths are presented, each with a substantial dragging distance and the presence of classic injury patterns. A 45-year old woman was attempting to intervene in an altercation at a bar parking lot when she stood in front of a vehicle as one of the participants in the altercation was attempting to flee. The driver intentionally ran over the woman, and she became pinned under the vehicle. Instead of stopping, the driver drove 1.2 miles down a roadway before finally stopping. The victim was dead at the scene. Autopsy disclosed multiple severe injuries, with classic grinding-type injuries of several body regions, including the back, the extremities, and the head/skull. A 53-yearold man who was riding on a moped was struck by a pick-up truck. Witnesses stated that the man remained conscious initially, and was screaming for help, as he was dragged on the roadway, underneath the pickup truck for a total distance of 1,758 feet before coming to rest on the roadway, as the truck continued driving away. He was pronounced dead at the scene. At autopsy, the victim had extensive injuries, including characteristic dragging-type injuries of his legs, left elbow, and right toes. Although friction-abrasions are common in vehicle versus pedestrian (and bicyclist) incidents, extensive grinding injuries are less common, typically because drivers usually stop before driving great distances when a victim is pinned under the vehicle. This report presents examples of classic “friction/grinding/dragging injuries” and addresses the difficulties incurred when faced with questions concerning consciousness and time of death. Acad Forensic Pathol. 6(1 Suppl):S-66–S-119. Watt Happened? A Case Report of Electrocution and Review of the Literature [357]LR Crowson LR Crowson ^1. Campbell University School of Osteopathic Medicine, Knightdale, North Carolina; Find articles by [358]LR Crowson ^1., [359]K Janssen K Janssen ^2. North Carolina Department of Health and Human Services, Raleigh, North Carolina Find articles by [360]K Janssen ^2., [361]S Venuti S Venuti ^2. North Carolina Department of Health and Human Services, Raleigh, North Carolina Find articles by [362]S Venuti ^2. * (BUTTON) Author information * (BUTTON) Copyright and License information ^1. Campbell University School of Osteopathic Medicine, Knightdale, North Carolina; ^2. North Carolina Department of Health and Human Services, Raleigh, North Carolina [363]PMC Copyright notice Abstract Despite often being preventable by simple safety measures, electrical injuries are relatively common accidents and up to 40 percent of serious electrical injuries result in death. Electrical injuries generate more than 5,000 visits to the emergency department per year and cause approximately 1,000 deaths each year in the United States. Fatal electrocutions in adults are most frequently job-related, high voltage electrocutions (greater than 600 to 1000 volts), and should be suspected in all deaths where the deceased was near an electrical device or using an electrical power tool or machinery. Sudden death following electrical shock results from the transmission of electrical current through the body – having entered through contact with the electrical source and exiting through another, more “grounded,” contact. Death is most often attributable to ventricular fibrillation with passage of the current through the heart, but apnea (respiratory arrest) and asystole can also occur. Detailed scene investigation is critical in these types of cases, and autopsy is important in correlating findings with the scene investigation. Asystole, arrhythmia, and apnea can have non-specific findings at autopsy. Burns are seen in nearly all high voltage electrocution deaths but less than half of low voltage electrocution deaths. These external findings generally do not help predict the path of current and can significantly underestimate the degree of internal thermal injury. It is important for medical examiners and coroners to consider this entity and provide a thorough scene investigation with autopsy. Identification of an electrocution death and the source of electrocution may prevent subsequent injuries or death. A case pertaining to a young agricultural worker sustaining a high-voltage electrocution while on the job will be presented, including scene, autopsy, and histological findings. A literature review will be performed to support the case findings as well as demonstrate classic injuries, and histological and radiographic findings seen peri- and postmortem in death by electrocution. Acad Forensic Pathol. 6(1 Suppl):S-66–S-119. An Unusual Suicide with a Firework Explosive in the Oral Cavity: A Case Report [364]ME Melo ME Melo ^1. Policia Civil do DIstrito Federal - Departamento de Policia Tecnica, Brasilia, Brazil Find articles by [365]ME Melo ^1. * (BUTTON) Author information * (BUTTON) Copyright and License information ^1. Policia Civil do DIstrito Federal - Departamento de Policia Tecnica, Brasilia, Brazil [366]PMC Copyright notice Abstract The use of fireworks to celebrate holidays or religion festivities is very common in many parts of the world. Nevertheless, accidents are not rare. But the intentional use of fireworks to promote injury is unusual, and it is even rarer to be self inflicted. We report a case of a 32-year-old depressive man who committed suicide with a festive explosive known as “Spanish cracker” inserted within his oral cavity. The artifact had a great energy, which provoked complex fractures of both mandibular and maxillary bones, besides damage to other facial bones, and extensive lacerations of soft tissues. By that time, we expected a central nervous system (CNS) trauma as well, but it was not significant. What was found to justify his death was the large amount of blood in the airways, as well as the sings of asphyxiation. Acad Forensic Pathol. 6(1 Suppl):S-66–S-119. A Suicidal Hanging with Injuries of the Cervical Spine: A Case Report [367]DL Shrock DL Shrock ^1. University of Iowa Hospitals and Clinics, Iowa City, Iowa Find articles by [368]DL Shrock ^1., [369]D Firchau D Firchau ^1. University of Iowa Hospitals and Clinics, Iowa City, Iowa Find articles by [370]D Firchau ^1., [371]M Nashelsky M Nashelsky ^1. University of Iowa Hospitals and Clinics, Iowa City, Iowa Find articles by [372]M Nashelsky ^1. * (BUTTON) Author information * (BUTTON) Copyright and License information ^1. University of Iowa Hospitals and Clinics, Iowa City, Iowa [373]PMC Copyright notice Abstract Cervical spine injuries are commonly associated with judicial hangings in which a long drop precedes the fracture of the cervical spine, which is the desired outcome. Injuries of the cervical spine are unusual in routine suicidal hangings and have been associated with a drop of some distance, complete suspension, anterior knot placement, obesity, degenerative disease of the cervical spine, diseases of the bone, and advanced age. We present a case of a 62 year old male with no known significant past medical history who was found hanging from a back porch trellis. Investigation revealed a text message from the decedent's phone that implied suicidal intent. The ligature was fashioned by braided rope threaded through another segment of the rope looped together and held by two steel rope clamps. There was an anterior suspension with the knot located on the anterior submental neck. The decedent was incompletely suspended with the heels off of the ground and immediately adjacent to a bench which introduced the possibility of a short drop. The circumferential ligature mark on the neck contained a braided pattern, corresponding to the rope. The posterior neck had a patterned injury where it was in contact with the steel rope clamp. Anterior and posterior neck dissections revealed focal hemorrhages in the soft tissues of the neck, a transverse fracture of the C6 vertebral body and C6-C7 disk space with corresponding compression and softening of the cervical spinal cord, and a posterior C1-C2 distraction. The cause of death was stated as blunt force injuries of the neck due to hanging. While injuries of the cervical spine are exceedingly uncommon in non-judicial hangings, they can occur and are associated with certain features specific to the mechanism of hanging and the individual. It is important that forensic pathologists are aware of the potential for cervical spine injuries in non-judicial hangings and the mechanisms which could potentiate them. Acad Forensic Pathol. 6(1 Suppl):S-66–S-119. Homicide-Suicide in Cuyahoga County, Ohio 1991-2012 [374]T Gilson T Gilson ^1. Cuyahoga County Medical Examiner's Office, Cleveland, Ohio; Find articles by [375]T Gilson ^1., [376]WC Regoeczi WC Regoeczi ^2. Cleveland State University, Cleveland, Ohio Find articles by [377]WC Regoeczi ^2. * (BUTTON) Author information * (BUTTON) Copyright and License information ^1. Cuyahoga County Medical Examiner's Office, Cleveland, Ohio; ^2. Cleveland State University, Cleveland, Ohio [378]PMC Copyright notice Abstract Homicide/Suicide (H/S) is defined as homicide(s) followed by perpetrator suicide within one week of the homicidal event. These are rare occurrences which share characteristics of homicide and suicide. Previous research has created various typologies for H/S classification and many events follow characteristic patterns, most frequently involving intimate partner (current or former) violence. Most previous studies have also involved relatively short study periods (approximately 5 years). Cuyahoga County (metropolitan Cleveland) is the largest county in Ohio with an average population of 1.36 million over the study period. Cleveland represents approximately one-third of the population with the remainder of the county being primarily suburban and rural. The Cuyahoga County Coroner/Medical Examiner Office (CCC/MEO) investigates all deaths occurring under violent, suspicious or sudden/unexpected circumstances. For the present study, case files from CCC/MEO were reviewed and cases of H/S were identified for further study. Over the 22 years (1991-2012), 65 H/S events occurred for an annual incidence of 0.21/100000 (similar to previous reports). Just under half occurred in Cleveland proper. There were a total of 81 homicide victims. Most (80%) H/S involved a single victim. Females were the most common (76.5%) homicide victims while males accounted for most perpetrators (95%). Just over half of the victims and perpetrators were black and all H/S events were intraracial. Firearms were used in 95% of homicide cases and 97% of suicides. Perpetrators were generally older than victims with average ages of 42.5 years and 33.8 years, respectively. Positive toxicology for alcohol or drugs was noted in one-third of victims and one-half of perpetrators. Depression was present or could be inferred in 41.5% of perpetrators. No specific day of the week was associated with H/S. The most common H/S subtype involved violence by a former or current intimate partner (58%). A clear history of domestic violence was noted in approximately 60% of these cases and 23% showed stalking behavior on the part of the perpetrator. Victims were killed at their own residence or a residence shared with the perpetrator in over half of cases. Acad Forensic Pathol. 6(1 Suppl):S-66–S-119. Death Resulting from Pneumocephalus Complicating Endoscopic Food Bolus Retrieval in a Patient with Eosinophilic Esophagitis [379]AK Fuhs AK Fuhs ^1. Indiana University School of Medicine, South Bend, Indiana; Find articles by [380]AK Fuhs ^1., [381]JA Prahlow JA Prahlow ^2. Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, Michigan Find articles by [382]JA Prahlow ^2. * (BUTTON) Author information * (BUTTON) Copyright and License information ^1. Indiana University School of Medicine, South Bend, Indiana; ^2. Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, Michigan [383]PMC Copyright notice Abstract Pneumocephalus has been reported as a complication of esophagogastroduodenoscopy (EGD) in a small number of cases, but there is no discussion of it in the literature in the setting of endoscopic food bolus retrieval. In this report, we present a death related to pneumocephalus occurring as a complication of endoscopic food removal from the esophagus. A 40-year-old male presented with dysphagia and suprasternal discomfort twelve hours following chicken ingestion. On flexible endoscopy performed under intravenous sedation at an endoscopy center, the chicken was seen lodged in the lower third of the esophagus, and the esophageal mucosa was more friable than usual. The food bolus was reportedly difficult to snare, and the patient experienced tremendous gagging and coughing during the procedure. After successful retrieval of the food bolus, a mucosal laceration was noted at the site where the chicken had been lodged. Following the procedure, the patient was unarousable, and was emergently transported to a hospital. A subsequent head CT revealed pneumocephalus, while a chest CT showed pneumomediastinum. The patient was later declared brain dead, and the case was referred for medicolegal autopsy. At autopsy, the brain was examined first, with evidence of rare air bubbles within meningeal vessels, and numerous petechiae-like hemorrhages throughout the grey and white matter. The esophageal mucosa was focally discolored and had a partial thickness laceration. Microscopic examination of the esophagus was consistent with eosinophilic esophagitis Eosinophilic esophagitis is a known risk factor for food bolus impaction, especially in children, but also in adults. The condition should be suspected in patients who present with food bolus impaction. Although rare, pneumocephalus is a possible complication of EGD for food bolus retrieval, even without full-thickness esophageal perforation. In patients unresponsive after endoscopy, the rapid radiographic detection of potential pneumocephalus should be encouraged, as it may allow for timely therapy and improved outcomes, or serve as a useful supplement to forensic autopsy in the event of patient death. Forensic pathologists should be aware that pneumocephalus may represent a potential mechanism of injury/death in patients experiencing esophageal trauma, including injury incurred during EGD. Acad Forensic Pathol. 6(1 Suppl):S-66–S-119. Butyrylfentanyl and Acetylfentanyl Levels in Driving under the Influence and Overdose Cases [384]KF Maloney KF Maloney ^1. Erie County Medical Examiner's Office, Buffalo, New York Find articles by [385]KF Maloney ^1., [386]CR Giffin CR Giffin ^1. Erie County Medical Examiner's Office, Buffalo, New York Find articles by [387]CR Giffin ^1., [388]CM Corcoran CM Corcoran ^1. Erie County Medical Examiner's Office, Buffalo, New York Find articles by [389]CM Corcoran ^1., [390]NA Yarid NA Yarid ^1. Erie County Medical Examiner's Office, Buffalo, New York Find articles by [391]NA Yarid ^1., [392]JM Blank JM Blank ^1. Erie County Medical Examiner's Office, Buffalo, New York Find articles by [393]JM Blank ^1., [394]TJ Mahar TJ Mahar ^1. Erie County Medical Examiner's Office, Buffalo, New York Find articles by [395]TJ Mahar ^1. * (BUTTON) Author information * (BUTTON) Copyright and License information ^1. Erie County Medical Examiner's Office, Buffalo, New York [396]PMC Copyright notice Abstract Analogs of the drug fentanyl are becoming increasingly common in the United States. While the potency of fentanyl is well known and recommended thresholds for therapeutic levels and toxic levels have been published, less is known about fentanyl analogs. Our office has seen a large number of butyrylfentanyl and acetylfentanyl overdoses and a smaller number of driving under the influence cases with butyrylfentanyl present. The goal of this paper is to assist toxicologists, forensic pathologists and coroners in determining if a given level of butyrylfentanyl or acetylfentanyl is consistent with toxicity. During the period of April 2015 to January 2016, 47 overdose deaths with butyrylfentanyl present and 10 overdose deaths with acetylfentanyl present were identified. During the same time period, 23 driving under the influence cases with butyrylfentanyl were identified. The level of butyrylfentanyl in overdose deaths ranged from 0.6 ug/L to 129.8 ug/L in blood. When butyrylfentanyl was the sole drug identified in a drug overdose death, the levels ranged from 3.4 ug/L to 85.7 ug/L in blood. The level of butyrylfentanyl in driving under the influence cases ranged from 2.3 ug/L to 51.4 ug/L in blood. The level of acetylfentanyl in overdose deaths ranged from 1.5 ug/L to 137.2 ug/L in blood. There were no cases where acetylfentanyl was the sole drug present. Other drugs present in the blood with butyrylfentanyl and acetylfentanyl included fentanyl, heroin (morphine), cocaine, oxycodone, hydrocodone, methadone, buprenorphine, trazodone, butalbital, phenobarbital, alprazolam, clonazepam, diazepam, quetiapine, sertraline, citalopram, pregabalin, diphenhydramine and ethanol. Fentanyl analogs including butyrylfentanyl and acetylfentanyl are being seen with increasing frequency in the United States; however, there is little in the literature regarding blood levels in overdose and non-overdose situations. In our experience, acetylfentanyl was never seen alone as a sole cause of death without the contribution of other drugs or medications. When it was seen alone, the lethal range of butyrylfentanyl seemed similar to that of fentanyl, and like fentanyl, the level of butyrylfentanyl in non-overdose situations showed significant overlap with overdose levels. Acad Forensic Pathol. 6(1 Suppl):S-66–S-119. Unusual Suicide Case by Self-Injection of Adrenaline in a 35-Year Old Female [397]M Barbesier M Barbesier ^1. Hôpital Edouard-Herriot, Hospices Civils de Lyon, Lyon, France; Find articles by [398]M Barbesier ^1., [399]C Palmiere C Palmiere ^2. Centre Universitaire Romand de Médecine Légale, Lausanne, Switzerland; Find articles by [400]C Palmiere ^2., [401]F Bévalot F Bévalot ^3. Laboratoire LAT LUMTOX, Lyon, France Find articles by [402]F Bévalot ^3., [403]L Fanton L Fanton ^1. Hôpital Edouard-Herriot, Hospices Civils de Lyon, Lyon, France; Find articles by [404]L Fanton ^1. * (BUTTON) Author information * (BUTTON) Copyright and License information ^1. Hôpital Edouard-Herriot, Hospices Civils de Lyon, Lyon, France; ^2. Centre Universitaire Romand de Médecine Légale, Lausanne, Switzerland; ^3. Laboratoire LAT LUMTOX, Lyon, France [405]PMC Copyright notice Abstract Adrenaline auto-injectors provide life-saving pre-hospital treatment for individuals experiencing anaphylaxis in community setting. Errors in handling adrenaline auto-injectors have been reported. Most unintentional adrenaline administrations from auto-injectors are due to poor knowledge of proper use of the device among patients, families and health care professionals. Though, device malfunctions and deficiency in device design may also be occasionally implicated. Reports of adrenaline overdoses and their outcomes are limited in the medical literature. In most of these cases, accidental adrenaline administration results from medical error, and is generally followed by the rapid onset of agitation, tachycardia, hypertension, and dysrhythmias. A 35-year-old Caucasian female was found dead outside her home, lying in the grass. Two adrenaline auto-injection devices (each containing 0.15 mg adrenaline) were found close to the body. A suicide note was discovered in the living room. The decedent's medical records showed that she had suffered from generalized anxiety disorder and severe depression since her husband's suicide seven months previously. At the autopsy, two fresh injection lesions on the left thigh were found. The heart weighed 260 g and the myocardium did not exhibit fibrosis or ischemic areas. The lungs were relatively edematous and congested. Histologic examination was unremarkable without evidence of subendocardial hemorrhage or acute myocardial ischemia in the heart. The postmortem toxicological screening revealed the presence of mirtazapine, citalopram, prazepam and ciamemazine in peripheral blood within therapeutic ranges. Catecholamines (adrenaline and noradrenaline), metanephrines (metanephrine, normetanephrine) and 3-methoxytyramine were analyzed in vitreous humor, urine, peripheral and cardiac blood using high-performance liquid chromatography with amperometric detection. The adrenaline concentration in cardiac blood (79.7 nmol/l) was markedly increased compared to the concentration found in peripheral blood (0.33 nmol/l). Analogously, metanephrine and normetanephrine levels in cardiac blood (30.02 and 19.37 nmol/l, respectively) were markedly increased compared to the concentrations found in peripheral blood (8.15 and 10.36 nmol/l, respectively). Catecholamines and metanephrines in vitreous were lower than or within plasma clinical reference values. Lastly, urine analysis revealed extremely high levels of all tested compounds (catecholamines, metanephrines and 3-methoxytyramine) compared to urinary clinical reference values. Based on the results of all postmortem investigations, the cause of death was determined to be cardiac dysrhythmia and cardiac arrest following adrenaline self-injection, and the manner of death was listed as suicide. To the best of our knowledge, no case of suicide following adrenaline self-administration using a prefilled auto-injector has been reported in the forensic literature. Acad Forensic Pathol. 6(1 Suppl):S-66–S-119. A Case of Suicide Using Diphenhydramine [406]A Ho A Ho ^1. Truman Medical Center, Kansas City, Missouri; Find articles by [407]A Ho ^1., [408]LJ Haldiman LJ Haldiman ^2. Jackson County Medical Examiner's Office, Kansas City, Missouri; Find articles by [409]LJ Haldiman ^2., [410]BR Pietak BR Pietak ^2. Jackson County Medical Examiner's Office, Kansas City, Missouri; Find articles by [411]BR Pietak ^2., [412]M Tarau M Tarau ^2. Jackson County Medical Examiner's Office, Kansas City, Missouri; Find articles by [413]M Tarau ^2., [414]CC Frazee CC Frazee ^3. Children's Mercy Hospitals and Clinics, Kansas City, Missouri Find articles by [415]CC Frazee ^3., [416]U Garg U Garg ^3. Children's Mercy Hospitals and Clinics, Kansas City, Missouri Find articles by [417]U Garg ^3., [418]DC Peterson DC Peterson ^2. Jackson County Medical Examiner's Office, Kansas City, Missouri; Find articles by [419]DC Peterson ^2. * (BUTTON) Author information * (BUTTON) Copyright and License information ^1. Truman Medical Center, Kansas City, Missouri; ^2. Jackson County Medical Examiner's Office, Kansas City, Missouri; ^3. Children's Mercy Hospitals and Clinics, Kansas City, Missouri [420]PMC Copyright notice Abstract Diphenhydramine (DPH), a histamine H1-receptor antagonist, is widely used as an over-the counter allergy, cold and sleep aid. When taken according to the recommended prescribed dosage, serum concentrations rarely exceed 0.1 mg/L. Although considered relatively safe, side effects of DPH include anticholinergic effects such as mydriasis, dry mucous membranes, ileus and urinary retention. DPH penetrates the blood-brain barrier, exhibiting muscarinic receptor blocking properties, producing sedation, anti-emesis, and hypnotic effects. Mild symptoms are noted after ingesting doses above 300 mg. Ingestion of 1,000 mg can cause psychosis, seizures and coma. A blood concentration of 8.0 mg/L is considered to be lethal. DPH can undergo postmortem redistribution with heart/femoral blood ratios of approximately 2.3:1. The case we present is a 22-year old male with a history of anxiety, depression, suicidal ideation, and drug abuse who was found deceased in his apartment. Scene investigation revealed several empty diphenhydramine and dextromethorphan bottles. Numerous notes to family and friends were written on various objects including the refrigerator, bathroom mirror, and multiple pink balloons scattered throughout the apartment. Autopsy revealed cerebral edema, marked pulmonary edema and a mass of blue pills within the stomach. Toxicological analysis of heart blood revealed diphenhydramine and dextromethorphan at concentrations of 110 mg/L and 0.27 mg/L, respectively. The concentration of diphenhydramine was well above the lethal level. The cause of death was found to be diphenhydramine overdose. The manner of death was suicide. Antihistamines are implicated in thousands of overdoses each year, mostly classified as mixed drug overdoses. Suicidal deaths due to antihistamine overdose are relatively rare. We reviewed all cases of suicide involving DPH intoxication from the years 1997 to 2016 at the Jackson County Medical Examiner's Office in Kansas City, MO. A total of 18 cases were identified. Of those, 14 were mixed drug intoxications, whereas four cases involved only DPH. One case involved DPH intoxication and subsequent suffocation using a plastic bag. The blood concentrations of DPH ranged from 0.248 – 110 mg/L with this case having the highest level. A review of literature reporting DPH overdose reveals only one other case with blood concentration levels higher than that seen in our presented case at 119 mg/L. Diphenhydramine is considered a relatively safe drug. However, its easy accessibility and hallucinogenic properties make it a potential drug of abuse. Although relatively rare, diphenhydramine has been used as a means of suicide, as seen in our presented case. Acad Forensic Pathol. 6(1 Suppl):S-66–S-119. Traditional Postmortem Toxicology Investigation Can Miss Drug Facilitated Sexual Assault Evidence [421]LM Labay LM Labay ^1. NMS Labs, Willow Grove, Pennsylvania Find articles by [422]LM Labay ^1., [423]F Diamond F Diamond ^1. NMS Labs, Willow Grove, Pennsylvania Find articles by [424]F Diamond ^1., [425]M Rieders M Rieders ^1. NMS Labs, Willow Grove, Pennsylvania Find articles by [426]M Rieders ^1. * (BUTTON) Author information * (BUTTON) Copyright and License information ^1. NMS Labs, Willow Grove, Pennsylvania [427]PMC Copyright notice Abstract A Drug Facilitated Sexual Assault is a crime that occurs while the victim is under the influence of a drug that renders them incapacitated. Forensic toxicology laboratories design panels to detect drugs that can produce these effects. Lower Limits of Quantification are validated at concentrations that ensure appropriate sensitivity since, in a living individual, there may be an extended time period between the event and specimen collection. Scopes of analysis for DFSA investigations are usually distinctly different as compared to those applied in postmortem investigations. For example, DFSA scopes tend to exclude those drugs that are not known to quickly cause an individual to be obtunded and then to recover without significant medical intervention. For postmortem investigations, the analytical scopes are usually more comprehensive, have higher Reporting Limits and are intended to quantify agents across a wide analytical measurement range. While this strategy is appropriate for most cases, at times it becomes necessary from an analytical perspective to handle the case more like a traditional Drug Facilitated Sexual Assault. To highlight this concept, we report the case of an eight-year old female who was abducted from a mobile home complex in 2009. Her body was located ten days later in an irrigation pond. Initial toxicology testing using a standard postmortem screen did not reveal the presence of any drugs in brain and liver tissue. When a list of medications that the suspect had was evaluated it was determined that additional testing was warranted. Part of this further testing included a directed analysis for benzodiazepines by Liquid Chromatography-Tandem Mass Spectrometry (LC-MS/MS). Results of analysis showed a trace concentration of alprazolam. Because of the nature of this case, a test by Ultra Performance Liquid Chromatography Tandem Mass Spectrometry (UPLC-MS/MS) was specifically developed to quantify low concentrations of alprazolam in different matrices. Results of testing showed alprazolam to be present in gastric fluid, brain and liver at concentrations of 18 ng/mL, 6.6 ng/g and 1.5 ng/g, respectively. Even though these concentrations are not directly related with a toxic outcome, it was relevant to the investigation as it allowed for a more complete interpretation regarding the events leading up to death. The purpose of this presentation is to highlight the need to apply the most appropriate style of analytical testing to each postmortem investigation. Acad Forensic Pathol. 6(1 Suppl):S-66–S-119. Volatile Abuse in Allegheny County – A 10-Year Retrospective Study of Autopsy and DUI Samples [428]WA Ennis WA Ennis ^1. Allegheny County Medical Examiner's Office, Pittsburgh, Pennsylvania Find articles by [429]WA Ennis ^1., [430]K Williams K Williams ^1. Allegheny County Medical Examiner's Office, Pittsburgh, Pennsylvania Find articles by [431]K Williams ^1., [432]J Janssen J Janssen ^1. Allegheny County Medical Examiner's Office, Pittsburgh, Pennsylvania Find articles by [433]J Janssen ^1., [434]N Love N Love ^1. Allegheny County Medical Examiner's Office, Pittsburgh, Pennsylvania Find articles by [435]N Love ^1., [436]A Shakir A Shakir ^1. Allegheny County Medical Examiner's Office, Pittsburgh, Pennsylvania Find articles by [437]A Shakir ^1. * (BUTTON) Author information * (BUTTON) Copyright and License information ^1. Allegheny County Medical Examiner's Office, Pittsburgh, Pennsylvania [438]PMC Copyright notice Abstract The deliberate inhalation of volatile substances in order to achieve intoxication can cause symptoms ranging from brief obtundation to severe permanent handicap and death. This retrospective study examines the incidence of volatile abuse (huffing) found in a busy medical examiner's office as well as those found in samples obtained during traffic stops for driving under the influence (DUI). During the 10-year period samples from a total of 24 deaths were associated with the abuse of volatile compounds. Additionally, 31 DUI samples from the Allegheny County Crime Laboratory were found to be positive of volatile compounds. The compounds involved included Isobutyl Alcohol (paint solvent/varnish remover), and Ethyl Chloride (gasoline additive), but 1,1-Difluoroethane (keyboard cleaner/gas duster) was the most common in Allegheny County, suspected or detected in 45/55 samples. Acad Forensic Pathol. 6(1 Suppl):S-66–S-119. Human Biospecimen Collection Programs to Accelerate Biomedical Research [439]HI Nunez HI Nunez ^1. National Disease Research Interchange, Philadelphia, Pennsylvania Find articles by [440]HI Nunez ^1., [441]A Flint A Flint ^1. National Disease Research Interchange, Philadelphia, Pennsylvania Find articles by [442]A Flint ^1., [443]J Lyons J Lyons ^1. National Disease Research Interchange, Philadelphia, Pennsylvania Find articles by [444]J Lyons ^1., [445]S Shad S Shad ^1. National Disease Research Interchange, Philadelphia, Pennsylvania Find articles by [446]S Shad ^1., [447]R Sassaman R Sassaman ^1. National Disease Research Interchange, Philadelphia, Pennsylvania Find articles by [448]R Sassaman ^1., [449]C Kelly C Kelly ^1. National Disease Research Interchange, Philadelphia, Pennsylvania Find articles by [450]C Kelly ^1., [451]M VonDran M VonDran ^1. National Disease Research Interchange, Philadelphia, Pennsylvania Find articles by [452]M VonDran ^1., [453]G Kopen G Kopen ^1. National Disease Research Interchange, Philadelphia, Pennsylvania Find articles by [454]G Kopen ^1. * (BUTTON) Author information * (BUTTON) Copyright and License information ^1. National Disease Research Interchange, Philadelphia, Pennsylvania [455]PMC Copyright notice Abstract The National Disease Research Interchange (NDRI) is a non-profit organization that serves as the link between individuals wishing to donate organs and tissues for research and the nation's leading investigators who are working to find new treatments or cures for a wide range of diseases. NDRI receives funding and oversight from the National Institutes of Health (NIH) to make biospecimens available to researchers in academia and non-profit organizations. NDRI's Donor Programs give individuals and their families an opportunity to leave a meaningful legacy for their loved ones, by providing a simple mechanism through which tissues and organs can be donated for research after death. NDRI works with patients and next-of-kin to obtain consent for donation and takes care of recovering tissues and providing them to approved researchers. To identify donors and coordinate these recoveries, NDRI partners with a nationwide network of Organ Procurement Organizations (OPOs), Tissue Banks, Hospitals, Medical Examiners and funeral homes; these industry professionals help champion the last wishes of donors and ultimately serve NDRI's registered research projects with biospecimens for their studies. NDRI's recovery network is critical for our participation in several ongoing research initiatives including efforts focused on neurological diseases such as Autism and traumatic brain injury (TBI), as well as the LungMAP initiative aimed to address lung diseases that develop during fetal growth and early childhood. In addition, NDRI's Private Donor Program is an excellent resource to support rare disease and HIV/AIDS researchers. Our private donor registry allows our recovery sites to collect various tissues from each donor with recoveries completed < 24 hours post mortem. Our high-quality biospecimens are commonly utilized to establish primary cell cultures and for rigorous molecular methodologies, such as RNAseq. NDRI specializes in establishing researcher specific protocols for donor eligibility and organ and tissue collection procedures for optimal biospecimens sampling and preservation. These well annotated samples provided through our collaboration with our nationwide network of recovery partners are needed to continue the vital work to discover new therapies for both common and rare diseases. Acad Forensic Pathol. 6(1 Suppl):S-66–S-119. Sudden Death Associated with Non-Toxic Megacolon [456]S Patel S Patel ^1. IU School of Medicine, Terre Haute, Indiana; Find articles by [457]S Patel ^1., [458]R Kohr R Kohr ^2. Terre Haute Regional Hospital, Terre Haute, Indiana Find articles by [459]R Kohr ^2. * (BUTTON) Author information * (BUTTON) Copyright and License information ^1. IU School of Medicine, Terre Haute, Indiana; ^2. Terre Haute Regional Hospital, Terre Haute, Indiana [460]PMC Copyright notice Abstract Two cases of sudden death associated with massive abdominal distention are presented. At autopsy, the first case was found to have massive colonic air distention without underlying anatomic causes, which was clinically consistent with Ogilvie's Syndrome. The second case was observed to have similar severe bowel loop distention, but on opening was packed with fecal material. Microscopic examination of the bowel demonstrated an absence of nerve ganglia elements, consistent with a diagnosis of Hirschsprung's disease. Neither case was associated with ischemia, bowel perforation or sepsis. Similarities in abdominal distention are observed in late pregnancy, and associated with compromised respiration and venous return. The exaggerated degree of distention in our cases, beyond that which is seen even in late gestation, allows us to draw the conclusion that there was severe compromise of respiratory effort from mechanical force exerted on the diaphragm, and compromise of venous return due to inferior vena cava compression. Ultimately, mechanical displacement of the diaphragm and inferior vena cava is proposed as the mechanism of death. __________________________________________________________________ Articles from Academic Forensic Pathology are provided here courtesy of SAGE Publications (BUTTON) Close ACTIONS * [461]View on publisher site * [462]PDF (2.8 MB) * (BUTTON) Cite * (BUTTON) Collections * (BUTTON) Permalink PERMALINK https://pmc.ncbi.nlm (BUTTON) Copy RESOURCES (BUTTON) Similar articles (BUTTON) Cited by other articles (BUTTON) Links to NCBI Databases Cite (BUTTON) * (BUTTON) Copy * [463]Download .nbib .nbib * Format: [NLM] Add to Collections ( ) Create a new collection (*) Add to an existing collection Name your collection * ____________________ Choose a collection Unable to load your collection due to an error [464]Please try again (BUTTON) Add (BUTTON) Cancel Follow NCBI [465]NCBI on X (formerly known as Twitter) [466]NCBI on Facebook [467]NCBI on LinkedIn [468]NCBI on GitHub [469]NCBI RSS feed Connect with NLM [470]NLM on X (formerly known as Twitter) [471]NLM on Facebook [472]NLM on YouTube [473]National Library of Medicine 8600 Rockville Pike Bethesda, MD 20894 * [474]Web Policies * [475]FOIA * [476]HHS Vulnerability Disclosure * [477]Help * [478]Accessibility * [479]Careers * [480]NLM * [481]NIH * [482]HHS * [483]USA.gov (BUTTON) Back to Top References