Acute myocardial infarction following off label retrobulbar injection of desmopressin for non-arteritic anterior ischemic optic neuropathy (NAION). Causal correlation or coincidence?

A 60-year-old man, apparently healthy with negative history for cardiovascular diseases, was hospitalized because of an unilateral sudden and painless severe visual loss. Diagnosis of NAION was made. Two separate and immediately consecutive injections of betamethasone (2 mg/0.5 mL) and desmopressin (2 mcg/0.5 mL) were performed in the retrobulbar space. Fifteen minutes later, the patient suddenly developed cold sweat, dyspnoea, thoracic pain and severe hypotension. Acute myocardial infarction was diagnosed by ECG. Desmopressin was the probable causative agent. Thrombotic events following intravenous or oral administration of desmopressin have been documented in the medical literature. To the best of our knowledge this is the first case in which a thrombotic event was associated with the retrobulbar route. Retrobulbar desmopressin administration in patients with NAION can be probably associated with AMI. Considering its invasiveness and the unproven benefit in the treatment of NAION, this therapeutic approach can not be currently recommende

Insects found on a human cadaver in central Italy including the blowfly Calliphora loewi (Diptera, Calliphoridae), a new species of forensic interest

In the case of unidentified bodies the estimation of the period since death or of the season of death plays an important role to focus the attention on a reduced number of people among the ones reported missing. Forensic entomology can be one of the most important methods for these estimations, as occurred in this case. Flies are typically the first insects to colonize a dead body. The case reported here concerns the colonisation by insects of a male body in advanced decay found during the winter in Central Italy. This case is of particular interest as few data are available on the entomological evidence in the cold season. In particular, in this case we recovered Calliphora loewi (Calliphoridae), a species never collected before on dead bodies in Southern Europe. Larvae of the black soldier fly Hermetia illucens (Stratiomyidae), pupae and larvae belonging to genus Hydrothea (Muscidae), and Necrobia rufipes (Cleridae) specimens were also collected. The estimated PMI enabled identification of the cadaver, confirmed by DNA analysis

Decomposition pattern and insect colonization in two cases of suicide by hanging

Hanging is one of the most common methods of suicide worldwide. Despite the high incidence, only a little knowledge about the pattern of cadaver colonization by insects on hanging corpse is available. Different types of hanging can alter the body decomposition process as well as the pattern and rate of insect colonization. Two case studies where the hanging occurred with a similar postmortem interval of 34 days are described. The two bodies showed different patterns of insect colonization and decomposition scored using the Total Body Score (TBS) and the TBS for hanging (TBShang). The first case was about the body of a 24-years-old male, with mummification of the unclothed upper anatomical parts. A TBS of 14 and a TBShang of 18 were assigned. The second body, belonging to a 15-years-old male, was found pre-skeletonized lying on the ground with the skull disarticulated. A TBS of 31 and a TBShang of 32 were assigned. Average temperatures of (21.5 ± 2.5) °C for the first body and (25.1 ± 2.7) °C for the second body were recorded in the 34 days preceding the bodies’ discovery for a total of 731 and 853 Accumulated Degree Days (ADD) respectively. According to previous studies, the different decomposition patterns were related to temperatures of exposition and to the diversity of arthropod community found on the bodies because of the different types of hanging: totally suspended vs. in contact with the soil. The limited insect activity caused by hanging explains the delay in decomposition of hanging bodies in which mummification can take place, especially on the upper body parts. In vertical body position, the body fluids accumulated in the lower body parts accelerating the desiccation of soft tissues on the upper parts. The effect of gravity can also explain the decrease of internal maggot mass as larvae easily fall from the hanging body to the drip zones below where they are unable to recolonize the body if totally suspended. Furthermore, in a hanging body a greater surface is exposed to wind and sun with a quicker skin drying preventing the additional Diptera colonization. This paper shows the weaknesses of scoring scales and regression models developed to predict ADD when irregular decomposition and mummification have not taken into account

Inborn Errors of Metabolism Explain a Suspected SIDS Case.

The goal of this presentation is to underline the difficulty of diagnosis of SIDS. According to San Diego SIDS diagnostic criteria, a clinical, anamnestic, circumstantial, and autoptic investigation must be performed. In most of cases death remains unjustified after the diagnostic procedures and SIDS is unresolved. This presentation concerns a case of resolved SIDS, in which the postmortem investigation led to diagnosis of dilated cardiomyopathy (DCM) with endocardial fibroelastosis, associated to tubular hypoplasia of the aorta and inborn errors of metabolism. This presentation will impact the forensic science community by showing the difficulty to diagnose clinical silent cardiomyopathy in children younger than one year old, and so an accurate clinical, anamnestic, circumstantial and instrumental investigation can lead to a timely diagnosis of DCM in life

CLEIA of humor vitreous in a case of suicidal insulin overdose

Insulin overdoses have been mostly described in literature as accidental and suicidal deaths, especially in diabetic patients. The present case study deals with a 68 years old male found dead in his bedroom. The victim worked as health care professional in a rescue team, suffering from depression for several years. At the death scene, two ampoules of soluble insulin were recovered close to the body, one of which was empty. At autopsy, no signs of trauma and no injection marks were found at common sub-cutaneous or intravenous injection sites. No other remarkable findings, but hemorrhagic pulmonary edema along with astrogliosis and neuronal degeneration/necrosis in the subcortical regions and corpus callosum were observed. The blood specimen was inadequate due to hemolysis, since it was not centrifugated soon after sampling. Biochemical analysis was performed on bilateral samples of vitreous humor by using electro-chemiluminescence immunoassay (CLEIA). The insulin concentration was 61.11 mU/L in the right vitreous humor and 74.23 mU/L in the left one; the C-peptide concentration was 0.166 ng/mL in right vitreous and 0.157 ng/mL in the left one. The results are in agreement with levels of insulin and C-peptide detected in previous case studies. Based on these findings the cause of death was determined as suicidal insulin overdoses probably by sublingual administration. This way of self-administration was a diagnosis for exclusion as it has been demonstrated that sublingual human insulin has hypoglycemic effects similar to insulin injected. The case study emphasizes the potential role of vitreous humor as reliable alternative substrate for biochemical analysis compared to post-mortem serum or blood samples in cases of fatal insulin intoxication. Furthermore, the CLEIA is an encouraging analytical method to be considered in such cases, although still not validated to perform quantitative analysis of post-mortem fluids

Four cases of sodium nitrite suicidal ingestion. A new trend and a relevant forensic pathology and toxicology challenge

Sodium nitrite (NaNO2) is an inorganic compound commonly used as a food additive, antifreeze admixture, and fertilizer. Its toxicity mechanism is mainly represented by the oxidation of ferrous iron to ferric iron of one of the four heme structures in haemoglobin with the onset of methaemoglobin. The mechanism of death by sodium nitrite toxicity is severe hypoxia. We present four cases of suicidal sodium nitrite ingestion that closely occurred within a two months-period. Self-poisoning with sodium nitrite actually represents an increasing trend in nitrates' related deaths. In order to reach a precise diagnosis of NaNO2 intoxication, a complete toxicological analysis should be carried out including not only MetHb blood levels but also nitrites and nitrites in standard or alternative matrices as a routine procedure. Autopsy should be carefully performed to detect common indicators of hypoxia or more rarely evident typical by themselves-non specific signs of sodium nitrite toxicity. Suicidal manner of death should be carefully considered when circumstantial data support that ingestion of large amounts of NaNO2 occurred as a consequence of a self-injurious behaviour. Relevant informations include victim's previous Internet or book researches about paths to follow to commit suicide with sodium nitrate, employment and past medical history, with strong regard to psychiatric diseases as well as eventual taking psycotropic drugs. Finally, an accurate integration of autoptic and toxicological results with circumstantial data is necessary to make correct diagnosis of death due to acute respiratory failure secondary to suicidal sodium nitrite ingestion

Accidental Injury or “Shaken Elderly Syndrome”? Insights from a Case Report

Subdural haemorrhage (SDH) as result of a traumatic brain injury (TBI) is a common cause of death in cases of fatal physical abuse. Since intracranial bleeding is a common finding in elderly due to age-related intracranial changes or increasing prevalence of anticoagulant medication, differential diagnosis between inflicted and non-inflicted head injury is challenging. A case of an elderly woman's death caused by TBI is reported. Autopsy showed multiple polychromatic bruises and a frontoparietal hematoma with bilateral subacute SDH. History excluded paraphysiological or pathological non-traumatic conditions that could justify SDH, while iatrogenic factors only played a contributory role. Since polychromatic bruises distributed on the face, the upper extremities and the chest were consistent with forceful grasping/gripping or repeated blows and SDH can form in absence of impact or by mild/minor blows, SDH was considered the result of repeated physical abuses. Differential diagnosis between traumatic and non-traumatic SDH is still challenging for forensic pathologists. As largely accepted in the pediatric population and occasionally described also in adults, however, violent shaking should be also considered as a possible mechanism of SDH-especially in elderly who do not have any sign of impact to the head