Fatal streptococcal toxic shock syndrome: report of four forensic autopsy cases (2023)

Here we present a case of necrotizing fasciitis after intra-articular injection of hyaluronic acid. A 73-year-old woman received intra-articular injections of hyaluronic acid for arthralgia in the left shoulder and knee and was found dead one day in her living room. At the forensic autopsy, traces of injections of bullae and erythema were found on the left shoulder and knee, and liquefactive necrosis of muscle tissue was observed on the left, but not the right, extremities. Histopathological examination of the left upper arm and thigh revealed severe rhabdomyolysis with many bacterial deposits. Bacteriological tests revealed group A streptococci from intracardiac blood and affected muscle tissue. Post-mortem biochemical blood analysis showed elevated blood urea nitrogen (133.8 mg/dL), creatinine (4.57 mg/dL), and C-reactive protein (45.0 mg/dL). The cause of her death was diagnosed as streptococcal toxic shock syndrome (STSS). In addition, it has been suggested that the injection was administered incorrectly and served as a gateway for bacteria.

Journal of forensic and legal medicine, jaargang 52, 2017, p. 93-97

A 4-year-old girl who had been treated for asthma since she was 2 years old had a severe cough and died suddenly. The patient had a history of intermittent severe coughing, which worsened in the week before her death. Before her death, she was taken to a doctor and on the basis of a chest X-ray, hypertrophy of the thymus was suspected. The clinician advised her to go to the general hospital later; however, she died that night. Postmortem radiology and autopsy revealed a large mass in the anterior mediastinum compressing the heart and airway, and no other findings attributable to sudden death were noted. We therefore concluded that patient death was due to acute respiratory and cardiac circulatory failure secondary to mass-induced pressure. Microscopically, the mass showed a hollow structure consisting of cystically dilated large blood-filled thin-walled vessels. The final diagnosis was cavernous hemangioma. Hemangiomas are the most common benign vascular anomalies in young children; However, mediastinal hemangiomas are rare and can cause life-threatening complications due to their size and location. Therefore, forensic pathologists must include hemangiomas as a differential diagnosis in children with anterior mediastinal masses.

Legal Medicine, Volume 50, 2021, Article 101820

Every year in Japan from 1990 to 1997 about 21,000 to 24,000 people committed suicide. In 1998 the number of suicides rose to >30,000, after which the trend of a high number of suicides continued for >10 years. Although Japan's annual suicide rate has fallen recently, it remains one of the highest in the world. Here we have estimated annual suicide data (rates and percentages) related to three economic and lifestyle indicators: (1) the difference between real income and consumer spending in one average month per year in one household, (2) the annual difference between exports and imports , and (3) annual total debt determined by statistical analysis for both sexes/men/women over the 40-year period from 1979 to 2018 in Japan. Our findings showed that [1] total debt can be related to both the suicide rate and the suicide rate for both sexes, for men and women, and [2] the difference between real income and consumer spending can be related to both the number of suicides and the number of suicides only among women. These findings have revealed factors clearly associated with suicide, and it is necessary to design suicide prevention strategies based on these factors. Relevant public and private entities should become aware of the involvement of both debt and the income-expenditure gap in suicide trends when planning suicide prevention measures. Further analysis of suicide data across a wide range of fields, including forensics, is needed to better understand suicide risk factors.

IDCases, Volume 19, 2020, Article e00693

An increasing number of reports indicate an increased prevalence of lung cancer in human immunodeficiency virus (HIV) positive patients with a poor prognosis. A 51-year-old HIV-positive man was diagnosed with stage IV squamous cell lung cancer. He had intermittent high fevers and persistently elevated white blood cell and C-reactive protein (CRP) counts. Although we suspected opportunistic infections, we did not detect any infection. Autopsy showed positive immunostaining for Interleukin-6 (IL-6) in stromal region plasma cells and G-CSF in tumor cells, which are believed to be responsible for significant tumor fever, leukocytosis and high CRP titers. This case report highlights the need to consider a cytokine-producing tumor as a differential diagnosis of fever and high inflammatory status in HIV-positive cancer patients.

Journal of forensic and legal medicine, jaargang 36, 2015, p. 32-36

Crimean-Congo hemorrhagic fever (CCHF) is an acute zoonotic infection caused by the CCHF virus. Virus activity peaks in April and May with a fatality rate of 3-30%. Transmission of the virus to humans occurs through a tick bite or exposure to tissue or blood from infected animals. The main risk group includes farmers living in endemic areas. Healthcare workers are the second most affected group. The virus has emerged in a diverse geographic area, including the Middle East, Asia, Africa and Eastern Europe, and is considered one of the most widespread tick-borne infections. The latest cases come from Iran and Turkey. This article presents the autopsy results of four cases infected with CCHF in 2011 and 2012 in Ankara, Turkey.

Legal Medicine, Volume 51, 2021, Article 101878

Cetuximab is mainly used for the treatment of advanced and metastatic colorectal cancer. Due to the oligosaccharide galactose-α-1,3-galactose (α-gal) in the heavy chain, cetuximab can cause severe IgE-dependent anaphylaxis. α-Gal is also the antigen responsible for the α-gal syndrome, known as mammalian meat allergy. Patients with α-gal syndrome may experience cetuximab-induced anaphylaxis upon first administration due to the development of α-gal specific IgE antibodies. A male patient in his fifties with metastatic colorectal cancer received chemotherapy that included scheduled administration of cetuximab. However, he died shortly after the first administration. A forensic autopsy confirmed rectal cancer, rectal cancer that had spread to the liver, and kidney cancer. Laboratory blood tests revealed the presence of IgE specific to cetuximab and beef before administration of cetuximab and an extremely high level of tryptase after administration. Therefore, we determined that death was caused by cetuximab-induced anaphylaxis due to a pre-existing α-gal syndrome. To our knowledge, this is the first forensic autopsy case of fatal anaphylaxis after the first administration of cetuximab.

Legal Medicine, Volume 50, 2021, Article 101868