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Streptococcal toxic shock syndrome (STSS) is a serious infection usually caused by group A streptococci. It is clinically characterized by rapidly progressing multi-organ failure and septic shock. This report presents four STSS-related deaths. In two cases (Cases 2 and 3), the portal may be an ulcer and mucosa at the site of surgery; the first symptoms in those cases were fever. In other cases, the front door was unknown; the first symptom was pain. In two cases (Case 1 and 3), malpractice was suspected even before the autopsy. At autopsy, the blood culture was positive for group A streptococcus in all of the present cases. Although C-reactive protein levels were elevated, procalcitonin levels were not significantly elevated. This is the first report of autopsy cases associated with STSS in which post-mortem computed tomography was performed; muscle swelling and increased concentrations of gas-free peripheral subcutaneous tissue may be characteristic findings. Histology revealed extensive bacterial colonies and necrosis with a mild neutrophil response in two cases (cases 3 and 4) and hemophagocytosis in two cases (cases 1 and 4). It is essential to perform the correct tests and make an accurate diagnosis, as STSS still has a high mortality rate and medical errors are often suspected. In addition, it is important to reevaluate STSS to reduce STSS-related deaths.
Streptococcal toxic shock syndrome (STSS), also called toxic shock-like syndrome , is usually caused by group A streptococci (GAS) . The progression of the condition from onset is extremely rapid and dramatic, leading to soft tissue necrosis, multiple organ failure and septic shock . Since the symptoms are non-specific and the progression is rapid and fatal, this disease cannot be diagnosed before death, and in addition, this disease can develop due to negligent treatment. Therefore, in some cases, forensic pathologists may be required to correctly diagnose this pathology. Here we describe autopsy cases associated with STSS where postmortem computed tomography (PMCT) was performed.
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The case report
A man in his 40s with no significant medical history visited the orthopedics department one day after the onset of right chest and abdominal pain. X-ray showed no pneumothorax, lung contusion or fracture. He received an injection of painkillers in the right abdomen and prescribed antibiotics. That same night he developed shortness of breath and pain in the right abdomen and called an ambulance. Laboratory investigations showed disseminated intravascular coagulation after transport.
STSS is associated with postoperative, postpartum, abortion, IUD placement, diabetes, alcoholism, burns, soft tissue injuries, infections (e.g., pneumonia, influenza, varicella, pharyngitis, and necrotizing fasciitis) , , [5 ], , , , . Two of the current cases (case 2 and 4) were diagnosed with diabetes. It is estimated that 5%–12% of STSS cases are related to the medical setting , . One of the current cases (case 3) was followed
We encountered four deaths related to STSS. Since STSS still has a high mortality rate and medical malpractice is often suspected, it is imperative to perform proper tests and make a proper diagnosis. In addition, it is critical to reevaluate STSS to reduce STSS-related deaths.
This case report did not receive specific support from funding agencies in the public, commercial, or non-profit sectors.
Statement of Conflict of Interest
The authors declare that they have no known conflicting financial interests or personal relationships that could affect the work reported in this article.
Toxic shock syndrome: major progress in pathogenesis but not in treatment
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Effect of bacterial pheromone peptide on host chemokine degradation in group A streptococcal necrotizing soft tissue infections
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Fulminant infection and toxic shock syndrome caused by Streptococcus pyogenes
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Streptococcal toxic shock syndrome in the intensive care unit
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A case of necrotizing fasciitis following intra-articular injections – iatrogenic or spontaneous?
2022, Legal Medicine
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.
Prognostic factors for streptococcal toxic shock syndrome: a systematic review and meta-analysis
2022., BMJ Open
Sudden death of a child caused by a giant cavernous hemangioma of the anterior mediastinum
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.
Indicators associated with rising suicide trends: the need for harmony in the discussion of suicide in forensics and other fields
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  total debt can be related to both the suicide rate and the suicide rate for both sexes, for men and women, and  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.
IL-6 and G-CSF production due to lung cancer in patients with HIV
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.
Medical researchers and the risk of infection with Crimean-Congo hemorrhagic fever
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.
Fatal anaphylaxis due to alpha-gal syndrome after first administration of cetuximab: first forensic case report
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.
Cut or burnt? – Classification of morphological features of fractures caused by heat and trauma caused by sharp forces
Legal Medicine, Volume 50, 2021, Article 101868
Distinguishing trauma from heat-induced fractures is a challenge faced by forensic anthropologists and pathologists during forensic investigations where perpetrators have used fire to destroy evidence. This work aims to validate the given identification characteristics to differentiate between fire-induced changes and blunt force injuries.
In this work, a total of 80 adults were cremated: 3 recently deceased embalmed cadavers from the Cementerio Sur de Madrid were used for a blunt trauma experiment in which 55 preburns were inflicted with a machete and a serrated blade in different anatomical regions. And 77 cremated from the osteological collection of the Laboratory of Forensic Anthropology and Odontology. From this collection, five cremated long bones were selected and 10 cuts were made by hand with a serrated blade for post-burn trauma analysis. In this way, the heat-induced changes and the morphological features of the trauma were documented and analyzed. Investigating and documenting the morphological traits made it possible to create a visual guide to heat-induced changes and flowcharts. Two intraclass correlation tests were performed to confirm the observer's ability to distinguish between fire-related changes and tool marks.
The results obtained in the statistical analysis show that even if tool marks are visible and recognizable upon macroscopic observation by an observer, some features, such as steps and transverse fractures, can be mistaken for inflicted trauma. The use of the proposed features along with careful anthropological research is recommended and has been shown to be functional for participants with no prior knowledge of cremated remains analysis.
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