Medical examiners are physicians tasked with conducting medicolegal death investigations to determine cause and manner of death. Although the autopsy is the most frequent tool utilized in these investigations and the one most often associated with the practice of forensic pathology, there is a wide variety of tools available to the medical examiner, whose statutory duty mandates death certification. We discuss the evidence supporting the usage of these myriad tools, ranging from the older techniques of scene investigation, microbial cultures, and toxicology to the cutting edge of medicine such as advanced imaging, molecular genetic studies, and biochemical analysis/ metabolic testing. The forensic pathologist must select the correct tools for a particular investigation based on the evidence supporting their usage and a medical judgment of each tool's pretest probability to produce a useful result, its appropriateness for the case, and the resources required for its utilization. The incorporation of these techniques into the forensic pathologist's toolbox improves our ability to conduct thorough medicolegal death investigations beyond that which can be accomplished by invasive autopsy alone.
Neonatal herpes simplex virus (HSV) infection is an uncommon disease that rarely presents as sudden unexpected death of a previously healthy newborn. Clinical manifestations are variable; signs and symptoms may be subtle and nonspecific. Neonatal infection may present with mucocutaneous (skin, eye, and/or mouth), disseminated, or central nervous system disease. Morbidity and mortality are dependent upon disease presentation and treatment. The infection is most frequently transmitted during the peripartum period, although the majority of mothers have no known history of HSV infection at the time of delivery. Findings at autopsy include gastrointestinal or mucocutaneous ulcers, diffuse hepatic necrosis, adrenal necrosis, pneumonitis, and splenic necrosis. Characteristic intranuclear viral inclusions are identified on microscopic examination. Coinfection with bacterial organisms may contribute to death. Autopsy examination with appropriate ancillary studies, including cultures, is critical given that many infants lack cutaneous manifestations of disease and remain undiagnosed prior to death.
Although tuberculosis is a major infectious cause of morbidity and mortality worldwide, death from tuberculosis is uncommon in the United States. Sudden death due to this infection is most frequently a result of tuberculous pneumonia or massive hemoptysis. There are multiple etiologies for massive hemoptysis in pulmonary tuberculosis, including aneurysm formation, bronchial arteritis, lung cavitation, and tuberculous lymphadenitis. The identification of the exact anatomic etiology of massive hemoptysis, such as a fistulous connection or erosion of a pulmonary artery into a bronchus, is rare. We present a case of sudden death due to massive hemoptysis due to erosion of a pulmonary artery into a bronchus as a result of undiagnosed pulmonary tuberculosis.
Medical therapy-related deaths are incidents with great significance to public health and the medical community. However, there is controversy regarding the prevalence and the appropriate manner certification of these deaths given the paucity of guidelines regarding these cases. Our study aimed to identify potential medical therapy-related deaths in a large medical examiner jurisdiction and to determine the consensus rate regarding 1) identification of a case as being attributable to medical therapy, 2) manner of death, and 3) hypothetical utility of the “therapeutic complication” (TC) manner. Retrospective review over a 12-year period (2002–2013) revealed 113 appropriate cases, which were summarized and provided to forensic pathologists in our jurisdiction. Results were analyzed for consensus rate between pathologists and cases were categorized by complication type. The largest majority of these cases fell into the medication category (n=44; 39.0%) followed by operative (n=38; 33.6%), cases not medical therapy-related (n=31; 27.4%), and nonoperative (n=19; 16.8%). The interobserver agreement rate for original manner classification ranged from fair to moderate. The addition of TC as an available manner improved the consensus rate in four cases and decreased the consensus rate in 37 cases. There were 73 cases that at least one pathologist attributed to medical therapy, 19 of which were attributed to medical therapy by all pathologists. Our study indicates that there is disagreement about which cases are attributable to medical therapy and poor consensus in manner classification of medical therapy-related deaths. As such, guidelines are proposed for the classification of deaths thought attributable to medical therapy.
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