Animal-Related Fatalities-Part II: Characteristic Autopsy Findings and Variable Causes of Death Associated with Envenomation, Poisoning, Anaphylaxis, Asphyxiation, and Sepsis

Fatal Sea Snake Envenomation

ABSTRACT

A 23-year-old man working on a prawn trawler off the Northern Australian coast was bitten on the right hand by a black-banded sea snake (Laticauda colubrina), resulting in the rapid onset of ptosis, blurred vision, and respiratory difficulties with convulsions, loss of consciousness, and death. Resuscitation was unsuccessful. No antivenom was available because of the remote location. At autopsy, a small puncture wound was identified on the middle interphalangeal joint of the right little finger. No other significant abnormalities were detected. Elevations in creatine kinase (1558 μ/L) and myoglobin (24,800 μg/L) levels were found. Death was caused by respiratory failure after sea snake envenomation. This case demonstrates potential difficulties in establishing the diagnosis of lethal sea snake envenomation, including the inconspicuous nature of the bite marks with no local reaction and the underlying neurotoxic nature of the lethal mechanisms, which leaves very nonspecific pathological findings. Myonecrosis may occur but is variable. Unless reliably witnessed, sea snake envenomation may not be suspected. Failing vision or unexplained paresis in fishermen or individuals who have been in the sea may point to the diagnosis.

Awareness on tetrodotoxin of illegal activity: forensic issue from a rare homicide case report and literature review

The authors describe an extremely rare case of homicide by injecting tetrodotoxin (TTX) as lethal neurotoxin found in puffer fish. After a thorough investigation, the male victim was found to have a broken stalk from syringe needle in the subcutaneous tissue of left buttock and severe asphyxia confirmed by the main pathological findings at autopsy. During tortuous toxicological analysis，TTX was revealed by ultra high performance liquid chromatography tandem mass spectrometry (UPLC-MS/MS) as well as acute intoxication confirmed from forensic examination. The literature of qualitative and quantitative determination of TTX from human fluids was also reviewed to expect widely acceptable detection strategies. This case highlighted the importance of TTX toxicant with chemical formula name purchased through e-commerce，so as to improve particular emphasis and supervision on harmful substances possibly using hidden information or illegal means. Histopathological and toxicological results demonstrated here provided a reference and other useful information to the challenges of forensic casework. In general, the case report illustrates medico-legal issues of more attention to the possibility of TTX poisoning in rapid death and the need of routine postmortem tox screening in future practice.

Camel-Related Deaths-A Forensic Overview

ABSTRACT

Camels are ungulates of the genus Camelus and have been used for centuries in parts of Asia and Africa for transport and sustenance. Handling of camels is not without its dangers, and 4 cases from South Australia are reported with a review of lethal camel-related issues. Case 1 is a 56-year-old man who died of multiple blunt force injuries after he had attempted to move a 7-year-old female dromedary (Camelus dromedarius). Case 2 is a 65-year-old woman who was crushed by 1 or more camels that she had been training. Case 3 is a 1-year-old girl who died of blunt craniocerebral trauma after the car in which she was traveling rolled when the driver swerved to avoid a herd of camels that had strayed onto the road. Case 4 is a 66-year-old woman who died of ischemic and hypertensive cardiac disease exacerbated by physical activity while rounding up camels. Deaths associated with camels involve kicking, stomping, kneeling or sitting on a victim, or biting and shaking and throwing. Lethal mechanisms include hemorrhage from vascular injuries and internal organ disruption, crush asphyxia, and blunt craniospinal injuries. Death may also follow falls from camels or vehicle collisions. Camels also carry a wide range of zoonotic diseases, the most significant of which is Middle Eastern respiratory syndrome. Handling of camels may also exacerbate underlying organic illnesses such as cardiac disease. Those working with camels should be aware that the size, strength, and temperament of these animals may make them dangerous and that they also carry potentially lethal zoonotic diseases.

Injuries and deaths caused by non-human primate attacks: Paediatric vulnerability

A six-month-old girl was taken from her mother's lap by a macaque monkey (Macaca) that had entered the room through an open door. The monkey escaped with the infant but subsequently dropped her from a rooftop terrace. Death occurred soon after impact with the ground, and was found at autopsy to be due to blunt cranio-cerebral trauma with skull fractures and intracranial haemorrhage. Monkeys and apes may cause a variety of serious and potentially life-threatening injuries and may manifest quite unpredictable and aggressive behaviour around humans. The very young are particularly vulnerable to primate attacks, and 'baby theft' by apes and monkeys is an event that has now been reported, albeit rarely, in a number of different countries around the world. The fatally injured infants have died from bites, falls and drowning. Chimpanzees in the wild may also specifically hunt human infants for food.

Fatal rooster attack

A 76-year-old woman was attacked by a domestic rooster on her rural property while collecting eggs. The bird pecked her lower left leg causing significant hemorrhage with collapse and death. The decedent's past medical history included treated hypertension, hyperlipidemia, non-insulin dependent diabetes mellitus and varicose veins. At autopsy the major findings were limited to the lower left leg which was covered with adherent dried blood. Two small bleeding lacerations were present, one of which was located immediately over a perforated large varix. Death was therefore due to exsanguination from bleeding varicose veins following an attack by a rooster. This case demonstrates that even relatively small domestic animals may be able to inflict lethal injuries in individuals if there are specific vascular vulnerabilities present.

Characteristics and relative numbers of lethal snake bite cases in medicolegal practice in central Myanmar - A five year study

Clinical and pathological case files of lethal snakebites were reviewed from the Magway Region General Hospital, Magway, Myanmar, over a five-year period (January 2013 December 2017). A total of 2069 postmortem examinations were performed which included 84 cases of lethal snake bite (4.1%). The annual numbers ranged from 10 out of a total of 268 autopsies in 2013 (3.7%), to 31 out of a total of 501 autopsies in 2016 (6.2%). There were 54 males (64%) and 30 females (36%) (M:F = 1.9:1; age range 5-75yrs, mean 33yrs). The most common time for lethal envenomation was August (16/84-19%), the middle of the monsoon season. 45/84 (54%) had acute renal failure, 27/84 (32%) were shocked, and the remaining 12/84 (14%) had disseminated intravascular coagulation. Twenty cases (24%) died within 24 h after envenomation. Fang marks were identified on the legs (either right or left) in 73/84 cases (87%) and on the arms in five cases (6%). The predominant findings at autopsy were of acute renal injury (82/84-98%), pituitary haemorrhage/necrosis (36/84-43%), and adrenal gland haemorrhage (30/84-36%). Despite the reduction in fatalities over the years snakebite from Russell's viper in particular remains an important contributor to mortality in central Myanmar despite the availability of antivenom.

Autopsy Features of Fatal Donkey Attack

Lethal donkey attacks have very rarely been described. The case of a 65-year-old man who was found deceased on a country road with 2 domestic donkeys nearby is, therefore, reported. Examination of the body revealed contusions and lacerations of the face and scalp, a comminuted fracture of the left maxilla, comminuted fracturing of the right radius and ulna and of the left anterior superior iliac spine, a flail chest, and pulmonary contusions. In addition, there were bite marks on the left thigh, right buttock, right axilla/upper arm, and left cheek which corresponded to the dental arcades of the donkeys. Death had resulted from blunt chest trauma due to an attack by 1 or 2 donkeys. Deaths and serious injuries are much more commonly caused by horses; however, this case shows that even domesticated donkeys may also rarely be capable of inflicting significant trauma and so should be approached with circumspection.

Causes and Mechanisms of Death in Fatal Water Buffalo Attacks

Deaths due to buffalo attack have not been well described. A 72-year-old man was trampled by a water buffalo (Bubalus bubalis) while attempting to move the animal within an enclosed area at an abattoir. At autopsy, there were numerous injuries involving the chest, head, neck, and left upper arm. Blunt force injury had resulted in multiple rib fractures with a flail chest and fracture/dislocation of the mid-cervical vertebrae caused either by physical crushing by the animal against the walls of the enclosure or by stomping. There was also evidence of crush asphyxia with bilateral conjunctival hemorrhages and petechial hemorrhages. In addition, there was a deep degloving injury of the upper left arm compatible with goring by one of the buffalo horns. While large animal attacks may result in death from multiple injuries, careful dissection and examination of specific injuries at autopsy may clarify the complex interaction of lethal mechanisms.

Lethal Epistaxis

Epistaxis or nosebleed refers to bleeding from the nostrils, nasal cavity, or nasopharynx. Occasional cases may present with torrential lethal hemorrhage. Three cases are reported to demonstrate particular features: Case 1: A 51-year-old woman with lethal epistaxis with no obvious bleeding source; Case 2: A 77-year-old man with treated nasopharyngeal carcinoma who died from epistaxis arising from a markedly neovascularized tumor bed; Case 3: A 2-year-old boy with hemophilia B who died from epistaxis with airway obstruction in addition to gastrointestinal bleeding. Epistaxis may be associated with trauma, tumors, vascular malformations, bleeding diatheses, infections, pregnancy, endometriosis, and a variety of different drugs. Careful dissection of the nasal cavity is required to locate the site of hemorrhage and to identify any predisposing conditions. This may be guided by postmortem computerized tomographic angiography (PCTA). Despite careful dissection, however, a source of bleeding may never be identified.

A 51-year-old woman crushed by an elephant trunk

Wild and exotic animal attacks are not common in the United States. Animal-related injuries in the United States are usually caused by dog bites, followed by cattle and horse injuries. Exotic animal attacks can occur when the animals are provoked, depressed, or housed improperly by owners. We report the case of a 51-year-old woman who sustained multiple systemic traumatic injuries after she was pinned to a fence by an elephant's trunk. Upon arrival in the emergency department, she was hypothermic with a temperature of 35.1ºC (95.1ºF), hypotensive to 94/60 mm Hg after 5 L crystalloid, tachycardic at 108 beats/min, and intubated with oxygen saturation of 100%. Tranexamic acid was administered in addition to starting a massive transfusion protocol. Injuries included bilateral multiple rib fractures, left abdominal wall degloving injury, right pneumothorax, right hemothorax, left chest wall puncture wound, grade IV splenic laceration, 3 grade III liver lacerations, retroperitoneal hematoma, and degloving injuries to bilateral posterior thighs requiring more than 30 operations. Why should an emergency physician be aware of this? Several factors need to be considered when evaluating animal-related injuries, including type, age, and sex of the animal. Multisystem traumatic injuries should be assumed when a large animal is involved. Prehospital care and transport time are vital to a patient's survival in both urban and rural settings. During the initial resuscitation, administering antibiotics tailored to the specific animal can greatly decrease risk of infection and morbidity. Additionally, tetanus immunoglobulin, tetanus toxoid, and rabies immunoglobulin and vaccine may be needed, unless the victim has been previously vaccinated.

Sheep shearing and sudden death

A 29-year-old sheep shearer collapsed after walking across a shearing shed floor, holding his hand over an incised wound to his neck. Attempted resuscitation was unsuccessful. At the death scene fine arterial blood spatter was noted and at autopsy a single incised wound to the neck was observed, the patterned edges of which corresponded to the teeth of the shears. Dissection revealed injury to the underlying jugular vein and the mid portion of the common carotid artery. Death was attributed to blood loss from an incised wound of the left side of the neck. This case demonstrates the rare event of an accidental death related to the actions of a sheep. Although a relatively small animal, review of the circumstances and interviews with those present revealed that sudden and unexpected movement of the sheep during shearing had caused the shearer to lose control of his electrical shears resulting in a lethal incised wound to the neck. The blood spatter pattern at the scene was supportive of both witness descriptions and the findings at autopsy.

Perioperative temperature elevation: not all hyperthermia is malignant hyperthermia

OBJECTIVES

The objective of this review is to assist the readers, anesthesiologists, intensivists, and emergency physicians in making a more accurate diagnosis of perioperative fever or hyperthermia and subsequently choose the proper course of treatment.

AIM

To identify the many sources of perioperative fever and after a more accurate differential diagnosis, select appropriate treatment options. Most anesthesiologists, intensivists, and emergency physicians are not familiar with an expansive differential of perioperative fever. This article attempts to expose these physicians to that differential diagnosis.

BACKGROUND

Much of the medical literature has anecdotal reports, small case series, or limited reviews of the possible sources of hyperthermia or fever. This is especially true of the anesthesia literature.

RESULTS

A literature search was performed which identified many possible common and uncommon sources of fever. Some of these sources are quite relevant to the anesthesiologist. Other sources had potential relevance in obscure cases.

Acute kidney injury due to acute cortical necrosis following a single wasp sting

Acute kidney injury (AKI) can develop after multiple wasp or bee stings. The etiology is the acute tubular necrosis secondary to shock, pigment toxicity, interstitial nephritis, or direct nephrotoxicity of venom. We report a 40-year-old female who presented with oliguric AKI after a single wasp sting on her hand. Her history, examination, and investigations did not support any of the established causes of AKI in such settings. She did not improve with supportive management and dialysis, and kidney biopsy showed acute cortical necrosis (ACN). This is the first report of ACN after a single wasp sting.

Multiple bee stings, peritumoral mast cell degranulation and anaphylaxis--is there a relationship?

A case of a 58-year-old with fatal anaphylaxis due to multiple bee stings is reported. Supportive evidence for anaphylaxis included post-mortem serum tests, which demonstrated a markedly elevated tryptase level and increased sensitivity to bees on radioallergosorbent test (RAST). At autopsy a previously undiagnosed esophageal adenocarcinoma involving the gastroesophageal (GE) junction was also identified. Histology of the tumor demonstrated significant numbers of mast cells, many of which were degranulating. Increased numbers of mast cells, as in mastocytosis, are known to predispose to an allergic sensitivity to Hymenoptera. The finding of a significant peritumoral mast cell population with degranulating forms in this case, therefore, raises the possibility that death due to anaphylaxis was contributed to by mast cell proliferation in an occult esophageal carcinoma.