Toxoplasma encephalitis in HIV: case report

In Tanzania, no data are available on the prevalence of brain infection by toxoplasma in HIV-infected patients. A case of a 35-year old man with fulminant toxoplasma encephalitis (TE) is reported for the first time. TE was not suspected clinically in our patient who presented with a one week history of severe headache and treated empirically with antimalarial drugs. TE was diagnosed postmortem histologically by haematoxylin-eosin and immunohistochemical stain with P30 antibody for toxoplasma antigen. The findings in our case support the suggestion that a high index of suspicion for TE should be maintained in HIV-infected patients presenting with focal neurological symptoms. The case highlights the importance of autopsy studies in not only documenting a toxoplasma brain lesion but also in increasing the awareness for its diagnosis in HIV-infected patients in Tanzania and other developing countries.

Discrepancy of clinical symptoms and prognosis of a patient--forensic significance of "talk and die" head injury

Deaths of patients who had talked after sustaining a head injury and were then assumed clinically to be recovering from the head trauma raise medicolegal questions about the precise causes of deaths. A forensic autopsy on a 77-year-old man who had been talking after a road traffic accident and died on the sixth day showed slight subdural hematoma, bifrontal cerebral contusions and diffuse axonal injury. No natural diseases or delayed complications of injury were found. The cause of death was certified as head injury due to a traffic accident. This is a case of "talk and die" head injury. Forensic autopsy is important in patients with "talk and die" to clarify the causal relation to the head trauma in relation to any further forensic dispute.

Medico-legal implications of acute subdural haematoma in boxing

A 16-year-old male high school student with a history of fever (38-39 degrees C) for 4 days lost consciousness following the end of a three round boxing match. He was transferred to a neurosurgical unit located 48 km away 1 h 36 min after injury. Clinical assessment at the unit revealed a comatose patient with a left acute subdural haematoma, but because of advanced brain oedema surgical management was deemed futile. At autopsy an acute subdural haematoma and a severe brain oedema were confirmed. Evaluation of physical conditions before the fight should have been more rigorous in our patient. The observations in our case support the published literature that boxing matches should be held only where neurosurgical expertise is readily available.

[Aircraft crashes in sky sports. Report of two autopsy cases and review of the accidents during 1981 to 1997 in Japan]

The authors report two forensic autopsy cases of pilots who died in glider and ultra-light plane crashes in Aso, Kumamoto and review sky sports accidents in Japan (1981-1997). In the glider crash, sharp abdominal pain due to gallstones in a 78-year-old pilot was a possible cause of the accident. In the ultra-light plane crash, unskillful control of the plane by a 38-year-old pilot was the cause of the accident. The incidence of sky sports accidents increased from 12 cases in 1981 to 62 cases in 1997. The mortality rate of the victims of the accidents is very high. Investigation of natural diseases in pilots as a cause of accidents and the mechanisms of fatal injuries will help to assess preventive measures against sky sports accidents.

Pink spots of Hedley-White in the brain. Evaluation of the significance in the forensic autopsy

Pink spots are sharply demarcated round to oval discolorations with a white center in the deeper areas of the formalin-fixed brain. In 152 forensic autopsies with neuropathological examinations, the authors observed pink spots in three of 16 patients with bacterial infectious diseases. Pink spots could not be found in 136 patients without bacterial infectious diseases. These results verify the concept that pink spots correlate with bacterial infections. The presence of pink spots will be used as an indication of infectious diseases in the forensic autopsy.

Japanese monozygotic twins with familial amyloidotic polyneuropathy (FAP) (ATTR Val30Met)

Twenty-nine-year-old twin brothers having the amyloidogenic transthyretin (ATTR) Val30Met gene developed the clinical symptoms of familial amyloidotic polyneuropathy (FAP) in 1995. The twins had the same educational background and lived in the same district. FAP manifestations were similar in both cases, although electromyographic examinations revealed sensorimotor polyneuropathy in No. 1 and sensory polyneuropathy in No. 2. DNA analysis revealed that they were monozygotic twins. In addition to environmental factors, genetic factors may play an important role in determining the onset of FAP.

Traumatic basal subarachnoid hemorrhage due to rupture of the posterior inferior cerebellar artery--case report

A 20-year-old male presented with traumatic basal subarachnoid hemorrhage after being involved in a fight. Antemortem clinical examinations could not exclude the possibility of rupture of abnormal blood vessels because of the absence of external injuries. Careful postmortem examination of the head and neck regions and histological examination of the intracranial arteries demonstrated traumatic rupture of the left posterior inferior cerebellar artery due to a fist blow to the jaw. This case indicates the need for careful autopsy examination for the differentiation of traumatic and non-traumatic basal subarachnoid hemorrhages.

Fatalities by inhalation of volcanic gas at Mt. Aso crater in Kumamoto, Japan

Volcanic gas is one of the hazards which tourists rarely meet in mountains. We present six fatalities due to volcanic gas inhalation on Mt. Aso, an active volcano in Kumamoto, Japan, over a period of nine years (1989-1997). One accident occurred at the lip of the crater and the other five within a distance of 250 m from the lip of the crater. Four of the six fatalities had a history of bronchial asthma. A forensic autopsy was performed for a fatality with a history of hypertensive heart disease; pulmonary emphysema was disclosed for this victim. These findings supported the idea that individuals with chronic lung diseases were at higher risk of death by volcanic gas inhalation. Safety precautions are effected through regular surveillance of the area and monitoring of volcanic gas levels. The criterion for sulfur dioxide levels has been changed to a more rigorous one (from >5.0 ppm to >0.2 ppm) according to our advice based on the autopsy. Further forensic analyses will help to design additional preventive measures so as to reduce mortality resulting from inhalation of toxic volcanic gas.

Neuropathology of human immunodeficiency virus 1 infection. Significance of studying in forensic autopsy cases at Dar es Salaam, Tanzania

OBJECTIVE

In sub-Saharan Africa, only a few studies of neurologic complications of human immunodeficiency virus 1 (HIV-1) infection have been done. The authors studied neuropathology of HIV-1 infection in Tanzania.

DESIGN

Forensic autopsy study at Dar es Salaam, Tanzania.

SETTING

A joint research project between Dar es Salaam, Tanzania, and Kumamoto, Japan.

PATIENTS

Thirty patients with risk factors for HIV-1 infection.

MAIN OUTCOME MEASURES

Human immunodeficiency virus 1 infection was evaluated by HIV-1 antibody test on postmortem serum samples. The brains of HIV-1-infected persons were studied histopathologically.

RESULTS

Infection with HIV-1 was identified on postmortem serum samples in 10 of 30 forensic autopsy cases. Neuropathologic changes of the brain were observed in 8 of the 10 HIV-1-infected persons; these changes consisted of lymphocytic meningitis, bacterial meningoencephalitis, cryptococcal meningoencephalitis, tuberculous meningitis with brain abscesses, and intracerebral hemorrhage.

CONCLUSIONS

Because none of the persons studied was suspected to have had brain diseases before autopsy, the results suggest that brain diseases of HIV-1-infected patients are likely to go unrecognized in Tanzania. In addition, the high incidence of neuropathologic findings in HIV-1-infected persons indicates that HIV-1-related brain diseases are common in Tanzania, as they are in developed countries. Further forensic autopsy study will determine the range and prevalence of brain complications and have immediate impact on the management of HIV-1-infected patients in Tanzania and other developing countries.

Antiaggregatory, antithrombotic effects of MS-180, a novel platelet glycoprotein IIb/IIIa receptor antagonist

The antiaggregatory and antithrombotic effects of (S)-(-)-ethyl[6-[4-(morpholinoformimidoyl)benzamido]-3,4-dihydro-2 H-1-benzo-pyran-3-yl]acetate hydrochloride (MS-180), a novel platelet glycoprotein IIb/IIIa receptor antagonist, were investigated. Ma-HCl, (S)-(-)-[6-[4-(Morpholinoformimidoyl)benzamido]-3,4-dihydro-2H-1-b enzopyran-3-yl]acetic acid hydrochloride, the hydrochloride salt of Ma (active metabolite), inhibited the binding of fibrinogen to immobilized human glycoprotein IIb/III receptor with an IC50 value of 0.12+/-0.03 nM without affecting binding to either fibronectin or vitronectin receptors. In anesthetized guinea pigs, intraduodenal administration of MS-180 caused dose-dependent inhibition of both ADP- and collagen-induced ex vivo platelet aggregation. At the same dosages, occluded thrombus formation and platelet release reactions were also markedly suppressed. In anesthetized dogs, the bleeding time was prolonged slightly even when submaximal inhibition (< 90%) of ex vivo platelet aggregation was achieved following i.v. administration of Ma-HCl. Aspirin (100 mg/kg) prolonged the bleeding time to the same extent as MS-180 (1 mg/kg), although it suppressed only collagen-induced platelet aggregation. Therefore, MS-180 may be clinically useful for the treatment of thrombotic diseases.

Accidental decapitation: an unusual injury to a passenger in a vehicle

A case of decapitation of a vehicle passenger in an accident on a highway is reported. Evaluation of roadside evidence and the deceased's injuries revealed that the victim was partially ejected from a broken passenger-side window as the vehicle spun out of control, decapitation being due to the impact of his head against a barrier stanchion on the shoulder of the road. An unfastened seat-belt, high-speed driving and the construction of the road barrier were contributory factors.

Death as a result of heat stroke in a vehicle: an adult case in winter confirmed with reconstruction and animal experiments

A 54-year-old man was found dead in the driver's seat of his vehicle on a winter's day. Investigations of the vehicle revealed that the engine was running, and the car heater was left on with the maximum temperature and velocity. The body was found excessively sweating. Rectal temperature of the body was 43 degrees C at 10 h post mortem. In autopsy, several superficial skin burns were observed on the face, the shoulders and the legs. The lungs were heavily congested and hemorrhagic. The liver showed typical alcohol-induced micronodular cirrhosis. The alcohol concentrations were 0.17% in the blood of both the left and the right heart, 0.17% in the femoral-vein blood, 0.21% in the bladder urine and 0.34% in the gastric contents. A reconstruction experiment demonstrated that the temperature inside the vehicle rose rapidly and reached 50-58 degrees C in 3 h. Animal experiments showed that the temperature threshold for rats to succumb to heat was between 40 and 45 degrees C. This case shows that heat stroke in a vehicle can occur in adults with chronic diseases or alcoholism, such as in this particular case, even in the winter.

New platelet fibrinogen receptor glycoprotein IIb-IIIa antagonists: orally active series of N-alkylated amidines with a 6,6-bicyclic template

The design, synthesis, and pharmacological evaluation of (S)-(-)-ethyl [6-[4-(morpholinoformimidoyl)benzamido]-3, 4-dihydro-2H-1-benzopyran-3-yl]acetate hydrochloride ((S)-4.HCl, MS-180), an orally active glycoprotein IIb-IIIa (GPIIb-IIIa) antagonist, are reported. Pharmacophore mapping of amidino and carboxyl groups of already known GPIIb-IIIa antagonists led to the synthesis of nine amidino acids containing 6,6-bicyclic ring skeletons (10a-i). Among them, the compounds 10a,c,e having an amide bond and 1,2,3,4-tetrahydronaphthalene or 3, 4-dihydro-2H-1-benzopyran skeleton showed marked inhibitions with IC50 values of 46-57 nM in human platelet aggregation assay in vitro, but low oral activities. N-Alkylation of the amidino group coupled with the ester prodrug approach afforded MS-180 ((S)-4.HCl), which generates in vivo the corresponding carboxylic acid (S)-3 as an active species. In vitro, (S)-3 inhibited ADP-induced aggregation of guinea pig, dog, and human platelets (IC50 = 110, 253, and 35 nM, respectively) and inhibited the binding of fibrinogen to immobilized GPIIb-IIIa of human platelets (IC50 = 0.12 nM). After oral administration of MS-180 ((S)-4.HCl) to fasted beagle dog, ex vivo inhibition of platelet aggregation was observed. The maximal inhibitions were observed 2-4 h after dosing with dose dependency (60% inhibition at a dose of 1 mg/kg, 85% at 3 mg/kg, and 100% at 10 mg/kg, respectively) and the extent of the inhibitions paralleled the plasma concentration of the active species (S)-3. On the basis of these studies, we selected MS-180 ((S)-4.HCl) as a candidate for clinical evaluation as a drug for the treatment and prevention of thrombosis in patients.

[Forensic medicine in Dar-es-Salaam, United Republic of Tanzania]

The authors had opportunities to visit and see the present state of forensic medicine in Dar-es-Salaam, a capital city of United Republic of Tanzania. In this city, Department of Histopathology and Morbid Anatomy in Muhimbili University College of Health Sciences is in charge of education and practice of forensic medicine. All bodies of unusual death, about 3,000 cases per year, are brought to the university mortuary and examined by pathologists. An order of forensic autopsy from the Tanzanian police is submitted to the department with details of the case, i.e. circumstances of death, witnesses, weapons, etc. In each case, a pathologist signs out a death certificate and issues an autopsy report which is standardized throughout the country. Embalming after autopsy is essential in a tropical country. Tanzania in particular, to prevent both putrefaction of the body and dispersion of pathogens during its transportation. Preventive measures against biohazards from human immunodeficiency virus-infected bodies are considered in the autopsy room and laboratory. Although Tanzania is one of the developing countries in the world, the forensic medicine in the capital city is rendering great services in the promotion of public health.

Binswanger's disease. A rare cause of dementia in elderly persons

A 80-year-old in-patient with abnormal behaviors was strangulated in a hospital bed by another in-patient while he could not escape from the violence because of being restrained to the bed with safety belts. Neuropathological examination of the victim's brain showed characteristic pathological changes of Binswanger's disease (BD), a rare cause of dementia inducing abnormal behaviors. The authors methodically documented BD of the victim and at least justified the restraint as a preventive measure of his abnormal behaviors. Although the etiology of BD is unknown, immunostaining for glial fibrillary acidic protein of the white matter lesions showed neither hyperplasia nor hypertrophy of astrocytes. This result suggested that astrocytes may play an important role in the pathogenesis of BD.

[Neuropathological diagnosis of senile dementia of Alzheimer's type in forensic autopsy cases]

Senile dementia of Alzheimer's type is frequently an underlying cause of accidental death of elderly persons. Neuropathological diagnosis of dementia is therefore crucial to assess the contribution of dementia to the cause of accident. The authors applied two conventional neuropathological criteria described by Khachaturian and Mirra, et al. to three forensic autopsy cases of dementia-related accidental death. In all cases, the number of neocortical senile plaque, a hallmark of dementia, could not fulfill both criteria. This result indicates that foregoing neuropathological criteria derived from fully developed dementia are hardly applicable to elderly persons who died in an early stage of dementia in forensic settings. Further investigation will be required to establish a diagnostic criterion of early stage of dementia.

[The 4th international conference of World Police Medical Officers in Clinical Forensic Medicine in Kumamoto, Japan]

The World Police Medical-Officers in Clinical Forensic Medicine (WPMO) is an international conference on practice of forensic medicine and clinical forensic medicine to be taken place every three years. Its 4th international conference (WPMO-1996-KUMAMOTO) was held on 19-23 August 1996 in Kumamoto, Japan. A total of 294 participants, 89 overseas from 18 countries and 205 domestic, were attended. Four plenary lectures and 67 free papers were presented in the conference. Such social programs as welcome reception, one-day-tour, citizen's home visit, banquet etc were carried out. The two plenary entitled 'Current Status of Practice of Forensic Medicine in U.S.A.' by Prof. Thomas T. Noguchi and 'Origins and Development of the Police Surgeon Services in U.K.' by Dr. Reginald A. Bunting were tape-recorded and presented in this report as references of future activities of forensic medicine in Japan.

Neuropathology of human immunodeficiency virus infection at different disease stages

The authors studied the brains of 471 adults infected with human immunodeficiency virus type 1 (HIV-1): 123 asymptomatic carriers, 127 in an early stage of acquired immunodeficiency syndrome (AIDS) with pulmonary tuberculosis or bacterial infections, and 221 in fully developed AIDS with opportunistic infections or neoplasms. Lymphocyte infiltration of the leptomeninges and of perivascular spaces occurred at all stages, but the frequency was significantly higher in asymptomatic carriers. Microglial nodules appeared at all stages of disease; they were not an early indicator of HIV encephalitis (HIVE). The incidence of HIVE was unrelated to the stage of AIDS, suggesting that HIVE occurs before opportunistic infections and neoplasms. Drug abuse, such as cocaine and opiates, may enhance HIV replication and increase the incidence of HIVE in the early stage of AIDS. Opportunistic infections or lymphoma involved only the brain in 31.2% of persons with fully developed AIDS. Conversely, opportunistic infections or neoplasms involved only organs other than the brain in 55.7% of persons with fully developed AIDS. In 13.1% of persons with fully developed AIDS, opportunistic infections or neoplasms involved the brain and other organs. Multiple intracranial opportunistic infections and lymphoma coexisted in 4.1% of persons with fully developed AIDS. The authors identified cerebrovascular disease in 10.6% of asymptomatic carriers, 7.1% of early AIDS, and 5.0% of fully developed AIDS. The observed sequence of abnormalities may be useful in understanding the progression of HIV disease in the brain.

Cocaine induced intracerebral hemorrhage: analysis of predisposing factors and mechanisms causing hemorrhagic strokes

We analyzed 26 autopsy cases of cocaine induced intracerebral hemorrhage and compared those findings with those of 26 autopsy cases of cocaine induced cerebral aneurysm rupture. The incidence of hypertensive cardiovascular disease (HCVD) was significantly higher in persons with intracerebral hemorrhage than in those with aneurysm rupture. Our findings suggest that HCVD predisposes to cocaine induced intracerebral hemorrhage. We propose that the foregoing relationship results from a cocaine induced alteration of cerebral autoregulation in the context of increased cerebral blood flow.

[Two unusual cases of half-sibling test with DNA polymorphism]

In usual paternity cases, the putative man and the mother-child couple are alive. However, there are some cases in which putative man and mother were deceased and only children were available for analyses. It is difficult to determine the presence or absence of half-sibling relationship from analyses of conventional blood group markers (CBGM). In this study, five kinds of single locus DNA probes were applied to 2 half-sibling cases. To decide usefulness of single locus DNA probes, we defined likelihood ratio of half-sibling (LRHS) based on the likelihood ratio of paternity (LRP) and also investigated the distribution curves of log10 LRHS in cases of unrelated combinations and half-sibling combinations. Distribution curves of log10 LRHS from DNA analyses in the cases of unrelated combinations and half-sibling combinations is more clearly separated than from CBGM. Single locus DNA probes are considered to be more informative for half-sibling cases.

Differentiation between bruises and putrefactive discolorations of the skin by immunological analysis of glycophorin A

In a differential study to distinguish bruises from putrefactive discoloration, glycophorin A, a component of the erythrocyte membrane, was extracted from discolored skins and detected by immunological methods utilizing an anti-glycophorin A serum. Skin samples of 18 bruises, 8 postmortem hypostasises and 7 putrefactive discolorations were removed from 27 bodies in which postmortem intervals ranged from 4 h to 2.5 months. In 13 out of the 18 bruises (72.2%), glycophorin A was detected by the immunological methods. It was noted that glycophorin A was detectable even in a severely putrefied body 10 days after death. In contrast, no glycophorin A was detected in any of the postmortem lividities or the putrefactive discolorations. These results suggest that the absence of glycophorin A does not always indicate a skin discoloration of postmortem origin, but a positive glycophorin A reaction does indicate a skin discoloration due to bruise.

Differentiation of discolouration in a body by an erythrocyte membrane component, glycophorin A

In a differential study to distinguish antemortem bruise from postmortem infiltration of haemoglobin on the skin, a component of erythrocyte membrane, glycophorin A was extracted from experimental bruise and haemoglobin infiltration lesions over set periods of time. This extraction was accomplished by utilising anti-glycophorin A serum, after which the difference between the two lesions was evaluated. The glycophorin A was recovered from the bruise lesions satisfactorily up to the ninth to twelfth days and showed good resistance to putrefaction. In contrast, no glycophorin A was detected in haemoglobin infiltration lesions taken at any time. Glycophorin A was also detectable in human vital bruises which were taken in autopsies of four hours to ten days postmortem. These results suggest that a differential diagnosis of antemortem bruise and postmortem haemoglobin infiltration is possible in advanced stages of death.

Studies of felonious crimes by the University Department of Forensic Medicine in Kumamoto Prefecture, Japan

This paper gives an understanding of Japan in the respect of forensic medicine. The fight against felonious crimes in Kumamoto is introduced by reference to the police system, crime statistics, an association of police surgeons and medico-legal autopsy in Kumamoto Prefecture. The police have 23 local police stations with 2,670 police officers and the unique Hashutsu-sho and Chyuzai-sho systems. The crime rate is not very high, but crimes committed by Yakuza groups and traffic accidents are major problems in Kumamoto. Medico-legal autopsy is performed in the university department on only criminal and suspected cases after examination of the body externally by a police surgeon. Two illustrative cases are also introduced in this report, which shows good cooperation among the police force, the university department of forensic medicine, and police surgeons in Kumamoto, Japan.

Genetic polymorphism of complement component C6, C7 and C8(1) in Chinese Han population in northeast China

Distributions of complement phenotypes, C6, C7, and C8(1) were studied using thin agarose gel isoelectric focusing (AGIEF) or ultra-thin polyacrylamide gel isoelectric focusing (PAGIEF) and subsequent immunoblotting techniques in 203 Chinese Han population in Liaoning Province of northeast China. The gene frequencies were as follows: C6*A 0.4704, C6*B 0.5049, C6*B2 0.0148, C6*B3 0.0049, and C6*M 0.0049; C7*1 0.8251, C7*2 0.1108, C7*3 0.0320, and C7*4 0.0320; C8(1)*A 0.5567 and C8(1)B 0.4433, respectively. All the observed numbers of the phenotypes were in agreement with the expected numbers under the Hardy-Weinberg equilibrium. The gene frequencies among Chinese subpopulations and other various populations were compared.

Genetic polymorphism of human factor H (HF, beta 1H globulin) in Chinese Han population in northeast China

The distribution of human factor H of serum phenotypes were studied using ultrathin polyacrylamide gel isoelectric focusing (PAGIEF) and subsequent immunoblotting techniques in 203 Chinese of Han population in Liaoning Province of northeast China. The gene frequencies of HF*A and HF*B were 0.4828 and 0.5172, respectively. All the observed numbers of the phenotypes were in agreement with the expected numbers under the Hardy-Weinberg equilibrium. The gene frequencies among Chinese, Japanese, and Caucasian populations were compared.

Application of a computer assisted image analyzer to the assessment of area and number of sites of dental attrition and its use for age estimation

A simple method was devised to assess dental attrition in terms of its area and number of sites by using dental plaster casts and a computer assisted image analyser. The changes presented on the occlusal surfaces of teeth were investigated for age estimation using these criteria. The area of attrition on each tooth demonstrated a significant positive correlation with age, but a wide individual variation was observed in the values for each tooth. Therefore, this method was unsuitable for accurate age estimation of a single tooth. A strong negative correlation with age was observed in the number of sites of attrition. A multiple stepwise regression analysis using the variables 'attrition area' and 'attrition number' revealed multiple correlation coefficient values of 0.93. The quantitative assessment of both horizontal and vertical factors of dental attrition would be essential to improve the accuracy of this method.