Munchausen Syndrome by Proxy as a Cause of Child Abuse

Munchausen syndrome by proxy (MSBP) is a rare form of mental disorder and is known as a particular type of child abuse. MSBP has been described since 1977 as a severe form of abuse with illness falsification or the intentional harming by guardians, mostly mothers. The perpetrator of MSBP may inflict damage to the child directly or indirectly through medical procedures. The perpetrator’s alleged motive is to satisfy her psychological needs, and she has a history of mental illness, mostly, factitious disorder, personality disorder, and somatic disorder. The pathology is not well known; as such, it is difficult for medical personnel to detect it early. In addition, it is hard to be handled effectively by the police and child welfare agencies because of the scarcity of evidence. Therefore, the authors attempt to examine the essential information from early detection and child abuse prevention by analyzing its clinical characteristics and the perpetrator’s characteristics, including alerting signs of MSBP. For this purpose, we focus on the role of nursing staff to detect this unusual cause of child abuse.

Therapy-Related Acute Myeloid Leukemia Diagnosed at Postmortem in a Long-term Survivor of Advanced Hepatocellular Carcinoma

Acute myeloid leukemia (AML) is a common hematologic malignancy with high mortality and a short survival period in adults. About 10% of these cases, called therapy-related AML, are reported to be the consequence of chemotherapy or radiotherapy of previous malignancy. In a clinical setting, this is usually diagnosed by peripheral blood smear or bone marrow biopsy by assessing the proportion of blasts. However, postmortem blood samples are not suitable for smear analysis because of hemolysis. Therefore, ancillary tests for identifying leukemic infiltration or related molecular change can provide an alternative diagnostic clue for AML. The deceased had been treated for 3 years for a combined type of hepatocellular carcinoma with multiple pulmonary metastases. Treatments included the resections of primary and metastatic tumors, chemotherapy, and radiotherapy, which prevented further progression of his cancer. One year after the last treatment, he suddenly collapsed without any specific symptoms and shortly died. The microscopic examination of the autopsy samples revealed extensive extramedullary infiltration of leukemia, which was confirmed as an AML by a series of ancillary immunohistochemical staining. This case illustrates both the importance of careful hematologic observation in cancer survivors and the necessity of a detailed medical diagnosis in a medicolegal autopsy.

Sudden Cardiac Death Caused by Cardiac Small Vessel Vasculitis after COVID-19 Vaccination (BNT162b2 nCov-19): A Case Report

This study presents a case of sudden cardiac death due to cardiac small vessel vasculitis after coronavirus disease 2019 (COVID-19) mRNA vaccination (BNT162b2). The deceased was a 76-year-old woman with diabetes mellitus (DM) and chronic hypertension (HTN), who experienced generalized pain for a month after the first dose of vaccination, and unexpectedly died. Postmortem examination revealed small vessel vasculitis in the heart, lungs and vaccinated site of the left arm. These features were similar to those observed in a previously reported case of a patient with COVID-19 and cardiac endotheliitis and multisystem inflammatory syndrome. In addition, DM and HTN may contribute to vaccine-induced immunologic changes and vascular dysfunction. However, further studies with additional cases are needed.

An Autopsy Report of Hypoplastic Coronary Artery Disease Incidentally Identified in a Young Man

Hypoplastic coronary artery disease (HCAD) is a rare congenital abnormality characterized by underdevelopment of one or more major branches of the coronary arteries, which may lead to myocardial infarction and sudden death. We report a case of HCAD that was incidentally detected during autopsy in a 25-year-old male soldier who died during underwater escape training. On macroscopic examination, the right coronary artery measured 1 mm in diameter, which was significantly smaller than that of other coronary arteries. We observed no anomalies in addition to HCAD. Death was attributed to drowning, which was consistent with autopsy findings and the circumstances of death. Although extremely rare, if sudden cardiac death is suspected in children and young adults, it must be confirmed through careful evaluation.

Sudden Cardiac Death Caused by a Septic Coronary Artery Embolism as the First Clinical Presentation of Infective Endocarditis

This report describes an uncommon and fatal case of myocardial infarction due to coronary embolus arising from vegetation in the aortic valve with a background of infective endocarditis (IE). There are various causes of fatal IE. Myocardial infarction due to septic emboli is rare. We report a case of sudden death in a 69-year-old woman with hyperlipidemia and no known cardiac disease. She had severe general weakness and was hospitalized for colonoscopy. The patient unexpectedly presented with cardiac arrest and died. The autopsy showed total occlusion of the left anterior descending artery by an embolus, which originated from the septic vegetation of the aortic valve. Myocardial infarction from septic emboli associated with IE can be fatal and manifested as the first presentation. In autopsy practice of deceased patients with IE, careful examination of the coronary arteries is required.

A Statistical Analysis of Forensic Autopsies Performed in the Jungbu Province of Korea in 2020

We analyzed the manner and cause of death in 945 forensic autopsies from the Jungbu province (Central part of South Korea) conducted by the National Forensic Service Daejeon institute in 2020. Analysis of the manner of death revealed that 43.6% (412/945 cases) were natural deaths, 41.6% (393/945 cases) were unnatural deaths, and 14.8% (140/945 cases) deaths were unknown. Among the unnatural deaths, the major manner of death (40.7%, 160/393 cases) were by accidents, 29.5% (116/393 cases) were by suicide, 21.6% (85/393 cases) were undetermined, and 8.1% (32/393 cases) were by homicide. Among the unnatural deaths, the major cause of death (42.7%, 168/393 cases) were by trauma, 19.3% (76/393 cases) were by poisoning, and 16.5% (65/393 cases) were by asphyxia. Falling was the major cause of death by trauma (42.9%, 72/168 cases) and strangulation was the major cause of death by asphyxia (72.3%, 47/65 cases). Among natural deaths, heart disease was the major cause (43.7%, 180/412 cases), followed by vascular disease (18.9%, 78/412 cases). This study is the first statistical analysis of the manner and cause of deaths in the Jungbu province. A time-series statistical analysis of the manner and cause of deaths in this province might allow more advanced interpretations about both public safety and healthcare in the future.

Investigation of Mosaicism Detected in STR Typing

Short tandem repeats (STRs) are the most popular markers for human identification in forensics. These markers can be easily analyzed through a multiplex polymerase chain reaction and electrophoresis and provide high discrimination power. However, in STR analysis, several atypical phenomena can be observed such as allelic dropouts, drop-ins, or imbalance, which may be due to DNA polymerase slippage or DNA degradation effects. The observed atypical STR profiles can also provide information for mixed DNA samples or chromosomal abnormalities. In this study, we report a case of mosaicism detected in routine casework of paternity testing. Hair samples from a phenotypically normal male were tested, and the result presented a typical STR profile of a female for the amelogenin gene (XX). Through chromosome analysis using peripheral blood, it was found that 45,X/46,XY mosaicism resulted in the discrepancy between the genotype and the phenotype. In addition, the amount of Y chromosome detected was particularly low in hair compared to that in blood. This study shows that mosaicism can make interpretation difficult during STR analysis and suggests that sample types and repeated analysis should be considered even for routine STR testing.

Pathological Features of COVID-19 Pneumonia Diagnosed Following an Autopsy

After initial emergence at the end of 2019, coronavirus disease 19 (COVID-19) rapidly spread to become a pandemic. The causative agent is recognized as a novel coronavirus, named as severe acute respiratory syndrome coronavirus 2, which is known to primarily affect the respiratory system. We present the case of a 60-year-old man who was diagnosed to have COVID-19 pneumonia following an autopsy. Microscopic examination of the lung tissue showed acute (exudative) phase of diffuse alveolar damage, inflammatory infiltrates in alveolar spaces and interstitium, atypical pneumocytes with prominent nucleoli and expanded cytoplasm, and thrombi in small arterioles. Some megakaryocytes were observed, which were positive for immunohistochemical stain for CD61. The pathological findings observed in this case were consistent with those of previously published reports of COVID-19 pneumonia. This is the first case of COVID-19 pneumonia diagnosed with an autopsy in Korea.

Acute Myocardial Infarction with Microthrombi in Cardiac Small Vessels after COVID-19 Vaccination (ChAdOx1 nCov-19): A Case Report

We present the postmortem findings of an unexpected death due to acute myocardial infarction (AMI) with microthrombi and thrombosis in other vessels after the first dose of coronavirus disease 2019 (COVID-19) vaccination (ChAdOx1 nCov-19). The deceased was a 69-year-old woman who complained of nonspecific symptoms shortly after vaccination and was found dead on the sixth day. Postmortem examination revealed AMI and complications (left ventricular rupture, hemopericardium) with microthrombi in small cardiac vessels, which are similar to the characteristic findings of myocardial injury caused by microthrombi in patients with COVID-19. Nonobstructive thromboembolism in the pulmonary arteries and inferior vena cava, and fibrin microthrombi in some small vessels in the brain were also observed. It is unclear whether these findings are associated with COVID-19 vaccination, and further comprehensive studies are needed.

New Death Investigation System in Japan

Since after World War II, the death investigation system in Japan has been a dual system; with or without medical examiners. In areas without medical examiners, death investigation focused on unnatural death suspiciously involved with crime and depended on external postmortem examination for noncriminal cases. As a result, the forensic autopsy rate has been low, and several cases of missed homicide have been discovered. The social impact of the missed homicide of a young sumo player has encouraged the reformation of the death investigation system in Japan. “The Act on the Investigating of Cause of Death and on Identification of Bodies Handled by the Police” and the “Basic Act on Promotion of Death Investigation” were launched in 2013 and 2020, respectively. For noncriminal cases, a new type of autopsy becomes available without the consent of the bereaved family. Moreover, the concept and purpose of death investigation are not only to detect crime involvement, but also to extend respect for life and maintain personal dignity. The responsibility of the central government on death investigation service is stressed, including the establishment of a headquarters in the Ministry of Health, Labour and Welfare. This review aims to understand the background and major changes of the reform of the death investigation system in Japan and discuss the issues affecting forensic pathologists.