Highlights in Pathology: Forensic Pathology (April 2019)

Dr. Ashwyn Rajagopalan, Ontario Forensic Pathology Service

1. Modern post-mortem imaging: an update on recent developments

Grabherr S, et al. Forensic Sci Res. 2017 Jun 7;2(2):52-64

While this is a slightly older article, it does a great job of highlighting the (ever expanding) role of post-mortem imaging in the autopsy, for a general pathology audience.  

The article summarizes the advantages and limitations of the most common modern (i.e., beyond plain film radiography) post-mortem imaging methods – CT scan, CT angiography, and MRI – and introduces the audience to the ‘cutting edge’ of imaging, 3D surface documentation. 

  • The obvious uses of CT scan (fractures, metallic projectiles) are discussed, along with potential future directions, such as the identification of pulmonary emboli through post-mortem ventilation.  
  • MR is discussed, and its role in the investigation of sudden infant death syndrome and cardiomyopathies are highlighted.  
  • 3D surface documentation holds promise in wound-weapon matching, as injuries on the body surface can (in the future) be digitized and mapped to potential implements, in a manner suitable for courtroom presentation.

In short, this is an excellent overview of the value of advanced imaging techniques that are increasingly being adopted in forensic units worldwide.

2. The pathology of torture

Pollanen MS. Forensic Sci Int. 2018 Mar;284:85-96

This is an important article from last year, useful to any pathologist performing an autopsy on an individual who has died in custody; or who has died following an interaction with police.

While the identification of torture in these cases in the Canadian setting is not routine, this article informs the reader of what to look for, how to perform the proper dissections, and how to interpret the findings, so that such torture can be excluded.

Briefly, common findings in torture are placed into three broad categories:

  1. blunt force injuries
  2. thermal and electrical injuries
  3. injuries due to prolonged stress positioning.  

The necessary photographic documentation, special dissections (back, soles of the feet, joints), and common locations of such injuries are discussed. There is additional emphasis on the sequelae of such injuries, such that delayed deaths due to torture (e.g., renal failure due to rhabdomyolysis) are not missed.

3. Nodding syndrome in Uganda is a tauopathy

Pollanen MS, et al. Acta Neuropathol. 2018; 136(5): 691–697

This article (which has received a great deal of attention in the general press) clearly illustrates the value of the autopsy, and the contribution of the pathologist to the understanding of a new disease.

Nodding syndrome is a neurologic disorder that affects children in the subsistence-farming communities of East Africa, including Uganda. It is characterized by head dropping (‘nodding’) movements, impaired growth, and seizures. 

While the disease had emerged in Uganda as early as 1998, no neuropathological study on decedents had been published prior to this article.

Many causes had been proposed for this disease, and one leading and controversial theory is that this is caused through autoimmune reaction to Onchocerca volvulus, a nematode causing river blindness.

This study examined the brains of five individuals who had died with the classical features of nodding syndrome.

The brains demonstrated changes of tauopathy, specifically tau-reactive neurofibrillary tangles and plaques within the cerebral cortex, subcortical nuclei and brainstem. More specifically, the cortical involvement shows a frontotemporal predilection but parietal lobe involvement is also present. The prefrontal cortex and the anterior frontal lobe are the most severely affected. The brainstem involvement is principally centred on the substantia nigra, locus coeruleus, tegmental nuclei and the nuclei of the pontine base. Changes suggestive of a direct autoimmune response were not identified.

The distribution of the pathology does not match any known disease, and suggests that nodding syndrome may represent a novel neurodegenerative disease.

4. Contributions of prescribed and non-prescribed opioids to opioid related deaths: population based cohort study in Ontario, Canada

Gomes T, et al. BMJ. 2018; 362: k3207

Finally, an excellent recent article highlighting the opioid crisis here in Ontario, with data relevant to local pathologists.  

This cohort study examining opioid deaths from 2013 to 2016 vividly illustrates:

  • the scope of the problem in Ontario (approximately 2900 deaths over the study period)
  • the demographic characteristics of the decedents
  • the proportion of individuals who had an opioid prescription at the time of death.  

The relative ‘rise and fall’ of opioids (i.e., the increasing proportion of fentanyl deaths attributable to illicit or diverted fentanyl) are discussed in detail.  

The article makes it clear that both prescribed and illicit opioids still play large roles in the opioid crisis in Ontario.