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An autopsy case of fatal water intoxication with postmortem computed tomography findings of diluted intestinal content and hemodilution
Journal of Forensic Radiology and Imaging 7 (2016) 43–46
Contents lists available at ScienceDirect
Journal of Forensic Radiology and Imaging journal homepage: www.elsevier.com/locate/jofri
Case report
An autopsy case of fatal water intoxication with postmortem computed tomography findings of diluted intestinal content and hemodilution
crossmark
⁎
Hideto Suzukia, , Iwao Hasegawaa,b, Satoko Mishimaa, Tatsushige Fukunagaa a b
Tokyo Medical Examiner's Office, Tokyo Metropolitan Government, Japan University Center of Legal Medicine, Kanagawa Dental University, Japan
A R T I C L E I N F O
A BS T RAC T
Keywords: Water intoxication Forensic autopsy Postmortem computed tomography
No specific pathognomonic tissue changes establish death from water intoxication, which makes a postmortem diagnosis of water intoxication difficult. We report an autopsy case of fatal water intoxication in which the postmortem computed tomography (PMCT) examination showed findings suggestive of antemortem excessive water drinking, such as diluted intestinal contents and hemodilution. A 52-year-old man who had schizophrenia was found dead in his house. He frequently complained of polydipsia, and drank a large amount of water and vomited before his death. PMCT findings showed distention of the duodenum with low radiodensity content (7 HU). In addition, the right atrium showed a low radiodensity content (46 HU). Autopsy results showed moderate congestion in all the organs, a large amount of light-brownish liquid in the duodenum and upper jejunum, and aspiration pneumonia. Electrolyte concentrations of sodium in the vitreous humor of the right and left eyes were 105 and 107 mEq/L, respectively, and neither drugs nor alcohol was detected in the blood. On the basis of the autopsy and biochemical findings, we determined water intoxication as the cause of death. An evaluation of PMCT findings of cases of various causes of death indicated that the radiodensities of the right atrium and duodenal content in our case were lower than those of the cases of various causes of death, except for fresh water drowning. The present case showed that PMCT provides supplementary findings regarding antemortem excessive water drinking. In addition, PMCT may provide findings to consider death from water intoxication before autopsy.
1. Introduction Water intoxication is characterized by hyponatremia due to excessive water intake, and it is common among schizophrenic patients [1–3]. Moreover, cases of child abuse by forced water intoxication occur [4–7]. Water intoxication is associated with a substantial risk of mortality, and many fatal cases have been reported [7–11]. Clinically, water intoxication can be easily diagnosed by results of a biochemical analysis and an assessment of the patient's history and behavior. However, postmortem blood electrolyte levels do not accurately reflect antemortem levels [9]. In addition, no specific pathognomonic tissue changes establish death from water intoxication [8], which makes a postmortem diagnosis of water intoxication difficult. The vitreous humor is presumed to be more available for postmortem biochemistry analysis, because there are fewer postmortem influences [10,11]; however, the vitreous humor is not always sampled in daily forensic practice. Recently, the role of postmortem computed tomography (PMCT) as an adjunct to conventional autopsy has been well documented [12], ⁎
although only clinical cases and animal models have been reported in terms of water intoxication [13,14]. We present an autopsy case of fatal water intoxication in which the PMCT examination showed findings suggestive of antemortem excessive water drinking, such as diluted intestinal contents and hemodilution. In addition, we compare the PMCT findings of our case with those of cases of various causes of death, and discuss a possible role of PMCT in diagnosing water intoxication. 2. Case report A 52-year-old man was found dead in his house. He had been receiving medical treatment for schizophrenia, hypertension, and hyperlipidemia. According to his family, he frequently complained of polydipsia a few weeks before his death, and he repeatedly drank a large amount of water and vomited. He was immediately transported to an emergency hospital, but he did not respond to cardiopulmonary resuscitation. Unenhanced PMCT was performed 13 h after his death. The main
Corresponding author. E-mail address: [email protected] (H. Suzuki).
http://dx.doi.org/10.1016/j.jofri.2016.11.005 Received 15 July 2016; Received in revised form 26 September 2016; Accepted 4 November 2016 Available online 16 November 2016 2212-4780/ © 2016 Elsevier Ltd. All rights reserved.
Journal of Forensic Radiology and Imaging 7 (2016) 43–46
H. Suzuki et al.
Table 1 Results of the radiographic measurements in 15 cases. M, male; F, female. Radiodensity of the duodenal content (HU)
Radiodensity of the heart chamber and the great vessels (HU)
Case
Age (years)
Sex
Postmortem period (h)
Cause of death
Descending part
Horizontal part
Ascending part
Right atrium
Inferior vena cava
Aortic arch
1 2
52 62
M M
14.5 42
7 39.3
9.7 43
11.7 50.3
46 73
48 71
43 75
3 4 5 6
44 56 44 45
M M M M
21 40 52 28
39.3 32 41 31
43.3 34 43.7 46
49 33 41.3 45
61 63 62 58
69 62 69 64
59 53 N/E 62
7 8 9 10
56 69 66 27
M M M M
14 48 36 32
38.3 46 34 23
43.3 53 27 18
45 53 25 21
61 61 57 71
60 62 63 69
57 55 N/E 67
11
59
M
27.5
37
45
38
62
75
69
12
42
M
29
11.7
14.3
12.3
45
57
57
13
82
F
27
9
15.7
12.3
49
52
33
14
73
F
11
8.7
13
17
44
43
40
15
71
F
12
Water intoxication Intracerebral hemorrhage Ischemic heart disease Ischemic heart disease Aortic dissection Subarachnoid hemorrhage Cervical spine fracture Subdural hematoma Heat stroke Acute ethanol intoxication Psychotropic drug poisoning Drowning (fresh water) Drowning (fresh water) Drowning (fresh water) Drowning (fresh water)
16
19
18
46
43
44
N/E: not examined
Fig. 1. Representative postmortem computed tomography images. The attenuation of the circled areas (upper row: descending part of the duodenum, lower row: the right atrium) was measured in each case. The values of attenuation of the descending part of the duodenum were 7 HU (case 1), 39.3 HU (case 2), and 11.7 HU (case 12). The values of attenuation of the right atrium were 46 HU (case 1), 73 HU (case 2), and 45 HU (case 12).
findings from the computed tomography (CT) images included ground glass opacity with consolidation in both lungs, distention of the duodenum, and a pooling of low radiodensity content in the duodenum (descending part: 7 HU). There were no fluids in the maxillary or sphenoidal sinuses on PMCT. Physical examination did not show any injuries. The deceased was 171 cm tall and weighed 84 kg, with a body mass index of 28.7 kg/m2. A forensic autopsy was performed approximately 14 h after death. Internally, all the organs were moderately congested. Seven hundred mL of cadaveric blood was obtained when the heart was removed, which retained fluidity. The heart weighed 494 g without fibrotic spots. The coronary arteries had partial stenosis in the peripheral site of the right coronary artery, but no thrombus was observed. The left and right
lungs were edematous and weighed 479 and 505 g, respectively. In the abdominal cavity, there was a large amount of light-brownish liquid in the duodenum and upper jejunum, although only 50 mL of redbrownish liquid was observed in the stomach. The liver was moderately yellowish and weighed 2366 g. The other organs showed no remarkable pathological findings. Histopathology findings of the lungs showed extensive edema in the specimens of both lungs, and partial neutrophilic infiltration with brown-colored vomitus and fibrin deposition were observed in the specimen of the right lower lung. Other histopathological findings included fatty infiltration in the hepatocytes and mild hyaline arteriolosclerosis in the kidney. Neither drugs nor alcohol was detected in the blood. The serum electrolyte concentration of sodium was 85 mEq/L. Electrolyte concentrations of sodium in the 44
Journal of Forensic Radiology and Imaging 7 (2016) 43–46
H. Suzuki et al.
PMCT is a useful tool for providing objective findings related to fresh water drowning, such as hemodilution and distention of the upper gastrointestinal tract with water density [18–22]. In cases of fresh water drowning, a low density in the stomach is expected, despite the admixture with the dense contents of the digestive tract [18]. Hemodilution due to excessive fresh water drinking can be observed on CT images as a decrease in blood density [18]. A review of the PMCT results showed that the radiodensities of the right atrium and duodenal content in the present case were lower than those of the other cases of various causes of death, except for fresh water drowning. These results mirror excessive water intake and hemodilution of fatal water intoxication, which is similar to findings indicative of fresh water drowning; thus, PMCT results may serve as supplementary information when determining the cause of death. Furthermore, our case suggests that the detailed evaluation of PMCT findings before autopsy may help detect water intoxication early, thereby enabling forensic pathologists to perform sufficient sampling of the vitreous humor, even when premortem findings of polydipsia and hyponatremia are unavailable. However, there are several issues to consider when using PMCT findings in forensic practice. For instance, hemoglobin levels affect the attenuation of blood on unenhanced CT images [23]; therefore, further data accumulation is needed. Although further data accumulation is needed, the present case suggests that PMCT may provide supplementary information on water intoxication, as in death from fresh water drowning. In addition, it may provide information to consider death from water intoxication before autopsy.
vitreous humor of the right and left eyes were 105 and 107 mEq/L, respectively. 3. Comparison of CT images between our case and cases of various causes of death We examined the radiodensity of the right atrium as a marker of hemodilution [15,16] in cases of various causes of death without significant decomposition. Radiodensities of the inferior vena cava, aortic arch, and content of the duodenum were also examined. Wholebody PMCT was performed before autopsy with a 64-row CT scanner (Somatom Definition AS, Siemens Healthcare, Forchheim, Germany) with the following parameters: 120 kV; quality reference mAs: 535; thickness: 64×0.6 mm; and field of view: 500 mm. Image data were analyzed by forensic pathologists by using syngo.via software (Siemens Healthcare). To measure the radiodensity of the duodenum, we divided the duodenum into three portions: the descending part, horizontal part, and ascending part. The radiodensity was calculated as the mean of three measurements in the corresponding areas. Radiodensities of the aortic arch in case numbers 5 and 9 were not examined because of difficulty in identifying the lumen. As shown in Table 1, the radiodensity of the right atrium in the present case was lower than that of the other cases of various causes of death, except for fresh water drowning. Radiodensities of the inferior vena cava and the aortic arch had a similar tendency. In addition, the radiodensity of the content of the duodenum in the present case was lower than that of the other cases of various causes of death, except for fresh water drowning. Representative images are shown in Fig. 1.
References 4. Discussion [1] B.P. Illowsky, D.G. Kirch, Polydipsia and hyponatremia in psychiatric patients, Am. J. Psychiatry 145 (1988) 675–683. [2] S. Poirier, G. Legris, P. Tremblay, R. Michea, L. Viau-Guay, C. Mérette, et al., Schizophrenia patients with polydipsia and water intoxication are characterized by greater severity of psychotic illness and a more frequent history of alcohol use, Schizophr. Res. 118 (2010) 285–291. [3] J. De lemon, C. Verghese, J.I. Tracy, R.C. Josiassen, G.M. Simpson, Polydipsia and water intoxication in psychiatric patients: a review of the epidemiological literature, Biol. Psychiatry 35 (1994) 408–419. [4] A.I. Arieff, B.A. Kronlund, Fatal child abuse by forced water intoxication, Pediatrics 103 (1999) 1292–1295. [5] J.A. Tilelli, J.P. Ophoven, Hyponatremic seizures as a presenting symptom of child abuse, Forensic Sci. Int 30 (1986) 213–217. [6] C.Y. Lin, Y.K. Tsau, Child abuse: acute water intoxication in a hyperactive child, Acta Paediatr. Taiwan 46 (2005) 39–41. [7] N. Radojevic, B. Bjelogrlic, V. Aleksic, N. Rancic, M. Samardzic, S. Petkovic, et al., Forensic aspects of water intoxication: four case reports and review of relevant literature, Forensic Sci. Int 220 (2012) 1–5. [8] W.V. Vieweg, J.J. David, W.T. Rowe, G.J. Wampler, W.J. Burns, W.W. Spradlin, Death from self-induced water intoxication among patients with schizophrenic disorders, J. Nerv. Ment. Dis. 173 (1985) 161–165. [9] T. Hayashi, Y. Ishida, T. Miyashita, H. Kiyokawa, A. Kimura, T. Kondo, Fatal water intoxication in a schizophrenic patient – an autopsy case, J. Clin. Forensic Med. 12 (2005) 157–159. [10] S. Nagasawa, D. Yajima, S. Torimitsu, H. Abe, H. Iwase, Fatal water intoxication during olanzapine treatment: a case report, Leg. Med. 16 (2014) 89–91. [11] V.J. DiMaio, S.J. DiMaio, Fatal water intoxication in a case of psychogenic polydipsia, J. Forensic Sci. 25 (1980) 332–335. [12] P.M. Leth, Computed tomography used as a routine procedure at postmortem investigations, Am. J. Forensic Med. Pathol. 30 (2009) 219–222. [13] V.M. Berginer, A. Osimani, J. Berginer, E. Barmeir, CT brain scan in acute water intoxication, J. Neurol. Neurosurg. Psychiatry 48 (1985) 841–842. [14] P. Kozler, J. Pokorny, CT density decrease in water intoxication rat model of brain oedema, Neuro Endocrinol. Lett. 35 (2014) 608–612. [15] X. Chen, G. Huang, Autopsy case report of a rare acute iatrogenic water intoxication with a review of the literature, Forensic Sci. Int 76 (1995) 27–34. [16] N. Yanagi, T. Maruyama, S. Uehata, Y. Wakimoto, Y. Sasaki, M. Arita, Electrical and mechanical abnormalities in the heart of a schizophrenic patients with hyponatremia derived from water intoxication, J. Cardiol. 32 (1998) 197–204. [17] D.B. Mount, Fluid and electrolyte disturbances, in: D.L. Longo, D.L. Kasper (Eds.), Harrison's Principles of Internal Medicine, McGraw-Hill, New York, 2008, p. 347. [18] A. Christe, E. Aghayev, C. Jackowski, M.J. Thali, P. Vock, Drowning – postmortem imaging findings by computed tomography, Eur. Radiol. 18 (2008) 283–290. [19] S. Vander Plaetsen, E. De Letter, M. Piette, G. Van Parys, J.W. Casselman, K. Verstraete, Post-mortem evaluation of drowning with whole body CT, Forensic Sci. Int. 249 (2015) 35–41.
On the basis of the lower sodium concentrations in the serum (85 mEq/L) and vitreous humor (right: 107 mEq/L, left: 105 mEq/L) compared to those of the other cases of various causes of death (n =18, serum: 108.4 ± 9.58 mEq/L, 95% confidence interval 103.6– 113.2 mEq/L; right vitreous humor: 129.44 ± 8.84 mEq/L, 95% confidence interval 125.0–133.8 mEq/L; left vitreous humor: 132.76 ± 10.28 mEq/L, 95% confidence interval 127.6–137.9 mEq/L) reported in the literature [10], symptom before death, and negative findings suggestive of other causes of death, we determined the cause of death in our case to be water intoxication. In autopsy cases of water intoxication, cerebral edema has been found often [7,15]. In particular, diffuse cerebral edema subsequently causes cerebral herniation, leading to coma, seizure, and death [15]. In another study, electrical and mechanical abnormalities were observed in the heart of a schizophrenic patient with hyponatremia derived from water intoxication [16]. In the present case, significant cerebral edema was not found. Autopsy findings, including a large amount of cadaveric blood and pulmonary edema, suggest that cardiopulmonary dysfunction may have been an immediate cause of death in the present case. Nausea and vomiting are common symptoms of water intoxication [17], and concomitant aspiration pneumonia in the present case may have also contributed to the patient's death. The autopsy findings of the gastrointestinal tract for fatal water intoxication, an enlarged stomach, and a duodenum and small intestine with a large amount of fluid have been previously reported [7,9]. In our case, distention with a large amount of fluid was observed in the duodenum and the upper jejunum, but not in the stomach. There are several possible explanations for the absence of a large amount of fluid in the stomach in the present case. Most of the water may have passed through the stomach into the duodenum at the time of death, or the contents of the stomach may have been missed because the patient vomited before death. A medical intervention (e.g., the insertion of a gastric tube) in the emergency room may have affected the quantity of the gastric contents at autopsy, although details were not obtained from the medical record. 45
Journal of Forensic Radiology and Imaging 7 (2016) 43–46
H. Suzuki et al.
of drowning using post-mortem computed tomography based on the volume and density of fluid accumulation in the maxillary and sphenoid sinuses, Eur. J. Radiol. 82 (2013) e562–e566. [23] D.F. Black, A.E. Rad, L.A. Gray, N.G. Campeau, D.F. Kallmes, Cerebral venous sinus density on noncontrast CT correlates with hematocrit, AJNR Am. J. Neuroradiol. 32 (2011) 1354–1357.
[20] A. Usui, Y. Kawasumi, M. Funayama, H. Saito, Postmortem lung features in drowning cases on computed tomography, Jpn. J. Radiol. 32 (2014) 414–420. [21] G. Lo Re, F. Vernuccio, M.C. Galfano, D. Picone, L. Milone, G. La Tona, et al., Role of virtopsy in the post-mortem diagnosis of drowning, Radiol. Med. 120 (2015) 304–308. [22] Y. Kawasumi, T. Kawabata, Y. Sugai, A. Usui, Y. Hosokai, M. Sato, et al., Diagnosis
46
Contents lists available at ScienceDirect
Journal of Forensic Radiology and Imaging journal homepage: www.elsevier.com/locate/jofri
Case report
An autopsy case of fatal water intoxication with postmortem computed tomography findings of diluted intestinal content and hemodilution
crossmark
⁎
Hideto Suzukia, , Iwao Hasegawaa,b, Satoko Mishimaa, Tatsushige Fukunagaa a b
Tokyo Medical Examiner's Office, Tokyo Metropolitan Government, Japan University Center of Legal Medicine, Kanagawa Dental University, Japan
A R T I C L E I N F O
A BS T RAC T
Keywords: Water intoxication Forensic autopsy Postmortem computed tomography
No specific pathognomonic tissue changes establish death from water intoxication, which makes a postmortem diagnosis of water intoxication difficult. We report an autopsy case of fatal water intoxication in which the postmortem computed tomography (PMCT) examination showed findings suggestive of antemortem excessive water drinking, such as diluted intestinal contents and hemodilution. A 52-year-old man who had schizophrenia was found dead in his house. He frequently complained of polydipsia, and drank a large amount of water and vomited before his death. PMCT findings showed distention of the duodenum with low radiodensity content (7 HU). In addition, the right atrium showed a low radiodensity content (46 HU). Autopsy results showed moderate congestion in all the organs, a large amount of light-brownish liquid in the duodenum and upper jejunum, and aspiration pneumonia. Electrolyte concentrations of sodium in the vitreous humor of the right and left eyes were 105 and 107 mEq/L, respectively, and neither drugs nor alcohol was detected in the blood. On the basis of the autopsy and biochemical findings, we determined water intoxication as the cause of death. An evaluation of PMCT findings of cases of various causes of death indicated that the radiodensities of the right atrium and duodenal content in our case were lower than those of the cases of various causes of death, except for fresh water drowning. The present case showed that PMCT provides supplementary findings regarding antemortem excessive water drinking. In addition, PMCT may provide findings to consider death from water intoxication before autopsy.
1. Introduction Water intoxication is characterized by hyponatremia due to excessive water intake, and it is common among schizophrenic patients [1–3]. Moreover, cases of child abuse by forced water intoxication occur [4–7]. Water intoxication is associated with a substantial risk of mortality, and many fatal cases have been reported [7–11]. Clinically, water intoxication can be easily diagnosed by results of a biochemical analysis and an assessment of the patient's history and behavior. However, postmortem blood electrolyte levels do not accurately reflect antemortem levels [9]. In addition, no specific pathognomonic tissue changes establish death from water intoxication [8], which makes a postmortem diagnosis of water intoxication difficult. The vitreous humor is presumed to be more available for postmortem biochemistry analysis, because there are fewer postmortem influences [10,11]; however, the vitreous humor is not always sampled in daily forensic practice. Recently, the role of postmortem computed tomography (PMCT) as an adjunct to conventional autopsy has been well documented [12], ⁎
although only clinical cases and animal models have been reported in terms of water intoxication [13,14]. We present an autopsy case of fatal water intoxication in which the PMCT examination showed findings suggestive of antemortem excessive water drinking, such as diluted intestinal contents and hemodilution. In addition, we compare the PMCT findings of our case with those of cases of various causes of death, and discuss a possible role of PMCT in diagnosing water intoxication. 2. Case report A 52-year-old man was found dead in his house. He had been receiving medical treatment for schizophrenia, hypertension, and hyperlipidemia. According to his family, he frequently complained of polydipsia a few weeks before his death, and he repeatedly drank a large amount of water and vomited. He was immediately transported to an emergency hospital, but he did not respond to cardiopulmonary resuscitation. Unenhanced PMCT was performed 13 h after his death. The main
Corresponding author. E-mail address: [email protected] (H. Suzuki).
http://dx.doi.org/10.1016/j.jofri.2016.11.005 Received 15 July 2016; Received in revised form 26 September 2016; Accepted 4 November 2016 Available online 16 November 2016 2212-4780/ © 2016 Elsevier Ltd. All rights reserved.
Journal of Forensic Radiology and Imaging 7 (2016) 43–46
H. Suzuki et al.
Table 1 Results of the radiographic measurements in 15 cases. M, male; F, female. Radiodensity of the duodenal content (HU)
Radiodensity of the heart chamber and the great vessels (HU)
Case
Age (years)
Sex
Postmortem period (h)
Cause of death
Descending part
Horizontal part
Ascending part
Right atrium
Inferior vena cava
Aortic arch
1 2
52 62
M M
14.5 42
7 39.3
9.7 43
11.7 50.3
46 73
48 71
43 75
3 4 5 6
44 56 44 45
M M M M
21 40 52 28
39.3 32 41 31
43.3 34 43.7 46
49 33 41.3 45
61 63 62 58
69 62 69 64
59 53 N/E 62
7 8 9 10
56 69 66 27
M M M M
14 48 36 32
38.3 46 34 23
43.3 53 27 18
45 53 25 21
61 61 57 71
60 62 63 69
57 55 N/E 67
11
59
M
27.5
37
45
38
62
75
69
12
42
M
29
11.7
14.3
12.3
45
57
57
13
82
F
27
9
15.7
12.3
49
52
33
14
73
F
11
8.7
13
17
44
43
40
15
71
F
12
Water intoxication Intracerebral hemorrhage Ischemic heart disease Ischemic heart disease Aortic dissection Subarachnoid hemorrhage Cervical spine fracture Subdural hematoma Heat stroke Acute ethanol intoxication Psychotropic drug poisoning Drowning (fresh water) Drowning (fresh water) Drowning (fresh water) Drowning (fresh water)
16
19
18
46
43
44
N/E: not examined
Fig. 1. Representative postmortem computed tomography images. The attenuation of the circled areas (upper row: descending part of the duodenum, lower row: the right atrium) was measured in each case. The values of attenuation of the descending part of the duodenum were 7 HU (case 1), 39.3 HU (case 2), and 11.7 HU (case 12). The values of attenuation of the right atrium were 46 HU (case 1), 73 HU (case 2), and 45 HU (case 12).
findings from the computed tomography (CT) images included ground glass opacity with consolidation in both lungs, distention of the duodenum, and a pooling of low radiodensity content in the duodenum (descending part: 7 HU). There were no fluids in the maxillary or sphenoidal sinuses on PMCT. Physical examination did not show any injuries. The deceased was 171 cm tall and weighed 84 kg, with a body mass index of 28.7 kg/m2. A forensic autopsy was performed approximately 14 h after death. Internally, all the organs were moderately congested. Seven hundred mL of cadaveric blood was obtained when the heart was removed, which retained fluidity. The heart weighed 494 g without fibrotic spots. The coronary arteries had partial stenosis in the peripheral site of the right coronary artery, but no thrombus was observed. The left and right
lungs were edematous and weighed 479 and 505 g, respectively. In the abdominal cavity, there was a large amount of light-brownish liquid in the duodenum and upper jejunum, although only 50 mL of redbrownish liquid was observed in the stomach. The liver was moderately yellowish and weighed 2366 g. The other organs showed no remarkable pathological findings. Histopathology findings of the lungs showed extensive edema in the specimens of both lungs, and partial neutrophilic infiltration with brown-colored vomitus and fibrin deposition were observed in the specimen of the right lower lung. Other histopathological findings included fatty infiltration in the hepatocytes and mild hyaline arteriolosclerosis in the kidney. Neither drugs nor alcohol was detected in the blood. The serum electrolyte concentration of sodium was 85 mEq/L. Electrolyte concentrations of sodium in the 44
Journal of Forensic Radiology and Imaging 7 (2016) 43–46
H. Suzuki et al.
PMCT is a useful tool for providing objective findings related to fresh water drowning, such as hemodilution and distention of the upper gastrointestinal tract with water density [18–22]. In cases of fresh water drowning, a low density in the stomach is expected, despite the admixture with the dense contents of the digestive tract [18]. Hemodilution due to excessive fresh water drinking can be observed on CT images as a decrease in blood density [18]. A review of the PMCT results showed that the radiodensities of the right atrium and duodenal content in the present case were lower than those of the other cases of various causes of death, except for fresh water drowning. These results mirror excessive water intake and hemodilution of fatal water intoxication, which is similar to findings indicative of fresh water drowning; thus, PMCT results may serve as supplementary information when determining the cause of death. Furthermore, our case suggests that the detailed evaluation of PMCT findings before autopsy may help detect water intoxication early, thereby enabling forensic pathologists to perform sufficient sampling of the vitreous humor, even when premortem findings of polydipsia and hyponatremia are unavailable. However, there are several issues to consider when using PMCT findings in forensic practice. For instance, hemoglobin levels affect the attenuation of blood on unenhanced CT images [23]; therefore, further data accumulation is needed. Although further data accumulation is needed, the present case suggests that PMCT may provide supplementary information on water intoxication, as in death from fresh water drowning. In addition, it may provide information to consider death from water intoxication before autopsy.
vitreous humor of the right and left eyes were 105 and 107 mEq/L, respectively. 3. Comparison of CT images between our case and cases of various causes of death We examined the radiodensity of the right atrium as a marker of hemodilution [15,16] in cases of various causes of death without significant decomposition. Radiodensities of the inferior vena cava, aortic arch, and content of the duodenum were also examined. Wholebody PMCT was performed before autopsy with a 64-row CT scanner (Somatom Definition AS, Siemens Healthcare, Forchheim, Germany) with the following parameters: 120 kV; quality reference mAs: 535; thickness: 64×0.6 mm; and field of view: 500 mm. Image data were analyzed by forensic pathologists by using syngo.via software (Siemens Healthcare). To measure the radiodensity of the duodenum, we divided the duodenum into three portions: the descending part, horizontal part, and ascending part. The radiodensity was calculated as the mean of three measurements in the corresponding areas. Radiodensities of the aortic arch in case numbers 5 and 9 were not examined because of difficulty in identifying the lumen. As shown in Table 1, the radiodensity of the right atrium in the present case was lower than that of the other cases of various causes of death, except for fresh water drowning. Radiodensities of the inferior vena cava and the aortic arch had a similar tendency. In addition, the radiodensity of the content of the duodenum in the present case was lower than that of the other cases of various causes of death, except for fresh water drowning. Representative images are shown in Fig. 1.
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On the basis of the lower sodium concentrations in the serum (85 mEq/L) and vitreous humor (right: 107 mEq/L, left: 105 mEq/L) compared to those of the other cases of various causes of death (n =18, serum: 108.4 ± 9.58 mEq/L, 95% confidence interval 103.6– 113.2 mEq/L; right vitreous humor: 129.44 ± 8.84 mEq/L, 95% confidence interval 125.0–133.8 mEq/L; left vitreous humor: 132.76 ± 10.28 mEq/L, 95% confidence interval 127.6–137.9 mEq/L) reported in the literature [10], symptom before death, and negative findings suggestive of other causes of death, we determined the cause of death in our case to be water intoxication. In autopsy cases of water intoxication, cerebral edema has been found often [7,15]. In particular, diffuse cerebral edema subsequently causes cerebral herniation, leading to coma, seizure, and death [15]. In another study, electrical and mechanical abnormalities were observed in the heart of a schizophrenic patient with hyponatremia derived from water intoxication [16]. In the present case, significant cerebral edema was not found. Autopsy findings, including a large amount of cadaveric blood and pulmonary edema, suggest that cardiopulmonary dysfunction may have been an immediate cause of death in the present case. Nausea and vomiting are common symptoms of water intoxication [17], and concomitant aspiration pneumonia in the present case may have also contributed to the patient's death. The autopsy findings of the gastrointestinal tract for fatal water intoxication, an enlarged stomach, and a duodenum and small intestine with a large amount of fluid have been previously reported [7,9]. In our case, distention with a large amount of fluid was observed in the duodenum and the upper jejunum, but not in the stomach. There are several possible explanations for the absence of a large amount of fluid in the stomach in the present case. Most of the water may have passed through the stomach into the duodenum at the time of death, or the contents of the stomach may have been missed because the patient vomited before death. A medical intervention (e.g., the insertion of a gastric tube) in the emergency room may have affected the quantity of the gastric contents at autopsy, although details were not obtained from the medical record. 45
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