Abstract
The diagnosis of death due to violent asphyxiation may be challenging if external injuries are missing, and a typical acute emphysema (AE) “disappears” in pre-existing chronic emphysema (CE). Eighty-four autopsy cases were systematically investigated to identify a (histo-) morphological or immunohistochemical marker combination that enables the diagnosis of violent asphyxiation in cases with a pre-existing CE (“AE in CE”). The cases comprised four diagnostic groups, namely “AE”, “CE”, “acute and chronic emphysema (AE + CE)”, and “no emphysema (NE)”. Samples from all pulmonary lobes were investigated by conventional histological methods as well as with the immunohistochemical markers Aquaporin 5 (AQP-5) and Surfactant protein A1 (SP-A). Particular attention was paid to alveolar septum ends (“dead-ends”) suspected as rupture spots, which were additionally analyzed by transmission electron microscopy. The findings in the four diagnostic groups were compared using multivariate analysis and 1-way ANOVA analysis. All morphological findings were found in all four groups. Based on histological and macroscopic findings, a multivariate analysis was able to predict the correct diagnosis “AE + CE” with a probability of 50%, and the diagnoses “AE” and “CE” with a probability of 86% each. Three types of “dead-ends” could be differentiated. One type (“fringed ends”) was observed significantly more frequently in AE. The immunohistochemical markers AQP-5 and SP-A did not show significant differences among the examined groups. Though a reliable identification of AE in CE could not be achieved using the examined parameters, our findings suggest that considering many different findings from the macroscopical, histomorphological, and molecular level by multivariate analysis is an approach that should be followed.
Highlights
Death by violent asphyxia can be caused by various mechanisms, which may cause typical findings
Samples from all pulmonary lobes were investigated by conventional histological methods as well as with immunohistochemical markers Aquaporin 5 (AQP-5) and Surfactant protein A1 (SP-A) that have been described as being significantly differentially expressed in the lungs of asphyxiation victims than in other causes of death [42,43,44,45,46,47,48,49,50,51, 62]
Since acute emphysema can occur during resuscitation with artificial ventilation [37], we included these cases in the “AE” group
Summary
Death by violent asphyxia can be caused by various mechanisms (e.g., strangulation, covering of the external airways), which may cause typical findings. Other problematic examples are cases of burking (a combination of covered airways and thorax compression [5, 12, 13]) or deaths due to physical restraint [14] In such cases, the suspicion of violent death can only be substantiated by internal postmortem findings and histological examination [15,16,17,18,19,20,21,22]; otherwise, it becomes a diagnosis by exclusion [7, 17, 23]. It has to be noted that the many common findings are only typical, but not specific for violent asphyxiation [3, 4, 24, 25] and may occur with other causes of death
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