Molecular Autopsy Research Articles

SIDS associated RYR2 p.Arg2267His variant may lack pathogenicity

Sudden infant death syndrome (SIDS) is the sudden death of an infant under 1 year of age that remains unexplained after death scene and medicolegal investigation, including a complete autopsy and clinical history review. The fatal event typically occurs during sleep and heart rhythm during the event is rarely documented. Large series which have utilized molecular autopsy show that long QT syndrome (LQTS) associated cardiac channel mutations contribute to between 5 and 10% of SIDS deaths. In addition, rare novel RYR2 variants have been identified in SIDS victims. Given the lack of a phenotype, the pathogenicity of these variants is inferred from in vitro studies. We report a family with 5 members (mother and 4 children) who are carriers of a rare RYR2 variant (c.6800G > A, p.Arg2267His [Exon: 45], heterozygous) which has previously been identified in a SIDS victim and shown to confer a gain-of-function CPVT phenotype in vitro. All of these 5 family members including the mother (age range 7 to 41 years) have had negative exercise stress tests, echocardiograms and Holter monitors. These findings suggest that caution should be exercised in inferring pathogenicity of rare RYR2 variants based on in vitro functional data which does not always translate to human phenotype.

Triadin Knockout Syndrome Is Absent in a Multi-Center Molecular Autopsy Cohort of Sudden Infant Death Syndrome and Sudden Unexplained Death in the Young and Is Extremely Rare in the General Population.

Triadin knockout syndrome (TKOS) is a potentially lethal arrhythmia disorder caused by recessively inherited null variants in TRDN-encoded cardiac triadin. Despite its malignant phenotype, the prevalence of TKOS in sudden infant death syndrome and sudden unexplained death in the young is unknown. Exome sequencing was performed on 599 sudden infant death syndrome and 258 sudden unexplained death in the young cases. Allele frequencies of all TRDN null variants identified in the cardiac-specific isoform of TRDN in the Genome Aggregation Database were used to determine the estimated prevalence and ethnic distribution of TKOS. No triadin null individuals were identified in 599 sudden infant death syndrome and 258 sudden unexplained death in the young exomes. Using the Genome Aggregation Database, we estimate the overall prevalence of TKOS to be ≈1:22.7 million individuals. However, TKOS prevalence is 5.5-fold higher in those of African descent (≈1:4.1 million). TKOS is an exceedingly rare clinical entity that does not contribute meaningfully to either sudden infant death syndrome or sudden unexplained death in the young. However, despite its rarity and absence in large sudden death cohorts, TKOS remains a malignant and potentially lethal disorder which requires further research to better care for these patients.

Explaining sudden infant death with cardiac arrhythmias: Complete exon sequencing of nine cardiac arrhythmia genes in Dutch SIDS cases highlights new and known DNA variants

Previous studies suggested that Sudden Infant Death Syndrome (SIDS) can partially be genetically explained by cardiac arrhythmias; however, the number of individuals and populations investigated remain limited. We report the first SIDS study on cardiac arrhythmias genes from the Netherlands, a country with the lowest SIDS incidence likely due to parent education on awareness of environmental risk factors. By using targeted massively parallel sequencing (MPS) in 142 Dutch SIDS cases, we performed a complete exon screening of all 173 exons from 9 cardiac arrhythmias genes SCN5A, KCNQ1, KCNH2, KCNE1, KCNE2, CACNA1C, CAV3, ANK2 and KCNJ2 (∼34,000 base pairs), that were selected to harbour previously established SIDS-associated DNA variants. Motivated by the poor DNA quality from the paraffin embedded material used, the application of a conservative sequencing quality control protocol resulted in 102 SIDS cases surviving quality control. Amongst the 102 SIDS cases, we identified a total of 40 DNA variants in 8 cardiac arrhythmia genes found in 60 (58.8 %) cases. Statistical analyses using ancestry-adjusted reference population data and multiple test correction revealed that 13 (32.5 %) of the identified DNA variants in 6 cardiac arrhythmia genes were significantly associated with SIDS, which were observed in 15 (14.7 %) SIDS cases. These 13, and another three, DNA variants were classified as likely pathogenic for cardiac arrhythmias using the American College of Medical Genetics guidelines for interpretation of sequence variants. The 16 likely pathogenic DNA variants were found in 16 (15.7 %) SIDS cases, including i) 3 novel DNA variants not recorded in public databases ii) 7 known DNA variants for which significant SIDS association established here was previously unknown, and iii) 6 known DNA variants for which LQTS association was reported previously. By having replicated previously reported SIDS-associated DNA variants located in cardiac arrhythmia genes and by having highlighting novel SIDS-associated DNA variants in such genes, our findings provide additional empirical evidence for the partial genetic explanation of SIDS by cardiac arrhythmias. On a wider note, our study outcome stresses the need for routine post-mortem genetic screening of assumed SIDS cases, particularly for cardiac arrhythmia genes. When put in practise, it will allow preventing further sudden deaths (not only in infants) in the affected families, thereby allowing forensic molecular autopsy not only to provide answers on the cause of death, but moreover to save lives.

Diagnostic yield of hypertrophic cardiomyopathy in first-degree relatives of decedents with idiopathic left ventricular hypertrophy.

Idiopathic left ventricular hypertrophy (LVH) is defined as LVH in the absence of myocyte disarray or secondary causes. It is unclear whether idiopathic LVH represents the phenotypic spectrum of hypertrophic cardiomyopathy (HCM) or whether it is a unique disease entity. We aimed to ascertain the prevalence of HCM in first-degree relatives of decedents from sudden death with idiopathic LVH at autopsy. Decedents also underwent molecular autopsy to identify the presence of pathogenic variants in genes implicated in HCM. Families of 46 decedents with idiopathic LVH (125 first-degree relatives) were investigated with electrocardiogram, echocardiogram exercise tolerance test, cardiovascular magnetic resonance imaging, 24-h Holter, and ajmaline provocation test. Next-generation sequencing molecular autopsy was performed in 14 (30%) cases. Decedents with idiopathic LVH were aged 33 ± 14 years and 40 (87%) were male. Fourteen families (30%) comprising 16 individuals were diagnosed with cardiac disease, including Brugada syndrome (n = 8), long QT syndrome (n = 3), cardiomyopathy (n = 2), and Wolff-Parkinson-White syndrome (n = 1). None of the family members were diagnosed with HCM. Molecular autopsy did not identify any pathogenic or likely pathogenic variants in genes encoding sarcomeric proteins. Two decedents had pathogenic variants associated with long QT syndrome, which were confirmed in relatives with the clinical phenotype. One decedent had a pathogenic variant associated with Danon disease in the absence of any histopathological findings of the condition or clinical phenotype in the family. Idiopathic LVH appears to be a distinct disease entity from HCM and is associated with fatal arrhythmias in individuals with primary arrhythmia syndromes. Family screening in relatives of decedents with idiopathic LVH should be comprehensive and encompass the broader spectrum of inherited cardiac conditions, including channelopathies.

Methodological basis for determining a person's age

This paper presents a review of modern fundamental research studies investigating the age-related changes of connective, cartilage, nervous and bone tissues. A methodological and mathematical basis for the analysis of the obtained results is proposed. The conducted analysis enabled the formulation of a new scientific direction - the forensic medical determination of age in the identification of individuals in emergency situations with mass casualties. A scientifically grounded theory of digital forensic diagnostics of age, general regularities of development and some differences of age adaptation of connective, cartilage, nervous and bone tissues, including the phenomena of heterochronicity, heterotopy and heterogeneity resulted. The results of this research determine the direction of further research by improving the methods of quantitative age morphology, molecular autopsy, digital technologies and the formation of a technologically based concept for the registration of identifying biological features.

Prenatal diagnosis of fetal thanatophoric dysplasia type 1 with de novo c.2419T > G (p. Ter807Gly) (X807G) gene mutation in fibroblast growth factor receptor 3 (FGFR3) showing increased nuchal translucency at the first trimester of gestation: A case report with review of the literature

Thanatophoric dysplasia (TD) is a rare form of lethal skeletal dysplasia with underdevelopment of skeleton and dwarfism. The femur is curved in subtype 1, and straight in subtype 2 TD. Other characteristics include a narrow chest, small ribs and hypoplastic lungs. TD is due to activating mutations in fibroblast growth factor receptor 3 (FGFR3), which result in increased receptor activation and alterations in the process of endochondral ossification in all long bones. The aim of the present study was to present the perinatal ultasonographic findings at the 1st and 2nd trimester of a pregnancy and the underlying molecular defect in a fetus with TD type 1, due to a rare mutation in the FGFR3 gene. Ultrasonography performed at the 12w2d of gestation showed increased nuchal translucency (NT). Prenatal karyotype was normal for the XX fetus. Ultrasonography at 17 weeks and 5 days of gestation revealed narrow thorax, abdominal protrusion and a decreased rate of development of the femur (Femur Length, FL < 5th percentile). Molecular genetic analysis to exclude possible overlapping syndromes was performed and revealed de novo c.2419T > G (p. Ter807Gly) (X807G) gene mutation in FGFR3. Fetal autopsy confirmed the prenatal prediction of lethality. We conclude that a fetus with a heterozygous c.2419T > G mutation in FGFR3, presented characteristic biometric parameters and ultrasonographic and autopsy findings consistent with the diagnosis of TD type 1. In addition, the combination of ultrasonography, molecular genetic analysis and autopsy is helpful for the appropriate genetic counselling and perinatal management.

Systematic Review of the Genetics of Sudden Unexpected Death in Epilepsy: Potential Overlap With Sudden Cardiac Death and Arrhythmia-Related Genes.

BackgroundSudden unexpected death in epilepsy (SUDEP) is the leading cause of epilepsy‐related death. SUDEP shares many features with sudden cardiac death and sudden unexplained death in the young and may have a similar genetic contribution. We aim to systematically review the literature on the genetics of SUDEP.Methods and ResultsPubMed, MEDLINE Epub Ahead of Print, Ovid Medline In‐Process & Other Non‐Indexed Citations, MEDLINE, EMBASE, Cochrane Database of Systematic Reviews, and Scopus were searched through April 4, 2017. English language human studies analyzing SUDEP for known sudden death, ion channel and arrhythmia‐related pathogenic variants, novel variant discovery, and copy number variant analyses were included. Aggregate descriptive statistics were generated; data were insufficient for meta‐analysis. A total of 8 studies with 161 unique individuals were included; mean was age 29.0 (±SD 14.2) years; 61% males; ECG data were reported in 7.5% of cases; 50.7% were found prone and 58% of deaths were nocturnal. Cause included all types of epilepsy. Antemortem diagnosis of Dravet syndrome and autism (with duplication of chromosome 15) was associated with 11% and 9% of cases. The most frequently detected known pathogenic variants at postmortem were in Na+ and K+ ion channel subunits, as were novel potentially pathogenic variants (11%). Overall, the majority of variants were of unknown significance. Analysis of copy number variant was insignificant.Conclusions SUDEP case adjudication and evaluation remains limited largely because of crucial missing data such as ECGs. The most frequent pathogenic/likely pathogenic variants identified by molecular autopsy are in ion channel or arrhythmia‐related genes, with an ≈11% discovery rate. Comprehensive postmortem examination should include examination of the heart and brain by specialized pathologists and blood storage.

Defining screening panel of functional variants of CYP1A1, CYP2C9, CYP2C19, CYP2D6, and CYP3A4 genes in Serbian population.

Plethora of drugs and toxic substances is metabolized by cytochrome P450 enzymes (CYP450). These enzymes are coded by highly variable genes abundant with single nucleotide variants (SNVs) and small insertions/deletions (indels) that affect the functionality of the enzymes, increasing or decreasing their activity. CYP genes genotyping, followed by haplotype inference, provides substrate specific metabolic phenotype prediction. This is crucial in pharmacogenetics and applicable in molecular autopsy. However, high number of alleles in CYP450 superfamily and interethnic variability in frequency distribution require precise gene panel customization. To estimate informativeness of SNVs and alleles in CYP gene families 1, 2, and 3, associated with metabolic alterations, 500 unrelated individuals from 5 regions of Serbia were genotyped using TaqMan assays to determine frequencies of CYP2C9 *2 and *3, CYP2C19 *2 and *17 alleles, four variants in CYP2D6 (rs3892097, rs1065852, rs28371725, rs28371706) gene, and CYP3A4*1B allele. In addition, CYP1A1 rs4646903 and rs1048943 (m1 and m2) variants were genotyped by RFLP. Our results showed that frequencies of tested variants in Serbian population corresponded to general European population and somewhat differed from neighboring populations. SNV rs1065852, the main contributor to non-functional CYP2D6 *4, significantly departed from Hardy-Weinberg equilibrium. With the exception of rs28371706 in CYP2D6 and rs2740574 in CYP3A4, which were very rare in our sample, all other tested variants in CYP2 family are informative and appropriate for pharmacogenetic testing, molecular autopsy, and medico-legal genetic analyses.

Meaningful diagnostics: genetics

Molecular genetic analysis is an important component in the diagnostics of some cardiovascular diseases; however, genetic testing should not be used as ascreening technique as the diagnostic value strongly depends on anamnestic and clinical factors, such as apositive family history and the disease phenotype. In cardiovascular diseases with high mutation detection rates, e.g. hypertrophic cardiomyopathy and primary arrhythmia syndromes (long QT syndrome, catecholaminergic polymorphic ventricular tachycardia) genetic testing should be included in the diagnostic work-up. Family screening of first-degree relatives (cascade screening) is aparticularly important application of genetic diagnostics for a timely identification of asymptomatic mutation carriers and initiation of preventive treatment. A molecular autopsy, also known as postmortem molecular genetic DNA testing, is aspecial indication for genetic diagnostics. It is particularly useful in the analysis of sudden cardiac death victims for the identification of disease-specific gene mutations. Therefore, given aselective use and athorough evaluation of the test results, molecular genetic analyses can make a meaningful diagnostic and prognostic contribution. Potential applications of genetic analyses in the future are polygenic cardiovascular diseases. The use of new high-throughput technologies enables the analysis of multiple genetic variants, which can then be included in the calculation of apolygenic risk score for the prediction of the probability of a specific disease.

Re-analysis of whole-exome sequencing data uncovers novel diagnostic variants and improves molecular diagnostic yields for sudden death and idiopathic diseases

BackgroundWhole-exome sequencing (WES) has become an efficient diagnostic test for patients with likely monogenic conditions such as rare idiopathic diseases or sudden unexplained death. Yet, many cases remain undiagnosed. Here, we report the added diagnostic yield achieved for 101 WES cases re-analyzed 1 to 7 years after initial analysis.MethodsOf the 101 WES cases, 51 were rare idiopathic disease cases and 50 were postmortem “molecular autopsy” cases of early sudden unexplained death. Variants considered for reporting were prioritized and classified into three groups: (1) diagnostic variants, pathogenic and likely pathogenic variants in genes known to cause the phenotype of interest; (2) possibly diagnostic variants, possibly pathogenic variants in genes known to cause the phenotype of interest or pathogenic variants in genes possibly causing the phenotype of interest; and (3) variants of uncertain diagnostic significance, potentially deleterious variants in genes possibly causing the phenotype of interest.ResultsInitial analysis revealed diagnostic variants in 13 rare disease cases (25.4%) and 5 sudden death cases (10%). Re-analysis resulted in the identification of additional diagnostic variants in 3 rare disease cases (5.9%) and 1 sudden unexplained death case (2%), which increased our molecular diagnostic yield to 31.4% and 12%, respectively.ConclusionsThe basis of new findings ranged from improvement in variant classification tools, updated genetic databases, and updated clinical phenotypes. Our findings highlight the potential for re-analysis to reveal diagnostic variants in cases that remain undiagnosed after initial WES.

Massively parallel sequencing in sudden unexpected death in infants: A case report in South Africa

Sudden unexpected death in infants (SUDI) is a devastating event for a family, and unfortunately occurs relatively frequently in South Africa. These cases are referred for a forensic post-mortem investigation to establish the cause of death; however, despite thorough analyses, some cases remain undetermined. Internationally, a molecular autopsy has assisted in resolving these types of cases by revealing genetic variants which contributed to the demise. Motivated by lack of local research in this field, a study was launched at the University of Cape Town (South Africa) in 2015 to explore the use of molecular autopsies in the medico-legal investigation of local SUDI cases. An ethical framework was established and used to prospectively recruit SUDI cases from one of the busiest forensic facilities: Salt River Mortuary. A next generation sequencing approach was used to assess 43 genes previously associated with cardiac arrhythmias. In a particular infant, a putative pathogenic variant was identified (rs750771811 T/T) in the SCN10A gene. The variant is rare, but was homozygous in this infant, and appears to be the first time it has been observed in a SUDI victim. Previous functional studies on the amino-acid residue suggested that this variant may reduce SCN5A activity, which has been linked to Brugada syndrome. A genetic counselling session was arranged with the parents; a full family history was obtained, which revealed that the parents had a previous miscarriage and had recently had a second SUDI. The parents have subsequently been enrolled in the study for genetic screening and have been referred for electrocardiogram assessments. The findings highlight a new possible candidate variant to assess in SUDI cases, and also demonstrate the value of molecular autopsies to families.

P4172Prevalence and potential genetic determinants of young sudden unexplained death victims with suspected arrhythmogenic mitral valve prolapse

Abstract Background Mitral valve prolapse (MVP) is largely considered a benign condition. Recently, arrhythmogenic MVP, a sudden cardiac death (SCD)-predisposing condition characterized clinically by frequent/complex ventricular arrhythmias likely secondary to prolapsing leaflet-induced fibrosis of the left ventricle (LV), has emerged as an underappreciated cause of sudden unexplained death in the young (SUDY). Objective To determine the prevalence and potential genetic underpinnings of suspected arrhythmogenic MVP in a referral cohort of SUDY cases. Methods In this retrospective necropsy study, the medical records, autopsy reports, and whole exome molecular autopsy (WEMA) results for 77 SUDY victims (27 females; average age at death 20.6±8.9 years) were reviewed. Evidence of myxomatous MVP and concomitant LV pathology were noted. Variants detected in the pre-specified 164 WEMA gene panel with a frequency <0.001 in public exomes were classified using the 2015 American College of Medical Genetics (ACMG) guidelines. Results Overall, 6/77 (7.8%; 2 females; average age at death 20.7±6.9 years) SUDY cases had MVP as the lone abnormal post-mortem finding. The majority had bileaflet involvement (5/6; 83%) and microscopic LV fibrosis (5/6; 83%). Two SUDY cases (33%) were diagnosed with MVP by echocardiography prior to death. No gross hypertrophy, myocyte disarray, or fibrofatty replacement was noted. Unexpectedly, an ACMG pathogenic/likely pathogenic (P/LP) was more likely to be detected in SUDY cases with MVP than those without [3/6 (50%) vs 9/71 (13%); p<0.05]. Interestingly, the three variants identified in MVP-positive SUDY cases localized to genes associated previously with a cardiomyopathy/channelopathy predisposition (p.E1518fsX25-DMD, p.S285N-RYR2, and p.R109X-TTN). Conclusion This WEMA series provides additional evidence that the combination of bileaflet MVP and microscopic LV fibrosis underlies an unexpected number of SUDY cases. Whether P/LP variants in cardiomyopathy/channelopathy-susceptibility genes function as contributing factors or if unrelated, but poorly understood, molecular mechanisms account for the distinct cardiomyopathy-like phenotype observed in arrhythmogenic MVP requires further investigation.

Massive parallel sequencing and osteogenesis imperfecta: An essential tool for forensic investigation over child abuse

Osteogenesis imperfecta (OI) is a rare disease of collagen synthesis causing bone fragility. Also called “glass bone disease” since it manifests as spontaneous fractures, it is classified into nine types, both with dominant and recessive transmission. In 95% of cases OI is caused by mutations in COL1A1 and COL1A2 genes encoding the alpha1 and alpha2 chains of type 1 collagen, mainly null variants caused by frame-shift/nonsense mutations or splicing defects. In infants the differential diagnosis include not-accidental trauma, so child abuse. Families suspected of abuse often provide an unverified history of frequent fractures; conversely, the family history of individuals with OI often does not reveal any other affected individuals because of a de novo pathogenic variant in the proband or the presence of a mild phenotype in relatives. Therefore, legal medicine unit with DNA lab is crucial in these cases since it could early collect living or autopsy samples when a child abuse is suspected and then test DNA. We set up a MPS (massively parallel sequencing) panel including the coding regions of COL1A1 and COL1A2 and other 11 genes known to cause OI. We presented a case of suspected abuses in 2-month-old baby. MPS libraries were sequenced by Ion Torrent PGM platform; pathogenic variants and VUS (variants of uncertain significance) were confirmed by Sanger sequencing and familial segregation study was performed to better characterize the clinical significance of the mutation. This study remarks that MPS could help not only for identification, ancestry/phenotyping or molecular autopsy applications but also for forensic investigation over child abuse. The usefulness of this assay for diagnostic projects on victims of abuse together with post-mortem cases is discussed.

Pharmacogenetics and the postmortem molecular autopsy

AbstractThere are three possible outcomes from drug therapy: the drug performs as intended; the drug has no effect; or the drug causes an adverse reaction. Variation in drug and endogenous toxin metabolism among individuals in part can be due to genetic makeup. The goal of pharmacogenetics is to elucidate the genetic variation contributing to absorption, distribution, metabolism, excretion, and response (ADME‐R) so that adverse drug reactions can be avoided, and to characterize differential enzyme activity informing appropriate drug dosage on the individual and population levels. The postmortem molecular autopsy may use pharmacogenetic information from a decedent to make conclusions about cause (CoD) and/or manner of death (MoD) when traditional medico‐legal autopsies are negative. The cytochrome p450 family is a group of pharmacogenetically relevant targets with demonstrable utility in the postmortem setting and several key historical applications. ATP‐binding cassettes and opioid receptors are additional critical drug response proteins with essential rolls in additive and suicidal behaviors and drug overdose. Historically, the discipline relied on genetic variation with large effects on a broad spectrum of endogenous and foreign compounds. However, recent advances in pharmacogenomics highlight rare variants and noncoding variation as strong contributing factors to the accuracy of drug response prediction. Furthermore, there is a push to develop more comprehensive predictive models incorporating both rare and common variants contributing to drug response. These advanced genetic capabilities will enable more accurate predictions of drug‐related CoD and/or MoD determinations and contribute to the growing overlap between medical and forensic genetics.This article is categorized under: Forensic Biology > Forensic DNA Technologies Toxicology > Opioids Forensic Medicine > Methods for Certification of Cause and Manner of Death

Molecular Autopsy for Sudden Cardiac Death: Current State and Considerations

The study of the genetic basis of sudden cardiac death has been impacted by advances in sequencing technology, gene variant interpretation, and additional evaluation into the ideal clinical approach to assessing cause of death and the medical and psychological risks of surviving family members. This short review aims to summarize recent publications as well as provide context for future directions for the care of families faced with sudden cardiac death. The molecular autopsy is a critical method in determining cause of death, particularly in autopsy-negative sudden cardiac death. Although the cost and availability of exome sequencing have improved in the past few years, its utility in the postmortem evaluation has not significantly improved yield. This is primarily due to the increase in genetic variants detected through this sequencing modality and the difficulty in interpreting these results. Medical examiners are essential in the proper identification and referral of surviving relatives to multidisciplinary clinics that include an expert cardiologist, cardiac genetic counselor, and clinical psychologist that can provide appropriate education, clinical evaluation, and psychological support. Future studies need to build on the improvement in variant interpretation and appropriate education and support of medical examiners. This will ensure family members are referred to appropriate providers such that they can receive medical and psychological care that will improve overall health outcomes and reduce the incidence of subsequent sudden cardiac death in the family.

Postmortem genetic testing: Clinical diagnosis is not ended by the patient’s death

Abstract In up to one-third of cases of sudden death, the medico-legal autopsy finding is inconclusive, and the option to perform a molecular autopsy is covered in international guidelines. The importance of postmortem genetic testing lies in its ability to identify hereditary diseases, often those with an autosomal dominant transmission pattern, and, through consultations and screening of relatives, to identify family members with a pathogenic mutation, who are often asymptomatic, providing an opportunity to change the course of their lives. The authors present three clinical cases that highlight the importance of postmortem genetic studies and family studies, as well as the integration of the data obtained in a cardiology consultation, which may be for arrhythmology, coronary disease or cardiomyopathy, depending on the specific condition. This could modify the course of the disease in many relatives.

Identification of the abuse of performance-enhancing agents in medico-legal investigations; based on a death of a body-builder

Sportsmen abuse Performance-enhancing agents (PEA) to enhance their muscle mass and strength, while the side effects PEA may cause consequences and sudden deaths. However, the relatives usually are not aware of PEA-abuse, because most PEAs are purchased by the sportsmen from black-market. Therefore, the pathologists might miss PEA-abuse and may dispose of the postmortem with a wrong cause of death. This concept introduces a guideline to identify PEA-abuse and to give recommendations for the proper medico-legal investigation of deaths due to PEA-abuse. A 37-year-old bodybuilder who had a healthy-lifestyle died suddenly. Though the relatives were unaware, the Forensic pathologist profiled the findings and suspected PEA-abuse. The scene was visited but did not find PEA. Family physician revealed the abuse of PEA such as testosterone, cutting steroids, insulin-like growth factor and caffeine, and has had elevated liver enzymes. A high-risk autopsy was conducted. The face had acne and heart had concentric hypertrophy. Histopathology showed hypertrophy of the cardiac muscle and lung parenchyma and fatty liver. Therefore, we propose a postmortem guideline to identify PEA-abuse among sportsmen; (1) Establish seven PEA-abuse profiles; Social, physical, psychological, clinical, sports, pathological and toxicological, (2) Before autopsy, to identify the types of PEA (i) Contact the physicians and (ii) visit the scene, (3) At the autopsy, use special approaches; (i) Consider as high-risk autopsy and (ii) If gene doping is suspected, do molecular autopsy. (4) To ascertain COD, consider abuse profiles, scene and autopsy findings. (5) For prevention, organize awareness programmes and (6) to prevent premature deaths recommend to employ a clinical screening tool.

MOLECULAR AUTOPSY: EVALUATION OF SUDDEN UNEXPECTED DEATH CASES IN TERMS OF “KCNQ1” GENETIC VARIATION

Background: Deaths occuring without a known disease and/or a known cause, deaths with non-lethal diseases are interpretated as sudden-unexpected-suspected deaths. Autopsy should always required to evaluate the cause of death. Some of the cases can be termed as negative autopsy since the cause of death can not be determined. This is one of the main interests of the future forensics. Molecular autopsies are one of the main practices of to reduce the negative autopsy ratios. Thus, post-mortem KCNQ1 genetic variation tests are done in sudden unexpected death cases.
 Material and methods: In this study 0 – 50 years old sudden-unexpected deaths autopsy cases were handled. Samples taken from cases were evaluated and “KCNQ1” genetic variation tests were done in our Department.
 Results: This study included 47 cases of 42 sudden unexpected death cases (0 – 50 age group) and 5 control group. 15 cases were between 40 – 50 age group and number of cases were increasing with age. 29 of cases (% 69) were male. Evaluation of body-mass index of cases were done and normal weighted cases were the most common with 21 cases (% 50). According to death locations; 17 cases had died (% 45,9) at home. Death location records of 5 cases couldn’t be found. Pathological examinations of all cases were done. We had identified fibrosis and fatty change appearances in SA node of 9 cases (% 21,4) and AV node of 13 cases (% 30,9) especially in conduction tissue examinations. As the result of KCNQ1 genetic analysis of cases, we identified sequence variations in 1638th nucleotid of exon 13 and 1986th nucleotid of exon 16.
 Conclusion: Cases with conduction system pathology and sequence variations of KCNQ1 genetic analysis shows that we are in need of these tests among routine practice to reduce negative autopsy ratios.
 Key words: KCNQ1, molecular autopsy, sudden unexpected death, conduction system, negative autopsy.

Psychological adaptation to molecular autopsy findings following sudden cardiac death in the young

Sudden cardiac death (SCD) in the young is a devastating event occurring in otherwise healthy individuals. Postmortem genetic testing (molecular autopsy) may help identify a cause, though there is potential for uncertainty. We report psychological adaptation to molecular autopsy findings amongst family members after a young SCD. First-degree relatives who had experienced a SCD of a young relative and attended a specialized cardiac genetic clinic were invited to complete a cross-sectional, self-report survey comprising a number of validated scales. Clinical, genetic, and family history information was collected from the medical record. Thirty-three individuals from 27 families (response rate 48%) completed a survey (mean age 49 ± 12 years, 49% were mothers of the decedent). Eleven (36%) reported poor adaptation to genetic information, and compared with those with good adaptation, they were more likely to have worse posttraumatic stress symptoms (p = 0.0004) and depression (p = 0.01). Perceived support was lower in those reporting poor adaptation, including social support (p < 0.0001) and perceived support from significant others (p = 0.03), family members (p = 0.001), and friends (p = 0.0002). Adaptation to molecular autopsy findings may be difficult for some relatives following a young SCD. Careful pretest genetic counseling and integration of psychological support is needed.

Molecular autopsy by trio exome sequencing (ES) and postmortem examination in fetuses and neonates with prenatally identified structural anomalies

PurposeTo determine the diagnostic yield of combined exome sequencing (ES) and autopsy in fetuses/neonates with prenatally identified structural anomalies resulting in termination of pregnancy, intrauterine, neonatal, or early infant death. MethodsES was undertaken in 27 proband/parent trios following full autopsy. Candidate pathogenic variants were classified by a multidisciplinary clinical review panel using American College of Medical Genetics and Genomics (ACMG) guidelines. ResultsA genetic diagnosis was established in ten cases (37%). Pathogenic/likely pathogenic variants were identified in nine different genes including four de novo autosomal dominant, three homozygous autosomal recessive, two compound heterozygous autosomal recessive, and one X-linked. KMT2D variants (associated with Kabuki syndrome postnatally) occurred in two cases. Pathogenic variants were identified in 5/13 (38%) cases with multisystem anomalies, in 2/4 (50%) cases with fetal akinesia deformation sequence, and in 1/4 (25%) cases each with cardiac and brain anomalies and hydrops fetalis. No pathogenic variants were detected in fetuses with genitourinary (1), skeletal (1), or abdominal (1) abnormalities. ConclusionThis cohort demonstrates the clinical utility of molecular autopsy with ES to identify an underlying genetic cause in structurally abnormal fetuses/neonates. These molecular findings provided parents with an explanation of the developmental abnormality, delineated the recurrence risks, and assisted the management of subsequent pregnancies.