Keywords
sudden death - young female -
Leuconostoc mesenteroides
- postmortem ancillary investigations - Indian POCSO Act - mandatory reporting
Introduction
The death of an adolescent is a tragic event that can have a profound impact on family,
friends, and the wider community. Females have lower mortality rates than males in
these age groups. Causes of death in this age group can vary and may include accidents,
suicide, violence, self-harm, infectious diseases such as respiratory infections and
maternal conditions (complications for pregnancy) as leading causes of death among
adolescents and young adults. In sudden unexpected death, suspicious death, and death
due to unknown cause, a medicolegal autopsy is done to certain the cause and manner
of death. Medicolegal autopsies may be performed without any prior knowledge of the
deceased or any ailments or suspected causes of death; the deceased may even be unidentified
and just found dead. As a result, the forensic pathologist needs to be ready for everything
because it is possible for what was once thought to be presumed natural death to be
anything, including a homicide. Many a time medicolegal autopsy is supplemented by
ancillary investigations to help determine or corroborate the cause of death, and
manner of death and to positively identify unknown deceased individuals. Ancillary
investigations include radiology, histopathology, microbiology, and chemical analysis.
Postmortem microbiologic cultures have been used successfully as a diagnostic ancillary
investigation and epidemiologic tool in disease outbreak scenarios, as well as in
forensic autopsies and medicolegal investigations.[1]
[2]
[3]
[4] Their uses are usually taken into account during an autopsy in situations when there
has been a history of infection, when inexplicable inflammation is found, and when
traumatic and noninfectious causes of death have been ruled out. With proper practice
of sample collection and the right sample for microbiological analysis, postmortem
microbiological testing is one of the fundamental techniques in forensic pathology
for determining the etiology of infection.[5] Postmortem blood and tissue cultures can be used to learn more in-depth about the
severity of the infectious process that was already recognized or known antemortem
but resulted in the patient's rapid deterioration and death.
Lack of adequate nutrition and immunologic alterations during pregnancy can lead to
altered severity of and susceptibility to infectious diseases during pregnancy. Such
infectious diseases when not diagnosed timely can lead to serious complications and
even death. Also, pregnant women are at increased risk of aspiration due to several
factors including delayed gastric emptying, the gravid uterus, progesterone-mediated
lower esophageal sphincter relaxation, and decreased gastric pH.[6] Indian law recognizes consent for sexual intercourse only after the age of 18 and
warrants criminal investigation if it is before that age, including a consensual act.
For medical persons and persons with fiduciary responsibility, reporting to law enforcement
agencies is made mandatory once the case has come to their knowledge. This mandatory
reporting many times acts as a deterrent to seeking much-needed medical treatment
for the fear of legal implications.
Case Report
Alleged History
The deceased is alleged to 18-year-old female, who had eloped with her boyfriend and
had settled with his family working as a laborer. Her own family had disowned her.
For the past 1 month, she was having complaints of vomiting and weakness that kept
worsening. Fifteen days back she was taken to hospital by her mother-in-law, where
she was advised treatment and investigations for pregnancy check-ups. But she did
not get the investigation done and was found dead at home 2 weeks later due to the
worsening of her illness. The family was not aware of the pregnancy status.
External Examination
The deceased was a young emaciated adolescent female ([Fig. 1A]), 148 cm in height, weight 30 kg (body mass index: 13.7 kg/m2). Eyeballs were sunken with hollowing of temporal fossa and cheeks. The abdomen was
scaphoid in shape and devoid of subcutaneous fat, and the ribs were prominent. No
signs of decomposition were evident externally. No injuries were evident on the body.
Fig. 1 (A) Thin emaciated body. (B) Yellowish granular material as aspirate along with mucoid material in the bronchus
and bronchioles. (C) Uterus dimensions: 21 (length) × 17 cm (width) × 4 cm (anteroposterior). (D) Fetus of length 19 cm with placenta.
Internal Examination
The weight of the right lung and left lung were 167 and 151 g, respectively. Interlobar
adhesions between the right upper and middle lobes were seen. On dissection of the
lungs, a yellowish mucoid substance with some granular material is evident in terminal
bronchioles resembling gastric content ([Fig. 1B]). The uterus was enlarged and gravid ([Fig. 1C]), containing a male fetus of length (crown—heel) 19 cm aged approximately 4 to 5
months ([Fig. 1D]). Other organs were congested in appearance.
Histopathological Examination
Tissues from different organs were microscopically examined using hematoxylin and
eosin stain and congestion of all the organs was seen. Significant interstitial inflammation
and mild septal thickening with inflammatory changes around the bronchial cartilage
and congestion of the lungs ([Fig. 2]) were observed that corroborated with findings of aspiration seen grossly in the
airways.
Fig. 2 Inflammatory changes around the bronchial cartilage and interstitial inflammation.
40x Hematoxylin and eosin stain.
Microbiological Examination
Blood samples were collected with an aseptic technique and injected into adult BacTAlert
3D medium bottles (BACT/ALERT FA Plus) that were then incubated under normal atmospheric
conditions, at 37°C in an automatic BacTAlert 3D blood culture machine (BioMérieux,
Okhala, New Delhi, India). The blood culture bottle flashed positive indicating a
critical mass of organisms. Gram staining was done that showed Gram-positive ovoid
cocci or coccobacilli in pairs and chains. It was then subcultured on the blood agar,
MacConkey's agar, and chocolate agar incubated at 37°C for 24 hours. The colonies
grown were again subjected to Gram staining and were subjected to VITEK 2 Compact
System (BioMérieux, France), an automated identification system used for the identification
of microorganisms grown. The strain was identified as Leuconostoc mesenteroides by the automated system. Postmortem microbiological analysis suggested pre-existing
bacteremia by Leuconostoc mesenteroides.
Radiology
Radiological examination of shoulders, elbow, wrist, and jaw and pelvis was done on
PRORAD digital X-ray machine and the age of the female was ascertained to be 15 to
16 years. The third molar had not erupted, and the shoulder joint, elbow joint wrist
joint, and hip joint were not fused ([Fig. 3A–D]).
Fig. 3 (A) X-ray lateral view of skull showing: all teeth erupted except for third molar. Crown
of third molar formed to the cementoenamel junction and pulp chamber with a trapezoidal
form, Acromion process appeared and not fused. Head of humerus not fused. (B) X-ray AP view of both elbow joints showing: Medial epicondyle of humerus not fused
and head of radius partially fused with shaft. (C) X-ray AP view of both hands and wrist joints showing: Head of first metacarpal fused,
distal end of radius and ulna partially fused. (D) X-ray AP view of pelvis and hip joints showing: Iliac crest, ischial tuberosity
appeared but not fused. Head of femur not fused.
Toxicological Examination
Viscera preserved for toxicological analysis did not reveal any metallic or nonmetallic
poisoning.
After the postmortem, the cause of death was given as aspiration of gastric contents
into the airway. Ancillary investigations played a crucial role in establishing the
comprehensive diagnosis of the presented case. Radiological examination confirmed
the victim's age; microbiological analysis identified Leuconostoc mesenteroides bacteremia, shedding light on a pre-existing infection that contributed to the clinical
deterioration; and histopathology corroborated aspiration of gastric contents, culminating
in the determination of death's cause and the underlying infection.
Discussion
Adolescent pregnancy is linked to school abandonment, violence, unfavorable pregnancy
terminations, obstetric problems, and other outcomes that could endanger the woman's
quality of life and the lives of those around her. Although most early adolescent
pregnancies happen in vulnerable circumstances, late-stage teens are voluntarily bearing
children in many cultures, with or without a committed spouse. Pregnancy in adolescents
carries risks for both the mother and the unborn child. Pregnancy in women less than
18 years of age is considered illegal and falls under POCSO Act (the Protection of
Children from Sexual Offenses Act) as per Indian law. Valid (legal) consent for sexual
intercourse cannot be given by a woman under 18 years of age. A case of rape (sexual
assault) would be registered against the offender.[7] Adolescent pregnancy faces higher risks of eclampsia, puerperal endometritis, and
systemic infections than women of older age.[8] Because of the immune system's natural suppression during pregnancy, women may be
more vulnerable to the consequences of infection.[6] In this case the family was alleging the age of the girl to be 18 years that could
be a reason to escape the legal implications. The postmortem examination revealed
the age to be 15 to 16 years and this may be the best reason that the young female
could not continue the advised treatment and investigations for fear of law.
The growth of a single microbial isolate is generally considered a true positive.
The strain identified in this case was Leuconostoc mesenteroides, which belongs to the members of the Streptococcal family and has been regarded as
nonpathogenic by some[9] but some recognized as potential pathogens.[10] It is known to found in dairy products, pickles, skin of fruits, and other processed
food. Leuconostoc is considered not part of the normal human microbiome and is potentially pathogenic
causing endocarditis, urinary tract infections, intra-abdominal infections, and catheter-associated
bloodstream infections. Most of the Leuconostoc mesenteroides are nosocomial infection in immunocompromised patients.[10] It is responsible for bacteremia, encephalomeningitis, peritonitis, and pneumonia.[10]
[11] Infective endophthalmitis,[12] infections, and outbreaks of Leuconostoc infections have also been reported.[13]
Leuconostoc infections are said to be directly associated with mortality as reported in a study
of 88 cases of Leuconostoc infections.[14] Many infections caused by these bacteria have also been reported especially in vancomycin-treated
individuals and immunocompromised patients[14] since the first instance of Leuconostoc infection in humans that was described in 1985.[15] However, detection of these bacteria during pregnancy is not reported. In this case,
the deceased was emaciated and pregnant. Pregnancy-related immunologic changes and
inadequate nutrition might affect how infectious illnesses are transmitted and how
susceptible pregnant women are to them. This alteration in the body's immunity might
have played a role in facilitating the Leuconostoc infection in this case. Gastric reflux and fatigue are very common during pregnancy
that could have led to aspiration as the cause of death in the company of Leuconostoc infection.
Aspiration occurs when foreign material enters the airway. Mode of death in aspiration
includes asphyxiation brought on by a blocked airway, inflammation or infection of
the respiratory system brought on by inhaled debris, or aspiration pneumonia. In this
case, the bronchioles were filled with yellowish mucoid with some granular substances
and also there was microscopic evidence of acute lung injury in the form of congestion,
interstitial thickening with inflammation, and inflammatory changes around the bronchial
cartilage. This was confirmed by gross autopsy findings and was corroborated by histopathological
examination as well. A meticulous autopsy along with appropriate postmortem ancillary
investigations led to concocting the contributory elements leading to the cause of
death of a young female with an incidental diagnosis of pregnancy on autopsy.
The right of minors to aware and responsible motherhood is guaranteed by laws in our
country, but there are no measures that make it possible to readily implement these
laws. Therefore, only a health professional can interpret the law's requirements and
put them into practice. Health workers interpret and apply these laws, ensuring minors'
rights while attending to pregnancies. Mandatory reporting of pregnant minors to the
police, as mandated by obstetricians, contradicts the child's best interests and may
deter seeking medical help, potentially endangering lives. Reporting such cases, even
consensual ones, can be detrimental, particularly in rural settings where early marriages
occur. Excessive reporting strains families and worsens burdens caused by teenage
pregnancies. Re-evaluating reporting practices is essential to safeguard minors' rights
and well-being.[16]
[17]
Conclusion
While the autopsy itself provides valuable information, postmortem ancillary investigations
can provide additional insight into the cause of death providing a more complete understanding
of the circumstances surrounding the death. In this case, radiological examination
helped in the estimation of the correct age and unraveling the discrepancies of the
alleged age. Microbiological investigation helped in identifying an infection that
contributed to the death and microscopic evidence of acute lung injury on histopathological
examination that corroborates with aspiration as the cause of death and also established
the manner of death as natural.
