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Noninvasive analysis and identification of an intramuscular fluid collection by postmortem 1H-MRS in a case of a fatal motor vehicle accident

  • Jakob HeimerEmail author
  • Dominic Gascho
  • Carlo Tappero
  • Michael J. Thali
  • Niklaus Zoelch
Case Report

Abstract

In a case of a fatal traffic accident, a suspicious finding was identified in the muscular tissue of the left thigh by whole-body postmortem computed tomography. To better interpret the finding, the lower extremities were investigated by magnetic resonance imaging (MRI) and proton magnetic resonance spectroscopy (1H-MRS). MRI revealed the presence of an evenly distributed intramuscular fluid and 1H-MRS of a volume within the fluid detected concentrations of acetate and lactate. The fluid was assumed to be an extravasation of an intraosseous infusion, erroneously administered to the intermediate vastus of the left thigh during resuscitation, which was later confirmed when access to resuscitation protocols was granted. Further ex situ 1H-MRS investigations of five different infusion fluids showed the possible discrimination of the fluids and further indicated the unknown fluid to be a Ringer’s acetate solution. This paper presents the case-based application of postmortem intramuscular 1H-MRS and introduces the possibility of its use to differentiate exo- and endogenic fluids for forensic interpretation. Further research for this method regarding problems in forensic pathology is needed.

Keywords

Postmortem computed tomography Postmortem magnetic resonance imaging Postmortem magnetic resonance spectroscopy Biofluids Intravenous fluids 

Abbreviations

CT

Computed tomography

MRI

Magnetic resonance imaging

1H-MRS

Proton magnetic resonance spectroscopy

NMR

Nuclear magnetic resonance

TE

Echo time

TR

Repetition time

PPM

Parts per million

TMA

Trimethylammonium-containing compounds (cholines + carnitine)

CR3

Methyl group of creatine

EMCL

Extramyocellular lipids

IMCL

Intramyocellular lipids

HES

Hydroxyethyl starch

Notes

Acknowledgments

The authors express their gratitude to Emma Louise Kessler, MD for her generous donation to the Zurich Institute of Forensic Medicine, University of Zurich, Switzerland.

Compliance with ethical standards

This article does not contain any studies with (living) human participants or animals performed by any of the authors. No informed consent was required. Ethical approval was obtained by the Ethics Committee of the Canton of Zurich, Nr. KEK ZH-Nr. 15–0686 and 18–0758.

Conflict of interest

The authors declare that they have no conflict of interest.

References

  1. 1.
    Olds K, Byard RW, Langlois NEI (2015) Injuries associated with resuscitation – an overview. J Forensic Legal Med 33:39–43CrossRefGoogle Scholar
  2. 2.
    Hashimoto Y, Moriya F, Furumiya J (2007) Forensic aspects of complications resulting from cardiopulmonary resuscitation. Legal Med 9(2):94–99PubMedCrossRefGoogle Scholar
  3. 3.
    Myburgh JA, Mythen MG (2013) Resuscitation fluids. N Engl J Med 369(13):1243–1251PubMedCrossRefGoogle Scholar
  4. 4.
    Gault DT (1993) Extravasation injuries. Br J Plast Surg 46(2):91–96PubMedCrossRefGoogle Scholar
  5. 5.
    Shields LB, Hunsaker DM, Hunsaker JC (2003) Iatrogenic catheter-related cardiac tamponade: a case report of fatal hydropericardium following subcutaneous implantation of a chemotherapeutic injection port. J Forensic Sci 48(2):414–418PubMedCrossRefGoogle Scholar
  6. 6.
    Booth S, Norton B, Mulvey D (2001) Central venous catheterization and fatal cardiac tamponade. Br J Anaesth 87(2):298–302PubMedCrossRefGoogle Scholar
  7. 7.
    Orme RLE, McSwiney M, Chamberlain-Webber R (2007) Fatal cardiac tamponade as a result of a peripherally inserted central venous catheter: a case report and review of the literature. Br J Anaesth 99(3):384–388PubMedCrossRefGoogle Scholar
  8. 8.
    dos Santos Modelli ME, Cavalcanti FB (2014) Fatal cardiac tamponade associated with central venous catheter: a report of 2 cases diagnosed in autopsy. Am J Forensic Med Pathol 35(1):26–28PubMedCrossRefGoogle Scholar
  9. 9.
    Bartlett CS, DiFelice GS, Buly RL, Quinn TJ, Green DS, Helfet DL (1998) Cardiac arrest as a result of intraabdominal extravasation of fluid during arthroscopic removal of a loose body from the hip joint of a patient with an acetabular fracture. J Orthop Trauma 12(4):294–299PubMedCrossRefGoogle Scholar
  10. 10.
    Zech W-D, Jackowski C, Buetikofer Y, Kara L (2014) Characterization and differentiation of body fluids, putrefaction fluid, and blood using Hounsfield unit in postmortem CT. Int J Legal Med 128(5):795–802PubMedCrossRefGoogle Scholar
  11. 11.
    Zech W-D, Schwendener N, Persson A, Warntjes MJ, Riva F, Schuster F, Jackowski C (2015) Postmortem quantitative 1.5-T MRI for the differentiation and characterization of serous fluids, blood, CSF, and putrefied CSF. Int J Legal Med 129(5):1127–1136PubMedCrossRefGoogle Scholar
  12. 12.
    Ala-Korpela M (2007) Potential role of body fluid 1H NMR metabonomics as a prognostic and diagnostic tool. Expert Rev Mol Diagn 7(6):761–773PubMedCrossRefGoogle Scholar
  13. 13.
    Bell JD, Brown JC, Sadler PJ (1989) NMR studies of body fluids. NMR Biomed 2(5–6):246–256PubMedCrossRefGoogle Scholar
  14. 14.
    Lindon JC, Nicholson JK, Holmes E, Everett JR (2000) Metabonomics: metabolic processes studied by NMR spectroscopy of biofluids. Concepts in Magnetic Resonance: An Educational Journal 12(5):289–320CrossRefGoogle Scholar
  15. 15.
    Santos ADC, Dutra LM, Menezes LRA, Santos MFC, Barison A (2018) Forensic NMR spectroscopy: just a beginning of a promising partnership. Trends Anal Chem 107:31–42CrossRefGoogle Scholar
  16. 16.
    Tkáč I, Starčuk Z, Choi IY, Gruetter R (1999) In vivo 1H NMR spectroscopy of rat brain at 1 ms echo time. Magn Reson Med 41(4):649–656PubMedCrossRefGoogle Scholar
  17. 17.
    Wilson M, Andronesi O, Barker PB, Bartha R, Bizzi A, Bolan PJ, Brindle KM, Choi IY, Cudalbu C, Dydak U (2019) Methodological consensus on clinical proton MRS of the brain: review and recommendations. Magn Reson MedGoogle Scholar
  18. 18.
    Klose U (1990) In vivo proton spectroscopy in presence of eddy currents. Magn Reson Med 14(1):26–30PubMedCrossRefGoogle Scholar
  19. 19.
    Boesch C (2007) Musculoskeletal spectroscopy. J Magn Reson Imaging 25(2):321–338PubMedCrossRefGoogle Scholar
  20. 20.
    Fuchs B, Weishaupt D, Zanetti M, Hodler J, Gerber C (1999) Fatty degeneration of the muscles of the rotator cuff: assessment by computed tomography versus magnetic resonance imaging. J Shoulder Elb Surg 8(6):599–605CrossRefGoogle Scholar
  21. 21.
    Hawley RJ Jr, Schellinger D, O'Doherty DS (1984) Computed tomographic patterns of muscles in neuromuscular diseases. Arch Neurol 41(4):383–387PubMedCrossRefGoogle Scholar
  22. 22.
    Cui Q, Lewis IA, Hegeman AD, Anderson ME, Li J, Schulte CF, Westler WM, Eghbalnia HR, Sussman MR, Markley JL (2008) Metabolite identification via the Madison metabolomics consortium database. Nat Biotechnol 26(2):162–164PubMedCrossRefGoogle Scholar
  23. 23.
    Lange T, Dydak U, Roberts T, Rowley H, Bjeljac M, Boesiger P (2006) Pitfalls in lactate measurements at 3T. Am J Neuroradiol 27(4):895–901PubMedGoogle Scholar
  24. 24.
    Simmons CM, Johnson NE, Perkin RM, van Stralen D (1994) Intraosseous extravasation complication reports. Ann Emerg Med 23(2):363–366PubMedCrossRefGoogle Scholar
  25. 25.
    Moscati R, Moore GP (1990) Compartment syndrome with resultant amputation following intraosseous infusion. Am J Emerg Med 8(5):470–471PubMedCrossRefGoogle Scholar
  26. 26.
    Greenstein YY, Koenig SJ, Mayo PH, Narasimhan M (2016) A serious adult intraosseous catheter complication and review of the literature. Crit Care Med 44(9):e904–e909PubMedCrossRefGoogle Scholar
  27. 27.
    Fayad LM, Salibi N, Wang X, Machado AJ, Jacobs MA, Bluemke DA, Barker PB (2010) Quantification of muscle choline concentrations by proton MR spectroscopy at 3 T: technical feasibility. Am J Roentgenol 194(1):W73–W79CrossRefGoogle Scholar
  28. 28.
    Fineschi V, Picchi M, Tassini M, Valensin G, Vivi A (1990) 1H-NMR studies of postmortem biochemical changes in rat skeletal muscle. Forensic Sci Int 44(2–3):225–236PubMedCrossRefGoogle Scholar
  29. 29.
    Arús C, Bárány M (1986) Application of high-field 1H-NMR spectroscopy for the study of perifused amphibian and excised mammalian muscles. Biochim Biophys Acta 886(3):411–424PubMedCrossRefGoogle Scholar
  30. 30.
    Ntziachristos V, Kreis R, Boesch C, Quistorff B (1997) Dipolar resonance frequency shifts in 1H MR spectra of skeletal muscle: confirmation in rats at 4.7 T in vivo and observation of changes postmortem. Magn Reson Med 38(1):33–39PubMedCrossRefGoogle Scholar
  31. 31.
    Asllani I, Shankland E, Pratum T, Kushmerick M (1999) Anisotropic orientation of lactate in skeletal muscle observed by dipolar coupling in 1H NMR spectroscopy. J Magn Reson 139(2):213–224PubMedCrossRefGoogle Scholar
  32. 32.
    Boesch C, Machann J, Vermathen P, Schick F (2006) Role of proton MR for the study of muscle lipid metabolism. NMR Biomed 19(7):968–988PubMedCrossRefGoogle Scholar
  33. 33.
    Krššák M, Roden M, Mlynárik V, Meyerspeer M, Moser E (2004) 1H NMR relaxation times of skeletal muscle metabolites at 3 T. MAGMA 16(4):155–159.  https://doi.org/10.1007/s10334-003-0029-1 CrossRefPubMedGoogle Scholar
  34. 34.
    Brooks GA (2009) Cell–cell and intracellular lactate shuttles. J Physiol 587(23):5591–5600PubMedPubMedCentralCrossRefGoogle Scholar
  35. 35.
    Juel C (2001) Current aspects of lactate exchange: lactate/H+ transport in human skeletal muscle. Eur J Appl Physiol 86(1):12–16PubMedCrossRefGoogle Scholar
  36. 36.
    Mainwood G, Worsley-Brown P (1975) The effects of extracellular pH and buffer concentration on the efflux of lactate from frog sartorius muscle. J Physiol 250(1):1–22PubMedPubMedCentralCrossRefGoogle Scholar
  37. 37.
    Roth DA, Brooks GA (1990) Lactate and pyruvate transport is dominated by a pH gradient-sensitive carrier in rat skeletal muscle sarcolemmal vesicles. Arch Biochem Biophys 279(2):386–394PubMedCrossRefGoogle Scholar
  38. 38.
    Needham DM (1927) A quantitative study of succinic acid in muscle. II: the metabolic relationships of succinic, malic and fumaric acids. Biochem J 21(3):739PubMedPubMedCentralGoogle Scholar
  39. 39.
    Taegtmeyer H (1978) Metabolic responses to cardiac hypoxia. Increased production of succinate by rabbit papillary muscles. Circ Res 43(5):808–815PubMedCrossRefGoogle Scholar
  40. 40.
    Chouchani ET, Pell VR, Gaude E, Aksentijević D, Sundier SY, Robb EL, Logan A, Nadtochiy SM, Ord EN, Smith AC (2014) Ischaemic accumulation of succinate controls reperfusion injury through mitochondrial ROS. Nature 515(7527):431–435PubMedPubMedCentralCrossRefGoogle Scholar
  41. 41.
    Sacks J, Ganslen RV, Diffee JT (1954) Lactic and pyruvic acid relations in frog muscle. Am J Physiol 177(1):113–114PubMedCrossRefGoogle Scholar
  42. 42.
    Sacks J, Morton JH (1956) Lactic and pyruvic acid relations in contracting mammalian muscle. Am J Physiol 186(2):221–223PubMedCrossRefGoogle Scholar
  43. 43.
    Solonen KA, Tarkkanen L, Närvänen S, Gordin R (1968) Metabolic changes in the upper limb during tourniquet ischaemia: a clinical study. Acta Orthop Scand 39(1–3):20–32PubMedCrossRefGoogle Scholar
  44. 44.
    Markenstein L, Appelt-Menzel A, Metzger M, Wenz G (2014) Conjugates of methylated cyclodextrin derivatives and hydroxyethyl starch (HES): synthesis, cytotoxicity and inclusion of anaesthetic actives. Beilstein J Org Chem 10:3087–3096PubMedPubMedCentralCrossRefGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Institute of Forensic Medicine, Department of Forensic Medicine and ImagingUniversity of ZurichZurichSwitzerland
  2. 2.Department of RadiologyHôpital FribourgeoisFribourgSwitzerland
  3. 3.Hospital of Psychiatry, Department of Psychiatry, Psychotherapy and PsychosomaticsUniversity of ZurichZurichSwitzerland

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