Ong Beng Beng, Gole Glen A, Robertson Thomas, McGill James, de Lore Danny, Crawford Maree
Forensic Pathology, Forensic and Scientific Services, Cooper Plains, Brisbane, QLD, Australia.
Forensic Sci Med Pathol. 2009 Dec;5(4):307-12. doi: 10.1007/s12024-009-9108-6. Epub 2009 Oct 23.
A 9-month old infant presented in a state of shock to a district hospital. She was subsequently referred to the regional tertiary hospital. On admission, bruises were noted on the vertex of the skull. Retinal hemorrhages were present on ophthalmological examination. CT scan of the brain showed poor grey-white matter differentiation with apparent frontoparietal fractures of the skull. Her case was subsequently referred to the relevant authorities as it was suspicious for nonaccident injury (NAI). Her condition deteriorated and she died the next day. Postmortem examination showed that the bruises on the vertex were caused by rapid widening of the sutures of the skull, caused by rising intracranial pressure. There was no skull fracture or evidence of trauma. Histological examination of the brain showed meningitis which had extended to the optic nerve sheath. Hemorrhages were noted in the retinas as well as the optic nerve sheath. An incidental congenital disorder of glycosylation (CDG) was diagnosed on brain histology and confirmed by metabolic tests. Retinal hemorrhages are known to occur in head injuries especially in association with NAI. In this case, suspicion of NAI was further augmented by the presence of apparent bruises on the head. The full postmortem examination showed no evidence of injuries and instead showed that the child was suffering from meningitis. Blood culture grew Group A Streptococcus pyogenes. The underlying mechanisms for such a presentation and the association with CDG are discussed.
一名9个月大的婴儿因休克状态被送往一家地区医院。随后她被转诊至地区三级医院。入院时，发现其颅骨顶部有瘀伤。眼科检查发现视网膜出血。脑部CT扫描显示灰白质分化不良，颅骨有明显的额顶骨折。由于怀疑是非意外性损伤（NAI），她的病例随后被提交给相关当局。她的病情恶化，第二天死亡。尸检显示，颅骨顶部的瘀伤是由颅内压升高导致颅骨缝线迅速增宽引起的。没有颅骨骨折或外伤迹象。脑部组织学检查显示脑膜炎已蔓延至视神经鞘。视网膜和视神经鞘均有出血。通过脑部组织学诊断出一种偶然的先天性糖基化障碍（CDG），并经代谢测试证实。视网膜出血在头部受伤时很常见，尤其是与NAI相关时。在这个病例中，头部明显的瘀伤进一步增加了对NAI的怀疑。完整的尸检显示没有受伤迹象，反而表明该儿童患有脑膜炎。血培养培养出A组化脓性链球菌。本文讨论了这种表现的潜在机制以及与CDG的关联。
