Pneumomediastinum and Soft Tissue Emphysema in Pediatric Hanging

Postmortem computed tomography (CT) is increasingly being used as a tool in forensic pathology. The exact value of postmortem imaging in detecting specific conditions has not yet been established, but in specific cases, it can be used as a diagnostic tool demonstrating findings that remain undetected during autopsy, as in this case. Pneumomediastinum and soft tissue emphysema were detected with postmortem CT in a 3‐year‐old girl after hanging. It was not found during autopsy. This radiological finding matches 3 adult cases previously described. It is assumed that in this case, the first reported in a child, hanging was the most likely cause as well. In the adult cases, it was interpreted as a vital sign; the person must have been alive to create a pressure gradient causing rupture of the alveoli. This case demonstrates one of the added values of postmortem imaging, the possibility of demonstrating findings that remain undetected during autopsy.     

Diagnosis of Hemorrhagic Stroke in an Exhumed Brain After Three Years of Burial in a Deep Grave

Abstract: We present the forensic neuropathologic analysis of an exhumed decomposed brain following long‐term interment in a 50‐year‐old white woman, who had been buried for 34 months. Next of kin authorized exhumation of the body for an autopsy to determine the cause of death. The embalmed body was anatomically intact and revealed decompositional changes with mold colonies. Internal viscera showed intact histomorphology. The brain revealed diffuse congestive swelling and extracellular edema with dissecting parenchymal hemorrhage and hematoma originating from the left putamen and thalamus and extending to the left lateral ventricle. Excitotoxic neuronal injury as well as penumbric parenchymal changes was noted. Cause of death was determined to be a hypertensive cerebral parenchymal hemorrhage. This case and our previously reported case are sentinel cases, which should encourage and guide the forensic neuropathologic work‐up and investigation of causes of death in spite of long‐term burial in deep graves.     

Sudden Unexpected Death Due to Graves' Disease During Physical Altercation

We report a case of a 30‐year‐old woman who suddenly collapsed after having a physical altercation with her husband. Despite immediate resuscitation, she died on arrival at the hospital. The victim's parents requested an autopsy because they believed that their daughter was killed by her husband. Postmortem examination revealed that the victim had a diffusely enlarged thyroid gland and cardiomegaly with left ventricular hypertrophy. There was no evidence of significant trauma on the body. Further postmortem thyroid function tests and review of her medical history indicated that her death was due to Graves' disease. To the best of our knowledge, this is the first case reported of sudden death due to cardiac arrhythmia from Graves' disease induced by physical and emotional stress associated with the criminal activity of another person. The autopsy findings are described. In addition, the literature is reviewed and the significance of postmortem evaluation of thyroid hormones in the cases of sudden death is discussed.     

Ketoacidosis and Adrenocortical Insufficiency

We herein report an autopsy case involving a 27‐year‐old Caucasian woman suffering from chronic adrenocortical insufficiency with a background of a polyendocrine disorder. Postmortem biochemistry revealed pathologically decreased aldosterone, cortisol, and dehydroepiandrosterone levels in postmortem serum from femoral blood as well as decreased cortisol and 17‐hydroxycorticosteroid in urine. Decreased vitreous sodium and increased 3‐beta‐hydroxybutyrate and C‐reactive protein concentrations were observed. The cause of death was determined to be acute adrenocortical insufficiency. Fasting ketoacidosis was postulated to have precipitated the Addisonian crisis. Traumatic causes of death and third‐party involvement were excluded. The case highlights the importance of systematically performing exhaustive postmortem biochemical investigations to formulate appropriate hypothesis regarding the pathophysiological mechanisms involved in the death process.     

Fatal Drowning Accident and Undiagnosed Hydrocephalus

Abstract: Bodies found in water present several diagnostic challenges for the forensic examiner, such as the identification of the time and mechanism of death, the postmortem submersion time, and above all the circumstances of drowning. We report the case of a 33‐year‐old security guard found dead in Venice, in the water of the lagoon, who at autopsy presented a previously undiagnosed hydrocephalus with macrocephaly. The victim remained asymptomatic until 2 months before death and had never undergone a neurological or radiological examination. In the article, we emphasize the need to perform a thorough autopsy in all suspected drownings, discuss the etiopathogenesis of the neurological disease and hypothesize a possible relationship between the hydrocephalus and the drowning accident. Finally, we discuss the major clinical and forensic implications of macrocephaly and hydrocephalus in adults.     

The Interest of Postmortem Bacteriology in Putrefied Bodies

A 27‐year‐old man was found dead in an advanced decomposition stage at home. On external examination, his body showed petechial hemorrhages of the skin. At autopsy, petechial hemorrhages of the epicardium were found, but no sign of meningitis was detected. Toxicological investigations remained negative. Bacteriological conventional analyses showed no significant result. Neisseria meningitidis serogroup B was finally isolated on cerebrospinal fluid by a specific real‐time polymerase chain reaction. To our knowledge, there are no available data about the postmortem diagnosis of an infectious cause of death in a decomposed corpse. In such situations, the polymicrobial overgrowth usually hampers the interpretation of bacteriological conventional methods and questions their diagnostic value. Such molecular bacteriological approaches appear to constitute an important diagnostic tool for forensic scientists and should be widely processed in case of suspected infectious death or sudden death whatever the postmortem interval.     

Sudden Death Due to Infiltration of Left Bundle Branches by Interventricular Septal Cardiac Fibroma

Cardiac fibromas are benign conditions; however, their location and size may cause ventricular arrhythmias and sudden cardiac death. We report a case of a 68‐year‐old female who died suddenly. Postmortem investigation detected a huge cardiac fibroma in the pars muscularis of the interventricular septum, occupying almost the entire muscular septum, and restricting the volume of left ventricular chamber. Histological examination revealed numerous foci of calcification in the alternating complex interlacing or strictly parallel collagenous fiber mass. Tumor mass was mainly demarcated, but in some places, fibrous infiltration of surrounding working cardiac muscle was found. We present a case when direct tumor involvement in the descending left bundle branches was evidenced. Mainly, the branches of septal fascicle were disrupted, entrapped, and degenerated by the tumor mass. This case report emphasizes that postmortem histological examination of conduction system in all sudden cardiac death cases may substantially improve the accuracy of postmortem diagnosis.     

Death by Ram Attack: A Case Report from Greece and a Brief Review of the Literature

A case of a ram attack that caused injuries to a 73‐year‐old man is presented. The deceased survived the attack and had the opportunity to speak with a friend over the phone before being transferred to the hospital. After a 21‐day hospitalization, the patient passed away. A postmortem examination was performed to ascertain the cause of death. The autopsy findings are presented along with a brief review of the literature. Attacks by agricultural animals (or livestock) around the world are reported in the scientific literature. Fatalities from ram attacks are extremely rare. The need to implement specific codes in the ICD system, relevant to each animal attack, appears to be of great importance, in order to allow tracking of animal‐related deaths.     

Sudden Unexpected Death Due to Left Subclavian Artery‐esophageal Fistula Caused by Fish Bone

A 53‐year‐old woman was admitted to the hospital due to unexpected dizziness and died the following morning. To investigate the cause of death, a forensic autopsy along with histological examination was performed 3 days after her death. The major findings of the autopsy were that a fish bone had pierced the left subclavian artery after perforating the esophagus with 680 mL of blood in the stomach and bloody and tarry contents were present in the intestines, and the cause of death was confirmed to be subsequent hemorrhagic shock. Unfortunately, none of her family realized that she had eaten a fish 4 days before the tragedy until the fish bone was found. The present case is rare and instructive. The histopathological findings of left subclavian artery‐esophageal fistula induced by a fish bone can be used as a reference in forensic practice.     

Commotio cordis: A case report of a fatal blow

Commotio cordis secondary to a blunt blow to the chest wall can result in ventricular fibrillation and sudden death in children. While it is commonly reported in adolescents during sporting activities, it may result from non-accidental trauma especially in infants and younger children. We report a case of a 6-month-old baby boy who presented to the emergency department in cardiac arrest. The patient's hospital records, postmortem imaging, and the autopsy results were reviewed. External examination of the infant did not reveal any evidence of trauma. Postmortem imaging revealed multiple healing posterior rib fractures and a metaphyseal corner fracture, both considered fractures highly specific for physical abuse. The autopsy revealed a structurally normal heart with no microscopic abnormalities. The infant's father confessed to hitting the child on the chest after which the child became unresponsive. Given the constellation of postmortem imaging and autopsy findings in addition to the father's confession, the child's death was ruled as a homicide secondary to commotio cordis. Since there are no structural and microscopic abnormalities in the heart autopsy in cases of commotio cordis, timely on-scene investigation and a thorough investigation regarding the mechanism of injury are required to make this diagnosis. Early identification of non-accidental trauma is crucial and can prevent further abuse in other siblings.     

Early Repolarization,Acute Emotional Stress and Sudden Death

We herein report the case of a 36‐year‐old man who died suddenly after a fight with another man. Forensic investigations included unenhanced computed tomography, postmortem angiography, autopsy, histology, neuropathology, toxicology, and biochemistry and allowed a traumatic cause of death to be excluded. An electrocardiogram recorded some years prior to death revealed the presence of an early repolarization pattern. Based on the results of all investigations, the cause of death was determined to be cardiac arrhythmia and cardiac arrest during an emotionally stressful event associated with physical assault. Direct third party involvement, however, was excluded, and the manner of death was listed as natural. The case was not pursued any further by the public prosecutor.     

K2 Toxicity: Fatal Case of Psychiatric Complications Following AM2201 Exposure

Limited forensic and clinical experience and the lack of confirmatory testing strategies for synthetic cannabinoids (SC) prevent adequate characterization of SC toxicity and the potential impact on public health. A statewide surveillance system identified a fatality involving a 23‐year‐old man found with a large stab wound to the neck following use of a SC product suspected of containing AM2201. Analytical testing for common SCs, SC metabolites, routine drugs of abuse, and over‐the‐counter medications was performed on heart blood obtained at autopsy. Additionally, assays were performed on the SC raw material and drug paraphernalia found on the decedent. High concentrations of AM2201 were detected in all samples. AM2201 metabolites were detected in postmortem blood. Other than a trace amount of JWH‐073 found in smoke residue, no other substances were detected. Psychiatric complications including self‐induced, lethal trauma can occur after the use of SC products.     

An Unplanned Complex Suicide by Multiple Blank Cartridge Gunshots and Cutting

Blank firing guns are readily accessible in most countries due to an absence of legal regulations. These weapons are capable of causing lethal injuries. We report a rare case of secondary (unplanned) complex suicide committed with a knife and blank cartridge pistol. A 59‐year‐old man was found dead with three superficial incisions in his neck and a gunshot wound to the chest. The external examination revealed an entrance wound in the left chest region consistent with contact shooting. The appearance of a muzzle imprint suggested two discharges. The autopsy showed a slightly hemorrhaged but otherwise intact pericardium, blood in the pericardial sac, and a channel‐like defect in the anterior wall of the left cardiac ventricle. The cause of death was attributed to cardiac tamponade. To the best of our knowledge, this is the first reported case of unplanned complex suicide involving an unmodified blank firing gun.     

An Unusual Pattern of Decomposition Associated with Suicidal Electrocution in a Bath

A 51‐year‐old man was found dead face down and partially submerged in a bathtub alongside two hairdryers. The hairdryers had continued to work, as the victim had bypassed the electrical board of the house prior to dropping them into the water. This had resulted in death due to electrocution, with subsequent heating of the bath water causing marked putrefaction and softening of the immersed body parts. The back and feet, which were not submerged, were preserved. The degree of anterior decomposition was not in keeping with the postmortem interval; however, regional decomposition with sparing of the back and feet provided a clue at autopsy as to the sequence of events. Individuals with training in, or knowledge of, electrical circuitry are capable of modifying domestic wiring so that safety switches and/or fuses can be bypassed ensuring that electrical devices will continue to function even while under water.     

Fatal Fentanyl Patch Misuse in a Hospitalized Patient with a Postmortem Increase in Fentanyl Blood Concentration

Opioid‐related mortality happens, even in healthcare settings. We describe serial postmortem fentanyl blood concentrations in a hospital inpatient who fatally abused transdermal fentanyl. This is a single‐patient case report. A 42‐year‐old man with lymphoma was started on transdermal fentanyl therapy while hospitalized for chronic abdominal pain. The patient was last seen awake 1.3 h prior to being found apneic and cyanotic. During the resuscitation attempt, a small square‐shaped film was removed from the patient's oropharynx. Femoral blood was collected 0.5 and 2 h postmortem, and the measured fentanyl concentration increased from 1.6 to 14 ng/mL. Study limitations include potential laboratory or collection errors and missing data. (i) Providers must be vigilant for signs of fentanyl patch abuse. (ii) Postmortem blood concentrations are not static postmortem, likely secondary to decreasing pH, increased aqueous solubility, and tissue redistribution, and are therefore unlikely to accurately represent antemortem blood concentrations.     

The Need for an Interdisciplinary Approach in Forensic Sciences: Perspectives from a Peculiar Case of Mummification

The finding of a mummified body raises many problems, also because of the limits of the medico‐legal investigations in case of mummification. Psychological autopsy and behavioral analysis have demonstrated a significant impact in case of equivocal death. The mummified corpse of a woman was found sealed in a wardrobe during the death investigation of a 36‐year‐old man, later discovered to be the woman's son. The woman's corpse was well preserved and no external injuries were found. Autopsy could not ascertain the cause of death. The state of the premises and the writings on the walls offered an opportunity to investigate the man's psychological profile and to better understand how the events might have taken place. The role of an accurate investigative analysis of the crime scene is a cornerstone of forensic pathology and the case presented underlies the importance of an interdisciplinary approach in forensic sciences.     

Postmortem Aortic Dissection: An Artifact of the Embalming Process

Aortic dissection (AD) is a serious condition that affects 3/100,000 individuals a year. Recently, a case report was published describing an embalmed patient with an aortic dissection. The purpose of this study was to examine the frequency of AD among 80 embalmed cadavers and confirm the AD with histopathologic evaluation. In seven cases of grossly identified AD, six were determined to be due to the embalming procedure and only one case of true antemortem AD was confirmed. These results suggest that aortic morphology can be altered by administration of the embalming fluid and that alterations can mimic AD, not only on gross inspection but also on postmortem imaging. Awareness of this embalming artifact may prevent misdiagnosis of an aortic dissection in an embalmed patient, a point particularly useful for autopsy pathology that may include postmortem examination of an embalmed patient.     

Acute Fatal Coronary Artery Dissection Following Exercise‐related Blunt Chest Trauma

Coronary artery injury such as acute coronary dissection is an uncommon and potentially life‐threatening complication after blunt chest trauma. The authors report an unusual autopsy case of a 43‐year‐old healthy man who suddenly collapsed after receiving a punch to the chest during the practice of kung fu. The occurrence of the punch was supported by the presence of one recent contusion on the left lateral chest area at the external examination and by areas of hemorrhage next to the left lateral intercostal spaces at the internal examination. The histological examination revealed the presence of an acute dissection of the proximal segment of the left anterior descending coronary artery. Only few cases of coronary artery dissection have been reported due to trauma during sports activities such as rugby and soccer games, but never during the practice of martial arts, sports usually considered as safe and responsible for only minor trauma.     

An Unusual Case of Strychnine Poisoning

Strychnine‐related death has been described since the 19th century. This alkaloid was discovered in 1818. Historically, strychnine was used by the South‐East Asian autochthones on their arrows. However, its production was modified by legislation, which was used to protect people against accidental intoxications. Here, we present the case of a 69‐year‐old man who was found dead at home. During the autopsy, we found a blue substance in the stomach. Toxicological analysis measured strychnine at 0.29 μg/mL in the blood sample, which is a relatively low level in comparison with the results given in the literature. However, histologic examination and toxicological findings permitted the conclusion of strychnine poisoning.     

An Unusual Case Showing Fatal Rupture of a Gastric Ulcer or Gastromalacia? The Importance/Role of Histology for Differential Diagnosis

Gastromalacia is the acute autolytic erosion of the gastric wall. It generally occurs postmortem, and it appears as a slimy brownish black region of the wall which occurs principally in the gastric fundus. A 59‐year‐old woman died in the Emergency Department following a 2‐day period of mild abdominal pain, vomiting, and diarrhea. A forensic autopsy was performed which revealed a rupture of the gastric fundus that had caused leakage of gastric content into the abdominal cavity. There was no macroscopic evidence of peritonitis, and the stomach wall adjacent to the rupture site showed marked thinning. The gross appearance was typical of gastromalacia. In contrast, histological observations revealed the presence of an ulcer at the site of perforation and a severe acute inflammatory reaction indicating a robust reaction with an antemortem rupture.