Death caused by DF-2, following a dog-bite

The Gram-negative rod DF-2 was isolated from blood-cultures, the blood sample taken 3 days after death from a 65-year-old woman who had been bitten in her finger by her dog. At the medico-legal external examination marbling of the skin was found, suggesting septicemia. In persons found dead with a history of dog exposition and with no other obvious cause of death, examination for DF-2 should be performed.     

Symmetrical "mirror-image" injuries and the "chessboard" pattern: useful markers of self-mutilation

The evaluation of injuries due to self-mutilation may be complicated by atypical lesions and fabricated histories of the causative events. Four cases are described where one of the most striking findings was the presence of "mirror-image" injuries and/or a "chessboard" pattern of intersecting parallel lines from self-inflicted incised wounds. Case 1: A 32-year-old man was dead in his burnt-out car, with symmetrical, "mirror-image", circular burns from the car cigarette lighter over his forehead, cheeks, ears, upper and lower arms, the dorsal and palmar aspects of the hands, the anterior chest wall including the nipples, the anterior abdomen, thighs, lower legs, and the back of his neck. The deceased had a history of psychotic depression and had died of burns and inhalation of products of combustion. Case 2: A 19-year-old woman who fabricated a history of assault demonstrated multiple, superficial, "mirror-image" injuries of her thighs and forearms. Case 3: A 32-year-old man who exsanguinated from cut wrists showed multiple, superficial, and "mirror-image" incised wounds of the wrists, with a "chessboard" pattern. Case 4: A 26-year-old man died after jumping from a building. He had multiple superficial, "mirror-image" incised wounds of his anterior chest and thighs, with a typical "chessboard" pattern. Given the difficulties that sometimes arise in determining whether injuries have been self-inflicted or not, the finding of symmetrical "mirror-image" injuries, and/or a "chessboard" pattern formed by 2 groups of regular, parallel, superficial incised wounds running at right angles to each other provides compelling evidence of self-mutilation, unless a plausible alternative explanation is available.     

Swollen Lips After a Night of Partying—An Allergic Reaction to Ecstasy?

Ecstasy (MDMA) is a mood‐lifting drug with numerous somatic side effects, for example, dehydration or continuous chewing and biting. We describe the case of a young woman who underwent a forensic medical examination for suspected sexual assault. She claimed to have suffered from a memory lapse, and she had a painful swelling of her lips with a plaque‐like coating on her lips and buccal mucosa. The attending physician suspected that these findings might have been caused by strong sucking pressure on her lips within the context of a sexual assault. A toxicological examination of a blood specimen verified that she had been under the influence of an extremely high dose of ecstasy (1.456 mg/L MDMA and 0.0213 mg/L MDA). Pursuant to the forensic medical assessment, the described findings on her lips, and buccal mucosa were interpreted as an allergic and mechanical reaction (through continuous chewing and biting) to ecstasy.     

"Natural" death of a person under the care of a custodian

An ambulance service doctor was called to the death of a 76-year-old woman and attested cardiac arrest and psycho-organic brain syndrome as the cause of death on the death certificate. At the second external examination mandatory before cremation, extensive hematomas were detected on the right thorax and multiple haematomas in the face and on the forehead. The autopsy initially ordered by the public health officer revealed serial rib fractures and a fractured skull. After notifying the prosecutor, a forensic autopsy was ordered and death was found to have been caused by fat embolism following massive blunt force to the thorax with serial rib fractures and haematopneumothorax. After that, the adopted son, who had been appointed care custodian for the woman, and his wife were suspected, because they had given contradictory explanations for the injuries. At first, they were only suspected of failure to render assistance, but in the end they were both charged with murder. Only because of the second external examination prescribed by the law still in force could the errors of the improper first external examination be corrected.     

A cause célèbre: the so-called "ballpoint murder"

Transorbital intracranial injuries are uncommon but classic ophthalmologic traumas. This report describes a case of a woman who was found dead. Postmortem examination revealed a Bic ballpoint which had penetrated her head through her right eye. Detective forces believed a murder to be the most likely cause; however, medical expert consultants indicated that a tragic accident was more likely. The case and the results of crossbow test-firing on human cadavers are presented.     

Unusual basal skull fracture in a vehicle equipped with an air bag

A woman who was the lap/shoulder belt-restrained driver of a car equipped with a full-size air bag was involved in an oblique frontal collision with a tractor-trailer combination. She was extremely out of position, i.e., witnessed to be slumped over the steering wheel before impact. This preimpact positioning led to fatal injuries resulting from the inflating air bag. Postmortem examination showed an unusual partial ring fracture of the base of the skull, which to the authors' knowledge has not previously been reported.     

Hypothermia and undressing associated with non-fatal bromazepam intoxication.

A 42-year-old woman with a history of depression was found unconscious, lying near her car in an early autumn morning. The lower part of her body was undressed and there were multiple purple spots and excoriations on the body suggesting at first a sexual assault. On admission to the intensive care unit, she presented a hypothermia with a central temperature of 28.4 degrees C. The biological samples obtained at the hospital were analysed. Blood concentration of bromazepam was 7.7 mg/l, which is above the highest level reported till now in a case of fatal intoxication.     

Alteration of the Death Scene After Self‐stabbing: A Case of Sharp Force Suicide Disguised by the Victim as a Homicide?

This paper reports a case of a 72‐year‐old woman who was found dead in her bedroom with a 4 cm vertical stab wound in the abdomen. A bloodstained knife was found in the top drawer of her bedside table. The clothes worn by the victim showed no damage. A bloodstained vest and a sweater with frontal incisions were found far from the victim, in the bathroom and in the bedroom respectively. Several bloodstains were found in every room of the apartment. The evidence found during the forensic examination and, in particular, the Bloodstain Pattern Analysis, led the investigators to determine the manner of death, being consistent with a suicide with a long‐lasting physical activity after self‐stabbing. This report describes an unusual case of “disguised suicide,” in which the victim tried to cover‐up the suicide by changing her clothes and concealing the weapon, in the last minutes of her life.     

Homicide due to intravenous metallic mercury injection followed by sodium cyanide injection

We report a case of homicide due to intravenous mercury injection followed by meperidine and sodium cyanide injection. A 35-year-old woman was found dead in bed at home by her husband. Reportedly, she had been sick for more than 5 months. Initial death investigation revealed no evidence of foul play. Her death was believed to be natural. Therefore, her body was buried without an autopsy. Two months after death, her family requested an autopsy because they suspected her physician husband killed her. Her body was exhumed, and an autopsy was performed. Postmortem examination revealed numerous metallic mercury globules in the pulmonary arteries. Toxicological analysis revealed a high concentration of mercury in the tissue samples of the lungs, liver, heart, and kidney. In addition, cyanide and meperidine were also found in the heart and liver. The detailed case history and postmortem examination findings are described.     

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.     

Sudden death from hyponatremia and hypokalemia in a woman with Gardner syndrome.

The authors present the case of a 39-year-old woman with Gardner syndrome who died from marked hyponatremia and hypokalemia. Gardner syndrome is a rare variant of the familial adenomatous polyposis syndrome in which the affected individual develops thousands of polyps within the gastrointestinal tract, with a 100% risk of eventual malignant change. Individuals with Gardner syndrome also develop a variety of extra gastrointestinal abnormalities. In the case presented, a woman with a clinical history of Gardner syndrome who had previously undergone a total colectomy with ileorectal anastomosis presented to the hospital with a recent history of sore throat, fever, diarrhea, and abdominal pain. The symptoms were considered clinically to be due to a viral gastroenteritis. She was admitted to the hospital, where she had episodes of collapse believed to be vasovagal in origin. She suffered a cardiorespiratory arrest and died 24 hours after admission. After her death, electrolyte estimation performed on blood taken shortly before death revealed severe hyponatremia and hypokalemia. Postmortem examination showed the gastric mucosa to be virtually covered by innumerable adenomatous and hyperplastic polyps. Fewer polyps were seen within the small bowel. There was no evidence of malignancy. The features were consistent with Gardner syndrome. Hyponatremia and hypokalemia have been described in patients with villous adenomas and in familial adenomatous polyposis syndromes associated with numerous colonic polyps. The cause of death in this case was considered to be hyponatremia and hypokalemia associated with florid gastric polyps in a woman with Gardner syndrome. Viral gastroenteritis contributed to the death by causing further electrolyte depletion. To the best of the authors' knowledge, death in Gardner syndrome has not been described as attributable to such metabolic disturbance, in particular in those who have only gastric, small bowel, and rectal polyps remaining after total colectomy.     

A case of homicidal intoxication by chloropicrin

An 18-year-old girl and her boyfriend were sprayed with toxic chemicals from the left front door of their parked car. The girl died of intoxication about 4 h later. The main findings of postmortem examination were spotty discolorations on her skin and severe pulmonary edema. The unknown chemical was identified as chloropicrin by gas-liquid chromatography and gas chromatography-mass spectrometry of her lung and on samples from the car's console box, cassette tape case, and floor mat, all of which were wet with chemicals. The content of chloropicrin in her lung was calculated at 1.6 ng/g of wet weight.     

The "last vestiges of life"

On 4 June 2010, Deputy State Coroner Schapel of the Coroner's Court of South Australia ruled that he had jurisdiction to conduct an inquest into the death of Tate Spencer-Koch, who was declared deceased following complications during her home-birth. Coroner Schapel considered he had jurisdiction on the basis that Tate was a "person in the eyes of the law" under the born alive rule, as she had completely left her mother's body and she could be shown to have been alive after birth, evident from the PEA detected in her heart 10 minutes following her delivery. Close consideration of this ruling, however, reveals issues with the application of the born alive rule in the case.     

Death after anal "fisting"

A 45-year-old homeless woman was found dead at her usual sleeping place. Apart from traces of blood on the lower abdomen of the body, the police investigations did not produce any clues pointing to an unnatural death. At autopsy, it was found, however, that death had been caused by extensive disruptions of the intestine. After being confronted with the results, the sexual partner of the victim admitted manual anal penetration, but claimed that this had been done by mutual agreement. The court did not accept that statement and sentenced him to life imprisonment for murder. The frequency of such fatal outcomes of anal penetration, the relationship between the perpetrator and the victim and the special features at the scene are discussed.     

Three unusual neuropathologic-related causes of sudden death

We discuss the autopsy findings of three medico-legal cases of sudden death associated with uncommon neuropathologic findings of which the general forensic pathologist may not be familiar. Case 1 was a 43-year-old man who died of a seizure due to malignant melanoma of the temporal lobe associated with neurocutaneous melanosis (NCM). Case 2 was a 57-year-old woman with a history of mental retardation and incoordination because of chronic lead poisoning, who died of a pulmonary thromboembolism due to deep venous thrombosis status post left leg fracture after a fall down a staircase. Autopsy revealed atrophy and gliosis of her cerebellum as a result of childhood lead poisoning. The third patient was a 75-year-old woman who died as a result of acute bacterial leptomeningitis at the cervico-medullary junction with acute inflammation of the connective tissue of her upper cervical spinal column associated with subluxation of her atlantoaxial (AA) joint, also known as Grisel's syndrome.     

Unusual carbon monoxide poisoning

Despite of indicative death scenes or characteristic findings of the external examination, about 40% of the accidental fatal intoxications due to carbon monoxide are not recognized before the performance of the autopsy. Six cases are reported which illustrate possible reasons for the delayed establishment of the diagnosis: unusual circumstances of the intoxication or sources of carbon monoxide, only subtle degree or lack of external signs of the intoxication or a competing cause of death at autopsy.--Cases 1 and 2: 53, respectively 54-year-old couple, found dead in a caravan, extreme putrefaction of the bodies, spectrophotometric detection of the fatal carboxyhaemoglobin level in oedema fluid of the scalp.--Case 3: 23-year-old lorry driver, found dead in the tightly closed cab of his lorry, operation of a source of electricity with "environmentally friendly" fuel, carboxyhaemoglobin level 83%.--Case 4: 19-year-old man, found dead in the flat of friends, removal of the CO-source before alerting the police forces, lack of the bright pink coloration of livor mortis, haemopericardium due to atrial rupture at postmortem examination, carboxyhaemoglobin level 65%.--Case 5: 27-year-old man, found dead in his flat, advanced decomposition of the body, residues of a charcoal fire in a metal bucket in the sink, carboxyhaemoglobin level 80%.--Case 6: 42-year-old woman, lying dead in the garage beside her car, engine switched-off, ignition key next to the body on the floor under the car, carboxyhaemoglobin level 46%.     

Giant Diaphragmatic Lipoma: Two Autopsy Case Reports and Review of the Literature

Lipomas are common benign tumors most frequently found within the subcutaneous areas of the body. Deep-seated lipomas are rare and tend to be larger than cutaneous ones. Lipomas are rarely seen in the thoracic cavity, and they are usually located in the mediastinum, bronchiole, and lungs. Diaphragmatic lipomas have been occasionally reported in the literature, the first being described by Clark et al. in 1886. The authors report two rare cases of giant diaphragmatic lipoma incidentally found during forensic autopsies. In the first case, a Caucasian 85-year-old woman burned to death with another passenger, after her methane-fueled car collided with another car on a highway near Terni, Umbria, Italy. In the second case, a Caucasian 45-year-old man collapsed while walking through the countryside of Perugia. In either case, a large mass in the thorax was observed. The definitive pathologic diagnosis was giant intrathoracic diaphragmatic lipoma without evidence of malignancy. The authors also review the relevant literature and discuss differential diagnoses. These case reports contribute to the establishment of the actual incidence of diaphragmatic lipomas.     

Inferior Vena Cava Tumor Thrombosis Secondary to Metastatic Uterine Cancer: A Rare Cause of Sudden Unexpected Death

Pulmonary tumor thromboembolus (PTTE) secondary to uterine cancer is a rare cause of sudden unexpected deaths in the elderly population. Additionally, tumor extension to the inferior vena cava (IVC) makes it rarer. No such cases have been previously reported in the forensic literature. We report this phenomenon in a previously healthy 70‐year‐old woman with no other known risk factors for the development of deep vein thrombosis. The deceased was found dead while watching television with her relatives. Autopsy examination revealed that her death was attributed to a saddle embolus lodged in the main pulmonary arteries. A uterine tumor was discovered, and microscopic examination revealed low‐grade endometrial stromal sarcoma with angiolymphatic invasion. The tumor cells were also found in the embolus and the remnant thrombosis attached to the inner wall of the IVC. This case demonstrates a sudden unexpected death caused by acute PTTE following seeding of uterine cancer into the IVC and raises awareness of such events.     

A case of Churg-Strauss syndrome

A 54-year-old woman died after being battered, but the forensic autopsy revealed that her injuries were not serious or lethal. A detailed histological examination revealed that the basic disease had been Churg-Strauss syndrome. The differentiation of this syndrome of pulmonary infiltration and eosinophilia (PIE syndrome) from other allergic and noninfectious granulomatoses needs cautions consideration.