Attempted Serial Neonaticides: Case Report and a Brief Review of the Literature

Neonaticide is an infant murder occurring on the day of birth. The case reports found in the literature are often focused on the mother as the agent in the context of pregnancy denial, dissociative symptoms, or psychosis. However, this report describes a rare case of attempted serial neonaticides, in which the acts were committed by a nurse at the nursery of a referral hospital in Brazil. The authors describe a forensic psychiatric evaluation for criminal responsibility and correlate the information from this particular case with relevant forensic themes, namely neonaticide, Munchausen by proxy syndrome, and serial healthcare killers.     

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.     

The Role of Fantasy in a Serial Sexual Offender: A Brief Review of the Literature and a Case Report

Abstract: Extensive research has attempted to elucidate the role of fantasy in sexual offending. In this paper, the authors summarize the main results of the literature, especially the contents, themes, dynamics, etiopathogenesis, and potential functions of fantasy in sexual offending. Further, the authors analyze the case of a serial sexual offender who assaulted 39 women. The forensic‐psychiatric assessment revealed that his fantasies of forced sex, sexual coercion, and dominance, which were linked to narcissistic personality organization and functioning, were the primary drive mechanism in his crimes, because he imagined himself in the role of the aggressor, identified with the power associated with the role of perpetrator, and was sexually aroused by such images of omnipotent control of the victim. In conclusions, the authors suggest that fantasies of sexual aggression, coercion, and dominance of women may stimulate grandiosity and omnipotence and, in a minority of cases, may lead to sexual offending.     

The mourning process and “living with the dead”: Two case reports and a review of the literature

The discovery of mummified bodies in domestic settings is not unusual in the medico‐legal context. It is often a marker of social isolation, even in our urban modern society, and usually occurs among elderly people living alone or in precarious conditions. However, bereaved subjects can sometimes be found managing their grief by deliberately keeping the corpses of their loved ones at home. Investigation of these atypical cases can be challenging and often requires a multidisciplinary effort by different forensic specialists. We report two cases of people who lived for several months with the mummified remains of a relative. In both cases, the judge ordered a forensic psychiatry assessment of the survivors’ competency and the reasons for this peculiar behavior, which is regarded as abnormal in our society. Case 1 describes a shared psychosis, which developed out of a condition of extreme seclusion of the entire family. Case 2 shows that even a mild personality disorder on which a series of traumatic events operates can trigger psychotic decompensation, causing extreme denial of the reality of death. The analysis of these cases contributes to our knowledge of the scantly studied phenomenon of “Living with the Dead” and raises questions about the psychopathology behind it. It is useful to identify subjects who are more prone to developing this “deviant” behavior, in order to distinguish people with mental illness from those who merely want to profit from the death of a loved one.     

Suicide Case Due to Phosphoric Acid Ingestion: Case Report and Review of Literature

Ingesting caustic substances represents a common event which may result in serious injuries of the gastrointestinal system. Severity of injury depends on the type of ingested substance: Caustic burns are more frequently associated with acid ingestion and their severity depends on type, concentration, time of exposure, and amount of the ingested substance. We report a case of phosphoric acid ingestion leading to death in a patient with depressive disorder. While reports ingestion of other acids and organophosphates can be found in the literature, there are no reports detailing a death due to phosphoric acid ingestion. We hope that presenting the findings in this case can aid death investigators in future cases that may involve ingestion of such a substance. After autopsy pH, phosphate and calcium ions concentration in the blood were analyzed. The cause of death was due to systemic effects: metabolic acidosis, hypophosphatemia, hypocalcemia, and hyperkalemia.     

Complex Suicide by Self‐stabbing and Drowning: A Case Report and a Review of Literature

Sharp force injuries and drowning are methods exceptionally combined in complex suicides. We report a challenging case of complex suicide by self‐stabbing and drowning that illustrates the difficulty in discriminating between homicide and suicide in such circumstances of death. The corpse of a young man was found submerged in a river, stabbed nine times with two wounds that had penetrated the thorax and had caused lung injuries and a hemopneumothorax. The postmortem and histological examinations were consistent with a death caused by drowning, but the manner of death still remained undetermined. Police investigation finally concluded to a suicide, although no suicide note had been left and the victim had no underlying diagnosed mental disorder. The parameters that may help distinguish suicide from homicide at the autopsy should be interpreted in light of a thorough forensic investigation to determine the exact manner of death in such a case.     

Death Due to Decapitation in Two Motorcyclists: A Description of a Unique Case and a Brief Review of the Literature

Deaths due to decapitation, especially related to traffic accidents, are rarely found in forensic practice. The present case involves a man and a woman who died from decapitation due to an unusual mechanism while they were riding on a motorbike down a mountain road. The autopsy, which was completed as a physics study, allowed the accident to be reconstructed as follows: A plastic cable that had detached from a timber‐transporting machine whipped the road and hit the two motorcyclists. The impact resulted in the complete severing of both riders’ heads. Involving different scientists in this accident investigation was crucial to understanding the dynamics of the accident. In fact, in addition to scene inspection and autopsy, a physics study was carried out on the cable and the clamp involved, which led to an explanation for the abrupt movement of the cable and, thus, to a thorough reconstruction of the accident.     

Medicolegal Implications of Nosocomial Infections: A Case Report of Aspergillus Contamination during Cardiac Surgery

Nosocomial infections have become a major issue of public health and lead to an increasing number of suits for damages. We present a rare case of Aspergillus contamination during cardiac surgery, describe the medicolegal investigation, and present the new system for compensation of bodily injury after nosocomial infection in France, based on the law of March 4, 2002 on patient rights and quality in the health system. This case demonstrates the limits of compensation for nosocomial infections on the grounds of national solidarity. The expert report requested by the regional commission for conciliation and compensation is of fundamental importance in enabling the commission to decide between fault and inherent risk of treatment.     

Unpredictable Behavior Under the Influence of “Magic Mushrooms”: A Case Report and Review of the Literature

Fatalities implicating psychedelic mushrooms are not a common clinical situation in everyday forensic medicine. Despite classification as an illegal drug in many countries, psilocybin mushrooms have the reputation of being safe. We report the case of a young man who jumped from a second story balcony under the influence of psilocybin mushrooms. The psilocin assay was performed by gas chromatography coupled to an electron‐impact ionization time‐of‐flight detector (GC‐EI‐TOF) after solid‐phase extraction. Total psilocin was quantified in peripheral and cardiac blood as 60 and 67 ng/mL, respectively, and in urine (2230 ng/mL), bile (3102 ng/mL), and vitreous humor (57 ng/mL). This case report and review of literature highlights the danger of psilocybin mushrooms. Isolated use of psilocybin mushrooms by a regular consumer without psychiatric history, even under “safe” circumstances, can lead to a fatal outcome.     

Suicidal Decapitation by Guillotine: Case Report and Review of the Literature

Abstract: Suicidal decapitation is seldom encountered in forensic medicine practice. This study reports the analysis of a suicide committed by a 31‐year‐old man with a self‐fabricated guillotine. The construction of the guillotine was very interesting and sophisticated. The guillotine‐like blade with additional weight was placed in a large metal frame. The movement of the blade was controlled by the frame rails. The steel blade was triggered by a tensioned rubber band after releasing the safety catch. The cause of death was immediate exsanguination after complete severance of the neck. The suicide motive was most likely emotional distress after the death of his father. In medico‐legal literature, there has been only one similar case of suicidal complete decapitation by a guillotine described.     

Acute Psychosis Induced by Bath Salts: A Case Report with Clinical and Forensic Implications

Bath salts are new designer drugs with stimulant effects on the central nervous system. White or brown powder sold online and in mini‐marts under different brand names, bath salts can be used by injecting, snorting, smoking, or ingesting with food or drink. The case of a 30‐year‐old Caucasian male who developed acute psychosis within a few hours of injecting himself with bath salts is described. The patient was hospitalized with a complaint of hearing voices. The drug also induced in the patient a state of euphoria, increased energy level, along with decreased need for sleep and decreased appetite. The psychological effects of the bath salts subsided within a few hours of injection and his reality testing remained consistently intact over the next 3 days of hospitalization. This case brings to attention the fact that bath salts were legal throughout the United States until recently and is still not completely controlled. This report informs clinicians of harmful effects of bath salts, including severe agitation with possible rhabdomyolysis, psychosis, suicidal ideation, hypertension, tachycardia, and death.     

Fatal Cleistanthus collinus Toxicity: A Case Report and Review of Literature

Cleistanthus collinus is an extremely toxic plant poison. We report a case of suicidal ingestion of boiled water decoction of C. collinus where the patient presented with abdominal pain and giddiness. There was persistent metabolic acidosis and fluctuation in the level of serum potassium. The ECG changes indicated a probable myocardial injury with conduction abnormality. At autopsy, the viscera were found to be congested. The toxins were detected in the viscera and blood by TLC and HPLC. Cleistanthin A and B, collinusin, and diphyllin are the principal toxic constituents of the plant. Consumption of a boiled decoction of leaves is highly toxic and, medical management of patients is mainly supportive because the molecular mechanisms of toxin action are unknown. In the recent years, C. collinus has created a considerable amount of interest because of its complex metabolites and their cytotoxic activities. Through this study, the authors have tried to highlight different properties pertaining to C. collinus.     

Repeat Coronary Artery Dissection in Pregnancy: A Case Report and Review of the Literature

Non‐atherosclerotic spontaneous coronary artery dissection (NA‐SCAD) is a rare cause of morbidity and mortality with a propensity for young, healthy, and often peripartum women. NA‐SCAD etiology is poorly understood, with possible hormonal and hereditary mechanisms. Current treatment strategies range from conservative management (often showing resolution on angiographic follow‐up) to invasive angiographic procedures. Rarely, NA‐SCAD has recurred in another coronary artery, ranging hours to years later. We report NA‐SCAD of the right coronary artery (RCA) in a 30‐year old, 3‐month postpartum female with an additional autopsy finding of remote myocardial infarction (MI) in the left anterior descending (LAD) coronary artery territory. The remote MI is consistent with prior NA‐SCAD of the LAD and, given the medical history, may have occurred in the peripartum period of the decedent first pregnancy 3 years earlier. As such, to the best of our knowledge, this may represent the first reported case of NA‐SCAD recurrence in a subsequent pregnancy.     

Ricochet of a Bullet in the Spinal Canal: A Case Report and Review of the Literature on Bullet Migration

Abstract: Ricochet of a bullet in the spinal canal is well known by neurosurgeons but relatively not a common event in usual medico‐legal autopsy practice. This article presents a homicide case of a penetrating gunshot injury of the lumbar spine through the T12‐L1 intervertebral foramen with active movement of the projectile within the spinal canal to the L5‐S1 level. This case illustrates a bullet intradural and intramedullary active movement because of a ricochet of the body of T12 with active redirection of the path. In the current literature, different types of migration in caudal or cranial direction, intradural, or intramedullary are reported. If spontaneous migration of T10 to S1 seems to be more frequent, some authors reported a C1 to S2 migration. Such migration could be asymptomatic or induce neurological impairment. The medico‐legal consequences of these migrations within the spinal canal are described.     

Coincidence of Nicolau Syndrome and Rhabdomyolysis: Report of a Forensic Autopsy Case and Review of the Literature

Nicolau syndrome (NS) is a dermatological adverse reaction of intramuscular injections and is caused by several mechanisms. The etiopathogenesis remains unclear, and several hypotheses have suggested a vascular origin. Rhabdomyolysis (RM) is the destruction of striated muscle, with the subsequent release of muscle cell contents into circulation. NS and RM diagnoses may overlap. Herein, we present the autopsy findings of a 40‐year‐old female with NS complicated with RM. On clinical follow‐up, creatine kinase (CK) was 7146 IU/L, and urea and creatinine levels were elevated on the third day after intramuscular diclofenac injection. Possible ischemic process triggered the RM and subsequent acute renal failure. The opportunity for an early diagnosis was missed because the patient delayed seeking medical aid. The prognosis worsened, and the patient died due to secondary sepsis. Early diagnosis of NS before the occurrence of complications is the most important issue in patient education and can be life‐saving.     

Combined Statistical Analyses of Forensic Evidence in Sexual Assault: A Case Report and Brief Review of the Literature

DNA analysis has been widely used in the forensic field in order to contribute to identifying the perpetrator of a crime. Forensic investigation in sexual assaults usually focuses on locating and identifying biological fluids, followed by DNA analysis. The identification of certain compounds present in condoms can be useful to reconstruct the occurred event, especially in cases of sexual assaults where the DNA analysis did not show the presence of a male profile and where RNA analysis did not show the presence of sperm markers. Herein we describe the case of a woman reporting to be victim of sexual assault, who was not able to provide accurate information concerning the dynamics of the event; she remembered only forced penile–vaginal penetration by a single perpetrator. We performed short tandem repeat (STR) analyses and mRNA typing for forensic genetics testing on vaginal and rectal swabs collected on the victim, and Fourier-transform infrared spectroscopy (FTIR) followed by chromatographic analyses for the detection of condom compounds on the same swabs. The STR analysis showed only the victim’s genetic profile, and RNA analysis showed only the presence of vaginal and skin markers. In this situation, the identification of condom compounds residues on vaginal swabs became important as it complemented other collected evidences allowing the Court to reconstruct the events. A proposal of likelihood ratio (LR) calculation for the assessment of the weight of evidence in this case is described.     

Methylenedioxypyrovalerone (“Bath Salts”),Related Death: Case Report and Review of the Literature,

Cathinone derivatives (bath salts) have emerged as the latest drugs of abuse. 3,4‐methylenedioxypyrovalerone (MDPV) is the primary active ingredient in bath salts used in this country. This article presents the second reported cause of death by MDPV intoxication alone. In April 2011, a delusional man was emergently brought to a hospital, where he self‐reported bath salt usage. He became agitated, developed ventricular tachycardia, hyperthermia, and died. Comprehensive alcohol and drug testing was performed. Using the alkaline drug screen, heart blood contained 0.7 mg/L MDPV and peripheral blood contained 1.0 mg/L MDPV. His bizarre behavior with life‐threatening hyperthermia was consistent with an MDPV‐induced excited delirium state. MDPV is not yet found by routine immunoassay toxicology screens. Testing for MDPV should be considered in cases with a history of polysubstance abuse with stimulant type drugs, report of acute onset of psychogenic symptoms, excited delirium syndrome, or presentation in a hyperthermic state.     

Fatal Fat Embolism After Penis Enlargement by Autologous Fat Transfer: A Case Report and Review of the Literature

Fat embolism is an incidental finding in cases of long bone fractures or other trauma, but it is also associated with liposuction and autologous fat transfer, a procedure where fat from liposuction is injected back into the same patient's face, breast, buttocks or penis. We here present a case of sudden death by fat embolism in a healthy young male, caused by a simple penis enlargement procedure, in which fat was injected into the penis shaft. We suggest that the risk of fat embolization might be higher when pretraumatized tissue is subjected to fat injection, like in this case, where a penis elongation was performed before the fat injection.     

Missed Opportunities for Diagnosis of Post‐traumatic Thrombosis: A Case Series and Literature Review

Thrombosis is caused by abnormalities in the composition of the blood, the quality of the vessel wall, and the nature of the blood flow. Herein, we present four cases of fatal thrombus formation after a trauma, which were missed at clinical diagnosis as the symptoms were misinterpreted. We stress that a blunt trauma can be fatal because of its direct and indirect kinetic energy effects at the subacute phase. This report highlights the importance of considering thrombosis in the diagnosis of closed trauma, which is usually missed because of lack of awareness for early diagnosis and treatment or is detected too late for any therapeutic intervention, which can result in avoidable morbidity and mortality.     

Acute Bacterial Meningitis with Coincident Methamphetamine Use: A Case Report and Review of the Literature

Methamphetamine is a synthetic stimulant that can adversely affect the central nervous system and the immune system. Through various mechanisms, methamphetamine is toxic to neurons, endothelial cells, lymphocytes, granulocytes, and macrophages resulting in systemic damage. Reported is the sudden demise of an otherwise healthy 31‐year‐old woman with a history of stimulant abuse. At autopsy, acute bacterial meningitis was identified. Microbiology cultures grew a single isolate of Streptococcus pneumoniae. Toxicology was positive for amphetamine (0.13 mg/L) and methamphetamine (0.8 mg/L). The cause of death was classified as acute bacterial meningitis with methamphetamine use. Either the acute bacterial meningitis or the methamphetamine toxicity would have been sufficient to result in death; however, the concurrent pathophysiology of the two entities must be understood. A review of the current literature assesses the mechanisms of injury attributed to acute and chronic methamphetamine use, bacterial meningitis, and the synergy between the two.