Combined suicide by drinking acetic acid with subsequent hanging

Three late emigrants of German origin from Russia (1 man, 2 women) drank 70- and 86% acetic acid respectively before hanging themselves. In one of the suicides the hanging noose was running across the face. None of the cases presented showed any perioral chemical burns. At autopsy an intense odor of acetic acid was noticeable. The mucosa of the upper digestive tract showed a whitish, grey, brown or black discoloration and was partially detached. In two cases intravascular clotting of blood was discernible in the area affected by the acid; in one case the vessels were imbibed with haemoglobin due to haemolysis. Highly concentrated acetic acid is generally available in the successor states of the former USSR and its use in suicides is thus not uncommon. The legal regulations applying in Germany to the sale of acetic acid and the toxicological data are briefly described.     

Death due to hydrofluoric acid

A case of death caused by an acid attack is presented. The victim, a young woman, was attacked by a person who threw acid onto her face. She reached the casualty department of a hospital where she died, a few hours later, from acute respiratory insufficiency due to the inhalation of acid vapors. The autopsy revealed severe chemical burns of her skin and lungs, with intense pulmonary hemorrhagic edema caused by the acid and its vapor. The subsequent chemical-toxicological analysis and the police investigation confirmed that death was due to hydrofluoric acid.     

Fatal Phenol Toxicity Following Attempted Tattoo Removal

Tattoo removal is increasingly required as the number of, particularly young, people acquiring tattoos is increasing. A 21‐year‐old man is reported who underwent attempted removal of large dragon tattoo utilizing a tattoo machine that injected a phenol‐containing solution. At the end of the 3‐h procedure, he collapsed and died. At autopsy, large areas of white skin discoloration with focal necrosis and sloughing were present overlying areas of previous tattooing. Histological examination showed collections of eosinophilic fluid with a minimal chronic inflammatory infiltrate in better preserved areas, with focal areas of dermal necrosis. Toxicology was positive for phenol in cardiac blood and liver tissue. There were no underlying organic disease or injuries present which could have caused or contributed to death. This idiosyncratic method of tattoo removal involving subcutaneous injection of phenol had resulted in death most likely from cardiotoxicity.     

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.     

Fatal Methemoglobinemia Due to Acute Inhalation of Methyl Nitrite in an Industrial Accident

Methyl nitrite is suggested to cause methemoglobinemia by generating methemoglobin, which may be lethal when the methemoglobin concentration exceeds 70%. However, intoxication with methyl nitrite is seldom reported compared with that with other nitrites. Here, we present an industrial accident involving methyl nitrite inhalation during its synthesis process that resulted in three fatalities and one survivor. The autopsy revealed conspicuous blue-gray discoloration in various parts of the body, including the skin, airway mucosa, vessels, brain, heart, and among other areas. The toxicological tests on the deceased showed methemoglobin concentrations in the blood over the lethal level and increased nitrite ion levels in the blood, gastric contents, liver, and lung tissue compared with those in control samples. The cause of death was determined to be methemoglobinemia-induced hypoxia due to methyl nitrite inhalation. This report provides evidence that in methyl nitrite intoxication, exposure duration has a significant influence on the postmortem changes and likelihood of a fatal outcome may be related to the age of the victim. More attention is required regarding the industrial hazards of this substance.     

Unusual intravascular hemolysis in a case of fatal hypothermia.

A 55-year-old man was discovered dead inside a deep freezer maintained at -40 degrees C. After consuming a large quantity of alcohol, the man had become trapped in the freezer approximately 11 h before his body was found. The body was still frozen at the time of autopsy, but subcutaneous dendriform vessel repletion phenomenon was observed on the upper and lower extremities. Although this intravascular hemolysis resembled that which develops during putrefaction, in this case it was thought to be due to pooling and freezing of blood in subcutaneous vessels. Contributory factors included alcohol ingestion, vasodilation following vasoconstriction, vasomotor paralysis, and red cell sludging. Hemolysis followed freezing of the blood. When such phenomena are observed in a corpse, exposure to extreme cold should be suspected.     

A case of a fatal Himalayan black bear attack in the zoo

We present a case of a 22-year-old male, who was found inside the cage of Himalayan black bears in the Belgrade Zoo. The victim attended the Belgrade Beer festival the previous night, drinking a lot of beer and acting aggressively. A medico-legal autopsy was performed at the Institute of Forensic Medicine in Belgrade. Autopsy findings showed numerous excoriations all over the body surrounded by bruises, as well as spindle-shaped, oval, and partly irregular wounds of variable size, large defects of skin and subcutaneous soft tissue, fractures of the thyroid and cricoid cartilage, and fracture of ribs. Postmortem toxicological analysis revealed the presence of ethanol in vitreous humor and urine and 11-nor Δ9 tetrahydrocannabinolic acid found in the urine. We discussed similar cases from the available literature in different regions of the world. In conclusion, we pointed out that the presented case does not follow the general pattern of Himalayan bear attacks.     

Differential diagnosis: blue gastric mucosa. Post-mortem staining of the gastric mucosa with methylene blue

An intense discoloration of the gastric mucosa or the gastrointestinal tract found at autopsy gives rise to the question of its cause. Such discolorations are mostly described in the context of intoxications. However, traditional foods and diagnostic procedures using indicator dyes can also lead to an unusual discoloration of the mucous membranes. The authors report on the autopsy findings in a man who died from a bleeding gastric ulcer and whose gastric mucosa showed intense blue discoloration. Experimental postmortem examinations (on stomachs) were performed with methylene blue, a dye used in gastroenterology, resulting in a blue discoloration resembling the appearance of the stomach in the autopsy case. Together with the outcome of the toxicological analyses, the experiments pointed to a diagnostic procedure using methylene blue (chromoendoscopy).     

Ochronosis Presenting as Methemoglobinemia

Ochronosis is the blue‐gray discoloration of collagen‐containing tissues due to homogentisic acid (HGA) deposition, secondary to endogenous alkaptonuria or exogenous enzyme inhibition. In renal disease, accumulation of HGA in serum can cause methemoglobinemia. A 60‐year‐old woman with renal disease and anemia presented with 3 days of weakness and months of gray skin discoloration. Her hemoglobin was 8.1g/dl with 24.5% methemoglobin. Despite treatment with methylene blue, exchange transfusion, and continuous renal replacement therapy, the patient died. Autopsy revealed gray discoloration and ochronotic pigment in the ribs and cartilage. Based on these findings, the patient was diagnosed with ochronosis, suggestive of alkaptonuria, complicated by methemoglobinemia. The differential diagnosis for blue‐gray skin discoloration includes argyria, methemoglobinemia, and ochronosis. This patient's clinical and autopsy findings suggested alkaptonuria complicated by methemoglobinemia due to progressive renal dysfunction. Development of methemoglobinemia in the setting of chronic skin discoloration and renal failure should prompt consideration of alkaptonuria.     

Hydrofluoric acid poisoning

A case of suicidal ingestion of hydrofluoric acid is presented. Death of the victim while in police custody was one of the more unique aspects of the case. This is the sixth case of poisoning of this type reported in Dade County. Clinical, pathological, and toxicological aspects of fluoride poisoning are discussed.     

Dissecting Thoracic Aortic Hematoma Masquerading as Blunt Force Injury of the Neck

Discoloration of the skin of the anterior and lateral neck may raise suspicion for blunt force injury, particularly cervical compression, in an unwitnessed death. We present a case of an elderly woman with an unwitnessed death at home which highlights an external examination finding of blue/purple discoloration of the skin of the neck and links this finding with those from internal examination at autopsy. Pertinent negatives include absence of conjunctival and mucosal petechiae, absence of cutaneous abrasions of the neck, and absence of contusions of the anterior neck musculature. This case illustrates a natural disease entity, spontaneous dissection of a thoracic aortic hematoma, masquerading as blunt force injury externally and highlights the importance of having an appropriate index of suspicion when triaging jurisdictional cases for postmortem examination to accurately determine cause and manner of death.     

Nontraumatic clostridial myonecrosis.

We describe three cases of nontraumatic clostridial myonecrosis seen at the Victorian Institute of Forensic Medicine. Nontraumatic clostridial myonecrosis is an uncommon and often fatal condition that requires immediate institution of appropriate medical and surgical therapy. It is most commonly caused by Clostridium perfringens and Clostridium septicum and is associated with gastrointestinal and hematologic malignancies, diabetes mellitus, and peripheral vascular disease. The clinical features include a rapidly evolving acute illness with severe pain, marked tachycardia, and brawny discoloration of the skin with bullae formation and crepitus, followed by hypotension and acute renal failure. Features at autopsy include reddish brown skin discoloration with bullae formation and necrotic skeletal muscle. Radiographs may be of use prior to the postmortem in detecting gas within the soft tissues. Gram stain and microbiologic culture are important in establishing a definitive diagnosis; although the major factors in suggesting the diagnosis are the recognition of the typical clinical history and macroscopic autopsy findings.     

Death by lightning

Deaths from lightning injuries are infrequent, amounting to 0.2-0.8 per million people per year, and are associated with climatologic conditions. The victims are mostly young, active people who are struck during various outdoor activities during the summer months. Even though many people can be struck by the same bolt of lightning, multiple casualties are uncommon. Among the fatalities, various types of skin burns are regularly present, often at an entry site on or near the head, and at an inferiorly located exit site. These skin injuries often consist of superficial burns and singed hair; deep burns and charring are uncommon. Arborescent skin marks seem to occur less frequently. Internal findings at autopsy are nonspecific.     

Deaths related to chemical burns

The authors present a series of 6 deaths due to the uncommon cause of chemical burns. Of the 6 deaths due to chemical burns, 4 deaths were due to ingestion of a chemical, 1 death was caused by chemical burns of the skin, and 1 death resulted from rectal insufflation of a chemical. Seven additional cases where chemical burns may have been a contributing factor to the death or an incidental finding are also presented. Four cases are related to an incident involving chemical exposure during an industrial explosion. Three cases involve motor fuel burns of the skin. Two cases concern a plane crash incident, and 1 case involved a vehicular collision. Cases are derived from the records of the Dallas County Medical Examiner's Office and those of the authors' consultation practices. Each of the cases is presented, followed by a discussion of the various mechanisms of chemical injury.     

Unusual and Fatal Case of an Undiagnosed Intravascular Large B-cell Lymphoma: The Oncologist’s Great Imitator†

Intravascular lymphoma (IVL) is a rare subtype of extranodal lymphomas that is characterized by the selective growth of neoplastic cells within the lumen of small vessels. Authors document the case of an unexpected death caused by an undiagnosed intravascular large B-cell lymphoma with multi-organ involvement, which had initially manifested as an infection and then as an unclarified central nervous system pathology. Histological examination showed a diffuse intravascular large B-cell brain lymphoma with prominent cerebral involvement. The relevance of the case report reveals the importance of an autopsy of an extremely rare and threatening pathology that in most cases is diagnosed only postmortem. As a result, the role of the forensic pathologist becomes particularly important. When specifically performing an in-depth autopsy evaluation with a specific histologic analysis, it is possible to identify the intravascular lymphoma and declare a more accurate cause of death.     

Hemolytic staining of the intima of the aortic root in freshwater drowning: a retrospective study

A retrospective study was conducted of files at the Institute of Legal Medicine in Hamburg, Germany from 1998 to 2003 of all cases of drowning where there was no putrefaction, to document the rate of recording of hemolytic staining of the intima of the great vessels. All cases had full police investigations with reviews of previous histories, circumstantial evidence, and autopsy findings. A series of control subjects who had died of various natural and nonnatural, nondrowning deaths, matched for age, sex, and postmortem interval, was also reviewed. One hundred twenty cases of freshwater drowning were identified. Drowning occurred in a garden pool in 1 case, in a bath in 2, and in the river Elbe in 117. The age range was from 2 to 91 years (mean = 55 years; M:F = 1:1.8). Hemolytic intimal staining of the aortic root was documented in 6 cases (6 of 120; 5%). This consisted of reddened discoloration of the proximal portion of the aortic root, without any significant staining of the proximal pulmonary artery. No significant hemolytic staining of the intima of the great vessels was recorded in any of the 120 control cases. Although under-reporting of findings may occur in retrospective analyses, this study has shown that at least 5% of freshwater drowning cases showed differential staining of the pulmonary trunk and aorta, with hemolytic discoloration of the aortic intima. When present, hemolytic staining of the aortic root intima may be a useful and possibly under-recognized corroborative sign of freshwater drowning.     

Fatal hemorrhage from a periumbilical wound: Stabbing or hemorrhage from a caput medusae?

Varices are the main clinical manifestation of portal hypertension, and their bleeding is the predominant cause of mortality from this condition. Periumbilical varices are known as “caput medusae.” Reports of their bleeding are rare, with only three fatal cases described in the literature. The antemortem diagnosis is relatively simple, while the postmortem diagnosis is more complex. This paper is the first report of fatal hemorrhage from a caput medusae for which the diagnosis was made postmortem, thanks to a complete diagnostic process including scene and circumstances, medical history, and autopsy with detailed histology. The circumstantial analysis showed the presence of a large amount of blood at the scene, blood which originated from a small abdominal wound; an analysis of the subject's clinical data reported that he was affected by portal hypertension. The autopsy revealed some dilated and convoluted veins in the subcutaneous tissue of the umbilical region; a fistula between these veins and the abdominal wound was detected. The histological study confirmed the presence of periumbilical varices, one of them ruptured and connected with the overlying skin. The cause of death was attributed to a massive hemorrhage generated by a periumbilical varix in a patient affected by portal hypertension.     

On an accident by liquid nitrogen — histological changes of skin in cold

Two young researchers were found lying beside 3 Dewar flasks for liquid nitrogen in a cold experimental room of a university. They were sent to a hospital but died 1.5 h after cardiopulmonary resuscitation. One of the cadavers had dark red discoloration of the skin on the left arm at autopsy. By the histological investigation of the discolored region karyopyknosis and vacuolation of the keratinocytes were noticeably observed in the epidermis. In addition, hyperemia and edematous changes were seen. Hemoglobin (Hb) was not immunodetected in the skin tissue except intravascular erythrocytes. Therefore, these histological findings of the discolored skin can indicate that the skin damage was produced by cold due to liquid nitrogen before death. The cause of death was asphyxia due to oxygen deficiency. There were few autopsy findings which showed the participation of liquid nitrogen in the accident. But, the histological findings of the discolored region demonstrate that liquid nitrogen was involved in this accident.     

Postmortem decomposition of neutral lipids. Use of modern methods of analysis (HPLC, capillary GC, GC-MS and NMR) in adipocere formation

The chemical composition of subcutaneous fats was analyzed in a corpse that had died from drowning. The skin of the cadaver examined postmortem showed different stages of adipocere. Samples from these regions were chemically compared with the fatty tissue of a person who had died recently. HPLC, GC, GC-MS, NMR (1H- and 13C-NMR), TLC and titrimetrical methods were used to evaluate the degree of decomposition. The fatty acid pattern of the triglycerides (TG) and the free fatty acids (FFA) obtained by TLC separation was also investigated. Some discrepancy was observed between the autopsy findings and the results of the chemical analysis. It is suggested that the autopsy should be supplemented by chemical analysis in order to describe the state of adipocere correctly.     

Caustic Ingestion—A Forensic Overview

The ingestion of corrosive substances may produce severe burns to the upper aerodigestive tract and stomach, particularly if the pH is greater than 12 or less than two. There is a biphasic age grouping with adult cases most often involving self‐harm and pediatric cases accidental ingestion. Three cases are reported to demonstrate characteristic features following the ingestion of potassium hydroxide, glacial acetic acid and Lysol^®, respectively. All deaths were due to the effects of caustic burns to the upper aerodigestive tract, esophagus and stomach with perforation and/or hemorrhage. The extent of injuries in these cases depends on the nature, amount, and concentration of the agent and on the exposure time. A point to note at autopsy is that tissue damage may also occur from postmortem exposure. Typical injuries involve perioral, limb, and trunk burns, with extensive aerodigestive liquefactive/coagulative necrosis causing hemorrhage and perforation.