Fatal hemorrhage from an undiagnosed rectal carcinoma in a case of Diogenes syndrome

Abstract

Case report A 61-year-old male was found dead at his home address after a strong putrefactive odor was noted. The decedent was lying on a couch, with his underpants pulled down to his knees, and a blood stained towel located beneath his buttocks. A large amount of blood had dried over his exposed groin region and thighs. Inspection of the house revealed blood-stained towels, underwear, and newspaper pages strewn on the floor in various rooms, with trails of blood droplets on the floor in the hallways and in various rooms. Several chairs had blood stained impressions where he had been sitting (Fig. 1). The toilet bowl and seat were also covered in blood. The house was noted to be quite untidy with rotting food and empty drink and take-away food containers throughout. The decedent was described as a ‘‘very private person’’ who had been unwell in recent times with loss of weight. There was a family history of bowel cancer, however, the decedent had no significant medical history. On external examination the decedent appeared older than his stated age, cachectic with moderate scleral jaundice. Changes of early decomposition were noted. The most striking external feature was the presence of copious amounts of fresh blood draining from the anus covering his buttocks and inner thighs (Fig. 2). On internal examination, the most significant finding was a blood filled rectum associated with a large (60 9 80 mm) ulcerated carcinoma at the recto-anal verge which had infiltrated through the full thickness of the rectum (Fig. 3). Metastatic deposits were noted in the liver (Fig. 4) which weighed 5,551 g, lung, lymph nodes, and left sixth rib. These were confirmed histologically to be metastatic deposits of moderately well differentiated adenocarcinoma. Death was attributed to hemorrhage from a rectal adenocarcinoma exacerbated by end stage metastatic liver disease.