Forensic Case Report Research Articles

Could the screening for correct oral health reduce the impact of death due to bolus asphyxia in adult patients? A forensic case report

Introduction“Bolus death” or “Café Coronary syndrome” refers to death due to asphyxia caused by an occlusion of the upper airways due to food. In this kind of asphyxia, the food bolus obstructs the larynx or the bronchial branches. This kind of event often affects subjects with acute intoxication due to alcohol or drugs, or with edentulism and with neurological or psychiatric diseases. Case reportAn elderly woman, suffering from schizophrenia, was found dead in her house due to food bolus asphyxia. The post-mortem toxicological analysis on the deceased’s biological fluids revealed the presence of tricyclic antidepressants, antipsychotics and neuroleptics. Study of the oral cavity showed the presence of partial edentulism and periodontal disease. HypothesisWe hypothesize that this kind of asphyxia in adults can be prevented. We believe that there are two major preventable factors: edentulism and salivation disorders in elderly and neuropsychiatric patients. The primary prevention of these pathologies would deal with the basic physician, similarly to other screenings already effectively in place. ConclusionsIt is possible to prevent fatal asphyxia in subjects who suffer from this kind of diseases through appropriate screening. This prevention strategy would greatly reduce the amount of choking deaths in adults.

Evaluation of attempted older adults suicides admitted to a University Hospital Emergency Department: Izmir study.

Advanced age is one of the risk factors for attempting suicide. Suicide attempts are one of the reasons for elderly patients to admit emergency services. The aim of this study was to investigate the relationship between suicidal behavior and sociodemographic factors and concurrent somatic diseases. The medical records of patients aged 60 years and over who presented to the emergency department of our university hospital for attempted suicide between the dates of January 1, 2007 and December 31, 2015 were screened retrospectively. Individuals recorded as cases of suicide on the forensic case report form were identified, the data recorded at our hospital were obtained, and telephone interviews were conducted to acquire any missing data. A total of 63 patients with a mean age of 65.88 years were included in the study. A large proportion of the suicide attempts occurred in the years 2014 and 2015. Overall, 23.8% of the patients had a previous history of suicide attempt. Overdose was the method in 74.6% of the suicide attempts, and 70.2% were impulsive; 63.5% of the patients had a history of psychiatric disease. The most common psychopathology was major depressive disorder. We found that suicide attempts were more common among older adults with a history of depression, that approximately one in four had previously attempted suicide, and that the majority of individuals attempting suicide chose to use their own medication.

Panoramic radiograph as a clue for human identification: A forensic case report

Forensic odontology works in the interface between dentistry and law. Human identification is an important procedure performed by Forensic Dentists. The present study reports a case of dental human identification of a highly decomposed human body identified through the comparison of antemortem (AM) and postmortem (PM) panoramic radiographs. The AM radiograph was performed for planning dental implants, while the PM radiograph reproduced the same AM technique to enable a reliable comparative procedure. Radiographic dental similarities observed AM and PM led to a positive human identification. The importance of forensic odontology for legal purposes is highlighted and illustrated in the current study.

Water monitors; implications in forensic death investigations

Introduction: Outdoor postmortem animal scavenging is frequent and the predators responsible vary from ants, foxes, bluebottles to monitor lizards. Postmortem scavenging by water monitors is not uncommon. The water monitor (Varanus salvator) is a large lizard native to South East Asia. The sub species V.s salvator, is limited to Sri Lanka and are efficient carnivores and scavengers. Therefore, there is significant impact on forensic death investigations Case report: Case 1: A woman went missing. A vigorous search lead to the recovery of the body in a river, surrounded by water monitors. Injuries on the limbs simulated cut injuries. The skull had a depressed slashed cut exposing brain matter. Case 2: The dead body was located by searching along a path formed by water monitors. The neck injuries simulated cut throat. These two cases are discussed to highlight the medico-legal implications of water monitors in forensic death investigations. Conclusion: The presence of water monitors can be helpful in locating a missing body. However, it is necessary to interpret postmortem features cautiously in such cases as injuries caused by water monitors may result in artifacts, make injury interpretation difficult, make identification difficult, pose challenges to ascertaining the cause of death, and move objects from the scene.

Evaluation of forensic medical history taking from the child in cases of child physical and sexual abuse and neglect

BackgroundSuspected child physical abuse, sexual abuse and neglect are not uncommon presentations. As part of the assessment of these cases, a forensic medical history may be taken. This forensic history is used not only to determine the steps necessary to address the child's wellbeing but also to direct the forensic examination. Currently, there is no clear consensus on whether or not a forensic medical history should consistently be considered an integral element within the paediatric forensic evaluation. This study examines the value derived by the medical practitioner taking a forensic medical history rather than relying on hearsay evidence when a child presents for an assessment. MethodsA retrospective review of paediatric cases seen by the Victorian Forensic Paediatric Medical Service (VFPMS) between 2014 and 2015 was undertaken. 274 forensic case reports were reviewed and the data was entered into an Excel spread sheet and analysed using chi squared tests within STATA®. ResultsWith increasing age of the child, a forensic medical history is significantly more likely to be taken. Additional information is made available to the medical practitioner what would otherwise have been provided if the medical practitioner relied only on the interview conducted by the police. Discrepancies observed between the official third parties (police or child protection) report of what a child has said and what the child says to the medical practitioner decrease with age, as do discrepancies observed between the child's version of events and a third party's (eg. parents, caregivers, friends) version of events. ConclusionsThe study showed that by taking a forensic medical history from the child additional information can be obtained. Further, that there is a value in the examining medical practitioner taking a forensic medical history from children in cases of child physical and sexual abuse and neglect.

Sudden death due to asymptomatic myocarditis – a forensic case report

Sudden death due to asymptomatic myocarditis – a forensic case report

Postmortem Analysis of Injuries by Roadkill of a White-eared Opossum (Didelphis Albiventis) by Radiographs and Forensic Necropsy-A Virtopsy Case Report

The white-eared opossum (Didelphis albiventris) is one of the most road-killed animals in Brazil, especially due to its opportunistic habits and great adaptation to urban environment. Although radiology is present in the veterinary daily routine, it is uncommon in forensic necropsies, especially in wild animals. A white-eared opossum killed by a vehicle in a road of the State of Sao Paulo, Brazil was submitted to entire-body radiographs followed by forensic necropsy. The images revealed diffuse increased radio-opacity in both hemi-thoraces possibly of hemorrhagic origin, whereas the forensic necropsy findings were consistent with bloody pleural effusion. It was possible to conclude that postmortem radiographs in wild animals could contribute to determine the cause of death and improve forensic investigations.

Case reports in forensic toxicology

Case reports in forensic toxicology

Sudden, unexpected death from severe chronic obstructive pulmonary disease with giant bullae. A forensic case report

Abstract A 41-years old man died suddenly and unexpected after one day with influenza-like symptoms. A forensic autopsy, including post mortem computed tomography, showed severe chronic obstructive pulmonary disease, pneumothorax and air- and fluid-filled giant pulmonary bullae ranging up to 12 cm in diameter.

Detection of diabetic metabolism disorders post‐mortem – forensic case reports on cause of death hyperglycaemia

Diabetic coma is the most severe form of hyperglycaemic metabolic disorders. The post-mortem diagnosis of this disorder of glucose metabolism can be difficult and vague due to a lack of characteristic morphological findings. Six death cases caused by diabetic coma are described with special focus on biochemical (and histological) findings. The possible glycaemia markers glucose, lactate, HbA1c, fructosamine, anhydroglucitol, and ketone bodies were measured and the usefulness of these parameters is evaluated and discussed. Estimations of glucose concentrations in vitreous humour or cerebrospinal fluid and of ketone bodies in blood or other matrices are obligatory while measurements of HbA1c, fructosamine, or anhydroglucitol can only provide additional information on the long-term adjustment of diabetes in the deceased. Lactate concentrations (addition of glucose and lactate levels to form the sum formula of Traub) do not give more information than the glucose concentration itself and can be therefore omitted.

How to do identify single cases according to the quality assurance from IOFOS. The positive identification of an unidentified body by dental parameters: A case of homicide

The positive identification of skeletal by individual dental parameters is one of the objectives of the criminal investigation. The intervention of Forensic Dentistry in some circumstances may represent the only way to obtaining a positive identification of an unidentified bodies. The teeth constitute a scientific method in forensic identification, principally due to the great resistance to the agents who provoke the destruction of the soft tissues in the corpses (putrefaction, traumatic, physical and chemical agents) and to the high morphological variability of the human teeth. The human identification in Forensic Dentistry is made by two ways: comparative and reconstructive. The identification allows to determine several parameters of forensic interest: specimen, population affinity, sex, age, stature and individualization's factors. The Forensic Dentistry is one of the most important fields in individual identification, because teeth have less variability in the chronology of events in terms of the reconstructive way. On the other side, in terms of the comparative way, this area is also important, because of the individualization's factors: positive identification in individual cases and in mass disasters. In this forensic case report, a homicide case, the objective of the medico-legal investigation was a positive identification of the unidentified corpse found one year after the crime, July 2010. The Portuguese Criminal Police of Lisbon, Homicide Group, requested to South Branch of the Portuguese National Institute of Forensic Medicine, a forensic examination by a Forensic Odontologist for dental positive identification. The objectives were: 1) post mortem reconstruction of the dental status of the victim; 2) obtain the ante mortem information of the presumable victims; 3) comparison of the post mortem information with the ante mortem information, for a positive identification of the presumable homicide victim. Materials and methods: in this field of dental investigation, the guidelines of the International Organization of Forensic Odontology were used for reconstruction of the post mortem dental profile, to register ante mortem information of the presumable victims and to compared for individualized dental factors, by using Interpol DVI Forms for Individual Case, post mortem and ante mortem forms F1 and F2. Results: the unidentified victim of homicide was positive identified where it was established the identity by more than 12 individual dental characteristics. Conclusion: the Forensic Dentistry is a very important and simple field for individual identification of unidentified corpses for application of the criminal law.

Writing for publication: What about case reports?

Writing for publication: What about case reports?

Heparin-induced thrombocytopenia complicated by bilateral adrenal haemorrhage: A forensic autopsy case report

A 70-year-old woman developed, seven days after a right hip replacement surgery, a sepsis shock due to diverticular sigmoid for physicians. A forensic autopsy was performed because outcome was unfavourable and liability was engaged against physicians. A bilateral adrenal hemorrhage was diagnosed during postmortem examination and histological investigations demonstrated infarction of two adrenal glands. Before death, laboratory findings showed Heparin-induced thrombocytopenia (HIT). The main cause of death was bilateral adrenal hemorrhage due to anticoagulant use complicated by HIT, seven days after orthopedic surgery. Acute adrenal hemorrhage is often overlooked because symptoms are attributed to other conditions, especially to sepsis. Death after adrenal insufficiency is rare and the diagnosis is frequently made at autopsy. The goal of this case report is to submit physiopathological characteristics and aspects of bilateral adrenal hemorrhage. Involvements of them are not completely elucidated, because HIT is not necessary to adrenal infarction. Risk factors are identified as thrombocytopenia, heparin usage and sepsis which exposes the patient to bilateral adrenal hemorrhage. Forensic pathologists had to examine carefully adrenal glands during macroscopic examination and their histological examination could be useful if necessary. Une femme de 70 ans a fait, sept jours après une intervention de la hanche, un choc septique dû à une diverticulite segmoïdale. Une autopsie médicolégale a été exécutée suite au décès de la patiente et la responsabilité des médecins a été engagée. Une hémorragie surrénale bilatérale a été diagnostiquée pendant l’examen postmortem et des investigations histologiques ont montré l’atteinte de deux glandes surrénales. Avant la mort, des analyses de laboratoire avaient indiqué une thrombocytopénie induite par l’héparine (TIH). La cause principale du décès était l’hémorragie surrénale bilatérale en raison de la prescription d’anticoagulants liée à la TIH, sept jours après la chirurgie orthopédique. L’hémorragie surrénale aiguë est souvent sous-diagnostiquée, les symptômes étant attribués à d’autres éléments, particulièrement à la septicité. La mort après insuffisance surrénale est rare, et le diagnostic est fréquemment fait à l’autopsie. Le but de ce cas clinique est de proposer des caractéristiques physiopathologiques et de synthétiser les différents aspects de l’hémorragie surrénale bilatérale. Les implications ne sont pas complètement élucidées, parce que la TIH n’est pas la seule cause d’infarctus surrénal. Les facteurs de risque sont identifiés comme étant la thrombocytopénie, l’utilisation d’héparine et la septicité, qui exposent le patient à une hémorragie surrénale bilatérale. Les pathologistes médico-légaux doivent examiner attentivement les glandes surrénales pendant l’examen macroscopique et l’examen histologique complémentaire de ces glandes peut s’avérer très utile dans certains cas.

Medical Malpractice Allegations of Iatrogenic Addiction in Chronic Opioid Analgesic Therapy: Forensic Case Reports

The objectives for presenting these medico-legal forensic case reports are the following: 1) detail three cases where chronic opioid analgesic therapy (COAT) was alleged to cause iatrogenic addiction and/or re-addiction; 2) detail the plaintiff's and defendant's medical experts' opinions on these allegations; and 3) through analyzing these cases, develop some recommendations for future prevention of such allegations during COAT. Case Reports. Medico-legal issues surrounding the allegation of iatrogenic addiction were identified in each case. Before starting COAT, physicians should obtain and document patient informed consent for the risk of addiction/re-addiction with COAT treatment. Patients with a history of addictions pre-COAT should be placed on adherence monitoring immediately on beginning COAT.

Allegations of Medical Malpractice in Chronic Opioid Analgesic Therapy Possibly Related to Collaborative/Split Treatment and the P-450 Enzyme System: Forensic Case Report

The objectives of this forensic medicolegal case report were the following: 1) present details of a patient on chronic opioid analgesic therapy (COAT) where a disastrous outcome resulted in allegations of malpractice; 2) detail the plaintiff's and defendant's medical experts' opinions on this allegation; and 3) discuss issues potentially related to these allegations, i.e., split treatment and the P450 enzyme system. METHODS CASE REPORT RESULTS: Medicolegal issues surrounding these malpractice allegations are discussed. Split treatment can increase the difficulties in performing COAT. Clinicians should routinely consider the effects of all utilized drugs on the ability of the P450 enzyme system to metabolize/clear opioids.

Death due to blood transfusion-induced anaphylactic shock: A case report

In medical practice, many clinical accidents due to blood transfusion reactions have been reported, among which, nonhemolytic transfusion reactions (NHTRs) have been mainly reported in recent years. NHTRs induce reactions such as anaphylactic shock and transfusion-related acute lung injury (TRALI); however, few forensic autopsy case reports with blood transfusion reactions including anaphylactic shock have been published.A marker for anaphylactic shock is serum tryptase, which indicates systematic mast cell activation in living patients. In forensic medicine, serum tryptase has been used in the postmortem diagnosis of anaphylactic shock. In this autopsy case report, the blood tryptase level was elevated to 49.0ng/mL (reference standard level <13.5ng/mL). When considered comprehensively with autopsy findings and blood typing, we concluded that this patient was suspected to have suffered from anaphylactic shock as a result of blood transfusion.

P02-148 Structural brain abnormalities in homicidal patient: Forensic case report

Background:Studies have revealed that areas associated with violent behaviour are located in the prefrontal cortex, medial temporal regions and limbic regions. Key regions commonly found to be impaired in population of violent homicide offenders include prefrontal cortex, temporal gyrus, amygdala-hippocampal complex, and anterior cingulate cortex. Recent findings have confirmed link between large arachnoid cysts and psychotic symptoms. There is no scientific data in literature on the case of homicidal forensic patient with large arachnoidal cyst and lesion of frontal and temporal brain regions.Clinical presentation:We present the first forensic clinical case of male homicidal patient, age 29, with arachnoidal cyst (Galassi III) occupying large portion of the right brain hemisphere. The patient is presented with acute psychotic behavior after he killed his father and was escorted to our department for psychiatric evaluation. The patient was catatonic upon admission to the hospital and completely non-cooperative (mute). After interviewing patient's family members we have collected data regarding visible changes in his behaviour in the last two years accompanied with frequent attacks of headache. MRI study revealed large arachnoid cyst in the right brain hemisphere compressing right frontal and temporal cortex with lesions in frontal and temporal cortex and lesion of the white brain matter in insular region of both hemispheres. The patient was ordered antipsychotic therapy (clozapin) and schedulled for further psychiatric observation.Conclusion:This clinical case represents highly probable link between structural brain changes and homicidal forensic patient. We have shown multiple structural brain abnormalities supporting neuroscientific hypothesis that impulsive homicide offenders lack the prefrontal “inhibitory” machinery.

Factors that predispose, prime and precipitate NREM parasomnias in adults: Clinical and forensic implications

Sleepwalking and related disorders are the result of factors that predispose, prime and precipitate episodes. In the absence of one or more of these factors sleepwalking is unlikely to occur. Predisposition to sleepwalking is based on genetic susceptibility and has a familial pattern. Priming factors include conditions and substances that increase slow wave sleep (SWS) or make arousal from sleep more difficult. These factors include sleep deprivation, alcohol, medications, situational stress and fever among others. The patient with a genetic predisposition to sleepwalking and with priming factors still requires a precipitating factor or trigger to set the sleepwalking episode in motion. Classical theories of sleepwalking were based primarily on case reports. Recently some of these theories have been tested in the sleep laboratory. Experimental sleep deprivation studies of sleepwalkers generally report an increase in complex behaviors during SWS, although one prominent study reported the opposite effect. However, the generally accepted theory that alcohol and medications can induce sleepwalking episodes remains entirely based on clinical and forensic case reports. Alleged cases of alcohol related sleepwalking often involve individuals lacking the generally accepted characteristics of sleepwalkers but with very high blood alcohol levels that could in and of itself account for complex behaviors noted without the presence of sleepwalking. Further, the effects of high levels of alcohol dramatically decrease SWS, a finding inconsistent with sleepwalking. Case reports of medication-related induction of apparent sleepwalking most often present a complex medical and psychiatric history associated with multiple medications. These patients often lack the clinical history and other criteria currently required for the diagnosis of sleepwalking. The medication-related behaviors may instead represent some other condition in an awake, but impaired patient. Sleep laboratory research has identified sleep disordered breathing, periodic leg movements, noise and touch among others as proximal triggers of sleepwalking episodes. Treatment of these triggers may result in resolution of sleepwalking without medication. Further sleep laboratory research is needed before experimental findings can be used for routine diagnostic and forensic purposes.

Sickle Cell Anemia: Conclusions from a Forensic Case Report of a Young African Woman Who Died After Anesthesia

A 20-year old African woman underwent anesthesia for interruption of an unwanted pregnancy. As a consequence of the anesthesia, she went into coma because of an as yet unknown and untested homozygotic state of sickle cell anemia. Her vital functions were maintained for more than 1 year by intensive medicine, but she died finally in multiorgan failure and aspiration pneumonia. Because of the complications under anesthesia and the missing preanesthetic test for hemoglobinopathy, autopsy was conducted in the forensic medicine department and not in the department of pathology. The sickle cell disease was diagnosed by electrophoresis of the blood, by molecular detection of mutation in the hemoglobin gene, as well as by postmortem light and electron microscopy. Sickle cells were found in capillaries of brain, liver, lung, bone marrow, and spleen. Electrophoretic analysis revealed 80.2% HbS in addition to 3.2% HbA2 and 16.6% HbF, whereas no HbA0 could be detected in blood, confirming the homozygosity of sickle cell anemia. Because of sickle cell crisis, occluded blood vessels, and severe brain cortex necrosis, the patient died in spite of reanimation and intensive medicine. This case demonstrates that it is still important to realize the possibility of this disease and diagnostic obstacles even in regions where its manifestation is not endemic, as in Northern and Central Europe.

Sudden death in childhood due to varicella pneumonia: a forensic case report with clinical implications

Varicella (chickenpox) is one of the most frequent highly infectious diseases in childhood. It is caused by varicella-zoster virus. Lethal complications are rare. Focused on histological findings, we present a case of a sudden unexpected death of an otherwise healthy 18-month-old girl due to varicella-induced pneumonia. The histological and immunohistochemical investigations of the lung tissue revealed typical findings of a varicella pneumonia: haemorrhagic and necrotic nodules, intra-alveolar fibrin, numerous neutrophilic granulocytes, lymphocytes, plasmacells, macrophages, multinucleated giant cells and hyaline membranes. Varicella-related deaths are preventable by vaccine. To prevent complications and lethal outcome of varicella as reported here, the recommendations concerning vaccination against varicella must be taken into account in paediatric practice.