Annamaria Govi

Sudden death due to acute adrenal crisis

A 50-year-old man was found dead in the bed of his hotel room. Heavy fecal staining was present on the bed sheets and on the floor adjacent to the bed, as well as on the bathroom floor. According to the man’s medical history he had suffered from Addison’s disease from the age of 16 years. His history included prescribed medication of 100 mg hydrocortisone per day, but no therapeutic drugs were found at the scene. The man had also been suffering from recurrent respiratory tract infections and mycosis of the nails. A medicolegal autopsy was ordered by a prosecutor to clarify the cause and manner of death, and to rule out third party involvement. External examination of the body revealed an obese adult male (body length 171 cm, body weight 129 kg, body mass index 44 kg/m) with no external injuries. There was marked brownish hyperpigmentation of the skin of the penis and scrotum as well as sporadic depigmentation in the inguinal region (Figs. 1, 2). The surface of the tongue showed a whitish plaque indicating a fungal infection. Autopsy findings included brain edema (weight 1,560 g) and fatty liver. Although slightly enlarged, the heart (weight 480 g) had no valve abnormalities or coronary artery disease. The thyroid gland was unremarkable. The mucosa of the stomach and the small and large intestines showed no evidence of acute inflammation or any underlying chronic bowel disease. Additionally, all of the components of the gastrointestinal tract were completely empty. Besides the brownish skin pigmentation, the most remarkable aspect of the autopsy was the difficulty to macroscopically identify any adrenal gland tissue. For this reason, all the fatty tissue surrounding the superior pole of each kidney was retained for histological examination. A thorough histological examination of this fatty tissue verified the diagnosis of Addison’s disease. The sparse appearance of adrenal gland tissue indicated a notable decrease in the width of the original adrenal cortex, atrophy of the adrenal cortical cells, and a collapsed vascular reticulin framework. Parts of the adrenal cortex had been replaced by dense accumulations of lymphocytic and plasma cell infiltrates (Fig. 3), thus confirming the histological diagnosis of autoimmune adrenalitis. Fibrosis was not observed within the adrenal glands. Toxicology results were negative for both alcohol and drugs and a urine screen for hyperglycemia was negative. However, the vitreous humor was not examined. Taking into account the circumstances of the death, the previous medical history of the deceased, and the autopsy findings, cause of death was attributed to acute adrenal crisis (Addisonian crisis).

Examples of tramline bruises in clinical forensic medicine

A 9-year-old deaf boy was brought to our institute by a social worker. He reported that a woman who worked in the children’s home where he lived had beaten him with a wooden stick the day before. He added that this was the third time that it had happened. When the woman was questioned about the events, she denied the physical abuse and claimed that the injuries had been caused by playing with other children. Physical examination of the boy revealed several injuries on his upper body; notably, six tramline bruises were present on his right arm (Fig. 1a, b), and six tramline bruises were present on his left forearm (Fig.1c). The injuries were 4.0 cm long and 1.2 cm wide. According to our expert report, the morphology and location of the injuries as well as the clustering of injuries was proof that these injuries were abuse-related (intentional). An accidental origin of the injuries was excluded.

Fatal varicella in immigrants from tropical countries: case reports and forensic perspectives.

The primary Varicella Zoster Virus (VZV) infection results in varicella, a generally benign, self-limiting disease in immunocompetent children. Despite the usual course a possible fatal evolution of the primary infection is observed predominantly in immunocompromised subjects and in adults, especially emigrating from tropical regions. Two cases of fatal varicella have been investigated and discussed. Death occurred in two patients over 40 years of age, coming from South Asia and receiving chronic immunosuppressive therapy. The forensic expert must be cautious and consider all clinical records in managing fatal varicella cases, bearing in mind risk factors and pre-existing conditions such as age, geographical provenance and pathological comorbidity, which may lead to a bad prognosis irrespective of therapies. Based on the severe and fatal course observed in the reported cases, an extension of the immunization program appears advisable for immigrants from tropical countries, especially before scheduled immunotherapy.

Clinical forensic aspects of self-inflicted neck injuries

The distinction between self-inflicted injuries and other types of injuries is crucial in forensic medicine, and relevant features of wounds should be identified by pathologists, even when they are observed at atypical sites. Herein we report two cases of self-inflicted injuries of the neck involving two young women who had reported being attacked by men.

Superficial vein thrombosis: differential diagnosis of circumscribed skin discolorations at autopsy.

An 88-year-old woman was found by her grandson, who had last seen her 4 days earlier, lying on the floor of her flat. The woman was immediately transferred to a primary care hospital where exacerbation of severe cardiac failure was diagnosed. Despite pharmacological treatment, she died 3 days later. A medico-legal autopsy was performed to clarify the cause and manner of death, and to exclude intoxication or violence. On external examination the woman was found to be slightly overweight (height 1.61 m, weight 67 kg, body mass index 25.5 kg/m). There were areas of circumscribed reddish-brown skin discoloration on both legs. Discoloration was present in a linear pattern on the skin of the left thigh, and in areas 22 cm long, and between 0.5 and 2 cm wide; it was also seen around the right knee in a semicircular question-mark shape 23 cm long, and between 0.5 and 2 cm wide (Fig. 1). At autopsy, the heart was enlarged (weight 430 g) and there were signs of chronic heart failure, such as hepatic congestion, and edema and congestion of the lungs (weight of right lung 950 g, weight of left lung 900 g). Widespread severe general arteriosclerosis was also evident, but the main finding was of fresh bilateral pulmonary artery emboli that were loosely adherent to the vessel walls. There were also fresh deep vein thromboses in both lower legs, with thrombi loosely adherent to the vessel wall but completely occluding the vessel lumen. In addition, there was massive fresh thrombosis of the superficial veins of both legs, corresponding to the circumscribed linear skin discoloration of the left thigh and the semicircular discoloration around the right knee (Fig. 2a, b). Layered dissection of both legs and arms yielded no evidence of bruising or other signs of trauma preceding death. Toxicology results were negative for both alcohol and drugs. Histology confirmed the diagnosis of fresh thrombosis, with densely layered erythrocytes and to a lesser extent leukocytes and platelets, together with fibrin deposition (Fig. 3a, b). Considering the medical history, the circumstances of death, the autopsy findings and the results of toxicological and histological examinations, death was attributed to pulmonary thromboembolism.

Central pontine myelinolysis.

A 45-year-old woman was found dead on a sofa in her flat by her male partner. She was known as a chronic alcoholic with nearly three decades of heavy alcohol abuse and more than 40 clinical treatments for alcohol withdrawal in her previous medical history. Because of the young age of the deceased, the unknown circumstances surrounding her death and both an undetermined cause and manner of death, a medicolegal autopsy was performed. External examination of the body showed an overweight adult female (body mass index: 29) without any external injuries. At autopsy, all inner organs appeared pale. Several mucosal lacerations of the lower esophagus were present. 150 ml of bloody fluid were found in the stomach. A large amount of tarry stool was present in the small and large bowel. In addition, edema of the lungs and fatty liver were seen. The most remarkable finding was a region of gray and light brownish discoloration, measuring 1 cm in diameter, that was located in the middle of the base of the pons within the brainstem, corresponding to central pontine myelinolysis (CPM) (Figs. 1, 2). Histology of the pons lesion verified the diagnosis of CPM by revealing demyelinization with reactive astrocytes and large numbers of foamy lipid-laden macrophages and scanty lymphocytes (Figs. 3, 4). Toxicology results were negative for both alcohol and drugs. Death was attributed to exsanguination due to Mallory– Weiss syndrome of the lower esophagus.