Carlo Moreschi

Post-mortem diagnosis of anaphylaxis: A difficult task in forensic medicine

The lack of reliable laboratory biomarkers and common standard definitions of signs and symptoms represents the main problem for clinicians when a suspected anaphylactic event must be diagnosed, while a post-mortem diagnosis of anaphylaxis is often a very difficult task in forensic medicine. Significant necroscopic signs as well as the data reported from witnesses or medical records may be absent, biological fluids as blood or urine may be unavailable or under thanatological modifications. The aim of this review is to focus on the diagnostic difficulties with which coroners and forensic pathologists have to cope when a confirmation of anaphylactic death is required by judicial authorities. Investigation methods for a prudent forensic diagnosis of anaphylactic death as well as the need of new potential laboratory or histological investigation techniques coming from immunological research are discussed too.

Neck injury patterns resulting from the use of petrol and electric chainsaws in suicides. Report on two cases

Suicides due to neck injuries caused by chainsaws are uncommon events. The cutting elements of petrol and electric chainsaws produce different features in lethal neck injuries. The accurate evaluation of the death scene, of the power and mechanical characteristics of the chainsaw and of wound morphology are all essential in distinguishing a case of suicide.

Medico legal and epidemiological aspects of femicide in a judicial district of north eastern Italy

Femicide is the intentional killing of a woman because she is female, and often occurs when there are pre-existing relations, intimate or otherwise, between the victim and the murderer. A retrospective epidemiological study was made of 34 female homicides recorded in a university departmental register of post-mortems, pertaining to a judicial district of about 700,000 inhabitants in north eastern Italy, during a 21-year period from January 1st 1993 to December 31st 2013. The temporal trend, the socio-demographic characteristics of victims and perpetrators, the circumstances surrounding the crime and the risk factors for femicide were studied with the aim of identifying and developing preventive strategies.

The Eluana Englaro Case: Cause of death after the withdrawal of artificial nutrition and hydration in a subject in a permanent vegetative state and with quadriplegia

A 38-year-old woman, who had been in a permanent vegetative state with quadriplegia for 17 years following a motor vehicle accident, died 87 h after the judicially authorised suspension of artificial nutrition and hydration. Medico-legal investigations, requested by the Judicial Authorities and focusing on the evaluation of clinical and necroscopic data, aimed to explain the cause of death, to exclude any lethal cause other than one deriving from the withdrawal of artificial nutrition and hydration and to verify the level of perceived discomfort and the correctness in the application of the supportive protocol during the end of life phase. The inability of quadriplegic patients to compensate critical hyperthermic and haemodynamic disturbances induced by dehydration was considered to be the cause of a rapid demise after the withdrawal of artificial sustenance.

Medicolegal Investigations Into Deaths Due to Crush Asphyxia After Tractor Side Rollovers

Farm tractors are large, heavy, powerful vehicles with a high center of gravity. When driven carelessly on sloping, irregular, or slippery ground, tractors can overturn sideways and cause the death by crush asphyxia of the driver or passengers, especially if appropriate safety equipment is not fitted or used. The aim of this review is to focus on the diagnostic difficulties with which coroners and forensic pathologists have to cope when a confirmation of crush asphyxia after tractor side rollover is required by judicial authorities. Forensic investigations in such cases must involve the meticulous analysis of the death scene and the mechanical characteristics of the vehicle together with accurate postmortem and toxicological examination.

Medico-legal implications of traumatic cataract.

Traumatic cataract is due to lens damage when mechanical, irradiative, electrical or chemical agents injury the globe. The appearance of a traumatic cataract is typically short and unilateral with rare spontaneous resolution and often involves other ocular anatomical areas. Medico-legal evaluation of the appearance and the consequences of a traumatic cataract requires a correct methodological approach with the support of qualified ophthalmological competences.

Paradoxical air embolism through patent foramen ovale during consensual intercourse in a non-pregnant young female

Sudden vaginal bleeding and a cardiac arrest occurred in a 18-year-old female during consensual intercourse. Resuscitation procedures, applied at the arrival of a medical emergency team, restored the cardiac function allowing admission to hospital, where two vaginal mucosal lacerations were diagnosed and sutured. Cardiological investigations diagnosed a left ventricle myocardial infarction and a patent foramen ovale while a brain CT scan showed ischemic signs and intravascular air images. Death occurred after 48 h, due to heart failure, cerebral anoxia and multiorgan failure. Autopsy confirmed a patent foramen ovale considered as responsible for a paradoxical air embolism. Judicial Authority evaluated the fatal paradoxical air embolism as a consequence of an unpredictable accident occurred during consensual intercourse without sexual violence.

Gastric mucosal tears and wall micro perforations after cardiopulmonary resuscitation in a drowning case.

A fifty year-old woman died after drowning in a swimming-pool. Rescue and ambulance paramedic teams started resuscitation attempts followed by a medical care helicopter team. Acute haematemesis, mucosal tears and gastric micro perforations occurred, due to the cardiorespiratory resuscitation manoeuvres. Death occurred seven days later due to the cerebral anoxia and multiorgan failure. Forensic investigations excluded possible malpractice during external cardiac massage as responsible for the womans death, while Judicial Authority considered the death as the consequence of the delayed intervention of the swimming-pool rescue team.

Diffuse pulmonary ossification in permanent vegetative state

Diffuse pulmonary ossification (DPO) is a rare condition characterized by diffuse metaplastic bone formation in the lungs. Two patterns have been described: dendriform, with a coral‐like network of bone spiculae along the alveolar septa; and nodular, with lobulated fragments in the alveolar spaces. Dendriform DPO is frequently associated with chronic pulmonary pathologies. We present here the first case of DPO associated with a long‐lasting vegetative state. Micro‐computed tomography (MicroCT) was applied to analyze the distribution of pulmonary ossification in volumes of lung samples. It showed a mean volume percentage of ossification of 0.79% and 3‐D reconstructions permitted to reveal the branching pattern and internal cavities of some ossifications. The occurrence of DPO in a persistent vegetative state (PVS) may be favored by recurrent pulmonary infections, due to aspiration and immunological defects, and respiratory instability, due to brain damage and the fact of being bedridden. Fibrotic reactions probably represent a preliminary step in bone formation. Further studies could examine the incidence and clinical significance of DPO in subjects in PVS or patients who are bedridden for other reasons. MicroCT may facilitate analysis of more case histories, with greater sensitivity with respect to classic microscopic analyses.

Medico legal aspects of self-injection of metallic mercury in cases of suicide or self-harming

Metallic mercury may be self-injected for suicidal or self-harm purposes or sometimes for superstitious or other inadvisable reasons. Local tissue or systemic consequences such as mercurialism can frequently occur in cases of subcutaneous or deep injection, while death due to pulmonary embolism and cardiac, brain, hepatic or renal toxicity may occur in cases of high dosage intravenous administration. The aim of this review is to focus on the diagnostic difficulties facing coroners and forensic pathologists when the courts require confirmation that evidence of self-injection of metallic mercury is the result of suicide or self-harming. Forensic examination performed on the corpses of victims who died in or out of hospital or on surviving injured or intoxicated victims showing signs of mercurialism, demands the careful evaluation of the death scene, of all related circumstances and of the clinical and autopsy data. Close interaction between forensic pathologists and toxicologists is also needed to identify and quantify mercury levels in blood, urine and tissue.