Fatal Rapunzel Syndrome: Gastric and Intestinal Trichobezoars in a Child With Trichotillomania.

ABSTRACT: We report a rare case of a young child, younger than10 years, who died of complications related to trichophagia and multiple gastrointestinal trichobezoars. One year before death, the child's clinical history yielded a diagnosis of iron deficiency anemia, believed to be related to poor diet, and alopecia areata, the etiology of which was unknown. Two weeks before death, the child presented with complaints of intermittent "flu-like" symptoms and vomiting. The child reported abdominal pain, anorexia, and fatigue on the night before death. The next morning, the child ate breakfast and was subsequently discovered unresponsive.On external examination, there were areas of thinning head hair. Postmortem computed tomography, magnetic resonance imaging, and internal examination revealed 3 distinct trichobezoars, occupying the stomach, jejunum, and ileum. This was complicated by small bowel obstructions and perforations due to the trichobezoars. The cause of death was peritonitis secondary to small bowel perforations due to small bowel obstruction with multiple trichobezoars. This is the first case report to demonstrate the utility of postmortem computed tomography and magnetic resonance imaging in characterizing the nature and extent of trichobezoars in a fatal case of Rapunzel syndrome.

An experimental model of tool mark striations by a serrated blade in human soft tissues.

Tool mark analysis is a method of matching a weapon with the injury it caused. In a homicidal stabbing using a serrated knife, a stab wound that involves a cartilage may leave striations from the serration points on the blade edge. Assessing tissue striations is a means of identifying the weapon as having a serrated blade. This prospective study examines the possibility that similar striations may be produced in human soft tissues. Using tissues taken at the time of hospital-consented autopsies, stab wound tracks were assessed in a variety of human tissues (aorta, skin, liver, kidney, and cardiac and skeletal muscle). Stab wounds were produced postmortem with similar serrated and smooth-edged blades. The walls of the stab wounds were exposed, documented by photography and cast with dental impression material. Striations were identified by naked-eye examination in the skin and aorta. Photodocumentation of fresh tissue was best achieved in the aorta. Striations were not identified in wound tracks produced by the smooth-edged blade. Three blinded forensic pathologists were assessed for their ability to detect striations in photographs of wound tracks and had substantial interobserver agreement (κ = 0.76) identifying striations. This study demonstrates that tool mark striations can be present in some noncartilaginous human tissues.

Thalamic infarct presenting as catastrophic life-threatening event in an older adult.

An 84 year old woman with history of moderate Alzheimer's disease, depression, and an anxiety disorder presented to our emergency room at Victoria Hospital, London, Ontario in an 'unresponsive' state. The patient was akinetic with mutism, and clonic perseveration induced in the upper limbs was evident while she was examined. Heart attack, massive stroke, or intracranial bleed were ruled out, and an electroencephalogram showed no epileptiform activity. Despite a normal CT, a magnetic resonance scan was ordered and showed bilateral acute paramedian thalamogeniculate infarction arising from occlusion of the artery of Percheron. Bilateral thalamic infarcts can cause sudden onset of akinetic mutism with clonic perseveration, which may be confused with coma and seizures due to life threatening conditions such as a massive stroke. Thorough clinical assessment and early use of MRI scanning will assist physicians with a more accurate diagnosis of older adults with this kind of presentation.