Immunohistochemical detection of Fibronectin, P-Selectin, FVIII, HSP-70 and MRP-8 in the skin of ligature marks of suicidal hangings.

The determination of vitality of skin injuries is one of the most central research areas in forensic pathology for it is often necessary to discern antemortem from postmortem damage. Typical is the case of a hanging, which should be distinguished from the postmortem suspension of a body. In this study, 15 human skin samples from ligature marks (study group) of victims of suicidal hanging and 15 uninjured skin samples (negative control group) were analyzed. In addition, 15 skin samples from ecchymoses in homicide victims with short survival intervals were investigated as a positive control group. Sections were processed for immunohistochemistry in order to detect the expression of Fibronectin, P-Selectin, FVIII, HSP-70, and MRP8. Immunohistochemical reactions were classified semiquantitatively (mild - score 1, moderate - score 2, and intense - score 3). In the ligature marks, Fibronectin was significantly less expressed compared to ecchymoses. The expression was similar to hanging marks and uninjured skin. In both ligature marks and ecchymoses, the expression of P-Selectin was significantly increased compared to uninjured skin. In both ligature marks and ecchymoses, expression of HSP-70 was significantly decreased in the epidermis compared to uninjured skin. In both ligature marks and ecchymoses, the expression of FVIII and MRP8 was significantly increased in the dermis and hypodermis compared to uninjured skin. The results of this study show that the immunohistochemical study of early inflammatory and coagulation factors could help determine the vitality of ligature marks. The combined analysis of P-Selectin, FVIII, HSP-70, and MRP-8 can be considered for this purpose.

Non-traumatic ecchymoses: A literature review from a medico-legal perspective.

Ecchymosis, as a general term, refers to discoloration of the skin due to the presence of extravasated blood into the dermis and/or subcutaneous tissue. However, it can occasionally be observed without any trauma, as a symptom of disease, a clinical condition, or even during the course of treating a disease. It is extremely important that these non-traumatic lesions are known and recognized and can be distinguished from traumatic ecchymoses by both clinicians and forensic scientists. This review of the literature includes detailed descriptions of non-traumatic periorbital ecchymosis, Slapped Cheek Syndrome, Cullen's Sign, Grey Turner's Sign, Stabler's Sign, Ransohoff Sign, Bryant's Sign, postsacral ecchymosis, perianal ecchymosis, Fox's Sign, other lower leg ecchymosis, and ecchymosis on various body regions. In this article, it is emphasized that failure to correctly identify these findings may subject practitioners to malpractice lawsuits, and failure to correctly identify findings by forensic experts may result in unjust legal judgments against people or loss of rights. It is also this review encourages accurate diagnosis of non-traumatic ecchymoses.

Ecchymosis in critical coronavirus disease 2019 (COVID-19) patient in Tangerang, Indonesia: a case report.

We have read with great interest the articles regarding cutaneous manifestations in Coronavirus Disease 2019 (COVID-19) infection. Studies showed 20.4% of COVID-19 patients developed cutaneous manifestations. COVID-19 causes vascular endothelial injury, vasculitis and prothrombotic state which might be the underlying cause of hemorrhagic cutaneous manifestations, disseminated intravascular coagulation (DIC), and multiple organ failures. To date, hemorrhagic cutaneous manifestations reported are chilblain-like lesion, purpura to ecchymosis, livedo reticularis, and dry gangrene. We present a case of ecchymosis in COVID-19-positive ICU hospitalized patient.

Is Nasal Skin Thickness a Prognostic Indicator to Postoperative Edema and Ecchymosis?

BACKGROUND: The size, shape, and symmetry of the nose contribute significantly to the facial aesthetic, so it is understandable why rhinoplasty is one of the most popular cosmetic procedures undertaken nowadays. Several factors are associated with the rates of both success and postoperative complications of rhinoplasty. AIM: To determine the relationship between nasal skin thickness and postoperative periorbital ecchymosis and edema among patients who underwent rhinoplasty at King Abdulaziz University Hospital. METHODOLOGY: A prospective study was conducted among all patients operated on for rhinoplasty at King Abdulaziz University Hospital in the Department of Otolaryngology, Riyadh, Saudi Arabia, between May and December 2018. To determine the relationship between nasal skin thickness and postoperative periorbital edema and ecchymosis, demographic data (gender, age), mean nasal skin thickness, surgical factors (time of surgery, extent of intraoperative bleeding), and scoring for periorbital ecchymosis and edema were obtained. The statistical analysis was done by comparing means and frequency using analysis of variance. RESULTS: A total of 54 patients participated in this study with ages ranging from 19 to 33 years and a mean age of 24.43. According to this study, postoperative edema presentation on the first, third, and seventh days upon examination was higher among patients with thicker nasal skin (6 mm), and results are statistically significant (P = .001). Ecchymosis was also higher among patients with thicker nasal skin (6 mm) on day 1 examinations, but there was no correlation with nasal thickness during the other examinations. Therefore, there is some degree of correlation between ecchymosis and nasal skin thickness overall, but the results are not significant (P = .26). CONCLUSION: This study concludes that the severity of edema and ecchymosis correlates with nasal skin thickness. The degree of edema and ecchymosis was higher during the initial postoperative examinations, but following that, it was reduced and completely diminished by the 21st day post-surgery.

Systemic Amyloidosis Caused by Monoclonal Immunoglobulins: Soft Tissue and Vascular Involvement.

Clinical features of soft tissue amyloid light-chain (AL) amyloidosis include macroglossia, arthropathy, muscle pseudohypertrophy, skin plaques, and carpal tunnel syndrome. Vascular manifestations of AL amyloid include periorbital ecchymosis, jaw or limb claudication, and even myocardial infarction caused by occlusion of small vessel coronary arteries. Some of these features, such as macroglossia, periorbital ecchymosis, and the so-called shoulder-pad sign, are pathognomonic for AL amyloidosis. These findings may be the initial presenting features of the disease, and the recognition of these red flag symptoms is very important for the diagnosis and early intervention on the underlying plasma cell disease.

Fatal Spontaneous Retropharyngeal Hematoma with Airway Obstruction in the Setting of Treatment with Dipyridamole.

We report a fatal case of airway obstruction caused by spontaneous retropharyngeal hematoma (RH) in the setting of treatment with dipyridamole. A 90-year-old woman presented with cervical swelling, neck and chest ecchymoses, and complaints of dyspnea. She suffered cardiopulmonary arrest in the ambulance, and her death was confirmed after transportation to the hospital. The major finding of postmortem computed tomography (PMCT) prior to autopsy was widening of the prevertebral soft tissue. The results of the autopsy indicated that the cause of death was mechanical asphyxia, secondary to pharyngeal and laryngeal compression caused by the RH. There were no evident injuries, medical interventions, or particular diseases, suggesting the spontaneous cause of the RH. To the best of our knowledge, this is the first report of a fatal case secondary to spontaneous RH that was revealed through PMCT imaging.

Fatal entrapment in a pool drainage system: a case report.

Swimming pool suction injuries are rarely encountered in forensic medicine. Infants under 8 years of age are most frequently involved in such accidents with high risk of serious injuries and fatal consequences due to drowning. We report, for the first time, a case of a 13-year-old boy trapped at the abdomen by an uncovered suction drainage hole. External examination of the body revealed a round ecchymosis which had the same diameter as the pool drain. Post-mortem examination established that death had occurred due to drowning, possibly in combination with traumatic shock from the suction mechanism involving the intestinal loops. Furthermore, this case may be remarkable as it raises other medico-legal issues regarding the safety standards at swimming pools, including pool management and lifeguard attendance. Preventative measures are needed in order to make sure this sort of injury or death does not occur. Moreover, the awareness of the occurrence of these accidents should be increased.

Late Occurrence of Raccoon Eyes: The Role of the Ligature.

This case represents a planned complex suicide in which the victim combined gunshot to the head and hanging. The most interesting finding in the presented case was pale face, but without any visible injury to it at the time the body was found (more than 24 hours after death), whereas at autopsy (20 hours later), black eyes were prominent. The removal of the ligature led to the decompression of the neck and its blood vessels with consequential blood redistribution, which, alongside the liquid state of blood, resulted in the aforementioned finding. Considering the described postponed appearance of periorbital ecchymosis, this kind of finding suggests that great caution is necessary when interpreting hematomas in terms of their vitality.

Use of toluidine blue dye in detection of anogenital injuries in consensual sexual intercourse.

The usefulness of Toluidine blue dye in the detection of anogenital injuries in sixty females aged 16-40 years of age with a history of consensual sexual intercourse within 48 h of intercourse were included for the study from the Gynaecology outpatient department of the Institute of Medicine, Maharajgunj, Kathmandu, Nepal over a period of 10 months. Injuries were identified and documented using TEARS classification (tears-ecchymosis-abrasion-redness-swelling) before and after the application of toluidine blue dye (TBD). Anogenital injuries were detected in 6.7% participants (4 out of 60) before the dye application and 20% participants (12 out of 60) after the dye application. Thus, TBD application increased the detection of anogenital injuries three times compared to that of the naked-eye examination. Applying the Chi-square test, there were significant differences in the detection of tears and abrasions after TBD application (p-value - 0.035 and 0.042 respectively).

Chest wall hematoma after central venous hemodialysis catheter insertion.

There were few case reports discuss about iatrogenic chest wall hematoma. Although it is rare life threatening, it still can result in significant morbidity. A 68-year-old woman with histories of end-stage renal disease under regular hemodialysis and congestive heart failure was sent to our emergency department because of progression of ecchymosis over the anterior chest wall a few hours after hemodialysis. The right subclavian hemodialysis catheter was inserted for hemodialysis on the same day. She did not have a history of bleeding disorders and was not taking any antiplatelet or anticoagulant agents. Additionally, she had no recent trauma episodes. Physical examination revealed a large ecchymosis over the anterior right chest wall with swelling and tenderness. Blood examination showed no specific finding. Contrast-enhanced computed tomography of the chest revealed a hyperdense lesion with extravasation over the right chest wall, suggesting the presence of a hematoma with active bleeding. Local compression was applied. However, hematoma expansion was still noted. Therefore, we consulted a thoracic surgeon concerning surgical intervention. During the operation, active bleeding of the intramuscular arterial branch of the right pectoralis major was encountered. After surgical repair, no more bleeding was noted. It is important to confirm the possible cause of chest wall hematoma. Treating the underlying disease and discontinuing anticoagulation and antiplatelet agents should be considered. For iatrogenic chest wall hematoma, bleeding control should be the priority. Contrast-enhanced computed tomography could be arranged if there are no contraindications.

Cutaneous Findings of Crimean-Congo Hemorrhagic Fever: a Study of 269 Cases.

Crimean-Congo hemorrhagic fever (CCHF) is a zoonotic viral disease. We aimed to investigate the cutaneous manifestations of CCHF and reveal their associations with fatality. Two hundred and sixty-nine patients diagnosed with CCHF were assessed. Skin findings were observed in 170 (63.2%) patients. A facial rash was the most common cutaneous finding (n = 82, 30.5%). In severe cases, hemorrhagic cutaneous manifestations (petechiae and ecchymoses) were recognized. A statistically significant correlation was obtained between cutaneous manifestations and fatality, and it was determined that there was a strong positive correlation between fatality and ecchymosis (r = 567, p < 0.001). In addition, a logistic regression analysis was performed, and death occurred 4.69 times more in those with skin signs than in those without. We hypothesize that CCHF patients with ecchymosis are at the highest risk and that cutaneous findings can contribute to the prognosis of CCHF.

Physical Findings Mimicking Sexual Abuse in a Drowning Patient Who Was Treated in the Intensive Care Unit: A Report on a Fatal Case.

Specific or nonspecific findings of sexual abuse may be observed upon examination of a child. Examination of the genital area is extremely important for the identification of child sexual abuse (CSA). However, medical conditions detected in the child's genital area may be misinterpreted as signs of CSA. Herein, we present a case of a child with suspected CSA who was treated in the intensive care unit. The following incidental findings were obtained upon anal examination: dilatation, ecchymosis, laceration, and hemorrhage. This report aims to discuss the anal examination findings that can mimic CSA.