Two Bullet Wounds, One Bullet: The Atypical Fragmentation of a .223 Caliber Ammunition.

ABSTRACT: As the fifth leading cause of death in individuals aged 1 to 64 years in the United States, forensic pathologists frequently encounter firearm-related deaths and are trained to approach these cases by utilizing information from the investigation, radiographs, and autopsy findings to discern the logical sequence of events that lead to death. We also emphasize the importance and utility of various factors such as bullet wound characteristics, type of ammunition used, and type of tissues involved in a forensic pathologist's determination of events and in medicolegal investigations. However, the unusual presentations of firearm-related deaths can cause confusion and even frustration when there are contradicting circumstances or findings at work. We present the case of a 61-year-old woman with an atypical pattern of 2 distinct irregular entrance gunshot wounds determined to be caused by a single projectile.

Suicide Via Multiple Shotgun Wounds: A Case Report and Review of Literature.

ABSTRACT: Suicide via multiple gunshot wounds is an uncommonly encountered phenomenon, which is important to recognize in the forensic community. Suicide by multiple shotgun wounds is a fleeting rare entity with few previously reported cases in the literature. In a review of autopsies performed at our institution during a 20-year period from 2000 to 2020, only 4 prior cases of suicide by multiple gunshot wounds were identified with no previously recorded cases of suicide by multiple shotgun wounds. Here we describe the case of a 20-year-old man with a history of depression who was discovered deceased in his secured residence with shotgun wounds of the head, neck, and chest. Because of the presence of 3 shotgun wounds, coupled with concerning initial investigative findings, an autopsy was performed. We illustrate how careful examination of the wounds and thorough investigation can allow for reconstruction of a plausible self-inflicted wound scenario.

A pen as an intermediate target becomes a secondary projectile.

Firearm projectiles striking intermediate targets have the potential to create secondary projectiles, which can produce identifiable patterns of injury. We present a case in which a father, manipulating a handgun, was demonstrating how the firing pin worked to his adolescent son. He placed a pen inside the barrel of the gun for demonstration but did not recognize that a bullet was loaded into the firing chamber. The weapon was discharged causing fatal injury to the son. The pen, as an intermediate target, created identifiable injuries on the decedent, which were consistent with typical patterns of injury seen with secondary projectiles including a discrepant number of skin defects to number of counted projectiles and pseudo-stippling. Recognition of these identifiable patterns of injury in intermediate target involved gunshot wound cases can help support other autopsy findings and scene investigation.

Suicidal iron overdose: A case report and review of literature.

Acute iron toxicity in adults is rare, usually occurring due to intentional ingestion in suicide attempts. Few cases of the clinical and autopsy findings in acute iron toxicity have previously been reported in the literature. Ingestion of large amounts of iron salts can lead to hemorrhagic shock, multi-system organ failure, coagulopathy, and death. We present the case of a 25-year-old man who reportedly ingested a large quantity of iron tablets along with ethanol in a suicide attempt and subsequently died approximately 65.5 h later. His clinical course and laboratory findings demonstrated hepatic and renal compromise with markedly elevated serum iron levels. At autopsy, iron encrustations were present over the gastric rugae. Superficial deposits of stainable iron were present overlying areas of mucosal necrosis with underlying submucosal fibrin thrombi. No significant stainable iron was present in the liver. Literature review revealed that the clinical course and laboratory testing of severe acute iron overdose is fairly non-specific. The length and type of treatment may alter the clinical course and laboratory results. Peak serum iron levels may be helpful in differentiating acute toxicity from chronic iron overload states. Gross findings of gastric iron encrustation are specific for acute ingestion when present.

Sudden Unexpected Death in a Child From Acute Myeloid Leukemia.

ABSTRACT: Acute myeloid leukemia can rarely cause sudden, unexpected death in children. Presentation may be non-specific and death may occur in children with no prior medical history. Herein we present the case of a previously healthy 2-year and 2 month-old White girl, who on autopsy, was found to have acute myeloid leukemia with KMT2A rearrangement extensively involving all major thoracic and abdominal organs. This case is presented to the forensic community to discuss the presentation and findings in sudden death caused by acute leukemia. The case highlights when acute leukemia should enter the differential as a potential cause of death, as well as potential resources available in the postmortem workup of acute leukemias.

Hyperoxalosis Secondary to Intravenous Vitamin C Administration as a Non-Allopathic Treatment for Cancer.

Vitamin C (ascorbic acid) has long been known to have antioxidant properties, with associated claims that it can boost the immune system, fight off infection, and help in the treatment of cancer. Similar to many other over-the-counter and herbal medicines, vitamin C can cause potential side effects with significant morbidity and rarely mortality. We discuss a case of an elderly woman with metastatic adenocarcinoma of the lung that was treated with several rounds of allopathic chemotherapy; however, treatment was stopped because of worsening quality of life and disease progression. She was treated with 10 courses of intravenous high-dose vitamin C at a local homeopathic medical center as an alternative treatment method. Five days after the last vitamin C administration, she was admitted to an allopathic hospital due to acute renal failure and oliguria culminating in a myocardial infarct due to underlying atherosclerotic disease. Workup revealed dehydration secondary to poor oral intake and acute renal failure which was clinically concerning for calcium oxalate- induced kidney injury. At the time of autopsy, in addition to her widely metastatic adenocarcinoma and myocardial damage, hyperoxalosis of the kidney with acute kidney injury was present. Hyperoxalosis of the kidney is a documented phenomenon related to administration of intravenous and oral vitamin C at superphysiologic doses as recommended by some natural and homeopathic practitioners and is, therefore, a significant complication of treatment. This case highlights the renal complications of supertherapeutic vitamin C administration and the associated morbidity which can contribute to death.

Forensic Radiology Pitfalls: CT Imaging in Gunshot Wounds of the Head.

Computed tomography (CT) imaging is increasingly used in emergency departments and trauma services and is being offered as a supplemental tool with autopsy in coroner's and medical examiner's offices throughout the United States. The availability of CT images in lieu of traditional X-rays for medicolegal autopsies may lead to misinterpretation of images for forensic pathologists who are not familiar with these types of images. Forensic pathologists must become familiar with CT imaging, the basis of CT image formation and how to interpret CT images appropriately. We highlight potential pitfalls of CT image interpretation through two cases of fatal gunshot wounds of the head. Antemortem CT imaging available at the time of autopsy led to discrepancy between the initial image findings and the autopsy due to inexperienced manipulation of the images. With appropriate understanding of CT image interpretation and manipulation, forensic personnel should be able to avoid most sources of misinterpretation.