A sudden death, an aortic rupture, and an unexpected cause: a report about suspected child abuse.

All unexpected deaths of children require an autopsy to determine the cause of death. In cases of aortic rupture, the immediate cause of death is easily identified at autopsy. Although the majority of aortic ruptures are caused by high-energy trauma, other causes should not be missed.We present and discuss the case of a 29-month-old child who died suddenly at home. Her recent medical history and the ecchymotic lesions observed on external examination of the body appeared potentially suspicious of physical abuse. The autopsy concluded that death was due to complete rupture of the abdominal aorta with associated vertebral disjunction. At first glance, the overall forensic picture could suggest a traumatic death. However, careful inspection of the retroperitoneum revealed a discrete atypical mass of infiltrative tissue within the hematoma. Histopathological examinations confirmed tumor proliferation of the soft tissues, triggering vascular and spinal injuries. Other paraneoplastic elements or metastases were ultimately revealed (orbital and subcutaneous). Overall, this was a rare and fatal case of abdominal aortic rupture induced by tumors. Due to the mechanisms and the forces needed to cause vertebral dislocations and aortic rupture, the combination of the two is highly suggestive of child abuse when an accidental traumatic history is absent or inconsistent with the injuries. Nevertheless, this case illustrates the importance of a systematic and rigorous forensic examination, rather than ignoring other possible diagnoses.

Medico-legal considerations for Morel-Lavallée lesions.

The Morel-Lavallée lesion is an infrequent traumatic lesion that the forensic physician may need to evaluate during examination of a victim. Using a review of the literature and an illustrative case, the objective of this paper is to discuss the medico-legal issues (accountability, functional recovery and healing times, and aftermath) associated with Morel-Lavallée lesions. We describe the case of a 24-year-old motorcycle driver who was hit by a car. Clinically, the right lumbar region had a large 16 × 15 cm ecchymosis with subcutaneous fluid swelling found by palpation. A body scan revealed a Morel-Lavallée lesion among other lesions. On day 7, its thickness was decreased by half. Morel-Lavallée lesions are specifically induced by shearing force with moderate-to-high kinetics in an anatomical area with an underlying fascia. The associated functional disability is globally moderate, but a large lesion or recurrences can extend the time needed to recover. Apart from some exceptions, care without any delay in diagnosis and treatment allows evolution of the lesion without functional consequences, but these lesions are frequently unnoticed in the initial phase.

Determination of the age of bruises using a bilirubinometer.

The dating of bruises can be of crucial interest in clinical forensic medicine, but the macroscopic or photographic evaluation of a bruise has not been regarded as reliable. Several methods have thus been regularly evaluated for this purpose, with reflectance spectrometry yielding promising results. The objective of this study is to evaluate the value of a bilirubinometer as a tool for dating bruises on living victims. A clinical follow-up was carried out on patients presenting a bruise with a known onset. Using a bilirubinometer, we obtained daily measurements of the bruise (bili-bruise) and of healthy skin (bili-skin). Potential confounding factors were collected: age, sex, body mass index, trauma mechanism and Fitzpatrick skin phototype. We followed 20 patients for a total of 88 measurements of bruises. Bili-skin values showed significant differences according to skin phototype. Differences between the bili-bruise and bili-skin values (Δ-bili) followed an increase phase, peaking between 3 and 5 days, and then there was a decrease phase. No significant Δ-bili value differences were observed based on the suspected confounding factors. Our results are in favour of a peak Δ-bili value generally at day 4 or 5 post-trauma. Notably, decreasing values were not observed before day 3. Decreasing Δ-bili values would then indicate a bruise resulting from an injury formed at least 3 days before the first measurement. Complementary work confirming such data would enable improvement of the performance of bruise dating in forensic medicine.

Fatal Overdose of Gamma-hydroxybutyrate Acid After Ingestion of 1,4-Butanediol.

We report a case of fatal intoxication from 1,4-butanediol (1,4-BD), which was ingested by a young and "naïve" gamma-hydroxybutyrate (GHB) consumer during a party with the co-ingestion of alcohol, cannabis, and methylene-dioxy-methamphetamine. The following drug concentrations were found using gas chromatography coupled with mass spectrometry on autopsy samples and on a cup and a glass found at the scene: 20,350 mg/L (bottle) for 1,4-BD; 1020 mg/L (femoral blood), 3380 mg/L (cardiac blood), 47,280 mg/L (gastric content), and 570 mg/L (vitreous humor) for GHB. The concentration of GHB is difficult to interpret in forensic cases due to the possibility of an endogenous production of GHB. The variable tolerance of the user may also modify the peri- and postmortem GHB concentrations. This case underscores the need to have many different sources of toxicology samples analyzed to avoid the hypothesis of endogenous production of GHB.

Is bone analysis with µCT useful for short postmortem interval estimation?

The evaluation of the postmortem interval (PMI) is an important consideration in forensic medicine. The time between death and the discovery thereof is extremely important, not only in terms of the legal process, but also for the course of the investigation. At the time of the discovery of human bones, the evaluation of the PMI is extremely difficult. To date, there is no really effective tool for this evaluation. The objective of our study is to characterize the architectural modifications of human bones using micro-tomography (µCT) in the postmortem period. Ten bone samples were extracted from a single fresh human cranial vault (no freezing, no embalming) from a body donation. The samples were conserved in a controlled environment (a laboratory hood at 20 °C with 60% humidity) for 10 weeks. Every 2 weeks after the death and the sample extraction from the vault, the samples were analyzed with µCT (resolution 10 µm, Bruker HR1172 ®). The 3D analysis focused on general 3D data related to the trabeculae: the total volume (TV), the bone volume (BV), and the bone surface (BS), as well as specific trabeculae data; namely: the number of trabeculae (TbN), trabecular thickness (TbTh), the average distance between the trabeculae (TbSp), and the trabecular pattern factor (TbPf). Each sample was observed separately and compared to itself over time; no comparisons among samples were made. We used a linear mixed model for repeated measures (an unstructured covariance pattern model) and post hoc comparisons between each consecutive time using linear contrast with an SAS software package, release 9.3 (SAS Institute, Cary, NC). We showed a statistical difference for BS/BV (p = 0.046) over time, with a significant decrease during the first 2 weeks (p = 0.003; mean decrease, - 0.99, 95% CI [- 1.61; - 0.36]), while TbSp (p < 0.0001) showed a significant increase during the first 2 weeks (p < 0.0001; mean increase, 0.022, 95% CI, [- 0.016; - 0.028]).Our study highlighted architectural trabecular modifications on postmortem bones using the µCT. These modifications occurred at an early stage, during the first 2 weeks of conservation. Complementary work will need to be performed to allow for better understanding of the biological phenomena observed and to create databases of osseous taphonomy, starting with various individuals, mediums of conservation, types of bone, and with varying techniques for analysis.

Domestic Predation of an Elder: A Fatal Dog Attack Case.

We present the case of a 91-year-old woman lived alone at her home with two domestic dogs, that is,, a Labrador Retriever and a Staffordshire Bull Terrier and found dead. The investigation of the scene revealed that the Bull Terrier's jawbone and chest were covered with blood. The autopsy revealed multiple, histologically confirmed, life-threatening skin and bone lacerations without scavenging marks. The punctures and tearing of each of the wounds on the skin were compatible with bites. A left humeral fracture and multiple fractures of the right facial bones were observed. The death was attributed to external hemorrhages due to several dog bites. A veterinary physical and behavioral examination indicated that the Bull Terrier was involved in the attack. A domestic predation hypothesis was deemed here most likely due to the presence of food supplies at the scene, the dog's previous history of attack, and the breed of the dog.

The precision of micro-tomography in bone taphonomic experiments and the importance of registration.

Micro-computed tomography (µCT) provides micrometric 3D images and has been used in forensic studies for anthropology pubis measurement or insect description for post mortem interval estimation. Studies have suggested using registration, a superimposing images method between a reference and a target. This technique avoids positioning bias and increase the precision of µCT. However, no clear study has reported the precision with µCT analysis before or after registration in a forensic field. One fresh post mortem sample of a human cranial vault was collected. Two successive µCT acquisitions (resolution 10µm) of it were performed without repositioning. The data from the second acquisition were copied and registered by two trained operators (operators 1 and 2). Operator 1 performed a second registration process after 1 week (operator 1 bis). The images were analysed. The bone volume (BV), bone surface (BS), number of trabeculae (TbN), trabecular thickness (TbTh) and mean trabecular distance (TbSp) were compared before and after registration. The mean (±SD), the coefficient of variation (%CV), and the precision error of the standard deviation absolute value and of the coefficient of variation between operators 1 and 2 (inter-subject variability) and between operator 1 and 1 bis (intra-subject variability) were calculated. We also collected the second phalanx of the 2nd, 3rd and 4th fingers on the hands of a second individual. Two successive scans (resolution 27µm) were performed without repositioning. A comparison (mean±SD of BV, BS, TbN, TbTh, TbSp) was made between the first and second scans with and without registration, and an ANOVA repeated measures procedure was performed. For the vault, we show that after 30 registrations for each operator (1, 2 and 1 bis), the mean and %CV were very close for each variable and between operators. For BV and BS, the difference in the mean value was approximately 0.01 (mm3 and mm2, respectively). The precision error was higher in the inter-subject registrations for each variable. The precision error magnitude for all variables was very low (<0.01) in absolute value and of %CV. For the fingers, the difference between the first and second scans may be approximately 50% without registration. We found that the second scan without registration is significantly different for BV (p=0.006), BS (p=0.007), TbN (p=0.019) and TbSp (p=0.002). Knowing the precision of the device (with and without registration) is important to ensure that the accuracy of the µCT results.

Technical note: early post-mortem changes of human bone in taphonomy with µCT.

Post-mortem interval (PMI) estimation is an important issue in forensic medicine, particularly for criminal purposes and legal limitation periods. The goal of the present study is to examine the evolution of the trabecular cranial vault bone after 4 weeks of conservation in a controlled environment with micro-tomography (µCT) analyses.Four bone samples were extracted from a fresh human cranial vault (a donation to science according to the French law) and conserved in an air-controlled environment. The samples were weighed and µCT scanned at a 10-µm resolution every week after death for a month. The µCT features were identical for every sample. Each set of data from the µCTs was reconstructed, registered, and analyzed in terms of the total volume, bone volume, bone surface, number of trabeculae, trabeculae thickness, and mean distance of the trabeculae. The samples were conserved in a glass box in 20 °C air with 60% humidity in a laboratory hood between each µCT acquisition. Descriptive statistics were determined. Each sample was observed and compared to itself over time.After 1 month of conservation, the mean bone volume (-1.9%), bone surface (-5.1%), and trabecular number (-12.35%) decreased, whereas the mean trabecular separation (+5.55%) and trabecular thickness (+12.7%) increased. Many variations (i.e., increases and decreases) were observed between the extraction of the sample and the end of the 4 weeks of conservation. The present observations may be explained by bone diagenesis. Previous observations have indicated that protein and lipid losses occur with bone weight and volume losses. These diagenesis effects may explain the trabecular modifications observed in the present work. We observed many bone variations with the µCT scans between the beginning and the end of the conservation that had no explanations. Additional studies, particularly studies involving statistics, need to be performed to confirm our observations and explain these results more clearly.

Extensive Necrotic Purpura in Levamisole-Adulterated Cocaine Abuse - A Case Report.

Levamisole, which is used as an adulterated compound of cocaine, is currently being seen year after year in cocaine intoxication. For a few cases in the last decade, necrotic purpura and neutropenia after levamisole/cocaine intoxication have been described in the medical community. Herein, we present an original case of levamisole intoxication of a 40-year-old woman who smoked heroin and cocaine few during a month. She rapidly presented an extensive necrotic purpura of the nose, cheeks and extremities (lower and upper), and immunologic reactions (positive anti-MPO and anti-HNE). Levamisole was detected on hairs with ultra-high performance liquid chromatography and tandem mass spectrometry. The case reports also a probable cocaine supplier deceit, which bring pure drug for hospital investigation after the intoxication of his client. The intoxicated woman had survived with several skin and chronic pain complications. That case recalls the knowledge about levamisole with a short review of the forensic literature.

Cyanide Suicide After Deep Web Shopping: A Case Report.

Cyanide is a product that is known for its use in industrial or laboratory processes, as well as for intentional intoxication. The toxicity of cyanide is well described in humans with rapid inhibition of cellular aerobic metabolism after ingestion or inhalation, leading to severe clinical effects that are frequently lethal. We report the case of a young white man found dead in a hotel room after self-poisoning with cyanide ordered in the deep Web. This case shows a probable complex suicide kit use including cyanide, as a lethal tool, and dextromethorphan, as a sedative and anxiolytic substance. This case is an original example of the emerging deep Web shopping in illegal drug procurement.

Effects of the environment on bone mass: A human taphonomic study.

An experiment was designed using human ribs placed in different environments to document how moisture and temperature affect the bone mass according to the postmortem interval. The bones were defleshed, weighed and partially buried, with some ribs being left unburied as controls. The ribs were weighed daily, and the mass loss was monitored over a period of 90days. The results showed that significant differences in bone mass loss exist between environments, where the bone mass loss was significantly faster in an environment with low moisture content. This mass loss is thought to be primarily associated with the desiccation of the body and then for a greater part, with the atmospheric moisture content. However, the loss of bone mass can also be explained by early alterations in the organo-mineral matrix which were highlighted by Raman spectroscopy method.

The mechanism of the keyhole lesion reassessed: An experimental approach.

The initial description of the keyhole defect was detailed as a peculiar gunshot entrance wound in the cranial vault due to firearm discharge in a tangential path. This injury may be described in two parts: a rounded section with inner table beveling and a triangular section with outer table beveling. We report a case of a gunshot skull wound "keyhole" shaped, appeared to have been made perpendicularly to the bone. Performing an experimental study on cranial bones with shots made perpendicularly to the skull approved this hypothesis, and bone injuries were then architecturally characterised using high-resolution micro computed tomography. The singular link between the tangential gunshot path and the keyhole pattern has been refuted several times, and some authors have hypothesised that there is an important role for concentric fractures that occur far away from the initial impact point of the bullet. Micro computed tomography analysis of the bone showed these keyhole defect features with a particular high description. Then, the whole pattern has a spider-web effect, and these concentric fractures could explain the keyhole pattern even in a perpendicular gunshot path.

Homemade Firearm Suicide With Dumbbell Pipe Triggering by an Air-Compressed Gun: Case Report and Review of Literature.

Firearm suicides are frequent and well described in the forensic literature, particularly in Europe and the United States. However, the use of homemade and improvised firearms is less well described. The present case reports a suicide with an original improvised gun created using an air-compressed pellet gun and a dumbbell pipe. The aims of this study were to describe the scene, the external examination of the corpse, the body scan, and the autopsy; to understand the mechanism of death; and to compare the results with a review of the forensic literature to highlight the epidemiology of homemade firearm use, the tools used for homemade and improvised firearms in suicides versus homicides, and the manners in which homemade firearms are used (homicide or suicide, particularly in complex suicide cases).