Forensic Medicine: Case 2
Author(s): Flora Campbell and Ralph Bouhaidar
For the purposes of this case study, imagine that you are the forensic histopathology trainee who has been set the task of formulating a likely cause of death.
Part 1 of 11
Police were called to the address of Maureen Smith, a 81 year old female, at approximately 1145 of 15th November, following concerns from a neighbour that she had not been seen for a while.
Following their inquiries, you have been provided with a copy of the police report.
Police Sudden Death Report:
- The deceased was found in her own home which she owns and lives alone.
- The deceased was last seen by her neighbour a few days prior.
- The neighbour reports occasionally seeing the deceased take in deliveries but has rarely seen her leave the house.
- On seeing the curtains closed and mail piling up after returning from a trip the neighbour called the police.
- Police arrived at 1115 on 15th November and forced entry to the property.
- The deceased was found in the kitchen and life pronounced extinct at 1118. Cardiopulmonary resuscitation was not attempted.
- The police noted the deceased was partially undressed, underneath the kitchen table and a window was open.
- The house was in a state of disarray but on searching the house, there did not appear to be anything taken.
General Practitioner (GP) Summary Part 2 of 11
Post Mortem: External Examination Part 3 of 11
Post Mortem: Internal Examination Part 4 of 11
Preliminary Cause of Death Part 5 of 11
You have taken a number of samples, including tissue samples for histology and a sample of ilio-femoral blood, urine and vitreous humour for toxicological analysis.
In the interim, you conclude that there is no evidence that this is a suspicious death. Although initially the scene looked suspicious, there are no signs or injuries to suspect there has been any foul play. You issue a death certificate as follows:
1a Unascertained, pending laboratory studies
This means that the body of the Deceased can be released to the family while investigations are pending, which could take some time.
Histology Part 6 of 11
Toxicology Part 7 of 11
The toxicology screen comes back negative.
Death Certificate Part 8 of 11
Summary of Findings Part 9 of 11
Hypothermia occurs when the body’s temperature is 35 degrees or less. Clinically is is categorised into mild, moderate or severe depending on the temperature. It can occur as a primary event; with a drop in environmental temperature the bodies mechanisms of preventing heat loss are insufficient or it can occur secondarily; when the bodies ability to maintain core temperature are hindered due to underlying medical problems.
The very old and very young have been identified as being high risk for hypothermia. In the elderly, this risk may be further enhanced by physiologic reductions in muscle and fat, chronic diseases such as hypothyroidism, undernourishment and socioeconomic issues such as lack of food, inadequate clothing or poor indoor heating.
In this case, the deceased has several risk factors for fatal hypothermia including her age, anorexia and hypothyroidism.
The finding of the deceased in a seemingly strange place and partially undressed is initially cause for alarm. However this phenomenon has been described not infrequently. The so called ‘hide and die’ syndrome. The deceased is usually an old person and when found dead may be partially or completely naked, in addition they appear to be hiding out of sight, and can be found burrowed in corners or cupboards with furniture pulled on top of them or in a heap. The setting may be in such a state of disorder that a homicide or robbery may be suspected. It is not clear if in these cases the deceased became hypothermic first, which led to mental confusion that caused the strange behaviour or whether the deceased due to some mental aberration (perhaps underlying cognitive impairment) started acting strangely including taking off their clothes which caused them to become fatally hypothermic.
The deceased’s brain showed signs in keeping with a cognitive impairment, however it is not possible to say how this would have manifested clinically and when they were alive.
There may be no signs at post mortem in a death from hypothermia and therefore the history is important. The findings may be slight, non specific or absent. In the classical example, the deceased will be an elderly person and the external examination will show ‘freeze erythema’ – pink-brown patches over the extensor surfaces of the joints and the extremities may be cyanosed or white. The face may show features suggestive of hypothyroidism, such as puffy eyes and loss of eyebrow hair.
Internally, there may be no specific features. Coronary artery disease, hypertension, chronic kidney disease and obstructive airways disease are common.
More specific lesions are;
- Acute gastric erosions or Wischnewsky spots
- Microinfarcts – from cold agglutinins occluding small vessels
Test yourself! Part 10 of 11
Take home points Part 11 of 11
Risk factors for Hypothermia include; Extremes of age, hypothyroidism, poor nutrition and low environmental temperature
There are no specific post mortem findings in hypothermia but they can include; Frost erythema, Wischnewsky’s spots, pulmonary oedema, pancreatitis and tubular necrosis.
‘Hide and die’ syndrome can raise suspicions about foul play and is commonly seen in the elderly.