Multidrug-related leukocytoclastic vasculitis raising suspicion of sexual homicide-things are not always what they seem

Occult cardiac amyloidosis: the last chapter of a 2-year long story

Amyloidosis is characterized by deposition of insoluble fibrillar proteins in organs and tissues. The prognosis depends on where in the body amyloid deposition occurs, the amount of deposition, and the symptoms, which are often unspecific. Cardiac involvement is commonly associated with the immunoglobulin light-chain amyloidosis (AL) and may lead to sudden death. The case of a 53-year-old man's death due to unsuspected, undiagnosed AL predominantly involving the myocardium has been reported. His medical history had begun with gastroenterological symptoms. Angina pectoris and brain stroke occurred in the following years. He died after two years during the surgical implantation of a cardioverter-defibrillator because of cardiogenic shock. Post-mortem histologic examination revealed the presence of amyloid material in the lymph nodes, lungs, liver, spleen, kidneys, adrenal glands, stomach, and heart. The cause of death was cardiac failure secondary to primary systemic amyloidosis predominantly involving the heart. This case demonstrates that amyloidosis should be considered within the differential diagnoses and actively investigated in patients with unspecific and long-lasting symptoms; medical liability may also be suspected.

A mimic of sexually-motivated homicide: insect stings and heat exhaustion in a forest

We report the case a woman who was found dead in a forest. The body was nude and the position of the body suggested a sexually motivated homicide. We concluded that death was not related to homicide, but was related to the conjunction of environmental factors, including insect stings, and acute psychosis. A medicolegal death investigation with postmortem examination was undertaken to determine cause of death. At the scene, the body was supine with legs spread apart and the knees flexed, exposing the external genitalia. There were multiple apparent bruises on the body and neck. At autopsy, based on macroscopic and microscopic examination, the apparent bruises were found to be hemorrhagic insect bites. No significant injuries were present and no semen was found. Death appeared to be related to heat exhaustion and innumerable insect stings. Investigation of the medical history revealed longstanding schizoaffective disorder with episodic psychotic decompensations. In the past, during an acute psychotic episode the decedent removed her clothing and ran wildly in a forest, until she was rescued in a state of exhaustion and marked agitation, and taken to hospital for treatment. We concluded that the same circumstances had been repeated but with a fatal outcome. This case is an example of a mimic of sexually-motivated homicide and is a reminder to forensic pathologists to avoid tunnel vision. We need to be skeptical of the allure of common sense based on first impressions of the scene and the body. Forensic pathologists must be unafraid to scientifically explore improbable, but true, alternate explanations.