Wischnewsky spots are disseminated, dark lesions in gastric mucosa reflecting hemorrhage associated with fatal hypothermia, and are a phenomenon well known to forensic pathologists. We applied luminol and leucomalachite green tests to formalin-fixed gastric mucosa with Wischnewsky spots in autopsy cases of hypothermia. Both luminol and leucomalachite green tests showed positive reactions. We describe the technical significance of these tests in forensic diagnosis, in that luminol and leucomalachite green tests may be useful in forensic autopsy cases, and may also be useful for formalin-fixed organs.

While abrasions and lacerations are typically easily identified, darker pigmentation of the skin may obscure contusions. Forensic pathology literature shows a disproportionate number of illustrations of contusions on lighter skin tones compared to darker ones. Skin and soft tissue dissection is the most reliable method to confirm contusions.The authors seek to establish a correlation between skin tone and the visual identification of contusions, confirmed by soft tissue dissection. Additionally, they aim to determine the utility of specialized dissections for identifying contusions on different skin tones to identify cases that may benefit from such procedures.A review of cases from the Cook County Medical Examiner's Office from 2014 to 2024 was conducted. The office database was searched for deaths in custody, causes including "assault," and "child abuse." Autopsy photos were compiled into predissection and postdissection sets, reviewed for skin tone, visual identification of contusions, and final confirmation of soft tissue hemorrhage.Results found a negative association between skin color and accurate visual identification of contusions and determined that decedents with a skin tone of 7 or higher on the Massey-Martin scale may benefit from specialized dissections.

Forensic investigation of intrauterine and perinatal deaths can be challenging, given their relative infrequency and the possible involvement of maternal substance use, trauma, and socioeconomic factors. Intrauterine and perinatal deaths investigated by the Cuyahoga County Medical Examiner's Officer between 2013-2023 were reviewed. One hundred twenty-eight cases were identified (83 stillborn and 45 live births). The predominant indications for referral were concern for maternal substance use (57.8%) or trauma (35.2%). Gestational ages ranged from 11.5 to 42.5 weeks; 36.7% were <22 weeks, and only 10.2% were full term (>37 weeks). The maternal age range was 16-41 years, with most (65.2%) between 20-34 years. Not all case files included obstetric history or home address; of those which did, 53.0% received no prenatal care and 81.7% came from zip codes in the bottom quartile of household incomes. Causes of death included acute and/or chronic maternal substance use (28.9%), chorioamnionitis (21.9%), and abruption (19.5%). Manners of death (when applicable) included natural (53.3%), accident (26.7%), homicide (8.9%), and undetermined/unassigned (11.1%). Potentially confounding socioeconomic factors were identified in most cases. This demonstrates the importance of considering these factors and exercising caution when assigning specific causes and manners to intrauterine and perinatal deaths.

Necrotizing wound infections are potentially lethal complications of surgeries, including cesarean deliveries. A 32-year-old female with obesity and hidradenitis suppurativa (HS) underwent uncomplicated cesarean section. Four days later, she developed abdominal pain and imaging showed ascites; she was treated with antibiotics. She progressed to septic shock and expired the following day from cardiopulmonary arrest. Hospital blood cultures grew no microorganisms. Autopsy revealed soft tissue purulence around the incision and copious purulent ascites without evidence of tubo-ovarian abscess, retained products of conception, or emboli. Microscopic examination of the tissues demonstrated inflammatory debris with neutrophils and gram-positive cocciform bacteria. Postmortem bacterial cultures had no growth. Paraffin blocks submitted to the Centers for Disease Control Infectious Disease Pathology Branch revealed Streptococcus pyogenes. Historically, group A streptococcus (GAS) was a major cause of peripartum mortality, and the prevalence of puerperal sepsis-associated deaths declined with antibiotic usage. Although the rates of mortality have remained stable in the United States, GAS has made a resurgence over recent decades. Additionally, there is some evidence in the literature of cutaneous bacterial biofilms associated with HS. Theoretically, this could have increased the risk of perioperative infection due to colonization or secondary infection of HS lesions.

Pedestrian and bicyclist fatalities have increased over the past decade in the United States. Factors proposed to explain this increase include the increased popularity of larger passenger vehicles, road design to accommodate faster-moving traffic, and poor road infrastructure. We analyzed a series of 102 pedestrian and bicyclist fatalities to determine which factors were involved. Results demonstrated substance abuse as the most common pertinent decedent medical history, a disproportionate number of crashes occurred during evening/nighttime hours, and most crashes involved larger passenger vehicles. The percentage of cases involving sport utility vehicles (SUVs) has increased over time. Injury pattern analysis demonstrated that smaller passenger vehicles at lower speeds were more likely to cause lower extremity fractures compared to SUVs. Alcohol was the most common decedent substance detected on toxicology, and decedents with a previous mental health history were more likely to have positive toxicology for illicit substances than those without. Sixty-three percent of cases lacked sidewalks, and 85% of cases lacked bike lanes. We compared the trends that we saw on a small scale to those seen nationally and uncovered certain novel associations from the perspective of medical examination.

Deaths by homemade suicide machines naturally capture public attention given the sensationalism of the subject matter and the complexity of the mechanisms involved. In this case, a self-made apparatus designed to administer a fatal dose of fentanyl, leading to an intentional acute toxicity, was used. As detailed in his 19-page manifesto discovered posthumously, the decedent engineered this device with the express purpose of testing the Many-Worlds Interpretation of quantum mechanics. This interpretation posits that for every time one outcome is observed, there are "parallel universes" in which a different outcome becomes reality; these "parallel universes" are collectively called the "multiverse." By programming his homemade device to kill the versions of himself in the "parallel universes" where he did not achieve a desired outcome-that is, having the winning numbers of a Powerball lottery drawing-the decedent sought to experience a reality where he did win the lottery, which would somehow through his convoluted logic thereby prove the existence of the "multiverse."Initially, the bizarre details of the scene led investigators to consider possibilities like intentional electrocution or even homicide executed by remote means. Thorough death scene and background investigation was critical to determine that it was an elaborate act of suicide.

There are few reports that discuss the nebulous entity known as posttraumatic subacute meningitis. Herein, we describe a case where a male was found deceased with Streptococcus pyogenes meningitis 7 days after experiencing head trauma inflicted with a tow chain. Computed tomography scan prior to death revealed a scalp laceration with subcutaneous gas and a subdural hematoma. On autopsy, the lacerations had exposed the cranial bone, but no fracture was identified. Purulence and a pinpoint defect were observed on the dura. Histologic sections of the dura and brain showed a chronic inflammatory infiltrate, ventriculitis, and vascular involvement by bacteria. Toxicology studies were positive for methamphetamine, fentanyl, and oxycodone. Post-mortem cerebrospinal fluid and blood cultures grew S. pyogenes, complementing the gram-staining of the bacteria seen in the brain sections.While the overlying parietal bone in the area of purulence was notably thinned, a direct route of infection from the soft tissue laceration to the meninges was not grossly identified. The middle ear mastoid cells did not display purulence, and the antemortem computed tomography scan did not provide any support for an otorhinolaryngeal source for the Streptococcus meningitis. To our knowledge, this is the first published report linking head trauma to S. pyogenes meningitis.

The sudden death of a previously healthy infant is a devastating event for a family-the death of 2 even more unimaginable. Prior to the debunking of Meadow's law, a legal concept attributing multiple unexplained infant deaths to Munchausen by proxy, these events could lead to the wrongful prosecution of those who had lost their children to "sudden unexpected infant death (SUID)." Today, these cases, wherein multiple infants within one family pass inexplicably, raise suspicion for a possible genetic cause and point toward a need for postmortem genetic testing.We present the case of 2 siblings who passed suddenly in infancy, with no structural cause of death identified at autopsy. Genetic testing in both infants found the same variant of uncertain significance, a heterozygous single nucleotide substitution, denoted c.3191C>T, in SCN10A, which encodes a sodium channel with pathogenic variants possibly implicated in sudden cardiac death syndromes. Although it is unclear at this time if the variant of uncertain significance identified was a contributing factor in the deaths, the case emphasized the importance of involving a multidisciplinary team to ensure appropriate pretest and posttest counseling, interpretation of nuanced testing results, and medical follow-up for surviving family members of SUID.

Tension gastrothorax is a rare and potentially fatal complication of a diaphragmatic hernia, in which a massively dilated, intrathoracic stomach compresses the lungs and mediastinum, causing cardiorespiratory compromise, in a mechanism akin to tension pneumothorax. Although it is very rare, tension gastrothorax has been reported in the literature; however, such reports are almost exclusively restricted to its clinical presentation and treatment in emergency departments. To the best of our knowledge, no adult autopsy case reports of tension gastrothorax have been reported in the literature. We present 2 adult autopsy case reports in which we believe the cause of death was tension gastrothorax, followed by a discussion of what a tension gastrothorax is and its potential etiology, and finally, we discuss the difficulties of making the diagnosis at autopsy, including how postmortem computed tomography imaging can be hugely beneficial as it was in one of our cases.

Chronic alcohol exposure is common in all societies and is seen at high rates during coronial (medicolegal) postmortem examinations. In both setting of acute alcohol intoxication and chronic misuse, a wide range of pathologies and mechanisms of death may be encountered, particularly with regard to sudden, unexpected or violent deaths. These warrant special attention. In this review, we examine the approach to postmortem examination where alcohol is likely to have played a key role in death. Attention is given to the scene of death, patterns of traumatic injury, systemic pathology (particularly of chronic alcohol exposure), seizures related to alcohol, and appropriate biochemical investigations.

Constipation is found in individuals with intellectual disabilities, autism, and cerebral palsy. Although generally a benign condition, it may lead to life-threatening intestinal obstruction, with or without volvulus, or to stercoral ulceration with enteritis and/or perforation. Two unusual cases of lethal chronic constipation are reported to demonstrate other very rare fatal mechanisms that may occur. Case 1: A 17-year-old male with cerebral palsy and autism was found deceased in bed. Death was due to pulmonary thromboembolism arising from compression of pelvic veins by acquired megacolon due to constipation (fecal mass 4.6 kg). Case 2: A second 17-year-old male with intellectual disability, global developmental delay, attention deficit disorder, seizures, and hypotonia collapsed and died during a medical evacuation from a remote community. Death was due to abdominal compartment syndrome in the context of medical air transport (medical retrieval), chronic constipation with acquired megacolon and megarectum (fecal mass 6.5 kg), global developmental delay, intellectual disability, and a suspected underlying genetic syndrome. These cases demonstrate that individuals with constipation may present for medicolegal assessment following sudden collapse/death and that pulmonary thromboembolism and abdominal compartment syndrome should be considered as rare possibilities in the evaluation of vulnerable individuals.

Stillborn and perinatal deaths may be referred to medical examiners and coroners for investigation and determination of cause and/or manner of death. One of the key questions is determining a live birth from a stillbirth. We surveyed 147 forensic pathologists to assess their investigative practices for these deaths and for their ability to diagnose a live birth and a stillbirth. The results of this survey demonstrate the wide variability of investigative practices and policies between offices within the United States. Clinical history, maceration of the fetus, and food in the stomach were the only 3 factors considered by a majority of forensic pathologists to reliably distinguish liveborn from stillborn infants. High-quality research and expert guidance from national organizations are needed to ensure standardized adoption of evidence-based practices. The investigation and certification of these deaths is complex, yet the determination of stillborn or liveborn and cause and manner of death can have significant legal implications for the mother.