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The SARS-CoV-2 pandemic involved several changes and difficulties in the work of forensic pathologists. Postmortem nasopharyngeal swabs for the diagnosis of the SARS-CoV-2 infection are recommended before an autopsy examination by the Centers for Disease Control and Prevention.Autopsy examinations must not be performed for SARS-CoV-2 infection cases when airborne infection isolation rooms or other suitable spaces are unavailable. However, it has not yet been reported whether the presence of SARS-CoV-2 at a low viral load may be enough to infect and disseminate the contagion.Here, we report the case of a 67-year-old man found dead at home on November 9, 2020, and transferred immediately after to the Genova District Mortuary. As the first postmortem molecular nasopharyngeal swab resulted positive, a weekly sampling was carried until February 4, 2021. All the molecular tests were positive for SARS-CoV-2, including the last swab performed 87 days after the arrival of the corpse at the morgue. Virus isolation conducted on VERO E6 cells revealed no cytopathic effect indicating no viral replication as early as 18 days after the corpse's arrival at the morgue and until January 2021.Our findings suggest that the presence of the genome of SARS-CoV-2 at low viral load should not be considered a sign of an active infection but a trace of a remaining viral genome from a previous infection. Then, if the virus shows no replication activity, its molecular detection should not constitute a threat to public health. Further studies are required to establish the infection's potential and its correlation with viral load.

We report the case of a 28-year-old patient with a history of post-traumatic epilepsy who, following a spinal cord injury and the onset of nosocomial infection, went into a deep coma. A brain MRI revealed non-specific findings, anti-Glutamate Receptor 3 (GluR3) auto-antibodies were detected in the liquor, and the patient's serum and immunomodulatory therapy proved ineffective. Autopsy and histological investigations led to the diagnosis of autoimmune encephalitis. This case highlights the diagnostic difficulties of a rare and still poorly researched disease and the possible role that traumatic and infectious episodes may play in the progression or acceleration of an immune response. As for patients with unexplained encephalitis, tests for autoantibodies against GluR3 in cerebrospinal fluid and serum should be considered. Forensic pathologists should be aware of encephalitis and epilepsies and that complete post-mortem investigations are required in such cases.

The diagnosis of drowning is considered one of the most difficult in forensic medicine. Due to the paucity of signs, it is a classical diagnosis by exclusion. For this reason, specific immunohistochemical markers would be useful. Far too little has been done to analyze in-depth the differences between SWD and FWD. We focused on the renal immunohistochemical expression of aquaporin 2, AVP, V2R, and renin in cases of drowning. This study has two purposes: (1) to better understand the differences between saltwater drowning (SWD) and freshwater drowning (FWD), which may indicate different pathophysiology and (2) to eventually identify markers useful for the diagnosis of drowning. We retrospectively investigated 10 cases of SWD gathered from the Institute of Legal Medicine in Genoa (Italy), and 10 cases of FWD from the University Center of Legal Medicine in Geneva (Switzerland). As a control group, we investigated 10 cases of death by gunshot to the head. A strong expression of AQP2 and AVP was significantly (p

The finding of a partially mummified body presenting signs of trauma requires the forensic pathologist to conduct a careful and complex examination; multidisciplinary analysis is often necessary. We report a case where the partially mummified corpse of an elderly man was found in his own home more than seven years after death. Complete post-mortem investigation revealed a cranial fracture and an acute subdural haematoma. An in-depth multidisciplinary analysis provided important information on the modality and cause of death but it was not possible to establish whether the trauma and death resulted from an accidental event or from an assault.

Healthcare-related SARS-CoV-2 infection is an issue of particular concern during the pandemic. It has important repercussions on the National Health System, which represents a source of medical-legal health disputes. In the healthcare context, there are reports of negative screening at hospital admission (via nasopharyngeal swabs) and subsequent diagnosis of SARS-CoV-2 infection during hospitalization. Such cases cannot be considered a priori of healthcare-related infections but require extensive in-depth evaluation. In this study, we propose an empirical classification to frame cases of SARS-CoV-2 infection diagnosed in the hospital (first negative admission swab, with subsequent positive test during hospitalization). The classification is based on five categories: nosocomial, probably nosocomial, indeterminate, probably community, and community cases. We analyzed patients who died after testing positive for SARS-CoV-2 during hospitalization (with initial negative screening) in the largest hospital in Northwest Italy from February 2020 to 31 December 2021. A total of 383 cases were tracked and are listed as follows: 41 cases (11%) were classified as nosocomial (i.e., 3.2% of COVID-19 deaths). In contrast, 71 cases (19%) were classified as probably nosocomial, 69 (18%) were indeterminate (i.e., the clinical, radiological, and laboratory characteristics did not provide information on the genesis of the infection), 166 (43%) were classified as probably community cases, and 36 (9%) were defined as community cases. Deceased patients with nosocomial SARS-CoV-2 infection constituted the following: 3.23% (41/1266) with respect to the total number of COVID-19 deaths, 1.1% (41/3789) with respect to those who entered the hospital with a negative swab and 0.82% (41/4672) with respect to the total of deaths from any cause of death. In this paper we discuss the topic and issues of nosocomial COVID-19 in hospitalized patients and address the medicolegal implications.

INTRODUCTION We conducted a retrospective analysis of cases of sudden unexpected infant death (SUID) referred to the SIDS-ALTE Center of the Liguria Region (Italy) from 2010 to 2018. In all cases, the death scene was inspected, and a multidisciplinary post-mortem evaluation was conducted. Our aim was to analyze the epidemiological data and etiological distribution. EVIDENCE ACQUISITION We examined 15 cases initially classified as sudden infant death. EVIDENCE SYNTHESIS In all cases, the death was initially unexplained. Seven cases involved males and eight involved females. Their mean age was 67.47 days; the youngest victim was 2 days old, while the oldest was 8.5 months (253 days). In 7 cases, the post-mortem analysis showed an infection of lung. In 4 cases, the prone position of the infant during sleep was identified as a risk factor. Only in one case the cause of death remains unexplained, and it was classified as sudden infant death syndrome II according to San Diego Classification. CONCLUSIONS In the forensic approach to cases of SUID, it is always important to conduct a thorough multidisciplinary investigation. In order to avoid procedural errors that might compromise the post-mortem investigation, it is necessary to consider the medical and social history of both mother and child, in addition to the circumstances of the death. Moreover, a complete pediatric post-mortem examination and multidisciplinary discussion are required in order to identify potentially important causative or contributory factors.

According to the ILO (International Labor Organization), an occupational accident is that which occurs in the course of work and results in either a fatal or non-fatal injury. Occupational-related deaths are increasingly a concerning issue, also worldwide, with severe social repercussions: it is clear that when a person loses their life, it has a permanent impact on all their family, as well as incurring direct and indirect costs for employers, workers and the community at large. The aim of the present retrospective-observational study is to investigate, from an autoptic and forensic point of view, the characteristics of occupational-related deaths of victims received between the 10-year period of 2011–2020 by the Municipal Morgue of Genoa, which forms part of the Institute of Forensic and Legal Medicine, for the purpose of providing a Forensic and Coroner's overview of this important phenomenon. The study comprises of a list of 47 people who died as a result of an occupational injury: 46 males and 1 female. It was observed that workers in the construction and steel manufacturing industries were in the category most at risk of fatal accidents (40.5%). In 41 cases (87.2%), death was related to major mechanical trauma, from falling from a height (42.5%) objects falling directly onto the victim (38.3%) and lastly, from pedestrian road accidents (6.4%). Fatal head traumas with endocranial haemorrhage accounted for deaths in 23 of all the cases studied (63.4%). As shown in our study, death in the workplace is still today having to be considered as an important social issue and it is still necessary to improve the workers' knowledge of the related hazards and risks involved at work, together with preventative procedures. An in-depth analysis of such risks in the workplace, as well as the monitoring and training of workers is fundamental if we are to achieve an overall improvement in working conditions.

The worldwide spread of SARS-CoV-2 and the pandemic has resulted in a serious global crisis in the health, social and economic spheres. After an initial period of enthusiasm related to the efficacy of vaccines, in many European countries, a growing distrust in the population has matured, due to the reporting of severe adverse effects. Throughout the world, some cases of adverse events after the administration of the vaccine have been reported. In this communication, we want to discuss all the medico-legal aspects related to the global vaccination companion in terms of medical professional responsibility, informed consent and vaccination obligation, with particular attention to the Italian situation. Health professionals are tasked with promoting confidence in vaccination for the general population. Complete and detailed information and reliance on scientific research is essential to understand the great importance of the vaccination campaign. From a criminal point of view, we must avoid blaming health professionals in the case of side effects. At the same time, we must protect the population, ensuring compliance with the indications, guidelines, and an adequate method of administration. On the other hand, from a civil law perspective, it is correct to ensure full protection of those rare cases in which the administration of the vaccine is related to adverse events. Without a broad and global vaccination campaign, it will be impossible to overcome COVID-19.

The postmortem diagnosis of acute myocardial infarction is one of the main problems in forensic practice, especially in cases in which death occurs soon after (from minutes to a few hours) the onset of the ischemic damage. Several authors have highlighted the possibility to overcome the limits of conventional histology in this diagnosis by utilizing immunohistochemistry. In the present research, we examined over 30 scientific studies and picked out over 20 main immunohistochemical antigens analyzed with a view to enabling the rapid diagnosis of early myocardial infarction. The aim of our review was to examine and summarize all the principal markers studied to date and also to consider their limitations, including protein alteration because of cadaveric autolysis and putrefaction.

Intravascular lymphoma (IVL) is a rare subtype of extranodal lymphomas that is characterized by the selective growth of neoplastic cells within the lumen of small vessels. Authors document the case of an unexpected death caused by an undiagnosed intravascular large B-cell lymphoma with multi-organ involvement, which had initially manifested as an infection and then as an unclarified central nervous system pathology. Histological examination showed a diffuse intravascular large B-cell brain lymphoma with prominent cerebral involvement. The relevance of the case report reveals the importance of an autopsy of an extremely rare and threatening pathology that in most cases is diagnosed only postmortem. As a result, the role of the forensic pathologist becomes particularly important. When specifically performing an in-depth autopsy evaluation with a specific histologic analysis, it is possible to identify the intravascular lymphoma and declare a more accurate cause of death.

Generally, the term complex suicide refers to a form of suicide in which more than one traumatic method is applied, simultaneously or consecutively, through multiple self-injurious actions using different methods and involving various bodily sites. A distinctive feature of complicated suicides is the failure of the initial attempt of the self-suppressive method that, nonetheless, results in death due to a subsequent accidental occurrence. In such cases, forensic pathologists and coroners are faced with the challenging differential diagnosis that generally includes homicide as well as suicide. We retrospectively analyzed autopsies from complex and complicated suicides registered at the Medicolegal bureau of Genoa (Italy) from 2006 to 2017. In the considered period, nineteen cases of complex suicides were identified and with only one case of a complicated suicide. In our series, the most frequent method of complex suicide was the cutting of the wrists followed by (unplanned) hanging for a total of eight cases (42.1%). The next most common cause (21% of cases) involved the jumping from a height after wrist cutting. In each case, it was necessary to meticulously examine the crime scene, reconstruct the chain of events, confirmed by the testimonies of relatives or eyewitnesses, review any medical history, particularly for psychiatric conditions, and perform a thorough autopsy so as to firmly establish the methods and causes of death.

Acute pulmonary emphysema (APE) is describedin cases of drowning and can be considered as a sign of vitality. In our experience, however, APE is not very evident in cases of saltwater drowning. The present study aims at investigating whether APE is present in both fresh and saltwater drowning by means of digital morphometric analysis of lung tissue. We investigated and compared a group of saltwater drowning and a group of freshwater drowning, while cases of acute external bleeding were investigated as negative control group. Tissue samples from each pulmonary lobe were collected during autopsy and examined by optical microscope. The area of alveolar spaces was calculated by means of image analysis software, recording the mean alveolar area (MAA) for each group. MAA was 24,852 μm2 in the saltwater drowning group, 34,133 μm2 in the freshwater drowning group and 21,871 μm2 in the negative control group. The MAA in freshwater drowning was significantly higher than in saltwater drowning and controls. No statistical differences were observed between saltwater drowning and controls. The results of this study suggest that APE is not a typical sign of death by saltwater drowning.

Meigs syndrome is the triad of ascites, hydrothorax, and benign ovarian tumor (mostly fibroids). It is a diagnosis of exclusion, and the characteristic symptoms disappear after resection of the tumor. Instead, in Pseudo-Meigs syndrome, the triad includes a nonfibroma ovarian tumor. The latter may consist of benign tumors (ie, of fallopian tube or uterus, struma ovarii, and ovarian leiomyomas) but can also comprise ovarian or metastatic gastrointestinal malignancies.The authors describe a case of sudden death in a 43-year-old woman, with no noteworthy reported history of present illness or medical history and in apparently good health before death.The autopsy showed a picture of bilateral hydrothorax with lung collapse, ascites, and a large left-sided ovarian mass, approximately 15 cm in diameter. Histopathological examinations revealed an ovarian epithelial malignancy (cystadenocarcinoma). There was also lung atelectasis with accompanying thrombosis of small and medium blood vessels. The combination of autopsy and histological findings allowed us to establish the diagnosis of Pseudo-Meigs syndrome, undiagnosed antemortem, resulting in death due to pulmonary and thrombotic complications. Our subsequent review of the literature found no case reports of undiagnosed Pseudo-Meigs syndrome presenting as sudden death, highlighting the uniqueness of the case presented herein.

Sudden death is described as a natural but unexpected death occurring within one hour from the onset of the patient’s final symptoms. Despite cardiac disease being recognised as the cause of death in most people, sudden and unexpected death can also be non-cardiac related. Often a natural but sudden death is not subject to an autopsy, but only to an external examination, and this runs the risk of wrongly attributing the death to a cardiac cause. The present review is a retrospective-observational study which looks into the cases of sudden non-cardiac death recorded in the Genoa District (Italy) from 2014 to 2019 and investigated through complete autopsy examinations. Amongst these cases, 39 (31.5%) were attributable to gastrointestinal diseases, mostly due to the rupture of oesophageal varices; 39 (31.5%) to respiratory diseases, especially pulmonary infections; 31 (25%) to peripheral vascular disease, mostly attributable to pulmonary thromboembolisms or the acute dissection of aneurysms whilst the remaining 15 cases (12%) were attributable to intracranial haemorrhages.

We report a particular case study of the unexpected death of a 70-year-old caucasian man (affected by crohn's disease) due to the laceration of the ileocolic mesentery and its blood vessels following a colonoscopy procedure carried out only a few hours previously.The autopsy showed that the lacerated blood vessels (i.e. the collateral and terminal branches of the superior mesenteric artery), which run along the section of the intestines between the end of the ileum and the ascending cecum, had led to a severe intra-abdominal hemorrhage and, consequently, fatal hemorrhagic shock.In such cases, both an autopsy and complete histological analysis are essential in order to determine the exact point responsible for the intestinal hemorrhage and to better understand the pathological mechanism involved.The unexpected death due to severe peritoneal hemorrhaging following a minimally invasive diagnostic clinical procedure, such as a colonoscopy, is particularly rare in Literature. In fact, amongst the several endoscopy procedures commonly used today, it is one of the safest procedures with the lowest recorded rate of complications. Furthermore, it is an even rarer event that a routine diagnostic colonoscopy can result in a fatality, with only two cases reported.In the case of sudden death following such a routine diagnostic clinical procedure, the forensic scientist should not disregard the fact that also damage, which appears negligible (caused by the normal procedures used in carrying out a colonoscopy) can actually also result in severe and fatal hemorrhaging.Colonoscopy, Fatal hemorrhage, Forensic pathology.Un uomo di 70 anni (affetto da Morbo di Crohn) decedeva improvvisamente poche ore dopo l’esecuzione di una colonscopia operativa. L’autopsia mostrava la lacerazione del mesentere e dei vasi sanguigni (rami collaterali e terminali dell’arteria mesenterica superiore) che decorrono nel tratto di intestino compreso tra l’ileo terminale e il cieco-colon ascendente, La morte improvvisa ed inaspettata dovuta ad emorragia peritoneale massiva a seguito di procedure diagnostiche ambulatoriali minimamente invasive risulta particolarmente rara. Fra le varie procedure endoscopiche diffuse oggi, la colonscopia risulta molto sicura e gravata da un basso tasso di complicanze. Risulta estremamente raro che una colonscopia diagnostica di routine possa provocare complicanze fatali quale la lacerazione del mesentere e dei vasi sanguigni, in assenza di perforazione intestinale. Nel nostro caso questa complicanza provocava una massiva emorragia intra-addominale e quindi uno shock emorragico fatale. In questi casi è importante un’analisi autoptica ed istologica completa per comprendere l’origine precisa della massiva emorragia intestinale e capire il meccanismo patologico. Nei casi di morte improvvisa a seguito di procedure diagnostiche ambulatoriali, il patologo forense deve sempre tener presente che anche lesività trascurabili (quali quelle prodotte dalle comuni manovre necessarie per l’esecuzione di una colonscopia approfondita e corretta) possono determinare un’emorragia massiva fatale.

Functional neurological disorders can have different clinical manifestations, including coma, in the setting of an unknown etiology. In this article, we present a case of a young man affected by intellectual disabilities who, after a physical assault reported serious neurological alterations and a functional coma. This case shows how a stressful psychophysical event can bring acute and variable neurological manifestations of functional significance to a victim with previous intellectual disabilities. Despite the growing interest in this field, research is still very limited and studies in this field could better explain the nature of the psychogenic coma. From a medico-legal point of view, problems of evaluation may emerge for these disorders emerge as a result of acute psycho-physical stress and without any detectable structural alterations.

Methadone is a synthetic opioid, a pure agonist of the μ receptor. It is used for opioid maintenance therapy in heroin addiction. In recent years, Italian studies of incidence and prevalence have indicated an increase in the illegal sales of methadone and, consequently, an increase in deaths due to acute methadone intoxication as well. The present review is a prospective-observational study regarding epidemiological and toxicological analyses of methadone-related deaths recorded in the district of Genoa (Italy) from 2013 to 2018. The study includes a list of twenty-six people that have died from methadone toxicity: twenty-two males and four females. The concentration of methadone in the blood samples ranged from 181 to 4058.53 ng/mL, with an average of 964.29 ng/mL. Six subjects tested positive for methadone alone; twenty cases, however, presented drugs or substances in different concentrations in the blood samples. Illegal sales and consumption of methadone have a negative impact on the self-administration therapy of opioid addiction, inducing patients to increase their dosage or sell methadone in order to purchase illegal drugs. As shown in our study, this behaviour is associated with an increase in methadone-related deaths. Accordingly, careful monitoring of dosage administrated to patients is required in order to render the system safer.

Rationale: Only a few cases of accidental deaths due to speargun injuries are reported in the literature. Murder or suicide cases are even rarer. Patient concerns: A 59-year-old male with a history of major depression and previous suicide attempts, was found, still alive and conscious, with a spear in his mouth and a fishing speargun a few meters away. The spear then penetrated the cranium and crossed the entire left cerebral hemisphere. Diagnoses: The patient underwent a retrograde removal of the spear. During the surgery, there was a massive encephalic bleeding. After about 2 days of coma, brain death was confirmed. An autopsy was performed to determine the cause of death. Interventions: The scalp presented hemorrhagic infiltrates in the left parieto-temporal region. There were an acute subdural hematoma and subarachnoid hemorrhage. At the opening of the lateral ventricles a massive fronto-parieto-temporal hematoma was evident. The skull base had a massive hemorrhagic infiltration and a circular fracture of about 0.5 cm in diameter, due to the penetration of the spear. The hard palate showed a circular solution of continuity with net margins whose diameter was consistent with the size of the spear. Outcomes: The cause of death was attributed to the traumatic cranial-encephalic lesions due to the speargun shot in the mouth. Lessons: The investigation into unusual cases of death constitutes a complex matter and requires a careful evaluation on the part of the forensic pathologist. A differential diagnosis may be necessary in order to rule out simulated suicide/homicide. In this particular case, the analysis of the scene of the self-suppression event and available circumstantial information, the evaluation of clinical data, the complete autopsy and the comparison between the injuries of the victim and the characteristics of the weapon used led to the confirmation of the suicidal nature of the death.

Background: The COVID-19 outbreak rapidly became a public health emergency affecting particularly the frail category as cancer patients. This led oncologists to radical changes in patient management, facing the unprecedent issue whether treatments in oncology could be postponed without compromising their efficacy.Purpose: To discuss legal implications in oncology practice during the COVID-19 pandemic.Perspective: Treatment delay is not always feasible in oncology where the timing often plays a key role and may impact significantly in prognosis. During the COVID-19 pandemic, the oncologists were found between the anvil and the hammer, on the one hand the need to treat cancer patients aiming to improve clinical benefits, and on the other hand the goal to reduce the risk of COVID-19 infection avoiding or delaying immunosuppressive treatments and hospital exposure. Therefore, two rising scenarios with possible implications in both criminal and civil law are emerging. Firstly, oncologists may be “accused” of having delayed or omitted the diagnosis and/or treatments with consequent worsening of patients' outcome. Secondly, oncologists can be blamed for having exposed patients to hospital environment considered at risk for COVID-19 transmission.Conclusions: During the COVID-19 pandemic, clinical decision making should be well-balanced through a careful examination between clinical performance status, age, comorbidities, aim of the treatment, and the potential risk of COVID-19 infection in order to avoid the risk of suboptimal cancer care with potential legal repercussion. Moreover, all cases should be discussed in the oncology team or in the tumor board in order to share the best strategy to adopt case by case.

The Covid-19 pandemic is also a considerable risk for forensic workers, among other healthcare providers. The risk of contamination is serious in post-mortem procedures. SARS-CoV2 is a microorganism classified as Hazard Group 3. However, the lack of adequate scientific work on Covid-19 should prompt us to be even more cautious when handling potentially infected persons or materials. Before starting the post-mortem investigation a risk assessment should be carried out and the suitability of facilities, personnel and equipment should be evaluated. An autopsy room conforming to BSL 3 standards would be ideal but is not mandatory. For suspicious or approved cases however a number of procedural changes must be made concerning the body's removal, storage and inspection procedures. Facilities, equipment and training issues need to be revised against existing and potential risks of infection. In addition to proper ventilation and insulation, personal protective equipment, aerosol reduction measures and disinfection applications are required. As of yet it is still unclear how long this public health issue, which has grown to become a pandemic, will last. This article highlights preventive measures to be taken into consideration in post-mortem processes when a Covid-19 infection is suspected or confirmed. It should be noted that there is no standard guide yet in this regard. A guide should be created according to international standards and revised according to changing conditions.

Background : Discovery of evidence of acute brain ischemia or hypoxia and its differentiation from agonal hypoxia represents a task of interest but extremely difficult in forensic neuropathology. Generally, more than 50% of forensic autopsies indicate evidence of brain induced functional arrest of the organ system, which can be the result of a hypoxic/ischemic brain event. Even if the brain is the target organ of hypoxic/ischemic damage, at present, there are no specific neuropathological (macroscopic and histological) findings of hypoxic damage (such as in drowning, hanging, intoxication with carbon monoxide) or acute ischemia. In fact, the first histological signs appear after at least 4 to 6 hours. Numerous authors have pointed out how an immunohistochemical analysis could help diagnose acute cerebral hypoxia/ischemia. Data sources: This review was based on articles published in PubMed and Scopus databases in the past 25 years, with the following keywords “immunohistochemical markers,” “acute cerebral ischemia,” “ischemic or hypoxic brain damage,” and “acute cerebral hypoxia”. Objectives : Original articles and reviews on this topic were selected. The purpose of this review is to analyze and summarize the markers studied so far and to consider the limits of immunohistochemistry that exist to date in this specific field of forensic pathology. Results : We identified 13 markers that had been examined (in previous studies) for this purpose. In our opinion, it is difficult to identify reliable and confirmed biomarkers from multiple studies in order to support a postmortem diagnosis of acute cerebral hypoxia/ischemia. Microtubule-associated protein 2 (MAP2) is the most researched marker in the literature and the results obtained have proven to be quite useful. Conclusion: Immunohistochemistry has provided interesting and promising results, but further studies are needed in order to confirm and apply them in standard forensic practice.

Acute bacterial meningitis in infants and newborns represents a medical emergency and a significant cause of mortality and morbidity worldwide. Moraxella catarrhalis has been considered a microorganism with low pathogenic potential, and only in exceptional cases has it been found to cause meningitis in infants and immunocompetent people. We will now document an unusual case of an unexpected and sudden death of a 40-day-old infant due to acute meningitis from M. catarrhalis, apparently asymptomatic and subsequently diagnosed by an autopsy. According to our knowledge this is the first case of unexpected infant death due to undiagnosed M. catarrhalis meningitis.The suggested case, as well as for the rarity of such a fatal event, should be considered a caution to pediatrics and neonatologists for M. catarrhalis can cause paucisymptomatic meningoencephalitis in infants which can be potentially fatal.From a forensic point of view, an autopsy accompanied by a multidisciplinary assessment is always necessary in cases of unexpected infant deaths to identify the causes.

Acute myeloid leukemia (AML) is characterized by the rapid growth of abnormal white blood cells in the bone marrow that interferes with the production of normal blood cells. This disease is burdened by a high risk of bleeding complications involving central nervous system hemorrhages, purpura, gingival bleeding, and gastrointestinal bleeding. In this article, the authors report a case of a fatal intracerebral hemorrhage in a 21-year-old man who was affected by an undiagnosed AML. The subject practiced a combat sport (Muay Thai), and 2 days before his last training, he was involved in a fight where the aggressor punched him in the face; however, after the fight, he did not claim of any symptoms. The current case highlights the importance of the role of the forensic pathologist because only through a careful and complete circumstantial, autoptic, and histological analysis it is possible to date the origin of a cerebral hemorrhage and establish whether it is spontaneous or posttraumatic in subjects with undiagnosed preexisting diseases. Through an integrated study, it is also important to date the lesion and identify the traumatic event responsible of the bleeding. Finally, this case has a relevant clinical importance relatively to sports medicine, where it would be appropriate that athletes undergo blood test as a preventive measure. In fact, in presence of an acute hematological disease, such as AML, even mild traumatic injuries may be fatal.

Death in water is a challenging issue in forensic pathology since from natural death to homicide all circumstances of death in water are conceivable. Therefore, the correct interpretation of all abnormal autopsy findings is important. In order to determine a death by drowning, numerous internal and external signs of drowning are already described. However, these are supposed to be influenced by various factors reducing their significance and evidence. Moreover, the autopsy of water corpses often reveals further pathological findings that should not be underestimated for determining the cause of death. The aim of this study was to set frequencies of the observed drowning signs in context to the forensic literature and to identify possible influencing factors. In this study, we observed that pathological organ changes of the cardiovascular system were significantly more common in corpses after shortened (atypical) drowning processes than in classical drowned victims. Furthermore only a complete formation of external foam, immediately after the corpse’s recovery, was exclusively found in drowning victims. All other drowning signs were either also observed in non-drowning deaths in water or no information could be provided with reasonable assurance. In addition, many of the examined drowning signs were negatively affected by prolonged postmortem intervals, putrefaction, or resuscitation attempts. It can be concluded from our analysis that morbidity is an important factor in deaths in water. Morbidity can support a death by drowning in case of incidents in water. For the examined drowning signs, no high diagnostic certainty could be observed. Nevertheless, these findings can increase their diagnostic value—if forensic physicians take influencing factors into consideration.

Death due to lightning strikes is infrequent, above all indoors. Some cases may take on a medical legal interest due to the unusual and uncommon circumstances in which they occur. The authors report an extremely rare case of electrocution occurred inside a house in a rural area. A 53-year-old man was reached by an electrical discharge originating from lightning while he was doing renovation work on a cottage. In this case, the correct interpretation of the autopsy and histological aspects and the attentive analysis of the circumstantial and environmental data led to the correct diagnosis of death and to the reconstruction of the dynamics with which it occurred. It was in fact possible to reconstruct that during a violent thunderstorm, lightning, discharging from the bottom upward formed an electric arc. The victim, who was close to metal objects (sawhorses), was struck on the left foot and the current exited from the right hand passing through the heart causing immediate death.

The 2019 coronavirus infection (called SARS-CoV-2) began in Wuhan, spread rapidly throughout the world. In many countries the exponential growth of Covid-19 cases is overwhelming health care systems with overcrowding of hospitals and overflowing Intensive Care Units. While people must stay at home to reduce the spread of this virus health-care workers do the exact opposite. In some countries doctors are working with insufficient protection and are constantly at risk of contracting Covid-19. Health-care workers should be constantly monitored because if they are infected they may spread the virus to colleagues, hospitalized patients and even family members. Increased rates of infection in health-care workers could cause the health-care system to collapse and a further worsening of the pandemic; if there are too few doctors it will be even more difficult to manage.

The sudden and unexpected death of an infant or child due to cancer is a particularly rare event. Most of the cases concern primary growths located in vital organs such as the heart or the brain. Only in an extremely small number of cases does it occur in infants or children affected by liver cancer. Herein we report the sudden and unexpected death of a 3-and-a-half-year-old infant, who due to an undiagnosed tumor of the liver, namely hepatoblastoma, suffered a major intra-abdominal (hemoperitoneum) bleed, leading to a fatal hemorrhagic trauma. In cases like these, it is of utmost importance to carry out both an autopsy as well as complete histological tests in order to determine if the hepatic tumor is the real cause of death or if it was a mere chance finding. In the case of sudden and unexplained deaths in infancy and childhood, the forensic pathologist should always consider that other complications, for example, those correlated with hepatoblastoma could, in fact, cause sudden death given that this particular tumor is often scarcely symptomatic and can remain undiscovered for a long period of time.

Varices are the main clinical manifestation of portal hypertension, and their bleeding is the predominant cause of mortality from this condition. Periumbilical varices are known as "caput medusae." Reports of their bleeding are rare, with only three fatal cases described in the literature. The antemortem diagnosis is relatively simple, while the postmortem diagnosis is more complex. This paper is the first report of fatal hemorrhage from a caput medusae for which the diagnosis was made postmortem, thanks to a complete diagnostic process including scene and circumstances, medical history, and autopsy with detailed histology. The circumstantial analysis showed the presence of a large amount of blood at the scene, blood which originated from a small abdominal wound; an analysis of the subject's clinical data reported that he was affected by portal hypertension. The autopsy revealed some dilated and convoluted veins in the subcutaneous tissue of the umbilical region; a fistula between these veins and the abdominal wound was detected. The histological study confirmed the presence of periumbilical varices, one of them ruptured and connected with the overlying skin. The cause of death was attributed to a massive hemorrhage generated by a periumbilical varix in a patient affected by portal hypertension.

Fatalities due to stabbings are usually caused by large blood vessels or organs injuries resulting in hemorrhagic shock. Vagal inhibition from a stab to the neck is an undeniably exceptional event, infrequently described in the literature. In our case report, we describe one such fatality.The body of a deceased 38-year-old man was found near a public garden. According to a bystander, the victim had been assaulted by 2 individuals, sustaining a stab wound to the neck with a broken glass bottle. At the autopsy, there was a large, inverted L-shaped cut wound in the left cervical region, measuring approximately 4.5 × 3 cm. The carotid artery and the jugular vein, as well as their main branches, were uninjured. The trachea and bronchi contained no exudate or blood. There was a hematoma near the trunk of the vagus nerve and its branches.The cause of death was attributed to the deep stab wound to the neck via vasovagal inhibition and parasympathetic nervous system stimulation.

A bezoar is a mass of undigested, or partially digested, material forming in the lumen of the gastroenteric tract, causing occlusive or subocclusive events. The most frequent types of bezoars are those composed of vegetable fibers, also called phytobezoars, which, by virtue of their high content in cellulose, hemicellulose, and lignin, remain undigested in the stomach and intestines and, from there, can migrate and occlude the narrowest portions of the bowel. The areas that are most frequently affected by occlusive phenomena related to the presence of bezoars are the stomach and the small intestine, although colic localizations are extremely rare. In this article, we have studied the case of a fatal colic obstruction caused by a phytobezoar in an 84-year-old woman who was found dead at her home. The autopsy revealed that the cause of the obstruction was a large artichoke fragment occluding the central part of the descending colon. Additional histological examinations confirmed that the death was attributable to bowel obstruction resulting in acute peritonitis.

Sudden and unexpected death in epilepsy (SUDEP) represents the predominant cause of premature deaths in young adults with epilepsy and is more common with patients with poorly controlled and generalized convulsive seizures. It is reported that there are 1,16 cases for every 1000 subjects affected with epilepsy. This review takes stock of the current problems and issues in the autopsy of cases of sudden death with epileptic people. For this purpose, all the possible findings of post-mortem examinations reported in the literature were analyzed and summarized, which can currently be considered useful for autopsy diagnoses as well as in the comprehension of the physiopathology of SUDEP. The enormous limitation of forensic pathology studies is the complete lack of a specific SUDEP diagnostic marker. Only in a few cases was it possible to find pathological signs of the brain that would clarify epilepsy-related deaths. Genetic research has tracked down variants of neurocardiac genes of ion channels in a restricted percentage of suspected SUDEP cases. The actual pathogenicity test requires an in-depth statistical analysis in order to prove there is a real excess of variants and evidence that the mutation alters the function. Despite scientific efforts, it is often difficult to distinguish SUDEP from other causes of sudden death. For these reasons, it will be necessary to create an international standard SUDEP death scene investigation and postmortem examination protocols. Further future studies of immunohistochemistry or genetics may help and may facilitate post-mortem diagnosis in cases of presumed SUDEP.

3,4-Methylenedioxymethamphetamine (MDMA), more commonly known as "ecstasy," is a semi-synthetic entactogenic phenylethylamine. In recent years it has gained popularity as a recreational drug whose use has registered an upward trend especially among adolescents and young adults. Despite its unwarranted reputation of being a "safe" drug, the actual scientific data denote that it actually leaves a trail of cardio-toxicity, above and beyond its neurotoxicity and other somatic effects. Both experimental and clinical data, in fact, indicate that ecstasy can alter cardiac function leading to rhythm disturbances, myocardial infarction, and even sudden cardiac death. We reviewed and summarized the bio-medical literature on the cardiovascular response to MDMA both in humans and laboratory animals. The aim was to elucidate the various pathophysiological mechanisms involved, as well as the clinical, autoptic, and experimental findings underlying MDMA-induced cardio-toxicity. Finally, an illustrative case report of ecstasy-induced adolescent death due to acute cardio-toxicity was described so as to highlight some key features.

The diagnosis of drowning is one of the most difficult in forensic medicine. The aim of this study was to analyze pulmonary tissue reactions in death by drowning. In particular, we focused on the immunohistochemical expression of P-selectin, SP-A, HSP70, AQP-5, and fibronectin to investigate our expression in drowning and to understand whether there are differences between saltwater drowning (SWD) and freshwater drowning (FWD), which may indicate a different pathophysiology. We retrospectively investigated 10 cases of SWD (Mediterranean Sea) from the Institute of Legal Medicine of Genoa (Italy), and 10 cases of FWD (Lake of Geneva) from the University Center of Legal Medicine of Geneva (Switzerland). As control group, we examined 10 cases of death by acute external bleeding, characterized by minimal respiratory distress. As compared with controls, in SWD cases, the results showed a decrease of SP-A expression with membrane patterns. Furthermore, we observed a greater SP-A expression with granular pattern in drowning cases without statistically significant difference between SWD and FWD. For the markers AQP-5, HSP70, fibronectin, and P-selectin, no statistically significant differences were found between SWD, FWD, and controls.

The whole population is susceptible to infection but elderly people with previous diseases are at greater risk. All these epidemiological data show that older age represents an important risk factor for infection and especially for mortality. In recent weeks an increase in mortality among the elderly has been observed in many Italian residential care homes. In these accommodations a worrying spread of COVID-19 cases has been ascertained. According to the ISS report, 7.4% of the total deaths in care homes for elderly involved patients with SARS-CoV-2 infection and 33.8% involved patients with flu-like symptoms. Herein, we discuss the dangerous spread of COVID-19 in residential care homes for elderly. In addition, we present a case of an elderly person admitted to a residential care home, whose COVID-19 diagnosis was performed only after death.

Despite numerous measures to contain the infection and limit its spread, cases of SARS-CoV-2 infections acquired in hospitals have been reported consistently. In this paper, we will address issues of hospital-acquired COVID-19 in hospitalized patients as well as medico-legal implications. After having conducted a literature search, we will report on papers on hospital-acquired SARS-CoV-2 infections. Ten scientific papers were selected and considered suitable for further analysis. According to several reports, the SARS-CoV-2 hospital-acquired infection rate is 12–15%. Hospital-acquired COVID-19 represents a serious public health issue, which is a problem that could create reluctance of patients to seek hospital treatment for fear of becoming infected. Healthcare personnel should do all that is necessary to address the problem and prevent further spreading, such as rigorous compliance with all procedures for containing the spread. From a medical-legal point of view, multiple aspects must be considered in order to understand whether the infection is a result of “malpractice” or an inevitable condition.

Biliary atresia (BA) is a fatal condition resulting in the lack of effective biliary drainage leading invariably to liver failure and cirrhosis within a year, and it is often lethal within a few months in the absence of corrective surgery or liver transplantation. In fact, BA is the most common indication for pediatric liver transplantation.Herein, we present a rare case of unexpected infant death due to BA diagnosed only postmortem in a context of child neglect and carelessness on the part of the parents. It emerged from the clinical history that after a few months, the parents no longer took their daughter to any medical checkups despite the indications and express recommendations for follow-up. The autopsy revealed agenesis of the gallbladder with BA and complete disruption of the hepatic architecture and parenchyma from biliary cirrhosis. Histological examinations documented severe biliary cirrhosis from hypoplasia of the biliary ducts.The child neglect in this case proved fatal inasmuch as an early diagnosis by a pediatrician would have likely allowed appropriate surgical treatment, thus avoiding the untimely death of the child. We highlight the importance of educating and informing parents (especially the disadvantaged) in matters of health. At the same time, primary care physicians should closely monitor the conditions and development of infants so as to recognize the early warning signs and symptoms of BA, bearing in mind that a timely diagnosis and proper surgical treatment can save the lives of most of these children.