Asamura, Hideki MD, PhD*; Oki, Takahito MD*; Masao, Ota PhD*; Fukushima, Hirofumi MD, PhD†
From the *Department of Legal Medicine, Shinshu University School of Medicine, Nagano, Japan; and †National Research Institute of Police Science, Chiba, Japan.
Manuscript received February 20, 2008; accepted November 13, 2008.
Reprints: Hideki Asamura, Department of Legal Medicine, Shinshu University School of Medicine, Asahi 3-1-1, Matsumoto, Nagano 390–8621, Japan. E-mail: email@example.com.
This report concerns a case in which the decedent was found in a highly unusual posture, one resembling a yoga backbend pose. Several findings in this case pointed to death by strangulation, including facial congestion, extensive petechiae of the conjunctivae and mucosal membranes of the oral cavity, and congestion and hemorrhaging in the lingual root, laryngopharynx, and cervical lymph nodes. However, no hemorrhaging of the cervical skin or soft tissue was observed. The cause of death was ultimately identified as pulmonary thromboembolism caused by an embolus originating from a deep leg vein thrombosis. If the pulmonary thromboembolism had not been detected, the cause of death may have been misidentified as strangulation.
Both a careful investigation of the death scene and an autopsy are essential for determining the manner and cause of death. Body posture at the scene is critical for correctly interpreting postmortem appearances, such as localized areas of livor mortis. Recent reports from numerous physicians indicate that a head-down posture may itself lead to so-called positional asphyxia.1–3 This article describes a case involving a highly unusual body posture at the scene of death that helped produce signs similar to those found in cases of strangulation.
An 89-year-old woman was found dead in the dining room of her house. Her hips were positioned on the surface of the chair, while her head drooped toward the floor, the overall posture suggesting a backbend yoga pose (Fig. 1A, B). All entrances to her house had been locked, and no signs of disturbance were observed in any of the rooms. The victim had suffered for some time from hypertension, chronic heart failure, osteoporosis, senile dementia, and pemphigoid, conditions for which she took amlodipine besylate, digoxin, alfacalcidol, and prednisolone.
The autopsy findings were as follows. The decedent was 138 cm in height and weighed 38.1 kg. With the exception of occipital bruising in an area measuring 4 × 4 cm, an external examination showed no signs of injury. Livor mortis was apparent on the upper surfaces of the breasts and in the lower legs and had been fixed. This distribution was compatible with the configuration of the body as found at the scene. Rigor mortis was fully developed. The face appeared congested and swollen with visible signs of epistaxis. Marked mucosal hemorrhaging was visible in the conjunctivae, while petechial hemorrhaging was visible in the oral mucosa (Fig. 2A, B). Skin petechiae had developed at the back of the neck. No external evidence of strangulation was found on the neck (Fig. 3A). Upon internal examination, the lingual root and laryngopharynx showed significant congestion and mucosal hemorrhaging (Fig. 3B). The cervical lymph nodes were also remarkably congested and hemorrhagic. Additionally, the superior horn (right side) of the thyroid cartilage was found to be fractured. In the thoracic cavity, observations showed that the bilateral main pulmonary arteries had been completely occluded by massive dark tan emboli. These embolic masses could be readily detached from the vascular lumen. Histologically, the emboli were composed primarily of clotted red blood cells and a fibrin meshwork, with varying amounts of leukocytes. These findings are consistent with fresh emboli no more than several days old. The emboli appeared to be loosely attached to the intimal endothelial surface, but no organizing reaction was observed. An extensive search for the source of the pulmonary embolism identified a proximal deep vein thrombosis of the lower limbs.
The findings in the present case—indicating facial congestion, extensive mucosal petechiae in the conjunctivae and oral cavity, and congestion or hemorrhaging in the lingual root, laryngopharynx, and cervical lymph nodes—would appear to point to strangulation as the cause of death. However, no hemorrhaging was observed in the cervical skin or soft tissue. If the pulmonary thromboembolism had not been detected, strangulation might have been regarded as the prime candidate for cause of death, despite the highly unusual posture in which the body was found.
In decedents in whom death is attributable to strangulation, obstruction of the cervical veins and the resulting impaired venous return to the heart generates facial congestion and extensive petechiae of the conjunctivae, oral mucosa, and facial skin. Congestion and hemorrhaging of the lingual root,4 laryngopharynx, and cervical lymph nodes5 are also frequently encountered during autopsies in such cases. Hemorrhaging of the cervical skin and soft tissue constitutes a primary sign of strangulation. But such primary signs may be absent in rare instances of strangulation by smooth, soft, and wide ligatures, such as a woolen scarf, or by the arms, as with a judo strangle hold. In such cases, in which hemorrhaging of the cervical skin and soft tissue may be absent, strangulation must be deduced from other findings, including facial congestion, mucosal petechiae, and congestion or hemorrhaging of the lingual root, laryngopharynx, and cervical lymph nodes. Forensic pathologists have often encountered great difficulty in identifying the cause of death in cases in which typical signs of trauma of the cervical skin or soft tissue are absent, even when other autopsy findings point to strangulation.
In the present case, pulmonary thromboembolism was identified as the cause of death, with the emboli believed to originate from a deep leg vein thrombosis. We assume that at the moment at which the thrombus from the deep leg vein occluded the pulmonary arteries, the decedent fell backward in the chair, remaining fixed thereafter in a highly unusual position resembling a yoga backbend pose. The superior horn of the thyroid cartilage in this case may be an artifact of removal in an elderly woman with osteoporosis, since little hemorrhaging was found in this area. In this case, the decedent's unusual posture after death contributed to several findings (discussed above) more often associated with strangulation. Marked hemorrhaging of the conjunctivae is often encountered in cases of positional asphyxia.3 In these cases, the posture of the decedent while alive contributes to hemorrhaging.
We believe that a decedent's posture after death constitutes major factors in such hemorrhaging. For positions in which the head is held at a lower position, stagnant blood pooling in the cranial-side area may cause postmortem hemorrhaging of the conjunctivae, while settling of the blood in the lingual root of the lower area by gravity may cause postmortem hemorrhaging of the lingual root. It is generally difficult to distinguish postmortem lividity from true antemortem hemorrhaging, and information on the postmortem posture of the body is required to make this distinction.
For forensic pathologists, the case described here underscores the importance of the posture of the body, as found at the scene of death, in correctly identifying the cause of death.
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4. Quan L, Zhu BL, Ishida K, et al. Hemorrhages in the root of the tongue in fire fatalities: the incidence and diagnostic value. Legal Med.
5. Yen K, Vock P, Christe A, et al. Clinical forensic radiology in strangulation victims: forensic expertise based on magnetic resonance imaging (MRI) findings. Int J Legal Med
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