Original ArticlesAppearance/Image- and Performance-Enhancing Drug Users A Forensic ApproachLusetti, Monia MD*; Licata, Manuela PhD*; Silingardi, Enrico MD*; Bonsignore, Alessandro MD†; Palmiere, Cristian MD‡ Author Information From the *Section of Legal Medicine, Department of Diagnostic Medicine, Clinical Pathology and Public Health, University of Modena and Reggio Emilia, Modena; and †DISSAL, University of Genova, Genova, Italy; and ‡CURML, University Center of Legal Medicine, Lausanne, Switzerland. Manuscript received May 1, 2018; accepted June 26, 2018. This study was not financially supported. The authors report no conflict of interest. Reprints: Cristian Palmiere, MD, CURML, Chemin de la Vulliette 4, 1000, Lausanne 25, Switzerland. E-mail: [email protected]. The American Journal of Forensic Medicine and Pathology: December 2018 - Volume 39 - Issue 4 - p 325-329 doi: 10.1097/PAF.0000000000000424 Buy Metrics Abstract Image- and performance-enhancing drugs include a wide range of substances used to promote physical changes to enhance appearance. Anabolic androgen steroids are the most widely used image- and performance-enhancing drugs along with a wide variety of additional substances. The aim of this study was to identify the pathological changes pertaining to the cardiovascular system possibly involved in the death and characterize the substances associated with steroid use and their possible role in the death. A series of deaths involving image- and performance-enhancing drug users were selected. Nandrolone and testosterone were the most frequently identified steroids. The most commonly illegal drugs found were tetrahydrocannabinol, cocaine, and methadone. Antidepressants, opioids, benzodiazepines, and barbiturates were also found. These findings highlight that results obtained from postmortem investigations should be meticulously evaluated to understand the weight that each identified substance may have played in the death process and exclude any alternative causes of death. Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.