Fourteen Deaths from Suspected Heparin Overdose in an Italian Primary-Level Hospital

Healthcare-related homicidal cases are not novel within the medical-legal landscape, but investigations are often made difficult with the scarcity of material evidence related to the crime. For this reason, it is necessary to carefully analyze the clinical documentation and employ ancillary forensic resources such as radiology, histopathology, and toxicology. In the presented scenario, the observation of 14 deaths from abnormal bleeding in a First-Level Italian Hospital revealed the administration of massive doses of heparin by a nurse. On behalf of the Judicial Authority, a multidisciplinary medical team investigated the case through the following steps: a thorough review of the clinical documentation, exhumation of the bodies belonging to the deceased patients, performing PMCT and autopsy, and collecting tissue samples for histopathological, immunohistochemical, and toxicological investigations. All the analyzed cases have been characterized by the observation of fatal hemorrhagic episodes not explained with the clinical conditions of the patients, confirmed using autopsy observations and the histological demonstration of the vitality of the lesions. However, due to the limited availability of biological material for the toxicological analysis, the indirect evidence from hematological analyses in hospitalized patients was crucial in demonstrating heparin overdose and its link to the recorded deaths. The present scenario demonstrates the fundamental importance of a multidisciplinary approach to cases of judicial interest related to the healthcare context. Therefore, the illustrated methodologies can be interpreted as an operational framework for similar future cases.

Endovascular embolization and needle aspiration of a life-threatening cervical hematoma due to a neurofibromatosis type 1-associated arteriovenous fistula: illustrative case

BACKGROUND

In cases of neurofibromatosis in which the bleeding source is considered strongly related to a neurofibroma, an open surgical approach could risk uncontrollable bleeding from the vascular wall infiltration by neurofibroma. The case of a neurofibromatosis type 1 (NF1)-associated arteriovenous fistula presenting with a life-threatening cervical hematoma that was successfully treated with alternative treatment is described.

OBSERVATIONS

A 68-year-old woman diagnosed with NF1 presented with sudden onset of a spontaneous right cervical mass. Neck imaging on admission showed a massive subcutaneous hematoma with tracheal deviation and abnormal vascular structure in the hematoma. Digital subtraction angiography showed that an arteriovenous fistula (AVF) fed from a vertebral artery located within the hematoma cavity was the primary source of bleeding and feeding arteries from the occipital artery to the neurofibroma. Embolization of the cervical neurofibroma, as well as the AVF, was performed to reduce the secondary risk of bleeding, and was accomplished. After endovascular treatment, needle aspiration of the cervical hematoma was performed to reduce the mass effect.

LESSONS

When performing open surgery via tissues with neurofibromatosis proliferation, uncontrollable bleeding can occur. Therefore, endovascular embolization and needle aspiration of the hematoma should be considered in this setting.

A Rare Case of Fatal Thyroid Hemorrhage After Fine-Needle Aspiration: Case Report and Review of the Literature

ABSTRACT

Sudden death due to massive hemorrhage after a mini-invasive ambulatory diagnostic procedure is extremely rare. Fine-needle aspiration (FNA) of thyroid nodules is very safe, displaying a low rate of complications, all of which mild and often self-limiting. In few cases do these complications necessitate surgical decompression, and rarely does FNA of a thyroid nodule lead to the death of the patient.We report a case of sudden death caused by respiratory insufficiency after compression of the vascular and nervous structures of the neck and obstruction of the upper airways by hemorrhages dissecting the thyroidal and perithyroidal tissues in a 78-year-old woman. These hemorrhages were the result of vascular lacerations caused during diagnostic FNA of a nodule suspected of malignancy. In such cases, it is important to conduct a complete autopsy and histological analysis to ascertain the origin of massive hemorrhage involving the structures of the neck and to attribute the cause of death to the aforementioned procedure. The forensic pathologist must bear in mind that even extremely small damage, such as that produced by a fine needle, may cause a fatal hemorrhage in subjects with a subverted anatomo-pathological picture (such as, for example, the massive fibrosis of an organ).

Bleeding varicose veins' ulcer as a cause of death: a case report and review of the current literature

Abstract

Chronic venous insufficiency (CVI) and varicose veins (VVs) of the lower limbs are very frequent vascular diseases in Western countri-es. One possible complication of these conditions is skin ulceration and its consequent rupture, which can be spontaneous or due to mild or trivial trauma. In some cases, the resulting hemorrhage is fatal. When the victim is found dead, a large amount of blood around the body might lead to the hypothesis of violent death. The Forensic Pa-thologist needs to be very careful in the corpse's examination, in order to exclude any alternative cause of death. Herein, an illustrative case is reported, as well as a literature review of the literature concerning sudden hemorrhages from VVs. We found 27 scientific papers, the total reported cases of VVs rupture with profuse hemorrhages were 36, 32 of which were fatal. The main characteristics of such forensic scenario have been collected. Corpse examination of the victims showed pallor of the skin and mucous membranes, as well as marked pallor of organs as a sign of hemorrhagic shock, but these pathological findings are unspecific. Usually, the skin near the ulcer presented color alteration (discoloration and atrophy or pigmentation and hyperemia). Besides, the histological examination of the skin could be a valid instrument to demonstrate the presence of the ulcer, even if it could be very difficult to sample, because of its small size. An important limit of our study is the small number of collected cases. More studies in this field are needed to improve evidence concerning death due to VVs rupture.

A rare suicide case involving fatal bleeding from varicose veins

This case report deals with a sharp force suicide case, which may challenge the experience of many forensic pathologists as well as the studies published to date. An overview of the published cases shows that sharp force suicides account only for 1.6%–3% of all suicides and the self‐inflicted injuries are usually localized on the body parts easily accessible with one's hand including the neck, thorax, or upper extremities, as well as in locations of major vascular bundles or vital organs. Reported, however, is a case in which the victim relied on the knowledge of her medical condition and used a kitchen knife to incise her varicose veins, which resulted in fatal bleeding. The case is rare on a number of grounds: incision of varicose veins is rarely the method of choice in suicide cases, injuries of peripheral veins are rarely fatal, and so are injuries of isolated veins where no damage to arteries is suffered.