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The determination of vitality of skin injuries is one of the most central research areas in forensic pathology for it is often necessary to discern antemortem from postmortem damage. Typical is the case of a hanging, which should be distinguished from the postmortem suspension of a body. In this study, 15 human skin samples from ligature marks (study group) of victims of suicidal hanging and 15 uninjured skin samples (negative control group) were analyzed. In addition, 15 skin samples from ecchymoses in homicide victims with short survival intervals were investigated as a positive control group. Sections were processed for immunohistochemistry in order to detect the expression of Fibronectin, P-Selectin, FVIII, HSP-70, and MRP8. Immunohistochemical reactions were classified semiquantitatively (mild - score 1, moderate - score 2, and intense - score 3). In the ligature marks, Fibronectin was significantly less expressed compared to ecchymoses. The expression was similar to hanging marks and uninjured skin. In both ligature marks and ecchymoses, the expression of P-Selectin was significantly increased compared to uninjured skin. In both ligature marks and ecchymoses, expression of HSP-70 was significantly decreased in the epidermis compared to uninjured skin. In both ligature marks and ecchymoses, the expression of FVIII and MRP8 was significantly increased in the dermis and hypodermis compared to uninjured skin. The results of this study show that the immunohistochemical study of early inflammatory and coagulation factors could help determine the vitality of ligature marks. The combined analysis of P-Selectin, FVIII, HSP-70, and MRP-8 can be considered for this purpose., (Copyright © 2023 Elsevier Ltd and Faculty of Forensic and Legal Medicine. All rights reserved.)

Ecchymosis, as a general term, refers to discoloration of the skin due to the presence of extravasated blood into the dermis and/or subcutaneous tissue. However, it can occasionally be observed without any trauma, as a symptom of disease, a clinical condition, or even during the course of treating a disease. It is extremely important that these non-traumatic lesions are known and recognized and can be distinguished from traumatic ecchymoses by both clinicians and forensic scientists. This review of the literature includes detailed descriptions of non-traumatic periorbital ecchymosis, Slapped Cheek Syndrome, Cullen's Sign, Grey Turner's Sign, Stabler's Sign, Ransohoff Sign, Bryant's Sign, postsacral ecchymosis, perianal ecchymosis, Fox's Sign, other lower leg ecchymosis, and ecchymosis on various body regions. In this article, it is emphasized that failure to correctly identify these findings may subject practitioners to malpractice lawsuits, and failure to correctly identify findings by forensic experts may result in unjust legal judgments against people or loss of rights. It is also this review encourages accurate diagnosis of non-traumatic ecchymoses., Competing Interests: Declaration of competing interest This review article entitled “Non-Traumatic Ecchymoses: A Literature Review from a Medical-Legal Perspective” was performed in cooperation with all authors. There is not any financial or ethical conflict., (Copyright © 2023 Elsevier Ltd and Faculty of Forensic and Legal Medicine. All rights reserved.)

We have read with great interest the articles regarding cutaneous manifestations in Coronavirus Disease 2019 (COVID-19) infection. Studies showed 20.4% of COVID-19 patients developed cutaneous manifestations. COVID-19 causes vascular endothelial injury, vasculitis and prothrombotic state which might be the underlying cause of hemorrhagic cutaneous manifestations, disseminated intravascular coagulation (DIC), and multiple organ failures. To date, hemorrhagic cutaneous manifestations reported are chilblain-like lesion, purpura to ecchymosis, livedo reticularis, and dry gangrene. We present a case of ecchymosis in COVID-19-positive ICU hospitalized patient., (© 2020. Springer Science+Business Media, LLC, part of Springer Nature.)

Background: The size, shape, and symmetry of the nose contribute significantly to the facial aesthetic, so it is understandable why rhinoplasty is one of the most popular cosmetic procedures undertaken nowadays. Several factors are associated with the rates of both success and postoperative complications of rhinoplasty., Aim: To determine the relationship between nasal skin thickness and postoperative periorbital ecchymosis and edema among patients who underwent rhinoplasty at King Abdulaziz University Hospital., Methodology: A prospective study was conducted among all patients operated on for rhinoplasty at King Abdulaziz University Hospital in the Department of Otolaryngology, Riyadh, Saudi Arabia, between May and December 2018. To determine the relationship between nasal skin thickness and postoperative periorbital edema and ecchymosis, demographic data (gender, age), mean nasal skin thickness, surgical factors (time of surgery, extent of intraoperative bleeding), and scoring for periorbital ecchymosis and edema were obtained. The statistical analysis was done by comparing means and frequency using analysis of variance., Results: A total of 54 patients participated in this study with ages ranging from 19 to 33 years and a mean age of 24.43. According to this study, postoperative edema presentation on the first, third, and seventh days upon examination was higher among patients with thicker nasal skin (6 mm), and results are statistically significant ( P = .001). Ecchymosis was also higher among patients with thicker nasal skin (6 mm) on day 1 examinations, but there was no correlation with nasal thickness during the other examinations. Therefore, there is some degree of correlation between ecchymosis and nasal skin thickness overall, but the results are not significant ( P = .26)., Conclusion: This study concludes that the severity of edema and ecchymosis correlates with nasal skin thickness. The degree of edema and ecchymosis was higher during the initial postoperative examinations, but following that, it was reduced and completely diminished by the 21st day post-surgery.

Clinical features of soft tissue amyloid light-chain (AL) amyloidosis include macroglossia, arthropathy, muscle pseudohypertrophy, skin plaques, and carpal tunnel syndrome. Vascular manifestations of AL amyloid include periorbital ecchymosis, jaw or limb claudication, and even myocardial infarction caused by occlusion of small vessel coronary arteries. Some of these features, such as macroglossia, periorbital ecchymosis, and the so-called shoulder-pad sign, are pathognomonic for AL amyloidosis. These findings may be the initial presenting features of the disease, and the recognition of these red flag symptoms is very important for the diagnosis and early intervention on the underlying plasma cell disease., Competing Interests: Disclosure The authors have nothing to disclose., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Swimming pool suction injuries are rarely encountered in forensic medicine. Infants under 8 years of age are most frequently involved in such accidents with high risk of serious injuries and fatal consequences due to drowning. We report, for the first time, a case of a 13-year-old boy trapped at the abdomen by an uncovered suction drainage hole. External examination of the body revealed a round ecchymosis which had the same diameter as the pool drain. Post-mortem examination established that death had occurred due to drowning, possibly in combination with traumatic shock from the suction mechanism involving the intestinal loops. Furthermore, this case may be remarkable as it raises other medico-legal issues regarding the safety standards at swimming pools, including pool management and lifeguard attendance. Preventative measures are needed in order to make sure this sort of injury or death does not occur. Moreover, the awareness of the occurrence of these accidents should be increased.

Competing Interests: Competing interests: None declared.

This case represents a planned complex suicide in which the victim combined gunshot to the head and hanging. The most interesting finding in the presented case was pale face, but without any visible injury to it at the time the body was found (more than 24 hours after death), whereas at autopsy (20 hours later), black eyes were prominent. The removal of the ligature led to the decompression of the neck and its blood vessels with consequential blood redistribution, which, alongside the liquid state of blood, resulted in the aforementioned finding. Considering the described postponed appearance of periorbital ecchymosis, this kind of finding suggests that great caution is necessary when interpreting hematomas in terms of their vitality.

The usefulness of Toluidine blue dye in the detection of anogenital injuries in sixty females aged 16-40 years of age with a history of consensual sexual intercourse within 48 h of intercourse were included for the study from the Gynaecology outpatient department of the Institute of Medicine, Maharajgunj, Kathmandu, Nepal over a period of 10 months. Injuries were identified and documented using TEARS classification (tears-ecchymosis-abrasion-redness-swelling) before and after the application of toluidine blue dye (TBD). Anogenital injuries were detected in 6.7% participants (4 out of 60) before the dye application and 20% participants (12 out of 60) after the dye application. Thus, TBD application increased the detection of anogenital injuries three times compared to that of the naked-eye examination. Applying the Chi-square test, there were significant differences in the detection of tears and abrasions after TBD application (p-value - 0.035 and 0.042 respectively)., (Copyright © 2019 Elsevier Ltd and Faculty of Forensic and Legal Medicine. All rights reserved.)

Specific or nonspecific findings of sexual abuse may be observed upon examination of a child. Examination of the genital area is extremely important for the identification of child sexual abuse (CSA). However, medical conditions detected in the child's genital area may be misinterpreted as signs of CSA. Herein, we present a case of a child with suspected CSA who was treated in the intensive care unit. The following incidental findings were obtained upon anal examination: dilatation, ecchymosis, laceration, and hemorrhage. This report aims to discuss the anal examination findings that can mimic CSA.

Crimean-Congo hemorrhagic fever (CCHF) is a zoonotic viral disease. We aimed to investigate the cutaneous manifestations of CCHF and reveal their associations with fatality. Two hundred and sixty-nine patients diagnosed with CCHF were assessed. Skin findings were observed in 170 (63.2%) patients. A facial rash was the most common cutaneous finding (n = 82, 30.5%). In severe cases, hemorrhagic cutaneous manifestations (petechiae and ecchymoses) were recognized. A statistically significant correlation was obtained between cutaneous manifestations and fatality, and it was determined that there was a strong positive correlation between fatality and ecchymosis (r = 567, p < 0.001). In addition, a logistic regression analysis was performed, and death occurred 4.69 times more in those with skin signs than in those without. We hypothesize that CCHF patients with ecchymosis are at the highest risk and that cutaneous findings can contribute to the prognosis of CCHF.

There were few case reports discuss about iatrogenic chest wall hematoma. Although it is rare life threatening, it still can result in significant morbidity. A 68-year-old woman with histories of end-stage renal disease under regular hemodialysis and congestive heart failure was sent to our emergency department because of progression of ecchymosis over the anterior chest wall a few hours after hemodialysis. The right subclavian hemodialysis catheter was inserted for hemodialysis on the same day. She did not have a history of bleeding disorders and was not taking any antiplatelet or anticoagulant agents. Additionally, she had no recent trauma episodes. Physical examination revealed a large ecchymosis over the anterior right chest wall with swelling and tenderness. Blood examination showed no specific finding. Contrast-enhanced computed tomography of the chest revealed a hyperdense lesion with extravasation over the right chest wall, suggesting the presence of a hematoma with active bleeding. Local compression was applied. However, hematoma expansion was still noted. Therefore, we consulted a thoracic surgeon concerning surgical intervention. During the operation, active bleeding of the intramuscular arterial branch of the right pectoralis major was encountered. After surgical repair, no more bleeding was noted. It is important to confirm the possible cause of chest wall hematoma. Treating the underlying disease and discontinuing anticoagulation and antiplatelet agents should be considered. For iatrogenic chest wall hematoma, bleeding control should be the priority. Contrast-enhanced computed tomography could be arranged if there are no contraindications., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Competing Interests: Competing interests: None declared.

A 7-year-old girl was admitted to Xiangya Hospital due to systemic lymphadenectasis for 2 months and skin ecchymosis for 3 days. Nine months ago, the girl experienced painless nodules in the left lower extremity with no apparent causes. Three months later, dermatorrhagia and ecchymosis occurred in many regions such as the periocular areas, conjunctiva, oral mucosa, perineal area, and groin, with a "raccoon sign" in both eyes; superficial lymphadenectasis and hepatosplenomegaly were also observed in many regions. The pathological sections for the skin nodules showed malignant tumors in lymphohematopoietic cells, and in combination with clinical manifestations, immunohistochemistry, and positive results for CD4, CD56, and CD123 by bone marrow flow cytometry, the girl was diagnosed with blastic plasmacytoid dendritic cell neoplasm. Then high-risk ALL regimen was applied as the chemotherapy for this girl. At present, the girl has been followed up for 3 months; ecchymosis has disappeared, and the enlarged lymph nodes have shrunk. No abnormal cells have been found in bone marrow morphological examination, and bone marrow flow cytometry has shown that primitive precursor cells account for 1.5% and express CD33, CD34, CD123, and CD117.

Cupping is a traditional treatment method that has been used for thousands of years to diminish pain, restore appetite and improve digestion, remove tendency to faint or remove 'bad blood' from the body. The suction of the cup is created by fire or mechanical devices. This procedure may result in circular erythema, petechiae, purpura, ecchymosis, burns and may be mistaken for trauma-related ecchymosis or livor mortis. Forty-year-old male was died by shotgun injuries in the same day of the wounding. Circular ecchymoses were observed on the forehead, within the scalp of occipital region, the back of the neck, and on the back. They were defined as ecchymoses in the first examination made by a general practitioner. In the external examination during the legal autopsy superficial incisions were observed on the circular ecchymoses. The shape, localization and color of and the characteristics of incisions on the circular lesions were concluded to be caused by the dry cupping therapy and wet cupping therapy procedures. These lesions and their formation mechanisms should be well-known by the forensic medical examiners and the other medical personnel involved in the forensic medical examination., (Copyright © 2015 Elsevier Ltd and Faculty of Forensic and Legal Medicine. All rights reserved.)

Discoloration of the skin of the anterior and lateral neck may raise suspicion for blunt force injury, particularly cervical compression, in an unwitnessed death. We present a case of an elderly woman with an unwitnessed death at home which highlights an external examination finding of blue/purple discoloration of the skin of the neck and links this finding with those from internal examination at autopsy. Pertinent negatives include absence of conjunctival and mucosal petechiae, absence of cutaneous abrasions of the neck, and absence of contusions of the anterior neck musculature. This case illustrates a natural disease entity, spontaneous dissection of a thoracic aortic hematoma, masquerading as blunt force injury externally and highlights the importance of having an appropriate index of suspicion when triaging jurisdictional cases for postmortem examination to accurately determine cause and manner of death., (© 2015 American Academy of Forensic Sciences.)

Hobnail hemangioma (HH), initially termed targetoid hemosiderotic hemangioma, is a rare, often solitary lesion classically characterized by a central brown or violaceous papulonodule surrounded at times by an ecchymotic halo. This lesion is typically found on the trunk or limbs of children or young to middle-aged adults. Numerous case reports have found HHs to have a reproducible histologic appearance. Although the exact histogenesis of these lesions is unknown, multiple recent immunohistochemical studies suggest a lymphatic origin of these lesions. We present six cases of children with HHs with classic histology but with variability in their clinical appearance. Because the clinical presence of a targetoid halo is inconsistent and the hobnail phenomenon is not specific, we favor the designation of superficial hemosiderotic lymphovascular malformation instead of HH or targetoid hemosiderotic hemangioma as a more unifying term for this rare clinical entity. By eliminating confounding terminologies (in this case, incorporation of "hemangioma" in the name of this entity), we also hope to encourage a swifter change in practice to move away from erroneous diagnostic considerations., (© 2014 Wiley Periodicals, Inc.)

The research compound 25I-NBOMe, also known as CIMBI-5 or INBMeO, was created in academic laboratories as a potent serotonin 2A receptor agonist. Because of its high affinity and ambiguous legal status, recreational drug enthusiasts have used this compound as a powerful alternative to other hallucinogenic drugs such as lysergic acid diethylamide. We report 2 deaths after 25I-NBOMe ingestion by decedents who attended separate "rave" parties. The first case involved a 21-year-old male who admitted taking "acid" to his friend. A sudden violent rage caused him to flail about, and he subsequently became unresponsive. The postmortem examination revealed numerous external injuries that were consistent with physical aggression. The second case involved a 15-year-old female who was socializing outside a rave party, became ill, and rapidly deteriorated as her friend transported her to the hospital. The postmortem assessment was similar to the first case in that external contusions featured prominently. Comprehensive toxicology screens in both cases revealed only evidence of marijuana use. A deeper analysis using time-of-flight mass spectrometry revealed the presence of 25I-NBOMe, which was further confirmed by tandem-mass spectrometry. The behavior and injuries in these cases reveal a consistent pattern preceding fatal 25I-NBOMe toxicity.

The number of the suicides is increasing all around the world. In this study, the cases autopsied between 2000 and 2007 in The Konya Branch of Forensic Medicine Council were retrospectively investigated. Fifty-seven shotgun suicides were determined. The cases were evaluated in terms of their demographic characters, site of entrance wound, the type of the cartridge used, shooting distance, the place of incident, the place of death, motive for suicide, and the presence of previous suicide attempts. The most preferred site of entrance wound was the head with 34 cases (59.7%). Of 34 cases in which the entrance wound was on the head, there was indirect mandibular fracture in 16 cases (47.1%). In 11 cases (19.3%), there observed small ecchymosed abrasions on the finger surfaces, which are thought to have resulted from the trigger kicking back during triggering or the finger having been stuck between the trigger and the trigger guard. It is concluded that there is a need for a legal regulation that makes obtaining of shotguns more difficult and the people who have them are to be educated not to keep them in easily accessible places.

Hemorrhagic fevers (HF) caused by viruses and bacteria are a major public health problem in China and characterized by variable clinical manifestations, such that it is often difficult to achieve accurate diagnosis and treatment. The causes of HF in 85 patients admitted to Dandong hospital, China, between 2011-2012 were determined by serological and PCR tests. Of these, 34 patients were diagnosed with Huaiyangshan hemorrhagic fever (HYSHF), 34 with Hemorrhagic Fever with Renal Syndrome (HFRS), one with murine typhus, and one with scrub typhus. Etiologic agents could not be determined in the 15 remaining patients. Phylogenetic analyses of recovered bacterial and viral sequences revealed that the causative infectious agents were closely related to those described in other geographical regions. As these diseases have no distinctive clinical features in their early stage, only 13 patients were initially accurately diagnosed. The distinctive clinical features of HFRS and HYSHF developed during disease progression. Enlarged lymph nodes, cough, sputum, and diarrhea were more common in HYSHF patients, while more HFRS cases presented with headache, sore throat, oliguria, percussion pain kidney area, and petechiae. Additionally, HYSHF patients displayed significantly lower levels of white blood cells (WBC), higher levels of creations kinase (CK) and alanine aminotransferase (ALT), while HFRS patients presented with an elevation of blood urea nitrogen (BUN) and creatinine (CREA). These clinical features will assist in the accurate diagnosis of both HYSHF and HFRS. Overall, our data reveal the complexity of pathogens causing HFs in a single Chinese hospital, and highlight the need for accurate early diagnosis and a better understanding of their distinctive clinical features.

Levamisole is a veterinary anthelmintic drug with immunomodulatory properties in humans. It has become increasingly common as a contaminant in cocaine and is now detected in the majority of cocaine seized in the United States. A variety of adverse reactions have been reported in association with levamisole, the most severe being agranulocytosis, vascular occlusive disease, and thrombotic vasculopathy, with or without vasculitis. The combination of rapidly progressive cutaneous ecchymosis and purpura leading to necrosis, often affecting the ears and cheeks; neutropenia or agranulocytosis; serologic autoantibodies; and thrombotic vasculopathy, with or without associated vasculitis, in a patient who has recently used cocaine is characteristic of exposure to contaminant levamisole. We report the case of a 54-year-old man who presented with the clinical findings of levamisole-contaminated cocaine use and review the literature regarding cutaneous reactions associated with levamisole. Our case highlights this important public health issue and represents a clinical course that is unusually severe.

Hanging is a common suicidal means adopted. Careful inspection and noting of ligature mark is a vital factor during medico-legal postmortem. Ligature material used by the deceased is an important factor causing ligature mark in hanging. Apart from the ligature mark there are other injuries over neck surrounding it, which are called as 'peri-ligature injuries'. Peri-ligature injuries such as blisters, bruise, abrasion, etc. are influenced by different types of ligature material involved. These peri-ligature injuries are important for commenting on the antemortem nature of hanging in addition to other factors. Thus the present study on hanging deaths was carried out to see the relation of ligature material and different injuries occurring over the neck., (Copyright © 2013 Elsevier Ltd and Faculty of Forensic and Legal Medicine. All rights reserved.)

We report a case of lethal acute aortic dissection revealed by a large ecchymotic area at the root of the neck; the subject was an 86-year-old man who died suddenly in his hospital room. His medical history included ischemic heart disease with pacemaker implantation and an aortic surgical prosthesis. Forensic autopsy showed a major subcutaneous hemorrhage in the neck and large left pleural and pericardial adhesions secondary to thoracic surgery. The cause of death was an acute aortic dissection. Large adhesions led to an extensive mediastinal hemorrhage, spreading to the subcutaneous tissues of the neck. This case report highlights the difficulties in differentiating between traumatic and pseudo-bruising during a death scene investigation. The etiologies of pseudo-bruising are reviewed.

Deaths due to positional asphyxia are most often accidental, associated with alcohol and/or drug intoxication. A 19-year-old male is reported who was assaulted and placed in a head-down position in the back of a car were he was later found dead. Brush abrasions indicated that he had been dragged to the vehicle. The head and right shoulder were wedged into the foot well with the body uppermost. At autopsy, there was marked congestion of the face, neck, and upper chest with conjunctival ecchymoses, bruising of the face and scalp, focal subarachnoid hemorrhage, minor cerebral contusion, and diffuse cerebral swelling with early hypoxic ischemic encephalopathy (HIE). Toxicology was negative. Death was attributed to HIE resulting from the unusual positioning of the body. Cases of positional asphyxia involving others may not always include restraint, and when encountered should initiate a careful evaluation of the possible events and lethal pathophysiological processes., (© 2013 American Academy of Forensic Sciences.)

Background: Subcutaneous ecchymosis caused by venous reflux is a preventable complication following lymphaticovenular anastomosis. The authors developed a series of operative procedures to prevent venous reflux. This is probably the first report on valvuloplasty for small subcutaneous veins (diameter, <1 mm)., Methods: A total of 165 anastomoses in 39 limbs were operated on using this novel procedure (study group). Extended vein dissection was performed to ensure inclusion of some venous valves. Venous regurgitation was assessed using a retrograde milking test. When regurgitation was observed at all peripheral branches, external valvuloplasty was performed at the small subcutaneous vein to prevent backflow. The rate of venous reflux was compared with 151 anastomoses in 34 limbs operated on using conventional procedures (control group). Moreover, the amount of volume reduction was compared between the patients with and without venous reflux., Results: In the study group, the rate of regurgitation was reduced (3.0 percent) by extended vein dissection compared with that in the control group (9.9 percent), whereas the regurgitation ceased completely following external valvuloplasty (0 percent). In addition, postoperative ecchymosis was prevented completely in the study group (8.8 percent in the control group). Perioperative improvement in the lower extremity lymphedema index was significantly different between the patients with and without venous reflux (with venous reflux, 0.0706 ± 0.0742; without venous reflux, 0.0904 ± 0.0614)., Conclusions: The authors' results suggest that these operative procedures could be highly effective in preventing venous reflux. Moreover, venous reflux, if not corrected, leads to worsening of the results. Excellent results were consistently achieved by preventing venous reflux., Clinical Question/level of Evidence: Therapeutic, III.

Human ecchinococcosis also known as hydatid disease is a zoonotic infection caused by the tapeworm Ecchinococcus with 2-3 Million cases worldwide. We hereby report a 6 years period study of Sudden death due to hydatidosis aiming to analyze the epidemiological criteria, death circumstances, and autopsy observations attributed to hydatid disease. During the past 6 years, 26 death cases were due to hydatid disease. Our analysis shows that the sex ratio (M/F) was 1.6, the mean age was 31-year old, and 65% of the subjects lived in rural places. In 17 cases, death occurred in the victim's place, five victims died after a heavy exercise, and in two cases, death occurred immediately after trauma. At autopsy, 91% of the cysts were found in the liver. In three cases, death followed a septic state, and in two cases, it followed an acute respiratory failure. Death was attributed to anaphylaxis in 17 cases., (© 2013 American Academy of Forensic Sciences.)