Inter-play of trauma and disease ― a case report

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INTRODUCTION

One of the prime duties of a forensic pathologist is to opine about the cause and manner of death. It helps the investigating officer when deaths are to be differentiated into natural and unnatural ones. Some times while investigating unnatural deaths, accidents and suicides may appear as homicides and vice versa. In rare circumstances cases brought by the police for autopsy as homicides turns out to be natural deaths. First visit to the death scene by the police may be misleading; body, surroundings and the initial investigation may suggest homicide to the eyes of the police. Later when body is subjected for autopsy it is revealed that the death is from natural causes.

Deciding the cause of death often decides the manner of death. Injuries on the body are non-fatal but can precipitate death in a short time from natural causes [1].

The severity and compatibility with life of any natural disease or injury and extent of interaction between them needs to be thoroughly evaluated before cause and manner of death is finalized. Here we present a case where a body of a 29 year old lady was brought with history of assault for autopsy and it ended up being a death due to natural causes expedited by assault.

CASE REPORT

The deceased a 29 year old lady was living with her boyfriend since 4 years after having separated from her husband. She was physically assaulted by her boyfriend on an evening. He had strangled her neck, punched and kicked her on the face and had left home later. Next day morning he returned home to find his girlfriend dead. As per initial investigation by the police the couple frequently quarreled over the deceased speaking over phone with some other person.

Body was subjected to forensic autopsy on the subsequent day. It was a dead body of an adult female aged about 29 years, measuring 4 feet 10 inches in length; moderately built and poorly nourished; light brown in complexion. Both eyes were contused. Post-mortem staining was faintly present over the back and fixed. Rigor mortis appreciated was all over the body.

Multiple contusions, varying in sizes from 5 cm × 3 cm to 1 cm × 0.5 cm were present over left side of forehead, both the eyes, root of nose, right side of both lips. Scratch abrasion vertically placed measuring 1cm in length was present over front of neck. Two linear horizontally placed ligature mark placed 1cm apart, measuring 4 cm × 0.5 cm and 5 cm × 0.5 cm present over front of neck, situated below the thyroid cartilage (Fig. 1). Right sternomastoid muscle was contused in the middle and at its lower end. Haemorrhage around the muscle was observed over an area of 3 cm × 2 cm. Carotid and Jugular vessels were intact. Thyroid cartilage and hyoid bone were intact. On reflection of scalp, extravasation of blood was observed in left frontal and parietal region. Skull was intact; a thin layer of purulent exudate was present on the leptomeninges covering both cerebral hemispheres and the cerebellum (Fig. 2). Both lungs were consolidated all over. Heart, valves and coronaries were unremarkable. Other organs were intact and pale. There were no signs of asphyxia. Brain and other organ tissue samples collected were fixed in formalin. Histopathological examination revealed features of acute on chronic meningitis, bronchopneumonia of both lungs. Liver, spleen, kidneys, heart and myocardium were unremarkable. Blood and viscera were sent for chemical analysis to the State Forensic Science Laboratory and was tested negative for alcohol and other poisons.

 

Fig. 1. Ligature mark present over front of neck.

 

Fig. 2. Purulent exudate present on the leptomeninges.

 

Police were advised to further investigate the circumstances of death. It was revealed that the deceased had history of on and off fever, drowsiness, confusion, altered sensorium for few months and was still alive when her boyfriend left home after assaulting her. Considering facts of the case provided by the police, autopsy findings, histopathology and toxicology report cause of death was attributed to Chronic Meningitis. It was also opined that the assault could have hastened the process of death from natural causes. There were no findings suggesting ligature strangulation or assault by blunt force has alone caused death.

DISCUSSION

One of the main objectives of medicolegal autopsy is opining cause and manner of death. The manner of death as determined by the forensic pathologist is an opinion based on the known facts concerning the circumstances leading up to and surrounding the death, in conjunction with the findings at autopsy and the laboratory tests [2]. However it becomes difficult in certain situations where a person dies after trauma and also has pre-existing natural disease. The relative contributions of trauma and disease may then become an acute medico-legal problem. It is very important to deduce whether death was entirely caused by disease or trauma or a combination of both [3].

A potential source of confusion in medicolegal death investigations (MLDIs) arises when death from natural causes occurs in circumstances that suggest violence. Consequently, the pathologist involved in MLDI is confronted with distinguishing between natural disease and trauma or a combination of both [4, 5].

The nature and severity of disease and injury has to be considered before coming to the conclusion. Commonly such situations involve trauma and pre-existing coronary artery disease. In the present case the deceased had head ache, confusion and intermittent fever since 6 to 8 weeks; autopsy revealed features suggestive of acute on chronic bacterial meningitis. Such cases when untreated will succumb in their due course due to complications. Shock, respiratory failure, organ failure, coagulation disorders are systemic complications; whereas stroke, seizures or brain herniation are the local (intracranial) complications [6]. The deceased had bilateral bronchopneumonia as a systemic complication of meningitis which resulted in respiratory failure and death. Meningitis was acute on chronic in nature and the injuries caused by assault could not have caused it.

Faint ligature mark and multiple bruises were external injuries observed and the deceased was alive when her boyfriend left her after assaulting. There were no internal injuries and asphyxia stigmata which could suggest us to attribute death solely to injuries. These injuries alone would not cause death if the deceased did not have pre-existing meningitis.

Considering the autopsy findings and the inter play between meningitis and injuries, cause of death was attributed to meningitis and the process of death was expedited by the injuries resulting from assault.

Based on the initial investigation and external injuries over the body, the police had registered the case as culpable homicide amounting to murder. Much fatal meningitis was masked by the ligature mark and multiple bruises making the police to investigate the case in lines of homicide. After the receipt of autopsy report and further deliberations with the forensic pathologist, the boyfriend was charged with culpable homicide not amounting to murder as per the Indian Penal Code which is much lesser charge compared to murder.

CONCLUSION

Ascertaining cause and manner of death is a prime objective of medico legal autopsy. Case history, circumstantial evidence and autopsy findings should be properly interpreted and any mismatch between these should be viewed with suspicion before deciding on a final opinion.

This would lead the death investigation in the right direction and would help in bringing justice.

ADDITIONAL INFORMATION

Funding source. No funding.

Competing interests. The authors declare no obvious and potential conflicts of interest related to the content of this article.

Authors’ contribution. All of the authors read and approved the final version of the manuscript before publication, agreed to be responsible for all aspects of the work, implying proper examination and resolution of issues relating to the accuracy or integrity of any part of the work. J.S. Hosahally carried out the autopsy and wrote the manuscript; A. Singh carried out the autopsy along with J.S. Hosahally, took the autopsy pictures and reviewed the literature; Y.P. Girish Chandra wrote the manuscript along with J.S. Hosahally.

About the authors

Jayanth S Hosahally

Dr Chandramma Dayananda Sagar Institute of Medical Education and Research, Dayananda Sagar University, Kanakapura

Email: veejay02@gmail.com
ORCID iD: 0000-0001-5209-1133

MBBS, MD (Forensic Medicine), Associate Professor

India, Karnataka

Ankita Singh

Bangalore Medical College and Research Institute

Email: drsing11991@gmail.com
ORCID iD: 0000-0001-9233-8030

MBBS, MD (Forensic Medicine), Senior Resident

India, Bangalore

Chandra Y.P. Girish

MS Ramaiah Medical College

Author for correspondence.
Email: girishchandra14@gmail.com
ORCID iD: 0000-0002-5446-8114

MBBS, MD (Forensic Medicine), Professor & HOD

India, Bangalore

References

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