Forensic Sci Med Pathol (2014) 10:651–653 DOI 10.1007/s12024-014-9589-9
IMAGES IN FORENSICS
Unusual patterned skin lesions caused by postmortem fungal activity Roger W. Byard
Accepted: 25 June 2014 / Published online: 16 July 2014 Ó Springer Science+Business Media New York 2014
Case report A 28-year-old male who had been missing for 14 days was found deceased lying under a tree. His past history included insulin-dependent diabetes mellitus, a borderline personality disorder, paranoid schizophrenia, amphetamine use and previous suicide attempts using inhaled gas and insulin overdose. He had recently been having hypoglycemic fits. At autopsy the body was that of an adult white male of around the stated age of 28 years. Rigor mortis was absent and early changes of decomposition were present with skin slippage and focal green putrefactive discoloration. Small fly larvae were present over the neck and face without pupal cases. An unusual feature consisted of multiple irregularly circular to oval discolored lesions over the left upper arm and left side of the chest (Fig. 1), as well as on the right forearm. These measured approximately 15–50 mm in diameter and were dark in color. Sectioning revealed no associated interstitial hemorrhage (Fig. 2). Internal examination demonstrated scattered Wischnewski ulcers of the stomach (superficial erosive gastritis) in keeping with hypothermia, and bilateral cortical pallor of the kidneys which was shown histologically to be due to basal epithelial cell vacuolization with surrounding formalin pigment deposition. There were no other significant findings and toxicology demonstrated only a therapeutic R. W. Byard (&) School of Medical Sciences, The University of Adelaide, Frome Rd; Forensic Science SA, Divett Place, Adelaide, SA, Australia e-mail: [email protected] R. W. Byard Discipline of Anatomy and Pathology, Level 3 Medical School North Building, The University of Adelaide, Frome Road, Adelaide, 5005, Australia
level of risperidone. No vitreous humor was available due to changes of decomposition, although a urine dipstick test showed a moderate amount of ketones and glucose. Death was therefore attributed to hypothermia complicating diabetes mellitus. Histological examination of the circular skin lesions revealed numerous predominantly superficial linear fungal organisms (Figs. 3, 4) that were shown on culture to be Mucor hiemalis, with no evidence of dermal hemorrhage or vital reaction.
Discussion The assessment of apparent skin injuries at the time of autopsy is often crucial in determining the nature of possible trauma, the forces involved and whether there are any impressions that may indicate the type of weapon that has been used or the surface against which the body has impacted [1]. The most useful information often derives from injuries that show a particular pattern. Unfortunately cases occur where traumatic lesions are mimicked by other entities. An example of this reported previously in the journal was a case of metastatic carcinoma of the breast which had created skin lesions that closely resembled the typical targetoid lesions that occur with electrocution [2]. Changes of decomposition, involving both autolysis and putrefaction, also result in a variety of alterations to the skin and soft tissues which may complicate the identification and evaluation of injuries [3]. While the stages have been clearly delineated there is considerable variation in the time course that is influenced by a range of factors [4]. The body and its tissues may also be considerably changed after death by the activity of organisms that range from microscopic bacteria to large animals. These changes are more likely to be encountered if bodies have been
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Fig. 1 Unusual oval to round skin lesions on the left upper arm and left side of the chest showing yellow to brown discoloration and measuring approximately 15–50 mm in diameter
Forensic Sci Med Pathol (2014) 10:651–653
Fig. 3 Periodic acid-Schiff (PAS) staining of the skin revealing numerous predominantly superficial fungal hyphae that were subsequently shown on culture to be characteristic of Mucor hiemalis (PAS 9280)
Fig. 4 Grocott methenamine silver staining of the skin again showing the characteristic fungal hyphae (Grocott 9280)
Fig. 2 Incising one of the skin lesions showing no interstitial hemorrhage to indicate bruising
deliberately concealed or if decedents have been socially isolated resulting in delay in finding of the body [5]. While changes due to bacterial activity are not usually confused with antemortem activity, determining whether the injuries caused by animals, or insects such as ants, are ante- or post mortem may be difficult [6]. Fungal lesions are not as well recognized as mimickers of traumatic lesions, however the current case demonstrates clustered, irregularly-circular lesions with darkened areas (Fig. 1) that were suggestive of inflicted burns and/or bruising. Sectioning of the lesions at autopsy did not, however, reveal interstitial hemorrhage supportive of bruising, and histology showed fungal organisms which subsequently produced a pure growth of Mucor hiemalis on
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culture. The absence of an inflammatory infiltrate was in keeping with post mortem colonization. Mucor hiemalis is a member of the order Mucorales that may be responsible for invasive fungal disease in immunocompromised individuals. However, as the optimal growth temperature for Mucor hiemalis is only 32°, it is usually limited to cutaneous and rarely subcutaneous infections [7]. Despite the effects of decomposition, findings were able to be identified at autopsy which enabled the cause of death to be determined. Specifically, Wischnewski ulcers of the gastric mucosa stomach indicated hypothermia [8], with cortical pallor of the kidneys due to basal epithelial cell vacuolization [9] with surrounding formalin pigment deposition. The latter has been shown to be a useful histological maker for ketoacidosis when cellular morphology has been compromised by putrefaction [10]. Clearly, differentiation of non-traumatic lesions from those due to injury is an important part of the autopsy
Forensic Sci Med Pathol (2014) 10:651–653
examination [11]. Thus, the reported case demonstrates that fungal lesions due to Mucor hiemalis colonizing a body after death should be added to the list of injury mimickers, and artefacts introduced by decomposition.
References 1. Prahlow J, Byard RW. An atlas of forensic pathology. New York: Springer Publishers; 2012. 2. Byard RW. Infiltrating carcinoma of the breast mimicking electrocution. Forensic Sci Med Pathol. 2010;6:71–2. 3. Byard RW, Farrell ER, Simpson E. Diagnostic yield and characteristic features in a series of decomposed bodies subject to coronial autopsy. Forensic Sci Med Pathol. 2008;4:9–14. 4. Zhou C, Byard RW. Factors and processes causing accelerated decomposition in human cadavers. An overview. J Forensic Leg Med. 2011;18:6–9.
653 5. Byard RW, Tsokos M. Forensic issues in cases of Diogenes syndrome. Am J Forensic Med Pathol. 2007;28:177–81. 6. Byard RW. Autopsy problems associated with postmortem ant activity. Forensic Sci Med Pathol. 2005;1:37–40. 7. Desai RP, Joseph NM, Ananthakrishnan N, Ambujam S. Subcutaneous zygomycosis caused by Mucor hiemalis in an immunocompetent patient. Australas Med J. 2013;6:374–7. 8. Bright F, Winskog C, Byard RW. Wischnewski ulcers and hypothermia—sensitive, specific or serendipitous? Forensic Sci Med Pathol. 2013;9:88–90. 9. Zhou C, Yool A, Byard RW. Renal cortical pallor—a useful macroscopic marker for metabolic derangements at autopsy. J Forensic Sci. 2013;58:693–6. 10. Zhou C, Gilbert JD, Yool A, Byard RW. Basal epithelial formalin pigment deposition in the kidneys—a useful marker for ketoacidosis in decomposed bodies. J Forensic Leg Med. 2013;20:305–7. 11. Hammer U, Bu¨ttner A. Distinction between forensic evidence and post-mortem changes of the skin. Forensic Sci Med Pathol. 2012;8:330–3.
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IMAGES IN FORENSICS
Unusual patterned skin lesions caused by postmortem fungal activity Roger W. Byard
Accepted: 25 June 2014 / Published online: 16 July 2014 Ó Springer Science+Business Media New York 2014
Case report A 28-year-old male who had been missing for 14 days was found deceased lying under a tree. His past history included insulin-dependent diabetes mellitus, a borderline personality disorder, paranoid schizophrenia, amphetamine use and previous suicide attempts using inhaled gas and insulin overdose. He had recently been having hypoglycemic fits. At autopsy the body was that of an adult white male of around the stated age of 28 years. Rigor mortis was absent and early changes of decomposition were present with skin slippage and focal green putrefactive discoloration. Small fly larvae were present over the neck and face without pupal cases. An unusual feature consisted of multiple irregularly circular to oval discolored lesions over the left upper arm and left side of the chest (Fig. 1), as well as on the right forearm. These measured approximately 15–50 mm in diameter and were dark in color. Sectioning revealed no associated interstitial hemorrhage (Fig. 2). Internal examination demonstrated scattered Wischnewski ulcers of the stomach (superficial erosive gastritis) in keeping with hypothermia, and bilateral cortical pallor of the kidneys which was shown histologically to be due to basal epithelial cell vacuolization with surrounding formalin pigment deposition. There were no other significant findings and toxicology demonstrated only a therapeutic R. W. Byard (&) School of Medical Sciences, The University of Adelaide, Frome Rd; Forensic Science SA, Divett Place, Adelaide, SA, Australia e-mail: [email protected] R. W. Byard Discipline of Anatomy and Pathology, Level 3 Medical School North Building, The University of Adelaide, Frome Road, Adelaide, 5005, Australia
level of risperidone. No vitreous humor was available due to changes of decomposition, although a urine dipstick test showed a moderate amount of ketones and glucose. Death was therefore attributed to hypothermia complicating diabetes mellitus. Histological examination of the circular skin lesions revealed numerous predominantly superficial linear fungal organisms (Figs. 3, 4) that were shown on culture to be Mucor hiemalis, with no evidence of dermal hemorrhage or vital reaction.
Discussion The assessment of apparent skin injuries at the time of autopsy is often crucial in determining the nature of possible trauma, the forces involved and whether there are any impressions that may indicate the type of weapon that has been used or the surface against which the body has impacted [1]. The most useful information often derives from injuries that show a particular pattern. Unfortunately cases occur where traumatic lesions are mimicked by other entities. An example of this reported previously in the journal was a case of metastatic carcinoma of the breast which had created skin lesions that closely resembled the typical targetoid lesions that occur with electrocution [2]. Changes of decomposition, involving both autolysis and putrefaction, also result in a variety of alterations to the skin and soft tissues which may complicate the identification and evaluation of injuries [3]. While the stages have been clearly delineated there is considerable variation in the time course that is influenced by a range of factors [4]. The body and its tissues may also be considerably changed after death by the activity of organisms that range from microscopic bacteria to large animals. These changes are more likely to be encountered if bodies have been
123
652
Fig. 1 Unusual oval to round skin lesions on the left upper arm and left side of the chest showing yellow to brown discoloration and measuring approximately 15–50 mm in diameter
Forensic Sci Med Pathol (2014) 10:651–653
Fig. 3 Periodic acid-Schiff (PAS) staining of the skin revealing numerous predominantly superficial fungal hyphae that were subsequently shown on culture to be characteristic of Mucor hiemalis (PAS 9280)
Fig. 4 Grocott methenamine silver staining of the skin again showing the characteristic fungal hyphae (Grocott 9280)
Fig. 2 Incising one of the skin lesions showing no interstitial hemorrhage to indicate bruising
deliberately concealed or if decedents have been socially isolated resulting in delay in finding of the body [5]. While changes due to bacterial activity are not usually confused with antemortem activity, determining whether the injuries caused by animals, or insects such as ants, are ante- or post mortem may be difficult [6]. Fungal lesions are not as well recognized as mimickers of traumatic lesions, however the current case demonstrates clustered, irregularly-circular lesions with darkened areas (Fig. 1) that were suggestive of inflicted burns and/or bruising. Sectioning of the lesions at autopsy did not, however, reveal interstitial hemorrhage supportive of bruising, and histology showed fungal organisms which subsequently produced a pure growth of Mucor hiemalis on
123
culture. The absence of an inflammatory infiltrate was in keeping with post mortem colonization. Mucor hiemalis is a member of the order Mucorales that may be responsible for invasive fungal disease in immunocompromised individuals. However, as the optimal growth temperature for Mucor hiemalis is only 32°, it is usually limited to cutaneous and rarely subcutaneous infections [7]. Despite the effects of decomposition, findings were able to be identified at autopsy which enabled the cause of death to be determined. Specifically, Wischnewski ulcers of the gastric mucosa stomach indicated hypothermia [8], with cortical pallor of the kidneys due to basal epithelial cell vacuolization [9] with surrounding formalin pigment deposition. The latter has been shown to be a useful histological maker for ketoacidosis when cellular morphology has been compromised by putrefaction [10]. Clearly, differentiation of non-traumatic lesions from those due to injury is an important part of the autopsy
Forensic Sci Med Pathol (2014) 10:651–653
examination [11]. Thus, the reported case demonstrates that fungal lesions due to Mucor hiemalis colonizing a body after death should be added to the list of injury mimickers, and artefacts introduced by decomposition.
References 1. Prahlow J, Byard RW. An atlas of forensic pathology. New York: Springer Publishers; 2012. 2. Byard RW. Infiltrating carcinoma of the breast mimicking electrocution. Forensic Sci Med Pathol. 2010;6:71–2. 3. Byard RW, Farrell ER, Simpson E. Diagnostic yield and characteristic features in a series of decomposed bodies subject to coronial autopsy. Forensic Sci Med Pathol. 2008;4:9–14. 4. Zhou C, Byard RW. Factors and processes causing accelerated decomposition in human cadavers. An overview. J Forensic Leg Med. 2011;18:6–9.
653 5. Byard RW, Tsokos M. Forensic issues in cases of Diogenes syndrome. Am J Forensic Med Pathol. 2007;28:177–81. 6. Byard RW. Autopsy problems associated with postmortem ant activity. Forensic Sci Med Pathol. 2005;1:37–40. 7. Desai RP, Joseph NM, Ananthakrishnan N, Ambujam S. Subcutaneous zygomycosis caused by Mucor hiemalis in an immunocompetent patient. Australas Med J. 2013;6:374–7. 8. Bright F, Winskog C, Byard RW. Wischnewski ulcers and hypothermia—sensitive, specific or serendipitous? Forensic Sci Med Pathol. 2013;9:88–90. 9. Zhou C, Yool A, Byard RW. Renal cortical pallor—a useful macroscopic marker for metabolic derangements at autopsy. J Forensic Sci. 2013;58:693–6. 10. Zhou C, Gilbert JD, Yool A, Byard RW. Basal epithelial formalin pigment deposition in the kidneys—a useful marker for ketoacidosis in decomposed bodies. J Forensic Leg Med. 2013;20:305–7. 11. Hammer U, Bu¨ttner A. Distinction between forensic evidence and post-mortem changes of the skin. Forensic Sci Med Pathol. 2012;8:330–3.
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