title: Multidrug-related leukocytoclastic vasculitis raising suspicion of sexual homicide-things are not always what they seem.
abstract: Ambiguous findings during external examination of a deceased in combination with dubious autopsy findings can raise doubts concerning the manner and cause of death. We report the case of a 35-year-old female deceased who had suffered from a borderline personality and depressive disorder with suicidal ideation. At the death scene, the body showed massive facial swelling accompanied by complete reddening of the skin of the face, with patchy skin abrasions on the forehead and neck, and purple bruise-like discolorations distributed symmetrically over both shoulders, elbows, hands, hips, knees, lower legs, and feet, raising the suspicion of underlying massive external blunt force injury. Police investigators strongly suspected sexual homicide. At autopsy, dissection in layers revealed massive subcutaneous hemorrhages as the cause of the reddish skin discolorations. Toxicological analyses showed fatal levels of lamotrigine with additional proof of zopiclone, zolpidem, diphenhydramine, O-desmethylvenlafaxine, pregabalin, tramadol, and modafinil in venous blood. Histologically, both the macroscopically impressive purple skin changes with underlying bleeding into the subcutaneous tissue and the skin abrasions were due to leukocytoclastic vasculitis, a form of acute hypersensitivity vasculitis that was a reaction to the multiple therapeutic drugs that the woman had taken shortly before death. The manner of death was classified as suicide, and sexual homicide was ruled out.
authors.affiliation: Department of Public Health and Pediatrics, Section of Legal Medicine, University of Turin, Corso Galileo Galilei 22, 10126, Torino, Italy. luciatattoli@libero.it.
authors.forename: Lucia
authors.initials: L
authors.lastname: Tattoli
authors.affiliation: State Institute of Forensic Medicine and Pathology, Berlin, Germany.
authors.forename: Klaus
authors.initials: K
authors.lastname: Krocker
authors.affiliation: State Institute of Forensic Medicine and Pathology, Berlin, Germany.
authors.forename: Julia
authors.initials: J
authors.lastname: Sautter
authors.affiliation: Institute of Legal Medicine and Forensic Sciences, Charité - Universitätsmedizin Berlin, Berlin, Germany.
authors.forename: Michael
authors.initials: M
authors.lastname: Tsokos
mesh_terms: D000328:Adult; D000701:Analgesics, Opioid / Q000097:blood; D014151:Anti-Anxiety Agents / Q000097:blood; D000928:Antidepressive Agents / Q000097:blood; D053961:Azabicyclo Compounds / Q000097:blood; D001559:Benzhydryl Compounds / Q000097:blood; D002121:Calcium Channel Blockers / Q000097:blood / Q000506:poisoning; D000069468:Desvenlafaxine Succinate / Q000097:blood; D004155:Diphenhydramine / Q000097:blood; D005260:Female; D049429:Forensic Pathology; D006470:Hemorrhage / Q000139:chemically induced; D006801:Humans; D006993:Hypnotics and Sedatives / Q000097:blood; D000077213:Lamotrigine; D000077408:Modafinil; D010879:Piperazines / Q000097:blood; D000069583:Pregabalin / Q000097:blood; D011725:Pyridines / Q000097:blood; D040521:Subcutaneous Tissue / Q000473:pathology*; D014147:Tramadol / Q000097:blood; D014227:Triazines / Q000097:blood / Q000506:poisoning; D018366:Vasculitis, Leukocytoclastic, Cutaneous / Q000139:chemically induced* / Q000473:pathology; D064690:Wakefulness-Promoting Agents / Q000097:blood; D000077334:Zolpidem
chemical_list: D000701:Analgesics, Opioid; D014151:Anti-Anxiety Agents; D000928:Antidepressive Agents; D053961:Azabicyclo Compounds; D001559:Benzhydryl Compounds; D002121:Calcium Channel Blockers; D006993:Hypnotics and Sedatives; D010879:Piperazines; D011725:Pyridines; D014227:Triazines; D064690:Wakefulness-Promoting Agents; C515050:zopiclone; D014147:Tramadol; D000069583:Pregabalin; D000077334:Zolpidem; D004155:Diphenhydramine; D000077408:Modafinil; D000077213:Lamotrigine; D000069468:Desvenlafaxine Succinate
keywords: Blunt force injury; Bruising; Lamotrigine; Leukocytoclastic vasculitis; Polytoxicomania; Sexual homicide