Diagnosis of drowning using postmortem computed tomography combined with endoscopic autopsy: A case report

Abstract

Rationale: Postmortem forensic imaging technologies provide a noninvasive/minimally invasive approach for imaging of internal organ structures of the human body to detect injuries, diseases, and other morphologic changes. Currently, postmortem forensic imaging methods have been widely used in determination of the cause of death. However, these methods do not allow histologic examinations. Endoscopic autopsy emerged in the 1990s. Thoracoscopy and laparoscopy are mainly used to examine organs and tissues in the thoracic and abdominal cavity. Target tissues are also sampled for histologic examination. By combining postmortem forensic imaging with endoscopic autopsy, comprehensive examination of the corpse, organs, and sampling for histologic examination can be carried out.

Patient concerns: A 34-year-old woman was witnessed jumping into the river, sinking after struggling in the water. The body was found 24 hours later and confirmed with no vital signs. No preexisting medical conditions were known.

Diagnosis, interventions, and outcomes: Postmortem computed tomography, target coronary postmortem computed tomography angiography, and endoscopic autopsy were performed before conventional autopsy. Laparoscopic examination was used to examine the abdominal organs. The diaphragm and pericardium were cut open from the abdominal cavity to allow access to the examination of lungs and heart. Tissue samples were collected from various organs for histologic examination, and a diatom test was carried out on lung samples. Postmortem computed tomography revealed fluid in the paranasal sinuses, airways, stomach, and duodenum; emphysema aquosum; and mosaic pattern of the lung parenchyma. Endoscopic examination additionally detected Paltauf spots. The results were consistent with those of conventional autopsy. Histologic examination revealed pulmonary congestion, pulmonary edema, pulmonary emphysema, pulmonary hemorrhage, and congestion in multiple organs such as the liver, spleen, and kidneys. Diatoms were detected in lung tissues, which were identical in morphology to diatoms in water samples collected from the scene. The cause of death was determined as drowning.

Conclusion: Combining forensic imaging and endoscopic autopsy for postmortem examination yields a more comprehensive and scientific finding, and the combination is minimally invasive and more acceptable to the family members. This method can be used as an alternative for conventional autopsy under specific circumstances.

Figure 1

Postmortem computed tomography shows (A) air/fluid in the sphenoidal sinus (arrowheads) and the left maxillary sinus (arrowhead); (B) mosaic patterns of the lungs; (C, D) air/fluid in the trachea (arrowhead) and fluid in the main bronchi (arrows) with an air/fluid level on the right side (arrowhead); and (E) air/fluid in a distended stomach (arrowhead).

Figure 2

Three-dimensional reconstruction of coronary postmortem computed tomography angiography shows no abnormalities in the various major branches.

Figure 3

Endoscopic autopsy views of the (A, B) lungs, (C) heart, (D) liver, (E) spleen, and (F) kidney. Note the hemorrhage spots in the lungs, that is, Paltauf spots (circles) and pericardial effusion (circles).

Figure 4

Histologic examinations and diatom tests show (A) pulmonary edema accompanied with pulmonary emphysema; (B) pulmonary hemorrhage; and (C) diatoms in lung tissues.