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 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.
DiscussionThe 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 chan...