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| Anil Aggrawal's Internet Journal of Forensic Medicine and Toxicology Anil Aggrawal's Internet Journal of Forensic Medicine and Toxicology Partner with a Pioneering Forensic Science Publication Established in 2000, Anil Aggrawal's Internet Journal of Forensic Medicine and Toxicology is a biannual, peer-reviewed, open-access journal dedicated to advancing forensic medicine, toxicology, and related disciplines. With over 25 volumes published, the journal continues to serve as a reputable platform for professionals, educators, and researchers worldwide. The journal is indexed in several major abstracting services, including Chemical Abstracts Service, EMBASE, Index Copernicus, SCOPUS, and Web of Science (Clarivate). Sponsorship Opportunities: We invite organizations to collaborate with us and gain targeted visibility among a specialized audience. Sponsorship benefits include: Brand Exposure: Prominent placement of your organization's logo and promotional materials on our journal's website and publications. Global Reach: Access to a diverse readership comprising forensic professionals, toxicologists, legal experts, and academics from around the world. Thought Leadership: Opportunity to contribute articles or case studies, positioning your organization as a leader in the field. Align your brand with a respected publication at the forefront of forensic science and toxicology.

Main Page > Vol-26 No- 1 > Paper 1 (you are here) LinkedIn X (Twitter) Facebook Copy link Share Anil Aggrawal's Internet Journal of Forensic Medicine and Toxicology Volume 26 Number 1 (January - June 2025) Received: Feb 17, 2024 Reviewers comments received: Mar 19, 2024 Revised paper received: May 29, 2024 Accepted: June 30, 2024 First published online as Epubahead: July 5, 2024 Ref – Shruthi, J Damodharan J. Knowledge and Attitude Towards End-of-Life care and Advance Directives amongst Medical Students and Postgraduates in a Tertiary care Hospital of South India. Anil Aggrawal's Internet Journal of Forensic Medicine and Toxicology [serial online], 2025; Vol. 26, No. 1 (Jan - June 2025): [about 19 p]. Available from: https://anilaggrawal.com/ij/vol-026-no-001/papers/paper001 . Published : Oct 18, 2023 DOI : 10.5281/zenodo.12666258 Email: shrupvs@gmail.com ( All photos can be enlarged on this webpage by clicking on them ) Knowledge and Attitude Towards End-of-Life care and Advance Directives amongst Medical Students and Postgraduates in a Tertiary care Hospital of South India Abstract Aim This study was conducted to assess the knowledge and attitude towards end-of-life care and advance directives amongst medical students and postgraduates of Saveetha Medical College and Hospital which is located in the city of Chennai, India. Methodology A cross-sectional questionnaire based observational study was conducted taking 369 medical students including interns and 83 postgraduates of Saveetha Medical College and Hospital as participants. A structured, pre-tested and validated questionnaire was prepared containing 18 questions related to end of life care and advance directives which was provided to the participants via google forms after obtaining informed consent. In addition, sociodemographic parameters such as sex, religion, phase of study and health insurance were obtained. Results Out of the 1077 individuals surveyed, majority of the respondents were females (61.1%). Most of the respondents were Hindus (67.1%), followed by Christians (19.1%) and Muslims (13.8%). Only 39.5% of the population had health insurance coverage. 96.2% of the participants in the study were unaware of Advance Directives (AD) or its legalization in India. None of them had created an AD, with the lack of promotion in medical education being cited as the primary reason by 94% of respondents. 31.4% of the population found the existence of AD reasonable, 75.8% of them were uncertain about whether it should be mandatory for all citizens of India. 80.2% were oblivious that adhering to Do Not Resuscitate (DNR) orders without an AD is illegal in India, while 61.1% were uncertain whether passive euthanasia and DNR are components of an AD in India. More than 90% of the population lacked awareness regarding the legal age for drafting an AD or the involvement of a Surrogate in its preparation. Nobody was familiar with the process of preparing an AD or the modifications to SC. Conclusion This study highlights insufficient awareness concerning Advance Directives (AD). However, attitudes toward AD preparation and End-of-Life care discussions appear to be mixed. Keywords Advance Directive, Attitudes, End-Of-Life Care, Epistemology, Hospice Program, Living Will, Medical Students

Main Page > Vol-27 No- 1 > Paper 2 (you are here) LinkedIn X (Twitter) Facebook Copy link Share Anil Aggrawal's Internet Journal of Forensic Medicine and Toxicology Volume 27 Number 1 (January - June 2026) Received: May 20, 2025 Revised Manuscript Received: June 8, 2025 Accepted: June 20, 2025 Ref: Hamzah NH, Osman K, Nadarajan N, Tham JC, Khairuddin N, Sabri MI, Nasir AM, Isa NM. Can Lip Prints Change Overnight?: A Study of Lip Print Stability Across Day and Night as a Forensic Identification Tool. Anil Aggrawal's Internet Journal of Forensic Medicine and Toxicology [serial online], Vol. 27, No. 1 (January - June 2026): [about 9 p]. Available from: https://www.anilaggrawal.com/ij/vol-027-no-001/papers/paper002 Published as EpubAhead: June 26, 2025 DOI: 10.5281/zenodo.15743496 Email: khairos@ukm.edu.my [Epub Ahead] ( All photos can be enlarged on this webpage by clicking on them ) Can Lip Prints Change Overnight?: A Study of Lip Print Stability Across Day and Night as a Forensic Identification Tool Abstract Aim Lip prints have long been considered unique and stable over time, causing a boost of cheiloscopy research to understand the potential of lip prints for forensic identification. While studies looking at lip print stability over time are common, this study investigates the stability based on the day and night phenomenon. Methodology Lip prints were taken from 200 participants from the campus population using the standardised paper technique, wherein lip prints were made on A4 papers then digitised using a high- resolution scanner. Lip prints similarity percentage were formed by comparison of the prints collected at the morning and evening, then analysed using Contrastive Language-Image Pre- training (CLIP) image analysis model. Statistical analysis included repeated-measures ANOVA to compare the lip print similarity percentage obtained at Day 1, Day 7 and Day 14. Intra-class correlation coefficient (ICC) is used to test the reliability of the CLIP model to analyse lip print images. Results Repeated measures ANOVA indicated significant variation in lip prints similarity percentage obtained at Day 1, Day 7 and Day 14. The intraclass correlation coefficient (ICC) was rated 0.649, between fair and good. Conclusion The study concludes that lip print morphology may not be as stable over short time intervals as previously assumed, and this variability should be considered in forensic evidence collection. Keywords Cheiloscopy, Lip Prints, Deep Learning, Digital Analysis, ICC Abbreviations CLIP Contrastive Language-Image Pre-training ICC Intra-Class Correlation SD Standard Deviation SPSS Statistical Package for the Social Sciences Introduction Lip print analysis raises questionable potential for forensic identification, known as cheiloscopy, and faced a turning point after the study by Tsuchihashi in 1974.[1] Lip prints are considered relatively stable over time and unique, similar to fingerprints. [2-5] However, the assumption of temporal stability has not been sufficiently challenged, particularly over short-term intervals such as within the day and night of the same day. Previous studies have primarily assessed long-term consistency of lip prints and their uniqueness among populations over long time intervals. [6,7] However, these studies are conducted with manual observation and no quantitative analysis was utilised to measure lip print similarity, thus invalidating efforts to ensure lip prints can adhere to the Daubert’s standard of evidence. [8] This study aims to explore the short-term variability of lip prints across different times of day using a novel digital approach. We employed Contrastive Language-Image Pre-training image analysis model (CLIP), a deep learning model capable of analysing images and calculating similarity percentage based on the potential changes of lip print patterns from day to night. Our hypothesis is that the lip print morphology may vary during the morning and evening due to natural biological fluctuations based on the circadian rhythm. Need for ‘this’ study Despite most studies describing lip prints as being stable, there is only a study measuring lip print stability quantitatively using similarity percentage. [9] This study presented new insights to lip print stability by classifying the similarity rate of lip print patterns into three categories based on their similarity percentage. Based on the results, the lip print similarity percentage was classified as medium (73.8%), meaning there may be potential changes in lip print patterns. The authors would like to provide new insights to these lip print pattern changes. On the other hand, digital analysis needs to be utilised in lip print analysis to accurately measure potential changes in lip prints. The application of digital analysis methods in forensic science allows better visualization, easier identification, and complete recording of images. [10] Our research findings would be able to provide new insights in measuring lip print similarity percentage. This study also presents a new perspective to measuring lip print stability. While time is usually the parameter used, the authors believe potential changes of lip print patterns based on the circadian clock system. The circadian clock plays an important role in oral and maxillofacial physiological and pathological processes. [11] In this present work, we studied the similarity of lip prints collected in a university campus population during the day and night phenomenon. Methodology This descriptive cross-sectional comparative study of 200 individuals was conducted periodically from November 2024 to March 2025. Every subject underwent a sample collection period of 2 weeks where the prints were collected on Day 1, Day 7 and Day 14. Collection sessions were divided into morning and evening. The suitable sample size, 200 was calculated based on these factor considerations as suggested by the Cohen’s D convention. [12] The factors are as below: i) Effect size Set at a value of 0.2, a small effect size magnitude is used to observe the potential small variations in lip print patterns. ii) Significance level, α Set at 5% as the majority of studies in this field which has a similar motive of observing lip print changes. [13, 14, 15] iii) Power Set at 80% as the majority of studies in this field with similar motives mentioned as above. [13, 14, 15] The G*Power statistical software is used to calculate an appropriate sample size. The supporting figure from the software is as below where the suggested sample size is 199, and rounded up to 200 subjects [Figure. 1] . Figure 1. Sample size calculation on G*Power software The Ethical Committee from Universiti Kebangsaan Malaysia approved this study. It was made sure all subjects were above 18 years old. Written consent from the subjects were taken before collecting their lip print as samples. The subjects consisted of both students and staff. 57 of the subjects were staff while 143 were students. From the 143 students, 50 were 2nd year undergraduate students, 83 were final year undergraduate students while 40 were postgraduate students as mentioned in [Figure 2] . Figure 2. Phase wise Distribution of Study Population From the consent form, several sociodemographic parameters related to the study such as sex, race, university campus and age are included in a table [Table 1]. Table 1. Sociodemographic profile of subjects Smeared lip prints, with unclear structure visualisation, or lip prints which were too dark due to excess lipstick smear were not included in analysis. Excluded lip prints were lips and/or nearby surrounding structures with inflammation/trauma, lips with malformation or deformity, lips with surgical scars, lips with ulcers, lips with wounds, lips with abnormalities, dry and chapped lips, and history of smoking cigarettes/vaping. Materials Lipstick (crimson poppy shade, non-glossy; IN2IT brand), white A4 sized papers (Double A brand, 80 gms), facial tissues (Premier brand, 2 Ply), facial wipes (Guardian brand), disposable lip brush (Cleo brand), digital printer (Brother DCP- J100 brand, 600 dpi). Software Google Colaboratory, Contrastive Language-Image Pre-training (CLIP) image processing model Sample collection 1. Sample preparation The lip prints were compared from the same subject at Day 1, Day 7, and Day 14. The collection sessions were held at the morning and evening of these days. The subjects cleaned their lips with facial wipes. A thin lipstick layer was applied using a clean disposable lip brush to the lips in a singular motion. [16] The subject then rubbed their lips to spread the lipstick more uniformly. [17] A plain white paper was used to take a print while minimal pressure was applied with the index finger (by the researcher). The slightest movement of the lips while recording print can smear the samples hence, the subject was advised to remain still and maintain the position of their lips so they could be adequately traced. Facial wipes were used to clean the lips after the procedure. Three lip prints were collected at each collection period where the best print in terms of clarity was chosen for analysis. 2. Image Digitization Three replicated lip print samples were taken from each subject at every collection period, where the clearest print would be digitised with a high-resolution printer (600 dpi). All selected lip prints were scanned in grayscale (8-bit) format. The digital images were standardized to a uniform dimension (550 x 232 pixels, 72-point resolution) and saved in Tag Image File Format (TIFF). These images were inputted in the Google Drive folder. Digital Analysis A modified Python code is used train the CLIP model for image recognition. The code is run on Google Colaboratory (Colab) platform. This study just uses the CLIP model alone for all image analysis tasks, making it quite different compared to traditional image recognition studies that needs different models for different tasks. [18,19] In this study, the image encoder feature and the zero-shot feature from the CLIP model are widely used for feature extraction and classification of these lip print images. The zero-shot feature is useful for model training to match up the lip prints between two subjects. The comparison between the lip print collected in the morning and evening of the same day was quantified as a percentage based on the cosine similarity of their respective feature vectors [Figure. 3] . A value closer to 100% indicates a higher probability of a match between both prints. Figure 3. Detection of lip print’s unique features with the CLIP image analysis model Prior to analysis, control samples were processed as a validation and testing step to ensure accuracy. A negative control (clean blank paper) was used to establish a baseline. A positive control (lip print from an existing database) was used to verify script functionality. The workflow is as below [Figure. 4]. Figure. 4 Methodology Workflow Statistical Analysis The software used for statistical purposes was the Statistical Package for Social Sciences (SPSS) software, IBM manufacturer, Chicago, USA, version 29.0. The similarity index of lip prints collected day and night on Day 1, Day 7 and Day 14 was analysed with repeated measures ANOVA. The reliability of the CLIP model was determined using Interclass Correlation Coefficient (ICC). A threshold of 0.75 was used to define good reliability. [20] Results Based on the CLIP analysis model, the mean of lip print similarity percentage obtained after comparing the lip prints collected on the day and night of Day 1, Day 7 and Day 14 were plotted in a graph as below [Figure 5] . Figure 5. Similarity Scores graph across Day 1, Day 7 and Day 14 The mean ± SD values of day and night similarity percentage values at Day 1 (87.97±7.08), Day 7 (86.46±6.76) and Day 14 (85.15±7.94) shows a slight decrease in similarity as the week progresses. Repeated Measures ANOVA test evaluated the effect of the day and night phenomenon on lip print similarity. Based on the Mauchly test with rejected sphericity, χ²(2) = 6.795, p < 0.05, the degrees of freedom were corrected using Greenhouse-Geisser, (ε = .967). ANOVA results portrayed a significant difference of the day and night phenomenon towards lip print similarity, F(2,398 ) = 9.163, p < .05, partial η² = .044. Reliability test type used is the test-retest reliability, to assess the reliability of the CLIP image analysis model in analyzing lip prints. The ICC test is conducted using a two-way mixed-way model with a single rating mode. The generated value was 0.649, which is in between the fair and good range (0.556-0.726). Discussion The authors aim to challenge the assumption of lip prints temporal stability which has always been considered consistent and does not change over time. [6, 7, 9] We aim to challenge this using digital analysis as a more robust method and by measuring lip print stability, using a different physiological factor such as the circadian rhythm which strongly influences the morning and evening phenomenon. Our results challenge this assumption of lip prints stability, especially in high- resolution digital contexts. Lip prints were analysed with a customised Python script to train the CLIP image analysis model to measure the similarity percentage of lip prints taken on different collection times over several days. The Python script was run on Google Colab for free of charge. Using this platform, we are not required to install specific modules to run codes and the platform is user friendly to non-technical individuals who do not possess programming knowledge. [21] The computing power is also not dependant on your machine but on Google servers, which ensures performance of your local machine or computer. [22] The data were also obtained in a week. The whole analysis method ensured optimization to lip print analysis as results were obtained in a short period of time with no costs. As a whole, the study also demonstrates the feasibility of using artificial intelligence (AI) tools like CLIP for forensic image analysis. Our findings suggest that lip print morphology may exhibit changes from day to night in a same day. The reduced similarity observed between the day and night prints supports the hypothesis that circadian or physiological factors may influence lip features. Cortisol, a steroid hormone crucial in the body’s metabolic reaction to stress are interconnected to the circadian rhythm and can influence human facial appearance. [23] Cortisol levels normally exhibit a circadian pattern throughout the day, peaking in the early morning and dropping in the late afternoon and night. [24] Therefore, the facial features may appear slightly plumper and more defined in the morning to increase alertness. As for the evening, the skin is more relaxed because of the low level of cortisol. [25, 26] This factor will indirectly influence the perception of the lips, producing different lip print changes throughout the day. The moderate ICC values suggest that lip prints are not as temporally robust as previously assumed. This has important implications for forensic identification, where the assumption of immutability underpins evidentiary reliability. As there is no standardised procedure in the collection method, the procedure should be explored. In this study, the lip prints were replicated three times after an one-time lipstick application. The application of lipstick for every lip print transfer on paper should be explored to see if it increases the accuracy of lip print similarity . Limitations of the study include the usage of small sample size, potential artifacts from lipstick application and scanning inconsistencies. Further research with larger, more diverse populations and controlled imaging protocols is warranted. Changes of lip prints during the day and night phenomenon should also be explored with other sociodemographic factors such as sex which are also affected by the circadian rhythm to in future research. Conclusion Lip prints may not be entirely stable over short time intervals, particularly between day and night. This finding raises important considerations on the forensic use of lip prints for personal identification. Future studies should investigate biological and environmental factors that may affect lip morphology and explore standardized protocols to enhance reliability. Ethical committee clearance Obtained [JEP-2024-947, dated: 21-11-2024] Conflict of Interest None Source of funding Faculty of Health Sciences, Universiti Kebangsaan Malaysia Acknowledgements The authors express their gratitude to the student committee from all Residental Colleges, postgraduate students from the Faculty of Medicine and the staff from Hospital Canselor Tuanku Muhriz, Universiti Kebangsaan Malaysia (UKM) for their support. What’s new in our Paper 1. What is already known on this topic? Lip prints stability are quite known in cheiloscopic research, as being unchanged over long time intervals, usually across several months. Time intervals are usually the condition used to measure temporal stability of lip prints. Most studies conduct lip print stability research using manual observations. 2. What question did this study address? As specific lip print collection times in previous research are unknown, authors decided to measure lip print stability across day and night. Till date, there are no studies investigating lip print stability over one-day intervals within the morning and evening of the same day. Digital analysis is also used by utilizing the CLIP, a deep learning image analysis model to generate similarity scores of lip prints changes from the morning to the evening of the same collection day. 3. What does this study add to our knowledge? Authors discovered that lip prints pattern do changes across day and night and believe this is due to the natural biological fluctuations based on the circadian rhythm. We also discovered a novel digital analysis method, using a custom Python code on Google Colaboratory as a language to train the CLIP model to conduct various image analysis tasks such as lip print recognition, lip print feature extraction and lip print similarity match. This whole procedure was conducted at no cost and used a very short period of time for analysis. 4. Suggestions for further development We suggest future research into identifying a potential correlation among sex and day and night lip print pattern changes as there is much evidence about the different hormonal fluctuations among male and female. More quantitative and robust studies like these would determine the feasibility of lip prints as a potential identification tool that may be accepted by the judicial system. References Tsuchihashi Y. Studies on personal identification by means of lip prints. Forensic Science. 1974; 3:233-248. Neo XX, Hamzah NH, Osman K, Hamzah SPAA. Lip Prints in Sex and Race Determination. Jurnal Sains Kesihatan Malaysia. 2012; 10(1): 29-33. Udin NHMD, Rahman NSSABD, Gabriel GF, Hamzah NH. Digital Approach for Lip Prints Analysis in Malaysian Malay Population (Klang Valley): Photograph on Lipstick-Cellophane Tape Technique. Jurnal Sains Kesihatan Malaysia. 2019; 17(2): 43-50.doi:10.17576/JSKM- 2019-1702-05. Jamaludin UK, Gabriel GF, Osman K, Hamzah NH. Digital Approach for Lip Prints Analysis in Malaysian Malay population (Klang Valley): Scanning Technique. Jurnal Sains Kesihatan Malaysia. 2021;19(1): 31-38.doi:10.17576/JSKM-2021-1901-04. Hamzah NH, Gabriel GF, Osman K, Fung MLA, Isa NMMd. Gender Discrimination Based on Lip Prints Analysis in Malaysian Chinese Population (Klang Valley): Photograph on Lipstick-Cellophane Tape Technique. Buletin Sains Kesihatan. 2022;4(2):1-10. Eldomiaty MA, Anwar RI, Algaidi SA. Stability of lip-print patterns: a longitudinal study of Saudi females. J Forensic Leg Med. 2014;22(1):154-158. doi:10.1016/j.jflm.2013.12.011 Kapoor N, Badiye A. A study of distribution, sex differences and stability of lip print patterns in an Indian population. Saudi J Biol Sci. 2017;24(6):1149-1154. doi:10.1016/j.sjbs.2015.01.014 Blinka, Daniel D. The Daubert Standard in Wisconsin: A Primer. Faculty Publications. 2011;197. Moshfeghi M, Iranparvar P, Mortazavi H, Nasrabadi N. Study of Lip Print Patterns Distribution and Their Stability in Time Pass. Journal of Iranian Medical Council. 2023;7(1):147-155.doi:10.18502/jimc.v7i1.14222. Zhou H. Lip Print Recognition Algorithm Based on Convolutional Network. J Appl Math.2023;1:1-8.doi:10.1155/2023/4448861 Feng G, Zhao J, Peng J, Luo B, Zhang J, Chen L, Xu Z. Circadian clock - A promising scientific target in oral science. Front Physiol. 2022;13.doi:10.3389/fphys.2022.1031519 Cohen J. Statistical Power Analysis for the Behavioral Sciences. 2nd ed. Lawrence Erlbaum Associates; 1997. Patil DV, George J, Singh A, Ahuja P. Assessment of lip and finger print patterns in patients with type 2 diabetes mellitus and dental caries: A cross-sectional study. J Oral Maxillofac Pathol. 2024;28(3):409–414. doi:10.4103/jomfp.jomfp_78_24 Vanguru R, Pasupuleti S, Manyam R, Supriya AN, Shrishail BS, Yoithapprabhunath TR. Analysis of inheritance patterns, gender dimorphism and their correlation in lip and palm prints – a cross-sectional study. J Oral Maxillofac Pathol.2023;27(1):130–137. doi:10.4103/jomfp.jomfp_535_22 Vanguru R, Pasupuleti S, Alapati NS, Manyam R, BK A, BR P. Sexual dimorphism in the lip size and finger pattern by digital method - A cross-sectional study. Advancements in Life Sciences - International Quarterly Journal of Biological Sciences. 2023;10(2). Gardezi S, Hassan N, Memon S. Analysis of lip print for Gender Identification in Karachi (Pakistan) population. Journal of Advances in Medicine and Medical Research. 2017;24(11):1–6. doi:10.9734/jammr/2017/38406 Rastogi P, Parida A. Lip Prints – an aid in identification. Australian Journal of Forensic Sciences. 2011;44(2):109–116. doi:10.1080/00450618.2011.610819 Hentschel S, Kobs K, Hotho A. CLIP knows image aesthetics. Front Artif Intell. 2022;5.doi:10.3389/frai.2022.976235. Li P. Application of clip on advanced gan of zero-shot learning. In: Proceedings from the 2021 International Conference on Signal Processing and Machine Learning. 2021 14 Nov ;Stanford, CA; 2021. p. 234-238. Koo TK, Li MY. A guideline of selecting and reporting intraclass correlation coefficients for Reliability Research. Journal of Chiropractic Medicine. 2016;15(2):155–163. doi:10.1016/j.jcm.2016.02.012 7 advantages of using google colab for python. python.plainenglish.io. Published June 5, 2020. Accessed May 16, 2025. https://python.plainenglish.io/7-advantages-of-using-google- colab-for-python-82ac5166fd4b Carneiro T, Medeiros Da Nobrega RV, Nepomuceno T, Bian G-B, De Albuquerque VH, Filho pp. Performance analysis of google colaboratory as a tool for accelerating deep learning applications. IEEE Access. 2018;6:61677-61685. doi:10.1109/access.2018.2874767 Jones C, Gwenin C. Cortisol level dysregulation and its prevalence—is it nature’s alarm clock? Physiol Rep. 2020;8(24). doi:10.14814/phy2.14644 Azmi NASM, Juliana N, Azmani S, Effendy NM, Abu IF, Teng NIMF, Das S. Cortisol on Circadian Rhythm and Its Effect on Cardiovascular System. Int J Environ Res Public Health. 2021;18(2):1-15. doi:10.3390/ijerph18020676 Elverson CA, Wilson ME. Cortisol: Circadian Rhythm and Response to a Stressor. Newborn Infant Nurs Rev. 2005;5(4):159-169. doi:10.1053/j.nainr.2005.09.002 Lyons AB, Moy L, Moy R, Tung R. Circadian Rhythm and the Skin: A Review of the Literature. J Clin Aesthet Dermatol. 2019;12(9):42-45. *Corresponding author and requests for clarifications and further details: Dr. Khairul Osman Associate Professor, Forensic Science Program Centre for Diagnostic, Therapeutic and Investigative Studies (CODTIS) Faculty of Health Sciences Universiti Kebangsaan Malaysia, Bangi, Malaysia Email: khairos@ukm.edu.my

Forensic Toxicology THE FOLLOWING ARTICLE APPEARED IN THE NOVEMBER 1997 ISSUE THE POISON SLEUTHS POISONING BY CAPSAICIN -Dr. Anil Aggrawal "Good morning doctor. Oh, my God, what are you doing today. You seem to be doing the post-mortem on a very young infant. What happened to her? Please tell me." "Good morning Tarun. The name of this young 5 month old girl is Neeta. She was born to Pyarelal and his first wife Seema. Just after her birth, Seema expired because of some complication. Pyarelal soon remarried another woman Anita, apparently because he wanted someone to look after his young daughter. But from her behavior it did not appear that Anita had any great liking for Neeta. She would often keep her hungry and would torture her in several other ways. There were rumors that Anita even wanted to do away with Neeta for good. In fact she wanted that her own children - as and when they were born- get due importance in the family....." "So you think that Anita has killed this young child?" "No, I didn't say that. But certainly all facts have to be kept in mind while investigating suspicious deaths." "What do the parents of the girl say?" "The father Pyarelal was in the office when the girl died. The girl's stepmother Anita says that she had given milk to the child at 10 am in the morning, soon after Pyarelal left home for office. After that Anita put her to sleep and got busy in her household chores. At 2 pm when she wanted to give her the second feed, she found that the child was lying listless in the cot. She panicked and immediately phoned Pyarelal. He came home at once. A doctor was called, but when he found that the child was dead, he suspected some foul play, and informed the police. The police conducted some preliminary investigations, and then handed over the body to me, to find the cause of death." "So what have you found out?" "Tarun, you won't believe it but I have found a very strange cause of death in this case. She was poisoned by a very exotic poison.." "What is that poison doctor? Please tell me, I am getting curious." "Tarun, the poison in this case is a chemical known as Capsaicin. It might sound a very alien name to you, but it is found in a very common household item- chilies. In other words, Neeta was done to death with chilies!" "What? I don't believe that. How can anyone kill with chilies?" "Tarun, Chilies contain an exceedingly acrid, volatile poisonous substance Capsaicin. It is because of this substance that capsicum has a pungent smell and taste. In India, capsicum fruits are powdered and universally employed as a condiment known as red pepper or lal mirch. You may be surprised but chilies are used in India for a lot of criminal activities. They are used by the police for the purpose of torture for instance...." "Really? Well, I am beginning to believe that Capsaicin indeed is an interesting poison. Why don't we begin from the beginning doctor?" "Oh sure Tarun. There are so many interesting tales to tell about capsicum and its active principle capsaicin. While capsaicin in small quantities may tickle our palates, in large quantities, it may act as a poison. The fatal dose of capsaicin has been estimated to be about 150 mg/kg in mice and rats. Taking the same figure to be true for a human being, it would take almost 9 g of capsaicin to kill an adult human being weighing 60 Kg. This is rather a large amount as far as homicidal poisons go, but small children can be killed with far lesser doses. Experimental rats and mice die within 4 to 26 min after the fatal dose, so it appears to be rather a quick poison..." "Doctor, how does a person die of capsaicin?" "Tarun, as I told earlier death by chilies is unusual except in very small children. Death by capsaicin is due to fall in blood pressure and stoppage of respiration. At autopsy, the stomach lining is found to intense red due to irritation and there may be erosions and even ulcers." "Doctor, you said there are so many interesting tales about chilies and capsaicin. Please let me know some of them." "Sure. Tarun, chili plant belongs to the family Solanaceae. History of this plant is most interesting. Archaeological findings show that capsicum was eaten in Mexico already in prehistorical ages back to 7000 B.C. It was one of the first plants domesticated in the Americas. Beautiful pictures of Capsicum fruits are seen on pottery of the Nazca Culture in the Southern part of Peru; the fruits are linked to the forelegs of the "Mottled Cat" which was a fructiferous symbol. It is said that when Columbus arrived in 1492 in San Salvador, Cuba and Haiti, it was not only the first step into the New World, but also the entrance right into the center of the "Capsicum Countries". In his first letter to the Spanish Catholic Majesties Ferdinand and Isabella, he already mentioned the habit of the people to eat meat with very hot spices. On his second voyage he was accompanied by the physician Dr. Diego Alvarez Chanca from Sevilla. He gave the first detailed report about the hot spice called Agi, which was nothing but modern day chili. Fernandez de Ovieto described the plant in detail and mentioned already its common use by the Spaniards. Cortez regarded in a letter in 1526 Agi as one of the most valuable products of Mexico, saying clearly that he enjoyed the hot taste of this spice. Quite soon an exchange of seeds and plants between the Old and the New World took place: oranges, lemons, melons and grapes were brought to the West, capsicum, tobacco and maize to the East. It is remarkable that the ancient name Agi or Aji remain in use until present days in the territory formerly governed by the Inca. Tschudi, a Swiss traveller, who gave a detailed description of life in Peru around 1840, mentioned the meal "Piccante" being served for lunch every day. It contained so much Agi that after a few spoons the mouth started to burn like glowing coal. He mentioned that one soon got adapted and acquired a preference for the condiment; even the ingestion of large amounts of these hot fruits was devoid of any adverse effects on the gastro-intestinal tract. I may tell you here that an acetic acid extract of only two capsicum fruits, when applied to the skin, produces severe pain and reddening, followed by the formation of a blister." "Oh, so chilies were very common in South America, even in prehistoric ages. Were they used for killing in those times too?" "If they were, no records exist of such killings. Capsicum however captured the imagination of people as a condiment. Within a few decades after Columbus, Capsicum had been distributed world-wide. Its distribution in Europe started with the cultivation and use as a spice in the Iberian peninsula. It is however unknown whether Capsicum came from there to other parts of Europe. It seems more likely that Portuguese trade connections to Ormuz in Persia in 1513 and Diu in India in 1538 opened the way for Capsicum to Ottoman Turks. Capsicum probably reached Central Europe concomitantly with their invasion of the Balkan peninsula and of Hungary which was occupied by them for about 150 years. The collection of Herbal woodcuts, published by Leonhard Fuchs in 1545 in Basle, contained already three plates of Capsicum under the name of Indian and Calicut pepper. Capsicum was cultivated in monastery gardens of that time, as documented e.g. in Brünn (Brno) in Moravia in 1566. It seems that Capsicum was highly welcomed as spice in Europe to substitute for black pepper. From Greek and Roman times on, aromatic spices and frankincense came from the Orient to Europe via secret trade connections. These links between the Lands of Spices and Europe were for centuries the monopoly of Arabs and Venetian merchants, resulting in an exorbitant price for pepper. So costly was pepper that only very rich traders could expect to trade in it. It may interest you to know that in Germany even today, rich traders are called "Pfeffersäcke" which means pepper sacks! Black pepper, the spice most sought after, was so costly in old days that it was counted out peppercorn by peppercorn!" "Doctor, earlier you mentioned about the name Aji for chilies. I usually eat pepperoni pizza which contains lot of chilies. Now after talking to you, I realize the word "pepperoni" contains the word "pepper" too." "Yes, that's a good observation. Chili is known by a number of names around the world. In the West Indies and South America the ancient name "Aji" is still in use. In Mexico the Nahuatl word "Chili" was used when the Spaniards arrived; the name remained in use not only in Mexico but also in Northern America as chili or chili. The name of the long black pepper of India, Piper longum, was soon also used for Capsicum and remained in use as "pepper" in most English-speaking countries. Pepperoni is actually the name of a fairly hot variety of capsicum which is eaten in Italy. In Europe, Capsicum found its main domicile in Hungary. The Hungarian name paprika stems from the Slavic name peperke used in Balkan countries for pepper. Another version, although not based on linguistic sources, seems to be more charming: The Hungarian diminutive form for Ilona is Ilonka, and Mary is Marika. On the same lines it has been suggested that paprika was the definition for a small pepper!" "Doctor, how many varieties of capsicum exist in the world?" "Tarun, there are about 1600 to 1700 varieties of Capsicum in the world, but only around 200 of them are commercially available. The Mombasa variety, the black chili from Africa, is too hot to be eaten; it would blister the mouth! Other varieties are as mild as green peas and do not contain capsaicin." "That's interesting. Doctor, tell me why do people eat peppers, chili or paprika at all? Doesn't it appear more or less like a paradox to you? Chilies are so hot; by no stretch of imagination can they be called pleasant, yet people seem to enjoy the hot taste of chills. Why?" "Tarun, you must remember that highly spiced meals, flavored with chili, chili-containing curry, black or green pepper or ginger are preferentially consumed in countries with hot climates such as India. The common experience during such a fairly hot meal is sweating beginning in the face. This occurs only in hot climates or in a warm restaurant, but not in a cold environment. It is called gustatory sweating because it differs from sweating following physical exercise, protecting against hot environment or expressing emotional stress. The effect of gustatory sweating is explained by the action of capsaicin on thermoregulation. It stimulates heat sensitive fibers in the periphery and the temperature regulation center. This results in sweating, which is basically a heat loss reaction. This effect is observed not only in man but also in rats. This also counteracts the heat production by a heavy meal and facilitates food intake in hot climates. All these facts explain the enormous fascination of people with chilies. So high is the consumption of chilies in the world, especially in hot climates that the world-wide production of Capsicum is estimated to be in the range of 6 million metric tons each year. There is even an International Chili Society which arranges Local and World Championship Chili Cookoffs, thus connecting peppers with entertainment! Capsicum plays a very interesting cosmetic role in chickens too which has nothing to do with the action of pungent capsaicin..." "What is that?" "Tarun, when chickens have access to green food in springtime their feet become bright yellow and the yolk of their eggs almost orange red. This is based on the rising intake of carotenoils. Thus bright yellow color of chicken's feet and orange red color of egg yolks is indicative of the fact that chickens have had a lot of green food. In fact this is often touted as a "healthy color" to the customers. Quite strangely poultry owners can produce a similar color in their chickens without giving them green food." "How?" "Tarun, besides capsaicin, chilies also contain Capsanthin which is the red pigment of ripe paprika pods and accounts for about one third of their colorants. The red color of chilies is because of this pigment. When this red pigment is included in the food of chickens, a similar change in color in chicken's legs and in their egg yolks appears because Capsanthin accumulates there. The interpretation that the "healthy color" of legs or egg yolk is linked to life of chickens in open air is therefore suggested to the customer!" "That is certainly highly interesting doctor. You said earlier, that chilies are used for a lot of criminal activities in India. Can you tell me about some?" "Oh, sure. To begin with, I must tell you that homicide by pepper although a rarity, is a distinct possibility. The first report of a case of homicide by pepper in world's literature was published in 1964. Homicidal asphyxia by pepper has also been reported. In such cases, the pepper is forcibly introduced in the nostrils and mouth of very young children who get asphyxiated. Another reported criminal use of pepper is by robbers. They often throw chili dust in the eyes of their victims to "blind" them temporarily to facilitate robbery. This act can in fact be done by anyone to temporarily inactivate his enemy or opponent. Chili powder is often used by police in our country- and in fact in several third-world countries- to extract confession from criminals. It may be introduced in the mouth, nose, anus, urethra or vagina to torture a suspect and extract confession from him. It is said that during emergency in India in 1976, chilies were used as a means of torture by introducing them in rectum! This process was known as Hyderabadi Goli. In India, superstitious people use chili fumes to "scare away" ghosts and spirits. These fumes are very irritating to the eyes and the nasal passages and can cause severe inflammation. Such practices can cause severe breathing problems in children, if they are around. Finally, in our country, chili powder is often introduced in the vagina as a punishment for infidelity." "Doctor, what symptoms does the victim experience when chili powder is given to him?" "Tarun, capsaicin is mainly an irritant poison. Applied to skin, it causes irritation and vesication. When ingested in sufficient quantities, it acts as an irritant poison, with the usual symptoms of vomiting and diarrhoea and a burning sensation in the mouth, throat and stomach. Burning sensation also occurs during defecation. When thrown in the eyes, it can cause severe burning pain, watering of the eyes, intense spasm of the eyelids and photophobia, which is another term for sensitiveness to intense light. It is for this reason, that robbers and thugs use chili powder on their victims to rob them. Capsaicin is volatile and because of this, fumes arising from burning capsicum are highly irritant. Major toxic symptoms in experimental rats and mice are salivation, erythema of skin, staggering gait, slowing of respiration often leading to difficult and labored breathing, blueness of skin, tremor, convulsions." "Doctor, I feel now I know fair enough about capsaicin. I am now ready to see the autopsy of this young child. What important findings are present in this child?" "Tarun, when this child was brought to my dissection table, I noticed some pepper, or lal mirch as you would call it, sticking to her clothes. This immediately alerted me of some foul play, especially as I knew that pepper can be used to liquidate unwanted children. I asked about the relationship of the mother with the child in detail and the history made me still more suspicious. Then I looked at her mouth, and I was stunned to see lot of red pepper in her mouth. On opening her food pipe and stomach, I found still larger quantities of red pepper there too, which almost solved my case. Not only that, there were large quantities of red pepper in her windpipe and bronchi too. I can now imagine what must have happened. When Pyarelal left for office, Anita waited for some time. Then she brought a fistful of red pepper from her kitchen and forcibly introduced it in the child's mouth. The poor child could not resist. Whatever resistance she did make only helped to introduce chilies in her nose too. Needless to say, with so much of pepper in her stomach and windpipe, the child soon died. Anita then smoothed out everything, removed the traces of chili powder from her face and from the cot, and phoned her husband at 2 pm. She hoped that she could pass the death off as a natural death. She however forgot to clean Neeta's clothes completely, and I could find traces of chili powder in her clothes which immediately alerted me. Well, even if she had assiduously cleaned her clothes, I would still have found out the cause of death by looking at her stomach and windpipe. Come, let us tell the police that Neeta did not die a natural death; Anita is her killer." "Oh, how very clever of you doctor. This was a most interesting discussion. I never could imagine that chilies could be put to such a draconian use. Tell me what are you going to tell me the next time?" "Tarun, next time, I would tell you about a very deadly poisonous gas- Lysol "

Main Page > Vol-27 No- 1 > Paper 1 (you are here) LinkedIn X (Twitter) Facebook Copy link Share Anil Aggrawal's Internet Journal of Forensic Medicine and Toxicology Volume 27 Number 1 (January - June 2026) Received: March 20, 2025 Accepted: June 16, 2025 Ref: Tsranchev I , Timonov P , Yancheva S , Hadzhieva K , Gudelova T , Sotirova M , Fasova A , Dzhambazova E , Uchikov P. Posttraumatic Ischemic Brain Stroke After Sharp Neck Injury: A Case Report Based on Autopsy. Anil Aggrawal's Internet Journal of Forensic Medicine and Toxicology [serial online], Vol. 27, No. 1 (January - June 2026): [about 11 p]. Available from: https://www.anilaggrawal.com/ij/vol-027-no-001/papers/paper001 Published as Epub Ahead: June 25, 2025 DOI: 10.5281/zenodo.15743623 Email- tsranchev@inbox.ru [Epub Ahead] ( All photos can be enlarged on this webpage by clicking on them ) Posttraumatic Ischemic Brain Stroke After Sharp Neck Injury: A Case Report Based on Autopsy Abstract Neck injuries usually are emergency medical conditions which require special medical attention. Several complications following neck trauma could be fatal, if they are not correctly treated and diagnosed. Present case is of a 56-year- old male patient sustained sharp neck trauma, who was immediately admitted for hospital treatment, with following surgical reconstruction of the left carotid artery. Two days after the surgical intervention, the patient showed clinical signs of coma and sudden respiratory and cardiac failure, resulting in a lethal outcome. Autopsy and microscopic findings revealed a life-threatening post-traumatic complication following such type of trauma. In each case of sharp or blunt neck trauma, the diagnosis “post-traumatic ischaemic brain stroke” must be ruled out as a possible serious complication by a detailed examination, including laboratory, ultrasonography, contrast angiography and various specific imaging methods. All these medical actions as standard medical algorithm can save the patient’s life. Keywords: Neck injury, posttraumatic brain stroke, sharp force trauma, fatal outcome, medico-legal case Introduction In routine forensic practice, various types of trauma can contribute to neck injuries, potentially leading to severe consequences or even a fatal outcome for the patient. Death could be directly attributed to the source of the injury or as a result of a complication following such a neck injury [1]. One possible cause of death can be a post-traumatic ischaemic brain stroke after blunt or sharp neck trauma involving blood vessels in the neck, which supply the brain with blood, which in turn can be a reason for blood clots and/or emboli, causing critical cerebrovascular blood flow blockage and death of brain tissue. In these emergency cases, if such an injury to the arteries can be diagnosed at the time after the trauma, a patient could be treated with different types of anti-clotting medications to prevent thrombosis and potential stroke formation, thus saving the patient's life. Case Presentation Fig.1 showing the neck region represented with a zigzag wound A 56-year-old male patient after excessive alcohol consumption fell to the floor in a bar and injured his neck on pieces of a broken glass. Immediately after, he was transported by emergency medics to the University Hospital "St George", Plovdiv, Bulgaria. After a detailed emergency room assessment, he was transferred to the Department of Vascular Surgery with the diagnosis of an "incised wound in the neck region with severance of the left carotid artery." An emergency reconstruction of the vessel wall was performed. Two days after the surgical intervention, the patient presented with clinical signs of coma and sudden respiratory and cardiac failure, resulting in a lethal outcome. After death, the body was transferred to the Department of Forensic Medicine for routine forensic examination. During the examination of the cadaver in the autopsy room, it was observed that on the frontal surface of the neck, in its upper third, just below the tip of the chin and slightly to the left, a slit-shaped incised wound was found, which had been surgically treated and stitched with 4 sutures. The length of the wound was 5cm. The edges of the wound were relatively clean and smooth; the edges were sharp. On the left half of the frontal surface of the neck, in the upper, middle and lower thirds, a large zigzag wound was found, stitched with 15 sutures. The length of the wound was 17 cm. The edges of the wound were also relatively smooth and clean, slightly congested, with scattered necrotic areas (Fig. 1). The wound was additionally assessed by performing several deep surgical cuts. A slit-shaped wound, 1 cm long and treated with one stitch, was found 2 cm to the left of the zigzag wound in the middle third of the neck. Fig.2 showing the left common carotid artery and inserted prosthesis inside with a greyish-reddish dense thrombus The skin in the neck area was carefully dissected, and the zigzag wound was examined in depth. The muscles in the left half of the neck were diffusely blood-soaked with a dark reddish colour. The middle third of the sternocleidomastoid muscle had impaired integrity and had undergone surgical suturing. The muscle was dissected, and the left carotid artery was reached. It was found that a 2.5 cm long section from the common carotid artery to the carotid sinus was replaced by an artificial Dacron-type prosthesis. The left common carotid artery was opened during the autopsy, and at the upper end of the inserted prosthesis, a greyish-reddish dense thrombus was found inside, adhered to the prosthesis-vessel transition (Fig. 2). The thrombus occluded the lumen of the carotid artery by about 90%. Along the course of the external carotid artery at its beginning, two transverse tears in its intima with lengths of 0.2 and 0.4 cm were found. There was a tear in the wall of the left jugular vein at the level of the described carotid artery prosthesis. The tear is sutured. Its length was 0.5 cm. During the internal examination of the cadaver, all soft tissues forming the scalp were intact, with a moist surface and a pale pink colour. The bones of the cranium were intact. The dura mater was pearly in colour and had a smooth surface. The cerebral gyri were smoothed, and the sulci were narrowed. In the left parieto-temporal region, there was a section of the cerebral cortex, sunken below the level of the surrounding brain tissue, with a pale greyish-yellowish colour, sized 4cm by 3.5 cm. We fixed the brain in a 10% formaldehyde solution for 48 hours before conducting a detailed examination. Fig.3 showing the infarction of brain matter over the left cerebral hemisphere The cerebral vessels at the base of the brain were well developed without malformations. A detailed examination revealed a hard, greyish-reddish thrombus occulting the left middle cerebral artery. Consecutive sections of the brain were made. In the left parieto-temporal region of the brain, a large area of softening with a livid-greyish colour was found, with peripheral reddish haemorrhages (infarction) around it. The border between the grey and white brain matter was obliterated (Fig. 3). This area measured approximately 8 cm x 7 cm as dimensions on the surface of the left cerebral hemisphere with depth measured 7 cm in the left cerebral hemisphere. The left middle cerebral ventricle narrowed, and the left cingulate gyrus (gyrus cinguli) was shifted to the right. In the hypothalamus in the left cerebral hemisphere, a dark reddish round haemorrhage measuring 0.5 cm x 0.5 cm was also found. A similar haemorrhage was found in the basal nuclei of the left hemisphere, measuring 1 cm x 0.5 cm. Along the course of the brainstem (pons and medulla oblongata), numerous dark reddish haemorrhages measuring from punctate to 0.5 cm in diameter were found. In cross-section, the cerebellum was clear and normally developed. Fig. 4 showing multiple haemorrhages and oedema in the left frontal and left parietal cortex. H-E staining. Samples from brain matter were taken, and further microscopic examination was performed with H-E staining under Primo Star Zeiss microscopes with enlargements of 10x, 40x, and 100x. The detailed microscopic examination showed haemorrhages, oedema and multiple massive punctate haemorrhages in the left frontal cortex with multiple massive punctate haemorrhages in the left parietal cortex (Fig. 4), in combination with hyperaemia of blood vessels in the arachnoid layer. Additional microscopic findings were stated during this examination as follows: corpus callosum – mild oedema, hypothalamus – massive punctate haemorrhages and mild oedema, pons – areas with haemorrhages and severe oedema, medulla oblongata – severe oedema, cerebellum – oedema, cortex – mild oedema 2. Carotid artery vessel wall – part of a vessel with mixed thrombus (fig. 5). Other samples from internal organs showed no significant pathologic changes. Fig.5 showing the carotid artery vessel wall – part of a vessel with mixed thrombus. H-E staining Discussion Ischaemic strokes resulting from carotid artery thrombosis following open and closed head and neck trauma have been recognised with increasing frequency recently, and these cases involve not only adults but even children [2-6]. They can lead to life-threatening consequences or even a fatal outcome if they are not diagnosed correctly [7-10]. Ischaemic strokes resulting from carotid artery thrombosis are observed in both blunt and sharp injuries, such as in the case report described above. Carotid artery thrombosis is a rare but potentially devastating complication that can follow even reconstructive surgery of any major traumatised blood vessel of the neck region [11, 12]. The non-traumatic genesis of carotid artery thrombosis, which can lead to ischemic stroke, should also be considered in such cases. The most common cause of non-traumatic carotid artery thrombosis is atherosclerosis [13]. In the presence of an unstable atherosclerotic plaque or an ulcerated atherosclerotic plaque, the endothelium of the arteries is compromised. In these cases, coagulation factors are activated, which predisposes to the formation of thrombi. In our case report during the autopsy, no atherosclerosis of the carotid arteries was detected. Other factors, of a non-traumatic nature, also predispose to the formation of thrombi in the body, such as obesity, pregnancy, smoking, arterial hypertension, and hyperlipidemia. Our case lacks previous patient history on whether the patient had any of the above-listed diseases based on medical documentation, and no pathological changes or malformations of the vessels in the brain were identified during the autopsy and on microscopy. Other causes of ischemic stroke are emboli. Most often, emboli form in the heart in the area of a post-infarction aneurysm, in the left auricle of the heart in patients with ventricular fibrillation, and in patients with bacterial endocarditis. No such conditions were found in our case report. Taking certain medications, such as oral contraceptives, can cause blood clots to form in women. Different mechanisms can cause traumatic internal carotid artery thrombosis, including direct traumatic force delivered to the neck, the head, or the oral cavity, resulting in trauma to the soft tissues or even to the cranial bones, other possible mechanisms are whiplash trauma, seatbelt trauma or even procedures in the neck region [14]. Studies have shown that factors significantly increasing the risk of developing carotid thrombosis due to carotid artery injuries include non-penetrating head injury, basilar fractures of the skull, facial fracture, cervical spinal fractures and thoracic injuries [15], with the non-penetrating head injury being the most common single associated injury. In the literature is suggested that combined injuries to the upper part of the body /head and neck injuries especially skull and spinal fractures and combined injuries to the head and chest/ increase the risk of damage to the carotid arteries. In our case the patient did not sustain any other trauma, except to the neck. In this case, we concluded that the cause of death is an ischaemic brain stroke caused by vascular injury resulting from sharp force trauma to the neck. He sustained a reconstructive operation on the traumatised section of the common carotid artery, which was replaced with an artificial Dacron-type prosthesis, despite additional anticoagulation therapy. During the autopsy, a thrombus was found adhered to the prosthesis-vessel transition. The macroscopical and histological examinations determined ischaemic brain stroke.These results imply that the carotid artery damage location is where the thrombus originated. It is therefore very likely that the thrombus formed as a result of an intimal tear in the carotid artery caused by the sharp force trauma. The patient died three days later, with clinical signs of coma and sudden respiratory and cardiac failure. In summary, for patients admitted for treatment as a result of neck trauma caused by a sharp object, it is important to monitor them, especially in the first few days, for the appearance of neurological symptoms [16]. It is known that in the early stages of development of an ischaemic stroke of the brain, changes may not be visualised with standard imaging techniques like a CT scan. Therefore, numerous tests have been developed that can provide an early evaluation of a neurological condition, such as the MMSE (mini mental state examination) or Folstein test, the Hodkin-son abbreviated mental test score. Highly sensitive imaging methods have also been developed, such as diffusion-weighted magnetic resonance imaging (DWI or DW-MRI), which is highly sensitive to the changes occurring in the lesion and revealing subclinical neurological changes. These imaging-specific methods could be used in combination with specific biochemical markers, proving the diagnosis [17]. CT angiography is also a highly sensitive and informative imaging method which could be in helpful use for the correct diagnosis. Conclusion Different diagnostic methods, clinical assessing tests and biochemical markers could be used in cases of sharp force neck trauma to diagnose this type of life-threatening post-traumatic complication in trauma patients. In each case of sharp or blunt neck trauma, the diagnosis “post-traumatic ischaemic brain stroke” must be ruled out as a possible serious complication. A detailed examination, including laboratory, ultrasonography, contrast angiography and various specific imaging methods with the rich patient’s history, periodic neurologic consultation and physical examination, must be performed as a standard algorithm for medical action in such types of clinical cases. That could prevent fatal complications and can save a patient’s life. References Tawil I, Stein DM, Mirvis SE, Scalea TM. Posttraumatic cerebral infarction: incidence, outcome, and risk factors. J Trauma. 2008 Apr;64(4):849-53. doi: 10.1097/TA.0b013e318160c08a. PMID: 18404047 Yılmaz S, Pekdemir M, Sarısoy HT, Yaka E. Post-traumatic cerebral infarction: a rare complication in a pediatric patient after mild head injury. Ulus Travma Acil Cerrahi Derg. 2011 Mar;17(2):186-8. PMID: 21644101. Chaturvedi S, Sohrab S, Tselis A. Carotid stent thrombosis: report of 2 fatal cases. Stroke. 2001 Nov;32(11):2700-2. PMID: 11692038. Moulakakis KG, Kakisis J, Tsivgoulis G, Zymvragoudakis V, Spiliopoulos S, Lazaris A, Sfyroeras GS, Mylonas SN, Vasdekis SN, Geroulakos G, Brountzos EN. Acute Early Carotid Stent Thrombosis: A Case Series. Ann Vasc Surg. 2017 Nov;45:69-78. doi: 10.1016/j.avsg.2017.04.039. Epub 2017 May 5. PMID: 2848362 Caldwell HW, Hadden FC. Carotid artery thrombosis; report of eight cases due to trauma. Ann Intern Med. 1948 Jun;28(6):1132-42. doi: 10.7326/0003-4819-28-6-1132. PMID: 18864120 Hockaday TD. Traumatic thrombosis of the internal carotid artery. J Neurol Neurosurg Psychiatry. 1959 Aug;22(3):229-31. doi: 10.1136/jnnp.22.3.229. PMID: 14402209; PMCID: PMC497379 Schneider RC, Lemmen LJ. Traumatic internal carotid artery thrombosis secondary to nonpenetrating injuries to the neck; a problem in the differential diagnosis of craniocerebral trauma. J Neurosurg. 1952 Sep; 9(5): 495-507. doi: 10.3171/jns.1952.9.5.0495. PMID: 12981571. Moulakakis KG, Mylonas SN, Lazaris A, Tsivgoulis G, Kakisis J, Sfyroeras GS, Antonopoulos CN, Brountzos EN, Vasdekis SN. Acute Carotid Stent Thrombosis: A Comprehensive Review. Vasc Endovascular Surg. 2016 Oct;50(7):511-521. doi: 1177/1538574416665986. Epub 2016 Sep 19. PMID: 27645027 Julia C. Schmidt, Dih-Dih Huang, Andrew M. Fleming, Valerie Brockman, Elizabeth A. Hennessy, Louis J. Magnotti, Thomas Schroeppel, Kim McFann, Landon D. Hamilton, Julie A. Dunn, Missed blunt cerebrovascular injuries using current screening criteria — The time for liberalised screening is now. Injury, Volume 54, Issue 5, 2023, Pages 1342-1348, ISSN 0020-1383, https://doi.org/10.1016/j.injury.2023.02.019 Macdonald S. Brain injury secondary to carotid intervention. J Endovasc Ther. 2007 Apr;14(2):219-31. doi: 10.1177/152660280701400215. PMID: 17488181. Setacci C, de Donato G, Setacci F, Chisci E, Cappelli A, Pieraccini M, Castriota F, Cremonesi A. Surgical management of acute carotid thrombosis after carotid stenting: a report of three cases. J Vasc Surg. 2005 Nov; 42(5):993-6. doi: 10.1016/j.jvs.2005.06.031. PMID: 16275459. Iancu A, Grosz C, Lazar A. Acute carotid stent thrombosis: review of the literature and long-term follow-up. Cardiovasc Revasc Med. 2010 Apr-Jun; 11(2):110-3. doi: 10.1016/j.carrev.2009.02.008. PMID: 20347802.] Torvik A, Svindland A, Lindboe CF. Pathogenesis of carotid thrombosis. Stroke. 1989 Nov; 20(11): 1477-83. doi: 10.1161/01.str.20.11.1477. PMID: 2815181. Karnecki K, Jankowski Z, Kaliszan M. Direct penetrating and indirect neck trauma as a cause of internal carotid artery thrombosis and secondary ischaemic stroke. J Thromb Thrombolysis. 2014 Oct; 38(3): 409-15. doi: 10.1007/s11239-014-1077-2. PMID: 24748050; PMCID: PMC4143597. Hayakawa A, Sano R, Takahashi Y, Fukuda H, Okawa T, Kubo R, Takei H, Komatsu T, Tokue H, Sawada Y, Oshima K, Horioka K, Kominato Y. Post-traumatic cerebral infarction caused by thrombus in the middle cerebral artery. J Forensic Leg Med. 2023 Jan; 93:102474. doi: 10.1016/j.jflm.2022.102474. Epub 2022 Dec 24. PMID: 36577210 Fisher M, Paganini-Hill A, Martin A, Cosgrove M, Toole JF, Barnett HJ, Norris J. Carotid plaque pathology: thrombosis, ulceration, and stroke pathogenesis. Stroke. 2005 Feb;36(2):253-7. doi: 10.1161/01.STR.0000152336.71224.21. Epub 2005 Jan 13. Erratum in: Stroke. 2005 Oct; 36(10): 2330. Capoccia L, Speziale F, Gazzetti M, Mariani P, Rizzo A, Mansour W, Sbarigia E, Fiorani P. Comparative study on carotid revascularisation (endarterectomy vs stenting) using markers of cellular brain injury, neuropsychometric tests, and diffusion-weighted magnetic resonance imaging. J Vasc Surg. 2010 Mar; 51(3):584-91, 591.e1-3; discussion 592. doi: 10.1016/j.jvs.2009.10.079. Epub 2010 Jan 4. PMID: 20045614 *Corresponding author and requests for clarifications and further details: Ivan Tsranchev, Medical University of Plovdiv, Republic of Bulgaria, Europe Email- tsranchev@inbox.ru

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SCIENCE IN CRIME DETECTION-13 HOW DO WE RECOGNIZE A PERSON FROM HIS SKULL ? This time I am going to tell you about a remarkable technique by which we can positively identify a person from his skull. On May 23, 1992 the police found a skull floating in a local river and I was called to opine upon it. I was to give the police all possible information from that skull. But the most important question was, who was that person? From the villages Rampur and Phoolpur which were lying on either side of the river, at least seven persons were reported missing during the last one year under mysterious circumstances. Of these 4 were females and 3 were males. It was quite possible that the skull belonged to one of these seven persons. When I examined the skull closely, I found that the skull belonged to a female. Telling the sex of a person from the skull is not difficult and we have already talked at length about it in our Feb.1994 issue (pp.21‑23). So obviously the 3 males were out of our contention and our task was reduced somewhat. The four females were 15‑year old Sona, 32 year old married Ramwati, 47‑year‑old Phulwanti and 83 year‑old widow Kashi. The police had much to gain if I could tell them whose skull was it, because they could then concentrate their investigations only on that female and her possible enemies. In effect, their task would be reduced to one‑fourth, if I could tell them this vital question. I would like to digress here somewhat and say something about the anatomy of the skull. The skull of every person is unique. It has got distinct bumps, projections and curvatures. If you touch your eyebrows you will find that the skull underneath is somewhat raised. Similarly if you touch your check prominences you will find that the cheek bones beneath are somewhat raised. But what is most important to comprehend is that these 'bumps' are different in each individual. Similarly the skull shows many curvatures. The curvature of the top your skull in unique. All persons have different curvatures of their skull. Similarly the curvature of the chin is different in each individual. In the same way, the shape of the teeth is different in each individual. If we see the margins of the teeth in a particular individual, the margin forms a distinct outline in each individual. So if you see the photographs of a smiling individual, you would find that the upper teeth, which are usually visible in smiling individual, form a distinct outline. The face is molded over the skull, much like plaster of Paris molded over an underlying mould. This cause the face to reflect the same bumps, curves and projection as are present in the individual's skull. Now if we have a photograph of the individual, we have got a record of all the peculiarities of that person skull. If has been now possible to take the photograph of a missing person and superimpose it over the negative of the skull so that all bumps, curvatures and projections could be compared. Teeth outline of smiling individual can also be compared to the teeth outline of the skull. If all the outlines match perfectly with each other, then we can be hundred percent sure that the skull belonged to that individual only. I asked for the photographs of all 4 missing females ‑ Sona, Ramvati, Phulwanti and Kashi. I enlarged the photographs to life‑size and then superimposed the negative of the skull over the various photographs. You can see some examples of these superimpositions in the accompanying photographs although they are from different cases. This will give you some idea of what superimposition in all about. Only the facial outline of Sona matched the outline of the skull and I could tell the of the skull and I could tell the Police that it was the skull of Sona. Police was in fact suspecting for sometime that 15‑year‑old Sona had been murdered by her paramour Ramesh. However they could not lay their hands on Ramesh as Ramesh was the son of a powerful Zamindar. In addition, they did not have any solid proof that Sona had even been murdered. Ramesh kept asserting that Sona had run away with one of her lovers. But now, after my opinion, the police had solid proof that Sona had indeed been murdered. Armed with this information, they raided the house of Ramesh and apprehended him. Ramesh again tried to repeat the same old story, but now the police knew better. When they told him, how they had found about the identity of the skull, Ramesh broke down and told them the whole story. Ramesh had enticed Sona with his money and had promised to get married to her. Under this presumption, Sona allowed Ramesh to have sex with her. After some weeks Sona fell pregnant and began pressing Ramesh to marry her. Ramesh never wanted to marry her. He began to think of ways to dispose her off somehow. Finally one day he called her at the bank of the river to finalize the matter. There he strangulated her and threw her dead body into the river, thinking that the body will drown. Actually the fishes, and other aquatic animals of the river ate the flesh of Sona's body till only the skeleton remained. From this skeleton, the skull got separated and landed ashore. That is how the police got hold of that skull. This case is one of my best cases as I solved a murder mystery by utilizing one of the latest techniques in crime investigation.

Main Page > Vol-26 No.- 2 > Paper 3 (you are here) LinkedIn X (Twitter) Facebook Copy link Share Anil Aggrawal's Internet Journal of Forensic Medicine and Toxicology Volume 26 Number 2 (July - December 2025) Received : April 28, 2025 Accepted : June 18, 2025 Published : June 18, 2025 Ref: Kumar J, Khan IA, Reyazuddin M, Haroon A, Khan FA. Proposing a Single centre as a Drug and Toxicology Unit for Complete Care of Substance Abuse and Poisoning Patients at Tertiary Care Centers. Anil Aggrawal's Internet Journal of Forensic Medicine and Toxicology [serial online], 2025 ; Vol. 26, No. 2 (July - December 2025): [about 17 p]. Available from: https://www.anilaggrawal.com /ij/vol-026-no-002/papers/paper003 DOI: 10.5281/zenodo.15708358 Email: dr.jitendrak2@gmail.com ( All photos can be enlarged on this webpage by clicking on them ) Proposing a Single centre as a Drug and Toxicology Unit for Complete Care of Substance Abuse and Poisoning Patients at Tertiary Care Centers Abstract A Registered medical practitioner is qualified to manage all the cases of poisoning and substance abuse after passing their graduate medical education. The qualification of managing poisoning cases comes from Toxicology taught to them under the subject "Forensic Medicine and Toxicology". At tertiary care centres, the post-graduates in Internal Medicine manage poisoning and substance abuse cases under emergency care based on the knowledge they received during their undergraduate studies. However, the Teacher who taught the subject is practically not involved in managing such patients, i.e. preaching without practice. This results in a gross deficiency in the quality of care for poisoning cases. To overcome this, we propose one centre as a Toxicology unit at every tertiary care centre, corroborating Medicine, Forensic Medicine, Pharmacology, Psychiatry and various other disciplines dealing with all the aspects of Substance abuse and Poisons. With the help of this unit, we can run a single centre catering to the management of poisoning and substance abuse patients, their mental health, diagnostic centres for drugs and poisons, drugs and poison information centre (DPC) including drugs de-addiction and treatment centre (DDAC), an integrated rehabilitation centre for addicts (IRCA), Outreach and Drop-in centres (ODIC), De-addiction drug pharmacy and various training courses to the health care professionals. Keywords: Toxicology, Poisoning, Substance abuse, Mental health, Suicide Introduction Suicide is one of the preventable forms of death. Suicide is not only a personal tragedy that takes the life of an individual prematurely, but it has a continuing ripple effect, affecting the lives of families, friends and communities. The global burden of death due to suicide is more than seven lakhs per year (1). Suicide is among the top 20 leading causes of death in the world (WHO) and among the top 10 leading causes of death in India (NCRB data) (2). Although we don't have actual data on the suicide attempters, as per WHO, for each suicide, there are likely more than 20 suicide attempts (3). In that way, if we consider suicide as a preventable disease, then this will become the most prevalent disease in the world, and 2nd commonest will be far behind. Sadly, 77% of global suicide occurs in middle- and low-income countries. Suicidal behaviour is a complex phenomenon that demands a holistic approach of care and support by multiple agencies. Mental Health Care Act, 2017 and India Under Indian Penal Code (IPC) section 309, the attempt to commit suicide is a criminal offence and is punishable with one-year imprisonment with or without a fine. With the implementation of the Mental Health Care Act 2017 (4), Section 309 of IPC was decriminalized, and it was stated that "Any person who attempts to commit suicide shall be presumed, unless proved otherwise, to have severe stress. And the appropriate government shall have a duty to provide care, treatment and rehabilitation to a person having severe stress and who attempted to commit suicide to reduce the risk of recurrence of attempt to commit suicide”. This has changed the approach of every stakeholder towards suicide patients. Although suicidal behaviour was seen as a mental illness, treatment for the same is provided by the Psychiatry department of the hospital for a long apart from their regular treatment (5-9). But with this commendatory step taken under the Mental Health Care Act, every attempt of suicide shall now be seen as a disease rather than an offence for which the appropriate government and healthcare provider will provide proper care, treatment and rehabilitation as per the standard guidelines. Poisoning and Mental Health It has been observed that most of those patients who survive suicide and get admitted to the hospital, the majority of them are with poisoning incidences, and poisoning is the most typical method practised. Also, it has been reported that most of the poisoning cases are suicidal (More than 75%), followed by accidental (10, 11). In view of this, the majority of cases of poisoning need care of their mental health. Substance Abuse, Mental Illness and Toxicology Substance abuse, i.e., the harmful or hazardous use of psychoactive substances, including alcohol and illicit drugs, is a form of toxicity itself and is an essential part of pharmacology and toxicology. They are taught to undergraduates under the drug dependence chapter of Forensic Medicine and Toxicology. The emergency care of such patients is done at casualty by post-graduates in Internal Medicine and further care in the Psychiatry department. At present, we don't have substance abuse testing labs in hospitals. Essential care of such patients in a routine manner is avoided due to medico-legal reasons. Substance abuse is a shared Medicine, Pharmacology, Forensic Medicine and Psychiatry domain. So, a multi-disciplinary approach is essential for proper care of such patients. Pharmaceutical Drugs, Environmental Poisons and Toxicology lab Indiscriminate use of drugs without proper prescription is rampant in the society. This results in toxicity, resistance, chronic renal diseases and various other pathologies. We don't have toxicology labs even at the tertiary care centre for the testing of chronic drug toxicity. Similarly, air pollution, water pollution, household poisons, and other factors resulting in chronic diseases and ill health are totally ignored areas of toxicology management. We need toxicology labs and research in this part to provide proper care for such cases. Present practice in the care of Poisoning cases and Forensic Medicine and Toxicology Understanding of the management of poisoning cases is developed among Indian medical graduates through their teaching of the Subject "Forensic Medicine and Toxicology" during their second or third professional. However, Forensic Medicine and Toxicology faculties are not practically involved in the care of poisoning patients. They develop their training only theoretically. Poisoning cases at tertiary care centres are dealt mainly as emergency cases. Post-graduates in Internal Medicine provide emergency symptomatic care to the patients along with other routine emergency patients. At our hospital, ACMO (Assistant Casualty Medical Officer, mostly Post-graduate students of different disciplines posted temporarily in the casualty) sees all patients coming to casualty first, including poisoning cases. In poisoning cases, ACMO takes the patient's history, notes vitals, and categorizes the patient as stable or unstable. In case of an unstable poisoning patient, he gives a distress call to Anesthesia. The Anesthesia team does resuscitative measures and accordingly takes to a ventilator or stabilizes the patient. Once the patient is stable, Gastric lavage is done, and the patient is referred to the Medicine unit in case of an adult. Most antidotes for poisoning are unavailable. Routinely, Normal saline and sometimes charcoal are used. In the Medicine unit, routine blood testing for non-critical poisoning cases includes CBC, LFT, KFT, ABG and ECG (sometimes) are done. If nothing abnormal in the above parameters, only symptomatic supportive treatment is given, and the patient is observed for up to 24 hours and then discharged. In case of any abnormal parameters, the patient is managed in the ICU or CCU ward. In most cases, no MLC is prepared, and neither gastric lavage is preserved for MLC purposes. Also important to note is that all the care related to poisoning is done along with other emergency or ward cases. Poisoning cases in government or private are medico-legal cases, whether accidental, suicidal or homicidal. This becomes another reason for the cold approach in the care of such patients. Proper Medico-legal formalities are not done, and cases are usually sent to the home after recovery without proper medico-legal formalities. Also, the doctors of Internal Medicine don't get any separate training for poisoning cases, but they manage patients like other routine emergency cases based on the knowledge of Forensic Medicine and Toxicology taught long back. So, overall, poisoning management is developed more theoretically than practically, i.e. preaching without practice. This results in a gross deficiency in the quality of care for poisoning cases. Most tertiary centres face the unavailability of toxicology management related medicines like activated charcoal, various antidotes, etc., as well as the availability of other resources and space constraints. To overcome this, Faculties and Residents of Forensic Medicine and Toxicology need to be involved in managing poisoning patients and dedicated centres for the care of Toxicology patients are the need of the hour, particularly at the tertiary care centres. Since toxicology care is multi-disciplinary, we propose a Drug and Toxicology unit. Drug and Toxicology Unit We are proposing one single centre as a Drug and Toxicology unit at every tertiary care centre, corroborating Internal Medicine, Forensic Medicine and Toxicology, Pharmacology, Psychiatry and various other disciplines dealing with all the aspects of Substance abuse, Drugs and Poisons for better care and compliance with such patients. It shall be established near the hospital's emergency department for better patient care and to admit patients of the above categories after their emergency care. The unit shall have The Drug and Toxicology Division and the Substance Abuse and Mental Health Division. The following parts shall be attached to each division, as shown in Fig. 1. Figure 1: Different centres under the Drug and Toxicology Division and Substance Abuse and Mental Health Division Drug And Toxicology Division Substance Abuse And Mental Health Division Drug and Toxicology out-patient department Drug and Poison Information Centre (DPC) Diagnostic lab (Drug level estimation) Diagnostic lab (Poison level estimation) Drug and toxicology ward (Min. 20 bed) Antidote Bank Substance abuse out-patient department Drug de-addiction centre and treatment (DDAC) Outreach and drop-in centres (ODIC) De-addiction drug pharmacy Integrated rehabilitation centre for addicts (IRCA) Objectives A single centre dealing in all aspects of Drugs, Poisonous Substances, Substance abuse and mental health for the convenience of the patients and administration. Human resource and workforce development by training medical undergraduates, post-graduates, research scholars, and other staff in all aspects of drugs and toxicology for better running of such centers. Benefits The facility will support the hospital and the public in better diagnosis and management of drug-related events, poisoning cases and substance abuse cases. It will have a Drug and Poison information centre that will provide knowledge about all the aspects of Drugs, Poisonous substances and Substance abuse to the public and health care providers, which will save the lives of many. All the drug and toxicology-related investigations shall be available in the Drug and toxicology unit. The earliest diagnosis of the Poison can help save the lives of many and support the investigating agencies in regulating the availability of such poisons. Unit shall estimate the drug levels through therapeutic drug monitoring (TDM) in case of life-threatening events and low therapeutic index drugs. De-addiction and treatment centre (DDAC), an integrated rehabilitation centre for addicts (IRCA), and Outreach and Drop-in centres (ODIC) will be beneficial in the prevention and management of Substance abuse cases. A de-addiction pharmacy and antidote bank will provide de-addiction drugs and poison antidotes that will be very helpful in patient care and compliance. De-addiction drug pharmacies will be very supportive of patient of substance abuse to avail their prescribed drugs at ease with following norms as per the NDPS Act, 1985. Teaching and training medical undergraduates and post-graduates in clinical pharmacology and toxicology can be imparted. Various courses like DM (Pharmacology), DM (Toxicology), DM (Psycho-pharmacology), DM (Addiction Psychiatry) along with PhD programs, MSc, DMLT and other related courses in clinical pharmacology, toxicology and Substance abuse may be undertaken. New Research avenues may be inculcated through this unit. We can collaborate with institutes of high eminence for further enhancement. We can also generate good revenue from various sources, as mentioned in Table 1. For substance abuse management and care, the Department of Social Justice and Empowerment provides massive funding to such centres. Table 1: Revenue for the above unit can be generated from the below sources Drug And Toxicology Division Substance Abuse And Mental Health Division Ward admission charges OPD charges Drug and poison estimation charges Therapeutic Drug Monitoring charges Different academic and training courses Antidote bank charges Ward admission charges De-addiction pharmacy EEG Bio-feedback MBT (Aversive Therapy) Motivational enhancement therapy Social skill Training Funding by department of Social justice and empowerment. Our Proposal under HEFA Higher Education Financing Agency (HEFA) is a joint venture of the Ministry of Education, Government of India and Canara Bank to finance the creation of capital assets in premier educational institutions in India. This idea of the Drug and Toxicology unit evolved from inter-departmental activity that started while preparing such proposals that will be a revenue-generating model. HEFA provides funds for infrastructure and equipment, with the condition that they return 10% of the amount in 10 years. In brief, we have proposed an infrastructure with the Ground and first floors having the Drug and Toxicology division and the Second and third floors having the Substance abuse and Psychiatry division (as shown below in Fig. 2-5). Figure 2 : Layout plan for ground floor Figure 3 : Layout plan for first floor Figure 4 : Layout plan for second floor Figure 5 : Layout plan for third floor Tentative Cost And Revenue Generation We estimated the cost of infrastructure and equipment separately as per government norms for both divisions, along with tentative revenue generation as shown in Table 2. Table 2: Tentative cost and revenue generation for the Drug and Toxicology unit as calculated forour proposal under HEFA Drug and Toxicology Division Substance abuse and Mental health division Tentative cost Building (Ground + First floor) = 6.07 crores Instruments/Lab=20.30 crores Total cost= 26.37 crores Building (Second + Third floor) = About 6 crores Instruments/ Lab= 6.35 crore Total cost= 12.42 crores Tentative revenue About 3150 patients were considered per month as per the current hospital load. Ward admission + OPD Charges + Lab investigations (Drug and Poison analysis + TDM) may generate a revenue of about 28.23 lakhs per month and approximately four crores per year. About 750 patients were considered per month as per the current hospital load. Ward admission + OPD charges + De- addiction drug pharmacy + EEG + Biofeedback + MBT + Motivational enhancement therapy + Social skill training = 7,47,500 per month and 89.7 lakh per year further funding by the Ministry of Social Justice and Empowerment approximated to be about 1.46 crore per year for DDAC's, IRCA's, ODIC and Nasha Mukti Abhiyan. Total revenue generation = About 2.5 crore Similar Successful Projects As per our information, we could not find any such unit that incorporates drugs, toxicology and Substance abuser care under one centre all over India. However, many centres run separately for each division, with limited facilities. Drug and Toxicology Division All India Institute of Medical Sciences, Raipur, has started caring for poisoning patients under the Forensic Medicine Department and is also running a DM course in toxicology with two intakes per year. They are taking patients with poisoning cases after the emergency stabilization. The Poison Information Centre is being run at various centres, mainly under the Pharmacology department like AIIMS, New Delhi, which runs the National Poison Information Centre with toll-free (1800 116 117). Amrita School of Medicine, Cochin, runs the Poison Control Centre and Clinical Forensic Medicine with an Analytical toxicology laboratory attached and accredited by the NABL under the Forensic Medicine department. They are not directly involved in the treatment of patients. Substance Abuse and Mental Health Division National Drug Treatment Centre, Ghaziabad (NDDTC), under AIIMS, Delhi, has been established as the apex centre for the management of drugs and substance abuse disorders in India. The centre provides clinical care to patients through community-based OPD and In-patient care, speciality clinics, wards, etc. Health education & preventive measures for substance abusers are done on a community basis. The centre works as a nodal centre for evaluating the prevalence of addiction in society. The centre is involved in staff training and human resources development to cater to such services nationwide, apart from testing, documentation and research in substance abuse disorders. PhD Programme and DM in the area of Addiction Psychiatry running under this centre. Also, they are designated as a WHO Collaborating Centre on Substance Abuse (12). Further, 90 DDAC, 95 ODIC, and 375 IRCA are running under the Ministry of Social Justice and Empowerment all over the country at present (13). Conclusion Healthcare management is interdisciplinary and involves teamwork rather than individual activity. Both the poisoning patients and patients of substance abuse need the care of their mental health. All the poisoning cases and substance abuse cases are medico-legal cases and need the support of Forensic Medicine and Toxicology for Management and other formalities. Hence, the proposed Drug and Toxicological unit at tertiary care centres, with the collaboration of the Departments of Internal Medicine, Pharmacology, Forensic Medicine & Toxicology and Psychiatry for effectively managing substance abuse and poisoning patients, can be paramount. Also, their support in estimating the drug and poison level will help adequately plan healthcare management. Such centres can be nodal centres for the training and research on all aspects of substance abuse and toxicology, including general, pharmaceutical, occupational, environmental, household and others. 1. What is already known on the topic? Answer: Poison information centre is a known concept where the diagnostic facility is also provided at many centres run under Pharmacology and Forensic Medicine. Various centres for the care and management of Substance abuse are also running under the various social initiatives by the WHO and the Government of India. 2. What this study adds? Answer: The paper puts forward a concept of a single centre for the care and management of poisoning cases, substance abuse cases and accessibility of all the aspects of toxicology under a single umbrella, like a One-stop center in case of sexual assault cases. This will improve the quality of care of poisoning and substance abuse case. Also, this paper highlights the need of involvement of Forensic Medicine and Toxicology Department in the management of poisoning cases. 3. Suggestions for further development. Answer: Such a Toxicology unit may be proposed under the different health schemes and government policies to be established at tertiary care centres for streamlined management of poisoning and substance abuse cases. References World Health Organization: WHO. Suicide. Who.int . Published July 8, 2019. [ Link ] . Sharma S. The top 10 causes of death in India. https://www.hindustantimes.com/ . Published September 30, 2017. Accessed April 10, 2019. [ Link ] World Health Organization. “Suicide.” World Health Organization, World Health Organization: WHO, 28 Aug. 2023, [ Link ] The Mental Healthcare Act, 2017|Legislative Department | Ministry of Law and Justice | GoI. [ Link ] . Carrigan CG, Lynch DJ. Managing Suicide Attempts: Guidelines for the Primary Care Physician. Prim Care Companion J Clin Psychiatry. 2003 Aug;5(4):169-174. doi: 10.4088/pcc.v05n0405. PMID: 15213779; PMCID: PMC419387. Sarkhel S, Vijayakumar V, Vijayakumar L. Clinical Practice Guidelines for Management of Suicidal Behaviour. Indian J Psychiatry. 2023 Feb;65(2):124-130. doi: 10.4103/indianjpsychiatry.indianjpsychiatry_497_22. Epub 2023 Jan 30. PMID: 37063624; PMCID: PMC10096207. Wasserman, D., Rihmer, Z., Rujescu, D., Sarchiapone, M., Sokolowski, M., Titelman, D., . . . Carli, V. (2012). The European Psychiatric Association (EPA) guidance on suicide treatment and prevention. European Psychiatry, 27(2), 129-141. doi:10.1016/j.eurpsy.2011.06.003 Hill, N.T.M., Shand, F., Torok, M. et al. Development of best practice guidelines for suicide-related crisis response and aftercare in the emergency department or other acute settings: a Delphi expert consensus study. BMC Psychiatry 19, 6 (2019). [ Link ] Jacobs DG, Baldessarini RJ, Conwell Y, et al. Assessment and Treatment of Patients with Suicidal Behaviors WORK GROUP on SUICIDAL BEHAVIORS.; 2006. [ Link ] Das A, Datta A, Nath A, Bhowmik A. Profile of poisoning cases treated in a teaching hospital of Northeast India with special reference to Poison severity score: A cross-sectional study. J Family Med Prim Care. 2022 Nov;11(11):7072-7076. doi: 10.4103/jfmpc.jfmpc_1076_22. Patel NS, Choudhary N, Choudhary N, Yadav V, Dabar D, Singh M. A hospital-based cross-sectional study on suicidal poisoning in Western Uttar Pradesh. J Family Med Prim Care. 2020 Jun 30;9(6):3010-3014. doi: 10.4103/jfmpc.jfmpc_306_20. “National Drug Dependence Treatment Centre.” AIIMS NEW, [ Link ] . Accessed 31 Oct. 2023. Department of Social Justice and Empowerment National Action Plan for Drug Demand Reduction (NAPDDR) Nasha Mukt Bharat Abhiyaan (NMBA): Annual Action Plan (2021-22) for 272 Most Affected Districts. [ Link ] *Corresponding author and requests for clarifications and further details: Dr. Jitendra Kumar Assistant Professor, Department of Forensic Medicine, Jawaharlal Nehru Medical College, Aligarh Muslim University, Aligarh, UP Email- dr.jitendrak2@gmail.com

Main Page > Vol-26 No.- 2 > Paper 2 (you are here) LinkedIn X (Twitter) Facebook Copy link Share Anil Aggrawal's Internet Journal of Forensic Medicine and Toxicology Volume 26 Number 2 (July - December 2025) Received : Jan 25, 2025; Revised : manuscript received; May 22, 2025 Accepted : June 18, 2025 Published : June 18, 2025 Ref: Mukesh R, Toi PC , Chaudhari VA, Pandiyan KS, Kumaran M. Death due to Clinically Undiagnosed Hematolymphoid Malignancy: An Autopsy Case Report and Review. Anil Aggrawal's Internet Journal of Forensic Medicine and Toxicology [serial online], 2025 ; Vol. 26, No. 2 (July - December 2025): [about 16 p]. DOI: 10.5281/zenodo.15708004 Available from: https://www.anilaggrawal.com/ij/vol-026-no-002/papers/paper002 Email: mukeshfmt22@gmail.com ( All photos can be enlarged on this webpage by clicking on them ) Death due to Clinically Undiagnosed Hematolymphoid Malignancy: An Autopsy Case Report and Review Abstract B-cell lymphomas, a type of hematolymphoid malignancy, constitute 90% of all lymphomas. We report an autopsy of a 33-year-old male with a clinical history of hypothyroidism and anemia brought unresponsive to casualty. The body exhibited no external injuries. Sparse and fine hairs were present in the face, chest, axilla and pubic region, with reduced right testicular size and scrotal volume. The thyroid gland was grossly not palpable and internally untraceable. The spleen was enlarged and softened with a wedge-shaped infarct in the cortical region and a hilar abscess. Under microscopy, the liver showed periportal chronic inflammation, bridging fibrosis and focal interface hepatitis. Acute tubular necrosis with thyroidization of tubules and focal tubular atrophy was reported in the kidney. Lymphoid infiltrates were found in the testis, brain parenchyma, pituitary, and liver, positive for markers like Tdt (Terminal deoxynucleotidyl transferase), CD34, and CD79a. The cause of death was opined as acute tubular necrosis due to septicemia secondary to B-cell lymphoma. After tissue or organ infiltrations, B-cell lymphomas are frequently linked with immunosuppression and multiorgan dysfunction, leading to death. Postmortem immunohistochemistry has helped in finding the key diagnosis in this case. In cases of unexplained anemia or endocrinological abnormalities, autopsy surgeons should rule out hematolymphoid malignancy. Clinicians must include the workup for hematolymphoid diseases in cases with atypical presentation. Keywords- B cell lymphoma; Splenic infarction; Thyroidization; Immunohistochemistry in lymphoma; Hypothyroidism; Thyroid Dysgenesis; life threatening anemia Glossary Bcl: B-cell lymphoma, a general term for lymphomas affecting B cells. ● CD: Cluster of Differentiation, a system used to classify different types of white blood cells. It was suggested in 1982. ● CD34 – CD 34 is a cell surface protein that is commonly used as a marker to identify hematopoietic stem cells (the cells that give rise to all other blood cells) and endothelial cells. ● Clone QBEnd/10 -A specific monoclonal antibody that targets the CD34 protein. Q is a designation given by the laboratory or company that developed the antibody. BEnd: indicate the target [end part refers to endothelial cells]. CD34 is commonly used to identify endothelial cells. 10 represents a sequential identifier, indicating that this is the 10 th clone developed in a series. ● DIC - Disseminated Intravascular Coagulation ● DLBCL : Diffuse Large B-cell Lymphoma, a common type of Non-Hodgkin Lymphoma. ● ECG: Electrocardiogram ● HLM: Hematolymphoid Malignancy ● IVBCL: Intermediate-grade B-cell Lymphoma, another type of Non-Hodgkin Lymphoma. ● Ki: Ki-67, a protein marker used to assess cell proliferation. ● MUM-1: Multiple Myeloma 1. It plays a role in the differentiation of B-cells into plasma cells. It is often used as a marker in immunohistochemistry to identify certain types of lymphomas and myelomas ● NHL: Non-Hodgkin Lymphoma, a type of cancer affecting the lymphatic system. ● PAX: PAX genes - a family of genes involved in the development ● RBC - Red Blood Cells ● Tdt: Terminal deoxynucleotidyl transferase, an enzyme involved in DNA synthesis. It is a specialized DNA polymerase. TdT is primarily expressed in immature, pre-B, and pre-T lymphoid cells, as well as in acute lymphoblastic leukemia/lymphoma cells ● Thyroidization - Thyroid like appearance in renal tissue Introduction Natural deaths due to disease and senility may be unexplained, where the cause of death is not known or unclear to the treating physician[1,2]. "Sudden unexplained death" refers to an unexpected and sudden death in an individual older than 1 year [3]. Unexplained sudden death (Intrinsic Factor(s) Identified) is a type of cause of death statement when the causality of death can be determined. However, intrinsic natural abnormalities like known intrinsic risk factors for sudden death or those of unknown significance are present. Trauma and other unnatural etiologies are properly excluded in such cases [4,5]. In a study, about 6-12% of cases subjected to medicolegal autopsies were determined to have died of natural causes [6]. About 35% of brought dead cases were reported to have a natural cause of death at autopsy [7]. About 8% of adult cases revealed clinically undiagnosed malignancy in autopsy [8]. About 20% of the clinically unsuspected malignancy was detected at the time of autopsy, while 16% presented with metastasis. Among the autopsy-diagnosed cancers, the primary cause of death was malignancy in 16% of such cases, which also includes hematolymphoid malignancies [9]. Hematolymphoid malignancies (HLM) are primary cancers affecting blood, bone marrow, and lymphoid organs, originating from either myeloid or lymphoid cell lines. Lymphomas, lymphocytic leukemia, myelomas and other plasma cell dyscrasias arise from lymphoid cell lines. In contrast, acute myeloid leukemia (AML), chronic myeloid leukemia (CML), myelodysplastic syndromes (MDS) and other myeloproliferative disorders (MPD) are myeloid in origin. Immunohistochemical markers like CD1a(Cluster of Differentiation 1a), CD3 (Cluster of Differentiation - 3), CD7 (Cluster of Differentiation 7), CD8(Cluster of Differentiation 8), CD20 Cluster of Differentiation 20), CD30 (Cluster of Differentiation 30), CD 34 (Cluster of Differentiation - 34), CD 79a (Cluster of Differentiation -79a), TdT (Terminal deoxynucleotidyl transferase), MIB (Cell Proliferation Marker), LCA (Leucocyte Common Antigen), etc. are used in the biopsy diagnosis of various types of HLMs with their expressivity in staining. Organ infiltration from leukemia, lymphoma, myeloma, and related conditions is less likely to be symptomatic than from carcinoma. Patients with HLM are at risk of complications from the neoplasm and treatment [10]. We present an autopsy case report with a postmortem diagnosis of lymphoma in the deceased, who was brought dead to casualty in our hospital after a brief period of hospitalization in another health care center. Case Report We conducted an autopsy of a moderately built 33-year-old man. The deceased allegedly had anemia and hypothyroidism and was suffering epigastric pain along with reduced urine output for 3 days prior to death. As per the clinical records, prior to death, he was admitted to a hospital for management for 13 days. The lab values during the admission period were as follows: Hb-4.5g%, WBC- 12800/mm3, Neutrophils - 67%, Lymphocytes - 29%, Eosinophils - 4%. T3- 46.96 ng/dl (Normal- 70-204 ng/dl)), T4- 2.6 microgram/dl (Normal- 4.6-10.5 microgram/dl), TSH - 1.76 microIU/ml (normal - 0.4 - 4.2 microIU/ml), Blood urea - 40 mg/dl, Serum Creatinine- 1.2 mg/dl, Blood sugar - 87 mg%. ECG showed T wave inversion in V1-V3. The treatment included diuretics, iron supplementation, packed RBC transfusion, antibiotic prophylaxis, and thyroxine supplementation. On external general examination, the body had no injuries, measuring 165 cm in length and 55 kg in weight. The conjunctiva was pale, while fingernails and toenails had nail paint. Natural orifices were free without any discharges. Sparse and fine hairs were present in the face, chest, axilla and pubic region (Figure 1A, 1B, 1C). The volume of the scrotum appeared relatively reduced (Figure 1C). Fig 1. Immature & sparse hairs: Face (A), Axillary region (B) and Pubic region (C) hairs. Reduced testicular size (Arrow mark in C) On internal exploration, the thyroid was not traceable in the anatomical or reported ectopic locations. In front of the arch of the aorta above the tracheal bifurcation, there was a solid grey-white mass measuring 1.5cm X 0.8cm X 0.8cm situated in the superior mediastinum. The adjacent muscle tissue was flabby and more softened. The spleen was soft with an intact capsule measuring 18cm X 11cm in frontal view and 750 g in weight. The cortex showed a coalesced pale infarct involving the entire organ and a wedge-shaped advanced infarct (Figure 2A). A splenic abscess measuring 3cm X3 cm had developed in the hilar region. Liver was congested with intact capsule. Lungs were congested and edematous (Figure 2B). Most segments were firm in consistency. There were multiple petechial hemorrhages in the right atrium and at the base of great vessels, and coronaries were patent. Examination of the kidneys revealed fatty infiltration with renal pelvis hemorrhage (Figure 2C). The right testis was smaller, measuring 4cm X 2cm X 2cm. Left testis appeared grossly normal. The thoracic cavity contained straw-brown colored fluid estimated to be about 750ml (Figure 2D). Fig 2. Significant internal findings In Figure-2 2A Infected pleural fluid in thoracic cavity (Arrows) 2B Frothy edematous fluid in lungs & trachea (Arrow Heads) 2C Infarcts in spleen (asterisk - advanced) 2D Infarcts (Asterisk) & hemorrhagic extravasation with necrosis (arrow head) in kidney Under microscopy, the lungs showed dilated alveoli with interstitial congestion, chronic inflammatory cells with bacterial clumps, and hemosiderin macrophages. The liver showed chronic inflammation, fibrosis, and sinusoidal dilatation with lymphoid cells. The testes showed atrophy of seminiferous tubules and immature lymphoid cells in the interstitium with thickened tunica (Figure 3A). The thymus showed hyperplasia and thick-walled vessels (Figure 3B). Kidney tubules showed acute tubular necrosis, thyroidization, and atrophy with tubular hyaline casts (Figure 3C). Tonsil showed increased lymphoid cells, while lymph nodes showed reactive changes (Figure 3D). The brain showed dilated vessels filled with lymphocytes and parenchymal lymphocytic infiltrates (Figure 3E). The pituitary showed diffuse infiltration of immature lymphoid cells, highlighted with CD79a. The left ventricle showed pericardial fat with chronic inflammation, interstitial oedema, and lymphoid aggregates. The right ventricle of the heart showed thick- walled vessels and lymphoid aggregates. The aorta shows atherosclerotic changes along with lymphoid aggregates (Figure 3F). The unidentified thick mediastinal mass from the thorax showed interstitial spaces and lymphoid aggregates in the background of skeletal muscle cells. The suitable tissues were subjected to immunohistochemistry. Fig 3. Microscopic examination (Hematoxylin & Eosin) showing lymphoid infiltrates in various oegans: A- Testis (10x) B- Thymus (40x) C- Kidney (10x) D- Tonsil (4x) E- Brain (40x) F- Aortic wall (4x) Immunohistochemical staining with primary and secondary antibodies (PathnSitu Biotechnologies) was performed using Ventana platform for CD3 (clone Polyclonal), CD20 (clone L26), CD34 (clone QBEnd/10), CD79a (clone HM47) and TdT (Polyclonal Rabbit Anti-Human TdT Antibody (Abcam, Cat# ab19515)) in a dilution of 1:200 with standard operating protocol. The moderate intensity of DAB chromogen in the slide image was considered positive expressivity. On immunohistochemistry, Tdt, CD34, and CD79a highlighted the immature (probably blast) cells in the pituitary, liver and testis. CD3 and CD20 were negative in the immature B cells. Hence, the possibility of B cell leukemia or lymphoma was reported from histopathological impressions. Blood and sterile fluid culture showed the growth of Escherichia coli. Toxicological examination did not detect any poison or drugs in this case. The cause of death was opined as acute tubular necrosis due to septicemia as a complication of B cell lymphoma. Discussion More than 30% of HLM cases diagnosed in autopsy, were earlier clinically undiagnosed [10,11]. Diffuse Large B cell lymphoma is the most common type of NHL (Non-Hodgkin Lymphoma), frequently observed in adults, and so is indolent lymphoma [12]. The mean age range of autopsy confirmation of HLM is about 36-46 years [10,11,13], whereas the age of the deceased was 33 years in the present case. Lymphoma may be localized, and it may later tend to be rapidly progressive. Diffuse Large B Cell Lymphoma (DLBCL) involves nodal or extranodal sites, including the Waldeyer ring, lung, bone marrow, spleen, liver, and gut, manifesting as a rapidly growing mass [14,15]. Intravascular B Cell Lymphoma (IVBCL), a rare type of non-Hodgkin lymphoma, primarily invades blood vessels and presents with neurological or hemophagocytic symptoms depending on the variant [16]. The spectrum of clinical features in lymphoma includes low- grade intermittent fever, nausea, oliguria, anorexia, abdominal pain, weight loss, oedema, pallor, progressive dyspnea, cognitive decline, painless lymphadenopathy, splenomegaly and lactic acidosis [17-24]. Lymphoid malignancy may be further clinically associated with anemia, hypertension, hypothyroidism, paraplegia and multiorgan failure [25,26]. The present case had an antemortem diagnosis of anemia and hypothyroidism. T wave inversion in lead V1-V3 ECG is a normal variant in children but indicates cardiac pathology in adults [27], which does not exclude secondaries or lymphoid infiltration in the present case. In aggressive cases of lymphoma, autopsy may reveal septic and disseminated intravascular coagulation- like picture bone marrow hyperplasia and hepatosplenomegaly [18,19]. The correlation of gross autopsy features with histopathological findings remains crucial for diagnosis, especially in cases with atypical presentations of HLMs [17,18,29]. Generally, painless lymphadenopathy is found in most HLMs [17]. Enlargement of peripancreatic, mesenteric, hilar, paratracheal, paraaortic and mediastinal lymph nodes have been reported [10]. In cases of NHL, diffuse infiltration by tumor cells causes complete architectural effacement. In our case, lymph nodes showed reactive changes, which could be attributed to infection. Tonsils, in HLM, may show monomorphic proliferation of large lymphoid cells, distinct plasmacytoid features, eccentrically placed nuclei, thick nuclear membranes, variably prominent nucleoli, clumped chromatin, and copious pyroninophilic cytoplasm [36]. In the present case, diffuse infiltration of immature lymphoid cells was found in the tonsils. Diffuse infiltration with angiotropic features, CD20 positivity and decreased ACTH immunoreactivity in the pituitary with associated hypogonadotropic hypogonadism has been reported [37,38]. Diffuse infiltration of lymphoblast cells is found in the pituitary gland with associated hypogonadotropic hypogonadism. Hatem reported diffuse lymphoid infiltration of skeletal muscle in multiple cores with pseudo-glandular structures and sheets observable in low-power microscopy [39]. Skeletal muscle exhibited immature lymphoblast infiltration, with features like large cells, irregular nuclear contours, vesicular chromatin, prominent nucleoli, and moderate cytoplasm in high-power microscopy. Thyroid dysgenesis, which includes thyroid agenesis, hypoplasia and ectopic thyroid, amounts to 80-85% of congenital hypothyroidism [40,41]. Acute leukemia is linked to autoimmune thyroid diseases like Graves' and Hashimoto's thyroiditis, with hypothyroidism being a common outcome of thyroid lymphoma [42]. Also, secondary hypothyroidism is most commonly associated with pituitary disorders/abnormalities [43, 44]. A case study by Foresti showed a cause-effect relationship between leukemic infiltration of the thyroid gland and hypothyroidism, with progressive reduction in thyroid hormones and increases in TSH levels [45]. In our case, there was no trace of thyroid in the neck or mediastinum. Clinically, the thyroid profile has shown decreased secretion of thyroid hormone levels, suggesting the possibility of ectopic thyroid. However, no glandular tissue was identifiable or appreciable in the usual reported areas of ectopic thyroid during the autopsy [46]. A mediastinal unidentified tissue excised in an autopsy suspected of ectopic thyroid also did not show any histological components of thyroid tissue; only lymphoid aggregates were found in the background of skeletal muscle cells. This is similar to a study by Waghmare TP et al. where 18% of the NHL cases had soft fleshy yellow-white mass [10]. The thymus showed hyperplasia with a preponderance of immature B cells in our case. Lymphoma may cause thymus enlargement either by primary involvement or secondary infiltration following the invasion of adjacent lymph nodes. Medullary B-cell lymphoma in the thymus is found in 2% of cases with NHL [47]. Malignant lymphoma in the thymus can resemble hyperplastic thymus. Histologically proven invasion in the thymus was not revealed even in advanced imaging methods like FDG or chemical shift MRIs.[48]. Petechial hemorrhages in the ventricular subendocardial region and cardiac hypertrophy were reported in the literature [10, 49]. The tumor cell infiltrates are reported in the myocardium, epicardium, conduction pathway [49,50], cardiac septum and valves [10]. In the present case, the heart displayed petechiae, inflammation with interstitial oedema, lymphoid aggregates, thick aortic and vessel walls, myxoid changes, and enhanced fibrosis. Pulmonary nodules, mostly calcified and peripheral lung oedema, have been reported [18,19]. Doran reported extensive neoplastic infiltration, generally filling vessels and spilling out into the alveoli while associated with thrombo-embolism and infection (pneumococcus, aspergillus) in the lungs [51]. Microscopic examination of the edematous lung, in our case, revealed dilated alveoli with interstitial congestion with chronic inflammatory cells with bacterial clumps and hemosiderin macrophages. Reported findings of lymphoma in the liver include neoplastic infiltration, fibrosis, cancerous nodules, necrotic areas, Reed–Sternberg cells, hypocellular regions, diffuse organ filtration by leukemic cells, profound infiltration of CD30 (Ki-1) positive lymphoma cells [11,52,53]. Enlarged hemorrhagic lymph nodes at porta hepatis were also reported by Waghmare TP et al. [10]. Infiltrates in sinusoidal and periportal regions with nodular aggregates were recorded. Liver, in the present case, periportal chronic inflammation with bridging fibrosis, focal interface hepatitis, sinusoidal dilatation with large lymphoid cells, despite normal hepatic architecture. Hemorrhagic splenic infarcts involve vascular congestion, hemorrhage, and necrosis, while septic infarcts involve acute or chronic inflammatory infiltrates. Lymphoma-induced splenic infarctions result from blood flow interruption and hence bland infarcts are pale, wedge-shaped, and subcapsular. Septic infarcts have suppurative necrosis and large depressed scars during healing. Splenic abscesses show chronic inflammatory infiltrates and necrotic cells [54]. In our case, the spleen was enlarged with massive pale infarcts, implying the possibility of splenic vessel thrombosis. About 10% of splenic infarcts progress to bacterial abscesses in immunocompromised individuals [55,56]. In the present case, there was a progression into a splenic abscess in the hilar region. Renal enlargement and deposits are reported in HLM [10], while renal pelvic hemorrhage was found in our case. The microscopic findings include acute tubular necrosis, thyroidisation of tubules and focal tubular atrophy with hyaline casts. Tubular atrophy involving broader areas and delineated interstitial fibrosis along the medullary rays forming a striped scarring pattern suggest chronic ischemia. The thyroidization pattern is often seen in urinary reflux or chronic pyelonephritis [57]. Testicular infiltration in leukemia cases is typically bilateral but asymmetric in severity, starting in one testis before affecting both. Specific size measurements of affected testis were hardly found in autopsy-based literature. Its severity is similar to other sites but can be second only to marrow, lymph nodes, and spleen involvement. Microscopic infiltration is most common in acute leukemia, less common in chronic leukemia, and less frequent in lymphoma [58]. Atrophy of the seminiferous tubules with immature lymphoid cells with thickened tunica was observed in our case. Abnormally small testes, smaller than the 50th percentile for age, can be caused by congenital or acquired factors.[59]. Waghmare & Moller reported leukemic infiltrates in the brain parenchyma, meningeal and Virchow robin space [10,60]. Thirunavukkarasu reported patchy myelin pallor in subcortical areas without over-demyelination due to lymphoma cell infiltration [61]. In our case, cerebral vessels were dilated, along with increased vascular and parenchymal lymphocytic infiltrates. Immunohistochemical studies help to type the tumor cells infiltrating various organs like the lungs, liver, spleen, pituitary gland, ovaries, uterus, and bone marrow. Diffuse large cell B-cell lymphoma (DLBCL) tests positive for CD20, CD79a, bcl-2, and MUM1 but negative for CD3, CD5, CD10, CD 56, bcl-6, and cyclin D1 [20, 26]. Reportedly, diffuse CD20 positivity is found in lymphoid cells in sinusoidal and interstitial sites with a Ki-67 index of about 80% to 90% [26]. The CD20 negative subtype of DLBCL is rare and aggressive, with lesser survival rates [62]. B cell lymphoblastic leukemia also tests positive for TdT, CD34, CD79a or PAX5 [63]. IVLBCL exhibits strong intravascular CD20 and CD45 positivity [21]. In the present case, immature B cells in the pituitary, liver and testis tested positive for Tdt, CD34, and CD79a and negative for CD3 and CD20, suggesting B cell lymphoma or leukemia as a final impression on immunohistochemical confirmation. Following flow cytometry, fluorescence in situ hybridization (FISH) analysis is the method of choice for confirmatory diagnosis [64]. CD34 is a transmembrane phosphoglycoprotein found on cell surfaces in humans and animals, used to identify and isolate cancer stem cells (CSC). It is positive in leukemia, breast and lung cancer, and other types of tumors [65]. Terminal Deoxynucleotidyl Transferase (Tdt) is a DNA polymerase found in high levels in the thymus, low levels in normal bone marrow, and absent in normal peripheral blood leukocytes. In adult leukemias, the Tdt level is elevated primarily in lymphoblastic leukemia and low in myeloblastic leukemia [66]. CD79, pan B-cell marker, is a dimeric, transmembrane protein, which, along with surface immunoglobulin, is expressed from the pre-B stage to the plasma cell stage of differentiation. It is found in B-cell lymphomas, B-cell lines, most acute leukemias of precursor B-cell type, megakaryocytic lesions and certain myelomas [67]. Hematological malignancies exhibit a dynamic spectrum of infections among the affected patients [68]. Most of the infections were either systemic or pulmonary [69]. Klebsiella pneumoniae, Escherichia coli and Pseudomonas aeruginosa were the most frequent organisms isolated, resulting in mortality rates up to 48% in diagnosed cases of HLMs [70]. Escherichia Coli is isolated from blood and fluid culture in the present case, forming the primary foci for septicemia like in other cases [70-73]. The specific subtype of B-cell lymphoma may also influence the primary cause of death [10,74]. The progression and transformation into aggressive subtypes, such as diffuse large B-cell lymphoma, has an unfavourable prognosis and increased mortality rates [20]. Complications from the disease, treatment-related side effects and comorbidities contribute to mortality [28, 75-77]. Death was commonly caused by Disseminated malignancy followed by fatal respiratory illness or complications [10,71]. Any infiltrative diseases involving the spleen can also lead to spleen rupture, causing intraperitoneal bleeding, shock, and death [78- 80]. Other causes of death include infection, hemorrhagic shock, hemoperitoneum, thromboembolism, increased intracranial tension with cerebral oedema and conduction abnormalities and associated congenital heart disease [10,20]. Significant autopsy findings in cases of septicemia include pulmonary oedema, diffuse alveolar damage with micro- thrombosis, inflammation & ischemic necrosis of cardiac tissues, acute tubular necrosis, cholestatic jaundice, liver necrosis with sinusoidal aggregates, partial liquefaction of spleen, hemorrhagic adrenal gland, cerebral petechiae, sub-serosal or submucosal hemorrhages in the gastrointestinal tract and features of disseminated intravascular coagulation [81]. In the present case, death is attributed to septicemia secondary to B cell lymphoma in its advanced stage involving multiple organs. Multiple conditions, including syndromic abnormalities like hypogonadism and Kallmann syndrome, were in consideration before concluding the autopsy cause of death in this case. However, the findings from ancillary investigations of the tissues and fluids, in corroboration with the gross features of the case, directed the focus of causality towards B cell lymphoma. Conclusion The unexpected discovery of B-cell lymphoma in this 33-year-old man with a history of anemia and hypothyroidism demonstrates th e potential for these conditions to remain undetected until postmortem investigation. The gross findings, extensive lymphoid infiltration observed across multiple organs on microscopy, and immunohistochemical findings provided crucial evidence for diagnosing B-cell lymphoma. Septicemia, the common fatal complication of B-cell lymphoma as in any HLM, had caused death in this case. The case report highlights the importance of comprehensive autopsy examinations in identifying clinically undiagnosed malignancies, particularly HLMs. Limitations The spleen and bone marrow were not subjected to microscopic studies using cytomorphology, histomorphology, and immunohistochemistry, thereby posing difficulty in locating the lymphoma's primary origin. Suggestions For Autopsy Surgeons: The case highlights the importance of autopsy in medical education, quality assurance, and disease understanding. Postmortem diagnosis of B-cell lymphomas can be challenging due to heterogeneity and limited tissue samples. Understanding gross autopsy findings in HLM is crucial for prompt recognition and management. In unexplained anemia or endocrinological abnormalities, an autopsy should also rule out HLM. For Clinicians: The case report emphasizes the importance of clinicians detecting underlying malignancies in cases with atypical presentations or unexplained deterioration. Advancements in diagnostic techniques like noncoding RNAs, Next-Generation Sequencing, and radiomics provide new insights into disease pathogenesis and development, while tissue proteomics and digital pathology can enhance early detection [82-86]. Conflicts of interest The authors have declared no conflict of interest in the submitted work. Funding/services All authors have declared that no financial support or service was received from any organization for the submitted work. Ethical Approval & Informed Consent This article does not contain any studies with animals. This is a retrospective case report of a medicolegal autopsy. The case data has been completely anonymized with proper de- identification of contents in this report. References Hanzlick R, Hunsaker JC, Davis GJ. Guidelines for Manner of Death Classification. Atlanta. GA. National Association of Medical Examiners. 1st ed. 2002. Available online from: Link Our role in investigating deaths [Internet]. Scotland. Crown Office and Procurator Fiscal Service. 2023 June 9 [Updated on 2024 July 16. Cited on 14 September 2024]. 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Detection of elevated levels of tumor‐associated microRNAs in serum of patients with diffuse large B‐cell lymphoma. Br J Haematol. 2008;141(5):672-5. https://doi.org/10.1111/j.1365-2141.2008.07077.x Gillies RJ, Kinahan PE, Hricak H. Radiomics: images are more than pictures, they are data. Radiology. 2016;278(2):563-77. https://doi.org/10.1148/radiol.2015151169 Griffin J, Treanor D. Digital pathology in clinical use: where are we now and what is holding us back? Histopathology. 2017;70(1):134-45. https://doi.org/10.1111/his.12993 Zheng GX, Terry JM, Belgrader P, Ryvkin P, Bent ZW, Wilson R, Ziraldo SB, Wheeler TD, McDermott GP, Zhu J, Gregory MT. Massively parallel digital transcriptional profiling of single cells. Nat commun. 2017;8(1):14049. https://doi.org/10.1038/ncomms14049 *Corresponding author and requests for clarifications and further details: Dr Mukesh R, Assistant Professor, Department of Forensic Medicine & Toxicology,JIPMER, Pondicherry. Mail at: mukeshfmt22@gmail.com

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Main Page > Vol-27 No- 2 > Paper 1 (you are here) LinkedIn X (Twitter) Facebook Copy link Share Anil Aggrawal's Internet Journal of Forensic Medicine and Toxicology Volume 27 Number 2 (July - December 2026) Received: Apr 1, 2025 Revised manuscript received: May 3, 2025 Accepted: June 16, 2025 Ref: Chaldun I, Yudianto A, Permana PBD. Domestic Violence Leading to Pediatric Burns: A Clinical Forensic Case From East Java, Indonesia. Anil Aggrawal's Internet Journal of Forensic Medicine and Toxicology [serial online], Vol. 27, No. 2 (July - December 2026): [about 11 p]. Available from: https://www.anilaggrawal.com/ij/vol-027-no-002/papers/paper001 Published as Epub Ahead: June 26, 2025 DOI: 10.5281/zenodo.15743408 Email- ibnu.chaldun-2022@fk.unair.ac.id [Epub Ahead] ( All photos can be enlarged on this webpage by clicking on them ) Domestic Violence Leading to Pediatric Burns: A Clinical Forensic Case From East Java, Indonesia Abstract Background : Burns encompassed all types of injuries to the skin and underlying tissues caused by heat, cold (e.g., frostbite), chemicals, electricity, radiation, or trauma. They often result in significant physical, psychological, and legal implications, especially in determining the extent of injury and potential criminal liability. In East Java, Indonesia—a region with a dense population and varied socio-economic conditions—burn cases require meticulous clinical forensic examinations to support law enforcement and legal processes. Method: This study presents a clinical forensic examination conducted at the request of law enforcement through a visum et repertum letter (No. VER/B/92/IV/YAN.2.14/2023/SPKT Polsek Lakarsantri). The case involved a 17-year-old male patient treated at Dr. Soetomo General Academic Hospital in Surabaya, Indonesia. Result: The patient sustained burns covering 68% of his total body surface area, involving the face, neck, chest, upper limbs, and lower limbs, accompanied by inhalation trauma. The burns occurred during a fire at his stepfather's house while he was asleep. Clinical management included debridement and wound dressing to prevent infection, reduce exudate, and maintain a moist environment for healing. The forensic evaluation concluded that the injuries could be classified as fatal based on Article 90 of the Indonesian Penal Code. Conclusion: Comprehensive clinical forensic examinations are vital in burn cases, as the findings are essential for assessing the severity of injuries and determining legal accountability. This case highlights the critical role of forensic evaluations in supporting justice and ensuring appropriate care for burn victims in East Java. Keywords : forensic sciences; burns; visum et repertum; east java; burn injury severity Introduction Burns are thermal injuries with a wide range of clinical consequences, including minor injuries and death. From a medicolegal standpoint, numerous factors must be taken into account when assessing both fatal and non-fatal burn injuries .¹ Burn injuries are a significant global health concern, accounting for approximately 180,000 deaths annually, with nearly two-thirds occurring in low- and middle-income regions such as Africa and Southeast Asia, according to WHO statistics. ² The Indonesian Ministry of Health’s survey data revealed a 35% increase in burn cases from 2014 to 2018, with 1,701 cases (20.19%) reported in 2018, compared to 1,570 cases (18.64%) in 2017, 1,432 cases (17.03%) in 2016, 1,387 cases (16.46%) in 2015, and 1,209 cases (14.35%) in 2014. 3 East Java, a province in Indonesia, accounted for 1.66% of burn cases out of 964 total samples, highlighting the regional prevalence of burn injuries in this region.³ Traumatic burns requiring legal intervention may result from various circumstances, including household accidents, workplace incidents, negligence, or cases of abuse involving children or parents. The patient’s history collected during the clinical evaluation is vital in identifying potential abuse. Inconsistent or illogical explanations for burns, unexplained injuries, or delayed symptoms should raise suspicions of maltreatment. Additionally, the type, pattern, and location of burns are critical factors to assess during the physical examination to establish a connection with possible abuse .¹ Case Report On April 14, 2023, at approximately 11:30 PM, the patient, a 17-year-old male, was transported by the Indonesian Red Cross Society “ Palang Merah Indonesia ” (PMI) team to the Emergency Room of Dr. Soetomo General Academic Hospital in Surabaya, following a traumatic incident in which he sustained extensive burns. The local law enforcement of Lakarsantri Police Sector, Surabaya formally submitted a request for a clinical forensic examination of the victim through an official visum et repertum request letter (No. VER/B/92/IV/YAN.2.14/2023/SPKT Polsek Lakarsantri). The accompanying documentation specified that the burn injuries sustained by the victim were allegedly inflicted by the stepfather, who set the victim on fire while the latter was asleep. Upon arrival at the hospital, the patient was fully alert and responsive to the situation. General Examination The subject of the clinical forensic evaluation was a 17-year-old male, measuring 165 cm in height, weighing 60 kg, with dark skin, and in a state of good nutritional health. Upon examination, the patient was conscious and oriented despite the evident burn injuries sustained. Vital signs recorded were as follows: blood pressure of 107/77 mmHg, pulse rate of 88 beats per minute, and respiratory rate of 20 breaths per minute. Examination of the chest revealed symmetrical movements without retractions, vesicular breath sounds, and the absence of adventitious sounds such as rhonchi or wheezing. Cardiac auscultation was unremarkable, with no abnormal heart sounds detected. The abdomen was soft, non-tender, with normal bowel sounds. Capillary refill time in the extremities was less than 2 seconds, indicating adequate peripheral perfusion. Wound Examination In this case, wounds of varied degrees and depths were observed on each affected body area. Second-degree burns (2a / mid dermal - deep dermal ) affected 6% of the face and neck (Figure 1). The skin was a reddish-brown color, with the epidermis flaking off in parts. There were also blisters with clear fluid within them. They burned the nose and scorched some of the front hair. They discovered second-degree burns (2a / mid dermal - deep dermal ) covering 15% of the chest and belly, as well as a reddish-brown color, epidermis peeling on some regions of the skin, and clear fluid-filled blisters. They discovered second-degree burns (2a / mid dermal - deep dermal ) covering 11% of the back, along with a reddish-brown tint, epidermis peeling on some portions of the skin, and blisters filled with clear fluid. A second-degree burn (2a / mid dermal - deep dermal ) covering 9% of the area was discovered on the right upper limb, encircling the entire upper side from the upper arm to the fingertips, with a reddish-brown color and epidermis peeling on some parts of the skin, as well as blisters containing clear fluid. A second-degree burn (2a / mid dermal - deep dermal ) covering 9% of the area was also discovered on the left upper limb, encircling the entire upper side from the upper arm to the fingertips, with a reddish-brown color, epidermal peeling, and blisters containing clear fluid. On the right lower limb, from the knee to the tips of the toes, there was a 1st to 2nd degree burn covering 9% of the area and ranging from the epidermal to the mid-dermal . The skin was peeling off in some places, and there were blisters with clear fluid inside them. The left lower limb had a 1st to 2nd degree burn, covering 9% of the area and extending from the skin's surface to the middle layer. The burn was reddish-brown, and blisters were filled with clear fluid. It did not cover the limb from the knee to the toe tips. Figure 1. Patient external wound examination photographs taken from the right side (top image), face upfront (middle left), front torso (bottom left), right upper extremity (middle center), left upper extremity (bottom center), right lower extremity (middle right), and left lower extremity (lower right). Supporting Examination A comprehensive blood test was conducted, revealing a significant increase in white blood cell (leukocyte) count, with a rise of 21,380 g/dL. Blood chemistry tests, including serum albumin, blood urea nitrogen (BUN), serum creatinine, and electrolyte levels, yielded the following results: serum albumin at 3.97 g/dL, serum BUN at 14.2 mg/dL, serum creatinine at 1.1 mg/dL, and electrolytes at 134 Na, 3.8 K, and 103 Cl/L. These clinical chemistry results remain within normal reference ranges. The patient was subsequently referred to a pulmonologist for evaluation of inhalation trauma, which was diagnosed as Ocular Dextra Sinistra (ODS) thermal injury. A chest X-ray was performed, which revealed no abnormalities. Management The patient received treatment from a plastic surgeon for his burn injuries. An internal medicine specialist was also consulted, and an insertion of a nasogastric tube (NGT) was performed. The patient was kept on a fasting regimen for the first 24 hours, after which modified Parkland fluid resuscitation therapy was initiated, accompanied by fluid balancing and the insertion of a urinary catheter. Additionally, the patient was referred to an anesthesiologist for the implantation of an endotracheal tube (ETT) and administration of oxygen therapy. A pulmonologist was consulted for inhalation trauma, resulting in the administration of high-dose antibiotics, a chest/thorax examination, and nebulization therapy. Lastly, the patient was referred to an ophthalmologist, who diagnosed corneal and conjunctival sac burns, and prescribed antibiotic eye drops and eye ointment for treatment. Discussion Trauma and accidents are typical in forensic cases. Wounds, bleeding, and/or scarring, as well as organ function impairment, are the results of trauma or accidents. Mechanical forces, temperature action, chemical agents, electromagnetic agents, hypoxia, and embolic trauma are among the various types of agents that cause trauma.⁴ Trauma patients are classified as minor or major based on a set of medical triage criteria. As a result, in forensics, medical practitioners must describe trauma in a way that is suitable and understandable to the judicial system, as well as indicate its etiology. ⁵ The patient in this case was burned by a thermal agent at a high temperature (hyperthermia). Flames or hot solid or liquid substances can cause hyperthermia, often known as high temperature. Burns are caused by the impact of heat on skin or body parts that come into contact. ⁴ Burns are traumatic injuries that are typically produced by thermal events, although they can also be caused by chemical, electrical, or radiation exposure to the skin, mucous membranes, and deep tissues. The injured area has increased capillary permeability, which allows fluids and big molecules such as albumin to escape out of circulation. This results in considerable fluid loss, particularly if the burns cover a vast surface area, impacting metabolism and body cell function. This patient's burns were caused by thermal damage.⁶⁻⁸ Thermal burns are caused by a heat source raising the skin's temperature, causing tissue cells to die or char. A temperature of at least 44°C is required for the skin to burn. Burns from high temperatures, such as hot metal, boiling liquids, steam, or fire, are the most prevalent cause. Determination of burn wound qualifications in burn cases is based on the assessment of the depth of damaged tissue, the extent of affected tissue, and injuries accompanying the burn. Burn wound classification based on the depth of tissue damage is divided into first degree, second degree, and third degree burns (Table 1).⁹ Table 1. Burn wound classification based on depth/thickness Burn Thickness Description First Degree (superficial thickness) Involves only the epidermis. Painful, dry, red, and blanches with pressure. No blisters. Heals without scarring. Second Degree (partial thickness) Involve the epidermis and part of the dermis. Superficial partial thickness (2a): Involves epidermis and superficial dermis. Painful, red, blisters form within 24 hours, blanches with pressure. Heals in 1–2 weeks. Deep partial thickness (2b): Extends deeper into dermis. Reduced pain, reduced/absent blanching, higher risk of scarring. Healing takes weeks. Third Degree (Full thickness) Involves destruction of epidermis, dermis, and often subcutaneous tissue. Eschar formation, dry and stiff. Sensation absent due to nerve damage. Requires surgical intervention (e.g., grafting). The classification of burn severity is divided into three based on the cause, depth, and surface area of the burn as seen from the percentage of TBSA, namely minor, moderate, and major burns (Table 2). The patient had varying degrees and depths of burns on each affected body part. On the face and neck, there are 2nd-degree burns/2a covering 3% and 2nd-degree burns/2b covering 3%. On the chest and abdomen, there are 2nd-degree burns/2a covering 7.5% and 2nd-degree burns/2b covering 7.5%. On the back, there are 2nd-degree burns/2a covering 5.5% and 2nd-degree burns/2b covering 5.5%. On the right upper limb, there are 2nd-degree burns/2a covering 4.5% and 2nd-degree burns/2b covering 4.5%. On the left upper limb, there are 2nd-degree burns/2a covering 4.5% and 2nd-degree burns/2b covering 4.5%. On the right lower limb, there are 1st-degree burns covering 4.5% and 2nd-degree burns/2a covering 4.5%. On the left lower limb, there are 1st-degree burns covering 4.5% and 2nd-degree burns/2a covering 4.5%. In 1st-degree burns, only the epidermis layer of the skin is affected. In 2nd-degree burns, the epidermis and part of the dermis layer of the skin are affected, which is then classified as superficial dermis. In contrast, a second-degree burn extends into the deep dermis .⁹ Table 2. Burn wound classification based on severity. Criteria Minor burn Moderate burn Major burn TBSA <10% in adults, <5% in children or elderly, <2% for full thickness burn 10-20% in adults, 5-10% in children or elderly, 2-5% for full thickness burn >20% in adults, >10% in children and elderly, >5% for full-thickness burn Other N/A Low-voltage burn, suspected inhalation injury, circumferential burn, concomitant medical problem predisposed to infection (e.g. diabetes, sickle cell disease High-voltage burn, chemical burn , any clinically significant burn to face, eyes, genitalia or major joints, clinically significant associated injuries (e.g. fracture, other major trauma) To assess the area of burn wounds accurately and correctly, the use of calculation methods such as the " Rule of Nines " is required to produce the total burn area percentage (Figure 2). The Wallace’s " Rule of Nines " divides the body's surface area into multiples of 9%, except for the perineum, which is estimated to be 1%. [10,11] However, evidence have shown that this method of estimation is not recommended for use in those younger than 12 years as children exhibit dissimilar body proportions than adults. A more advanced version of burn injury extent estimation is by using the Lund-Browder chart, which was developed by Dr. Charles Lund and Dr. Newton Browder based on their experiences treating burn victims from the 1942 Cocoanut Grove fire. Unlike the Wallace rule of nines, it accounts for age-related variations, adjusting the percentage BSA for the head and legs as children grow, making it particularly effective in managing pediatric burn cases.[12,13] (click to enlarge) Figure 2. Estimation of the total body surface area affected from burn injury based on the Lund and Browder Chart. Based on the examination of the patient using the Total Body Surface Area (%TBSA) method, the total burn area was calculated to be 68%, involving the face, neck, chest, abdomen, back, both upper limbs, and both lower limbs, caused by exposure to high temperatures (Figure 1). According to the classification of burn severity based on cause, depth, and surface area, this case falls under the category of severe burns, as it exceeds 10% in children (Figure 2). Table 3. Abbreviated Burn Severity Index. Parameter Finding Points Parameter Finding Points Sex Female 1 TBSA (%) 1-10 1 Male 0 11-20 2 Age 0-20 1 21-30 3 21-40 2 31-40 4 41-60 3 41-50 5 61-80 4 51-60 6 81-100 5 61-70 7 Inhalation Injury Yes 1 71-80 8 No 0 81-90 9 Full-thickness burn Yes 1 91-100 10 No 0 ABSI Threat to life Probability of survival (%) 2-3 Very low >99% 4-5 Moderate 98% 6-7 Moderately severe 80-90% 8-9 Serious 50-70% 10-11 Severe 20-40% ≥12 Maximum ≤10% In this case, it is essential to consider the prognosis to predict the patient’s mortality. One commonly used method is the Abbreviated Burn Severity Index (ABSI), introduced in 1982 and widely utilized to estimate mortality in burn patients (Table 3).¹⁴⁻¹⁶ The ABSI scoring system involves five variables: gender, age, presence of inhalation trauma, presence of full-thickness burns, and the percentage of TBSA affected. For this patient, the ABSI score was calculated to be 9, indicating a severe prognosis with only a 50–70% probability of survival. The score was determined as follows: gender (male = 0), age (0–20 = 1), inhalation trauma (yes = 1), full-thickness burns (no = 0), and TBSA% (61–70 = 7) (Table 3). Based on the ABSI score, the patient was treated in the intensive care unit to provide the required level of care. Medico-legal aspects In this case, the burn injuries are classified under the Indonesian Penal Code (KUHP) Article 90, which pertains to injuries or wounds that cause a fatal danger, and KUHP Articles 353(1) and 353(2), which address premeditated assault resulting in injuries that do not lead to severe harm or death, as well as premeditated assault that causes severe injuries.¹⁷ The examination of burn wounds in a living person constitutes a form of clinical forensic examination conducted by a forensic doctor, general practitioner, or other medical professionals to assist in the enforcement of law and judicial proceedings, in accordance with the Indonesian Criminal Procedure Code (KUHAP) Articles 120(1) and 133(1) and (2).¹⁷ In this case, the victim is a child, and the perpetrator is the victim's stepfather, making this a case of domestic violence (KDRT), in accordance with the Indonesian Law No. 23 of 2004 on the Elimination of Domestic Violence, specifically Articles 1, 2, 44(1), and 44(2).¹⁸ Additionally, as the victim is a child, this case falls under the scope of Law No. 35 of 2014, which amends Law No. 23 of 2002 on Child Protection, particularly Articles 76C and 80(1), (2), and (3).¹⁹ Conclusion The case involves a young male patient with extensive burn injuries covering 68% of his body surface area, compounded by inhalation trauma. 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Acknowledgements The authors acknowledge the use of ChatGPT 4.0, a Generative AI tool developed by OpenAI, during the preparation of this manuscript. Specifically, ChatGPT 4.0 was utilized for translation, grammar checking, and paraphrasing to enhance the clarity and professionalism of the text. This use complies with the Taylor & Francis AI Policy, and the authors confirm that all content generated or revised using ChatGPT 4.0 was reviewed and validated to ensure its accuracy and relevance to the manuscript. Disclosure The authors declare no financial or non-financial conflict of interest. Accompanying Sheet 1. What is already known on this topic? Burn injuries are a global public health problem, especially in low- and middle-income countries, with high morbidity and mortality rates. Pediatric burns resulting from domestic violence are particularly severe and challenging, requiring clinical and forensic evaluation to ensure both medical care and legal justice. 2. What question did this study address? This study examined how clinical forensic assessment can support legal processes in cases of pediatric burns suspected to result from domestic violence, using a real-life case from East Java, Indonesia. It aimed to highlight the role of visum et repertum in identifying life-threatening injuries and guiding judicial outcomes. 3. What does this study add to our knowledge? This case report underscores the importance of comprehensive clinical and forensic documentation in suspected child abuse cases involving burns. It provides detailed insights into the severity classification, prognosis estimation (using ABSI), and legal interpretations under Indonesian law. Furthermore, it demonstrates the practical application of forensic medicine in supporting child protection efforts. 4. Suggestions for further development Future studies should explore a larger series of burn cases resulting from domestic violence to identify patterns, improve forensic protocols, and inform preventive policies. Interdisciplinary collaboration among healthcare, law enforcement, and social services is also essential for more effective interventions and protection of vulnerable populations. *Corresponding author and requests for clarifications and further details: Ibnu Chaldun, Forensic Medicine and Medicolegal Specialist Program, Faculty of Medicine, Universitas Airlangga, Surabaya, Indonesia Email- ibnu.chaldun-2022@fk.unair.ac.id