ArticlePDF AvailableLiterature Review


The identification of hypothermia as the cause of death has always been somewhat problematic in forensic pathology because of unspecific, inconstant, or even negative macroscopic and microscopic findings. Though the simultaneous presence of frost erythema, Wischnewski spots, hemorrhages into the synovial membrane, bloody discoloration of synovial fluid of the knee, and basal vacuolization of the renal tubular epithelial cells has been indicated as strongly supportive of fatal hypothermia, their absence does not allow the diagnosis of hypothermia to be ruled out. Postmortem biochemical investigations are valuable in detecting adaptation responses to cold stress and metabolic changes that occur following cold exposure. However, ethanol intoxication prevents appearance of adaptation responses to cold, rendering the diagnosis less obvious. Immunohistochemistry, postmortem imaging, and molecular pathology have shown promising results, although at present, they do not provide pathognomonic signs of fatal hypothermia. The aim of this article is to present a review of the literature covering the significance of different postmortem investigations that are associated with hypothermia fatalities.
Postmortem diagnosis of hypothermia
Cristian Palmiere &Grzegorz Teresiński &Petr Hejna
Received: 11 November 2013 /Accepted: 4 February 2014
#Springer-Verlag Berlin Heidelberg 2014
Abstract The identification of hypothermia as the cause of
death has always been somewhat problematic in forensic
pathology because of unspecific, inconstant, or even negative
macroscopic and microscopic findings. Though the simulta-
neous presence of frost erythema, Wischnewski spots, hem-
orrhages into the synovial membrane, bloody discoloration of
synovial fluid of the knee, and basal vacuolization of the renal
tubular epithelial cells has been indicated as strongly support-
ive of fatal hypothermia, their absence does not allow the
diagnosis of hypothermia to be ruled out. Postmortem bio-
chemical investigations are valuable in detecting adaptation
responses to cold stress and metabolic changes that occur
following cold exposure. However, ethanol intoxication pre-
vents appearance of adaptation responses to cold, rendering
the diagnosis less obvious. Immunohistochemistry, postmor-
tem imaging, and molecular pathology have shown promising
results, although at present, they do not provide pathogno-
monic signs of fatal hypothermia. The aim of this article is to
present a review of the literature covering the significance of
different postmortem investigations that are associated with
hypothermia fatalities.
Keywords Hypothermia .Forensic pathology .Autopsy .
Histology .Postmortem biochemistry .Postmortem imaging
Hypothermia occurs when the core body temperature is 35 °C
or less, approximately 2 °C below the normal body tempera-
ture. In clinical terms, hypothermia is classified according to
severity as mild, moderate, and severe. Mild hypothermia is
usually defined as 3532 °C, moderate as 3228 °C, and
severe as <28 °C [1].
Hypothermia from environmental exposure to cold (prima-
ry hypothermia) appears when the bodys heat production and
heat retention mechanisms fail to prevent continuous heat
loss. By contrast, secondary hypothermia occurs inthe context
of underlying clinical conditions or concurrent medications
that affect the bodys ability to maintain its internal core
temperature (e.g., hypothalamic diseases or medications that
impair central thermoregulation). Exposure to low tempera-
tures may result in focal (localized hypothermia), systemic
(general hypothermia) injury and, possibly, death.
The risk of death by hypothermia is particularly high
during prolonged exposure to subfreezing environmental tem-
peratures (0 °C), though fatal hypothermia may also be en-
countered at higher environmental temperatures. Not surpris-
ingly, both the very young and the elderly havebeen identified
as being especially susceptible to fatal cold exposure. Com-
pared to adults, infants have an increased body surface area
and decreased body mass index in conjunction with underde-
veloped thermoregulatory mechanisms.
In the aged, the risk of hypothermia may be enhanced by
reduced heat production, increased heat loss and impaired
thermoregulation. These may the consequence of physiologic
decreases in subcutaneous fat and muscle, chronic diseases,
C. Palmiere (*)
University Centre of Legal Medicine, Lausanne University Hospital,
Rue du Bugnon 21, 1011 Lausanne, Switzerland
G. Teresiński
Department of Forensic Medicine, Medical University of Lublin,
Lublin, Poland
P. Hejna
Department of Forensic Medicine, Charles University in Prague,
Faculty of Medicine and University Hospital Hradec Králové,
Sokolská 581, 500 05 Hradec Králové, Czech Republic
Int J Legal Med
DOI 10.1007/s00414-014-0977-1
undernourishment, primary or secondary disorders of the cen-
tral nervous system and inactivity related to senescence.
Although fatal cases of hypothermia usually occur follow-
ing exposure to extreme environmental temperatures, deaths
may also occur indoors. An elderly person, for instance,
suffering from preexisting, debilitating conditions may be-
come hypothermic even at temperatures as high as 2224 °C
Other cases particularly vulnerable to the development of
fatal hypothermia include the homeless, the chronically ill, the
isolated or socially deprived individuals, and those suffering
from psychiatric diseases as well as drug or alcohol
As far as the last is concerned, ethanol is the most com-
monly detected drug in the blood of victims succumbing to
primary hypothermia. This is not surprising for a myriad of
reasons. First, ethanol can accelerate body heat loss through
continuous peripheral vasodilatation, thereby leading to a
false feeling of warmth that may also inhibit heat production
through shivering. Additionally, its intoxicating effects impair
appropriate decision-making in cold environments and disturb
the thermoregulatory set point by acting on the hypothalamus.
Furthermore, ethanol-induced shifts in the hepatocyte redox
potential influence biochemical responses to cold, e.g., keto-
genesis and gluconeogenesis. Many chronic alcoholics are
also malnourished and thus more prone to hypothermia [4].
Some pharmacologic agents can cause central thermoreg-
ulatory failure (e.g., paracetamol, barbiturates, opioids, tricy-
clic antidepressants, and benzodiazepines). Phenothiazines
can both impair central thermoregulation and inhibit periph-
eral vasoconstriction in response to cold through their α-
blocking activity. Other α-blockers, such as prazosin, have
been reported to cause hypothermia, the elderly being partic-
ularly susceptible to this effect. Valproic acid has also been
reported to cause hypothermia in a handful of cases with a
mechanism possibly related to the γ-aminobutyric acid ago-
nistic effect [2,5,6].
In the forensic setting, hypothermia may occur on land (dry
hypothermia) or in water (wet or immersion hypothermia).
Based on pathophysiological changes, hypothermia can also
be classified as acute, subacute, or chronic. Acute hypother-
mia occurs most commonly following immersion in cold
water. In these situations, intense cold stress may overwhelm
heat production so that the body cools before its energy
reserves are exhausted. Indeed, the thermal conductivity of
water is 20 times that of air. In addition, water aspiration may
be responsible for or contributeto a fatal outcome, the cause of
death then being drowning rather than hypothermia. Immer-
sion in cold water may also precipitate vagal reflexes, possibly
leading to sudden cardiac arrest. In subacute hypothermia, the
cold is less severe and cooling only occurs when energy
reserves are exhausted. In chronic hypothermia, victims are
exposed to moderate cold for days. Such situations can be
typically encountered by the elderly living in poor housing or
by those with malnutrition and debilitating diseases, as previ-
ously described [7,8].
Macroscopic findings
The identification of hypothermia as the cause of death has
always been somewhat problematic in forensic pathology due
to unspecific, inconsistent, or even negative autopsy findings.
The macroscopic changes with the highest diagnostic validity
were described by Keferstein (frost erythema), Wischnewski
(hemorrhagic spots of the gastric mucosa), and Krjukoff at the
end of the nineteenth century and beginning of the twentieth
century. Although extensive research carried out over the
years has aimed to define more reliable criteria, significant
advances in diagnosing hypothermia as the cause of death
have been relatively limited [7,9].
In 1976, Hirvonen [10] concluded that in fatalities due to
hypothermia the necropsy findings event at their best can be
scarce. There are cases where no morphological signs are
noticed and the diagnosis must be based solely on circum-
stantial evidence. Textbooks of forensic sciences and other
sources report cadaveric signs such as red livores, purple
patches on extremities, red blood, Wischnewski erosions in
the stomach, pancreatic haemorrhage, lipid depletion from the
adrenal cortex and even vacuolization of the liver cells and
other similar minute signs of hypoxia.
Similar conclusions were reported by Coe [11]in1984,
who emphasized that death by hypothermia is very difficult
to verify, because there are no diagnostic autopsy findings.
Gross lesions that have been observed include swollen,
discolored extremities, ears, and nose; hemorrhage or petechi-
al ulcers of the gastric mucosa; and hemorrhagic pancreatitis.
Microscopic foci of myocardial degeneration have been de-
scribed. The skin changes are suggestive but not diagnostic of
frostbite, and all the internal findings, both gross and micro-
scopic, are manifestation of stress that may be found in other
conditions than hypothermia. As a consequence, the diagnosis
of death by hypothermia is made by a combination of obser-
vations, including an appropriate history of exposure, certain
nonspecific pathological finds when present, and the absence
of other lethal factors.
There are no pathognomonic signs of fatal hypothermia at
autopsy. Furthermore, morphological changes are generally
unspecific and do not allow unambiguous diagnoses of death
from hypothermia to be reached. However, there is a general
consensus in the literature regarding hemorrhagic spots of the
gastric mucosa (Wischnewski spots) in conjunction with red-
dish brown skin discoloration over the extensor surfaces of the
large joints (frost/cold erythema) as classical signsor as
highly indicativeor supportiveof fatal hypothermia.
Int J Legal Med
Hemorrhages of the synovial membrane, bloody discolor-
ation of the synovial fluid, bright red or pink lividity, pancre-
atic hemorrhages, hemorrhages into the large muscles of the
body, especially the iliopsoas muscle, as well as hemorrhagic
spots in the duodenum and jejunum have also been reported in
association with fatal hypothermia, albeit less frequently. All
these findings must, nevertheless, be correlated with the cir-
cumstances from the death scene [7,9,1214].
Hemorrhagic spots of the gastric mucosa (Wischnewski
spots) are disseminated, dark lesions of the gastric mucosa
that may be associated with fatal hypothermia. Similar find-
ings may also be found, though less commonly, in the lower
gastrointestinal tract and, rarely, in the esophagus or regions
with ectopic gastric mucosa. Wischnewski spots may vary in
size and quantity from 1 mm up to about 2 cm in diameter and
from only a few up to more than 100 in number. Their
incidence in fatal hypothermia has been reported in literature
to vary between 40 and 100 %. Such a wide variation in the
occurrence of Wischnewski spots may likely be due to the
lack of diagnostic homogeneity in the algorithms used for
postmortem confirmation of hypothermia death [7,9,14,15].
Tsokos et al. [14] postulated that Wischnewski spots do not
represent true erosions or ulcerations in terms of histopatho-
logic diagnosis, even though they are frequently termed gas-
tric erosionsor ulcerationsor erosive gastritis.These
authors observed that neither the lesions nor the adjacent
gastric mucosa is characterized by inflammatory infiltrates
or fibrin exudates. In order to explain their pathogenesis,
Tsokos et al. formulated the hypothesis that the bodys cooling
in cold environmental conditions may primarily lead to dis-
crete, circumscribed hemorrhages of the gastric glands in vivo
or during the agonal period. Owing to subsequent erythrocyte
autolysis, the released hemoglobin would be hematinized by
gastric acid, thereby leading to the typical blackish-brownish
appearance of Wischnewski spots at postmortem examination.
Despite the convincing arguments proposed by some authors,
both the morphology and pathogenesis of Wischnewski spots
remain contentious. Their sensitivity and specificity as
markers of hypothermia have therefore not been clearly deter-
mined. Moreover, while the absence of Wischnewski spots
does not exclude the diagnosis of hypothermia, their presence
does not necessarily indicate it. Indeed, a range of factors,
beyond the simple lowering of body temperature, may influ-
ence Wischnewski spots formation.
Frost erythema forms reddish purple to violet or brownish
areas of skin discoloration that are most commonly located
over the extensor surfaces of the large joints, typically the
knees, elbows, and great trochanter region. Frost erythema can
also be observed on projecting areas of the face (ears, nose,
and zygomatic areas), over the shoulders, and, in rare cases,
on the male external genitalia. Discolorations of exposed skin
areas have been reported to occur in up to 72 % of cases of
fatal dry hypothermia. However, they have not been observed
following wet-cold exposure and must not be mistaken for
hematomas. Microscopically, frost erythema is not character-
ized by erythrocyte extravasation and infiltration, although
hemoglobin can be immunohistochemically visualized within
the lesion, possibly originating from damaged erythrocytes
due to cold hemolysis. Frost erythema is explained by cold
hemolysis in superficial vessels running under the skin just
above protruding bony surfaces (knee cap, olecranon, zygo-
matic bones, i.e., areas with rather thin subcutaneous fat tissue
coverings) as superficially located bones are cooled more
rapidly in the conduction mechanism. Frost erythema should
not be mistaken for hemolytic pseudo-marbling staining of the
skin that can sometimes appear alongside subcutaneous ves-
sels after thawing of a frozen body. Skin incision and histo-
logic sampling of suspected frost erythema areas are therefore
highly recommended [7,9,16].
Classic frostbites developing concomitantly with fatal hy-
pothermia usually reveal edema and hyperemia without skin
blistering or inflammation, the telltale signs of vital reaction in
thawed survivors [17].
Hemorrhages of the synovial membrane and bloody dis-
coloration of synovial fluid (inner knee sign)haverecently
been proven to be reliable, vital signs for the diagnosis of
death caused by hypothermia, with a diagnostic value compa-
rable to that of frost erythema. Even though the pathogenesis
of these findings is not entirely understood at present, their
appearance might be related to the particularity of the synovial
membranes vascular supply as well as to the phenomena of
erythrocyte congestion and extravasation into the synovial
space within the synovial membrane following cold exposure.
Similar to other morphologic signs suggesting hypothermia,
the absence of these findings does not, however, exclude the
diagnosis, and their appearance may be influenced by other
factors. This is especially true regarding the presence of si-
multaneous antemortem trauma to the knees preceding death
as well as other possible postmortem influences [12].
Bright red or pink lividity is of no diagnostic value since it
may be found not only in hypothermia fatalities but also in
many other situations characterized by exposure of the corpse
to low environmental temperatures. Moreover, the phenome-
non can be artificially reproduced by keeping the corpse in a
cold environment [7,9,12,16].
A large variety of pancreatic changes has been mentioned
in the literature over the years, including local and diffuse
hemorrhages and hemorrhagic pancreatitis [10,13]. Accord-
ingtoPreussetal.[13], who examined 143 cases of fatal
hypothermia, bleeding on a macroscopic or microscopic level
and signs of pancreatic inflammation can be ruled out as
diagnostic criteria for death due to hypothermia. Most of the
pancreatic changes traditionally associated with death by hy-
pothermia might more likely be the expression of preexisting
pancreatic diseases or the result of autolysis occurring with the
onset of decompositional changes.
Int J Legal Med
Hemorrhages into the skeletal, paravertebral muscles, e.g.,
the iliopsoas muscles, have been reported to be associated
with death by hypothermia, though not systematically. Skele-
tal muscle hemorrhages in hypothermia death were firstly
mentioned in the classic German textbook of forensic medi-
cine by von Hofmann and Haberda as early as 1927. Aside
from the hypothesis concerning the increased capillary per-
meability resulting from hypoxic damage during hypother-
mia, the mechanisms responsible for their formation were not
explored in more detail and their appearance remained a minor
matter of debate in the literature [7,9]. Ogata et al. [18]
reported a case of fatal hypothermia characterized by hemor-
rhages in the pectoralis minor, first intercostal, and iliopsoas
muscles in the absence of skin injury or damage to the sub-
cutaneous fat tissues, muscles, internal organs, or bones else-
where. These investigators ruled out the possibility that these
hemorrhages were the consequence of antemortem mechani-
cal injuries or positional bleeding that occurred after death.
They postulated that extremely intense shivering following
cold exposure might be responsible for muscular hemor-
rhages. Furthermore, the intense effort of ventilation that
occurs with shivering could contribute to bleeding into the
pectoralis minor and intercostal muscles. Similarly, Simons
bleedings (stripe-like hemorrhages on the ventral surface of
the intervertebral disks most commonly seen in the lumbar
part of the spinal column) have also been occasionally ob-
served in autopsy cases of fatal hypothermia, a possible con-
sequence of intensive shivering [19].
Macroscopic findings that have been episodically or ex-
ceptionally described in association with fatal hypothermia
include acute hemorrhagic necrosis of the esophagus (black
esophagus,possibly due to vasoconstriction in the splanchnic
region), ulceration in the colon and ileum, as well as hemor-
rhagic infarctions of the colon. The latter was reported follow-
ing hemodynamic and rheologic alterations characterizing
hypothermia, with subsequent thromboses in the submucosal
veins [9,20]. Hypothermia-related circulation disorders were
found to be responsible for portal vein thrombosis in a report
by Wolf et al. [21].
Paradoxical undressing and hide-and-die syndrome
Two peculiar aspects to some hypothermia cases are worth
mentioning: paradoxical undressing and the hide-and-die
syndrome.Paradoxical undressing is a phenomenon charac-
terized by the fact that victims, despite low environmental
temperatures, paradoxically remove their clothes due to a
sudden feeling of warmth. Clothes are often found close to
the corpse. Paradoxical undressing may occur when body
temperature drops to 29 °C and has been reported to occur
both in children and adults. This irrational behavior has been
explained by terminal changes in peripheral vascular
resistance occurring in profoundly hypothermic individuals,
possibly associated with diminished mental capacity due to
advancing central cooling. Paradoxical undressing might rep-
resent a final effort on behalf of the victim, immediately
followed by loss of consciousness and death.
The so-called hide-and-die syndrome or terminal
burrowing behavior may also be observed in some cases of
fatal hypothermia. The corpse is generally found in a hidden
position, located under or behind furniture or other objects,
reproducing a primitive, burrowing-like behavior of protec-
tion, as seen in hibernating animals. This phenomenon has
mostly been observed in elderly persons but may occur in
younger victims as well. Some authors have described corpses
found under piles of books pulled from bookcases, hidden
under a mound of clothes and newspapers, or burrowed under
vegetation. It has been suggested that the hide-and-die syn-
drome may be either the result of mental confusion or a
terminal, primitive reaction pattern, i.e., an autonomous be-
havior triggered by the brain stem in the final state of hypo-
thermia. Care must be taken to evaluate the above scenario,
especially in the concomitant presence of undressing found at
the scene, as these signs might otherwise suggest crime and
sexual assault [3,7,15,22].
Microscopic findings
Several histologic findings associated with hypothermia fatal-
ities have been described in medicolegal literature including
depletion of hepatic glycogen, fatty degeneration of the renal
tubular epithelium (subnuclear vacuolization of renal tubular
epithelial cells or Armanni-Ebstein phenomenon), pancreatic
changes (focal necrosis of pancreatic and peripancreatic adi-
pose tissue, hemorrhagic and nonhemorrhagic pancreatitis,
adenocyte vacuolation), vacuolization of anterior pituitary
gland cells, hepatocytes, adrenal cells and renal cells, hypoxic
cardiac changes as well as fatty changes of cardiac myocytes
and hepatocytes. A strong correlation among frost erythema,
Wischnewski spots, and basal vacuolization of renal tubular
epithelial cells has been observed by some authors who pos-
tulated that the Armanni-Ebstein phenomenon might be con-
sidered the most indicativehistological finding of hypother-
mia fatalities [7,9,13,2328].
Several groups of researchers have performed immunohis-
tochemical investigations focusing on adrenocorticotropic
hormone (ACTH), thyroid-stimulating hormone, noradrena-
line, dopamine, chromogranin A, ubiquitin, myoglobin, heat
shock protein 70, microtubule-associated protein 2, basic fi-
broblast growth factor, glial fibrillary acidic protein, S100β,
single-stranded DNA, pulmonary surfactant-associated pro-
teins A and D, atrial and brain natriuretic peptides, matrix
metalloproteinase-2, matrix metalloproteinase-9, intercellular
adhesion molecule-1, claudin-5, clusterin, and aquaporin
Int J Legal Med
immunoreactivities in various organs and tissues. These in-
clude the lungs, myocardium, anterior pituitary gland, adrenal
medulla, hypothalamus, midbrain periaqueductal gray matter,
renal tubular epithelium, distal and collecting renal tubules,
glomerular podocytes, brain parietal lobe, hippocampus, and
cerebral cortex, with extremely promising results in some
cases. However, immunohistochemistry has still not provided
significantly reliable diagnostic criteria for the postmortem
diagnosis of hypothermia [24,2833].
Postmortem biochemistry
In recent years, there has been a significant revival, expansion,
and development in postmortem biochemical investigations
regarding hypothermia fatalities. The first reports concerning
biochemistry in hypothermia in the forensic setting were
published by Mant and focused on vitreous magnesium
values. Since then, numerous molecules have been measured,
and postmortem samples other than blood have been collected
and analyzed in order to better understand the metabolic and
biochemical changes occurring during hypothermia and find
the most helpful combination of biomarkers to allow a reliable
diagnosis of fatal hypothermia to be made. In addition, these
investigations aimed to identify alternative biological fluids
should blood prove insufficient or unavailable at autopsy [24].
Exposure to cold is characterized by significant stress
reactions that enhance catecholamine and counter-regulatory
hormone release. Enhanced fat catabolism and increased
acetoacetate/β-hydroxybutyrate production are the metabolic
consequences of hypothermia-induced secretion of insulin
antagonist hormones [3438].
Recent observations have revealed that ketone production
during controlled, intraoperative cardiac hypothermia re-
quired a much lower core temperature than the 3435 °C used
in coronary artery bypass/valve replacement surgery since
increased blood ketone levels were observed exclusively in
those cooled to 16 °C during aortic aneurysm surgery [36].
There is a general consensus in the literature that increased
levels of blood β-hydroxybutyrate, acetone, isopropyl alco-
hol, and glucocorticosteroids as well as increased urine adren-
aline and cortisol concentrations should be considered poten-
tial biochemical hallmarks of fatal hypothermia [24,3437].
Indeed, β-hydroxybutyrate and acetone should be system-
atically determined in the blood of all suspected hypothermia
cases as should levels of isopropyl alcohol. The latter may
appear higher in blood in hypothermia fatalities due to in-
creased acetone concentrations and subsequent enhanced ace-
tone metabolism (if not of congeneric origin as a fermentation
impurity of consumed ethanol). Blood β-hydroxybutyrate,
acetone, and isopropyl alcohol show an inverse relationship
with blood ethanol levels, though recent data has revealed that
the antiketonemic effect of ethanol intake in hypothermia
victims mainly influences acetone levels. Alternative biologi-
cal samples including vitreous, urine, pericardial, and cerebro-
spinal fluids may be collected and analyzed for the determina-
tion of β-hydroxybutyrate, acetone, and isopropyl alcohol
should blood be unavailable at autopsy [4,24,34,35,3841].
It has been demonstrated that decompositional changes are
not associated with β-hydroxybutyrate production. Further-
more, blood β-hydroxybutyrate levels in decomposed bodies
can be considered an appropriate biochemical parameter in the
estimation of β-hydroxybutyrate concentrations at the time of
death. Indeed, β-hydroxybutyrate concentration does not in-
crease after death and may, at most, decrease as a result of
spontaneous molecule degradation [4143].
Recent studies have indicated that β-hydroxybutyrate can
be reliably measured in liver homogenates and may prove
useful in confirming the presence of metabolic disturbances
at the time of death. Liver homogenates can therefore be
considered an alternative biological sample for β-
hydroxybutyrate determination; limited amounts of biological
fluids must be reserved for toxicology and biochemical anal-
yses [43].
Normal levels of blood β-hydroxybutyrate, acetone, and
isopropyl alcohol in suspected hypothermia fatalities do not
allow this diagnosis to be excluded, particularly in cases with
increased blood levels of ethanol. Furthermore, the severity of
the metabolic disturbances present at the time of death cannot
be evaluated based on levels of vitreous, urine, pericardial, or
cerebrospinal fluid alone. Indeed, the blood-vitreous, blood-
pericardial fluid, and blood-cerebrospinal fluid equilibrium is
established following different time courses. Rapid increases
in blood β-hydroxybutyrate and acetone levels cannot be
reflected in simultaneous increases in the concentrations of
vitreous, pericardial, and cerebrospinal fluid β-
hydroxybutyrate and acetone. An even more careful interpre-
tation is required when evaluating concentrations of urine β-
hydroxybutyrate and acetone, since urine production in the
kidneys follows different mechanisms from those of vitreous,
pericardial, and cerebrospinal fluid production [4,39,40,42].
Urine catecholamine, blood free fatty acids, blood cortico-
steroids (especially cortisol), and urine free cortisol may be
increased in hypothermia fatalities, irrespective of blood eth-
anol concentrations. Though their determination may provide
further information to confirm the diagnosis of death by
hypothermia, preservation measures during sample collection
and time after death may significantly influence catechol-
amine stability in urine. Thus, normal levels of urine adrena-
line in suspected hypothermia fatalities do not allow this
diagnosis to be excluded. Similarly, increases in blood free
fatty acids and corticosteroid levels cannot be regarded as the
sole criterion for the diagnosis of fatal hypothermia, and
likewise, normal blood levels of these molecules do not allow
this diagnosis to be ruled out. Increased and decreased corti-
costeroid levels in both blood and urine can also be the
Int J Legal Med
expression of preexisting diseases, leading to the conclusion
that glucocorticosteroids, like other biochemical parame-
ters, may be treated as potential markers of fatal hypo-
thermia in the context of all postmortem investigation
results [24,34,35,37,44].
Postmortem imaging and molecular pathology
Postmortem imaging and molecular pathology are relatively
more recent fields of research in the forensic setting and have
shown encouraging results pertaining to the diagnosis of
hypothermia [4551]. Aghayev et al. [45] observed that post-
mortem magnetic resonance imaging (MRI) allowed iliopsoas
and back muscle hemorrhages to be easily identified, whereas
Wischnewski spots remained undetected. Michiue et al. [46]
investigated postmortem lung air distribution in forensic au-
topsy cases using computed tomography (CT) and observed
that hypothermia was characterized by diffuse hyperaeration
with decreased vascularity, indicative of diffuse pulmonary
emphysema and increased airway dead space. The authors
postulated that these results could be the consequence of
respiratory center impairment occurring in the process of
death. This same radiologic pattern was nonetheless observed
in obstructive pulmonary disease and starvation, suggesting
that alternative pathophysiologic mechanisms may explain
radiological increased airway dead space and limited hypo-
static opacification (such as reduced pulmonary blood flow
caused by alveolar overinflation in obstructive pulmonary
disease and terminal hyperventilation due to acidosis in star-
vation). Kawasumi et al. [47] observed that many hypother-
mic deaths presented urine retention in the bladder (probably
reflecting the effect of cold diuresis) on postmortem CT.
Additional observations included blood clotting in the heart,
pulmonary artery, or thoracic aorta (possibly indicating
prolonged death process) and the lack of an increase in lung-
field concentration (suggesting underlying dried lungs). Last-
ly, Hyodoh et al. [48] investigated postmortem lung air distri-
bution in forensic autopsy cases using CT and found that
hypothermia cases had higher aerated lung volumes and
higher percentages of aerated lung volume compared to con-
trol cases. Based on these findings, the authors postulated that
hypothermia fatalities were characterized by preserved pul-
monary aeration and less important pulmonary hypostasis.
Investigations in molecular pathology performed in study
populations including hypothermia fatalities revealed high
messenger RNA (mRNA) expression levels of pulmonary
surfactant-associated proteins A and D (SP-A1b, SP-A2b,
and SP-D), increased mRNA expression levels of
intrapulmonary matrix metalloproteinase-9 (suggesting partial
damage of extracellular matrix), and high mRNA expression
levels of atrial and brain natriuretic peptides in both left and
right atrial and ventricular walls, possibly indicating persistent
congestion and heart failure without substantial myocardial
damage during cold exposure [4951].
Despite promising advances in several fields of forensic re-
search in recent years, the postmortem diagnosis of fatal
hypothermia remains problematic. While the absence of sup-
portive macroscopic, microscopic, and biochemical findings
does not allow the diagnosis to be ruled out, their presence
does not necessarily indicate it. Indeed, macroscopic and
microscopic findings as well as biochemical results may vary
considerably from case to case and may be influenced by
numerous factors and circumstances, thus making them only
a possible indication of hypothermia.
Diagnosis is particularly difficult in cases of acute hypo-
thermia where physiological reactions against cold (e.g., hor-
monal release and biochemical response) could not be fully
activated and death occurs before energy reserves (i.e., glyco-
gen content) are utilized. In forensic practice, the most com-
mon factor accelerating cooling and shortening exposure time
to cold (thus preventing macroscopic and microscopic hypo-
thermia sign appearance) is alcohol intoxication.
The results of biochemical investigations are useful in
detecting adaptation responses to cold stress as well as meta-
bolic changes occurring after exposure to cold. Some param-
eters (blood ketones, cortisol, and free fatty acids as well as
urine catecholamine and cortisol) can be considered reliable
markers of fatal hypothermia. Nevertheless, abnormalities in
biochemical results must be interpreted carefully, as they do
not allow the diagnosis to be either categorically excluded or
formally confirmed. Blood ethanol levels, postmortem inter-
val, preservation measures during sampling as well as
preexisting metabolic dysfunctions and endocrine disorders
may all contribute to the increasing or decreasing of certain
molecule concentrations. Simultaneous analyses focusing on
a combination of biomarkers are therefore strongly recom-
mended in order to reach appropriate conclusions.
Hypothermia may be responsible for the death of healthy
people (either sober or under the influence of alcohol or other
drugs) who can accidentally be exposed to cold temperatures
in winter and are unable to obtain help. This scenario implies
that hypothermia is the sole and exclusive cause of death and
represents only a portion of the cases that may be encountered
in forensic pathology routine. In these situations, the diagnosis
remains essentially a medley of macroscopic, microscopic,
and biochemical observations and can only be established
per exclusionem by ruling out all other possible causes of
death. Postmortem imaging, autopsy, histology, toxicology,
and biochemistry are therefore mandatory.
However, most cases of forensic interest are much more
nuanced. These cases pertain to subjects suffering from
Int J Legal Med
preexisting diseases (coronary atherosclerosis, respiratory dis-
ease, intracranial hemorrhage, chronic alcohol misuse, meta-
bolic disturbances) or trauma (accidental or inflicted), or both,
which can potentially be responsible for loss of consciousness,
coma, and death on their own. When these subjects are found
dead in environmental conditions possibly suggesting expo-
sure to cold and postmortem investigations reveal also, though
not exclusively, some of those findings supporting the diag-
nosis of hypothermia, the question of whether hypothermia is
the main or only a contributing cause of death must be
legitimately raised. Moreover, metabolic syndromes such as
diabetic and alcoholic acidosis have typically negative autop-
sies and share specific biochemical features with hypothermia
fatalities (i.e., increased blood ketones), rendering the identi-
fication of the cause(s) of death extremely challenging.
In these situations, the most appropriate medicolegal ap-
proach should allow preexisting diseases and trauma to be
characterized as best as possible, in order to distinguish the
ultimate cause of death from other contributing or secondary
disorders. To do this, thorough, exhaustive, and complete
medicolegal investigations including imaging, histology, im-
munohistochemistry, biochemistry, and toxicology are inevi-
tably compulsory. Meticulous investigations at the death scene
as well as the evidence of exposure to low environmental
temperatures are of utmost importance for the accurate eval-
uation of all potentially hypothermia-related mortalities. All
possible environmental risk factors for hypothermia should
therefore be minutely sought out and documented.
Lastly, a multidomain approach focusing on a more inte-
grated panel of postmortem investigations should be promot-
ed among forensic pathologists. Such a multidisciplinary ap-
proach would allow more accurate diagnoses of hypothermia
to be reached. In addition, some of the hypotheses formulated
in (at present) isolated studies by distinct groups of authors
might be validated, confirmed, or invalidated, thus contribut-
ing to a better understanding of the pathophysiological re-
sponses that take place during hypothermia-related deaths.
Acknowledgments The authors are grateful to the anonymous re-
viewers whose constructive and useful comments improved the quality
of the article.
1. Soar J, Perkins GD, Abbas G, Alfonzo A, Barelli A, Bierens JJ,
Brugger H, Deakin CD, Dunning J, Georgiou M, Handley AJ,
Lockey DJ, Paal P, Sandroni C, Thies KC, Zideman DA, Nolan JP
(2010) European Resuscitation Council Guidelines for Resuscitation
2010 Section 8. Cardiac arrest in special circumstances: electrolyte
abnormalities, poisoning, drowning, accidental hypothermia, hyper-
thermia, asthma, anaphylaxis, cardiac surgery, trauma, pregnancy,
electrocution. Resuscitation 81:14001433
2. Nixdorf-Miller A, Hunsaker DM, Hunsaker JC 3rd (2006)
Hypothermia and hyperthermia medicolegal investigation of
morbidity and mortality from exposure to environmental temperature
extremes. Arch Pathol Lab Med 130:12971304
3. Lim C, Duflou J (2008) Hypothermia fatalities in a temperate climate:
Sydney, Australia. Pathology 40:4651
4. Teresiński G, Buszewicz G, Mądro R (2005) Biochemical back-
ground of ethanol-induced cold susceptibility. Leg Med (Tokyo) 7:
5. Zachariah SB, Zachariah A, Ananda R, Stewart JT (2000)
Hypothermia and thermoregulatory derangement induced by
valproic acid. Neurology 55:150151
6. Kreuzer P, Landgrebe M, Wittmann M, Schecklmann M, Poeppl TB,
Hajak G, Langgut B (2012) Hypothermia associated with antipsy-
chotic drug use: a clinical case series and review of current literature.
J Clin Pharmacol 52:10901097
7. Türk EE (2010) Hypothermia. Forensic Sci Med Pathol 6:106115
8. Dolinak D, Matshes E, Lew E (2005) Hypothermia. In: Forensic
pathology. Principles and practice. Elsevier, Academic, 1st ed. San
Diego pp 248249
9. Madea B, Tsokos M, Preuss J (2008) Death due to hypothermia.
Morphological findings, their pathogenesis and diagnostic value. In:
Tsokos M (ed.), Forensic pathology reviews, vol. 5, pp 321
10. Hirvonen J (1976) Necropsy findings in fatal hypothermia cases.
Forensic Sci 8:155164
11. Coe JI (1984) Hypothermia: autopsy findings and vitreous glucose. J
Forensic Sci 29:389395
12. Hejna P, Zátopková L, Tsokos M (2012) The diagnostic value of
synovial membrane hemorrhage and bloody discoloration of synovial
fluid (inner knee sign) in autopsy cases of fatal hypothermia. Int J
Legal Med 126:415419
13. Preuss J, Lignitz E, Dettmeyer R, Madea B (2007) Pancreatic chang-
es in cases of death due to hypothermia. Forensic Sci Int 166:194
14. Tsokos M, Rothschild MA, Madea B, Risse M, Sperhake JP (2006)
Histological and immunohistochemical study of Wischnewsky spots
in fatal hypothermia. Am J Forensic Med Pathol 27:7074
15. Mizukami H, Shimizu K, Shiono H, Uezono T, Sasaki M (1999)
Forensic diagnosis of death from cold. Leg Med 1:204209
16. Türk EE, Sperhake JP, Madea B, Preuss J, Tsokos M (2006)
Immunohistochemical detection of hemoglobin in frost erythema.
Forensic Sci Int 158:131134
17. Hirvonen J (2000) Some aspects on death in the cold and concomitant
frostbites. Int J Circumpolar Heath 59:131136
18. Ogata M, Ago K, Kondo T, Kasai K, Ishikawa T, Mikuzami H (2007)
A fatal case of hypothermia associated with hemorrhages of the
pectoralis minor, intercostals, and iliopsoas muscles. Am J Forensic
Med Pathol 28:348352
19. NikolićS, ZivkovićV, JukovićF, BabićD, Stanojkovski G (2009)
Simon's bleedings: a possible mechanism of appearance and forensic
importancea prospective autopsy study. Int J Legal Med 123:293
20. ZivkovićV, NikolićS (2013) The unusual appearance of black
esophagus in a case of fatal hypothermia: a possible underlying
mechanism. Forensic Sci Med Pathol. doi:10.1007/s12024-013-
21. Wolf DA, Aronson JF, Rajaraman S, Veasey SP 3rd (1999)
Wischnewski ulcers and acute pancreatitis in two hospitalized pa-
tients with cirrhosis, portal vein thrombosis, and hypothermia. J
Forensic Sci 44:10821085
22. Rothschild MA, Schneider V (1995) Terminal burrowing behav-
iour”—a phenomenon of lethal hypothermia. Int J Legal Med 107:
23. Preuss J, Dettmeyer R, Lignitz E, Madea B (2004) Fatty degeneration
in renal tubule epithelium in accidental hypothermia victims.
Forensic Sci Int 141:131135
24. Palmiere C, Mangin P (2013) Postmortem biochemical investigations
in hypothermia fatalities. Int J Legal Med 127:267276
Int J Legal Med
25. Preuss J, Dettmeyer R, Lignitz E, Madea B (2006) Fatty degeneration
of myocardial cells as a sign of death due to hypothermia versus
degenerative deposition of lipofuscin. Forensic Sci Int 159:15
26. Ishikawa T, Miyaishi S, Tachibana T, Ishizu H, Zhu BL, Maeda H
(2004) Fatal hypothermia related vacuolation of hormone-producing
cells in the anterior pituitary. Leg Med (Tokyo) 6:157163
27. Doberentz E, Preuss-Wössner J, Kuchelmeister K, Madea B (2011)
Histological examination of the pituitary glands in cases of fatal
hypothermia. Forensic Sci Int 207:4649
28. IshikawaT,QuanL,LiDR,ZhaoD,MichiueT,HamelM,MaedaH
(2008) Postmortem biochemistry and immunohistochemistry of ad-
renocorticotropic hormone with special regard to fatal hypothermia.
Forensic Sci Int 179:147151
29. Preuss J, Dettmeyer R, Poster S, Lignitz E, Madea B (2008) The
expression of heat shock protein 70 in kidneys in cases of death due
to hypothermia. Forensic Sci Int 176:248252
30. Wang Q, Ishikawa T, Michiue T, Zhu BL, Guan DW, Maeda H
(2012) Evaluation of human brain damage in fatalities due to extreme
environmental temperature by quantification of basic fibroblast
growth factor (bFGF), glial fibrillary acidic protein (GFAP), S100β
and single-stranded DNA (ssDNA) immunoreactivities. Forensic Sci
Int 219:259264
31. Kitamura O, Gotohda T, Ishigami A, Tokunaga I, Kubo S, Nakasono
I (2005) Effect of hypothermia on postmortem alterations in MAP2
immunostaining in the human hippocampus. Leg Med (Tokyo) 7:
32. Wang Q, Ishikawa T, Quan L, Zhao D, Li DR, Michiue T, Chen JH,
Zhu BL, Maeda H (2009) Immunohistochemical distribution of basic
fibroblast growth factor (bFGF) in medicolegal autopsy. Leg Med
(Tokyo) 11(Suppl 1):S161S164
33. Ishikawa T, Zhu BL, Li DR, Zhao D, Michiue T, Maeda H (2006)
Age-dependent increase of clusterin in the human pituitary gland.
Leg Med (Tokyo) 8:2833
34. Bańka K, TeresińskiG,Buszewicz,Mądro R (2013)
Glucocorticosteroids as markers of death from hypothermia.
Forensic Sci Int 229:6065
35. Palmiere C, Bardy D, Letovanec I, Mangin P, Iglesias K, Augsburger
M, Ventura F, Werner D (2013) Biochemical markers of fatal hypo-
thermia. Forensic Sci Int 226:5461
36. Teresiński G, Buszewicz G, Dąbrowski W, Mądro R (2007) Ketone
bodies in controlled intraoperative hypothermiapreliminary study.
Arch Med Sadowej Kryminol 57:389393
37. Pakanen L, Kortelainen ML, Särkioja T, Porvari K (2011) Increased
adrenaline to noradrenaline ratio is a superior indicator of antemortem
hypothermia compared with separate catecholamine concentrations. J
Forensic Sci 56:12131218
38. Teresiński G, Buszewicz G, Mądro R (2002) The influence of ethanol
on the level of ketone bodies in hypothermia. Forensic Sci Int 127:
39. Teresiński G, Buszewicz G, Mądro R (2009) Acetonaemia as an
initial criterion of evaluation of a probable cause of sudden death.
Leg Med (Tokyo) 11:1824
40. Palmiere C, Sporkert F, Werner D, Bardy D, Augsburger M, Mangin
P (2012) Blood, urine and vitreous isopropyl alcohol as biochemical
markers in forensic investigations. Leg Med (Tokyo) 14:1720
41. Buszewicz G, Teresiński G, Bańka K, Mądro R (2007) Diagnostic
usefulness of the β-hydroxybutyrate/acetone ratio in medico-legal
diagnostics of sudden death. Arch Med Sadowej Kryminol 57:289
42. Palmiere C, Mangin P, Werner D (2014) Postmortem distribution of
3-beta-hydroxybutyrate. J Forensic Sci 59:161166
43. Palmiere C, Mangin P, Werner D (2013) Preliminary results on the
postmortem measurement of 3-beta-hydroxybutyrate in liver homog-
enates. Int J Legal Med 127:943949
44. Bańka K, Teresiński G, Buszewicz G (2014) Free fatty acids as
markers of death from hypothermia. Forensic Sci Int 234:7985
45. Aghayev E, Thali MJ, Jackowski C, Sonnenschein M, Dirnhofer R,
Yen K (2008) MRI detects hemorrhages in the muscles ofthe backin
hypothermia. Forensic Sci Int 176:183186
46. Michiue T, Sakurai T, Ishikawa T, Oritani S, Maeda H (2012)
Quantitative analysis of pulmonary pathophysiology using postmor-
Forensic Sci Int 220:232238
47. Kawasumi Y, Onozuka N, Kakizaki A, Usui A, Hosokai Y, Sato M,
Saito H, Ishibashi T, Hayashizaki Y, Funayama M (2013)
Hypothermic death: possibility of diagnosis by post-mortem comput-
ed tomography. Eur J Radiol 82:361365
48. Hyodoh H, Watanabe S, Katada R, Hyodoh K, Matsumoto H (2013)
Postmortem computed tomography lung findings in fatal of hypo-
thermia. Forensic Sci Int 231:190194
49. Miyazato T, Ishikawa T, Michiue T, Maeda H (2012) Molecular
pathology of pulmonary surfactants and cytokines in drowning com-
pared with other asphyxiation and fatal hypothermia. Int J Legal Med
50. Chen JH, Michiue T, Ishikawa T, Maeda H (2012) Molecular pathol-
ogy of natriuretic peptides in the myocardium with special regard to
fatal intoxication, hypothermia, and hyperthermia. Int J Legal Med
51. Wang Q, Ishikawa T, Michiue T, Zhu BL, Guan DW, Maeda H
(2013) Molecular pathology of pulmonary edema in forensic autopsy
cases with special regard to fatal hyperthermia and hypothermia.
Forensic Sci Int 228:137141
Int J Legal Med
... Frost erythema (reddish-brown discolouration of the skin over the elbows and knees) and Wischnewsky spots (acute gastric erosions) have been identified as classic signs of hypothermia [10], especially when both occur concomitantly. However, these classic morphological changes are insufficient for establishing an unequivocal diagnosis of death from hypothermia [11,12]. Furthermore, such changes are rarely detected in hypothermia-induced fatalities that occur while under the influence of ethanol because ethanol accelerates lowering the body temperature and hastens death [1]. ...
... Based on the core body temperature, the severity of hypothermia is categorized as either mild, moderate or severe. The core body temperature ranges from 32°C to 35°C under mild hypothermia and decreases to <28°C under severe hypothermia [12]. ...
... Exposure to cold is a stressor that accelerates metabolic rates and helps generate reactive oxygen species (ROS). When ROS production exceeds the cellular antioxidative defence mechanisms, oxidative stress occurs [12,14]. ...
Full-text available
ABSTRACT Reaching a postmortem diagnosis of hypothermia is challenging in forensic practice. Therefore, this study was conducted to detect the histopathological, histochemical and biochemical changes that occur in adult albino rats following exposure to induced fatal hypothermia. Twenty-four adult albino rats were divided into the negative control, moderate hypothermia, severe hypothermia and hypoxia groups. Rats in the control group were euthanized when those in the moderate hypothermic group died. Blood samples were collected via heart puncture, and the cerebrum, heart, suprarenal gland, kidney, liver and skeletal muscle were removed to investigate the biochemical, histochemical and histopathological changes. Postmortem assessment depicted significant changes in lipid peroxidation, represented by increased malondialdehyde levels in the studied organs of the rats in hypothermic and hypoxia groups. Histopathological examination of the rats’ organs revealed degeneration and necrosis in the hypothermia and hypoxia groups. Sections taken from the severe hypothermic rats revealed a loss of normal cardiac tissue architecture, necrotic changes in the pyramidal cells in the cerebral cortex, and massive necrosis, mainly in the tubules of the renal cortex and medulla. These findings suggest that histological changes might be used as biochemical markers for postmortem diagnosing of fatal hypothermia, particularly in severe hypothermic conditions. KEY POINTS • Death by hypothermia is a serious public health problem worldwide. • Confirming a diagnosis and determining the cause of death in cases of hypothermia are among the most difficult practices in forensic medicine. • Death by hypothermia might be associated with structural abnormalities in various organs. • Studies using different tissue staining techniques will enable an overall illustration of the role of histopathological changes in body organs as indicators of hypothermia.
... Wischnewski reported a percentage of 91% [3]; Mant WS spots have been described as multiple hemorrhages, of a dark blackish color, present on the surface of the gastric mucosa, in particular on the apex of the gastric folds in variable numbers (up to 100), with oval or punctiform shape, ranging in diameter from 1 mm to 2 cm. Microscopic investigations found in our review suggested that WS cannot be considered as simple ulcerations of the mucosa but as peculiar, multiform and multidimensional injuries of the gastric folds, characterized by lymphoplasmacellular infiltrate with surrounding erosions [17]. Besides, Tsokos et al. have not found a correspondence of WS with ulcerations, describing them in HE (hematoxilin-eosin) sections as amorphous material with a pink color with the possibility of lymphoplasmacellular infiltrate and infarcts of the surrounding mucous glands [23]. ...
... WS spots have been described as multiple hemorrhages, of a dark blackish colo present on the surface of the gastric mucosa, in particular on the apex of the gastric fol in variable numbers (up to 100), with oval or punctiform shape, ranging in diameter fro 1 mm to 2 cm. Microscopic investigations found in our review suggested that WS cann be considered as simple ulcerations of the mucosa but as peculiar, multiform and mul dimensional injuries of the gastric folds, characterized by lymphoplasmacellular infiltra with surrounding erosions [17]. Besides, Tsokos et al. have not found a correspondence WS with ulcerations, describing them in HE (hematoxilin-eosin) sections as amorpho material with a pink color with the possibility of lymphoplasmacellular infiltrate an infarcts of the surrounding mucous glands [23]. ...
Full-text available
Hypothermia is an emergency caused by the lowering of the central body temperature with a slowdown of basic vital functions. Reduced mobility, old age, psychiatric or metabolic disorders are relevant risk factors. Diagnosis of death from hypothermia is a challenge, as there are no pathognomonic signs, and supportive findings can be inconstant. Wischnewsky Spots (WS) are blackish lesions of gastric mucosa, typically associated with hypothermic death. The pathophysiology of these lesions is still uncertain. The aim of this paper is to investigate the pathological mechanisms determining the appearance of WS by analyzing the current scientific knowledge in this area. We performed a narrative review of the literature published in the last 20 years, comparing the results with three cases of hypothermia reported from our experience. The review proved that WS show a multifactorial etiology, i.e., not only body temperature decrease, but also various extrinsic and intrinsic factors, such as physical and psychological stress, agony, causa mortis and metabolic comorbidities. The review summarizes the current knowledge in the field of incidence, pathology and morphology of WS by proposing some scientific and technical points for clinical and forensic analysis of this phenomenon.
... Analysis of BHB enables the diagnosis of alcoholic ketoacidosis (AKA) post mortem [4,5]. It has also proved important in the diagnosis of diabetes and related acute complications [6] and in the diagnosis of hypothermia [7]. ...
... There are some classical morphological signs of hypothermia, such as frost erythema and Wischnewski's spots, but these are unspecific. An elevated blood BHB concentration is now a widely accepted marker for hypothermia, although a normal concentration of BHB does not exclude hypothermia [7]. Thus, as the diagnosis of hypothermia can be made without BHB analysis, our assumption was that the number of deaths from hypothermia would remain fairly stable or slightly increase. ...
Full-text available
Although beta-hydroxybutyrate (BHB) analysis has proved its importance in forensic pathology, its effects on cause-of-death diagnostics are unaddressed. Therefore, this study aims at evaluating the effects of BHB analysis on the number of deaths by DKA (diabetes ketoacidosis), AKA (alcoholic ketoacidosis), HHS (hyperosmolar hyperglycaemic state), hypothermia, diabetes, alcoholism, and acidosis NOS (not otherwise specified). All 2900 deaths from 2013 through 2019 in which BHB was analysed at the National Board of Forensic Medicine, and 1069 DKA, AKA, HHS, hypothermia, diabetes, alcoholism, and acidosis cases without BHB analysis were included. The prevalence of BHB-positive cases for each cause of death, and trends and proportions of different BHB concentrations, were investigated. The number of BHB analyses/year increased from 13 to 1417. AKA increased from three to 66 and acidosis from one to 20. The deaths from alcoholism, DKA, and hypothermia remained stable. It is unclear why death from alcoholism remained stable while AKA increased. The increase in unspecific acidosis deaths raises the question why a more specific diagnosis had not been used. In conclusion, BHB analysis is instrumental in detecting AKA and acidosis. The scientific basis for the diagnosis of DKA and hypothermia improved, but the number of cases did not change.
... Hypothermia is an uncommon and challenging diagnosis in veterinary medicine (Wohlsein et al, 2016). In humans, Wischnewski spots (WS) on the gastric mucosa and reddishebrown erythematous discolouration of the skin of the extensor surface of the larger joints are generally considered to be indicative of hypothermia (Palmiere et al, 2014). WS have been reported in 43.5e100% of humans with fatal hypothermia (Gwaltney-Brant, 2016;Wohlsein et al, 2016). ...
... WS are due to body cooling in low environmental temperatures and are characterized by discrete, circumscribed haemorrhages on the gastric mucosa. Due to autolysis and erythrocyte lysis, released haemoglobin exposed to gastric acid becomes haematinized (Palmiere et al, 2014). Histologically, WS are distinguished from mucosal erosions and ulcerations by the absence of inflammatory infiltrates, fibrin exudates or other vascular changes (Tsokos et al, 2006), and are classified as a periagonal, hypothermia-related phenomenon (Ball and Herath, 2018). ...
Fatal hypothermia represents a diagnostic challenge in veterinary pathology. Wischnewski spots (WS) and black oesophagus (BO) have been described in human cases of fatal hypothermia but rarely in animals. We now describe WS and BO in suspected fatal hypothermia in a free-ranging brown howler monkey (Alouatta guariba clamitans) and a pet rabbit (Oryctolagus cuniculus). Both animals had dark spots resembling WS on the gastric mucosa and the monkey also had BO with haematin deposition. In both cases, stress factors and relatively cold environmental conditions were present prior to death.
... The diagnostic criteria of the pathologic background are shown in Table 2. 20 If there were several possible causes, we chose the most affected factor as the predominant cause considering the patient's circumstances, clinical information, and histopathologic findings. ...
Context.— Basal vacuolization (BV) in renal tubules is a histopathologic hallmark of advanced ketoacidosis that enables us to retrospectively diagnose these cases. Objective.— To clarify the pathologic background and serologic findings of ketoacidosis with BV, and to reveal the pathologic findings by each pathologic background. Design.— We examined 664 serial autopsy cases. A systemic histopathologic examination and measurement of serum β-hydroxybutyrate concentration were performed for the cases with BV. The extent of steatosis and fibrosis in the organs and the degree of coronary artery stenosis were semiquantitatively investigated. Immunohistochemistry for adipophilin was also performed to analyze its usefulness for the pathologic diagnosis. Results.— Basal vacuolization was found in 16 cases, all of which showed a pathologic serum β-hydroxybutyrate concentration. The main background of ketoacidosis was considered as alcohol abuse in 6 cases, diabetes in 5, malnutrition in 3, and hypothermia and infection in 1 case each. Severe hepatic fibrosis was observed only in the alcohol-abuser group. Moreover, cardiac steatosis was more severe in patients with possible alcohol abuse than in those with other causes. Immunohistochemistry for adipophilin showed immunoreactivity consistent with BV in 13 of 16 cases. There was no correlation between β-hydroxybutyrate concentration and either the postmortem or storage interval. Conclusions.— Basal vacuolization may be a useful finding for detecting ketoacidosis cases in a postmortem investigation. Serum β-hydroxybutyrate was a stable and reliable compound for the definitive diagnosis of ketoacidosis in such cases. The present study showed that pathologic changes in some organs may vary by each pathologic background of ketoacidosis with BV.
... Blood-alcohol concentrations tend to be low or even absent in AKA, and the condition typically evolves after a short period of abstinence [3,4,28,36,38]. There is an inverse relationship between blood-alcohol and ketone body concentrations [24,39,40]. Our results confirm that alcohol concentrations are generally low in AKA, although a few cases have high alcohol, the highest measuring 3.05‰. ...
Background Post-mortem biochemistry, including the analysis of beta-hydroxybutyrate (BHB), is increasingly employed in forensic medicine, especially in conditions such as diabetes and chronic alcoholism. However, not much is known about the associations between age, body mass index (BMI), and sex and BHB concentrations in ketoacidotic conditions. Aim To retrospectively study the association between age, BMI and sex in several conditions, such as diabetic ketoacidosis (DKA), alcoholic ketoacidosis (AKA), and elevated post-mortem BHB concentrations. Methods 1407 forensic autopsy cases analysed for BHB were grouped by diagnosis: DKA, AKA, HHS [hyperosmolar hyperglycaemic state], acidosis NOS [not otherwise specified], or hypothermia. Age, sex, BMI and the concentrations of blood alcohol, vitreous glucose and blood BHB were recorded. Results Cases of AKA and DKA were most numerous (184 and 156, respectively). In DKA and in its male subgroup, cases with severe ketosis (BHB > 1000 µg/g) were younger and had a lower BMI than those with moderate ketosis (BHB 250 to 1000 µg/g) and controls (P<0.001). In DKA and in its female subgroup, cases with moderate ketosis cases were older (P=0.0218 and P=0.0083) than controls. In AKA and in its male subgroup, cases with severe ketosis had a lower BMI than those with moderate ketosis (P=0.0391 and P=0.0469) and controls (P<0.001). Cases with moderate ketosis had a lower BMI than controls (P<0.001). Conclusions BHB concentration is associated with BMI in DKA and AKA, and with both BMI and age in DKA. Constitutional factors should, therefore, be considered in potential AKA and DKA cases.
Macromorphological findings can be missing in cases of fatal hypothermia when the agonal period is very short because of a large difference between environmental and core body temperatures. Expression of heat shock proteins (Hsps) increases under endogenous and exogenous cellular stresses such as thermal stress. These stress proteins can be revealed by immunohistochemical staining. Forty-five cases of death due to hypothermia and a control group of 100 deaths without any antemortem thermal stress were examined for Hsp27, 60, and 70 expression in renal tissue because renal tissue is sensitive to cellular stress. The results revealed no significant difference between Hsp27, 60, and 70 expression in both groups (28.8% positive staining in the study group and 19.0% positive staining in the control group), which is contradictory to a previous study on expression of Hsp70 in renal tissue in cases of fatal hypothermia. Hence, it is currently unclear whether immunohistochemical staining of Hsps supports a morphological diagnosis of fatal hypothermia.
Full-text available
Brought dead cases are of concern not only clinically with regards to medical certification of cause of death, but also medico legally. Generally, brought dead cases are considered as medico legal, which in fact need not be always. Need has arisen to study the provisions and practice of handling brought dead cases with respect to whether medico legal post-mortem is required for all such cases or not. A retrospective, cross-sectional, observational study was carried out by examining case files, police papers and post�mortem reports of brought declared dead cases (n=62) received at a tertiary care hospital in Ahmedabad with the objective being to observe the epidemiology of brought dead cases and to review the provisions and practice of handling brought dead cases, as well as, medico legal post-mortem examination (Under S. 174 Cr.P.C.) for such cases. Majority cases belonged to more than 50 years of age with a history of previous/current major illness. Hence, ascertaining the cause of death became quite obvious after excluding common unnatural causes. Only 23.72% cases were subjected to autopsy. In some cases police denied permission for performing the autopsy. A protocol to handle brought dead cases is suggested which might require some reforms in relevant law(s) and state resolutions. The centers with high load of autopsies of brought dead cases from natural manner should carry out such a study to decide whether really medico legal autopsy is required in such cases or not and to request the state authorities to amend the provisions accordingly
Background Accidental hypothermia results in various dysfunctions in the human body. Additionally, coagulation disorder can lead to a life-threatening condition. We previously demonstrated that platelets stored in the spleen were activated and thus triggered coagulation disorder in a mouse model of hypothermia. In the present study, we wanted to investigate if this phenomenon in mice also occurs in humans as a reaction to hypothermia. Methods We analyzed splenic tissue collected from 22 deceased subjects who have died from hypothermia. These samples were compared with 22 control cases not exposed to cold environment. We performed immunohistochemical staining for CD61 (a marker of all platelets) and CD62P (a marker of activated platelets). We also evaluated the morphology of platelets in the spleen with scanning electron microscopy. Results Immunohistochemical analysis revealed no significant changes in the amounts of CD61-positive platelets between the hypothermia and control cases. However, the hypothermia cases contained abundant CD62P-positive platelets compared with those of the control cases. Immunohistochemical analysis also revealed that the activated platelets formed aggregates and adhered to splenic sinusoidal endothelial cells in the hypothermia cases. However, we observed no significant fibrin formation around the activated platelets. Conclusions Hypothermia resulted in splenic platelet activation, which may be used as a postmortem marker of hypothermia. The release of activated platelets from the spleen into to circulation upon rewarming may promote coagulation disturbances.
Full-text available
Referring to our experience with post-mortem computed tomography (CT), many hypothermic death cases presented a lack of increase in lung-field concentration, blood clotting in the heart, thoracic aorta or pulmonary artery, and urine retention in the bladder. Thus we evaluated the diagnostic performance of post-mortem CT on hypothermic death based on the above-mentioned three findings. Twenty-four hypothermic death subjects and 53 non-hypothermic death subjects were examined. Two radiologists assessed the presence or lack of an increase in lung-field concentration, blood clotting in the heart, thoracic aorta or pulmonary artery, and measured urine volume in the bladder. Pearson's chi-square test and Mann-Whitney U-test were used to assess the relationship between the three findings and hypothermic death. The sensitivity, specificity, accuracy, positive predictive value (PPV) and negative predictive value (NPV) of the diagnosis were also calculated. Lack of an increase in lung-field concentration and blood clotting in the heart, thoracic aorta or pulmonary artery were significantly associated with hypothermic death (p=0.0007, p<0.0001, respectively). The hypothermic death cases had significantly more urine in the bladder than the non-hypothermic death cases (p=0.0011). Regarding the diagnostic performance with all three findings, the sensitivity was 29.2% but the specificity was 100%. These three findings were more common in hypothermic death cases. Although the sensitivity was low, these findings will assist forensic physicians in diagnosing hypothermic death since the specificity was high.
The possibilities of using morphological markers of fatal hypothermia are limited; therefore, other diagnostic criteria of deaths from hypothermia are being researched. The initiation of protective mechanisms against adverse effects of low temperatures results in activation of hormonal systems and development of characteristic biochemical changes that can be impaired by alcohol intoxication. The aim of the study was to assess the usefulness of determinations of the profile of free fatty acid concentrations as potential markers of hypothermia-related deaths, particularly in intoxicated victims. The study group consisted of blood samples collected during autopsies of 23 victims of hypothermia. The control group included blood samples collected from 34 victims of sudden, violent deaths at the scene of an incident (hangings and traffic accidents) and 10 victims who died because of post-traumatic subdural hematomas with prolonged agony. The study and control groups were divided into three subgroups according to blood alcohol concentrations: 0.0-0.99; 1.0-2.99 and ≥3.0‰. Statistical analysis in the individual subgroups demonstrated significant increases in concentrations of palmitic, stearic and oleic acids (P<0.05), independent of blood ethanol concentration. Palmitic, stearic and oleic acids can be considered the potential markers of fatal hypothermia, including the cases of intoxicated individuals.
The concentrations of 3-beta-hydroxybutyrate (3HB) in femoral blood, urine, vitreous humor as well as pericardial and cerebrospinal fluids were retrospectively examined in a series of medico-legal autopsies, which included cases of diabetic ketoacidosis, hypothermia fatalities without ethanol in blood, bodies presenting mild decompositional changes, and sudden deaths in chronic alcoholics. Similar increases in 3HB concentrations were observed in blood, vitreous, and pericardial fluid, irrespective of the cause of death, suggesting that pericardial fluid and vitreous can both be used as alternatives to blood for postmortem 3HB determination. Urine 3HB levels were higher than blood values in most cases. Cerebrospinal fluid 3HB levels were generally lower than concentrations in blood and proved to be diagnostic of underlying metabolic disturbances only when significant increases occurred.
To identify lung findings specific to fatal hypothermia on postmortem computed tomography (CT) imaging. Whole body CT scans were performed followed by full autopsy to investigate causes of death. There were 13 fatal hypothermia cases (group A) and 118 with other causes of death (group B). The chest cavity (CC), dead space including fluid/pneumothorax (DS), aerated lung volume (ALV), percentage aerated lung (%ALV), and tracheal aerated volume (ATV) were measured. Autopsy findings of groups A and B were compared. Receiver operating characteristics (ROC) curves were used to identify factors specific to fatal hypothermia. There were no differences in age, sex, number with emphysema, or time from death to CT examination between the 2 groups. CC, DS, ALV, %ALV, and ATV were 2601.0±247.4(mL), 281.1±136.5(mL), 1564.5±281.1(mL), 62.1±6.2(%), and 21.8±2.7(mL) in group A and 2339.2±67.7(mL), 241.1±38.0(mL), 739.9±67.0(mL), 31.4±2.3(%), and 15.9±0.8(mL) in group B, respectively. There were statistically significant differences between groups A and B in ALV, %ALV and ATV. The multiple comparison procedure revealed that ALV and %ALV differed significantly between fatal hypothermia and other causes of death (p<0.05). Using ROC evaluation, %ALV had the largest area under the curve (0.819). This study demonstrates that the %ALV is greater in fatal hypothermia cases than in those with other causes of death on postmortem CT chest imaging. Based on CT, hypothermia is very likely to be the cause of death if the %ALV is >70%.
The concentrations of 3-beta-hydroxybutyrate (3HB) in blood and two liver samples were retrospectively examined in a series of medicolegal autopsies. These cases included diabetic ketoacidosis, nondiabetic individuals presenting moderate to severe decompositional changes and nondiabetic medicolegal cases privy of decompositional changes. 3HB concentrations in liver sample homogenates correlate well with blood values in all examined groups. Additionally, decompositional changes were not associated with increases in blood and liver 3HB levels. These results suggest that 3HB can be reliably measured in liver homogenates when blood is not available at autopsy. Furthermore, they suggest that metabolic disturbances potentially leading or contributing to death may be objectified through liver 3HB determination even in decomposed bodies.
Fatalities due to an extreme ambient temperature might present with poor or nonspecific pathologies; thus, the diagnosis of the cause of death in such cases is one of the most difficult tasks in forensic pathology. The present study investigated the molecular pathology of alveolar damage involving pulmonary edema with special regard to hyperthermia (heatstroke) and hypothermia (cold exposure) in forensic autopsy cases (total, n=122; within 48h postmortem). Intrapulmonary mRNA and immunohistochemical expressions of matrix metalloproteinases (MMPs), intercellular adhesion molecule-1 (ICAM-1), claudin-5 (CLDN-5) and aquaporins (AQPs) were examined. Relative mRNA quantification using Taqman real-time PCR assay demonstrated higher expressions of all markers except for AQP-5 in fatal hyperthermia, and higher expression of MMP-9 in fatal hypothermia. Acute cardiac death, mechanical asphyxiation, fire fatality and intoxication did not present any characteristic findings. In immunostaining, only MMPs showed evident differences among the causes of death: MMP-9 was intensely positive in most cases of hyperthermia and hypothermia, but MMP-2 expression was evident only in hyperthermia. These findings suggest alveolar damage involving pulmonary edema, characteristic of fatal hyperthermia and hypothermia. Systematic analysis of gene expressions using real-time PCR might be a useful procedure in forensic death investigation.
The aim of this study was to investigate the usefulness of postmortem biochemical investigations in the diagnosis of fatal hypothermia. 10 cases of fatal hypothermia and 30 control cases were selected. A series of biochemical parameters, such as glucose, acetone, 3-beta-hydroxybutyrate, isopropyl alcohol, free fatty acids, adrenaline, growth hormone, adrenocorticotropic hormone, thyroid-stimulating hormone, cortisol, calcium, magnesium, C-reactive protein, procalcitonin as well as markers of renal and cardiac functions were measured in blood, postmortem serum from femoral blood, urine, vitreous and pericardial fluid. The results suggested that deaths due to hypothermia, especially in free-ethanol cases, are characterized by increased ketone levels in blood and other biological fluids, increased adrenaline concentrations in urine, increased cortisol levels in postmortem serum from femoral blood and increased free cortisol values in urine. Increased or decreased levels of other biological parameters are either the result of terminal metabolic changes or the expression of preexisting diseases and may provide information to elucidate the death process on a case-by-case basis.