Death in head-down position in a heavily intoxicated obese man.

Dying in a head-down position is rare, and autopsy may reveal no morphological findings which can sufficiently explain the cause of death. The authors describe a case of positional asphyxia of a 78-year-old man, found dead hanging in head-down position inside a blackberry bush. The subject was suspended by his left leg and wedged inside a thick blackberry bush, while his right leg was free and inflected. Investigation revealed that the elderly man had last been seen after lunch in the early afternoon (about 2.00 p.m.), two days before being found. The subject had no pre-existing physical or mental condition which might have explained his death. He was 164 cm tall and weighed 90 kg (BMI: 33.4). External examination of the body revealed abrasions on the head and multiple superficial scratch marks on the hands; no external signs of violence were observed. The deceased's head was cyanotic and revealed marked petechial haemorrhages of the conjunctiva. Rigor mortis was fully developed and reddish fixed livor was observed on the face, neck and upper chest. The distribution of livor was consistent with the position of the body at the scene. Autopsy revealed marked pulmonary and cerebral oedema; the liver showed fatty vacuolization with a mild increase of connective tissue and thickening of the walls of the central veins and centrilobular sinusoids. The heart was enlarged, particularly the left ventricle, with a slight, calcified, diffuse and increased thickness of the aortic and coronary arteries. The remains of meat and vegetables in the initial phase of digestion were found inside the stomach, and there was a strong smell of alcohol. The blood alcohol concentration, ascertained by GC (Gas Chromatography), was 2.10 g/l. Toxicological assays for addictive drugs (cocaine, heroin, THC) yielded negative results. There were no features suggesting that the deceased had been the victim of an assault. The authors of this case report illustrate the main pathophysiological and diagnostic features of positional asphyxia and possible relevant co-causes of death, with an emphasis on the combined role of acute alcoholic intoxication and obesity in the hastened demise of a subject in the head-down position.