Frothing in a Case of Electrocution: A Rare Case and Review of Literature

Abstract

Electrocution is a leading cause of unnatural deaths, especially in industrial and developing regions like India. In a recent case, an individual was brought in for autopsy following an apparent accidental electrocution. Strikingly, the postmortem examination revealed no typical entry or exit wounds associated with electric shocks. The body exhibited rigor mortis and a unique sign: reddish froth draining from the nasal cavities. Internal examination unveiled distinctive findings. Multiple tiny hemorrhages were observed over the heart’s left ventricle, while the heart’s blood vessels and valves remained unobstructed. In contrast, the lungs showed a frothy, whitish-red appearance extending into the bronchioles. This case presents an unprecedented observation: the presence of froth in the respiratory tract during electrocution. This case underscores the need for thorough autopsies. Even when specific indicators are absent, it highlights the importance of considering electrocution when froth is found in the respiratory tract. Such cases remind forensic pathologists of the diverse and occasionally unexpected manifestations they may encounter, encouraging the exploration of new phenomena within forensic medicine.

Introduction

Electrocution is a life-threatening and serious condition (1). The morphological results of the current mark and the circumstances of death are used to make the electrocution diagnosis (2). All currently available forensic instruments should be employed because some electrocution deaths don’t leave identifiable current imprints on the skin, which makes determining the cause of death more challenging, especially when considering other or concurrent causes (3). The most fatal primary injuries are cardiac and the most worrying are the neurological ones. However, lung lesions have equal clinical importance, but they can be unnoticed and underdiagnosed (4). The case study at hand pertains to an intriguing incident involving the electrocution death of an eyewitness. The individual in question had been reported to have experienced electrocution, and this aspect was central to the investigation. What made this case particularly challenging and distinctive was the absence of any discernible entry or exit electric marks on the skin during the autopsy. This absence of external evidence added a layer of complexity to the examination, as the conventional indicators of electrocution, such as visible burn marks or electrical injuries, were conspicuously missing. In such cases, where the history of electrocution is alleged but external findings are not in alignment, the forensic examination delves into a realm where the subtler, internal aspects come into focus. This necessitates a comprehensive assessment of the body’s internal conditions, including vital organs and tissues, to uncover potential clues and ascertain the precise cause of death. The absence of visible external marks should not deter the forensic investigation but rather encourage a more meticulous exploration of the internal factors that might shed light on the circumstances surrounding the individual’s electrocution-related demise. Such cases underscore the intricate nature of forensic pathology and the need for a multidisciplinary approach to unravel the mysteries of unusual and challenging scenarios. To the best of our knowledge, this is the first case of human-reported froth in the respiratory tract following electrocution. This case study demonstrates the value of forensic investigations and demonstrates how an unusual finding like froth in the lungs can be utilized to diagnose electrocution and may also be beneficial in situations when electrical markings can be seen.

Case Presentation

This case involves a male in his thirties who was brought for autopsy due to an alleged electrocution incident at a construction site. According to the preliminary information obtained during the police inquiry, the victim was operating an electric cutter to trim an iron rod when the electrocution occurred. The victim had no known preexisting medical conditions, as reported by his family. Upon the completion of a detailed crime scene investigation, the investigating officer requested an autopsy to ascertain the cause of death. During the autopsy, no external injuries associated with electric shock were identified. The body was observed to be in rigor mortis, a characteristic sign of post-mortem muscle stiffening, and an unusual finding was the presence of whitish-red foam draining from the nasal passages. Internal examination of the organs revealed several tiny petechial hemorrhages on the left ventricle of the heart, while the coronary vessels and valves appeared to be unobstructed. The lungs displayed a frothy, whitish-red appearance extending into the bronchioles (Figures 1 and 2). As part of the forensic investigation, solid viscera, including the stomach and its contents, pieces of the small and large intestines, liver, kidneys, spleen, and lungs preserved in saturated salt solution, and blood in sodium fluoride were subjected to toxicological analysis. The toxicology examination, performed using gas chromatography-mass spectrometry, returned negative results for metallic poisons, ethyl and methyl alcohol, cyanide, alkaloids, barbiturates, tranquilizers, and pesticides. This case underscores the challenges in diagnosing causes of death in electrocution incidents, especially when external injuries are absent. The peculiar findings during the autopsy raise questions about the underlying mechanisms of electrocution-related fatalities and the need for further research in forensic medicine.

Figure 1:

Collection of whitish-red froth around the hilum of the lung.

Figure 2:

Dissected lungs show a whitish-red color froth up to lung bronchioles.

Discussion

Epidemiological data indicates that electrical damage is a frequent and serious accidental kind of injury, with prevalence rates of roughly 21% to 30% in impoverished nations and 3% to 5% in industrialized nations. The kind of injury caused relies on a number of variables, including the voltage (high voltage is arbitrarily defined as >1000 V and low voltage as 1000 V), lightning damage, and so on. Mortality is highest in lightning strikes (17.6%) and lowest in electric arc injuries (1.1%), followed by high voltage (5.3%), low voltage (2.8%), and lightning strikes (17.6%) (4, 5). Renal failure is a well-documented consequence of electrical injuries and can occur in as many as 20% of cases. However, it’s noteworthy that noncardiogenic pulmonary edema, a condition characterized by fluid accumulation in the lungs in the absence of heart-related issues, has not been extensively reported in children under the age of 18 who have experienced electrical injuries. Electrocution has the potential to cause a range of physiological disturbances. It can lead to endothelial damage, which, in turn, increases the permeability of pulmonary blood vessels. This heightened vascular permeability can result in the movement of fluid from the blood vessels into the interstitial spaces of the lungs or even into the alveoli themselves. The accumulation of fluid in the pulmonary tissue can severely impair respiratory function, causing a condition known as pulmonary edema. While this phenomenon has been more closely associated with adult electrical injury cases, its occurrence in pediatric cases raises unique challenges and necessitates further research and clinical attention to better understand and address the complexities of electrical injury-related pulmonary edema in this age-group (4, 6). The path that electrical current takes through the body, from the point of entry to the point of exit, is a critical factor in determining the extent of organ damage and overall impact. In cases of high-voltage electrical injuries, even when there are no specific visible injuries to the lungs or airways, one of the primary causes of sudden death is respiratory arrest. This occurs when the electrical pathway involves the thorax, leading to direct injury to the respiratory control center, which in turn disrupts normal respiration. The interruption of breathing can also be induced by tetanic contractions of the respiratory muscles, further complicating the situation (7). In situations where electrical current flows from hand to hand, it can result in spinal cord transection, typically occurring at the C4-C8 level. This type of injury leads to direct damage to the spinal cord, causing significant neurological impairment. Notably, this form of electrical injury often leads to a phenomenon known as “locking-on.” In this scenario, the victim’s hand becomes physically stuck or “locked” onto the power source, preventing them from disconnecting themselves from the electrical circuit. Understanding the complex and sometimes devastating consequences of electrical injuries is crucial for medical professionals to provide appropriate care and treatment to those affected by such incidents (8).

Gal et al. (2016) published a case of accidental electrocution in a horse that showed reddish froth draining from the nasal canals and the presence of unchewed feed (straw) in the mouth, all of which suggested a quick demise. Poor blood coagulability, hemorrhagic diathesis throughout the body, and hemorrhages of varied diameters in various body locations were discovered on interior inspection of the corpse. The respiratory system is where hemorrhages are most frequently found in electrocution cases, as was also the case in our instance (9).

Our case came up shortly after an electrical mishap with an eyewitness involving an electric cutter at a building site. The subject presented with symptoms and clinical findings that initially raised concerns about various potential causes, including sepsis and aspiration-induced pulmonary edema. However, as the medical team delved into the patient’s past medical history, it became apparent that there were no previous indications of underlying illnesses such as pneumonia or a history of aspiration events. This information was instrumental in narrowing down the possible causes and focusing the diagnostic process on the aftermath of the electrical mishap, shedding light on the unique challenges and considerations that electrical injuries present in the medical field (10, 11). The presentation was marked by the rapid onset of symptoms, including a notable alteration in their level of consciousness. In light of these clinical indicators, the medical team carefully considered the possibility of frothing in the lungs. Frothing within the respiratory system is known to be associated with various conditions, including drowning, certain types of poisoning, and neurological disorders such as seizures and epilepsy. One plausible explanation for the development of frothing is the destabilization of the pulmonary autonomic neural system. This destabilization can be the result of either a mechanical disruption or an electrical disconnection of the central nervous system’s vasomotor centers, ultimately leading to pulmonary complications. The consideration of these factors formed a vital part of the diagnostic process, as it assisted in narrowing down potential causes and guiding the medical team toward a more accurate understanding of the patient’s condition and its underlying mechanisms (9, 12). These modifications are followed by pulmonary vein constriction, the pulmonary capillary hydrostatic pressure rising, alveolar wall damage, fluid leakage into the intra-alveolar and interstitial regions, bleeding resulting in frothing, and damage to the alveolar wall. The autopsy revealed a history of electrocution, no entry or exit electric mark across the skin, eyewitness death, and a whitish-red color froth up to the bronchioles of the lungs. To the best of our knowledge, this was the first reported case in humans where there is presence of froth in the respiratory tract in electrocution.

Conclusion

Electrocution can resemble conditions such as drowning, poisoning, and neurological diseases, often showing frothing in the lungs. This case is unique as it involved electrocution with no visible entry or exit marks. It highlights the forensic significance of identifying froth in the lungs to diagnose electrocution when external electric marks are absent. This diagnosis can be made only when other causes of frothing have been ruled out. This finding could aid in cases where visible electrical markings are lacking, showcasing the importance of thorough forensic investigations.

Authors

Sahil Thakral, MBBS, MD, DNB, Department of Forensic Medicine and Toxicology, All India Institute of Medical Sciences, Bathinda

Roles : A, B, 1

Sarthak Aeron, MBBS, MD, DNB, Department of Forensic Medicine and Toxicology, Hamdard Institute of Medical Sciences & Research

Roles : C

Puneet Setia, MBBS, MD, DNB, Department of Forensic Medicine and Toxicology, All India Institute of Medical Sciences, Jodhpur

Roles : D, E