Forensic Science, Medicine and Pathology

, Volume 15, Issue 4, pp 671–674 | Cite as

Differential diagnosis on discolorations of the skin in a case of suspected positional asphyxia

  • Alberto AmadasiEmail author
  • Michael Tsokos
  • Claas T. Bushmann
Differential Diagnosis


A 65-year-old man was found lifeless in his apartment, laying in a peculiar head-down position. His head was on the floor and his neck was over-flexed, with his trunk flexed on his neck. Examination of the body showed intense violet lividity of the head, torso and limbs, according to the position of the body. Moreover, diffuse hemorrhagic spots on the shoulders, upper part of the back and upper arms, along with an intense arch-shaped purple area on the anterior neck were detected at external examination. Suspicions of neck injuries due to strangulation and death due to positional asphyxia arose, but a thorough examination of circumstantial data and autopsy findings enabled a correct identification of cause and manner of death, and excluded strangulation and positional asphyxia as the cause of death. This case raises several issues on differential diagnosis and underlines the importance of a correct combined analysis of the findings provided by on-scene investigation and autopsy.


Forensic pathology Head-down position Positional asphyxia pseudo-bruising Lividity 


Compliance with ethical standards

Conflict of interest

The authors declare no conflict of interest.

Ethical approval

Ethical approval was not required for this type of paper.


  1. 1.
    Pollanen MS, Perera SD, Clutterbuck DJ. Hemorrhagic lividity of the neck: controlled induction of postmortem hypostatic hemorrhages. Am J Forensic Med Pathol. 2009;3:322–6.CrossRefGoogle Scholar
  2. 2.
    Bockholdt B, Maxeiner H, Hegenbarth W. Factors and circumstances influencing the development of hemorrhages in livor mortis. Forensic Sci Int. 2005;149:133–7.CrossRefGoogle Scholar
  3. 3.
    Bell MD, Rao VJ, Wetli CV, Rodriguez RN. Positional asphyxiation in adults. A series of 30 cases from the Dade and Broward County Florida Medical Examiner Offices from 1982 to 1990. Am J Forensic Med Pathol. 1982, 1992:101–7.Google Scholar
  4. 4.
    Schaefer AT. Death in a head-down position. In: Tsokos M, editor. Forensic pathology reviews, vol. 3. Totowa: Humana Press Inc; 2008. p. 137–54.CrossRefGoogle Scholar
  5. 5.
    Byard RW, Wick R, Gilbert JD. Conditions and circumstances predisposing to death from positional asphyxia in adults. J Forensic Legal Med. 2008;15:415–9.CrossRefGoogle Scholar
  6. 6.
    Hayashi T, Buschmann C, Correns A, Herre S, Tsokos M. Fatal positional asphyxia. Forensic Sci Med Pathol. 2012;8:470–2.CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Department of Medical and Surgical Sciences, Section of Legal MedicineUniversity of BolognaBolognaItaly
  2. 2.Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, and Berlin Institute of Health, Institute of Legal Medicine and Forensic SciencesHumboldt-Universität zu BerlinBerlinGermany

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