Case Report Child abuse followed by fatal systemic Pseudomonas aeruginosa infection Massimo Senati a , Matteo Polacco a,c , Vincenzo M. Grassi a , Arnaldo Carbone b , Fabio De-Giorgio a,⇑ a Institute of Legal Medicine, Catholic University, Medical School, Rome, Italy b Institute of Pathologic Anatomy, Catholic University, Medical School, Rome, Italy c Unit of Radiology, University Campus Bio-Medico, Rome, Italy article info Article history: Received 3 May 2012 Received in revised form 3 August 2012 Accepted 7 August 2012 Available online 13 September 2012 Keywords: Child neglect Thymic involution Immunosuppression Pseudomonas aeruginosa Forensic autopsy abstract Child abuse has become an increasingly serious diagnostic challenge for physicians. The clinical manifes- tations include malnutrition and sometimes infection. In fact, stress in children has been reported to increase corticosteroid levels. As a consequence, the thymus begins an involution process, producing a severe impairment in cellular and humoral immunity. Here, we report the case of a 7-year-old child who suffered a prolonged history of abuse and died from a systemic Pseudomonas aeruginosa infection. An initial local chronic infection propagated to the pelvic lymph nodes in an immunologically weak body and evolved into abscesses/phlegmons of the pelvic tis- sue, sepsis, acute respiratory distress syndrome, multiple organ failure and finally, death. Abused children have to be considered as potentially immunologically impaired patients; therefore, it is very important to screen them for opportunistic infections. Moreover, a history of unusual or recurring infections may indicate abuse, especially neglect or malnutrition. In these cases, further investigations should be conducted to determine if a protective service case should be opened. Thus, there is a need for multidisciplinary cooperation to ensure the early identification and prevention of child abuse. Ó 2012 Elsevier Ireland Ltd. All rights reserved. 1. Introduction Child abuse has become an increasingly serious diagnostic chal- lenge for forensic doctors, emergency department physicians, gen- eral practitioners, pediatricians and psychiatrists. The American Board of Pediatrics recently recognized child abuse as an official subspecialty of pediatrics [1]. According to the classification proposed by the World Health Organization [2], there are four types of child abuse: physical abuse, neglect, sexual abuse and emotional abuse. Clinical manifes- tations of physical abuse are typically represented by a combina- tion of both old and new traumatic lesions of various types. Physical abuse and neglect can also result in malnutrition and, in some cases, infection. In fact, psychological and physical stress in children has been reported to increase corticosteroid levels. As a result, the CD4 + CD8 + double positive thymocytes decrease in num- ber and therefore the thymus begins an involution process, which depresses cell-mediated immunity [3]. Thymic involution, i.e., de- creased thymic weight and volume, has been reported in cases of child abuse [3–6], drug abusers [7] and in elder abuse, although the latter can be masked by age-associated thymic fatty replace- ment [8]. This thymic atrophy has also been described as ‘‘nutri- tional thymectomy’’ [4] because it is often caused by nutritional disturbances. It is characterized by a severe impairment of both cellular and humoral immunity. Thus, abused children who suffer a thymic involution, and con- sequently a dysfunction of the two branches of the immune sys- tem, are at a greater risk of infection, which eventually may lead to sepsis. Furthermore, a small thymus size has been reported as an independent risk factor for infant mortality [5]. 2. Case report We report the case of a 7-year-old child who suffered a pro- longed history of abuse and died from a systemic infection follow- ing a state of neglect. The child was found unresponsive at home by his mother, who immediately called an ambulance. Upon their arrival at the site, the paramedics declared the child dead. He was lying on the floor and he was wearing just a bathrobe. Because the home was found in poor sanitary conditions and a previous complaint of child abuse had been filed, a forensic autopsy was ordered by the Public Prosecutor. In fact, the Public Prosecutor had ordered a medical examina- tion six months earlier because repeated episodes of violence against the child had been reported to the local Police Department by neighbors. The child was examined at a specialized pediatric 1344-6223/$ - see front matter Ó 2012 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.legalmed.2012.08.001 ⇑ Corresponding author. Address: Institute of Legal Medicine, Catholic University, Medical School, Largo F. Vito 1, 00168 Rome, Italy. Tel.: +39 06 35507031; fax: +39 06 35507033. E-mail address: fabio.degiorgio@rm.unicatt.it (F. De-Giorgio). Legal Medicine 15 (2013) 28–31 Contents lists available at SciVerse ScienceDirect Legal Medicine journal homepage: www.elsevier.com/locate/legalmed