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The 2-year-old boy was brought to the Seattle Children’s Hospital emergency room with sores around his mouth, which appeared to be impetigo. The doctors and nurses were suspicious of how it looked, but the evidence did not appear at the time to warrant referral to Child Protective Services. He was prescribed an antibiotic, and at a follow-up with dermatologists five days later, the infection had mostly cleared—but now visible were wounds resembling strange burns around the mouth and chin. The referral to CPS was made the following day—but agents could not find the family.

Three days later, 911 was called. The boy was not breathing, and his body was covered with bruises. But investigators did not immediately know what wound, impact or apparent burn had finally, and horrifically, ended the abused boy's life.

But a full battery of tests, and particularly a computed tomography (CT) scan, allowed pathologists to determine the child’s cause of death, as reported in the latest issue of the Journal of Forensic Sciences.

The boy’s scalding wounds on his mouth and chin, which originally prompted attention from abuse investigators, showed irregular flow marks, according to the authors. They resembled the force feeding of a hot liquid while the boy’s face had been held upward, they concluded.

But the bruises were noted during the autopsy immediately, on virtually all surfaces of the body, including the scalp, chest, limbs, penis, scrotum and perineum, among other places.

A full battery of tests was ordered.

“A full autopsy plus ancillary studies were performed, including external and internal examination of the body with layered neck dissection, subcutaneous back dissection, anoscopic examination, fixation of the brain and eyes with neuropathology examination, microscopic examination of organs and decalcified bones, toxicologic analysis of the blood, full-body X-rays, Dexis imaging of selected ribs, and full-body high-resolution post-mortem computed tomography (CT) scan,” they write.

The CT scan showed a series of broken bones, both healed and not healed. It also showed a large pericardial effusion.

That detail led the full autopsy to the 1 cm laceration through the tip of the left ventricle of the heart, they write. Normally, internal pressure presents a kind of “normal safety valve” preventing heart damage from blunt-force trauma to the torso, they found. However, in the case of the boy, he had contusions in the thymus and cardiac base, which compressed the left ventricular outflow tract.

The bruises could have come at the time of the fatal blow—or from a previous injury, they add.

Previous published studies have shown cardiac lacerations of this type from major thoracic trauma such as car accidents, horse kicks and falls.

The case has not yet gone to court—but the CT scans could bolster any potential prosecution, they add.

“With this and other cases, CT has been an aid to excluding other radiologically visible injuries,” they write. “It has helped direct the autopsy to site of potential injury, such as leading to the excision, gross, and microscopic examination of the sternal and public ramus fractures in this case.

“Cardiac ventricular lacerations should be considered among the consequences of abusive blunt thoraco-abdominal trauma in young children,” add the medical examiners.

CT scans have been advocated by the National Institutes of Justice as being a highly-detailed forensic method of catching nuances of pathologic examinations. A New Mexico study of strangulation deaths published earlier this year determined that CT scans showed fractures and tissue hemorrhages that may have otherwise been missed.

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