"Excited delirium syndrome": is it a cause of death?

Excited delirium syndrome (EDS) has become a controversial and vexing forensic issue due to its association with restraint and sudden unexpected death. Although some authorities and jurisdictions recognised EDS as a cause of death there is no consensus among the medical community in this regard. The overlapping nature of the spectrum of antemortem behaviours and signs with many natural disease processes complicates this issue further. We describe two deaths which initially presented as EDS-like behaviour during restraint. In the first case, the deceased was travelling on a long distance flight when he died while in the custody of air cabin crew. The autopsy revealed the cause of death as air travel-related pulmonary thromboembolism. Acute alcoholic intoxication, nicotine withdrawal, hypoxia due to acute pulmonary thromboembolism, and hypobaric environment in the air plane cabin appeared as the potential reasons for EDS-like behaviour. In the second case, the deceased died while in the custody of immigration officials. At autopsy the cause of death turned out to be tense pericardial effusion due to fibrinous pericarditis. In this case, hypoperfusion of the brain following systemic hypotension as a result of cardiac tamponade associated with pericardial effusion likely led to the EDS-like behaviour. Clinicopathologic correlation in these two cases would strongly suggest EDS as the cause of death, had the decedents not had fatal anatomical causes of death. This alerts the forensic pathologist that not all the individuals dying with signs and symptoms of EDS during restraint are accounted for EDS as the immediate cause of death.