Sudden Death Due To Excited Delirium Syndrome: From Pathophysiology To Postmortem Assessment: Case Reports

Excited Delirium Syndrome is a rare disease which can be re-sponsible for sudden/unexpected death. ExDS-related death frequently occur during or immediately after a physical effort, typically a scuffle with law enforcement workers. Its incidence is underestimated, and the pathophysiological mechanism is yet unclear. It is suggested the occurrence of factors acting as trigger of the syndrome such as abuse substance (i.e. cocaine) assumption and psychiatric illness. Moreover, other conditions that can determine the sudden death are hyperthermia and lactic acidosis. Here, two forensic cases of ExDS involving male subjects, respectively of 42 and 34 years, were described. In the first case the use of drugs was documented, in the second one a psychiatric illness was diagnosed. In both cases, after scuffling with police, the men suddenly died. The cases have been discussed on the basis of the main literature evidence on the disease pathophysiology, "clinical" manifestation, trigger factors and post-mortem findings. The reported cases and the evidence of the literature highlighted that ExDS forensic analyses requires applying multiple diagnostic investigations aimed at ascertaining both the presence of trigger factors and the cardiac catecholaminergic hyperstimulation. Thus, the forensic pathologist can improve the knowledge on this disease, helping the law enforcement office and healthcare practitioners to prevent and manage these medical emergencies.