Case Report

Phosgene Inhalation in Fire-Related Deaths: A Case Report of

Two Lovers Burnt in a Travelling Carousel
Enrica Callegari 1, * , Enrico Mazzobel 1 , Silvano Zancaner 2 , Paolo Fais 3 , Guido Viel 1 and Giovanni Cecchetto 1

1 DSCTV—Department of Cardiac, Thoracic, Vascular Sciences and Public Health, Legal Medicine Section,
University of Padova, 35121 Padova, Italy
2 Legal Medicine, ULSS 3 Serenissima, 30174 Venice, Italy
3 DIMEC—Department of Medical and Surgical Sciences, Legal Medicine Section, University of Bologna,
40126 Bologna, Italy
* Correspondence: [email protected]

Abstract: Fire deaths present several diagnostic challenges for the forensic examiner, the most
significant of which is the identification of the cause of death and the evaluation of the morphological
consequences of heat injuries in the ante-mortem and post-mortem periods. Here, we describe the
case of two young lovers found dead inside a travelling carousel destroyed by a fire. Circumstantial
evidence of disputes between families running the town fair raised the suspicion of intentional
arson. Comparative analysis of crime scene investigation, radiological, autoptic, histological, and
toxicological findings revealed signs of vitality (i.e., presence of soot deposits inside the respiratory
and digestive tracts, heat damage to the respiratory mucosa) and identified fatal asphyxia from
haemorrhagic pulmonary oedema as the cause of death. Since the experimental burning of plastic
samples collected from a similar carousel demonstrated the significant production of phosgene, the
death of the two lovers was attributed to the probable inhalation of this gas. The case presented
here underlines the importance of a multidisciplinary approach of any fire-related death, providing
an insight into circumstantial and forensic (autopsy, toxicological, and immunohistopathological)
elements useful in raising suspicion of possible toxic gas inhalation. In the presence of high levels of
Citation: Callegari, E.; Mazzobel, E.; PVC materials at the fire scene and pulmonary oedema at the autopsy, with no alternative causes of
Zancaner, S.; Fais, P.; Viel, G.; death, the forensic pathologist must suspect a fatal exposure to phosgene.
Cecchetto, G. Phosgene Inhalation in
Fire-Related Deaths: A Case Report of Keywords: fire victim; burned body; charred corpse; crime scene investigation; forensic radiology;
Two Lovers Burnt in a Travelling forensic pathology; forensic histopathology; time since death; identification; forensic toxicology
Carousel. Forensic Sci. 2024, 4, 257–263.
https://doi.org/10.3390/
forensicsci4030018

Academic Editors: Simone Grassi

1. Introduction
and Rosario Barranco Among the most challenging forensic investigations, fire deaths are not uncommon
in medical–legal practice. Forensic pathologists are often asked to interpret the cause,
Received: 16 April 2024
time, and dynamics of death, as well as to identify the body, with only limited evidence
Revised: 8 June 2024
available. Although charred bodies are often extensively damaged, the morphological
Accepted: 24 June 2024
Published: 26 June 2024
findings may cover a broad spectrum, ranging from minor, local, superficial burns of the
skin, to complete incineration, with calcined skeletal remains and loss of any soft tissue [1,2].
In general, fire-related deaths may be immediate or delayed, as a result of direct thermal
injuries to the body, hypovolemic shock, acute respiratory distress syndrome (ARDS) or
Copyright: © 2024 by the authors. smoke inhalation [3–5]. Indeed, several toxic gases released during thermal combustion,
Licensee MDPI, Basel, Switzerland. such as carbon monoxide, cyanide or phosgene have been demonstrated to cause noxious
This article is an open access article asphyxiant effects [6,7]. As regards the latter substance, human exposure to phosgene
distributed under the terms and concentrations greater than 1 ppm × min may produce a transient protective vagus reflex
conditions of the Creative Commons with rapid shallow breathing and moderate irritation of the eyes and upper respiratory
Attribution (CC BY) license (https:// tract. When the inhaled dose is superior to 300 ppm × min, it may result in the death
creativecommons.org/licenses/by/ of some individuals [8]. At the dose of 500 ppm × min, significant pulmonary oedema
4.0/).

Forensic Sci. 2024, 4, 257–263. https://doi.org/10.3390/forensicsci4030018 https://www.mdpi.com/journal/forensicsci

Forensic Sci. Sci.
Forensic 2024, 4 4, FOR PEER REVIEW
2024, 2 258

appears
death of within 3 h, with death
some individuals [8]. At following
the dose of within
500 ppm the next significant
× min, 24 h [9], and a higheroe-
pulmonary dose of
phosgene
dema appears(~600 ppm3×h,min)
within with may
deathcause death
following within
within theminutes
next 24 h[10].
[9], and a higher dose
To our knowledge,
of phosgene (~600 ppm ×onlymin) amayfewcause
studies have
death beenminutes
within conducted[10]. on phosgene intoxication,
To our
primarily forknowledge,
clinical or only a few studies
toxicological have been
purposes conducted
[11–14]. on phosgene
In contrast, intoxication,
this topic is not currently
primarily
studied for clinical
from or toxicological
a forensic perspective,purposes [11–14]. In contrast,
with its medico-legal this topicespecially
implications, is not cur-in fire-
rently studied
related deaths.from a forensic
Here, we report perspective,
two cases with its medico-legal
examined throughimplications,
an integrated especially
radiological,
immunohistochemical, and toxicological approach and discuss the possible role radio-
in fire-related deaths. Here, we report two cases examined through an integrated of phosgene
inlogical, immunohistochemical,
producing extensive and fatal andlung
toxicological
oedema.approach and discuss the possible role
of phosgene in producing extensive and fatal lung oedema.
2. Case Report
2. Case Report
Early in the morning, at the conclusion of a local festival, a blaze burned a travelling
Early in the morning, at the conclusion of a local festival, a blaze burned a travelling
carousel placed in a town square. After the firefighters extinguished the flames, two burned
carousel placed in a town square. After the firefighters extinguished the flames, two
bodies on the pavement of the carousel were found. The victims were a couple of lovers
burned bodies on the pavement of the carousel were found. The victims were a couple of
known in the community: a 20-year-old boy and a 16-year-old girl. As there were disputes
lovers known in the community: a 20-year-old boy and a 16-year-old girl. As there were
between the families
disputes between who organized
the families the fair,
who organized thethe
fair,authorities immediately
the authorities immediately considered
consid- the
possibility
ered the possibility that the fire might have been intentionally started. The forensic de- was
that the fire might have been intentionally started. The forensic department
therefore
partment instructed
was thereforeto detect any to
instructed evidence indicative
detect any evidenceofindicative
third-party action andaction
of third-party to establish
the cause and the dynamic of the deaths.
and to establish the cause and the dynamic of the deaths.

2.1.
2.1. Death Scene Investigation
Death Scene Investigation
Both
Both victims werefound
victims were foundlying
lyingononthethe pavement
pavement of carousel,
of the the carousel,
with with the and
the male male and
the
thefemale
female in aa supine
supineand
anda aprone
prone position,
position, respectively
respectively (Figure
(Figure 1). Fire
1). The TheDepartment
Fire Department
technicians pinpointedthe
technicians pinpointed theorigin
originofof
thethe
firefire right
right between
between the bodies,
the two two bodies, excluding
excluding both both
thepresence
the presence of
of accelerants
accelerantsand
andaccidental
accidentalelectrical ignition.
electrical ignition.

Figure 1. Death scene: (A) the burnt carousel, and (B) a similar intact travelling carousel.
Charred bodies found lying on the pavement of the carousel (C): the female (pink arrow, and in
particular (D)), and the male (blue arrow, and in particular (E)).
Forensic Sci. 2024, 4, FOR PEER REVIEW 3

Figure 1. Death scene: (A) the burnt carousel, and (B) a similar intact travelling carousel. Charred
Forensic Sci. 2024, 4 bodies found lying on the pavement of the carousel (C): the female (pink arrow, and in particular259
(D)), and the male (blue arrow, and in particular (E)).

2.2. Post-Mortem
2.2. Radiological Examination
Post-Mortem Radiological Examination
A comprehensive
A comprehensive analysis
analysis using
using Multi
Multi Slice
Slice Computed
Computed Tomography
Tomography (MSCT)(MSCT) waswas
conducted on both corpses prior to autopsy (Figure 2). The results highlighted
conducted on both corpses prior to autopsy (Figure 2). The results highlighted burst burst frac-
tures of the
fractures of skulls, withwith
the skulls, loss of bone
loss and cerebral
of bone material,
and cerebral multiple
material, rib fractures
multiple and distal
rib fractures and
limb amputations. No retained metal objects were detected.
distal limb amputations. No retained metal objects were detected.

Figure 2. Post-mortem
Post-mortemMulti
MultiSlice
SliceComputed
ComputedTomography
Tomography(MSCT, CTCT
(MSCT, bone window):
bone (A) (A)
window): male, (B)
male,
female.
(B) female.

2.3. Autopsy Findings

At external examination, the corpses presented a typical “pugilistic attitude”, with
flexion of elbows and knees and clenching hands (Figure 1C,D). The soft tissues appeared
 Forensic Sci. 2024, 4, FOR PEER REVIEW 4

Forensic Sci. 2024, 4 2.3. Autopsy Findings 260

At external examination, the corpses presented a typical “pugilistic a itude”, with
flexion of elbows and knees and clenching hands (Figure 1C, D). The soft tissues appeared
widelyincinerated,
widely incinerated, with interruption
interruptionofofabdominal
abdominaland and thoracic
thoracic walls integrity.
walls The The
integrity. ob-
servation ofofthe
observation thebone
bonefractures
fracturesradiologically
radiologicallydetected
detectedled
ledtotothe
theevaluation
evaluationofofthe
theburned
burned
marginsand
margins andthethe absence
absence of haemorrhagic
of haemorrhagic infiltration.
infiltration. TheThe major
major internal
internal findings
findings con-
consisted
ofsisted
oedemaof oedema and hyperaemia
and hyperaemia of the
of the upper upper
airway airwaywith
mucosa, mucosa,
pinkishwith pinkish
foam foaminside
and soot and
soot
the inside the tract
respiratory respiratory
of bothtract of both
victims, victims,
from from the
the trachea trachea
to the to thebronchial
terminal terminal bronchial
branches.
branches.soot
Similarly, Similarly,
depositssoot deposits
were were
observed inobserved in the oesophagus
the oesophagus and stomach. and stomach.
Massive and Massive
diffuse
and diffuse haemorrhagic oedema affected the lung parenchyma. There
haemorrhagic oedema affected the lung parenchyma. There was no structural abnormality was no structural
inabnormality
the hearts of inboth
the hearts of both
deceased deceased
victims, withvictims,
pervious with pervious
coronary coronary
arteries. arteries. Wide-
Widespread poly-
spread heat
visceral poly-visceral heat lesions
lesions were were alsoNo
also detected. detected.
evidenceNo of
evidence
traumaofwastrauma was revealed
revealed in both
in corpses.
the both the corpses.

2.4.
2.4.Histological
Histologicaland
andImmunohistochemical
ImmunohistochemicalAnalysis
Analysis
Histological examination detected
Histological examination detected thethe presence
presence of soot deposits
of soot in trachea
deposits andand
in trachea bronchial
bron-
mucosa, along with
chial mucosa, alongmucosal oedema,
with mucosal vascular
oedema, congestion,
vascular and epithelial
congestion, detachment.
and epithelial detach-
Massive oedemaoedema
ment. Massive and erythrocytes were also
and erythrocytes weredetected in the lungs
also detected in the and
lungsthe alveoli.
and There
the alveoli.
was
Thereno was
evidence of fibrin
no evidence and/or
of fibrin inflammatory
and/or inflammatory infiltrates. The
infiltrates. immunohistochemical
The immunohistochemi-
evaluations of lung
cal evaluations samples
of lung were
samples performed
were performed totoidentify
identifythe
thecell
celltypes
types involved
involved in thethe
damage.
damage. Epithelial membraneantigen
Epithelial membrane antigen(EMA)
(EMA) andand endothelial
endothelial markers
markers (CD-34
(CD-34 and F-
and F-VIII)
VIII)
werewere
usedused
[15],[15], revealing
revealing severe
severe alveolar
alveolar necrosis,
necrosis, without
without significant
significant damage
damage of en-
of the the
endothelium (Figure
dothelium (Figure 3). 3).

Figure3.3.Histological
Figure Histological and
and immunohistochemical
immunohistochemical results:
results: (A,B)
(A,B) upper
upper respiratory
respiratory tract,
tract, H&EH&E stain-
staining—
ing—magnification 62× and 125×, respectively. Soot deposits in trachea–bronchial mucosa (black
magnification 62× and 125×, respectively. Soot deposits in trachea–bronchial mucosa (black arrows)
arrows) and epithelial detachment; (C) lungs, H&E staining—magnification 125×. Haemorrhagic
and epithelial detachment; (C) lungs, H&E staining—magnification 125×. Haemorrhagic alveolar
alveolar oedema; (D) lungs, IHC CD34 stain—magnification 160×. Integrity of the vascular endothe-
oedema;
lium; (E)(D) lungs,
lungs, IHC
IHC CD34
F-VIII stain—magnification
stain—magnification 320×. ×. Integrity
160Integrity of the
of the vascular
vascular endothelium;
endothelium; (F)
(E) lungs, IHC F-VIII stain—magnification 320 × . Integrity of
lungs, IHC EMA stain—magnification 160×. Diffuse alveolar necrosis. the vascular endothelium; (F) lungs,
IHC EMA stain—magnification 160×. Diffuse alveolar necrosis.
2.5. Toxicological Analyses
2.5. Toxicological Analyses
Toxicological analyses were performed on post-mortem blood (sampled from the car-
Toxicological analyses were performed on post-mortem blood (sampled from the
diac left ventricle), urine and tissues using gas chromatography coupled with mass spec-
cardiac left ventricle), urine and tissues using gas chromatography coupled with mass
trometry (GC-MS) for different classes of drugs of abuse and psychoactive substances.
spectrometry (GC-MS) for different classes of drugs of abuse and psychoactive substances.
Blood was tested for alcohol, and for other volatile substances, by headspace gas chroma-
Blood was tested for alcohol, and for other volatile substances, by headspace gas chro-
tography with flame ionization detection (HS-GC/FID). The cyanide determination in
matography with flame ionization detection (HS-GC/FID). The cyanide determination
blood was performed using solid phase microextraction and gas chromatography coupled
in blood was performed using solid phase microextraction and gas chromatography cou-
pled with mass spectrometry [16]. The analysis of carboxyhaemoglobin (CO-Hb) in the
post-mortem blood was carried out by UV–visible determinations performed on a Varian
CARY50 (Torino, Italy) spectrophotometer at 532 and 558 nm. In a 10 mL glass tube,
Forensic Sci. 2024, 4 261

20 µL of blood was suspended in 5 mL of 0.1% sodium carbonate, and 4 mg of sodium

dithionite was added and gently shaken for 5 min to obtain cell lysis. The solution was
added to 0.5 mL of sodium hydroxide and incubated at room temperature for 5 min. The
absorbance at 558 and 532 nm was read; the ratio (558 nm/532 nm) was correlated to
%COHb [17]. Toxicological results excluded any alcohol or drug intoxication; CO-Hb and
cyanide blood concentrations were 14% and 0.3 µg/mL, respectively, in the male victim;
15% and 0.4 µg/mL, respectively, in the female victim.

2.6. Technical Inspections and Experimental Burning Analyses

As the carousel was destroyed by the fire, a similar carousel was examined by technical
experts. The structure was found to be formed of a steel frame, with partition panels and
internal tools largely made of polyvinyl chloride (PVC). Samples of this plastic material
were then collected and experimentally burnt, together with uncombusted residues seized
at the death scene, to analyse the fumes produced during the fire. For this purpose, a
Chemcassette Toxic Gas Detection device, with an optical system, scanned the presence of
gas, evaluating the colour changes of a chemically impregnated paper tape. These analyses
demonstrated an extensive production of phosgene (carbonyl dichloride).

3. Discussion
In the present case, circumstantial evidence immediately suggested that the fire might
be either a concealment of the corpses or an effort to financially harm the carousel owners,
which resulted in the deaths of the two victims. Since the crime scene inspection, even
with the cooperation of the Fire Department engineers, could not differentiate accidental
ignition from arson, the role of the forensic pathologist in identifying the causes of death
was essential. Radiological investigations and external cadaveric examinations excluded
the presence of traumatic injuries; likewise, the toxicological analysis refuted the hypothesis
of an acute drug/alcohol intoxication. The autopsy revealed signs of vitality: presence of
soot deposits inside the respiratory (only partially occluding the airways) and digestive
system, along with heat damage to the mucosa of the upper respiratory tract (with oedema,
mucosal bleeding, and vesicular detachment) [18]. These findings indicated that the victims
were still alive during the fire and that they inhaled hot fire fumes. Such evidence disproved
the hypothesis of corpse concealment and confirmed the role of fire in the death of the
two victims.
As for the manner of death, carbon monoxide and cyanide are common substances
involved in the determination of fire-related deaths [6,7]. In the case here presented,
in both victims, CO-Hb concentrations were above 10%, suggesting that the persons
were exposed to fire fumes while alive; although being potentially toxic, CO-Hb and
cyanide blood levels were considered non-lethal [19,20]. Instead, the gross and microscopic
findings identified a massive pulmonary oedema, the extension of which was clearly
incompatible with life. Based on the immunohistochemical analysis of specific markers for
endothelium and alveolar epithelium [15], severe alveolar necrosis was identified as the
cause of the extensive lung damage induced by the inhalation of irritative toxic gases [21,22].
Together with the results of the experimental incineration of the plastic samples collected,
which demonstrated the significant production of phosgene, this consideration led to
the conclusion that toxic gas inhalation was the most probable cause of the two deaths.
Despite the absence of detectable phosgene concentrations in the cadaveric fluids, phosgene
indeed is a colourless, extremely volatile compound (with a very short half-life), which
is a combustion product of certain chlorinated hydrocarbons such as PVC, integrated
analyses of the collected data revealed the major role played by this gas in the cause of
the deaths. The inhalation of this gas entails surfactant depletion, increased permeability
of the alveolar–capillary membrane, chemical reactions with proteins, lipids, and nucleic
acids in the alveolar tissue, along with the significant release of inflammatory mediators
and reactive oxygen species (ROS). When these excessive ROS are insufficiently scavenged,
they contribute to the damage of the pulmonary endothelial cells and alveolar epithelial
Forensic Sci. 2024, 4 262

cells, resulting in pulmonary oedema and atelectasis, and finally the development of ALI
(acute lung injury). This may result in exudate and accumulation of erythrocytes in the
alveolar spaces and the formation of fatal pulmonary oedema [23,24].
The elevated concentration of phosgene in the air inside the carousel, resulting from
the presence of a high quantity of PVC, along with the absence of apparent escape attempts
by the victims from the source of the fire, suggest that the deaths occurred rapidly. Thus,
based on the cause of death, the absence of accelerants, and the identification of the origin
of the fire right between the two lovers, an accidental asphyxia by inhalation of phosgene
was considered the most likely manner of death. The file was dismissed by the judge.
As demonstrated in this case, exposure to toxic substances other than carbon monoxide
and cyanides must be considered as a potential cause of death when charred corpses are
discovered. There are very few reports dealing with lethal phosgene inhalation in forensic
literature, and none addresses the topic from an autoptic perspective. Consequently, our
work aims to provide forensic pathologists with information useful for raising suspicion
of fatal phosgene poisoning, such as the presence of high levels of PVC at the death scene
and the evidence of pulmonary oedema and severe alveolar damage found at autopsy
and histology.
Furthermore, this study emphasizes the absolute need for a standardized protocol
in approaching fire-related deaths, which has not yet been established. Currently, there
are only recommendations, such as those proposed by Baldino et al. [25], which suggest
using a multidisciplinary approach (including circumstantial, autoptic, histopathological,
toxicological, and genetic analyses), while leaving wide discretion to individual experts.
With the implementation of an accredited algorithm, it will be possible to identify the
specific steps required to determine the cause and dynamics of death in complex autopsy
cases, thus reducing the subjectivity of evidence interpretation [26–28].

4. Conclusions
The presented two fatal phosgene inhalations underline the importance of integrating
all available information (death scene investigation, radiology, histology, and toxicology
data) for identifying the exact cause and manner of death. As proposed in our brief report,
the presence of a high level of PVC materials at the fire scene and pulmonary oedema at
the autopsy, with no alternative causes of death, are valuable elements in raising suspicion
of a possible toxic gas inhalation. These findings should lead the forensic pathologist to
perform immunohistochemical analyses and experimental burnings, which can be useful
investigative tools when dealing with compounds (such as phosgene) characterized by
a very short half-life in body fluids and tissues, for which even well-timed toxicological
analyses might test negative.

Author Contributions: Conceptualization, P.F. and G.C.; data curation, E.C. and E.M.; investigation
S.Z., P.F. and G.C.; writing—original draft preparation, E.C. and E.M.; supervision, G.V. and G.C. All
authors have read and agreed to the published version of the manuscript.
Funding: This research received no external funding.
Institutional Review Board Statement: Not applicable.
Informed Consent Statement: Not applicable.
Data Availability Statement: Data are contained within the article.
Conflicts of Interest: The authors declare no conflicts of interest.

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