Forensic Sci Med Pathol (2013) 9:568572

DOI 10.1007/s12024-013-9462-2

CASE REPORT

Pathological changes in the thyroid gland in crush asphyxia

Roger W. Byard

Accepted: 19 May 2013 / Published online: 13 August 2013

Springer Science+Business Media New York 2013

Abstract To determine whether crush asphyxia may be

associated with macro- and microscopic changes in the
thyroid gland, four cases of death due to crush asphyxia
were evaluated where the decedents (males aged 36, 37,
45, and 65 years respectively) suffered lethal chest compressions. The diagnosis of crush asphyxia in each case
was suggested by the death scene description and confirmed by the finding of injuries to the torso, with marked
congestion of the face, neck, and upper body associated
with petechial and subconjunctival hemorrhages. In addition to other pathological findings, each decedent had
intense congestion of their thyroid gland resulting in a
dark/black appearance. Microscopically, stromal capillaries were engorged, with bulging of capillaries into the
follicles. Rupture of these small vessels had created focal
intrafollicular aggregates of erythrocytes within the colloid.
As intense suffusion of the thyroid gland with blood in
cases of crush asphyxia may impart an appearance of
black thyroid this may be another feature of this condition to look for at autopsy, in addition to intrafollicular
blood lakes on histology.

Keywords Black thyroid
Crush asphyxia

Blood lake
Thyroid
Congestion

R. W. Byard (&)
Discipline of Anatomy and Pathology, The University of
Adelaide, Frome Road, Level 3 Medical School North Building,
Adelaide, SA 5005, Australia
e-mail: roger.byard@sa.gov.au

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Introduction
Black thyroid is a descriptive term that refers to black
discoloration of the thyroid gland that is most often associated with the use of the antibiotic minocycline [1, 2]. It
was first described in humans in 1976, although it had been
recognized in monkeys, rats, and dogs for some time prior
to this [3]. By 2010 there were less than 100 cases reported
in the literature [4]. Although sometimes considered to be
pathognomonic for prolonged minocycline treatment for
acne vulgaris [3], it is now recognized that dark discoloration of the thyroid gland may also be caused by other
processes that are detailed below.

Case reports
Case 1: A 45-year-old man was run over by the rear
wheel of a tractor. Death was due to a combination of crush
asphyxia and multiple injuries, particularly to the chest and
pelvis. The thyroid gland was very dark in color (Fig. 1)
with histologic sections showing intense congestion with
engorgement of stromal and perifollicular capillaries. The
latter were often bulging into the adjacent colloid with
scattered follicles containing islands of aggregated red
blood cells where these vessels had ruptured.
Case 2: A 36-year-old man was trapped underneath a
vehicle that he was working on when it slipped off
retaining blocks. Death was due to crush asphyxia. The
thyroid gland was black in color with histologic sections
showing similar appearances to Case 1.
Case 3: A 37-year-old man was crushed between a conveyor belt and an overhanging beam. Death was due to a
combination of crush asphyxia and multiple injuries,

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Fig. 1 Neck dissection showing the thyroid gland with surrounding

capsule in situ in Case 1. Reflection of the strap muscles shows the
darkly congested gland

particularly to the chest and abdomen. The thyroid gland

was black in color compared to a normal control (Figs. 2,
3) with histologic sections showing the characteristic
appearances of intense congestion with intrafollicular
blood lakes.
Case 4: A 65-year-old man was found trapped beneath a
tractor. Death was due to crush asphyxia. The thyroid gland
was again black in color with histologic sections showing
intense congestion and intrafollicular blood lakes.
Histologic features of the cases are shown in Fig. 4; in
no case was there pigment deposition. Each decedent had
characteristic features of crush asphyxia with signs of
compressive injuries to the torso (Fig. 5), and marked
congestion of the face, neck, and upper torso associated
with petechial and subconjunctival hemorrhages (Fig. 6).

Discussion
Black thyroid syndrome is a rare finding at autopsy that
usually suggests exposure to minocycline, although the
mechanism for its formation has not been definitely
established [5]. Most likely it is caused by an interaction
between minocycline and thyroid peroxidase, resulting in
deposition of pigment within the follicular epithelium and
colloid of the gland [6]. Primary thyroid tumors such as

Fig. 2 En bloc removal of the tongue, oropharynx, larynx, and

trachea in Case 3. Stripping of the thyroid capsule reveals the black
appearance of the parenchyma more clearly

medullary carcinomas may occasionally appear black if

there is concomitant production of melanin [7, 8]. Black
thyroid has also been described following doxycycline
treatment, and lithium carbonate, doxepin, and tricyclic
antidepressant therapy, the latter possibly due to lysosomal
accumulation of drugs [911]. Other conditions where the
thyroid may appear black include hemochromatosis,
ochronosis, and cystic fibrosis [10, 1214]. It is unclear
whether the thyroid may be pigmented in ceroid storage
disease [3, 6, 15].
It is of interest that although bruising and hemorrhage
are occasionally listed among the causes of black thyroid
[6], the forensic literature on this topic is sparse. In the
reported cases the thyroid glands appeared very dark/black
due to intense congestion arising from lethal chest compression. Crush asphyxia in this situation results from
direct compressive forces to the torso that restrict respiratory excursion [16]. It differs from positional asphyxia in
that respiration is impeded by significant pressure, not
merely by the position of the body, although on occasion
both mechanisms may occur [17]. Crush or traumatic
asphyxia may be found at all ages [18] and results from a
variety of situations ranging from entrapment beneath a
vehicle, to compression in crowd surges. Specific situations

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Fig. 5 Superficial abrasions across the lower back in Case 3

Fig. 3 Dissected thyroid gland from Case 3 (below) compared to a

thyroid gland (from a smaller individual) with a normal tan color
(above)

involving vehicles also include entrapment between a car

door and the chassis of a moving vehicle [19].
A direct effect of crush asphyxia is that the return of
venous blood to the heart is impeded by raised intrathoracic
pressure. This results in venous and capillary engorgement
with marked congestion of the face, neck, and upper chest
and widespread cutaneous and conjunctival petechial
hemorrhages. Petechiae may not, however, develop in
areas where there is pressure applied to the skin such as

Fig. 4 a Microscopy showing an intensely congested thyroid gland in

Case 3 with follicles separated by engorged capillaries and areas of
stromal interstitial hemorrhage; b Points of rupture of dilated
capillaries (arrowheads) in Case 1 with leakage of blood into the

adjacent colloid; c Higher power view in Case 2 showing small blood

lakes within follicles arising from perifollicular capillaries; d A
centrally-placed blood lake within a follicle in Case 3 (Hematoxylin
and Eosin 9 70, 70, 140, 140)

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Key Points
1.

2.

3.

Crush asphyxia may be associated with intense congestion of the thyroid gland resulting in a dark black
appearance.
Microscopically, stromal capillaries may rupture into
the follicles producing focal intrafollicular aggregates
of erythrocytes within the colloid.
As these are manifestations of intense congestion it is
possible that these changes may also be observed in
other situations where there is marked suffusion of the
head and neck.

Fig. 6 Typical congestion of the conjunctiva with petechial hemorrhages on the inner aspect of the lower eyelid in Case 4

References

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Although pathological changes within the thyroid gland
have not been previously emphasized, the current cases
demonstrate that in addition to marked vascular congestion
and engorgement of the skin and subcutaneous tissues of
the head and face in cases of trunk compression the richly
vascular thyroid gland may also become intensely suffused
with blood. This may impart a very dark appearance to the
gland that can be seen at autopsy (Figs. 1, 2, 3), thus
expanding the differential diagnosis of black thyroid to
include crush asphyxia.
The scattered blood lakes observed within colloid
appeared to arise from leakage of intensely congested
stromal capillaries, with rupture into the adjacent follicles.
The apparent continuity of aggregated intrafollicular and
stromal blood would be supportive of this association
(Fig. 4). Both a black thyroid gland observed macroscopically at autopsy and intrafollicular thyroid blood lakes on
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where there has been pronounced congestion of the head
and neck. These may include congestive cardiac failure,
superior vena caval syndrome, head down positional
asphyxia, and some hangings and strangulations. Evaluation of such cases may provide a more complete picture of
situations where these striking findings may be observed in
the thyroid gland.

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