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Suicide is a major public health issue and the risk of attempting and committing suicide increases with age. We present the case of an elderly couple who decided to commit suicide together by self-poisoning using levamisole-adulterated cocaine. The choice of committing a double suicide, the method selected (self-poisoning), the drug self-administered (cocaine), and the route of administration (ingestion) are events rarely encountered in the forensic pathology practice, especially not in combination. In this article, we will review the literature regarding the frequency and features of these methods of suicide. An overview of the effects and mechanism of action of levamisole is also provided, highlighting the importance of including this substance and its metabolites in the routine toxicological analyses for cocaine deaths.

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Chronic venous insufficiency is generally not lethal, but massive bleeding from ruptured varicose veins can be fatal. A 79-year-old woman was found dead in her apartment in Rome. Pools of blood and contact pattern bloodstains were observed around the body. She lived alone and suffered from vascular dementia. On the medial aspect of the right leg, a circular ulcer communicating with the lumen of a varicose vein was noted. Death was attributed to hypovolemic shock caused by bleeding from the rupture of the varicose vein. Our case confirms that varicose veins rupture is a potentially fatal medical emergency. Conditions such as dementia may lead to failure to understand the gravity of the bleeding and to seek help. Recognition of this issue is important especially when the care of people suffering from mental illness is involved.