As previously stated, ulceration and haemorrhage are known complications of chronic venous disease, although usually benign (Serinelli et al. 2020).
There are two types of ulceration: acute perforation, usually involving a superficial tributary vein around the medial malleolus (Jelev and Alexandrov 2011), consisting of a small lesion (< 0.5cm) with marginal cutaneous involvement, and chronic ulceration, comprising a wider lesion (1–10 cm) associated with skin pigmentation, induration and erosion (Fragkouli et al. 2012).
Regarding the haemorrhagic event, it can happen spontaneously or as a result of minor trauma (Serinelli et al. 2020). Irrespective of its cause, when a varicose vein ruptures, profuse bleeding may occur and can possibly lead to unconsciousness and fatal exsanguination in less than 20 min (Jelev and Alexandrov 2011). Despite rare, fatal haemorrhages from varicose vein ruptures are well documented in scientific literature (Serinelli et al. 2020; Fragkouli et al. 2012; Cocker and Nyamekye 2008). Because they may be severe, with a rapid onset of loss of consciousness, these events constitute a true medical emergency (Serinelli et al. 2020; Fragkouli et al. 2012).
Fatal haemorrhage can be triggered by factors such as advanced age, social isolation, alcohol abuse, anticoagulation medication and comorbidities like dementia, chronic ischemic heart disease and liver cirrhosis (by impairing the normal production of coagulation factors) (Fragkouli et al. 2012).
In the presented cases, both victims had chronic venous disease, with several skin changes in their lower limbs. Family members, who helped the first victim and called the emergency services upon the deterioration of his clinical condition, accompanied him. On the contrary, the second victim was alone and tried to get help from a friend without success.
The gathered circumstantial information, the presence of large amounts of blood on the bodies’ surfaces and clothes, and malleolus ulcers agree with the fatalities reported in scientific literature.
In cases like the ones presented, death might be perceived as violent, due to the large amount of blood found at the scene (Fragkouli et al. 2012).
It is generally perceived that patients with chronic venous disease do not get routine medical counselling on haemostasis control (Cocker and Nyamekye 2008), and these victims are unaware of the complications associated with such a disease. That fact, combined with the lack of health care providers’ knowledge on this subject, leads to an incorrect assessment of the situation’s severity and, as a result, no early preventive nor, ultimately, life-saving intervention takes place (Fragkouli et al. 2012).
In addition, circumstances of death are also not always clear, and additional information is sometimes unavailable.
These cases are peculiar, both from a forensic pathology and from a clinical perspective, bearing an important and preventive message. In that sense, it is our aim to help the medical community to acknowledge this major complication linked with a disease generally recognised as benign. In fact, in some cases, its manifestations can be severe or even result in death. Likewise, we intend to emphasise the need to alert patients for this outcome, so that they can recognise the need to call emergency services, as well as accurately explain their situation when doing so.