Infant postmortem CT pitfalls: Misleading tales of pneumothoraces

• Post-mortem CT (PMCT) can demonstrate gas patterns in infants that closely mimic traumatic pneumothoraces, posing a risk for misinterpretation in suspected non-accidental injury or infanticide cases. • Two infant cases with PMCT-demonstrated pneumothoraces were ultimately proven to represent non-traumatic, misleading gas accumulations, one iatrogenic from peri-resuscitative needle injury and one decomposition-related due to a congenital diaphragmatic defect. • Correlation of PMCT findings with the post-mortem interval, case history, autopsy dissection techniques, and histopathology is essential to distinguish true antemortem pneumothoraces from post-mortem or artefactual gas. • Cadaveric gas can accumulate in pleural, peritoneal, and intracranial spaces and may mimic tension physiology on PMCT, underscoring the importance of recognising decomposition-related gas distribution patterns in paediatric cases. • Misinterpretation of PMCT gas findings in infants may lead to serious medico-legal consequences, highlighting the need for education on common PMCT pitfalls and the potential for false-positive indicators of trauma. Post-mortem computed tomography (PMCT) is a valuable tool in forensic practice, aiding in the medico-legal investigation of infant deaths, especially when evaluating for possible non-accidental injury or trauma. However, PMCT findings can sometimes highlight findings of unclear significance, such as iatrogenic or post-mortem gas accumulation, which complicates the interpretation of antemortem pathology, such as traumatic or spontaneous pneumothoraces. Pneumothoraces in general are often associated with trauma in the clinical context, posing a risk for misinterpretation in autopsy investigations. We present two cases: an 8-month-old infant and a newborn involving concealment of birth, both of whom presented with pneumothoraces on PMCT. In each case, PMCT demonstrated gas patterns that could be misinterpreted as signs of trauma or non-accidental injury. Careful examination of the PMCT findings, post-mortem interval analysis, autopsy planning and special dissection technique to ascertain the distribution and origin of the gas allowed for recognition of these features as spurious findings (or false indicators) rather than indicators of trauma.