When Trichophagia Becomes Lethal: Forensic Identification of Fatal Rapunzel Syndrome at Postmortem Examination

Abstract Rapunzel syndrome is an extremely rare and severe form of the trichobezoar characterized by a gastric hairball with a tail-like extension into the small intestine. This condition is frequently associated with trichotillomania (hair-pulling) and trichophagia (hair-eating), primarily affecting children and adolescent females. Due to the nonspecific nature of symptoms, diagnosis is often delayed, increasing the risk of severe complications such as obstruction, perforation, and peritonitis. We report a case of a 15-year-old female who had a known history of psychiatric illness, including autism spectrum features, chronic psychotic disorder, and long-standing schizophrenia-like symptoms. She was found deceased and referred to the forensic department for external and internal examination to determine the cause of death. External examination revealed a severely cachectic female with poor nutritional status. Upon autopsy, abdominal and pelvic dissection revealed a large segment of the distal small intestine that showed thinning of the wall, multiple areas of mucosal ulceration, focal necrosis, and six parallel areas of perforation with leakage of intestinal contents. Surrounding the perforation was a zone of purulent peritonitis, with fibrinous exudate, offensive odor, and reactive inflammation of the peritoneal surfaces. Furthermore, the terminal ileum revealed a large intraluminal trichobezoar, a densely packed mass of intertwined human hair. This elongated hair mass measured approximately 12 cm × 6 cm × 5 cm, extending proximally by several centimeters and completely obstructing the intestinal lumen. Distal to the obstruction, loops of the small intestine were markedly dilated and fluid-filled. Rapunzel syndrome requires a low threshold of suspicion in young females, with a concurrent history of mental disorders.