While it can be treated with medical support, death may also occur as a result of these diseases. As in our case and observed in other studies, it causes lack of hygiene due to self-neglect, poor nutrition which causes anemia and vitamin deficiencies, and due to take or refuse medical care it may lead aggravation of diseases such as congestive heart failure, bronchopneumonia, diabetes mellitus, ischemic heart disease, cerebrovascular disease, and different malignancies (11). Therefore, these cases can be classified as secondary Diogenes Syndrome (11). At least in 50% of the cases a kind of psychiatric disorder was described (3). However, differences among the cases in cognitive and socio-economic levels were reported (11). In some studies, it was reported that there were no mental illness in patients affected by the illness on the contrary they have average or high intellectual level (6,8,10). However, it was indicated that an exaggerated sense of self disorganized lifestyle or indifference depending on the aggravation can occur together with older ages (6). Although exact causes of this kind of behavior and way of life are not still well known, it has been hypothesized that illness may occur as a result of a response given to the various stress factors such as death of spouse or a significant medical illness among people with subclinical personality disorder (7,8). The syndrome was identified in 30 elderly patients treated by Clarke and colleagues for the first time in 1975 (6). The syndrome, defined as self-neglect, depression, lack of care and social isolation, is known as ‘Diogenes Syndrome’ because of having similarities to the lifestyle of a Greek philosopher Diogenes’ lived in 4th century BC. With no significant feature in toxicological analysis and having metastatic laryngeal carcinoma, the person’s death was diagnosed as a result of the combination of old ground effects of an acute myocardial infarction and having pneumonia. In the histopathological examination of larynx, squamous cell carcinoma, neck metastasis on the left side, healed and new myocardial infarction areas at the heart, and pneumonia were identified. An ulserovegetan tumor, settled on the left side of the supraglottic region of larynx spreading to the epiglottis was revealed (Figure 2). In autopsy examination when the skin and subcutaneous tissues of the neck were dissected, in sections of the mass in the neck on the left side it was found to be associated with submandibular gland with areas of firm consistency in dirty yellow color, with multifocal hemorrhage areas. Lung sections were edematous and had pale appearance. Lung surfaces were in anthracotic appearance and the right lung was 850 gr and the left lung was 600 gr. In the heart, in septum myocardial sections, 6x4 cm of full-thickness old silvery colored myocardial infarction area was detected (Figure 1). At autopsy, in pericardium, 50 cc of liquid in serous character and 90% occlusion of the left anterior descending branch of coronary artery was found. In external examination he was in cachectic appearance and on the left submandibular region 4.5圆x3 cm of mass was detected, on the left side chest post-mortem abrasions and on abdomen presence of a 12 cm-old operation scar beginning on umbilicus was seen. In the examination of death report, he was found lying on his right side on the benches at the edge of the street and dead, according to the registered testimony of one of his relative: the dead man lived alone and there were a variety of diseases he had. Our case was a 62 year old male living alone. A squamous cell carcinoma of the larynx was identified in the presented case and his evaluation in terms of Diogenes Syndrome, aimed to be discussed by using the recent medicolegal literature. Although psychiatric and clinically well-defined patients are reported beforehand the forensic aspect of this kind of life style or conditions, the number of cases reported and studies are very low. In these cases accumulation of a large amount of substances such as garbage, paper, newspaper in their environments is characteristic (4.5). Because of the way of life Diogenes live, some older individuals who have social isolation and severely neglect their personal self-care, including a characterized collection of symptoms and the psychopathology associated with the lack of concern about a person’s living conditions were defined as ‘Diogenes Syndrome’ (2- 5). Diogenes of Sinop (412-323 BC) was a man, philosopher, who rejected whole tradition by developing a different philosophy in religion, behavior, dressing, housing, food, manner and although was said to walk around in a vat, he was also said to live in a pot made of soil used for funerals (1).
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