What is the differential diagnosis for assault victims?

Differential Diagnosis for Assault Victims

The differential diagnosis for assault victims must systematically address traumatic injuries, infectious complications, and mimics of abuse, with particular attention to head trauma, sexually transmitted infections, pregnancy risk, and conditions that can masquerade as intentional injury.

Traumatic Injuries

Head and Neurological Injuries

• Traumatic brain injury is the most critical consideration, particularly in pediatric victims where abusive head trauma occurs in 0.54%-2.5% of cases presenting with concerning symptoms 1
• Subdural hematoma represents the most important head injury with regard to death in assault victims 2
• Diffuse axonal injury results from angular or rotational acceleration of the head and presents with immediate and prolonged coma or altered mental status; the diagnostic triad includes focal lesions in the corpus callosum and brain stem, plus microscopic axonal damage 2
• Epidural bleeding can occur and requires urgent identification 3
• Retinal hemorrhages are a key component of abusive head trauma diagnosis, particularly in pediatric cases 4

Facial and Skeletal Injuries

• Nasal fractures are the most common specific diagnosis in assault victims, occurring in approximately 4% of cases 3
• Facial trauma affects 30% of geriatric assault victims and is the most commonly injured body region overall 5
• Rib fractures are consistent with the mechanism of abusive trauma, particularly in pediatric cases 4
• Multiple skeletal injuries in various stages of healing should raise suspicion for ongoing abuse 1

Thoracoabdominal Injuries

• Pneumothorax can occur from blunt or penetrating trauma 3
• Penetrating injuries occur in 32% of geriatric assault victims 5
• Intra-abdominal injuries must be systematically evaluated, particularly in pediatric victims 1

Infectious and Reproductive Complications (Sexual Assault)

Sexually Transmitted Infections

• Gonorrhea requires culture from throat, cervix/urethra, and anorectal sites 1
• Chlamydia requires culture from cervix/urethra and anorectal sites, with NAAT testing from vagina and cervix/urethra 1
• Trichomonas, bacterial vaginosis, and candidiasis require vaginal microscopy 1
• HIV, hepatitis B, and syphilis require baseline blood testing with repeat testing at 6 weeks, 3 months, and 6 months 1

Pregnancy-Related

• Pregnancy occurs in 5% of female rape victims aged 12-45 years and requires baseline urine pregnancy testing 1
• Emergency contraception failure should be considered at 2-week follow-up 1

Differential Diagnoses That Mimic Abuse

Pediatric Mimics

• Bone fragility disorders (osteogenesis imperfecta, metabolic bone disease) must be excluded through laboratory evaluation 1
• Bleeding disorders (hemophilia, von Willebrand disease, thrombocytopenia) require coagulation studies 1
• Cerebral sinovenous thrombosis can present similarly to abusive head trauma 4
• Hypoxic-ischemic injury must be distinguished from traumatic brain injury 4
• Apparent life-threatening events (ALTE/BRUE) may represent abusive head trauma in 2.5% of cases 6

Other Medical Conditions

• Accidental trauma must be distinguished from intentional injury through careful history and pattern recognition 1
• Caregiver-fabricated illness (Münchausen by proxy) can present with similar symptoms but lacks radiologic findings 1
• Smothering and poisoning may not be identified by standard radiologic evaluations 1

Psychological and Behavioral Sequelae

Acute Psychological Conditions

• Post-traumatic stress disorder occurs in up to 80% of rape victims 1
• Acute stress reaction with disbelief, anxiety, fear, and emotional lability 1
• Suicidal ideation requires immediate psychiatric assessment 1

Substance-Related

• Alcohol intoxication is present in approximately 40% of adolescent sexual assault cases and 30% of geriatric assault victims 7, 5
• Drug-facilitated assault with voluntary or coerced substance use 7

Key Clinical Pitfalls

• Head trauma in male patients should raise suspicion for assault, as 75% of male assault victims have head injuries 3
• Absence of physical injury does not exclude assault, as consensual and nonconsensual sexual activity may result in no physical injury 1, 7
• Normal physical examination does not rule out abusive head trauma in pediatric cases; thorough history and examination remain the best screening tools 1
• Geriatric assault victims have significantly higher injury severity, mortality, and ICU requirements compared to younger victims, even when controlling for injury severity 5
• Female victims with spouse as perpetrator represent 9% of assault cases and require specific safety assessment 3