Sudden cardiac death due to giant cell inflammatory processes

Granulomatous inflammation of the myocardium may occur in a number of systemic disease processes including those with infectious etiologies such as fungal, mycobacterial and parasitic infections, as well as hypersensitivity reactions, and rarely autoimmune disorders. In many of these disorders, giant cells are components of the inflammatory infiltrate. Systemic granulomatous processes of unknown pathogenesis, most notably sarcoidosis, may also be associated with involvement of the myocardium. Occasionally, these disorders are associated with sudden death due to pathologic involvement of the heart. In contrast, giant cell myocarditis, also known as idiopathic myocarditis, a rare, frequently fulminant and fatal disorder of unknown etiology, is isolated to the heart and lacks systemic involvement. This disorder is most commonly diagnosed at autopsy. We present two cases in which sudden death resulted from a giant cell inflammatory process affecting the myocardium. Both individuals lacked antemortem diagnoses and collapsed at their respective places of employment. These cases compare and contrast the clinical and pathologic issues involved in the differential diagnoses of the subgroup of sudden cardiac deaths resulting from giant cell inflammatory processes that affect the myocardium, as well as the value of histologic examination and immunohistochemical studies.     

Sudden death due to an unrecognized cardiac hydatid cyst

Echinococcosis is an endemic disease, most common in sheep-raising communities, usually caused by the larval or cyst stage of the tapeworm Echinococcus granulosus. Isolated cardiac hydatid cyst is uncommon at any age, occurs through the coronary circulation, and accounts for less than 3% of all hydatid disease. We describe a case of an 1%-year-old female, who died suddenly. The post-mortem examination revealed an isolated cyst in the left ventricle of the heart with intact wall. The cytologic examination of the cyst fluid demonstrated the presence of the characteristic scolices and hooklets and established the diagnosis of cardiac hydatid cyst. The present case is of special interest because of the rare primary localization and the onset of sudden death in a young person as the initial manifestation of the disease.     

Sudden death from saccular laryngeal cyst

Laryngeal cysts are benign, uncommon lesions of the larynx that have been reported on rare occasions to cause sudden death in infants and adults by acute airways obstruction. In this report, we document the sudden death of a 36-year-old woman from a previously undiagnosed, asymptomatic laryngeal saccular cyst that presented with acute, and consequent fatal, airway obstruction. Difficulty during intubation, both in theater and in emergency settings, is a frequent presenting problem. This can have significant medicolegal implications in determining possible negligence. The diagnosis, classification, and management of such cysts, and their importance to both the forensic pathologist and clinicians are discussed.     

Sudden death in infancy due to bicuspid aortic valve

Symptoms of bicuspid aortic valve usually occur in the age group of 50-70 years, but rarely, it can also lead to sudden unexpected death in infancy and early childhood. The autopsy of a 2-month-old baby boy, found dead in his cot, revealed the heart weight as 25 g, and the macroscopic examination showed the circumference of the aortic valve consisting of two leaflets as 8 mm. The thickness of the left ventricle, right ventricle, and septum was measured as 8, 7, and 10 mm, respectively. Microscopically, the heart revealed hypertrophic changes of myocytes. Subendocardial areas displayed necrosis of myocytes, and severe and diffuse ischemic changes characterized by loss of myofibers and vacuolization. Interstitial pneumonia was identified in the lungs. Death occurred as a result of a congenital bicuspid aortic valve obstructing the left ventricular outflow tract complicated by lung infection. As there are only a few reported cases in infancy, and congenital bicuspid aortic valve can lead to sudden unexpected death, this case is presented to the forensic community.     

Sudden unexpected death due to a previously undiagnosed plasma cell dyscrasia

The plasma cell dyscrasias are a diverse group of disorders characterized by the production of a clonal paraprotein. Sudden death is a recognized complication of the plasma cell dyscrasias, most commonly in individuals with cardiac involvement by amyloidosis. However, the current forensic literature has no reported cases in which sudden death resulted from complications of a plasma cell dyscrasia that was first diagnosed by postmortem histologic examination. We present the case of a woman whose sudden and unexpected death resulted from a seizure. Postmortem examination revealed no evidence of trauma or a grossly identifiable natural disease process that would have accounted for her death. However, microscopic and immunohistologic studies revealed a previously undiagnosed plasma cell dyscrasia, the clonality of which was determined by immunohistochemical studies for immunoglobulin light chains, that was not associated with amyloid deposition. This case elucidates a previously unrecognized cause of sudden unexpected death and illustrates the importance of microscopic studies in selected cases examined in medical examiner/coroner offices.     

Sudden death from tubercular myocarditis

Tuberculous myocarditis is a rare finding. We present the case of a 33-year-old woman who was in good health and who died suddenly at home. Autopsy and histopathologic examinations revealed granulamatous lesions in the myocardium, lungs, lymph nodes, liver, and spleen. No fast acid bacilli were demonstrated on histological examination. The presence of a Mycobacterium tuberculosis DNA complex was identified using a polymerase chain reaction (PCR) on formalin-fixed paraffin-embedded histological samples. An HIV test carried out on the blood obtained during the autopsy was negative according to the DNA amplification technique (PCR) and enzyme-linked immunosorbent assay serological test. We hypothesize that the mechanism of death was severe ventricular arrhythmia due to granulomatous proliferation in the structures of the interventricular septum.     

Sudden and unexpected death from pituitary tumor apoplexy

Pituitary tumor apoplexy refers to a clinical syndrome precipitated by the expansion of a pituitary adenoma by hemorrhage or infarction. Individuals may present with myriad signs, including sudden onset of severe headache, visual changes, altered mental status, cranial nerve palsies, and hormonal dysfunction. This disorder constitutes a medical emergency and warrants an expedited evaluation, diagnosis, and treatment to prevent the potential sequelae of permanent visual loss, endocrine abnormalities, or death. We report a case of sudden death from undiagnosed pituitary tumor apoplexy. The decedent was evaluated by medical personnel on three occasions in the week prior to her death for severe headache, nausea, vomiting, and photophobia. Postmortem examination demonstrated a hemorrhagic infarction of a pituitary adenoma with necrosis and expansion out of the sella turcica. The recognition of and treatment for a patient with pituitary tumor apoplexy requires a rapid multidisciplinary effort. Failure of prompt diagnosis may be fatal and require a medico-legal death investigation for sudden and unexpected death.     

Sudden death owing to right atrial hemangioma

Primary cardiac tumors are rare, with an autopsy incidence of 0.03%. Seventy-nine percent to 85% of primary cardiac tumors are benign, and of the benign tumors, cardiac hemangiomas account for 5-10% of cases. Most cardiac hemangiomas are asymptomatic and are discovered incidentally at autopsy, or by echocardiography, computerized tomography, or magnetic resonance imaging. We report a case of sudden death owing to cardiac hemangioma in a 22-year-old woman who collapsed while shopping and became unresponsive. The autopsy revealed a hemorrhagic mass on the surface of the right atrium which was infiltrating and replacing the wall of the right atrium; histopathological examination confirmed the tumor was a cavernous hemangioma. Fewer than 20 cases of right atrial cavernous hemangiomas have been reported in English literature, emphasizing the rarity of our case.     

Sudden death in toddlers caused by influenza B infection: a report of two cases and a review of the literature

Sudden fatal cases of influenza B infection in a 4-year-old girl and a 2-year-old boy are presented. Both children complained of abdominal pain without respiratory, neurologic or cardiac symptoms; additionally the girl had vomiting within 2 days of death. Autopsy revealed histological changes in the respiratory system consistent with a viral infection. Influenza B infection was identified by immunohistochemistry in the girl and real-time polymerase chain reaction in the boy. Additional testing including cultures, toxicology, and screening for metabolic disorders were negative. These cases illustrate the usefulness of viral testing, especially for influenza, in the medical legal autopsy of children even when the classic respiratory symptoms of flu are lacking.     

A case of sudden infant death due to a primary cardiac sarcoma

The case reported herein concerns the unexpected death of a 3-month-old female newborn who suddenly collapsed in her mother's arms and was dead on arrival at the hospital. The clinical histories of the baby and her parents were negative for symptoms or signs of illness, even those of cardiovascular origin. Furthermore, no clinical appearance of a pathologic status was noted by pediatricians after the birth until the last emergency recovery. The autopsy excluded external and internal signs of violence but revealed a large primary cardiac tumor arising from the free wall of the left ventricle, which had totally invaded the heart causing mitral valve deformation. Histological examination showed a low-grade sarcoma that completely infiltrated the myocardial tissue. The pathogenesis of this sudden infant death was postulated as being owing to a fatal ventricular fibrillation combined with a tumor-related restrictive cardiomyopathy obstructing left ventricular filling.     

婴儿猝死综合征的法医学鉴定

近20多年来,婴儿猝死综合征（sudden infant death syndrome,SIDS）一直是西方发达国家医学界尤其是法医学和儿科学领域研究的热点。目前,随着对SIDS广泛而深入的研究,对其病因、发病特点、危险因素以及致病机制等都有了更明确的认识。虽说近年来SIDS的发病率已有明显下降,在欧美洲、澳洲等发达国家,SIDS仍然是导致1个月到1岁婴儿死亡的首要原因。在亚洲国家和地区,尤其是发展中国家SIDS的报道很少见。本文通过总结文献并结合美国马里兰州近20年（1990—2006）来对SIDS的调查研究资料,介绍SIDS的发展历史、研究现状和新的发展趋势,并对SIDS法医学鉴定程序及鉴定要素进行讨论。     

300例心源性猝死案例的法医学鉴定分析

目的探讨心源性猝死案例的病因、诱发因素及法医病理学特点,以期为心源性猝死案件的法医病理诊断提供参考。方法收集法医病理检案中的心源性猝死案例,对其年龄、性别、死亡时间、死因、诱因及场所等流行病学特点进行回顾分析。结果 300例心源性猝死案例中男性多于女性,18~45岁发病最多;病因包括冠心病(129例),心肌病(78例),心肌炎(36例)等;应激为SCD最常见的诱发因素(157例)。结论 1应激和冠心病是心源性猝死的重要危险因素。2心源性猝死的法医学鉴定除了要进行系统的尸检及病理学检查外,还要对死者的相关资料如:基础疾病、诱因、死亡时间、死亡经过等进行全面系统的分析以明确死因。     

Sudden Death due to Brainstem Leukemic Hemorrhage: A Case Report

Introduction Leukemia is a hematologic neoplasm character- ized by potential infectious and hemorrhagic com- plications. In adult patients with acute leukemia, in- fection is the most common complication. Intracra- nial hemorrhage （ICH） is the second most common complication. However, ICH has been identified as the major cause of morbidity and mortality in pa- tients with leukemia[1-6].     

97例心性猝死的法医病理学分析

目的探讨心性猝死（SCD）的特点、病理基础及致死因素和诱因等。方法对本系2002年12月至2006年12月期间，所作450例法医病理检案的97例心性猝死案例进行分析研究。结果97例SCD患者中，冠心痛猝死38例，心肌炎23例，心肌痛16例，高血压性心脏病12例，主动脉瘤破裂4例，肺栓塞4例。结论SCD病程短骤、凶险，以老年男性多见，冠心病占首位。由于猝死的因素繁多，因此对猝死事件的法医学鉴定要根据其发生特征和变化规律，作出客观、全面、准确的签定结论。     

Sudden cardiac death in young adults: environmental risk factors and genetic aspects of premature atherosclerosis

Familial hypercholesterolemia (FH) is a genetic disorder that may lead to premature coronary heart disease (CHD) and sudden cardiac death (SCD). Mutations in the LDLR or APOB genes cause FH. We have screened the LDLR and the ligand-binding region of APOB genes in 52 cases of SCD. Deceased patients were younger than 40 years of age and were suspected of having FH. The LDLR and APOB genes were examined via PCR, high-resolution melting, and DNA sequencing. Therein, it was observed that 7.7% of the screened patients exhibited a rare sequence variant in the LDLR gene, with 5.7% suspected of being pathogenic mutations. Lipid profiles and genetic testing for FH could be considered when autopsy reveals significant atherosclerosis of the coronary arteries in young adults. First-degree family members are advised to seek medical advice and testing to determine their own risks of atherosclerosis to prevent premature CHD and SCD.     

316例急死的法医学分析

对重庆地区316例急死进行分析。结果表明:男性多于女性,中青年及小于10岁的婴幼儿居多,第三季度增多,呼吸系统疾病居首位,其次为循环系统疾病,死亡场所是医院占多数。     

连接蛋白43与心性猝死的相关性研究进展

部分心性猝死者死后尸检时心脏没有发现明显病理学异常征象,过去均将其归属原因不明的猝死范畴。近年来研究显示,心肌连接蛋白43（connexin43,Cx43）表达对于心性猝死的诊断具有十分重要的意义。本文就Cx43结构、功能以及在心血管疾病发生发展中的作用与法医学意义作一综述。     

抗精神病药物致心源性猝死的机制及其法医学意义

精神障碍患者是由各种原因导致脑功能障碍并伴有一系列功能缺失和寿命缩短的群体,其死亡率为普通人群的2~5倍,且服用抗精神病药物导致猝死的发生率明显高于不服药者。大量案例报道和临床资料的回顾性研究表明,精神障碍患者发生心源性猝死风险与服用APs相关。本文简要介绍APs致心源性猝死的机制和危险因素,以期为法医学鉴定提供参考依据。     

Diagnostic dilemma of sudden deaths due to acute hemorrhagic pancreatitis

Sudden death due to acute pancreatitis has been rarely determined. A review of 3305 autopsies performed between 1991 and 2001 at the Council of Forensic Medicine found 12 cases (0.36%) with sudden death due to acute hemorrhagic pancreatitis without symptoms. A history of chronic alcohol ingestion was obtained from family in four cases (33%), and no stones were found in the bile ducts or in the gall bladders. During the autopsies, hemorrhage and edema were localized on the head of the pancreas in three cases and the whole pancreas in nine cases. The most common extrapancreatic pathology was found in the lung including pulmonary edema, alveolar hemorrhage, pleural effusion, and pulmonary congestion. There was no correlation between pulmonary and pancreatic damage. It is suggested that the forensic pathologists who are dealing with sudden unexpected death must not ignore the examination of pancreatic and extrapancreatic regions to avoid missing acute pancreatitis.     

致死性心律失常的法医学研究进展

据文献报道,有很多心源性猝死是由于致死性心律失常所致。在法医学鉴定工作中,心律失常所引起的猝死往往很突然,尸检及镜下病理学检查又缺乏特征性的改变,使得鉴定其死亡机制成为一大难点。因此,寻找一种客观、准确的心律失常鉴定方法,对于致死性心律失常所致心源性猝死的鉴定尤为重要。本文将就上述问题,从致死性心律失常的定义、分类、产生原因、致死机制、形态学所见及死后生化检测指标等方面进行综述,以期为心源性猝死致死原因的法医病理学分析、鉴定提供帮助。