Posttraumatic acute cholecystitis. Relationship to the initial trauma

Posttraumatic acute cholecystitis is an often unrecognized and potentially fatal complication seen among patients hospitalized for trauma, and differs in etiology from cholecystitis which develops de novo. The cause, although not yet clearly defined, is believed to be related to bile stasis, ischemia, bacterial infection, sepsis, the activation of factor XII, and the Shwarzman reaction. A case is described in which a 53-year-old man with pelvic fractures developed acute acalculous cholecystitis and died of multiple organ failure 3 weeks following cholecystectomy. The histopathological findings are also reported; these are most likely attributed to the Shwarzman reaction or the activation of the factor XII pathways. There has been a tendency to regard posttraumatic acute acalculous cholecystitis as induced by trauma, and calculous as mere coincidence. We believe, however, that it is not calculous but histopathological findings that determine whether acute cholecystitis following trauma was more than coincidence or just mere coincidence. Although progress in clinical care has improved the chances of survival of severely traumatized patients, posttraumatic acute cholecystitis has been increasing in frequency. We cannot be careful enough in judging the relationship of this fatal complication to the initial trauma.     

Rupture of ascending aorta secondary to esophageal perforation by fish bone

Perforations of both esophagus and aorta after swallowing foreign bodies have been described, with aorto-esophageal fistulas at the level of the descending aorta or aortic arch. We present the case of a 48-year-old man with esophageal perforation by fish bone, mediastinitis, and evidence of perforation of the ascending aorta during surgical drainage of the mediastinum. At autopsy, a fish bone was found under the aortic arch. Serial histological macrosections of the mediastinic block allowed reconstruction of the type of injury suffered and a thorough analysis of mediastinic structures, with preservation of topographic relationships. Direct demonstration of the perforation of the posterior wall of ascending aorta was provided. Histological examination ascribed aortic perforation to migration of the fish bone and direct injury. This is the first anatomical and pathological study of an autopsy case of perforation of the ascending aorta by fish bone.     

Medium‐Chain Acyl‐CoA Dehydrogenase Deficiency in Adulthood: A Potential Diagnosis in a Patient with Mental Status Changes Suspected of Drug Toxicity

Medium‐chain acyl‐CoA dehydrogenase (MCAD) deficiency is a rare but important component of the differential diagnosis for adults with a history of premortem mental status changes and the postmortem finding of hepatic steatosis. This case report describes a 30‐year‐old white man who, following a period of nausea and vomiting, was admitted to the hospital with sudden mental status deterioration followed rapidly by clinical deterioration and death. Treating physicians in this case suspected acute illicit drug toxicity with synthetic cathinones based on social history. Clinicians and medical examiners should be aware that the presentation, signs, and symptoms described may indicate an underlying inborn error of metabolism such as MCAD deficiency and take action accordingly.     

Biparietal Thinning: Accidental Death by a Fall from Standing Height

Biparietal thinning resulting in bilateral and symmetrical resorption and loss of thickness of the parietal bones is an uncommon to rare condition in the anthropological and clinical literature. This enigmatic condition of unknown etiology was first reported in the 18th century and has been variously described as a nonmetric trait, anatomical variant, anomaly, and pathology. Biparietal thinning presents grossly and radiographically as oval‐shaped depressions in 0.25–0.8% and 0.4–0.5% of individuals and with a higher frequency in females over the age of 60 years. A review of the literature revealed only one example of cranial trauma associated with biparietal thinning and none of fatal trauma associated with this condition. This case reports a rare example of fatal trauma in an elderly man that resulted from a backward fall from a standing height and highlights the increased risk of craniocerebral trauma in individuals with this condition.     

A Case of Fatal Spontaneous Varicose Vein Rupture—An Example of Incorrect First Aid

Abstract:  Severe external bleeding due to varicose vein rupture is a rare complication of this frequent venous pathology. Venous bleeding can be very intensive and can be mistaken for arterial hemorrhage. A rare case of fatal varicose vein rupture with an example of an incorrect and ineffective first-aid technique in a 43-year-old man is reported here with a review of the recent literature. The victim was found on a sand stack, not far from his domicile in a large pool of blood. The external examination revealed a flat ulcer on the internal surface of the right shank. On dissection, the lesion contained a perforation that was continuous with superficial veins arising from a varicosed saphenous vein. The man tried to give himself first aid, due to the massive bleeding that he probably predicted arterial bleeding and applied the ligature closer to the heart above the bleeding defect, thereby not stopping the venous bleeding but exacerbating it. Death was caused by a hypovolemic shock because of external hemorrhage from a varicose vein.     

Fatal suicidal crossbow injury--the ability to act

We report a case of a 58-year-old man who committed suicide using a modern crossbow. The victim shot himself in the chest with a conical field-tip arrow from close proximity. We first presumed that this was a case of homicide committed with a firearm. We were, however, subsequently proved wrong. The reasons for the primary statement were as follows: the external morphology of the entrance wound being typical of a firearm discharged from long distance; the perforation found on the victim's clothing; the absence of the firearm at the place of death; the absence of the arrow in the wound. All of these reasons forced us initially to conclude that the case was one of homicide. In the reported case, the man, after having been shot with an arrow, was further able to act, even though the abdominal aorta and liver were seriously injured. While the arrow was in the wound, the injuries may not have led to massive bleeding because of incomplete tamponade of the defects by the arrow shaft. Pulling the arrow out of the victim's wound track initiated massive bleeding. Despite all these injuries, the man was capable of pulling the bow string again and reloading the crossbow with the arrow used in the first attempt. This case demonstrates that forensic investigations into crossbow injuries can be very difficult, especially when the bolt has been removed from the body.     

Bile analysis in heroin overdose

Abstract:  Following its metabolism in the liver, morphine and its metabolites can be directly eliminated in bile. Then, they undergo the enterohepatic cycle (EHC) and mostly reappear in the circulation. We report a case showing the presence of morphine in bile (21.3 μg/mL) and hair (4.8 ng/mg) but not in blood, urine or the liver of an addict who survived in hospital for about 144 h (6 days). These data would indicate that the EHC does not play any role about 144 h after the last injection, and directly confirms that gall bladder is a storage depot for morphine. They constitute the first report of a demonstration of the effect of the EHC on morphine bioavailability in an addict, and could be considered as indication, without supporting circumstantial evidence, that the morphine level in bile is related to chronic opiate use.     

Occlusion of left and right coronary arteries and coronary sinus following blunt chest trauma

Blunt chest trauma from rapid automobile airbag deployment causing coronary artery occlusion and myocardial infarction is a rare but potentially fatal condition. We present the case of a 37-year-old man who developed extensive anterior and inferior myocardial infarction because of occlusion of both left anterior and right coronary arteries following blunt injury to the chest in a car accident. The patient was scheduled for emergency coronary angiography but left and right coronary ostia were not cannulated because of thrombus formation probably. The patient died, and the autopsy revealed external compression by epicardial hematomas involving separately left and right coronary arteries and the coronary sinus without signs of coronary and/or aortic dissection. To our knowledge, this is the first case presenting occlusion of both coronary arteries secondary to blunt chest trauma causing acute myocardial infarction in a young man without signs of prior coronary artery disease.     

Sudden Death Due to Undiagnosed Rheumatic Heart Disease in a Child

We report the case of a 5‐year‐old boy who died from complications of rheumatic heart disease with atypical presentation. He was hospitalized for recent inflammatory and neurological symptoms. He was diagnosed with viral encephalitis. He died the day after he was discharged. The macroscopic autopsy findings were unremarkable. Histology revealed typical rheumatic heart disease. Neuropathology showed cerebral infarction due to an embolic event linked with the rheumatic valvulitis. The cause of death was determined as heart failure due to rheumatic heart disease secondary to an undiagnosed acute rheumatic fever. It is related to an autoimmune response to infection with group A streptococcus. It mainly affects children in developing countries. In our case, viral encephalitis was consistent with the medical history and the proper diagnosis was made on histological analysis. Forensic pathologists should consider this diagnosis facing a sudden unexpected death in childhood, even in industrialized countries.     

An Unusual Case Showing Fatal Rupture of a Gastric Ulcer or Gastromalacia? The Importance/Role of Histology for Differential Diagnosis

Gastromalacia is the acute autolytic erosion of the gastric wall. It generally occurs postmortem, and it appears as a slimy brownish black region of the wall which occurs principally in the gastric fundus. A 59‐year‐old woman died in the Emergency Department following a 2‐day period of mild abdominal pain, vomiting, and diarrhea. A forensic autopsy was performed which revealed a rupture of the gastric fundus that had caused leakage of gastric content into the abdominal cavity. There was no macroscopic evidence of peritonitis, and the stomach wall adjacent to the rupture site showed marked thinning. The gross appearance was typical of gastromalacia. In contrast, histological observations revealed the presence of an ulcer at the site of perforation and a severe acute inflammatory reaction indicating a robust reaction with an antemortem rupture.     

Aortic Dissection and Sudden Unexpected Deaths: A Retrospective Study of 31 Forensic Autopsy Cases

Acute aortic dissection (AAD) is the most common cause of sudden unexpected death related to aortic diseases. A retrospective study of 31 sudden unexpected deaths caused by AAD was conducted at Xi'an Jiaotong University Forensic Center from 2001 to 2012. We summarized the forensic characteristics of AAD and assessed the clinically diagnostic accuracy of AAD. The characteristics of sudden unexpected death due to AAD were male predominant (male: female = 6.7:1), relatively young with the mean age of 44, and predominance of type A dissection (77.4%). Cardiac tamponade was the most frequent cause of sudden death (87.1%). Of the 31 cases, 26 (83.9%) patients were not recognized clinically and were misdiagnosed with acute myocardial infarction, coronary artery disease, cholecystitis, acute gastroenteritis, renal/urinary lithiasis, or acute pancreatitis. In summary, AAD can be difficult to recognize, diagnosis is therefore sometimes delayed or missed. The medicolegal death investigation can help physicians have a better understanding of AAD.     

Aqua-eroticum: an unusual autoerotic fatality in a lake involving a home-made diving apparatus

The term Aqua-eroticum was first introduced in 1984 by Sivaloganathan to describe the unusual autoerotic death of a man using submersion as an asphyxia method. This was the first case of that kind, and since then, no other case of autoerotic submersion has been reported, nor other autoerotic fatality in open water. Here we report the case of a 25-year-old man, nude under a home-made plastic body suit, overdressed for the season with winter clothes and restrained by complex bondage. He was submersed, tied underwater to a boat and was using a home-made diving apparatus for air supply. Death was ruled as accidental autoerotic asphyxia from rebreathing, caused by the faulty air-supply device.     

Endobronchial/Tracheal Metastasis and Sudden Death

Endobronchial and endotracheal metastases are rare lesions that may cause acute occlusion of major airways. A case is reported of a 62‐year‐old man with history of renal cell carcinoma and hemoptysis who died after having suddenly become short of breath with cyanosis. At autopsy, recurrent renal cell carcinoma was identified with metastases to the lungs, pulmonary hilar lymph nodes, and brain. In addition, a solitary papillomatous metastasis arising from the mucosa of the carina was obstructing both the main bronchi and distal trachea. Death was due to acute airway obstruction by a metastatic deposit at the bifurcation of the trachea in a case of disseminated renal cell carcinoma. This case demonstrates an extremely rare cause of sudden death that may complicate disseminated malignancy.     

Sudden Death by Occult Metastatic Carcinoma

A 33-year-old female collapsed and died suddenly after presenting with acute dyspnea and increasing cough over the preceding several months. Autopsy revealed poorly differentiated linitis plastica adenocarcinoma of the stomach. Microscopic examination of the lungs showed features consistent with pulmonary tumor thrombotic microangiopathy (PTTM). PTTM is a well-described complication in patients with adenocarcinoma. The typical presentation involves acute pulmonary hypertension, right-sided heart failure, and sudden death, often before the adenocarcinoma is discovered. The pathophysiology of PTTM remains elusive; it has been suggested that carcinoma cells may produce substances that influence pulmonary vasculature. Our patient had classic clinical and histologic features of PTTM in addition to prominent extravascular compression by intralymphatic tumor cells. These features undoubtedly caused her precipitous decline and lethal pulmonary hypertension, induced by underlying adenocarcinoma. This case demonstrates that sudden death can occur from pulmonary hypertension induced by metastatic carcinoma with remarkably little prior symptomatology.     

Incapacity of the Mind Secondary to Medication Misuse as a Not Criminally Responsible Defense

The manifestations of disorders of the mind may play a role in the occurrence of criminal behavior. In the majority of the cases, the presence of a psychiatric disorder is cited as the reason that an individual was not fully aware of his behavior. However, other conditions, such as seizure disorders or hypoglycemia, have also been linked to an inability to understand the nature and consequences of one's actions. On occasion, these situations can be explained by a state of automatism that may be described as insane or noninsane. In this article, we describe the case of a 77‐year‐old man, suffering from Parkinson's disease, where the issue of criminal responsibility associated with incapacity of the mind secondary to medication misuse was raised. We elaborate on the thinking behind this opinion and the implications according to Canadian law. Although the legal outcome of this case is specific to our jurisdiction, the clinical implication may be common to any patient suffering from a similar condition and may inform physicians, families, and lawyers.     

Acute Fatal Coronary Artery Dissection Following Exercise‐related Blunt Chest Trauma

Coronary artery injury such as acute coronary dissection is an uncommon and potentially life‐threatening complication after blunt chest trauma. The authors report an unusual autopsy case of a 43‐year‐old healthy man who suddenly collapsed after receiving a punch to the chest during the practice of kung fu. The occurrence of the punch was supported by the presence of one recent contusion on the left lateral chest area at the external examination and by areas of hemorrhage next to the left lateral intercostal spaces at the internal examination. The histological examination revealed the presence of an acute dissection of the proximal segment of the left anterior descending coronary artery. Only few cases of coronary artery dissection have been reported due to trauma during sports activities such as rugby and soccer games, but never during the practice of martial arts, sports usually considered as safe and responsible for only minor trauma.     

Left Ventricular Aneurysm: Sudden Unexpected Deaths in a 29‐Year‐Old Man

Left ventricular aneurysm (LVA) is an abnormal dilated heart structure, either congenital or acquired. LVA is a rare cardiac condition with no symptoms in most cases, thus occasionally diagnosed during investigations of other diseases. Its association with certain cardiac complications and sudden cardiac deaths has been reported. However, its role as a cause of sudden unexpected death is rare. The author reported a sudden cardiac death in a 29‐year‐old man with LVA. Without a significant coronary artery disease and known etiologies of LVA, such an abnormal heart structure in the present case was considered congenital LVA. As no other possible mechanisms of death could be identified other than LVA with its associated pathologic lesions, mural thrombi, and dilated cardiomegaly, his death was attributable to fatal cardiac arrhythmia (most commonly ventricular tachycardia) secondary to LVA.     

Possible Fatal Acetaminophen Intoxication with Atypical Clinical Presentation

Acetaminophen or paracetamol, a commonly used over‐the‐counter analgesic, is known to elicit severe adverse reactions when taken in overdose, chronically at therapeutic dosage or, sporadically, following single assumptions of a therapeutic dose. Damage patterns including liver damage and, rarely, acute tubular necrosis or a fixed drug exanthema. We present a case of fatal acetaminophen toxicity with postmortem blood concentration 78 μg/mL and unusual clinical features, including a visually striking and massive epidermolysis and rhabdomyolysis, disseminated intravascular coagulation and myocardial ischemia. This case is compared with the most similar previous reports in terms of organ damage, clinical presentation, and cause of death. We conclude that a number of severe patterns of adverse effects to acetaminophen are emerging that were previously greatly underestimated, thus questioning the adequacy of the clinical spectrum traditionally associated with acetaminophen intoxication and leading to the need to review this spectrum and the associated diagnostic criteria.     

A distant-range, suicidal shotgun wound of the back

The case being reported is one of a shotgun fatality with a thoracic back wound. A 23-year-old man was shot from a distance with trajectories going from back to front and on a nearly horizontal level. These findings observed in the autopsy could represent homicide, but scene investigation and police records were interpreted and it became clear that the case was suicide. Thus, this case shows that the determination of the manner of death requires a careful forensic investigation including autopsy findings, scene investigation, and reconstruction of the events.