Acute poisoning involving the pyrrolidinophenone-type designer drug 4'-methyl-alpha-pyrrolidinohexanophenone (MPHP)

A 36-year-old woman consulted the medical emergency unit of a private health center for abdominal pain and gastroenteritis of 5 days duration. Acute right pyelonephritis was diagnosed. Five hours after admission she became unconscious in a state of clinical shock. She was transferred to an intensive care unit but resuscitation attempts were unsuccessful and she died 3 h later. Three days after death, she was buried in the family vault. Five days after the burial, her husband lodged a complaint with the public prosecutor because he had not received a clear explanation from the physicians concerning the cause of his wife's death. After analysis of the medical records of the deceased by two forensic pathologists, a medicolegal autopsy was ordered by the public prosecutor. The corpse was exhumed and autopsy performed 9 days after death. Massive hemoperitoneum was diagnosed with a macroscopically ruptured subcapsular hematoma. Pathological study confirmed acute right pyelonephritis and demonstrated the precise cause of the hemorrhage: rupture of the hepatic artery at the hilar part, following infectious arteritis which was probably secondary to the acute pyelonephritis. To the best of our knowledge, this is the first published report of such a case.     

Sudden Death by Spontaneous Epiglottic Hematoma Secondary to High Blood Levels of Warfarin

A 67‐year‐old man was found dead, at his home. On external examination, we found a voluminous purplish black ecchymosis of the anterior neck area. On internal examination, we found a voluminous epiglottis hematoma completely obstructing the upper airway. It was associated with other sites of intra‐abdominal hemorrhage. Toxicological studies revealed the presence of warfarin at a concentration of 8.4 mg/L in peripheral blood, which supposes an INR well above 4.5. To conclude, we supposed death was due to asphyxia secondary to a spontaneous epiglottic hematoma caused by a high blood concentration of warfarin. Hemorrhage in the epiglottis is very rare. To our knowledge, our patient is the only case of “sudden death” reported with spontaneous epiglottic hematoma due to high blood concentration of warfarin. In forensic practice, an anterior neck ecchymosis, without trauma, may suggest hemorrhage into soft airway tissues. Pathology findings make it possible to exclude exogenous trauma.     

Genesis of atraumatic liver hemorrhages

Hepatic hemorrhages are not unusual after sharp or blunt abdominal traumata. They are of particular interest when deadly hepatic hemorrhages are under discussion as the single or contributory cause of death in forensic investigations, for instance after reanimation or acts of violence. The test results in rabbits demonstrate that artificial and specific enzyme-assimilation conditions can cause atraumatic hepatic hemorrhages in only a few days. With and without concomitant injuries, liver bleeding may have an atraumatic genesis. An additional human case report shows the possibility of confusion with atraumatic rhexis hemorrhage in the liver.     

Death Due to Coronary Artery Insufficiency Following Blunt Trauma to the Chest

There have been numerous reports of sudden cardiac death following blunt trauma to the chest, but there is lack of such references in forensic literature. It is the court of law which makes decision about trauma precipitating natural events. The forensic pathologist is scientifically trained in the medical field and would be in a better position to give clear picture about the victim's general status at the time of death, exact nature and severity of the illness he is suffering from if any. He can also assess the nature and severity of injuries sustained, and thus, his opinion as to the possible role played by the traumatic event in bringing about the death is valuable. This paper will discuss the mechanism of cardiac injury or possible cardiac injury and sudden death of an apparently healthy 36‐year‐old male following blunt chest trauma sustained during alleged assault by his neighbor.     

Rupture of liver cell adenoma with fatal massive hemoperitoneum resulting from minor road accident

Blunt abdominal trauma can cause rapid death resulting from serious injuries of internal organs. The liver is commonly involved and may show tearing, usually in its upper surface, resulting in hemoperitoneum eventually leading to death. Minor trauma implies serious liver damage only when previous pathologic changes causing enlargement of the organ are present. The case of a 25-year-old woman who died as a consequence of a minor road accident is reported. At autopsy, the body showed no external injuries, the only relevant finding being a massive hemoperitoneum from the rupture of an unusually large liver cell adenoma. Liver cell adenomas carry a serious risk of spontaneous rupture, which may result in the death of the patient. The occurrence of the rupture after a minor blunt abdominal trauma is highly unusual.     

Histologic evidence of repetitive blunt force abdominal trauma in four pediatric fatalities

In cases of acute fatal child abuse, certain injuries, including cutaneous blunt force trauma, skull fractures, subdural hematomas, intra-abdominal hemorrhage, and retinal hemorrhages are common and well described in the pediatric and forensic literature. These gross findings at autopsy, when taken into consideration with scene investigation and interviews with caregivers, may indicate both a clear manner and cause of death. In such cases, the discovery of additional pathologic changes attributable to older abusive injuries helps support a conclusion of death due to inflicted trauma. We discuss four cases of fatal child abuse in which acute blunt force abdominal trauma was the cause of death. In each of these cases, careful examination with proper sectioning and microscopy of select abdominal tissues revealed that the acute tissue trauma was superimposed on a background of older, healing injury. This older trauma was characterized by classic histologic elements of tissue repair, including fibroblast proliferation, early scar formation, increased vascularity, and hemosiderin-laden macrophages. Iron and trichrome stains were used to confirm the presence of hemosiderin and fibrosis in all four cases, but the recognition of fibroblast proliferation and a reactive vascular pattern was best seen on routine hematoxylin and eosin stains. The gross and microscopic autopsy findings, along with available investigative information, established the diagnosis of chronic physical abuse.     

A Rare Presentation of Sudden Death due to Pulmonary Thromboembolism Possibly as a Result of Giant Hepatic Hemangioma

Hepatic hemangiomas are usually detected incidentally when investigating for other nonrelated pathologies. When symptomatic, they are usually large and cause symptoms such as abdominal discomfort or other digestive issues. Occasionally, uncommon presentations such as bleeding with coagulopathy (Kasabach–Merritt syndrome) or even fever of unknown origin may occur. As hepatic hemangiomas are benign, they do not result in tumor emboli and pulmonary thromboembolism due to hepatic hemangiomas is extremely rare. This is a case report of a rare case of a female with no known past medical history who presented with sudden death due to pulmonary thromboembolism, possibly as a result of an underlying giant hepatic hemangioma. Incidentally, she also had three other tumors—pancreatic cystic lymphangioma, cerebral capillary telangiectasia, and papillary thyroid carcinoma, and their potential contribution to the cause of death will be discussed.     

Ventricular septal necrosis after blunt chest trauma

Ventricular Septal Defect (VSD) after blunt chest trauma is a very rare traumatic affection. We report here a case of blunt chest injury-related VSD and pseudoaneurysm. A 30-year old male truck driver was referred from a trauma center to our hospital seven days after a blunt chest trauma and rib fracture. The patient had severe pulmonary edema and echocardiography showed large VSD. Several mechanisms are involved in the pathogenesis of this affection including an acute compression of the heart muscle between the sternum and the spine, leading to excessive changes in the intrathoracic and most likely the intracardiac pressure after blunt chest injury. Traumatical patients with the same symptoms may be at risk of sudden death. Therefore, a high grade of suspicion is mandatory even without solid evidence of myocardial damage on the initial evaluation. In continue some hidden angles of this case was discussed. Given the prognostic implications of traumatic VSD with associated pseudoaneurysm, its detection has critical value for preventing its clinical sequelae.     

A death due to perirenal hematoma complicating extracorporeal shockwave lithotripsy

Perirenal hematoma is an occasional complication of extracorporeal shockwave lithotripsy (ESWL) which does not usually require treatment. A 79-year-old woman died 23 h after ESWL. Forensic autopsy was performed to determine whether medical treatment contributed to her death. The cause of death was hemorrhagic shock due to massive hematoma from a ruptured small vein in the perirenal adipose capsule. No injury to other organs was found and the patient had neither coagulation abnormality nor venous disease. Perirenal hematoma can easily be diagnosed with abdominal sonography, if pain or symptoms of anemia develop. Doctors must be aware of the possibilities of severe renal hematomas after ESWL.     

Spontaneous acute subdural hematoma complicating arachnoid cyst

The overwhelming majority of cases of acute subdural hematoma in the forensic setting occur as a result of head trauma. We report a case of sudden unexpected death in a middle-aged woman with a history of arachnoid cyst who had sudden spontaneous onset of severe headache that was rapidly followed by collapse and death. A postmortem multiple-slice computed tomographic scan showed a large acute subdural hematoma associated with hemorrhage into an arachnoid cyst. Subdural hemorrhage is an uncommon but well-described complication of an arachnoid cyst.     

Capacity for physical action in traumatically-induced epidural hemorrhage

Authors report the case of a 55-year-old man with a nearly normal capacity to act for appr. 48 hours following epidural hematoma due to a blunt trauma of the head with skull fracture. The man was amnestic for the period of time since the trauma. According to the computertomographic findings, the cause for the mild clinical symptoms was a pre-existent atrophy of the brain.     

Death Due to Isolated Jejunal Tear Following Blunt Abdominal Trauma

Small intestinal injury following blunt abdominal trauma has been widely reported. Isolated jejunal tear which is caused by blunt abdominal trauma is rare and is most often seen in road traffic accidents. Here, we report a case of isolated jejunal tear in a 24‐year‐old male truck driver. He was admitted to a tertiary care hospital in a South Indian Metropolitan city with complaints of acute abdominal pain and tiredness following alleged accidental blunt trauma sustained to abdomen due to steering wheel impact. An isolated jejunal tear and adjacent mesenteric contusion and tear were missed by the treating physician even after preliminary investigations, and thus, the conservative management was instituted. The condition deteriorated gradually, and he succumbed to death. The autopsy revealed transverse tear of jejunum almost involving whole of its circumference on the antimesenteric border and peritonitis. Proper use of radio‐diagnostic techniques and timely undertaken explorative laparotomy would have saved the life.     

A case of aortic dissection caused by blunt chest trauma

A 74-year-old woman was struck by a car travelling at about 50 km/h. On arrival at hospital, a CT scan showed dissection of the ascending and descending aorta. She collapsed and died suddenly 8h later. At autopsy, there was massive bleeding into the left pleural cavity, ruptures of the pericardium and right ventricle, and a type A thoracic aortic dissection. The cause of death was haemorrhagic shock due to rupture of the pericardium and delayed rupture of the right ventricle following trauma to the chest. The thoracic aortic dissection was not the direct cause of death although histological examination did reveal that it occurred in the accident. Traumatic aortic dissection is rare although traumatic aortic rupture is a major cause of death after blunt chest trauma. This paper discusses the mechanisms, and factors involved in aortic dissection caused by blunt trauma.     

Sudden Death Due to Recent Hemorrhage From an Intrathoracic Chronic Expanding Hematoma

Chronic expanding hematoma (CEH) is a rare disease that can develop in any region of the body, but it most frequently develops in the thorax. When intrathoracic CEH is left untreated, gradually expanding hematoma can be life‐threatening, leading to respiratory failure or hemoptysis. We encountered an 89‐year‐old man with cardiopulmonary arrest on arrival. He had been healthy, and it was unclear whether CEH had previously been detected. A very large mass was observed on chest computed tomography (CT), but the cause of death could not be determined. In the autopsy, this mass was identified as CEH and no malignant findings were noted. A fresh hemorrhage had occurred in the hematoma and perforated the bronchial lumen, which caused airway obstruction/asphyxia and resulted in sudden death. CEH should be suspected when a very large tumorous lesion occupying the entire hemithorax is observed on chest imaging, and it is important to recognize that sudden death can occur in the natural course of CEH.     

Traumatic venous aneurysm of the popliteal vein with outcome: a case report and review of the literature.

A case of sudden death due to recurrent pulmonary thromboembolism is described. The fatality took place three and a half weeks following blunt trauma to the left popliteal region. The patient died unexpectedly. Autopsy revealed the source of the emboli as a sacciform venous aneurysm of the popliteal vein, an entity seldom described, but important to consider in cases of soft tissue popliteal masses or unexplained pulmonary embolism, especially in otherwise healthy individuals.     

Cardiopulmonary resuscitation-related injuries and homicidal blunt abdominal trauma in children

Defendants accused of inflicting fatal abdominal injuries to children occasionally raise the defense that the injuries were caused by cardiopulmonary resuscitation (CPR). The purpose of this study is to answer the question: Does closed chest CPR result in fatal blunt abdominal injuries that can be mistaken for homicidal assault? To that end, a retrospective study was conducted of all homicidal blunt abdominal injuries in children 10 years and younger from the Dade, Broward, and Palm Beach Medical Examiner's Offices from 1981 through 1997. These were compared to cases of children who died of natural causes during the same time period in Broward County who had CPR (control group 1) and to children who died of nonvehicular accidental blunt abdominal trauma (control group 2). Children with life-threatening head injuries were excluded. Medical examiner records, autopsy reports, documenting photographs, and clinical records were reviewed. The data analyzed included subject demographics, whether CPR was performed and by whom, and autopsy findings. Thirty-three child homicides with fatal abdominal injuries were reviewed. Twenty-four (73%) of the homicides received CPR. There was no difference in the nature and severity of injuries between the 24 children who received CPR and the 9 who did not. Three hundred and twenty-four cases of pediatric natural deaths were reviewed, all of which had CPR. No traumatic abdominal injuries were found in any of the children who died of natural causes. Only four children who died of natural causes had evidence of extraabdominal trauma related to CPR. No cases of nonvehicular accidental blunt abdominal trauma were identified during the 17-year period, although there were nonvehicular accidental fatalities due to extraabdominal injuries. The likelihood of CPR-related primary abdominal trauma in child homicides is very low.     

Cardiac rupture due to severe fatty infiltration in the right ventricular wall

An extremely rare case of sudden death caused by cardiac rupture due to severe fatty infiltration in the right ventricular myocardium is presented. The patient, a 74-year-old woman, had no history of chest trauma, hypertension, or pulmonary disease. The autopsy showed a small tear in the right ventricle and cardiac tamponade, but no coronary artery lesion. In the right ventricular myocardium, muscle fibers were definitely atrophic or absent, with massive fatty replacement. Fatty infiltration of the myocardium, if severe, can be a cause of serious cardiac dysfunction or, occasionally, sudden death.     

Azygos vein laceration due to blunt trauma

The azygos vein ascends along the thoracic spine through the mediastinum and drains into the superior vena cava at the level of the fourth thoracic vertebra. Fracture-dislocation of the mid-thoracic spine, as a result of blunt thoracic trauma, can tear the azygos vein. Four such fatal cases (three motor vehicle accidents and one fall) were studied, only one of which was recognized prior to death. The vein can also be torn, in the absence of skeletal injuries, by horizontal acceleration/deceleration forces. The pathologist must consider azygos vein laceration as a possible cause of either hemothorax or hemomediastinum or both in a victim of a blunt chest trauma, if that individual had persistent hypotension during the few hours before death and no identifiable source of hemorrhage can be found postmortem in sites such as the heart, great vessels, lung, and chest wall. A fracture-dislocation of the thoracic spine may not necessarily be present. Azygos vein laceration seems to be an uncommon cause of hemothorax and hemomediastinum; however, this injury is probably more frequent than is implied by the few cases described in the medical literature.     

Fatal renal hemorrhage after extracorporeal shock wave lithotripsy

Renal hematoma is one of the most severe complications of extracorporeal shock wave lithotripsy (ESWL). ESWL is used in the noninvasive treatment of urinary calculosis. The shock waves can lead to capillary damage, renal parenchymal or subcapsular hemorrhage. We present a case with fatal complication and the result of the medico-legal evaluation. A 71-year-old woman was treated by ESWL, renal hematoma was detected during the clinical observation, and the patient died. The death occurred despite close clinical observation as a consequence of a rare complication of ESWL. The mechanism of death was hemorrhagic hypovolemic shock due to renal hemorrhage complications due to ESWL for treatment of renal calculi. This therapeutic complication is a known complication of appropriate treatment.     

Suture Embolism of the Left Superior Lobar Pulmonary Artery

Endogenous pulmonary thromboemboli are a common cause of noncardiac sudden natural death. Embolism of exogenous material is a rare but potential finding in autopsies following surgeries, medical procedures, penetrating trauma, and nonparenteral drug abuse. This report describes the first case of a suture embolism of the left superior lobar pulmonary artery following complicated abdominal surgery.