Inferior Vena Cava Tumor Thrombosis Secondary to Metastatic Uterine Cancer: A Rare Cause of Sudden Unexpected Death

Pulmonary tumor thromboembolus (PTTE) secondary to uterine cancer is a rare cause of sudden unexpected deaths in the elderly population. Additionally, tumor extension to the inferior vena cava (IVC) makes it rarer. No such cases have been previously reported in the forensic literature. We report this phenomenon in a previously healthy 70‐year‐old woman with no other known risk factors for the development of deep vein thrombosis. The deceased was found dead while watching television with her relatives. Autopsy examination revealed that her death was attributed to a saddle embolus lodged in the main pulmonary arteries. A uterine tumor was discovered, and microscopic examination revealed low‐grade endometrial stromal sarcoma with angiolymphatic invasion. The tumor cells were also found in the embolus and the remnant thrombosis attached to the inner wall of the IVC. This case demonstrates a sudden unexpected death caused by acute PTTE following seeding of uterine cancer into the IVC and raises awareness of such events.     

Intracoronary Thrombus Formation Following Carbon Monoxide Poisoning

Thromboembolic events in the context of carbon monoxide (CO) exposure have been well described in the literature. Six cases of clinically significant coronary thrombosis following CO exposure were previously reported. However, factors affecting the development of coronary thrombus in CO exposure are poorly understood, and the significance of this finding in a forensic context is not clear. This article discusses a case of coronary thrombosis found at autopsy following a death in which CO poisoning was suspected. A 67‐year‐old man was found dead in his garage with four vehicles with their ignition in the “on” position and their tanks empty. At autopsy, severe coronary atherosclerosis and an acute nonocclusive coronary thrombus were found. Given the dissimilarities among cases and the presence of CO exposure, it was suggested that the coronary artery thrombosis is likely due to the inherent prothrombotic mechanism of CO, the only common denominator in all the cases.     

Cardiac Sudden Death as a Result of Acute Coronary Artery Thrombosis During Chemotherapy for Testicular Carcinoma

Abstract: We report the first acute coronary fibrin thrombus arising upon atherosclerosis detected at autopsy in a man receiving chemotherapy for testicular carcinoma. The decedent was a smoker with no other known atherosclerotic risk factors. Histology revealed superficial atherosclerotic plaque erosion with endothelial necrosis and no intraplaque hemorrhage. A focus of intimal lymphoid infiltrates was noted away from the plaque. These findings raise the possibility of chemotherapy‐induced vascular damage as a factor in thrombogenesis. A review of Pubmed was performed which documented clinical reports of an association of chemotherapy with acute cardiac ischemia but no well described autopsy findings. Our case highlights the need for careful assessment of the coronary system in chemotherapy patients dying suddenly, particularly in the absence of significant atherosclerotic risk factors. Such postmortem examination will ensure thorough death investigation and may elucidate the pathogenesis of thrombosis with potential reduction in cardiac ischemic risks of chemotherapy patients.     

Forensic Considerations in Cases of Myotonic Dystrophy at Autopsy

Myotonic dystrophy (DM) is a chronic, slowly progressive, autosomal‐dominant disorder with delayed muscle relaxation after contraction, distal skeletal muscle weakness, and atrophy. It has a reduced life expectancy due predominantly to respiratory failure or sudden cardiac death. The mortality rate is approximately 7.3 times greater than the general population with a mean age at death of 53 years. Degeneration of the cardiac conduction system causes atrioventricular block, arrhythmias, and ventricular failure. A case of sudden death in a 44‐year‐old woman with DM type 1 is reported to demonstrate an alternative lethal mechanism. At autopsy, there was extensive infiltration of skeletal muscles with adipose tissue. The heart was structurally normal. A deep venous thrombosis of the right calf was identified with a large saddle pulmonary thromboembolus and bilateral peripheral thromboemboli. DM1‐related thrombosis had most likely occurred because of the decedent's impaired mobility, possible hypercoagulable state, and serum changes from muscle necrosis.     

Saddle Pulmonary Embolism with Paradoxical Coronary Artery Embolism through a Patent Foramen Ovale

A 35‐year‐old male patient was found in cardiac arrest in his vehicle, with no apparent injuries after a minor motor vehicle collision. The decedent was found to have a saddle pulmonary embolus with a thromboembolus impacted across a patent foramen ovale and a paradoxical embolism in the circumflex coronary artery, as well as significant clotting in the deep veins of both lower extremities. There were no risk factors in his history to explain the deep venous thrombosis; family history suggested the possibility of an unrecognized clotting disorder.     

Sudden Unexpected Death Due to Graves' Disease During Physical Altercation

We report a case of a 30‐year‐old woman who suddenly collapsed after having a physical altercation with her husband. Despite immediate resuscitation, she died on arrival at the hospital. The victim's parents requested an autopsy because they believed that their daughter was killed by her husband. Postmortem examination revealed that the victim had a diffusely enlarged thyroid gland and cardiomegaly with left ventricular hypertrophy. There was no evidence of significant trauma on the body. Further postmortem thyroid function tests and review of her medical history indicated that her death was due to Graves' disease. To the best of our knowledge, this is the first case reported of sudden death due to cardiac arrhythmia from Graves' disease induced by physical and emotional stress associated with the criminal activity of another person. The autopsy findings are described. In addition, the literature is reviewed and the significance of postmortem evaluation of thyroid hormones in the cases of sudden death is discussed.     

Lower extremity deep venous thrombosis with fatal pulmonary thromboembolism caused by benign pelvic space-occupying lesions--an overview

Venous stasis predisposes to thrombosis. One hundred and sixty cases of fatal pulmonary thromboembolism were reviewed to determine how many cases had deep venous thromboses associated with venous blood flow reduction caused by external pressure from benign pelvic masses. Three cases were identified, representing 2% of cases overall (3/160): a 44-year-old woman with a large uterine leiomyoma (1048 g); a 74-year-old man with prostatomegaly and bladder distension (containing 1 L of urine); and a 70-year-old man with prostatomegaly and bladder distension (containing 3 L of urine). Although a rare cause of fatal deep venous thrombosis and pulmonary thromboembolism, space-occupying pelvic lesions can lead to extrinsic pressure on adjacent veins reducing blood flow and causing stasis and thrombosis. Individuals with large pelvic masses may, therefore, be at increased risk of pulmonary thromboembolism from deep venous thrombosis, particularly in the presence of concurrent risk factors such as immobility, thrombophilias, malignancy, and significant cardiopulmonary disease.     

Fatal Venous Air Embolism Following Intravenous Infusion*

Abstract: Venous air embolism has been reported as a complication of invasive diagnostic and therapeutic procedures or accidental trauma. Little is known about the incidence of air embolism after minimal intravenous manipulations such as the insertion of a peripheral intravenous cannula. Only when large amounts of air sufficient enough to block the cardiovascular system enter, the patient develops symptoms and signs of severe neurological injury, cardiovascular collapse, or death. The dead body of a 14‐year‐old boy was brought for postmortem examination with allegations of death from negligence during treatment. He was treated for pain in the abdomen in a hospital by attendants in telephonic consultation with a medical practitioner. Following intravenous infusions, the boy died suddenly in respiratory distress. Gross findings indicated the death to be from venous air embolism. Chemical analysis, histopathology, and microbiology ruled out other causes of death. Dilemmas of the case with difficulties in diagnosis are being presented herewith.     

Pathologic Findings of Coronary Stents: A Comparison of Sudden Coronary Death Versus Non‐cardiac Death

There are few histologic studies of intracoronary stents found at autopsy. We studied histologic findings of 87 intracoronary stents from 45 autopsy hearts. There were 40 patients with chronically implanted stents and five shorter than 30 days. Of five patients with recent stent placement, the cause of death was related to the stent (in‐stent thrombosis) in one case. Of the 40 patients with chronic stents, there were 16 sudden coronary deaths and 24 noncoronary deaths (controls). There were no late stent thromboses in the coronary deaths. In the coronary deaths, 26% of stents showed restenosis versus 11% in controls (p = 0.1). The rate of healed infarcts and cardiomegaly was similar in the coronary and noncoronary groups, and acute thrombi in native arteries were seen only in three hearts in the coronary group. We conclude that the cause of death is rarely impacted by in‐stent findings at autopsy, especially in chronically implanted stents.     

Hypothermia Secondary to Glioblastoma Multiforme? Autopsy Findings in Two Cases

Death due to accidental primary hypothermia in cold climates is relatively common, with previous case series reflecting this. In contrast, hypothermia‐related death as a result of an underlying medical cause, such as a brain tumor, is rare. The literature clearly illustrates a theoretical causal relationship between brain neoplasms and hypothermia through the infiltration of the hypothalamus; however, the number of reported cases is minimal. Two cases are presented where autopsy confirmed hypothermia as the cause of death with both cases revealing widespread glioblastoma multiforme in the brain. Both decedents were elderly with a number of comorbidities identified during autopsy that could explain death; however, hypothermia was deemed the most likely cause. It is proposed that both decedents died of hypothermia as a result of the tumor's effect on thermoregulation. These cases underline the importance of forensic pathologists to be aware of the relationship between brain tumors and hypothermia and to not dismiss death as being due to other disease processes.     

Fatal Folic Acid Toxicity in Humans

Folic acid is B‐9 vitamin. Folic acid is prescribed commonly for pregnant women to prevent neural tube defects in the fetus, patients under chemotherapy, pernicious anemia and to reduce the risk of stroke and cardiovascular disease. Acute or chronic ingestion of a large dose of folic acid generally manifests as neurological complications, which are reversible. In this present case, a 23‐year‐old pregnant woman committed suicide by consuming folic acid tablets and succumbed to death within 36 h. Postmortem toxicological analysis detected folic acid in viscera. Death following acute consumption of folic acid is rare and has been not reported in the literature, to the best of our knowledge.     

Ruptured Syphilitic Aneurysm: A Cause of Sudden Death in a Man with Human Immunodeficiency Coinfection

Syphilis, a sexually transmitted infection caused by the bacterium Treponema palladium, is experiencing a worldwide resurgence. The risk of syphilis infection is particularly high in men who have sex with men (MSM), especially those who are human immunodeficiency virus (HIV)‐positive. Untreated syphilis can lead to rare but severe late‐stage complications, including syphilitic aortitis. Herein, we present an autopsy case of a ruptured thoracic aneurysm that resulted from an undetected case of syphilitic aortitis in an HIV‐positive Japanese MSM with undiagnosed syphilis. Although no syphilitic skin lesions were observed on the body, anatomical changes consistent with a syphilitic etiology were present at the site of the rupture, including medial aortic scarring with “tree‐bark”‐like atherosclerotic plaque. In addition, heart blood was positive for T. palladium in a latex agglutination test. This case highlights for forensic pathologists the importance of recognizing syphilis as a possible underlying cause of sudden death among HIV‐positive MSM.     

Infant death due to air embolism from peripheral venous infusion

An otherwise healthy male infant was brought to the hospital because the mother suspected superficial infection at the operative site 5 days after an inguinal hernia repair. He was admitted to the pediatric unit overnight to be evaluated by his surgeon the next morning. When a venous infusion of maintenance fluids was started, the patient immediately went into cardio-respiratory arrest and was pronounced dead after resuscitation efforts failed. Subsequently, air collections were found in both venous and arterial circulations, including the splenoportal system. Detailed review of the clinical presentation and course, laboratory results, radiological, and pathological findings, along with a review of pertinent literature provides an explanation for the death by air embolism. Apparent inconsistent findings both radiographically and at autopsy are resolved. The mechanism of distribution of air to both systemic and splenoportal circulation is discussed. We believe this to be only the eighth case reported in English-language literature of infantile death from peripheral venous infusion. In all age groups, we find only six other cases in the English-language literature of gas found concomitantly in both the systemic and portal venous systems.     

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.     

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.     

Attempted Drug‐facilitated Sexual Assault—Xylazine Intoxication in a Child

There are only a few cases of drug‐facilitated sexual assaults on children reported in the literature so far. Here, a case of a four‐year‐old boy is presented. He was unconscious, and the accompanying adults reported that the child had been at a playground on his own. Returning home, he complained of having been stung and collapsed immediately. Urine and serum samples of the child were investigated. In the toxicological analysis, xylazine, a sedative and muscle relaxant used in animals, was detected. Subsequent quantification by GC/MS after solid‐phase extraction revealed 0.053 mg/L xylazine in serum and approximately 0.63 mg/L in urine. Furthermore, the child was examined by a forensic medical specialist. Police investigations revealed that the godfather, who had been previously accused of sexual abuse of children, had injected the child with the drug, possibly in preparation for a shared bath.     

Cardiovascular Conditions and the Evaluation of the Heart in Pregnancy‐Associated Autopsies

Abstract: Pregnancy‐associated death is defined as the death of a woman from any cause during pregnancy or in the year after delivery. This review concentrates on cardiac conditions that may result in pregnancy‐associated death including, but not limited to, acute myocardial infarction, endocarditis, peripartum cardiomyopathy, and prolonged QT syndrome. Lethal vascular conditions may also occur involving arterial dissection and thromboembolism, on occasion exacerbated by hypercoagulability, and altered hormonal and physiologic states. The autopsy evaluation of these patients includes a careful assessment of the medical history particularly for prior pregnancy‐related conditions, fetal loss, and episodes of unexplained collapse. A family history of sudden death at an early age may be significant. At autopsy, evaluation for underlying syndromes such as Marfan, or evidence of intravenous narcotism should be undertaken. Autopsy examination involves careful dissection of the heart and vessels with consideration of conduction tract studies and possible genetic evaluation for prolonged QT syndrome.     

Fatality During Servicing of Fire Extinguisher

Fire extinguisher is an integral part of emergency responses to small fires. Different types of fire extinguisher exists; cartridge‐based fire extinguisher is commonly used. Despite their intended use for safety, such devices can become dangerous if not properly handled or maintained. This case report describes the death of a soldier from the explosion of a cartridge‐based fire extinguisher during routine servicing. The case is the first reported in the medical literature. A safety device like fire extinguisher can become dangerous if not handled with care and due steps should be taken for the maintenance of such devices before being operated in the public domain.     

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.     

“Tampering to Death”: A Fatal Codeine Intoxication Due to a Homemade Purification of a Medical Formulation

Many homemade tamper processes of medical codeine formulations are available on selected “forums” on the Internet, where recreational codeine users claim to be able to purify codeine by removing additives, such as acetaminophen, to avoid or limit adverse effects. In this work, it is reported and discussed a fatal case of codeine intoxication. The findings of objects such as jars, filters, and tablets, and amounts of unknown liquid material at the death scene investigation suggested a fatal codeine intoxication after the tampering procedure called “cold water extraction.” Toxicological results obtained from the analysis of both the nonbiological material and the body fluids of the decedent integrated with the information collected at the death scene investigation confirmed the above‐mentioned hypothesis. This report underlines the importance of a tight interconnection between criminalistics and legal medicine to strengthen the identification of the cause of death and the reconstruction of the event.