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 associated with solitary intracavitary right atrial metastatic tumour deposit.

We report a case of cardiac metastasis of primary adrenal cortical carcinoma to the endocardium of the right atrium resulting in an intracavitary mass which we believe caused sudden death by blocking the tricuspid valve orifice. We have been unable to find a similar case previously reported although primary atrial myxoma is well known to be a rare cause of sudden cardiac death by the same mechanism. Modern non-invasive imaging techniques have facilitated recognition of intracavitary cardiac metastases, and with surgical intervention, when feasible, the risk of sudden cardiac death can be reduced.     

Abnormal heart rate response during newborn sucking behavior study: Subsequent sudden infant death syndrome with cardiac conduction abnormality

This report concerns a four-month-old white female infant who exhibited abnormal feeding behavior and EKG irregularities during a newborn sucking behavior study. The immediate post-birth history showed an irregular heart rate on two occasions, but a cardiac consultation elicited no unusual findings. During sucrose sucking conditions, the heart rate increased with a beat-to-beat variation of 50 beats per minute, noted to be due to premature atrial beats. At 39 days, an EKG showed a marked sinus tachycardia of 156, a PR interval of 0.08, QRS of 0.05 and a QT of 0.26. The infant was diagnosed as a sudden infant death syndrome (SIDS) following an unexpected death at home. Subsequent cardiac pathology revealed an anomalous tract between the right atrium and the atrioventricular (AV) bundle which formed an extensive bypass of the AV node (atrio-His tract), and two accessory AV connections between the left atrium and posterior left ventricle. These findings are consistent with the Wolff-Parkinson-White syndrome type A. Only further studies can determine whether such abnormal feeding behavior with EKG irregularities can be used to identify infants who are at high risk for sudden death.     

Fatal traumatic rupture of an aortic aneurysm of the sinus of Valsalva: an autopsy case

This report describes an autopsy case of a rare type of aortic sinus of Valsalva aneurysm, which caused fatal rupture from a blunt chest impact. A 51-year-old male was hit in the chest with a fist, lost consciousness after about 15min and died after approximately 7h. The postmortem examination revealed a large saccular aneurysm of the right coronary sinus bulging on the right atrium, which had a full laceration causing pericardial hematoma (cardiac tamponade). A related chest wall injury was observed in the right outer mammary region. A rare type of bulging onto the right atrium and subsequent sclerosis of the right coronary artery appeared to have greatly contributed to the fatal rupture.     

Roentgenologic heart volume determination for the diagnosis of fatal heart failure

In order to investigate the connection between the cardiac volume and the cardiac shadow plane, 385 anterior-posterior radiographs of the thorax have been selected comparing their cardiac shadow plane with the corresponding cardiac volumes determined by the autopsy of the cadavers. The comparison showed a connection of both magnitudes by means of the formula Hvol = 0.49 x Fa x square root of Fa (Hvol = cardiac volume in cm3, Fa = cardiac shadow plane of the anterior-posterior radiograph in cm2, corrections were made from the radiation divergence). A verification of the formula showed a very high correlation (r = 0.984) in 25 cadavers to be dissected. The comparing volume of the cardiac shadow plane has been investigated by means of the water displacement method, in which the cardiac vessels were ligated and the heart taken out of the cadaver. The cardiac volume, evaluated from the cardiac shadow plane showed a significant correlation at the cardiac death by internal natural cause. The comparison of the mathematical evaluated cardiac blood volumes of the symptoms causing death showed that the cardiac blood volumes in the group of poisonings and the group of drowning, suffocations and hanging with 231 ml and 211 ml in the men collective were at the same level as the cardiac death (246 ml). About the same applied to the women collective.(ABSTRACT TRUNCATED AT 250 WORDS)     

Microbiota Composition and Pulmonary Surfactant Protein Expression as Markers of Death by Drowning

Pathological diagnosis of drowning remains a challenge for forensic science, because of a lack of pathognomonic findings. We analyzed microbiota and surfactant protein in the lungs for a novel diagnosis of drowning. All rats were divided into drowning, postmortem submersion, and control groups. The water, lungs, closed organs (kidney and liver), and cardiac blood in rats were assayed by targeting 16S ribosomal RNA of Miseq sequencing. Lung samples were analyzed by immunohistochemical staining for surfactant protein A. The closed organs and cardiac blood of drowned group have a lot of aquatic microbes, which have not been detected in postmortem submersion group. Furthermore, intra‐alveolar granular staining of surfactant protein A (SP‐A) was severely observed in the drowned group than the postmortem submersion and control groups. The findings suggested that the presence of aquatic microbiota in the closed organs and increased expression of SP‐A could be markers for a diagnosis of drowning.     

A sudden death with lung embolism after inadvertent infusion of zinc oxide shake lotion

A 74-year old woman in postoperative treatment after a colonic surgery died immediately after perfusion of about 1.5 mL of a white emulsion which was believed to contain 1% propofol via cardiac catheter into the right atrium. It was strongly suspected that a syringe with a zinc oxide shake lotion (consisting of 20% ZnO, 20% talc, 25% glycerol and 35% water) which was intended for external treatment had been mistaken for the propofol syringe. During autopsy, an anatomic cause of death could not be found. In order to exclude an intoxication and to determine the significance of the perfusion fluid in this context, toxicological and histological investigations were performed. Propofol and other drugs applied to the patient were found in therapeutic or sub-therapeutic range. However, in comparison to a control case, the zinc concentrations determined by AAS were about 200 times higher in lung tissue, 10 times higher in heart blood and 3–4 times higher in kidney and liver tissue. No increase was seen in venous blood. Histology showed a strong embolism of the lung tissue with birefingent sharp-edged crystals, which were identified as the talcum, and an amorphous component (ZnO). The same embolism was seen to a medium extent also in the brain sections and to a low extent in heart, liver, pancreas and kidney. Pulmonary embolism by talcum and zinc oxide was established as the cause of death which occurred by syringe swap due to insufficient security precautions in the drug administration. The results are discussed in context of pulmonary microembolism cases frequently described for drug addicts after injection of crashed talcum containing tablets.     

Immunofluorescence demonstration of digoxin in human myocardial tissue and isolated rat cardiac myocytes with monoclonal antibodies

The aim of the present investigation was to identify the morphological correlates of digoxin binding sites in human heart muscle tissue and isolated viable rat heart myocytes. Cardiac glycoside linked to myocardial cells was demonstrated by monoclonal digoxin specific antibody and by FITC-conjugated anti-mouse immunoglobin serum. This versatile immunofluorescence method can be used in diagnostic and experimental studies of cardiac glycoside binding.     

NMDAR1在成人心脏中的分布及其法医学意义

目的 检测成人心脏中NMDAR1蛋白,观察其分布情况,并探讨法医学意义。方法以12例高坠死亡成人心脏为标本,提取左、右心室和心传导系统（窦房结、房室结、房室束及左右束支）组织作为实验组;取大脑额部组织作为阳性对照组。所取标本各两份,一份采用westernblot技术检测NMDAR1蛋白,另一份采用免疫组化染色法观察NMDAR1在成人心脏中的分布。结果两组中用westernblot均可检出NMDAR1蛋白表达,其强弱程度：脑组织最强,其次为窦房结和房室结,左右心室肌最弱;用免疫组化方法观察,结果在心脏传导系统可见NMDAR1阳性表达,而在心室肌中未见表达。结论成人心脏中存在NMDAR1,主要分布在心传导系统,NMDAR1可能在心脏电生理和病理生理中起作用。     

A fatal case of oleandrin poisoning

The study presents a case of fatal poisoning with oleander leaves in an adult diabetic male. After repeated vomiting, and gastrointestinal distress the patient was admitted at the hospital with cardiac symptoms 1h after the ingestion. Urine samples were assayed immunochemically and by GC-MS for drugs of abuse and for general toxicological screen. Blood was analyzed for alcohol and volatiles by static head space GC-MS. Blood and oleander leaves were analyzed by LC-MS/MS for oleandrin and related compounds, the main cardiac glycosides of Nerium oleander. Oleandrin was detected by LC-MS/MS in the blood sample at a concentration of approximately 10 ng/ml. Another cardiac glycoside with pseudo-molecular ion of m/z 577, a likely structural isomer of oleandrin, was also detected in the blood and oleander leaves. However, by using the response as a function of concentration for oleandrin, this cardiac glycoside was roughly estimated at a concentration of approximately 10 ng/ml in the deceased blood. This would give a total fatal blood concentration of cardiac glycosides of about approximately 20 ng/ml in the deceased blood.     

Detection of apoptosis in ischemic heart. Usefulness in the diagnosis of early myocardial injury

Myocardial samples of hearts with histologic findings of acute myocardial infarction (group A), sudden coronary deaths without histologic changes (group B), and chronic ischemic heart disease (group C) were analyzed to investigate the appearance of apoptosis in acute and chronic ischemic cardiac disorders. This analysis involved the morphologic detection of DNA strand breaks in myocyte nuclei by the terminal deoxynucleotidyl transferase-mediated dUTP nick-end labeling (TUNEL) assay and the biochemical determination of DNA laddering in the myocardium using archival formalin-fixed, paraffin-embedded tissue sections of human myocardium. The authors demonstrated that apoptosis of myocardial cells could occur after ischemic myocardial cell injury. In all documented cases of acute myocardial infarction (group A), the infarcted area included extensive presence of both apoptosis and necrosis. In the tissue bordering on and away from the obviously infarcted areas, positive nuclei were intermingled with nonstained normal myocytes. The number of positive nuclei decreased with the distance from the infarction foci. In group B, myocardial samples showed focal or diffuse nuclear positivity of varying degrees for apoptosis, confirming the presence of myocardial ischemic cell death, whereas the histologic diagnosis remained inconclusive. This finding suggests that apoptosis could be used as a marker for acute ischemic injury. In group C, stained nuclei were dispersed with intermingled normal cardiomyocytes.     

The presence of trace amines in postmortem cerebrospinal fluid in humans

The postmortem levels of biogenic amines in cerebrospinal fluid may represent a useful tool in defining some pathological conditions; no information is available concerning the occurrence of trace amines in postmortem cerebrospinal fluid. Thus, the occurrence of octopamine, synephrine and tyramine were evaluated by using a HPLC system in 20 postmortem samples of cerebrospinal fluid (obtained from 11 males and 9 females) and their levels were compared with those of 20 living subjects (obtained from 11 males and 9 females). The results show that trace amines dramatically increase in the postmortem cerebrospinal fluid (100, 20, and 4 fold increase for tyramine, octopamine, and synephrine respectively). To our knowledge, our data represent the first time trace amines have been identified in postmortem cerebrospinal fluid and the dramatic increase observed for tyramine has the potential of becoming a new tool in forensic science for better defining the time of death.     

Esophageal-atrial fistula resulting in systemic "meat and vegetable" emboli.

An 85-year-old demented woman died in the state hospital and her death was investigated by our office, based on allegations of neglect. At autopsy, a feeding catheter was found passed through an esophageal-atrial fistula into the left atrium. Fragments of striated muscle and plant wall (cellulose) embolized to the systemic organs including heart, kidney, and brain. Her dilated esophagus suggests a premortem esophageal motility disorder that contributed to the formation of the fistula. This is the first reported case of an esophageal-atrial fistula in the medical literature.     

Cor triatriatum sinistrum: a rare congenital cardiac anomaly presenting in an adult with chronic atrial fibrillation

Cor triatriatum is a rare congenital cardiac anomaly in which the left atrium is divided into proximal (dorsal or upper) and distal (ventral or lower) chambers by a fibromuscular septum. The upper chamber receives the pulmonary veins and the lower chamber contains the atrial appendage and the mitral valve. The 2 chambers communicate through a defect in the membrane. Cor triatriatum is often associated with other congenital cardiac anomalies. Most frequently, the upper chamber communicates with the right atrium through a patent foramen ovale or atrial septal defect, and the clinical symptoms simulate anomalous pulmonary venous return. Less commonly, the foramen ovale communicates with the distal chamber and the clinical features mimic mitral stenosis. When cor triatriatum is the only abnormality, the clinical findings are also similar to mitral stenosis with development of pulmonary hypertension and subsequent right ventricular hypertrophy and atrial enlargement. The diagnosis is usually made in infancy or childhood, and the lack of treatment results in death in 75% of patients.We report the case of a woman who presented much later in life. The patient was a 57-year-old female with a clinical history of chronic atrial fibrillation who presented to the emergency department because of a "funny sensation" in her chest, though she denied chest pain, nausea, vomiting, or diaphoresis. EKG revealed atrial fibrillation with a rapid ventricular response and a tachycardic rate of 157. She had a therapeutic level of digoxin, and cardiac enzymes were normal. The patient was admitted and placed on Cardizem drip. Serial EKGs remained normal and heart rate control was achieved. On hospital day 2, the patient became dyspneic and cyanotic. She went into cardiac arrest and died.Autopsy revealed cardiomegaly (610 g) with 4-chamber dilatation. A septum divided the left atrium into 2 chambers. The defect in the dividing membrane measured 1 cm in diameter. No other congenital defects were noted. The large size of the defect in the membrane likely accounted for the late onset of symptoms that allowed this patient to survive into adulthood without previous diagnosis or surgical intervention (which is usually required in childhood).     

Police patrol and the deterrence of crime

A nonrecursive model of the deterrent effect of police presence was formulated and tested for 26 cities. Victimization data were employed as measures of crime, unpublished FBI data on the number of police patrol units as the measure of levels of police presence, and data for 11 exogenous variables were derived from FBI and census reports. It was found that per capita, police are a positive function of rates of violent crime and that clearance rates are a positive function of police presence. However, some offenses that have traditionally been thought to be deterrable are not inversely related to clearance rates. The equations were re-estimated using official measures of crime and found to be more consistent with the deterrent hypothesis. It is suggested that official data may generate a spurious correlation. Finally, caution is suggested in consideration of alternative forms of police presence.     

Fatal Intoxication with α‐PVP,a Synthetic Cathinone Derivative

This study presents the fatal case of a young man who was admitted to the ICAU due to sudden cardiac arrest. An interview revealed that the patient had taken some unspecified crystals. From the moment of admission, his condition deteriorated dramatically as a result of increasing circulatory insufficiency. After a few hours, sudden cardiac arrest occurred again and the patient was pronounced dead. In the course of a medicolegal autopsy, samples of biological material were preserved for toxicology tests and histopathological examination. The analysis of samples using the LC‐MS/MS technique revealed the presence of α‐PVP in the following concentrations: blood—174 ng/mL, urine—401 ng/mL, brain—292 ng/g, liver—190 ng/g, kidney—122 ng/g, gastric contents—606 ng/g. The study also presents findings from the parallel histopathological examination. Based on these findings, cardiac arrest secondary to intoxication with alpha‐PVP was determined as the direct cause of the patient's death.     

Comparative electron-microscopic investigation of postmortem human heart muscle biopsy

Based on Harvard criteria findings, comparative morphological investigation on postmortem heart muscle biopsy following coronary insufficiency after sudden cardiac death have been reported. The subendothelial layer of the left ventricular wall has revealed a severe interstitial edema, various types of actin-myosin filamental destruction, mitochondrial damage, and disseminated muscle fiber necrosis. One of the first alterations observed was the change in transmembrane calcium and intracellular calcium metabolism. A decrease in succinic dehydrogenase and cytochrome oxidase activity was discovered early.     

Comparative topo-optical investigation of cardiac glycoside localization

The aldehyde-bisulfite-toluidine blue (ABT) reaction is a selective topo-optical test of vicinal-OH and amino-OH groups. The localization of cardiac glycoside was investigated morphologically. After digoxin the sarcolemma membranes, capillaries and sinus node showed strong basophilia and negative birefringence. The topo-optical reaction are useful for the histopathological examination. The new method gives the possibility to the digoxin intoxication with a high specificity.     

多发性软组织挫伤后对肺及其他脏器的影响

目的观察多发性软组织挫伤后短时间内死亡案例的脏器病理学改变。方法应用常规组织学及免疫组织化学染色技术进行光学显微镜检查。结果光镜检查见肺组织毛细血管扩张充血，白细胞集聚，肺组织散在片状出血、灶状坏死及透明膜形成；心脏间质血管扩张充血，点灶状纤维溶解；脑组织充血水肿，肝脾充血。免疫组化发现肺泡腔及部分血管内纤维蛋白染色阳性，部分脾脏血管内及肾髓质集合管中肌红蛋白染色阳性。结论本研究结果提示多发性软组织挫伤后短时间内死亡的死因为成人呼吸窘迫综合征（ARDS）合并多脏器功能衰竭。     

An autopsy case of heart rupture from a scooter accident with 3 riders

A 15-year-old male died of cardiac rupture due to blunt chest trauma from a traffic accident involving a low-speed scooter carrying 3 people and a head-on collision with a tree. The victim was sitting on the footrest of the scooter. It was concluded that the victim was compressed between the handlebar of the scooter and the other 2 passengers, causing cardiac ruptures via bidirectional compression and intravascular hydrostatic pressure. The victim may have served as a cushion for the other 2 passengers, who were not thrown from the scooter and sustained only minor injuries.