Fatal thrombosis of the basilar artery due to a minor head injury

A case is reported where a 20-year-old alcohol-intoxicated man was admitted to the hospital after a minor head injury. Initially there was no neurologic disturbances or complaints but after a few hours he became comatose, and he died 4 days later without regaining consciousness. The autopsy revealed no lesions of the upper cervical spine or the vertebral arteries, but the basilar artery was occluded in its entire length. No traumatic lesions could be seen by naked eye examination of the artery, and there was no accompanying subarachnoid haemorrhage. A thorough microscopic examination, however, using step-sectioning technique revealed a significant incomplete arterial rupture with an occluding luminal thrombosis superimposed, consisting predominantly of aggregated platelets. Only the very thin adventitia separated the vascular lumen from the subarachnoid space preventing the more well known fatal complication to a minor head injury: A subarachnoid haemorrhage. To the best of our knowledge, fatal thrombosis of the basilar artery due to a minor head injury has not previously been reported. The pathogenetic mechanism seems to be identical to that underlying fatal subarachnoid haemorrhage following a similar trauma apart from the resulting arterial rupture being incomplete instead of complete.     

Fatal myeloencephalopathy due to accidental intrathecal vincristin administration: a report of two cases

We report on two fatal cases of accidental intrathecal vincristine instillation in a 5-year old girl with recurrent acute lymphoblastic leucemia and a 57-year old man with lymphoblastic lymphoma. The girl died seven days, the man four weeks after intrathecal injection of vincristine. Clinically, the onset was characterized by the signs of opistothonus, sensory and motor dysfunction and ascending paralysis. Histological and immunohistochemical investigations (HE-LFB, CD-68, Neurofilament) revealed degeneration of myelin and axons as well as pseudocystic transformation in areas exposed to vincristine, accompanied by secondary changes with numerous prominent macrophages. The clinical course and histopathological results of the two cases are presented. A review of all reported cases in the literature is given. A better controlled regimen for administering vincristine and intrathecal chemotherapy is recommended.     

Sudden, unexpected death due to massive, nontraumatic intra-abdominal hemorrhage in association with cirrhosis of the liver

Hemoperitoneum is usually due to rupture, laceration, or perforation of a blood vessel or organ. The author describes three deaths due to massive intra-abdominal hemorrhage, all in alcoholics with cirrhosis of the liver, in which no source for the bleeding was found. One of the three individuals, who was briefly hospitalized, showed evidence of a disseminated intravascular coagulopathy (DIC). In the author's opinion, this is the most likely cause of the intra-abdominal hemorrhage in the two other cases and is related to the cirrhosis of the liver.     

Fatal intoxication due to tramadol alone: case report and review of the literature

Poisoning may also lead to both coma and multiple organ failure, also in youngsters without a known major medical history. As not all toxic agents are routinely screened when a poisoning is suspected, it is useful to consider less frequently encountered poisons in certain cases. We describe the occurrence of asystole and multiple organ failure which occurred in a young man after a suspected tramadol overdose. The tramadol concentration on admission in the ICU was indeed 8 microg/ml (mg/l), far above the therapeutic range. Subsequently, the patient developed severe acute liver failure, finally leading to death. Post-mortem toxicology did not reveal any other poison responsible for this unfavourable course as only very high serum and tissue tramadol and desmethyltramadol concentrations were found. Only a few fatal poisonings attributable to tramadol alone, as observed in our case, have been reported. An overview of these cases is presented.     

Fatal birth trauma due to an undiagnosed abdominal teratoma: case report and review of the literature

The fetus is subjected to mechanical forces during labor and delivery, which may result in traumatic injuries. Such injuries include intracranial hemorrhage, spinal cord lesions, cephalhematoma, cranial or peripheral nerve palsies, intraabdominal organ rupture, or bony fractures. Risk for perinatal trauma and mortality is increased in primigravidas, multiple gestations, abnormal presentations, maternal-fetal disproportion, oligohydramnios, forceps or vacuum extractions, and internal version maneuvers. Very-low-birth-weight neonates (<1500 g) are at high risk due to ease of deformity of the cranium. Infants with certain congenital anomalies or pathologic processes that distort normal anatomy are also at increased risk, especially when a prenatal diagnosis is lacking. The authors present a case of a term gestation neonate who sustained a cervical spine dislocation fracture of C5-7, with subtotal transection of the spinal cord and resultant paralysis. The fetus was in vertex presentation, and a manual vaginal delivery was attempted. When the infant lodged in the birth canal following a difficult delivery of the head and arms, its enlarged abdomen was palpated, and the delivery was converted to an emergent cesarean section. The infant lived for 3 days and then expired due to neurologic complications of trauma sustained during the attempted vaginal delivery. Autopsy revealed a previously undiagnosed intraabdominal immature teratoma. The pathology of teratomas, the most common neonatal tumor and occasionally implicated in cases of birth trauma, will be addressed, followed by a review of the literature concerning birth trauma.     

Fatal ischemic stroke due to dissecting aneurysm of the intracranial arteries presenting as sudden unexpected death in childhood

Sudden unexpected death is any nontraumatic death in healthy individuals with normal activities for age until acute demise. Whereas not uncommon in adults and infants, it is considered a rarity in children, with most cases due to infection or occult cardiovascular abnormalities. Pathologic intracranial findings are rarely found in sudden unexpected death in childhood, with most cases due to occult intracranial neoplasms. Cerebral arterial dissection is an uncommon cause of arterial ischemic stroke in childhood. Outcome is poor, with more than 20% of patients dying. We report 4 cases of sudden unexpected death due to arterial ischemic stroke after cerebral arterial dissection in childhood and present a review of the literature.     

Fatal impalement with transfixion of the neck in a road traffic accident

The authors describe a singular case of fatal impalement due to penetration of a metal tube at the level of the neck in a victim of a road traffic accident. The man was traveling in the passenger seat ("death seat") of a car that hit the parapet of a bridge head on; death was attributed to hemorrhagic shock, which was brought on virtually instantly at the moment of impact.     

Development of rust stains on the skin due to contact with a gun

In order to study the conditions for the formation of so-called rustmarks on the skin after contact with weapon steel tests to provoke rustmarks were performed on corpses and living bodies. These tests were only successful under the condition of a firm contact with the weapon steel and a certain minimum contact time between the weapon and the skin. The experiments showed that the critical parameters for the appearance of rustmarks are, first, the humidity of the skin and the environment, respectively, as well as the contact time, and second, the state of the weapon surface (greased or ungreased). Both the ambient temperature and the pH value of the skin (alkaline or acid) are irrelevant to the formation of rust. The longest time period until rustmarks appeared was observed on dry skin in contact with a greased weapon, namely 22 hours on a corpse and 170 min on a living subject. When using a greased gun humidity accelerated the formation of rust. An ungreased surface of the weapon also resulted in faster rust formation. The minimum time necessary for the formation of rust determined under the most favourable circumstances was 135 min for a corpse and 27 min for a living person. During the early postmortal interval the rustmark may therefore be another piece in the jigsaw towards determining the time of death on suicides committed with firearms.     

Clinical ethics committees, due process and the right to a fair hearing

The development of clinical ethics committees in the United Kingdom raises a number of important questions about the extent to which they are compatible with the normative values of due process. If committees are to be active in delivering ethics services, it is argued that attention to due process is important. Based on research outcomes, it seems that the chairs of the United Kingdom clinical ethics committees who responded are reasonably satisfied about the ability of their committees to make ethical decisions and slightly less confident about their ability to make legal decisions. If these committees are to make potentially far-reaching decisions (whether or not involving live consultations), it is argued here that they must pay attention to the rules associated with the legal concept of due process. Equally, evaluation of the clinical ethics committee's counterpart in the United States suggests that they may become increasingly authoritative, especially as their role becomes entrenched. This makes attention to due process even more important. However, it is also proposed that, when committees become concerned about due process, their ability to "do ethics" is constrained.     

Sudden death due to a paraganglioma of the organs of Zuckerkandl

A 20-year-old woman died suddenly in a hospital emergency room after presenting with nausea, vomiting, back pain, and hypertension. At autopsy, an extra-adrenal pheochromocytoma (paraganglioma) of the organs of Zuckerkandl was found, with microscopic focal myocardial necrosis similar to that described in death from adrenal pheochromocytomas. Tumors of the organs of Zuckerkandl are extremely rare; less than 100 such cases have been reported in the world's literature, and only six, including the present case, have presented as a sudden, unexpected death. The symptoms of catecholamine storm may mimic those of acute drug intoxications, leading to misdiagnosis by both clinical physicians and pathologists.     

Undiagnosed progressive supranuclear palsy in a patient with neuroleptic malignant syndrome due to use of neuroleptics: the utility of autopsy in deaths due to known drug reactions

Medical examiners must decide whether or not a complete autopsy is warranted in evaluation of deaths that have been referred to their office. This decision is influenced by many factors. In most cases, the choice to perform only an external examination occurs in deaths where the decedent had previously documented potentially lethal natural disease or well-documented trauma. We report a patient who apparently died of the sequelae of a well-known complication of pharmacotherapy (neuroleptic malignant syndrome following Haldol administration). The death was referred to the medical examiner's office, where, based upon the history, an external examination was performed. Subsequently, the family requested an autopsy by the treating hospital. The autopsy established the diagnosis of progressive supranuclear palsy (PSP). The patient's presenting signs and symptoms were not typical of the disease; however, PSP most likely played a role in the neuroleptic malignant syndrome-like manifestations the patient exhibited following the Haldol administration. The results of the complete autopsy highlight its importance in identifying and enhancing our understanding of the underlying conditions in natural disease-based causes of death involving known therapeutic complications.     

Fatal hypokalemic thyrotoxic periodic paralysis presenting as the sudden, unexplained death of a Cambodian refugee.

For the last decade, death investigators have been aware of an unexplained syndrome of sudden death occurring among young adult Southeast Asian refugees. Presented here is a rare instance of fatal hypokalemic periodic paralysis associated with thyrotoxicosis masquerading as the sudden, unexplained death of a Cambodian refugee. The usual features of this syndrome were present, including relatively occult thyrotoxicosis, paralysis upon awakening following a high-carbohydrate meal, and hypokalemia. This case illustrates the value of thorough background death investigation and also illustrates the potential of misinterpreting traditional folk medicine coin rubbing (Cao Gio) as signs of physical abuse.     

Sudden, unexpected death due to cardiac fibroma. Report of a case and review of the literature

A case of cardiac fibroma in a 58-year-old woman with a history of atrioventricular block is described. The patient died suddenly at home 6 days following the insertion of a pacemaker. Review of the pertinent literature is presented.     

Sudden unexpected death due to Taxus poisoning. A report of five cases, with review of the literature.

The toxicity of yew (Taxus) has been known since antiquity. However, in the past 31 years, to our knowledge only six cases of Taxus poisoning have been reported in the literature. In the present paper we add five cases. From a forensic point of view, intoxication with Taxus has three important aspects: (i) the clinical presentation, which among other causes should suggest Taxus intoxication; (ii) the fact that the diagnosis may often be easily made by examination of the contents of stomach, duodenum and small bowel and (iii) the widespread availability in the near future of Taxol, an anti-neoplastic drug which is an alkaloid extracted from Taxus. The clinical and autopsy findings are summarized, the diagnostic aspects are discussed and the literature concerning Taxus is reviewed.     

Suicide due to oral ingestion of lidocaine: a case report and review of the literature

The Authors describe a rare case of suicide in a 31-year-old woman, due to oral ingestion of lidocaine; the histological and toxicological findings are discussed to provide useful information to the present experience with this particular modality of death. Histological examination revealed generalized stasis. In the myocardium we observed segmentation of the myocardial cells and/or widening of intercalated discs and associated group of hypercontracted myocardial cells with "square" nuclei in line with hyperdistended ones. Non-eosinophilic bands of hypercontracted sarcomeres alternating with stretched, often apparently separated sarcomeres, small foci of paradiscal contraction band necrosis, and perivascular fibrosis were observed too. Lidocaine was detected in the subject's urine through immunoenzymatic screening. Toxicological analysis by solid-liquid extraction and gas chromatography-mass spectrometry (GC-MS) analysis, was carried out to identify and quantify the individual substances present in the biological fluids and organs. Lidocaine concentrations were as follows: blood 31 microg/mL, gastric content 2.5 g, liver 10 microg/g, kidney 12 microg/g, brain 9 microg/g, spleen 24 microg/g, lung 84 microg/g, heart 9 microg/g, urine 9 microg/mL, and bile 6 microg/mL. No other drugs or alcohol were detected. When blood lidocaine reaches toxic levels, serious toxic symptoms associated with the central nervous system and cardiac system are noted. The overdose of lidocaine produces death from ventricular fibrillation or cardiac arrest. In this case, according to macroscopic and microscopic findings, the cause of death was most likely cardiac and possibly related to ventricular fibrillation.     

Spontaneous rupture of the liver associated with a primary angiosarcoma: case report

A case of fatal spontaneous rupture of the liver caused by primary angiosarcoma is described. Spontaneous rupture of the liver is a rare clinical and pathological entity associated with high morbidity and mortality rates. Possible causes include infections such as hydatid disease, infiltrating conditions such as amyloidosis, inflammatory disorders such as the vasculitides, malignant and benign tumors, and tumorlike conditions. As in the case presented, the finding of a ruptured liver raises the possibility of blunt abdominal trauma, and the circumstances and scene should be assessed. The possibility of terminal resuscitation attempts should also be considered as a possible cause.     

Fatal Candida tropicalis infection in an 8-month-old infant with an aplasia of the thymus as a rare cause of death in infancy

Anomalies of the thymus can lead to immunodeficiencies that are often associated with complex syndromes. The clinical relevance of those anomalies varies a lot. Regarding mortality and morbidity, opportunistic infections play a major role in immunocompromised individuals. Case report: An 8-month-old infant died of a sepsis with multi-organ failure after 32 days in intensive care. At autopsy, no thymus gland could be found; toxicological examinations yielded high morphine concentrations. Autopsy findings and the results of further examinations performed postmortem are discussed in view of the clinical findings, the classification and the cause of death.