Gas embolism as a cause of death

Systemic venous gas embolism other than that due to air is a great rarity. A case is reported and the criteria for the diagnosis are discussed. The clinical similarities between embolism of systemic venous air and that of systemic venous gas are emphasized. The two conditions can be differentiated by laboratory investigation only.     

SCUBA tank corrosion as a cause of death.

Corrosion of compressed air breathing tanks may result in dangerous oxygen depletion. In every SCUBA mishap the residual air should have, as one of the tests, a measurement of oxygen content. The tank should also have a visual inspection. All compressed air breathing tanks should have a routine visual inspection on a regular basis, even if the tank is made or lined with corrosion resistant material.     

Vaginal "fisting" as a cause of death

We describe the death of a young girl that resulted from the insertion of a clenched hand and forearm into her vagina during heterosexual activity. (The male homosexual practice of rectal fist insertion has been described previously.) We believe this death to be the first reported case of a "fisting" death due to vaginal fist insertion during heterosexual activity. This death is reported to alert forensic pathologists, medicolegal death investigators, and coroners aware of the role of aberrant sexual activity and its potential to cause death.     

Endocardial fibroelastosis as a cause of sudden unexpected death

We present a case of primary endocardial fibroelastosis (EFE) which had been diagnosed in a 16-year-old girl who died suddenly and unexpectedly. This exceptional cause of death in adolescence led to a short literature review comparing our findings with previous medicolegal reports.     

Hypopharyngeal lipoma as a cause for sudden asphyxial death

Lipomas of the hypopharynx are uncommon tumors that are rarely life threatening. When positioned in the hypopharynx, asphyxia may be the result of the tumor size or sudden displacement into the oropharynx. We present a case of a large hypopharyngeal lipoma, review the literature, and discuss mechanisms by which these lesions may cause sudden asphyxial death.     

Complex brain malformation as a rare cause of neonatal death

A dead female neonate was brought to a children's hospital by the mother. The MRI scan suggested a malformation of the brain. Because of the other circumstances of the case (the mother left the hospital unauthorizedly), a forensic autopsy was ordered, in the course of which the brain was removed while the head was totally immersed in water. This method, which was introduced by Prahlow et al., helps to obtain intact brain specimens without interfering with the necessary medicolegal preparations to determine whether the child was born alive. Neuropathological examinations classified the cerebral malformation as (lethal) lissencephaly. Further investigations showed that the mother had lived in Germany without a residence permit.     

Myocardial sarcoidosis as a rare cause of sudden cardiac death

Two relatively young women died suddenly due to myocardial sarcoidosis. Necropsy in both cases revealed compact infiltration of the ventricular septum by fibrous tissue. Histologic sections elucidated extensive granulomatous degeneration and giant cells of the Langhans' and foreign body type without central necrosis of the granulomas. Both women had been entirely free of symptoms, but in the second case of a 35-year-old, who had been 6 months pregnant, an ultrasound sonography of the heart had documented a suspicious area in the ventricular septum interpreted as a scar. Further investigations had been postponed until delivery. Isolated myocardial sarcoidosis should be taken into account as one possible cause of sudden death, especially in young people.     

Asplenia as a cause of sudden unexpected death in childhood

Sudden unexpected death in childhood is rare. The commonest causes of such deaths are a result of fulminating infections of the respiratory or nervous systems. Other causes include unsuspected congenital abnormalities of the heart, acute metabolic disorders, and rarities such as internal hemorrhages and pulmonary thrombosis. Recognition of children with congenital asplenia who are otherwise normal but have an increased susceptibility to overwhelming sepsis is extremely difficult. We reviewed 1763 autopsy files from our institution over 5 years (1990-1995), of which 293 were classified as pediatric cases. The vast majority of the cases were stillbirths and deaths within the first year of life as a result of complex congenital anomalies. Four cases of asplenia were identified in our entire series, 3 of which were of the congenital syndromal variety and 1 of which was a case of isolated sporadic congenital asplenia. All 4 cases of asplenia were analyzed in detail with respect to autopsy findings and cause of death. Severe complex cardiac malformations were present in the congenital syndromal asplenia patients; these other malformations contributed significantly to their death. In this report, we discuss in detail the autopsy findings in a previously healthy 4-year-old girl who presented with a brief 8-hour history of being unwell and died within 4 hours of admission into the hospital. She had sporadic, isolated congenital asplenia complicated by high-grade type 6B pneumococcemia and acute bilateral adrenal hemorrhage (Waterhouse-Friderichsen syndrome). Previously healthy children who clinically deteriorate very rapidly should have a blood smear done as part of their clinical workup. The detection of Howell-Jolly bodies on a peripheral blood smear can be an indicator of asplenia, and this diagnosis can be confirmed by medical imaging of the abdomen. Such steps may aid in the aggressive management of isolated congenital asplenia and thereby avert untimely death.     

Homicide as a cause of the sudden infant death syndrome

The homicidal asphyxiation of a 10 1/2-month-old male infant and the attempted asphyxiation of his 4-month-old sibling, documented by parental confession, is presented as evidence that murder may sometimes be mistaken as sudden infant death syndrome (SIDS). A review of the literature of the relationship between murder and SIDS deaths reveals the suspicions of some physicians but few published cases; this reflects not only the difficulties of making a determination of murder by suffocation, since no injuries may be present, but also a lack of awareness among physicians who must evaluate infant deaths. It is recommended that murder should be considered in the differential diagnosis of sudden, unexpected death in infants and that the autopsy should include full-body x-rays and at least an initial look at the social history of the child.     

Cardiac hydatid cyst rupture as cause of death

Echinococcosis is a frequent parasitic human infection in sheep-farming areas. It is caused by the larval or the cyst stage of a tapeworm, mainly Echinococcus granulosis. Humans can be infected by ingesting tapeworm eggs, from which cysts will be developed mostly in the liver and the lung. Cardiac involvement of echinococcosis is rare and its clinical evolution is silent till the complication stage. A young adult died suddenly. The autopsy showed a ruptured hydatid cyst hollowed on the right side of the interventricular septum, protruding in the ventricle. The left pulmonary artery contained white-colored fragments of a membrane, similar to the one found in the right ventricle, associated to small vesicles. All these elements were obstructing this vessel, extending to small pulmonary arterial branches. Dissection of the other organs did not show other locations. Microscopic examinations ascertained the diagnosis of echinococcosis. Death was imputed to a right ventricular hydatid cyst rupture with pulmonary artery embolism.     

Gas dispersal potential of bedding as a cause for sudden infant death

We assessed the gas dispersal potential of bedding articles used by 14 infants diagnosed with sudden unexpected infant death at autopsy. Of these cases, eight exhibited FiCO₂ values greater than 10% within 2.5 min, six of which were found prone and two supine. The results demonstrated that these eight beddings had a high rebreathing potential if they covered the babies’ faces. We did not, however, take into account in our model the large tissue stores of CO₂. As some bicarbonate pools will delay or suppress the increase of FiCO₂, the time–FiCO₂ graphs of this study are not true for living infants. This model, however, demonstrated the potential gas dispersal ability of bedding. The higher the FiCO₂ values, the more dangerous the situation for rebreathing infants. In addition, FiO₂ in the potential space around the model's face can be estimated mathematically using FiCO₂ values. The FiO₂ graph pattern for each bedding item corresponded roughly to the inverse of the FiCO₂ time course. The FiO₂ of the above eight cases decreased by 8.5% within 2.5 min. Recent studies using living infants placed prone to sleep reported that some babies exhibited larger decreases in FiO₂ than increases observed in FiCO₂. While the decrease of FiO₂ in our model is still theoretical, CO₂ accumulation and O₂ deprivation are closely related. If a striking O₂ deficiency occurs in a short period, babies can lose consciousness before an arousal response is evoked and all infants could be influenced by the poor gas dispersal of bedding; the main cause of sudden death in infancy would thus be asphyxia. When the bedding is soft, the potential for trapping CO₂ seems to be high; however, it is impossible to assess it by appearance alone. We sought to provide some objective indices for the assessment of respiratory compromise in relation to bedding using our model. When a baby is found unresponsive with his/her face covered with poor gas dispersal bedding, we should consider the possibility of asphyxia.     

Amniotic fluid embolism as cause of death in a car accident--a case report

Amniotic fluid embolism (AFE), a relatively rare complication in pregnancy, has a high mortality rate. We describe a case of a 38-week pregnant woman with such an embolism leading to almost immediate death after a blunt abdominal trauma inflicted in a motor vehicle accident and probably associated with improper positioning of a seat belt. It has been assumed that the pathophysiology of amniotic fluid embolism is related to an anaphylactoid reaction and that mast cell degranulation indicates this mechanism. Moreover, immunohistochemical antitryptase staining of pulmonary tissue samples in our case revealed mast cell degranulation.     

Splenic rupture as a cause of sudden death in undiagnosed chronic myelogenous leukemia

A 35-year-old man died suddenly in a clinic waiting area after repeated visits for flu-like symptoms. At autopsy, hemoperitoneum, splenic capsular rupture, and splenomegaly were found. Microscopic examination, special stains, and immunoperoxidase studies revealed findings consistent with chronic myelogenous leukemia. Spontaneous splenic rupture is an unusual presenting feature of chronic myelogenous leukemia. The symptoms of leukemia may mimic those of other "benign" disorders and misdiagnosis may lead to catastrophic consequences in some instances.