Sudden death from massive pulmonary tumor embolism due to hepatocellular carcinoma

Massive pulmonary embolism in cancer patients can be due to detached thrombi or tumor. Pulmonary tumor embolism is often undiagnosed antemortem. We report a 52-year-old Chinese man admitted for management of hepatocellular carcinoma (HCC). Computerized tomography showed tumor involvement of hepatic vein and inferior vena cava. He died suddenly on the day of admission. At autopsy the main pulmonary arteries of both lungs were blocked by large tumor emboli, the immediate cause of death. Although rapid death in patients with HCC is usually caused by intraperitoneal hemorrhage from spontaneous rupture of tumor, massive pulmonary tumor embolism should also be considered in these patients, especially when antemortem evidence of hepatic vein and/or inferior vena cava invasion is present.     

Right ventricular damage due to pulmonary embolism: examination of the number of infiltrating macrophages

To investigate the pathological changes in the heart induced by pulmonary embolism, 20 autopsy cases of pulmonary embolism and 10 control cases of acute death from traumatic injury were examined. Adding to the routine hematoxylin-eosin (HE) staining, immunostaining with CD68 pan-macrophage marker was performed on the specimens obtained from both right and left ventricular walls. The number of macrophages was counted semi-quantitatively in 100 random high-power fields (HPF). Although typical pathological findings of myocardial infarction was not observed in any of the cases, 16 of the 20 pulmonary embolism cases showed an increase in the number of macrophages, mainly in the right ventricular wall. Four cases showed massive macrophage infiltration in the entire right ventricular wall. It is speculated that ischemia due to pulmonary embolism may be connected to its pathogenesis.     

Sudden death due to right ventricular cardiomyopathy

A 21-year-old man died suddenly at a small party. He had had no clinical signs of cardiac disease except for a slightly abnormal electrocardiogram (occasional premature ventricular contractions) since he was 15 years of age. Autopsy examination revealed cardiomegaly (469 g), with right atrial and ventricular dilatation. The right ventricular myocardium was massively replaced with adipose tissue, and there was one isolated fatty lesion in the right side of the ventricular septum. There were no congenital malformations such as a septal defect or valvular deformity. Histologically, muscular fibers remaining in the right ventricular wall showed neither degenerative nor inflammatory changes. An isolated lesion of the ventricular septum consisted of almost complete replacement of the muscle bundles with adipose tissue. Such a pathologic condition has recently been termed right ventricular cardiomyopathy. Postmortem examination is necessary to make a definite diagnosis of the disease, because in most adult cases of the disease, sudden death occurs before there have been any critical signs.     

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.     

Activated protein C resistance is uncommon in sudden death due to pulmonary embolism

Activated protein C resistance (APC-R) is the most common inherited defect of the coagulation system known to date, affecting 3-5% of Americans. It is an autosomal dominant disorder associated with an increased risk of venous thrombosis and is reportedly found in 21% of individuals with deep venous thrombosis. Medical examiners are in a unique position to make the diagnosis since a fatal pulmonary embolism may be the first manifestation of the disorder. This study examines the prevalence of APC-R in individuals who die suddenly of pulmonary embolism to help medical examiners decide if routine testing is indicated. We examined 66 cases of sudden death due to pulmonary embolism seen at the Bexar County Forensic Science Center in San Antonio, Texas, from 1993-1997. The median age was 46 years with a range of 14 to 93 years. Fifty-three percent were Caucasian, 24% were African-American, and 23% were Hispanic. Twenty-seven percent had no known risk factors for pulmonary embolism. Whole blood was tested for the factor V codon 506Q mutation responsible for APC-R using polymerase chain reaction. The prevalence of APC-R was 4.5%, which is similar to the prevalence of APC-R in the general American population. These data imply that individuals with APC-R are not in increased risk for sudden death due to pulmonary embolism, or, conversely, that most fatal pulmonary emboli seen in the medical examiner setting are not induced by APC-R. Routine postmortem testing for the factor V 506Q mutation does not appear indicated at this time, given the low prevalence and high cost of testing.     

Arrhythmogenic right ventricular dysplasia cases in forensic autopsies

Arrhythmogenic right ventricular dysplasia or cardiomyopathy (ARVD or ARVC) is an increasingly recognized entity with clinical and forensic implications. This is the first series documenting ARVD in 5 separate cases in forensic autopsies from Turkey declared as natural sudden cardiac death following complete autopsy and toxicologic analysis. There was a male preponderance (M/F=4), with a mean age of 50.     

Intravascular bullet embolism to the right atrium

Bullet embolism is a relatively unusual complication of gunshot wounds. Embolism to the right atrium comprises <5% of all reported intravascular bullet emboli. We report an additional case of bullet embolus to the right atrium of a 0.38-caliber bullet following a gunshot wound to the chest. The intracardiac bullet was recognized radiologically on presentation, but the patient was hemodynamically stable and managed conservatively, with the bullet left in place. The missile remained within the heart without clinical significance for several years and was recovered from the right atrium only at the time of autopsy. To the best of our knowledge, this is the first documented case of a 0.38-caliber bullet which embolized to the right atrium and remained inconsequential for an extended period of time.     

Maternal death due to non-traumatic fat embolism

The aim of this report is to document a case of non-traumatic fat embolism (NTFE) and to address the need for considerition of fat embolism in suspicious deaths resulting from respiratory distress in the postpartum period. A 28-years-old woman autopsied at the Morgue Department of the Council of Forensic Medicine is included to the study. This female became unconscious and developed respiratory distress 4 h after delivery, and this was followed by respiratory arrest. External examination revealed resuscitation marks and normal postmortem changes. Light microscopy revealed massive fat embolization involving most of the alveolar capillaries on several sections. Only in one particular area was a bone marrow embolus. Pathological diagnosis of the lung was diffuse pulmonary fat embolism. There was no evidence of other organ involvement with emboli. Other visceral organs showed no striking findings other than mild congestion. The cause of death was considered to be respiratory insufficiency resulting from severe fat embolism of the lungs.     

Sudden death from secondary massive pulmonary embolism derived from marrow emboli trapped by Chiari's network.

We report a case of fatal massive pulmonary embolism in an 86-year-old woman. The embolus occurred as a result of embolic bone marrow particles from a fractured femur becoming trapped by a Chiari's network which then acted as a source for propagation of a large thrombus which detached and caused sudden death from massive pulmonary embolism. To our knowledge this is the first report of such a case.     

Embolism of massive hepatic tissue in inferior vena cava and right atrium after closed liver injury

Embolism from liver tissue in a major vessel in coincidence with a severe injury to the liver is a rare phenomenon. We report a case of a 4-year-old boy who was involved in a traffic accident and died shortly after the accident. An autopsy revealed that an intrahepatic inferior vena caval injury was accompanied by a severe closed injury to the liver; the crushed liver fragment was driven through the lacerated wall into the inferior vena cava and almost completely occluded its lumen. The crushed liver flap further extended over into the right atrial cavity. Careful microscopic examination of the lungs showed no emboli of hepatic tissue.     

Hypernatremia due to amniotic fluid embolism during a saline-induced abortion

A case of fatal amniotic fluid embolism leading to hypernatremia during a hypertonic saline-induced abortion is reported. This sequence of events has not, to our knowledge, been previously reported. Hypernatremia as a diagnostic aid for amniotic fluid embolism is discussed.     

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.     

An autopsy case of sudden unexpected death due to atherosclerotic coronary heart disease associated with simple right ventricular outflow tract stenosis

A case of a 35-year-old male who died suddenly after a blow on the chest by his opponent during a quarrel. From both the clinical and autoptical examinations there was no evidence of trauma found anywhere, even in the chest. The heart was the only one of all the internal organs whereon significant pathologic changes were observed during autopsy. It's lesions were as follows: (I) The right ventricle was greatly enlarged simply due to the simple right ventricular outflow tract stenosis (SRVOTS); the heart weight was 587 g. (II) All the main trunks of coronary arteries were involved by atherosclerosis. In addition, the appearance of the lumen at the proximal end of the left anterior descending artery narrowed by an atheromatous plaque (grade II) was completely occluded by a newly formed thrombus. The authors believed that both the coronary atherosclerotic changes and the enlarged heart due to the SRVOTS played a role in the pathogenesis of death (Kelberlus, H.E. and Wellens, H.J.J., Sudden Death, Developments in Cardiovascular Medicine, Vol. 4, Martinys Nijhoff Publishers, London, 1980, pp. 34-48; Jinming, Qin, A study of cardiac sudden death (51 cases) on the clinical pathologic view, Tianjin Med., 8 (1980) 458-461). The quarrel and blow were the disposing factor.     

Sudden, unexpected death due to fourth ventricular subependymoma

A case of sudden, unexpected death due to fourth ventricular subependymoma (subependymal glomerate astrocytoma) in a 60-year-old man is presented. Sudden, unexpected death due to uncomplicated subependymoma has not been previously described.     

Methamphetamine body packer: acute poisoning death due to massive leaking of methamphetamine

We encountered three methamphetamine (MA) body packers presenting simultaneously, one of whom died. Three Nigerian men (39, 35, and 37 years old) who attempted to smuggle were found to contain 35 (498 g), 21 (292 g), and 5 packages (73 g) of methamphetamine hydrochloride (MA-HCl) in their stomachs, respectively. Packages were wrapped with plastic film and Scotch tape. The 39-year-old man died with acute poisoning from c. 20 g of MA-HCl that had leaked from the packages into the stomach. His plasma MA concentration was 8.6 microg/mL when he was hospitalized (17 h before his death). Autopsy findings showed extreme pulmonary congestion and edema as well as moderate hepatic edema and several petechiae. Quantitative analysis was performed by gas chromatography/mass spectrometry. Extremely high concentrations of MA and its metabolite amphetamine (AP) were found in cardiac blood (63.5 microg/mL and 1.2 microg/mL), urine (4,518 microg/mL and 72.4 microg/mL), gastric contents (8,490 microg/mL and 16.9 microg/mL), and in all other autopsy samples. These high concentrations confirmed that the cause of death was acute MA poisoning. Furthermore, impurity-profiling analysis of the seized MA revealed that the MA smuggled by the three suspects originated from the same batch.     

Lethal head injury due to tear-gas cartridge gunshots

We report a fatal head injury caused by a tear-gas cartridge and point out the underestimated potential injury of this type of weapon. Gas pressure wounds and the death mechanisms are also described. A review of the literature and forensic considerations of head injury without projectile are presented.     

致心律失常性右室心肌病研究进展

致心律失常性右室心肌病(ARVC)是一种新命名的原发性心肌病,其病因和发病机制至今未明。过去研究报道的病因发病机制有炎症、免疫、退行性变及个体发育不良等几种学说,但新近越来越多的研究表明其与凋亡和基因突变有关。ARVC以青壮年男性多见,多有家庭病史和遗传倾向,属常染色体显性遗传,是年轻人较常见的猝死原因之一。心脏病变的特征是右心室心肌局灶性或大片被脂肪和纤维脂肪组织所取代,正常心肌被分隔成岛状或块状,散在分布于纤维脂肪组织间,右心室壁变薄、右心室腔扩张。鉴别诊断主要是扩张型心肌病和脂肪心等。尸检时除应全面系统地解剖外,心脏需多部位,特别是右心室取材做病理切片检查。     

Cutaneous current marks due to a stun gun injury

Histological changes of the skin following electrical injury with a stun gun have rarely been described. We report the case of a 61-year-old man who died after having been tortured with a stun gun during a robbery. At autopsy two reddish, dot-like lesions where found on the chest and histological examination revealed electric current-related changes. Only a few reports concerning micromorphological cutaneous changes following stun gun injury have been reported; therefore further investigations concerning the frequency and type of histological findings due to stun gun injuries will be necessary in order to provide sufficient characteristic data for a conclusive interpretation.     

A work-related death due to a penetrating chest injury

Penetrating injuries of the chest are uncommon in the work-place. We report an unusual case of a machinist who was killed when a drill press broke and a flying metallic fragment penetrated his thorax.