Sudden death due to streptococcal infection

Sudden unexpected deaths form a large population of medical examiner caseloads. Presented are the clinical, pathologic, and virulence features of sudden death due to Group A beta-hemolytic streptococcus. Emphasis is placed on the importance of post-mortem cultures. Case histories are included to illustrate the sometimes unusual presentation of this disease. Recent publicity has led to a heightened public awareness of this unusually virulent entity.     

Sudden death as a complication of bacterial endocarditis

Three cases are reported to demonstrate the range of possible lesions and wide variation in lethal mechanisms that may be found in cases of unexpected death subsequently shown to be due to bacterial endocarditis. Case 1: A 36-year-old man was found dead on his bedroom floor surrounded by drug paraphernalia. At autopsy, acute myocardial ischemia was present caused by coronary artery ostial occlusion complicating acute bacterial endocarditis of the aortic valve. Case 2: A 54-year-old man with chronic renal failure was found dead in bed at home. At autopsy, a left middle cerebral artery territory cerebral infarct was present due to septic embolization from bacterial endocarditis involving the aortic valve. Case 3: A 23-year-old man was found collapsed in a pool of blood. At autopsy, upper airway hemorrhage from an arteriobronchial fistula was present caused by septic pulmonary infarction from previous endocarditis of a congenital ventricular septal defect. This report demonstrates that bacterial endocarditis may still be a cause of sudden and unexpected death presenting to forensic mortuaries and that the underlying mechanisms may involve complex sequences of pathological changes that compromise vascular function.     

Unexpected death as a result of infective endocarditis

Thirteen cases of infective endocarditis (IE) diagnosed for the first time at autopsy or, in those patients with a previous diagnosis of IE, not thought to be active at the time of death, are presented. Of the six patients who died within 24 h of the onset of symptoms, two died of obstruction of a valve orifice, two died of sepsis, one died of sepsis and alcoholic cardiomyopathy, and one died of a coronary artery embolus. Of the five patients with symptoms lasting more than 24 h, three died of sepsis and congestive heart failure. One died from sepsis alone and one died from congestive heart failure (CHF). In two patients whose duration of symptoms is unknown, one died of sepsis and CHF, and in the other the mechanism of death is unknown. Predisposing factors present in 11 of 13 patients included alcoholism (three), intravenous (IV) drug abuse (three), prosthetic valves (three), aortic stenosis (two), past rheumatic fever (one), and nonstenotic congenitally bicuspid valves (two). The reasons for no antemortem diagnosis were a missed or incorrect clinical diagnosis in three patients seen by a physician shortly before death, no signs or symptoms or found dead (four), non-specific signs and symptoms (three), refusal of medical treatment (one), and a solitary lifestyle (one); there was insufficient information about one patient. Individuals with needle tracks, generalized petechiae. Osler's nodes, splinter hemorrhages, intravenous catheters, pacemaker wires, and infected aortic-valve (A-V) shunts are at risk of IE. Blood and the vegetations should be cultured. The attending physician should be notified of the diagnosis in such cases.     

Sudden cardiac death in a 5-year-old girl associated with parvovirus B19 infection

We report on a 5-year-old girl who suddenly collapsed and died while dancing at a family party. Histological examination of the heart including the cardiac conduction system revealed lymphocytic infiltrations of the sinu-atrial node and perivascular infiltration in the atrio-ventricular region. Additionally, foci of mononuclear infiltrates were observed in the myocardium. Consequently, myocarditis was diagnosed as cause of death. The child also had lymphocytic conjunctivis, parotitis and tracheitis. Evaluation of infections by means of nested polymerase chain reaction revealed parvovirus B19 DNA (PVB19) in tissue samples of the trachea.     

Sudden death in cardiac myxoma

Nonmalignant tumour (heart myxoma) is often a cause of sudden death. Morphological investigation of 11 heart myxomas (8 in the left atrium, 1 in the right atrium) was performed. These myxomas were generally attached to endocardium in the area of the oval foramen. Sudden death occurred due to infarction of the brain, heart and other vitally important organs as a result of embolism of greater circulation vessels by disintegrated tumour located at the left side of the heart, then due to lung failure caused by embolism of lesser circulation vessels by tumour located at the right half of the heart, and due to heart failure as a result of occlusion of atrioventricular foramen by big myxoma.     

Sudden death in the alcoholic

A study of victims of alcohol abuse was performed on the case files of the Office of the Medical Examiner of Metropolitan Dade County in Miami, Florida. During the year 1983, all cases in which alcoholism, either acute or chronic, was the cause of death primarily or contributory in a natural or accidental manner of death were collected. These 118 cases were then analyzed as to the age, race, sex, and cause of death of the victim along with the blood alcohol content, the drugs detected at autopsy, the scene circumstances, the geographic location of the terminal incident, noting whether or not there was a history of drinking prior to the terminal incident, the average weights of key target organs, and the histopathology of the liver. The most common victim is an older (greater than 50 years) white male who dies from "chronic alcoholism" with a terminal negative blood alcohol. This victim is usually "found dead" at home with a past history of drinking, and histopathologically the liver depicts fatty metamorphosis rather than cirrhosis.     

Sudden death in hemodialysis patients

Hemodialysis patients may die suddenly and unexpectedly from a number of causes. These may be divided into those deaths due directly to and occurring during hemodialysis, those deaths occurring while the patient is not undergoing dialysis, and those deaths that may occur at any time. The first group includes brain herniation, air embolism, acute hemorrhage as a result of machine malfunction or fistula rupture, electrocution, cardiac arrhythmia caused by hypokalemia, complications of subclavian intravenous catheter insertion, third-degree heart block as a result of triglyceride emulsion, and disseminated intravascular coagulation (DIC) or hyperkalemia caused by overheated dialysate. The second group includes deaths due to pericardial tamponade because of effusion and suicidal causes of death (exsanguination, electrolyte imbalance as a result of excessive intake of salt, fluid, or potassium) as well as more conventional methods of suicide. The last category includes people dying of arteriosclerotic cardiovascular disease, hypertensive cardiovascular disease, and internal hemorrhage. Investigation of these deaths, including pertinent historical, laboratory, and autopsy data and investigation of dialysis equipment, is discussed.     

Sudden death in cerebral hemiatrophy

Hemiatrophia cerebri is a rare disease, and the etiology and pathogenesis remain unclear in most cases. In the present case, the marked hemiatrophy of the brain in a 19-year-old patient who died suddenly is attributed to encephalitis during early childhood and subsequent prolonged seizures.     

Sudden death in urticaria pigmentosa

A case of sudden death of a 25-year-old man, with a six years history of Urticaria pigmentosa, is reported. On a cold morning in November he was found lying dead on the lawn. Histology revealed no signs of systemic mastocytosis. The biochemical investigations (high free histamine level in urine) in addition to a BAC of 0,72 mg/g and the scene conditions (cold irritation) explained the mechanism of death, a systemic anaphylactoid reaction.     

Sudden unexpected death in epilepsy: a retrospective study

Patients with epilepsy have a mortality rate higher than that of the general population; sudden unexpected death represents a significant category of mortality in these patients. The precise frequency of occurrence of sudden unexpected death in epilepsy (SUDEP) is not well defined, with a range of 1 in 370 to 1100 in the general epileptic population. A major difficulty with incidence studies is the continued reluctance in using the term SUDEP as a cause of death, making reliance solely on death certificates inconsistent and incomplete. Knowledge about SUDEP remains limited, as no single common risk factor has yet been identified, although predisposing conditions have been suggested. The purpose of this study is to review the association between several clinical variables and SUDEP to elucidate risk factors. The characteristics of the 67 cases in this series correlate with published findings in previous studies. Attributes that may be used to define an at-risk group of epileptics include age less than 40 years, male gender, long history of seizure disorder, undermedication or poorly controlled seizure activity, and mental or physical stress. Education of physicians as to the existence of SUDEP and risk factors is imperative in improving patient education and reduction in mortality.     

Sudden death in a patient with Von Recklinghausen's neurofibromatosis

Sudden death caused by tumors is uncommon. Death attributable to an unsuspected primary intracranial neoplasm is especially rare. An undiagnosed brain tumor is particularly unusual in a patient with Von Recklinghausen's neurofibromatosis (NF). A young man with known NF, with no manifest central nervous system involvement, died less than 24 hours after plastic surgery. A glioblastoma multiforme was discovered at autopsy.     

Principles of records and coding causes of death as a result of craniocerebral injury

Discusses modern requirements to coding of death causes in cases of craniocerebral injury in accordance with the 10th revision of International Statistical Classification of Diseases and Health-Related Problems (ICD-10). Offers the ways to fill in medical certificates of death with consideration for the items of ICD-10 and classification of craniocerebral injuries.     

Sudden death due to a laryngeal cyst.

A 68-year-old woman died suddenly at home; her body was found in an armchair in a sitting position. Autopsy revealed a laryngeal cyst of a dilated secretory gland, located above the vocal cords, which obstructed the glottis, causing asphyxia. A review of the literature with forensic implications is given.     

Sudden death associated with a cardiac diverticulum.

We describe the unusual case of a 20-year-old Aboriginal man who was admitted to hospital with chest pain. He died 1 day later. Necropsy showed extensive anterior myocardial infarction in the left ventricle. An isolated diverticulum arising from the subaortic valve region of the left ventricle had compressed the left main coronary artery.     

Sudden death due to a central neurocytoma.

The central neurocytoma is a common, usually intraventricular tumor with bland histologic features. We report a case of a 51-year-old man who died suddenly. At autopsy, a neurocytoma with acute hemorrhage filled the anterior left lateral ventricle. The tumor matrix and surrounding brain tissue contained accumulations of hemosiderin. Previously, 2 cases of central neurocytoma with associated hemorrhage have been reported. Hemorrhage appears to be a serious complication associated with these neoplasms.