Arterial-esophageal fistulae in patients requiring nasogastric esophageal intubation

A rare and potentially fatal cause of hematemesis is fistula formation between the esophagus and the vascular system. A case report of a 39-year-old woman with congenital aortic arch anomalies hospitalized for treatment of head injuries demonstrates the potential for iatrogenic esophageal trauma to initiate fistula formation between the esophagus and an anomalous arterial system. A literature review revealed 6 other cases of vascular-esophageal fistulae caused by nasogastric esophageal intubation. It is concluded that aortic arch anomalies increase the risk of esophageal injury and subsequent fistula formation from nasogastric esophageal intubation. In addition, the clinical features and pathologic findings of vascular-esophageal fistulae are reviewed.     

Barrett esophagus and unexpected death

Barrett esophagus is characterized by the presence of columnar mucosa in the lower esophagus in continuity with gastric mucosa. Complications include ulceration and adenocarcinoma. Although sudden and unexpected death is not a usual outcome, the case of a 63-year-old man is presented who died unexpectedly following perforation of an ulcerated Barrett esophagus, with development of an esophagopleural fistula. Sudden and/or unexpected death in individuals with Barrett esophagus may result from hemorrhage due to erosion into mural vessels, the aorta or heart, or from penetration into the pleural space, trachea, bronchi, and pericardial sac, with the development of tension pyopneumothorax, bronchial fistula, and mediastinitis. Ulceration of the lower esophagus at autopsy should prompt consideration of the possibility of a Barrett esophagus and initiate careful dissection/examination of the surrounding mediastinal tissues and vessels.     

Sudden death by inhalation of cyclopropane

This paper reports the case of a 22-year-old white male who was found dead in a storage room as a result of a fatal ingestion of cyclopropane. Cyclopropane is a sweet-smelling, irritating gas. Autopsy findings revealed congestion and hemorrhagic edema of the lungs, congestion of the trachea, and early autolysis. Cyclopropane was determined by headspace gas chromatography and mass spectrometry. To our knowledge, this is the first reported fatality involving cyclopropane.     

Esophagoaortic perforation by foreign body (coin) causing sudden death in a 3-year-old child.

We report an extremely unusual consequence to foreign body ingestion in a case of a 3-year-old boy who died suddenly and at autopsy was found to have an esophagoaortic fistula. This fistula was caused by a coin which lodged posteriorly and eroded through the esophagus into the aorta. Serious complications following foreign body ingestion are rare and include stricture formation, intramural abscess, and the formation of fistula tracts. This case illustrates the potentially unpredictable behavior of impacted foreign bodies. The child's parents were initially suspected of child abuse based on the terminal hemoptysis.     

Traumatic false aneurysm of descending aorta with aortoesophageal fistula

We report a case of traumatically induced false aneurysm with secondary bacterial aortitis of the descending aorta and fistula formation between the aorta and esophagus. This lesion was diagnosed at autopsy and caused death in a 68-year-old female 19 years after an automobile accident. Aortoesophageal fistula (AEF) formation as a result of any cause is rare. To our knowledge, this is the second reported case of traumatic aortic aneurysm as a result of an automobile accident with subsequent AEF formation.     

Massive, fatal aspiration of blood: not necessarily a result of trauma

We report the rare pathologic finding of massive, fatal aspiration of blood in an 82-year-old woman, originating from a ruptured atherosclerotic aneurysm of the ascending part of the thoracic aorta eroding into the left lung. This case demonstrates that lethal bilateral hemoaspiration does not necessarily have to be the result of trauma and that in such cases, the bleeding site does not have to be situated above the trachea.     

Coronary arteritis diagnosed at autopsy: three case reports and review of the literature

Coronary arteritis is rare but can be fatal either by itself or in conjunction with other diseases. The authors report cases of three men in whom coronary arteritis was an interesting finding that may have caused or contributed to death. One 45-year-old man collapsed at work, another 56-year-old man was found dead in his parked car, and one 80-year-old man had a recent cerebrovascular accident. All three men had coronary arteritis, arteriosclerotic cardiovascular disease, some form of myocardial disease, and fatty liver change. Two had different lung diseases. The findings suggest that coronary arteritis may be an independent cause of death, part of a systemic disease, or, as these three cases illustrate, part of a constellation of cardiac and cardiovascular pathologies with a possible relation to other medical conditions. Coronary arteritis is an important finding in forensic pathology and merits consideration in a case of unexplained 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.     

Fatal big cat attacks

Two cases of fatal attacks by large cats are presented. In the first case, a 30-year-old female zoo worker was attacked by a jaguar that had escaped its cage. In the second case, a 2-year-old girl was fatally injured by her father's pet leopard. The pattern of injuries in these cases is nearly identical to those of these cats' prey in the wild.     

Sudden suffocation by surgical sponge retained after a 23-year-old thoracic surgery

A 70-year-old male patient with a 23-year-old history of right lower lung lobectomy for primary pulmonary adenocarcinoma (T1 N0 M0) presented with recurrent bronchopneumonia and purulent sputum. Pleural callus, lung abscess, bronchopleural fistula, and stitch granulomas were confirmed by chest x-ray, computed tomography scan, and bronchoscopy in the background of his complaints. An attempt to remove the bronchial purulent discharge and tissue sampling was made by using a flexible bronchoscope. The area of the lower trachea suddenly became clogged during bronchoscopic removal of the suspected piece of tissue (which later turned out to be organizing surgical gauze). The resuscitation following ventricular fibrillation failed to save the patient's life. The forensic postmortem examination confirmed the position of the foreign body extending from the abscess cavity, crossing the midline at carina and obstructing the lower trachea. This foreign body was a remnant of the surgical gauze left behind during a thoracic surgery 23 years ago.     

Sudden death of an alcoholic elderly man with acute esophageal necrosis (black esophagus)

We report a fatal case of acute esophageal necrosis (black esophagus) in an elderly male with alcohol abuse who was found dead with coffee-ground vomiting. A postmortem examination revealed severe anemia and marked black coloring of the esophagus from the upper to the bottom end. This was accompanied by histologic evidence of extensive mucosal necrosis. Alcohol abuse and esophagitis-related vomiting were both considered to be factors that led to the acute fatal esophageal necrosis. The cause of death was undetermined. We discuss the possible role of acute esophageal necrosis in the cause of sudden death.     

Traumatic rupture of intracranial vertebral artery due to hyperextension of the head: reports on three cases

In three cases of fatal basal subarachnoid hemorrhage due to rupture of the normal intracranial vertebral artery, the ruptures appeared to have been caused by overstretching of the vertebral artery from traumatic hyperextension of the head. In the first case, that of a 31-year-old male pedestrian who, while intoxicated, had been hit from behind by a car, symmetrically located bilateral complete and incomplete tearing of the vertebral arteries was found. In both of the other two cases, involving women aged 37 and 51 found dead after receiving fist blows to the face while intoxicated, complete rupture of the vertebral artery was found. The blood alcohol concentrations of the three cases ranged from 1.6 to 1.7 mg/g at autopsy.     

Fatal hemothorax due to rupture of an intrathoracic extramedullary hematopoietic nodule

Intrathoracic extramedullary hematopoiesis (TEMH) is an unusual but well-described entity, which is typically found in patients who have chronic hemolytic anemias, myelofibrosis, or myeloproliferative disorders. It is seldom symptomatic, rarely fatal. We report a case of a 26-year-old African-American male with a past medical history of sickle cell trait/beta thalassemia who developed multiple intrathoracic nodules of extramedullary hematopoiesis. One of these nodules spontaneously ruptured and produced a fatal hemothorax.     

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.     

Vertebral artery rupture in traumatic subarachnoid haemorrhage detected by postmortem angiography

A fatal subarachnoid haemorrhage from a ruptured normal intracranial vertebral artery in a 49-year-old male, following a blow to the head, was revealed by a postmortem angiographic technique using radiopaque silicone rubber as a contrast medium vulcanizing at room temperature. No fracture of the atlas or connection between intracranial vessels and extracranial soft tissue haematoma could be visualized. We advocate the use of postmortem angiography in the diagnosis of suspected head trauma sustained in fights.     

Sudden death in an adolescent due to undiagnosed classic Hodgkin lymphoma

Few cases of natural sudden death presenting as an undiagnosed lymphoma have been reported in the literature, especially in adolescents. Herein we provide a report of sudden death caused by undiagnosed classic Hodgkin lymphoma (cHL). We describe an 18-year-old female who collapsed after several weeks of weight loss, decreased appetite, and dyspnea. At autopsy, a bulky mass arising in the mediastinum and neck compressed the esophagus and trachea, surrounded the great vessels, obliterated the pericardial sac, and infiltrated the myocardium. The lungs were collapsed and large pleural effusions were present. The tumor burden, which weighed at least 2710 g in aggregate, was entirely above the diaphragm. Microscopic examination of the masses showed features typical for nodular sclerosis cHL including large bands of sclerosis, numerous Hodgkin/Reed-Sternberg (HRS) cells, and an eosinophil-rich mixed inflammatory cell infiltrate. Immunohistochemical stains showed the HRS cells to be uniformly positive for CD30 and CD15 and negative for CD3, CD20, CD45, and PAX5. This case exemplifies a rare sudden natural death due to previously undiagnosed cHL in a young patient.     

Epithelial cell mitotic arrest--a useful postmortem histologic marker in cases of possible colchicine toxicity

Following ingestion of 30 mg of presumed benztropine (Cogentin) a 39-year-old male developed nausea, vomiting and diarrhea. His admission to hospital was soon followed by collapse and death. Histological examination, however, revealed increased numbers of mitotic figures in otherwise normal epithelial cells of the esophagus and bronchioles, a feature characteristic of colchicine toxicity. Subsequent toxicological analyses confirmed the presence of colchicine in the urine, but not in the blood. A dispensing error had resulted in substitution of colchicine for Cogentin. Histological findings had, therefore, provided evidence of colchicine toxicity and had guided subsequent toxicological evaluation. In suspected cases of colchicine toxicity, histological samples should, therefore, be taken from multiple sites along the gastrointestinal and respiratory tract in addition to other organs and tissues so that diagnostic morphological changes can be looked for.     

Fatal childhood vascular injuries associated with seat belt use

The deaths of two children who were passengers in motor vehicles involved in accidents were directly attributable to vascular injuries derived from seat belts. In the first case, a 10-year-old boy died as a result of abdominal aortic transection by a lap seat belt, and in the second case a 15-year-old boy died as a result of transection of his common carotid artery by a lap-shoulder seat belt. Although these cases demonstrate rare fatalities associated with seat belt use, there is no doubt that seat belts have significantly reduced mortality and morbidity from traffic accidents. Although it is possible that a fatal outcome might have occurred in each of these cases from other injuries that might have been sustained had seat belts not been worn, appropriate positioning and size of seat belt harnesses might have avoided the lethal injuries.     

Pathologic features of fatal shark attacks

To examine the pattern of injuries in cases of fatal shark attack in South Australian waters, the authors examined the files of their institution for all cases of shark attack in which full autopsies had been performed over the past 25 years, from 1974 to 1998. Of the seven deaths attributed to shark attack during this period, full autopsies were performed in only two cases. In the remaining five cases, bodies either had not been found or were incomplete. Case 1 was a 27-year-old male surfer who had been attacked by a shark. At autopsy, the main areas of injury involved the right thigh, which displayed characteristic teeth marks, extensive soft tissue damage, and incision of the femoral artery. There were also incised wounds of the right wrist. Bony injury was minimal, and no shark teeth were recovered. Case 2 was a 26-year-old male diver who had been attacked by a shark. At autopsy, the main areas of injury involved the left thigh and lower leg, which displayed characteristic teeth marks, extensive soft tissue damage, and incised wounds of the femoral artery and vein. There was also soft tissue trauma to the left wrist, with transection of the radial artery and vein. Bony injury was minimal, and no shark teeth were recovered. In both cases, death resulted from exsanguination following a similar pattern of soft tissue and vascular damage to a leg and arm. This type of injury is in keeping with predator attack from underneath or behind, with the most severe injuries involving one leg. Less severe injuries to the arms may have occurred during the ensuing struggle. Reconstruction of the damaged limb in case 2 by sewing together skin, soft tissue, and muscle bundles not only revealed that no soft tissue was missing but also gave a clearer picture of the pattern of teeth marks, direction of the attack, and species of predator.