All that Wheezes is not Asthma—Alternative Findings at Autopsy

Abstract: A number of questions must be asked before asthma can be accepted as a valid diagnosis: were the episodes of shortness of breath investigated? Are there changes at autopsy in keeping with asthma? Did asthma either contribute to the terminal episode, cause death, or was it coincidental? Finally, is it possible that other conditions may have accounted for the clinical manifestations? A review of files at FSSA over a 10‐year period from 1999 to 2008 identified six cases where shortness of breath and/or wheezing had been incorrectly attributed to asthma. Five were due to pulmonary thromboembolism and one to multiple injuries. In the latter case, an irreducible, left‐sided diaphragmatic hernia was present. There was no morphological evidence of asthma in any case. Autopsy examination may, therefore, be crucial in revealing other conditions that may have caused or contributed to episodic breathlessness that may have been incorrectly attributed to asthma.     

Transmesenteric hernia due to double-loop formation in the small intestine: a fatal case involving a toddler

We report a unique case of transmesenteric hernia resulting in death, which went undiagnosed during a recent hospital visit. The victim was a 2.5-year-old girl who - with the exception of chronic constipation - had no medical history. One night she complained of abdominal pains and was taken to a pediatric hospital where doctors performed an abdominal X-ray and echography. No significant findings suggesting bowel obstruction (e.g. air-fluid levels or dilation of the bowel) were obtained on examinations and bloody feces were not observed in this particular episode. As her abdominal pain gradually attenuated, the doctor allowed her to return home. A few hours later, she lost consciousness and expired despite resuscitation efforts attempted at an emergency hospital. A subsequent autopsy revealed that the small bowel had herniated through a defect in the mesentery resulting in two consecutive and inversely forming loops, in which each loop protruded on either side of the mesentery. This rare morphological anatomy seems to have progressed in a two-step process. The girl's mild abdominal pain was likely induced by herniation and formation of the first intestinal loop, followed by severe shock occurring when the subsequent intestinal segment invaginated into the same defect forming the second loop on the opposite side of the mesentery. This case illustrates the difficulty of diagnosing transmesenteric hernia due to the presentation of unspecific symptoms; especially in infants and toddlers. Furthermore, this report demonstrates the value of a complete autopsy in cases of sudden and unexpected deaths involving children.     

Littre hernia--a rare cause of unexpected death in the elderly

A rare case of sudden and unexpected death is reported in an 87-year-old woman who was found dead at her home. At autopsy, the most striking finding was of a right-sided direct inguinal hernia containing a 20 mm infarcted Meckel diverticulum, with proximal small intestinal obstruction. Significant stenosing atherosclerosis was present in all three major epicardial coronary arteries, but with no histological evidence of acute or chronic ischemic myocardial damage. Death was attributed to small intestinal obstruction due to direct inguinal herniation (and infarction) of a Meckel diverticulum (a Littre hernia), complicating ischemic heart disease. Although Littre hernias are not a reported cause of sudden death in the elderly, congenital gastrointestinal anomalies may rarely play a significant role in terminal episodes well beyond childhood years. The autopsy assessment of sudden death at any age involves detailed examination of the entire length of the intestinal tract.     

Perforation of the superior vena cava during ECMO catheterization in two neonates with congenital diaphragmatic hernia: a cause of accidental death

Congenital diaphragmatic hernia (CDH) is a defect seen in approximately 1 in 3500 live births. A complication of CDH is the herniation of abdominal contents into the chest cavity through the defect, which may prevent normal intrauterine development of the lungs. The resultant pulmonary hypoplasia and pulmonary hypertension causes respiratory distress in the newborn, usually requiring some form of intervention before the defect is surgically corrected (Embryology for Surgeons. Baltimore, MD: Williams & Wilkins; 1994:491-539). Extracorporeal membrane oxygenation, which involves cannulation of the superior vena cava (SVC), is often used to manage these infants. However, the mediastinal shift that often occurs with CDH can cause an abnormal acute angulation of the SVC, which during cannulation can result in trauma and possible perforation of the SVC. We present 2 autopsy cases where the infants accidentally died as a result of extracorporeal membrane oxygenation cannulation.     

Sudden death due to delayed rupture of hepatic subcapsular hematoma following blunt abdominal trauma

Blunt abdominal trauma can cause sudden, unexpected death due to injuries to internal organs. Rupture of a hepatic subcapsular hematoma is a relatively rare cause of sudden death following minor blunt abdominal trauma. Death may be delayed several days to weeks. The autopsy is an invaluable diagnostic tool that can be utilized to uncover sudden deaths due to abdominal trauma. The case of an alcoholic who died of a ruptured hepatic subcapsular hematoma is presented. The death investigation revealed that the victim had sustained blunt abdominal trauma during a fall a few days prior to death.     

Suture Embolism of the Left Superior Lobar Pulmonary Artery

Endogenous pulmonary thromboemboli are a common cause of noncardiac sudden natural death. Embolism of exogenous material is a rare but potential finding in autopsies following surgeries, medical procedures, penetrating trauma, and nonparenteral drug abuse. This report describes the first case of a suture embolism of the left superior lobar pulmonary artery following complicated abdominal surgery.     

A fatal elephant attack

A rare case of an elephant attack is presented. A 44-year-old man working as an elephant keeper was attacked by a cow elephant when he tripped over a foot chain while the animal was being medically treated. The man fell down and was consequently repeatedly attacked with elephant tusks. The man sustained multiple stab injuries to both groin regions, a penetrating injury to the abdominal wall with traumatic prolapse of the loops of the small bowel, multiple defects of the mesentery, and incomplete laceration of the abdominal aorta with massive bleeding into the abdominal cavity. In addition to the penetrating injuries, the man sustained multiple rib fractures with contusion of both lungs and laceration of the right lobe of the liver, and comminuted fractures of the pelvic arch and left femoral body. The man died shortly after he had been received at the hospital. The cause of death was attributed to traumatic shock.     

Pulmonary embolism: a rare cause of sudden infant death

Pulmonary embolism can be observed at any age, but it occurs very rarely in the infant. The authors report the case of a 12-month-old boy who suddenly died during clinical improvement of gastroenteritis associated with otitis. Autopsy showed signs of dehydration and acute left pulmonary embolism, which was the cause of death. Thrombosis of the inferior vena cava extending into renal veins was seen. In this case, plasma hyperosmolality caused by dehydration might have favored the formation of venous thromboses. The various risk factors of pulmonary embolism in the child are discussed, including genetic factors.     

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.     

Spontaneous Coronary Artery Dissection: Case Report and Literature Review

Spontaneous coronary artery dissection (SCAD) is a rare cause of acute myocardial infarction and sudden cardiac death. It occurs most commonly in otherwise healthy women during pregnancy or the postpartum period. The true incidence of SCAD is underestimated, as most cases are diagnosed at autopsy. The pathophysiology of SCAD is still not fully understood, and its management can be challenging. This report describes a 35‐year‐old pregnant female who presented with an acute antero‐lateral ST elevation secondary to spontaneous dissection of the left anterior descending artery and the circumflex artery. The diagnosis was established by coronary artery angiography. However, the patient died following cardiac tamponade. The examination of this case represented a starting point for the reviewing of the diagnosis, clinical course, and management of SCAD, and for the placing of this in context with the existing literature. This study highlights the importance of prompt diagnosis and subsequent lifesaving treatment.     

Sudden Unexpected Death Due to Left Subclavian Artery‐esophageal Fistula Caused by Fish Bone

A 53‐year‐old woman was admitted to the hospital due to unexpected dizziness and died the following morning. To investigate the cause of death, a forensic autopsy along with histological examination was performed 3 days after her death. The major findings of the autopsy were that a fish bone had pierced the left subclavian artery after perforating the esophagus with 680 mL of blood in the stomach and bloody and tarry contents were present in the intestines, and the cause of death was confirmed to be subsequent hemorrhagic shock. Unfortunately, none of her family realized that she had eaten a fish 4 days before the tragedy until the fish bone was found. The present case is rare and instructive. The histopathological findings of left subclavian artery‐esophageal fistula induced by a fish bone can be used as a reference in forensic practice.     

Fatal salmonella aortitis with mycotic aneurysm rupture

Salmonellae most commonly cause uncomplicated cases of gastroenteritis but have a predilection for damaged blood vessels, especially those damaged by atherosclerosis. The abdominal aorta is most frequently affected. The most serious complication of aortitis is mycotic aneurysm formation with subsequent rupture. The authors present the case of a 61-year-old man who was found unresponsive at home 3 days after discharge from the hospital for treatment of gastroenteritis with bacteremia. Postmortem examination revealed a ruptured mycotic aneurysm with a large retroperitoneal hematoma. Numerous gram-negative rods were embedded in the wall of the aorta and surrounding inflammatory infiltrate, compatible with the patient's previously isolated. Whereas abdominal aortic aneurysm rupture is most commonly associated with atherosclerosis, the isolation of from blood cultures, coupled with radiographic evidence of gas surrounding the aorta, should raise the suspicion of infectious aortitis. Whereas fatal rupture of an aortic aneurysm secondary to atherosclerosis alone or in conjunction with aortitis will not have an impact on the manner of death, infections are reportable and thus have public health implications.     

Nonfracture-associated fatal fat embolism in a case of child abuse

Fatal fat embolism is usually thought of as a sequel to long-bone fracture, although cases secondary to soft tissue injury and atraumatic conditions have been infrequently reported. In this case of a two-year-old child-abuse victim who sustained multiple blunt traumatic injuries without skeletal fractures, pulmonary and systemic (brain and kidney) fat emboli were identified. At autopsy, all thoracic and abdominal viscera were intact; cranial contents exhibited only diffuse symmetrical petechial hemorrhages of the white matter. Because of the severe and widespread nature of soft tissue hemorrhage, and the absence of a grossly discernible cause of death, fat embolism was suspected. Using a combination of frozen section with oil red O staining and formalin-fixed osmium stained tissues, the immediate cause of death was determined to be diffuse fat embolism. Review of the literature reveals a pathophysiologic basis for fat embolism in the absence of fracture, both as a consequence of an acute increase in local pressure at the site of trauma and an alteration of the emulsification of blood lipids during shock. In light of these findings, we present this case to remind the forensic science community to consider fat embolism as the cause of death in cases of blunt-force injury without fracture.     

Sudden Collapse due to Medullary and Cervical Cord Infarction—An Unusual Presentation of Hepatocellular Carcinoma

Hepatocellular carcinoma (HCC) is a common cancer worldwide with a great potential for metastatic spread. Hepatocellular carcinoma often arises in people with underlying viral hepatitides or liver cirrhosis and may present in various ways including abdominal pain, liver mass, and signs of hepatocellular decompensation. Many tumors may have metastasized to other organs such as the lungs, lymph nodes, bone, and adrenal glands at the time of diagnosis. However, it is uncommon for HCC to present purely due to its metastasis, such as spinal cord compression from vertebral metastasis. Here, an unusual presentation of a sudden cardiovascular collapse due to medullary and cervical cord infarction from compression of the cervical cord is presented. The importance of clinical investigations, the usefulness of postmortem computed tomography scans, and the examination of the cervical spine and cervical cord in people with no obvious cause of death after standard autopsy procedures are emphasized.     

Rupture of liver cell adenoma with fatal massive hemoperitoneum resulting from minor road accident

Blunt abdominal trauma can cause rapid death resulting from serious injuries of internal organs. The liver is commonly involved and may show tearing, usually in its upper surface, resulting in hemoperitoneum eventually leading to death. Minor trauma implies serious liver damage only when previous pathologic changes causing enlargement of the organ are present. The case of a 25-year-old woman who died as a consequence of a minor road accident is reported. At autopsy, the body showed no external injuries, the only relevant finding being a massive hemoperitoneum from the rupture of an unusually large liver cell adenoma. Liver cell adenomas carry a serious risk of spontaneous rupture, which may result in the death of the patient. The occurrence of the rupture after a minor blunt abdominal trauma is highly unusual.     

Death from spontaneous coronary artery dissection in a healthy postmenopausal woman

Spontaneous dissection of the coronary arteries, in the absence of trauma, is an unusual but well-documented entity that occurs usually in middle-aged women. It is a rare cause of sudden death and myocardial infarction. Coronary eosinophilic arteritis is suggested to result in a predisposition to intimal disruption and dissection. We present the case of the sudden death of a previous healthy, 53-year-old postmenopausal female, while working, in a town of Thessalia in Greece. The cause of death was left anterior descending coronary dissection with histologic findings of eosinophilic arteritis and autoimmune thyroiditis.     

Genesis of atraumatic liver hemorrhages

Hepatic hemorrhages are not unusual after sharp or blunt abdominal traumata. They are of particular interest when deadly hepatic hemorrhages are under discussion as the single or contributory cause of death in forensic investigations, for instance after reanimation or acts of violence. The test results in rabbits demonstrate that artificial and specific enzyme-assimilation conditions can cause atraumatic hepatic hemorrhages in only a few days. With and without concomitant injuries, liver bleeding may have an atraumatic genesis. An additional human case report shows the possibility of confusion with atraumatic rhexis hemorrhage in the liver.     

Meckel's diverticulum and intestinal obstruction--report of a fatal case

Meckel's diverticulum is an uncommon cause of intestinal obstruction in adult life. Rarely Meckel's diverticulum is complicated by a mesodiverticular band, which is believed to be a remnant of a vitelline artery. When this abnormality occurs it is associated with high mortality. We present a case of a 48-year-old man with increasing abdominal pain and vomiting for 3 days. Meckel's diverticulum was not taken into diagnostic consideration, and the man died. Autopsy revealed a Meckel's diverticulum with a mesodiverticular band and intestinal obstruction. Histological examination of cross sections of the mesodiverticular band showed the presence of an artery. Because of the high mortality of this rare anatomic anomaly in adults, we find the case of interest.