Sudden Unexpected Death Due to Graves' Disease During Physical Altercation

We report a case of a 30‐year‐old woman who suddenly collapsed after having a physical altercation with her husband. Despite immediate resuscitation, she died on arrival at the hospital. The victim's parents requested an autopsy because they believed that their daughter was killed by her husband. Postmortem examination revealed that the victim had a diffusely enlarged thyroid gland and cardiomegaly with left ventricular hypertrophy. There was no evidence of significant trauma on the body. Further postmortem thyroid function tests and review of her medical history indicated that her death was due to Graves' disease. To the best of our knowledge, this is the first case reported of sudden death due to cardiac arrhythmia from Graves' disease induced by physical and emotional stress associated with the criminal activity of another person. The autopsy findings are described. In addition, the literature is reviewed and the significance of postmortem evaluation of thyroid hormones in the cases of sudden death is discussed.     

A Fatal Mediastinitis Due to a Neck Trauma from an Undeclared Assault

History of neck trauma should be promptly investigated in patients with severe infections of the chest as mediastinitis. We present a forensic case of a death due to a mediastinitis in a patient with an undetected fracture of the superior horn of the thyroid cartilage that was exclusively revealed at autopsy examination. Histological analyses of the neck tissues showed signs of pharyngeal mucosal microperforation caused by the fracture and surrounded by an inflammatory reaction. The fracture was caused by a not declared manual strangulation attempt, happened several days before medical evaluations. We share our experience to emphasize the importance of revealing the etiologies of fatal infections of the mediastinum both for clinical and forensic purposes.     

Fatal thyrotoxic crisis

Graves' disease is a form of hyperthyroidism. A rare complication of Graves' disease is thyrotoxic crisis. Although the crisis is frequently fatal, it is a distinctly unusual cause of sudden death. We investigated the case of a young woman with Graves' disease who died suddenly. Radioimmunoassay tests of thyroid function were used to establish the diagnosis.     

Age-dependent morphologic findings of the thyroid in sudden infant death

Age (eight days to 12 months) and degree of colloid depletion or colloid content of the follicles (normal, partially depleted, depleted) were correlated on the basis of 176 thyroid investigations in cases of sudden infant death syndrome (SIDS). In the 176 SIDS cases, a resting thyroid gland with normal colloid content could only be found in 14%, whereas partially depleted follicles were found in 35% and depleted follicles in 51%. 60% of all cases showed a large degree of epithelial desquamation up to collapse of all follicles. A marked capillary hyperemia was found in 48%. 80% of the cases showed a normal colloid content in the first month of life, and colloidfree follicles should not be detected in any case. An increased incidence of thyroid activation was obtained in the total number of cases only from the second month of life. The histomorphological appearance of the thyroid gland thus corresponds to that of healthy infants only in the first month of life. The question as to why there is an evidently raised thyroid activity in the subsequent months of life in SIDS cases is discussed.     

Antemortem chemical hypothyroxinemia

Based on reports of hypothyroidism in intensive care unit patients, a preliminary study was instituted in which 40 patients coming to autopsy, with no history of thyroid disease, were studied to include gross and microscopic study of the thyroid gland and the performance of thyroid function tests on all serum specimens submitted within seven days of death. Initial studies show that with the exception of sudden cardiac death, all of the autopsy patients showed evidence of chemical hypothyroxinemia within three days preceding death without any histologic abnormalities of the thyroid gland. Thyroid function tests were subsequently studied of decedents and survivor controls matched for age, sex, disease, and stage of disease if applicable. The findings were similar.     

Delimitation of the time of death by immunohistochemical detection of thyroglobulin

To improve the possibilities to delimit the time of death after longer laytime it was examined if this is possible by immunohistochemical detection of thyroglobulin. The results show that in our examination material the colloid and the follicular cells of the thyroid glands of up to 5-day-old corpses produce a positive immunoreaction towards thyroglobulin in all cases whereas none of the corpses older than 13 days show such a reaction. This means that in case of a negative immunoreaction the time of death can be assumed to lie more than 6 days before the autopsy. The fact that a negative immunoreaction occurrs consistently after 13 days leads to the conclusion that when thyroglobulin has been stained in a specimen, the death of the respective person must lie a maximum of 12 days earlier, whereby these time-limits may change in considerably different surrounding conditions.     

Delimitation of the time of death by immunohistochemical detection of calcitonin.

To improve the possibilities of delimitating the time of death after longer laytime it was examined if this is possible by immunohistochemical detection of calcitonin. The results show that in our examination material the c-cells of the thyroid glands of up to 4-day-old corpses produce a positive immunoreaction towards calcitonin in all cases whereas none of the corpses older than 13 days show such a reaction. This means that in the case of a negative immunoreaction the time of death can be assumed to lie >4 days before the autopsy. The fact that a negative immunoreaction occurred consistently after 13 days leads to the conclusion that when calcitonin has been stained in a specimen, the death of the respective person must lie a maximum of 12 days earlier, whereby these time-limits may change in considerably different surrounding conditions.     

Delimitation of the time of death by immunohistochemical detection of thyroglobulin

To improve the possibilities to delimit the time of death after longer laytime it was examined if this is possible by immunohistochemical detection of thyroglobulin. The results show that in our examination material the colloid and the follicular cells of the thyroid glands of up to 5-day-old corpses produce a positive immunoreaction towards thyroglobulin in all cases whereas none of the corpses older than 13 days show such a reaction. This means that in case of a negative immunoreaction the time of death can be assumed to lie more than 6 days before the autopsy. The fact that a negative immunoreaction occurs consistently after 13 days leads to the conclusion that when thyroglobulin has been stained in a specimen, the death of the respective person must lie a maximum of 12 days earlier, whereby these time-limits may change in considerably different surrounding conditions.     

A Rare Presentation of Sudden Death due to Pulmonary Thromboembolism Possibly as a Result of Giant Hepatic Hemangioma

Hepatic hemangiomas are usually detected incidentally when investigating for other nonrelated pathologies. When symptomatic, they are usually large and cause symptoms such as abdominal discomfort or other digestive issues. Occasionally, uncommon presentations such as bleeding with coagulopathy (Kasabach–Merritt syndrome) or even fever of unknown origin may occur. As hepatic hemangiomas are benign, they do not result in tumor emboli and pulmonary thromboembolism due to hepatic hemangiomas is extremely rare. This is a case report of a rare case of a female with no known past medical history who presented with sudden death due to pulmonary thromboembolism, possibly as a result of an underlying giant hepatic hemangioma. Incidentally, she also had three other tumors—pancreatic cystic lymphangioma, cerebral capillary telangiectasia, and papillary thyroid carcinoma, and their potential contribution to the cause of death will be discussed.     

Homicidal and suicidal ligature strangulation--a comparison of the post-mortem findings

Suicides by ligature strangulation are rare events. In Berlin (3.5 million inhabitants; ca. 500 suicides per year) approximately one case per year occurs. Here, we present the main findings of 19 cases investigated between 1978 and 1998, compared to 47 cases of homicidal ligature strangulation. Two of the 19 suicidal victims had single fractures of the upper thyroid horns and one victim a fracture of a lower thyroid horn; other types of laryngohyoid injuries were not observed. In the homicidal series, the laryngohyoid structures were unaffected in 26 cases (12 of these victims were children or adolescents), single thyroid horn fractures were present in three cases and more significant injuries in 18 cases. Macroscopic bleedings of the laryngeal muscles were found in 12 victims of the homicidal group and in none of the suicidal. Bleedings in the neck muscles seldom occurred in suicides. According to these findings, the laryngohyoid injuries can be helpful in the differentiation of suicide from homicide, if more than a single thyroid horn fracture or a laryngeal soft tissue trauma is present.     

Throat-cutting of accidental origin

Abstract:  Incised wounds of the neck can be accidental, homicidal, or suicidal. In this paper, a death case has been presented where a spinning circular saw of a cutting machine in a workshop came off its place and cut the throat of a 30-year-old male who was operating the machine. There was an incision (15 cm × 5 cm) that began in the middle of the neck down the thyroid cartilage, extended horizontally to the left of the neck and ended on the outer part of the neck in the outer left side of m. trapezius. Death occurred because of exsanguination caused by the cutting of carotis artery and jugular vein. In the case we presented, although the cut in the neck initially suggested homicide, it was found to have occurred as a result of an accident after the autopsy and death scene investigation.     

Age estimation using radiographic analysis of laryngeal cartilage

The laryngeal cartilages undergo age changes, including mineralization and ossification. Keen and Wainwright defined, in male and female subjects, recognizable stages of radiopacity of the thyroid, cricoid, and arytenoid cartilages. The present study analyzed quantitatively the degree of laryngeal radiopacity to determine whether radiography of the larynx can be used routinely in forensic pathology to estimate age at death. In each of 82 subjects, the larynx was removed during forensic autopsy and subjected to radiography in an anteroposterior orientation. Each radiograph was independently scored by two observers. For each case, the degree of laryngeal radiopacity was evaluated according to the classification of Keen and Wainwright. There was a positive correlation between the total score of laryngeal radiopacity and age (correlation coefficient = 0.74). It was concluded that this method is simple, fast, and nondestructive and has a good reproducibility between observers. Because there was a wide interindividual variability in the same age class, this method must be associated with more accurate methods.     

Correlation of circumstances with pathological findings in asphyxial deaths by hanging: a prospective study of 61 cases from Seattle, WA

Correlation of the circumstances of death with the pathologic findings in this prospective study of deaths by hanging affords insight pertaining to certain of the pathophysiologic mechanisms involved in fatalities of this type. The presence of conjunctival and facial/periorbital petechial hemorrhages correlates with increasing levels of body support below the point of ligature suspension. Hyoid bone and/or thyroid cartilage fractures (found in 26% of cases) are most frequently identified in those persons found completely suspended and in victims in the older age ranges. No hyoid bone/thyroid cartilage fractures, internal soft tissue injury, or petechiae were present in 13 (21%) of the study cases.     

PMCT在机械性窒息方面的研究进展

机械性窒息是公安法医日常检案中最常见的死因之一.如何快速准确的判断死者是否为机械性窒息死亡、以及作案手段是判断案件性质、指引案件侦破方向的重要因素.在法医鉴定过程中,诊断机械性窒息需要结合尸体体表征象、尸体内部征象、组织病理学检验等多方面综合判断.PMCT在骨折的检测、异物的检测和气体的检测方面具有极大的优势,在许多国...     

Comparative histologic and hormonal studies of the thyroid gland with special reference to sudden infant death (SIDS)

In 53 cases of death - including 12 cases of sudden infant death syndrome (SIDS) - where blood samples could be taken within 18 h postmortem, the thyroxines T4, FT4, T3 and FT3 were determined (ELISA and RIA). These hormone values were compared with the corresponding histological thyroid findings in 43 cases (11 SIDS, 32 controls). Nearly identical T4 and FT4 mean values were found in both groups which were within the norms. In contrast to the average values of the control group, the T3 and FT3 concentrations of the SIDS group showed an increase of 3.7-fold and 1.9-fold. Accordingly, histological examination of the SIDS group showed highly activated and extensively released follicles whereas normal colloidal-containing follicle structures were observed in nearly all control cases. The present findings indicate that neither postmortem T4 T3 conversion nor intensified agonal hormone secretion is likely to be the only cause of the increasing T3 and FT3 values. In SIDS cases chronic or recurring chronic stress situations are supposed to be the cause for the hormonal and histological thyroid findings. Some differential diagnoses are discussed. Within 18 h after death, increased concentrations of T3 and FT3, together with simultaneous colloid release, represent a diagnosis of SIDS.     

Histologic thyroid gland findings in the newborn infant and infant, with special reference to sudden infant death

The morphological picture of the thyroid gland, the only endocrine organ with a follicle structure, allows a limited conclusion to be drawn with respect to the functional state in spite of any physiological variability. The thyroid of the newborn shows total colloid release and collapse of the follicles. The regular structure of the thyroid will be rebuilt within several weeks after birth. Total colloid absorption can be found in cases of stress-activated thyroids as well as in cases of death due to freezing. A histological examination was done on 88 thyroids of fetuses, newborns and infants. About 70% of the results on 27 cases of sudden infant death syndrome (SIDS) may be interpreted as a morphological correlate of a premortal chronic or recurrent stress reaction. The value of these results is discussed.     

Suicidal Shotgun Wound Employing a Shotgun Barrel,a Shotgun Shell,and a BB*

Abstract: A vast majority of firearms‐related suicides involve the conventional use of a properly functioning, intact firearm. Occasionally, forensic investigators encounter a case wherein the firearm suicide victim employs some form of unconventional use of a weapon, or utilizes an unusual weapon type. In this case report, the authors present an unusual case in which a man committed suicide by using a shotgun shell, a shotgun barrel (separate from the rest of the gun), and a BB. Some confusion as to the cause and manner of death was present during the initial scene investigation. Examination at autopsy revealed the cause of death to be a shotgun wound of the chest and prompted further scene investigation. Therefore, this case serves as another example of the importance of cooperation between scene investigators and forensic pathologists when investigating a death. A review of suicidal firearm cases using unconventional means and/or firearms is presented.     

An Unexpected Finding in SUDEP Involving a Child: Focal Myocardial Infarct Adjacent to Bundle of His

Sudden unexpected death in epilepsy (SUDEP) is a nontraumatic, nondrowning death of an individual with epilepsy in which an autopsy with appropriate ancillary studies does not identify a cause of death. The mechanism of death in SUDEP is unknown, but is thought to involve cardiac and/or respiratory mechanisms. Research in SUDEP is hindered by a lack of consensus regarding required components of a death investigation before a cause of death may be certified as SUDEP. Histopathologic examination of the cardiac conduction system is not routinely performed in SUDEP death investigations. We present a case of SUDEP where histopathologic examination of the cardiac conduction system revealed a focal myocardial infarct of the summit of the ventricular septum abutting the bundle of His, which potentially provides insight into the mechanism of SUDEP for this particular case, and suggests that routine examination of the cardiac conduction system in SUDEP may be beneficial.     

An Autopsy Case of Sudden Unexplained Death Caused by Malaria*

Abstract: Sudden unexplained deaths, especially those unwitnessed can lead to forensic issues and would necessitate the need for a meticulous and complete postmortem examination including ancillary investigations to discover the cause of death. We herein report a case of sudden unexplained death caused by malaria in an apparently healthy individual. This fatal case is presented to remind the forensic pathologist of the possibility of malaria as a cause of sudden unexplained death in malaria‐endemic regions. In the present case, histopathological examination demonstrated the presence of parasitized red blood cells with malarial pigment in the blood capillaries in the brain, myocardium, pericardium, lungs, kidneys, liver, and the spleen. Cerebral malaria with acute renal insufficiency or pulmonary edema with an acute respiratory distress syndrome might have been the cause of death.     

Numerous cortical tubers and rhabdomyomas in a case of sudden unexpected infant death

Sudden infant death syndrome is the leading cause of death in infants between the ages of 1 month to 1 year. Sudden infant death syndrome, a diagnosis of exclusion, can only be made after other explanations for unexpected death have been ruled out. Tuberous sclerosis complex is occasionally the findings in these patients with unexpected infant death. Here, we present a case of an unexpected infant death during sleep with multiple factors that confound the cause of death. We discuss these factors and attempt to delineate their contributions to arrive at a cause and mechanism of death.