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.     

Sudden Death by Occult Metastatic Carcinoma

A 33-year-old female collapsed and died suddenly after presenting with acute dyspnea and increasing cough over the preceding several months. Autopsy revealed poorly differentiated linitis plastica adenocarcinoma of the stomach. Microscopic examination of the lungs showed features consistent with pulmonary tumor thrombotic microangiopathy (PTTM). PTTM is a well-described complication in patients with adenocarcinoma. The typical presentation involves acute pulmonary hypertension, right-sided heart failure, and sudden death, often before the adenocarcinoma is discovered. The pathophysiology of PTTM remains elusive; it has been suggested that carcinoma cells may produce substances that influence pulmonary vasculature. Our patient had classic clinical and histologic features of PTTM in addition to prominent extravascular compression by intralymphatic tumor cells. These features undoubtedly caused her precipitous decline and lethal pulmonary hypertension, induced by underlying adenocarcinoma. This case demonstrates that sudden death can occur from pulmonary hypertension induced by metastatic carcinoma with remarkably little prior symptomatology.     

Sudden Death Due to Hydatid Disease: A Six‐Year Study in the Northern Part of Tunisia

Human ecchinococcosis also known as hydatid disease is a zoonotic infection caused by the tapeworm Ecchinococcus with 2–3 Million cases worldwide. We hereby report a 6 years period study of Sudden death due to hydatidosis aiming to analyze the epidemiological criteria, death circumstances, and autopsy observations attributed to hydatid disease. During the past 6 years, 26 death cases were due to hydatid disease. Our analysis shows that the sex ratio (M/F) was 1.6, the mean age was 31‐year old, and 65% of the subjects lived in rural places. In 17 cases, death occurred in the victim's place, five victims died after a heavy exercise, and in two cases, death occurred immediately after trauma. At autopsy, 91% of the cysts were found in the liver. In three cases, death followed a septic state, and in two cases, it followed an acute respiratory failure. Death was attributed to anaphylaxis in 17 cases.     

Sudden death due to an unrecognized cardiac hydatid cyst: three medicolegal autopsy cases

Echinococcosis is a human infection caused by the larval stage of Echinococcocus granulosus. The most common sites of infection are the liver and the lungs. Cardiac hydatid cysts are very rare, even in regions where hydatic cysts are endemic (the Mediterranean, South America, Africa, and Australia). It has been reported that cardiac involvement is seen in about 0.5-3% of human echinococcosis cases. Three cases of cardiac hydatid disease that caused sudden death and which were histopathologically diagnosed are reported. Cardiac echinococcosis is rare, but due to its insidious presentation and affinity to cause sudden death, it is important that it be identified in the histopathological examination.     

Sudden death in infancy due to bicuspid aortic valve

Symptoms of bicuspid aortic valve usually occur in the age group of 50-70 years, but rarely, it can also lead to sudden unexpected death in infancy and early childhood. The autopsy of a 2-month-old baby boy, found dead in his cot, revealed the heart weight as 25 g, and the macroscopic examination showed the circumference of the aortic valve consisting of two leaflets as 8 mm. The thickness of the left ventricle, right ventricle, and septum was measured as 8, 7, and 10 mm, respectively. Microscopically, the heart revealed hypertrophic changes of myocytes. Subendocardial areas displayed necrosis of myocytes, and severe and diffuse ischemic changes characterized by loss of myofibers and vacuolization. Interstitial pneumonia was identified in the lungs. Death occurred as a result of a congenital bicuspid aortic valve obstructing the left ventricular outflow tract complicated by lung infection. As there are only a few reported cases in infancy, and congenital bicuspid aortic valve can lead to sudden unexpected death, this case is presented to the forensic community.     

Sudden Unexpected Death due to Chiari Type I Malformation in a Road Accident Case

This case concerns a sudden death of a patient with Chiari I malformation. A 17‐year‐old female was seen unconscious then fell off a motorbike during the vehicle acceleration. The girl was confirmed dead on the way to hospital, being previously asymptomatic and with a clean medical record. Autopsy findings showed an extremely extra‐long cerebellar tonsillar herniation in the left side and unexplained multiple small cavities in cerebral hemispheres. Microscopic findings revealed loss and abnormal migration of the Purkinje cells, as well as capillary congestion in the herniated tonsil. The cause and mechanisms of this sudden death are considered as the cardiopulmonary dysfunction and arrest resulted from compression of the medulla and cervical cord, which was induced by both the positional insult and minor head trauma. In addition, this study stresses the importance of cervical cord examination in the case of unexpected sudden death following road accidents.     

Identification of Arrhythmogenic Right Ventricular Cardiomyopathy‐Causing Gene Mutations in Young Sudden Unexpected Death Autopsy Cases

Arrhythmogenic right ventricular cardiomyopathy (ARVC) results in an increased risk of sudden death. We sought mutations of desmoglein‐2 (DSG2), desmoplakin (DSP), and plakophilin‐2 (PKP2) in 15 cases of sudden death whose causes of death could not be determined at autopsy. In three victims, mutations were identified in DSP. Two of these mutations were novel; one had previously been reported in a patient with ARVC that had been diagnosed clinically. Histological findings were not typical of ARVC; however, it was notable that these mutations were present in three of 15 cases, a relatively high proportion. The causal relationship between the mutations and ARVC is unclear, but the mutations might have been associated with faulty desmosomal proteins resulting in fatal arrhythmia. Combining information gathered by the traditional means of gross and histological examination with postmortem genetic analysis of young victims would assist in identifying their cause of death.     

Multiple Giant Coronary Artery Aneurysms: A Rare Cause of Sudden Cardiac Death

Multiple giant aneurysms involving the coronary arteries are uncommon and rarely reported. In the presented case, a 63‐year‐old man with poorly controlled hypertension died suddenly. Gross autopsy examination showed multiple giant thrombus‐filled coronary artery aneurysms, atherosclerotic coronary artery disease, and cardiomegaly. Histological sections of the coronary aneurysms showed atherosclerotic changes with both organized and fresh thrombus. Giant coronary aneurysm is defined as a segmental enlargement of a coronary artery with a diameter exceeding 20 mm or more. The main etiology of this nebulous entity is attributed to atherosclerosis and inflammatory or inherited connective tissue disorders with the remainder being congenital, infectious, or idiopathic. Before its cataclysmic presentation, when ruptured or thrombosed, giant coronary aneurysm usually has a silent clinical course. Sudden death owing to giant multiple coronary aneurysms is rare and mandates careful classification of the aneurysms and prudent search for autoimmune‐mediated or genetically based factors for subsequent ancillary autopsy studies.     

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.     

Sudden Death Caused by Anomalous Origin of the Coronary Artery During Exercise

Anomalous origin of the coronary artery (AOCA) is a rare, but important cause of sudden cardiac death among young athletes. Nine autopsy cases (8 male, 1 female; mean age, 17.9 years; age range, 11–31 years) of sudden death during or just after exercise caused by AOCA were reviewed. The exercises performed at the time of death were running (4 cases), soccer (2 cases), and baseball, swimming and kendo (Japanese swordsmanship) (1 case each). In 6 cases, the left coronary artery arose from the right sinus of Valsalva, and in 3, the right coronary artery from the left sinus. The coronary arteries passed between the pulmonary artery and the aorta with an acute angle takeoff from the orifice. Three cases had cardiovascular manifestations prior to death. In cases with cardiovascular manifestations, novel imaging methods should be considered to prevent sudden death.     

Cardiac Sudden Death as a Result of Acute Coronary Artery Thrombosis During Chemotherapy for Testicular Carcinoma

Abstract: We report the first acute coronary fibrin thrombus arising upon atherosclerosis detected at autopsy in a man receiving chemotherapy for testicular carcinoma. The decedent was a smoker with no other known atherosclerotic risk factors. Histology revealed superficial atherosclerotic plaque erosion with endothelial necrosis and no intraplaque hemorrhage. A focus of intimal lymphoid infiltrates was noted away from the plaque. These findings raise the possibility of chemotherapy‐induced vascular damage as a factor in thrombogenesis. A review of Pubmed was performed which documented clinical reports of an association of chemotherapy with acute cardiac ischemia but no well described autopsy findings. Our case highlights the need for careful assessment of the coronary system in chemotherapy patients dying suddenly, particularly in the absence of significant atherosclerotic risk factors. Such postmortem examination will ensure thorough death investigation and may elucidate the pathogenesis of thrombosis with potential reduction in cardiac ischemic risks of chemotherapy patients.     

Undetermined Manner of Death: An Autopsy Series

A manner of death may be ruled undetermined by the forensic pathologist when there is insufficient information about the circumstances surrounding the death to make a ruling. The aim of our study was to retrospectively analyze a series of autopsy cases that were classified as undetermined manner of death after complete investigations. In all, 48 cases were examined. In 23 cases (48%), the cause of death was determined. The most frequent cause of death was toxic death (n = 11). More than one manner of death was deemed conceivable for most cases (n = 39). The most frequent and the most probable manner of death was accident (n = 37). Homicide was not excluded in about 23% of the cases. Our study showed that the manner of death may remain undetermined despite an established cause of death, and even when two or more conceivable causes of death are considered. Our study pointed out that undetermined manner of death covers a wide range of situations and that homicide may be underestimated.     

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.     

A Case of Sudden Infant Death Due to Incomplete Kawasaki Disease

Although Kawasaki disease (KD) is a self‐limiting disease, it may cause sudden cardiac death. Diagnosis of KD is principally based on clinical signs; however, some infant cases do not meet the criteria. Such cases are identified as incomplete KD. The sudden death risk in incomplete KD cases is similar to conventional KD. In our 5‐month‐old case, he had been admitted to a hospital for a fever and suppuration at the site of Bacille de Calmette et Guerin (BCG) vaccination. However, after discharge from the hospital, his C‐reactive protein (CRP) levels declined, he got indisposed and died suddenly. A medico‐legal autopsy revealed myocarditis, coronaritis, platelet‐aggregated emboli in coronary arteries, and myocardial degeneration, suggesting that the fatal myocardial infarction was due to thrombus emboli in the coronary arteries. Forensic pathologists therefore should pay attention to the cardiac pathology originated from incomplete KD as a potential cause in cases of sudden infant death.     

Endobronchial/Tracheal Metastasis and Sudden Death

Endobronchial and endotracheal metastases are rare lesions that may cause acute occlusion of major airways. A case is reported of a 62‐year‐old man with history of renal cell carcinoma and hemoptysis who died after having suddenly become short of breath with cyanosis. At autopsy, recurrent renal cell carcinoma was identified with metastases to the lungs, pulmonary hilar lymph nodes, and brain. In addition, a solitary papillomatous metastasis arising from the mucosa of the carina was obstructing both the main bronchi and distal trachea. Death was due to acute airway obstruction by a metastatic deposit at the bifurcation of the trachea in a case of disseminated renal cell carcinoma. This case demonstrates an extremely rare cause of sudden death that may complicate disseminated malignancy.     

Usefulness of Systematic Histological Examination in Routine Forensic Autopsy*

Abstract: The forensic community does not agree on the need to perform histological examination at forensic autopsy. The aim of our study was to determine the usefulness of systematic standard histology in forensic autopsies. A prospective study was carried out on 428 autopsy cases for which standard histological examination was systematic. Mechanism of death not shown by gross anatomic findings was discovered by histology in about 40% of the cases. Cause of death was established by only histology in 8.4% of the cases. Microscopic findings affected the manner of death in 13% of the cases. Histology provided complementary information about prior medical condition of the deceased in about 49% of the cases. Traumatic lesions were better documented by histology in about 22% of the cases. According to the results of our study, systematic standard histology for the main organs should be used in routine forensic autopsies.     

Causes of Sudden Death in Patients with Obstructive Sleep Apnea

There are few autopsy studies of patients dying suddenly with obstructive sleep apnea (OSA). Twenty‐five forensic autopsies of unexpected sudden death in individuals with OSA were reviewed. The causes of death were as follows: cardiomyopathy (n = 11); sudden unexpected death without morphologic findings (SUDNA, n = 6); and other cardiovascular diseases not related to OSA (n = 8). The cardiomyopathy group comprised five hearts with concentric left ventricular hypertrophy without dilatation and six with left ventricular diameter >4 cm (dilated cardiomyopathy). Four of six hearts in the SUDNA group showed right ventricular dilatation compared with seven of 11 showed cardiomyopathy and one of eight miscellaneous. The degree of obesity was greatest in the dilated cardiomyopathy group (10 of 11 obese) followed by the SUDNA group (four of six obese). The cardiac findings in patients dying suddenly and unexpectedly with OSA include nonspecific cardiomyopathy, other cardiac conditions, and hearts without a morphologic cause of death, which show frequent right ventricular dilatation as the only finding.     

An Unusual Cause of Headache and Sudden Death of a Young Sailor—Postmortem Computed Tomography and Histological Findings of a Fatal Retroperitoneal Malignant Mixed Germ Cell Tumor

A 26‐year‐old Caucasian sailor, with no past medical history aside from headache for the last 1 week, was found dead in his cabin. The body was stored in a refrigerator on board and disembarked for autopsy 3 days later. Autopsy showed a large, nodular, necrotic and hemorrhagic retroperitoneal mass, and smaller hemorrhagic nodules in the brain, lungs, liver, and left kidney, with the brain being markedly edematous. Both testes were descended and normal. Histologically, the retroperitoneal mass showed a malignant mixed germ cell tumor comprising choriocarcinoma, embryonal carcinoma, and teratoma components. Retroperitoneal extragonadal germ cell tumors are uncommon, and this case of a young male who presented with headache and sudden death due to metastases is extremely rare.     

Unnatural and Violent Death in Cases with High Blood Alcohol Concentration— Autopsy Study

The use of alcohol increases the risk of dying from unnatural or violent causes. The presented study explored the distribution of age, gender, cause, and circumstances of death in persons who died in an unnatural and violent manner, with a blood alcohol concentration (BAC) higher than 0.3 g/dL, and where the cause of death was not alcohol intoxication. We defined the control (0 < BAC < 0.3 g/dL) and study (BAC ≥ 0.3 g/dL) groups, as in subjects with these concentrations, there is a significant risk of gross intoxication, stupor, and death. The subjects from the study group were older, with no difference in gender distribution. Traffic accidents were the most common fatal event in both groups, followed by suicides. Other accidents (choking on food and exposure to fire) were more frequent in the study group. Compared to the control group, subjects from the study group were older persons whose deaths were mainly accidental.     

Diagnostic dilemma of sudden deaths due to acute hemorrhagic pancreatitis

Sudden death due to acute pancreatitis has been rarely determined. A review of 3305 autopsies performed between 1991 and 2001 at the Council of Forensic Medicine found 12 cases (0.36%) with sudden death due to acute hemorrhagic pancreatitis without symptoms. A history of chronic alcohol ingestion was obtained from family in four cases (33%), and no stones were found in the bile ducts or in the gall bladders. During the autopsies, hemorrhage and edema were localized on the head of the pancreas in three cases and the whole pancreas in nine cases. The most common extrapancreatic pathology was found in the lung including pulmonary edema, alveolar hemorrhage, pleural effusion, and pulmonary congestion. There was no correlation between pulmonary and pancreatic damage. It is suggested that the forensic pathologists who are dealing with sudden unexpected death must not ignore the examination of pancreatic and extrapancreatic regions to avoid missing acute pancreatitis.