Sudden death owing to right atrial hemangioma

Primary cardiac tumors are rare, with an autopsy incidence of 0.03%. Seventy-nine percent to 85% of primary cardiac tumors are benign, and of the benign tumors, cardiac hemangiomas account for 5-10% of cases. Most cardiac hemangiomas are asymptomatic and are discovered incidentally at autopsy, or by echocardiography, computerized tomography, or magnetic resonance imaging. We report a case of sudden death owing to cardiac hemangioma in a 22-year-old woman who collapsed while shopping and became unresponsive. The autopsy revealed a hemorrhagic mass on the surface of the right atrium which was infiltrating and replacing the wall of the right atrium; histopathological examination confirmed the tumor was a cavernous hemangioma. Fewer than 20 cases of right atrial cavernous hemangiomas have been reported in English literature, emphasizing the rarity of our case.     

Airway obstruction by laryngeal masses in sudden and homicidal deaths

We present two cases of autopsy detection of laryngeal masses with medico-legal implications. The first is a 56-year-old man who died suddenly of asphyxia due to upper airway obstruction caused by a large glosso-epiglottic retention cyst and glottic oedema. Hypothesis of medical liability was raised, due to delayed tracheotomy as the result of repeated failed attempts at oral intubation by various physicians. Difficult oral intubation due to the presence of a laryngeal mass in an asphyxiating subject requires rapid tracheotomy. The second case deals with a 43-year-old woman who died of asphyxia due to airway obstruction, as a result of injury of a cavernous laryngeal haemangioma after homicidal manual strangulation, with severe haemorrhagic infiltration of the surrounding soft tissues. Damage to laryngeal/hypopharyngeal masses should be considered as a possible sign of manual strangulation, as well as neck skin bruises/abrasions and laryngeal haemorrhages.     

Asphyxiating laryngeal cyst

Cysts of the larynx are uncommon lesions that on rare occasions may cause sudden death. We report herein the asphyxial death by an obstructing vocal cord cyst in a woman whose body was found in a setting that aroused suspicions of foul play. Features of this case and the autopsy findings are compared with a literature review of laryngeal cysts.     

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.     

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.     

Soft tissue hemorrhage within the larynx following strangulation

The inner soft tissues of the larynx (i.e., true vocal cord, false vocal cord, paralaryngeal space) were examined by special preparation of the larynx: thyroid cartilage was detached from the cricoid and the laryngeal cords, which could then be examined. Bleeding (not visible before) was found in 18 of 40 cases of persons killed by throttling or choking; bleeding occurred whenever blunt trauma of the throat had taken place (n = 8). Hemorrhage develops even in cases without damage to the laryngeal skeleton; this bleeding can result from direct compression of the larynx (large and not well defined bleeding) and can originate indirectly (small hemorrhages mostly in the vocal muscles). The finding of hemorrhages like this can help to demonstrate that the victim has undergone a violent attack on the throat.     

Local vital reaction following injuries of the neck

Sixty-one cases of hemorrhaging of the laryngeal muscles are reported among 86 deaths due to compression of the neck (strangulation by ligature and/or with the hands, blunt force); the results of histological examinations of these cases (laryngeal muscles; hemorrhaging of the cervical muscles and tongue in numerous cases) are discussed, as well as 55 comparative cases (natural, violent death) with regard to vital changes from the hemorrhaging aspect. Although sanguineous infiltration of the laryngeal muscles can occur after death (prone position), it differs macroscopically and in some cases also microscopically from the vital type: extensive bleeding on the inside of the larynx or dorsally above the larynx (PCA muscle), possible combined with histologically detectable ruptures of muscle cells, must be viewed as the result of laryngeal compression suffered when still alive. No clear-cut evidence of emigration or infiltration of leukocytes was found in the cases of immediately fatal strangulation, but there was occasional evidence (6 cases) when protracted maltreatment had taken place. Although there was no clear correlation with age, sex, type of impact, cause of death, or amount of laryngeal bleeding, in 25 of the 61 cases leukocytes were sometimes detectable in enormous amounts within the extravasation; the ratio exceeded that to be expected from the composition of the blood. Findings of this nature have also been made in cases of vital bleeding in other violent or natural deaths; they are not a cell reaction in the proper sense but, when distinctly marked, a vital event--at least in the laryngeal region. These findings can support the assumption of the amount of hemorrhaging in deaths in which the survival time was inadequate for a leukocyte emigration. In 20 cases such findings were combined with localized leucocytosis, which is regarded as an early vital reaction.     

Occult Adrenocortical Carcinoma and Unexpected Early Childhood Death

A four‐year‐old previously well boy collapsed unexpectedly and was taken immediately to hospital, where he developed seizures and cardiogenic shock with lethal, rapidly progressing multi‐organ failure. At autopsy, the height was >90th percentile and there were indications of early virilization. Internally, a friable tumor of the left adrenal gland was identified that had invaded the left renal vein and inferior vena cava. Histology revealed typical features of an adrenocortical carcinoma with aggregated trabeculae of cells containing abundant eosinophilic cytoplasm and large pleomorphic nuclei. There was strong positive cytoplasmic staining for inhibin; mitochondria were shown on electron microscopy to contain prominent electron‐dense granules. Death was due to massive pulmonary tumor embolism. Although adrenocortical carcinomas are very rare and are more commonly found in adults, the current case demonstrates that they may also occur in childhood and be responsible for unexpected death by the very unusual mechanism of tumor embolism.     

Postmortem diagnostics using MSCT and MRI of a lethal streptococcus group A infection at infancy: a case report

Postmortem cross-sectional imaging using multislice computed tomography (MSCT) and magnetic resonance imaging (MRI) was considered as a base for a minimal invasive postmortem investigation in forensic medicine such as within the Virtopsy approach. We present the case of a 3-year-old girl with a lethal streptococcus group A infection and the findings of postmortem imaging in this kind of natural death. Postmortem MSCT and MRI revealed an edematous occlusion of the larynx at the level of the vocal cords, severe pneumonia with atelectatic parts of both upper lobes and complete atelectasis of both lower lobes, purulent fluid-filled right main bronchus, enlargement of cervical lymph nodes and pharyngeal tonsils, and additionally, a remaining glossopharyngeal cyst as well as an ureter fissus of the right kidney. All relevant autopsy findings could be obtained and visualized by postmortem imaging and confirmed by histological and microbiological investigations supporting the idea of a minimal invasive autopsy technique.     

Morphologic findings for airway occlusion in strangulation

Report of two cases of strangulation by hand. There were large submucous bleedings of the larynx (both sides of conus elasticus) of symmetrical arrangement, near the vocal processes of the arytenoid cartilages. They are believed to be the result of the violent contact of the vocal folds during laryngeal compression; perhaps while the arytenoid cartilages were subluxated inwards and downwards. Bleedings like this indicate the closure of the airway. In one case (50-year old woman) the ossified cricoid was broken; in the other (21-year old woman) the elastic laryngeal skeleton was intact, but large bleedings of the deeper tissues of both vocal folds indicated the vehement compression too. The analysis of 110 cases of attack against the neck (strangulation by hand -n = 30- or ligature -n = 30- alone or together -n = 32-; blunt force: n = 8, other types: n = 10) showed in 7 additional cases less typical but similar bleedings, especially in strangulation by hand.     

Instructions for the complete preparation of the larynx

A method of preparing the larynx in forensic cases is described especially when death occurs by strangulation (manually or using some form of ligature). After the usual dissection of the hyoid bone and the upper horns of the thyroid cartilage, the complete larynx is clipped and fixed in formaldehyde overnight. The first part of dissection after that is to cut away the thyroid gland and the remaining muscles in front of the larynx, except for the cricothyroid muscle and the esophagus and hypopharynx from the back of the larynx. The complete thyroid cartilage is dissected out, and then a horizontal cut is made through the cricoid cartilage. Median-sagittal halving of the remaining larynx completes the gross dissection. Arytenoid cartilages are exposed by dissection of the arytenoid muscles and opening the cricoarytenoid joints. Now all parts of the laryngeal skeleton and all articulations are examined, and all muscles and soft tissues are visible and can be clipped for histological examination.     

Brain arteriovenous malformation and its implication in forensic pathology

Despite the fact that brain arteriovenous malformations (BAVMs) are a possible cause of sudden and unexplained death, very few papers have discussed their importance in the forensic context. BAVMs consist of tangled masses of tortuous arteries and veins devoid of intervening capillaries that frequently extend from brain parenchyma into the subarachnoid space. Apart from BAVMs, three major groups of vascular malformations of the brain are known: cavernous hemangioma, venous angioma, and capillary telangiectasia. BAVMs and cavernous hemangioma often cause hemorrhages, while venous angioma and capillary telangiectasia are typically asymptomatic. Presented here is the case of a 14-year-old girl who died from a ruptured BAVM. The present case is a reminder that the forensic pathologist should be able to recognize BAVMs and to differentiate it from other types of vascular malformations. Although rare, it is a cause of sudden death not to be overlooked, especially in children.     

Death, after swallowing and aspiration of a high number of foreign bodies, in a schizophrenic woman

A 46-year-old woman who had had a long-term schizoid psychosis collapsed on the street. Upon admission to the hospital, she was determined to have an acute abdomen. The chest radiograph showed metallic foreign bodies in both main bronchi; foreign bodies in the stomach were not observed clinically. The woman died from repeated cardiac arrest shortly after hospital admission. At the autopsy a screw and a nail were found in both main bronchi. The abdominal cavity contained 2 L of greenish purulent fluid and a massive fibrinoid peritonitis was observed. Two perforations of the stomach, each 1 cm in diameter, were detected. The stomach was completely filled with a mass of metallic foreign bodies, greenish fluid, and a bezoar of a total weight of 1,400 g; 422 distinguishable and mostly metallic foreign bodies were counted. Death was attributed to cardiac arrest in delayed shock after massive purulent peritonitis caused by two gastric perforations combined with obstruction of the airways by aspirated foreign bodies. Cases of massive swallowing of foreign bodies are mainly restricted to mentally handicapped persons, especially schizophrenics, whereas acute impaction of the larynx by large food particles occurs nearly exclusively in heavily intoxicated adults.     

Analytical investigations in a death case by suffocation in an argon atmosphere

A 31-year-old engineer was found dead in a reaction vessel (diameter 0.8 m, height 1.8 m) of a bulb factory some minutes after he had entered it for repair work. Resuscitation attempts with artificial respiration were unsuccessful. Despite autopsy and usual toxicological analyses, no cause of death could be found. Since in the normal production process, argon was used as a protecting gas, the possibility of suffocation in an argon atmosphere was investigated. This was rendered more difficult because of the natural content of 0.93 vol.% argon in air and since the excessive argon could have been removed by the resuscitation attempts. Gas samples from larynx, esophagus, bronchi, and stomach, separated blood samples from both ventricles of the heart and from the vena iliaca externa as well as tissue samples from lung and liver were collected during autopsy into headspace vials in such a way that the loss of gas and a dilution by surrounding air was avoided as far as possible. The samples were analyzed by headspace GC-MS. The abundance of Ar+ (m/z = 40) was used for quantification with N2(2+) (m/z = 14) as internal standard. The following argon concentrations were measured (mean values, case under investigation/comparison cases): gas from larynx 1.79/0.96 vol.%, stomach gas 1.58/0.89 vol.%, heart blood (left ventricle) 7.2/2.7 microg/mL, heart blood (right ventricle) 5.8/2.7 microg/mL, blood from vena iliaca externa 3.6/2.7 microg/mL. A clearly increased concentration was also found in lung tissue, whereas in liver tissue no significant difference in comparison to other cases was measured. From the results, it follows that the deceased inhaled an increased amount of argon a short time before death. The concentrations are consistent with asphyxia and subsequent resuscitation attempts. They cannot be explained by a long-term inhalation of an atmosphere enriched with argon before the incident as it is likely to have occurred in this factory hall.     

Morphology of "asphyxia-induced epiglottis form" in newborn infants, infants and young children

A systematic histological study of cross-sections of the larynx from 52 fatalities (neonates, infants and young children) revealed a broad spectrum of anatomical variants in the epiglottis form, which were caused by variations in the epiglottic cartilage. There was no correlation between the epiglottis form and the age of the child. Furthermore, no differences in shape could be established between cases of SIDS and control cases. The term "asphyxial-related epiglottis form" appears to be inappropriate. The commonly found supraglottic laryngitis on the laryngeal aspect of the epiglottis was seen in combination with histologically proven infections in the upper and lower respiratory tract. Histological investigation of the larynx provides valuable information for the morphological diagnosis in fatal cases in early life.     

Virtopsy hemorrhage of the posterior cricoarytenoid muscle by blunt force to the neck in postmortem multislice computed tomography and magnetic resonance imaging

In forensic autopsies, one of the most important and common signs of violence to the neck is hemorrhages of the soft tissues. The Institute of Forensic Medicine in Bern evaluates the usefulness of postmortem multislice computed tomography (MSCT) and magnetic resonance imaging (MRI) of forensic cases prior to autopsy. The aim of this study was to prove the sensitivity of postmortem MSCT and MRI in the detection of hemorrhages of the neck muscles. A full body scan prior to and a detailed scan of the explanted larynx after autopsy were performed. MSCT detected multiple fractures of the larynx. Detailed MRI was able to demonstrate the hemorrhage of the left posterior cricoarytenoid muscle. The minor hemorrhage of the right posterior cricoarytenoid muscle could not be detected with certainty. Although more experience is required, we conclude that combined MRI and MSCT examination is a useful tool for documentation and examination of neck muscle hemorrhages in forensic cases.     

Coprophagic café coronary.

A 74-year-old man who had been institutionalized for severe multiinfarct dementia was found dead in bed. He had a history of compulsive ingestion of food and other materials, including feces. At autopsy, a 65-g bolus of fecal material was impacted within the laryngopharynx, occluding the inlet of the larynx. This case demonstrates an unusual coprophagic variant of cafe coronary syndrome and emphasizes that demented individuals with pica are at risk of sudden death from ingestion of a wide variety of materials, including, but not limited to, food.     

Planned Complex Occupation‐related Suicide by Captive‐bolt Gunshot and Hanging*

Abstract: Planned complex suicides are committed by using two or more previously planned methods simultaneously to make sure that death will occur even if one method fails. Herein, we presented a case of occupation‐related planned complex suicide, committed by captive‐bolt gunshot and hanging. A 29‐year‐old man, who worked as a butcher, was found dead in the stable, hanging by the neck with a captive‐bolt gun embedded in the forehead region of his head. The hanging was complete. Along the bolt canal were bone fragments, and at the end of the path was the punched‐out fragment of the skin and soft tissue. There were no fractures of the hyoid bone and laryngeal cartilages, and a superficial hemorrhage was present in the right sternocleidomastoid muscle. Our case underlines the utility of forensic autopsy and death scene investigation in reconstructing the mechanism of death, as well as the dynamics of the event.