Blood alcohol concentrations of sudden unexpected deaths and non natural deaths.

This study reports on the relationships between the blood alcohol concentration (BAC) and the cause of death - which is of course common knowledge for forensic scientists! Our special aim was to gain unselected data for generalizing conclusions. The blood of 2465 consecutive cases (86% of all 2852 sudden unexpected and unnatural fatalities investigated at the Institute for Legal Medicine in Hamburg during the year 1989) was analysed. The BAC was evaluated according to sex, age, cause of death and place of death. In natural causes of death there were 80% cases under 0.05% BAC. Endocrine and digestive system diseases in particular were associated with positive BAC values. In unnatural death cases the BAC under 0.05% was found in 64% of the suicides, 62% of the accidents, 54% of the homicides and 51% of the drug intoxications. The drowning cases showed higher BAC's than traffic accidents. In suicides middle aged males had high BAC's.     

Sudden epilepsy deaths and the forensic pathologist

Sudden unexpected deaths in epileptic persons are not rare events, most commonly encountered by the forensic pathologist rather than the clinician. Such deaths may represent 1-1.5% of all "natural" deaths certified by the medical examiner or coroner. The typical victim is a black male about 30 years of age who tends to abuse alcohol, with a history of generalized epilepsy for more than 1 year and likely for more than 10 years. There are a lack of obvious anatomic causes for the death at autopsy, but 60-70% of cases will have a lesion in the brain (most commonly old trauma) to explain the epilepsy. Most victims have no blood levels of anticonvulsant medications at the time of death. We have evolved a form for use by medical examiner/coroner's investigators at the scene to collect relevant information which will be of assistance to the pathologist in interpreting the case. Estimated prevalence of sudden epilepsy death, mechanisms, and other features of such cases are reviewed briefly.     

Blood alcohol in sudden and unexpected deaths

Blood alcohol concentration was determined in 1672 sudden and unexpected natural and non-natural out-of-hospital deaths. The material covered all medicolegal autopsies in the province of Uusimaa which has a population of approximately 1.1 million inhabitants. In general, the prevalence of cases with alcohol in the blood at the time of death was high but varied considerably according to sex, age, and the cause and manner of death. The blood alcohol result was positive in 36% of the male and in 15% of the female material. In 59% of the alcohol-positive male and in 54% of the alcohol-positive female cases the actual concentrations were at least 1.5%. Acute use of alcohol was regarded as a significant condition contributing to death in 23% of the whole male and in 8% of the whole female material. These gross results and the details presented indicate that the acute use of excess alcohol is a factor contributing to non-natural but also to sudden and unexpected natural deaths to an extent that is not generally known. The results also emphasize that simple blood alcohol determination should be a routine procedure in the autopsy praxis of all sudden and unexpected natural and non-natural out-of-hospital deaths.     

Sudden and unexpected death from pituitary tumor apoplexy

Pituitary tumor apoplexy refers to a clinical syndrome precipitated by the expansion of a pituitary adenoma by hemorrhage or infarction. Individuals may present with myriad signs, including sudden onset of severe headache, visual changes, altered mental status, cranial nerve palsies, and hormonal dysfunction. This disorder constitutes a medical emergency and warrants an expedited evaluation, diagnosis, and treatment to prevent the potential sequelae of permanent visual loss, endocrine abnormalities, or death. We report a case of sudden death from undiagnosed pituitary tumor apoplexy. The decedent was evaluated by medical personnel on three occasions in the week prior to her death for severe headache, nausea, vomiting, and photophobia. Postmortem examination demonstrated a hemorrhagic infarction of a pituitary adenoma with necrosis and expansion out of the sella turcica. The recognition of and treatment for a patient with pituitary tumor apoplexy requires a rapid multidisciplinary effort. Failure of prompt diagnosis may be fatal and require a medico-legal death investigation for sudden and unexpected death.     

Sudden unexpected nocturnal death syndrome in the Mariana Islands

Sudden unexpected nocturnal death syndrome (SUNDS) is a distinct clinical entity in previously healthy, young, Southeast Asian males. It is well known in the Philippines and more recently recognized in the U.S. by nonspecific autopsy findings, with no evidence of underlying disease and absence of toxic drug or alcohol levels. In 1973-89, 14 cases of apparent SUNDS came to coroner's autopsy in the Commonwealth of the Northern Marianas (CNMI) and Guam. All 14 cases, with the exception of one Yapese, were previously healthy, male Filipinos, aged 23 to 55, who were either found dead in bed, or described by their colleagues as having nocturnal seizure activity consisting of gurgling, frothing, and tongue biting immediately prior to death. Autopsy findings showed no anatomic findings to account for death. Comprehensive serum and urine drug analyses were negative. All decedents showed absence of significant atherosclerosis or grossly detectable structural cardiac anomaly, while four showed cardiomegaly. Migrants from Southeast Asia carry with them a pre-disposition to this syndrome, which appears to decline with longer residence in the new country. The mechanism of death in SUNDS is believed to be ventricular fibrillation, possibly precipitated by sudden sympathetic discharge. Studies suggest at least some deaths may be associated with an abnormal cardiac conduction system. Acute pancreatitis has been a finding in some series, but not our cases. Why the condition is virtually limited to males and seemingly sleep-triggered, has not been adequately explained. Stress and depression are believed to be predisposing factors.     

Sudden unexpected infant death due to fibroma of the heart

A 7-month-old previously healthy female infant was found dead in her crib by her mother shortly after having been laid down to sleep following the noontime feeding. Because the child did not suffer from an acute illness and no other evidence pointed to a cause of death, it was initially assumed by the police that she had died of sudden infant death syndrome. At autopsy, however, the cause of death was determined to be cardiac arrhythmia secondary to fibroma of the heart.     

Two anaphylactic deaths after chemonucleolysis.

Chemonucleolysis is a procedure for treatment of low back pain due to discogenic disease in which the drug chymopapain is injected into lumbar disks to produce chemical dissolution of the nucleus pulposus. More than 15,000 cases have been treated by chemonucleolysis world-wide. Anaphylaxis after the injection of chymopapain occurs in about 1% of such cases. The two cases described in this paper are the only known deaths due to anaphylaxis. Both patients suddenly became hypotensive after injection of chymopapain into a disk. One patient died shortly after this, whereas the second patient died of the complications of prolonged shock.     

Sudden, unexpected death due to cardiac fibroma. Report of a case and review of the literature

A case of cardiac fibroma in a 58-year-old woman with a history of atrioventricular block is described. The patient died suddenly at home 6 days following the insertion of a pacemaker. Review of the pertinent literature is presented.     

Sudden unexpected death following exercise and congenital anomalies of coronary arteries. A report of two cases

Two cases of anomalous origin of the left coronary artery from the pulmonary trunk with unusually prolonged post-childhood survival are presented. In both cases, death was associated with physical exertion. The pathological findings included enlarged right coronary ostium, myocardial hypertrophy, endocardial fibrosis, and focal myocardial scarring.     

Sudden unexpected death due to Taxus poisoning. A report of five cases, with review of the literature.

The toxicity of yew (Taxus) has been known since antiquity. However, in the past 31 years, to our knowledge only six cases of Taxus poisoning have been reported in the literature. In the present paper we add five cases. From a forensic point of view, intoxication with Taxus has three important aspects: (i) the clinical presentation, which among other causes should suggest Taxus intoxication; (ii) the fact that the diagnosis may often be easily made by examination of the contents of stomach, duodenum and small bowel and (iii) the widespread availability in the near future of Taxol, an anti-neoplastic drug which is an alkaloid extracted from Taxus. The clinical and autopsy findings are summarized, the diagnostic aspects are discussed and the literature concerning Taxus is reviewed.     

Sudden unexpected death due to papillary fibroma of the aortic valve. Report of a case and review of the literature

The case of the sudden unexpected death of a 21-year-old man due to embolization of segments of an aortic valve papillary fibroma to the left main and anterior descending coronary artery is presented. The literature regarding cardiac papillary fibroma is reviewed with particular reference to those cases associated with sudden death.     

Evaluation of diagnostic tools applied in the examination of sudden unexpected deaths in infancy and early childhood

During the period between 1984 and 1999, 309 cases of sudden unexpected death in infancy and early childhood (0-3 years) were investigated at the Institute of Forensic Medicine in Oslo. In 73 cases, an explainable cause of death was found. In this non-sudden infant death syndrome (SIDS) group, 42 cases were due to disease, 14 to accidents, 7 to neglect/abuse and 10 cases were due to homicide. In 43 cases, there were pathological findings at the autopsy or suspect features in the history and/or circumstances, which were, however, insufficient to explain death ("borderline" SIDS). In the remaining 193 cases, nothing of significance was detected ("pure" SIDS).The purpose of the present study was to evaluate the importance of the different diagnostic tools used in diagnosing non-SIDS and borderline SIDS cases. The definition of SIDS requires a negative history as well as a negative autopsy result. Thus, the following variables were analysed: circumstances, medical history and autopsy, which included a gross pathological investigation, histology, neuropathology, microbiology, radiology and toxicology. In diagnosing deaths due to disease, histology, neuropathology and microbiology were the most important diagnostic tools. In contrast, information about the circumstances of death and the gross pathological findings at autopsy most often revealed the cause of death in accidents and cases of neglect/abuse and homicide.Following the drop in SIDS rate in Norway after 1989, the share of pure SIDS in proportion to the total population of sudden unexpected deaths in infancy and early childhood has decreased. The increasing proportion of non-SIDS and borderline SIDS cases presents a challenge to improve the quality of the investigation in cases of sudden death in infancy and early childhood.     

Sudden death and sepsis after splenectomy

This paper has reported two deaths occurring in young adults who had undergone splenectomy for trauma several years before developing pneumococcal sepsis. Tissues at autopsy demonstrated a disproportionate autolysis for the postmortem interval. One victim also showed diffuse serosal hemorrhages, presumably as a result of disseminated intravascular coagulation. Both showed evidence of residual splenic implants but such implants clearly did not provide protection against sepsis. The mechanisms whereby the spleen protects from sepsis appear to be that of a mechanical filter and an immunological organ producing antibody or antibody-like substance. How much splenic tissue and what relationships to the system circulation are necessary to provide protection remain undiscovered.     

Sudden, unexpected death in a 5-year-old boy with an unusual primary intracranial neoplasm. Ganglioglioma of the medulla

This report documents sudden, unexpected death in a 5-year-old boy from a ganglioglioma of the medulla. Gangliogliomas are rare, primary brain tumors that are encountered predominantly in childhood. We are unaware of any previous report of a similar case.     

Cosleeping and sudden unexpected infant deaths in Kentucky: a 10-year retrospective case review

This retrospective case review investigates modifiable risk factors in sudden unexpected infant deaths, including those attributed to sudden infant death syndrome, and examines the impact of cosleeping with adults or siblings. The study examines sudden unexpected infant deaths from 1991 to 2000 in the state of Kentucky, excluding homicides and deaths from identifiable natural causes. Meta-analysis provides a cosleeping prevalence control in normal infants. Based on the findings described herein, we conclude that cosleeping may represent a risk factor in sudden unexpected infant deaths and that a full scene investigation, including whether the infant was cosleeping, should be sought in all cases of sudden infant death.     

Sudden unexpected death in a patient with splenic sequestration and sickle cell-beta+-thalassemia syndrome

Acute splenic sequestration crisis is a rare disorder that usually occurs in children, with sickle cell anemia, who are under the age of five years. A few cases have been described in adults with heterozygous sickle cell syndromes. Though this entity can be fatal there have been no reported cases associated with sudden death. We describe a case of sudden, unexpected death, associated with splenic sequestration, in a 29-year-old African-American man with undiagnosed sickle cell-beta-thalassemia syndrome.     

Postmortem diagnosis of diabetes mellitus. Quantitation of fructosamine and glycated hemoglobin

Fructosamine and glycated hemoglobin were determined in samples from 52 cadavers autopsied in the Forensic Pathology Institute of the University of Copenhagen (Denmark). The population studied comprised 15 adult subjects with history of diabetes mellitus and 37 adult non-diabetic subjects. The fructosamine/total protein ratio was 1.7 times higher in diabetic than in non-diabetic subjects, as was the case for glycated hemoglobin. Measurement of glycated serum protein appears to be a useful tool for the postmortem diagnosis of fatal diabetic coma and glucose concentration before death.     

Sudden unexpected death in infancy and childhood due to undiagnosed neoplasia: an autopsy study

Sudden unexpected death due to clinically undiagnosed neoplasia in infancy and childhood (SUDNIC) is a rare phenomenon, with only small numbers of cases reported in the literature. In the majority of instances, the tumors involve critical structures within the heart or central nervous system and include gliomas, medulloblastomas, rhabdomyomas, and neoplasms of stromal elements. A 20-year retrospective review of autopsy records from the Hospital for Sick Children, Toronto, was performed (1984-2003, n = 4926), and 7 cases of SUDNIC were identified (0.14%). In addition, 1 case was obtained from the files of the Children's and Women's Health Centre of British Columbia, Vancouver. Diagnoses included 2 cases of acute leukemia (1 myelogenous, 1 lymphoblastic), 2 cases of mediastinal lymphoblastic lymphoma (pre-T cell type), 1 papillary fibroelastoma of the mitral valve prolapsing into and totally occluding the left anterior descending coronary artery, 1 medulloblastoma, 1 Wilms tumor associated with fatal intraperitoneal hemorrhage, and 1 widely disseminated gastric carcinoma. These cases demonstrate that infants and children may have minimal or no symptoms in the presence of significant disease and highlight the need for a thorough autopsy examination in cases of sudden unexpected death in infancy and childhood.     

Sudden and suspicious deaths outside the deceased's own country — Time for an international protocol

Increased leisure time, international business commitments, and ease of travel have led to an increased incidence of sudden deaths outside the deceased's own country.Methods of investigation of sudden death, and the extent of such enquiries, vary greatly from country to country. The relatives of the deceased frequently make serious allegations relating to the circumstances of the death when they return to their homeland, and when the body is repatriated, a local pathologist may be directed to make an examination. This is frequently limited by inadequate police information, inadequate preservation of the organs and the absence of any autopsy report.Examples of these difficulties are presented, and suggestions offered for a basic protocol for the examination and report upon the death of a foreign national.Following the presentation of this paper at the International Association of Forensic Sciences Meeting in Bergen, considerable discussion took place and there have been further developments in the United Kingdom. These are briefly reported.