Undiagnosed, untreated acute promyelocytic leukemia presenting as a suspicious sudden death

Acute promyelocytic leukemia (APL) is a subtype of acute myelogenous leukemia frequently associated with clotting abnormalities and severe hemorrhagic diathesis. The disease is associated with a high incidence of early fatal hemorrhage. We report the sudden death of a 40-year-old male without significant medical history in which foul play had been initially suspected. A thorough postmortem investigation performed on the decedent lead to the diagnosis of APL. Cause of death was a cerebellar hematoma. Underlying APL should be considered in the differential diagnosis when unexplained bleeding is encountered in a decedent. This case emphasizes the value of routinely collecting bone marrow during an autopsy to enable accurate testing and diagnosis.     

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.     

Influenza A/H1N1 (2009) Infection as a Cause of Unexpected Out‐of‐Hospital Death in the Young*

Abstract: In March 2009, a new strain of influenza A/H1N1 virus was identified in Mexico, responsible for a pandemic. Worldwide, more than 13,500 patients died, most often from acute respiratory distress syndrome. Because sudden death cases were rare, involving mostly young apparently healthy persons, influenza A/H1N1 (2009)‐related deaths may be misdiagnosed, which can raise medico‐legal issues. Case history: we report on an unexpected out‐of‐hospital death involving a young male with no past medical history and no vaccination. Fever was his only symptom. Laboratory tests: histology showed patchy necrotic foci with mononuclear inflammation in the lungs. The heart was histologically normal, but virological analyses using molecular biology on frozen myocardial samples showed high virus load. In conclusion, this case report shows that influenza A/H1N1 (2009) virus can be a cause of sudden cardiac death in the young and demonstrates the importance of quantitative virological analyses for the diagnosis of myocarditis.     

A case of sudden infant death due to a primary cardiac sarcoma

The case reported herein concerns the unexpected death of a 3-month-old female newborn who suddenly collapsed in her mother's arms and was dead on arrival at the hospital. The clinical histories of the baby and her parents were negative for symptoms or signs of illness, even those of cardiovascular origin. Furthermore, no clinical appearance of a pathologic status was noted by pediatricians after the birth until the last emergency recovery. The autopsy excluded external and internal signs of violence but revealed a large primary cardiac tumor arising from the free wall of the left ventricle, which had totally invaded the heart causing mitral valve deformation. Histological examination showed a low-grade sarcoma that completely infiltrated the myocardial tissue. The pathogenesis of this sudden infant death was postulated as being owing to a fatal ventricular fibrillation combined with a tumor-related restrictive cardiomyopathy obstructing left ventricular filling.     

Death following injection sclerotherapy due to phenol toxicity

Prolapse rectum (PR) or protrusion of the rectum beyond the anus occurs frequently in populations at both extremes of age. In the pediatric population, in developed countries, the commonest cause for PR is thought to be cystic fibrosis (CF). Treatment options for CF include conservative management, surgical resection and fixation, suturing, and injection sclerotherapy (IS). The last is considered an attractive treatment option because it is minimally invasive. In this case report, the authors present the details about a 2-year-old female child, with PR and CF, who died after IS, using phenol as the sclerotherapeutic agent. Autopsy findings and toxicology tests performed to establish phenol toxicity are documented. The available literature is reviewed. This case report underscores the risks of using phenol for IS and emphasizes the point that the procedure is not innocuous and an adverse outcome including fatality is a possibility.     

Community Risk Management of High-Risk Sex Offenders in Canada: Findings From a Quasi-Experimental Study

Although considerable controversy surrounds capital punishment, there is no disagreement about the injustice of executing innocent persons. While critics of the death penalty have cited the risk of executing the innocent as a reason for its abolition, adherents have dismissed the risk of error as negligible, if not inevitable, and insufficient reason to halt capital punishment. Still others have proposed or enacted reforms designed to minimize the risk of erroneous capital convictions and sentences and, hence, allow executions to go forward in deserving cases in which doubts about guilt have largely been eradicated. In this article, we examine the principled tensions that accompany attempts simultaneously to safeguard the innocent from execution while promoting the objectives of capital punishment. We focus, in particular, on reforms recently incorporated into Maryland’s death penalty law. We suggest that the existing tensions between protecting the innocent from execution and promoting the objectives of capital punishment are so pronounced that attempted reconciliation of the competing interests is difficult to defend, either in principle or in practice.     

自救还是他救：受害人的权利救济问题研究

受害人是指所有认为自己的权利受到侵害的人,受害人的权利源于自然状态中人的生存需要和人作为人的道德资格,应当首先承认每个人都有认定自己权利受到侵害的主观权利,赋予每个人确认受害人的资格和自由。在这个前提下,区分"命不好的人"、"受苦的人"和"特殊的不幸的人"才具有现实基础,也为甄别不同形式的救济理论确立了立论的基础和方向。现代权利救济理论承认受害人作为权利主体和救济主体的双重身份,它的使命在于贯彻自我救济的权利这一核心观念,从而与道德范式下的怜悯论和神学意义上的救赎学拉开了距离,以此张扬人的价值和自我救赎的世俗意义,为与一种合乎正义的社会结构相契合的善政或权利的道德提供驱动力。     

Trigemino‐Cardiac Reflex as Lethal Mechanism in a Suicidal Fire Death Case

In the vast majority of immediate fire deaths, the mechanism of death is inhalation of toxic gases (especially carbon monoxide), direct thermal injury, or neurogenic shock due to the redistribution of the body's blood volume produced by surface heat on the skin. We present a suicidal case that is unusual because the mechanism of immediate fire death could arguably be explained in terms of a primitive autonomic reflex/the trigemino‐cardiac reflex. Although this reflex is well known to surgeons and anesthetists, with possible lethal consequences in the course of invasive surgical procedures on the head and neck region, it is much less familiar to forensic pathologists.     

Radiocarbon Analysis of Human Remains: A Review of Forensic Applications

Radiocarbon analysis of organic materials, with the comparison of values with those of the post‐1950 modern bomb curve, has proven useful in forensic science to help evaluate the antiquity of evidence. Applications are particularly helpful in the study of human remains, especially with those displaying advanced decomposition of soft tissues. Radiocarbon analysis can reveal if the remains relate to the modern, post‐1950 era and if so, also provide information needed to evaluate the death and birth date. Sample selection and interpretation of results must be guided by knowledge of the formation and remodeling of different human tissues, as well as contextual information and the approximate age at death of the individual represented. Dental enamel does not remodel and thus captures dietary radiocarbon values at the time of juvenile formation. Most other human tissues do remodel but at differing rates and therefore collectively offer key information relative to the estimation of the death date.     

The Drowning Index: Implementation in Drowning,Mechanical Asphyxia,and Acute Myocardial Infarct Cases

Drowning is a diagnosis of exclusion based on circumstantial and autopsy correlation. Sugimura proposed a threshold value of 14.1 for the Drowning Index (DI), the ratio of lung and pleural fluid to spleen weight, as a surrogate marker to diagnose drowning. We questioned the use of DI in diagnosing drowning. We compared DI between three groups—drowning, mechanical asphyxia, and myocardial infarct—seen at Broward MEO from 2008 to 2009. Only 9.4% of 53 drownings exceeded the DI threshold of 14.1, while 30% of 10 mechanical asphyxias and 40% of 10 myocardial infarcts had DI >14.1. Sensitivity for the DI test was <10% and specificity 60–70%. Median DI values for all groups were <10. Mann–Whitney U‐test was not statistically significant between groups. The DI is neither sensitive nor specific and lacks any utility in the diagnosis of drowning.