A sudden death due to cardiac conduction system injury from a blunt chest impact

We report a case of sudden death due to cardiac conduction system injury from a blunt chest impact. A 20 year old male, kicked in the precordial region, lost consciousness, and was confirmed dead on arrival at a hospital emergency care unit. According to his friends, they played a golf competition accompanied with a physical punishment. The victim, losing the game, allowed the winner to give him several kicks in the chest. Although well prepared against each kick, he fell down instantaneously after the final impact, and death was confirmed at a hospital. There was no apparent sign of injury on the body surface. At autopsy, there was no evident subcutaneous or intramuscular hemorrhages, rib or sternum fracture. Subendocardial hemorrhage in the region of the atrioventricular node and a contusion extending from the posterior wall of the left ventricle to the upper ventricular septum were observed. Histological examination revealed injury of atrioventricular node and His' bundle. Although the cardiac injury including contusion of the myocardium itself was not so extensive, it was considered that arrhythmia was induced by the cardiac conduction system failure, which was considered to be the cause of death.     

Sudden,unexpected infant death due to pulmonary arterial hypertension

A 3-year-old girl with no particular medical history complained of a stomachache and died on the way to the hospital. The autopsy revealed marked right ventricular hypertrophy and dilation with no other cardiac abnormalities. Microscopically, the pulmonary small arteries showed marked medial hypertrophy and varying degrees of intimal and adventitial thickening. We supposed that the cause of death was attributable to pulmonary arterial hypertension (PAH). PAH is a rare disease that can cause sudden, unexpected death at any age. Forensic pathologists should consider PAH in the differential diagnosis of sudden death.     

Sudden death of an infant with bronchopulmonary dysplasia and bilateral cervical lymphadenopathy--a vagal death?

A sudden unexpected death is reported in a 15-month old boy, born with an extremely low birth weight and then had suffered prolonged respiratory complications arising from infantile respiratory distress syndrome. The autopsy revealed severe bronchopulmonary dysplasia (BPD) in his lungs with secondary pulmonary heart disease; a tracheotomy was carried out to enable his survival. The cause of death was established as being acute cardiac and pulmonary failure due to severe BPD, rather than mechanical asphyxia. The perilaryngeal lymph nodes were also significantly enlarged and closely surrounded the vagus bilaterally. Such cervical lymphadenopathy could have resulted in the mechanical compression of the vagus upon movement of the neck. For this reason, anatomical examination of the cervical portion of the vagus and its path may be of great significance when analyzing the cause of death in the cases of sudden infant death.     

Forensic significance of conduction system abnormalities as a precise cause of accidental death

We examined the pathology findings of the cardiac conduction system in 42 human autopsies who were considered to have died an accidental death. Abnormalities in serial sections of the conduction system were found in seven and of these three had an accessory pathway in the conduction system. In one of these there was mild Ebstein's anomaly (ME), two had fibromuscular dysplasia of the atrioventricular node artery with mitral valve prolapse, and two others had abnormal routes showing fragmentation of the bundle of His with ME. A full investigation of the cardiac conduction system can therefore be useful for determining the precise cause in cases of accidental death.     

Cardiovascular disease in athletes

Cardiovascular disease (CVD) is the leading cause of death in the United States, resulting in increased awareness of the preventive importance of regular physical activity. Because athletes are considered physically fit, occurrence of sudden athlete death from CVD is perplexing. Regular intense physical activity can cause changes to the cardiovascular system that mimic known CVD processes. Therefore, screening of athletes for conditions that may increase risk for sudden cardiac death (SCD) is challenging. This article focuses on this problem, discussing the athlete's heart, SCD and associated CV conditions, and preparticipation screening. We also review recommendations of the 26th Bethesda Conference on determining eligibility for competition in athletes with known CV abnormalities, and how the recommendations relate to individual disease processes.     

Problems in Matching Young Athletes: Baby Fat,Peach Fuzz,Muscle, and Mustache

In brief: Exercise-related sudden death is a clinical syndrome that is well known both to the general public and to the medical community. Autopsy studies of victims have identified multiple structural cardiovascular diseases underlying sudden death in young athletes (aged 30 years and younger). These diseases include myocardial, coronary arterial, aortic, valvular, and cardiac conduction system disorders. In athletes over 30 years of age, the underlying cause is almost invariably severe coronary artery disease. The author discusses these diseases, along with apparent mechanisms of sudden death, clinical points, risks of exercise stress testing, and cardiac rehabilitation, as a basis for attempts to prevent these tragic events.     

Sudden cardiac death in a child affected by Prader-Willi syndrome

A case of sudden cardiac death in a 3-year-old young male affected by Prader-Willi syndrome, clinically diagnosed and confirmed by means of DNA methylation, is presented. The infant suddenly collapsed at home and was taken apparently unconsciousness by his mother to the emergency clinic where he was pronounced dead. A complete postmortem examination was performed and the histological findings led to the definition of cardiac death with a typical picture of contraction band necrosis. Pulmonary hypoxic alterations are frequently reported as the primary cause of death in PWS cases. In this fatal case according to the macroscopic and microscopic findings, the cause of death was most likely cardiac and possibly related to contraction band necrosis linked with ventricular fibrillation and sudden death.     

Exercise-related sudden death due to an unusual coronary artery anomaly

Coronary artery anomalies are, after hypertrophic cardiomyopathy, the second most common cause of exercise-related sudden cardiac death in young American athletes. These anomalies have been associated with myocardial ischemia, arrhythmia, and sudden death during exercise. A 14-yr-old male with no previous abnormal medical history collapsed during soccer practice and was successfully resuscitated without defibrillation. An extensive cardiac workup did not reveal any abnormalities. Two weeks later, he experienced a cardiac arrest while running and could not be resuscitated. Autopsy demonstrated an acute angle take-off of the left main coronary artery and a transverse slit-like opening with a fibrous cushion, which created a kink near its origin. This case report illustrates the difficulty in diagnosing coronary artery anomalies in general, and acute angle take-off and ostial ridges in particular.     

An autopsy case of sudden death in a patient with idiopathic scoliosis

A 38-year-old woman with idiopathic scoliosis (right convex thoracic scoliosis, 78 degrees; left convex lumbar curvature, 75 degrees) died suddenly. Forensic autopsy and histopathologic examination revealed chronic congestive oedema, numerous cavities and atrophic changes of heart. These changes, including both respiratory changes and biventricular failure caused by hypoplastic cardiac changes, were due to a deformed thoracic cage. This case illustrates that not only abnormalities of respiratory function and cor pulmonare, but also hypoplastic cardiac changes, may cause sudden death in a patient with untreated scoliosis.     

A forensic autopsy case: Sudden unexpected death due to cardiac inflammatory myofibroblastic tumor

We report an autopsy case of a 25-year-old man with no medical history who died suddenly in an Internet cafe. He was found in cardiorespiratory arrest and did not respond to cardiopulmonary resuscitation. Traumatic lesions were not observed on his body. An autopsy was performed to investigate the cause of death. Upon examination, we discovered a heart tumor that infiltrated from the outside wall to the outflow tract of the left ventricle. Left ventricular outflow tract obstruction due to a cardiac tumor was considered the mechanism of death. Histological examination identified an inflammatory myofibroblastic tumor (IMT). The final diagnosis was death secondary to circulatory failure due to a cardiac IMT. Additionally, a cardiac tumor was diagnosed using post-mortem computed tomography. Only few cases of sudden unexpected death due to cardiac IMT have been reported; we report this case along with a review of the literature.     

A heart of stone: an autopsy case of massive myocardial calcification

A case of massive calcification of the myocardium is presented that was diagnosed by postmortem computed tomography (PMCT) and confirmed by conventional autopsy. There are two types of pathologic calcification, dystrophic and metastatic. Massive calcification of the myocardium is associated with variable clinical outcomes, including sudden unexpected death. A 53-year-old man was found after he collapsed beside a walkway. He was transferred to hospital and died approximately two months later. To investigate the cause of death, PMCT and conventional autopsy were performed, which revealed massive calcification of the myocardium, a very rare finding at autopsy. Massive myocardial calcification was one of the possible causes of his collapse. PMCT may be a useful diagnostic tool for detecting massive calcification of the myocardium following sudden cardiac death.     

Seltene Todesursache bei Schizophrenie und Alkoholkrankheit

This article reports on a 43-year-old woman who died suddenly and unexpectedly. The woman was alcohol dependent and was being treated for schizophrenic psychosis with the neuroleptic drugs sertindole and pipamperone. As the autopsy did not reveal a cause of death, histological and toxicological investigations were performed. By toxicological analyses sertindole and pipamperone could be detected at levels above therapeutic concentrations and the blood alcohol concentration was 0.29?‰. In combination with sertindole and pipamperone an increased arrhythmogenic potential by an extension of the QTc time is discussed. The histological investigations of the cardiac conduction system revealed marked lipomatosis of the atrioventricular node and the bundle of His, which could have been caused by long-term alcohol abuse. In conclusion it is assumed that the cause of death was an acute cardiac event caused by interaction of sertindole and pipamperone therapy and an impaired cardiac conduction system.     

Autopsy case of Rosai–Dorfman disease presenting as fibrinous pericarditis

Rosai–Dorfman disease (RDD) is a rare non-Langerhans cell histiocytosis that is characterized histopathologically by accumulation of CD68-positive, S100-positive, and CD1a-negative histiocytes. Cardiac involvement of RDD is rare. We report here an autopsy case of cardiac involvement of RDD presenting as fibrinous pericarditis. A 14-year-old Japanese boy complained of loss of appetite and breathing difficulty when lying down. He was found dead on his back in his bedroom. One year before his death, he was diagnosed with RDD after skin biopsy. At autopsy, the deceased was 153 cm in height and weighed 38 kg with systemic edema. He had flat pigmented light-brown spots, as well as many pale reddish-brown papules on the abdomen and both thighs. Cervical and mediastinal lymphadenopathy was observed. A large amount of pleural and ascitic fluid was observed. The spleen weighed 381.9 g and showed splenomegaly. The heart weighed 620 g and showed acute fibrinous pericarditis with adhesion. Abundant fibrin was observed on the epicardial surface. The infiltrating cells were CD68-positive, S100-positive, and CD1a-negative histiocytes. The skin and spleen showed histiocytic involvement. Systemic edema, large amounts of pleural and ascitic fluid, a high brain natriuretic peptide level in blood, and hemosiderin-laden macrophages in the lungs suggested chronic heart failure. We speculate that the cause of death was extranodal cardiac involvement of RDD with chronic heart failure. This case highlights the need for forensic pathologists to perform a complete autopsy to determine the cause of sudden death when cardiac involvement of RDD is present.     

Cystic tumour of the atrioventricular node: three cases of sudden death

Cystic tumour of the atrioventricular nodal region is a rare primary cardiac tumour that can cause sudden death. Antemortem diagnosis and successful excision of this type of tumour are extremely rare. Three cases of sudden death are reported: A 25- and 40-year-old with a history of heart block and a 60-year-old with no medical history. There have been more than 120 cases of sudden death attributed to primary cardiac tumours in the literature. Although over 100 of these lesions were histologically benign, their intracardiac locations precipitated conductive and haemodynamic abnormalities that resulted in sudden death. The most common intracardiac lesion causing sudden death, cystic tumour of the atrioventricular node, however, may not be discovered unless the atrioventricular node is microscopically examined.     

Cardiovascular screening of athletes.

Cardiovascular screening of athletes is a challenging aspect of the preparticipation evaluation. While sudden cardiac death in young athletes is uncommon, preparticipation screening may identify some predisposing conditions that place individuals at increased risk. The most common pre-existing cardiac abnormalities in athletes causing sudden death in the United States are hypertrophic cardiomyopathy, congenital coronary anomalies, and Marfan syndrome. Preparticipation cardiovascular screening should pursue any history of cardiac symptoms or family history of premature cardiac disease, as well as abnormal cardiovascular physical findings. Positive findings should be investigated; an electrocardiogram, echocardiogram, or consultation with a specialist should be considered. Recommendations are then available to guide athletic participation according to the cardiovascular diagnosis.     

猝死型冠心病抑或J波综合征

目的：探讨无冠心病史而心脏性猝死患者病因及发病机制。方法：对我院2例典型患者,围绕其病史、发病时症状及相关检查化验,结合心肌电离子基础进行综合分析。结果：2例心脏性猝死患者1例生存,另1例死亡。但均不具备冠心病特征,发病后相关指标的异常应为心脏骤停及相关综合因素所决定。结论：无冠心病史而心脏性猝死患者本身可能存在心肌电紊乱基础,在特定的诱因下使心室外膜2期复极电位差的进一步增大出现折返诱发室颤而使心脏骤停,归属于J波综合征较为合理。     

Unexpected sudden death resulting from anomalous origin of the right coronary artery from the left sinus of Valsalva: a case report involving identical twins

An anomalous origin of the coronary arteries had been implicated as a cause of sudden cardiac death in a case involving a 16-year-old student who suddenly collapsed while running track at school. An autopsy revealed that the right coronary artery arose from the aorta in the left sinus of Valsalva. In order to determine whether the same anomaly was inherent in his brother--an identical twin--a complete cardiac medical examination was conducted. Multi-detector-row computed tomography (MDCT) coronary angiography showed no anomaly at the sinus of Valsalva, which indicates that the anomaly, in this case, was not hereditary. This case exemplifies instances where forensic medicine may intervene to prevent sudden deaths in surviving family members.     

An autopsy case of sudden unexpected nocturnal death syndrome with R1193Q polymorphism in the SCN5A gene

SCN5A (sodium channel, voltage-gated, type V, alpha subunit) gene encodes the cardiac sodium channel, a member of the voltage-gated sodium channel family. SCN5A mutations have been associated with a variety of inherited arrhythmias, including long QT syndrome and Brugada syndrome. We report an autopsy case of sudden unexpected nocturnal death syndrome. A man in his thirties died at night while sleeping. At autopsy, no traumatic injury, disease or drug intake was observed as a possible cause of death. We examined mutations in the SCN5A gene and identified a heterozygous mutation causing an R1193Q amino acid substitution. It was reported that the R1193Q polymorphism in the SCN5A gene destabilizes channel inactivation and may be a risk factor for Brugada and long QT syndrome. It may be considered that the cause of death in this case was sudden cardiac death.     

Plötzlicher Tod bei sexueller Aktivität

A case of sudden cardiac death in a 37-year-old man during sexual activity is reported. The only morphological findings which could explain death were determined with the histological investigation of the cardiac conduction system. The heart exhibited fibromuscular dysplasia of the atrioventricular node artery and individual small coronary arteries as well as fiber residues of the left bundle branch. The potential death mechanisms as well as the predisposing factors are discussed. This case is reported to supplement the causes described so far for sudden natural death during sexual activities.