心源性猝死

尽管近年来临床逐渐能够识别和改变猝死的危险因素,成功地进行心肺复苏(CPR),并且使用抗心律失常药物治疗防止再发,猝死率已有明显下降。但是人群中老年患者的增加,心源性猝死的总人数仍然保持不变[1]。从一般意义上讲,猝死是指在终末事件发生前,患者心脏功能稳定,死亡发生于症     

Parapharyngeal abscess and sudden death

This case-report illustrates a sudden asphyctic death of a 68-year-old female caused by an inflammatory obstruction in the upper airway. The autopsy revealed a peritonsillar-retropharyngeal abscess. Possible explanations for this rapid and lethal progress of a tonsillar infection are discussed.     

Tonsillitis and sudden childhood death

Critical reduction in upper airway diameter may result from tonsillar enlargement due to infection or from associated abscess formation. Other potentially lethal complications include hemorrhage and disseminated sepsis. Two cases are reported to illustrate features of specific cases: Case 1: a 12-year-old girl who exsanguinated from a pharyngocarotid fistula caused by a retropharyngeal abscess due to acute tonsillitis, and Case 2: a 17-year-old girl who asphyxiated from an aspirated blood clot following tonsillectomy. While most cases of acute tonsillitis resolve without sequelae, occasional cases may be associated with a lethal outcome. Massive hemorrhage may occur due to erosion of tonsillar vessels or subjacent larger vessels, or it may follow surgical extirpation of the tonsils. The autopsy assessment of cases where there has been possible lethal tonsillar pathology requires review of the presenting history and possible operative procedures, with careful dissection of Waldeyer's ring, adjacent soft tissues and major vessels. Presentations may not be straightforward and there may be misleading histories of epistaxis, hemoptysis, hematemesis and even melena.     

Cytokines and sudden infant death

Background

It has been hypothesised that inflammatory reactions could play an important role in the pathway(s) leading to sudden and unexpected death in infancy. On a molecular level, these reactions are regulated by various cytokines.

Methods

To characterise the role of IL-1?, IL-6 and TNF?? more precisely, the concentrations of these cytokines were determined quantitatively using specific ELISA techniques in serum and cerebrospinal fluid (CSF) in 119 cases of sudden infant death. The infants were grouped into four categories (SIDS, SIDS with infection, natural death due to infection and unnatural death).

Results

A good correlation was found between CSF and serum for IL-6 (Spearman correlation coefficients (SCC), 0.73) and also for TNF?? (SCC, 0.57), although the CSF concentrations were lower than that from the serum. There were no significant differences between the categories of death for any of the serum or CSF cytokines. Compared with normal values, increased serum concentrations of IL-1?, IL-6 and TNF?? were found in 70%, 69% and 38% of the cases respectively, indicating possible agonal or post-mortem changes of cytokine concentrations. In three cases very high cytokine concentrations were found (mainly for IL-6). This may have contributed to the mechanism of death (cytokine storm) in two of the cases.

Conclusions

In a small group of patients, very high cytokine concentrations are a possible explanation for the cause of death (??cytokine storm??).     

Occult cardiac lymphoma and sudden death

A 56-year-old man with no previous medical history collapsed and was not able to be resuscitated. The major findings at autopsy were enlargement of the heart (weight?=?527 g) which contained an infiltrating firm, homogeneous tumor in an epicardial location adjacent to the left anterior descending and right coronary arteries, with further extension into the right ventricular outflow tract, the interventricular septum and left ventricular free wall. Sections showed sheets of small lymphoid cells with scattered large lymphocytes amounting to a low-grade follicular non-Hodgkin lymphoma, as tumor cells were CD20, CD10, Bcl 2 and LMO 2 positive. This case demonstrates a very rare cause of sudden and unexpected death that resulted from a low-grade follicular lymphoma in an asymptomatic, immunocompetent individual.     

Negative autopsy and sudden cardiac death

Forensic medicine defines the unexplained sudden death as a death with a non-conclusive diagnosis after autopsy. Molecular diagnosis is being progressively incorporated in forensics, mainly due to improvement in genetics. New genetic technologies may help to identify the genetic cause of death, despite clinical interpretation of genetic data remains the current challenge. The identification of an inheritable defect responsible for arrhythmogenic syndromes could help to adopt preventive measures in family members, many of them asymptomatic but at risk of sudden death. This multidisciplinary translational research requires a specialized team.     

Mitral annulus calcification and sudden death

Mitral valve annulus calcification is a degenerative cardiac condition often found at autopsy in the elderly. While usually considered incidental to the cause of death, we report two cases where mitral valve annulus calcification with valve stenosis was associated with sudden death. Case 1: a 61-year-old female who had underlying atherosclerosis and hypertension collapsed at home. At autopsy there was marked mitral valve annulus calcification with valve stenosis and cardiomegaly. Case 2: a previously well 74-year-old female collapsed in a toilet. At autopsy there was marked calcification of the mitral valve annulus with valve stenosis. In both cases death was attributed to the effects of the calcified mitral valve annulus. Although such calcification may be unrelated to the terminal lethal mechanism, the association with left atrial enlargement, atrial fibrillation, mitral regurgitation, mitral stenosis, bacterial endocarditis, ischaemic and thromboembolic stroke, myocardial infarction, and arrhythmias, means that it should not be overlooked in the differential diagnosis in cases of sudden and unexpected death.     

Exertional sudden death in soldiers

To address the problem of a significant rise in the incidence of exertional sudden death worldwide, the medical records and necropsy reports of all deaths that occurred in the Israel Defence Forces (IDF) during 1974-1986 were scrutinized. Twenty male soldiers, aged 18-29 yr, died suddenly and unexpectedly within 24 h of strenuous exercise. Necropsy results, available for 90% of the subjects, included underlying cardiac disease in 50% and noncardiac causes of death in 33.3%; the cause of death was unidentifiable in 16.7% of the subjects. Prodromal symptoms in 70% of the subjects are presented as a main focus of this investigation. The most frequently reported symptom was exertional or nonexertional syncope in 40% of the subjects. Chest pain, acute gastrointestinal symptoms, or febrile disease were reported in 30% of the cases. The findings of this research suggest that syncope is a major antecedent symptom of exertional sudden death. An attack of syncope in young conditioned individuals should be followed by thorough medical surveillance, and strenuous exercise should be avoided until this procedure is completed. Sports and military officials have the obligation to promote awareness that strenuous exercise should not be performed in the presence of acute gastrointestinal symptoms or febrile illness.     

Hyperthermia in sudden infant death

To determine whether preterminal hyperthermia is significantly associated with sudden infant death (SID), 140 structured interviews with parents of SID victims were compared with questionnaires filled in by a control group of parents living in the same area. All SID autopsies were performed between 1986 and 1992 at the Institute of Legal Medicine of Hannover Medical School according to the same protocol. Signs of profuse sweating (i.e. moist head, damp clothing or bedding) were present at the scene of death in 35.7% of cases. SID victims with signs of profuse sweating were more frequently found under their bedding (p < 0.001), were older (178 vs. 130 days) and the time period between when they were last seen alive and when they were found dead was longer (6.5 vs. 4.5 hours p < 0.01) compared to cases without sweating. Sweat on the head [odds ratio (OR) = 1.9; 95% confidence interval (CI) = 1.0, 3.6], and sweaty clothing and bedding (OR = 17.9; 95% CI = 8.7; 37.1) showed a significant association with the risk for SID. The pathophysiological basis for hyperthermia in SID remains to be determined. Hyperthermia could result from infection, overinsulation from excessive clothing with high environmental temperatures, covering of the infant's head or immature central thermoregulatory centres. The influence on the fatal outcome and the role in the pathogenesis of these deaths requires further research.     

Simultaneous sudden infant death syndrome

The simultaneous sudden deaths of twins rarely occur and therefore it has received limited attention in the medical literature. When the deaths of the twins meet the defined criteria for sudden infant death syndrome (SIDS) independently and take place within the same 24 h range it can be called as simultaneous SIDS (SSIDS). The case(s): Twin girls (3.5-month-old) were found dead by their mother in their crib, both in supine position. The infants were identical twins and delivered at a hospital by cesarean section. Both infants were healthy and did not have any serious medical history. Two days prior to the incident, the twins had received the second dose of oral polio, DPT and the first dose of hepatitis B vaccines and they had fever on the first day of the vaccination and been given teaspoonful of acetaminophen. Death scene investigation, judicial investigation, parental assessment, macroscopic and microscopic autopsy findings and the toxicological analysis did not yield any specific cause of death. The case(s) were referred to a supreme board composed of multidisciplinary medical professionals at the Institute of Forensic Medicine, Ministry of Justice, in Istanbul. The Board decided that the available data was consistent with SIDS. These SIDS case(s) are presented because twin SIDS are rare and this is the first time that a simultaneous twin SIDS have been reported in Turkey. Simultaneous SIDS cases have many implications regarding definition, diagnosis and medico-legal approach.     

Arrhythmogenic left ventricular dysplasia' and sudden death

A 32-year-old man who died suddenly and unexpectedly was found at autopsy to have prominent fatty infiltration of his left ventricle with fibrous scarring, in the presence of normal coronary arteries. The right ventricle was minimally involved. A diagnosis of ventricular dysplasia largely limited to the left ventricle was made. Subsequent family screening identified a brother with clinical manifestations of ventricular dysplasia. This case provides further evidence for the association of left ventricular dysplasia with sudden death, and demonstrates that left ventricular involvement may also be inheritable. Whether predominantly left ventricular dysplasia is a manifestation of right ventricular dysplasia, or is a separate entity, is yet to be determined.     

Postmortem imaging of sudden cardiac death

Postmortem imaging is increasingly used in forensic practice in cases of natural deaths related to cardiovascular diseases, which represent the most common causes of death in developed countries. While radiological examination is generally considered to be a good complement for conventional autopsy, it was thought to have limited application in cardiovascular pathology. At present, multidetector computed tomography (MDCT), CT angiography, and cardiac magnetic resonance imaging (MRI) are used in postmortem radiological investigation of cardiovascular pathologies. This review presents the actual state of postmortem imaging for cardiovascular pathologies in cases of sudden cardiac death (SCD), taking into consideration both the advantages and limitations. The radiological evaluation of ischemic heart disease (IHD), the most frequent cause of SCD in the general population of industrialized countries, includes the examination of the coronary arteries and myocardium. Postmortem CT angiography (PMCTA) is very useful for the detection of stenoses and occlusions of coronary arteries but less so for the identification of ischemic myocardium. MRI is the method of choice for the radiological investigation of the myocardium in clinical practice, but its accessibility and application are still limited in postmortem practice. There are very few reports implicating postmortem radiology in the investigation of other causes of SCD, such as cardiomyopathies, coronary artery abnormalities, and valvular pathologies. Cardiomyopathies representing the most frequent cause of SCD in young athletes cannot be diagnosed by echocardiography, the most widely available technique in clinical practice for the functional evaluation of the heart and the detection of cardiomyopathies. PMCTA and MRI have the potential to detect advanced stages of diseases when morphological substrate is present, but these methods have yet to be sufficiently validated for postmortem cases. Genetically determined channelopathies cannot be detected radiologically. This review underlines the need to establish the role of postmortem radiology in the diagnosis of SCD.     

Petechial bleedings in sudden infant death

The autopsy reports of 484 cases of deceased infants (201 females, 283 males) were analysed retrospectively for the existence of external and internal petechial bleedings (PET). The cases were divided into five groups on the basis of the cause of death (sudden infant death syndrome, sepsis, airway infections, asphyxia and trauma). Internal PET (pleural, pericardial, epicardial, thymic and peritoneal) were observed in each group with a lower prevalence in cases of trauma. The highest prevalence of external (cutaneous and conjunctival) PET was detected in cases of asphyxia (38% and 31%, respectively). However, even if with low prevalence, such bleedings were detected in every group. Factors like sex, age, cardiopulmonary resuscitation and its duration did not influence the presence of PET. The detection of external PET at autopsy is a suspicious finding that suggests asphyxia. Because of the possible natural origin of these bleedings, the medicolegal investigation has to be as complete as possible and has to include histology as mandatory.