Sudden death: a clinicopathological study.

OBJECTIVE: To ascertain the causes of sudden death (SD) by autopsy examination. METHODS: All cases of sudden death were subjected to a postmortem examination. In addition previous postmortem reports of sudden death over a two years were also included. Postmortem findings were correlated to clinical state and the cause of death was ascertained. The information was analyzed to find out the cause of sudden death in our patients. RESULTS: Out of a total of 130 autopsies there were 13 cases of SD. All were males (age 23 to 50 years). Death was within one your of onset of symptoms in five (38.5%) cases and within 24 hours in eight (61.5%) cases. Death was due to coronary artery disease (CAD) in 10 (76.93%) cases, aortoarteritis, cardiomyopathy and cerebrovascular accident (CVA) in (7.69%) case each. Amongst CAD patients triple vessel disease (TVD) was seen in eight cases (which included one case of cardiomyopathy), two vessel disease (DVD) in two and single vessel disease (SVD) in one. No specific preponderance of right or left coronary artery was seen. One patient of 21 year who died following exertion showed anomalous origin of coronary arteries. His right and left coronary artery originated from aortic arch 1.5 cm above the aortic valve. Right coronary artery was ill developed and had atheromatous plaque. The case of cardiomyopathy also had TVD. In the case of aortoarteritis all vessels were affected (carotids, renal and coronary). In one case of CVA bleeding was from an arterio-venous malformation in right temporal lobe. Nine out of 11 cases of CAD had atheromatous plaque without coronary thrombosis. CONCLUSIONS: Coronary artery disease (Triple vessel disease) contributed to maximum number of cases of SD. Aortoarteritis, cardiomyopathy and cerebrovascular accident (CVA) was the cause of death in one case each. Postmortem identified the cause of death in all cases.

Carbon monoxide poisoning.

OBJECTIVES: We studied the clinical profile and autopsy findings of carbon monoxide (CO) poisoning encountered at a hospital located at the altitude of 5,000 ft above mean sea level. METHODS: Clinical and postmortem findings in 25 and 15 cases of accidental CO poisoning respectively were evaluated. The diagnosis was made on circumstantial evidences, definite history of "Bukhari" burning and positive Kunkel's test for carboxyhaemoglobin (COHb). Detailed routine investigations including pulse oxymetry, X-ray chest and electrocardiographical monitoring was carried out in all the 25 patients. Oxygen (100%) via an endotracheal tube in all the comatosed patients and by conventional non-rebreathing plastic face masks was the mainstay of treatment. All patients were monitored and followed up for any delayed neurological sequelae. RESULTS: Most of the patients were young adults and the duration of exposure varied between three to eight hours. The initial diagnosis was stroke in three, seizure in one, encephalitis in two and ischaemic heart disease (IHD) in four. Neurological and respiratory signs and symptoms were noted in 19 and 18 of 25 patients respectively. SPO2 measured by pulse oxymetry was normal in all cases. ECG was suggestive of IHD in four patients. No delayed neurological sequelae was noted in any patients. Autopsy revealed deep red discoloration of skin and serous membranes in 80%, pulmonary oedema in 100% and cerebral oedema with widespread multiple pin point haemorrhages mainly in thalamus and globus pallidus in 40%. CONCLUSION: A high level of suspicion and routine history about the kind of indoor heating, specially in cold climate areas during winter will help in early diagnosis and decrease the incidence of misdiagnosis of CO poisoning. Oxygen (100%) or hyperbaric oxygen, if available should be administered without waiting for COHb levels to decrease morbidity and mortality.

Medical problems in surgical patients.

OBJECTIVES: There has been an increase in surgical cases due to physical violence, accidents and weapon related injuries. This study was undertaken to assess the medical problems in general surgical cases and due to various injuries. METHODS: All general surgical cases and casualties arising out of weapon related, accidents and blunt injuries admitted to a zonal hospital over a period of one and half years were studied. Only cases who developed a medical illness due to surgical cause, anaesthetic or surgery were included. Evaluation and treatment was done alongwith the surgeon till discharge/death. Details were analysed to ascertain the type of surgical illness, medical complication and the outcome of treatment. RESULTS: There were seven hundred sixty two (53.8%) general surgery cases and six hundred fifty four (46.2%) cases due to various injuries. After excluding cases with prior known medical illness, thirty seven patients were studied. There were eight (1.05%) patients out of seven hundred sixty two general surgery cases and twenty nine (4.43%) out of six hundred fifty four injury cases. Weapon related injury cases were the maximum. Their medical problems related to the organ injury, fat embolism and sepsis. Soft tissue injury was next common, they all developed renal failure. Vehicle accident victim(3) were few and developed fat embolism, aspiration. Two patients out of thirty seven succumbed to post anaesthetic complications. CONCLUSION: The incidence of medical problem in injury related cases are more than in general surgery cases. The type of injury contributes to the medical problem. Increase in mortality and morbidity is because of emergency nature of surgery. This problem needs special study.

Experience on loading dose--quinine therapy in cerebral malaria.

Twelve cases of cerebral malaria due to plasmodium falciparum, treated with loading dose of quinine (20 mg/kg salt in 500 ml of 5% glucose infused IV in 4 hrs) are compared with eleven age and sex matched cases treated with conventional dose of 10 mg/kg. The parasite clearance rate was significantly faster in loading dose group. There was no difference in recovery time: the interval between the initiation of treatment to full recovery of consciousness in both groups. One patient had pretreatment hypoglycaemia and two cases in the conventional dose group developed hypoglycaemia during therapy. One patient died in conventional dose group due to multi-organ failure. Two litres blood exchange transfusion was also tried for this case. Mild cinchonism occurred in two cases after loading dose while this was observed only in one case in conventional dose group. There was no significant hypotension or ECG changes in any patient. Loading dose of quinine seems to be well tolerated and may clear parasitaemia faster in case of malaria due to Plasmodium falciparum (PF).

Ranitidine for the prevention of complications following endoscopic sclerotherapy for esophageal varices.

Thirty one patients with significant esophageal variceal bleed were allocated alternately to receive endoscopic sclerotherapy along with ranitidine 300 mg daily or endoscopic sclerotherapy alone till eradication of varices. The mean sclerotherapy sessions, time and volume of sclerosant required for obliteration of varices were similar for the two groups. The esophageal varices were eradicated in all the patients except three in sclerotherapy alone group. There was statistically significant reduction in frequency of post sclerotherapy mucosal ulcers (P < 0.05) after addition of ranitidine to sclerotherapy. Rebleeding was not only significantly reduced (P < 0.05) in the sclerotherapy with ranitidine group but was minor and did not even require blood transfusion. In sclerotherapy alone group rebleeding was controlled by surgery in two patients and one died due to massive bleeding. The results of this study suggest a beneficial role of ranitidine in reducing post sclerotherapy mucosal ulcers and rebleeding. This effect of ranitidine emphasises the role of acid-pepsin in pathogenesis of these ulcers and its associated morbidity.

Acute renal failure in severe exertional rhabdomyolysis.

During the last 6 years, 7 healthy individuals who were reasonably well acclimatised to physical exertion came under observation with acute renal failure due to exercise induced myoglobinuria. Their mean age was 20 years, and renal failure resulted after cross country run of 10-15 km in 6 cases and long route march of 90 km in 3 days in one case. There was no evidence of effects of heat, dehydration or hypotension. Apart from myoglobinuria and significant urinary sediments, serum aldolase (mean 69.0 SL u/ml) and serum creatinine phosphokinase (mean 120.0 Sigma u/ml) were also elevated. Maximum blood urea and creatinine were 224 mg/dl and 13.9 mg/dl respectively. Hypocalcaemia was noticed in 3 cases, hyperkalaemia in 4 cases and hyperuricaemia in one case during the oliguric phase. One case had features of non-oliguric acute renal failure. All cases recovered though 4 cases required dialysis support. Kidney biopsy in 3 cases showed recovering acute tubular necrosis with eosinophilic material in tubules. Lactate studies in the convalescent period revealed normal response and repeat physical exertion of same severity after 6 months did not reproduce the syndrome. It is concluded that exertional rhabdomyolysis unassociated with heat stress is a rare entity, and with prompt diagnosis and energic management results are rewarding.

Hypopituitarism following snake bite.

A patient who developed hypopituitarism after viperine envenomation is described. Thrombosis as a part of disseminated intravascular coagulation may have been the cause. Hypopituitarism should be suspected in such cases especially when there is associated acute renal failure.

Excessive polycythaemia of high altitude. Pulmonary function studies including carbon monoxide diffusion capacity.

Pulmonary function studies were done in 21 soldiers (low landers) posted at high altitude (average height 4773 metres) for prolonged periods (average 77.09 months), who had developed excessive polycythaemia, mean haemoglobin concentration being 23.06 g/dl. Studies revealed significant reduction in diffusion capacity of lungs which gradually returned to normal on sojourn at low altitudes for 70 days. Both the degree of polycythaemia and reduction in lung diffusion capacity were much more pronounced in smokers than in non-smokers. Vital capacity did not show any difference in these subjects while forced expiratory volume in 1 sec and ratio of forced expiratory volume to vital capacity (FEV1/VC) revealed only obstructive features in smokers.

Neurological manifestations of malignant diseases.

Four hundred and sixty three patients with malignant diseases were studied over a period of two years; of these, 53 (11.44%) had neurological syndrome, both metastatic (32) and non metastatic (21). The lymphoma-leukaemia group accounted for 34 of the 53 cases. The maximum manifestations were seen in the 21-40 years age group, with male preponderance. The metastatic manifestations were as a result of cerebral (16), brainstem, cerebellar (12) and cord (4) deposits. These were confirmed by CT scan and myelogram. The non metastatic manifestations were peripheral neuropathies (7), leukoencephalopathy and intracranial haemorrhage (6 each), and myasthenic syndrome and myopathy (one each). These findings were confirmed by electrophysiological studies, CT scan, and histopathological examination. Autopsy studies were carried out in 12 of the 53 cases.

A clinical study of adult leukaemias.

The incidence of adult leukaemias, their response to therapy and the complications of therapy were studied in 121 cases over seven years (1981-1987). All cases were followed up till recovery or death for periods ranging from seven days to seven years. Adult leukaemias accounted for 2.56% of all admissions due to malignancies. There were 21 cases of acute lymphoblastic leukaemia, 61 of acute myelogenous leukaemia, 36 of chronic myelocytic leukaemia and 3 chronic lymphocytic leukaemia. All received aggressive combination chemotherapy. Remission could be achieved in 57% to 60% of cases. Infection (34%), bleeding (34%), and central nervous system involvement (25%) were the complications during therapy. The cause of death was ascertained in 87 of 90 deaths by a detailed postmortem. Haemorrhage (34.5%), infection (31%) and uncontrolled leukaemia (22%) were the leading causes, either singly or in combination. Some of the uncommon causes of death were fulminant hepatic failure, coronary artery disease, gangrene of the colon and disseminated tuberculosis.

Systemic manifestations of systemic lupus erythematosus.

Twenty five cases with systemic lupus erythematosus admitted to a referral service hospital over a period of 6 years have been studied to analyse the pattern of multisystem involvement. Febrile polyarthritis, renal involvement and skin changes dominated the clinical picture. Important serological abnormalities included the presence of antinuclear antibody and anti ds DNA. Renal biopsy carried out in all cases helped to reveal lupus nephritis in subclinical cases. The pattern of renal involvement varied, with diffuse proliferative glomerulonephritis being the commonest. Oral steroids was given to all cases and cyclophosphamide was given to severe and resistant cases. The severity of system involvement, especially renal, influenced the response to treatment. Changes in presentation between Indian and Western patients are highlighted.

Nuclear, biological and chemical warfare. Part I: Medical aspects of nuclear warfare.

Casualties in earlier wars were due much more to diseases than to weapons. Mention has been made in history of the use of biological agents in warfare, to deny the enemy food and water and to cause disease. In the first world war chemical agents were used to cause mass casualties. Nuclear weapons were introduced in the second world war. Several countries are now involved in developing nuclear, biological and chemical weapon systems, for the mass annihilation of human beings, animals and plants, and to destroy the economy of their enemies. Recently, natural calamities and accidents in nuclear, chemical and biological laboratories and industries have caused mass instantaneous deaths in civilian population. The effects of future wars will not be restricted to uniformed persons. It is time that physicians become aware of the destructive potential of these weapons. Awareness, immediate protective measures and first aid will save a large number of persons. This series of articles will outline the medical aspects of nuclear, biological and chemical weapon systems in three parts. Part I will deal with the biological effects of a nuclear explosion. The short and long term effects due to blast, heat and associated radiation are highlighted. In Part II, the role of biological agents which cause commoner or new disease patterns is mentioned. Some of the accidents from biological warfare laboratories are a testimony to its potential deleterious effects. Part III deals with medical aspects of chemical warfare agents, which in view of their mass effects can overwhelm the existing medical resources, both civilian and military.(ABSTRACT TRUNCATED AT 250 WORDS)