Forensic Considerations in Postmortem Cases of Sudden Death during or after Percutaneous Coronary Intervention: Data from The National Forensic Service in Korea, 2015 to 2021 / 대한법의학회지

Sudden death during or after percutaneous coronary intervention (PCI) could be led to potential medicolegal disputes. This study aimed to investigate the clinical and postmortem findings in PCI-related deaths-focusing on the current statusto inform preventive strategies against these fatalities. Forty-three cases were retrieved from the National Forensic Service's postmortem records between 2015 and 2021, and the corresponding postmortem findings and clinical information were analyzed. The analyses revealed a relatively consistent annual incidence of PCI-related deaths. Immediate deaths during or shortly after PCI occurred in 17 cases (39.5%), and delayed PCI-related deaths after discharge from the hospital occurred in 26 cases (60.5%). The causes of PCI-related deaths in the postmortem cases were categorized into four groups: PCI complications (11 cases, 26%), acute myocardial infarction (23 cases, 53%), ischemic heart disease (8 cases, 19%), and others (1 case, 2%). Postmortem examinations played a critical role in determining the cause of death and obtaining medical evidence, including pathological findings of the heart as well as those of coronary artery and stent insertion. Our findings suggest that a detailed examination of the heart, coronary arteries, stent status, and atherosclerosis in PCI-related deaths could help provide more accurate information as medical evidence and prevent/resolve potential medicolegal issues. Further, this could advance our understanding of PCI-related deaths and inform future preventive strategies.

A Case Report of Pediatric Mechanical Asphyxia by a Daycare Center Teacher: Implications for Forensic Pathologists from the Perspectives of the Judicial Verdicts / 대한법의학회지

This study highlights a new case of an infant death caused by mechanical asphyxia, who was found dead after being wrapped and pressed by a daycare center teacher with the body and beddings. Moreover, we present a comparative review of four similar previously reported cases and the implications for forensic pathologists in the management of such cases from the perspectives of judicial verdicts of the cases. The previous report commented that the four cases could be considered as overlaying as a type of accidental asphyxia. However, a contextual comprehensive review including the whole scenarios of the cases and negative postmortem findings concluded that all the cases were explicitly different from overlaying cases. Furthermore, we followed up the judicial processes and verdicts in all five cases, including the present case and the four previously reported cases. In the four cases, the defendants were incarcerated for violation of ‘Act on Special Cases Concerning the Punishment of Child Abuse Crimes.’ The ruling trend revealed that the prison sentence durations had been prolonged from 4 to 19 years. Therefore, for a pediatric death suspecting mechanical asphyxia involving a daycare center, contextual comprehensive approach is essential to determine the cause of death and to provide appropriate medicolegal interpretation.

Acute Myocardial Infarction with Microthrombi in Cardiac Small Vessels after COVID-19 Vaccination (ChAdOx1 nCov-19): A Case Report / 대한법의학회지

We present the postmortem findings of an unexpected death due to acute myocardial infarction (AMI) with microthrombi and thrombosis in other vessels after the first dose of coronavirus disease 2019 (COVID-19) vaccination (ChAdOx1 nCov-19). The deceased was a 69-year-old woman who complained of nonspecific symptoms shortly after vaccination and was found dead on the sixth day. Postmortem examination revealed AMI and complications (left ventricular rupture, hemopericardium) with microthrombi in small cardiac vessels, which are similar to the characteristic findings of myocardial injury caused by microthrombi in patients with COVID-19. Nonobstructive thromboembolism in the pulmonary arteries and inferior vena cava, and fibrin microthrombi in some small vessels in the brain were also observed. It is unclear whether these findings are associated with COVID-19 vaccination, and further comprehensive studies are needed.

Sudden Cardiac Death Caused by Cardiac Small Vessel Vasculitis after COVID-19 Vaccination (BNT162b2 nCov-19): A Case Report / 대한법의학회지

This study presents a case of sudden cardiac death due to cardiac small vessel vasculitis after coronavirus disease 2019 (COVID-19) mRNA vaccination (BNT162b2). The deceased was a 76-year-old woman with diabetes mellitus (DM) and chronic hypertension (HTN), who experienced generalized pain for a month after the first dose of vaccination, and unexpectedly died. Postmortem examination revealed small vessel vasculitis in the heart, lungs and vaccinated site of the left arm. These features were similar to those observed in a previously reported case of a patient with COVID-19 and cardiac endotheliitis and multisystem inflammatory syndrome. In addition, DM and HTN may contribute to vaccine-induced immunologic changes and vascular dysfunction. However, further studies with additional cases are needed.

Fatal Case of Acute Pulmonary Embolism due to Venous Thrombosis after COVID-19 Vaccination: Based on Forensic Postmortem Examination / 대한법의학회지

We present an unexpected fatal case of pulmonary embolism due to venous thrombosis after vaccination for coronavirus disease 2019 (ChAdOx1 nCov-19). The deceased was a 64-year-old woman with Alzheimer disease. The deceased had fever shortly after vaccination, and presented sudden dyspnea and died 8 days after vaccination. On postmortem examination, pulmonary embolism and venous thrombosis were noted in deep veins of both lower legs. Even though the psychomotor function of the deceased became fragile due to Alzheimer disease, the deceased was not bed-ridden, and major known risk factors related to venous thrombosis were not explicit in this case. Because there are not enough data related to vaccination and thrombosis, we hope that this case would be helpful in unraveling pathogenesis of venous thrombosis after vaccination and in determining whether there is any association between thrombosis and vaccination.

Postmortem Findings in Two Cases of Chronic Methamphetamine Abuse / 대한법의학회지

We present two cases of death associated with chronic methamphetamine abuse. Several findings were observed in chronic methamphetamine abuse; pathologic changes in the heart and coronary artery, pulmonary embolism by foreign materials (drug materials), small scars on the subcutaneous vein on the arms with skin infection and sepsis, and so on. These complications can be fatal pathological findings that explain sudden death. The toxicological test results should be carefully interpreted; the presence of methamphetamine in the toxicological results should not automatically be interpreted as acute intoxication. A meticulous postmortem examination with review of the scene, circumstances and past history is crucial in identifying these findings and interpreting them appropriately.

Subdural Hemorrhage Related to Vitamin K Deficiency in an Infant with Choledochal Cyst / 대한법의학회지

The deceased was a 6-month-old male infant who was transferred to the hospital due to jaundice and vomiting. During admission, subdural hemorrhage and retinal hemorrhage were observed; additionally, a rib fracture was identified on the previous radiography images, which had eventually healed by the time of the follow-up study. This case was reported to the police, alleging child abuse, which led to a medicolegal dispute between the hospital and the deceased's parents. In addition, bleeding tendency and coagulopathy related to vitamin K deficiency were also found. The past history revealed that the deceased had diarrhea, jaundice, and experienced several episodes of acholic stools, and low levels of vitamin D at birth. On postmortem examination, the brain already revealed liquefactive necrosis, but subdural hemorrhage was still observed. The optic nerves of both eyes revealed hemorrhage with focal retinal hemorrhage.No definite fracture was identified; however, osteopenia was observed in the long bones. The liver showed septal fibrosis and cholestasis which is nearly biliary cirrhosis, and mild dilation of the intrahepatic and extrahepatic bile ducts, suggesting a choledochal cyst. This case illustrates that subdural hemorrhage related to vitamin K deficiency could occur in an infant with a choledochal cyst.When subdural hemorrhage is encountered in a child with what is considered an intentional head injury, the possibility of spontaneous hemorrhage should be excluded.

Traumatic Rupture of the Middle Cerebral Artery Followed by Acute Basal Subarachnoid Hemorrhage: Tailored Approach in Forensic Pathology by Aid of Post-mortem Angiographic Findings / 대한법의학회지

We present the case of a 23-year-old man who suddenly collapsed during a physical altercation with his friends while in a drunken state. The post-mortem computed tomography (CT) with angiography revealed acute basal subarachnoid hemorrhage with rupture of the left middle cerebral artery. On autopsy, the head, face, mandible and neck showed multifocal hemorrhages with fracture of the hyoid bone, and the pathologic findings of the brain was consistent with CT findings. However, the vascular rupture site was not observed macroscopically. On histologic examination, a microscopic focal rupture was identified at the proximal portion of the middle cerebral artery, and possibility of arteriopathy was considered. This case illustrates that other parts of intracerebral arteries (other than the vertebral arteries) can be the culprit of rupture in the case of traumatic basal subarachnoid hemorrhage, and the post-mortem angiographic findings can be helpful in targeting the site of vascular injury. Furthermore, meticulous sampling of intracranial vessels could help find the vascular rupture site and identify any histologic findings suspicious of arteriopathy. Therefore, we suggest that post-mortem angiography can be an effective and adjunctive tool for a tailored approach in finding the vascular injury, and that histologic examination of both the intracranial and extracranial arteries be important to medicolegally ensure the death of traumatic basal subarachnoid hemorrhage and to examine presence of arteriopathy as a predisposing factor.

Sudden Unexpected Death During Bronchoscopy of a Patient with Pulmonary Lymphangitic Carcinomatosis and Pulmonary Tumor Thrombotic Microangiopathy due to Gastric Cancer / 대한법의학회지

We present the case of a 48-year-old woman who complained of sustained dyspnea and newly developed dyspnea, who then suddenly and unexpectedly expired during bronchoscopy. On postmortem examination, the deceased had advanced gastric cancer as a primary tumor. Frequent lymphatic tumor emboli were observed with some pulmonary lymphangitic carcinomatosis (PLC), and pulmonary tumor thrombotic microangiopathy (PTMA). PLC and PTMA are lethal forms of pulmonary metastasis, and PTMA can lead to sudden death. The characteristic findings of PLC and PTMA in the deceased were not predominant, however, and the clinical manifestation was not acutely deteriorating. These findings are, therefore, insufficient to explain the deceased's sudden death. Clinically, the deceased manifested hypoxemia, bradycardia and cardiac arrest during bronchoscopy and then soon expired, suggesting the possibility of cardiovascular complication related to bronchoscopy. Despite several limitations, we assumed that the sudden unexpected death might have been induced by cardiovascular complications related to bronchoscopy and due to the underlying pathologic condition by PLC and PTMA.

Sudden Unexpected Death During Bronchoscopy of a Patient with Pulmonary Lymphangitic Carcinomatosis and Pulmonary Tumor Thrombotic Microangiopathy due to Gastric Cancer / 대한법의학회지

We present the case of a 48-year-old woman who complained of sustained dyspnea and newly developed dyspnea, who then suddenly and unexpectedly expired during bronchoscopy. On postmortem examination, the deceased had advanced gastric cancer as a primary tumor. Frequent lymphatic tumor emboli were observed with some pulmonary lymphangitic carcinomatosis (PLC), and pulmonary tumor thrombotic microangiopathy (PTMA). PLC and PTMA are lethal forms of pulmonary metastasis, and PTMA can lead to sudden death. The characteristic findings of PLC and PTMA in the deceased were not predominant, however, and the clinical manifestation was not acutely deteriorating. These findings are, therefore, insufficient to explain the deceased's sudden death. Clinically, the deceased manifested hypoxemia, bradycardia and cardiac arrest during bronchoscopy and then soon expired, suggesting the possibility of cardiovascular complication related to bronchoscopy. Despite several limitations, we assumed that the sudden unexpected death might have been induced by cardiovascular complications related to bronchoscopy and due to the underlying pathologic condition by PLC and PTMA.

Traumatic Rupture of the Middle Cerebral Artery Followed by Acute Basal Subarachnoid Hemorrhage: Tailored Approach in Forensic Pathology by Aid of Post-mortem Angiographic Findings / 대한법의학회지

We present the case of a 23-year-old man who suddenly collapsed during a physical altercation with his friends while in a drunken state. The post-mortem computed tomography (CT) with angiography revealed acute basal subarachnoid hemorrhage with rupture of the left middle cerebral artery. On autopsy, the head, face, mandible and neck showed multifocal hemorrhages with fracture of the hyoid bone, and the pathologic findings of the brain was consistent with CT findings. However, the vascular rupture site was not observed macroscopically. On histologic examination, a microscopic focal rupture was identified at the proximal portion of the middle cerebral artery, and possibility of arteriopathy was considered. This case illustrates that other parts of intracerebral arteries (other than the vertebral arteries) can be the culprit of rupture in the case of traumatic basal subarachnoid hemorrhage, and the post-mortem angiographic findings can be helpful in targeting the site of vascular injury. Furthermore, meticulous sampling of intracranial vessels could help find the vascular rupture site and identify any histologic findings suspicious of arteriopathy. Therefore, we suggest that post-mortem angiography can be an effective and adjunctive tool for a tailored approach in finding the vascular injury, and that histologic examination of both the intracranial and extracranial arteries be important to medicolegally ensure the death of traumatic basal subarachnoid hemorrhage and to examine presence of arteriopathy as a predisposing factor.

Fatal Pulmonary Thromboembolism Caused by Popliteal Vein Aneurysm / 대한법의학회지

Popliteal venous aneurysms can be a cause of fatal pulmonary thromboembolism. We report a case of a 47-year-old woman who suddenly died of fatal pulmonary thromboembolism. Deep vein thrombosis was not observed, but a venous aneurysm with intraluminal thrombi formation was identified on the left popliteal vein. This case illustrates that venous aneurysms can be presented as fatal pulmonary thromboembolism, and that they should be considered as a rare cause of pulmonary thromboembolism.

Pediatric Deaths and Venipuncture / 대한법의학회지

Venipuncture is a routine and relatively safe and painless medical procedure, necessary for accurate diagnosis and treatment. However, given that pain related to medical procedures may have adverse effects for children, could venipuncture cause deaths in infants and children? We analyzed our cases of unexpected death after venipuncture and conducted a literature review on them. A vasovagal response to noxious stimuli may explain such a sudden death immediately after venipuncture, commonly presented as needle phobia, breath-holding spell, and reflex anoxic seizure in the literature, despite the fact that the current medical evidence is not enough to prove their casual relationship. In addition, pain prevention and management during medical procedure is incorporated in clinical guidelines for pediatric patients, because painful medical procedures negatively affect child development. Thus, prevention and management of pain related to medical procedure may be helpful to avoid an adverse vasovagal response to noxious stimuli from occurring.

Sudden Cardiac Death due to Coronary Fibromuscular Dysplasia: Case Report and Literature Review / 대한법의학회지

Fibromuscular dysplasia (FMD) of the coronary artery is a rare cause of sudden cardiac death; however, its prevalence and fatality may have been overlooked so far. A 47-year-old man complained of pain in his back and shoulder and became unconscious. Despite resuscitation, he died 3 hours after symptom onset. The heart weight was in the normal range; however, all three major coronary arteries showed intimal thickening without atherosclerosis or inflammatory cell infiltration. Fragmentations and duplications of the internal elastic lamina which are histologic features of intimal fibroplasia, a focal-type FMD, were observed. The prevalence of coronary FMD remains unknown, although it may be related to spontaneous coronary artery dissection and sudden death. The histopathologic confirmation of coronary FMD and exclusion of other possible coronary diseases through autopsy are essential to reveal the nature of the disease and therefore apply the information in dealing with legal problems after death.

Pediatric Deaths and Venipuncture / 대한법의학회지

Venipuncture is a routine and relatively safe and painless medical procedure, necessary for accurate diagnosis and treatment. However, given that pain related to medical procedures may have adverse effects for children, could venipuncture cause deaths in infants and children? We analyzed our cases of unexpected death after venipuncture and conducted a literature review on them. A vasovagal response to noxious stimuli may explain such a sudden death immediately after venipuncture, commonly presented as needle phobia, breath-holding spell, and reflex anoxic seizure in the literature, despite the fact that the current medical evidence is not enough to prove their casual relationship. In addition, pain prevention and management during medical procedure is incorporated in clinical guidelines for pediatric patients, because painful medical procedures negatively affect child development. Thus, prevention and management of pain related to medical procedure may be helpful to avoid an adverse vasovagal response to noxious stimuli from occurring.

Sudden Cardiac Death due to Coronary Fibromuscular Dysplasia: Case Report and Literature Review / 대한법의학회지

Fibromuscular dysplasia (FMD) of the coronary artery is a rare cause of sudden cardiac death; however, its prevalence and fatality may have been overlooked so far. A 47-year-old man complained of pain in his back and shoulder and became unconscious. Despite resuscitation, he died 3 hours after symptom onset. The heart weight was in the normal range; however, all three major coronary arteries showed intimal thickening without atherosclerosis or inflammatory cell infiltration. Fragmentations and duplications of the internal elastic lamina which are histologic features of intimal fibroplasia, a focal-type FMD, were observed. The prevalence of coronary FMD remains unknown, although it may be related to spontaneous coronary artery dissection and sudden death. The histopathologic confirmation of coronary FMD and exclusion of other possible coronary diseases through autopsy are essential to reveal the nature of the disease and therefore apply the information in dealing with legal problems after death.

Fatal Pulmonary Thromboembolism Caused by Popliteal Vein Aneurysm / 대한법의학회지

Popliteal venous aneurysms can be a cause of fatal pulmonary thromboembolism. We report a case of a 47-year-old woman who suddenly died of fatal pulmonary thromboembolism. Deep vein thrombosis was not observed, but a venous aneurysm with intraluminal thrombi formation was identified on the left popliteal vein. This case illustrates that venous aneurysms can be presented as fatal pulmonary thromboembolism, and that they should be considered as a rare cause of pulmonary thromboembolism.

Maternal Death due to Acute Fatty Liver of Pregnancy / 대한법의학회지

Acute fatty liver of pregnancy (AFLP) is one of the sudden unexpected causes in pregnancy and maternal deaths. It has been considered as a potential fatal disease in pregnancy, but the postmortem findings of AFLP is not well known. Because an unexpected maternal death may lead to a legal dispute, forensic pathologists should be aware of clinical presentations and postmortem findings of AFLP. Therefore, we presented our case and reviewed with literatures.

Neonate Deaths in the Toilets / 대한법의학회지

Investigating neonatal deaths in the toilets is challenging for forensic pathologists. During the postmortem examination, they should evaluate whether the baby was alive or a stillbirth and determine any causes of death, such as prenatal cause, infection, anatomical abnormalities, birth or other blunt force injury, drowning, and asphyxia. We retrieved two cases of neonatal deaths in the toilets and reviewed their autopsy findings and circumstances. However, findings from the postmortem examination were insignificant. Their lung examinations revealed non-expanded alveoli, and hydrostatic tests were negative. However, the cases cannot be confirmed as stillbirths because of the possibility that they might be alive for a short period of time after birth and then exposed into the water in the toilet or to accidental or non-accidental asphyxia or that they might have died because of neglect. These cases illustrate that the death scene and the associated circumstances should be meticulously and carefully investigated.

Entire Mitochondrial DNA Sequencing on Massively Parallel Sequencing for the Korean Population

Mitochondrial DNA (mtDNA) genome analysis has been a potent tool in forensic practice as well as in the understanding of human phylogeny in the maternal lineage. The traditional mtDNA analysis is focused on the control region, but the introduction of massive parallel sequencing (MPS) has made the typing of the entire mtDNA genome (mtGenome) more accessible for routine analysis. The complete mtDNA information can provide large amounts of novel genetic data for diverse populations as well as improved discrimination power for identification. The genetic diversity of the mtDNA sequence in different ethnic populations has been revealed through MPS analysis, but the Korean population not only has limited MPS data for the entire mtGenome, the existing data is mainly focused on the control region. In this study, the complete mtGenome data for 186 Koreans, obtained using Ion Torrent Personal Genome Machine (PGM) technology and retrieved from rather common mtDNA haplogroups based on the control region sequence, are described. The results showed that 24 haplogroups, determined with hypervariable regions only, branched into 47 subhaplogroups, and point heteroplasmy was more frequent in the coding regions. In addition, sequence variations in the coding regions observed in this study were compared with those presented in other reports on different populations, and there were similar features observed in the sequence variants for the predominant haplogroups among East Asian populations, such as Haplogroup D and macrohaplogroups M9, G, and D. This study is expected to be the trigger for the development of Korean specific mtGenome data followed by numerous future studies.