A Case Report of Axillary Hibernoma: US, CT, MR, and Histopathologic Findings

Hibernoma is a rare benign tumor of brown adipose tissue. Herein, we report a case of axillary hibernoma in a 53-year-old female and discuss the various radiologic findings. The US revealed a 4.5-cm well-defined oval heterogenous hyperechoic mass in the right axilla with anterior displacement of the axillary vessels. Non-enhanced chest CT showed a 5.0-cm well defined, oval, and low-attenuated mass. MRI demonstrated a 5.5-cm mass with heterogeneous intermediate-to-high signal intensity on T1-and T2-weighted images and irregular enhancement at the peripheral portion. The patient underwent an US-guided core needle biopsy and the final diagnosis was hibernoma.

Sudden Infant Death Syndrome in Korea: A Retrospective Analysis of Autopsy-Diagnosed Cases

This study aimed to elucidate the demographic and sleeping environmental factors associated with sudden infant death syndrome (SIDS) in Korea. The autopsy reports of all SIDS cases reported to the National Forensic Service and Seoul National University College of Medicine between 1996 and 2008 were reviewed for data collection and analysis to identify the risk factors for SIDS. Analysis of the 355 SIDS cases reported within the study period revealed that of the 168 (47.3%) cases for which sleeping position before death had been reported, 75 (44.7%) cases had occurred after placement in prone or side position. Of the 204 (57.5%) cases for which bed-sharing situation had been reported, 121 (59.3%) deaths had occurred during bed-sharing, of which 54 (44.6%) infants were under 3 months of age, a significantly younger age than that of the non-bed-sharing cases (P = 0.0279). Analysis of the results indicated no tendency toward an increase or decrease in the use of a prone or side position. Rather, there was a statistically significant increasing trend for bed-sharing over the study period (OR, 1.087; 95% CI, 1.004-1.177; P = 0.04). These findings indicate the need for nationwide educational programs promoting a safe sleeping environment to enhance SIDS prevention.

Rupture and Spontaneous Sealing of a Coronary Aneurysm After Deployment of Drug-Eluting Stent

Lesions with coronary artery aneurysm (CAA) can become complicated during percutaneous coronary intervention. Here, we report a case of a 78-year-old man who developed a rupture, and spontaneous sealing of the CAA occurred after stent implantation, as shown by computed tomography coronary angiography.

Gastric Necrosis after Gastric Dilatation in a Patient with Bulimia / 대한법의학회지

Acute gastric dilatation leading to gastric necrosis is rare but potentially fatal condition that can occur in patients with bulimia. It usually develops after a bulimic episode and it is not diagnosed with sufficient rapidity it may lead to gastric perforation followed by peritonitis, sepsis, shock, and death. Because of the rarity of this condition and the patients in whom it occurs, the clinician must maintain a high degree of suspicion when treating patients with eating disorders who present with abdominal pain after a binge. This case report describes a 24-year old woman with acute gastric dilatation due to binge eating, who had the gastrotomy and died of complications such as gastric necrosis and disseminated intravascular coagulation.

An Autopsy Case of Severe Ovarian Hyperstimulation Syndrome with Multifocal Arterial and Venous Thromboembolism / 대한법의학회지

Ovarian hyperstimulation syndrome (OHSS) is a rare, serious complication of assisted reproductive procedures for fertility treatment. Although most cases of OHSS are mild to moderate in nature, its severe form causes life-threatening complications including respiratory distress, renal failure, liver dysfunction, and thromboembolism because of hemoconcentration. We herein report a rare autopsy case of severe OHSS in a 29-year-old woman who underwent controlled ovulation induction. Three days after the administration of human chorionic gonadotropin, she developed abdominal pain and distension. Two days after, she suddenly developed respiratory arrest, hypotension and semicomatose mentality and died of respiratory failure. At autopsy, multifocal thromboembolism was detected in the internal carotid arteries, internal jugular veins, pulmonary arteries, inferior vena cava, renal arteries, and deep leg veins. And there were cerebral edema, anasarca, pleural effusion, massive pulmonary edema, ascites, and bilateral ovarian enlargement. Microscopically, the bilateral ovaries showed multiple well-developed cyst formations consisting of membrana granulosa and theca interna. To the best of our knowledge, this is the first autopsy report of severe OHSS with multifocal arterial and venous thromboembolism.

Delayed Ventricular Septal Rupture Following Blunt Chest Trauma

Cardiac injury is a common but occasionally serious complication of blunt chest trauma. A ventricular septal rupture (VSR) is a rare complication and is variable in its presentation, temporal course and severity. Here, we report a rare case of 75-year-old man who developed delayed VSR following blunt chest trauma.

Drowning Death due to an Epileptic Attack of a Patient with Sturge Weber syndrome: An Autopsy Report / 대한법의학회지

Sturge Weber syndrome (SWS) is a rare, congenital neurocutaneous syndrome. We rarely experienced neurocutaneous disorders in forensic practice but there are unexpected sudden deaths of patients with SWS due to epilepsy, intracranial hemorrhage, thromboses and secondary accident. We introduce a case of drowning death probably due to an epileptic attack of a person diagnosed as a patient of SWS by an autopsy. We review some of the neurocutaneous syndromes and a discussion of autopsy approach is presented.

Fatal pulmonary embolism following percutaneous autologous marrow and MIIGTM115(Minimally-Invasive Injectable Graft) injection into simple bone cyst / 대한법의학회지

A 14-old girl presented to the general hospital with a fracture of the proximal metaphysis of the right humerus. Conventional radiography, CT and MR imaging revealed simple bone cyst of the right humerus. Percutaneous autologous marrow and MIIGTM115 injection into simple bone cyst were performed under general anesthesia. But the patient did not fully regain consciousness and showed no response to central pain. The post-interventional cardiac echocardiogram demonstrated pulmonary embolism. Despite subsequent thrombolytic therapy, the patient died 1hour later. The legal autopsy was performed at National Institute of Scientific Investigation.

A Death caused by Increased Intraabdominal Pressure due to Spontaneous Intraperitoneal Bladder Rupture / 대한법의학회지

A 45-year-old female with psychosis complained urological symptom of urinary incontinence and voiding difficulty with abdominal pains and expansion during her psychiatric hospitalization and suddenly collapsed at the 14th day of the admission. At autopsy, the urinary bladder showed a focal perforation and the abdominal cavity was filled with massive urinary ascites. The both lower lobes and the right upper lobe of the lung were accompanied by atelectasis. The death mechanism of this case could be explained that an increased abdominal pressure produced by massive uroperitoneum with spontaneous bladder rupture led to respiratory failure. The so-called abdominal compartment syndrome was manifested by massive uroperitoneum and caused a death. This would be the first forensic medical case that an undiagnosed spontaneous bladder rupture resulted in death of a psychiatric illness patient.

Multiple Glomus Tumors of the Ankle with Prominent Intranuclear Pseudoinclusions

Glomus tumors are neoplasms that are composed of modified smooth muscle cells of the glomus body. Here, we report a case of multiple glomus tumors of the ankle that showed various histologic types, including the solid type (glomus tumor proper) and angiomatous type (glomangioma). The tumor cells observed in this case also showed prominent intranuclear inclusions, which has not yet been reported in glomus tumors. Ultrastructural examination demonstrated that the nuclear inclusions were not true inclusion bodies but were intranuclear cytoplasmic pseudoinclusions formed by cytoplasmic invaginations that formed as a result of the deep and complex nuclear contours.

Mechanical Asphyxia Caused by Thymoma / 대한법의학회지

A 65 year-old female was suddenly expired soon after arriving in emergency room. Before arriving, she complained chest discomfort. Her neck mass was diagnosed as thyroid tumor about 11 years ago. She was recommended operation, but not taken due to arrhythmia. The neck mass was originally diagnosed as thyroid mass(goiter) by radiologic studies. The mass (10.5 x 9.5 x 7.0 cm, 319 gm) is mainly located in the lower neck and partly in the anterior superior mediastinum. The trachea is compressed by the mass and its tubal structure is flattened. The cause of death is mechanical asphyxia by thymoma(type B1 according to the WHO classification of thymoma, and stage I according to Masaoka's classification). On review of her past history, paraneoplastic syndrome including myasthenia gravis is not present. Generally, the patient with large thymic mass shows symptoms including chest pain, respiratory difficulty, hemoptysis, cough, superior vena cava syndrome. Although the symptoms related with its mass effect are common, but the death from mechanical asphyxia by thymoma is very rare in recent days.

Cortical Dysplasia of Brain: 2 Autopsy Cases / 대한법의학회지

Cortical dysplasia is used to designate any cerebral developmental malformation, and encompass a spectrum of pathologic changes from mild cortical disruption to more severe pattern of cortical dyslamination with large bizarre neurons, balloon cells, and astrocytosis. The gross appearance of the brian reveals focal or diffuse cortical thickening with no clear cortical-white matter junction due to excessive spillover of abnormal neurons. Cerebellar cortical dysplasias are uncommon but has been reported in cases with more widespread cerebral malformations. We present two autopsy cases of cortical dysplasia, one of which involves both cerebrum and cerebellum. Case 1 was a 4-year-old boy and presented with severe intractable epilepsy of neonatal onset , cerebral palsy, microcephaly, and severe neurologic deficits. Both cerebrum and cerebellum were markedly reduced in size. Microscopic examination of cerebrum showed disorganized cortical architecture with abnormal neurons in the cortex and white matter. The cerebellum disclosed massive spillover of Purkinje cells into white matter. Case 2 was a 51-year-old woman and found in dead in her house. No previous clinical history was informed. At autopsy, no gross abnormality of the brain was observed, but microscopic examination showed giant, dysmorphic neurons throughout the cerebral cortex.

A Case of Natural Death Misinterpreted as Electrocution / 대한법의학회지

When the circumstance of a death seems to be related with electric shock, most of the forensic pathologists tend to diagnose the cause of death as electrocution if they see the electric mark(s) with the notincompatible histology, and find no other definite causes of death at autopsy. But admittedly forensic pathologists know that the so-called electric mark(s) and its histology is not pathognomonic to diagnose electrocution, so the diagnosis should be confirmed by the appropriate investigation of the death scene and the electric devices. We present a case of a man who had a likely current mark that could be diagnosed as natural by ruling out the possibility of electrocution with the examination of the electric lamp which had been under the dead body at the scene. This case gives us the importance of appropriate probe about scene evidences supplied by forensic science in diagnosing and ruling out the electrocution.

A Case of Shoshin Beriberi Presenting as Acute Coronary Syndrome with Shock: Shoshin Beriberi Mimicking Acute Coronary Syndrome

Cardiac beriberi is caused by thiamine deficiency. Shoshin beriberi is a rare and fulminant form of cardiac beriberi characterized by hypotension, high output heart failure, lactic acidosis and anuria. Without early recognition and immediate treatment, most of these patients will be fatal. Therefore clinical diagnosis of shoshin beriberi is most important in emergency situation. We report a case of shoshin beriberi with clinical features mimicking acute coronary syndrome. Fifty year old male patient with chronic alcoholism was presented with shock, hypoxia, right heart failure and severe acidosis. Electrocardiogram showed abnormal Q in V1-3 and mild ST elevation and level of troponin I was slightly elevated. All manifestations including lactic acidosis were dramatically subsided in 18 hours by thiamine infusion. Even in developed country, shoshin beriberi can be occurred in patients with malnutrition and/or chronic alcoholism and should be differentiated with acute coronary syndrome.

Aortic dissection presenting as fever of unknown origin / 대한내과학회지

Aortic dissection most often presents with the severe chest pain and may have variable symptoms including fever. However, fever of unknown origin as the predominant manifestation of aortic dissection seems to be extremely rare. We report the case of a patient who sustained a prolonged spiking fever with unknown origin for 17 days following acute aortic dissection. The case serves as a reminder that prolonged fever may be the principal residual sequelae after aortic dissection.

Carotid artery remodeling in patients with acute coronary syndrome and chronic stable angina / 대한내과학회지

BACKGROUND: Acute adaptive vascular remodeling occurs in active and unstable inflammatory plaques. It has been suggested that the adaptive coronary vascular remodeling, in patients with acute coronary syndrome (ACS), may be systemic and may show similar vascular remodeling in the carotid arteries. We investigated the ultrasonographic features of the common carotid artery (CCA) to determine whether the arterial expansive remodeling found in the coronary artery occurs in the carotid arteries of patients with ACS. METHODS: We measured lumen diameter (LD), interadventitial diameter (IAD) and intima media thickness (IMT) using a B-mode ultrasound in both common carotid arteries in patients with ACS (N=74) and chronic stable angina (CSA) (N=31). Positive remodeling was arbitrarily defined as an IMTmax >1 mm and IAD >8 mm and negative remodeling as an IMTmax >1 mm and IAD <7 mm. Other values were defined as "no remodeling" RESULTS: There were no significant differences in LD IAD and maximal IMT of the right CCA and the left CCA in comparisons between the ACS and the CSA patient groups. There were no differences for number of cases with no remodeling or differences in positive and negative remodeling in the right common carotid artery and left common carotid artery in comparisons between the ACS and CSA patient groups. . Presence of plaque in both common carotid arteries showed similar frequency in the ACS and CSA patient groups. The characteristics of carotid artery plaques were not different in the two groups. The remodeling index (IAD/LD) was correlated with IMTmax (right CCA r=0.797, p<0.001; left CCA r=0.860, p<0.001). CONCLUSIONS: The common carotid arterial structure of ACS patients was not different from that of CSA patients. Therefore, these results suggest that the expansive arterial remodeling, due to coronary inflammatory plaques, appears to take place locally rather than systemically.

A Forensic Pathologic Study of Diffuse Axonal Injury of Brain / 대한법의학회지

Axonal swellings or retraction balls are the major histologic hallmark of diffuse axonal injury in craniocerebral trauma. However, traditional histologic methods have proven of limited use in identifying reactive axonal change early in the posttraumatic course. In the present study, we try to compare conventional histologic and immunohistochemical methods, and transmission electron microscopy for demonstrating axonal swellings in 18 cases of head trauma. Brain regions such as corpus callosum, cerebral cortex, and brain stem were examined with immunohistochemical markers for beta-Amyloid precursor protein (beta-APP), neurofilament, ubiquitin, and CD68. The result was as follows: In 2 out of 18 cases, eosiniophilic spheroid axon balls were demonstrated with hematoxylineosin stain. Ultrastructurally, the axon balls exhibited misalignment, clumping or loss of neurofilaments, and accumulation of organelles. The organelles consisted of mitochondria, dense membranous bodies, and SER. The overlying thin myelin sheath was distended. In 6 cases with no axonal swellings at the histologic section, electron microscopic examination revealed axonopathy as evidenced by disintegration of neurofilaments and aggregated organelles. Immunostaining with an antibody to beta-APP disclosed varying positive reaction in axonal swellings and axon balls, suggestive for injured axons. However, the axons which did not appear obviously swollen at short survival times disclosed beta-APP negativity. Our findings suggest that transmission electron microscopy was very useful to identify the early axonal events in the posttraumatic course, while the immunostain was of limited value. The pathogenesis of axonal swellings in injured axons was discussed.

Fatal Hemophagocytic Syndrome : Three Autopsy Cases / 대한법의학회지

Hemophagocytic Syndrome (HS) is a systemic lymphohistiocytic proliferative disorder associated with infection or malignancies, particularly Epstein-Barr virus (EBV) HS is presented with high fever, skin rash, hepatosplenomegaly, and cytopenia. The characteristic pathologic finding is massive lymphohistiocytic infiltration with hemophagocytosis in various organs including bone marrow, liver, and spleen. Hyperproduction of cytokines by activated T lymphocytes has been presumed to account for the hemophagocytosis and clinical manifestations of HS. We report three childhood autopsy cases with HS which was confirmed by histopathologic examination. According to medical records, all cases had high fever with or without skin rash, cytopenia, AST/ALT elevation, and hyperfibrinogenemia, and showed multiple organ failure eventually. At autopsy, there were no specific gross findings except splenomegaly, but extensive lymphohistiocytic infiltration with hemophagocytosis was seen in various organs including lymph nodes, spleen, liver, and bone marrow. In one of three cases, EBV was identified with in situ hybridization method. As this disease has rapidly progressive clinical course with fatal outcome during childhood, so the possibility of HS should be considered in children presenting with high fever and hepatosplenomegaly.

A Death Resulting from Imperforate Anus in the Newborn: A Case Report / 대한법의학회지

Congenital anomalies of the anus and rectum are relatively common. Minor abnormalities occur in approximately 1 per 500 live births; major anomalies occur in 1 per 5000 live births. Among the various anomalies associated with rectal abnormalities are malformations of the urinary tract and esophagus and, less often, the small bowel. The most useful clinical classification categorized lesions by whether the rectum passes through the puborectalis muscle sling. High lesions fail to pass through this muscle complexes and low lesions traverse this muscle complex. The lesions in the spectrum covered by the term imperforate anus rarely are fatal, although some associated anomalies can be life threatening. However, in some lesions without any type of fistula may be fatal per se, unless the necessary fecal diversion is not made. Routine newborn examinations usually detect anorectal anomalies early in life. Some types of malformations are less readily detected. In newborns, failure to pass meconium within the first 24 hours of life usually prompts an examination of the perineum but delayed presentation is common in areas where access to medical care is unavailable. The authors report a male newborn who died of the high type of anorectal anomaly without fistula in fourth day of life, because the doctor did not recognize the anomaly of the newborn. We believe that the forensic examiner should make medical doctors alert by notifying them that their trivial mistakes can cause mortal results.

A Death Resulting from Inadvertent Intravenous Injection of Antidiarrheal: A Case Report / 대한법의학회지

Although medication errors in hospital are common, medication errors that result in death rarely occur. We report a case of inadvertent intravenous injection of SMECTA(TM), a kind of oral antidiarrheal, in a 4-year-old boy, who underwent orthopedic surgery of foot to correct congenital malformation. After this medical accident seizure suddenly developed, mental change, and disseminated intravascular coagu-lopathy followed. The diagnostic confirmation of this fatal error was made after thrombi and foreign materials were identified the histopathologic examination in the lung, as well as by analyzing the components of the antidiarrheal such as magnesium, aluminum etc. We propose to make it a rule to keep the strategies, for examples, oral liquids should not be put in Luer-lock syringes for IV administration, avoid drugs with similar names or packages form placing in the same area to reduce errors.