Fatal Microscopic Pulmonary Tumor Thromboemboli: Unusual Presentation of Occult Cervical Carcinoma. Two Case Reports and Review of the Literature.

Cor pulmonale (right heart failure) due to microscopic pulmonary tumor emboli (MPTE) can arise from a variety of malignancies including breast, lung, and liver and carries significant morbidity and mortality. Tumor cell aggregates spread hematogenously to the lungs and occlude small pulmonary vessels leading to pulmonary hypertension through either a mechanical process or inducing vascular remodeling as a downstream result of interactions between the embolus and the vessel wall. Its presentation includes unexplained dyspnea, hypoxemia, tachycardia, pulmonary hypertension, right heart failure, and in some cases sudden death. The symptoms may suggest the more common entity of pulmonary thromboembolism, particularly in the setting of previously known metastatic cancer; however, computed tomography scans may appear normal and ventilation-perfusion scans which are the preferable diagnostic modality are not always ordered. In most cases of MPTE, the presentation reflects metastasis of an already known and advanced tumor, but, in rare cases, it may be the primary manifestation of an occult malignancy. We present here 2 unique cases of MPTE in women with occult cervical cancer. In both cases, the malignancy was discovered and diagnosed at autopsy. Microscopic pulmonary tumor emboli can be easily overlooked, and therefore, forensic pathologists and other death investigators should be aware of it and trained to at least consider the possibility in appropriate situations. Thorough microscopic examination of apparently normal tissues may be necessary, particularly in cases of unexplained right heart failure and sudden death, even if the decedent has few or no identifiable risk factors for cancer.

Fatal Pulmonary Thromboembolism in Patients with Diabetic Ketoacidosis: A Seven-Case Series and Review of the Literature.

Diabetes mellitus is a well-recognized risk factor for arterial thrombosis, however its relationship to venous thromboembolism (VTE) in adults is still debated. We report here seven cases of fatal pulmonary thromboembolism in adults with diabetic ketoacidosis as the underlying cause. In four of seven cases, there was no prior diagnosis of diabetes mellitus and patients were newly diagnosed either upon presenting to the hospital in diabetic ketoacidosis (DKA) or at the time of autopsy by the vitreous glucose concentration. None of the patients had family history, recent surgery, recent trauma, long distance travel, or other strong risk factors for VTE. Only two patients had a body mass index greater than 35 kg/m2 and the same two cases had hospital stays that ranged from three to five days. We believe that DKA is a frequently unrecognized and sometimes overlooked risk factor for VTE, particularly in the forensic setting where routine toxicology and vitreous glucose analysis may not be standard practices. We encourage forensic pathologists, medical examiners, and coroners to consider the possibility of diabetic ketoacidosis as a risk factor, and in some cases, the underlying etiology for pulmonary thromboembolism. Additionally, we recommend vitreous glucose testing be performed if there are any signs of DKA or diabetes present, such as acetone in the blood.

Postmortem diagnosis of invasive meningococcal disease.

We diagnosed invasive meningococcal disease by using immunohistochemical staining of embalmed tissue and PCR of vitreous humor from 2 men in New York City. Because vitreous humor is less subject than other body fluids to putrefaction, it is a good material for postmortem analysis.

Fulminant hepatic failure attributed to ackee fruit ingestion in a patient with sickle cell trait.

We report a case of fulminant liver failure resulting in emergent liver transplantation following 3 weeks of nausea, vomiting, and malaise from Jamaican Vomiting Sickness. Jamaican Vomiting Sickness is caused by ingestion of the unripe arils of the Ackee fruit, its seeds and husks. It is characterized by acute gastrointestinal illness and hypoglycemia. In severe cases, central nervous system depression can occur. In previous studies, histologic sections taken from patients with Jamaican Vomiting Sickness have shown hepatotoxicity similar to that seen in Reye syndrome and/or acetaminophen toxicity. We highlight macroscopic and microscopic changes in the liver secondary to hepatoxicity of Ackee fruit versus those caused by a previously unknown sickle cell trait. We discuss the clinical variables and the synergistic hepatotoxic effect of Ackee fruit and ischemic injury from sickled red blood cells, causing massive hepatic necrosis in this patient.

Laparoscopic management of presacral myelolipoma.

Myelolipomas are rare, benign nonfunctioning tumors, most commonly found in the adrenal glands. At least 43 cases of extra adrenal myelolipomas have been reported, with at least 50% of these reported cases occurring in the presacral region. Herein we report a case of presacral myelolipoma managed laparoscopically.

Ischemic bowel due to embolization from an isolated mobile thrombus of the ascending aorta: a case report and review of the literature.

Aortic thrombi are commonly present in atherosclerotic and aneurysmatic aortas. Thrombus formation in an aorta with or focal atherosclerosis in a patient without risk factors is rare. A 63-year-old woman with dementia and hypothyroidism presented with hypotension and respiratory distress. Work-up revealed leukocytosis, sinus tachycardia, and proximal small bowel obstruction. At emergent laparotomy, a superior mesenteric artery thomboembolus was identified with necrosis of surrounding bowel. The patient expired on hospital day five. Autopsy revealed a 1.4 cm thrombus overlying an isolated atherosclerotic plaque in the ascending aorta and infarctions of the spleen, liver, and right kidney as well as occlusive thromboembolism of the superior mesenteric artery. This case report illustrates lethal complications from an unsuspected aortic thrombus. Work-up for patients presenting with signs of peripheral embolization, or in this case, necrotic bowel, should include the aorta as a source of embolic thrombi.

Clinical setting and extent of premortem evaluation do not predict autopsy discrepancy rates.

Autopsy rates have been affected by a number of factors, including technological advances and clinician beliefs of the diminished value of the autopsy. Such factors have resulted in a cultural shift in medicine away from the autopsy. Despite this shift, a number of studies have shown significant differences between antemortem clinical diagnoses and postmortem findings. Surveys of clinician beliefs about the autopsy have pointed toward antemortem diagnostic advancements as an important factor in declining rates. No study to date has addressed the hypothesis that such perceptions in diagnostic certainty have been matched by an actual decay in the yield of valuable or new information obtained by the autopsy. To address this hypothesis, we retrospectively compared the class I and class II discrepancies identified in 284 patients who died in three clinical settings with differing intensities of antemortem diagnostic workup. Despite a significantly different intensity of antemortem workup for patients in each clinical setting, including patients on a medical intensive care unit, patients on a surgical service and patients in an affiliated nursing home, discrepancy rates were found to be similar. Overall discrepancy rates for the medical intensive care unit, surgery service and nursing home patients were 27.8, 32.7 and 31.3%, respectively (P=0.84). In addition, we found no statistical difference in the complexity of workup in discrepant and nondiscrepant cases in each clinical setting. Our study data refute the hypothesis that the intensity of antemortem diagnostic evaluation correlates with an actual decrease in the rate of major diagnostic discrepancies identified at autopsy.

Fatal influenza A(H1N1) respiratory tract infection in a patient having psoriasis treated with infliximab.

BACKGROUND: The use of biologic agents represents a remarkable advance for patients with psoriasis and psoriatic arthritis who have experienced an incomplete response to other therapeutic modalities. Decreased mortality and improved quality of life have been reported in patients undergoing treatment with these agents. Increased risk of bacterial, viral, granulomatous, and opportunistic infections also has been associated with the use of these medications. Enhanced patient education, watchful monitoring to promote early detection of infections, discontinuation of the medication when clinical symptoms are identified, and immediate availability of supportive care are advised to balance the benefit of treatment with biologic agents against the potential risk of infection. Herein, we discuss the risk of infection and the monitoring and vaccination guidelines in patients having psoriasis treated with biologic agents. OBSERVATIONS: A woman with obesity and psoriasis that had previously been successfully treated with efalizumab (Raptiva) for 3 years was started on a regimen of infliximab (Remicade) to treat a flare. She died 1 week after her first infusion of infliximab and was found to have had influenza A(H1N1). CONCLUSIONS: We report the first case to date of a patient with psoriasis who died of influenza A(H1N1) respiratory tract infection while undergoing treatment with infliximab. Further observations are needed to make a causal association.

Natural, unexpected deaths: reliability of a presumptive diagnosis.

We retrospectively analyzed 100 deaths because of suspicions and concerns expressed by the family. We compared the preautopsy cause of death, as determined by a thorough review of the clinical data and circumstances, to the autopsy-derived cause of death. In the majority (91/100), the preautopsy and postautopsy proximate causes of death were in agreement. In 9%, the autopsy provided information that resulted in a proximate cause of death different than anticipated. In four instances, the manner of death also was incorrect and was determined to be an accident rather than the originally presumed natural. No homicide or suicide would have been misclassified. In another nine instances, where the premortem and postmortem proximate causes of death were in agreement, the autopsy provided a specific mechanism of death. With a quality initial medicolegal death investigation, a subset of sudden deaths in adults may be reliably certified without an autopsy.

Ischemic colitis after endovascular aortoiliac aneurysm repair: a 10-year retrospective study.

OBJECTIVE: To examine the incidence, cause, and outcomes of ischemic colitis after endovascular stent graft repair of aortoiliac aneurysms (EVAR). DESIGN: Medical record review. SETTING: University teaching hospital. PATIENTS: Eight hundred nine patients treated during 10 years were included in the study. Preoperative data regarding the size of the aneurysm, hypogastric coil embolization, and inferior mesenteric artery patency were evaluated by means of computed tomographic scans and aortograms. Ischemic colitis was diagnosed by lower endoscopy or pathology reports. MAIN OUTCOME MEASURES: Ischemic colitis after EVAR. RESULTS: Eleven patients (1.4%) developed ischemic colitis. Seven patients' episode occurred less than 30 days from repair (early), whereas 4 occurred 30 days or more from repair (late). Ten of 11 patients had preoperative inferior mesenteric artery occlusion. Microembolization was seen histologically in 2 patients in the early group, both of whom died. A significant increase in ischemic colitis was seen in patients undergoing preoperative unilateral hypogastric coil embolization (P = .02). Three of the patients with late ischemic colitis had comorbidities other than the EVAR to explain the ischemia. CONCLUSIONS: The incidence of ischemic colitis is decreased in patients undergoing EVAR vs open repair. The cause of the ischemia is multifactorial and seems to differ between patients in the early and late groups. Microembolization tends to produce severe ischemic colitis and is usually fatal. There should be a low threshold for performing endoscopy in any patient thought to have ischemic colitis after EVAR.

Intravascular epithelioid hemangioendothelioma of the inferior vena cava: case report of an unusual and unpredictable vascular tumor.

Vascular neoplasms are uncommon and pose a diagnostic and treatment challenge to the pathologist and surgeon, respectively. Epithelioid hemangioendothelioma is a rare neoplasm of vascular origin with an unknown etiology. Its biologic behavior lies somewhere between that of a benign hemangioma and that of a malignant angiosarcoma; however, it is unpredictable at best. Intravascular epithelioid hemangioendotheliomas have been described more often in veins than arteries, and there are only about 30 reports in the English literature. We report here the case of an epithelioid hemangioendothelioma of the inferior vena cava, which presented with abdominal pain, ascites and pedal edema.

Candidate sulfonated and sulfated topical microbicides: comparison of anti-human immunodeficiency virus activities and mechanisms of action.

Poly(styrene 4-sulfonate), cellulose sulfate, polymethylenehydroquinone, and PRO 2000 are sulfated or sulfonated polymers (SPs) under development as topical microbicides. They are presumed to work through similar mechanisms of action, although to date there has been no extensive comparison of their anti-human immunodeficiency virus activities. To determine whether any of these candidate microbicides offers a potential advantage, their in vitro activities, mechanisms of action, stabilities in biological secretions, and toxicities were compared. All four compounds were found to be active against X4, R5, and dualtropic primary isolates and against X4 and R5 laboratory-adapted strains in CD4+ T cells, macrophages, and single-coreceptor cell lines. Our single-cycle experiments using pseudotyped virus suggest that all four SPs function at the binding and entry stages of the viral life cycle but differ in degree of postentry effect. Surface plasmon resonance analyses demonstrate that SPs bind to X4 and R5 monomeric glycoprotein 120 with similar high binding affinities. When mixed with cervicovaginal lavage fluid, SPs maintain inhibitory activity at concentrations achievable in formulations.