Muerte súbita por embolia cerebral de mixoma de la aurícula izquierda / Sudden death due to cerebral embolism from a left atrial myxoma

El mixoma es el tumor cardiaco primario más frecuente. Puede manifestarse con síntomas cardiacos, síntomas generales y embolismo tumoral sistémico. Aunque es un tumor benigno, las embolizaciones, especialmente las cerebrales, pueden ocasionar graves complicaciones neurológicas, de ahí que esté indicada su resección quirúrgica.Presentamos el caso de un varón de 47 años que, en ausencia de síntomas previos, presenta síncope mientras mantenía relación sexual, falleciendo a las pocas horas. En la autopsia se constató en la aurícula izquierda, un tumor pediculado y gelatinoso de 1 cm de diámetro adherido al tabique interauricular, y en la arteria carótida interna derecha, un trombo oclusivo. Al estudio histológico, el tumor presentaba la morfología típica del mixoma cardiaco recubierto por trombo de fibrina y la oclusión arterial estaba ocasionada por émbolo tumoral y trombo de fibrina, hallazgos que explicaron el cuadro clínico (AU)

Myxoma is the most common primary tumor of the heart. Clinical manifestations are due to cardiac disturbance, systemic embolism and constitutional symptoms. Although it is a benign tumor, embolism, especially cerebral ones, can produce neurological complications. Surgical treatment of the myxomas is indicated to prevent cerebral complications.We present the case of a previously asymptomatic 47 years-old man who suffer syncope during sexual intercourse, dying few hours later without recover conscientious. At autopsy, in the left atria there was a gelatinous tumor, 1cm length, attached to the interatrial septum and the internal right carotid artery was occluded by a thrombus. Microscopically, the tumor demonstrated the characteristic histological findings of cardiac myxoma covered by fibrinous thrombus and, the carotid artery was occluded by a tumoral embolism (AU)

Embolismo pulmonar biliar no traumático fatal tras colecistitis litiásica / No disponible

No disponible

Anabolizantes: Complicaciones cardio-vasculares. Muerte súbita e inesperada / Anabolic androgenic steroids. Cardiovascular adverse effects. Sudden unexpected death

No disponible

No disponible

Sudden unexpected death in a child with varicella caused by necrotizing fasciitis and streptococcal toxic shock syndrome.

A 4-year-old child with chickenpox infection for 5 days prior to death complained of swelling and pain in his right leg that required medical assistance in the emergency department. Radiologic study was normal, and analgesic and bandage of the leg were prescribed. Some hours later, he presented cyanosis, dizziness, and vomiting and collapsed. A complete forensic autopsy was performed 12 hours after death. External examination of the body showed numerous crusty varicella skin lesions, especially over the trunk, and swelling and reddening of his right leg. The brain was swollen, with cerebellar herniation, and both adrenal glands were hemorrhagic.Microscopically, neutrophilic infiltration and muscle fiber necrosis were observed in soft tissues of his right leg, and fibrin microthrombus were numerous in capillaries of the plexus choroideus, larynx, lungs, and adrenals. Bacterial emboli were present in most of the tissues. Microbiologic cultures of blood and cerebrospinal fluid showed group A beta-hemolytic streptococcus (Streptococcus pyogenes). Death was attributed to fulminant streptococcal toxic shock syndrome, with necrotizing fasciitis as a complication of varicella.

Rotura de quiste aracnoideo tras traumatismo craneoencefálico leve. Exposición de un caso y revisión de la literatura / Traumatic rupture of arachnoid cyst resulting in acute subdural haematoma. Case report and literature review

La presencia de un hematoma subdural (HSD) en personas ancianas no constituye un hallazgo inusual, aunque puede ser objeto de complejas consideraciones medicolegales cuando se produce el fallecimiento tras un traumatismo leve reciente. Presentamos el caso de una mujer adulta añosa (87 años) que es asistida en un servicio de urgencia hospitalario tras sufrir traumatismo craneoencefálico (TCE) por caída en una residencia de la tercera edad, al presentar deterioro progresivo del nivel de conciencia y anisocoria transcurridas varias horas desde el trauma. Se practica tomografía axial computerizada (TAC) craneal sin contraste donde se aprecian lesiones compatibles con HSD crónico con resangrado. El estudio neuropatológico pone de manifiesto la existencia de un HSD agudo sobre quiste aracnoideo roto, hipertensión intracraneal, enclavamiento y hemorragias compatibles con daño axonal difuso grado III

The presence of a subdural hematoma (SDH) in aging people is not uncommon, although it can be the cause of complex medicolegal deliberations when death occurs after a recent head trauma. We present the case of an old woman (87 years old) who is attended in a hospital emergency service after suffering a fall with closed head injury, because of progressive stupor and anisocoria several hours later. A chronic SDH with new hemorrhage was diagnosed in a cranial computerized tomography (CT) without contrast. The neuropathological examination showed an acute SDH, arachnoid cyst elements, raised intracraneal pressure lesions with Duret hemorrhage and hemorrhages characteristic of grade III diffuse axonal injury

Latex agglutination for bacterial antigens and meningococcus PCR: two useful tools in legal sudden deaths.

Bacterial infections are considered to be a major cause of sudden deaths. The recognition of infections caused by Neisseria meningitidis is an essential duty of medicolegal offices due to the risk of secondary cases. Since other microorganisms, such as Haemophilus influenzae and Streptococcus pneumoniae, are also involved in infectious sudden deaths, the identification of the pathogen responsible for death is essential in order to establish a positive diagnosis while also preventing secondary meningococcal cases. However, because of the unreliability of culture methods used for autopsy specimens and the fragile nature of the microorganisms, other techniques were used. In this study, the detection of specific antigens of N. meningitidis (serogroups A, B, C, Y and W135), H. influenzae type b, S. pneumoniae and Group B Streptococcus was undertaken in 40 samples from sudden death cases in legal procedures with a latex agglutination test. In addition, a meningococcus polymerase chain reaction (PCR) assay (ctrA, crgA and siaD genes) was also used as a corroboration method for positive N. meningitidis agglutinations. Eleven cases of sudden death were confirmed to be due to meningococcus while one case was confirmed to have been caused by H. influenzae type b fulminant epiglottitis. Rapid laboratory diagnosis of meningococcal infection allowed contacts management and notification to the health authorities. From the point of view of the authors, forensic diagnosis of unascertained deaths should include latex agglutination and meningococcus PCR when a fulminant infection by N. meningitidis or H. influenzae is suspected as well as in deaths where the cause is unclear.

Mitochondrial DNA haplotyping revealed the presence of mixed up benign and neoplastic tissue sections from two individuals on the same prostatic biopsy slide.

DNA typing was requested to investigate a presumptive cancer diagnosis error by confirming whether benign and cancerous prostatic tissue in the same presurgical haematoxylin and eosin stained slide belonged to the same person. After independent histological re-examination of the slide by a pathologist, manual slide dissection was used to guarantee independent and high recovery DNA isolation from each tissue section, avoiding carryover and background contamination. Nuclear DNA quantification performed by real time polymerase chain reaction (PCR) revealed the absence of human DNA for short tandem repeat (STR) typing. Mitochondrial DNA was only obtained by performing PCR of very short fragments ( approximately 100 bp), indicating high DNA degradation. Different low frequency hypervariable region I haplotypes were obtained from each tissue section (normal tissue section haplotype: 16224C, 16234T, 16311C, 16356C; cancer tissue section haplotype: 16256T, 16270T, 16293G). Only the normal tissue section haplotype matched that obtained from the patient's blood sample, indicating that the cancer tissue section originated from an unknown patient. These results supported the hypothesis of sample mix up during block processing or slide preparation by a carryover mechanism. Mitochondrial genetic typing is recommended to exclude the possibility of carryover artefacts when low DNA content and high degradation compromise conventional STR typing.

La importancia de la investigación del lugar de la muerte y de la entrevista familiar en casos de muerte súbita e inesperada del lactante / The importance of the death scene investigation and family interview in cases os sudden unexpected infant death

El Síndrome de Muerte Súbita del Lactante (SMSL) es la principal causa de muerte súbita e inesperada del lactante durante el período postneonatal en los países desarrollados. Se define como la muerte súbita e inesperada de un lactante que permanece inexplicada después de la revisión de la historia clínica, examen del lugar de la muerte y realización de una autopsia completa, incluyendo análisis complementarios. En los últimos tiempos se ha puesto en evidencia que casos de muerte intencional fueron catalogados como SMSL por una deficiente investigación de las circunstancias y el lugar de la muerte. Queremos hacer hincapié en la importancia de esta parte de la investigación postmortem y resumimos algunas de las recomendaciones publicadas al respecto (AU)

Brain stem lesions in the sudden infant death syndrome: variability in the hypoplasia of the arcuate nucleus.

In the present study we investigated quantitatively the incidence of hypoplasia of the arcuate nucleus (ARCn) of the medulla oblongata, reported earlier [Gozal D, Hathout GM, Kirlew KAT (1994) J Appl Physiol 76:207], as well as its distribution in 62 cases of sudden infant death syndrome (SIDS; mean age 14 postnatal weeks, 39 male and 23 female) and 25 controls (mean age 16 postnatal weeks, 14 male and 11 female), using detailed histopathological and morphometric analyses performed on serial sections of medulla oblongata. The SIDS cases were divided into four subtypes: SIDS A (27 cases, 43%) with histologically well-developed ARCn; SIDS B (16 cases, 26%) with severe bilateral hypoplasia along the whole length; SIDS C (11 cases, 18%) with partial bilateral hypoplasia, located mainly in the lateral portions of the caudal two thirds of the nucleus, and SIDS D (8 cases, 13%) with right monolateral hypoplasia of the ARCn. ARCn hypoplasia was detected in 56% of cases (35 cases). Three-dimensional volume reconstruction showed that in the SIDS A victims the mean volume was analogous to controls, whereas in the SIDS group with ARCn hypoplasia, severe or partial, the mean volume was significantly different from controls on both sides of the medulla oblongata (SIDS B group: P=0.003, P=0.002; SIDS C group: P=0.007, P=0.008). The mean ARCn volume in the SIDS D group was statistically significant only on the right side ( P=0.005). We also observed reduced neuron density of the ARCn, associated with a decrease in the total number of neurons over the whole length of the nucleus itself. On the basis of the morphometric results of neuronal population in the different portions of the ventrolateral medulla in SIDS cases, we hypothesized that infants without the full complement of neurons and neuropil (ARCn hypoplasia) are at risk for SIDS because they are unable to develop appropriate cardioventilatory control during this crucial developmental period.

Anabolizantes. Complicaciones cardiovasculares. Muerte súbita e inesperada / Anabolic androgenic steroids. Cardiovascular adverse effects. Sudden unexpected death

Los esteroides androgénicos-anabolizantes son compuestos sintéticos relacionados estructuralmente con la testosterona que promueven el desarrollo de los caracteres sexuales secundarios masculinos (efecto androgénico) y aceleran el crecimiento muscular (efecto anabolizante). Su uso está extendido en atletas, gimnasios, población adolescente y joven, y también en drogadictos. Algunas de las complicaciones asociadas al consumo de estas sustancias pueden ser mortales y harán necesaria la realización de una autopsia judicial, bien por muerte súbita inesperada (por las complicaciones cardiovasculares) como por muerte violenta (accidental, suicida y homicida) (por los trastornos psiquiátricos). La presencia de signos externos como hipertrofia muscular marcada, estrías en músculo pectoral o biceps, ginecomastia, atrofia testicular y acné cutáneo, nos pueden alertar sobre la posibilidad del consumo de anabolizantes en alguno de estos fallecidos. Se presenta una revisión de aquellos aspectos más relevantes en relación a las complicaciones que pueden conducir a la muerte súbita e inesperada de los consumidores de este tipo de esteroides (AU)

Trombosis de vena ovárica derecha: complicación mortal en la mujer puérpera, a propósito de un caso / Right ovarian vein thrombosis: fatal complication in puerperium. Case report

Tras el parto, la mujer entra en un período, el puerperio, durante el cual pueden sobrevenir múltiples complicaciones, algunas de ellas mortales. Describimos el caso de una puérpera que, transcurridos catorce días del alumbramiento, fallece por un tromboembolismo pulmonar masivo cuyo origen es una trombosis de la vena ovárica derecha.Se revisan la incidencia, etiopatogenia, sintomatología y manejo de estos pacientes, así como el abordaje necrápsico (AU)

Sudden unexpected non-violent death between 1 and 19 years in north Spain.

AIMS: To study the epidemiological, clinical, and pathological characteristics of sudden unexpected non-violent deaths between 1 and 19 years. METHODS: Population based observational study of all sudden unexpected non-violent deaths between 1 and 19 years, from 1990 to 1997, in a north Spain county (Bizkaia). In each case, clinical information and circumstances of death were obtained and a complete forensic autopsy was performed. RESULTS: There were 34 sudden unexpected non-violent deaths. The mortality rate was 1.7 per 100 000 persons per year (representing 9% of the mortality rate of all non-violent deaths). In 10 cases the cause of death was cardiac, in 13 cases extracardiac, and 11 cases were unexplained. In 17 cases there were no pathological antecedents and in nine cases death occurred in patients with known disorders. Syncopes prior to death were present in five cases. Exercise related deaths occurred in seven cases (mainly associated with cardiac causes). Eight cases were "death in bed".

An unusual site for the AV node tumor: report of two cases.

Atrioventricular (AV) node tumors are very uncommon primary cardiac tumors located exclusively in the AV nodal region. The nomenclature has been diverse according to different histogenetic theories proposed since the first description in 1911. Histochemical, ultrastructural, and immunohistochemical studies have demonstrated its endodermal origin. Patients with these tumors can develop complete heart block or sudden death, but the tumor can also be an incidental finding at autopsy. We present two accidental deaths cases in which multiple foci of atrioventricular node tumor (Case 1) and an isolated cyst (Case 2) were observed in the atrial septum, sparing the conduction system.

[Arrhythmogenic cardiomyopathy as cause of sudden death in Spain. Report of 21 cases]. / Miocardiopatía arritmogénica como causa de muerte súbita en España. Presentación de 21 casos.

INTRODUCTION AND OBJECTIVES: Arrhythmogenic cardiomyopathy is a myocardial disease of unknown origin characterized by progressive replacement of right and/or left ventricular myocardium by fibrofatty tissue. Young adult people are more frequently affected and symptoms include palpitations, syncopes or sudden death. The objective of this study is to assess the frequency and characteristics of arrhythmogenic cardiomyopathy as a cause of sudden death in a series of cases in Spain. MATERIAL AND METHODS: Among the sudden death cases studied at the Toxicology Institute of Madrid between 1991 and 1997, those with arrhythmogenic cardiomyopathy diagnosis were analysed. RESULTS: 21 cases were diagnosed (0.62% of all sudden deaths and 6.8% of sudden deaths under 35 years). There were 20 males and one female (mean age 24.5 +/- 9.37 years); eleven (52.3%) died during sport activity and 8 (38%) had previous exercise related symptoms. In only two cases other members of the family had died suddenly and only one had been diagnosed in life. Biventricular involvement was observed in 13 cases; isolated involvement of the left ventricle in 4, and isolated involvement of the right ventricle in 4. CONCLUSIONS: Arrhythmogenic cardiomyopathy is a relatively frequent cause of sudden death in the young population in Spain. It is very often the first manifestation of the disease. The myocardial involvement is more frequently biventricular than isolated in the right ventricle. The diagnosis could be difficult for cardiologists, pathologists and forensic doctors.

Supravalvular aortic stenosis, Williams syndrome and sudden death. A case report.

Supravalvular aortic stenosis (SVAS) is an uncommon but well characterized congenital narrowing of the ascending aorta above the level of the coronary arteries. It can be a familial disorder, can occur sporadically, or associated with Williams syndrome (WS) which is a neurodevelopmental disorder affecting connective tissue and the central nervous system. Sudden death is a well-known complication of non-syndromic SVAS but few cases have been reported associated with WS. We present a case of sudden death in a woman with the diagnosis of SVAS and WS since the age of 3 years who refused surgical correction and died at the age of 27 years. At autopsy, the aorta and pulmonary trunk were narrowed and the walls showed peculiar microscopical characteristics. In the cardiac conduction system the His bundle was small and intramyocardial. The incidence, pathology, pathogenesis and prognosis of both conditions (SVAS and WS) are reviewed.

Atrioventricular node fetal dispersion and His bundle fragmentation of the cardiac conduction system in sudden cardiac death.

OBJECTIVES: This study sought to examine the frequency of persistent fetal dispersion of the atrioventricular (AV) node and fragmentation of the atrioventricular bundle (His) bundle in the cardiac conduction system of sudden cardiac death cases and control subjects to establish their importance as the cause of death. BACKGROUND: These are two of the most frequent lesions reported in published reports in the cardiac conduction system in unexplained sudden deaths. METHODS: We have studied the conduction system of 347 hearts: 249 hearts from sudden cardiac death cases and 98 control hearts. The sudden cardiac death cases were divided, according to the pathology found, in three groups: group I: ischemic heart disease, 137 cases; group II: nonischemic heart disease, 48 cases, and group III: unexplained sudden cardiac deaths, 64 cases. The control group (group IV) consisted of patients with unnatural deaths and extracardiac natural deaths. RESULTS: Persistent fetal dispersion of the AV node was observed in 70 cases (20.17%) of all groups with a frequency (40.81%) statistically higher in the control group. Fragmentation of the His bundle was observed in 95 cases (31.77%), and the frequency was statistically higher in the control group, too (47.67%). CONCLUSIONS: Persistent fetal dispersion of the AV node and fragmentation of the His bundle can be a normal variation present during many years in life and must not be considered the anatomic substrate for arrhythmias and sudden death without electrocardiographic abnormalities.

Pathologic changes of the cardiac conduction tissue in sudden cardiac death.

We report the pathologic changes of the cardiac conduction tissue (CS) in 33 cases of sudden cardiac death. The cases were divided into two groups: those with severe atherosclerotic coronary lesion (> 75% cross-sectional area stenosis of at least one coronary artery), 15 cases, and those without significant coronary disease, 18 cases. In the first group, we observed major changes of the CS in eight cases. The changes consisted of abnormalities in His bundle position (branching bundle in pars membranacea or left-sided bundle), atrioventricular (AV) node fibrosis, and interatrial lipoma. Other age-related minor abnormalities such as mild fibrosis, fatty change, or fibrointimal hyperplasia of CS arteries were observed in nine cases. In the second group, major lesions of the CS were recognized in 13 cases: abnormalities in bundle branch position in eight cases (left-sided, inside the membranous septum), downward displacement of the tricuspid valve with AV node elongation in three cases, and a single case with one of the following: His compression by hypertrophic cardiomyopathy, Mahaim fibers, focal ischemia of bundle, AV node division, AV node dissection by edema, intramural left bundle branch, or tumor of the AV node. In the study of the pathogenesis of sudden death, the conduction system lesions always have to be considered, even in cases with severe coronary disease.

[Appendicular endometriosis. Clinicopathologic study of 12 cases]. / Endometriosis apendicular. Estudio clinicopatológico de 12 casos.

Endometriosis of the Digestive Tract is an uncommon pathology, especially when ileocecal appendix is involved. Authors report twelve cases of appendiceal endometriosis reviewed from surgical and anatomopathological records. The preoperative diagnosis is almost impossible. The most usual clinical presentation is compatible with that of acute or chronic appendicitis. The definitive diagnosis is confirmed by anatomopathological study of the surgical specimen. The Surgical treatment consists of appendicectomy alone or associated with extirpation of other concomitant neighbouring lesions.

[Mesenteric venous thrombosis as a complication of surgery for portal hypertension by the Romero-Torres technic. Apropos a case]. / Trombosis venosa mesentérica como complicación de la cirugía de la hipertensión portal según la técnica de Romero-Torres. A propósito de un caso.

A case is presented of mesenteric venous thrombosis which affects about 30 cm of small intestine in a patient operated one month before for portal hypertension and bleeding from esophagogastric varices, in which an interruption of the portal-azygous venous circulation was made with splenectomy, using the Romero-Torres procedure. We consider that postsplenectomy thrombocytosis has been the first pathogenic factor in the mesenteric venous thrombosis.