Death resulting from a mesenteric hemorrhage due to acute myeloid leukemia: an autopsy case.

Acute leukemia causes hemorrhage in various sites throughout the body, such as the brain parenchyma, resulting in serious complications. Here, we present an autopsy case where the patient succumbed to a ruptured mesenteric hematoma caused by acute leukemia. A 58-year-old man, without a significant past medical history, was found dead at his workplace. An external examination showed subcutaneous hemorrhage on the left upper extremity. Macroscopic autopsy findings revealed a massive hemoperitoneum (1000mL) and extensive hematoma in the mesentery. Histopathological findings showed monotonous cell proliferation not only in the mesentery, but in many organs, such as the liver, spleen, and kidney; aggregates of the infiltrating cells were also observed in the microvessels of various organs. Immunohistochemical staining indicated that the infiltrating cells showed variable myeloperoxidase positivity, and the cells were strongly positive for CD68 (PG-M1). From the autopsy findings and the immunohistochemical staining, we concluded that the underlying cause of death was acute myeloid leukemia (M5). This case was not only a rare presentation of acute leukemia, but provides a lesson to forensic pathologists regarding noting underlying hematological disease, particularly when a case of massive hemorrhage of unknown etiology is encountered.

Accidental death of elderly persons under the influence of chlorpheniramine.

Older individuals are susceptible to accident, such as falls, some of which are fatal. In such cases, autopsies and toxicological analysis may be deemed unnecessary, especially if the critical injuries and manner of death can be determined conclusively based on information at the scene and an external investigation. Here, we report the results of two autopsies performed on elderly individuals who died accidentally under the influence of chlorpheniramine. These autopsies revealed valuable additional information. Case 1: A woman in her 70s, who was living alone, was found dead under the stairs in her house. She had no history of a condition that could have led to sudden death. The autopsy revealed a neck fracture, multiple rib fractures, and a coccyx fracture. The histopathological findings showed fat embolisms in numerous small vessels of the interalveolar septum. Toxicological analysis of blood samples revealed the presence of chlorpheniramine (0.41µg/ml). Case 2: A woman in her 70s, who was living alone, was found dead in the bathtub in her house. There was no past medical history other than diabetes mellitus and vertigo. The autopsy revealed hyper-inflated lungs and brown-red fluids in the trachea, but there was no evidence of a pathology or injury that could have induced a loss of consciousness. Toxicological analysis of the fluids in the right thoracic cavity revealed the presence of chlorpheniramine (0.57µg/ml). In both cases, re-examination of the scene after the autopsy revealed the presence of common cold medicine containing chlorpheniramine. The victim may have accidentally overdosed on common cold medicine. This overdose would have been compounded by anti-histamine-induced drowsiness. The present cases suggest that forensic pathologists should always notify physicians/pharmacists of findings pertaining to unexpected drug side effects. Such intervention would prevent many accidental deaths. In addition, each autopsy must be performed in conjunction with a detailed postmortem investigation. Such efforts would also increase the accuracy of the public health record's mortality statistics.

An autopsy case of a homeless person with unilateral lower extremity edema.

We present an autopsy case of a homeless person showing remarkable unilateral lower extremity edema, which was strongly associated with the cause of death. A 55-year-old homeless man without any past medical history was found dead in a flophouse. External examination showed evidence of malnourishment and remarkable swelling of the right, lower extremity. Putrefactive discoloration in the same area was evident at the time of autopsy (approximately 30h post-mortem). The autopsy revealed focal pneumonia in the right lower lobe, dehydration and chronic pancreatitis. Dissection of the edematous extremity revealed massive abscess formation in the subcutaneous tissue and superficial fascia around the right knee joint. Histopathological findings were compatible with necrotizing fasciitis and blood chemistry results showed an elevation of HbA1c (6.3%). The cause of death is considered to be necrotizing fasciitis and secondary pneumonia/dehydration. This case suggests that necrotizing fasciitis should be differentiated during postmortem diagnosis, especially in cases showing lower extremity edema with early putrefactive changes. In addition, forensic pathologists should closely examine a lower extremity of such cases to detect a true cause of death, even if other pathological findings which can be a cause of death, such as pneumonia and dehydration, are observed in major internal organs.

Fatal amniotic fluid embolism with typical pathohistological, histochemical and clinical features.

Despite the decrease in maternal mortality rate, amniotic fluid embolism (AFE) is still one of the most feared complications of pregnancy due to the high rate of mortality in Japan. The authors present a fatal case of a healthy 39-year-old woman who died during delivery after a normal 40-week second pregnancy. Shortly after the arrival at hospital, an abrupt drop of foetal heart rate was observed, followed by deterioration of consciousness and cardiac arrest of the patient. Prompt cardiopulmonary resuscitation (CPR) was performed but the patient died about an hour and a half after her arrival at hospital. Forensic autopsy confirmed the pathohistological diagnosis of amniotic fluid embolism supported by histochemical analysis results and excluded other possible causes of death. This paper stresses the fundamental importance of autopsy in an unexpected maternal death in conjunction with the significance of data accumulation on maternal death.

Potential medical adverse events associated with death: a forensic pathology perspective.

OBJECTIVE: To determine the incidence of potential medical adverse events among patients undergoing forensic autopsy, and to present the characteristics of potential medical adverse events. DESIGN: Retrospective review of consecutive autopsy records. SETTING: Department of Forensic Medicine, the Jikei University School of Medicine, Tokyo, Japan. PARTICIPANTS: A total of 3355 forensic autopsy cases between 1983 and 2006. MAIN OUTCOME MEASURES: Incidence of potential medical adverse events identified in decedents undergoing forensic autopsy, classified by actual occurrence as 'confirmed', 'equivocal' and 'negative' cases; proportion of potential diagnostic, performance and system errors among potential medical adverse events. RESULTS: Of 291 autopsies (8.7%) with potential medical adverse events, 66 cases (22.7%) were confirmed, 42 cases (14.4%) were negative and 183 cases (62.9%) were equivocal. Confirmed cases consisted of potential diagnostic errors in 49 cases (74.2%) and performance errors in 17 cases (25.8%). Equivocal cases included 99 cases associated with potential diagnostic errors (54.1%) and 60 cases associated with potential system errors (32.8%). In 38 of the confirmed cases (57.5%), serious exacerbation of patient condition occurred outside the medical facility. CONCLUSIONS: Potential medical adverse events are not uncommon in decedents undergoing forensic autopsy. They are particularly associated with potential diagnostic errors. Forensic autopsy may provide information that could be used to improve care and reduce deaths due to potential medical adverse events.

Fatal vascular injury as a result of operations: experience of two surgery-related autopsies.

We experienced two autopsy cases of unexpected death during surgical operation. Case 1 was a 60-year-old male. Salvage esophagectomy was performed from the right side of the thrax. After dissection of the lymph node, blood pressure decreased suddenly. Emergency thoracotomy was done for diffuse hemothorax in the left thoracic cavity. The patient died despite aggressive hemostasis. Autopsy findings revealed that the operator dissected the left subclavian artery instead of the lymph nodes. Case 2 was a 60-year-old male with advanced thyroid cancer with pelvic metastasis. Surgical removal of the sacrum was attempted for pain relief. The operation was interrupted because of massive hemorrhage from the iliac veins. After the operation, the patient's left leg quickly became necrotic. Despite the bypass grafting from the right to the left femoral artery, the patient died of reperfusion injury. Autopsy revealed ligation of the left common iliac artery along with the accompanying vein. The leg necrosis was thought to have resulted from the vascular ligation. In these two cases, the demonstration and elucidation of the causes of deaths were required with medicolegal autopsies. However, it proved difficult to visualize the operated vessels in detail. In autopsy investigations related to surgical operations, detailed information of the clinical course is valuable and should be provided by the operators themselves, as well as being obtained from clinical charts.

[Statistical investigation on cases associated with medical implication in administrative autopsy within the 23 wards of Tokyo: the role of the medical examiner system in investigation of cases associated with medical implication].

Actual circumstances of administrative autopsies which proved connections between medical implication and death had not been very clear in the past. Therefore, using the records of administrative autopsies performed from 2003 to 2005 at Tokyo Medical Examiner's Office, this study looked into the cases in which a certain level of connection between medical implication and death was proved or suspected. This study dealt with 877 cases. The largest age group among the male was the one between 65 and 74, and the number of female cases increased as the age increased. The percentage of the studied cases among all the administrative autopsy cases has become larger after 2004. As regarding medical departments for implication, "internal medicine" had the largest number of the cases, and "unknown", "psychiatry", and "emergency" followed in order. 30 percent were being hospitalized during the final medical consultations, and the percentage went up to just over 60 when the deaths during and on the day after the final consultations were added to the figure. Regarding the causes of death, the great majority was natural death, and the other causes were 'unknown', 'fall', and 'asphyxia'. Also, about 80 percent of the natural deaths were caused by circulatory, gastroenteric and respiratory diseases. Contradictions between clinical and forensic diagnoses were found in approximately 10 percent of the cases. In any case, medical examiners are to diagnose the causes of deaths by autopsy, not to evaluate the quality and safety of medical treatment. But if the quality and safety of medical treatment could be improved through the diagnoses of administrative autopsy, the medical examiner system would function practically as a part of administration for health and welfare. However, as it handles not only deaths by medical treatment but also all the other types of unnatural deaths, the system can also deal with other social problems, for which the correct causes of death must be diagnosed initially. It is socially very unhealthy to focus only on death associated with medical implication, as other types of unnatural death could be seen as relatively less important. Therefore, it is considered that the medical examiner system is effective for investigation of a variety of unnatural death as well as cases associated with medical implication.

Non-traumatic rupture of the intracranial vertebral artery of a man found dead in a severe car accident - histopathological differentiation by step-serial sections.

A 58-year-old male with untreated hypertension was found dead in his car after a traffic accident on his way to the office. Emergency head CT showed diffuse subarachnoid hemorrhage at cerebral base. On autopsy examination, traumatic injuries were seen on his face and lower extremities. The skull was not fractured and there were no brain contusions except subscalp bleeding at the frontal head. The brain weighed 1510g and showed diffuse subarachnoid hemorrhage due to a rupture of the left vertebral artery (VA). Histopathological examination using serial step sections of every 0.1mm of the whole VA revealed multiple arterial dissections (AD) with fresh and old states at bilateral VA. Previous dissections at the basilar artery and internal carotid artery were also observed. The symptoms that he reported a week before the accident, left sided headache and shoulder pains, could have come from previous dissections. We concluded that the AD occurred while driving and was the cause of death, with the car accident then being caused by the stroke. Other specific histopathological findings were medial degeneration and serrate changes of the internal elastic lamina which resembled lesion of the segmental arterial mediolysis. These would suggest a pathogenesis of intracranial AD. Differential diagnosis of subarachnoid hemorrhage from the ruptured VA, distinguishing between idiopathic AD and traumatic trilaminar rupture, is still a difficult matter in forensic autopsy. However, this serial step sections procedure could be useful for the morphological differentiation.

Risk factors, diagnosis and prevention of sudden unexpected infant death.

The diagnosis of the cause of sudden unexpected infant death (SUID) is often difficult work for forensic pathologists. Its misdiagnosis or misclassification is the cause of crucial epidemiological and medicolegal problems. During the sudden infant death syndrome (SIDS) epidemic, many reports described the risk factors of SIDS as well as mechanical suffocation during sleep. Meadow's report has invited worldwide debate over whether the cause of SUID is attributable to SIDS or suffocation. On the basis of this background, the problems concerning causal diagnosis and risk factors, particularly the accidental suffocation of infants during sleep, and the specific pattern of suffocation, was reviewed from the forensic pathological viewpoint. The following tasks remain to be done for the future: (1) to avoid preventable SUIDs, the most effective measure worldwide is to identify high-risk factors for all SUIDs, including SIDS, accidental suffocation and undetermined causes, and then transmit this information to the public. (2) SIDS should be uniformly defined and diagnosed as strictly as possible to gain its reliability in the public health community and in a legal framework.

Sudden death due to undiagnosed acute promyelocytic leukemia: a case report.

Acute promyelocytic leukemia (APL) is associated with severe hemorrhagic coagulopathy induced by the release of procoagulant, plasminogen, and protease from leukemic cells. The case described in this report is of a 15-year-old male who unexpectedly died due to a cerebral hemorrhage caused by underlying APL within 12 h after presentation. This case suggests that underlying APL should be considered as a differential diagnosis when sudden death occurs with a fatal spontaneous hemorrhage, although it is rare.

Analysis of fatal injuries to motorcyclists by helmet type.

To clarify the characteristics of injuries of motorcyclists dying in accidents in relation to helmet type, we retrospectively analyzed forensic autopsies of 36 helmeted motorcycle riders. The presence of major injuries and injury severity were evaluated with the injury severity score and the 1990 revision of the Abbreviated Injury Scale. Persons with open-face helmets (19 cases) were significantly more likely to have sustained severe head and neck injuries, especially brain contusions, than were persons with full-face helmets (17 cases). Furthermore, major injuries of the chest or abdomen, rib fractures, lung injuries, and liver injuries were each present in more than one quarter of all cases (26.3% to 70.6%), but their prevalences did not differ significantly between riders with different types of helmet. Because many types of head and neck injuries cannot be prevented and fatal chest and abdominal injuries occur despite the use of full-face helmets, more effective helmets and devices for protecting the chest and abdomen are needed to decrease deaths from motorcycle accidents.

Prediction of injuries to the heart and thoracic aorta in unrestrained drivers.

The purpose of the study was to investigate factors predicting injuries to the heart and/or thoracic aorta (H/TA) of unrestrained drivers in frontal motor vehicle collisions. We retrospectively analyzed findings of forensic autopsies of 37 unrestrained drivers of automobiles without airbags involved in frontal collisions. Mechanisms of injury, injury severity, presence of major injuries, and the number of fractured ribs were examined in each case. Victims were subdivided for comparison into those with (19 cases) and without (18 cases) H/TA injuries. The injury severity score and the abbreviated injury scale of the chest were significantly higher in persons with H/TA injuries (65.3+/-15.7 and 5.4+/-0.9) than in persons without (31.6+/-22.0 and 1.8+/-1.9). Because univariate analysis showed that the presence of multiple fractured ribs was an important predictor of H/TA injuries, we examined the relation between H/TA injuries and the number of fractured ribs. Copas's nonparametric smooth binary regression model showed that H/TA injuries were more likely in persons with eight or more fractured ribs. The presence of eight or more fractured ribs predicts H/TA injuries in unrestrained drivers.