ruptured infective aneurysm presenting as an isolated subdural hematoma a rare cause of death in a drug addict

Abstract

A ruptured infective aneurysm presenting as an isolated subdural hematoma is rare. Subdural hematomas are primarily caused by blunt trauma to the head. In this case of a 25-year-old drug addict who was found unresponsive, taken to the hospital where a Subdural Hematoma (SDH) was discovered, and subsequently expired six days later, the initial presentation was that of a homicidal death. Upon post-mortem examination, a previously undiagnosed infective endocarditis of the mitral valve as well as multiple infarctions of the brain, spleen, and kidneys were identified. The subdural hematoma originated from a superficial cortical hemorrhage which perforated into the subdural space. Microbiological investigation revealed colonization by Methicillin resistant Staphylococcus aureus. The manner of death in this case was natural, which is rare given that the typical manner of death in drug-related deaths is accidental or homicidal. All deaths of drug addicts should be subjected to a complete forensic autopsy since various causes of death can be contributory. Introduction Cause of Death (COD) in drug addicts is predominantly ac• cidental or intentional overdoses [3]. Research has found that about 20% suffer lethal traumas, and • 10% die from natural causes [3]. Inflammatory diseases such as pneumonia, myocarditis, endo• carditis, and hepatitis may play a contributory role in natural COD in drug addicts [3]. Intravenous drug use can be associated with needle sharing, • infective pathogens such as Hepatitis B and C, and Human Immunodeficiency Virus (HIV) [3]. A majority of drug-related fatalities are due to opiates [3]. • Recent studies show that mixing different psychotropic sub• stances including alcohol is prominent [3]. Since COD in patients with a history of drug abuse use can • be attributed to multiple factors, a complete forensic autopsy including histology, microbiology, and toxicology should be performed in all cases. Case History A 25-year-old female found unresponsive on Aug 18, 2017 • face down, partially clothed, and covered in emesis and feces Taken to a local emergency room where a subdural hemor• rhage was discovered Underwent a craniotomy and evacuation of the hematoma and • died in the hospital on Aug 24, 2017 Autopsy confirmed a subdural hematoma, endocarditis, HIV • infection, hepatitis C infection, and evidence of intravenous drug abuse. Medical History Human Immunodeficiency Virus (HIV) • Hepatitis C infection • Hospital In-Patient Laboratory Results Methicillin resistant • Staphylococcus aureus (MRSA) Blood culture • Citation: Vasquez D, Hays M (2019) Ruptured Infective Aneurysm Presenting as an Isolated Subdural Hematoma: A Rare Cause of Death in A Drug Addict. Int J Clin Pathol Diagn: IJCP-126. DOI: 10.29011/2577-2139.000026 2 Volume 2019; Issue 01 Int J Clin Pathol Diagn, an open access journal ISSN 2577-21439 Gram stain: aerobic and anaerobic bottles gram-positive cocci • in groups Culture results: aerobic and anaerobic bottles MRSA • Drug screen, urine positive for THC (THcannabinol) and • Cocaine Autopsy Gross Description Heart 293 g. The coronary artery distribution is normal with • no atherosclerosis or thrombi; the epicardium shows patchy purulent exudate. There is a friable, polypoid, soft 1” vegetation on the anterior mitral valve leaflet. Scattered microabscesses are grossly visible in the epicardium and myocardium to include the papillary muscles. Lungs left 933 g., right 1026 g. Marked congestion and • edema with no definite purulence on sectioning. Both lower lobes are firm and airless. Kidneys left 250 g., right 190 g. Scattered cortical scars • with grossly visible microabscesses on the cortical surfaces on both kidneys. Figure 1: Friable, polypoid, soft 1” vegetation on the anterior mitral valve leaflet. Photo by medical examiner personnel at Tidewater Office of the Chief Medical Examiner, Virginia. Brain Examination Weight fixed: • 1184 g External findings: • Bilateral cerebellar Subarachnoid Hemorrhage (SAH) R>L • Diffuse edema R>L • R. parietal lobe herniating at the dural graft site • R. uncus soft, suggestive of herniation • 2.7 cm x 2.5 cm superomedial parieto-occipital SAH with a • 0.8 cm rupture into Subdural (SD) space. Figure 2a: Superomedial parieto-occipital subarachnoid hemorrhage. Figure 2b: Rupture of the right superficial cortical vessel. Photo by Michael Hays, MD at Tidewater Office of the Chief Medical Examiner, Virginia. Leptomeninges: • Dura partly removed; clotted blood • R. dural graft, 12.5 cm x 10.0 cm • R. Subdural Hematoma (SDH) supra/infra tentorial • Figure 3: Partly removed dura and clotted blood. Photo by Michael Hays, MD at Tidewater Office of the Chief Medical Examiner, Virginia. Coronal section findings: • R. uncal necrosis/herniation • Compressed R. ventricle • 0.5 cm ruptured aneurysm • Citation: Vasquez D, Hays M (2019) Ruptured Infective Aneurysm Presenting as an Isolated Subdural Hematoma: A Rare Cause of Death in A Drug Addict. Int J Clin Pathol Diagn: IJCP-126. DOI: 10.29011/2577-2139.000026 3 Volume 2019; Issue 01 Int J Clin Pathol Diagn, an open access journal ISSN 2577-21439 Additional embolic sites with microabscesses in the right • Middle Cerebral Artery (MCA) distribution at grey/white matter junctions, 0.2-0.3 cm Figure 4: Microabscesses in right middle cerebral artery distribution at grey/white matter junctions. Photo by Michael Hays, MD at Tidewater Office of the Chief Medical Examiner, Virginia Histological Examinations Heart: • multifocal parenchymal abscesses. The epicardium shows a variable, predominantly mononuclear inflammatory response with variable numbers of hemosiderin-laden macrophages. Mitral valve: • valve leaflet with acute inflammation, abscess formation, and polypoid masses of fibrin admixed with confluent geographic bacterial colonies. Spleen: • geographic areas of infarction with bacterial overgrowth. The edges of infarction show variability in acute inflammatory response. Lung: • congestion, anthracosis, edema, terminal changes. Patchy bronchopneumonia with acute inflammation variably present within the bronchial lumina and alveolar spaces. Kidney: • patchy interstitial mixed inflammation. There are confluent, geographic areas of infarction and abscess formation. Liver: • slight fatty change, patchy portal triaditis with an increase in portal fibrous tissues without overt cirrhosis. Micrographs of Cerebral Tissue H&E Stain Figure 5a: Clot with inflammatory response. Figure 5b: Microabscess. Slide images by Michael Hays, MD at Tidewater Office of the Chief Medical Examiner, Virginia Grocott’s Methenamine Silver (GMS) Stain Figure 6: Negative for fungal infection. Slide images by Michael Hays, MD at Tidewater Office of the Chief Medical Examiner, Virginia Gram Stain Figure 7: Gram-positive cocci. Citation: Vasquez D, Hays M (2019) Ruptured Infective Aneurysm Presenting as an Isolated Subdural Hematoma: A Rare Cause of Death in A Drug Addict. Int J Clin Pathol Diagn: IJCP-126. DOI: 10.29011/2577-2139.000026 4 Volume 2019; Issue 01 Int J Clin Pathol Diagn, an open access journal ISSN 2577-21439 Slide images by Michael Hays, MD at Tidewater Office of the Chief Medical Examiner, Virginia Elastin Stain Figure 8: Vessel wall damage from the inflammatory response. Slide images by Michael Hays, MD at Tidewater Office of the Chief Medical Examiner, Virginia Toxicology Hospital blood positive for benzoylecgomine, 0.027 mg/L Pathological Diagnosis R. subdural hemorrhage status post right craniotomy with • evacuation of the subdural hematoma and dural repair Bacterial endocarditis of the mitral valve due to MRSA • Purulent pericardial fluid • Grossly visible abscesses of the myocardium, spleen, and kid• ney Bronchopneumonia • History of Human Immunodeficiency Virus (HIV) and hepa• titis C infection Pulmonary anthracosis and bullous emphysema. • Cause of Death Subdural hematoma from ruptured infective cerebral aneurysm due to MRSA endocarditis as a complication of IV drug use Discussion With a history of drug abuse and being found at a known drug • house, the patient was initially thought to have succumbed to a drug overdose. When the SDH was discovered at the hospital, COD was pos• sibly trauma. SDH is rare and can be caused by various etiologies: cortical • artery bleeding, vascular lesions, coagulopathy, neoplasms, spontaneous intracranial hypertension, cocaine, and arachnoid cyst [1]. From autopsy, confirmation of bacterial infection suggested • an infection-related COD. The etiology of infective aneurysms (IAs) is not clearly de• fined, since they may be difficult to identify by neuroimaging. IA-related hemorrhage may be subarachnoid (~20% of patients), intraparenchymal (~25%) or even intraventricular (~5%). Treatment is largely medical (antibiotics) rather than surgical [1,5]. IAs account for 5-6% of intracerebral aneurysms [1]. • IAs arise from microbe-carrying emboli, usually originating • from an infected heart valve or pulmonary vein [2]. Most frequently IAs occur in the distal branches of the ce• rebral arteries, particularly where due to bacterial infection, with particular predilection for the MCA. Bacterial colonization may be facilitated by the absence of vasa vasorum in branches of these vessels. Inflammation and destruction of the artery appear to proceed from adventitia inwards making the subarachnoid space locally disappear causing the blood to flow directly to the subdural space or the brain parenchyma [2, 4]. May present with SAH, brain hemorrhage, infarction, or • headache [1]. IAs have a mortality of approximately 30% if bacterial and • approximately 90% if fungal [1]. Infection-induced acute/chronic inflammation weakens the • vessel wall, resulting in ectasia leading to formation of an IA [1-13]. 65% of patients with IAs have underlying endocarditis [5]. • Other common sources of infection: intravenous drug abuse • (6.3%), bacterial meningitis (5.2%), poor dental hygiene (4.2%) and cavernous sinus thrombosi