Barry D. Lifschultz

Fatal anaphylaxis: postmortem findings and associated comorbid diseases

Background Anaphylaxis is an infrequent cause of sudden death. Death often results from circulatory collapse, respiratory arrest, or both. Objective To investigate the causes of death, anatomical findings, and comorbid diseases in cases of fatal anaphylaxis. Methods This is a retrospective case review of 25 unselected cases of documented fatal anaphylaxis. Each case report contained details of the fatal reaction, a review of the medical record, and laboratory and autopsy findings. Serum tryptase concentrations were measured in 7 cases. Results The anaphylactic deaths included 7 reactions to medications, 6 to radiocontrast material, 6 to Hymenoptera stings, and 4 to foods. The mean age was 59 years. The anaphylactic reaction began within 30 minutes of exposure in 21 of 25 cases, with death occurring within 60 minutes in 13 of 25 cases. Urticaria occurred in only 1 of 25 cases. Anatomical findings consistent with anaphylaxis were present in 18 of 23 patients undergoing autopsy. At least 1 significant comorbid disease was identified in 22 of 25 cases. Conclusions (1) Elderly patients with substantial comorbid conditions constituted a significant number of the anaphylactic fatalities; (2) the onset of severe anaphylaxis occurred in less than 30 minutes in nearly every case; (3) 18 of 23 cases were associated with specific anatomical findings of anaphylaxis; (4) self-administered epinephrine was used in just 1 of 5 cases; and (5) serum total tryptase concentrations were elevated markedly in 4 of 7 cases tested.

Deaths due to foreign body aspiration in children: the continuing hazard of toy balloons.

Asphyxia due to aspiration of a foreign body is a common cause of accidental death in children. Foreign body aspiration is the most likely cause of accidental fatalities in children under 1-year-of-age. Children may die due to airway obstruction by food objects such as hot dogs, nuts, candies, grapes, seeds, and egg shells. Non-food objects such as balloons, coins, pop tops of beverage cans, pills, safety pins, ball bearings, marbles, and baby powder also may be fatally aspirated. To better understand and help prevent this well recognized health risk to children, we reviewed 10 years of cases at the Cook County Medical Examiners Office in which deaths in children 14-years-of-age and younger were due to aspiration of foreign objects. The most common item that caused fatal aspiration in our series was a toy balloon.

Circumstances surrounding deaths from asthma in Cook County (Chicago) Illinois.

The death rate from asthma has been increasing in the U.S. and in many other countries and is considered unacceptably high. There is little information as to circumstances surrounding these fatalities that would lead to effective interventions to prevent deaths. In this study, cases of asthma deaths from the Office of the Medical Examiner in Cook County, (Chicago), Illinois were identified in subjects 45 years of age or less who died from asthma. We reviewed clinical information surrounding the deaths, contacted surviving kin, friends, or informants, and reviewed autopsy findings and toxicologic results. Deaths were classified as (1) from asthma, (2) probably from asthma, (3) of indeterminate cause, and (4) coincidental to but not from asthma. From 39 cases from one pathologists cases of asthma deaths during 1985-1992, deaths were from or probably from asthma in 22/39 (56.4%) of cases. Eight (20.5%) cases were classified as indeterminate because of a positive or unknown asthma prodrome but in which toxicologic results were positive. Nine (23.1%) cases were classified as death coincidental to but not from asthma because of the absence of a prodrome of increased symptoms associated with positive toxicologic results. Overall from 23 cases where some toxicologic testing was performed, 14 (60.8%) were positive, individually or in combination, for cocaine, benzoylecgonine (cocaine metabolite), codeine, phencyclidine (animal tranquilizer), morphine, methadone, and ethanol (> 0.8 g/L). Out-of-hospital asthma deaths in 39 subjects were complicated by a high incidence of illicit drug use, lack of identifiable managing physicians, lack of antiinflammatory medications, and in some cases not having been examined by a physician in the past year.(ABSTRACT TRUNCATED AT 250 WORDS)

Air Embolism During Intercourse in Pregnancy

Air embolism may rarely cause sudden death during or shortly after pregnancy. Certain obstetric techniques, douching procedures, and blowing air into the vagina have been associated with this phenomenon. A case of venous air embolism in a pregnant woman occurring during sexual intercourse in a rear entry position is presented.

Multiple Mycotic Aneurysms and Transverse Myelopathy Complicating Repair of Aortic Coarctation

The case of an 18-year-old man with coarctation of the aorta discovered on routine physical examination and subsequently surgically repaired is reported. Four months postoperatively, aneurysms developed at the repair site and thrombosis of both femoral arteries was noted. Following an attempt to repair the aneurysm and remove the thrombi, the patient became paraplegic; Aspergillus fumigatus was found infecting the aorta and femoral vessels. After additional operations and a course of amphotericin B to control the fungal infection, the patient died of intrathoracic bleeding originating from infected, aneurysmally dilated intercostal vessels in the area of the original coarctation repair. The complicating fungal infection of the operative site and the paraplegia are discussed. This report is among the first to present a patient with fungal endarteritis complicating operation for coarctation of the aorta.

Pathological case of the month: sudden death in a child as a result of pancreatitis during valproic acid therapy.

Valproic acid is a widely used drug in the treatment of epilepsy and, compared to other anticonvulsant drugs, is considered safe. The most common side effects of valproic acid ingestion or therapy are transient nausea, vomiting, abdominal cramps, and diarrhea. Most of these complaints are mild. However, more serious adverse reactions can occur such as hepatotoxicity and pancreatitis. It has been proposed that, whenever possible, valproic acid not be used in the younger child, the child with a severe seizure disorder or other neurological disorders, mental retardation, developmental delay, organic brain disease, congenital abnormalities, or the child who is taking multiple anticonvulsant drugs, as these factors may increase the likelihood of hepatotoxicity and/or pancreatitis. In the present report, we describe a fatal case of acute hemorrhagic pancreatitis in a four and a half-year-old Hispanic female child who was receiving valproic acid in combination with another anticonvulsant drug for control of focal seizures. The patient also received the macrolide antibiotic azithromycin. For pediatricians and forensic pathologists valproic acid-induced pancreatitis can be a challenging diagnosis which must not be mistaken for abdominal trauma. We discuss the workup of the patient and differential diagnosis.

Sudden death in a neonate as a result of herpes simplex infection.

This paper describes a case of a neonate with disseminated herpes simplex born to a 14-year-old asymptomatic mother. The infants physical examination was normal at birth, and subsequent abnormalities were so subtle that infection was not recognized during life. Postmortem cultures of liver and spleen grew herpes simplex virus, and immunofluorescent direct antibody typing revealed Type 2. A cervical culture of the mother obtained after the infants death was negative.

Stomach Rupture by Infusion Pump and Foley Catheter

A nine-month-old girl who had successfully undergone surgery for esophageal atresia sustained a rupture of the stomach when an infusion pump was inadvertently connected to the balloon port of a Foley catheter being used as a gastrostomy tube. A strong similarity in appearance and feel of the balloon port and the drainage port of the catheter was created when a clear plastic adapter was inserted in the drainage port for connection of the pump tubing. Other factors contributing to the accident were poor lighting at the time of the connection, failure of the infusion pump occlusion alarm to activate at pressures low enough to prevent injury, and the reduced size of the childs stomach following surgery.