Dwayne A. Wolf

The cardiac pendulum: Blunt rupture of the pericardium with strangulation of the heart

BACKGROUND Blunt injury of the pericardium with strangulation of the heart is a rare clinical injury. METHODS We conducted a review of clinical records and performed prospective collection of forensic data from a large urban medical examiners office. RESULTS Ten cases of blunt injury to the pericardium were identified. All were secondary to blunt trauma. Nine of the 10 cases had associated chest wall injuries and 5 of the 10 cases had cardiac strangulation. CONCLUSION Pericardial lacerations are common findings at autopsy. Clinically, those that survive to the hospital have a confusing presentation. They are often diagnosed during emergent thoracotomy for hemodynamic instability. Hemodynamic deterioration associated with change in patient position may be a clue to cardiac strangulation.

Death following minor head trauma in two adult individuals with the Chiari I deformity

Reports of sudden death associated with minor head trauma in adults with the Chiari I malformation are rare. We describe two such cases, occurring in a 71-year-old individual and in a 22-year-old individual. In both cases, postmortem examination revealed prominent cerebellar tonsillar herniation and, in one, associated tonsillar sclerosis and hydrocephalus. Evidence of trauma was minimal in both, and was not sufficient to explain these fatalities. We describe the neuropathologic findings and discuss the differential diagnostic considerations in these cases of sudden death. The implications regarding manner of death are also emphasized.

Uncertainties remain in the catabolism of valine

Abstract The oxidative degradation of valine is known to proceed through a methylmalonate semialdehyde intermediate to succinyl-CoA. Good evidence suggests that at least one C 3 intermediate is involved in the conversion of methylmalonate semialdehyde to succinyl-CoA. However, the details of this conversion, at least in higher organisms, remain unclear.

Postmortem findings in eight cases of influenza A/H1N1

In March and early April 2009, cases of a new swine-origin influenza A (H1N1) virus were diagnosed in Mexico and the United States. Influenza virus presents as a respiratory infection with high morbidity and mortality. We describe the postmortem findings of eight confirmed cases of influenza A/H1N1 in a medical examiner setting. The eight cases falling under the jurisdiction of the Harris County Medical Examiner (Houston, TX, USA) with confirmed influenza A/H1N1 infection between June and September 2009 were included in this study. All cases were males between 6 months and 54 years of age. All adult patients had a body mass index from 31 to 49.8 kg/m2. Five cases had comorbid conditions including one case with sleep apnea and mental retardation, three cases with chronic ethanolism, and one case with thymoma, sarcoidosis, and myasthenia gravis. The remaining three cases had no pre-existing medical conditions. All patients presented with severe flu-like symptoms; yet, only five were febrile. Rapid influenza diagnostic tests were performed in three cases by primary-care physicians, two of which were negative. None of the patients received antiviral medication. The average disease duration time was 8.2 days (3–14 days). A wide range of histopathological findings including tracheitis, necrotizing bronchiolitis, alveolitis, intra-alveolar hemorrhage, and hyaline membranes, both in a focal and in a diffuse distribution, were identified. Influenza A/H1N1 viral infection presents with a wide range of histological findings in a diffuse or focal distribution; most consistently with tracheitis, necrotizing bronchiolitis, and alveolitis with extensive alveolar hemorrhage. These histopathological findings at autopsy along with a clinical history of flu-like symptoms should raise suspicion for influenza A/H1N1 infection, and postmortem analysis by the reverse transcription-polymerase chain reaction (RT-PCR) is recommended for an accurate diagnosis.

Heimlich trauma: A violent maneuver

The Heimlich maneuver is a life-saving technique for dislodging foreign material from the respiratory tract. This report illustrates intraabdominal injuries, including a large mesenteric laceration, mesenteric contusions, and intraperitoneal hemorrhage, that occurred in a recipient of a vigorously applied Heimlich maneuver. The potential for confusing such injuries with homicidally inflicted injuries is emphasized.

Wischnewski ulcers and acute pancreatitis in two hospitalized patients with cirrhosis, portal vein thrombosis, and hypothermia

Accidental hypothermia has been described in the forensic literature but reports of occurrence in hospitalized patients are rare. Associated anatomic lesions include acute hemorrhagic pancreatitis and characteristic acute gastric ulcers termed Wischnewski ulcers. We report here two patients with cirrhosis and ascites; one also had hepatocellular carcinoma. Portal vein thrombosis, acute hemorrhagic pancreatitis and Wischnewski ulcers were present in both. The clinical records documented hypothermia that progressed over several days. Temperature nadirs of 31.0 degrees C (87.8 degrees F) and 32.2 degrees C (90.0 degrees F) were recorded in each patient, respectively, one day before death, although each transiently reached temperatures that did not register on standard monitoring devices. This is the first report that chronicles antemortem body temperatures in hypothermic patients with Wischnewski ulcers and pancreatitis at autopsy. Also, the association of these findings with portal vein thrombosis and cirrhosis has not been previously described. We discuss this constellation of findings with regard to possible mechanistic interrelations.

Sudden Death Following Rupture of a Right Ventricular Aneurysm 9 Months After Ablation Therapy of the Right Ventricular Outflow Tract

WOLF, D.A., et al.: Sudden Death Following Rupture of a Right Ventricular Aneurysm 9 Months After Ablation Therapy of the Right Ventricular Outflow Tract. Aneurysm formation has not been previously described as a complication of radiofrequency ablation. A 49‐year‐old woman with Wolff‐Parkinson‐White Syndrome underwent ablation of abnormal conduction pathways in Kochs triangle and in the outflow tract of the right ventricle. Nine months after the procedure, she died suddenly, and was found at autopsy to have a hemopericardium due to rupture of an aneurysm in the right ventricular outflow tract. The gross and histological features of the aneurysm suggest that it developed because of radiofrequency ablation. The possibility of this potentially fatal complication should be considered during follow‐up evaluation of ablation therapy patients.

Hyperostosis Cranii Ex Vacuo in Adults: A Consequence of Brain Atrophy from Diverse Causes

Hyperostosis cranii ex vacuo is diffuse thickening of the bones of the cranium occurring after successful ventricular shunting in hydrocephalic children, presumably as a compensatory phenomenon. We present three adults with severe brain atrophy and correspondingly severe skull thickening. In each, the cause of cerebral atrophy was well defined, and none had undergone ventricular shunting. In two, brain atrophy resulted from different temporally discrete insults sustained in adult life, ischemic in one and traumatic in the other. In the third case. progressive brain atrophy resulted from a primary neurodegenerative disorder, Hallervordan Spatz disease. Our observations suggest that hyperostosis cranii ex vacuo is a more general phenomenon than has been previously recognized, and point to a relationship between dynamic changes in brain size and skull thickness. We suggest that such relationships should be taken into account in anthropometric evaluation of the skull.

Undetermined cause and manner of death after organ/tissue donation.

The Harris County Medical Examiners Office (HCME) is proactive and supportive with regard to organ and tissue donation. Steps taken to facilitate donation include development of standardized multiagency protocols for organ/tissue requests and transfer of decedents out of the facility for tissue recovery prior to autopsy. The organ/tissue agencies have 24-hour access to a liaison staff member. No blanket denials are issued for any case type; instead each case is evaluated for feasibility of donation. In rare instances donation of one or more organs is considered detrimental to the mission of determining cause and manner of death. In these cases, the HCME requests that specific organ(s) not be recovered. In this jurisdiction, the organ procurement organization often proceeds with organ recovery despite medical examiner objection. In such cases, the autopsy examination is incomplete and the cause of death cannot be determined. A series of 5 organ donation cases are presented for illustration. Four of these cases are infant deaths in which the HCME requested specific organs not be donated. In the fifth case no denial was issued, but release was granted on incomplete or erroneous information. The cause and manner of death in each case remains undetermined.

Incarceration and the acquired immunodeficiency syndrome: Autopsy results in Texas prison inmates

The Texas Department of Criminal Justice (TDCJ) houses many subjects with acquired immunodeficiency syndrome (AIDS) who receive medical care in a comprehensive AIDS treatment center. In this case-control autopsy survey, we compared pathological outcomes of TDCJ inmates treated at the center (n = 155) with nonincarcerated patients who died during the same period (n = 155). Using multiple regression analysis and a proportional hazards model, survival time in the prisoners was equivalent to that in the controls. With few exceptions, the prevalences of opportunistic viral, fungal, protozoal, and bacterial infections contributing to mortality were equivalent between groups. Mycobacterium tuberculosis was isolated more frequently in the inmates, and M avium intracellulare was isolated less frequently (P < .0001). The inmates had a higher prevalence of bacterial infection of the central nervous system (CNS) (9.1% v 1.4%; P < .006); half of all CNS bacterial infections were caused by M tuberculosis. Inmates had significantly lower prevalences of vacuolar myelopathy (P < .006) and severe wasting disease (P < .0009). We conclude that survival of prison inmates with AIDS treated in a comprehensive AIDS treatment center was equivalent to that of nonincarcerated subjects with AIDS. Prevalences of certain complications of AIDS differed in the inmates, showing that the prison environment influenced some of the underlying causes of AIDS morbidity and mortality.