Sarathchandra Kodikara

Uneventful Recovery from Suicidal Hanging

Although hanging accounts for a considerable number of suicidal deaths in Sri Lanka, on rare occasions the victims survive. A few cases have been reported in the literature where victims survived after varying periods of unconsciousness. It has been observed that death does not necessarily result from hanging, provided the victim is brought down promptly and resuscitated actively and vigorously. This paper focuses on an unusual case of a 39-year-old male who survived after resuscitation, without any adverse neurological outcome, after a suicide attempt by hanging.

Mechanisms of delayed splenic rupture: A new hypothesis

A 46-year-old man was assaulted with a club to the face, chest and abdomen. On admission there were no signs of circulatory shock. The abdominal examination was unremarkable. During his stay in hospital he had light diets. He was managed symptomatically and discharged 5 days after the incident. Two hours after discharge he was admitted again with a complain of severe abdominal pain. Immediately after a heavy diet, he experienced this abdominal pain. On admission, he was pale with features of circulatory shock. There was a marked tenderness with rigidity and guarding on abdominal palpation. Without a proper diagnosis he was pronounced dead 13 h after admission. Autopsy revealed a haemoperitoneum. A haematoma was seen overlying a splenic laceration on the gastric area of the visceral surface. The body of the empty stomach was in contact with this haematoma. Histological examination confirmed the perisplenic haematoma of otherwise normal spleen. The pressure exerted by full stomach after heavy solid meals may disturb perisplenic haematoma overlying a laceration on the gastric surface of the spleen causing delayed splenic rupture leading to sudden fatal intraperitoneal haemorrhage.

Bilateral pulmonary artery aneurysms

Pulmonary artery aneurysms are rare. The estimated incidence is 1 in 14,000 in autopsies. Bilateral main pulmonary artery aneurysms have not been previously reported in the literature. A 36-year-old woman who has been diagnosed as having an ostium secundum defect with severe pulmonary hypertension was found dead. Autopsy revealed an emaciated body. The heart was enlarged. Right atrium and ventricle were dilated. There were bilateral unruptured main pulmonary artery aneurisms. Atheromatous plaques of the pulmonary artery were seen. There was no thrombosis. Histology confirmed the pulmonary artery aneurysm and pulmonary atheroma. The cause of death was concluded as right heart failure due to bilateral main pulmonary artery aneurisms caused by an ostium secundum defect of the heart.

Strychnine in amoxicillin capsules: A means of homicide

Fatal strychnine poisoning is uncommon. It is no longer used as a therapeutic drug and its availability to the public is controlled by legislations in various jurisdictions, but it is still in use as a rodenticide and an adulterant in street drugs. Homicide by strychnine is extremely rare. As the autopsy findings are subtle, strychnine poisoning could easily be overlooked and a homicide may go undetected. This communication highlights an unusual case of homicide by strychnine. It is important that in deaths where there are no gross autopsy findings, sudden death in particular, that routine toxicology be performed, in which strychnine is likely to be detected.

Practice of clinical forensic medicine in Sri Lanka: Does it need a new era?

Clinical forensic medicine is a sub-specialty of forensic medicine and is intimately associated with the justice system of a country. Practice of clinical forensic medicine is evolving, but deviates from one jurisdiction to another. Most English-speaking countries practice clinical forensic medicine and forensic pathology separately while most non-English-speaking countries practice forensic medicine which includes clinical forensic medicine and forensic pathology. Unlike the practice of forensic pathology, several countries have informal arrangements to deal with forensic patients and there are no international standards of practice or training in this discipline. Besides, this is rarely a topic of discussion. In the adversarial justice system in Sri Lanka, the designated Government Medical Officers practice both clinical forensic medicine and forensic pathology. Practice of clinical forensic medicine, and its teaching and training in Sri Lanka depicts unique features. However, this system has not undergone a significant revision for many decades. In this communication, the existing legal framework, current procedure of practice, examination for drunkenness, investigations, structure of referrals, reports, subsequent legal procedures, undergraduate, in-service, and postgraduate training are discussed with suggestions for reforms.

Pericardium: An exceedingly rare site for a primary biphasic synovial sarcoma

Pericardial neoplasms are rare. Among pericardial neoplasms, metastatic spread is more common and primary synovial sarcomas of the pericardium are exceedingly rare. A 61-year-old man was found dead in bed. Autopsy revealed the cause of death as atherosclerotic and hypertensive heart disease. There was a pericardial soft tissue mass lying predominantly over the left atrium. The cut surface was bulging out and grayish white in color with cystic changes. Microscopy showed spindle cells in densely cellular fascicles surrounding the epithelial cells. The epithelial cells were cuboidal and formed glandular structures and cleft-like spaces. Immunohistochemistry demonstrated cytokeratin and vimentin positivity in the spindled areas. Molecular analysis confirmed the diagnosis. Synovial sarcoma may be mistaken for other common neoplasms occurring in the pericardium due to its rarity. In all cases of pericardial tumors, a diligent search for synovial sarcoma by way of histological analysis including, immunohistochemistry and molecular analysis is indicated.

Left-sided ventricular cardiomyopathy with minimal right ventricular involvement

Left-sided ventriclular arrhythmogenic cardiomyopathy is rare and represents a rather different expression of the arrhythmogenic right ventricular (RV) cardiomyopathy (ARVC). Among sudden cardiac deaths, ARVC plays a significant role. ARVC is considered as a cardiomyopathy of unknown aetiology that primarily involves the right ventricle (RV) and is characterized by progressive replacement of myocytes by fibro-fatty tissue, complicating a spectrum of arrhythmias. Predominant ARVC with left ventricular (LV) involvement is also reported. The LV variant of arrhythmogenic cardiomyopathy with minimal or no RV involvement is rare. A 31-year-old previously healthy young man, without a significant family history, was found dead in bed. Autopsy revealed an enlarged heart and asymmetrical LV hypertrophy with widely patent coronary arteries. LV myocardium demonstrated evidence of prominent epicardial fibro-fatty tissue that is predominantly fatty in nature and infiltrates into the myocardium. Microscopy of the LV free wall showed fibro-fatty tissue infiltration into the epicardial aspect of the LV that extends well into the mid-myocardium. A moderate to marked degree of interstitial fibrous tissue deposition was noted about adipocytes and cardiomyocytes. There was no evidence of chronic ischaemic changes or of significant myofibre disarray. The RV showed minimal fibro-fatty infiltration with normal myocytes. This report highlights a rare case which confirms previous observations that the LV variant of arrhythmogenic cardiomyopathy could occur with minimal or no involvement of the RV. Further studies are required in this context to elicit the spectrum and the exact nature of this disease.

A Death Following Hemopericardium Due to Rupture of a Right Ventricular Aneurysm Due to a Congenital Ventricular Septal Defect

Right ventricular aneurysm (RVA) is a rare clinicopathological entity. Although it occurs as a consequence of a variety of conditions, congenital ventricular septal defect (VSD) as an etiology for the RVA has not been previously reported. A 42‐year‐old man without a significant family or past medical history was found dead in bed. At autopsy, the internal examination revealed a hemopericardium of 280 mL. There was a 1.5 cm diameter ruptured aneurysm of the free wall of the right ventricle. A VSD was present in the lower part of the muscular interventricular septum. The RVA was directly facing to the VSD without any obstruction in between. Microscopically the wall of the aneurysm consisted only of a thin layer of fibrous tissue transmurally with minimal interspersed cardiomyocytes. Cause of death was concluded as hemopericardium following rupture of RVA caused by a congenital VSD.