A case of persistent severe sequelae of COVID-19 infection: potential role in sudden death?

Depending on the stage of the disease, autopsy findings of COVID-19 may include a spectrum of cardiopulmonary pathologies including alveolar hyaline membrane formation, vascular thrombosis, and intracardiac thrombi. Identification of a COVID-19 positive decedent in the absence of clinical history relies primarily on post-mortem nasopharyngeal (NP) or oropharyngeal (OP) swabs for real time polymerase chain reaction (RT-PCR). In the absence of definitive microbiology testing, post-mortem computed tomography (PMCT) may be a powerful adjunct tool for screening. Persistence of pathological changes may prolong physiological alterations and increase the risk of cardiopulmonary compromise. This current case outlines the forensic presentation, utilization of screening tools including PMCT, and the autopsy findings of a recent toxicology related sudden death case in the context of severe sequelae of COVID-19 pneumonia. This case demonstrates the limitation of NP and OP swabs in the post-mortem setting, the value of PMCT as an adjunct screening tool, and raises the consideration of COVID-19 sequelae as a potential contributing risk factors in sudden death cases in the community.

Fatal Fluorosilicic Acid Exposure After a Motor Vehicle Crash: A Case Report.

ABSTRACT: Fluorosilicic acid (FSA) is a corrosive liquid used in manufacturing and other processes. High-level exposures to FSA cause fluoride toxicity resulting in profound hypocalcemia, potentially leading to sudden death. Prompt recognition of exposure risk allows appropriate environmental management precautions, reducing the risk of further casualties. Herein, we present a case report of death due to FSA exposure sustained during a motor vehicle crash involving a truck transporting the material and the management thereof.

Suicide Decapitation by a Detonating Cord: A Case Report.

In the field of forensic pathology, suicides consist of a considerable portion of the workload. Among the many methods used to commit suicide, using a detonation cord explosive is quite unique. We report the case of a man who committed suicide by detonation cord resulting in decapitation. This case report highlights the fact that the injury patterns observed in explosion-related deaths can be highly variable and that in cases with isolated injuries postmortem imaging and histology are an important adjunct to the standard death investigation. The ultimate goal of explosion-related investigations should be geared toward a well-documented and complete postmortem examination with the appropriate use of ancillary studies that provide a clear interpretation of the mechanism, cause, and manner of death.

Maternal and fetal death at 22 weeks following uterine rupture at the site of the placenta percreta in a C-section scar.

Placenta percreta is the abnormal invasion of the placenta through the myometrium and serosa of the uterus. It is the most invasive of the placenta accreta spectrum followed by placenta increta. This paper presents a case of a maternal and fetal death in the second trimester due to rupture of the uterus at the site of placenta percreta in a C-section scar. Postmortem MRI showed a large hemoperitoneum and thinning of the anterolateral uterine wall. Internal examination revealed two liters of blood in the abdomen and rupture of the anterolateral uterine wall at the site of placenta percreta in a previous C-section scar. Placenta percreta is a rare complication of pregnancy, however, it is becoming more common with the increasing rate of C-section, the most common and significant risk factor.

Delayed rupture of a vertebral artery laceration: a case report and challenges for the forensic pathologist.

Vertebral artery laceration/dissection (VALD) resulting in fatal subarachnoid hemorrhage (SAH) is a rare, but well-known phenomenon encountered in the forensic setting. Delayed ruptures are exceptionally rare, and pose several challenges to the forensic pathologist. In this paper we present a case of a 47-year-old male who collapsed suddenly following recent complaints of a headache and a reported seizure. He had a reported history of potential head trauma that occurred several days prior. Attempts at resuscitation were unsuccessful, and an autopsy examination was ordered. Computer tomography (CT), autopsy, histological and ancillary studies were performed. External examination showed mild, healing trauma to the head and upper limbs, and pre-autopsy CT demonstrated a SAH. Examination of the brain showed basally oriented SAH, and there was a laceration of the left vertebral artery. Histological examination demonstrated a delayed rupture, and there was no significant blood vessel abnormality. Molecular testing was negative for collagen vascular disorders. Delayed rupture of the vertebral arteries following head trauma is rare. The presence of remote and/or mild trauma may be difficult to establish at autopsy, and it is important to identify underlying aortopathies. Several autopsy techniques and ancillary studies should be performed in these cases.

Differentiation of antemortem pulmonary thromboembolism and postmortem clot with unenhanced MRI: a case report.

We report a case of a 39-year-old woman who died of fulminant pulmonary thromboembolism (PE). Autopsy showed classical findings of fulminant PE with occlusion of the bilateral main stem pulmonary arteries. Ancillary testing revealed inherited thrombophilia (Prothrombin 20,210 G > A and MTHFR 677 C > T mutation). Pre-autopsy postmortem computed tomography was used to test whether virtual imaging studies alone (virtual autopsy) would be sufficient to detect PE. Our studies show that computed tomography (CT) can differentiate antemortem clots from a postmortem clot in certain cases, particularly when combined with magnetic resonance imaging (MRI), which is superior in the assessment of soft tissue. We show that postmortem CT and MRI can aid in the diagnosis of pulmonary embolism by virtual autopsy, especially when used in conjunction.

Death of a Neonate With a Negative Autopsy and Ketoacidosis: A Case Report of Propionic Acidemia.

Facing a sudden neonatal death in the forensic setting brings to mind enormous differential diagnostic possibilities. This case report demonstrates that at times, when no anatomical cause of death is apparent after a postmortem examination, ancillary testing can lead to diagnosis. In this case, ancillary testing showed ketosis and further workup showed presence of propionic acidemia in a 3-day-old neonate.

Firsthand Experience in Graduating Three Cohorts of Forensic Pathologists Trained With Competency by Design (CBD) Curriculum.

INTRODUCTION: The University of Toronto experienced graduating three cohorts of forensic pathologists trained with Competency by Design (CBD) curriculum. We achieved this as a result of multiyear development of Entrustable Professional Activities (EPAs), Required Training Experience (RTEs), and Specialty Competency Requirements (SCRs) by the Royal College of Physicians and Surgeons of Canada's Forensic Pathology Speciality Committee, the Ontario Forensic Pathology Service, and the University of Toronto. METHOD: Our academic year is comprised of 13 blocks. We divided the 13-block period into 4 stages to map all the EPAs and RTEs. The first stage, Transition to Discipline, is 1 block, the second stage, Foundation of Discipline, consists of 3 blocks; the third stage, Core of Discipline, consists of 6 blocks, and the final fourth stage, Transition to Practice, consists of 3 blocks. Board-certified faculty members in Forensic Pathology with more than five years of experience supervised the trainees. We graduated 5 Canadian and 4 international trainees at the end of the third cycle of CBD-based training program. CONCLUSION: Using the Royal College Speciality Committee blueprint, the University of Toronto started in 2016 planning the CBD curriculum in the forensic pathology training program. By the end of June 2021, we graduated nine trainees from our CBD-based Forensic Pathology training program. We are training the fourth cohort, and they will be graduating at the end of June 2022. This article aims to share our firsthand experiencing in CBD training in forensic pathology.

Earth, Air, Water, and Fire: Histopathology of Environmental Death.

Interpretation of deaths in hostile environments may be informed by postmortem microscopic examination of injured tissues. In context with their macroscopic correlates, the commonly observed histologic changes seen in environmental deaths are reviewed-these include exposure (i.e., hypothermia and hyperthermia), fire, electrocution, and water. Rarely observed pathognomonic findings are highlighted. While it may not yield specific findings, microscopic examination is one of the necessary steps of a thorough postmortem examination.

Clinical Examination and Reporting of a Victim of Torture.

Torture is the most inhuman form of punishment. Forensic practitioners should be aware of the common forms of torture, their presentation, and the after effects. Forensic practitioners should examine victims and issue an impartial report to serve mankind in accordance with the United Nations organization. Clinical forensic medicine is the application of medical knowledge for the assessment of injuries in living persons for the purposes of administering justice. Unfortunately, the forensic examination of living individuals is a comparatively neglected field of forensic practice in some countries. In this article, common presentations of torture in the clinical forensic medicine setting are discussed, with special attention to physical forms of torture, common presentations, after effects of torture, and recognizing the difficulties encountered by refugee claims of torture victims. We also describe how to examine and report a victim of torture in clinical forensic medicine. It is a known fact that some of the refugee claimants who come before the refugee claim board have been subjected to torture. They are walking reminders of the worst ways people can treat to fellow human beings. It is sad to see some doctors still participate or collaborate with perpetrators and at the same time there are some reported cases of physicians being imprisoned due to reporting of torture victims in certain countries.

Sudden Death of a Young Man by Acute Hemorrhagic Leukoencephalitis.

We report a case of acute hemorrhagic leukoencephalitis in an adult man with a prodrome of "feeling unwell" two days prior to this death. At autopsy, external examination revealed minor external injuries including contusions on the scalp and left thigh and abrasions on the forehead and right eyebrow. Gross examination of the brain after coronal sectioning revealed multiple petechial hemorrhages in the white matter in the cerebral hemispheres, corpus callosum, basal ganglia, brainstem, and cerebellum. Microscopic examination of these lesions revealed demyelination, hemorrhage, and necrosis with fibrin exudation in a perivenular distribution with radial extension into the white matter. The remainder of the autopsy was unremarkable. This case highlights the death of a young man by a rare fatal complication of a natural disease only identified by a singular set of gross and microscopic findings at autopsy in circumstances that would otherwise suggest a nonnatural death. The case demonstrates the importance of a thorough autopsy in settings where the clinical history, scene, and circumstances may be misleading or absent.

Traumatic and other non-natural childhood deaths in Manitoba, Canada: a retrospective autopsy analysis (1989-2010).

OBJECTIVE: The goals of analyzing all non-natural childhood deaths in Manitoba for the 22-year period (1989-2010) are to highlight preventable causes of death and to document temporal trends that might be influenced by changes in society. METHODS: The 1989 to 2010 pediatric autopsy database at the Winnipeg Health Sciences Centre and records from the Office of the Chief Medical Examiner were searched for all non-natural deaths ≤ 18 years age. All files were reviewed in detail. Data collected included demographic characteristics, manner of death, details of cause and circumstances leading to death, and survival time after the event. RESULTS: For the 22-year period, the total number of non-natural childhood deaths after which autopsy was performed in Manitoba was 581 for males and 409 for females in a population of approximately 1.23 million (2010 estimate). This represents 22.1% of the total childhood deaths in Manitoba during the study period. A higher proportion of children living in rural and northern communities died from non-natural causes. Of all accidents, which peaked in 1999, road traffic incidents accounted for the majority. Of suicides, which peaked in 2005, hanging in the 15-18 year group accounted for almost all cases. Of homicides, child abuse deaths at <3 years age was the most frequent cause. For all causes, most individuals were dead at the scene or died shortly thereafter. CONCLUSIONS: Most non-natural childhood deaths in Manitoba might be avoidable through education about prevention strategies and by correction of social inequities. Improved transportation to hospital from remote locations would likely have little impact on survival.