First Identified Case of Fatal Fulminant Necrotizing Eosinophilic Myocarditis Following the Initial Dose of the Pfizer-BioNTech mRNA COVID-19 Vaccine (BNT162b2, Comirnaty): an Extremely Rare Idiosyncratic Hypersensitivity Reaction.

RATIONALE: Transient myopericarditis has been recognised as an uncommon and usually mild adverse event predominantly linked to mRNA-based COVID-19 vaccines. These have mostly occurred in young males after the second dose of mRNA COVID-19 vaccines. OBJECTIVES: Fulminant necrotising eosinophilic myocarditis triggered by a variety of drugs or vaccines is an extremely rare hypersensitivity reaction carrying a substantial mortality risk. Early recognition of this medical emergency may facilitate urgent hospital admission for investigation and treatment. Timely intervention can lead to complete cardiac recovery, but the non-specific clinical features and rarity make early diagnosis challenging. FINDINGS: The clinical and pathological observations from a case of fatal fulminant necrotising myocarditis in a 57-year-old woman, following the first dose of the Pfizer-BioNTech vaccine, are described. Other causes have been discounted with reasonable certainty. CONCLUSION: These extremely rare vaccine-related adverse events are much less common than the risk of myocarditis and other lethal complications from COVID-19 infection. The benefits of vaccination far exceed the risks of COVID-19 infection.

Heart Weight Is an Independent Factor Associated With, But Is a Poor Predictor for, Sudden Cardiac Death.

ABSTRACT: An enlarged heart can cause electrical instability and impaired contractility, leading to fatal arrhythmia and acute heart failure, and is associated with sudden cardiac death. However, there is limited postmortem evidence on whether heart weight is an independent factor associated with sudden cardiac death. This 18-month retrospective study examined 108 adult heart weights in which all the hearts were weighed after dissection, blood and blood clots removed, rinsed in water, and pat dried. The multivariate logistic regression analysis showed heart weight was an independent factor associated with sudden cardiac death. However, after normalization, the heart weight was a poor predictor of sudden cardiac death with an area under the curve less than 0.7 in the plotted receiver operating characteristic curve.

An analysis of child suicide from three centers (2008-2017).

Although the overall suicide rate worldwide has changed minimally over the past 100 years, different trends have been observed over time in the USA, Australia, and New Zealand (NZ). However, few studies have focused on suicides in children (< 18 years), making evaluation of possible trends difficult. The last 20 years has also seen an increase in childhood obesity, eating disorders, and body image issues for children in many developed nations; however, few studies have shown whether a significant proportion of child suicides have an abnormal BMI. The current study evaluates child suicides (from 2008 to 2017) in South Australia (Australia), compared with the jurisdictions of Auckland (NZ) and Hennepin County (USA). Demographic data (age, sex, ethnicity), body mass index (BMI), the number of cases of youth suicide, and the method of suicide from these three regions were collected and analyzed. Across the 10-year period, the jurisdiction of Auckland had a downward trend, while Hennepin County and South Australia had increasing numbers of cases. The most common method of child suicide in all centers was hanging, occurring in > 80% of cases in South Australia and Auckland and 56% in Hennepin County. Hennepin County had a greater proportion of suicides using firearms (28%), compared to 1.9% in Auckland and 5.1% in South Australia. Unusual means of suicide were used less frequently by youth than previously.

Sudden cardiac deaths have higher proportion of left stellate ganglionitis.

One of the hypothesized mechanisms of sudden cardiac death in humans is an arrhythmia precipitated by increased sympathetic outflow to a compromised heart. The stellate ganglia provide the main sympathetic innervation to the heart, where the left stellate ganglion appears to play a role in arrhythmogenesis. Case reports of sudden cardiac death have described left stellate ganglion inflammation but no larger studies have been performed. Thus, we have specifically assessed whether the left stellate ganglion was inflamed in those dying from sudden cardiac death versus other causes of death. Thirty-one left stellate ganglia were resected from cadavers diagnosed with sudden cardiac deaths and compared with 18 ganglia from cadavers diagnosed with non-sudden cardiac deaths. Ganglia were stained with hematoxylin and eosin and lymphocytic aggregates compared. The proportion of left stellate ganglion inflammation (77%) was significantly higher in deaths from sudden cardiac deaths than non-sudden cardiac deaths (33%). This study provides information on a previously recognized, but understudied, structure that may help understand sudden cardiac death. We found high prevalence of stellate ganglion inflammation and propose that this may trigger sympathetic storms.

Hemorrhagic Pseudocyst: A Rare Cerebral Mass Lesion Causing Death. A Case Report and Brief Review of Literature.

ABSTRACT: Mass lesions in the brain encompass a wide range neoplastic and nonneoplastic entities. These can present as a diagnostic pitfall, with nonspecific, overlapping symptoms and similar appearances on radiology. They may cause death through varied mechanisms, either specific to the underlying pathophysiology or due to the space-occupying effect of the lesion. We report a case of fatal hemorrhagic cerebral pseudocyst, a rare mass lesion, associated with a cerebral varix, causing death in a morbidly obese individual. To the best of our knowledge, there is no previous documentation in the postmortem literature of this entity as a cause of death. This case aims to document this rare entity in the differential diagnosis of a tumor-like lesion in the brain, highlight the clinical difficulty in its assessment, and demonstrate an uncommon mechanism of death, of a mass lesion acting as a focus causing seizures, with resulting hypoxia due to effects of morbid obesity and heart failure.

Terminal Ileum Perforation: A Rare Complication of Verocytotoxigenic Escherichia coli Infection in an Adult With Prader-Willi Syndrome.

ABSTRACT: Intestinal perforation is an uncommon complication and presentation of verocytotoxigenic Escherichia coli (VTEC) infection in individuals with Prader-Willi syndrome (PWS). The common site of perforation from VTEC infection is in the colon (and almost exclusively in the pediatric population), whereas PWS is in the stomach. Terminal ileum perforation is uncommon and is not reported in either these 2 conditions. We report a death from terminal ileum perforations in an adult who had PWS and was infected with VTEC. Potential reasons why the perforation occurred at this rare location, rather than in other more common location, in an adult are discussed.

A 5-Year Retrospective Study on Infant Homicide Presenting as Cot Death: Are We Missing Infant Homicides?

ABSTRACT: Being found dead in cot or bed is the most common presentation encountered with infant deaths. These deaths are often associated with unsafe sleep environment. The postmortem examination in such cases is often negative, and along with family objections, cultural, and other factors, may lead to a coroner considering not authorizing a postmortem examination. However, not identifying a homicide is a potential risk if a postmortem examination is not performed. This 5-year retrospective study investigated the proportion of infant homicide death initially presenting as cot death. Of a total of 103 cases of infants initially presenting as being found dead in cot or bed, 3 (approximately 3%) were classified as homicides after postmortem examination. During the study period, a total of 9 infant homicides were reported, translating to 33% (3 of 9) of infant homicides presented as cot deaths. Postmortem radiology was a valuable adjunct, but was unable to recognize 2 of the homicide cases with traumatic head injuries (with subdural hemorrhage and brain injury only). We strongly advocate that all infant deaths presenting as cot death require a full postmortem examination.

Classifying Microscopic Acute and Old Myocardial Infarction Using Convolutional Neural Networks.

ABSTRACT: Convolutional neural network (CNN) has advanced in recent years and translated from research into medical practice, most notably in clinical radiology and histopathology. Research on CNNs in forensic/postmortem pathology is almost exclusive to postmortem computed tomography despite the wealth of research into CNNs in surgical/anatomical histopathology. This study was carried out to investigate whether CNNs are able to identify and age myocardial infarction (a common example of forensic/postmortem histopathology) from histology slides. As a proof of concept, this study compared 4 CNNs commonly used in surgical/anatomical histopathology to identify normal myocardium from myocardial infarction. A total of 150 images of the myocardium (50 images each for normal myocardium, acute myocardial infarction, and old myocardial infarction) were used to train and test each CNN. One of the CNNs used (InceptionResNet v2) was able to show a greater than 95% accuracy in classifying normal myocardium from acute and old myocardial infarction. The result of this study is promising and demonstrates that CNN technology has potential applications as a screening and computer-assisted diagnostics tool in forensic/postmortem histopathology.

Differences Between Central and Peripheral Postmortem Tryptase Levels.

ABSTRACT: Postmortem tryptase is a commonly used biochemical test to aid in the diagnosis of fatal anaphylaxis, which is currently recommended to be sampled from peripheral (femoral) veins because of a research showing comparatively elevated levels from central blood sources. Previous studies have used nonstandardized or nondocumented sampling methods; however, more recent research demonstrates that tryptase levels may vary depending on the sampling method. This study used the recommended sampling method of aspirating the femoral vein after clamping and compared in a pairwise comparison with aspiration of central venous and arterial blood sources (inferior vena cava and aorta) in 2 groups of 25 nonanaphylactic deaths. We found no statistically significant differences in postmortem tryptase between central and femoral vein blood; however, sporadic outliers in central blood (particularly aortic blood reaching levels above documented cutoffs for fatal anaphylaxis) were observed. Our findings provide evidence for the existing recommendations that femoral vein blood remains the preferred sample for postmortem tryptase over central blood.

Ruptured Esophageal Varices From Metastatic Tumor in the Liver: A Case Report and Brief Review of Literature.

Ruptured esophageal varices can present as sudden death from gastrointestinal hemorrhage. The most common underlying pathology causing esophageal varices is cirrhosis leading to portal hypertension. However, not all esophageal varices arise from portal hypertension, and not all portal hypertensions are caused by cirrhosis. We present a rare case of ruptured esophageal varices casing death in an individual with metastatic tumor (high-grade) neuroendocrine tumor in the liver causing portal hypertension. This is, to the best of our knowledge, the first case report in the literature reporting a neuroendocrine tumor causing esophageal varices. This case report aims to document this rather rare entity, highlight another mechanism on how metastatic disease can result in sudden death, and give a brief review of literature on metastatic tumor in the liver causing esophageal varices.

Ventricular Weight Increases Proportionally With Total Heart Weight in Postmortem Population.

Heart weight is routinely measured at postmortem examination and is critical to determine whether the heart is enlarged (ie, cardiomegaly). Cardiomegaly has the potential to cause sudden death by being electrically unstable, resulting in fatal arrhythmias. The majority of fatal cardiac arrhythmias is ventricular in origin and is assumed that ventricular size is disproportionately larger in cardiomegaly. This prospective study compared ventricular weight (VW) and total heart weight (THW) in 40 consecutive cases. The results, unexpectedly, showed that VW increases proportionally and linearly with THW in normal and enlarged hearts (THW, >500 g) and did not increase disproportionally with increased THW. The ratio of VW/THW did not have any significant correlation or difference with sex, height, weight, and cardiac causes of death but did have a negative correlation with age. Further studies are indicated to document the morphological changes when the heart enlarges, which may aid in understanding the pathophysiology of sudden death from cardiomegaly.

Combining Postmortem Cerebrospinal Fluid Biochemistry With Lung-to-Body Ratio to Aid the Diagnosis of Salt Water Drowning.

Diagnosing drowning as a cause of death can pose many challenges for the forensic pathologist and a number of ancillary tests have been proposed to assist in the diagnosis, whether the body was in salt water or fresh water. Although elevated vitreous humor sodium and chloride is a reliable marker, its limitation to prolonged immersion has resulted in the recent investigation of cerebrospinal fluid (CSF) sodium and chloride as alternative matrix in cases of longer or unknown immersion times. This study investigated postmortem CSF from lumbar puncture (CSF_L_Na_Cl) and ventricular aspiration (CSF_Vent_Na_Cl), as well as lung/body (LB) ratio in the diagnosis of salt water drowning and performed comparison and combination testing of methods to improve diagnostic accuracy of the drowning diagnosis. This study found that CSF_L_Na_Cl was the most accurate method (89%) in the given cohort, but that CSF_Vent_Na_Cl and LB combined was the second most accurate method (83%), exceeding CSF_Vent_Na_Cl (77%) and LB (81%) used alone. These findings are useful for stratifying and prioritizing postmortem samples in the investigation of salt water drowning and also have significance for future studies using this methodology to combine and compare the accuracy of different investigations.

Black Esophagus (Acute Necrotizing Esophagitis) and Wischnewsky Lesions in a Death From Diabetic Ketoacidosis: A Possible Underlying Mechanism.

Acute esophageal necrosis (AEN), also known as black esophagus, is a rare clinical entity. It is recently described to be associated with diabetic ketoacidosis (DKA) in a few case reports. Wischnewsky lesions (WLs) are a classic postmortem finding seen in fatal hypothermia but are recently described to be associated with DKA. Interestingly, the pathogenesis and morphology of AEN and WLs appear to share similar characteristics. Both AEN and WLs are reported to be seen simultaneously in hypothermic deaths and deaths related to alcohol abuse, but not in DKA. We report a death in a 67-year-old woman who died of DKA. At postmortem examination, the esophagus and stomach showed AEN and WLs, respectively. Although not previously reported together, both AEN and WLs have separately been described in cases of DKA. This case raises a possible unifying etiology of AEN and WLs in DKA (and probably also in hypothermic deaths and deaths related to alcohol abuse), manifested in different parts of the gastrointestinal tract.

Neisseria meningitidis Isolated in Vitreous Humor in a 5-Month-Old Infant Death From Meningococcal Sepsis.

Diagnosing sepsis at postmortem is challenging. With respect to meningococcal sepsis, the postmortem microbiological identification of Neisseria meningitidis is nearly always due to true infection, including in cases of decomposition. Previous case series and case reports were able to isolate N. meningitidis in vitreous humor in adult deaths from meningococcal sepsis when blood and/or cerebrospinal fluid was unavailable. It was suggested that vitreous humor polymerase chain reaction (PCR) may be useful in the diagnosis of meningococcal sepsis. We describe a fatal case of meningococcal sepsis in a 5-month-old infant where N. meningitidis was detected in vitreous humor, cerebrospinal fluid, and blood through PCR. The presented case report gives further evidence in the potential use of vitreous PCR analysis in suspected meningococcal sepsis, particularly in the pediatric population.

Biochemical Differences Between Vitreous Humor and Cerebral Spinal Fluid in a Death From Diabetic Ketoacidosis.

Biochemical analysis of cerebrospinal fluid (CSF) and vitreous humor (VH) forms an important diagnostic ancillary test at autopsy. Cerebrospinal fluid can be sampled from the ventricular system (VA) and from lumbar puncture (LP), whereas VH can be sampled from the orbits. Biochemical electrolytes seem to vary between VH and CSF collected from different sites, but whether there is any difference in glucose and ß-hydroxybutyrate is unclear. We present a case report of a 21-year-old man who died of diabetic ketoacidosis confirmed at autopsy. Ventricular system, LP, and VH were biochemically analyzed and showed that glucose was highest in VH (41 mmol/L) and was 6 and 8 mmol/L higher than CSF in the LP and VA, respectively. ß-Hydroxybutyrate was also highest in VH (20 mmol/L) and was 5 and 6 mmol/L higher than LP and VA, respectively. Our findings suggest that postmortem CSF glucose and ß-hydroxybutyrate may not truly reflect that of VH and vary between CSF sampling sites.

Elevated Cerebrospinal Fluid Sodium and Chloride Levels in a Saltwater Drowning Death.

To ascribe a cause of death from drowning in a body immersed in water can be difficult because of the absence of specific postmortem findings and unreliable ancillary tests. Postmortem vitreous biochemical analysis is documented to be a useful adjunct ancillary test to aid the diagnosis of saltwater drowning. A major confounding factor in using postmortem vitreous is the effect of electrolyte diffusion and water osmosis during immersion. A recent animal study suggested that cerebrospinal fluid (CSF) biochemical analysis, which is unaffected by immersion, may be an alternative. However, to date, there are no human data to support this. We report a saltwater drowning death from presumed suicide in which the postmortem CSF sodium and chloride level was elevated compared with nonimmersion deaths. This case gives evidence to support the potential use of postmortem CSF sodium and chloride level as an adjunct to the diagnosis of saltwater drowning.

Rapid Streptococcus Pneumonia Antigen Detection on Postmortem Urine in a Death Due to Pneumococcal Meningitis.

Streptococcus pneumoniae is the leading cause of adult bacterial meningitis. Differing from Neisseria meningitidis (the second most common cause of acute bacterial meningitis), contact tracing and chemoprophylaxis are not required. At postmortem, the differentiation between S. pneumoniae and N. meningitidis is traditionally done by culture and polymerase chain reaction performed on blood or cerebrospinal fluid, but may take hours, if not days, to analyze. We present a death from bacterial meningitis in a 73-year-old woman in which a rapid urinary pneumococcal antigen testing was able to identify S. pneumoniae as the causative organism within 1 hour. This was confirmed by subsequent brain swab culture. The rapid urinary pneumococcal antigen test in the case prevented the need for contact tracing and chemoprophylaxis. This case highlights the potential use of this test to rapidly identify the culprit organism at postmortem examination when acute bacterial meningitis is detected.

Postmortem Tryptase Level in 120 Consecutive Nonanaphylactic Deaths: Establishing a Reference Range as <23 µg/L.

Postmortem tryptase is a useful biochemical test to aid the diagnosis of anaphylaxis. Multiple perimortem and postmortem factors have been documented to cause an elevation in postmortem tryptase level. One factor that was recently recognized to have an impact on postmortem tryptase level is correct sampling technique. A recent study recommended aspirating blood samples from a clamped femoral/external iliac vein to be used for reliable postmortem tryptase analysis. This study sampled 120 consecutive nonanaphylactic deaths in which all the peripheral bloods were sampled as recommended. Postmortem interval, resuscitation, different nonanaphylactic causes of death, sex, and age did not show any statistical significant relation to postmortem tryptase level in Student t test, Pearson correlation, and univariate and multivariate analyses. The mean (SD) postmortem tryptase level was 8.4 (5.2) µg/L (minimum, 1.0 µg/L; maximum, 36.1 µg/L; median, 7.3 µg/L). Using nonparametric methods, the postmortem tryptase reference range in nonanaphylactic death was established as <23 µg/L (97.5th percentile).

Elevation of Postmortem Cerebrospinal Fluid Sodium and Chloride Levels Is a Potential Adjunct Test in the Diagnosis of Salt Water Drowning.

Postmortem vitreous humor biochemistry is a useful test in the diagnosis of salt water drowning (SWD). A significant limitation of vitreous humor is the potential effect of prolonged immersion. A recent animal study and case report suggested that cerebrospinal fluid biochemistry may be an alternative to vitreous because it is more resistant to the effects of immersion, given its protected anatomical location. This study compared postmortem cerebrospinal fluid sodium and chloride (PMCSC) levels collected via ventricular aspiration (PMCSC_V) and via lumbar puncture (PMCSC_L) in 13 SWD and 31 nonimmersion deaths. It showed a significant elevation in PMCSC levels in SWD deaths for both PMCSC_V and PMCSC_L (P < 0.05). The areas under the curve on the receiver operating characteristic curves for PMCSC_V and PMCSC_L were 0.73 and 0.83, respectively. The optimal cutoff for PMCSC_V was 216 mmol/L (sensitivity, 0.60; specificity, 0.72; likelihood ratio, 1.80; positive predictive value, 0.45) and for PMCSC_L was 241 mmol/L (sensitivity, 0.78; specificity, 0.73; likelihood ratio, 2.89; positive predictive value, 0.46). This study supports PMCSC levels as another biochemical test that can potentially aid in the diagnosis of SWD, particularly in cases where vitreous humor samples are unavailable or uninterpretable.

A Rare Case of Hemopericardium From a Ruptured Dissecting Pulmonary Artery Aneurysm: Postmortem Computed Tomography Scan and Autopsy Findings.

Nontraumatic hemopericardium is a potentially fatal pathology that is most commonly caused by myocardial wall rupture, ruptured aortic dissection, aortic aneurysm rupture, or a neoplastic process. A rare potential cause of hemopericardium is pulmonary artery dissection, with less than 100 reported cases in the literature. Pulmonary artery dissection is associated with pulmonary artery aneurysm, pulmonary artery hypertension, and congenital heart disease. We report a fatal case of nontraumatic hemopericardium caused by a ruptured dissecting pulmonary artery aneurysm in a 16-year-old girl with patent ductus arteriosus. The unenhanced postmortem computed tomography performed before autopsy was able to identify a large hemopericardium with a pulmonary artery aneurysm and lifting of mural calcification suggestive of a dissecting aneurysm. This enabled the pathologist to locate the exact rupture site that caused the hemopericardium.