Large multifocal cardiac myxoma causing the sudden unexpected death of a 2-month-old infant--a rapidly growing, acquired lesion versus a congenital process?: a case report.

We report the occurrence of a clinically undiagnosed biatrial myxoma with left ventricular involvement in a 2-month-old male infant, resulting in sudden death. During a routine well-baby examination, a grade (34) holosystolic murmur was detected at the left sternal border with radiation to the axilla and back. On the following day, the patient collapsed and died suddenly. An autopsy revealed a large multifocal neoplasm diffusely involving the aortic valve while displaying mitral, tricuspid, and left ventricular extensions. The ensuing histopathologic and immunohistochemical studies were diagnostic for myxoma. We discuss the occurrence of cardiac myxoma within the pediatric population and review the literature as to theorize whether this lesion was a congenital process versus a rapidly growing tumor that developed after the child was born. Lastly, we address the potential for sudden death in patients with such tumors.

Sudden death from massive gastrointestinal hemorrhage associated with crack cocaine use: case report and review of the literature.

Cocaine is associated with many health complications including gastrointestinal ischemia/infarction, and hemorrhage. The clinical medical literature describes such entities, but no case exists within the forensic literature describing life-threatening intraluminal gastrointestinal hemorrhage and sudden death associated with cocaine. A 48-year-old black man died suddenly in his home, with drug paraphernalia near the body. Further investigation revealed blood stains on upholstery, and a toilet filled with fresh blood. External examination of the body revealed fresh blood draining from the anus. Internal examination revealed a dusky portion of distal ileum filled with an abundance of fresh blood. Toxicology confirmed the suspicion of acute cocaine intoxication.Review of the clinical literature revealed several case reports describing an association between cocaine use and intestinal infarction, one with hemoperitoneum. Review of the forensic literature returned one case describing an association between cocaine toxicity and intestinal infarction, but without hemorrhage. To our knowledge, our case represents the first report in the forensic literature describing massive gastrointestinal hemorrhage associated with acute cocaine intoxication. It is important that the forensic pathologist recognize cocaine toxicity as a potential cause of gastrointestinal bleeding, especially in younger male decedents without significant comorbidities. Scene investigation may reveal useful clues pointing to this unusual etiology.

Papillary glioneuronal tumor: a case report and review of the literature.

Papillary glioneuronal tumor is a recently described central nervous system neoplasm that almost always occurs adjacent to the lateral ventricle. We present a case of this rare entity, representing the 21st case of this lesion, which exhibits a mixed astrocytic and neuronal differentiation. This case was an incidental finding in a young woman who presented secondary to a traumatic injury to the left eye. Histologic evaluation after surgical removal showed a cystic tumor consisting of 2 distinct components: a unique pseudopapillary architecture admixed with foci of solid areas. The pseudopapillae were composed of thick hyalinized vessels enclosed by a single layer of glial fibrillary acid protein-positive astrocytes and variously sized synaptophysin-positive and chromogranin-negative neuronal cells in the interpapillary regions. Abundant Rosenthal fibers, foci of calcification, areas of hemosiderin deposition, gliosis, areas of vascular proliferation associated with piloid gliosis, and chronic inflammatory infiltrate were identified. The combination of cytologic benignity, lack of necrosis, and low proliferative index as evidenced by immunohistochemistry using antibody to Ki-67 confirmed the low malignant potential of this tumor. Knowledge and precise classification of this entity are important to avoid unnecessary use of chemo- and/or radiotherapy for treatment.

Psychosocial complications of Crohn's disease and cause of death.

Patients who suffer from Crohn's disease are prone not only to the complications of a relapsing, unpredictable disease, but also to feelings of stigmatization; depression; and increased risk of suicidal ideation, suicide, or drug and alcohol abuse. Cases performed at the Jackson County Medical Examiner's Office from 2008 to 2010 were reviewed. Autopsy findings, investigator reports, toxicology results, medical records, and interviews with survivors were analyzed. Twelve cases of Crohn's disease were recovered. In 10 of these cases, inflammatory bowel disease was not the cause of death. Instead, psychosocial consequences of the disease had significant implications in the deaths. The mean age of decedents was 45 years, with a female predominance. In eight cases, the decedents lived alone. Five patients had issues of acute or chronic drug or alcohol use. Five patients committed suicide. These cases underscore the role of psychosocial factors that can contribute significantly to the cause of death in patients with Crohn's disease.

Challenges to diagnose metaplastic carcinoma of the breast through cytologic methods: an eight-case series.

Because metaplastic carcinoma of the breast encompasses a great variety of histopathology, diagnostic challenges abound, especially within the realm of cytology. The authors compiled and studied an eight-case series comprised of metaplastic breast carcinomas and lesions initially suspicious cytologically for metaplastic carcinoma in order to assess the degree of cytologic-histologic correlation and to identify recurring problematic themes surrounding the cytology-based diagnosis of this neoplasm. The cytologic and histologic slides from eight cases suspicious for metaplastic breast carcinoma diagnosed by fine needle aspiration (FNA) were collected and analyzed through a seven-year retrospective search of case files at our institution. Based on cytologic characteristics, the cases were separated into three groups. Group 1 consisted of three cases presenting with poorly differentiated adenocarcinoma and squamoid components on FNA. Group 2 was composed of two cases that featured a monophasic, malignant ductal cell population on cytology, while the cytologic specimens for the third group of cases presented with a mesenchymal component with or without a malignant glandular constituent. Cytologic-histologic correlation was present in two of three cases demonstrating a mesenchymal component, and there was 100% sensitivity in the cytologic detection of those mesenchymal elements. However, in only one of three cases was there an accurate cytologic diagnosis of metaplastic carcinoma when squamoid changes were present on FNA. Both cases demonstrating only malignant glandular elements on cytologic specimens revealed an additional component of malignant squamous differentiation upon the examination of mastectomy-derived tissue.These results indicate that squamous-like changes identified on FNA should be interpreted with caution and that sampling error remains a problematic recurrence in cytology. Regardless, there appears to be promise concerning the accurate cytologic diagnosis of metaplastic carcinoma when the lesion is characterized by a mesenchymal component. A study implementing a larger case number is essential in determining the significance of these findings.

Optic nerve trauma with unilateral edema as a result of head injury.

We encountered a patient who suffered a head injury that translated to the optic nerves, leading to dramatic unilateral right optic nerve edema. The decedent was a 20-year-old unsecured passenger in a convertible. The car collided with a pickup truck. The patient survived for 8 h. At autopsy, a comminuted skull fracture involving the right frontal bone including the right orbital plate was found. The right optic nerve measured 1.2 cm in diameter, compared to only 0.4 cm for the left optic nerve. Microscopically, the right optic nerve was markedly edematous, but the nerve fibers and nuclei were viable and intact. The dramatic difference in size between the right and left optic nerves can be attributed to several mechanisms. The survival interval was essential for the asymmetrical swelling to take place. Optic nerve trauma is relatively rare in head injuries, reported to be present in 0.5% of automobile accidents and assaults. Other causes of optic nerve trauma and edema include tumors, osteopetrosis, or reaction to a peripheral hemodialysis shunt.

Fatal hemopericardial tamponade due to primary pericardial mesothelioma: a case report.

BACKGROUND: Primary mesothelioma of the pericardium comprises less than 1% of all mesothelioma cases. Its typical presentation is insidious, with nonspecific signs and symptoms, and usually results in heart failure due to cardiac tamponade, either by a serous effusion or by direct tumorous constriction of the heart. With the exception of several case reports, the outcome is uniformly fatal, and patients typically die within six months of diagnosis. CASE PRESENTATION: A 45-year-old African American female presented to the emergency department with several days of dizziness, difficulty walking, and low blood pressure. The patient suddenly suffered cardiac arrest, and her death was pronounced. The medical examiner assumed jurisdiction of the case due to the sudden death nature of the case without known medical history. At autopsy, a one-liter hemopericardium was present, and the pericardial sac was thick, granular and adhesed to the heart, suspicious for pericarditis. Microscopic examination of the pericardial tissue instead led to a diagnosis of primary pericardial mesothelioma. CONCLUSION: Our case demonstrates a pericardial mesothelioma initially masquerading grossly as pericarditis. Microscopic examination of any grossly abnormal pericardial tissue therefore may be warranted so that a neoplastic disease process does not go undetected. Additionally, of the approximately 200 such tumors reported in the medical literature, a case demonstrating marked hemopericardium and resulting in sudden death has not been described until now.

An unusual suicidal death by automobile antenna: a case report.

Worldwide, over one million people commit suicide every year. In the United States, the majority of these cases consist of gunshot wounds, hangings, and drug overdoses. Nevertheless, on rare occasions will individuals exhibit extraordinary creativity in how they decide to end their lives. A decomposing white male was found lying beside his vehicle; blood was noted on the hood. Beneath the deceased's head was a copious amount of blood, and clutched within his right hand was a vehicle radio antenna. A search of a nearby storage shed uncovered drug paraphernalia and in the decedent's bedroom were two handwritten suicide notes. At autopsy, a defect was discovered in the right posterior oropharnyx. Immediately posterior to this injury were fractures of the right transverse processes and interarticular portions of the C2 and C3 vertebrae, with perforation of the right vertebral artery. No other injuries were noted externally. Radiographs of the head and neck showed no evidence of a projectile, and no corresponding exit defect was identified. Postmortem toxicology was positive for cocaine and methamphetamine. We present a case report of a man under the influence of cocaine and methamphetamine employing a car antenna to cause self-inflicted, intraoral penetrating trauma to the cervical spine and right vertebral artery, resulting in exsanguination and his subsequent death.

Infiltrating myoepithelial carcinoma of the breast, a case report and cytologic-histologic correlation.

INTRODUCTION: Infiltrating myoepithelial carcinoma remains a rarely encountered lesion of the breast. The few cases that have surfaced firmly document the histopathology of this tumor, but its cytologic characteristics seemingly have been described in only one other report. CASE PRESENTATION: Here we present the cytologic findings from a case of infiltrating myoepithelial carcinoma of the breast in a 52-year-old female and provide a histologic correlation with the subsequent biopsy and mastectomy specimens. While the cytology specimens displayed more myoepithelial cellular heterogeneity than was present on histology, a number of cytologic features including hypercellularity, pleomorphic spindle cells, and mitotic activity correlated well with the histopathology. CONCLUSION: The role of fine needle aspiration in the diagnosis of mammary myoepithelial carcinoma, in this case, was to establish malignancy rather than to arrive at a specific diagnosis, as a number of different entities potentially can mimic this neoplasm on cytologic specimens.

Giant atypical carcinoid of the liver with vascular metastases and local sinusoidal invasion: a case report.

We present the case of a 46 year old woman with a giant, 23-centimeter, atypical carcinoid of the liver. A primary site for this neoplasm could not be identified despite multiple radiographic imaging studies, including a somatostatin scan, and a thorough inspection of the bowel during surgical resection of the lesion. Histologically, the tumor displayed mild cytologic atypia, abundant necrosis, and intravascular metastases, the last feature of which was identified by immunohistochemical markers for chromogranin and synaptophysin. Also described is the unusual sinusoidal infiltration, or "spillage," of tumor cells into the surrounding liver parenchyma, a feature that has not been described as far as we are aware but may suggest an aggressive clinical course. Even though an exact definition of atypia for these lesions apparently does not exist at this point, the multiple atypical features in this case strongly suggest the diagnosis of atypical carcinoid of the liver, thus far an altogether rare and vaguely reported entity. As more cases arise in the medical literature, it may be worthwhile to establish a set of guidelines to define atypical hepatic carcinoids and other gastrointestinal carcinoids, although survivorship data thus far indicates no significant difference in the prognosis between typical versus atypical variants.

Adenoid basal carcinoma of the cervix in a 20-year-old female: a case report.

BACKGROUND: Adenoid basal carcinoma of the cervix is a rare condition mostly occurring among postmenopausal women. Although it can be confused with adenoid cystic carcinoma of the cervix, adenoid basal carcinoma has several clinicopathologic features that will allow distinction from adenoid cystic carcinoma. CASE PRESENTATION: This is the case of a twenty-year old African-American female who initially presented with a high-grade squamous intraepithelial lesion on Pap smear, with a subsequent cervical LEEP specimen revealing adenoid basal carcinoma. The lesion showed the characteristic histologic features of adenoid basal carcinoma and was positive for the immunohistochemical marker EMA and negative for collagen IV, further defining the tumor while helping to rule out the possibility of adenoid cystic carcinoma. As far as the authors are aware, this is the youngest reported case of adenoid basal carcinoma to date. CONCLUSION: This case shows that adenoid basal carcinoma can deviate markedly from its typical postmenopausal demographics to affect women as young as 20 years of age. In addition, adenoid basal carcinoma has several identifiable features that will differentiate it from adenoid cystic carcinoma including histologic and cellular morphologies, as well as immunohistochemistry. Treatment for most patients involves hysterectomy, LEEP, or a conization procedure which provides a favorable prognosis because of this lesion's low potential for recurrence and metastasis.

Deep penetrating nevus: a case report and brief literature review.

BACKGROUND: Deep penetrating nevus (DPN) is a distinct variant of melanocytic nevus and remains a histopathologic challenge to pathologists because of its resemblance to blue nevus, malignant melanoma, pigmented Spitz nevus, and congenital melanocytic nevus. It often goes unrecognized due to its relative rarity. CASE PRESENTATION: Here we report a case of DPN of the left anterior leg in a 51-year old female. A brief review of the literature shows that these lesions have a distinct growth pattern and cellular morphology that can differentiate these lesions from other entities including malignant melanoma. CONCLUSION: It is important to recognize these features because DPN carries a better prognosis than malignant melanoma.