Hepatic angiomyolipoma.

An angiomyolipoma of the liver was an incidental autopsy finding in a 65-year-old man. This is the third recorded primary hepatic angiomyolipoma. There were no stigmata of tuberose sclerosis but tuberose sclerosis has been reported previously in association with fatty tumors of the liver, suggesting that such lesions, like their renal counterparts, may be choristomas.

Pineal germinoma with syncytiotrophoblastic giant cells: a case with panhypopituitarism and isosexual pseudopuberty.

A previously healthy boy, aged 12 years, developed hypopituitarism due to suprasellar metastases from a pineal germinoma with syncytiotrophoblastic giant cells (SGC). Despite the hypopituitarism, the patient showed pubertal development, which was associated with abnormal levels of human chorionic gonadotropin (hCG) in the cerebrospinal fluid. This case adds support to the theory that precocious puberty in children with pineal germinomas may be due to the secretion of hCG by SGC, a minor component of the germinoma. It also illustrates the point that, although abnormal levels of circulating hCG in children with pineal tumors may indicate a diagnosis of choriocarcinoma with its encumbent poor prognosis, other pineal germ cell tumors may also secrete hCG. Although this patient had abnormal levels of hCG, his cerebral tumor exhibited behavior more commonly associated with pineal germinoma than with choriocarcinoma.

Fatty tumours of the uterus.

Uterine fatty tumours (UFT) are uncommon and have received little attention in the English literature. They have aroused interest as a consequence of occasional diagnostic confusion with sarcomas and the continuing unresolved dispute as to their histogenesis. Three cases of UFT are described and the pathological features of note discussed. The viewpoint that these tumours are hamartomas/choristomas is rejected. UFT most probably represent tumour metaplasia within a leiomyoma. There is no uniform accepted nomenclature for such tumours and it is suggested that they be designated "uterine fatty tumours" and subdivided into "lipoma" and "mixed lipoma/leiomyoma" (synonym lipoleiomyoma).

Myocardial fibre calcification.

Three cases of myocardial fibre calcification found at post-mortem examination are described. In one case there was antemortem hypercalcaemia and hyperphosphataemia and the case was clearly an example of metastatic calcification. In the other two cases there was ischaemic myocardial necrosis and calcification was seen in fibres which were not overtly necrotic, but which were both in proximity to (the majority) and remote from the necrotic zones. Since renal failure with hyperphosphataemia was present in both cases, these were considered to be examples of augmented (by the hyperphosphataemia) dystrophic calcification. The histological, histochemical and ultrastructural features were identical in the three cases. Hydroxyapatite formation was observed initially in mitochondria, followed by spillage of crystals into the cytosol and ultimately into the interstitium. It is suggested that the fundamental lesion is a dysfunction of the fibre membrane; the similarity of this reaction with the calcification seen in skeletal muscle fibres in various myopathies is noted and a unifying hypothesis of the mechanism of skeletal and cardiac muscle fibre calcification is thereby suggested.

Alcohol estimation at necropsy: epidemiology, economics, and the elderly.

AIMS: To gather data on blood alcohol concentrations in a forensic necropsy population and to analyse the information on trends that may predict where alcohol testing is going to prove cost-effective. METHODS: Alcohol assays were performed on blood, urine, and vitreous samples in 1620 consecutive medicolegal necropsy examinations. RESULTS: Alcohol was detected in only 7% of natural deaths from all causes and in four of 40 deaths categorised as unknown/obscure. Alcohol concentrations > or = 350 mg/100 ml were found in nine drug/alcohol abuse deaths (range 362-506 mg/100 ml), five accidental deaths (356-504 mg/100 ml), and one homicide victim (400 mg/100 ml). Those categorised as alcohol abusers were represented in all but one category of death (unknown/obscure deaths in males), showing that many true alcoholics die with their alcoholism rather than of it; 39% of males and 34% of females with histories of alcohol abuse had alcohol present in their blood at necropsy at concentrations > or = 50 mg/100 ml, v only 9% (male) and 6% (female) without such history. CONCLUSIONS: The study highlights the problems of elderly and "hidden" alcoholics and illustrates cases where routine assays would provide additional significant information. Routine alcohol testing is useful in all cases of suspected unnatural death but universal testing of forensic necropsies is not cost-effective.

Angiodysplasias of the colon.

We studied 14 large bowel resections from patients with a provisional clinical diagnosis of a bleeding vascular lesion of the colon. For the purpose of this study we developed a barium-gelatine vascular injection technique. Six of the 14 cases were proven to be angiodysplasias with an identifiable mucosal vascular ectasia. The pathological findings in these six cases are described. We conclude that angiodysplasia represent a significant cause of lower gastrointestinal haemorrhage in the elderly. It is our opinion that only the mucosa vascular ectasia seen in these cases is histologically diagnostic and that sub-mucosal venous ectasia, while characteristic of angiodysplasia, is non-specific. the differential diagnostic features which will allow the histological distinction of angiodysplasia from other vascular lesions of the colon are discussed.

Hepatocellular calcification.

A rare example of hepatocellular calcification is described. The lesion is characterized by the presence of granular calcific deposits within the cytoplasm of hepatocytes. In this instance the calcification was dystrophic, developing on the basis of centrilobular necrosis secondary to cor pulmonale. A transient hyperphosphatemia probably augmented the calcification process. Intracellular calcification was also observed in occasional cardiac myocytes. The intracytoplasmic calcific granules represent mineral-laden mitochondria. Sequestration of calcium by mitochondria is a common biochemical mechanism mediating various forms of toxic cell death. Pathological cellular calcification can be viewed as an uncommon morphological expression of this biochemical process.

Death investigation in colonial South Australia: the early years 1836-1839.

An account is given on the basis of contemporary records, of the investigation of violent or other unnatural deaths during the first three years of the colony of South Australia.

Hepatic pseudolipoma.

A pseudolipoma of the liver was an incidental finding in a 63-yr-old man. This is the 9th recorded case of hepatic pseudolipoma. Macroscopically these innocent lesions may mimic metastatic carcinoma whilst microscopically they must be distinguished from the equally rare true hepatic lipomas. Hepatic pseudolipomas probably represent trapped, detached appendices epiploicae.

A teratoma-like lesion of the placenta: a case report.

Teratoma-like lesions of the placenta are rare and of disputed histogenesis. We describe one such tumour arising in the placenta of a normal full-term male infant delivered to a 33-yr-old woman. This lesion and all previously reported cases appear histologically and clinically benign. The authors favour the viewpoint that the so-called placental teratoma represents an extreme form of fetus amorphus.

Tracheopathia osteoplastica: report of four cases.

We describe 4 florid examples of tracheopathia osteoplastica (TPO) discovered incidentally at autopsy. The sparsity of previously reported cases of TPO from Australia possibly reflects a lack of awareness of this entity rather than its true incidence. The more recent literature concerning the etiopathogenesis, pathology and clinical complications of this uncommon condition is reviewed. In our view TPO is a distinct entity and does not represent a late stage of diffuse tracheal amyloidosis.

Coronary artery aneurysms presenting as sudden death 14 years after Kawasaki disease in infancy.

A 17-year-old boy who collapsed and died suddenly was found to have aneurysms of the right and left coronary arteries and evidence of a burned-out arteritis. There was a history, in infancy, of a severe febrile illness and skin rash that, in retrospect, was an acute episode of Kawasaki disease (mucocutaneous lymph node syndrome). The observations support the contention that a previous episode of Kawasaki disease should be entertained as a possible cause of proximal, discrete coronary artery aneurysms presenting in adolescence or adulthood.

Xanthogranulomatous endometritis associated with endometrial carcinoma.

We studied a case of xanthogranulomatous (XG) endometritis associated with endometrial adenocarcinoma. Isolated XG endometritis is a rare entity that may mimic carcinoma as a consequence of the replacement of the endometrium and the invasion of the myometrium by friable yellowish tissue composed of foamy histiocytes. To our knowledge, it has not previously been described as coexisting with a carcinoma. The XG reaction is characterized by pigment-laden foamy cells. Electron microscopy demonstrated that the foamy cells belong to the macrophage/histiocyte series and are not endometrial stromal cells. Histochemical studies revealed the pigment to be composed of hemosiderin and lipofuscin. The absence of calcispherites or a uniform immunoperoxidase staining reaction for alpha 1-antitrypsin excluded the diagnosis of malacoplakia. We have postulated that XG endometritis has a similar etiopathogenesis to XG pyelonephritis and XG cholecystitis. It is a rare morphologic expression of the clinical syndrome of benign senile pyometrium.

Uterine leiomyosarcoma with myxoid stroma.

Myxoid leiomyosarcomas present a diagnostic problem. They are said to have low mitotic counts and are considered to be exceptions to the general rule that uterine smooth-muscle tumors with a mitotic rate of less than five per ten high-power fields rarely recur. We present two cases of myxoid leiomyosarcoma, both of which show high mitotic counts. In addition, one of the cases presented initially as a typical leiomyosarcoma, but contained abundant myxoid stroma in the metastases. The role of the myxoid stroma in influencing prognosis in leiomyosarcomas is, as yet, uncertain.

Sudden, unexpected death following typhoid-cholera vaccination.

A previously healthy 33-year-old Australian male died suddenly and unexpectedly 8 h after a typhoid-cholera vaccination. Such fatalities are extreme rarities and the present case is the first in which postmortem measurement of serum immunoglobulins has been undertaken. The clinical course and necropsy findings suggest that death was the result of a slowly evolving systemic anaphylactic reaction which terminated in hypotension and right heart failure. The deceased was probably atopic. The current recommendations for the vaccination of international travellers against typhoid and cholera are discussed.

Floppy aortic valve presenting as sudden death.

A previously healthy 34-year-old Dutch immigrant to Australia died unexpectedly in his sleep. At autopsy the only significant finding was a floppy aortic valve (FAV). Histologic, histochemical and electron microscopic studies corroborated the macroscopic diagnosis. Previously described associations of the FAV include the floppy mitral valve, Marfan's syndrome, aortic root dilatation and aortic cystic medial necrosis. None of these features were found in the present case which is the first recorded example of isolated FAV presenting as sudden death. The mechanism of death is obscure, and while it is presumed to be dysrhythmic, a detailed histological examination of the cardiac conducting system revealed no anatomic abnormality.

Changing patterns of male suicide in Scotland.

Mortality statistics published annually by the Registrar General Scotland for 1970-1989 are analysed. There has been a recent increase in the suicide rate amongst younger males in Scotland which cannot be explained by changes in the misattribution between suicides (ICD E950-E959) and undetermined deaths (ICD E980-E989). The increase is almost entirely attributable to hanging and the use of motor vehicle exhaust fumes. Analysis of the sex/age/method-specific suicide rates demonstrates that age-specific increases in the male suicide rate are linked to age-specific increases in the use of these two methods. The increased suicide rate involving motor vehicle exhaust fumes can be explained by changes in method availability and acceptability. The increased suicide rate involving hanging may be explained by increased acceptability, possibly flowing from the abolition of judicial hanging in 1965. The increased suicide rate in younger males may reflect a change in the proportion of suicidal attempts resulting in a completed suicide consequent on an age-specific shift to the use of more lethal methods, namely hanging and motor vehicle exhaust fumes. This possibility needs to be evaluated before assessing the influence of other social factors on the suicide rate.

Zopiclone poisoning: tissue distribution and potential for postmortem diffusion.

Zopiclone is the first cyclopyrrolone hypnotic and is chemically unrelated to any existing drug. The authors studied the tissue distribution and postmortem redistribution of zopiclone in a fatal suicidal overdose. A 29-year-old female weighing 64 kg had cardiac blood ethanol 153 mg% and zopiclone blood concentrations in the range 0.9-2.0 microgram/ml in 10 distinct sampling sites. After 40 h at room temperature the range was 0.9-1.8 micrograms/ml in 15 samples. Portal venous blood and urine concentrations were 3.0 and 10.5 micrograms/ml, respectively. Tissue concentrations (microgram/g) were spleen 5.8, peri-renal fat 5.0, psoas muscle 3.3, brainstem 2.8, gastrocnemius muscle 1.9, myocardium 1.6, and kidney 1.7. Eight liver samples had concentrations in the range 0.5-4.9 micrograms/g, with highest concentrations in the left lobe and adjacent to the gallbladder, probably reflecting postmortem diffusion from gastric residue (700 ml, 55.1 micrograms/ml) and bile (14.1 micrograms/ml). Of six lung samples, paired upper and middle samples had concentrations in the range 2.1-2.3 micrograms/g, the right postero-basal 1.3 micrograms/g and the left postero-basal 3.4 micrograms/g. Drug concentration in putrefactive pleural fluid was also higher on the left (2.1 micrograms/ml) than the right (1.4 micrograms/ml), probably reflecting postmortem diffusion from gastric residue. The authors conclude that zopiclone showed little preferential concentration in solid organs and consequently has relatively stable postmortem blood concentrations, with little drug redistribution artefacts. Postmortem diffusion from gastric drug residue elevates drug levels in the left lobe of the liver and left lung lower lobe.

Post-mortem drug redistribution--a toxicological nightmare.

Detailed human case data is presented to illustrate the dramatic extent of the phenomenon of post-mortem drug redistribution. The data suggests that there is a post-mortem diffusion of drugs along a concentration gradient, from sites of high concentration in solid organs, into the blood with resultant artefactual elevation of drug levels in blood. Highest drug levels were found in central vessels such as pulmonary artery and vein, and lowest levels were found in peripheral vessels such as subclavian and femoral veins. In individual cases, in multiple blood samples obtained from ligated vessels, concentrations of doxepin and desmethyldoxepin ranged from 3.6 to 12.5 mg/l and 1.2 to 7.5 mg/l, respectively; amobartital, secobarbital and pentobarbital from 4.3 to 25.8 mg/l, 3.9 to 25.3 mg/l and 5.1 to 31.5 mg/l respectively; clomipramine and desmethylclomipramine from 4.0 to 21.5 mg/l and 1.7 to 8.1 mg/l, respectively and flurazepam 0.15 to 0.99 mg/l; imipramine and desipramine from 4.1 to 18.1 mg/l and 1.0 to 3.6 mg/l, respectively. We conclude that this poorly studied phenomenon creates major difficulties in interpretation and undermines the reference value of data bases where the site of origin of post-mortem blood samples is unknown.

Postmortem absorption of drugs and ethanol from aspirated vomitus--an experimental model.

Using human cadavers an experimental model was developed to simulate the agonal aspiration of drug- and alcohol-laden vomitus. By needle puncture, an acidified (N/20 HCl) 60-ml slurry of drugs (paracetamol 3.25 g, dextropropoxyphene 325 mg) and ethanol 3% w/v was introduced into the trachea. After 48 h undisturbed at room temperature, blood samples were obtained from ten sites. Ethanol and drug concentrations were highest in the pulmonary vessels in all five cases studied. Pulmonary vein mean ethanol was 58 mg% (range 13-130), paracetamol 969 mg/l (range 284-1934), propoxyphene 70 mg/l (range 11-168). Pulmonary artery mean ethanol was 53 mg% (range 10-98), paracetamol 476 mg/l (range 141-882), propoxyphene 29 mg/l (range 7.6-80). Ethanol and drug concentrations in aortic blood were higher than in the left heart and concentrations in the superior vena cava were higher than in the right heart, suggesting direct diffusion into these vessels rather than diffusion via the pulmonary and cardiac blood. Potential interpretive problems arising from this phenomenon can be avoided by using femoral vein blood for quantitative toxicological analysis.