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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.

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.

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.

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.

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

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.

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.

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.

Cerebral venous thrombosis is a rare condition which constitutes 0.5% to 2% of all types of stroke and carries a mortality of up to 20% to 50%. It leads to cerebral edema, infarction, hemorrhage and venous hypertension. Clinically the diagnosis is confirmed using enhanced computed tomography (CT) angiography which demonstrates an empty delta sign in cerebral veins, particularly in the superior sagittal sinus. However, postmortem CT (PMCT) findings on cerebral venous thrombosis have not been documented in the literature. We present a case report of a 69-year-old man who on unenhanced PMCT scan showed an empty delta sign in the cerebral veins. The empty delta sign was able to be demonstrated in unenhanced PMCT which can be explained by hyper attenuation of the dural veins at postmortem forming an internal contrast highlighting the thrombus.

Cerebrospinal fluid (CSF) is often analyzed at postmortem. The presented preliminary study compared postmortem CSF samples for biochemical analysis from the subarachnoid space around the spinal cord and ventricular space of the brain. This study compared 15 paired CSF samples in which the CSF from the subarachnoid space via lumbar puncture had higher sodium and chloride levels and lower magnesium and potassium levels than CSF from the ventricles. The differences correlated significantly with the deceased's age and had a similar trend with postmortem interval. This study suggests that CSF from different collection sites has different electrolyte concentrations, which are age and possibly postmortem interval dependent. When collecting CSF, the pathologist should document the collection site, age, and postmortem interval, and the mixing of CSF samples from different sites should be avoided. Further studies are warranted to clarify other possible reasons to explain the observed differences.

Lung weights are often increased in drowning deaths as well as in other types of deaths. Lung weights may also vary with age, sex, and body weight. A variety of methods have been proposed to utilize lung weight data to assist with the diagnosis of drowning. The present study compared lung weight, lung-heart ratio (LH), and lung-body ratio (LB) between 50 consecutive drowning and 50 nonimmersion deaths in order to assess the accuracy in diagnosing drowning. Analysis revealed both LH and LB to be statistically higher in drowning deaths (P < 0.05), with LB being the most robust measurement. However, the overall diagnostic accuracies of lung weight, LH, and LB were poor to fair, and should therefore be used only in conjunction with the other diagnostic criteria.

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.

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.

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.

Hypothermia and diabetic ketoacidosis are both potentially fatal conditions, which have historically been considered to have associated pathognomonic pathologies. Hypothermia and diabetic ketoacidosis share similar pathological mechanisms, which result in metabolic derangement, with increased post mortem vitreous glucose and β-hydroxybuyrate, and are able to exacerbate and precipitate one another. Although Wischnewsky lesions are associated with hypothermia, and Armanni-Ebstein lesions and basal subnuclear vacuolization are associated with diabetic ketoacidosis, recent studies have demonstrated that there is a significant overlap between the pathological findings of these 2 conditions. We report a case of a 50-year-old woman with type 1 diabetes who was found deceased in the middle of winter. Autopsy showed Wischnewsky lesions, Armanni-Ebstein lesions, and basal subnuclear vacuolization, together with elevated vitreous glucose and β-hydroxybuyrate. The cause of death was the combined effects of hypothermia and diabetic ketoacidosis. This case highlights the overlapping clinical presentation, pathophysiology, and pathology of these 2 conditions.

Acute myocarditis is a potentially fatal cardiac pathology that is thought to cause sudden death through arrhythmia and cardiac failure. Of the different subtypes, lymphocytic myocarditis is the most common form. The pathophysiology of myocarditis can be generally diffuse or focally involve the ventricles, but less frequently affects the atria. Although the clinical literature reports isolated atrial myocarditis as a cause of atrial fibrillation and enlargement, there is scant postmortem literature on the findings of this pathology. We report a fatal case of isolated lymphocytic atrial myocarditis affecting only the left atrium in a 56-year-old man, where microscopy of the left atrium confirmed a florid lymphocytic myocarditis. Retrospective postmortem computed tomography scan review did not show any abnormalities on the left atrial wall.