Search

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.

Blood and blood clots should be removed from the heart chambers before being weighed. The actual method in removing blood and blood clots may vary and can include manual removal with subsequent rinsing the heart in water. It is unclear whether drying the rinsed heart affects the heart weight. The objective of this article was to investigate the effects drying the rinsed dissected heart (residual rinsing water) on postmortem heart weight. The prospective study compared 44 dissected heart weights after being rinsed and after being pat dried. An average 18-20 g of residual rinsing water (4% of heart weight) was present in the dissected heart. The amount of residual rinsing water correlates positively with heart weight. The effects of drying the rinsed dissected heart were considered clinically insignificant. Although being clinically insignificant, this study highlights the lack of standardized approach in weighing the heart and the potential implications in interpreting heart weights.

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 ( 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.

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.

Haemolysis is reported to be an artefact that may alter post-mortem tryptase levels. However, previous studies did not sample peripheral blood using newly standardised methods. Recent studies have shown that some previously recognised peri- and post-mortem confounders can be muted by careful sample collection with first clamping and then sampling the femoral vein. This prospective study investigated the relationship between the degree of haemolysis of the blood samples and femoral vein post-mortem tryptase levels when sampled using this recommended method. Seventy consecutive post-mortem tryptase levels in non-anaphylactic deaths were compared to the degree of haemolysis of these samples, and results showed no significant correlation between them. The mean post-mortem tryptase level was 9.5 μg/L. This study demonstrated that the effects of haemolysis on femoral vein post-mortem tryptase was negligible when the blood was sampled using the recommended sampling method. Future studies on post-mortem tryptase as well as other typically used blood markers in forensics are recommended to adopt this method of blood sampling in routine practice.

International audience; Globally, autosomal recessive IFNAR1 deficiency is a rare inborn error of immunity underlying susceptibility to live attenuated vaccine and wild-type viruses. We report seven children from five unrelated kindreds of western Polynesian ancestry who suffered from severe viral diseases. All the patients are homozygous for the same nonsense IFNAR1 variant (p.Glu386*). This allele encodes a truncated protein that is absent from the cell surface and is loss-of-function. The fibroblasts of the patients do not respond to type I IFNs (IFN-α2, IFN-ω, or IFN-β). Remarkably, this IFNAR1 variant has a minor allele frequency >1% in Samoa and is also observed in the Cook, Society, Marquesas, and Austral islands, as well as Fiji, whereas it is extremely rare or absent in the other populations tested, including those of the Pacific region. Inherited IFNAR1 deficiency should be considered in individuals of Polynesian ancestry with severe viral illnesses.

Identifying organs/tissue and pathology on radiological and microscopic images can be performed using convolutional neural networks (CNN). However, there are scant studies on applying CNN to post-mortem gross images of visceral organs. This proof-of-concept study used 537 gross post-mortem images of dissected brain, heart, lung, liver, spleen, and kidney, which were randomly divided into a training and teaching datasets for the pre-trained CNN Xception. The CNN was trained using the training dataset and subsequently tested on the testing dataset. The overall accuracies were >95% percent for both training and testing datasets and have an F1 score of >0.95 for all dissected organs. This study showed that small datasets of post-mortem images can be classified with a very high accuracy using a pre-trained CNN. This novel area has the potential for future application in data mining, education and teaching, case review, research, quality assurance, auditing purposes, and identifying pathology.

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 computed tomography (PMCT) is a relatively recent advancement in forensic pathology practice that has been increasingly used as an ancillary investigation and screening tool. One area of clinical CT imaging that has garnered a lot of research interest recently is the area of "artificial intelligence" (AI), such as in screening and computer-assisted diagnostics. This feasibility study investigated the application of convolutional neural network, a form of deep learning AI, to PMCT head imaging in differentiating fatal head injury from controls. PMCT images of a transverse section of the head at the level of the frontal sinus from 25 cases of fatal head injury were combined with 25 nonhead-injury controls and divided into training and testing datasets. A convolutional neural network was constructed using Keras and was trained against the training data before being assessed against the testing dataset. The results of this study demonstrated an accuracy of between 70% and 92.5%, with difficulties in recognizing subarachnoid hemorrhage and in distinguishing congested vessels and prominent falx from head injury. These results are promising for potential applications as a screening tool or in computer-assisted diagnostics in the future.

Correctly assessing heart weight can be critical at postmortem examination. The current international guidelines advocate using the short-axis method in dissecting the heart and the heart weighed when the blood is emptied. However, it did not specify at what point the heart should be weighed or how the blood should be emptied. This study compared heart weights at three different time points during the heart examination (immediately after dissecting out of the pericardial sac with blood still in chambers, blood washed/removed from heart chambers without the heart opened, and the heart completely opened, blood emptied, and pad dried). This was to illustrate the variation in measurement and potential errors when the heart is weighed at different time of dissection. The results show that there were statistical and clinical significant differences between the heart weights at each weighing points. We recommend the heart to be completely dissected with any blood and residual washing/rinsing water emptied before being weighed. Although performed in this study, the effect of pad drying the heart on heart weight was not explored and was a limitation in this study.

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.

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

Many previous studies have investigated the use of post-mortem biochemistry to estimate the post-mortem interval (PMI). Vitreous humour (VH) potassium and sodium/chloride levels are well recognized...

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.

Sudden cardiac death (SCD) is the most common natural cause of death. The hypothesized mechanism of death is an arrhythmia precipitated by increased sympathetic outflow. The left stellate ganglion provides sympathetic innervation to the heart and plays a role in arrhythmogensis. We present a SCD with stellate ganglionitis in which the inflammatory cells were characterized. The case was 37-year-old man who died from ischemic and hypertensive heart disease. The left stellate ganglion showed lymphocytic inflammation with features of humoral immune response. This case report provides evidence that stellate ganglionitis can be seen in SCD and raises the possible association between the two.

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.

Weighing of organs is a standard requirement in post-mortem examination. Ideally, the lungs should be weighed intact to prevent pulmonary fluids loss. However, there are instances where the lungs a...

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.

Using post-mortem vitreous humour (VH) electrolyte in estimating the post-mortem interval (PMI) is not well studied in the infant population. We hypothesize that VH can be useful in estimating PMI ...

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.

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.

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.

Background AMB-FUBINACA is a synthetic cannabinoid that has been associated with periodic outbreaks of acute poisonings, but few fatalities. In late May, June and July 2017 Auckland, New Zealand, experienced an outbreak of deaths associated with AMB-FUBINACA that continued at a rate of about 2–3 per month through February 2019. The aim of this study was to define the demographic, circumstantial, pathological and toxicological characteristics of this outbreak. Methods All records of the Northern Forensic Pathology Service, Auckland Hospital, were reviewed in which the word “AMB-FUBINACA” was referenced, including initial police reports, autopsy reports and toxicology reports. Recorded data included age, sex, race/ethnicity, times and locations, cause of death, autopsy and toxicology findings, and a brief summary of the circumstances of death. Descriptive statistics were performed using IBM® SPSS® Statistics Version 24 and Microsoft® Excel® Version 14.7.2. Findings Sixty-four cases were identified. One sudden infant death and five cases where cause of death was due to trauma were excluded. Of the remaining 58 cases, 88% were male. Mean age was 42 years. In 95% of the deaths, AMB-FUBINACA alone or in combination with alcohol or another drug was listed as the primary or contributory cause of death. In 41 cases postmortem blood concentrations of AMB-FUBINACA acid were available, ranging from 1000 ng/mL, mean 229 ng/mL, median 140 ng/mL. Comorbidities identified included mixed intoxications (29%), heart disease (47%) and obesity (16%). A mental health diagnosis was reported in 50%, and 40% were on antipsychotic medications. Interpretation This study presents characteristics, comorbidities and toxicological findings in a unique outbreak of deaths associated with the synthetic cannabinoid AMB-FUBINACA in Auckland, NZ. Funding All work was funded as part of the usual employment of the authors in their respective institutions. No special funding sources are reported.

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.

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.