Elsevier

Cardiovascular Pathology

Volume 10, Issue 6, November–December 2001, Pages 271-274
Cardiovascular Pathology

The negative autopsy: Sudden cardiac death or other?

https://doi.org/10.1016/S1054-8807(01)00107-7Get rights and content

Abstract

One of the most frustrating challenges faced by the forensic pathologist is the inability to determine the cause of death in a young person previously thought healthy. The four steps in the investigation of a sudden death include obtaining the history and scene information, performing a gross and microscopic autopsy, performing appropriate laboratory tests, and making the diagnosis. When examining the heart grossly it is important to preserve the anatomic landmarks, section the coronary arteries closely, and recognize lethal abnormalities such as anomalous origin of the coronary arteries. Specimens useful for toxicologic analysis include whole blood, serum, vitreous humor, gastric contents, bile, urine a purple top tube of blood, and frozen myocardium and spleen. Lethal cardiac diseases with minimal or no anatomic findings include Brugada and Garg's syndromes, the long QT syndrome, and Wolff–Parkinson–White (WPW) syndrome. Consultation with other experts, including cardiac pathologists, cardiologists, electrophysiologists, and molecular biologists, may be helpful in determining a cause of death.

Introduction

Few challenges in the practice of forensic pathology are so frustrating as the failure to determine a cause of death, particularly in a previously healthy young person who has died suddenly and unexpectedly. We define sudden unexpected death as death within 6 hours of symptoms (e.g., syncope or chest pain) in a person thought to be previously healthy. In a typical medical examiner practice, approximately 50% of the deaths they investigate are natural, 5–10% are unexplained after a gross autopsy, and 1–5% are negative after completion of the gross and microscopic autopsy and other laboratory tests [1]. Upon determination that an autopsy is grossly negative, the forensic pathologist should review the history and laboratory tests to determine whether additional history needs to be obtained or studies need to be performed. Because some subtle causes of sudden, unexpected natural death may be hereditary, a special effort to determine the cause of death is necessary to prevent death in relatives. It is also important to make a maximal effort to determine cause of death in order to assist the relatives of the deceased to deal with the death and proceed with the grieving process.

Section snippets

The approach to the investigation of sudden unexpected death

There are four steps in death investigation: (1) history and scene examination, (2) autopsy (gross and microscopic), (3) laboratory tests, and (4) making the diagnosis.

History and scene investigation

It is important to determine a history of syncopal episodes, chest pain, dizziness, prior electrocardiograms (whether positive or negative), a family history of sudden death/lethal heart disease, a history of allergies, epilepsy, and diabetes mellitus. In some cases, such a review may provide the cause of death, for example, an electrocardiogram indicating a potentially fatal disease such as long QT syndrome or Wolff–Parkinson–White (WPW) disease. Even if a specific cause of death is not

The autopsy

On the external examination of the autopsy, it is particularly important to examine the body for needle punctures or needle track scars (suggestive of intravenous drug abuse) and therapeutic transdermal patches, such as for nitroglycerin and fentanyl. In a low-voltage electrocution, the soles of the feet or the clothing may have electrical burns that can easily be missed.

When examining the heart, the coronary arteries should be sectioned every 2–3 mm. It is generally not necessary to fix the

Laboratory tests

A comprehensive drug screen should be performed on every case of sudden, unexpected death, especially those without significant anatomic findings. However, although a “comprehensive drug screen” should include most prescribed and illicit drugs, it cannot detect every lethal drug or toxin. For example, digoxin, thioxanthenes, insulin, volatiles (e.g., Freon, toluene), etc. are not detected on most routine drug screens. In addition, heavy metals such as arsenic, thallium, lead, and mercury must

Making the diagnosis

Specimens that can be useful for additional study if necessary include whole blood, serum, vitreous humor, gastric contents (at least a representative sample of 50–100 ml), bile, portions of organs such as liver, urine, a purple top tube of blood, and frozen myocardium and spleen.

Causes of cardiac death with minimal or negative findings include commotio cordis, cardiac conduction abnormalities, and coronary artery spasm. Noncardiac causes of death with negative or minimal autopsy findings

Conclusion

Chugh et al. [13] recently showed the utility of an in-depth investigation in cases with a negative autopsy. In a study of sudden cardiac death covering a 13-year period involving 270 hearts, they identified cases in which the heart was structurally normal. Analysis of these cases revealed two cases of preexcitation (WPW syndrome), one case with atrial fibrillation with a rapid ventricular response, two with a history of seizures, two morbidly obese patients, and benzoyl ecgonine (the major

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This article is being reprinted from Cardiovascular Pathology 10(5): 219–222.

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