Friday, March 11, 2011

What's the Diagnosis March 11, 2011

These photos are from a 30-year-old-man found dead in bed. His history is significant only for remote substance abuse. The histology of the coronary arteries and the myocardium shown below were the only pathological findings at autopsy. His toxicology was negative. What's going on and how would you sign this case out (both cause and manner)?



10 comments:

  1. I'm thinking about fibromuscular dysplasia of the coronary arteries. And the myocardium shows signs of recurrent ischemia in the form of fibrosis.

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  2. Nice eyes, Vosbeck. You're almost there... It's not fibromuscular dysplasia. I will give you a hint: it's acquired. And yes, there is recurrent ischemia of the myocardium.

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  3. Actually, in our country, there are not lots of cases of drug abuse, so.. I can't convince my answer... but I know that cocaine use make AMI in heart... right?

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  4. Perhaps it is drug related, but I don't know anything about drug effects. I don't see anything in favor of large vessel vasculitis. I don't know what it is ...

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  6. I had to edit some spelling in my comments. I am doing this on my iPhone!

    Nice work!! This is a great example of a cocaine heart. Cocaine is a bad drug. One thing to keep in mind with cocaine related deaths is the effect the drug has on the heart. Cocaine can acutely cause vasoconstriction, which can be bad in itself, but if the person has diseased coronaries, the spasm can be deadly. Cocaine also accelerates the development of atherosclerosis. And as if that wasn't enough, cocaine can cause a fibrointimal hyperplasia of the coronaries. The thickened arteries (wether by ascvd or fibrointimal hyperplasia) in conjunction with repeated episodes of vasospasm can cause microinfarcts. These lesions tend to be perivascular, for obvious reasons.
    The photos above demonstrate nice fibrointimal hyperplasia and microinfarcts.
    I would sign this out as complications of chronic substance abuse and call it an accident.

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  7. In the absence of acute intoxication, you classify these deaths as accidents? Always interested in policy in different offices!

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  8. I was hoping someone was going to jump on the cause and manner in this case, thanks JH!! I almost feel like it was a planted question.

    This was signed out as accident. It's a case I had many years ago while I was working in another state (that shall remain nameless). In Boston we call them natural, as I think you do in NYC. I can see the merits of both approaches. But if someone is not acutely intoxicated, the natural disease state takes precedence.

    However, these pathologic changes are the result of an injury caused by a toxin. In that regard they can be considered true injuries and thereby classified as accidents. If someone dies of liver failure months or years after a tylenol overdose with negative tox for tylenol, is the death natural? No, it's still a suicide or an accident, depending on the circumstances. I think the same principal can be applied to chronic substance abuse. I think either natural or accident can work with these case. Many years ago I called them accidents, now I call them natural. I have heard of places that call the manner of acute intoxications 'undetermined' as they can never be sure if the overdoes was intentional or not (in the absence of a suicide note, of course!).

    Determining the manner of death is often one of the hardest parts of the job and it's always fun to hear how other people sign things out. Thanks for the comment!

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  9. We do not give a manner in England & Wales - it is the function of the Coroner, whose verdicts are often 'death due to non-dependent (or dependent) drug use', rather than natural or accidental. They are increasingly delivering 'narrative verdicts', which set out all of the significant factors relevant to the death, recognising that a single word can't always accurately reflect the complexity of many cases. Pathologists are finding that 'narrative' causes of death are also more intellectually honest in many cases, for example deaths in police custody involving many factors such as psychosis, stimulant use, restraint and extreme exertion etc.

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  10. Excellent comment RMJ! I do the same with my death certs and getting very descriptive!

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