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Abstract: A 3-year-old girl with no particular medical history complained of a stomachache and died on the way to the hospital. The autopsy revealed marked right ventricular hypertrophy and dilation with no other cardiac abnormalities. Microscopically, the pulmonary small arteries showed marked medial hypertrophy and varying degrees of intimal and adventitial thickening. We supposed that the cause of death was attributable to pulmonary arterial hypertension (PAH). PAH is a rare disease that can cause sudden, unexpected death at any age. Forensic pathologists should consider PAH in the differential diagnosis of sudden death. [Copyright &y& Elsevier]

Gallbladder injuries are extremely rare in blunt trauma, with a reported incidence of <2%. We report an autopsy case of fatal hemorrhagic shock due to intra-abdominal bleeding resulting from complete avulsion of the gallbladder associated with liver cirrhosis. Multiplanar images derived from multislice computed tomography (MSCT) performed as part of pre-autopsy screening showed complete avulsion of the gallbladder without any other associated intra-abdominal injuries, facilitating forensic autopsy planning. In this report, we discuss the role of MSCT in cases of fatal intra-abdominal bleeding caused by avulsion of the gallbladder and discuss the mechanism of this injury. [ABSTRACT FROM AUTHOR]

A middle-aged female patient with a depressive disorder presented to a mental hospital because of a 2-month worsening history of headache, dizziness, and nausea. The next morning, she was observed to be sleeping, but was then found dead 1h later. Postmortem computed tomography and autopsy revealed a large cyst in the right cerebellar hemisphere, hydrocephalus, and transforaminal herniation. Careful observation revealed an approximately 0.4cm×0.8cm slightly grayish discoloration in the cyst wall that was diagnosed as hemangioblastoma based on its histological features. Finally, we concluded that the cause of death in this case was attributable to the brain stem compression, which was caused by obstructive hydrocephalus secondary to the cystic hemangioblastoma in the cerebellum. The symptoms for 2 months before her death had most likely resulted from increased intracranial pressure. Hemangioblastomas usually appear as nodules in the wall of the cyst, but the tumor in our case looked like just a slightly grayish discoloration. Therefore, cystic lesions in the CNS need to be carefully examined. [ABSTRACT FROM AUTHOR]

A man in his 40s was found unconscious on a sofa in a communal residence for people with various disabilities. He appeared to have drunk 800 ml of undiluted citric acid from a commercial plastic bottle. The instructions on the label of the beverage specified that the beverage be diluted 20- to 30-fold before consumption. The patient was admitted to an emergency hospital with severe metabolic acidosis (pH, 6.70; HCO 3 − , 3.6 mEq/L) and a low ionized calcium level (0.73 mmol/L). Although ionized calcium and catecholamines were continuously administered intravenously to correct the acidosis, the state of acidemia and low blood pressure did not improve, and he died 20 h later. Citric acid concentrations in the patient’s serum drawn shortly after treatment in the hospital and from the heart at autopsy were 80.6 mg/ml and 39.8 mg/dl, respectively (normal range: 1.3–2.6 mg/dl). Autopsy revealed black discoloration of the mucosal surface of the esophagus. Microscopically, degenerated epithelium and neutrophilic infiltration in the muscle layer were observed. In daily life, drinking a large amount of concentrated citric acid beverage is rare as a cause of lethal poisoning. However, persons with mental disorders such as dementia may mistakenly drink detergent or concentrated fluids, as in our case. Family members or facility staff in the home or nursing facility must bear in mind that they should not leave such bottles in places where they are easily accessible to mentally handicapped persons. [ABSTRACT FROM AUTHOR]

A middle-aged female patient with a depressive disorder presented to a mental hospital because of a 2-month worsening history of headache, dizziness, and nausea. The next morning, she was observed to be sleeping, but was then found dead 1h later. Postmortem computed tomography and autopsy revealed a large cyst in the right cerebellar hemisphere, hydrocephalus, and transforaminal herniation. Careful observation revealed an approximately 0.4cm×0.8cm slightly grayish discoloration in the cyst wall that was diagnosed as hemangioblastoma based on its histological features. Finally, we concluded that the cause of death in this case was attributable to the brain stem compression, which was caused by obstructive hydrocephalus secondary to the cystic hemangioblastoma in the cerebellum. The symptoms for 2 months before her death had most likely resulted from increased intracranial pressure. Hemangioblastomas usually appear as nodules in the wall of the cyst, but the tumor in our case looked like just a slightly grayish discoloration. Therefore, cystic lesions in the CNS need to be carefully examined., (Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.)

A 40-year-old man was scheduled for video assisted thoracoscopic surgery due to pneumothorax. He had been diagnosed with inclusion body myositis and received nocturnal non-invasive positive pressure ventilation. Anesthesia was induced with propofol, remifentanil, and rocuronium, and maintained with propofol, remifentanil and fentanyl. The dosage of rocuronium was 10 mg. Although we administered neostigmine at the end of the operation and TOF ratio was over 90%, he was transported to the ICU with tracheal intubation because of poor spontaneous respiration. On POD 1, the tracheal tube was extubated and NPPV was administered again. Minitrach was inserted on POD 2, and he left the ICU on POD 4. Generally, in patients with myopathy the dose of muscle relaxant should be decreased in proportion to their muscle atrophy. Rocuronium 10 mg was administered in this case and we thought it could be antagonized by neostigmine, but extubation on the day of operation was impossible. We think this is not because of the residual effect of muscle relaxant, but because of decreases in pulmonary function. In this case, we expected long-term mechanical ventilation might be necessary, but he showed a good postoperative course owing to minimally invasive surgery, NPPV, and suctioning of sputum via Minitrach.