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The discovery of a hydatid cyst at autopsy poses the problem of its involvement in the mechanism of death. The aim of this study is to analyse the epidemiological and etiopathogenic characteristics of death attributed to hydatid disease, to discuss the mechanism of death and to propose preventive measures. This is a retrospective descriptive study of 26 cases of death with hydatid cyst autopsic discovered, collected at the forensic department of Fattouma Bourguiba University Hospital of Monastir (Tunisia) over a period of 27 years (from 1990 until 2017). In 26 cases, hydatid cyst was observed during autopsy of sudden death cases, which corresponds to 0.33% of the total of autopsies in this period. Of the 26 victims, 13 (50%) were men; the mean age was 43 years. Most victims were from rural zones (18 cases). In 20 cases, the complicated cyst was hepatic. It was cardiac in two cases. Of all cases, three cysts were cracked, and nine were broken. Of the 26 cases, only 15 were implicated in the death mechanism. Death was attributed to anaphylaxis in 12 cases, hydatid pulmonary embolism in 1 case, cardiac arythmia in one case and hemothorax in one case. Sudden death is the most dangerous complication of the hydatid cyst which can be discovered at autopsy. Several causes may explain its occurrence, the most common of which is anaphylactic shock., (Copyright © 2019 Elsevier B.V. All rights reserved.)

The natural history of the echinococcosis can be studded with multiple complications; the most formidable is sudden death. We studied the epidemiological, pathological, and thanatological features of 34 sudden deaths due to hydatid cyst. The mean age was 33.2 years. A male predominance was observed with a sex ratio of 1.8. Most of our victims were from rural areas (79.4%). Sudden death was preceded by prodromal symptoms in 61.7% of cases. The most common was dyspnea (23.5%), followed by hemoptysis (11.8%). In 85.3% of cases, the cyst location was liver. It was cracked in 25 cases and broken in 6 cases. The rupture was spontaneous in 25 cases (73%). It was preceded by trauma in 7 cases. Death was related to an anaphylactic shock in 82.3% of cases, infection in 14.7%, and respiratory distress in 3% of cases. Sudden death is a serious and not exceptional complication of hydatid cyst. Several mechanisms may explain the sudden death.

Human ecchinococcosis also known as hydatid disease is a zoonotic infection caused by the tapeworm Ecchinococcus with 2-3 Million cases worldwide. We hereby report a 6 years period study of Sudden death due to hydatidosis aiming to analyze the epidemiological criteria, death circumstances, and autopsy observations attributed to hydatid disease. During the past 6 years, 26 death cases were due to hydatid disease. Our analysis shows that the sex ratio (M/F) was 1.6, the mean age was 31-year old, and 65% of the subjects lived in rural places. In 17 cases, death occurred in the victim's place, five victims died after a heavy exercise, and in two cases, death occurred immediately after trauma. At autopsy, 91% of the cysts were found in the liver. In three cases, death followed a septic state, and in two cases, it followed an acute respiratory failure. Death was attributed to anaphylaxis in 17 cases., (© 2013 American Academy of Forensic Sciences.)

Fatal or life-threatening anaphylactic reactions to food occur in infants, children and adults. Atopic individuals with bronchial asthma and prior allergic reactions to the same food are at a particularly high risk, whereby even the mere inhalation of the allergenic food can be fatal. Not only peanuts, seafood and milk can induce severe, potentially lethal anaphylaxis, but indeed a wide spectrum of foods, according to the different patterns of food sensitivity in different countries. Foods with "hidden" allergens and meals at restaurants are particularly dangerous for patients with food allergies. Similarly, schools, public places and restaurants are the major places of risk. However, the main factor contributing to a fatal outcome is the fact that the victims did not carry their emergency kit with adrenaline (epinephrine) with them. In cases of death where food anaphylaxis is suspected, it is important for forensic reasons to preserve uneaten portions of the food in order to identify (hidden) allergens. It is also important to determine postmortem specific serum IgE, tryptase and histamine levels to document the anaphylaxis. There is a need to raise awareness of the diagnosis and treatment of anaphylaxis among doctors, those called upon to administer emergency medical care, and the public, and also to provide increased support for those with potentially fatal food allergies through the help of patients' organizations, and national and international medical societies. The food industry should ensure a policy of comprehensive labelling of ingredients so that even the smallest amount of potentially lethal foodstuffs can be clearly identified. Finally, the pharmaceutical industry should be persuaded to reintroduce an adrenaline inhaler onto the market.

We measured mast-cell tryptase in postmortem blood from 22 heroin addicts dying suddenly after injection. In 32%, the concentration of tryptase was elevated (> or = 10 micrograms/l), and the mean value of tryptase was significantly different from a control group dying from known, nonimmunologic causes (P < 0.05). The increased tryptase concentrations indicate that death was preceded by systemic mast-cell degranulation. All victims of drug deaths had morphine in blood, most below 0.2 microgram/ml. In 71% of the victims of drug-related deaths with tryptase values > or = 10 micrograms/l, the intermediate degradation product, 6-monoacetyl-morphine, was not found in blood, whereas this was the case in only two victims with values below that cutoff point. This indicates that those with high tryptase concentrations survived longer than those with lower values. No correlation was found between the IgE levels and tryptase in either group, supporting the hypothesis that tryptase release was not mediated by an allergic reaction. The well-known property of opiates to stimulate unspecifically the liberation of histamine and other constituents of mast-cell granules offers one explanation of our observations. The results suggest that many heroin fatalities are caused by an anaphylactoid reaction.

Many of the large number of people who are stung each year by bees experience frightening systemic reactions, but the vast majority of such reactions are not life-threatening. There is no evidence that the very few who die as a result of a bee sting come from the pool of those who once before sustained a systemic reaction. On the contrary, no reaction at all may be a more ominous predictor of a lethal outcome on a subsequent sting. Death comes about through multiple mechanisms, and not through anaphylaxis alone. Like most cases of sudden death, underlying coronary atherosclerosis appears to be the principal mechanism. External factors that affect mortality include environmental temperature and site of sting. In general, however, because the numbers of deaths are so small, death comes unpredictably, and those at risk have not been identified. Immunotherapy, whether with venom or whole-body extract, has not been proven to prevent death from a bee sting.

During a 21-year period in Denmark a total of 26 deaths were caused by wasp or bee stings (according to the National Health Service). The deaths might be classified, with some overlapping, as caused by either anaphylactic/anaphylactoid shocks (between 65% and 80%), suffocation after stings in the airways (about 15%) or preexisting diseases, especially arteriosclerotic heart disease (approx. 20%). Characteristically, in most persons with shock reactions unconsciousness and death occurred very shortly after the sting (within 45 min), while the interval between sting and death was longer (30 min to a couple of hours) when death was caused by suffocation. In more than 21 of the 26 cases it seemed reasonable to assume that insect allergy might have contributed to the fatal outcome. Six of these cases had a previous history of abnormal reactions to insect venom, thus only a small group would have benefited from the prophylactic effect of hyposensitisation. There was no known previous history of reactions to insect stings in the other cases, but it is likely that more than six persons had had severe reactions to insect stings on other occasions. Presumably many deaths where insect stings have been involved--through not verified as causal--are classified as inexplicable or accidental, thus the real number of deaths caused by wasp or bee stings could be substantially greater. Consequently hyposensitisation after severe insect sting reactions of verified allergic genesis can still be advised.

In the reported case the authors discuss the possible role of thymomegaly in the pathological mechanism of sudden death explaining the observed clinical changes (fainting and cardiac murmurs) as due to pressure exerted by the enlarged thymus on the heart and airways. Sudden death was preceded by ingestion of amidoquine tablet and slight trauma to the head.