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Pathology of Sudden Natural Death

Overview

Determination of cause of death in natural deaths, particularly when the death occurred suddenly, unexpectedly, or in the young, is an important part of forensic autopsy practice, for reasons including the following:

Performance of a complete and thorough autopsy on apparent natural deaths can provide invaluable information in the interest of public health by identifying public health risks and monitoring disease trends

Identification of disease processes and patterns provides epidemiologic data that can be used to control disease outbreaks, identify emerging infectious disease or changes in disease patterns, or to identify reportable diseases, such as meningococcal meningitis, so that close contacts can receive prophylactic treatment

The timely and accurate diagnosis of medically important diseases can have a significant impact on the relatives of the deceased by allowing them the opportunity to seek treatment for certain hereditary diseases in which the presenting symptom may in fact be sudden death

Finally, performance of an autopsy when there is no readily obvious cause of death can provide the deceased’s family and friends with answers, thereby helping with the grieving process

Accidental or intentional injuries comprise the leading cause of death in individuals from ages 1 to 44 years; still, at least half of the deaths coming to the attention of the medical examiner will be due to natural causes.
Most natural deaths are due to cardiac-related disorders, malignancy or infection. In rare cases, a definitive cause of death may not be identified following a complete and thorough autopsy. Although this quite unsatisfying for the pathologist and the family, a “negative” autopsy can still prove to be of vital importance. The lack of a definitive cause may prompt further investigations; rare hereditary diseases, hazardous environmental conditions, unusual toxic exposures, or unsafe consumer products may only be suspected or identified after a complete, detailed and through autopsy rules out more likely causes.

Even when a death is unequivocally due to a natural disease process, careful attention should be paid to an individual’s risk factors for that particular disease. A number of common natural diseases can occur spontaneously or can be secondary to a non-natural, injurious event. The inciting event may be recent, but it does not have to be to be; care should be taken when reviewing the decedent’s history. Identification of a non-natural proximate cause can significantly change the manner of death, as illustrated in the example provided below:

A quadriplegic man who had been living in an assisted living facility dies of aspiration pneumonia, which is both natural and is a known complication of quadriplegia. However, the manner of death in this case should be based not on the pneumonia (the immediate cause of death) but on the event that caused the man to become quadriplegic in the first place. If he was quadriplegic due to a non-traumatic myelopathy, the manner remains natural. However, if he was quadriplegic from a gunshot wound to the neck, the manner of death becomes a homicide, because the gunshot wound set in motion the chain of events that ultimately lead to the man getting the pneumonia.

The following image is from the autopsy of a young boy who suddenly collapsed and died during a walk with his family.

Cardiomegaly (220 g) and symmetric left ventricula

Cardiomegaly (220 g) and symmetric left ventricular hypertrophy from the autopsy of a 6-year-old boy who suddenly collapsed while on a walk with his family. These findings are consistent with symmetric hypertrophic cardiomyopathy. Other autopsy findings included pulmonary edema and ascites, as well as hypertensive changes in the lungs and early cardiac cirrhosis.

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See also Autopsy Request Process, The Autopsy Report, Adjuncts to the Forensic Autopsy, Religions and the Autopsy, Autopsy of the Transplant Recipient, Autopsy Rate and Physician Attitudes Toward Autopsy, Universal Precautions and High-Risk Autopsies, Autopsy Quality Control Metrics, and Medicolegal Issues and the Autopsy.

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