Sudden death due to pulmonary embolism from right atrial myxoma

Sudden death by massive systemic embolism from cardiac myxoma. Role of the clinical autopsy and review of literature

Cardiac myxoma is a rare benign neoplasm of the heart. Historically myxomas were incidental findings during autopsies, however improved imaging techniques made these diagnosis possible in living patients, making the surgical treatment of these neoplasms achievable. Cardiac myxomas may occur both sporadically and in a familial context, often in the clinico-pathological picture of the Carney complex. While familial myxomas occur in the context of well-known genetic mutations, the molecular etiology of sporadically occurring myxomas is still not completely clear. We must note however that many of the patients affected by myxomas are asymptomatic; when symptoms are present they are often nonspecific and hard to decipher, especially when referring to sporadically occurring heart myxomas. In this paper we describe a case of sudden death from the massive embolization of a left atrial cardiac myxoma. We also reviewed all the cases in the literature of sudden death from heart myxoma embolism. An accurate epidemiology of heart myxomas would be the key to outline the best treatment practices and the etiology of sporadic myxomas, nevertheless this target could only be pursued with a deep revaluation of the clinical autopsy as a fundamental diagnostic tool.

Pulmonary embolism as the initial manifestation of right atrial myxoma: A case report and review of the literature

RATIONALE

Pulmonary embolisms (PEs) are caused by emboli, which mostly originate from deep venous thrombi that travel to and suddenly block the pulmonary arteries. The emboli are usually thrombi, and right atrial myxoma emboli are rare.

PATIENT CONCERNS

A 55-year-old man presented with shortness of breath and syncope. We proceeded with computed tomography pulmonary angiography (CTPA) and transthoracic echocardiogram (TTE), the results of which suggested that the diagnosis was a right atrial mass.

DIAGNOSIS

A definitive diagnosis compatible with a right atrial myxoma (RAM) with tumoral pulmonary emboli after surgical excision was made.

INTERVENTION

Right atrial and pulmonary artery embolectomy.

OUTCOMES

The patient followed an uneventful course during the 6 years of follow-up after surgery. According to a review of the literature, RAMs are often not diagnosed in a timely manner or even go completely undiagnosed. TTE, transesophageal echocardiography (TEE), CT, magnetic resonance imaging (MRI), and positron emission tomography/computed tomography may be helpful in the preoperative diagnosis. Surgical removal of the masses from the atrium and pulmonary arteries was relatively uneventful.

LESSONS

RAMs should be considered unlikely reasons for fatal pulmonary embolisms.

Pulmonary and coronary foreign particle embolism after central venous injection of liquid nutrition

A man was found dead in his nursing bed. The responsible assistant nurse explained that she had administered liquid nutrition (Isosource Energy Fibre 500 ml) via perfusion pump into the Hickman catheter, insisting that the Hickman catheter was a percutaneous endoscopic gastric tube. Autopsy findings were unspecific and could not reveal the cause of death. Histopathological examinations showed severe pulmonary foreign particle emboli, partially even emboli of the small coronary arteries. We present the pathological findings of the case in regard to the underlying pathophysiology.

Case report of death from falling: Did heart tumor cause syncope?

A healthy man in his 30s was working on the balustrade of stairs on the second floor. He suddenly fell downstairs without saying anything. On emergency hospitalization, chest echogram showed left hemothorax. Cardiac echogram showed a floating mass from the mitral valve in the left ventricle and severe mitral regurgitation. Surgery for hemothorax and pulmonary contusion was immediately undertaken. However, bleeding from pulmonary contusion could not be controlled and he underwent cardiopulmonary arrest. Autopsy showed a white, elastic, pendulous mass in the left atrium and a white mass in the lower lobe of the left lung. Tumor histology showed a reticular pattern, Schiller-Duval bodies, eosinophilic hyaline globules, and positive staining for α-fetoprotein. We diagnosed primary lung yolk sac tumor with metastatic intracardiac yolk sac tumor, a rare and highly malignant germ cell tumor. It usually arises in the ovaries and testes, and intracardiac yolk sac tumor is rare. Intracavitary tumors induce obstruction of inflow into and outflow from the ventricular cavity. The most common clinical presentation is dyspnea and syncope. In the present case, metastatic cardiac yolk sac tumor might have disturbed cardiac outflow and affected hemodynamics, probably causing syncope. Unfortunately, he was in a high place at that time and fell to receive pulmonary contusion that led to death. Autopsy may sometimes reveal latent diseases which might be related to the cause of death. We should perform autopsy thoroughly to diagnose not only the cause of death but also the factors leading to death.

Lethal thyroid storm after uncontrolled intake of liothyronine in order to lose weight

Thyroid hormones are sometimes used for purposes for which they are not approved. Reasons for off-label use can be overweight, prevailing depressive mood, or various somatic symptoms. Information about the intake of thyroid hormones in order to lose weight can be easily obtained from inappropriate/nonmedical websites. The objective of this case report is to describe the first case of a lethal abuse of liothyronine. The case was a 29-year-old male (BMI 32) without relevant illnesses. An autopsy was performed and followed by histological, toxicological, and clinical chemistry examinations. The autopsy revealed no relevant pathology. Histology showed multiple areas of focal cell necrosis in the myocardium and signs of acute heart failure including severe edema of the lungs; the follicles of the thyroid gland were markedly plump. Postmortem laboratory results indicated lethal liothyronine intoxication. Despite prevailing opinion, uncontrolled intake of liothyronine can cause lethal thyroid storm in a euthyroid patient without manifested cardiac illnesses.