Sudden unexpected death due to Graves' disease during physical altercation

Case Report: A Sudden Thyroid-Related Death of a 15-Year-Old Girl

A 15-year-old young girl was found dead at home. There were no indications of any intervention or the application of force. On the previous day, she was admitted to hospital because of palpitations, fatigue, a headache, and a swollen neck. During a physical examination, a swollen thyroid gland and tachycardia were found. In the family history, her mother had thyroid disease. According to the laboratory values, she had elevated thyroid hormone levels. After administration of beta-blockers, the patient was discharged and died at home during the night. The parents denounced the hospital for medical malpractice; therefore, a Forensic Autopsy was performed. Based on the available clinical data, the autopsy, histological and toxicological results, the cause of death was stated as multiorgan failure due to disseminated intravascular coagulation (DIC) caused by the autoimmune Graves disease. The forensic assessment of the case does not reveal medical malpractice. Post-mortem diagnoses of thyroid disorders in cases of sudden death can be challenging. However, as the reported case illustrates, the diagnosis could be established after a detailed evaluation of antemortem clinical data, autopsy results, histology, and a toxicological examination.

An Overview of the Thyroid Gland and Thyroid-Related Deaths for the Forensic Pathologist

The thyroid gland is a butterfly-shaped organ situated in the anterior neck whose functions have system-wide effects. Thyroid diseases represent some of the most commonly encountered endocrine disorders and therefore are commonly encountered at the time of autopsy. Knowing how the gland functions and the effects it may have on vital organs is important when determining the cause of death and significant contributory conditions. Endocrine-related deaths may be anatomically subtle, therefore histologic examination, review of medical records, and selected postmortem testing must be performed to correctly identify and document their presence. For this reason, it is recommended that pathologists consider regularly examining the thyroid gland histologically, particularly on decedents where no apparent anatomic cause of death is identified after the autopsy. This article provides an in-depth review of the thyroid gland, thyroid hormones, and thyroid diseases, including potential thyroid-related deaths and incidental autopsy findings.

Sudden unexpected death in the setting of undiagnosed Graves' disease

Graves' disease is the most common cause of hyperthyroidism and is classically characterized by the clinical triad of diffuse toxic goiter, infiltrative ophthalmopathy with exophthalmos and an infiltrative dermopathy. While the name of the Irishman Robert Graves has received the eponymous honor, the first description of the condition in the English language can be attributed to the Englishman Caleb Perry, while in continental Europe the entity in name once honored Karl von Basedow. We present the case of a previously well 43 year old woman who presented in supraventricular tachycardia and acute pulmonary edema and died despite treatment and without a diagnosis for cause of death. At autopsy the significant positive macroscopic findings were confined to the lungs (acute pulmonary edema) and thyroid (diffusely enlarged). Histology revealed features typical of Graves' disease while post mortem thyroid function tests supported a diagnosis of thyrotoxic crisis in the setting of undiagnosed Graves' disease.