Sudden, unexpected, natural death in childhood

Causes of Sudden Unexpected Death in Childhood: Autopsy Findings from a Specialist Centre

OBJECTIVES

To investigate the aetiologies of sudden unexpected death from natural causes in children aged 1-18 years by retrospective examination of autopsy records from a single centre.

MATERIALS AND METHODS

The post-mortem findings from 548 children (1996-2015) were examined. Details were entered into an established research database and categorized according to >400 pre-defined criteria.

RESULTS

There were 265 previously apparently healthy children and 283 with pre-existing, potentially life-limiting, conditions. There were more males than females (M:F 1.4:1), and deaths were more frequent in the winter. Infection was commonest accounting for 43% of all deaths. Non-infectious diseases were identified as cause of death in 28%, and 29% of all deaths were unexplained. There was no significant difference in the proportions of deaths in each category between the previously healthy children and those with pre-existing conditions.

CONCLUSION

Sudden unexpected death is a rare presentation of death in childhood and those with pre-existing conditions may be more at risk. Standardisation of the post-mortem procedure in such cases may result in more ancillary investigations performed as routine and may reduce the number of cases that are 'unexplained'.

Sudden unexpected death in a 17-year-old boy due to unacknowledged adamantinoma-like Ewing sarcoma

A 17-year-old male with no previous medical history was admitted 2 days before his death to a local hospital after mild dyspnea. Electrocardiography, chest radiography, and blood analysis revealed no abnormalities. Blood oxygen saturation was 99%, and SARS-CoV-2 nasopharyngeal swabs tested negative; thus, he was discharged without prescriptions. After 2 days, the subject died suddenly during a pool party. Forensic autopsy was performed analyzing all anatomical districts. Cardiac causes were fully excluded after deep macroscopic and microscopic evaluation; lung and brain analyses showed no macroscopic pathology. Finally, a large subglottic solid mass was detected. The whitish neoplasm showed an aggressive invasion pattern to the thyroid and adjacent deep soft tissues and occluded the trachea. High-power microscopy showed sheets of small, uniform cells with scant cytoplasm; round nuclei; and small, punctate nucleoli, with immunohistochemical expression of CK8-18, AE1/AE3, and CD99. Using FISH analysis, the break-apart molecular probes (EWSR1 (22q12) Break - XL, Leica Biosystem, Nussloch, Germany) showed distinct broken red and green fluorochromes, diagnostic of Ewing sarcoma. The neoplasm was characterized as adamantinoma-like Ewing sarcoma, and the mechanism of death was identified as airway obstruction. The rarity of the case resides in the circumstances of death, which pointed to the possibility of sudden unexpected death due to heart disease, but an oncological cause and the underlying mechanism were finally diagnosed. The best method to perform autopsies is still complete, extensive, and systematic macroscopic sampling of organs and districts followed by histopathological analysis, in addition to immunohistochemical and molecular investigations in those cases in which they are necessary. In fact, when neoplasms are detected, the application of advanced techniques such as immunohistochemistry and molecular diagnostics is fundamental to accurately certify death.

Sudden Unexplained Death in Childhood: A Neuropathology Review

Sudden Unexplained Death in Childhood (SUDC) is the unexpected death of a child over age 12 months that remains unexplained after a thorough case investigation, including review of the child's medical history, circumstances of death, a complete autopsy and ancillary testing (1). First defined in 2005, SUDC cases are more often male, with death occurring during a sleep period, being found prone, peak winter incidence, associated with febrile seizure history in ~28% of cases and mild pathologic changes insufficient to explain the death (1, 2). There has been little progress in understanding the causes of SUDC and no progress in prevention. Despite reductions in sudden unexpected infant death (SUID) and other causes of mortality in childhood, the rate of SUDC has increased during the past two decades (3-5). In Ireland, SUID deaths were cut in half from 1994 to 2008 while SUDC deaths more than doubled (4). Surveillance issues, including lack of standardized certification practices, affect our understanding of the true magnitude of unexplained child deaths. Mechanisms underlying SUDC, like SUID, remain largely speculative. Limited and inconsistent evidence implicates abnormalities in brainstem autonomic and serotonergic nuclei, critical for arousal, cardiorespiratory control, and reflex responses to life-threatening hypoxia or hypercarbia in sleep (6). Abnormalities in medullary serotonergic neurons and receptors, as well as cardiorespiratory brainstem nuclei occur in some SUID cases, but have never been studied in SUDC. Retrospective, small SUDC studies with non-standardized methodologies most often demonstrate minor hippocampal abnormalities, as well as focal cortical dysplasia and dysgenesis of the brainstem and cerebellum. The significance of these findings to SUDC pathogenesis remains unclear with some investigators and forensic pathologists labeling these findings as normal variants, or potential causes of SUDC. The development of preventive strategies will require a greater understanding of underlying mechanisms.

Childhood neoplasms presenting at autopsy: A 20-year experience

OBJECTIVE

The aims of the review are to establish the number of undiagnosed neoplasms presenting at autopsy in a single centre and to determine the incidence and most common causes of sudden unexpected death due to neoplasia in infancy and childhood (SUDNIC).

DESIGN

Retrospective observational study of paediatric autopsies performed on behalf of Her Majesty's Coroner over a 20-year period (1996-2015; n = 2,432). Neoplasms first diagnosed at autopsy were identified from an established database and cases meeting the criteria for sudden unexpected death were further categorised.

RESULTS

Thirteen previously undiagnosed neoplasms were identified, including five haematological malignancies, two medulloblastomas, two neuroblastomas, two cardiac tumours and two malignancies of renal origin. Eight cases met the criteria for SUDNIC (0.33% of autopsies), the commonest group of which were haematological malignancies (n = 3).

CONCLUSIONS

Neoplasms presenting as unexpected death in infancy and childhood and diagnosed at autopsy are rare. The findings suggest that haematological malignancies are the commonest cause of SUDNIC and highlight the importance of specialist autopsy in cases of sudden unexpected death.

Undiagnosed heart disease leading to sudden unexpected death in childhood: a retrospective study

OBJECTIVES

Heart disease accounts for a significant proportion of sudden unexpected deaths among children. We describe here demographic features, pathological conditions, and the frequency of premonitory symptoms in a retrospective series of cases of sudden unexpected cardiac death (SUCD) attributable to undiagnosed structural heart disease.

METHODS

A chart review of autopsies involving children 0 to 17 years of age that were performed at the Hospital for Sick Children (Toronto, Ontario, Canada) between 1984 and 2003 was conducted. Cases of sudden unexpected death within 24 hours after clinical presentation with previously undetected fatal heart disease were included. Cases with multiple or thoracic trauma and chronic or multisystem disease were excluded.

RESULTS

During the 20-year study period, 4926 autopsies were performed. A total of 103 cases (2.1%), involving 51 male patients and 52 female patients 1 day to 15 years of age (mean: 2.9 ± 4.2 years), were diagnosed as having SUCD. The most common diagnoses were myocarditis (n = 37 [35.9%]), hypoplastic left heart syndrome (HLHS) (n = 19 [18.4%]), dilated cardiomyopathy (DCM) (n = 16 [16.5%]), coronary artery anomalies (n = 6 [5.8%]), and aortic stenosis (n = 5 [4.9%]). There was a significant difference in the mean age of presentation between leading causes of SUCD (6.5 days for HLHS, 1.7 years for DCM, and 5.4 years for myocarditis; P < .0001). Of 103 cases, 27 (26.2%) had premonitory symptoms documented.

CONCLUSION

SUCD accounted for 2.1% of all autopsies, and HLHS, DCM, and myocarditis were the 3 most common diagnoses, which presented at increasing ages.

Fatal ischemic stroke due to dissecting aneurysm of the intracranial arteries presenting as sudden unexpected death in childhood

Sudden unexpected death is any nontraumatic death in healthy individuals with normal activities for age until acute demise. Whereas not uncommon in adults and infants, it is considered a rarity in children, with most cases due to infection or occult cardiovascular abnormalities. Pathologic intracranial findings are rarely found in sudden unexpected death in childhood, with most cases due to occult intracranial neoplasms. Cerebral arterial dissection is an uncommon cause of arterial ischemic stroke in childhood. Outcome is poor, with more than 20% of patients dying. We report 4 cases of sudden unexpected death due to arterial ischemic stroke after cerebral arterial dissection in childhood and present a review of the literature.

Investigating sudden unexpected death in infancy and early childhood

Sudden unexpected death is one of the most frequent ways of dying in the first year of life after the neonatal period. It is however, much less frequent after the first birthday. Investigations into the cause of death are very important, for a significant proportion of these sudden deaths can be explained only after a thorough investigation. Of the causes identified, infection is the most frequent cause; metabolic disorders and cardiovascular diseases play a role as well, although the proportion of cases is much smaller. There is now evidence that cardiac channel gene mutations also play an important role; however, identification of these conditions relies on costly testing that is not readily or widely available. The physician's role as primary care provider is critical in ensuring that families understand the results of the investigation into their child's death. It is important that everything be done to identify the cause of death so that no such tragedy recurs in the same family.

Brain Arteriovenous Malformation and Its Implication in Forensic Pathology

Despite the fact that brain arteriovenous malformations (BAVMs) are a possible cause of sudden and unexplained death, very few papers have discussed their importance in the forensic context. BAVMs consist of tangled masses of tortuous arteries and veins devoid of intervening capillaries that frequently extend from brain parenchyma into the subarachnoid space. Apart from BAVMs, three major groups of vascular malformations of the brain are known: cavernous hemangioma, venous angioma, and capillary telangiectasia. BAVMs and cavernous hemangioma often cause hemorrhages, while venous angioma and capillary telangiectasia are typically asymptomatic. Presented here is the case of a 14-year-old girl who died from a ruptured BAVM. The present case is a reminder that the forensic pathologist should be able to recognize BAVMs and to differentiate it from other types of vascular malformations. Although rare, it is a cause of sudden death not to be overlooked, especially in children.

Postmortem computed tomography for detecting causes of sudden death in infants and children: retrospective review of cases

PURPOSE

The aim of this study was to investigate the usefulness of postmortem computed tomography (PMCT) in detecting causes of sudden death in infants and children.

MATERIALS AND METHODS

Our subjects were 15 nontraumatically deceased patients (nine boys and six girls, ranging in age from 20 days after birth to 12 years old, mean age 1.6 years), who had been in a state of cardiopulmonary arrest on arrival at our hospital. PMCT was performed within 2 h after certification of death: head (15 cases), chest (11 cases), and abdomen (12 cases). Blood was collected from 11 of the patients at the time of cardiopulmonary resuscitation. An autopsy was conducted on two.

RESULTS

PMCT did not show any traumatic changes indicating child abuse. It was difficult to presume the cause of death with PMCT alone, but the cause of death in 14 of 15 cases could be presumed by combining information from their medical history, clinical course before death, PMCT findings, laboratory data, and bacterial culture. The remaining subject was classified as cause unknown.

CONCLUSION

The causes of sudden death in infants and children were detected at a high rate when we comprehensively investigated the PMCT and other examination findings.

The value of the metabolic autopsy in the pediatric hospital setting

OBJECTIVE

To determine the utility of the metabolic autopsy in the hospitalized pediatric patient.

STUDY DESIGN

This was a retrospective review of all metabolic autopsies performed at a large pediatric hospital over a 5-year period. Premortem clinical diagnoses were correlated with autopsy findings and results of postmortem testing.

RESULTS

Of the 23 metabolic autopsies performed, a metabolic disorder was diagnosed before death in 4 and after death by extensive studies initiated before death in 2. In the remaining 17 cases, postmortem samples were inadequate for subsequent enzymatic analysis in 2, a nonmetabolic explanation for symptoms was identified in 4, and no unifying diagnosis could be defined in 8. A metabolic disorder was diagnosed by postmortem tissue study in 3 of the 17 cases; in all 3 of these cases the patient died in the neonatal period after limited premortem investigation for primary lactic acidosis. For the 8 subjects who had undergone an extensive laboratory workup before death, in each case metabolic autopsy failed to establish a diagnosis.

CONCLUSIONS

In a small but significant percentage of cases (18%), the metabolic autopsy successfully identified an undiagnosed metabolic disease. However, metabolic autopsy following an extensive nondiagnostic clinical workup is unlikely to yield a specific metabolic diagnosis.

Sudden Unexpected Death in Infancy and Childhood Due to Undiagnosed Neoplasia

Sudden unexpected death due to clinically undiagnosed neoplasia in infancy and childhood (SUDNIC) is a rare phenomenon, with only small numbers of cases reported in the literature. In the majority of instances, the tumors involve critical structures within the heart or central nervous system and include gliomas, medulloblastomas, rhabdomyomas, and neoplasms of stromal elements. A 20-year retrospective review of autopsy records from the Hospital for Sick Children, Toronto, was performed (1984-2003, n = 4926), and 7 cases of SUDNIC were identified (0.14%). In addition, 1 case was obtained from the files of the Children's and Women's Health Centre of British Columbia, Vancouver. Diagnoses included 2 cases of acute leukemia (1 myelogenous, 1 lymphoblastic), 2 cases of mediastinal lymphoblastic lymphoma (pre-T cell type), 1 papillary fibroelastoma of the mitral valve prolapsing into and totally occluding the left anterior descending coronary artery, 1 medulloblastoma, 1 Wilms tumor associated with fatal intraperitoneal hemorrhage, and 1 widely disseminated gastric carcinoma. These cases demonstrate that infants and children may have minimal or no symptoms in the presence of significant disease and highlight the need for a thorough autopsy examination in cases of sudden unexpected death in infancy and childhood.

Sudden unexpected death in childhood: a report of 50 cases

Sudden unexplained death in childhood (SUDC) is rare, with a reported incidence in the United States of 1.5 deaths per 100,000 live births compared with 56 deaths per 100,000 live births for sudden infant death syndrome in 2001. The objectives of this study include a proposal for a general definition for SUDC and presentation of 36 cases of SUDC and 14 cases of sudden unexpected death in childhood. Cases were accrued through referrals or unsolicited via our Web page (http://www.sudc.org ). Our analyses tentatively suggest a SUDC profile characterized by cases being 1 to 3 years in age, predominantly male, and frequently having a personal and family history of seizures that are often associated with a fever. A history of recent minor head trauma is not uncommon. They are usually born at term as singletons and occasionally have a family history of sudden infant death syndrome or SUDC. Most are found prone, often with their face straight down into the sleep surface. Minor findings are commonly seen at postmortem examination but do not explain their deaths. Comprehensive review of the medical history and circumstances of death and performance of a complete postmortem examination including ancillary studies and extensive histologic sampling of the brain are critical in determining the cause of death in these cases of sudden unexpected childhood death. Legislation enabling research and formation of a multicenter research team is recommended to unravel the mystery of SUDC.

Prospective study of coroner's autopsies in Benin City, Nigeria

A prospective study of 726 cases of coroner's autopsies carried out over a period of two years (1st January, 1996 - 31st December, 1997) was reviewed. The causes and circumstances of death are defined and classified into natural and unnatural deaths. Fifty cases (6.3%) were children while the remaining 676 cases (93.1%) were adults in a male to female ratio of 2.6 to 1. The most common indications for coroner's autopsies were sudden unnatural deaths (SUDs) accounting for 485 cases (66.8%) and also sudden unexpected natural deaths (SUNDs) (241 cases) accounting for 33.2%. In the first category, road traffic accidents accounted for 86.7% of cases with deaths involving motor vehicle drivers and their passengers (41.8%); pedestrians (37.1%); and motorcyclists and their passengers (18.6%). The commonest causes of death in all road traffic accidents were craniocerebral injuries and haemorrhagic shock. In the second category the most common causes of sudden unexpected natural death were cardiovascular diseases resulting from complications of hypertension (54.7%) occurring in apparently healthy individuals. Other causes of death were pneumonia, pulmonary tuberculosis, typhoid fever and neoplastic diseases. This study showed that in Nigeria, with an increasing acquisition of dietary and life style habits of the developed western world, there is becoming a concomitant risk of deaths from road traffic accidents and sudden unexpected natural deaths from hypertensive cardiovascular disease.

[Incidence and causes of sudden death in persons less than 36 years of age]

BACKGROUND

Epidemiological, clinical and pathological study of sudden death in children and young adults under 36 years old. SUBJECTS, MATERIAL AND METHOD: Sudden deaths between 1 and 35 years that occurred in Bizkaia (North of Spain) from 1991 to 1998 were analyzed. In all cases a complete forensic autopsy including histopathological, toxicological and occasionally microbiological studies were performed. Also, pathological antecedents were investigated.

RESULTS

107 sudden death cases between 1 and 35 years occurred, being the mortality rate of 2.4/100,000/year. Males were threefold at risk of sudden death than females. Mortality rate was higher in youngs than children. 4.5% of natural deaths were sudden deaths.43% were sudden cardiac deaths, and atheromatous coronary disease was the most frequent over 30 years. Myocardial diseases and conduction system abnormalities were common between 15 and 29 years. 39% were extracardiac sudden deaths. Infections were frequent in children, and epilepsy and asthma between 15 and 29 years. Intracraneal hemorrhage was also frequent. In 19 cases (18%), specially in children, the cause of death was unexplained. Cause of death was different according to gender and age.

CONCLUSIONS

Sudden death is infrequent in children and youngs, and causes are numerous. This study supports the importance of complete forensic autopsies in order to encourage epidemiological and preventive studies on sudden death.

Sudden, unexpected death in subjects with undiagnosed gliomas

We report two cases in which a medicolegal autopsy disclosed small and previously undiagnosed gliomas. The first case was a 38-year-old woman who was found dead in bed; her autopsy revealed a 1.3-cm low-grade astrocytoma in the right subthalamic area. The second case involved a 32-year-old man who drowned in shallow water after his canoe capsized. A 0.5-cm oligoden-droglioma of the left temporal lobe and a 0.1-cm ganglionic hamartoma of the hypothalamus were found. In both cases the tumors may, directly or indirectly, have been the underlying cause of death. We emphasize the importance of a thorough neuropathological examination for all cases of sudden unexpected death in which no extracerebral cause of death has been found.

A prospective study of coroner's autopsies in University College Hospital, Ibadan, Nigeria

The present study reviews 876 consecutive coroner's autopsies performed in the Department of Pathology, University College Hospital, Ibadan over a two-year period (1 February 1991 to 31 January 1993). The hospital autopsy rate during the study period was 36.2%, and 62.5 per cent of these post-mortems were medico-legal cases. The most common indications for coroner's autopsies were sudden natural deaths (55.6%), followed by accidental deaths (35.3%). The proportions of maternal (4.3%), homicidal (3.1%) and suicidal (0.3%) deaths were much lower. The male to female ratio was 1.7 to 1. Ninety-one (10.4%) of the cases fell within the paediatric age group and the peak age incidence for these cases was in the 5-14 years age group. The remaining 785 (89.6%) cases were adults and the peak age incidence for these cases was in the fourth decade of life. The most common cause of sudden natural death was cardiovascular disease, of which hypertension constituted the majority of cases. Other major causes of sudden death included pneumonia, meningitis, typhoid fever and neoplastic diseases. Road traffic accidents accounted for 78 per cent of accidental deaths followed by falls (13.3%) and burns (4.6%). Abortions, post-partum haemorrhage and eclampsia were the major causes of maternal deaths in the present study. Homicidal deaths were eight times more frequent in male than female victims and the commonest mode of death was gunshot injuries. Suicidal deaths remain extremely uncommon in African patients, as confirmed by our study.

Supraglottic airway infections

Supraglottic infections are included among the more serious pediatric infections, although they are less common than other pediatric respiratory infections. Supraglottic infections include epiglottis (supraglottitis), retropharyngeal cellulitis, retropharyngeal abscess, and peritonsillar abscess. A high index of suspicion combined with rapid diagnosis and treatment are crucial to reducing the morbidity and mortality associated with these infections. A review of these infections, including diagnosis and treatment, is presented.

Overwhelming sepsis presenting as sudden unexpected death

Four children, including three infants, who died suddenly and unexpectedly are described. In three of the cases group A beta haemolytic streptococcus was cultured and in the fourth Streptococcus pneumoniae. The organism was grown from multiple sites including blood in two of them. Without microbiological investigation the diagnosis would have been sudden unexpected death syndrome.

Histochemistry of the atrioventricular conducting system during postnatal development

The atrioventricular conduction system of 27 infants coming to autopsy was examined by histochemical methods. Twenty one were sudden infant deaths; six were explained deaths. A decrease of oxidoreductases and hydrolases activities was found in clusters of conducting cells protruding from the atrioventricular (AV) node and His bundle left into the collagen of the septum. These findings reflect regressive changes connected with reduction of the AV conducting system during postnatal development.