A healthy 17-year-old Chinese male suddenly collapsed and died during a game of badminton. The autopsy examination revealed a solitary calcified aneurysm of the left common coronary artery with marked stenosis of the orifices of the anterior descending and circumflex branches. Histology of the aneurysm was non-specific with hyalinised scar tissue and foci of calcification. The only illness of significance in the past was an episode of 'pyrexia of unknown origin' at the age of 8 months. A review of the notes of that hospital admission revealed that the illness was most probably Kawasaki disease.
A 68-year-old diabetic and hypertensive woman presented with chronic autonomic diarrhoea, syncope and palpitations which were associated with QT prolongation and recurrent episodes of torsade de pointes. She was on glibenclamide, indapamide and probucol (for type V hyperlipidaemia). Despite intravenous infusions of potassium, lignocaine and amiodarone, the unstable rhythm persisted. However, intravenous magnesium sulphate with small doses of intravenous propranolol terminated the torsade de pointes. She was stabilised but following discharge she relapsed, and upon re-admission, succumbed to intractable ventricular fibrillation. Early recognition and aggressive treatment of this condition is emphasised. Multiple aggravating factors ie autonomic diarrhoea resulting in severe potassium and magnesium depletion, kaliuretic effect of indapamide, probable QT prolongation associated with diabetic autonomic neuropathy and probucol; probable underlying coronary artery disease and heightened emotional and sympathetic discharge could have contributed to this very unstable ventricular arrhythmia and sudden death.
Obstetric pulmonary embolism forms the most serious vascular problem during pregnancy. The following report is a retrospective study into maternal deaths in Malaysian mothers probably due to obstetrical pulmonary embolism. Obstetric pulmonary embolism can be divided into amniotic fluid embolism and obstetric blood clot embolism. There were 37 maternal deaths attributable to this cause -9.9 per cent of all maternal deaths to blood clot embolism and 6.7 per cent to amniotic fluid embolism. Most cases were diagnosed clinically because a postmortem examination was not done. Eleven cases of embolism were associated with Caesarean delivery. The typical profile of a Malaysian mother dying from obstetrical pulmonary embolism is that of a Malay mother in the "non-risk" parities of one to four and usually aged between 31-35 years. In the management of these patients, there should be an urgency in diagnosis and improvement in diagnostic procedures. Health staff at all levels should be trained to pick up patients who present with features of deep vein thrombosis.
Sudden maternal death from amniotic fluid embolism is a rare but serious complication which usually occurs during late pregnancy, often during labour or shortly after, with more than 80% mortality. Such a death causes immense stress to both the relatives and the attending doctors as it is sudden and unexpected. Three such deaths are discussed here. Traditionally, it was believed that this complication usually occurred in prolonged and difficult labour, but there is evidence contrary to this, and it is not possible to predict when and where this fatal complication will occur. Current views and various pathophysiologic mechanisms leading to the fatal outcome are also discussed.
Heat stroke, which is also known as "sun stroke," is a medical emergency, and fatalities can occur unless it is diagnosed early and treated efficiently. Heat stroke may manifest quite suddenly, giving little time to differentiate it from extreme physical exhaustion in collapsed subjects. It is also known to lead to serious disseminated intravascular coagulation. Sudden death in a young female is presented who collapsed after trekking in a hilly, jungle area in Malaysia on a warm, humid day. She had joined a weight reduction programme a few weeks earlier. She was found collapsed and in a semiconscious state in the jungle by her groupmates and was taken to hospital. On admission she was unconscious, hyperpyrexic, with rapid, thready pulse and a low blood pressure. Biochemical studies revealed metabolic acidosis, elevated liver and cardiac enzymes and impairment of renal function. Her coagulation profile was found to be impaired and she started bleeding through the mouth and nostrils. She also developed watery diarrhoea and initially a septicaemic condition, including acute enteritis was suspected. Despite active treatment, her condition deteriorated and she died eight hours after admission. Autopsy confirmed a generalised bleeding tendency, with pulmonary, oesophageal and gastrointestinal mucosal haemorrhages. Flame-shaped subendocardial shock haemorrhages were seen in the interventricular septum on the left side of the heart. The findings support a diagnosis of heat stroke. Various aspects related to heat stroke, the autopsy diagnosis and its prevention are discussed.
We report on a retrospective study of maternal deaths in Malaysia that occurred within 24 hours of delivery, abortion or operative termination of the pregnancy (defined as sudden deaths) in the years 1995-1996. There were 131 sudden maternal deaths (20.6% of all maternal deaths); postpartum hemorrhage, obstetric embolisms, trauma and hypertensive disorders of pregnancy were the main causes. There was a disproportionately increased risk of sudden maternal deaths in the Chinese and the 'other bumiputra' racial groups. The proportion of mothers who had no obstetric risk factors in the pregnancy that led to death was 16.8%. Fourteen mothers died in transit Twenty mothers died after a cesarean section. The findings of this review emphasize the fact that caregivers in obstetrics need to be forever vigilant. All maternity staff need to be well trained in emergency care and there needs to be quick referral to centers that can provide expertise in handling these emergencies.
Melioidosis was diagnosed in two cats at necropsy. The first cat presented with jaundice and anaemia but died of overwhelming sepsis soon after admission, despite blood transfusion and other supportive measures. The second cat died several days after developing neurological signs; an infected digital wound may have been the primary focus of infection in this patient. The cats had presumably acquired the infection in Malaysia and northern Australia, respectively, and in both cases disease may have represented reactivation of a latent infection brought on by the stress of relocation. The epidemiology, clinical presentation, diagnosis and treatment of melioidosis are discussed from a feline perspective.
Cardiac sarcoidosis is a disease of young adults. In most cases it presents with sudden death, arrhythmias, conduction disorders, heart failure or cardiomyopathy. The authors describe two cases of myocardial involvement by sarcoidosis that lead to death of the patients. Case one was a 26-year-old Indian man who was previously well and presented with sudden death. Autopsy showed nodules of sarcoid granuloma involving the heart, lungs and lymph nodes. Case two was a 47-year-old Indian lady who complained of reduced effort tolerance. Echocardiography showed that she had restrictive hypertrophic cardiomyopathy with heart failure. Seven months after initial presentation, she developed worsening of heart failure and died. Autopsy revealed involvement of the heart, lungs and liver by sarcoidosis.
The main aim of this study is to determine the causes and the epidemiological aspects of sudden natural deaths. Data were collected from 545 sudden natural autopsies in UMMC, Kuala Lumpur over a five-year period, from 1st January 2000 to 31st December 2004. There were 475 males and 70 females. The largest number of sudden natural deaths was in the age group of 41-50 years. 35.8%, 30.5% and 11.7% of the patients were Chinese, Indian and Malay, respectively. A majority of the patients were married (59.8%) and came from the semiskilled-unskilled group (30.6%). The monthly distribution was almost constant. Cardiovascular diseases were the most important cause contributing 64.9% in sudden natural deaths.
Radiotherapy has an established role in reducing the local relapses in breast cancer patients. The objective of this review was to investigate whether radiotherapy or its omission after breast surgery has measurable consequences on local tumor recurrence and patient survival. The late excess of cardiac deaths has also been published in various reports but important advances in the delivery of radiotherapy have overcome this problem to the extent that, excess cardiac deaths do not appear to be occurring in more recent trials. In this article some recent data, suggesting that radiotherapy following mastectomy and/or breast conserving surgery has a beneficial effect on survival is reviewed. Omission of radiotherapy is associated with a large increase in risk of ipsilateral breast tumor recurrence and with a small increase in the risk of patient's mortality.
This is a case report of 16-year-old adolescent school boy who died due to unusual calcification of coronary arteries. He died while cycling with his friends. While cycling fast he fell. He was brought dead to hospital. At times unsuspected cardiac lesions cause sudden death during extraneous physical activities in healthy persons. Sudden death in adolescents is not very common. It is an unusual case as apparently healthy adolescent boy actively participating in sports had stony hard coronary arteries. The coronaries showed advanced calcification and early bone formation. The myocardial septum had extensive fibrosis. The pathogenesis and other possible similar conditions are also discussed in the report.
Primary cystic tumors of papillary muscles of the heart are extremely rare. Here, one case of unusual cystic tumor in papillary muscle of the heart in a 37-year-old Myanmar migrant worker has been reported. He came to Malaysia 2 weeks before and one morning was found dead in sleep. Autopsy revealed cystic lesion in the papillary muscle of the mitral valve of heart, which was prolapsing into ventricular cavity. The cyst had white-jelly like sticky mucus material. The cyst was present in papillary muscle with slight invasion in septum area; it was lined by cuboidal-columnar epithelium and contained mucinous contents. There was no evidence of an inflammatory reaction in the cyst and in cardiac muscles. In addition to cystic neoplasm, the deceased also had histoplasmosis of the lungs. The case is presented with macroscopic and microscopic photographs of the cyst and histoplasmosis of the lungs. This case is reported because of its rarity, unique position, and unusual appearance.
Monoamniotic twin pregnancy is a rare type of twin pregnancy which poses risk of cord entanglement and
sudden death of either one or both fetuses. The role of antenatal surveillance by Ultrasound Doppler for
umbilical cord and ultrasonic evidence of cord entanglement or knotting may predict the pregnancy outcome
but yet unavoidable. The discussion will include antenatal surveillance in this rare type of pregnancy.
A 43-year-old man presented with acute extensive anterior ST-segment elevation myocardial infarction. During coronary angiogram, a segment of myocardial bridging was noted in the mid-segment of left anterior descending artery. The association of myocardial bridging and an anterior ST segment elevation is rarely reported in the medical literature. Myocardial bridging is caused by systolic compression of a coronary artery by overlying myocardium tissue. It is a rare coronary artery anomaly, which usually has a benign prognosis despite some case reports of myocardial ischemia leading to myocardial infarction, lethal arrhythmias and sudden cardiac death. We report one such case of myocardial bridging that was complicated with acute extensive anterior myocardial infarction.
Our aim is to determine mortality and morbidity in Asian patients under clinical management for heart failure (HF). Specifically, we will define the incidence of, and risk factors for, sudden cardiac death, as well as the socio-cultural factors influencing therapeutic choices in these patients. Methods This is a prospective observational multinational Asian registry of 5000 patients with symptomatic HF (stage C) and LV systolic dysfunction (EF ≤ 40%) involving 44 centres across 11 Asian regions (China, Hong Kong, India, Indonesia, Japan, Korea, Malaysia, Philippines, Singapore, Taiwan and Thailand). Data collection includes demographic variables, clinical symptoms, functional status, date of HF diagnosis and prior cardiovascular investigations, clinical risk factors, lifestyle factors, socio-economic status, and survey of cultural beliefs, health practices, and attitudes towards device therapy. Centre-level characteristics (case load, referral pattern, specialization, and infrastructure) are also obtained. Patients uniformly undergo standard 12-lead ECG and transthoracic echocardiography at baseline, and are followed over 3 years for outcomes of death or hospitalization. The mode of death and cause of hospitalization are adjudicated by a central event adjudication committee using pre-specified criteria. Perspective By providing prospective data regarding the demographics, risk factors, and outcomes of Asian patients under treatment for HF, the ASIAN-HF registry is expected to advance fundamental understanding of the burden and predictors of death and hospitalization among these patients. The knowledge gained will be important for guiding resource allocation and planning preventive strategies to address the unmet and growing clinical needs of patients with cardiovascular disease in Asia. Trial registration NCT01633398.
Electrical or electrocution injury is a common accidental occurrence and mostly workplace related. Fatal arrhythmias, skin injury and sudden death may ensue. However, it is rare for electrocution to result in permanent low rate sinus bradycardia, incompatible with an active lifestyle. The probable mechanisms for this pathological sinus bradycardia are sinus node dysfunction and autonomic dysfunction with vagal predominance. We describe a young patient who suffered a non fatal electrocution with resultant low rate sinus bradycardia and its successful treatment with a dual chamber rate responsive pacemaker.
Ruptured dissecting aortic aneurysm more commonly occur in men in the 40 to 70 age group, and most commonly is associated with atherosclerosis. Uncommon causes are previous heart surgery, connective tissue disorders and aortitis. Despite its rarity, Clostridium spp aortitis progresses very rapidly with a mortality rate of approximately 79% in adults, typically occurring within 48 hours of infection. We present a case of sudden death due to clostridial aortitis causing ruptured aortic dissection in an apparently healthy adult female, 7 weeks post-spontaneous vaginal delivery. This case highlights the pathology of aortic dissection and cystic media necrosis as presentations of clostridium spp infection in young female adult.
To determine if coronary computed tomographic angiography enhances prediction of perioperative risk in patients before non-cardiac surgery and to assess the preoperative coronary anatomy in patients who experience a myocardial infarction after non-cardiac surgery.
AIMS: To characterize regional and ethnic differences in heart failure (HF) across Asia.
METHODS AND RESULTS: We prospectively studied 5276 patients with stable HF and reduced ejection fraction (≤40%) from 11 Asian regions (China, Hong Kong, India, Indonesia, Japan, Korea, Malaysia, Philippines, Singapore, Taiwan, and Thailand). Mean age was 59.6 ± 13.1 years, 78.2% were men, and mean body mass index was 24.9 ± 5.1 kg/m2. Majority (64%) of patients had two or more comorbid conditions such as hypertension (51.9%), coronary artery disease (CAD, 50.2%), or diabetes (40.4%). The prevalence of CAD was highest in Southeast Asians (58.8 vs. 38.2% in Northeast Asians). Compared with Chinese ethnicity, Malays (adjusted odds ratio [OR] 1.97, 95% CI 1.63-2.38) and Indians (OR 1.44, 95% CI 1.24-1.68) had higher odds of CAD, whereas Koreans (OR 0.38, 95% CI 0.29-0.50) and Japanese (OR 0.44, 95% CI 0.36-0.55) had lower odds. The prevalence of hypertension and diabetes was highest in Southeast Asians (64.2 and 49.3%, respectively) and high-income regions (59.7 and 46.2%, respectively). There was significant interaction between ethnicity and region, where the adjusted odds were 3.95 (95% CI 2.51-6.21) for hypertension and 4.91 (95% CI 3.07-7.87) for diabetes among Indians from high- vs. low-income regions; and 2.60 (95% CI 1.66-4.06) for hypertension and 2.62 (95% CI 1.73-3.97) for diabetes among Malays from high- vs. low-income regions.
CONCLUSIONS: These first prospective multi-national data from Asia highlight the significant heterogeneity among Asian patients with stable HF, and the important influence of both ethnicity and regional income level on patient characteristics.