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Sudden cardiac death in a young adult man due to spontaneous coronary artery dissection

Subramaniam K, Siew SF, Mahmood MS

Malays J Pathol, 2019 Apr;41(1):51-54.
PMID: 31025638

Spontaneous coronary artery dissection is a rare event and commonly associated with pregnancy and female gender. This condition can reduce or completely obstruct the blood flow to the heart, causing a myocardial ischaemia, abnormalities in heart rhythm or sudden death. We present a case of a 28-year-old Indian male with no previous medical illness who complained sudden onset of chest pain prior to his death. Autopsy revealed a left anterior descending coronary artery dissection associated with plaque rupture. The anterior wall of left ventricle showed contraction band necrosis. There was also atheroma present in the right coronary artery which was insignificant. Histologically, dissection was associated with atherosclerosis. There was no evidence of vasculitis. The cause of death was given as coronary artery dissection due to coronary artery atherosclerosis.
Isolated hyoid bone fracture in a child due to a fall

Chainchel Singh MK, Siew SF, Lai PS

Int J Pediatr Otorhinolaryngol, 2020 Dec;139:110443.
PMID: 33068949 DOI: 10.1016/j.ijporl.2020.110443

Hyoid bone fractures due to blunt trauma are rare accounting for only 0.002% of all head and neck fractures with most documented fractures being due to strangulation, hanging, motorcycle helmet straps, sports injuries and rarely as a complication of intubation. However, they are even rarer in the paediatric age group. We present a hyoid bone fracture in a two-year-old child as a result of a fall down three steps. Hyoid bone fractures though generally heal well with conservative treatment must be diagnosed early to avoid air way obstruction leading to morbidity and mortality.
Post mortem computed tomography (PMCT) guided lung biopsy: A preliminary case report

Abdul Hadi D, Mansharan Kaur CS, Effat O, Siew SF

Trop Biomed, 2019 Dec 01;36(4):850-854.
PMID: 33597457

Tuberculosis (TB) is a highly infectious disease on the rise caused by the organism Mycobacterium tuberculosis and health care workers working in emergency departments, medical wards and autopsy rooms are in danger of contacting this disease. We present a case of a 42 year old man found dead under a pedestrian bridge with no medical history available. Post mortem computed tomography showed multiple cavities involving upper lobes of both lungs and areas of consolidation in both lung fields raising the suspicion of pulmonary tuberculosis. This was followed by a computed tomography guided lung biopsy and a limited conventional autopsy done in situ in a special high risk autopsy suite with appropriate ventilation. This case highlights the importance of cross sectional imaging which can be coupled with image guided biopsy in cases of infectious disease to reduce the risk of transmission to health care workers.
Linear lucency of the skull vault: Fracture or accessory skull suture

Koo ZP, Siew SF, Chainchel Singh MK

Leg Med (Tokyo), 2022 Feb;54:101971.
PMID: 34656422 DOI: 10.1016/j.legalmed.2021.101971

Sutures are a type of fibrous joint that occur only in the skull. However, partial or complete division of bones resulting in anomalous or accessory skull sutures may be misinterpreted as fractures when identified on radiological examination. Thus, it is of paramount clinical and medicolegal importance that these sutures be differentiated from actual fractures which can lead to severe consequences such as false accusation and mis-management of patient. It must be remembered though that the diagnosis in such cases is not straight forward even during postmortem examination which requires careful evaluation of findings with the aid of histology examination and radiology imaging. We present a case of a mis-diagnosis of an anomalous parietal suture in a three-month-old infant.
Management of unidentified and unclaimed bodies: a comparison of model from four countries in the Asia Pacific Region

Khoo LS, Lai PS, Siew SF, Ibrahim MA

Forensic Sci Med Pathol, 2023 Jul 31.
PMID: 37523136 DOI: 10.1007/s12024-023-00683-6

Managing mass fatality incidents or disasters involving multiple deaths are not uncommon among forensic practitioners. In fact, management of unidentified or unknown bodies is also a vital component of the day-to-day mortuary work practice. The unidentified and subsequently unclaimed bodies have always been a "silent mass disaster," a problem that needs to be tackled within the forensic community and raises the global issue of ethics, law, and human rights. Unidentified bodies' in Malaysia make up an average of 4.02% of all death cases where a total postmortem examination was performed which is comparable with other developing countries within 4-10% which can go up to 25%. Moreover, unstandardized procedures in all mortuaries in different states and districts in Malaysia have worsened the scenario even with guidelines in place. This study aims to address the issues surrounding unidentified and unclaimed bodies including body disposal from a social and legal perspective using case study methodology by comparing four different countries in the Asia Pacific Region through document analysis and interview methods. One of the major findings is evident in 3 out of the 4 models, whereby there is a considerable gap in consolidating the missing person report and information to match with the unidentified bodies received in forensic institutions in an attempt to enhance the identification process which ultimately intends as a closure for the family members. It is also timely to think out of the box beyond dental records and DNA profiling to improve the identification rate for skeletonized remains through means of anthropology biometrics comparison. With the limited literature published surrounding this domain, it is hoped that the suggestions and recommendations to standardize the management of unidentified and unclaimed bodies can benefit many forensic institutions and public mortuaries in this region.
Methanol related death in National Institute of Forensic Medicine, Hospital Kuala Lumpur: A case series

Chng KL, Lai PS, Siew SF, Md Yaro SW, Mahmood MS

Malays J Pathol, 2020 Apr;42(1):99-105.
PMID: 32342937

INTRODUCTION: Methanol is a widely available chemical with a range of uses including as solvent, as a fuel, in chemical synthesis and anti-freeze preparations. Most of the cases are accidental exposures to drinking beverages contaminated with methanol.
MATERIALS AND METHODS: In mid-September 2018, there was a single outbreak of methanol poisoning in Malaysia especially involving the state of Federal Territory Kuala Lumpur and Selangor. There were 33 reported deaths suspected due to methanol poisoning in this current outbreak where 11 of them were brought in to the Institute of Forensic Medicine (NIFM), Kuala Lumpur. The last outbreak was in the year 2013 with 29 deaths reported out of 44 cases.
RESULTS: There were 3 cases (27.2%) died in hospital and the remaining 8 cases (72.8%) were found dead at home and were later brought in dead to the hospital. A full autopsy was carried out for each case. Autopsy findings, as well as lab results pertaining to cases that survived and directly brought in dead, were of a different spectrum.
CONCLUSION: Methanol related deaths are almost always as a result of greed. The running truism is 'methanol poisoning is a result of deliberate addition/adulteration with industrial methanol'. Prevention of the illegal production of methanol and methylated spirits should be established to curb this matter in the future.
Post-mortem pulmonary tuberculosis: comparison of available diagnostic methods

Chainchel Singh MK, Johari B, Naik VR, Lai PS, Siew SF

Trop Biomed, 2023 Jun 01;40(2):165-169.
PMID: 37650402 DOI: 10.47665/tb.40.2.006

Tuberculosis (TB) caused by Mycobacterium tuberculosis remains a serious public health threat with the World Health Organisation (WHO) reporting 5.8 million cases and 1.3 million deaths in the year 2020 due to TB. TB can be diagnosed by imaging, histopathological and bacteriological methods with culture remaining the gold standard. This study was performed to look at the sensitivity and specificity of post-mortem computed tomography (PMCT) imaging when compared to culture in diagnosing pulmonary tuberculosis. This was a retrospective comparative study looking at post mortem cases where lung tissue samples sent for TB culture at Hospital Kuala Lumpur were compared against PMCT imaging. Exclusion criteria included contaminated samples, decomposed cases, immunocompromised subjects and those below 18 years of age. Subjects included 80 medico-legal autopsy cases at the National Institute of Forensic Medicine, Hospital Kuala Lumpur, Malaysia who had whole body PMCT done in accordance with the Institute's protocol and tissue samples sent for bacteriology culture for tuberculosis. PMCT findings were positively associated with acid-fast organisms in 23.5 out of 33 cases (71.2%). Our study also showed that PMCT had a sensitivity of 71.3% and specificity of 54.3% (95% CI: 39.5-68.4) in diagnosing TB based on the protocol set in this study. This study showed that there was relatively good agreement between radiological PMCT findings and bacterial culture, suggesting that radiological examination is a relatively reliable tool for preliminary screening and possible diagnosis of TB prior to a postmortem examination which would be beneficial in reducing the risk of transmission of TB to health workers during autopsy.
The effect of post-mortem computed tomography angiography (PMCTA) on biomarkers of coronary artery disease

Woon CK, Omar E, Siew SF, Nawawi HM, Kasim NAM, Chainchel Singh MK

J Forensic Leg Med, 2024 Feb 01;102:102654.
PMID: 38310784 DOI: 10.1016/j.jflm.2024.102654

Coronary atherosclerosis is due to build-up of plaque within the coronary arteries. Post-mortem computed tomography (PMCT) allows non or minimally invasive visualization of abnormalities prior to an autopsy, however PMCT-angiography (PMCTA) greatly enhances relevant findings, especially in viewing the cardiovascular system which is important in the diagnosis of coronary atherosclerosis. Contrast media used in PMCTA however has been reported to cause distortion of tissue which may interfere with post-mortem investigation outcomes. A cross sectional study to investigate the effect of PMCTA on tissue biomarkers in coronary arteries was performed involving cases brought in dead to the Institute and Accident and Emergency Unit. Sixty-three autopsy cases were included in this study, whereby 18 cases underwent PMCT while 45 cases underwent PMCTA. The subjects subsequently had a conventional autopsy where coronary artery sections were collected for standard histological examination and immunohistochemistry examination for endothelial inflammatory (CD36), prothrombogenic (TPA) and plaque stability (MMP-9) markers. The subjects consisted of 55 males and 8 females with a mean age ±SD of 49 ± 18.11 years. There were no significant differences in the coronary artery endothelial expression of CD36, MMP-9 and TPA between PMCT and PMCTA subjects. PMCTA does not alter CD36, TPA and MMP-9 markers supporting the safe use of PMCTA in post-mortem examinations.
Fatal anterior mediastinal mass in a pregnant lady

Koo ZP, Chainchel Singh MK, Mohamad Noor MHB, Omar NB, Siew SF

Forensic Sci Med Pathol, 2024 Mar;20(1):226-232.
PMID: 37436679 DOI: 10.1007/s12024-023-00669-4

We report a fatal case of a 26-year-old nulliparous woman who presented with an anterior mediastinal mass in her late pregnancy. She had complained of a progressively increasing neck swelling and occasional dry cough in the early second trimester, which was associated with worsening dyspnoea, reduced effort tolerance and orthopnoea. Ultrasound of the neck showed an enlarged lymph node, and chest X-ray revealed mediastinal widening. At 35 weeks' gestation, the patient was referred to a tertiary centre for a computed tomography (CT) scan of the neck and thorax under elective intubation via awake fibreoptic nasal intubation as she was unable to lie flat. However, she developed sudden bradycardia, hypotension and desaturation soon after being positioned supine, which required resuscitation. She succumbed after 3 days in the intensive care unit. An autopsy revealed a large anterior mediastinal mass extending to the right supraclavicular region, displacing the heart and lungs, encircling the superior vena cava and right internal jugular vein with tumour thrombus extending into the right atrium. Histopathology examination of the mediastinal mass confirmed the diagnosis of a primary mediastinal large B-cell lymphoma. This report emphasizes the severe and fatal outcome resulting from the delay and misinterpretation of symptoms related to a mediastinal mass.
Fulltext Use of Post-Mortem Computed Tomography During the COVID-19 Pandemic: The Malaysian Experience

Chainchel Singh MK, Mohd Noor MH, Ibrahim MA, Siew SF, Lai PS

Malays J Med Sci, 2022 Oct;29(5):83-92.
PMID: 36474535 DOI: 10.21315/mjms2022.29.5.9

BACKGROUND: COVID-19 was declared a pandemic by the World Health Organization (WHO). COVID-19 is highly contagious, making it a threat to healthcare workers, including those working in mortuaries. Therefore, it is important to determine if the cause of death (COD) could be identified using limited autopsy, diagnostic tests and post-mortem imaging modalities instead of full autopsy. This study aims to examine the effectiveness of post-mortem imaging, specifically post-mortem computed tomography (PMCT) at determining the COD during a pandemic.
METHODS: This cross-sectional study included 172 subjects with suspected or unknown COVID-19 status brought in dead to the institute's mortuary during the pandemic in Malaysia. PMCT images reported by forensic radiologists and their agreement with conventional autopsy findings by forensic pathologists regarding COD were analysed to look at the effectiveness of PMCT in determining COD during a pandemic.
RESULTS: Analysis showed that 78.7% (133) of cases reported by forensic radiologists concurred with the COD certified by forensic pathologists. Of these cases, 85 (63.9%) had undergone only external examination and real-time reverse transcriptase polymerase chain reaction (rRT-PCR) COVID-19 testing, meaning that imaging was the sole method used to determine the COD besides history from available medical records and the investigating police officer.
CONCLUSION: PMCT can be used as a complement to medicolegal autopsies in pandemic contexts, as it provides significant information on the possible COD without jeopardising the safety of mortuary health care workers.
Fulltext The craniotomy box: an innovative method of containing hazardous aerosols generated during skull saw use in autopsy on a COVID-19 body

Hasmi AH, Khoo LS, Koo ZP, Suriani MUA, Hamdan AN, Yaro SWM, et al.

Forensic Sci Med Pathol, 2020 09;16(3):477-480.
PMID: 32500339 DOI: 10.1007/s12024-020-00270-z

During a disease pandemic, there is still a requirement to perform postmortem examinations within the context of legal considerations. The management of the dead from COVID-19 should not impede the medicolegal investigation of the death where required by the authorities and legislation but additional health and safety precautions should be adopted for the necessary postmortem procedures. The authors have therefore used the craniotomy box in an innovative way to enable a safe alternative for skull and brain removal procedures on suspected or confirmed COVID-19 bodies. The craniotomy box technique was tested on a confirmed COVID-19 positive body where a full postmortem examination was performed by a team of highly trained personnel in a negative pressure Biosafety Level 3 (BSL-3) autopsy suite in the National Institute of Forensic Medicine (IPFN) Malaysia. This craniotomy box is a custom-made transparent plastic box with five walls but without a floor. Two circular holes were made in one wall for the placement of arms in order to perform the skull opening procedure. A swab to detect the presence of the SARS-CoV-2 virus was taken from the interior surface of the craniotomy box after the procedure. The result from the test using real-time reverse transcriptase polymerase chain reaction (rRT-PCR) proved that an additional barrier provided respiratory protection by containing the aerosols generated from the skull opening procedure. This innovation ensures procedures performed inside this craniotomy box are safe for postmortem personnel performing high risk autopsies during pandemics.

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