Faculty Bibliography

Importance/UNASSIGNED:The true incidence of sudden unexplained death in childhood (SUDC), already the fifth leading category of death among toddlers by current US Centers for Disease Control and Prevention estimates, is potentially veiled by the varied certification processes by medicolegal investigative offices across the United States. Objective/UNASSIGNED:To evaluate the frequency of SUDC incidence, understand its epidemiology, and assess the consistency of death certification among medical examiner and coroner offices in the US death investigation system. Design, Setting, and Participants/UNASSIGNED:In this case series, 2 of 13 forensic pathologists (FPs) conducted masked reviews of 100 cases enrolled in the SUDC Registry and Research Collaborative (SUDCRRC). Children who died aged 11 months to 18 years from 36 US states, Canada, and the United Kingdom had been posthumously enrolled in the SUDCRRC by family members from 2014 to 2017. Comprehensive data from medicolegal investigative offices, clinical offices, and family members were reviewed. Data analysis was conducted from December 2014 to June 2020. Main Outcomes and Measures/UNASSIGNED:Certified cause of death (COD) characterized as explained (accidental or natural) or unexplained, as determined by SUDCRRC masked review process. Results/UNASSIGNED:In this study of 100 cases of SUDC (mean [SD] age, 32.1 [31.8] months; 58 [58.0%] boys; 82 [82.0%] White children; 92 [92.0%] from the United States), the original pathologist certified 43 cases (43.0%) as explained COD and 57 (57.0%) as unexplained COD. The SUDCRRC review process led to the following certifications: 16 (16.0%) were explained, 7 (7.0%) were undetermined because of insufficient data, and 77 (77.0%) were unexplained. Experts disagreed with the original COD in 40 cases (40.0%). These data suggest that SUDC incidence is higher than the current Centers for Disease Control and Prevention estimate (ie, 392 deaths in 2018). Conclusions and Relevance/UNASSIGNED:To our knowledge, this is the first comprehensive masked forensic pathology review process of sudden unexpected pediatric deaths, and it suggests that SUDC may often go unrecognized in US death investigations. Some unexpected pediatric deaths may be erroneously attributed to a natural or accidental COD, negatively affecting surveillance, research, public health funding, and medical care of surviving family members. To further address the challenges of accurate and consistent death certification in SUDC, future studies are warranted.

Artifacts due to decomposition may cause confusion for the initial death investigator, leading to an incorrect suspicion of foul play. Putrefaction is a microorganism-driven process that results in foul odor, skin discoloration, purge, and bloating. Various decompositional gases including methane, hydrogen sulfide, carbon dioxide, and hydrogen will cause the body to bloat. We describe 3 instances of putrefactive gas distension (bloating) that produced the appearance of inappropriate rigor, so-called putrefactive rigor. These gases may distend the body to an extent that the extremities extend and lose contact with their underlying support surface. The medicolegal investigator must recognize that this is not true rigor mortis and the body was not necessarily moved after death for this gravity-defying position to occur.

Sudden fatal cases of influenza B infection in a 4-year-old girl and a 2-year-old boy are presented. Both children complained of abdominal pain without respiratory, neurologic or cardiac symptoms; additionally the girl had vomiting within 2 days of death. Autopsy revealed histological changes in the respiratory system consistent with a viral infection. Influenza B infection was identified by immunohistochemistry in the girl and real-time polymerase chain reaction in the boy. Additional testing including cultures, toxicology, and screening for metabolic disorders were negative. These cases illustrate the usefulness of viral testing, especially for influenza, in the medical legal autopsy of children even when the classic respiratory symptoms of flu are lacking

The investigation of sudden death of infants varies, and death rates may depend on local practices of death certification. We studied the extent of the investigation and the final cause of death (COD) in 3 regions: New York, New York, USA (NY); King County, Washington, USA (KC); and Montevideo, Uruguay (MU). We conducted a retrospective review of 543 cases (NY 258, KC 56, MU 229) of previously healthy babies who died suddenly without obvious trauma, at ages 0 to 12 months, over a 3-year period (1998 to 2001). All cases included a complete autopsy and histologic examination. Cases were assessed for completion of special studies (including radiographs, photos, toxicology and metabolic sampling, cultures, and vitreous humor chemistry), measurements, and scene investigation. Specialized pediatric measurements and testing were done less often than routine procedures, and were done less often in cases overall compared with cases certified as sudden infant death syndrome (SIDS). Fifty-five percent of SIDS cases in NYC and 12% of SIDS cases in KC had no scene investigation. Manhattan had a complete workup in 42% of SIDS cases, whereas the remaining sites had fewer that 15% of cases completely worked up. The most common non-natural COD was suffocation at all 3 sites. The overall most common COD were respiratory infection in MU (22%) and SIDS in NY (45%) and KC (86%). We conclude that the sudden death of infants requires special consideration and still lacks consistency. SIDS investigations are not done completely in all cases and rates may depend on regional differences in certifying infant deaths

Nine people died of traumatic asphyxia due to an uncontrolled crowd at a community basketball game in New York City in 1991. We reviewed the circumstances, postmortem findings, and the causes of death. The majority of people had petechiae of the conjunctivae and face consistent with chest compression. There were minimal superficial blunt injuries and no fractures or acute intoxications. These deaths are often incorrectly attributed to blunt force injuries, while the cause typically is asphyxia due to chest compression

OBJECTIVE: Laryngeal atresia is a rare, life-threatening congenital malformation. Prenatal sonographic diagnosis has been described; however, in many cases, the precise diagnosis is established only at autopsy. Our aim was to describe an atypical prenatal presentation of congenital laryngeal atresia in which the final diagnosis was made only at autopsy. METHODS: Sonographic and postmortem examinations were performed on a fetus with bilateral enlarged echogenic lung fields, an everted diaphragm, and polyhydramnios, which were initially noted on prenatal sonography at 26 weeks' gestation. RESULTS: Unfortunately, the mother was lost to follow up at our inner-city clinic, thus precluding a definitive diagnosis. At birth, tracheostomy was not performed because of the anomalous appearance of the neonate and the suspicion of multiple congenital anomalies. Neonatal death occurred after 18 minutes of life. Autopsy revealed laryngeal atresia with a right hemidiaphragmatic defect and multiple other congenital anomalies. CONCLUSIONS: This was a rare case with prenatal sonographic findings in a fetus with congenital laryngeal atresia associated with partial diaphragmatic obliteration