Faculty Bibliography

Recently, there have been several advances in the field of adult congenital heart disease, such as the percutaneous pulmonic valve implantation (PPVI) to treat right ventricular outflow obstruction. Complications from this technique are seldom but essential to understand. We present a case of a 37-year-old Caucasian male with complicated congenital heart disease, including prior Melody valve implantation, who presented to our hospital with recurrent episodes of pneumonia of two months duration. He was diagnosed with prosthetic valve endocarditis (PVE) from an unusual organism, Rothia dentocariosa. He eventually underwent surgical replacement of the infected valve. Our report is the first case of Melody valve endocarditis due to Rothia dentocariosa reported from the United States.

Evidence of prior autoerotic asphyxia is often difficult to establish due to the decedent's efforts to hide the activity from others. In this case report, we suggest that a healed fracture of the thyroid cartilage is indicative of prior autoerotic asphyxia activity. The decedent was a 45-year-old man who was found unclothed on the floor of his bedroom with a belt ligature around the neck. A second rope ligature was loosely wrapped around the decedent's wrists, scrotum, and penis. A definitive escape mechanism was not identified, but a nearby towel and barbell weight may have comprised a possible escape mechanism. There was no known history of depression or prior autoerotic activity. Autopsy was notable for the presence of a healed fracture of the right superior horn of the thyroid cartilage. Three-dimensional (3D) surface scanning and 3D printing was utilized to preserve the anatomical findings prior to histologic sampling. To our knowledge, this is the first reported use of 3D surface scanning and 3D printing for the purpose of documenting a forensic finding prior to alteration of the anatomical specimen for histologic sampling. Acute fractures of the superior horns of the thyroid cartilage are not infrequently seen in ligature hanging. Therefore, the presence of a healed fracture in the setting of autoerotic asphyxia likely indicates prior activity. Histologic sampling of the laryngeal cartilages to detect occult healed fractures in autoerotic asphyxia may be useful. Three-dimensional scanning and printing may alleviate concerns for specimen alteration due to histology sampling.

Pulmonary hypertension is one of the well-known clinical manifestations of polyneuropathy, organomegaly, endocrinopathy, monoclonal gammopathy, and skin changes (POEMS) syndrome, occurring in approximately 25-30% of the affected individuals. However, the histopathologic spectrum of pulmonary hypertension associated with POEMS syndrome has not been fully documented in the literature. Herein, we report an autopsy case of POEMS syndrome in a patient whose lung tissues showed histopathology indistinguishable from that of idiopathic pulmonary arterial hypertension with abundant plexiform lesions in the small pulmonary arteries.

UNLABELLED:A 67-year-old man with myelodysplastic syndrome, disseminated histoplasmosis, and mitral valve replacement presented with dyspnea and peripheral edema. Transthoracic echocardiography demonstrated abnormal pulmonic valve with possible vegetation. Color flow imaging showed laminar flow from main pulmonary artery into right ventricular outflow tract (RVOT) in diastole. The continuous wave Doppler signal showed dense diastolic envelope with steep deceleration slope. These findings were consistent with severe pulmonic valve regurgitation, possibly due to endocarditis. Transesophageal echocardiography demonstrated an echodense mass attached to the pulmonic valve. The mitral valve bioprosthesis appeared intact. Bacterial and fungal blood cultures were negative; however, serum histoplasma antigen was positive. At surgery, the valve appeared destroyed by vegetations. Gomori methenamine silver-stains showed invasive fungal hyphae and yeast consistent with a dimorphic fungus. Valve cultures grew one colony of filamentous fungus. Itraconazole was continued based on expert infectious diseases diagnosis. After surgery, dyspnea and ankle edema resolved. To the best of our knowledge, histoplasma endocarditis of pulmonic valve has not been previously reported. Isolated pulmonic valve endocarditis is rare, accounting for about 2% of infectious endocarditis (IE) cases. Fungi account for about 3% of cases of native valve endocarditis. Characterization of pulmonary valve requires thorough interrogation with 2D and Doppler echocardiography techniques. Parasternal RVOT view allowed visualization of the pulmonary valve and assessment of regurgitation severity. As an anterior structure, it may be difficult to image with transesophageal echocardiography. Mid-esophageal right ventricular inflow-outflow view clearly showed the pulmonary valve and vegetation. LEARNING POINTS/CONCLUSIONS:Identification and characterization of pulmonary valve abnormalities require thorough interrogation with 2D and Doppler echocardiography techniques.Isolated pulmonary valve IE is rare and requires high index of suspicion. Histoplasma capsulatum IE is rare and requires high index of suspicion.

Homicidal injury is a leading cause of death among pregnant and postpartum women in the United States. We studied all homicides in which the victim was pregnant at the time of the lethal injury. Records of the New York City Office of Chief Medical Examiner were reviewed. There were 27 homicides: the age ranged from 15 to 41 years (mean 27 years). The causes of death were: 13 gunshot wounds, 7 asphyxial deaths (eg, neck compression), 5 stabs, 1 blunt, and 1 blunt/stab. The gestational age ranged from 8 weeks to 40 weeks with an average of 24.5 weeks. Two live born infants (40 and 28 weeks gestation) were delivered following gunshot wounds of the mother and infant, however, both subsequently died. The victim and suspect were known to each other in 19 homicides. Of these, 16 involved an existing or prior intimate relationship including: 2 current husbands, 1 ex-husband, 9 current boyfriends, 3 ex-boyfriends, and 1 father. The issues that arise for the forensic pathologist include proper collection of a DNA sample from the fetus, estimation of the gestational age, and certification of death

Delayed homicides result from complications of remote injuries inflicted by 'the hands of another.' The investigation of delayed homicides may be a challenge due to a number of factors including: failure to report the death to the proper authorities, lack of ready and adequate documentation of the original injury and circumstances, and jurisdictional differences between the places of injury and death. The certification of these deaths also requires the demonstration of a pathophysiologic link between the remote injury and death. In sorting through these issues, it is helpful to rely upon the definition of the proximate cause of death. Over a 2-year period in New York City, there were 1211 deaths certified as homicide of which 42 were due to injuries sustained greater than 1 year before death. The survival interval ranged from 1.3 to 43.2 years. The most common immediate causes of death were: infections (22), seizures (7), and intestinal obstructions/hernias (6). Common patterns of complications included infection following a gunshot wound of the spinal cord, seizure disorder due to blunt head trauma, and intestinal obstruction/hernia due to adhesions from an abdominal stab wound. Spinal cord injuries resulted in paraplegia in 14 instances and quadriplegia in 8. The mean survival interval for paraplegics was 20.3 years and 14.8 years for quadriplegics; infections were a frequent immediate cause of death in both groups, particularly infections due to chronic bladder catheterization. The definition of proximate cause originated with civil law cases and was later applied to death certification as the proximate cause of death. The gradual extinction of the 'year and a day rule' for the limitation of bringing homicide charges in delayed deaths may result in more of these deaths going to trial. Medical examiners/coroners must be able to explain the reasoning behind these death certifications and maintain consistent standards for the certification of all delayed deaths due to any injury (homicides, suicides, and accidents)