|Year : 2014 | Volume
| Issue : 3 | Page : 145-148
Autopsy review of sudden deaths in a tertiary hospital of northeastern India
Jesu R Pandian, Rajesh Singh Laishram, Laishram Deepak Kumar, Pinky Phuritsabam, Kaushik Debnath
Department of Pathology, Regional Institute of Medical Sciences, Lamphelpat, Imphal Manipur, India
|Date of Web Publication||5-Jan-2015|
Rajesh Singh Laishram
Department of Pathology, Regional Institute of Medical Sciences, Lamphelpat,
Source of Support: None, Conflict of Interest: None
Background: World Health Organization (WHO) defines sudden death as "deaths within 24 hours from the onset of the symptoms". It is also defined as death which is sudden, unexpected, clinically unexplained, or otherwise obscure even though there needs to be no unnatural element in their causation. This study was taken up to analyze histopathologically the possible cause of sudden deaths. Aims: To study the different histomorphological profile of sudden deaths in the autopsy/postmortem specimens received in the Department of Pathology, Regional Institute of Medical Sciences (RIMS), Imphal. Materials and Methods: A review of all autopsies/postmortem of sudden deaths performed between 1 st January 2000 and 31 st December 2013 at Department of Pathology, RIMS, were done. Results: A total of 120 cases were autopsied for sudden deaths during the study period. The age ranged from 17 to 70 years with male predominance. Maximum deaths occurred in the age group between 31 and 35 years and males were affected more than females. The cause of deaths in 67 cases (55.83%) were attributed to cardiac causes, the most common cause being coronary artery disease and the remaining 53 cases (44.17%) were due to noncardiac causes. Conclusion: It is found that sudden deaths are most commonly found in young adults (31-35 years) and most of them are attributed to a cardiac cause. This study highlights the serious health concern in our society and a necessity to create awareness among the population at risk so that sudden deaths can be averted and life expectancy can be improved.
Keywords: Autopsy, Coronary artery disease, Sudden death
|How to cite this article:|
Pandian JR, Laishram RS, Kumar LD, Phuritsabam P, Debnath K. Autopsy review of sudden deaths in a tertiary hospital of northeastern India. J Med Soc 2014;28:145-8
|How to cite this URL:|
Pandian JR, Laishram RS, Kumar LD, Phuritsabam P, Debnath K. Autopsy review of sudden deaths in a tertiary hospital of northeastern India. J Med Soc [serial online] 2014 [cited 2019 Nov 22];28:145-8. Available from: http://www.jmedsoc.org/text.asp?2014/28/3/145/148495
| Introduction|| |
Despite modernization in medicine, the diagnosing tools lack in accuracy to find clinical cause of death in comparison with autopsy cause of death.  The main aim of autopsy is to establish the final diagnosis and determine the most possible cause of death.
World Health Organization (WHO) defines sudden death as "death within 24 hours from the onset of the symptoms". It can also be defined as deaths which are sudden, unexpected, clinically unexplained, or otherwise obscure even though there need to be no unnatural element in their causation.  Such a rapid death is often attributed to a cardiac cause. Sudden cardiac death can be prevented if high risk patients are identified and referred to a cardiologist. 
According to Birth and Death Registration Act 1969 in India, it is mandatory to issue a death certificate. Hence, such deaths must undergo an autopsy to determine the exact cause of death. Even though there are comprehensive studies from the Scandinavians, England, and USA investigating the pattern of sudden deaths; there is no published study in northeast India regarding the patterns of sudden death. This cross-sectional study will emphasize on histomorphological profile of sudden death, age, and sex distribution in Regional Institute of Medical Sciences (RIMS).
| Materials and Methods|| |
This cross-sectional study is conducted in Department of Pathology, RIMS, Imphal. Out of 1,034 deaths autopsied in RIMS from January 2000 to December 2013, 120 were sudden deaths.
Inclusion criteria: (a) All age groups who died within 24 h from the onset of symptoms and b) stable diabetics and hypertensives. Exclusion criteria: (a) Deaths after 24 h of onset of symptoms, (b) found dead, (c) deaths due to road traffic accidents, homicides, suicides, and blast injuries, and (d) pregnancy-related deaths.
The duration of the patient's stay in hospital from admission until death was extracted from the Autopsy Report Form which stated the date of admission and date of death. The clinical cause of death (COD) was either derived from the Mortuary Registration Form or from the clinical case notes if the COD was not completed in that form.
Autopsied specimens were gross examined and the findings were noted and then fixed in 10% formalin. Multiple sections were taken with 4-5 mm thickness. Additional sections were taken wherever necessary. Tissues were processed and subjected to paraffin section at 4 μm thickness, and then were stained with routine hematoxylin and eosin staining method.  The CODs were reported as per the histopathological findings and data thus collected were analyzed.
| Results|| |
A total of 1,034 autopsied specimens were received in Department of Pathology, RIMS, Imphal from a period of January 2000 to December 2013; out of which 120 were sudden deaths which constitutes about 8.61% of total autopsies studied. Males (n = 104) were predominant over females (n = 16) in the ratio of 6.5:1. The age ranged from 17 to 70 years. Maximum number of death was in the age group of 31-35 years [Table 1].
Among the autopsied sudden deaths histomorphologically, most of the deaths were because of cardiovascular cause contributing 55.83% (n = 67) of all sudden deaths. Major cardiac cause for sudden deaths was coronary artery disease (CAD) (49.25%). Other cardiac causes for sudden deaths were cardiomyopathies (5.97%), atherosclerotic aorta (4.47%), and myocarditis (2.99%). About 37.31% of cardiac deaths were unascertained [Table 2].
[Table 3] shows the various noncardiac causes of sudden deaths. Noncardiac causes of sudden deaths were mostly due to pulmonary diseases (37.74%) followed by hepatobiliary diseases (30.19%). Other noncardiac causes were septicemia (18.87%), gastrointestinal diseases (3.77%), neurological diseases (7.55%), and angiosarcoma of spleen (1.87%).
| Discussion|| |
The main aim of the autopsy pathologist is to reason out the most appropriate cause of the death and to see possibility of toxic drugs and other unnatural deaths.  Most of the literature ,,,,,,,,,,,, reveals cardiovascular diseases as the common cause. Sequential autopsy examination in sudden death investigation was suggested by Sheppard et al. The first step is to consider natural death, followed by exclusion of noncardiac natural death-like hemorrhage. Next is to consider macroscopic findings (e.g., ischemic cardiac disease) and microscopic findings (e.g., myocarditis) in heart. Finally, reappraise history and do toxicology screen. ,
Among 120 autopsied cases of sudden death, 67 deaths (55.83%) were due to cardiovascular disease. CAD (49.25%) was found to be the major cardiac cause. These results are comparable with the study conducted by Farb et al., and they revealed sudden deaths are most commonly due to cardiac diseases and most commonly in males. ,, Maximum of the cases were seen in the age group of 31-35 years which is also comparable to the study done by Doolan et al. 
The incidence of CAD has recently increased. The number of deaths due to CAD in India is projected to increase from 1.591 million in 2000 to 2.034 million by 2010 (World Health Organization report; 1999).  While observing the various types of acute coronary events, nonocclusive mural thrombus was the commonest event in all the studies, followed by plaque rupture and occlusive thrombus. , Plaque rupture was more common in uncalcified plaques compared to calcified vulnerable plaques. Higher grade of inflammation plays a major role in plaque vulnerability.  The important characteristics of an unstable or vulnerable plaque are a large lipid core, a thin fibrous cap, and many inflammatory cells including macrophages. The fibrous cap is the only structure separating the blood compartment containing coagulation factors from the thrombogenic material in the lipid core. When such a fibrous cap ruptures, it allows contact of these coagulation factors with tissue factors and promotes thrombosis. 
Though CAD forms the main bulk of sudden cardiac deaths, there are variety of other cardiac diseases like cardiomyopathies and inflammatory diseases like myocarditis which are comparable to the study conducted by Ladich et al. ,
Apart from CAD, the main bulk of sudden cardiac deaths were unascertained (37.31%). This was grouped under unascertained because there are no active lesions. But still death could have been attributed to old infarct, arrhythmias, or vasospasm. Such cases may be because of myocardial ischemia caused by coronary spasm secondary to overdriven adrenergic activity. These results are comparable with study done by Cohle et al. ,
Pulmonary diseases contributed 20 deaths (16.67%) of all sudden deaths. The main causes were tuberculosis and pneumonia. This was comparable with the study done by Bobrowitz.  The principal acute complications of tuberculosis were hemoptysis and pneumothorax.  Majority of cases are latent infections. When the disease becomes active, 75% cases are pulmonary and 25% are non-pulmonary. The increase in frequency of sudden death due to undiagnosed tuberculosis is a major concern. Individuals may have had a coexisting condition masking it. 
Hepatobiliary and gastrointestinal diseases account for 16 (13.3%) and 2 (1.67%) deaths of all the sudden deaths, respectively. Severe hepatic steatosis was the major cause. This was comparable with the study done by Rosmorduc et al.  Sudden death in these cases has been attributed to abnormality in the conduction system of the heart, manifested as a prolonged QT interval.  We reported two deaths due to peptic ulcer disease. This was the commonest COD in acute abdomen because of its complication like gastrointestinal bleeding and perforation. 
Of all the sudden deaths, we reported 10 deaths (8.33%) due to septicemia. Septic screen culture in body fluids turns out to be positive in these cases causing multiorgan dysfunction. In brief, infections trigger a cytokine cascade via toll-like receptors on inflammatory cells, with the excess secretion of many proinflammatory mediators including interleukin (IL)-1, tumor necrosis factor (TNF)-α, IL-6, nitric oxide (NO), and platelet-activating factor (PAF). Systemically, these affect organ function via damage to epithelia and endothelial cells (with abnormal microcirculation), inflammatory cell infiltration, initiation of the coagulation system, endocrine stimulation, and activation of the autonomic nervous system. The microbial triggers include endotoxin (lipopolysaccharide) in gram-negative bacilli and superantigens in gram-positive cocci. The cholinergic nervous system appears to be important in that it suppresses the production of proinflammatory cytokines. 
Sudden deaths due to neurological diseases accounts for four deaths (3.33%). The chief COD was due to cerebrovascular accidents. This was comparable to the study conducted by Kuller et al. and Luke and Helpern. ,
We reported a death due to angiosarcoma of spleen. At the time of autopsy, the peritoneal cavity was found to be filled with blood and there was splenic rupture of about 1.5 cm. The tumor showed criss-crossing vascular channels lined by proliferating plump elongated cells and containing red blood cells (RBCs). Solid areas made up of sarcomatoid-looking elongated nuclei in fascicles intersecting with one another, vascular slits, and foci of large atypical nuclei replacing much of the white pulp areas of the spleen were also seen. The tumor cells expressed CD34 which is an endothelial marker. Primary splenic angiosarcoma is a rare and aggressive tumor. Abdominal pain is the most common presenting symptom. A dramatic and often fatal presentation is spontaneous splenic rupture. Half of these were diagnosed on postmortem examination. 
| Conclusion|| |
In this study we found a significant number of sudden deaths occurring in young adults, particularly in the population above 30years, posing a health concern in our society. Cardiac causes contributed the maximum number and atherosclerosis being the main culprit in causing CAD. It is a challenge to the healthcare providers and increased awareness is needed among the population at risk. Regular checkups after the age of 30 may be made mandatory so that sudden deaths can be averted and life can be improved.
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[Table 1], [Table 2], [Table 3]