Sudden cardiac arrest in a neonate with congenital adrenal hyperplasia

Congenital Adrenal Hyperplasia Presenting as Pulseless Ventricular Tachycardia in a Neonate

Congenital adrenal hyperplasia (CAH) comprises a group of autosomal recessive inherited disorders that arise due to defects in one of the enzymes of steroidogenesis pathway in the adrenal glands. Ninety-five percent of the cases occur due to deficiency in 21-hydroxylase (21-OH). Clinically, CAH due to 21-OH deficiency presents in two distinct forms, classic CAH and non-classic CAH. Females with classical forms present with genial ambiguity while the presentation in males is more subtle with severe electrolyte disturbances being the initial manifestation in many cases. Arrhythmias are a rare manifestation of CAH. We report the case of an 18-day-old male child who presented with pulseless ventricular tachycardia and was later diagnosed with congenital adrenal hyperplasia based on the laboratory findings of elevated 17-hydroxyprogesterone (17-OHP) levels. Our case reveals that fatal arrhythmias such as a pulseless ventricular tachycardia can be the primary manifestation of the adrenal insufficiency of CAH even in the absence of any physical findings and hence clinicians should always maintain a strong suspicion for CAH in any child presenting with unexplained arrhythmia. Furthermore, this case also highlights the need for CAH screening in neonates so that the appropriate hormone replacement can be initiated before the development of life-threatening adrenal crisis.

A Practical Forensic Approach to Fatal Pediatric Endocrinopathies

Of all of the organ systems in clinical medicine, the endocrine system is among the most difficult to master since it requires a detailed and knowledgeable integration of many of the body's separate systems. In forensic pathology, the evaluation of a sudden unexplained death can be challenging depending upon the particular disease processes and the organ systems that are affected. It is therefore not surprising that the investigation of sudden unexplained deaths involving the endocrine system can be particularly daunting. This review attempts to focus upon three of the major endocrine/metabolic conditions that may be potentially life-threatening and fatal in the pediatric population - hypoglycemia, adrenal insufficiency, and hyperthyroidism - and to provide forensic pathologists with a practical strategy for working up these cases. By adopting a more focused and selective approach to pediatric endocrine conditions rather than an exhaustive and comprehensive study of them, it is the intention of this review to make these disorders more manageable conceptually and to optimize the chance of arriving at a decisive and ultimately accurate postmortem diagnosis.