A fatal misdiagnosis of page kidney - case report

Page kidney is a condition where external compression of the renal artery and renal parenchyma leads to subsequent ischaemia and activation of renin-angiotensin-aldosterone axis. A 42-year-old female with hirsutism, hypertension and diabetes was diagnosed with a right adrenal mass and underwent laparoscopic adrenalectomy. Her hypertension worsened postoperatively and was managed medically. Subsequently she developed a right flank pain on the fifth postoperative day and died suddenly the next day. Autopsy revealed a pale body with cushingoid appearance. Surgical scars were healthy. Internal examination of the abdomen revealed a haemoperitoneum of 500 ml together with a large subcapsular haematoma measuring 1000 ml surrounding the right kidney, compressing the right renal artery. Kidneys were pale and the right kidney was soft and friable. Cortical surface of the right kidney demonstrated a possible surgical puncture site with an overlying thrombus together with a contused inferior vena cava. Other organs were pale but appeared otherwise normal. Histology revealed diffuse cortical necrosis of right kidney and features of adult respiratory distress syndrome in the lungs. Haemorrhagic shock following laparoscopic adrenalectomy for right adrenal tumor was declared as the cause of death, contributed by the development of the Page kidney. Trauma of several aetiologies including laparoscopic abdominal surgery may contribute to Page kidney. It presents with flank pain, hypertension and renal mass. Since postoperative blood loss usually manifests as hypotension, resulting hypertension may mislead the attending clinicians. Once diagnosed, it can be managed with surgical drainage and antihypertensives.

A death due to faulty airbag system-case report

Injuries due to automobile safety devices have been reported and we report a rare fatality due to a defective airbag system. A compact hybrid car driven by a 37-year-old male at moderate speed had crashed through an unprotected manhole. The car had moved around 200 m before it came to a halt. The passers-by had noticed that the driver was unconscious, partly leaning forward with an inflated airbag. He was pronounced dead on admission. The car had sustained minor indentation on front bumper. Autopsy revealed a circular perforated laceration on the neck associated with completely transected right carotid artery and partially transected jugular vein. There was a 2 × 2-cm cylindrical metal object lodged at C4-C5 vertebrae level, and the remaining part of this was retrieved during scene investigation and identified as a part of a metal canister in the inflator component of the airbag system. There was a perforation in the airbag which was similar in size to the retrieved foreign body. The cause of death was ascertained as hemorrhagic shock due to bleeding from ruptured neck vessels caused by primary shrapnel projected from the faulty airbag system. Following the incident, the manufacturers replaced faulty airbag systems in similar models. If abnormally fatal injuries are observed, a scene visit along with automotive expert opinion would provide valuable insight into the incident. Such information would alert the general public on regular screening of safety measures and prompt manufacturers to recall faulty products.

High-dose dexamethasone in quinine-treated patients with cerebral malaria: a double-blind, placebo-controlled trial

We compared placebo and dexamethasone (initial dose, 3 mg/kg; total, 11.4 mg/kg per 48 h) in a double-blind trial involving 10 stuporous and 28 comatose patients with cerebral malaria. Patients were 18 mo to 42 y of age (geometric mean, 10.2 y), and the 19 patients in each group were comparable on admission. All patients received intravenous quinine therapy. Four patients (21%) in each group died. There were no significant differences between the placebo- and dexamethasone-treated groups in time until patients became afebrile (median, 51 vs. 19 h), the level of consciousness became normal (mean, 80 vs. 83 h), or parasitemia was cleared (mean, 2.1 vs. 3.4 d) or in the incidence of complications. Coma or hyperparasitemia (greater than or equal to 5% of erythrocytes parasitized) at the time of admission and hypoglycemia at any time during hospitalization were significantly correlated with a fatal outcome, which was not improved by using dexamethasone. We conclude that high-dose dexamethasone is not indicated for treating cerebral malaria.