Sudden cardiac death of an adolescent during dieting. (Letters to the Editor).

To the Editor: I read with interest the report of Stevens et al (1) in which they described a 16-year-old girl who experienced cardiorespiratory arrest at school and died after a failed attempt at resuscitation. As is often the case in unexpected sudden death, many details of the final event are undocumented, as are many details of the patient's medical condition during the week immediately preceding death. The authors recognized electrolyte abnormalities in blood obtained during the final minutes of life, and they correlated this well with alterations in the patient's diet during the preceding 2 weeks. These were the focus of attention mostly because other historical data, laboratory results, and autopsy findings had seemed irrelevant as to the cause of death. Several recent reports (2-5) have confirmed the occasional unanticipated discovery of various types of medullary brain lesions in cases of unexpected sudden death that could not be otherwise explained. Although the mechanism of death in these cases is unknown, the location of these lesions near vital centers of cardiac and respiratory function makes a related cause of death plausible. Autopsies frequently do not include a neuropathologic examination. In reporting cases of unexpected unexplained sudden death, it is essential to document whether the brain specifically was pathologically examined in detail, as well as the extent to which the findings revealed the cause of death. Because the Stevens et al report (1) did not include this information, it is difficult to determine whether recent alterations in the patient's diet may simply have been a red herring.

J. Howard Jaster, MD

Delta Medical Center

Memphis, TN

References

(1.) Stevens A, Robinson DP, Turpin J, Groshong T, Tobias JD. Sudden cardiac death of an adolescent during dieting. South Med J 2002;95:1047-1049.

(2.) Ortiz-Reyes R, Dragovic L, Eriksson A. Sudden unexpected death resulting from previously nonsymptomatic subependymoma. Am J Forensic Med Pathol 2003;23:63-67.

(3.) Gleckman AM, Smith TW. Sudden unexpected death from primary posterior fossa tumors. Am J Forensic Med Pathol 1998;19:303-308.

(4.) Matturri L, Ottaviani G, Rossi L. Sudden and unexpected infant death due to an hemangioendothelioma located in the medulla oblongata. Adv Clin Path 1999;3:29-33.

(5.) Maisel JA, Lynam T. Unexpected sudden death in a young pregnant woman: Unusual presentation of neurosarcoidosis. Ann Emerg Med 1996;28:94-97.

In Reply: My colleagues and I appreciate Dr. Jaster's interest in and comments regarding our recent case report. (1) We agree that the association between the sudden death and dietary changes may be temporal and not causal. Given the lack of other etiologic possibilities and the associated electrolytic disturbances, however, we postulate that the change in diet may have resulted in the terminal event. Despite the fact that the autopsy included the central nervous system, no other etiologic factor was identified. Although histologic changes have been identified in other patients with unexpected sudden death, we are unaware of any evidence demonstrating a direct causal link between those changes and the terminal event. The only way to clarify these issues will be to have ongoing reporting of such events, especially in patients on various diet regimens as well as ongoing prospective research.

Joseph D. Tobias, MD

Department of Anesthesiology 

University of Missouri

Columbia, MO

Reference

(1.) Stevens A, Robinson DP, Turpin J, Groshong T, Tobias JD. Sudden cardiac death of an adolescent during dieting. South Med J 2002:95:1047-1049.