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Sudden death and acute myocarditis: a unique forensic case of double origin of coronary arteries
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  1. Isabella Aquila1,
  2. Pietro Tarzia1,
  3. Pietrantonio Ricci1,
  4. Santo Gratteri2
  1. 1University "Magna Graecia" of Catanzaro, Institute of Legale Medicine, Viale Europa, 88100, Catanzaro, Italy, Italy
  2. 2AO MaterDomini Catanzaro, Catanzaro, Italy
  1. Correspondence to Dr Isabella Aquila, isabella.aquila{at}hotmail.it

https://doi.org/10.1136/bcr-2017-221791

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    Description

    The doubling of the right coronary artery is a rare congenital coronary anomaly. Generally, this malformation is asymptomatic and therefore benign. But, in some cases, it constitutes a real silent killer. The aim of this study is to show how the double right coronary artery can cause fatal events without clinical signs of its presence. We reported the association between this anomaly and the acute necrotising myocarditis. In the forensic literature, cases of sudden death associated with the double coronary origin are not described.1 2

    We reported the case of a sudden death in a 14-year-old girl. At autopsy, the heart showed greyish areas and the histopathological surveys demonstrated the doubling of the right coronary artery (figures 1–4). The left ventricular myocardium showed a phlegmonous exudative inflammation, large necrotic areas and interstitial leucocyte infiltration, which resulted CD68 positive to the immunohistochemical investigations. The postmortem investigation of blood with haemoculture detected the presence of Staphylococcus aureus. The cause of death was: acute necrotising myocarditis (figure 5) with right coronary artery doubling. Probably, the coronary doubling represented an anatomical location that favoured the cardiac colonisation by S. aureus and so, the subsequent acute necrotising myocarditis.

    Figure 1
    Figure 1

    Doubling of the right coronary artery at autopsy.

    Figure 2
    Figure 2

    Identification of the duplication of the two coronary branches.

    Figure 3
    Figure 3

    Intracardiac course of the doubling right coronary artery.

    Figure 4
    Figure 4

    Histopathological image of arterial duplication.

    Figure 5
    Figure 5

    Histopathological image of acute myocarditis.

    This malformation is discovered occasionally during cardiac-CT or coronary angiography. It is necessary to report this anomaly because the bearers require a close cardiologic follow-up.3 For the first time, we point up how this anomaly is a risk factor for the acute myocarditis.

    Learning points

    • The doubling of the right coronary artery is a rare congenital coronary anomaly.

    • Generally, it is benign, but, in some cases, it can cause fatal events and it is a risk factor for other cardiac disease.

    • This malformation is discovered occasionally, but it is necessary to report it because the bearers require a close cardiologic follow-up.

    References

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      1. Erdogan O,
      2. Buyuklu M,
      3. Aktoz M
      . Anomalous origin of the right coronary artery from the left anterior descending artery in a patient with single left coronary artery: a rare coronary artery anomaly and review of the literature. Int J Cardiol 2008;127:280–3.doi:10.1016/j.ijcard.2007.04.121
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    2. ↵
      1. Wilson J,
      2. Reda H,
      3. Gurley JC
      . Anomalous right coronary artery originating from the left anterior descending artery: case report and review of the literature. Int J Cardiol 2009;137:195–8.doi:10.1016/j.ijcard.2009.03.140
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    3. ↵
      1. Aquila I,
      2. Boca S,
      3. Caputo F, et al
      . An unusual case of sudden death: is there a relationship between thyroid disorders and fatal pulmonary thromboembolism? A case report and review of literature. Am J Forensic Med Pathol 2017;38:229-232.doi:10.1097/PAF.0000000000000317
      OpenUrl
    View Abstract

    Footnotes

    • Contributors LA: is the forensic pathologist and the official responsible of the case. She performed the autopsy, conceived the idea and managed the whole realization of the paper. PT: has contributed through the writing of the paper. PR: has contributed through the realization of the histopathological analysis and the interpretation of the data. SG: performed the autopsy with IA and managed with her the realization of the work.

    • Competing interests None declared.

    • Patient consent Obtained.

    • Provenance and peer review Not commissioned; externally peer reviewed.