A one-month-old male infant was found dead in bed by his 24-year-old G2P2A0 mother. The infant was born at full term (40 weeks gestation) by uncomplicated vaginal delivery. The birth weight was 1990 grams (below 3rd percentile) with Apgar scores of 9, 10, and 10 at 1, 5 and 10 minutes, respectively. After routine immunization for tuberculosis and polio, both mother and infant were discharged from the hospital in good condition. The mother smoked approximately 10 cigarettes per day but had no other complications or co-morbidities. The mother breast-fed the infant for two weeks and then changed to formula feeding.
During the two days prior to the death of this infant, the mother noted a runny nose, mild wheezing and diarrhea in the infant. These symptoms improved with over-the-counter remedies, but he appeared less alert and slept more. The mother reported that he seemed "fussy" on the day prior to his death but fed well and, aside from sleeping more, did not appear ill.
A forensic autopsy was ordered and the parents gave permission for additional tissue procurement for PASS research. A death scene investigation was performed at time of death. On the night of the demise, the infant shared the double bed with a soft foam rubber mattress with his father and mother, sleeping on the side of the bed closest to his mother. The infant was put to bed in the prone position, no pillow, facing the side and was found in the same position.
At autopsy, the 2100 gram, 50.5 cm infant had mild peripheral edema, manifested by swollen eyelids. No evidence of traumatic injury, hemangiomas or other congenital abnormalities of the skin was noted. Multiple tumor nodules up to 2 cm in size were present throughout the liver (Figure 1). There were petechiae on the visceral pleura, epicardium, and thymus (Figure 1). Microscopic sections of the liver neoplasms (Figure 2) showed an infiltrative, richly vascular tumor with dilated vascular channels of varying caliber, lined by a single layer of endothelial cells surrounded by loose connective tissue. The endothelial lining cells were plump with regular, round to ovoid nuclei separated by loose connective tissue. There were no areas of significant fibrosis, thrombi, bile pooling, calcification or myxoid change. Mitotic figures were very scarce. The lungs demonstrated extensive congestion, pulmonary edema and hemosiderin laden macrophages, but no signs of pneumonia or metastases. Subpleural and septal petechial hemorrhages were present; mild prominence of the dilated pulmonary vasculature was present. Maturational age of the lungs was appropriate with well formed alveoli. The 25 gram heart was dilated with tense, blood filled chambers, particularly on the right side; numerous petechiae and focal hemorrhage was also present within the epicardium. There was marked congestion of the small blood vessels but no alterations in myocyte structure. Intense congestion was appreciated in the red pulp of the enlarged spleen (52 gm) and to a lesser extent in the adrenal medulla and kidneys. Thymic petechiae were present and Hassel corpuscle bodies appeared increased in number and size but the cortico-medullary junction was distinct and the cortex was well populated with lymphocytes without a starry sky infiltrate. There was mild lipid depletion of the adrenal cortex. The costo-chondral junction and bone marrow were normal in histologic sections. The remaining organs, including the brain, were unremarkable.