We report the case of a 36-year-old man with a history of choroidal melanoma of the right eye who underwent surgery (enucleation) four years prior to death, and who subsequently underwent a partial hepatectomy.
Since then, medical reviews, according to the family, have been normal.
He begins with respiratory distress and suddenly dies after a few minutes, finding debris of bilious vomiting next to the corpse.
External examination revealed generalized jaundiced dye, bilious remnants coming out of the right nasal fossa, edema in both lower limbs (especially in the foot, forefoot and ankle), and left abdominal conjunctival congestion in the right upper limb.
Internal examination revealed a 1.5 cm diameter nodule on the right frontal surface, penetrating the white matter brownish-neighbor colour.
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In the thoracic cavity we found bilateral pleural effusion and turbid pericardial effusion.
In the dissection of the pulmonary vessels, we observed a thrombus with vital characteristics attached to the right pulmonary artery that was introduced through the intraparenchymal branches.
In the inner wall of the right atrium there was a 1 x 2 cm tumor adhered to the latero-intern wall, occupying the cavity of the appendix, with a brownish base appearance pediculae.
The surface was slightly tapered and hemorrhagic in the infero-internal quadrant.
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In the abdominal cavity there were 1,500 cc of ascitic fluid with rest of stools, marked peritoneal adhesions, nodules increased for signs of ascitic fluid, from hard to hard lymphatic cut.
We also found nodules with similar characteristics attached to the peritoneal walls.
The liver presented a cystic lesion with remnants of coagulated blood and necrotic material stained with velvet dye.
The head of the pancreas had a congestive aspect and at the tacto had a hard and fibrous consistency.
The walls of the small intestine appeared thin and necrotic, with perforations in the ileum and iris, allowing the exit of fecaloid material and undigested food.
There were intestinal segments of obstructive aspect, which were coincided with necrotic tumor implants.
The large intestine also had brownish-needle malignant transformation areas.
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Chemical and toxicological studies of blood, vitreous humor and ascitic fluid were requested, as well as histopathological studies of the encephalon, cysts, lungs and pulmonary thrombi, pancreas, intestines and nodules around the heart.
In the former, negative results were obtained for all the substances studied.
Histopathological studies demonstrated the existence of a neoplasm composed of polygonal cells and fusiform cells arranged in sebabanas or solid nests.
These tumoral growths fixed the atrial myocardium but were not accompanied by desmotic reaction.
There are areas of necrosis within the tumor and a thrombus attached to an ulcerated area is identified on the external surface.
Tumor cells showed prominent nucleoli and frequent mitotic figures.
Frequently, there was abundant melanotic pigment in the cytoplasm.
The emboli seen in the pulmonary arteries presented different evolutionary stages.
Some were in the process of organizing vessels, while the rest were responsible for residual lumen andema that progressed from thrombotic formation; others, on the other hand, were completely covered with endothelium and in their sinus they began
The presence of emboli in different stages of evolution implies that, from the thrombus adhered to the atrial metastasis, there are three developments oscillating four weeks in a space of time.
Macroscopic and microscopic findings support the diagnosis of sudden death secondary to massive pulmonary thromboembolism, which has had its origin on the metastatic malignant tumor of a melanoma in the right pulmonary artery that causes completely different long-term deaths in the auricle.
On the other hand, in association with this, we found a picture of septic shock due to peritonitis secondary to intestinal perforation, in the context of a generalized metastatic disease whose origin is choroidal melanoma.
