Cases Of Sudden Unexpected Death Research Articles

Epilepsy-related sudden unexpected death: targeted molecular analysis of inherited heart disease genes using next-generation DNA sequencing.

Inherited heart disease causing electric instability in the heart has been suggested to be a risk factor for sudden unexpected death in epilepsy (SUDEP). The purpose of this study was to reveal the correlation between epilepsy-related sudden unexpected death (SUD) and inherited heart disease. Twelve epilepsy-related SUD cases (seven males and five females, aged 11-78 years) were examined. Nine cases fulfilled the criteria of SUDEP, and three cases died by drowning. In addition to examining three major epilepsy-related genes, we used next-generation sequencing (NGS) to examine 73 inherited heart disease-related genes. We detected both known pathogenic variants and rare variants with minor allele frequencies of <0.5%. The pathogenicity of these variants was evaluated and graded by eight in silico predictive algorithms. Six known and six potential rare variants were detected. Among these, three known variants of LDB3, DSC2 and KCNE1 and three potential rare variants of MYH6, DSP and DSG2 were predicted by in silico analysis as possibly highly pathogenic in three of the nine SUDEP cases. Two of three cases with desmosome-related variants showed mild but possible significant right ventricular dysplasia-like pathology. A case with LDB3 and MYH6 variants showed hypertrabeculation of the left ventricle and severe fibrosis of the cardiac conduction system. In the three drowning death cases, one case with mild prolonged QT interval had two variants in ANK2. This study shows that inherited heart disease may be a significant risk factor for SUD in some epilepsy cases, even if pathological findings of the heart had not progressed to an advanced stage of the disease. A combination of detailed pathological examination of the heart and gene analysis using NGS may be useful for evaluating arrhythmogenic potential of epilepsy-related SUD.

Long-term follow up and sudden unexpected death in Gaucher disease type 3 in Egypt

Objective: To describe the long-term follow-up and distinct phenotype of a large cohort of patients with Gaucher disease type 3 on enzyme replacement therapy (ERT) in Egypt. Methods: A prospective cohort study of 78 patients on ERT who were followed for up to 9 years with yearly evaluations that included EEG and cognitive testing. Results: Of the patients, 73% were homozygous for the L444P GBA1 mutation; all but 7 were neurologically symptomatic. Supranuclear gaze palsy with variable but stable cognitive function was present in 91% of patients. Convergent strabismus and bulbar dysfunction were noted in 22% and 37%, respectively. Features of oppositional defiant disorder were present in 54% of patients. Twenty-three patients (30%) developed seizures while on ERT for 1–9 years. Of those, 12 patients (15%) died suddenly and unexpectedly at a mean age of 6.7 ± 5.0 years (range 1.5–18). Sudden death was usually associated with a seizure disorder or a terminal seizure, but 7 of 12 patients had a preceding normal EEG. An additional 11% had background slowing or epileptogenic activity on EEG without clinical seizures. There were 3 familial cases of sudden unexpected death. Conclusions: Despite having the most common GBA1 genotype known to be associated with neuronopathic Gaucher disease, patients with Gaucher disease type 3 in Egypt have a phenotype and a clinical outcome on ERT that are very different from those observed in other populations. Identifying putative modifying genes of this ethnic group is likely to lead to better therapy for neuronopathic Gaucher disease generally.

Abstract 13165: Median Household Income and Rural Location Associated With Sudden Unexpected Death in Wake County, NC

Introduction: The incidence of sudden unexpected death (SUD) in a racially and socioeconomically diverse population has been inadequately studied. We collated all SUDs among the 18 to 64 year population over a 12-month period in Wake County, North Carolina, a racially and socioeconomically diverse predominantly urban county, population c1 million. We investigated the socioeconomic differences in incidence of SUD to assist in future development of targeted interventions. Methods: Cases of possible SUD were identified from the Wake County EMS. Expected deaths were excluded and determination for cohort inclusion was made by independent cardiologists from review of medical records and medical examiner’s reports. SUD cases were geocoded to the level of census tract using death certificate residence address and the U.S Census Geocoder. Wake County includes 185 census tracts, population 5022 ± 2285 (M±SD). Median household income and other demographic data were obtained from the 2013 American Community Survey and 2010 U.S Census. Univariate and multivariable analysis were used to identify associates of SUD. Results: The 2013 incidence of SUD in Wake County was 19.5/100,000. A majority (107 of 185) of census tracts had at least one SUD, with 190 total. Census tracts with ≥1 SUD had a higher population of African Americans, a greater proportion unmarried, and a lower median household income than those with no SUDs (figure, p≤.001). After multivariable analysis, only median household income and rural tract location remained significantly associated with sudden death. Conclusion: This examination exemplifies the importance of studying sudden unexpected death in a racially and socioeconomically diverse population. Multivariable analysis suggests that low household income and rural location are important potential contributing factors to sudden death. Educational interventions to reduce the incidence of sudden death should be developed with these populations in mind.

Abstract 12086: Differences in Risk Factors and Primary Cause of Sudden Unexpected Death by Timing Criteria

Background: The World Health Organization (WHO) criteria for sudden unexpected death (SUD) describes either witnessed death or unwitnessed death occurring no more than 24 hours after the subject was last seen alive. Sudden Unexpected Death in North Carolina (SUDDEN) is a population-based study of out-of-hospital unexpected deaths using a clinical definition of sudden death without restrictions on the timing of death. Use of time-limiting definitions was found to underestimate the incidence of SUD by 4 to 19 fold. We sought to explore the characteristics and risk factors of this underestimated population. Methods: From March 2013 to March 2014, all cases of possible sudden unexpected death were identified from electronic query of the Wake County EMS database. Expected deaths were excluded and independent cardiologists made determination for cohort inclusion by review of medical history. We stratified the cohort by timing of death (less than 24 hours versus above 24 hours and unknown) and analyzed the observed difference in incidence between the two groups. Results: Out of 1138 total EMS referrals, 190 were adjudicated as SUD cases into the final cohort. SUDDEN captured 70% more people than studies that used WHO-based criteria. In comparison with cases excluded by WHO criteria, cases meeting WHO criteria were younger (50.1 ± 9.8 years 54.5 ± 8.2 years, p&lt;0.001) and had a higher likelihood of a medical examiner issued death certificate (86.3% vs. 34.9%). WHO-based criteria also include significantly more cases with the primary cause of death listed as unknown (p&lt;0.01). Differences between the groups for BMI, smoking status and dyslipidemia were suggestive. There were no time-based differences in other comorbidities (coronary artery disease, diabetes mellitus, and hypertension) or demographic risk factors (race, gender, marital status, and educational status). Conclusion: Time-limiting definitions underestimate SUD incidence. Preliminary study shows trends in some demographic and clinical characteristics between SUDDEN and WHO-recommended criteria. An expanded study sample of a population-based cohort similar to SUDDEN is needed to understand the differences in this often misclassified population.

Two definite cases of sudden unexpected death in epilepsy in a family with a DEPDC5 mutation.

The DEPDC5 gene (OMIM #614191), mapped to 22q12.2-q12.3, encodes the DEP domain-containing protein 5. DEPDC5 has been associated with a variety of familial epilepsies, including familial focal epilepsy with variable foci, autosomal dominant nocturnal frontal lobe epilepsy, familial temporal lobe epilepsy, epileptic spasms, and cortical dysplasia.(1-4) Notably, DEPDC5 has never been linked to increased risk of sudden unexpected death in epilepsy (SUDEP). We report a family with epilepsy due to DEPDC5 mutation and 2 definite cases of SUDEP within this family.

Genetic investigations of sudden unexpected deaths in infancy using next-generation sequencing of 100 genes associated with cardiac diseases.

Sudden infant death syndrome (SIDS) is the most frequent manner of post-perinatal death among infants. One of the suggested causes of the syndrome is inherited cardiac diseases, mainly channelopathies, that can trigger arrhythmias and sudden death. The purpose of this study was to investigate cases of sudden unexpected death in infancy (SUDI) for potential causative variants in 100 cardiac-associated genes. We investigated 47 SUDI cases of which 38 had previously been screened for variants in RYR2, KCNQ1, KCNH2 and SCN5A. Using the Haloplex Target Enrichment System (Agilent) and next-generation sequencing (NGS), the coding regions of 100 genes associated with inherited channelopathies and cardiomyopathies were captured and sequenced on the Illumina MiSeq platform. Sixteen (34%) of the SUDI cases had variants with likely functional effects, based on conservation, computational prediction and allele frequency, in one or more of the genes screened. The possible effects of the variants were not verified with family or functional studies. Eight (17%) of the SUDI cases had variants in genes affecting ion channel functions. The remaining eight cases had variants in genes associated with cardiomyopathies. In total, one third of the SUDI victims in a forensic setting had variants with likely functional effect that presumably contributed to the cause of death. The results support the assumption that channelopathies are important causes of SUDI. Thus, analysis of genes associated with cardiac diseases in SUDI victims is important in the forensic setting and a valuable supplement to the clinical investigation in all cases of sudden death.

Structural imaging biomarkers of sudden unexpected death in epilepsy.

Sudden unexpected death in epilepsy is a major cause of premature death in people with epilepsy. We aimed to assess whether structural changes potentially attributable to sudden death pathogenesis were present on magnetic resonance imaging in people who subsequently died of sudden unexpected death in epilepsy. In a retrospective, voxel-based analysis of T1 volume scans, we compared grey matter volumes in 12 cases of sudden unexpected death in epilepsy (two definite, 10 probable; eight males), acquired 2 years [median, interquartile range (IQR) 2.8] before death [median (IQR) age at scanning 33.5 (22) years], with 34 people at high risk [age 30.5 (12); 19 males], 19 at low risk [age 30 (7.5); 12 males] of sudden death, and 15 healthy controls [age 37 (16); seven males]. At-risk subjects were defined based on risk factors of sudden unexpected death in epilepsy identified in a recent combined risk factor analysis. We identified increased grey matter volume in the right anterior hippocampus/amygdala and parahippocampus in sudden death cases and people at high risk, when compared to those at low risk and controls. Compared to controls, posterior thalamic grey matter volume, an area mediating oxygen regulation, was reduced in cases of sudden unexpected death in epilepsy and subjects at high risk. The extent of reduction correlated with disease duration in all subjects with epilepsy. Increased amygdalo-hippocampal grey matter volume with right-sided changes is consistent with histo-pathological findings reported in sudden infant death syndrome. We speculate that the right-sided predominance reflects asymmetric central influences on autonomic outflow, contributing to cardiac arrhythmia. Pulvinar damage may impair hypoxia regulation. The imaging findings in sudden unexpected death in epilepsy and people at high risk may be useful as a biomarker for risk-stratification in future studies.

Evaluation of meteorological and epidemiological characteristics of fatal pulmonary embolism.

The objective of the present study was to identify risk factors among epidemiological factors and meteorological conditions in connection with fatal pulmonary embolism. Information was collected from forensic autopsy records in sudden unexpected death cases where pulmonary embolism was the exact cause of death between 2001 and 2010 in Budapest. Meteorological parameters were detected during the investigated period. Gender, age, manner of death, cause of death, place of death, post-mortem pathomorphological changes and daily meteorological conditions (i.e. daily mean temperature and atmospheric pressure) were examined. We detected that the number of registered pulmonary embolism (No 467, 211 male) follows power law in time regardless of the manner of death. We first described that the number of registered fatal pulmonary embolism up to the nth day can be expressed as Y(n) = α ⋅ n (β) where Y denotes the number of fatal pulmonary embolisms up to the nth day and α > 0 and β > 1 are model parameters. We found that there is a definite link between the cold temperature and the increasing incidence of fatal pulmonary embolism. Cold temperature and the change of air pressure appear to be predisposing factors for fatal pulmonary embolism. Meteorological parameters should have provided additional information about the predisposing factors of thromboembolism.

Sudden deaths in adult-worn baby carriers: 19 cases.

Infant carriers represent an underestimated cause of death by suffocation in neonates. • Sudden unexpected deaths in infancy linked to infant carrier have been only sparsely reported. • We report a series of 19 cases strongly suggesting age of less than 3 months as a risk factor and suffocation as the mechanism of death.

Sudden death in young persons with uncontrolled asthma--a nationwide cohort study in Denmark.

BackgroundAsthma is a common chronic disease among young adults, and several studies have reported increased mortality rates in patients with asthma. However, no study has described sudden unexpected death in a nationwide setting in patients with uncontrolled asthma. We defined uncontrolled asthma as a previous hospital admittance because of asthma (of any severity) or when asthma was considered to have influenced the death according to the death certificate. The purpose of this study is to increase the medical focus on young persons with uncontrolled asthma and thereby hopefully aid in preventing sudden unexpected deaths. We therefore aimed to describe clinical characteristics, symptoms, causes of death, and contact with the healthcare system prior to sudden unexpected death in young persons with uncontrolled asthma.MethodsThrough the review of death certificates, we found 625 sudden unexpected death cases in individuals aged 1–35 years in Denmark from 2000 to 2006. Of those, 49 persons with uncontrolled asthma were identified.Previous contacts with the healthcare system were identified, and available records from general practitioners were retrieved.ResultsWe identified 49 individuals who suffered from uncontrolled asthma. This corresponds to an incidence rate of 0.32 per 100,000 person-years. The cause of death in 31 cases (63%) was sudden cardiac death, and in 13 cases (27%), it was a fatal asthma attack.Symptoms (chest pain, dyspnea, seizures, general malaise, syncope, and palpitations) prior to death were reported in 41 (84%) of the cases. In 34 (69%) of the cases, antecedent symptoms (symptoms >24 hours before death) were present, and 28 (57%) patients had prodromal symptoms (symptoms <24 hours before death). The most common antecedent symptoms were dyspnea and chest pain, whereas the most common prodromal symptoms were dyspnea, general malaise, and/or fatigue. Twenty-eight patients (57%) sought medical advice from a general practitioner and/or emergency department due to these symptoms.ConclusionThe cause of death was predominantly sudden cardiac death followed by fatal asthma attack. We found that 41 (84%) of patients suffered from symptoms prior to death and that 28 (57%) sought medical advice from the emergency department and/or general practitioners.Electronic supplementary materialThe online version of this article (doi:10.1186/s12890-015-0033-z) contains supplementary material, which is available to authorized users.

Pulmonary edema following generalized tonic clonic seizures is directly associated with seizure duration

PurposePostictal pulmonary edema (PPE) is almost invariably present in human and animal cases of sudden unexpected death in epilepsy (SUDEP) coming to autopsy. PPE may be a contributing factor in SUDEP. The incidence of postictal PPE is unknown. We retrospectively investigated PPE following generalized tonic clonic seizures (GTCS) in the epilepsy monitoring unit. MethodChest X-rays (CXR) following each GTCS were obtained in 24 consecutive patients. Relationship of CXR abnormality to seizure duration, ictal/postictal oxygen desaturation (SpO2), apnea and presence of postictal generalized EEG suppression (PGES) was investigated using logistic regression. ResultsEleven of 24 patients had CXR abnormalities following a GTCS. In these 11 patients, 22 CXR were obtained and abnormalities were present in 15 CXR. Abnormalities included PPE in 7 patients, of which 2 also had focal infiltrates. In 4 patients focal infiltrates were present without PPE. There was no significant difference in mean time to CXR (225min) following GTCS in the abnormal CXR group versus the normal group of patients (196min).Mean preceding seizure duration was longer (p=0.002) in GTCS with abnormal CXR (259.7s) versus GTCS with normal CXR (101.2s). Odds-ratio for CXR abnormality was 20.46 (p=0.006) with seizure duration greater than 100s versus less than 100s. On multivariable analysis, only the seizure duration was a significant predictor of CXR abnormality (p=0.015). ConclusionRadiographic abnormalities are not uncommon following GTCS. The presence of CXR abnormality is significantly associated with the duration of the preceding GTCS. Severe, untreated PPE may be relevant to the pathophysiology of SUDEP.

Undiagnosed Anaplastic Ganglioglioma Resulting in the Sudden Unexpected Death of a Young Woman

Intracranial neoplasm is a rare cause of death; most autopsy studies have reported the incidence as being under 1% [1]. Typically, the patient experiences related symptoms for a long time owing to the impaired brain function of the involved area. However, these tumors may not show any definitive manifestations of intracranial lesions. When undiagnosed, the patient experiences only mild symptoms for a relatively short period of time and rapidly progresses to death. In these cases, an autopsy, or at least post-mortem imaging tools such as computed tomography, is needed to diagnose the tumor and determine the cause of death. Although this particular type of sudden unexpected death has been reported, herein, we report a case due to a very rare type of brain tumor-anaplastic ganglioglioma. We share this experience and discuss a case of sudden unexpected death due to an undiagnosed

Incidence of sudden unexpected death in nocturnal frontal lobe epilepsy: a cohort study

ObjectiveMost cases of sudden unexpected death in epilepsy (SUDEP) follow a seizure, and most deaths occur while people are in bed, presumably sleeping. Nocturnal seizures are reported to be a risk factor for SUDEP. People with nocturnal frontal lobe epilepsy (NFLE) have seizures predominantly or exclusively during sleep, often many times per night. The present study aimed to assess whether NFLE represents a high-risk condition for SUDEP. MethodsThe present study retrospectively assessed the incidence of SUDEP in a cohort reconstructed from a dedicated database of consecutive patients referred to the Epilepsy and Sleep Centres of the Institute of Neurological Sciences of Bologna from 1980 to 2012 with: (1) a diagnosis of NFLE, (2) at least 90% of seizures during sleep, and (3) at least one-year of follow-up. ResultsOne hundred and three people were included. The median time from seizure onset to last observation was 26 years, equal to a follow-up of 2789 person-years. One person died of SUDEP during the follow-up period. The incidence rate of SUDEP was 0.36 per 1000 person-years (95% CI 0.01 to 2.0). ConclusionsThe incidence of SUDEP in the participant population was not higher than the rates previously reported in prevalent epilepsy populations (0.4 to 2.3 per 1000 person-years). The low prevalence of SUDEP might reflect the low occurrence of generalised tonic-clonic seizures in people with NFLE.

The Value of Molecular Autopsy: Genetic Testing Reveals Long QT Mutations in an Autopsy-Negative, Postpartum Sudden Unexpected Death

In forensic pathology, genetic testing is a luxury that is not readily entertained. With molecular advances, genetic testing can provide critical information to conclude cause and manner of death in otherwise sudden, undetermined deaths. An autopsy was performed on a 30-year-old woman who died suddenly three months postpartum. The patient's history was unremarkable and included a negative electrocardiogram test prior to pregnancy. Toxicology results were negative and there were no gross or histologic findings on a complete postmortem examination including the conduction system. Prompted by personal interest and knowledge, the spouse, an electrophysiology fellow, requested genetic testing be performed and personally financed the tests. The results revealed two genetic mutations strongly associated with Type 1 Long QT Syndrome, expected to be familial. This provided a cause and manner of death and also instigated preventive measures for testing in the child. This case supports previous studies that acknowledge the need for molecular testing in the autopsy-negative, sudden unexpected death cases in young patients. Forensic pathologists have a duty to the public to serve as their physicians and this may prove to be a key area that can contribute to the preventative medicine effort and provide closure to families that may have loved ones left with an undetermined cause and manner of death. Although financially a problem, the future of pathology is undeniably heading in the direction of molecular testing and an attempt to adjust an internal budget in order to include expenses for these tests should be considered.

Pulmonary hypertensive vascular changes in lungs of patients with sudden unexpected death. Emphasis on congenital heart disease, Eisenmenger syndrome, postoperative deaths and death during pregnancy and postpartum

AimsPulmonary hypertension (PH) in asymptomatic patients is a rare cause of sudden death. This study aims to determine the incidence of this entity and raise awareness among pathologists.MethodsWe retrospectively investigated...

Allergy in Extremis

Allergy-associated diseases have a multitude of confirmed or suspected etiologies and associations affecting organs and organ systems. The hyper-reactivity of the immune system in which the eosinophils are prominent plays a central role in organ-specific and systemic effects in these diseases. Patients may be plagued with nonspecific, episodic, or progressive signs and symptoms. Patients may also exhibit signs and symptoms that mimic more common conditions. Recognition of certain patterns of clinical signs and symptoms may lead to definitive clinical diagnosis and effective treatment, particularly of less common but potentially lethal disease entities. The lack of clinical recognition of these patterns, whether due to "red herring" historical information, lack of sign/symptom specificity, clinical presentation at early stage, or unfamiliarity with the constellation of disease presentation, may delay or preclude diagnosis and treatment. The forensic pathologist must also have an awareness of varied clinical presentations of diseases because these can provide us with direction toward the ultimate determination of cause and manner of death.The importance and contribution of the practice of forensic pathology are highlighted in the instance of sudden and unexpected death, whereby the previously unrecognized or unconfirmed disease entity that leads to the death is revealed via analysis of scene information, autopsy performance, and review of medical history and history of the most recent illness. Through this comprehensive approach, a greater understanding of the extent and potential lethality of disease with reiteration of the importance of early clinical diagnosis and treatment is reinforced. This benefits the medical community involved in diagnosis and treatment, clinicians and pathologists alike, with the ultimate goal of reduction of morbidity and mortality.Reported is a case of sudden unexpected death with historical, gross, and microscopic findings consistent with a multisystem, inflammatory, allergic disease entity.

Sudden Unexpected Death in North Carolina (SUDDEN): methodology review and screening results

ObjectivesThis paper describes the methodology for a prospective, community-based study of sudden unexpected death in Wake County, North Carolina.MethodsFrom 1 March to 29 June 2013, data of presumed cardiac arrest...

Burden of Sudden Cardiac Death in Persons Aged 1 to 49 Years

Background— Knowledge of the burden and causes of sudden cardiac death (SCD) is sparse in persons aged &lt;50 years; better understanding is needed to lower the risk of SCD. The aim of this study was to report SCD incidence rates and autopsy findings in persons aged 1 to 49 years. Methods and Results— All deaths in persons aged 1 to 49 years were included in 2007 to 2009. Death certificates were reviewed by 2 physicians. History of previous admissions to hospital was assessed, and discharge summaries were read. Sudden unexpected death cases were identified and autopsy reports were collected. In the 3-year study period, there were 7849 deaths of which we identified 893 (11%) SCD cases. The annual incidence rate per 100 000 persons increased from 2.3 (95% confidence interval, 2.0–2.7) to 21.7 (95% confidence interval, 20.2–23.4) in persons aged 1 to 35 and 36 to 49 years, respectively. Coronary artery disease was the most common cause of death and was found in 158 (36%) autopsied cases, followed by 135 (31%) cases of sudden unexplained death. Conclusions— In a nationwide cohort of persons aged &lt;50 years, the annual incidence rate of SCD was ≈10× higher in persons aged 36 to 49 years than in persons aged 1 to 35 years. Notably, coronary artery disease was the most common cause of SCD, followed by unexplained deaths. These findings may help in developing strategies to prevent SCD in the future.

Profiling the approach to the investigation of viral infections in cases of sudden unexpected death in infancy in the Western Cape Province, South Africa

BackgroundSudden unexpected death in infancy is one of the main contributory factors to high infant mortality rates world-wide. Several risk factors, including viral infection, have been implicated in SUDI cases, but no single factor has been confirmed as the main cause of death. At the Tygerberg Medico-legal Laboratory, Cape Town, South Africa, investigation of lung tissue for viral infection forms part of an institutional protocol for the examination of cases of sudden unexpected death in infancy. MethodsLung tissue from 82 cases of sudden unexpected death in infancy was collected over a 10 month period. Routine shell vial cultures and histological examination of the tissue were performed according to the standard institutional protocol on fresh and formalin-fixed tissue, respectively. In addition, real-time polymerase chain reactions and immunohistochemical staining for adenovirus, cytomegalovirus and respiratory syncytial virus were done on fresh and formalin-fixed lung tissue, respectively. ResultsHuge variation was found in the number of positive cases confirmed by shell vial culture, real-time polymerase chain reaction and immunohistochemistry (0, 2 and 0 for adenovirus; 3, 29 and 2 for cytomegalovirus; and 0, 0 and 4 for respiratory syncytial virus, respectively). ConclusionsIn the absence of a National Protocol for investigation of sudden unexpected death in infancy, we conclude that the selection of viruses and routine diagnostic technique included in the institutional investigation protocol might be suboptimal and should be re-evaluated.

Analysis of sudden deaths in a coastal region of South India

Sudden death as a term is used to describe deaths occurring in an apparently healthy individual within 24 hours with or without onset of symptoms. A medicolegal investigation is crucial to identify such deaths and exclude unnatural causes. The present research is an attempt to study the causes and profile of victims of sudden unexpected deaths in Mangalore, a coastal town in South India A registry based retrospective study was conducted in the Department of Forensic Medicine , Kasturba Medical College, Mangalore, India. All the cases of sudden unexpected deaths during December 2004 and December 2009, which were diagnosed to be due to natural causes after autopsy were included in the study and analysed. A total of 248 cases of sudden and unexpected deaths were analysed. The male to female ratio for sudden natural deaths was 7:1 and the peak age incidence (35.9%) was observed between 46 and 60 years. Cardiovascular diseases were found to be the predominant cause of sudden death (40.7%) followed by infections (25.8%) and respiratory disorders (15.7%). Middle aged males are observed to be the most affected population and the predominant causes of death are cardiovascular diseases and infections. Copyright © 2014, Indian Journal of Medical Specialities. Published by Reed Elsevier India Pvt. Ltd. All rights reserved.