A man with ischemic heart disease after consuming alcohol found collapsed while eating: a café coronary and intoxication. Which cause preceded the others?

Abstract

INTRODUCTION: Complete and abrupt upper airway obstruction by a bolus of food, with sudden onset of symptoms simulating acute myocardial infarction was described as ‘Café coronary’ in early 60s. Victims are speechless and breathless; thus, without assistance (e.g.Heimlich manoeuvre) they will die. A typical ‘café coronary’ was an obese middle aged man dying, while eating having a chest pain, with eye witness accounts of ‘choking on a piece of meat’ which was hurriedly eaten. Though various theories were postulated at that time regarding the mechanism, later studies showed that multiple factors could be associated. We report a death of an alcoholic with a history of ischemic heart disease found with a bolus of food lodged at the pharynx and larynx. CASE REPORT: 51 year-old male after having 1½ bottles of illicit liquor, quarreled with the wife and left home, was found dead two (2) hours later in a partly built house. The examination of the scene revealed half a bottle of alcohol, a partly consumed loaf of bread, a beef curry and a roasted chicken thigh beside. Autopsy revealed obstruction of the mid larynx with a piece of bread, mild laryngeal oedema, myocardial fibrosis, 80% narrowing of the anterior descending artery and a liquor smell from stomach. The toxicological screening revealed 200mg/dlethyl alcohol in the blood, while histology revealed fibrosis of the myocardium. CONCLUSION: Although obstruction of the airway with a food bolus was the apparent cause of death at autopsy, the high blood alcohol level with myocardial fibrosis pauses questions regarding the mechanism of death i.e. which caused which? Therefore, a forensic pathologist should not be hurried to arrive at conclusions during the autopsy without further investigations.