title: Case report of a rare complication of open-heart surgery masquerading as a gunshot wound: an autopsy diagnosis.
abstract: BACKGROUND
  Poststernotomy mediastinitis is a rare feared sequelae of open-heart surgery with low incidence of 1% to 3% but a high mortality rate (10%-35%). Poststernotomy mediastinitis can in uncommon instances give rise to sternocutaneous fistulas in 0.25% to 10% of cases. Although scant reports have documented prosthetic valve endocarditis occurring in a setting of deep sternal wire infections, it is an infrequent but well-documented fatal complication of valvular replacement surgery.
  
  
  METHODS
  A 52-year-old male smoker with aortic valve replacement (2011), on Coumadin and Monocor, was found dead on September 2013 with a hole along a surgical scar over the sternum, masquerading as a gunshot wound. Chest radiograph revealed no foreign body, and no evidence of homicidal/suicidal or accidental cause was found at autopsy. Examination revealed a chronic fistulous tract from a deep sternal wire infection to the skin, in addition to a chronic sinus tract eroding into the root of the aorta with recent prosthetic valve endocarditis.
  
  
  CONCLUSIONS
  To our knowledge, this is the first case report documenting poststernotomy mediastinitis causing a simultaneous occurrence of sternocutaneous fistula and prosthetic valve endocarditis. Either of these 2 exceptional but lethal complications would have sufficed as the cause of death.
authors.affiliation: From the *Department of Pathology and Molecular Medicine, McMaster University; and †Division of Anatomical Pathology, Hamilton General Hospital, Hamilton, Ontario, Canada.
authors.forename: Ipshita
authors.initials: I
authors.lastname: Kak
authors.forename: Vidhya
authors.initials: V
authors.lastname: Nair
mesh_terms: D001021:Aortic Valve / Q000601:surgery; D017577:Cutaneous Fistula / Q000209:etiology* / Q000473:pathology; D003937:Diagnosis, Differential; D004697:Endocarditis, Bacterial / Q000473:pathology; D006350:Heart Valve Prosthesis; D006801:Humans; D008297:Male; D008480:Mediastinitis / Q000175:diagnosis* / Q000209:etiology; D008875:Middle Aged; D016459:Prosthesis-Related Infections / Q000382:microbiology / Q000473:pathology; D056346:Sternotomy / Q000009:adverse effects*; D013898:Thoracic Injuries / Q000175:diagnosis; D014948:Wounds, Gunshot / Q000175:diagnosis