Chapter 1: Natural death Flashcards
The photograph bellow is mostly associated with what disease?
ETOH? DB? hepC? Iron overload? or metastatic cancer?
Hepatitis infection
Answer A is incorrect. The photograph depicts a liver that is cirrhotic. Of the choices listed, the one most often associated with hepatic cirrhosis is hepatitis C infection. Chronic alcoholism or chronic ethanolism (alcoholism) was the leading cause of cirrhosis but is now the second leading cause in the United States, causing approximately 21% of the cases of cirrhosis (see Wolf, David C. Cirrhosis. Located at http://emedicine.
medscape.com/article/185856-overview last updated January 8, 2017. Last accessed
May 30, 2017.)
what liver findings are associated with diabetes mellitus?
Diabetes mellitus would more likely manifest as fatty liver,
although it can cause cirrhosis. Nonalcoholic fatty liver disease is a frequent but not the most common cause of cirrhosis.
what liver findings are associated with iron overload?
Iron overload is classically seen in hereditary hemochromatosis, which is an autosomal recessive condition that causes excess deposition of iron in hepatocytes and can cause cirrhosis. Due to the relative rarity of the condition, it is not the most common cause of cirrhosis.
what liver findings are associated with metastatic cancer
Metastatic cancer would likely present as more discrete nododules with some normal appearing liver tissue.
A 50-year-old man with liver failure and a history of oxycodone abuse is found dead in bed. Autopsy reveals severe jaundice, a dark brown, cirrhotic liver, massive ascites, and esophageal varices. Liver histology demonstrates abundant dark brown intracytoplasmic
hepatocyte pigment that stains positive for iron. Which of the following mutations is likely present?
In what disease are the of the genes implicated?
BCR-ABL1
CYP2D6
EWSR1
HFE
KRAS
HFE (hereditary hemochromatosis)
BCR-ABL1 is a translocation associated with the Philadelphia
chromosome and is primarily associated with chronic myelogenous leukemia (CML). Detection of the BCR-ABL1 translocation is the defining diagnostic feature of CML. It is also found less commonly in acute lymphoblastic leukemia (ALL). It is not found in hereditary hemochromatosis.
CYP2D6 is the gene that encodes for the cytochrome p450
system in the liver that is responsible for metabolism of many drugs. Polymorphism in this gene can cause people to metabolize drugs more quickly (ultra-rapid metabolizers) or more slowly (poor metabolizers). Currently, there are no known gross or microscopic findings associated with CYP2D6 variations. The variations can only be confirmed by molecular methods.
EWSR1: sarcomas, mainly ewing
KRAS: neoplasia, often colorectal
What are the structure highlighted by the Bielchowsky stain?
Neuronal plaque
What is depicted in the retroperitoneum of this 56-year-old man?
Greenfield filter with thromboemboli
he gross photograph shows in situ dissection of the inferior vena
cava adjacent to the pelvic bowl. Where the lumen of the vein is exposed, a metal, several-pronged filter is present, and entangled in its tines is a red-brown thromboembolism or several thromboemboli. Inferior vena cava filters are placed in order to
capture thrombi that become dislodged from more peripheral veins, most commonly popliteal or femoral (deep venous thrombosis). A vena caval filter is also known as a Greenfield filter, which is a trademarked name for a specific device of this type.
The histological findings in the myocardium featured below are suggestive of what disease process?
WHat malignant condition is most often associated with the condition^
Amyloidosis and plasma cell myeloma
. Multiple regions of amorphic pink material appear to be in the
myocardial interstitium. In addition, the same pink material (see arrow in Figure 1.59) is seen in the artery in the photograph. These findings should raise suspicion of amyloidosis. Gross changes to the heart with a firm, tan-gray appearance may be seen but may also be subtle. Ischemic interstitial fibrosis likely has a different, more serpiginous pattern. However, if uncertain, the pathologist could perform special stains (Congo Red for amyloid or Masson trichrome stain for fibrosis) to more confidently differentiate the two processes. Histopathology of other organs may also be supportive of a diagnosis of amyloidosis, and history may assist in the evaluation as well. The photograph in Figure 1.59b is from the same general area of the H&E stained section depicted in 1.59a and shows the apple-green birefringence that can be seen upon polarization of Congo Red stained tissues in regions of amyloid deposition
What lesion is depected in the brainstem
Telangiectasia
he photograph demonstrates a capillary telangiectasia in the
pons. The pons is the most common CNS site for this lesion, which is usually asymptomatic but may hemorrhage. Thus, if a pontine hemorrhage is observed, it may be useful to sample the region histologically in order to discern the etiology of the bleed.
what is the most likely diagnosis?
Pneumocystis jiroveci infection
Answer A is incorrect. In alveolar proteinosis, the alveolar space is filled with homogeneous eosinophilic material.
* Answer B is incorrect. Cryptococcus infection is likely to elicit a granulomatous response if the individual is immunocompetent. The organisms may be viewed by hematoxylin and eosin (H&E) staining as round with slightly basophilic cell walls and surrounded by a clear zone. These organisms may be stained with mucicarmine, Periodic Acid Schiff, silver staining, and India ink staining.
* Answer C is incorrect. Diffuse alveolar damage (DAD; also termed hyaline membrane disease) is evidenced microscopically by eosinophilic material adherently lining the alveolar walls, although the early phase is exudative and may not show the hyaline membranes. The material essentially eliminates the alveolar-capillary interaction where present and leads to significant gas exchange deficits when extensive. DAD is most frequently encountered during long-term intubation.
* Answer D is correct. The photomicrograph shows an alveolar space filled with a granular or frothy-appearing eosinophilic substance that is characteristic of infection by Pneumocystis jiroveci. Reactive pneumocytes are also present. To better visualize the infectious agent, a Grocott-Gomori methylamine-silver stain may be utilized as
imaged in Figure 1.60. This organism frequents the lungs of the healthy as well, but only in immunocompromised states does it tend to lead to opportunistic infection. It is an indicator that the CD4 lymphocyte count is low when present and suggests a level less than 200 cells per milliliter in one diagnosed with HIV (human immunodeficiency) infection.
A 63-year-old male collapsed after experiencing acute chest pain. During autopsy the left
anterior descending coronary artery was sampled and a representative cross section is
pictured in Figure 1.7. What is the most likely underlying cause of death?
A 63-year-old male collapsed after experiencing acute chest pain. During autopsy the left anterior descending coronary artery was sampled and a representative cross section is pictured in Figure 1.7. What is the most likely underlying cause of death?
What is the manner of death?
Atherosclerotic cardiovascular disease
UNdetermined with only this information
accident is incorrect. There is no mention of any toxicological data in the question. You must account for the possibility of a stimulant drug such as methamphetamine or cocaine that may have contributed to death. If that was the case then the manner
would be classified as accident.
- homicide is incorrect. The circumstances indicate there is no reason to believe this was a homicide. If the decedent had collapsed at gunpoint during a robbery, a case for homicide as the manner of death could be made on the grounds that the sudden catecholamine release exacerbated the underlying heart disease, and the person would not have died without the added stress. However, it should be noted that this is a very controversial subject.
- Natural is incorrect. Although this appears to be a natural death on the surface, no mention is made of any toxicology data that if positive for drugs such as cocaine or methamphetamine could possibly change the manner from natural to accident.
- Suicide is incorrect. Nothing in the scenario suggests the person took his or her own life; thus, suicide is excluded.
- Undertermined is correct. Since there is no toxicology data, the possibility of two different manners of death exist, natural or accident. Since neither of these can be established without relevant toxicological data, the manner should be classified as undetermined.
What is the age of this infarct?
2 months or more (white scarring)
No grossly visible changes are observed the first 4 hours after an infarct. Mottling can appear as early as 4 hours and up to 24 hours after the infarct.
The myocardium has white scarring. Mottling, which is indicative of an acute infarct, is seen between 4 and 24 hours.
About 2 months after a myocardial infarction, white fibrous scar
tissue appears and would be expected to be seen at 6 months as well.
After 1–3 days, the infarct becomes tan-yellow. This is followed
by softening of the center with hyperemia at the border of the normal myocardium and infarcted tissue at around days 3–7.
A subacute infarct at 10 days would be expected to exhibit yellow-tan myocardium with red-tan margins. Days 7–10 show a transition of the infarct to yellow-tan with red-tan margins. The infarct is at its softest at this point, and the myocardium is most susceptible to rupture in this window.
Around 1 month the infarcted area becomes red-gray and has depressed borders. There is also some overlap as gray-white granulation tissue is seen at this stage and may be seen as early
as 2 weeks and as late as 2 months.
he following finding was documented at autopsy. Which of the following sites is most common for this anomaly?
Berry aneurysm. anterior communicating artery
The most frequent site of saccular (berry) aneurysms is the anterior circulation of the circle of Willis at the brain base. The probe demonstrates the most common site: anterior communicating artery. The incidence of intracranial aneurysm is approximately 2% on average and up to 6% in those with risk factors
(also see Rinkel GJE et al. Prevalence and risk of rupture of intracranial aneurysms— A systematic review. Stroke 1998, 29: 251–6.); although only a minority rupture.
What is the most likely source of hemorrhage?
Anterior communicating cerebral artery
Although any surface artery may form an aneurysm with consequent rupture, the most common is the anterior communicating cerebral artery. The arteries of the circle of Willis are frequently implicated in basilar subarachnoid hemorrhage such as that shown. However, in a case such as that illustrated, the pathologist may perform a directed dissection of the circle of Willis and vessels originating from
it in order to define the causative lesion.
What clinical finding is most likely associated with the finding?
Hemopericardium can present clinically as cardiac tamponade often associated with PEA. Tachycardi, tachypnea, cold extremities, becks triad (increased JVP, hypotension and diminished heart sound).
32-year-old man complained of shortness of breath and collapsed. He could not be revived. Based on histopathology, what is the most likely cause of death?
probably status asthmaticus
he photograph shows an influx of eosinophils and apparent loose
eosinophilic granules within the subepithelium. In addition, the basement membrane is thickened and inspissated mucus is in the airway. Although not exemplified here, another histological change found in asthma is smooth muscle hypertrophy.
A 54-year-old man developed altered mental status while in the hospital for a pulmonary infection from which he later died. Sections of brain were sampled because of the history. What special stain may help with the diagnosis?
A. Bielschowsky
B. Brown–Brenn
C. Mucicarmine
D. Nissl
E. Ziehl–Neelsen
The correct answer is C. Mucicarmine
* Answer A is incorrect. Bielschowsky Silver stain is commonly used to identify plaques
and tangles in Alzheimer disease as it highlights nerve fibers.
* Answer B is incorrect. Brown–Brenn is a form of Gram stain useful for finding bacteria, not fungal organisms.
* Answer C is correct. Fungal organisms are present within the meninges of this patient
and have the size and configuration of Cryptococcus species. Mucicarmine aids in identification of polysaccharide components in the prominent capsule. Alcian Blue Periodic
Acid Schiff stain will also highlight the capsule. A Gomori methenamine silver (GMS)
stain would also assist in identification of fungus and also will stain other organisms.
A good knowledge of fungal morphology is most important, but special stains can be
used to find rare organisms and assist in morphological analysis.
* Answer D is incorrect. Nissl is a cresyl violet stain that will stain neurons pink-violet.
* Answer E is incorrect. Ziehl–Neelsen, an acid-fast stain most commonly used to identify mycobacterium, may stain Blastomyces or Histoplasma, but is less specific and
does not stain Cryptococcus.
