Pathology of peliosis

Peliosis is a pathological entity characterized by the gross appearance of multiple cyst-like, blood-filled cavities within parenchymatous organs. Peliosis has been related to several underlying debilitating illnesses such as tuberculosis, hematological malignancies, the acquired immunodeficiency syndrome (AIDS), and post-transplant immunodeficiency, as well as intravenous drug abuse, chronic alcoholism, and in conjunction with the intake of oral contraceptives or steroids. The classical pathoanatomical concept is based upon the opinion that peliosis exclusively develops in organs belonging to the mononuclear phagocytic system (liver, spleen, bone marrow, and lymph nodes). However, a paucity of studies indicates that other organs such as lungs, parathyroid glands, and kidneys may be affected too. Concerning the underlying pathogenetic mechanisms of onset and maintenance of peliosis, the morphological data obtained by different investigators suggest that there is more than one path of formal pathogenesis (e.g., congenital malformation of vessels manifesting under altered local intravascular pressure conditions, acquired vascular disorder triggered by toxic noxae, active proliferation of vessels corresponding to the benign end on the spectrum of neoplastic vascular lesions). In the liver, at gross inspection, the peliotic lesions give the cut sections a "swiss cheese" appearance. Microscopically, two different types of peliosis can be distinguished in the liver: (1) "parenchymal peliosis" consisting of irregular cavities that are neither lined by sinusoidal cells nor by fibrous tissue, and (2) "phlebectatic peliosis" characterized by regular, spherical cavities lined by endothelium and/or fibrosis. One of the differential diagnoses that most closely resembles peliosis hepatis is secondary hepatic congestion due to veno-occlusive disease or the Budd-Chiari syndrome. In the spleen, the peliotic lesions may be arranged sporadically, disseminated, or in clusters in an uneven distribution pattern. Histologically, the cavities show frequently well-demarcated margins that may appear focally lined by sinusoidal endothelium, or totally lack a clear cell lining. Differential diagnoses are hemangiomas and involvement of the spleen in hairy-cell leukaemia. Since the disease may culminate in spontaneous rupture of the affected organ and thus may mimic a violent death at autopsy, peliosis is far more than just another morphological curiosity. Awareness of peliosis at autopsy as well as an appreciation for the histopathological changes in less characteristic or advanced cases may become an important issue for both the forensic and clinical pathologist.     

Fatal splenic rupture following Heimlich maneuver: case report and literature review

The most effective resuscitative procedure in choking by foreign bodies is the Heimlich maneuver, described for the first time by Henry Heimlich (1974) and recognized by the US Surgeon General (1985) as the "only method that should be used for the treatment of choking from foreign body airway obstruction." If performed correctly, this lifesaving maneuver is associated with rare complications, of which the most frequent are rib fractures and gastric or esophagus perforations. Other rare traumatic injuries such as pneumomediastinum, aortic valve cusp rupture, diaphragmatic herniation, jejunum perforation, hepatic rupture, or mesenteric laceration have been described.However, we are unaware of previous reports of splenic rupture after Heimlich maneuver. We present an interesting case of fatal hemoperitoneum due to a hilar laceration of the spleen following a correctly performed Heimlich maneuver.     

钝性暴力致脾破裂的发生机制研究

脾破裂与外伤之间因果关系的判断是法医学鉴定中一个十分常见但又非常棘手的问题。探究脾破裂的机制是解决上述问题的必要的理论基础。本文收集了２５例钝性暴力致脾破裂的案例，对脾破裂的部位与暴力打击部位及方向的关系进行了分析、整理，探讨了人体各部位遭受暴力作用后脾破裂的特点，及钝性暴力导致脾破裂的机制，发现脾破裂的机制主要包括直接暴力冲击以及脾脏在受外力作用后撞击胃、隔肌、脊柱、肋骨和胸后壁等两类，并指出对脾破裂机制的进一步研究将成为法医学鉴定研究工作中的一项重要课题。     

Sudden, unexpected death due to splenic artery aneurysm rupture

Splenic artery aneurysms are an uncommon form of vascular disease that have a significant potential for rupture, resulting in life-threatening intraperitoneal hemorrhage. We describe the case of a 33-year-old man who died suddenly and unexpectedly due to the rupture of a splenic artery aneurysm. At medicolegal autopsy, 3000 mL of fluid blood were recovered from the peritoneal cavity. The source of bleeding was a sack-like aneurysm of the splenic artery, measuring 2 cm in diameter. Histologic examination of the splenic artery aneurysm revealed fibromuscular dysplasia. No atherosclerotic lesions or any inflammatory changes were apparent within the wall of the splenic artery. Portal hypertension and pancreatitis, previously described as important factors promoting splenic artery aneurysm formation, were excluded by autopsy and histology. From the forensic pathologist's viewpoint, this rare case underlines the importance of splenic artery aneurysm rupture as a relevant differential diagnosis of intraperitoneal hemorrhage and sudden death, respectively, since such cases may be misinterpreted as a result of blunt-force trauma.     

Fatal virus-associated hemophagocytic syndrome in a young adult producing nontraumatic splenic rupture.

A 24-year-old man with no previous medical history was admitted to a local hospital with pancytopenia after a recent "viral illness." During his hospitalization, he developed sudden abdominal distension and hypotension. Surgical exploration of his abdomen revealed a ruptured spleen. The spleen was removed, but the patient did not survive the operation. We investigated this unexpected and unexplained hospital death for any traumatic or iatrogenic injury. The cause of death after review of the clinical history, autopsy, and microscopic sections was virus-associated hemophagocytic syndrome (VAHS). VAHS consists of a generalized histiocytic proliferation and marked hemophagocytosis associated with a systemic viral infection. Clinically it presents as pancytopenia and organomegaly. This recently described entity is often confused with malignant histiocytosis. This is the first case report of VAHS producing nontraumatic splenic rupture, thus adding to the differential diagnosis of spontaneous splenic rupture and sudden natural death.     

Sudden and unexpected death resulting from splenic artery aneurysm rupture: two case reports of pregnancy-related fatal rupture of splenic artery aneurysm

Rupture of a splenic artery aneurysm is a rare and usually catastrophic event, most commonly associated with pregnancy. In spite of increasingly common reliance on abdominal angiography, magnetic resonance imaging, and computerized tomography during the past quarter century, clinicians uncommonly recognize any of the various splanchnic arterial aneurysms absent premonitory signs or symptoms. Accordingly, rupture of a visceral aneurysm, including splenic artery aneurysm, typically presents as sudden, unexpected obtundation or death. As a consequence, the initial recognition and diagnosis of splenic artery aneurysm rupture take place only at autopsy. This report presents two such cases of sudden death resulting from splenic artery aneurysm in a pregnant woman and a postpartum woman, respectively.     

胶原纤维、Ⅳ型胶原及CD34诊断外伤性迟发性脾破裂

外伤性迟发性脾破裂的鉴定难点在于准确判断脾破裂与腹部受到外力事件之间是否存在直接延续的因果关系。经典的组织病理检查的结果虽然具有十分重要的作用,但存在假阴性的可能,因此需要寻找其他辅助诊断指标。本文通过一例明确的外伤性迟发性脾破裂病例,在损伤及正常脾组织中,利用HE染色、Masson染色、免疫组化染色,针对胶原纤维、Ⅳ型胶原、CD34三个指标进行组织形态学对比,并量化免疫组化结果。HE染色发现出血灶周围已经形成了肉芽组织;Masson染色发现出血区周围的胶原纤维密度明显高于远端正常组织,且形成包膜状纤维结构;免疫组化结果发现,出血区域的Ⅳ型胶原及CD34相比正常对照组织均呈强阳性,平均光密度具有统计学差异。在判断脾损伤后经过时间方面,HE染色判断为7~14d,Masson染色判断其大于6d,免疫组化判断为7~14d,三者结果基本一致。说明HE染色、Masson染色以及Ⅳ型胶原和CD34免疫组化染色均可获得较为准确的结果。与HE染色相比,胶原纤维、Ⅳ型胶原、CD34更为直观并易于识别判断,这为今后此类案件的鉴定提供了新的辅助指标。     

Rupture of splenic artery aneurysm.

Three cases of death from splenic artery aneurysm rupture were encountered from 1988 to 1991 at the Philadelphia Medical Examiner's Office. In two cases, cocaine was detected in the blood and was believed to have precipitated the rupture. Toxicologic testing for cocaine should be performed in all cases of splenic artery aneurysm rupture and its presence should be interpreted properly as contributory rather than incidental to death.     

Diving-related fatalities caused by underwater explosions: a report of two cases.

The authors report two cases of diving-related water blast with fatal outcome resulting from nearby underwater explosions. Water blast with fatal outcome almost exclusively occurs in wars at sea. Underwater explosions are extremely rare in diving because of the limited exposure. Forensic findings in both cases reported included expected injuries to gas-filled organs such as the middle ear, lungs, and intestine; some rarely described injuries such as rupture of the liver, spleen, and kidneys; and also some lesions that were not found in a search of the literature: rupture of the heart and contusion of the hypophysis. Injuries caused by fatal underwater explosions should be carefully evaluated in forensic medicine to provide data that may support a criminal investigation.     

Immediate anaphylactic death following antibiotics injection: splenic eosinophilia easily revealed by pagoda red stain

The comparison of 4 cases of immediate anaphylactic death following the intramuscular injection of antibiotics (different types of penicillin or cephalosporins) with 4 cases of immediate non-anaphylactic death (induced by different causes) recognized splenic eosinophilia, as the main feature for the differential diagnosis, in agreement with isolated previous studies. The use of a stain (pagoda red) little known and seldom employed in Pathology and in Forensic Medicine, showed the concomitant massive presence (immunohistochemically confirmed) of mast cells and degranulated mast cells, the latter mainly located in splenic sinuses. The whole of our findings led us to consider the spleen as the possible shock organ in man. Waiting for further judgment on our hypothesis, we seized the opportunity to remark the employment of the pagoda red stain when the contemporary demonstration of eosinophils, mast cells and degranulated mast cells is required.     

Death due to a rare complication of colonoscopy and the potential medicolegal implications

A 64‐year‐old woman was found dead at home after undergoing a screening colonoscopy. At autopsy, 1.9 L of blood was discovered within her abdominal cavity. The only major abnormality was nontraumatic avulsion of the splenic capsule. This was the only identifiable abnormality capable of causing the severe hemoperitoneum and demise of the patient. Although rare, splenic capsule avulsion is a recognized complication of colonoscopy. Many have theorized that it results from excessive traction on the splenocolic ligament resulting in a tear of the splenic capsule. Most patients present within the first 24 hours after the procedure with nonspecific symptoms, and many patients may not seek medical attention. The paucity of the literature in the area of splenic capsular avulsion after colonoscopy reinforces the importance of reporting known cases, and by doing so raise awareness of this rare but devastating complication of an otherwise beneficial screening procedure.     

Fatal amphetamine-associated cardiotoxicity and its medicolegal implications

Amphetamines are popular drugs of abuse, particularly among youngsters and at dance scenes. Cardiotoxicity (manifested as cardiomyopathy, acute myocardial infarction/necrosis, heart failure, or arrhythmia) after the recreational (mis)use of amphetamine and its synthetic derivatives has been documented but is rather rare. Amphetamine-related cardiac fatalities are even more rare. We present 6 cases of young persons who died unexpected after the chronic abuse of amphetamines. Death was not attributed to a lethal intoxication but to an acute myocardial necrosis, a right ventricle rupture, a cardiomyopathy, or an arrhythmia. Two of the deceased persons presented prior to their death to the emergency department, but their complaints were not considered (probably due to their young age) to be of cardiac origin. One case was a sport-related fatality where medical screening failed to identify the underlying cardiac pathology or the amphetamine abuse, and 1 case was a so-called idiopathic dilated cardiomyopathy where substance abuse was not considered by the treating physician. We think that amphetamine-associated cardiotoxicity is a rare but probably genuine entity that should be considered both in forensic and clinical/emergency medicine because of its potential medicolegal implications.     

Fatal hemothorax from mycotic celiac artery aneurysm.

We present two cases of ruptured mycotic aneurysms infected with Staphylococcus aureus. Each patient had hemoptysis and in each case there was hemothorax caused by a ruptured mycotic aneurysm of the celiac artery. In case 1, the pathogenesis was transient Staphylococcus aureus septicemia infecting an atherosclerotic plaque with subsequent aneurysm formation and rupture. In case 2, the septicemia arose from an infected knee. The presentation of a celiac artery aneurysm as hemoptysis and as the cause of hemothorax is rare.     

The forensic medical evaluation of subcapsular splenic injuries

Data on 63 cases of subcapsular spleen lesions are analyzed. Circumstances of trauma infliction period of the 2-nd stage of spleen capsule rupture, morphological types of subcapsular spleen lesions, microscopic changes in different posttraumatic periods are presented.     

Esophageal injury in fatal rear-impact collisions

Neck injuries resulting from motor vehicle collisions (MVC), often referred to as whiplash trauma and injury, often demonstrate little or no evidence of significant tissue damage. In rare instances, however, serious injury to the anterior neck organ injuries can result from such trauma. The present study describes esophageal injury associated with rear-impact collisions, based on a unique case report, review of the scientific literature and a query in the National Automotive Sampling System (NASS) database of the US National Highway Traffic Safety Administration. The Medline search and present case study totaled five cases of rear-impact collision-related serious esophageal injury (laceration or rupture). In the four published cases all patients survived, whereas in the presented case study, the patient died due to mediastinitis and sepsis. The NASS query revealed an additional three cases out of a total of 55,926 investigated crashes. All three cases were associated with fatalities. Although no anatomical or bioengineering studies have presented data on the behavior of the esophagus during rear-impact whiplash loading, sudden tensile and/or compressive forces is the likely explanation of injury, often in combination with a local fracture of a vertebral body. In these 8 cases significant esophageal injury carried a substantial (50%) risk of mortality. Clinicians should be aware of the potential for significant complications in the whiplash trauma-exposed patient who complains of chest pain, mid-thoracic pain, discomfort in the neck and throat, respiratory distress, or hoarseness. For those forensic specialists involved in whiplash cases these study results highlight the need to consider esophageal injuries as a rare but potential consequence of whiplash trauma.     

Sudden unexpected death in a patient with splenic sequestration and sickle cell-beta+-thalassemia syndrome

Acute splenic sequestration crisis is a rare disorder that usually occurs in children, with sickle cell anemia, who are under the age of five years. A few cases have been described in adults with heterozygous sickle cell syndromes. Though this entity can be fatal there have been no reported cases associated with sudden death. We describe a case of sudden, unexpected death, associated with splenic sequestration, in a 29-year-old African-American man with undiagnosed sickle cell-beta-thalassemia syndrome.     

Previously Unreported Complication of Coronary Artery Bypass Grafting: Suture Rupture Resulting in Patient's Death

Traditionally, the manner of death in most hospital autopsy cases is natural, in which death is due to the natural course of disease or reasonably anticipated outcomes of medical interventions. Some cases fall into a potential gray zone between natural and accident, including rare or unanticipated outcomes of medical interventions. We present a case of a patient postcoronary artery bypass graft. Autopsy revealed the proximal anastomosis of the aorta‐to‐first‐diagonal‐coronary‐artery‐to‐second‐obtuse‐marginal‐artery graft was detached from the aorta. A broken suture was present at the disconnected anastomosis, with intact knots but was broken along its length. In‐hospital mortality rates of CABG range from 1% to 3%, with several autopsy studies identifying surgical complications as the cause of death in one‐third of perioperative deaths. No publications were found that described suture rupture as directly relating to the cause of death. This case report describes a previously unreported complication of coronary artery bypass grafting.     

Vertebral artery rupture in a sudden death case after mild trauma

We report a case of subarachnoid hemorrhage at the skull base with possible rupture of a vertebral artery, and we present a new method to investigate rupture of this artery. In this method, the brain stem and cerebrum are divided with ligation of the internal carotid artery and basilar artery, and milk is injected from the original part of the vessel to find the rupture. We show that this method is particularly useful for cases of subarachnoid hemorrhage at the skull base in which there may be rupture of a vertebral artery.     

Blunt force injury of the abdomen complicating previously undiagnosed peliosis hepatis in a 2-year-old female

Peliosis hepatis is an abnormal accumulation of blood-filled lakes in the liver that is most commonly seen in adults and is generally associated with chronic wasting diseases, use of androgenic steroids or bacterial infection. Few cases have been reported in children. We report a case of a 2-year-old female with no past medical history who presented with homicidal blunt force abdominal injury. The autopsy revealed lacerations in the liver and previously undiagnosed peliosis hepatis.