Postmortem genetic testing in sudden unexplained death: A public health laboratory experience.

Sudden unexplained death in the young poses a diagnostically challenging situation for practicing autopsy pathologists, especially in the absence of anatomic and toxicological findings. Postmortem genetic testing may identify pathogenic variants in the deceased of such cases, including those associated with arrhythmogenic channelopathies and cardiomyopathies. The Wisconsin State Laboratory of Hygiene (WSLH) is a state-run public health laboratory which performs postmortem genetic testing at no cost to Wisconsin medical examiners and coroners. The current study examines sequencing data from 18 deceased patients (ages 2 months to 49 years, 5 females) submitted to WSLH, from 2016 to 2021. Panel-based analysis was performed on 10 cases, and whole exome sequencing was performed on the most recent 8 cases. Genetic variants were identified in 14 of 18 decedents (77.8%), including 7 with pathogenic or likely pathogenic variants (38.9%). Whole exome sequencing was more likely to yield a positive result, more variants per decedent, and a larger number of variants of uncertain significance. While panel-based testing may offer definitive pathogenic variants in some cases, less frequent variants may be excluded. Whole exome testing may identify rare variants missed by panels, but increased yield of variants of uncertain significance may be difficult to interpret. Postmortem genetic testing in young decedents of sudden unexplained death can provide invaluable information to autopsy pathologists to establish accurate cause and manner of death and to decedent's relatives to allow appropriate management. A public health laboratory model may be a financially advisable alternative to commercial laboratories for medical examiner's/coroner's offices.

COVID-19: Postmortem Diagnostic and Biosafety Considerations.

As a result of the 2019 novel human coronavirus (COVID-19) global spread, medical examiner/coroner offices will inevitably encounter increased numbers of COVID-19-infected decedents at autopsy. While in some cases a history of fever and/or respiratory distress (eg, cough or shortness of breath) may suggest the diagnosis, epidemiologic studies indicate that the majority of individuals infected with COVID-19 develop mild to no symptoms. Those dying with-but not of-COVID-19 may still be infectious, however. While multiple guidelines have been issued regarding autopsy protocol in cases of suspected COVID-19 deaths, there is some variability in the recommendations. Additionally, limited recommendations to date have been issued regarding scene investigative protocol, and there is a paucity of publications characterizing COVID-19 postmortem gross and histologic findings. A case of sudden unexpected death due to COVID-19 is presented as a means of illustrating common autopsy findings, as well as diagnostic and biosafety considerations. We also review and summarize the current COVID-19 literature in an effort to provide practical evidence-based biosafety guidance for medical examiner-coroner offices encountering COVID-19 at autopsy.

Death Certification: Errors and Interventions.

OBJECTIVE: Death certificates are legal documents containing critical information. Despite the importance of accurate certification, errors remain common. Estimates of error prevalence vary between studies, and error classification systems are often unclear. Relatively few studies have assessed the frequency at which death certification errors occur in US hospitals, and even fewer have attempted a standardized classification of errors based on their severity. In the current study, our objective was to evaluate the frequency of death certification errors at an academic center, implement a standardized method of categorizing error severity, and analyze sources of error to better identify ways to improve death certification accuracy. DESIGN: We retrospectively reviewed the accuracy of cause and manner of death certification at our regional academic institution for 179 cases in which autopsy was performed between 2013-2016. We compared non-pathologist physician completed death certificates with the cause and manner of death ultimately determined at autopsy. METHODS: Errors were classified via a 5-point scale of increasing error severity. Grades I-IIc were considered minor errors, while III-V were considered severe. Sources of error were analyzed. RESULTS: In the majority of cases (85%), death certificates contained ≥ one error, with multiple errors (51%) being more common than single (33%). The most frequent error type was Grade 1 (53%), followed by Grade III (30%), and Grade IIb (18%). The more severe Grade IV errors were seen in 23% of cases; no Grade V errors were found. No amendments were made to any death certificates following finalization of autopsy results during the study period. CONCLUSION: This study reaffirms the importance of autopsy and autopsy pathologists in ensuring accurate and complete death certification. It also suggests that death certification errors may be more frequent than previously reported. We propose a method by which death certification errors can be classified in terms of increasing severity. By understanding the types of errors occurring on death certificates, academic institutions can work to improve certification accuracy. Better clinician education, coordination with autopsy pathologists, and implementation of a systematic approach to ensuring concordance of death certificates with autopsy results is recommended.

Silicosis: Diagnosis and Medicolegal Implications.

Despite well-publicized sources of occupational hazard, silicosis continues to threaten industrial workers in the United States. We performed a retrospective search of the University of Wisconsin electronic pathology database to retrieve autopsy cases of silicosis and collaborated with the Wisconsin Department of Health Services to obtain statewide epidemiologic data regarding silicosis morbidity/mortality since 2003. Three silicosis autopsy cases were retrieved: all were men with ≥ 30 years of occupational crystalline silica exposure and similar histologic features of collagenous pulmonary nodules with admixed refractile particles. Overall, our state exceeds the national rate of silicosis-related hospitalizations and mortality, that is, 10.1 hospitalizations per million WI residents versus 1.2 nationally and 1.2 deaths per million WI residents versus 0.4 nationally. Surveillance is crucial to identify emerging occupational hazards and protect workers. A diagnosis of silicosis must be carefully considered at autopsy since it carries substantial implications for worker's compensation, compensatory losses, and employer liability.

U.S. Medical Examiner/Coroner capability to handle highly infectious decedents.

In the United States of America, Medical Examiners and Coroners (ME/Cs) investigate approximately 20% of all deaths. Unexpected deaths, such as those occurring due to a deceased person under investigation for a highly infectious disease, are likely to fall under ME/C jurisdiction, thereby placing the ME/C and other morgue personnel at increased risk of contracting an occupationally acquired infection. This survey of U.S. ME/Cs' capabilities to address highly infectious decedents aimed to determine opportunities for improvement at ME/C facilities serving a state or metropolitan area. Data for this study was gathered via an electronic survey. Of the 177 electronic surveys that were distributed, the overall response rate was N = 108 (61%), with 99 of those 108 respondents completing all the questions within the survey. At least one ME/C responded from 47 of 50 states, and the District of Columbia. Select results were: less than half of respondents (44%) stated that their office had been involved in handling a suspected or confirmed highly infectious remains case and responses indicated medical examiners. Additionally, ME/C altered their personal protective equipment based on suspected versus confirmed highly infectious remains rather than taking an all-hazards approach. Standard operating procedures or guidelines should be updated to take an all-hazards approach, best-practices on handling highly infectious remains could be integrated into a standardized education, and evidence-based information on appropriate personal protective equipment selection could be incorporated into a widely disseminated learning module for addressing suspected or confirmed highly infectious remains, as those areas were revealed to be currently lacking.

Autopsy Biosafety: Recommendations for Prevention of Meningococcal Disease.

INTRODUCTION: As invasive meningococcal disease progresses rapidly, often affects youth, and has a fairly high mortality rate, such cases are likely to fall under medical examiner/coroner (ME/C) jurisdiction. Morgue personnel may be at risk of contracting secondary meningococcal disease. We review the current scientific literature regarding Neisseria meningitidis infection and provide recommendations for the prevention of meningococcal disease at autopsy. METHODS: A PubMed search utilizing applicable medical subject heading terms was performed retrieving articles for review from the preceding two decades. Pertinent current guidelines from multiple national organizations were also retrieved. RESULTS: Invasive meningococcal disease is transmitted by direct contact with large respiratory droplets or oral secretions. While a surgical mask would normally provide adequate protection from large droplet spread, it does not prevent inhalation of smaller aerosolized particles such as those generated at autopsy. Prosectors are advised to routinely wear N-95 respirator masks or powered respirator hoods. All published cases of secondary meningococcal disease transmission to healthcare workers invariably arose in scenarios in which face masks/respirators were not employed; none of these cases involved meningococcal disease transmission to ME/C or other morgue staff. DISCUSSION: In the event that no mask-or inadequate coverage such as a surgical mask-is employed during autopsy of a decedent suspected/confirmed to have invasive meningococcal disease, antibiotic prophylaxis is advisable. Assuming appropriate personal protective equipment is utilized, chemoprophylaxis is unnecessary. Routine meningococcal vaccination is not recommended, except for ME/C with specified immunocompromising conditions or traveling to hyperendemic/endemic meningococcal regions. Acad Forensic Pathol. 2018 8(2): 328-339.

Serratia marcescens Bacteremia: Nosocomial Cluster Following Narcotic Diversion.

OBJECTIVE To describe the investigation and control of a cluster of Serratia marcescens bacteremia in a 505-bed tertiary-care center. METHODS Cluster cases were defined as all patients with S. marcescens bacteremia between March 2 and April 7, 2014, who were found to have identical or related blood isolates determined by molecular typing with pulsed-field gel electrophoresis. Cases were compared using bivariate analysis with controls admitted at the same time and to the same service as the cases, in a 4:1 ratio. RESULTS In total, 6 patients developed S. marcescens bacteremia within 48 hours after admission within the above period. Of these, 5 patients had identical Serratia isolates determined by molecular typing, and were included in a case-control study. Exposure to the post-anesthesia care unit was a risk factor identified in bivariate analysis. Evidence of tampered opioid-containing syringes on several hospital units was discovered soon after the initial cluster case presented, and a full narcotic diversion investigation was conducted. A nurse working in the post-anesthesia care unit was identified as the employee responsible for the drug diversion and was epidemiologically linked to all 5 patients in the cluster. No further cases were identified once the implicated employee's job was terminated. CONCLUSION Illicit drug use by healthcare workers remains an important mechanism for the development of bloodstream infections in hospitalized patients. Active mechanisms and systems should remain in place to prevent, detect, and control narcotic drug diversions and associated patient harm in the healthcare setting. Infect Control Hosp Epidemiol 2017;38:1027-1031.

Incorporation of autopsy case-based learning into PhD graduate education: a novel approach to bridging the "bench-to-bedside" gap.

Given the current rapid expansion of biological knowledge and the challenges of translating that knowledge into clinical practice, finding effective methods of teaching graduate students clinical medicine concepts has become even more critical. The utility of autopsy in medical student and resident education has been well established. Multiple studies have reported it to be a helpful means of teaching anatomy, pathophysiology, clinical problem-solving skills, and medical diagnostic techniques. Although various models of training PhD candidates in clinical medicine have been reported, an autopsy-based curriculum has not been previously described. For over 4 years, our pathology department has offered a novel semester-long autopsy-based course to educate future Cellular and Molecular Pathology scientists about clinical medicine. Our results indicate that this "hands-on" approach is a popular as well as effective means of teaching the pathogenesis of disease at the level of the cell, organ, and patient. The course reputation has recently led to requests to open registration to graduate students from other university programs as well as undergraduate students. Additionally, it has played an important role in our Cellular and Molecular Pathology program's recent receipt of a 5-year renewal National Institutes of Health-funded T32 award. Overall, this course model has been successful at our own institution and could provide a useful template for other institutions seeking to provide graduate investigators with in-depth exposure to clinical medicine.

Blastomycosis in Wisconsin: Beyond the Outbreaks.

In the summer of 2015, many individuals visiting the Little Wolf River in Waupaca County were exposed to the pathogenic fungus, Blastomyces. Over time, 59 confirmed and 39 probable cases were reported to the Wisconsin Department of Health Services (W-DHS), making this one of the largest outbreaks in recent state history. Though most instances of blastomycosis are not associated with common source outbreaks, cases such as this highlight the need for vigilance regarding this preventable cause of death. In the state of Wisconsin, an average of 118.6 cases (range, 84-174) of confirmed blastomycosis are diagnosed annually; the majority of these cases are sporadic rather than outbreak-associated. In the current study, we review characteristics of blastomycosis cases diagnosed at our academic medical center, as well as examine statewide W-DHS data, in order to familiarize pathologists with the epidemiologic and histologic characteristics of this disease.

Giant Cell Myocarditis: A Brief Review.

Giant cell myocarditis (GCM) is a rapidly progressive and frequently fatal disease that mainly affects young to middle-aged previously healthy individuals. Early diagnosis is critical, as recent studies have shown that rapidly instituted cyclosporine-based immunosuppression can reduce inflammation and improve transplant-free survival. Before the 1980s, GCM was mainly a diagnosis made at autopsy. Owing to advancements in diagnostic and therapeutic options, it is now increasingly diagnosed on the basis of endomyocardial biopsies, explanted hearts, or apical wedge sections removed at the time of ventricular assist device placement. Histologic examination remains the gold standard for diagnosis; however, there are many possible etiologies for cardiac giant cells. Having a working knowledge of the clinicopathologic features that distinguish GCM from other giant cell-containing lesions is essential, since such lesions can have widely divergent management and outcome.

Enhancing preclinical year pathology exposure: the Angevine approach.

Less than 2% of graduating US medical seniors select pathology residencies. One major obstacle to attracting prospective residents is the relative "invisibility" of pathology; medical students lacking positive preclinical exposure to pathology are unlikely to later select pathology clerkships or residencies. The Angevine Fellowship is a 10-week competitive pathology internship medical students may apply for the summer following their first year of preclinical training at our institution. We sought to determine whether it was an effective pathology recruitment tool and how it compared with the postsophomore pathology fellowship (PSF). Angevine fellow and PSF data from 2000 to 2014 were retrospectively analyzed. Specialty choices of former fellows already matched into residency programs were tabulated. Data regarding annual percentage of graduating seniors at our institution who matched into pathology during the years former fellow cohorts matched were also examined. Our results showed that of the former Angevine fellow cohorts already matched into residency programs, 40% (8/20) matched in pathology and 20% (4/20) at our own institution. Angevine fellows comprised a disproportionately high number of the graduating seniors matching in pathology at our medical school (26.7%). PSFs comprised 6.67%. Although we have endowment funding for 2 Angevine fellows annually, the level of interest among applicants has increased to the point that our department has consistently contributed funding for 1-2 additional fellowship spots since 2011. We conclude that the Angevine Fellowship offers an effective alternative to the postsophomore fellowship. It has proven successful at our institution and could be implemented at others to potentially improve pathology recruitment trends nationwide.

Host contributions to construction of three device-associated Candida albicans biofilms.

Among the most fascinating virulence attributes of Candida is the ability to transition to a biofilm lifestyle. As a biofilm, Candida cells adhere to a surface, such as a vascular catheter, and become encased in an extracellular matrix. During this mode of growth, Candida resists the normal immune response, often causing devastating disease. Based on scanning electron microscopy images, we hypothesized that host cells and proteins become incorporated into clinical biofilms. As a means to gain an understanding of these host-biofilm interactions, we explored biofilm-associated host components by using microscopy and liquid chromatography-mass spectrometry. Here we characterize the host proteins associated with several in vivo rat Candida albicans biofilms, including those from vascular catheter, denture, and urinary catheter models as well as uninfected devices. A conserved group of 14 host proteins were found to be more abundant during infection at each of the niches. The host proteins were leukocyte and erythrocyte associated and included proteins involved in inflammation, such as C-reactive protein, myeloperoxidase, and alarmin S100-A9. A group of 59 proteins were associated with both infected and uninfected devices, and these included matricellular and inflammatory proteins. In addition, site-specific proteins were identified, such as amylase in association with the denture device. Cellular analysis revealed neutrophils as the predominant leukocytes associating with biofilms. These experiments demonstrate that host cells and proteins are key components of in vivo Candida biofilms, likely with one subset associating with the device and another being recruited by the proliferating biofilm.

Principles and Pitfalls: a Guide to Death Certification.

Death certificates serve the critical functions of providing documentation for legal/administrative purposes and vital statistics for epidemiologic/health policy purposes. In order to satisfy these functions, it is important that death certificates be filled out completely, accurately, and promptly. The high error rate in death certification has been documented in multiple prior studies, as has the effectiveness of educational training interventions at mitigating errors. The following guide to death certification is intended to illustrate some basic principles and common pitfalls in electronic death registration with the goal of improving death certification accuracy.

Testing for Infectious Diseases in Sudden Unexpected Infant Death: A Survey of Medical Examiner and Coroner Offices in the United States.

OBJECTIVES: To determine interoffice variability in routinely performed sudden unexpected infant death (SUID) postmortem studies for infection and to assess availability and perceived utility of various tests of infectious diseases. STUDY DESIGN: Online surveys were sent to all 154 offices of US medical examiners and coroners serving populations >300,000 people. Surveys included a set of potential laboratory tests for infectious disease. Respondents were asked to select which tests were available in their offices, and which tests were performed routinely in SUIDs vs which tests should be performed routinely. RESULTS: Of the 45 complete responses, 4.4% did not routinely perform histology, 8.9% did not routinely perform viral studies (ie, culture or molecular diagnostics), 22.2% did not routinely perform blood cultures, 26.7% did not routinely perform lung bacterial cultures, and 44.4% did not routinely perform cerebrospinal fluid cultures. CONCLUSIONS: Our findings suggest that there is considerable interoffice variability with testing for infectious diseases in SUIDs. This appeared to be largely the result of a perceived lack of testing utility rather than a lack of test availability. Evidence-based practice guidelines regarding the interpretation of microbial testing results, as well as common testing protocols/algorithms, may lead to more accurate and standardized data, thus improving SUID investigation and surveillance.

Eosinophilic Coronary Periarteritis with Arterial Dissection: The Mast Cell Hypothesis.

A subset of coronary arterial dissections is associated with eosinophilic coronary periarteritis (ECPA); however, the pathogenesis of the process remains unclear. Mast cells normally reside in coronary arterial adventitia and are known mediators of eosinophilic inflammatory conditions such as type I hypersensitivity reactions. We report two cases in which coronary arterial dissection with ECPA was detected at autopsy. Tryptase, CD68, CD4, CD8, and CD1a immunohistochemical staining was performed to better characterize inflammation. While eosinophils represented a prominent periadventitial inflammatory cell, there were slightly more lymphocytes: CD4/CD8 ratios were within expected reference ranges. There were moderate numbers of macrophages, and few neutrophils or dendritic cells. Numbers of mast cells in dissected versus nondissected sections were compared: adventitial mast cell densities were threefold higher in dissected portions and showed a trend toward increased degranulation. These findings suggest that mast cells may play a role in orchestrating inflammation in cases of ECPA.

Rat indwelling urinary catheter model of Candida albicans biofilm infection.

Indwelling urinary catheters are commonly used in the management of hospitalized patients. Candida can adhere to the device surface and propagate as a biofilm. These Candida biofilm communities differ from free-floating Candida, exhibiting high tolerance to antifungal therapy. The significance of catheter-associated candiduria is often unclear, and treatment may be problematic considering the biofilm drug-resistant phenotype. Here we describe a rodent model for the study of urinary catheter-associated Candida albicans biofilm infection that mimics this common process in patients. In the setting of a functioning, indwelling urinary catheter in a rat, Candida proliferated as a biofilm on the device surface. Characteristic biofilm architecture was observed, including adherent, filamentous cells embedded in an extracellular matrix. Similar to what occurs in human patients, animals with this infection developed candiduria and pyuria. Infection progressed to cystitis, and a biofilmlike covering was observed over the bladder surface. Furthermore, large numbers of C. albicans cells were dispersed into the urine from either the catheter or bladder wall biofilm over the infection period. We successfully utilized the model to test the efficacy of antifungals, analyze transcriptional patterns, and examine the phenotype of a genetic mutant. The model should be useful for future investigations involving the pathogenesis, diagnosis, therapy, prevention, and drug resistance of Candida biofilms in the urinary tract.

2009 H1N1 fatalities: the New Mexico experience.

Histopathologic features of New Mexico 2009 H1N1 fatalities have not been representative of those reported nationwide. We retrospectively reviewed medical records of all New Mexico 2009 pandemic influenza A (pH1N1) fatalities (n = 50). In cases in which autopsy was performed (n = 12), histologic sections and culture results were examined. In contrast to previously published studies, the majority of our fatalities did not have diffuse alveolar damage (DAD) (2/12; 16.7%). Common findings included pulmonary interstitial inflammation and edema, tracheobronchitis, and pneumonia. Two cases had significant extra-pulmonary manifestations: myocarditis and cerebral edema with herniation. The majority had a rapid disease course: range from 1 to 12 days (median, 2 days), and Native Americans were disproportionately represented among fatalities. These findings suggest that New Mexico H1N1 fatalities generally did not survive long enough to develop the classic picture of DAD. Pathologists should be aware that H1N1 may cause extra-pulmonary pathology and perform postmortem cultures and histologic sampling accordingly.

Valves of the deep venous system: an overlooked risk factor.

Deep venous valves are frequent sites of deep venous thrombosis initiation. However, the possible contribution of the valvular sinus endothelium has received little attention in studies of thrombosis risk. We hypothesized that the endothelium of valve sinus differs from that of vein lumen with up-regulation of anticoagulant and down-regulation of procoagulant activities in response to the local environment. In pursuit of this hypothesis, we quantified endothelial protein C receptor (EPCR), thrombomodulin (TM), and von Willebrand factor (VWF) by immunofluorescence in great saphenous veins harvested at cardiac bypass surgery. We found significantly increased expression of EPCR and TM in the valvular sinus endothelium as opposed to the vein lumenal endothelium, and the opposite pattern with VWF (paired t test for TM and EPCR, each P < .001; for VWF, P = .01). These data support our hypothesis and suggest that variation in valvular sinus thromboresistance may be an important factor in venous thrombogenesis.

Validation of HLAMatchmaker algorithm in identifying acceptable HLA mismatches for thrombocytopenic patients refractory to platelet transfusions.

BACKGROUND: HLAMatchmaker (HLAMM) is an algorithm that determines donor-recipient histocompatibility based on HLA type. This study determines the effectiveness of HLAMM in identifying suitable platelet (PLT) donors for refractory patients. STUDY DESIGN AND METHODS: Data from a previous prospectively randomized multicenter study comparing cross-reactive group (CREG)-matched versus serologic crossmatch-selected PLT transfusions in refractory patients were analyzed. By use of HLAMM, the compatibility of donor-recipient pairings was determined as the number of donor triplet mismatches (TMMs) and eplet mismatches (EMMs) and compared against the posttransfusion PLT corrected count increment (CCI). The data included 73 patients who received up to two CREG-matched and crossmatch-selected PLT transfusions each (214 transfusions analyzed). RESULTS: TMM and EMM values correlated well with CREG match grade. A and BU matches had TMM and EMM values of 0; BX matches had TMMs and EMMs of 4 and 6 respectively; and C and D matches had TMMs of 10 to 21 and EMMs of 13 to 24. Fewer mismatches (TMM or EMM) predicted better transfusion outcomes (p < 0.05). The median 1-hour CCI was 8000 with TMMs of not more than 9 versus 6000 with TMMs of more than 9. The median 1-hour CCI was 7954 with EMMs of not more than 11 versus 6356 with EMMs of more than 11. The positive predictive value of the different methods in producing a 1-hour CCI of more than 7500 were comparable: TMM, 56 percent; EMM, 54 percent; CREG, 50 percent; and crossmatching, 45 percent (p > 0.05). CONCLUSIONS: HLAMM (both TMM and EMM) successfully identified donors associated with good transfusion outcomes in refractory recipients and represents an acceptable method of choosing donors for refractory patients.