When Cultures Fail: Postmortem Decoy Receptor 3 (DcR3) as a Marker of Antemortem Sepsis.

INTRODUCTION: Decoy receptor 3 (DcR3) has shown utility as a reliable surrogate marker. Levels of DcR3 in the serum increase and remain elevated in several disease states including cancer and sepsis. In inflammatory conditions, DcR3 is upregulated in inflammatory cells to suppress exponential immune propagation. The use of DcR3 as an indication of sepsis has been documented in the antemortem setting, but its use in the postmortem setting is unknown. The purpose of this study is to evaluate postmortem DcR3 as a marker of antemortem sepsis. METHODS: A retrospective investigation was performed to identify patients whose primary cause of death fell into one of four cohorts (control, cancer, culture-positive sepsis, and suspected culture-negative sepsis). Serum was obtained and tested by a commercially available enzyme-linked immunosorbent assay to quantify DcR3 levels. RESULTS: Twenty-five of 47 samples contained detectable levels of DcR3 (average 0.75 ± 0.3 ng/mL). Comparing culture-positive sepsis to the control cohort at a cutoff value of 0.26 ng/mL, DcR3 positivity showed a sensitivity of 64% and a specificity of 73%. Compared to each other, patients with cancer had similar values to those with culture-positive sepsis (P = .90). Time of specimen collection had a negative role in detection and quantification (P = .038). DISCUSSION: Several studies have shown DcR3 may be a viable antemortem biomarker of sepsis, but its use in postmortem sepsis testing has not been adequately investigated. This study shows that in postmortem testing, DcR3 shows less sensitivity and specificity with a relatively short window for proper testing.

Idiopathic cervical tracheal stenosis in an 11-year-old male.

Idiopathic laryngotracheal stenosis is a fibroinflammatory stenosis in persons without alternative explanation such as trauma, intubation, or autoimmune disease. Patients are usually females of child-bearing age. We report on an 11-year-old male who developed progressive dyspnea and stridor. Bronchoscopy revealed 90% stenosis of the cervical trachea. He underwent serial balloon dilation with steroid injection; stenosis decreased to 20%. He had no history of intubation or trauma. Histologic and laboratory workup for autoimmune disease was negative. This report highlights occurrence of a well-known disease in an uncommon population, and alerts providers to consider this when seeing new pediatric patients with symptoms of progressive airway restriction.

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.

The Shock of Strep: Rapid Deaths Due to Group a Streptococcus.

Streptococcus pyogenes, also known as group A beta-hemolytic strep, is a Gram positive coccus responsible for several million infections every year. The types of infections vary widely from pharyngitis to myositis, but all can advance to severe life threatening invasive disease. Of those infected, approximately 1100 to 1600 people die each year due to invasive disease. Why certain individuals contract severe infections is not known, but many strains of Streptococcus pyogenes are known to produce toxins and superantigens. Invasive Streptococcus pyogenes infections have been shown to cause significant morbidity and rapid mortality. In many cases, patients expire before full antemortem testing can be performed, causing physicians and families to look to forensic pathologists for answers. Understanding the pathogenesis of invasive group A strep infections, relevant gross and microscopic findings, and proper culturing techniques is critical for forensic pathologists to diagnosis this condition and assist in the education and protection of the communities they serve.

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.