Post mortem computed tomography is highly sensitive for pyelonephritis. A radiologic-pathologic correlation series.

Pyelonephritis is a potentially lethal disease occasionally encountered in the forensic setting. Post mortem computed tomography (PMCT) is an important investigative tool for the forensic pathologist. In particular, it may be used to document and screen disease prior to traditional autopsy methods. While the sensitivity and specificity of computed tomography for pyelonephritis is well studied in the antemortem clinical setting, the test characteristics of PMCT are not yet described in the forensic pathology literature. A series of all cases of fatal pyelonephritis identified at the Ontario Forensic Pathology Service, over the course of 1 year was studied. Radiologic, clinical and pathologic findings were reviewed. A fulsome autopsy, including histopathologic examination, was considered the gold standard for sensitivity and specificity calculations. A control group consisting of 16 cases without pyelonephritis (ex: opiate toxicity) in which both PMCT and histologic data were available by way of comparison. Sixteen cases of pyelonephritis were identified. Post mortem computed tomographical signs of pyelonephritis included asymmetric renal enlargement, perinephric fat stranding, and ectopic renal air. The most (57%) individually sensitive of these findings was perinephric fat stranding but sensitivity increased to 100% if any of the three signs were present. The control group analysis revealed the specificity of air asymmetry (81%), asymmetric renal enlargement (81%), and fat stranding (69%). PMCT findings may rule in a diagnosis of pyelonephritis, and should prompt the pathologist to grossly and microscopically examine the kidneys.

Valve-in-valve prosthesis-late morphological findings.

Since its implantation in 2002, transcatheter aortic valve implantation (TAVI) has become the preferred intervention for patients with severe aortic stenosis and significant co-morbidities. In 2007, it was adopted as a rescue procedure for failed bioprosthetic valves, now known as the valve-in-valve (VIV) procedure. Unlike other modes of treatment with a multitude of phase 4 post-marketing surveillance (PMS) data, use of these valves have increased rapidly even without long term durability data on this procedure and the near lack of information on the pathology of failed transcatheter aortic valve replacement (TAVR) bioprosthesis and especially after the VIV procedure. We present a case of a late explanted VIV bioprosthesis (ten (10) years post-initial aortic valve replacement and five (5) years post-VIV procedure) in a 65-year-old male with multiple morphologic findings. Further availability of standardized morphologic data from explanted bioprosthetic valves is essential to aid in understanding the pathophysiology of tissue degeneration of the TAVI valve, and ultimately to improve patient outcomes by identifying possible early interventional strategies.

Acute hemorrhagic leukoencephalomyelitis in a man with viral myocarditis.

We report a case of acute hemorrhagic leukoencephalomyelitis in a man with viral myocarditis. A 48-year-old previously healthy male was found dead in his locked apartment. At autopsy he was found to be malnourished, and his lungs showed gross evidence of bilateral pneumonia with abscess formation and bullous emphysema. Multiple petechial hemorrhages were observed in the brain and mainly involved white matter in the cerebral hemispheres including the corpus callosum and internal capsule, as well as the cerebellum, brainstem, and spinal cord. Microscopy of the brain and spinal cord revealed perivenular hemorrhages, central microthrombi in venules with fibrin exudation into the subcortical white matter, and early perivenular demyelination associated with scanty mixed cellular infiltrates. Other microscopic features included widespread diffuse viral myocarditis, extensive suppurative bronchopneumonia, and chronic bronchitis. This case illustrates the death of a man with a rare fatal disease associated with two other potentially lethal diseases. The case also illustrates the importance of a holistic approach when determining the cause of death, especially when there are competing causes of death.

Osmium impregnation detection of pulmonary intravascular fat in sudden death: A study of 65 cases.

Pulmonary fat embolism is widely recognised in forensic pathology. Pulmonary fat embolism requires mobilisation of free fat, entry of free fat into the circulation and lodging of fat globules in fine venous capillaries. This paradigm of fat embolisation has been used to support the evidence of antemortem fat depot disruption when the presence of intravascular fat is confirmed at autopsy. However, sporadic reports of intravascular fat in various medical conditions, which contradict the above mechanism, have opened questions about the alternative pathogenesis. In this study, 65 cases of sudden deaths were examined for the presence of pulmonary intravascular fat (PIF) by osmium impregnation. Cases were selected based on the criteria that were designed to eliminate the possible confounding effect from medical intervention or postmortem changes. Slides were graded based on their ease of search and only the fat droplets confined by the blood vessel or capillary wall were considered as a positive finding. The results show surprisingly high PIF incidences of varying degrees in all the categories of sudden deaths. Further study is needed to devise criteria for diagnosis of fatal fat embolism since the histological appearance of the high-grade PIF in natural sudden death may not be easily distinguishable from the traumatic fat embolism.

Sudden death related myocarditis: a study of 56 cases.

Fifty-six cases of sudden death from myocarditis were reviewed to characterize the range of histologic appearances of myocarditis. All autopsy cases of myocarditis over 13 years (1996-2008) in the Toronto Forensic Pathology Unit, Ontario Forensic Pathology Service, were studied. In each case, historical documentation and histological slides were reviewed. The severity of myocarditis was graded qualitatively and quantitatively (the inflammatory index). We established the inflammatory index in order to classify the severity of myocarditis, by counting the mean number of inflammatory foci per section of myocardium. Based on the inflammatory index, myocardial inflammation was classified into four grades. Based on this classification, 47% of the cases were classified as marked myocarditis having an inflammatory index over 5, with the number of foci per slide varying from 3 to more than 10, while 20% were classified as mild myocarditis with an inflammatory index between 1.1 and 1.9 with the number of foci per slide varying from 0 to 6. The diagnosis of mild myocarditis is dependent on adequate sampling. We believe that the use of this inflammatory index enhances the post-mortem diagnostic sensitivity of myocarditis, especially in its mild form and correlates with qualitative assessment of the histologic severity of myocarditis.