Alka Mary Mathai

An Autopsy Case of Sudden Unexplained Death Caused by Malaria

Abstract:  Sudden unexplained deaths, especially those unwitnessed can lead to forensic issues and would necessitate the need for a meticulous and complete postmortem examination including ancillary investigations to discover the cause of death. We herein report a case of sudden unexplained death caused by malaria in an apparently healthy individual. This fatal case is presented to remind the forensic pathologist of the possibility of malaria as a cause of sudden unexplained death in malaria‐endemic regions. In the present case, histopathological examination demonstrated the presence of parasitized red blood cells with malarial pigment in the blood capillaries in the brain, myocardium, pericardium, lungs, kidneys, liver, and the spleen. Cerebral malaria with acute renal insufficiency or pulmonary edema with an acute respiratory distress syndrome might have been the cause of death.

Megakaryocytic alterations in thrombocytopenia: a bone marrow aspiration study.

CONTEXT Dysplastic changes are well documented in myelodysplastic syndromes (MDS). However, they are also observed in non-MDS hematological conditions. AIMS To evaluate the megakaryocytic alterations in the bone marrow aspirations in cases of non-MDS related thrombocytopenia. SETTING AND DESIGN A prospective study of 144 bone marrow aspirates was conducted in the department of pathology, Kasturba Medical College, Mangalore. The aspirates were studied to assess the number and morphology of the megakaryocytes in non-MDS related thrombocytopenia and evaluate their significance when compared to changes in MDS. MATERIALS AND METHODS The bone marrow aspiration smears were stained with Leishman stain and examined under light microscope. STATISTICAL ANALYSIS USED Fishers exact test. A P value less than 0.05 was considered significant. Sensitivity and specificity was calculated for those features which were significant in the relevant hematological disorders. RESULTS The sensitivity of immature megakaryocytes, dysplastic forms and micromegakaryocytes in cases of immune thrombocytopenic purpura was 100%, 89% and 42% respectively. The specificity of emperipolesis was 74%. In cases of infection-associated thrombocytopenia, immature megakaryocytes had a sensitivity of 100% and cytoplasmic vacuolization were 86% specific. The sensitivity of the dysplastic forms in megaloblastic anemia was 75%. However, no platelet budding was observed. The presence of micromegakaryocyte had a specificity of 83% in MDS, and was statistically significant when compared to cases of non-MDS conditions (P 0.05). CONCLUSIONS Careful understanding of the morphological changes of megakaryocytes in bone marrow aspirates can improve the diagnostic accuracy for a wide range of hematological disorders thereby enabling proper therapeutic interventions.

Postmortem diagnosis of acute haemorrhagic pancreatitis

Forensic pathologists can help in the investigation of sudden unexpected deaths in co-operation with the officials responsible for the maintenance of law and order to administer justice. Sudden unexpected deaths form the subject of medicolegal investigation if they occur in apparently healthy individuals, wherein an autopsy would shed light regarding the cause of death. A 4 year retrospective review of autopsy files at the Department of Forensic Medicine, Kasturba Medical College, Mangalore, South India was undertaken for cases of sudden unexpected deaths due to acute haemorrhagic pancreatitis occurring between May 2004 and April 2008. A total of seven cases of acute haemorrhagic pancreatitis diagnosed at autopsy as the cause of sudden unexpected death during the study period are discussed herein.

Microwave histoprocessing versus conventional histoprocessing

The aim of the study is to compare the histologic quality of the microwave histoprocessing with that of conventional method and to determine its positive impact on turnaround times and reduction of costs of tissue processing. One hundred and eighty-five paired tissue sections from different organs were taken. Each tissue sections were of size of 15 mm x 10 mm x 3 mm and divided into two; one set as experimental group and the other as control group. The tissues in the experimental group were further divided into six groups and processed by vacuum-microwave method according to six protocols from I to VI. Other tissues in the control group were processed by the conventional method and compared. Overall, the quality of microscopic tissue from both the methods was identical. Microwave processing shortened the time of processing without compromising the overall quality of the histologic section and was cost-effective.

Bone marrow biopsy in non-Hodgkin lymphoma: A morphological study

CONTEXT Bone marrow (BM) biopsy is an integral part of staging work-up for non-Hodgkin lymphoma (NHL). AIMS To study the characteristics of BM involvement in NHL with respect to incidence, histologic pattern and morphology of infiltration and its discordance with the histology of primary anatomic site. SETTINGS AND DESIGN Forty-nine cases of NHL in which BM biopsy was performed for staging were included in this study, the primary site being classified according to the WHO classification for NHL. MATERIALS AND METHODS A prospective study of 49 cases was conducted. Bilateral BM biopsy was obtained from the posterior superior iliac spine. The biopsies were fixed in 10% buffered formalin solution and decalcified using 10% formal - formic acid for 4 - 6 h followed by routine processing. The serial sections were stained by hematoxylin and eosin and reticulin stains. RESULTS BM biopsy showed involvement by lymphoma in 27 cases (55.10%). Unilateral positivity was found in four cases (14.81% cases). The overall incidence of marrow involvement by NHL was 55.1%. The incidence of involvement was higher in T-cell lymphomas when compared with B-cell lymphomas and predominant pattern of involvement was mixed. Diffuse large B-cell lymphomas had the lowest incidence in all the B-cell lymphomas. A discordant histology between BM and primary anatomic site was found in 29.63% (8/27) of the cases, where it was seen more in follicular lymphomas and diffuse large B-cell lymphomas. CONCLUSIONS Critical examination of BM biopsies can increase the diagnostic accuracy, thereby contributing to the prognosis and appropriate treatment modalities.

Morphometric evaluation of endometrial blood vessels.

Five hundred endometrial specimens were studied to document the changes in blood vessels in various phases of menstrual cycle, menstrual disturbances and in unexplained infertility. Sixty-three cases were taken as control and 437 cases as study group which included cases of dysfunctional uterine bleeding (DUB), endometrial polyps, fibroids, adenomyosis, infertility and atrophic endometrium. Using light microscopy, the vascular morphology was studied. The blood vessels were concentrated more in basal layer in the proliferative phase and in functional layer in the secretory phase. Cases of complex hyperplasia and pill endometrium had significantly higher vessel concentration. Congestion and dilatation of blood vessels were significantly higher in cases of DUB. The present study showed a positive correlation between endometrial angiogenesis and menstrual disorders. The alteration in blood vessel morphology has significant role in prognosis and in various anti-angiogenic therapies.

Coexistent gastric primary choriocarcinoma and adenocarcinoma

Choriocarcinomas are commonly gestational and intrauterine or gonadal in origin. Nongestational and extragonadal disease, especially in the stomach is extremely rare with a poorer prognosis and early metastasis. We herein describe a case of primary gastric choriocarcinoma with liver metastasis in a 69-year-old male. The patient presented with abdominal pain and irregular bowel habits of one month duration. Both endoscopic and radiographic imaging revealed an ulcerated and necrotic circumferential tumor in the pyloric antrum of the stomach. The histopathologic findings of the resected tumor were that of an extensively necrotic and hemorrhagic neoplasm with combined choriocarcinomatous and adenocarcinomatous element. A strongly positive immunohistochemical staining for beta- subunit of human chorionic gonadotropin (beta-HCG) in the choriocarcinomatous component and a proper correlation with elevated serum beta-HCG levels confirmed the diagnosis.

Neuronal hypertrophy and mast cells in histologically negative, clinically diagnosed acute appendicitis: a quantitative immunophenotypical analysis.

Introduction and AimIn about 20–25% of appendicectomies performed for clinically suspected acute appendicitis, definite morphological changes are lacking on histopathological examination. The present study was done to investigate whether any changes in neurons and mast cells could be detected in patients presenting with clinical acute appendicitis but found to have normal appendix at histopathology.MethodsA descriptive study was conducted on 50 appendix specimens which were categorized as histology-positive acute appendicitis (HPAA), clinically acute appendicitis but histologically negative (HNAA), appendices resected for other causes and appendices from forensic autopsy. A morphometric and quantitative evaluation of nerve fibers and ganglion plexus and its relation to mast cell density were studied. All sections were subjected to hematoxylin and eosin stain, toluidine blue stain, S 100 protein and neuron specific enolase (NSE) immunostaining and a quantitative image analysis system.ResultsMucosal and submucosal neuronal components highlighted by NSE and S100 immunostaining observed in cases of HNAA were comparable to cases of HPAA. With S 100 immunostaining in HNAA cases, the increase in number and size of myentric neuronal plexus were mild in 40% (10/25) cases, moderate in 40% (10/25) and marked in 20% (5/25) cases as compared to 66.7% (10/15) cases of HPAA showing moderate and 33.3% (5/15) cases showing marked increase (p = 0.018). The mean mast cell count was highest in the HNAA cases (2.74) in all the four layers as compared to the HPAA (1.85) and control group (2.05). There was no difference in the relationship of the size of ganglion cells and the mast cell concentration.ConclusionsNeuronal hypertrophy and mast cells may play a role in the pathogenesis of appendicitis-like pain in patients with histologically normal appendices.

Congenital cystic adenomatoid malformation of lung type 1.

Congenital cystic adenomatoid malformation, a rare developmental, hamartomatous abnormality of the lung, usually is unilateral, is localized, and presents in early infancy. Delayed occurrence in older children and multilobar involvement are rare. We describe a case of congenital cystic adenomatoid malformation type 1 with multilobar involvement, associated emphysema, and coexistent tracheobronchopathia osteochondroplastica in an adolescent girl for whom the correct diagnosis was achieved only on histologic examination. The importance of an accurate diagnosis of this entity enables proper subtyping, management to minimize the risk of infections and malignancy, and exclusion of associated malformations.

A fetal autopsy case of body stalk anomaly

Body stalk anomaly (BSA) is a sporadic polymalformative syndrome incompatible with extrauterine life. In utero detection of BSA by two-dimensional and three-dimensional ultrasonography and magnetic resonance imaging has been well documented. We herein describe a case of body stalk anomaly diagnosed at autopsy. The fetus had a large anterior midline abdominal wall defect with eventration of the visceral organs into the amnio-peritoneal sac and a completely absent umbilical cord. The associated anomalies included club foot, absent diaphragm, genitourinary, and gastrointestinal defects. The observed congenital anomalies supported the theory of embryonic dysgenesis as the etiologic factor. One of the major objectives in the performance of fetal autopsy is to be able to detect abnormalities that can have implications in future pregnancies. Despite the negligible familial recurrence rate of the broad spectrum of anomalies associated with this abdominal wall defect, the present case of fetal autopsy indeed delights to serve the living.