Nicholas I. Batalis

Intravascular large B-cell lymphoma.

A rare type of diffuse large B-cell lymphoma, intravascular large B-cell lymphoma primarily affects the middle-aged to elderly population, with a slight predominance in men. By the time of presentation, most patients have advanced, disseminated disease, and often the diagnosis is made at autopsy. Patients may present with any of a myriad of symptoms, with any tissue potentially being infiltrated. Central nervous system and cutaneous involvement is common, as is the presence of B symptoms including fever, weight loss, and night sweats. Morphologically, growth of neoplastic cells is restricted to the lumen of small vessels. The cells are large, with 1 or more prominent nucleoli, scant cytoplasm, and frequent mitotic figures, and are commonly positive for cluster of differentiation markers 79a, 20, and 19, as well as MUM1/IRF4 and Bcl-2. Intravascular large B-cell lymphoma is aggressive, and without treatment is rapidly fatal.

Imaging Coronary Artery Disease and the Myocardial Ischemic Cascade : Clinical Principles and Scope

On a subcellular level, atherogenesis is characterized by the translocation of proatherogenic lipoproteins into the arterial wall. An inflammatory response involving complex repair mechanisms subsequently causes maladaptive vascular changes resulting in coronary stenosis or occlusion. The chronology of the underlying processes occurring from atherosclerosis to myocardial ischemia affect the selection and interpretation of diagnostic testing. An understanding of the ischemic cascade, atherosclerosis, coronary remodeling, plaque morphology, and their relationship to clinical syndromes is essential in determining which diagnostic modalities are useful in clinical practice.

The Importance of Microscopic Examination of the Lungs in Decedents with Sustained Central Intravascular Catheters: A Nine‐Case Series

Indwelling intravascular catheters provide convenient access to healthcare personnel and also recreational intravenous drug users who inject suspensions of oral medications. A nine‐case series of autopsies of clinically stable decedents with indwelling catheters and sudden death is herein presented. Pulmonary histologic findings were consistent with intravenous administration of oral medications in all cases. In eight, the mechanism of death was directly attributed to occlusive vascular embolization of foreign material, with or without contribution of acute drug toxicity. In one, the mechanism of death was solely attributed to acute drug toxicity. Acute, massive embolization of foreign material may explain sudden death by vascular obstruction, whereas chronic repeated injections lead to obliteration of the pulmonary vasculature, increased pulmonary vascular resistance, and cardiac failure. Therefore, a complete autopsy with histologic examination of the lungs and toxicology testing is recommended in patients with indwelling catheters to determine the cause and mechanism of death.

Five-day Turnaround Time for Hospital Medical Autopsies: A Five-Year Experience

In order to improve the autopsy usefulness for quality assurance, teaching, and enhanced clinical relevance, a five-day turnaround time for medical autopsies within the Department of Pathology and Laboratory Medicine at the Medical University of South Carolina was implemented. Previously, turnaround times averaged approximately 30 days, with almost 20% extending to approximately 60 days. Procedures and processes were reviewed and changes were made in December 2009 in order to achieve an average turnaround time of five days on all medical autopsies, as was previously described in a 1996 article by Adickes and Sims; this is in lieu of the national standard as set by the College of American Pathologists, which recommends final reports be issued in 30 days for the majority of cases and a 60 days for all cases. Subsequently, turnaround times for the 2010–2014 calendar years averaged 4.72 days. Given our existing institutional framework, only minor changes were required to reduce turnaround times. Histology lab support is essential, as is commitment by the resident and attending physicians to review the cases in a timely fashion and order any case-appropriate special stains or immunostains upon review. In the instance where more time-consuming studies are required, the final report may be delayed or the additional studies may be reported in an addendum. The autopsy service has received mostly positive feedback from the clinical faculty, and the accelerated turnaround time improves teaching of residents and medical students on the autopsy rotation. The reduced turnaround time has not affected hospital billing.

Pulmonary Embolic Disorders

Deaths due to pulmonary thromboemboli are frequently encountered by the forensic pathologist and account for a significant percentage of sudden, unexpected deaths. Diagnosing these straightforward cases is often not a challenge, but unfortunately some cases in which a thromboembolism is expected can become complicated. Occasionally, a postmortem clot may mimic a thromboembolism and lead to a mistaken diagnosis, and in other situations it may become paramount to attempt to age a thrombus as part of a medicolegal lawsuit. Additionally, many individuals use the less specific term, “pulmonary emboli”, when referring to these cases in which a portion of a thrombus, usually originating in the deep veins of the lower extremities, breaks off and travels to the pulmonary vasculature bed where it occludes vessels and leads to a rapid demise. One must remember, though, that several other materials and tissues including fat, amniotic fluid, air, tumors, solid organs, synthetic materials, and parasites may be displaced and embolize to the lungs and cause significant disease. In the following pages we will provide a thorough review of pulmonary embolic disorders, focusing on those diseases most likely to be encountered by the forensic pathologist. The aim of this review is to aid the pathologist in using proper terminology, diagnosing various types of embolic disorders, and recognizing potential mimics.

Neurocutaneous Melanosis: A Case Report and Review of the Literature

This report concerns a case in which suicide by self-immolation occurred in an adolescent with neurocutaneous melanosis (NCM). A rare neurocutaneous syndrome, NCM has often been reported to occur concomitantly with psychiatric and neurologic disorders. While symptomatic disease is most often encountered in children, symptomatic disease at any age typically results in rapid morbidity and mortality. The gross and microscopic findings of NCM, the potential relevance of NCM to the case scenario, and a literature review of NCM will be presented. NCM may have a large influence on antemortem behavior and determination of cause of death, and for this reason it is important to be aware of its morphology and potential significance when encountered at autopsy.

Differential Diagnosis of Hepatic Necrosis Encountered at Autopsy

The liver is subject to a variety of extrinsic and intrinsic insults that manifest with both specific and nonspecific patterns of necrosis. In the autopsy setting, these patterns are often encountered as incidental findings or even causes of death. There are several etiologies of hepatic necrosis, including toxins, drug injuries, viral infections, ischemic injuries, and metabolic disease, all of which possess overlapping gross and histologic presentations. Nonetheless, patterned necrosis in the context of clinical and demographic history allows for the forensic pathologist to develop a differential diagnosis, which may then be pruned into a specific or likely cause. The aim of the following review is to elucidate these patterns in the context of the liver diseases from which they arise with the goal developing a differential diagnosis and ultimate determination of etiology. Acad Forensic Pathol. 2018 8(2): 256-295

First Report of Prenatal Ascertainment of a Fetus With Homozygous Loss of the SOX10 Gene and Phenotypic Correlation by Autopsy Examination

The SOX10 gene plays a vital role in neural crest cell development and migration. Abnormalities in SOX10 are associated with Waardenburg syndrome Types II and IV, and these patients have recognizable clinical features. This case report highlights the first ever reported homozygous loss of function of the SOX10 gene in a human. This deletion is correlated using family history, prenatal ultrasound, microarray analysis of amniotic fluid, and ultimately, a medical autopsy examination to further elucidate phenotypic effects of this genetic variation. Incorporating the use of molecular pathology into the autopsy examination of fetuses with suspected congenital anomalies is vital for appropriate family counseling, and with the ability to use formalin-fixed and paraffin-embedded tissues, has become a practical approach in autopsy pathology.

Success in Implementation of a Resident In-Service Examination Review Series

Objectives Primary pathology board certification has been correlated with senior resident in-service examination (RISE) performance. We describe our success with an annual, month-long review series. Methods Aggregate program RISE performance data were gathered for 3 years prior to and 3 years following initiation of the review series. In addition, mean United States Medical Licensing Examination Step 1 and 2 Clinical Knowledge scores for residents participating in each RISE examination were obtained to control for incoming knowledge and test-taking ability. Linear models were used to evaluate differences in average RISE performance prior to and following the initiation of the review series in addition to controlling for relevant covariates. Results Significant improvement was noted in the grand total, anatomic pathology section average, clinical pathology section average, and transfusion medicine section. Although not statistically significant, improvement was noted on the cytopathology and clinical chemistry sections. There was no significant difference in scores in hematopathology, molecular pathology, and the special topics section average. In addition, improvement in primary pathology board certification rates was also noted. Conclusions Institution of a month-long RISE review series demonstrated improved overall performance within our training program. The success could easily be replicated in any training program without significant disruption to an annual didactic series.

Opioid-Associated Deaths in South Carolina, 2013-2016: A Retrospective Review

Introduction Rising rates of opioid abuse in the United States have generated an overdose epidemic. Particularly in the last few years, many offices across the country have seen a shift from prescription opioid toxicity to heroin, illicitly produced fentanyl, and, more recently, various fentanyl analogs. Methods A retrospective review was performed to better characterize the incidence of licit opioid, heroin, fentanyl, and fentanyl analog-associated deaths in South Carolina. Three-thousand three-hundred and fifty autopsy records from the Medical University of South Carolinas forensic pathology division were reviewed to identify cases in which oxycodone, hydrocodone, heroin, fentanyl, and/or fentanyl analogs were detected. Results In 2013, the incidence of both heroin and fentanyl-associated deaths was relatively rare (2.2% and 0.4%, respectively), but increased somewhat steadily throughout the ensuing years. The incidence of fentanyl-associated death increased from 0.4% to 2.4% between 2013 and 2016. A decrease in fentanyl-associated deaths was noted between 2015 and 2016; however, 2016 saw a dramatic increase in fentanyl analogs, likely accounting for this slight dip. Heroin rose from 2.2% to 4.5% between 2013 and 2016. Combined, heroin and fentanyl accounted for 2.6% of autopsy deaths in 2013 and increased to 7.6% in 2016, with more substantial increases in 2014 and 2015. Licit opioid-associated deaths remained relatively stable throughout the study period and, when identified, were almost always polydrug comixtures. Discussion These data illustrate general increases in illicit opioid-related deaths. In contrast to larger jurisdictions, particularly in the Midwest and Northeast, heroin continues to contribute most significantly to intoxication deaths, although synthetic fentanyl and fentanyl analog-associated deaths increased dramatically beginning in 2014.