Medicolegal Forms With Legal Analysis P-47

^Within 1 h after consumption of diluted alcohol (approx 15%) on an empty stomach, assuming body weight of 140-180 pounds (63.6-81.7 kg) reproduced from (11) with permission.

ounce (about 30 mL) of whiskey or 12 oz (about 355 mL) of beer.

^Within 1 h after consumption of diluted alcohol (approx 15%) on an empty stomach, assuming body weight of 140-180 pounds (63.6-81.7 kg) reproduced from (11) with permission.

ounce (about 30 mL) of whiskey or 12 oz (about 355 mL) of beer.

What Is the Toxicity of Alcohol Other Than Ethanol?

In general, the toxicity increases as the number of carbon atoms in the alcohol increases. Thus, butyl alcohol is two times as toxic as ethyl alcohol,* but isopropyl alcohol is only two-thirds as toxic as isobutyl alcohol and one-half as toxic as amyl alcohol. Primary alcohols are more toxic than the corresponding secondary isomers (10).

References

1. Hirsch CS, Adelson L. Ethanol in sequestered hematomas. Am J Clin Pathol 1973;59:429-433.

2. Dubowsky KM. Stages of acute alcoholic influence/intoxication. In: Medicolegal Aspects of Alcohol. Garriott JC, ed. Lawyers & Judges Publishing Co., Phoenix AZ, 1997, p. 40.

3. Sturner WQ, Coe JI. Electrolyte imbalance in alcoholic liver disease. J Forensic Sci 1973;18:344-350.

4. Harper DR, Corry JEL. Collection and storage of specimens for alcohol analysis. In: Medicolegal Aspects of Alcohol. Garriott JC, ed. Lawyers & Judges Publishing Co., Phoenix, AZ, 1997, pp. 145169.

5. Garriott JC. Analysis for alcohol in postmortem specimens. In: Medicolegal Aspects of Alcohol. Garriott JC, ed. Lawyers & Judges Publishing Co., Phoenix, AZ, 1997, pp. 87-100.

6. Baselt RC, Danhof IE. Disposition of alcohol in man. In: Medicolegal Aspects of Alcohol. Garriott JC, ed. Lawyers & Judges Publishing Co., Tuscon, AZ, 1993, pp. 55-74.

7. Garriott JC. Pharmacology of ethyl alcohol. In: Medicolegal Aspects of Alcohol. Garriott JC, ed. Lawyers & Judges Publishing Co., Phoenix, AZ, 1997, pp. 36-54.

8. Caplan YH. Blood, urine and other tissue specimens for alcohol analysis. In: Medicolegal Aspects of Alcohol. Garriott JC, ed. Lawyers & Judges Publishing Co., Phoenix, AZ, 1997, pp. 74-86.

9. Chao TC, Lo DS. Relationship between postmortem blood and vitreous humor ethanol levels. Am J Forens Med Pathol 1993;14:303-308.

10. Larson CP. Alcohol: fact and fallacy. In: Legal Medicine Annual 1969. Wecht CH, ed. Appleton-Century-Crofts, New York, 1969, pp. 241-268.

11. Camps FE. Gradwohl's Legal Medicine, 2nd ed. Williams & Wilkins Company, Baltimore, MD, 1968, p. 554.

Aldosteronism

Synonyms and Related Terms: Bartter's syndrome; Conn's syndrome; hyperaldosteronism; idiopathic aldosteronism; primary aldosteronism; secondary aldosteronism.

Organs and Tissues

Procedures

Possible or Expected Findings

External examination

Vitreous

Heart Adrenals

Record presence or absence of edema.

Submit for sodium and potassium determination (pp. 16 and 33).

Weigh heart and measure thickness of ventricles. Dissect, weigh, and photograph both adrenal glands.

Place portion (including tumor, if present) of gland in deep freeze for hormone assay.

Submit samples for light and electron microscopic (p. 132) study.

Edema of lower extremities (absent in most uncomplicated cases). Changes reflecting high sodium and low potassium concentrations in the blood. Prominent left ventricular hypertrophy (1). Aldosterone-secreting adrenal cortical adenoma (Conn's syndrome), adrenal cortical nodular hyperplasia, or, rarely, adrenal carcinoma. Primary aldosteronism may be present in all these instances. Idiopathic aldosteronism is characterized by normal adrenal glands.

Organs and Tissues

Procedures

Possible or Expected Findings

Kidneys

Other organs

Brain

Weigh, measure, photograph. Submit samples for histologic and electron microscopic (p. 132) study. If there is a renal tumor, place portion in a deep freeze for hormone assay.

Procedures in secondary aldosteronism depend on expected cause.

For removal and specimen preparation, see p. 65. For cerebral angiography, see p. 80.

Vacuolar (osmotic) nephropathy due to hypokalemia. Various renal diseases may be associated with secondary hyperaldosteronism; features of juxtaglomerular cell hyperplasia may be present.

Manifestations of hypertension.* Cirrhosis,* nephrotic syndrome,* toxemia of pregnancy,* and many other conditions that may be associated with secondary aldosteronism.

Ruptured intracranial aneurysm* and hemorrhagic stroke (2).

References

1. Tanabe A, Naruse M, Naruse K, Hase M, Yoshimoto T, Tanaka M, et al. Left ventricular hypertrophy is more prominent in patients with primary aldosteronism than in patients with other types of secondary hypertension. Hypertension Res 1997;20:85-90.

2. Litchfield WR, Anderson BF, Weiss RJ, Lifton RP, Dluhy RG. Intracranial aneurysm and hemorrhagic stroke in glucocorticoid-remedi-able aldosteronism. Hypertension 1998;31:445-450.

Alkalosis

NOTE: There are no diagnostic findings. Postmortem chemical analysis is of limited value in these instances. See also under "Disorder, electrolyte(s)" and p. 115.

Alkaptonuria

Synonyms and Related Terms: Alkaptonuric ochronosis (1); familial (hereditary) ochronosis (2).

Organs and Tissues

Procedures

Possible or Expected Findings

External examination and skin

Urine

Heart and large arteries

Larynx and trachea Kidneys and prostate Other organs and tissues

Middle ears Eyes

Bones and joints

Record extent of discoloration of skin and eyes. Photograph these features. Prepare histologic sections of pigmented areas. Record appearance of joint deformities. Prepare skeletal roentgenograms.

Submit sample for biochemical study. Prepare histologic sections of pigmented areas. If electron microscopic study is intended, see p. 132.

Prepare histologic sections of pigmented cartilage.

Submit samples for histologic study. Submit samples for histologic study.

For removal and specimen preparation, see p. 72.

For removal and specimen preparation, see p. 85.

For removal, prosthetic repair, and specimen preparation, see p. 95. Submit samples of cartilage of diarthrodial joints and from adjacent tendons for histologic study. Prepare frontal section through spine.

Brown-black pigment in skin, eyes (conjunctivas, corneas, scleras), and external ears. Pigment in dermal sweat glands. Deformities of knees and other joints. Ochronotic arthropathy, particularly of knee joints; spondylosis and disk calcification with fusion of vertebrae. Hemogentisic aciduria. Pigmentation of heart valves (e.g., with stenosis [2]), endocardium, and intima of large arteries.

Pigmentation of laryngotracheal cartilage.

Nephrolithiasis;* prostatitis; ochronotic pigmentation.

Pigmentation in islets of Langerhans, pituitary gland, and other endocrine organs; pigment in reticuloendothelial system. Pigmentation of tympanic membranes and ossicles of middle ears. See under "External examination and skin."

Ochronotic arthropathy (see above under "External examination and skin"). Fragments of pigmented cartilage may be found in the synovia.

References

Aluminosis (See "Pneumoconiosis.")

1. Gaines JJ Jr. The pathology of alkaptonuric ochronosis. Hum Pathol 1989;20:40-46.

2. Cortina R, Moris C, Astudillo A, Gosalbez F, Cortina A. Familial ochronosis. Eur Heart J 1995;16:285-286.

Alveolitis, Extrinsic Allergic (See "Pneumoconiosis" and "Pneumonia, interstitial.") Amaurosis Fugax

Organs and Tissues

Procedures

Possible or Expected Findings

Eyes Brain

For removal and specimen preparation, see p. 85. For removal and specimen preparation, see p. 65. Other procedures depend on expected findings or grossly identified abnormalities as listed in right-hand column.

Papilledema.

Tumor of the brain or other cause of intracranial hypertension, including benign intracranial hypertension (pseudotumor cerebri*).

Amblyopia, Nutritional

Related Terms: Alcohol amblyopia; retrobulbar neuropathy; tobacco amblyopia.

NOTE: If chronic malnutrition is associated with corneal degeneration, glossitis, stomatitis, and genital dermatitis, the condition is referred to as Strachan's syndrome.

Organs and Tissues

Procedures

Possible or Expected Findings

Brain

Eyes with optic nerves

Other organs

For removal and specimen preparation, see p. 65. Leave optic nerve attached (see below).

For removal and specimen preparation, see p. 85. Request Luxol fast blue stain of optic nerves (p. 172).

Procedures depend on expected findings or grossly identified abnormalities as listed in right-hand column.

See below under "Eyes with optic nerves."

Bilateral symmetric loss of myelinated fibers in central parts of optic nerves. Ganglion cells in macula may be lost. Manifestations of alcoholism,* diabetes mellitus,* malnutrition,* megaloblastic anemia,* tobacco dependence, and tuberculosis* (isoniazid treatment may cause the optic nerve damage).

Amebiasis

Synonym: Entamoeba histolytica infection.

NOTE: (1) Collect all tissues that appear to be infected. (2) Request parasitologic examination as well as aerobic and anaerobic cultures. Bacterial infections may be associated with amebiasis. (3) Request Gram and Giemsa stains (p. 172). (4) No special precautions are indicated. (5) Serologic studies are available in many local and state health department laboratories (p. 135). (6) This is a reportable disease.

Possible Associated Conditions: Acquired immunodeficiency syndrome (AIDS)* (1).

Organs and Tissues

Procedures

Possible or Expected Findings

External examination and skin

Chest organs, abdominal cavity, retroperitoneal space, and pelvic organs

Photograph and prepare sections of cutaneous or mucosal lesions.

Record presence and course of fistulas before removal of organs. Material for parasitologic study and bacterial cultures is best removed at this time.

Perianal and perineal ulcers after extension of amebic colitis; rarely, destruction of external genitalia. Cutaneous amebiasis from fistulas after hepatic abscess, laparotomy, or, rarely, distant spread. Amebic pneumonia, often associated with hepatic abscess (see below). Pleuropulmonary amebiasis, with or without empyema. Amebic pericarditis or amebic peritonitis is rare. Intestinal perforation into peritoneal cavity, retroperitoneal space, or other hollow viscera.

Organs and Tissues

Procedures

Possible or Expected Findings

Intestine

Liver

Urinary tract

Other organs

Brain

Examine as soon as possible so as to reduce the effects of autolysis.

Photograph ulcers and collect samples for smears and histologic study. Specimens should include cecum; ascending, sigmoid, transverse, and descending colon; appendix; and ileum. If there is a hepatic abscess with fistulas, record their course before removal of liver. Use Letulle technique (p. 3) for organ removal, and open inferior vena cava along posterior midline.

Aspirate abscess contents and submit for micro-biologic study. Prepare smears and sections from periphery of abscess. If urinary tract system appears involved, incise kidneys in situ, in frontal plane from periphery toward pelvis (leave vessels attached); open renal pelves, ureters, and urinary bladder in situ. Procedures depend on expected findings or grossly identified abnormalities as listed in right-hand column.

For removal and specimen preparation, see p. 65.

Buttonhole or flask-shaped mucosal ulcers are always present, in an order of involvement as listed in the middle column.

Hepatic abscess(es) with or without perforation and fistula(s). Hepatic fibrosis and necroses. Portal vein thrombosis can occur. Abscess may communicate with inferior vena cava, gallbladder, bile ducts, and other structures. Amebae are difficult to demonstrate in amebic hepatic abscesses.

Rarely, ascending amebic infection associated with amebic colitis and perianal spread.

Rarely, spread to spleen, aorta, or larynx. Other sites may be affected by systemic hematogenous dissemination. Cerebral abscess* almost always associated with hepatic abscess and pulmonary amebiasis.

Reference

1. Fatkenheuer G, Arnold G, Steffen HM, Franzen C, Schrappe M, Diehl V, Salzberger B. Invasive amebiasis in two patients with AIDS and cytomegalovirus colitis. J Clin Microbiol 1997;35:2168-2169.

Aminoaciduria

Related Terms: Proprionic acidemia; methyl malonic acidemia; isovaleric acidemia; cystinuria; homocystinuria;* maple syrup urine disease;* urea cycle disorders; tyrosinemia; phenylketonuria.*

NOTE: Aminoaciduria is a collective name for all the conditions mentioned under "Related Terms." Because few autopsy studies of aminoaciduria have been done, each case should be considered a potential source of new, unpublished information. Multiple abnormalities of virtually all organ systems are possible.

Organs and Tissues

Procedures

Possible or Expected Findings

Blood, cerebrospinal fluid, and urine Fascia lata, liver, spleen, or blood

Other organs

For removal of cerebrospinal fluid, see p. 104. Freeze samples for biochemical study. These specimens should be collected using aseptic technique for tissue culture for chromosome analysis and biochemical studies (see Chapter 10). See above under "Note."

Many abnormalities may be present. For specific enzyme defects, see ref. (1). Rare translocations are described (2).

Multiple organs and tissues may be involved. Frequently affected is the central nervous system, eyes, liver, kidneys, and skeletal system (rickets).

References

1. Chalmers RA, Lawson AM. Organic Acids in Man: The Analytical 2. Hodgson SV, Heckmatt JZ, Hughes E, Crolla JA, Dubowitz V, Bobrow Chemistry, Biochemistry and Diagnosis of the Organic Acidurias. Chap- M. A balanced de novo X/autosome translocation in a girl with mani-

man and Hall, London, 1982. festations of Lowe syndrome. Am J Med Gen 1986;23:837-847.

Ammonia (See "Poisoning, gas" and "Bronchitis, acute chemical.")

Amphetamine(s) (See "Dependence, amphetamine(s).") Amyloidosis

Related Terms: Familial amyloidosis (multiple forms, including familial Mediterranean fever and familial amyloid nephropathy with urticaria and deafness; hereditary cerebral angiopathies); idiopathic or primary amyloidosis (AL protein) (1); localized or isolated amyloidosis (amyloid in islets of Langerhans and insulinoma; congophil cerebral angiopathy;* isolated atrial amyloid; medullary carcinoma of thyroid); reactive or secondary amyloidosis (AA protein); systemic senile amyloidosis.

Possible Associated Conditions: Alzheimer's disease;* Behçet's disease;* bronchiectasis;* chronic dialysis;* Creutz-

feldt-Jakob disease;* Crohn's disease;* diabetes mellitus type II; Down's syndrome;* leprosy;* malignant lymphoma, Hodg-kin's type; macroglobulinemia; multiple myeloma;* osteomyelitis;* paraplegia; Reiter's syndrome;* rheumatoid arthritis* and other immune connective tissue diseases (all types); syphilis;* tuberculosis;* Whipple's disease.*

NOTE: Stain 15-micron tissue sections with Congo red and examine under polarized light for green birefringence. In AA-type amyloid but not in AL amyloid, pretreatment of tissue with permanganate, followed by routine staining with Congo red, will abolish the green birefringence. An immunohisto-chemistry panel is available to differentiate the subtypes of amyloidosis. Crystal violet, methyl violet, Sirius red, sodium sulfate alcian blue, and thioflavin T also stain amyloid in many instances. Electron microscopic studies (2) are particularly useful if routine stains are negative or controversial. For macroscopic staining of amyloid, e.g., in the heart, see p. 133.

Organs and Tissues

Procedures

Possible or Expected Findings

External examination and skin

Mouth

Blood and urine Heart

Liver

Gastrointestinal tract Other organs

Eyes

Brain, spinal cord, and peripheral nerves

Bones and bone marrow, joints, tendons

Submit grossly involved and uninvolved skin for histologic study (look for amyloid in subcutaneous fat). For special stains, see above under "Note."

Submit gingiva, palate, and tongue for histologic study.

In unsuspected cases, submit samples for immunoelectrophoresis and immunofixation. Submit tissue from atria and myocardium of ventricles. Photograph endocardial lesions. For gross and microscopic staining, see above under "Note."

Record size and weight. For gross and microscopic staining, see above under "Note." Take sections of all segments of the gastrointestinal tract.

Microscopic samples should include respiratory system with larynx, gallbladder, pancreas, spleen, all portions of urogenital system, including prostate, seminal vesicles, and vasa deferentia, and all endrocrine glands, blood vessels, lymph nodes, and other tissues, such as omentum. For gross and microscopic staining methods, see above under "Note."

For removal and specimen preparation, see p. 85.

For removal and specimen preparation, see pp. 65, 67, and 79, respectively.

For removal, prosthetic repair of bones and joints, and specimen preparation, see p. 95.

Papules or plaques, particularly around eyes, ears, axillae, inguinal regions, and anus. Papules may be tumorous or pigmented. Periorbital ecchymoses may be present. Amyloid infiltrates; macroglossia.

Presence of monoclonal light chain.

Amyloid deposits may be identifiable under endocardium of left atrium. Nonischemic congestive heart failure (1).

Hepatomegaly with amyloid infiltrates.

Amyloid infiltrates with ulcerations and hemorrhages.

Almost all organs and tissues may be involved. Diffuse, nodular, or primary vascular deposits may predominate. Evidence of portal hypertension* may be found but splenomegaly also may be caused by amyloid infiltrates. Nephrotic syndrome;* renal involvement also may be associated with renal vein thrombosis.* See also above under "Possible Associated Conditions." Ocular amyloidosis (3).

Amyloid associated with senile plaques or neurofibrillary tangles; congophilic angiopathy (4). Spinal cord compression (5). Peripheral amyloid neuropathy. Amyloid in bone marrow, synovium, and carpal tunnel. Bone may contain osteolytic tumor (multiple myeloma*).

References

Gertz MA, Lacy MQ, Dispenzieri A. Amyloidosis: recognition, confirmation, prognosis, and therapy. Mayo Clin Proc 1999;74:490-494.

Lin CS, Wong CK. Electron microscopy of primary and secondary cutaneous amyloidosis and systemic amyloidosis. Clin Dermatol 1990; 8:36-45.

Gorevic PD, Rodrigues NM. Ocular amyloidosis. Am J Ophthalmol 1994;117:529-532.

Duchen LW. Current status review: cerebral amyloid. Intern J Exp Pathol 1992;73:535-550.

Villarejo F, Perez Diaz C, Perla C, Sanz J, Escalona J, Goyenechea F. Spinal cord compression by amyloid deposits. Spine 1994;19:1178-1181.

Amyotonia Congenita

NOTE: Amyotonia congenita encompasses several different neuromuscular disorders. See under "Disease, motor neuron." Anaphylaxis (See "Death, anaphylactic.")

Ancylostomiasis

Synonyms: Hookworm disease; miners' anemia; uncinariasis. NOTE: (1) Collect all tissues that appear to be infected. (2) Cultures are usually not necessary, only parasitologic examination. (3) Request azure-eosin stains (p. 172). (4) No special precautions are indicated. (5) Serologic studies are available at the state health department laboratories (p. 135). (6) This is not a reportable disease.

Organs and Tissues

Procedures

Possible or Expected Findings

Small intestine

Mesentery Liver and spleen Other organs

For in situ fixation and preparation for study by dissecting microscopy, see p. 54. Request PAS with diastase treatment, azure-eosin, Perl's (or Gomori's) stain for iron, and Verhoeff-van Gieson stains (p. 172).

Submit lymph nodes for histologic study. Submit tissue samples for histologic study. Procedures depend on expected findings or grossly identified abnormalities as listed in right-hand column.

Erosions; hemorrhages (1); mucus in lumen; thickening of wall. Sprue-like mucosal changes (atrophy of villi) with deposition of hemosiderin, necrosis of mucosa, eosinophils in wall, and fibrosis of submucosa. Worms in second and third portions of jejunum. Mesenteric lymphadenitis. Myeloid metaplasia.

Manifestations of iron deficiency anemia,* hypoproteinemia, and congestive heart failure.*

Reference

1. Kuo YC, Chen PC, Wu CS. Massive intestinal bleeding in an adult with hookworm infection. J Clin Gastroenterol 1995;20:348-350.

Anemia (See under specific designations.)

Anemia, Aplastic (See "Anemia, Fanconi's" or "pancytopenia.")

Anemia Associated With Chronic Systemic Diseases

Related Term: Normochromic normocytic anemia.

NOTE: This type of anemia occurs with chronic inflammatory conditions such as endocarditis,* osteomyelitis,* or tuberculosis* but may also be associated with connective tissue disorders such as lupus erythematosus* or rheumatoid arthritis.* Malignancies, uremia, chronic liver disease, endocrine disorders (e.g., Adrenal insufficiency,* hypothyroidism,* or pituitary insufficiency*), or poisoning with chemicals or drugs and radiation injury may also be involved.* The anemia in some of these conditions may be slightly microcytic or macrocytic.

Organs and Tissues

Procedures

Possible or Expected Findings

All organs

Bone marrow

Request iron stain.

For preparation of sections and smears, see p. 96.

See above under "Note." Extramedullary hematopoiesis and hemosiderosis, particularly of liver and spleen. Frequently hyperplastic. Hypoplastic in bone marrow failure (pancytopenia*).

Anemia, Fanconi's

Synonyms: Congenital aplastic anemia; congenital pancytopenia; constitutional infantile panmyelopathy; familial panmyelophthisis; Fanconi's pancytopenia; Fanconi's syndrome (see also under "NOTE"); pancytopenia-dysmelia syndrome.

NOTE: Another disease group, also named "Fanconi's syndrome," is marked by proximal renal tubular transport defect; this latter syndrome is unrelated to Fanconi's anemia.

Organs and Tissues

Procedures

Possible or Expected Findings

External examination

Blood, fascia lata, or liver (liver obtained by percutaneous biopsy) Other organs

Bone marrow

Eyes

Record and photograph abnormalities. Request radiographs of skeleton.

These specimens should be collected using aseptic technique for tissue culture for chromosome analysis (see Chapter 10). Culture any sites suggestive of infection. Record and photograph sites of bleeding. Record weight of spleen. Request iron stains.

For preparations of sections and smears, see p. 96. If the patient underwent bone marrow transplantation, follow procedures under that heading also.

For removal and specimen preparation, see p. 85.

Short stature; microcephaly; café au lait spots; dyskeratosis congenita; absent/ hypoplastic thumbs; hyperpigmentation; nail dystrophy; hypogonadism; microphthalmia. Chromosomal breaks.

Hemosiderosis. Small spleen. Small pituitary gland. Evidence of infection or hemorrhage at various sites. Solid tumors (1) (liver and other organs or tissues, including eyes and bones).

Pancytopenia;* myelodysplastic syndromes and leukemia* (1).

Epiphoria, blepharitis, cataracts.

Reference

1. Alter BP. Fanconi's anemia and malignancies. Am J Hematol 1996; 53:99-110.

Anemia, Hemolytic

Synonyms and Related Terms: Acquired hemolytic anemia; extracorpuscular hemolytic anemia; hereditary hemolytic anemia (hereditary elliptocytosis, pyropoikilocytosis, stoma-tocytosis. spherocytosis); immunohemolytic anemia; intracor-puscular hemolytic anemia; microangiopathic hemolytic anemia; spur cell anemia.

Possible Associated Conditions: Disseminated intravascular coagulation;* eclampsia;* glucose-6-phosphatase deficiency (G6PD); hemolytic uremic syndrome;* malignant hypertension; lymphoma* and other malignancies; paroxysmal nocturnal hemoglobinuria; sickle cell disease;* thalassemia;* thrombotic thrombocytopenic purpura.* (See also below under "NOTE.")

NOTE: Hemolysis also may be caused by conditions such as poisoning with chemicals or drugs, heat injury, snake bite,* or infections or may develop as a transfusion reaction* or be secondary to adenocarcinoma, heart valve prostheses (see below), liver disease (see below), renal disease, or congenital erythropoietic porphyria.*

Organs and Tissues

Procedures

Possible or Expected Findings

External examination

Prepare skeletal roentgenograms.

Blood

In the absence of in vivo studies, submit samples for bacterial and viral cultures, or toxicologic, immunologic, or other laboratory studies, depending on the expected cause.

For hemoglobin electrophoresis, autolyzed blood can be used; one can also use blood that was drained from tissues.

Jaundice; skin ulcers over malleoli. In young patients: thickening of frontal and parietal bones with loss of outer table ("hairon-end" appearance); paravertebral masses caused by extramedullary hematopoiesis; deformities of metacarpals, metatarsals, and phalanges. Osteonecrosis* of femoral heads. Osteoporosis.*

Bacteremia or septicemia. Viremia (e.g., parvovirus infection in hereditary spherocytosis). Chemical poisons or drugs. Beta-lipoprotein deficiency (abetalipo-proteinemia*). Abnormal antibodies. Hyperbilirubinemia. Abnormal hemoglobins.

Organs and Tissues

Procedures

Possible or Expected Findings

Urine Heart

Lungs Liver

Gallbladder and common bile duct

Spleen Kidneys

Other organs and tissues Bones and bone marrow

See above under "Blood."

Record weight. Request iron stain (p. 172).

Perfuse one lung with formalin (p. 47). Record weight. Request iron stain (p. 172).

Describe appearance of stones or request chemical analysis.

See above under "Liver" and below under "Kidneys." Request iron stain.

If abnormalities are present, photograph cut sections.

Extensive histologic sampling is indicated, particularly if the cause of the hemolysis is not known.

For preparation of sections and smears, see p. 96. Request Giemsa stains and Gomori's or Perl's iron stains (p. 172). Consult roentgenograms for proper sampling.

Hemoglobinuria.

Hemosiderosis and cardiomegaly. Valvular heart disease with or without inserted prosthesis may be cause of hemolytic anemia. Infarcts in sickle cell disease.* Hemosiderosis and hepatomegaly. Extramedullary hematopoiesis. Liver diseases such as viral hepatitis* and acute fatty change may cause hemolytic anemia. Cholelithiasis,* cholecystitis,* or choledocholithiasis associated with pigment stones (particularly in hereditary hemolytic anemia such as spherocytosis). Hemosiderosis and splenomegaly. Extramedullary hematopoiesis. Infarctions in sickle cell disease.*

Infarcts and papillary necrosis in sickle cell disease.* Renal diseases may also be cause of hemolytic anemia.

See above under "Possible Associated Conditions" and under "Note." Search for fibrin deposits in microvasculature as seen in thrombotic thrombocytopenic purpura.* Erythroid hyperplasia or, rarely, hypoplasia or normal marrow; hemosiderosis of bone marrow. Osteonecrosis* in sickle cell disease.*

Anemia, Hypochromic (See "Anemia, iron deficiency.")

Anemia, Iron Deficiency

Possible Associated Conditions: Conditions associated with blood loss (e.g., Crohn's disease;* diaphragmatic hernia,* diverticula,* malabsorption syndrome,* tumor,* ulcer of stomach or duodenum,* or ulcerative colitis); lead poisoning* in children.

Organs and Tissues

Procedures

Possible or Expected Findings

External examination

Record body weight and height.

Manifestations of malnutrition.* Angular

Your Heart and Nutrition

Your Heart and Nutrition

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