Info

Organs and Tissues

Procedures

Possible or Expected Findings

External examination and skin

Lungs

Other organs and tissues

Genital organs

Bones

Prepare sections of skin and of subcutaneous lesions. Submit scrapings of skin lesion for fungal cultures.

Request mucicarmine stain (p. 173).

Prepare chest roentgenogram and roentgeno-graphic survey of bones.

Perfuse one lung with formalin (p. 47). Photograph cut surface. For histologic staining, see above under "External examination and skin.' Prepare cultures of grossly affected organs and tissues. Other procedures depend on expected findings or grossly identified abnormalities as listed in right-hand column.

For dissection techniques, see Part I, Chapter 5.

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

Weeping and crusted elevated skin lesions, predominantly of face and hands. Abscesses, fistulas, and ulcers with central healing and scarring may be present. Organisms should not be stainable with mucicarmine.

Pulmonary infiltrates; osteomyelitis* and periostitis of thoracic, lumbar, and sacral spine, long bones of lower extremities, pelvic bones, and ribs (in this order of frequency). Chronic pneumonia; possibly, suppurative and granulomatous lesions; rarely, cavitation and calcification.

Involvement probably secondary to hematogenous dissemination; cerebral abscess;* meningitis;* adrenalitis; endocarditis;* pericarditis;* thyroiditis.* Other organs, such as eyes and larynx may also be affected.

Inflammatory infiltrates—rarely with fistulas—of prostate, epididymis, and seminal vesicles.

Osteomyelitis* or periostitis (see above under "External examination and skin"). Psoas abscess may be present.

Blastomycosis, South American (See "Paracoccidioidomycosis.")

Block (Heart) (See "Arrhythmia, cardiac.")

Bodies, Foreign

If a foreign body is discovered during a medicolegal autopsy or if the discovery of a foreign body may have medicolegal implications (e.g., presence of a surgical instrument in the abdominal cavity), the rules of the chain of custody apply (p. 17). For the handling of bullets or bullet fragments, see "Injury, firearm." For museum display of foreign bodies, see p. 137. Metallic foreign objects are particularly suitable for embedding in plastic for display (p. 138). If analysis of foreign material is required, commercial laboratories may be helpful.

Bolus (See "Obstruction, acute airway.")

Botulism

Synonym: Clostridium botulinum infection. NOTE: (1) Submit sample of feces (1). Best confirmation of diagnosis is demonstration of toxin in the same food that the victim ingested. (2) Cultures are usually not indicated. (3) Special stains are usually not indicated. (4) No special precautions are indicated. (5) Serologic studies and toxin assays are available from the state health department laboratories (p. 135). (6) This is a reportable disease.

Organs and Tissues

Procedures

Possible or Expected Findings

Blood

Other organs and tissues

Serum, gastric, or intestinal contents; stool return form sterile water enema; exudate from wound

Refrigerate a specimen until toxicologic study of serum can be done.

Submit for toxicologic study.

Toxin lethal to mice. Can be neutralized by specific antitoxin. No diagnostic morphologic findings. Aspiration;* bronchopneumonia; manifestations of hypoxia.* Clostridium botulinum and its toxins may be found in feces.

Reference

1. Dezfulian M, Hatheway CL, Yolken RH, Bartlett JG. Enzyme-linked immunosorbent assay for detection of Clostridium botulinum type A and type B toxins in stool samples of infants with botulism. J Clin Microbiol 1984;20(3):379-383.

Bromide (See "Poisoning, bromide.") Bronchiectasis

Possible Associated Conditions: Abnormalities of airway cartilage (Williams-Campbell syndrome; Mounier-Kahn syndrome); allergic bronchopulmonary fungal disease; alpharantitrypsin deficiency;* amyloidosis;* cystic fibrosis;* IgA deficiency with or without deficiency of IgG subclasses; Kartagener's syndrome (situs inversus, chronic sinusitis, and bronchiectasis) and other primary ciliary dyskinesias; obstructive azoospermia (Young syndrome); panhypogammaglobulinemia; ulcerative colitis; rheumatoid arthritis;* yellow nail syndrome (hypoplastic lymphatics).

Organs and Tissues

Procedures

Possible or Expected Findings

External examination

Chest cavity

Blood Heart

Lungs

Kidneys Other organs

Brain and spinal cord; nasal cavity and sinuses

Prepare chest roentgenogram.

For tests for pneumothorax, see under that heading.

Submit sample for microbiologic study (p. 102). Record weight and thickness of right and left ventricles.

Submit one lobe for bacterial and fungal cultures. If only one lobe contains bronchiectases, aspirate contents for microbiologic study.

For bronchography, see p. 50.

For bronchial arteriography, see p. 50.

Slice perfused lung along probes introduced into bronchiectases for guidance. Request Gram, Grocott's methenamine silver, and —if indicated because of suspected tuberculosis —Kinyoun's stains (p. 172).

Prepare sections of tracheobronchial cartilage.

If amyloidosis is suspected, request Congo red, crystal violet, methyl violet, Sirius red, and thioflavine T stains (p. 172).

If cystic fibrosis is present, follow procedures described under that heading.

For removal and specimen preparation, see pp. 65, 67, and 71, respectively.

Clubbing of fingers and toes. Pneumothorax;* pulmonary infiltrates; pleural effusion or exudate.* Pneumothorax;* pleural empyema.* Situs inversus in Kartagener's syndrome. Septicemia. Cor pulmonale.

Bronchiectasis, usually in lower lobes. In cystic fibrosis,* upper lobes are more severely affected. Purulent bronchitis.* Peribronchiectatic pneumonia or abscess. Allergic bronchopulmonary aspergillosis; tuberculosis.*

Fungus ball in cavity (aspergillosis*). Dilatation of bronchial arteries. Bronchopulmomary anastomoses. Saccular, tubular, or varicose bronchiectases. (See Fig. 4-6, p. 49.) Evidence of bacterial (P. aeruginosa; Staphylococcus aureus; H. influenzae; Escherichia coli), mycobacterial, or fungal (aspergillus sp.) infection. Abnormal cartilage; see above under "Possible Associated Conditions." Amyloidosis;* glomerular enlargement. Amyloidosis.*

Cystic fibrosis.*

Cerebral abscess.* Nasal polyps; sinusitis.

Bronchitis, Acute Chemical

NOTE: This occurs after inhalation of toxic gases, such as sulfurous acid (H2SO3), sulfur dioxide (SO2), chlorine (Cl2), and ammonia (NH3). See also under "Poisoning, gas" and under "Edema, chemical pulmonary."

Organs and Tissues

Procedures

Possible or Expected Findings

Upper airways and lungs

Remove lungs together with pharynx, larynx, and trachea. Open airways in posterior midline. Perfuse one lung with formalin under low pressure (tissue may be viable) (p. 47).

Acute chemical laryngotracheitis.

Necrotizing bronchitis; aspiration of acid vomitus; chemical pulmonary edema.*

Bronchitis, Chronic

Synonyms and Related Terms: Chronic asthmatic bronchitis; chronic bronchitis with obstruction; chronic chemical bronchitis; chronic mucopurulent bronchitis; infectious bronchitis.

Organs and Tissues

Procedures

Possible or Expected Findings

Heart Lungs

Diaphragm

Stomach and duodenum Kidneys

Brain and spinal cord

Record weight and thickness of right and left ventricles.

Submit one lobe for microbiologic study (p. 103). Slice fresh lung in sagittal plane. After submitting samples of cross-sections of bronchi for histologic study, open remainder of bronchi longitudinally. For bronchography, see p. 50. For bronchial arteriography, see p. 50.

Perfuse one lung with formalin (p. 47). For semiquantitative determination of severity of bronchitis, use the Reid index or related morphologic methods (1).

Request Gram and Grocott's methenamine silver stains (p. 172).

Record size and thickness of muscular diaphragm.

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

Cor pulmonale. See also under "Failure, congestive heart."

Bronchopneumonia. Bronchiectasis.* Emphysema.*

Dilatation of bronchial arteries; bronchopulmonary anastomoses. Most methods of wet inflation tend to distend bronchi and to overinflate lungs. Hyperplasia of submucosal bronchial glands and smooth muscle tends to parallel severity of chronic bronchitis.

Bacterial or fungal infection.

Decrease in surface area and thickness in chronic bronchitis. Peptic ulcers.* Glomerular enlargement.

Hypoxic changes.

Reference

1. Thurlbeck WM. Pathology of chronic airflow obstruction. In: Chronic Obstructive Pulmonary Disease, Chernack NS, ed. W.B. Saunders, Philadelphia, PA, 1991.

Bronchopneumonia (See "Pneumonia, all types or type unspecified.") Brucellosis

Synonyms: Brucella spp. infection; undulant fever; Mediterranean fever; Malta fever.

NOTE: (1) Collect all tissues that appear to be infected. (2) Request aerobic cultures for Brucella. (3) Request Gram stains (p. 172). (4) Special precautions are indicated (p. 146). (5) Serologic studies are available from local or state health department laboratories (p. 135). (6) This is a reportable disease.

Organs and Tissues

Procedures

Possible or Expected Findings

External examination

Blood

Lymph nodes Heart

Arteries and veins

For exposure of joints and microbiologic specimen preparation, see p. 96.

Prepare roentgenograms of skeletal system. Submit samples for culture and serum agglutination tests. See also above under "Note."

If endocarditis is suspected, follow procedures described on p. 103.

For angiography, see under specific site or organ. Submit samples for histologic study. Request Verhoeff-van Gieson stain (p. 173).

Subcutaneous abscesses. Purulent arthritis (sacroiliac and hip joints) and periarticular bursitis.

Osteomyelitis* of long bones and of spine.

Generalized lymphadenopathy. Infective endocarditis* (particularly with pre-existing aortic stenosis); myocarditis;* pericardial effusions.

Arterial aneurysms; arteriovenous fistulas. Granulomatous endophlebitis.

Organs and Tissues

Procedures

Possible or Expected Findings

Lungs

Liver

Gallbladder Spleen

Kidneys and ureters

Urinary bladder Ovaries, prostate, epididymides, and testes Bones and joints

Brain

Eyes

Submit sample for culture (see above under "Note" and p. 103).

Record weight. Submit sample for culture (see above under "Note" and p. 102).

Record weight. Submit sample for culture (p. 102). Submit samples of renal tissue for histologic study. Record appearance of renal pelvic and ureteral mucosa.

Photograph ulceration; submit for histologic study. Submit samples for culture (see also above under "Note.")

For removal, prosthetic repair, and specimen preparation, see p. 95. For removal and specimen preparation, see p. 65. Submit for culture (see p. 102). See also above under "Note." For cerebral arteriography, see p. 80.

For removal and specimen preparation, see p. 85.

Pleural effusions;* granulomas that may be associated with abscesses and calcification. Embolism secondary to granulomatous endophlebitis.

Hepatomegaly; granulomatous hepatitis; nonspecific reactive changes. Acute cholecystitis.* Splenomegaly with granulomas. Granulomas; ulceration of mucosa of renal pelvis. See also above under "Lungs."

Ulceration of mucosa. Abscesses.

Osteomyelitis* of long bones and of spine; arthritis (1).

Meningoencephalitis; mycotic intracerebral aneurysm* with rupture and hemorrhage.

Iritis; choroiditis; keratitis.

Reference

1. Colmenero JD, Reguera JM, Martos F, Sanchez-De-Mora D, Delgado M, Causse M, et al. Complications associated with Brucella meliten-sis infection: a study of 530 cases. Medicine 1996;75:195-211.

Burns

NOTE: Fatal burns should be reported to the medical examiner's or coroner's office. The questions to be answered by the pathologist depend on whether the incident was accidental, suicidal, or homicidal, and whether the victim survivied to be treated in the hospital. A pending death certificate should be issued if the fire and police investigators are not sure of the circumstances at the time of the autopsy. For electrical burns, see under "Injury, electrical."

For victims who were treated at the hospital, autopsy procedures should be directed toward the discovery or confirmation of the mechanism of death, such as sepsis or pulmonary embolism.* Death can be caused primarily by heart disease, with otherwise minor burns and smoke inhalation serving as the trigger that leads to lethal ventricular arrhythmia. Because carbon monoxide concentrations are halved approx every 30 min with 100% oxygen therapy, the pathologist must obtain the first clinical laboratory test results for CO-hemoglobin. Soot can be detected with the naked eye 2 or 3 d after inhalation of smoke. Ambulance records should be examined to determine whether a persistent coma might have been caused by hypoxic encephalopathy following resuscitation from cardiac arrest at the scene.

Admission blood samples should be acquired to test for CO-hemoglobin and alcohol. This may not have been done in the emergency room. Persons suffering from chronic alcoholism succumb to fire deaths more often than persons who do not drink. A very high initial serum alcohol concentration suggests a risk factor for the fire and presence of chronic alcoholism. Patients with chronic alcoholism typically are deprived of alcohol when they are in the burn unit and this can cause sudden, presumably cardiac, death,just as it occurs under similar circumstances, not complicated by burns. Under these circumstances, the heart fails to show major abnormalities. This mode of dying seems to have no relationship to the presence or absence of liver disease.

Organs and Tissues

Procedures

Possible or Expected Findings

External examination and skin

If the body is found dead and charred at the scene, prepare whole body roentgenograms, before and after removal of remnants of clothing. See also under "Identification of the body" (p. 11) and under "External examination" (p. 13). One or two fingerpads may yield sufficient ridge detail for identification. If this is not possible, ante- and postmortem somatic and dental radiographs must be compared for identification, or DNA comparison must be used.

Roentgenograms may detect bullets in cases where arson was used to mask murder. Bullets or knife blades must be secured as evidence. Objects such as hairpins, keys, jewelry, dentures, or other evidence, and demonstration of old fractures may help provisionally identify the victim. Fractures of bones and lacerations of soft tissue can all occur as heat artifacts and must be identified as such. See also above under "Note."

Organs and Tissues

Procedures

Possible or Expected Findings

External examination and skin

(continued)

Blood

Vitreous

Serosal surfaces

Neck organs and tracheobronchial tree

Other organs Pelvic organs

Durae and brain

Photograph burnt body and make diagrams of wounds.

Prepare histologic sections of blisters and of surrounding skin.

If victim was found burnt, submit samples for carbon monoxide determination and toxicologic study, primarily for alcohol and illicit drugs.

If victim survived for some time, submit samples for bacterial and fungal culture (p. 102). Submit sample for alcohol and other toxicologic studies (p. 85), particularly if no blood is available, and also for electrolyte determination. Record volume and character of exudate or transudate.

Remove carefully. Inspect hyoid bone; search for hemorrhages in soft tissues of neck. Record appearance and photograph mucosal surfaces of larynx and trachea. If patient had survived for some time and had been intubated, search for intubation trauma.

Inspect supraglottic area.

Submit samples of tracheobronchial mucosa for histologic study.

Follow routine autopsy procedures.

Examination of pelvic organs may permit sex determination in severely burnt bodies. In female victims whose burns are less severe, a search should be made for evidence of rape.

Inflammatory changes in the skin indicate a vital reaction.

Increased carbon monoxide concentration (saturation of >15-20%) is strong evidence that the victim was alive and breathing for some time during burning. CO-concentra-trations may not be elevated in flash-fire victims.

Septicemia and bacteremia.

Water and electrolyte loss in patients who had survived burns for some time.

Exudate indicates vital reaction. Watery transudate may develop with rigorous infusions of crystalloid during fruitless resuscitation efforts.

Strangulation effect (fractured hyoid bone).

Soot particles and other heat injuries indicate that the patient was breathing in fire. Absence of soot particles does not prove that the patient was already dead when fire started unless there is reasonable evidence that the fire was not a flash fire.

Supraglottic edema may cause sudden death in patients who had survived burns— particularly of face—for some time. Herpes virus inclusions in tracheobronchial ulcerations of victims who had survived burns for some time. Bronchopneumonia; pulmonary emboli; heart disease in victims who survive for some time. See also above under "Note." Sex determination.

Evidence of rape.*

Epidural hematomas may occur as heat artifacts.

Bypass, aortocoronary (See "Surgery, aortocoronary bypass.") Byssinosis (See "Pneumoconiosis.")

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