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Histopathology Current Cases

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Many cases that come to the forensic pathologist display straightforward causes of death. It may be argued that in such cases, ancillary studies are unnecessary. However, like toxicological analysis, vitreous chemistry analysis, metabolic studies, and other ancillary studies, there are many occasions when histopathological studies are vital in the determination of the cause of death and even the manner of death.

For example, in cases of sudden, unexpected death the gross findings at autopsy may be completely negative. Common sense would then dictate that microscopic findings may be fruitful. In the Western world, the most common causes of sudden unexpected death are cardiac. Early myocardial infarction, for example, may be invisible grossly but evident histologically as cardiomyocyte contraction band necrosis. In light of all available information on may determine whether the chain of events by history is consistent with the gross and histological findings.

Herein, a description and illustration of several such diagnoses and findings in which histologic examination will aid the pathologist in the determination of cause and/or manner of death will be presented. Although not comprehensive, perhaps such illustration will encourage the pathologist to perform histopathological studies in the pursuit of answers to perplexing case questions.

There are different approaches to the taking of tissue for histopathological examination. In some institutions, histopathology may be performed on each case in a deliberate and routine way. In other situations, histopathology may be only rarely utilized. Of note, certain causes of death cannot be made with such an examination, such as the controversial “Sudden Infant Death Syndrome”. In some current legal environments, only tissue expected to contribute to a determination of the cause and/or manner of death may be procured. It is generally accepted, though, that histopathological studies are of diagnostic value whether the finding be positive OR negative and thus, may be performed in most instances.

On the other hand, when diagnostic material will not be compromised, the pathologist should exhibit due concern when procuring tissue for histologic examination. Specifically, when taking sections of skin, the pathologist may try to follow the skin tension or Langer’s lines so any defect will be more easily corrected prior to viewing. Such issues clearly do not arise when sections are required from internal organs or viscera.

Special techniques should be entertained when forensic histopathologic specimens are reviewed. Special stains (Table 1), immunohistochemistry, and electron microscopy may be invaluable tools in specific cases. In addition, some diagnoses are greatly aided by polarization of histologic tissue such as the crystals that form in the kidney in ethylene glycol exposure. The forensic pathologist cannot miss such a diagnosis simply because s/he did not polarize the material (Table 2).

Herein, we will periodically present histologic case findings in several areas including cardiovascular, pulmonary, maternal-fetal, trauma and toxins and central nervous system.

Table 1: Special stains of utility in forensic histopathology

Stain Common Useage Positive Findings
Acid Fast Bacillus (AFB) Granulomatous inflammation M. Tuberculosis, atypical mycobacteria
Bielschowsky Silver Stain Alzheimer Disease Neuronal tangles, neuritic plaques
Brown and Brenn (tissue gram stain) Acute inflammation Bacterial infection
Colloidal iron Inborn errors Mucopolysaccharides
Giemsa Anaphylaxis Mast cells, eosinophils
Gomori Methanamine Silver Granulomatous inflammation Fungus
Masson Trichrome Stain Collagen Cirrhosis, chronic pancreatitis,
glial reaction (consider in
decomposing specimens)
Movat Amniotic fluid embolism Positive within pulmonary vasculature:
Black = nuclei and elastic fibers,
Yellow = collagen, Red = fibrin and
muscle, Blue-green = ground substance
Oil-Red-O Neutral lipid, fatty acid Pulmonary fat embolism,
hepatic steatosis
Periodic-Acid Schiff (PAS) Multiple: fat vs. glycogen,
granulomatous inflammation,
Glycogen, candidiasis, fungus, nodular
glomerulosclerosis, mucopolysaccharides
Prussian blue Hemosiderin/Iron Hemosiderin macrophages, ferruginous
bodies, hemachromatosis

Table 2: Commonly seen polarizable foreign material

Stain Common Useage
Calcium oxalate Look in renal glomeruli; suggestive of
chronic renal failure
Cotton Fiber Round to oval polarizable structures;
frequent in intravenous drug use if
drug drawn through cotton, may be
artifact of resuscitation – look in
lung parenchyma and vasculature
Ethylene glycol Look in renal glomeruli, often associated
with tubular vacuolization and acute
tubular necrosis
Silica double sharp sided rods in association with
granulomatous inflammation – look in lung
Starch Maltese cross appearance (similar to oval
fat bodies in urinalysis) – look in lung
and spleen, often in association with talc
Talc/Talcum powder Irregular crystalline structures, variously
sized; frequent in intravenous drug use often in
association with granulomatous inflammation –
look in lung, spleen, injection site (skin)
Miscellaneous foreign bodies Look in lungs; may provide support for water
inhalation in drowning death or other
aspiration etiologies
Table 2: An invaluable technique in forensic histopathology is polarization. Highest yields will be in lung and spleen, although polarizable material may also be concentrated in the skin (as in intravenous drug abuse), liver or kidney. Often inflammation, usually granulomatous, will accompany the finding. However, it is good practice to polarize all lung, spleen, and renal tissue in cases without known causes of death.

Carroll A. Campbell, Jr. Neuropathology Laboratory (Brain Bank)

Department of Pathology and Laboratory Medicine Chairman Dr. Steven L. Carroll
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