pathology – Lablogatory

Death in the Bathtub: A Classic Forensic Scenario

When the Medical Examiner’s office receives a report of someone dead in a bathtub, the reporting party often presumes that the individual must have drowned. Yet deaths in bathtubs can be surprisingly complex. We initially discussed drowning back in June of 2023 but to summarize, drowning is a diagnosis of exclusion. The few signs of drowning at autopsy (pulmonary edema, watery fluid in the stomach and sinuses), are neither sensitive nor specific, so it is critical to exclude other potential causes of death. Particularly when a bathtub (or hot tub) is involved, a methodical step-by-step approach is helpful to avoid jumping to inaccurate conclusions.

The first step for us is to determine if the tub contained water. While this may sound obvious, this critical detail isn’t always reported initially. The first person on scene often reflexively turns off running water and opens the drain – and (understandably) in the heat of the moment, this alteration of the scene might not be documented. Our investigators are experienced at identifying indirect evidence of a wet bathtub, such as a water line, wet clothing, or wet sponges and washcloths.

Simply having water in the tub isn’t sufficient, though. We need to know whether the person’s nose and mouth were beneath the water. Sometimes, the physical dimensions of the tub and the position in which the person was found are incompatible with complete submersion. If the body has been moved, though, this evidence may be lost. Conversely, just because someone’s face is under the water doesn’t prove that they drowned; someone may die suddenly from heart disease while filling the tub, for example, and subsequently the water rises.

As mentioned earlier, there are no pathognomonic signs of drowning at autopsy. This isn’t necessarily a problem in the proper context. Take this example: a person who doesn’t know how to swim (and isn’t wearing a flotation device), falls out of a boat into a natural body of water. The body is recovered a day later. An autopsy reveals no “typical” drowning findings, but no other potential causes of death. In this scenario, drowning is the only remaining reasonable option for a cause of death. But to diagnose drowning in a shallow body of water, we need to explain why the person couldn’t escape the environment. In other words, in a bathtub, why didn’t the decedent just sit up? Sometimes, the reason is the age of the deceased – infants or young toddlers clearly can’t escape a deep bathtub, but even large buckets can be dangerous if they fall head-first (figure 1). Elderly and frail individuals, or those with neuromuscular conditions, may be unable to pull themselves up to a sitting position. Conditions like epilepsy can be dangerous if a seizure occurs while the person is bathing, and intoxication by alcohol, opiates, or other sedative-hypnotic drugs may cause someone to lose consciousness and slip beneath the water.

As you can see, there are a lot of avenues for interrogation investigating a death in a bathtub. That’s why these cases can be excellent examples of forensic casework – the correct answer is only identified following thorough scene investigation, autopsy, toxicology, and a review of the medical history.

*Figure 1: This illustration released by the U.S. Consumer Product Safety Commission warns that 5-gallon buckets, in particular, are a drowning hazard for young children.*

References:

United States Consumer Product Safety Commission. “Large Buckets are Drowning Hazards for Young Children”. Originally published 07/12/1989. Available at: https://www.cpsc.gov/Newsroom/News-Releases/1989/Large-Buckets-Are-Drowning-Hazards-For-Young-Children

-Alison Krywanczyk, MD, FASCP, is currently a Deputy Medical Examiner at the Cuyahoga County Medical Examiner’s Office.

Microbiology Case Study: Tinea cruris in a Middle-Aged Male

Case Presentation

A middle-aged male presented for a chronic inguinal and back rash present for over two years (Figure 1A). Travel history was notable for trips to the Middle East and Canada during that time. He was clinically diagnosed with tinea cruris at an outside healthcare facility, and his history was notable for an extensive use of several topical antifungals including clotrimazole with betamethasone, ketoconazole, and triamcinolone without improvement. Months long oral therapy with terbinafine and fluconazole resulted in only mild improvement, after which he was started on itraconazole. The patient noted some improvement while taking itraconazole, but following subsequent disease recurrence, presented to our institution.

Figure 1: A) Red annular, scaly rash of the inguinal skin involving the inner thigh. Skin biopsy of the thigh rash (40X, PAS stain) revealing dermatophyte hyphal elements in the stratum corneum.

Laboratory workup

An inguinal skin scraping was obtained, which revealed the presence of a superficial fungal infection consistent with the diagnosis of tina cruris. Fungal cultures on Sabouraud Dextrose Agar (Figure 2A), lactophenol blue stain (Figure 2B), and a skin biopsy (Figure 1B) all confirmed a dermatophyte infection. The organism was morphologically consistent with Trichophyton sp. Due to the unusual clinical history of a recalcitrant dermatophyte infection persisting through multiple rounds of topical and oral antifungal therapy, additional testing for definitive identification was undertaken. MALDI-TOF identified the organism as a member of the Trichophyton tonsurans/mentagrophytes species complex, further confirmed to be Trichophyton indotineae by sequencing.

Figure 2: A) Dermatophyte growth from the skin scraping of the leg on Sabouraud Dextrose agar. Fungal colonies were fast-growing and peripherally white-beige to light brown, flat and granular. B) Lactophenol Cotton Blue stain revealing septate hyphae with cigar-shaped macroconidia, small round microconidia clustered on branched conidiophores.

Discussion

Ringworm, also referred to as “tinea” or “dermatophytosis,” is a commonly occurring fungal infection affecting the skin, hair, or nails, caused by dermatophytes.¹ Typical symptoms include itching, a ring-shaped rash, redness, scaliness, cracked skin, and/or hair loss. The transmission of ringworm happens through direct contact between individuals, contact with infected animals, or exposure to contaminated environments such as public showers.¹ Around 40 different species of fungi can lead to ringworm infection.² Over the last decade, healthcare providers have observed a rise in severe cases of ringworm that are resistant to topical antifungal treatment³ which are an emerging public health concern.

The emergence of drug-resistant dermatophyte infections is attributed to the inappropriate use of topical products containing combinations of antifungal agents and corticosteroids.⁴ T. indotiniae has a complicated taxonomic history. The organism was initially identified as a sequence type of the Trichophyton mentagrophytes complex which exhibited elevated MICs to terbinafine. The earliest cases of T. indotineae infection were reported in India, quickly spreading to Australia, Oman, Iran, and other middle-eastern countries. Subsequent spread to Europe and North America soon followed.⁵ Initial reports of T. indotineae infections in North America involved individuals with a history of travel to endemic locations. Recently however, local transmission of T. indotineae within the United States has been documented among patients without travel history.⁶ It is hypothesized that resistant strains of T. indotineae emerged due to inappropriate antibiotic use, as infections are frequently terbinafine-resistant and require prolonged therapies with second-line therapies or antifungals traditionally utilized for invasive fungal infections.⁷

Diagnosis of T. indotineae infection is challenging as it requires advanced molecular techniques like genomic sequencing or expansion of MALDI-TOF MS capabilities to discriminate within the T. mentagrophytes complex, which many clinical laboratories lack.¹ Thus, diagnosis is largely reliant on the activities of reference laboratories. A high level of clinical suspicion is required as well, as the degree of dermatophyte workup undertaken in the routine setting is variable among institutions. T. indotineae infections often show resistance to conventional antifungal therapies including allylamines (terbinafine) and azoles (itraconazole and fluconazole), further highlighting the importance of susceptibility testing before initiating treatment and reassessing nonresponsive cases,⁴ another testing capability not offered by routine laboratories. The patient in this case was managed with Posaconazole, leading to significant improvements symptomology.

References:

Emerging antimicrobial-resistant ringworm infections (2023) Centers for Disease Control and Prevention. Available at: https://www.cdc.gov/fungal/diseases/ringworm/dermatophyte-resistance.html (Accessed: 9 April 2024).

Havlickova B, Czaika VA, Friedrich M. Epidemiological trends in skin mycoses worldwideexternal icon. Mycoses. 2008 Sep;51 Suppl 4:2-15.
Hay RJ. The Spread of Resistant Tinea and the Ingredients of a Perfect Storm. Dermatology. 2022;238(1):80-81.
Gupta AK, Venkataraman M, Hall DC, Cooper EA, Summerbell RC. The emergence of Trichophyton indotineae: Implications for clinical practice. Int J Dermatol. 2023 Jul;62(7):857-861. doi: 10.1111/ijd.16362. Epub 2022 Jul 22. PMID: 35867962.
Jia S, Long X, Hu W, Zhu J, Jiang Y, Ahmed S, de Hoog GS, Liu W, Jiang Y. The epidemic of the multiresistant dermatophyte Trichophyton indotineae has reached China. Front Immunol. 2023 Feb 16;13:1113065. doi: 10.3389/fimmu.2022.1113065. PMID: 36874152; PMCID: PMC9978415.
Caplan AS, Chaturvedi S, Zhu Y, Todd GC, Yin L, Lopez A, Travis L, Smith DJ, Chiller T, Lockhart SR, Alroy KA, Greendyke WG, Gold JAW. Notes from the Field: First Reported U.S. Cases of Tinea Caused by Trichophyton indotineae – New York City, December 2021-March 2023. MMWR Morb Mortal Wkly Rep. 2023 May 12;72(19):536-537. doi: 10.15585/mmwr.mm7219a4. PMID: 37167192; PMCID: PMC10208369.
Lockhart, SR, Smith, DJ, and Gold, J.A.W. Trichophyton indotineae and other terbinafine-resistant dermatophytes in North America. J. Clin. Microbiol. 2023 Dec; 61(12): e00903-23. PMID: 38014979.

–Tasnim Alkayyali is a second-year AP/CP resident at UT Southwestern Medical Center in Dallas, Texas.

–Clare McCormick-Baw, MD, PhD, FACP is a board certified Anatomic and Clinical Pathologist with a subspecialty in Medical Microbiology. She has a love for Infectious Disease Pathology and teaching the pathologists of tomorrow. She is the Southwest Regional Medical Director for Quest Diagnostics, Inc and is based out of Dallas, Texas.

–Andrew Clark, PhD, D(ABMM) is an Assistant Professor at UT Southwestern in the Department of Pathology and Director of the Microbiology Laboratory at Parkland Health and Hospital System. He completed a CPEP-accredited postdoctoral fellowship in Medical and Public Health Microbiology at National Institutes of Health.

The Eyes Have It: Clues from Vitreous Humor at Autopsy

When it comes to laboratory testing at autopsy, our options are limited compared to those for living patients. We’ve previously discussed the complexities of postmortem toxicology testing (https://labmedicineblog.com/2023/05/23/toxicology-and-forensic-pathology-more-than-a-numbers-game/) but even basic laboratory studies like a glucose or sodium level cannot be reliably measured from postmortem serum specimens. Upon death, hemolysis and cellular breakdown rapidly set in; as tissue oxygen stores and ATP are depleted, the careful balance of intracellular and extracellular electrolytes is lost, making serum essentially useless as an analyte. This makes potentially lethal conditions which leave only non-specific clues (like diabetic ketoacidosis, dehydration, or hyponatremia) difficult or impossible to prove postmortem. Fortunately at autopsy we can access a unique, relatively protected body fluid which cannot be obtained from living patients- the vitreous humor.

Vitreous humor is the clear, thick fluid which fills the globe of the eye. It is nearly acellular, composed predominantly of water with admixed hyaluronic acid and collagen proteins, and its insulated location provides it relative protection from the effects of decomposition and hemolysis. Vitreous humor is typically collected it at the beginning of an autopsy by inserting a needle into the most lateral aspect of the eye and aspirating the fluid; using this method, one can avoid collecting bits of retina (which interfere with analysis of the sample), and avoid creating any noticeable puncture marks or hemorrhages.

Years of data have shown that vitreous fluid approximates serum levels of major electrolytes, glucose, urea nitrogen (VUN), creatinine, ketones, and ethanol. Vitreous fluid is also valuable in the detection of 6-monoacetylmorphine (6-MAM), a metabolite of heroin which is quickly metabolized to morphine in the blood. Identifying 6-MAM in vitreous fluid allows us to ascertain a decedent used heroin, rather than just morphine.

While vitreous fluid is less affected by decomposition, it is not completely immune. The changes are predictable, though, and learning these patterns prevents misinterpretation of decomposition changes, and allows the pathologist to identify which results are still meaningful.

Vitreous fluid potassium will increase with the postmortem interval – in fact, this electrolyte is often touted (erroneously) as a method to determine time of death. Unfortunately there are many other variables (for example, antemortem potassium levels and rate of decomposition) affecting the rise of vitreous potassium, and this method has not proven to be the “holy grail” many were hoping for.

In contrast, vitreous sodium, chloride, and glucose levels all decrease following death – so while a low level may just be an artifact, a high level can be very meaningful. Even “low” levels should be assessed in the clinical context of the case and the concomitant potassium level. If the potassium is normal or barely elevated, it’s unlikely a “low” value is just decomposition-related.

Vitreous humor poses some challenges in the laboratory, though. Because of the thick, viscous nature of the fluid, it can be challenging to actually run it through the instrument. As decomposition progresses, the eyes can desiccate and make the vitreous humor even thicker. In cases of eye trauma, intraocular hemorrhage can contaminate the vitreous humor as well. Importantly, in situations of suspected head trauma in infants, the recovery of vitreous fluid is deferred until the end of the autopsy. Retinal and optic nerve hemorrhages are usually not identified until the brain is removed, and we need to be sure that any trauma we identify was not created artificially during the autopsy.

In summary, the use of vitreous humor as an analyte is a great illustration of creative problem solving. At autopsy the quality of blood specimens is limited, but we aren’t limited to blood. This lesson can be translated to any area of the laboratory: thinking outside of the proverbial box can lead to unexpected, paradigm-shifting opportunities.

References

Rose KL, Collins KA. Vitreous postmortem chemical analysis. NewsPath. December 2008.

Wyman J, Bultman S. Postmortem distribution of heroin metabolites in femoral blood, liver, cerebrospinal fluid, and vitreous humor. J Anal Toxicol. 2004 May-Jun;28(4):260-3. doi: 10.1093/jat/28.4.260. PMID: 15189677.

-Alison Krywanczyk, MD, FASCP, is currently a Deputy Medical Examiner at the Cuyahoga County Medical Examiner’s Office.

Undetermined, Undetermined

I like to think most people who go into healthcare professions do so with the hope of helping others. For those of us who do autopsies, the greatest sense of reward comes when we can explain to someone how and why their loved one died. Inevitably, though, there will be situations where we need to accept what we don’t know – despite how disappointing it may be. In these situations, the most intellectually honest course of action is to issue a manner of “undetermined.”

Let’s recap briefly what we know about manners of death (see https://labmedicineblog.com/2022/11/25/please-dont-tell-me-i-died-of-cardiac-arrest/ for a more in-depth discussion). Manner of death describes the circumstances in which the cause of death is sustained, and there are five choices in most jurisdictions – natural, accident, homicide, suicide, or undetermined. Natural deaths are those due entirely to non-traumatic diseases (like cancer or coronary artery disease). Accidental deaths involve trauma or toxicity without an intention to harm. Homicide is death at the hands of another person, whereas suicide is death at one’s own hands. The final option is undetermined.

There are two main pathways by which we can arrive at an “undetermined” manner. There can either be 1) reasonable competing evidence between two manners of death, or 2) we may be unable to identify a cause of death due to loss or destruction of bodily tissue. Let’s look at some examples.

In the first pathway, consider an autopsy of a person with a single gunshot wound to the head. In a readily accessible region like the temple or beneath the chin, this wound could easily be self-inflicted. While this would be a “typical” location for a suicidal injury, such a wound could also be inflicted by another person. There are indicators we look for at autopsy which favor one scenario over the other. For example, most suicidal gunshot wounds (broadly speaking, of course) are contact wounds or intra-oral. A self-inflicted gunshot wound to the back of the head would be unusual, but (contrary to popular conception), not impossible depending on the firearm used. However, the same type of pattern could be elicited with another person holding a firearm to that individual’s head. We may examine the length of the firearm to determine if it’s possible for the decedent to have pulled the trigger themselves (keeping in mind that other items like a cane, coat hanger, or even the decedent’s toe, may have been used to depress the trigger). Similar questions can arise in autopsies of people who have fallen from height. There is no way an autopsy can tell with certainty whether an individual was pushed, fell accidentally, or left the edge of an elevated structure intentionally. The cause of death in both situations is undisputed – a gunshot wound in the first, and blunt force injuries in the second. This is why contextual information, like scene photographs and investigative records, is indispensable for forensic pathologists. Without context, we have no way to discern homicides, suicides, and accidents. Occasionally even with context, there can be competing narratives (one witness claims a gunshot wound was self-inflicted, while another claims it was inflicted by the first) or suspicious circumstances to cast doubt. Without clear cut evidence to support one story, the manner of undetermined is appropriate.

The second pathway by which we reach an undetermined manner is when extensive decomposition or other soft tissue loss (such as fire damage) interferes with our ability to determine a cause of death. Think of completely skeletal remains discovered in an abandoned building. Sometimes, indicators of potentially lethal injuries can still be identified – for example, a gunshot wound of the skull or knife marks on a rib. But, as the aphorism goes, “an absence of evidence isn’t necessarily evidence of absence” – a bullet or blade could be lethal while only striking soft tissue (especially in regions like the abdomen or neck). If we cannot rule out non-natural causes of death, the best choice for manner is “undetermined.”

An undetermined manner of death can understandably frustrate family members or law enforcement. I always try to explain that manner determinations are, as one of my mentors says, “written on paper and not in stone.” We reserve the right to change the ruling in the future if additional evidence comes to light. As forensics pathologists our primary responsibility is to speak honestly and truthfully, and sometimes that means admitting the limitations of our science.

-Alison Krywanczyk, MD, FASCP, is currently a Deputy Medical Examiner at the Cuyahoga County Medical Examiner’s Office.

Trust Your Gut

A 20 year old female patient referred herself to a surgical oncologist specializing in sarcomas after she presented to an outside hospital for a sudden onset of epigastric pain. The patient also reported a one-year history of decreased appetite without nausea, vomiting, or weight loss. The outside institution performed an abdominal ultrasound and identified a large nonvascular heterogenous masslike lesion in the left upper quadrant not definitively associated with the spleen or kidney. The mass measured 12.1 x 9.9 x 10.7 cm. The radiologist’s overall impression was a hematoma; however, a CT scan with contrast was recommended to further classify the lesion. Instead, an MRI was performed, and the same radiologist described the lesion as having a thick irregular enhancing rind with enhancing septations and central necrosis. With the lesion appearing distinct from adjacent organs, a retroperitoneal sarcoma was posited on imaging. Reviewing the outside imaging and clinical history, the surgical oncologist referred the patient to interventional radiology for an ultrasound-guided biopsy of the left-sided retroperitoneal mass.

When the cytologist arrived in the procedure room for the time-out, the radiologist informed her of the surgical oncologist’s and outside radiologist’s opinions of a retroperitoneal sarcoma. A 17-gauge coaxial needle was advanced into the peripheral and non-necrotic aspect of the retroperitoneal mass, and multiple 22-gauge fine needle aspirations were obtained and handed to the cytologist. She prepared two air-dried smears and two alcohol-fixed slides. The air-dried smears were stained in our Diff-Quik (DQ) set-up and deemed adequate. The pathologist’s immediate cytologic evaluation was “tumor cells present.”

Images 1-3: Retroperitoneum, Left-side, Ultrasound-guided FNA: DQ-stained smear.

The following morning, the cytologist primary screened the Papanicolaou-stained slides and H&E-stained cell block sections in addition to the DQ smears, with the former preparations presented below.

Images 4-7: Retroperitoneum, Left-side, Ultrasound-guided FNA. 4-5: Pap-stained smear; 6-7: H&E Cell Block section (400X).

The cytologist entered her results as positive for malignant cells with a note of “atypical cells in papillary fragments” and gave the case to the pathologist for the final interpretation. The pathologist reviewed the slides prior to ordering immunostains. He paused and thought, “there’s something about the morphology and her age… it just doesn’t make sense for this to be a retroperitoneal sarcoma. It doesn’t look like a sarcoma. The cells are just too round or ovoid, bland, and poorly cohesive, and the fibrovascular cores – I just don’t think this is a sarcoma. Maybe a melanoma? Or some type of renal tumor? The cytoplasmic vacuolization could suggest this, but the mass is distinct from the kidney, so it can’t be. The nuclear grooves are intriguing, almost like a papillary thyroid carcinoma. A neuroendocrine tumor is also possible, the delicate papillary fronds though… Hmm. But where would it be originating from? How could this be distinct from other organs in the abdominal cavity?” He hemmed and hawed, glancing over our list of in-house immunostains. With only nine pre-cut unstained sections associated with the three H&E cell block levels, the pathologist ordered additional unstained recuts. He knew this was going to be a challenge due to the discrepancy between the clinical history and the morphology.

With proper positive and negative controls, the tumor cells show positive staining for AE1/AE3, Cam 5.2, vimentin, CD99 (dot-like), CD56, beta catenin (nuclear), PR, AMACR, and SOX11, while negative staining for CK7, CK20, PAX-8, RCC, chromogranin, synaptophysin, GATA-3, EMA, GFAP, S100, calretinin, WT-1, E-cadherin, and p53 (wild type pattern). The proliferative index by Ki-67 is low at <1%.

Images 8-10: Retroperitoneum, Left-side, Ultrasound-guided FNA. 8: beta catenin (nuclear)-positive; 9: AMACR-positive; 10: SOX11-positive.

The combination of morphology with the extensive immunoprofile of the tumor is consistent with solid pseudopapillary neoplasm (SPN) of the pancreas.

Had there been any mention of the tumor involving or replacing the pancreas, this diagnosis and workup would have been much more straightforward. SPNs, albeit rare, account for 30% of tumors in women within their third or fourth decade of life.¹ This patient presented with the most common SPN symptoms of abdominal pain and early satiety, but the mass appearing extrapancreatic on imaging posed a diagnostic challenge, as extrapancreatic SPNs are rare.^2-3 Fortunately, SPNs are low-grade malignant neoplasms that respond well to surgical resection, and this patient is doing just fine after her distal pancreatectomy. In this case, both the patient and our pathologist listened to their guts with the patient pursuing advanced medical care for something much more complicated than a hematoma and the pathologist relying on his morphology expertise despite an odd clinical presentation.

References

La Rosa S, Bongiovanni M. Pancreatic solid pseudopapillary neoplasm: key pathologic and genetic features. Archives of Pathology & Laboratory Medicine. 2020;144(7):829-837. doi:10.5858/arpa.2019-0473-ra
Dinarvand P, Lai J. Solid pseudopapillary neoplasm of the pancreas: a rare entity with unique features. Archives of Pathology & Laboratory Medicine. 2017;141(7):990-995. doi:10.5858/arpa.2016-0322-rs
Cheuk W, Beavon I, Chui D, Chan JKC. Extrapancreatic solid pseudopapillary neoplasm. International Journal of Gynecological Pathology. 2011;30(6):539-543. doi:10.1097/pgp.0b013e31821724fb

-Taryn Waraksa-Deutsch, MS, SCT(ASCP)^CM, CT(IAC), has worked as a cytotechnologist at Fox Chase Cancer Center, in Philadelphia, Pennsylvania, since earning her master’s degree from Thomas Jefferson University in 2014. She is an ASCP board-certified Specialist in Cytotechnology with an additional certification by the International Academy of Cytology (IAC). She is also a 2020 ASCP 40 Under Forty Honoree.

It’s What’s on the Inside That Counts: Uses of Radiography at Autopsy

In several previous blogs, I’ve mentioned the topic of post-mortem radiography (or “x-rays”). While postmortem CT scanning is a hot topic in the field, plain films are a tool which has been in widespread use for decades. Autopsy standards of the National Association of Medical Examiners require, at a minimum, radiographs be performed on all infants, gunshot wound victims, explosion victims, and charred or decomposed remains. Let’s examine the reasons for these requirements and look at a few specific examples.

All infants must get full body x-rays to check for acute or healing rib and long bone (extremity) fractures, which could be indicative of physical abuse. The extremities are not usually dissected in the course of a typical post-mortem examination, but fractures that can’t be attributed to birth trauma (especially in a pre-mobile child) are a concerning finding that needs further investigation and dissection.

Radiographs taken of gunshot wound victims document the presence and location of retained projectiles, all of which need to be recovered as evidence.

This x-ray of a gunshot wound victim shows two separate types of ammunition, seen as radio-opaque (white) in the image. The smaller, circular pieces are “birdshot” shotgun ammunition (blue arrows) while the larger pieces are traditional handgun ammunition (red arrow).

Radiographs are commonly performed in any type of penetrating trauma, including sharp force injury and explosive injuries, to identify retained foreign bodies (especially broken fragments of the blade, which may pose a risk to the pathologist). Similar to projectiles, these fragments need to be recovered as evidence. Radiographs can also document the presence of an air embolism, which can be missed at autopsy if special dissection techniques aren’t performed.

This individual had sharp force injuries to their neck, which injured large veins. The x-ray in this case was performed to see if any fragments of the weapon were still in the body, but also showed a large air embolism in the right atrium and ventricle (blue arrows), seen as radiolucency (gray/black). Open injuries to veins in the head and neck can cause air emboli as breathing creates negative intra-thoracic pressure, drawing air inward though any open channels.

In pedestrians who have been struck by motor vehicles, radiography is the first step in examining trauma. As mentioned earlier, the extremities aren’t typically dissected during a traditional autopsy – but in pedestrians, lower extremity fractures can document the site of initial impact, and the distance of the fracture from the foot may indicate the bumper height of the car.

*This x-ray of a pedestrian struck by a motor vehicle shows displaced fractures of the right femur, tibia, and fibula. Note the body bag zipper in the lower right corner.*

Fire victims may have extensive thermal injuries and charring which can hide evidence of other injuries, and radiographs can help identify them. Radiographs are also one step toward identifying the victim. Decomposed bodies must be x-rayed for similar reasons – external and internal soft tissue alterations make assessment for trauma more difficult, and radiographs may be needed to confidently identify the body.

In this x-ray of a decomposed person, dental fillings are easily visible (red arrow), which are typically unique for an individual and can be used for identification. Note the irregular shapes of the fillings, which are just as important as their location. Also note the air-fluid level in the cranial cavity (blue arrow), indicating complete liquefication of the brain.

On occasion, radiographs can be performed on individual organs to help define anatomy or previous surgical alterations. Especially in the heart, radiographs can demonstrate coronary artery or valve calcifications, surgical clips from bypass grafts, or other radiopaque prostheses. Knowing the location of devices before dissection gives the pathologist a better chance at preserving and evaluating important structures.

This heart was x-rayed after removal, as the decedent had a history of heart disease with prior interventions. Coronary stents (red arrows) are easily visible; in practice, they can be difficult to find on gross dissection in patients with heavily calcified arteries.

Not all offices can afford the installation (or maintenance) of CT scanners, but access to x-ray machines is more widespread. As we’ve seen here, x-rays are a versatile tool which can document injuries, help identify decedents, and direct the pathologist to perform special autopsy procedures which aren’t part of the daily routine.

-Alison Krywanczyk, MD, FASCP, is currently a Deputy Medical Examiner at the Cuyahoga County Medical Examiner’s Office.

Weirdoma

A 36 year old male was referred to gastroenterology after presenting to the emergency room for hematemesis and severe fatigue. He was pale and tachycardic, and the CBC showed a hemoglobin of 4.5. An esophagastroduodenoscopy (EGD) at the time demonstrated erosive esophagitis with a visible vessel and was treated with a PPI. A repeat scope the following month no longer demonstrated a vessel but identified a 10 cm ulcerative gastric cardia mass at the GE junction. Forcep biopsies showed a gastric ulcer with granulation tissue, and the stains performed yielded results that were not consistent with carcinoma or lymphoma; however, the biopsy material was limited, and the patient was referred to our GI clinic for further workup.

The interventional gastroenterologist requested cytology be present for the patient’s endoscopic ultrasound to ensure an adequate specimen was obtained for a definitive diagnosis. During the rapid onsite evaluation (ROSE), we determined the Diff-Quik smear was adequate, and the pathologist could confidently suggest that tumor cells were present. We collected additional FNA passes in our cell block tube to run ancillary studies.

The following morning, all we could make of the case was that it was a poorly-differentiated malignant neoplasm with spindle and epithelioid features. The cytoplasm was minimal and fairly wispy while the nuclei were hypochromatic and fragile with nuclear grooves and nucleoli. On the Diff-Quik smears, the cytoplasm looked blue, which pointed us in the direction of possibly lymphoma or neuroendocrine, but the clustering made me favor neuroendocrine. With the pap-stained smears, were torn between carcinoma and a neuroendocrine tumor, maybe even an epithelioid GIST, albeit an odd location. And of course, there’s always the differential of melanoma, the great mimicker. Off to IHC we go!

Images 1-4: Stomach, GE Junction, EUS-FNA. 1-2: DQ-stained smear; 3-4: Pap-stained smear.

When our immunostains were delivered later that afternoon, our pathologist came up to me and said, “I got it! I know what it is!” Ecstatic, I replied, “What is it? Lymphoma? Carcinoma? GIST? MELANOMA?” “No, it’s a WEIRDOMA! Nothing is staining positive. No epithelial markers, no definitive lymphoid markers… nothing. It’s a weird case. I have to run additional stains.”

Images 5-7: Stomach, GE Junction, EUS-FNA. 5: H&E Cell Block section (600X); 6: Vimentin-positive; 7: CD56-positive

Back to the drawing board and 20 additional recut sections later, more immunostains were ordered and a mixed profile led us down a more confusing path. The tumor cells show positive staining for vimentin, CD56, and CD10 (focal), and negative staining for AE1/AE3, Cam5.2, CK7, desmin, SMA, HHF35, CD34, CD117, DOG-1, S100, SOX-10, synaptophysin, SALL4, CD45, CD68, and CD21. Proliferative index by Ki-67 was approximately 35%. The morphology and immunoprofile of the tumor were highly unusual, suggesting a mesenchymal neoplasm, possibly a sarcoma.

The concurrent forcep biopsies demonstrated rare atypical cells that were difficult to classify due to the limited number of cells, the non-specific morphology, and the following non-specific immunophenotype: positive staining for CD99, partial positive staining for D2-40 and NSE, and focal or weak positive staining for Cam5.2, while negative for AE1/AE3, CK7, EMA, S100, CD31, desmin, PAX8, BCL2, and myogen. The biopsy tissue consisted of predominantly ulcerative tissue and a fragment of squamous mucosa with a lamina propria infiltrate of atypical cells with spindle and epithelioid morphology.

Due to the FNA cell block consisting of 80% tumor compared to the limited forcep biopsy tissue, we sent FFPE cell block sections for RNA fusion studies to help us further classify the tumor. An EWSR1::ERG (in-frame) rsa(22;21)(q12.2;q22.2) gene fusion was detected in the tissue sample, which has been reported in extraskeletal Ewing sarcoma.

Stomach, GE Junction, EUS-FNA Final Diagnosis: Ewing Sarcoma

Fortunately, the patient’s PET scan did not demonstrate any evidence of metastatic disease, and the patient along with his care team decided to pursue systemic therapy as these tumors tend to be chemosensitive. The need for radiation therapy will be reviewed depending on the tumor’s response to systemic therapy. A strange presentation, this visceral Ewing sarcoma, and a reason why immunostains and molecular profiling are so important to rendering a definitive diagnosis. In our study set files, however, it will forever be dubbed my favorite weirdoma.

Critical Update for Hispanic/Latinx Heritage Month and Indigenous Peoples’ Day

What is the data regarding the number of physicians- and pathologists-in-training who self-identify as Native American, Alaska Native, Hispanic/Latinx, or Native Hawaiian/Pacific Islander?

Among all resident physicians in ACGME-accredited and in combined specialty training programs on duty as of December 2022, there were a total of 154,231 individuals. The number of physicians in training in Pathology and its subspecialties totaled 2261 individuals. Looking at the demographic data as self-identified, the following data are striking:

Reference: Data was derived from Table 8 from Brotherton SE, Etzel SI, Graduate Medical Education, 2022-2023, Appendix to *JAMA* 2023: 330(10):988-1011.

Clearly there is an enormous gap in training of people from Indigenous and Hispanic/LatinX background in both medical training generally and in pathology specifically. The COVID19 pandemic disproportionately affected people from groups who are considered Under-Represented in Medicine (URIM), which include these groups, as well as individuals who self-identify as African American/Black, and who are also significantly under-represented in pathology and laboratory medicine.

What about the numbers for the laboratory professions?

With respect to laboratory professionals in practice and in training, I searched unsuccessfully for rigorous data to compare to the data available for physicians in training; however, even from the numbers available, under-representation is a challenge in the laboratory professions.

Please also note that Asian heritage comprises over 50 different language and ethnic groups. Within the United States, some of these groups are disproportionately affected by poverty and adverse social determinants of health. Therefore, for strategies to improve representation, future analyses should avoid simply lumping individuals into large buckets of self-identified demographic categories.

To address the adverse health impacts of the social determinants of health for patients from ALL demographic backgrounds, it will be essential to recruit actively from groups who have been both URIM and also from communities grappling with the impact of low income; lack of access to health insurance; lack of access to clean water; lack of access to sanitation services; lack of access to high, quality fresh food; residence in historically redlined neighborhoods that have been zoned for hazardous industries; lack of access to air-conditioning and shade from trees; and over-representation in hazardous work conditions.

Even without addressing these subtleties within ethnic/demographic groups, the data presented in the table convey the obvious fact that we have work to do to increase the numbers of trainees in Pathology (and, by extension, in the laboratory professions) from populations who have been historically under-represented in our training programs and workplaces. ASCP has a great opportunity for focused efforts by our Career Ambassadors, our Pathology Ambassadors, and all members to increase awareness of career opportunities in laboratory medicine and pathology. Recruitment is an important piece. Equally important is building and sustaining climates in our training programs and workplaces where people feel welcomed, recognized, invited to participate in transforming our practices to serve our patients better and considered for opportunities to advance and to be considered for leadership positions. Being hired is not enough. We all need to participate in continuous quality improvement, which means continuous engagement and active participation in decisions that will transform the ways we provide care so that we meet the needs of all our patients, now and in the future.

-Melissa P. Upton, MD. Past-President of ASCP and Chair of the ASCP Diversity, Equity, and Inclusion Committee; Emeritus Professor of Pathology, Department of Laboratory Medicine and Pathology, University of Washington, Seattle, WA.

The Ins and Outs of Gunshot Wounds

In the United States, victims of gunshot wounds represent a significant majority of all homicides (and a high proportion of suicides). There’s a propensity among other medical specialties to think of forensic pathologists as “bullet pullers,” just collecting the used projectiles and moving on to the next case. However, autopsies of multiple gunshot wound victims can be some of the most detailed examinations we perform. Even though the cause of death isn’t a mystery, thorough observation and documentation is crucial for other questions which may arise – was the victim immediately incapacitated? Did the shooter reload during the assault? How close to the victim were the shots fired? To address these questions, it’s first helpful to understand the basics of gunshot wounds.

Gunshot wounds can be penetrating (entering the body without exiting) or perforating (entering and exiting the body). Full body x-rays are taken in all gunshot wounds to identify retained projectiles, all of which must be recovered as evidence. It’s important to not use metal tools (like forceps or scissors) when removing a projectile, which may scratch metal and interfere with ballistics comparison.

Under typical circumstances, distinguishing entrance from exit wounds is straightforward. Classic entrance wounds are circular, as the bullet hasn’t yet been deformed, and there is a surrounding rim of abrasion where the edges of the bullet scrape against the skin. In contrast, exit wounds have a stellate or slit-like appearance, but the wound edges can typically be reassembled and are not abraded. As with any area of medicine, though, real life doesn’t always follow the rules. An entrance wound can be atypical if the bullet has passed through an ‘intermediary target’ before striking the victim (say a piece of furniture or a car door). If the area of exit is pressed against a firm object (even a tight pants waistband), the skin edges will be abraded (or “shored”). Sometimes, the entrance and exit truly cannot be distinguished – this is more likely with superimposed decomposition, insect activity, or superficial wounds.

Range of fire is another important feature to note and is the reason we always take photographs of a wound before cleaning the body. When a gun is fired, smoke, soot, and unburnt particles of gunpowder exit the barrel as well as the bullet. The smoke creates “fouling,” dark discoloration which easily wipes away and can be seen if the end of the barrel is within approximately one foot of the victim. Stippling, caused by unburnt grains of gunpowder, are actual abrasions and can be seen when the projectile fired within 18” of the victim. These are gross generalizations, though, and in each individual circumstance the weapon itself must be tested to identify the distances. If soot or gunpowder particles aren’t visible on the skin surface, they may have been deposited on the victim’s clothing. ‘‘Bullet wipe’ is slightly different from fouling, in that it is dirt and residue on the actual bullet which gets ‘wiped’ off around the entrance wound on clothing – so it doesn’t tell you range of fire, but it can be helpful to identify tricky entrance wounds.

Now, for some of the common misconceptions around gunshot wounds …

Can you tell the caliber of the gun from the size of the wound? The answer is an emphatic “no.” Much of the injury caused by a bullet comes from the temporary wound cavity created by dissipation of kinetic energy; so no matter the size of the bullet, tissue will stretch and distort around it.

Can you tell the order in which gunshot wounds were sustained? Most often, no. In some autopsies, the first wounds cause so much blood loss that the later wounds lack hemorrhage, but this is the exception rather than the rule.

Can I tell what position the victim was in when they were shot? Again, usually not. In isolation, an autopsy can only tell you the trajectory of the bullet through the body; to determine the position of the victim when they were shot requires knowledge of either where the gun was when it was fired or where the bullet landed–two factors which are often not available.

These are just a few of the complexities faced by a pathologist when working with gunshot wounds, and we haven’t even covered different types of ammunition or firearms. Stay tuned for more in the future!

*This is an example of a classic entrance gunshot wound – nearly circular, with a thin rim of abraded (or scraped) skin.*

*In contrast, this exit wound is slit shaped, and the wound edges can be neatly reapproximated.*

*This entrance wound has stippling on the surrounding skin; occasionally gunpowder particles are still visible embedded in the abrasions.*

-Alison Krywanczyk, MD, FASCP, is currently a Deputy Medical Examiner at the Cuyahoga County Medical Examiner’s Office.

Drowning: A Diagnosis of Exclusion

With warmer weather approaching (or already arrived, depending on your location), it’s a good opportunity to review investigation of drowning deaths in forensic pathology. Drowning is the leading cause of deaths for children between the ages of 1 and 4 in the United States, but it can affect any age group.

Drowning is a diagnosis of exclusion – there are no pathognomonic signs of drowning, and a complete autopsy is required to rule out competing causes of death. Keeping an open mind during the investigation is the first step – discovering a body in water doesn’t automatically mean the cause of death is drowning. The body of a homicide victim may be disposed of in water as an attempt to destroy evidence, or someone may die of a cardiac arrythmia while they happen to be swimming.

The questions to answer in possible drowning deaths are much like those when faced with a body found after a fire (see “The Basics of Deaths by Fire” from February 23, 2023). Was the person alive when their body entered the water? And if they were, did they die from drowning – or did they die of another cause, and then become submerged?

Autopsies of drowned individuals commonly reveal findings supportive of, but not specific for, drowning. The lungs are typically over-expanded and edematous, and foamy fluid may be in the airways. A “foam cone” may protrude from the nostrils and/or mouth. Pulmonary effusions can be present, and the petrous ridges at the base of the skull may show red-purple discoloration due to vascular congestion and hemorrhage. The stomach and sphenoid sinus may contain large amounts of watery fluid. Wrinkling and pallor of the skin of the hands and feet (formerly called “washerwoman’s hands”) is often identified but doesn’t necessarily indicate drowning as it can occur with pre-mortem or post-mortem submersion.

A posterior neck dissection is necessary in most drownings to rule out high cervical spine injuries, which are often overlooked without this special autopsy technique. This type of trauma can be seen in divers or jumpers who strike head-first in shallow bodies of water and may cause death by itself or contribute to the decedent’s inability to self-extricate from the water. Pathologists also need to be aware that post-mortem injuries can happen as the body is passively carried by currents and bumps into rocks or other debris, known as “travel abrasions”.

The body of water is another consideration. It would be highly unlikely for a neurologically alert teenager or adult to drown in a bathtub, whereas an infant could easily drown if left unsupervised. In contrast, it may take a river or ocean with strong currents to overpower experienced swimmers. Personal medical history is important, as well – an adult with epilepsy could drown even in shallow water if they experience a seizure. The temperature of the water can also play a role. Cold water can trigger cardiac arrhythmias, contribute to fatigue of skeletal muscles, or incite hypothermia leading to a loss of consciousness. Toxicology testing is an important ancillary test in drowning deaths to provide context and may reveal intoxications that help explain someone’s inability to remove themselves from the water. Alcohol can contribute to the impairment of physical coordination and/or increase risk-taking behaviors, and has been associated with up to 70% of water recreation-associated deaths.

If the autopsy doesn’t show any indicators of drowning but reveals potentially lethal natural disease (such as severe coronary artery stenosis), then it’s likely the person died while they happened to be in the water and not because they were in the water. In every situation, though, the autopsy findings must be correlated with the decedent’s history, the results of scene investigation, and toxicology testing before a final diagnosis can be rendered. In this way, autopsies of water-associated deaths highlight the importance of context and investigation in forensic pathology.

Figure 1. A classic example of the “foam cone” seen at autopsy in instances of drowning. This finding results from marked pulmonary edema, and isn’t specific for drowning – it can be seen in many other conditions including opiate overdoses and heart disease.

Figure 2. Foamy fluid in the trachea and mainstem bronchi can be seen in any condition that causes pulmonary edema, and also is not specific for drowning.

Figure3. Wrinkling and paleness of the hands and feet is often seen in bodies recovered from water, whether or not the cause of death was actually drowning.

References

Armstrong EJ, Erskine KL. Investigation of drowning deaths: a practical review. Academic Forensic Pathology, Jan 2018.
Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Drowning Prevention. <https://www.cdc.gov/drowning/facts/index.html> Accessed 6/21/2023.

-Alison Krywanczyk, MD, FASCP, is currently a Deputy Medical Examiner at the Cuyahoga County Medical Examiner’s Office.