A HISTOPATHOLOGICAL ARRAY OF CARDIAC LESIONS ON AUTOPSY

Abstract

BACKGROUND: Cardiovascular diseases are the leading cause of death in the world. Many pathologies are picked up
only on histomorphological evaluation after a meticulously done autopsy, hence establishing the cause of death.
AIMS & OBJECTIVES: The aim was to study the histomorphological patterns of cardiac lesions on autopsy.
MATERIAL & METHODS: 52 cases which showed changes in heart on histopathology from a total of 408 cases were analysed retrospectively
for age and sex distribution, clinical details and various types of lesions on histopatholgy.
OBSERVATIONS & RESULTS: Atherosclerosis was the most common nding seen in 61.5% of cases. Rare and incidental ndings on
histomorphology such as Giant cell myocarditis, Electrocution, metastatic carcinoma and tuberculosis were also seen.
CONCLUSION: The study describes different types of lesions seen on histopathology in the heart. Incidental lesions noted helped in infering the
cause of death.

Full text

A HISTOPATHOLOGICAL ARRAY OF CARDIAC LESIONS ON AUTOPSY
Vijay Dhankar
Specialist and Head, Department of Forensic Medicine, Dr B.S.A. Hostipal and
Medical College, New Delhi.
Original Research Paper
Pathology
INTRODUCTION
The term autopsy is derived from ancient Greek word autopsia, means
1.
“to see for oneself”, autos (“oneself”) and opsis (“eye”) Autopsy
remains one of the most useful and precise tools in establishing
diagnosis of diseases. A well performed autopsy is important for
diagnosing most medical conditions. Cardiovascular diseases are a
leading cause of death in the world and have now become the leading
2
cause of morbidity in India . Many cardiac pathologies are concealed
and found incidentally on histomorphological evaluation of samples
sent after postmortem examination. The vast spectrum of lesions
which can be diagnosed on histopathology after autopsy can help in
studying the epidemiology, pat hophy siology and management
modalities of these diseases.
AIM – To study the histomorphological patterns of cardiac lesions on
autopsy that are important in determining the direct and indirect causes
of death.
MATERIAL AND METHODS
A retrospective study of 408 medico-legal autopsy consecutive
specimens was undertaken over a period of three and a half years from
January 2015 to June 2018 in the Department of Pathology, Dr BSA
Hospital, New Delhi. These autopsies were performed by a forensic
expert. 350 cases out of these 408 cases were analysed in which heart
specimen or tissue bits from heart were sent for histopathological
examination. In the rest of 58 cases cardiac tissue was not received.
The samples were received in 10% formalin as xative. The samples
were sent with history and clinical details. The tissue pieces were
measured and 4mm to 5mm thick sections were taken for routine
processing for histopathology. The heart specimens were measured,
weighed and inspected externally for any discoloration, infarcts,
rupture, or any other abnormality. Then the heart was dissected as per
inow outow technique. Vessels were examined for any hardening,
thickness, b lock age, plaques. Valves were examined for any
harde ning, vegetation or t hrombi. Sections were taken from
represent ative area s, such as walls of ventricles, atria, Aorta
pulmonary trunk, mitral and tricuspid valves and the three coronary
arteries for routine histopathology processing. All the histology
secti ons were stained with Haematoxylin and Eosin stain for
microscopic examination. The microscopic ndings were recorded.
These ndings could not be correlated with gross ndings as in many
of the cases only tissue bits were available and gross ndings were not
provided by the forensic expert.
OBSERVATIONS & RESULTS
A total of 408 autopsy specimens were received in the Pathology
Department. 39 cases out of these 408 cases were ill preserved and
completely autolysed to yeild any ndings. Another 58 cases did not
include heart tissue. A total of 259 cases showed a completely
unremarkable cardiac histomorphology. 52 cases showed some kind of
pathological features microscopically and have been taken for this
study.
Table 1 -Age and sex distribution of cases analysed ( n = 52 )
260 specimens were from deceased male subjects and 148 were from
females. Of the 52 cases with some sort of cardiac pathology 38 were
males and 14 were females. In the male group majority of the cases (17
cases) were in the age group of 21-40 years followed by 41-60 year age
group (11 cases), whereas in females majority of the cases were in 41-
60 years age group (6 cases).[ Table 1]
Table 2 - Clinical Features
These cases presented with a variety of symptoms pointing towards
cardiac or other organ/ system involvement [Table 2]. 40 out of 52
cases were brought dead or found dead following a collapse or an
uncommon preceding event. The second most common subset of cases
(5 cases) had symptoms related to heart disease such as chest pain,
dizziness, breathlessness etc. and died during treatment . There was
INDIAN JOURNAL OF APPLIED RESEARCH
67
KEYWORDS : Autopsy; histopathology; Heart.
BACKGROUND: Cardiovascular diseases are the leading cause of death in the world. Many pathologies are picked up
only on histomorphological evaluation after a meticulously done autopsy, hence establishing the cause of death.
AIMS & OBJECTIVES: The aim was to study the histomorphological patterns of cardiac lesions on autopsy.
MATERIAL & METHODS: 52 cases which showed changes in heart on histopathology from a total of 408 cases were analysed retrospectively
for age and sex distribution, clinical details and various types of lesions on histopatholgy.
OBSERVATIONS & RESULTS: Atherosclerosis was the most common nding seen in 61.5% of cases. Rare and incidental ndings on
histomorphology such as Giant cell myocarditis, Electrocution, metastatic carcinoma and tuberculosis were also seen.
CONCLUSION: The study describes different types of lesions seen on histopathology in the heart. Incidental lesions noted helped in infering the
cause of death.
ABSTRACT
Pratima Khare
Consultant, Department of Pathology, Dr B.S.A. Hospital and Medical College, New
Delhi.
Aditi Rawat
Senior Resident, Department of Pathology, Dr B.S.A. Hospital and Medical College,
New Delhi.
Renu Gupta*
Senior Specialist and Head, Department of Pathology, Dr B.S.A. Hospital and Medical
College, New Delhi. *Corresponding Author
Age Groups
Females (%)
Males (%)
Total (%)
0-20 Years
01(1.9)
05(9.6)
06(11.5)
21-40 Years
05(9.6)
17(32.7)
22(42.3)
41-60 Years
06(11.5)
11(21.1)
17(32.7)
61-80 Years
02(3.8)
05(9.6)
07(13.4)
14(26.9)
38(73.07)
52
Sl.No.
Clinical details
No. of Cases
1.
Brought Dead
40(76.9%)
2.
Cardiovascular symptoms (who died during
treatment for cardiac illness)
5(9.6%)
3.
GIT Symptoms
1(1.9%)
4.
Seizures
1(1.9%)
5.
Respiratory symptoms, tuberculosis
1(1.9%)
6.
Post partum illness
1(1.9%)
7.
Known case of Cancer
1(1.9%)
8.
Undocumented history
2(3.8%)
Total
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one case each with gastrointestinal symptoms, tuberculosis, seizure
disorder and malignancy undergoing treatment.
Table 3 - Various lesions seen on microscopy
On microscopy we came across a wide spectrum of histopathological
ndings. [Table 3]
Atherosclerosis either in coronary vessels and / or in great vessels was
seen in 32 cases and was the most common nding. Atherosclerotic
plaques were seen as sub-intimal collections of foamy macrophages,
few lymphocytes, cell debris and cholesterol clefts. Some of the
plaques were totally brotic and calcied. In 11 out of 32 cases aorta
also showed atherosclerotic plaques.
Five cases showed brosis and scarring. Fibrosis could be due to
healed myocardial infarction, myocarditis or any other previous
pathology.
Four cases were documented as myocarditis (Fig 1).In three cases
myocardium showed inltration by chronic inammatory cells such as
lymphocytes, histiocytes, plasma cells and occasional eosinophils.
Focal areas showed replacement brosis also. One of the four cases
showed presence of chronic inammatory cells along with granulomas
and giant cells in the myocardium and vessel walls in the myocardium.
These cases showed extensive areas of brosis and extension of
inammation into the pericardium also. This case was diagnosed as
Giant Cell Myocarditis (Fig 2) with pericarditis.
Two cases showed necrosis of myocytes with inltration of neutrophils
and hemorrhage. Five cases showed laceration and rupture of
myocardium and showed presence of blood in the pericardial cavity
during autopsy. The cause of death was labelled as cardiac tamponade.
Mi cro sco pica ll y myo ca rdi um sho we d myo cy te nec ro sis ,
inammatory cell inltrate and hemorrhage at the site of rupture.
An interesting and uncommon entity showing myocardial changes due
to electrocution was also encountered in our study. Features seen were
distended lightly staining bres alternating with hypercontracted
darkly staining myocardial bres. Few bres showed enlarged squared
up nuclei in myocytes. (Fig 3)
A single case of cardiomyopathy was seen wherein the microscopy
showed focal interstitial brosis with lymphocytes, macrophages and
mast cells. Myocytes showed nuclear enlargement and thinning of
bres.
Another case of interest in the series was that of squamous cell
carcinoma which showed nests of atypical squamous cells in the
myocardium.This patient was a known case of Cancer undergoing
treatment. (Fig 4)
A case of disseminated tuberculosis involving myocardium was also
seen. Myocardium showed presence of epithelioid cell granulomas
with caseous necrosis. However acid fast bacilli were not seen (Fig 5).
Figu re 1: Myoc ardium showing inflammat ory cell s in the
interstitium.
Fi gure 2: Gi an t c ells and Ly mphoc yt es in fil trati ng th e
Myocardium.
Figure 3: Lightly stained distended myocardial fibres alternating
with darkly stained hypercontracted fibres.
Figure 4: Atypical squamous cells infiltrating in between the
myocardial fibres.
Figure 5: Epithelioid cell granulomas with necrosis.
DISCUSSION
Postmortem examination with relevant history, clinical details and
histopathological examination of heart can help in establishing
whether the cause of death was related to cardiovascular disease or
not. Autopsy is the only way to study the morphological features of
heart which is not possible in the living and to correlate it with the
clinical diagnosis.
In this study 39 cases out of a total of 408 cases were autolysed. This is
a major pitfall seen in many studies which hampers in knowing the
cause of death. These cases were excluded from the study. Heart was
not sent in 58 cases and 259 cases did not show any abnormality in
cardiac tissue. 52 cases (12.74%) out of 408 cases had some sort of
abnormality in the heart and were included in the study.
Out of 52 cases with cardiac changes in histopathology 38 (73.0%)
cases were males and 14 (26.9%) were females. Majority of the cases
(17 cases) were seen in the age group 21- 40 years in males followed by
41 - 60 age group (11 cases).Whereas in females 6 cases were in age
group 41- 60 years and 5 cases in age group 21-40 years. However, the
mean age of cardiovascular changes seen in this study was similar in
both males and females, being 40.7 years and 40.9 years, respectively.
In a study conducted on 200 cases for a period of two and a half years
by also showed that histopathological changes in heart
3
Marwah et al
68
INDIAN JOURNAL OF APPLIED RESEARCH
Sl. No.
Lesions
No. of Cases
1.
Atherosclerosis
32 (61.53%)
2.
Myocarditis
3 (5.76%)
3.
Myocarditis-Giant Cell Type
1(1.9%)
4.
Fibrosis
5(9.6%)
5.
Myocyte necrosis
2(3.8%)
6.
Rupture / laceration of myocardium
5(9.6%)
7.
Cardiomyopathy
1(1.9%)
8.
Electrocution
1(1.9%)
9.
Squamous cell carcinoma
1(1.9%)
10.
Tuberculosis
1(1.9%)
Total
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were more common in males (92%) than in females (8%) with
4
maximum number of cases being in 41-50 years age group. Garg et al
in their study of 141 cases over a two years period also had most of the
cases (48.9%) with cardiovascular deaths in the age group 41- 60
years.
On microscopy varied lesions were seen. Atherosclerosis was the
most common nding either in coronary arteries or aorta. 32 cases
(61.5%) out of a total of 52 cases showed atherosclerosis. Similar
ndings have been reported by et al (55.3%), Garg Chandrakala Joshi
(64%) and al (77.3%) have shown atherosclerosis to be the Ekta Rani et
commonest nding in their studies4,5,6
Patchy areas of brosis of myocardium were seen in 5 cases. The
brosis could be because of old healed infarction or inammatory
causes. 2 cases showed necrosis of myocytes which again could be due
to myocardial infarction. We also came across 5 cases having either
laceration due to trauma or rupture of myocardium. One case was due
to blunt trauma having a laceration at the apex of heart. In the other 4
cases there was transmural rupture of ventricular wall with coronary
artery atherosclerosis. The rupture could be due to myocardial
infar cti on as there was myoc yte ne cro sis, h emorr hag e a nd
inammation at the site of rupture. In all the 5 cases there was hemo-
pericardium with cardiac tamponade. Therefore 6 (11.53%) cases
showing myocyte necrosis and 4 showing ventricular wall rupture
could have been due to acute myocardial infarction. Incidence of
Myocardial Infarction in various have been variable. Garg et al studies
reported 20(14.1%) out of total of 141 cases where as Marwah et al had
4,3
seen 14 (7%) out of a total of 200 cases in their studies . Though death
due to rupture of myocardium leading to hemopericardium post acute
7
myocardial infarction is rare but incidentally we had 4 cases in our
series. Ventricular septal rupture after myocardial infarction is
increasingly rare in the percutaneous coronary intervention era but
8
mortality remains high .
There were 4 cases (7.69%) of myocarditis out of which 1 case showed
features of Giant Cell myocarditis and the other three cases had
features of non-specic myocarditis. Incidence of myocarditis is low
and Giant Cell myocarditis is even rarer. Only 1.02 % of all autopsy
cases were diagnosed as myocarditis. 9
Okada et al showed 409 (0.11%)
cases of idiopathic, nonspecic, interstitial, or viral myocarditis and
25 cases (0.007%) as giant cell myocarditis in their study where they
analysed 377,841 autopsy records for Japan from year 1958 to 1977.
We came across one case of electrocution. Little is known about the
morphological changes in the heart in electrocution. Differing
10
anatomical alterations are described .Well documented effects are
acute myocardial necrosis, ischemia with or without necrosis, heart
failure, arrhythmias, hemorrhagic pericarditis and non-specic
electrocardiogram changes. In our case patient probably died of
electric shock and was brought dead.
Other rare lesions such as metastatic squamous cell carcinoma and
tuberculosis were also a part of this study. Cardiac metastases are seen
11
only in % of autopsy where primary tumor is found .Cardiac 9
tuberculosis is extremely rare, mostly involving myocardium and
pericardium. We came across 1 case of tuberculosis involving
myocardium and pericardium. et al came across only 19 cases of Rose
12
cardiac tuberculosis at autopsy over a 27 year period .
One known case of dilated cardiomyopathy was also seen which
showed histo-morphological features of cardiomyopathy. Data on
incidence and prevalence of the disease is ambiguous due to
geographic variations, patient selection and diagnostic criteria
adopted. Incidence of the disease discovered at autopsy was estimated
13
at 4.5 per 100,000 per year in study by et al .Rakar
CONCLUSION
The study describes the histopathology of cardiac lesions on autopsy.
Most common nding in the study was atherosclerosis. Autopsy
studies help in detection of unexpected and unknown pathologies
which can help formulate better management strategies for patients
with similar clinical backgrounds.
REFERENCES
1. Sulegaon R, Kulkarni D, Chulki S. Medicolegal autopsies - Interesting and incidental
ndings. Int J Forensic Sci Pathol. 2015;3(8):156-60.
2. Prabhakaran D, Je emon P, Ro y A. Cardiovascular Diseas es in India : Current
Epidemiology and Future Directions. Circulation. 2016;133(16):1605-20.
3. Marwah N, Sethi B, Gupta S, Duhan A, Singh S. Histomorphological spectrum of
various cardiac changes in sudden death: An autopsy study. Iranian J of Pathol.
2011;6(4):179-186.
4. Garg S, Hasija S, Sharma P, Kalhan S, Saini N, Khan A. A Histopathological analysis of
various heart diseases: an autopsy study. Int J Res Med Sci. 2018; 6(4):1414-18.
5. Joshi C. Postmortem study of histopathological lesions of heart in cases of sudden death
- An incidental ndings. J Evid Based Med Healthc 2016; 3(6), 184-188.
6. Ekta Rani, Kumar S, Mehrolia V. Morphological Patterns in Heart Diseases-An Autopsy
Study. Int. J of Current Advanced Research.2017; 06(08): 5391-5393.
7. Das A, Biswas S, Bandyopadhyay C, Bhattacharya c, Dalal D. Sudden death due to
ventricular free wall rupture following acute myocardial infarction: a rare one. J Indian
Acad Forensic Med. 2013; 35(3): 291-292.
8. Jones BM, Kapadia SR, Smedira NG, Robich M, Tuzcu EM, Menon V, Krishnaswamy
A. Ventricular septal rupture complicating acute Myocardial infarction: A contemporary
review. Eur Heart J. 2014 Aug 14;35(31):2060-8.
9. Okada R, Wakafuji S. Myocarditis in autopsy. Heart Vessels Suppl. 1985;1:23-9.
10. Fineschi V, Di Donato S, Mondillo S, Turillazzi E. Electric Shock: Cardiac effects of
nonfatal injuries and postmortem ndings in fatal cases. Int J Cardiol. 2006; 111(1):6-11.
11. Bussani R, De-Giorgio F, Abbate A, Silvestri F. Cardiac metastases. J Clin Pathol 2007;
60(1):27–34
12. Rose AG. Cardiac tuberculosis. A study of 19 patients. Arch Pathol Lab Med. 1987;
111(5):422–6.
13. Rakar S, SinagraG, Di Lenarda A, Poletti A, Bussani A, Silvestri F, Camerini F and the
Heart Muscle Disease Study Group. Epidemiology of dilated cardiomyopathy A
prospective post-mortem study of 5252 necropsies. Eur Heart J.1997;18(1):117-123
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