Histological examination in sudden unexpected death in infancy: evidence base for histological sampling. J Clin Pathol
Department of Paediatric Pathology, Great Ormond Street Hospital for Children, London, UK and UCL Institute of Child Health, London, UK. Journal of clinical pathology
(Impact Factor: 2.92).
09/2011; 65(1):58-63. DOI: 10.1136/jclinpath-2011-200224
Pathologists currently follow the 'Kennedy guidelines' when performing autopsies for sudden unexpected death in infancy (SUDI); these include extensive histological sampling. This study establishes the frequency with which histological examination of visceral organs determines cause of death and examines associations between clinical, macroscopic and microscopic findings.
Retrospective review of 546 SUDI autopsies performed for a 10-year period (1996-2005) at a single centre. The proportion of cases in which non-neuropathological histological examination directly determined the cause of death was identified, and clinical, macroscopic and histological findings at autopsy were compared.
Of 510 SUDIs included, 166 cases were explained SUDI, and of these, 54% (89/166) were identified solely on microscopic examination, based on histology of the lungs in 71 (43%), heart in 13 (8%), liver in 4 (2%) and kidneys in 1 (<1%). The proportions of macroscopically normal organs with significant histological findings were 26% lungs, 2% heart and 1% each of liver and kidneys, but none of spleen, thymus, pancreas or adrenals. Macroscopically abnormal organs were more likely to yield significant histological features. Symptoms preceding death were more common in cases with significant histological findings in lungs, heart, liver and adrenals.
A non-neuropathological cause of death in explained SUDI can be established from histological examination of lungs, heart, liver and kidneys. Significant histological abnormalities may be detected in selected organs with macroscopically normal appearances. Routine histological sampling of other organs in the absence of specific clinical history or macroscopic abnormalities has a low yield for establishing cause of death.
Available from: Johan Duflou
- "There are important lessons to be learnt, even from this small cohort where caution should be exercised in the post-mortem diagnosis of HCM and lung pathology on MR imaging. Macroscopic lung appearances at post-mortem do not correlate well with histological findings , and similarly post-mortem imaging studies of the lungs have been shown to be inaccurate, except in diagnosing major structural abnormalities . Indeed in our cohort, there was an incorrect diagnosis of pneumonia through MR imaging in a patient whose conventional autopsy diagnosis remained unexplained, while a diagnosis of pulmonary embolism was correctly identified by both MR and CT imaging. "
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Sudden death in the young is a tragic complication of a number of medical diseases. There is limited data regarding the utility of post-mortem Magnetic Resonance (MR) imaging and Computer Tomography (CT) scanning in determining the cause of sudden death. This study sought to compare the accuracy of post-mortem cross-sectional imaging (MR and CT) with the conventional autopsy in determining the cause of sudden death in the young.
Consecutive patients from 2010 to 2012 (aged 1–35 years) who had sudden death were included. Patients were scanned by CT and 1.5 T MR imaging prior to the conventional autopsy being performed. The primary outcome was diagnostic congruence between imaging and conventional autopsy.
In 17 patients studied, the mean age at death was 23 ± 11 years, with a male predominance (n = 12; 71%). The most common cause of death was a primary cardiac pathology (n = 8; 47%), including ARVC (24%) and ischemic heart disease (12%). Non-cardiac causes identified included pulmonary embolism (6%), and aortic dissection (6%). MR imaging correctly identified the diagnosis in 12 patients who subsequently had positive findings at conventional autopsy, while the diagnosis in the remaining 5 cases remained unexplained. MR imaging was found to be highly sensitive (100%) with a high negative (100%) and positive (80%) predictive value.
Dedicated post-mortem MR imaging of the heart and brain is a useful modality in determining the cause of sudden death in children and young adults, particularly in situations where a conventional autopsy cannot be performed for logistic, cultural or personal reasons.
Available from: Christoph Rüegger
- "In such scenarios, analysis of microstructure at the electron microscopic level as well as specific staining, would be informative . However, this is not possible with an imaging-based, non-invasive autopsy approach. "
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ABSTRACT: In light of declining autopsy rates around the world, post-mortem MR imaging is a promising alternative to conventional autopsy in the investigation of infant death. A major drawback of this non-invasive autopsy approach is the fact that histopathological and microbiological examination of the tissue is not possible. The objective of this prospective study is to compare the performance of minimally invasive, virtual autopsy, including CT-guided biopsy, with conventional autopsy procedures in a paediatric population.Methods/design: Foetuses, newborns and infants that are referred for autopsy at three different institutions associated with the University of Zurich will be eligible for recruitment. All bodies will be examined with a commercial CT and a 3 Tesla MRI scanner, masked to the results of conventional autopsy. After cross-sectional imaging, CT-guided tissue sampling will be performed by a multifunctional robotic system (Virtobot) allowing for automated post-mortem biopsies. Virtual autopsy results will be classified with regards to the likely final diagnosis and major pathological findings and compared to the results of conventional autopsy, which remains the diagnostic gold standard.
There is an urgent need for the development of alternative post-mortem examination methods, not only as a counselling tool for families and as a quality control measure for clinical diagnosis and treatment but also as an instrument to advance medical knowledge and clinical practice. This interdisciplinary study will determine whether virtual autopsy will narrow the gap in information between non-invasive and traditional autopsy procedures.Trial Registration: ClinicalTrials.gov: NCT01888380.
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ABSTRACT: Sudden infant death due to dengue virus infection is very rare. An 8-month-old male infant was found unresponsive during a nap in his nursery school. We emphasize the usefulness of dengue viral antigens as a postmortem diagnostic technique to demonstrate the presence of virus in human tissue specimens by immunohistochemistry and Western blotting.
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