An Autopsy Case Discussion

Case History
• A deceased- 55 year old male
• Cause of Death as mentioned in the postmortem report
was severe internal injuries as he was badly beaten.

His POST-MORTEM FINDINGS were:

• External Appearance
Subject was averagely built and nourished. Rigor
mortis was present. PM staining was present on back and
dependent parts of body. B/L pupils were dilated and
fixed. There was no visible external injury seen over
whole body from head to toe.
 • Cranium & Spinal Cord- healthy , NAD
• Thorax-
1. Walls, Ribs , Cartilages –healthy , NAD
2. Pleurae- B/L pleura thickened , adherent to lungs.
3. Larynx & Trachea - healthy , hyoid bone, thyroid
cartilage and tracheal rings were intact .
4. Lungs- B/L lungs show fibrosis, scarring of
parenchyma on multiple sites with greyish brown in
color, mostly on upper, middle lobes.
5. Pericardium - healthy , NAD.
6. Heart- Right side was full of blood and left side
empty.
7. Large Vessels - healthy , NAD.
 • Abdomen
1. Walls - healthy , NAD
2. Peritoneum – healthy , NAD
3. Mouth, pharynx, and contents – healthy , NAD
4. Stomach & its contents - healthy , NAD, contain
semi digested food.
5. Small & Large intestine & its contents – healthy ,
NAD.
6. Liver- congested
7. Spleen- slightly enlarged , congested
8. Kidneys- congested
9. Bladder- empty
 • Muscles , Bones and Joints
1. Injury - Nil
2. Diseases or deformity - Nil
3. Fracture - Nil
4. Dislocation- Nil
ON GROSSING-

Received a jar containing two pieces of lungs

weighing 51 gm & 30 gm, measuring 10 x 6 x 1 cm
and 10 x 5 x 1 cm respectively. External surface is
covered with pleura which was thickened. Cut
surface is greyish black with intervening greyish
white firm areas.
One section from each piece was given.
Microscopically

H & E stained sections showing 2

sclerotic nodules in this focus with
component of diffuse interstitial
fibrosis, inflammation , dilated and
emphysematous alveoli.
A single arteriole is seen entrapped in
the zone of fibrosis.
Sclerotic Nodule- Central large zone
of collagenisation seen as pink
eosinophilic bundles arranged in
concentric fashion surrounded by
numerous fibroblasts, carbon laden
macrophages, few lymphocytes &
plasma cells.
Hard granuloma
comprising of
epithelioid cells,
fibroblasts intermixed
with inflammatory cells.
Interstitial pneumonia
with fibrosis.
Dilated cystic
spaces with
proliferating
pneumocytes with
interstitial
fibrosisand foci of
emphysematous
changes.
Honeycombing seen , dilated
spaces with thickened walls.
Fibroblastic foci
changing into
sclerotic nodule
with changes of
emphysematous
and honey
combing seen.
Reticulin Stain
Van Gieson’s
Stain
 Masson’s Trichome Stain

Arteriole entrapped in interstitial fibrosis Sclerotic Nodule with interstitial fibrosis

 Masson’s Trichome Stain

Sclerotic nodule with interstitial fibrosis

 Diagnosis???
• Chronic Diffuse Interstitial (Restrictive)
Fibrosing Lung Disease
Differential Diagnosis of Fibrosing Chronic
Diffuse Interstitial Diseases
• Idiopathic Pulmonary Fibrosis (Usual interstitial
pneumonia
• Chronic stage of Farmer’s Lung progressing into
diffuse pulmonary fibrosis
• Nonspecific interstitial pneumonia
• Cryptogenic organising pneumonia
• Associated with connective tissue disorder
• Pneumoconiosis
• Drug Reactions
• Radiation pneumonitis
Differential Diagnosis
• Silicosis
• Chronic Stage of Farmer’s Lung caused by Moldy
hay (type of Hypersensitivity pneumonitis)
• Idiopathic Pulmonary Fibrosis
 Silicosis Farmer’s Lung Idiopathic
Pulmonary Fibrosis

GROSSLY Tiny, barely palpable Firm greyish white The pleural surfaces of
, discrete pale to nodular areas found the lung are
blackened nodules in in advanced stages. cobblestoned as a result
the upper zones of of the retraction of
lungs. On disease scars along the
progression, these interlobular septa. The
nodules coalesce into cut surface shows
hard, collagenous fibrosis (firm , rubbery
scars. Some may white areas ) of the lung
undergo central parenchyma with
softening & lower lobe
cavitation. Thin predominance and a
sheets of calcification distinct distribution in
occur in lymph the sub pleural
nodes (egg shell regions and along
calcification) interlobular septa.
 Silicosis Farmer’s Lung Idiopathic Pulmonary
Fibrosis
Microsc Nodular lesions Chronic forms are The hallmark of UIP is patchy
opically consist of characteristically interstitial fibrosis , which varies
concentric layers include: 1. interstital in intensity and age. The earliest
of hyalinised pneumonitis consisting lesions contain exuberant
collagen primarily of fibroblastic proliferation
surrounded by a lymphocytes, plasma (fibroblastic foci). With time
dense capsule of cells, & macrophages. 2. theses areas become more
more condensed non caseating collagenous and less cellular. The
collagen. On granulomas 3. interstial dense fibrosis causes the
polarised fibrosis , honeycombing destruction of alveolar
microscopy , & micronodularities may architecture and formation of
birefringent progress to diffuse cystic spaces lined by hyperplastic
silica particles fibrosis and obliterative type II pneumocytes or bronchial
are seen. bronchiolitis In some, epithelium (Honeycomb Fibrosis).
intra alveolar infilterate There is mild to moderate
is also present. inflammation within the fibrotic
areas , consisting mostly
lymphocytes and few plasma cells,
neutrophils, eosinophils, and mast
cells. Foci of squamous metaplasia
and smooth muscle hyperplasia
may be present.
Pathophysiology
Signs and Symptoms
▫ Dyspnea & Tachypnea
▫ Dry, hacking cough
▫ Weight loss
▫ Low grade fever
▫ Fatigue
▫ Arthralgias
▫ Myalgias
▫ Clubbing & cyanosis
Diagnosis
• The diagnosis of chronic diffuse interstitial
fibrosing disease is based on the clinical,
laboratory, radiological, and pathological data.
• Physical examination
▫ Fine bibasilar end inspiratory crackles (Velcro
crackles)
▫ Digital clubbing
▫ Pulmonary hypertension: Loud P2 component of
the second heart sound, a fixed split S2, a
holosystolic tricuspid regurgitation murmur,
pedal edema.
Laboratory testing may reveal nonspecific
findings-

• Pulmonary function studies: show restrictive pattern, i.e

RV and TLC is reduced , FVC is decreased but FEV1/FVC is
normal or increased (>70), DLCO is decreased.
• Arterial blood gas analysis: chronic hypoxemia
(common)
• Antinuclear antibodies or rheumatoid factor titres:
The presence of high titres may suggest a connective
tissue disease.
• C-reactive protein level and erythrocyte
sedimentation rate: Elevated but nondiagnostic.
• Complete blood cell count: polycythemia (rare).
Imaging studies
• High resolution computed tomography (HRCT)
scanning: Sensitive, specific, and essential for the
diagnosis of interstitial lung diseases. Demonstrates
patchy, peripheral, subpleural, and bibasilar reticular
opacities.
• Chest radiography: Abnormal findings but lacks
diagnostic specificity. Demonstrate peripheral reticular
opacities (netlike linear and curvilinear densities)
predominantly at the lung bases, honeycombing
(coarse reticular pattern), and lower lobe volume loss.
• Surgical lung biopsy (via open lung biopsy or video
assisted thoracoscopic surgery [VATS][preferred]):
Best sample for distinguishing usual interstitial
pneumonia from other idiopathic interstitial
pneumonias.
Management
• Treatment strategies include:
• The assessment and management of comorbid conditions
according to current practice guidelines, including chronic
obstructive pulmonary disease, obstructive sleep apnea,
gastroesophageal reflux disease, and coronary artery disease.
• Prescribe oxygen therapy in patients with hypoxemia at rest or
with exercise (partial pressure of oxygen [PaO 2] < 55 mmHg or
an oxygen saturation by pulse oximetry [SpO 2] < 88%). The goal
is to maintain an oxygen saturation of at least 90% at rest, with
sleep, and with exertion.
• Lung transplantation.
• Pharmacotherapy
▫ Systemic corticosteroids (eg, prednisone)
▫ Immunosuppressant agents (eg, azathioprine, cyclophosphamide)
▫ Tyrosine kinase inhibitors (eg, nintedanib)
▫ Antifibrotic agents (eg, pirfenidone)
THANK YOU!