help me with diagnosis of ...

[Ra7]

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hello
this is a case in a forensic department, i have difficulty in Interpretation of the results of the autopsy gross pathological findings and the histopathological report to reach a final diagnosis and cause of death

CIRCUMSTANCES OF DEATH
the decedent has got a history of rheumatic heart disease diagnosed in his teenage period , not on regular medical follow up , two weeks back he was complaining of chest pain, he went to the clinic and treated conservatively (analgesic treatment) ,no other important relevant medical history.

Heart dissection revealed enlarged heart, heart weight was about 700 gm , all coronaries were patent with bridging formation of left anterior descending coronary , thickening of the myocardium were noticed (left ventricular wall thickness is about 2.4 cm) and calcifications and erosions of the aortic valve noticed beside noticeable narrowing above the valve cusped, the area of narrowing measuring about 3.5 cm , there was massive adhesions of Both lungs and congestion were noticed in both of them.
Both kidneys showed pus formation on cross section

Pathology<O😛</O😛
The heart was sent completely and kidneys tissues also sent the result was:-<O😛></O😛>
The heart :- focal myocardial fibrosis, Valve (aortic) showed marked thickening of matrix with interstial fibrosis and signs of chronic inflammation and focal hemorrhage .<O😛></O😛>
Kidneys:- showed increased ischemia with focal glomerular hyalinization

heart left ventricl



heart left ventricle



Lung gross appearnce

more pics in next post

waiting for expert help

 

[Ra7]

another one

 

[Ra7]

mitral valve is o.k

 

[KeratinPearls]

It's not appropriate to seek consultation via the internet.

 

[Ra7]

i know
it is just a training case for me
still waiting for guideline

 

[pathstudent]

It's not appropriate to seek consultation via the internet.

Why not? It is done all the time now. I have seen many consultation cases where the slides are scanned in and viewed via a web-based virtual scope.

 

[tardieu]

You didn't say how old your decedent was. Your description of "focal glomerular hyalinization" makes me think he's in the second half of the average life span. You also don't give the circumstances of death - was the decedent witnessed to collapse suddenly when in apparent good health, or did he die after a long hospital course? Since you say it's a "forensic" case, I'm assuming it's more toward the former end of the spectrum.

The findings you decscribe sound like typical calcific aortic stenosis with sencodary cardiac hypertrophy and a resulting touch of heart failure. The mechanism of death in this case could be arrhythmia in that context.

Another possibility is RHD, given the history of RF. That can also lead to aortic stenosis and secondary hypertrophy, which can be helped along by chronic myocarditis (remember Aschoff bodies and Anitschkow cells? - path board darlings, btw). However, the mitral valve is almost always involved in RHD, and you say it's normal. According to the books that can happen in rare cases. The mechanism of death here could also be arrhythmia, but different underlying cause.

It's also possible the decedent died from an entirely uncardiac cause. With just your limited info, I can not rule that out.

I'm ignoring the "pus" in the kidneys because autopsy kidneys often exude a small amount of murky fluid when you cut them. I think it's just urine clouded by sloughed epithelium. Esp since your micro did not describe acute inflammation. Also, the kidney "ischemia" is likely autolysis (see kidney post).

 

[Ra7]

Tradiue many thanks to you for your great help
the decedent is 35 year old man thin. regarding circumstances of death, two weeks prior to his death he was complaining of chest pain, still ill, till the man died at home
i can not say it was sudden death since he was ill for two weeks
the medical history is poor cause the man was living in a distant rural area.
my problem was linking his death to RHD but his mitral valve was normal. or to aortic valve disease, Septicemia , or somthing else.
second thing regarding the kidneys some says it has granular surface but to me, it dose not show the typical granular kidney appearance
thanks again

 

[jackypath]

It's not appropriate to seek consultation via the internet.

Of course you can, as far as it cannot be linked with an id. However, we may need better images.

 

[djmd]

Why not? It is done all the time now. I have seen many consultation cases where the slides are scanned in and viewed via a web-based virtual scope.

What Kertinpearls mean is that it is not appropriate to seek consultation from an "anonymous" forum board... actual consultation cases done electronically are different...


It fine for people to post cases here as interesting cases.. and in theory people are free to post unknown cases but attempting to gain clinical dx, from this forum is fraught with legal problems.. (both for the person asking and for the advice giver)

Yaah is the moderator and the expert on what crosses the line on this...

 

[yaah]

This is borderline. Occasionally we get people posting autopsy or other info in an attempt to phish out medicolegal advice. This post seems to be from an actual pathologist or trainee who is seeing what others think. It's not really the purpose of the forum to seek out help for homework or cases, however. I would strongly encourage anyone to not respond to anything they think is potentially medical-legal. And I would even more strongly encourage people not to take anything they see posted about a case as gospel truth, especially because we rarely know the whole story.

 

[salt]

aww cmon. wth all due respect i think you guys are over blowing your own importance. "fraught with legal problems"? cite me a case where a poster or postee on a f0rum such as this has gotten into legal trouble by crapping on about some medical issue. Especially a medicolegal (or "medical-legal", however your prefer) issue. People fashion lucrative careers out of spouting wholesale SHE-ITE about medical matters in infomercials 24/7, and about medical-legal matters quite publically and completely nonymously every day in courts of law all over the nation. Do you really think there's some kind of evidence based truth patrol monitoring this forum?

Despite the danger involved, I take the OP at face value as seekiing help with some sort of study case or even (and I like to live on the edge) an actual case. Why shouldn't this forum be used to help out with homework or actual work? Or is its proper purpose is just to vent neuroses about job prospects and and salaries?

 

[yaah]

It's not really to overblow our own importance, most of it is to protect the site itself, as well as to prevent it from becoming something we do not want it to be. SDN does not want to become a repository for patient claims, medical advice, and lawyer consultation. As you said it is a stretch to foresee how the site will be involved, but there are issues that I don't need to get into. Suffice it to say that the mission of SDN is to foster discussion between students and practitioners of medical fields, not to foster discussion amongst these individuals and those outside the field who want their medical questions answered. That's probably the main reason. I do not know of any case where a virtually anonymous internet poster could ever be held legally liable for posting some advice or whatever. That would be a major stretch.

All of this is much less of a problem in the residency forums. But the premed exam forums, in particular, can quickly become a repository for "homework help" questions. And we get people posting medical advice questions daily in various forums.

 

[Ra7]

hello again
this case is a training case .. I posted here to get some usefull guidelines and comments.
I don't see any medicolegal risk of giving opinion.

best regards

 

[salt]

It's not really to overblow our own importance, most of it is to protect the site itself, as well as to prevent it from becoming something we do not want it to be. SDN does not want to become a repository for patient claims, medical advice, and lawyer consultation. As you said it is a stretch to foresee how the site will be involved, but there are issues that I don't need to get into. Suffice it to say that the mission of SDN is to foster discussion between students and practitioners of medical fields, not to foster discussion amongst these individuals and those outside the field who want their medical questions answered. That's probably the main reason. I do not know of any case where a virtually anonymous internet poster could ever be held legally liable for posting some advice or whatever. That would be a major stretch.

All of this is much less of a problem in the residency forums. But the premed exam forums, in particular, can quickly become a repository for "homework help" questions. And we get people posting medical advice questions daily in various forums.

fair enough. it is SDNs site and sDN can do what it wishes to channel the site use in whatever direction it wants. "fraught with legal problems" really means violating SDN site use preferences. And people are strongly encouraged not to respond to theswe kind of posts to "protect" the site , nothing more. htat's fine too. just keep some perspective.

now, Post away all you people who obsess about THE "top" x residency prgrams and quake in fear over pod labs and wnat advice about X-boxes. Just don't bother all these pathologists by aksing for help on your pathology study case.

 

[djmd]

fair enough. it is SDNs site and sDN can do what it wishes to channel the site use in whatever direction it wants. "fraught with legal problems" really means violating SDN site use preferences. And people are strongly encouraged not to respond to theswe kind of posts to "protect" the site , nothing more. htat's fine too. just keep some perspective.

now, Post away all you people who obsess about THE "top" x residency prgrams and quake in fear over pod labs and wnat advice about X-boxes. Just don't bother all these pathologists by aksing for help on your pathology study case.

Seeing as you are neither comment on this case, nor any other pathology related comments, I don't see how you are elevating the discussion.

I didn't say this case was "fraught with legal problems." I merely pointed out why KP said seeking consultation on these forum is frowned upon.

And lastly this is not a "study case" it is an actual autopsy, and if it were a study case then should we being doing a medical student/resident's homework?

 

[salt]

...it is not appropriate to seek consultation from an "anonymous" forum board... attempting to gain clinical dx, from this forum is fraught with legal problems.. (both for the person asking and for the advice giver)

This admonition and grave warning are stated pretty flatly and as if they are the "gospel truth." various verions of same are repeated here on a regular basis. I call BS. agian, cite me a case where someone has actually got into legal trouble by posting or reading or even following medical or medical-legal commnets, information, consultation, or whatever about study cases or real cases or fantasy cases or anything at all on an "anonymous" forum board like this one.

If you don't want to help residents with their "homework" - Fine. (You are a credit to your "attending" status.) If SDN does not want thier forum used in that way- it is their show. Fine again. But statements like "attempting to gain clinical dx, from this forum is fraught with legal problems.. " is just the kind of baseless BS that pretentious self appointed "appropriate posting police" fart out and other wannabe knowitalls suck in and "elevate disscussions" by repeating while wagging their fingers without ever bothering to devote 2 seconds of rational thought to examining whether or not such a thing is or even ever could be true. Why do they do it? To sound authoritative? Self important? Holier than thou? Get over yourself.

 

[djmd]

If you don't want to help residents with their "homework" - Fine. (You are a credit to your "attending" status.)

You are a credit to your unlisted status with your anonymous ad hominem attacks...

I help people (students, techs, other attendings) all the time, both on this forum and in real life.


Given that "curbside consults" can be used in lawsuits (and have had damages awarded), I don't see how suggesting that people behave with that in mind while responding to medical questions on this or any other forum.

Additionally, given the established danger of "curbside consults", I doubt any malpractice lawyer would say that internet forums are without potential legal implications. (so to counter I would say the burden of proof lies with you, to provide some legal proof or opinion that there is no legal implication)

 

[salt]

You are a credit to your unlisted status with your anonymous ad hominem attacks...

I help people (students, techs, other attendings) all the time, both on this forum and in real life.


Given that "curbside consults" can be used in lawsuits (and have had damages awarded), I don't see how suggesting that people behave with that in mind while responding to medical questions on this or any other forum.

Additionally, given the established danger of "curbside consults", I doubt any malpractice lawyer would say that internet forums are without potential legal implications. (so to counter I would say the burden of proof lies with you, to provide some legal proof or opinion that there is no legal implication)

By that logic, anyone can say that anything is not “without potential legal implications” and the burden of proof is on the rest of the world to proove them wrong. So let’s not do or say anything to anyone lest we get our asses sued.

“Curbside consults” and posting/reading medical or medical-legal comments about cases ranging from the insightful to the innane on message boards like this and on TV and in magazines and newspapers and drug co ads, and faith healing testimonials, and naturopathic medicine conferneces, etc ,m etc, ect happen all the time with utter impunity. All I’m askiing for is a – as in one single– actual example where someone has in the real world suffered some sort of legal consequence from posting or reading that kind of thing on a forum like this. Just some shred of evidence from the real world to back up the frequently stated claim that there’s a legal risk to posting or reading advice, input, whatever you wnat to call it about a case pretend or real in a forum like this. People self-rightously bandy about the "certainty” of the legal danger in all too knowing tones without ever seeming to qeustion its validity. So bring something. Is that too much to ask?

Besides, no one really gets sued for “curbside consulting”. People get sued because someone thinks they can make a case that they were “harmed”. Curbside consulting or reading garbage on internet forums is not going to harm anyone. Only if you act on it and do something someone wants to sue you for are you at risk. Then the fact that you “educated” yourself by getting advice from a forum like this one may, MAY, be used as evidence to show that you are a cavalier, careless or gullible person who simply believes and are guided by what other people post on anonymous internet forums without verifying it with any real evidence. (sound familiar?). And I suppose the other improbable way it could bite you is if you yourself provided some unsubstantiated not backed up by any evidence advice to someone (sound familiar?) who then in turn believed it and acted on it and then someone wanted to sue that person and then that person said they got the advice from you and then somehow someone tracked you down through this annonymous forum and hauled you into court. Possible? I suppose. But how likely? Even the venerated moderator yaah said it is a big stretch or something like that. So either cough up some acutal evidence – and I'd even accept a made up quote from some pretend "maparctice lawyer"- or man up and admit that when you siad "fraught with legal problems, etc" you were simply blowing somke out your external anal sphincter. cmon, this is an anonymous internet forum. No one will ever know it was "you' what slung such wholesale BS.

And btw, this is hardly an “ad hominem attack”. Do you know what that means? Or do you throw around little Latin phrases in the same pretentious and uninformed way you wag your little finger? the key to an ad hominem fallacy is to reject what someone says because of some irrelavent fact about them. I don’t disagree with your BS statement because, for example, I don’t like your anonymous SDN user name. I disagree with your BS statement because I think it’s BS, UNTIL PROVEN OTHERWISE. I also clearly state that the same thing you siad is said by others on a regular basis. So despite that you may think this is all about you, it isn’t.

 

[yaah]

OK, let's end that discussion please. It isn't productive any longer. Will close the thread if it continues.

 

[salt]

OK, let's end that discussion please. It isn't productive any longer. Will close the thread if it continues.

well since the discussion pretty much is the thread, ending the dicsussion pretty much closes the thread. OK by me. (Unless gthat is someone else want to risk professional disgrace and financial ruin by helping the original poster interpret his blurry autopsy photos.)