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FYFE | MILLER
ii
 Billie Fyfe, MD
Professor of Pathology
Rutgers Robert Wood Johnson Medical School
New Brunswick, New Jersey

Dylan V. Miller, MD
Clinical Associate Professor of Pathology
University of Utah School of Medicine
Director of Electron Microscopy and Immunostains
Intermountain Central Laboratory
Salt Lake City, Utah

iii
 1600 John F. Kennedy Blvd.
Ste 1800
Philadelphia, PA 19103-2899

DIAGNOSTIC PATHOLOGY: HOSPITAL AUTOPSY ISBN: 978-0-323-37676-1

Copyright © 2016 by Elsevier. All rights reserved.

No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including
photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Details
on how to seek permission, further information about the Publisher’s permissions policies and our arrangements with organizations
such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/
permissions.

This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be
noted herein).

Notices

Knowledge and best practice in this field are constantly changing. As new research and
experience broaden our understanding, changes in research methods, professional practices,
or medical treatment may become necessary.

Practitioners and researchers must always rely on their own experience and knowledge in
evaluating and using any information, methods, compounds, or experiments described
herein. In using such information or methods they should be mindful of their own safety
and the safety of others, including parties for whom they have a professional responsibility.

With respect to any drug or pharmaceutical products identified, readers are advised to check
the most current information provided (i) on procedures featured or (ii) by the manufacturer
of each product to be administered, to verify the recommended dose or formula, the
method and duration of administration, and contraindications. It is the responsibility of
practitioners, relying on their own experience and knowledge of their patients, to make
diagnoses, to determine dosages and the best treatment for each individual patient, and to
take all appropriate safety precautions.

To the fullest extent of the law, neither the Publisher nor the authors, contributors, or
editors, assume any liability for any injury and/or damage to persons or property as a matter
of products liability, negligence or otherwise, or from any use or operation of any methods,
products, instructions, or ideas contained in the material herein.

Publisher Cataloging-in-Publication Data

Diagnostic pathology. Hospital autopsy / [edited by] Billie Fyfe and Dylan V. Miller.
pages ; cm
Hospital autopsy
Includes bibliographical references and index.
ISBN 978-0-323-37676-1 (hardback)
1. Autopsy--Handbooks, manuals, etc. 2. Autopsy--Methods--Handbooks, manuals, etc.
I. Fyfe, Billie. II. Miller, Dylan V. III. Title: Hospital autopsy.
[DNLM: 1. Autopsy--methods--Atlases. QZ 35]
RB57 .I434 2015
616.07/59--dc23

International Standard Book Number: 978-0-323-37676-1

Cover Designer: Tom M. Olson, BA

Printed in Canada by Friesens, Altona, Manitoba, Canada

Last digit is the print number: 9 8 7 6 5 4 3 2 1

iv
 Dedications
To the giants who patiently mentored me at Mayo Clinic (Drs. Edwards, Parisi,
       
Baldwin basement and later Stabile 9. To Drs. Collins and Sinard and many
colleagues on the CAP Autopsy Resource Committee for opening my eyes to a
wider world of pathology practice. To the many able minds who helped conceive,
gestate, and deliver the book’s content and whose names dignify its pages. To
Dave, Angie, and Kellie at Amirsys/Elsevier for their patience and trust. And most
of all to Tonya, for her undying tolerance and support.

DVM

This book is dedicated with gratitude to my mentors, who gave me the courage
and opportunity to pursue autopsy pathology, and to my mentorees, who make
the work so rewarding. This project would not have been possible without
the forward vision of the Amirsys/Elsevier team, especially Angela Terry, who
supported this unique addition to their pathology collection, and the tremendous
expertise shared by Dylan Miller and all of the authors. As always, I must thank
my sons, Justin and Alexander, who make everything worthwhile, and my
parents, who encouraged me from the beginning.

BF

v
 Contributing Authors
Brandon T. Larsen, MD, PhD Leslie A. Litzky, MD
Assistant Professor of Pathology Professor, Department of Pathology and
Department of Pathology Laboratory Medicine
Banner – University Medical Center Perelman School of Medicine
University of Arizona College of Medicine University of Pennsylvania
Tucson, Arizona Chief, Section of Medical Pathology,
Hospital of the University of Pennsylvania
Subspecialty Director, Thoracic Pathology,
Monica P. Revelo, MD, PhD Section of Surgical Pathology
Professor of Pathology Philadelphia, Pennsylvania
Department of Pathology
University of Utah School of Medicine
Salt Lake City, Utah Harold Sanchez, MD, FCAP
Associate Chief of Pathology
Department of Pathology
Rebecca A. Irvine, MD, FRCPA Hospital of Central Connecticut
        New Britain, Connecticut
     
        
Glebe, NSW, Australia Roy H. Rhodes, MD, PhD
Professor
Director, Neuropathology
George P. Batsides, MD Medical Director, RWJUH EM Services
Assistant Professor of Surgery Department of Pathology
Chief, Section of Cardiac Surgery Rutgers Robert Wood Johnson Medical School
Surgical Director, Mechanical Circulatory Support New Brunswick, New Jersey
Division of Cardiac Surgery
Rutgers Robert Wood Johnson Medical School
New Brunswick, New Jersey Paisit Paueksakon, MD
Associate Professor
Associate Director
     Division of Renal Pathology/Electron Microscopy
Anatomic and Clinical Pathology Resident   !
Department of Pathology Department of Pathology, Microbiology, and Immunology
Rutgers Robert Wood Johnson Medical School Vanderbilt University Medical Center
New Brunswick, New Jersey Nashville, Tennessee

Christine Minerowicz, MD Hasini Reddy, MD, DPhil

Resident of Pathology Department of Pathology, Dalhousie University
Department of Laboratory Medicine and Pathology Director of Neuropathology
Rutgers Robert Wood Johnson Medical School The Moncton Hospital
New Brunswick, New Jersey Moncton, New Brunswick, Canada

vi
 Rachel Hudacko, MD
Medical Director, Department of
Pathology/Laboratory
St. Anthony Community Hospital
Warwick, New York
Clinical Instructor, Department of Pathology
Rutgers Robert Wood Johnson Medical School
New Brunswick, New Jersey

Patrick Lento, MD
Professor of Clinical Pathology and Medicine
New York Medical College
Valhalla, New York

Corinne L. Fligner, MD
Professor, Department of Pathology
Adjunct Professor, Department of
Laboratory Medicine
Director, Autopsy and After Death
Services, UW Pathology
University of Washington
Seattle, Washington

Vidhya Nair, MBBS, MD, FRCPC

Associate Professor
Department of Pathology and Molecular Medicine
McMaster University
Cardiovascular Pathologist, Hamilton Health Sciences
Hamilton, Ontario, Canada

Elizabeth H. Hammond, MD
Professor of Pathology and Adjunct Professor
of Medicine (Cardiology)
University of Utah School of Medicine
Pathology Consultant
Intermountain Healthcare
Salt Lake City, Utah

vii
viii
 Preface
Declining rates of hospital autopsies have not diminished the enthusiasm of those of us who
   " #$% & %  '    *    
'   " !   #

Engaging young pathologists in autopsy is vital to preserving what is arguably the bedrock of all
pathology knowledge. This volume aims to present the hospital autopsy as it is really practiced
— with real case presentations, approaches to dissection, chart review focusing, and reporting
% #$          +% &&    
trainees and new pathologists, as well as those who unfortunately don’t get the chance to
perform autopsies routinely.

The format follows other volumes related to surgical pathology in the Diagnostic Pathology
# " "   %   '  %   !   *% %   
sense as a way to emphasize the role that autopsy plays in modern medicine. Making diagnoses
 %         %        
processes in surgical pathology.

One key distinction between autopsy and surgical pathology is the number of stakeholders
 *  %   -"    ' 0    
    % #1 %     ' !  2%    
autopsies, impact families and communities through the answers that the autopsy can provide,
and help pathologists enjoy the diagnostic journey.

Billie Fyfe, MD
Professor of Pathology
Rutgers Robert Wood Johnson Medical School
New Brunswick, New Jersey

Dylan V. Miller, MD
Clinical Associate Professor of Pathology
University of Utah School of Medicine
Director of Electron Microscopy and Immunostains
Intermountain Central Laboratory
Salt Lake City, Utah

ix
x
Acknowledgments
Text Editors
Dave L. Chance, MA, ELS
Arthur G. Gelsinger, MA
Nina I. Bennett, BA
Sarah J. Connor, BA
Tricia L. Cannon, BA
$#
Lisa A. Gervais, BS

Image Editors
3 3#  4
Lisa A. M. Steadman, BS

Medical Editor
Michael B. Ward, MD

Illustrations
Lane R. Bennion, MS
Laura C. Sesto, MA
Richard Coombs, MS

Art Direction and Design

Tom M. Olson, BA
Laura C. Sesto, MA

Lead Editor
Angela M.G. Terry, BA

Production Coordinators
Angela M.G. Terry, BA
Rebecca L. Hutchinson, BA

xi
xii
 Sections
PART I - Autopsy Fundamentals
56$178-1 % 
56$179-%    
56$17:-%  6    

PART II - Organ System Approach to Autopsy

56$178-% ;'   
56$179-   < &1    

PART III - Disease Process Approach to Autopsy

56$178-$    
56$179-1 &  
56$17:-   &   
56$17=-7 6>   

xiii
 Endocrine System I-2-54
PART I Billie Fyfe, MD

Central Nervous System I-2-60

Autopsy Fundamentals Hasini Reddy, MD, DPhil

Peripheral Nervous System I-2-66

SECTION 1 Roy H. Rhodes, MD, PhD

Introduction Integumentary System I-2-70

Dylan V. Miller, MD
History of Autopsy I-1-2 Oral Cavity I-2-74
Harold Sanchez, MD, FCAP & Rebecca A. Irvine, MD,
Billie Fyfe, MD
FRCPA
Medical Devices I-2-78
Autopsy Safety I-1-6
Brandon T. Larsen, MD, PhD
Billie Fyfe, MD
Laboratory Testing
SECTION 2 Chemistry I-2-82
Autopsy Performance Rachel Hudacko, MD

Microbiology I-2-84
External Examination Harold Sanchez, MD, FCAP & Rebecca A. Irvine, MD,
FRCPA
Medical Intervention I-2-8
Brandon T. Larsen, MD, PhD Cytology I-2-88
Harold Sanchez, MD, FCAP & Rebecca A. Irvine, MD,
Postmortem Changes and External Examination I-2-12 FRCPA
Billie Fyfe, MD
Postmortem Imaging
Internal Examination Postmortem Radiography and Virtual Autopsy I-2-94
Body Cavities I-2-16 Billie Fyfe, MD
Harold Sanchez, MD, FCAP & Rebecca A. Irvine, MD,
FRCPA

Cardiovascular System I-2-20

SECTION 3
Dylan V. Miller, MD Autopsy Consent and Reporting
Respiratory System I-2-24
Leslie A. Litzky, MD
Autopsy Consent
Consent Process and Legal Considerations I-3-100
Hematopoietic System I-2-28
Dylan V. Miller, MD
Harold Sanchez, MD, FCAP & Rebecca A. Irvine, MD,
FRCPA
Autopsy Reporting
Gastrointestinal System I-2-34 Death Certificate I-3-102
Harold Sanchez, MD, FCAP & Rebecca A. Irvine, MD,
Billie Fyfe, MD
FRCPA
Autopsy Report I-3-106
Hepatobiliary System I-2-42
Corinne L. Fligner, MD & Dylan V. Miller, MD
Rachel Hudacko, MD & Jeanine Chiaffarano, DO
Presenting Autopsy Findings I-3-108
Genitourinary System I-2-48
Harold Sanchez, MD, FCAP & Rebecca A. Irvine, MD,
Harold Sanchez, MD, FCAP & Rebecca A. Irvine, MD,
FRCPA
FRCPA

xiv
 Genitourinary
PART II Pregnancy Complications II-1-68
Organ System Corinne L. Fligner, MD

Approach to Autopsy Acute Renal Failure II-1-74

Monica P. Revelo, MD, PhD & Paisit Paueksakon, MD

Endocrine
SECTION 1 Adrenal Insufficiency II-1-84
Sudden and Unexpected Death Dylan V. Miller, MD

Adrenocortical Excess II-1-88

Cardiovascular Patrick Lento, MD
Pulmonary Thromboembolism II-1-2
Billie Fyfe, MD CNS
Acute Myocardial Infarction II-1-4 Seizure Disorders II-1-92
Vidhya Nair, MBBS, MD, FRCPC & Dylan V. Miller, MD Hasini Reddy, MD, DPhil

Cardiomyopathy II-1-8 Subdural Hemorrhage II-1-96

Dylan V. Miller, MD Roy H. Rhodes, MD, PhD

Myocarditis II-1-12 Subarachnoid Hemorrhage II-1-100

Monica P. Revelo, MD, PhD & Dylan V. Miller, MD Roy H. Rhodes, MD, PhD

Cardiac Conduction System II-1-18 Stroke II-1-104

Dylan V. Miller, MD Hasini Reddy, MD, DPhil

Aortic Dissection II-1-24

Billie Fyfe, MD SECTION 2
Abdominal Aortic Aneurysm II-1-30 Postoperative/Post-
Billie Fyfe, MD Interventional Death
Respiratory Iatrogenic
Pulmonary Edema II-1-32
Therapeutic Complications II-2-110
Leslie A. Litzky, MD
Billie Fyfe, MD
Pulmonary Hemorrhage II-1-36
Leslie A. Litzky, MD
Cardiovascular
Coronary Artery Bypass Grafting II-2-114
Tension Pneumothorax II-1-40
Dylan V. Miller, MD
Leslie A. Litzky, MD
Coronary Artery Stenting II-2-118
Gastrointestinal Dylan V. Miller, MD
Upper Gastrointestinal Hemorrhage II-1-44
Valve Replacement (Including Transcatheter) II-2-122
Harold Sanchez, MD, FCAP & Rebecca A. Irvine, MD,
Brandon T. Larsen, MD, PhD
FRCPA
Ventricular Assist Devices II-2-128
Lower Gastrointestinal Hemorrhage II-1-48
Brandon T. Larsen, MD, PhD
Rachel Hudacko, MD & Jeanine Chiaffarano, DO
Thoracic Aortic Aneurysm Repair II-2-132
Intestinal Ischemia II-1-52
Billie Fyfe, MD & George P. Batsides, MD
Rachel Hudacko, MD & Jeanine Chiaffarano, DO

Hepatobiliary Gastrointestinal and Hepatobiliary

Pancreas Resection II-2-138
Hepatic Hemorrhage II-1-56
Rachel Hudacko, MD & Jeanine Chiaffarano, DO
Rachel Hudacko, MD & Jeanine Chiaffarano, DO
Gastrectomy and Esophagectomy II-2-142
Hemorrhagic Pancreatitis II-1-60
Rachel Hudacko, MD & Jeanine Chiaffarano, DO
Rachel Hudacko, MD & Jeanine Chiaffarano, DO
Bariatric Surgery II-2-146
Acute Liver Failure II-1-64
Rachel Hudacko, MD & Jeanine Chiaffarano, DO
Rachel Hudacko, MD & Jeanine Chiaffarano, DO

xv
 CNS Urosepsis III-2-64
Harold Sanchez, MD, FCAP & Rebecca A. Irvine, MD,
Central Nervous System Tumors II-2-150 FRCPA
Roy H. Rhodes, MD, PhD

Cerebral Aneurysm and Vascular Malformation II-2-156 SECTION 3

Roy H. Rhodes, MD, PhD
Neoplasia-Associated Death

PART III Neoplasia-Associated Death

Billie Fyfe, MD
III-3-68

Disease Process Death Due to Paraneoplastic Effect III-3-74

Approach to Autopsy Harold Sanchez, MD, FCAP & Rebecca A. Irvine, MD,
FRCPA

SECTION 1 SECTION 4
Transplantation Other Common Hospital Death
Heart Transplant III-1-2 Chronic Obstructive Pulmonary Disease III-4-78
Dylan V. Miller, MD & Elizabeth H. Hammond, MD Harold Sanchez, MD, FCAP & Rebecca A. Irvine, MD,
FRCPA
Lung Transplant III-1-8
Leslie A. Litzky, MD Ventilator Dependent Respiratory Failure III-4-82
Leslie A. Litzky, MD
Kidney Transplant III-1-12
Monica P. Revelo, MD, PhD & Paisit Paueksakon, MD Chronic Liver Failure III-4-86
Rachel Hudacko, MD & Jeanine Chiaffarano, DO
Liver Transplant III-1-22
Rachel Hudacko, MD & Patrick Lento, MD Chronic Renal Failure III-4-92
Monica P. Revelo, MD, PhD & Paisit Paueksakon, MD
Pancreas Transplant III-1-28
Monica P. Revelo, MD, PhD Dementia and Neurodegenerative Disease III-4-100
Hasini Reddy, MD, DPhil
Bone Marrow Transplant III-1-32
Dylan V. Miller, MD

Deceased Donor Autopsy III-1-36

Billie Fyfe, MD

SECTION 2
Infection-Related Death
Systemic Infection/Sepsis Overview
HIV/AIDS III-2-38
Harold Sanchez, MD, FCAP & Rebecca A. Irvine, MD,
FRCPA

Shock and Sepsis III-2-42

Billie Fyfe, MD & Christine Minerowicz, MD

Organ System Infection

Bronchopneumonia III-2-48
Leslie A. Litzky, MD

Infective Endocarditis III-2-52

Dylan V. Miller, MD

Clostridium difficile Enterocolitis III-2-56

Billie Fyfe, MD

Viral Hepatitis III-2-60

Rachel Hudacko, MD & Jeanine Chiaffarano, DO

xvi
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This page intentionally left blank
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