Newly recognized cerebral infarctions on postmortem imaging: a report of three cases with systemic infectious disease

Abstract

BackgroundPostmortem imaging (PMI) refers to the imaging of cadavers by computed tomography (CT) and/or magnetic resonance imaging (MRI). Three cases of cerebral infarctions that were not found during life but were newly recognized on PMI and were associated with severe systemic infections are presented.Case presentationsAn 81-year-old woman with a pacemaker and slightly impaired liver function presented with fever. Imaging suggested interstitial pneumonia and an iliopsoas abscess, and blood tests showed liver dysfunction and disseminated intravascular coagulation (DIC). Despite three-agent combined therapy for tuberculosis, she died 32 days after hospitalization. PMI showed multiple fresh cerebral and cerebellar infarctions and diffuse ground-glass shadows in bilateral lungs. On autopsy, the diagnosis of miliary tuberculosis was made, and non-bacterial thrombotic endocarditis that involved the aortic valve may have caused the cerebral infarctions.A 74-year-old man on steroid therapy for systemic lupus erythematosus presented with severe anemia, melena with no obvious source, and DIC. Imaging suggested intestinal perforation. The patient was treated with antibiotics and drainage of ascites. However, he developed adult respiratory distress syndrome, worsening DIC, and renal dysfunction and died 2 months after admission. PMI showed infiltrative lung shadow, ascites, an abdominal aortic aneurysm, a wide infarction in the right parietal lobe, and multiple new cerebral infarctions. Autopsy examination showed purulent ascites, diffuse peritonitis, invasive bronchopulmonary aspergillosis, and non-bacterial thrombotic endocarditis that likely caused the cerebral infarctions.A 65-year-old man with an old pontine infarction presented with a fever and neutropenia. Despite appropriate treatment, his fever persisted. CT showed bilateral upper lobe pneumonia, pain appeared in both femoral regions, and intramuscular abscesses of both shoulders developed. His pneumonia worsened, his level of consciousness decreased, right hemiplegia developed, and he died. PMI showed a newly diagnosed cerebral infarction in the left parietal lobe. The autopsy revealed bilateral bronchopneumonia, right-sided pleuritis with effusion, an intramuscular abscess in the right thigh, and fresh multiple organ infarctions. Systemic fibrin thrombosis and DIC were also found. Postmortem cultures showed E. coli and Burkholderia cepacia.ConclusionCerebral infarction that is newly recognized on PMI might suggest the presence of severe systemic infection.Electronic supplementary materialThe online version of this article (doi:10.1186/s12880-016-0174-4) contains supplementary material, which is available to authorized users.

Non-infectious thrombotic endocarditis associated with chronic rheumatic heart disease and disseminated tuberculosis

“…In autopsy series study of NBTE by Llenas-García et al 5 tuberculosis was associated in 3 cases (13.6% of total), of which one case also had systemic lupus erythematosus. In the post-mortem imaging study by Noriki et at, 6 one case with military tuberculosis also showed NBTE involving the aortic valve as a cause for emboli causing cerebral infarction. Though the precise pathogenetic association between tuberculosis and NBTE is not clear, endothelial damage and exposure of the subendothelial collagen to platelets as a result of septicemia may be the basic mechanism for the formation of thrombi over leaflets.…”

Pathological analysis of cadavers for educational dissection by using postmortem imaging

“…The PMI was performed at the Ai center at the University of Fukui, 3 months before dissection, using an 8‐slice multi‐detector CT scanner (Hitachi Medico, Tokyo, Japan) used exclusively for autopsies, as described previously . The corpus was placed in the supine position, and a full‐body scan from the vertex to the toes was performed.…”

“…First, two radiologists (KK and TS) read the postmortem images of the corpus without any medical information and deduced the immediate cause of death. The algorithm for diagnosis is described in a previous article . Then, the anatomy instructor (SI) revealed the medical information.…”

“…The PMI was performed at the Ai center at the University of Fukui, 3 months before dissection, using an 8-slice multi-detector CT scanner (Hitachi Medico, Tokyo, Japan) used exclusively for autopsies, as described previously. [24][25][26] The corpus was placed in the supine position, and a full-body scan from the vertex to the toes was performed. The scanning conditions were 120 kV, 250 mA, 8 × 2.5 collimation, 1.125 pitch, 0.8 s rotation time, 5 mm slice thickness and 5 mm increments.…”

“…The algorithm for diagnosis is described in a previous article. [24][25][26] Then, the anatomy instructor (SI) revealed the medical information. The medical information concerning the corpus included only the age, sex, cause of death and the place of death described in the death certificate.…”