Rom J Leg Med [21] 15-18 [2013] DOI: 10.4323/rjlm.2013.15 © 2013 Romanian Society of Legal Medicine Intraoperative death due to nodular amyloidosis cardiomyopathy associated with fat pulmonary embolism Mihai Ceauşu1, Lăcrămioara Luca2, Sorin Hostiuc3,*, Dana Sîrbu4, Adrian Sîrbu4, Ruxandra Negoi5 _________________________________________________________________________________________ Abstract: Cardiac amyloidosis is caused by extracellular deposits containing low molecular weight protein subunits arranged in a beta sheet configuration. By gross examination amyloid deposits are identifiable as localized tan, waxy appearing lesions affecting almost always the atria (usually atrial endocardium), valve leaflets, ventricular, but also in the coronary lumen, sometimes leading to severe coronary stenosis. Fat pulmonary embolism is a known complication of femoral fractures, being more frequent in untreated cases compared to those suffering surgical interventions. We present a case in which a female patient with cardiac amyloidosis died on the operating table, the direct cause of death being fat pulmonary emboli, and discuss the involvement of the associated cardiac amyloidosis in thanatogenesys. Key Words: cardiac amyloidosis, fat embolism, intraoperative death, femoral fracture. ardiac amyloidosis (amyloid associated with fibrous replacement lesions), but also the cardiomyopathy, AC) is caused by coronary lumen, sometimes leading to severe coronary C extracellular deposits containing low molecular weight stenosis (>75%) [5]. protein subunits arranged in a beta sheet configuration, Cardiac amyloidosis is almost always associated leading to restrictive cardiomyopathy [1] and electrical with amyloid deposits located in other organs [5]. The conduction disturbances [2, 3]. extent of amyloid deposition can be graded from 1 to 4 AC may mimic constrictive pericarditis, coronary (less than 10%, 10 to 25%, 26 to 50%, and more than artery disease, valve heart disease, and idiopathic 50% involvement of the myocardium, respectively) hypertrophic or congestive cardiomyopathy [4]. and the pattern of deposits can be classified as nodular, By gross examination amyloid deposits are perifibrilar, or mixed, with or without vascular identifiable as localized tan, waxy appearing lesions involvement [6]. Genetically AC can be primary light affecting almost always the atria (usually atrial chains amyloidosis (AL) or familial transthyretin-related endocardium), valve leaflets, ventricular walls (often (ATTR) amyloidosis. The AL amyloidosis is caused by 1) Lecturer, (a) Carol Davila University of Medicine and Pharmacy, Bucharest, Romania, Dept. of Legal Medicine and Bioethics (b) National Institute of Legal Medicine Bucharest, Dept. of Pathology 2) National Institute of Legal Medicine Bucharest, Dept. of Pathology 3) Assist. Prof., (a) Carol Davila University of Medicine and Pharmacy, Bucharest, Romania, Dept. of Legal Medicine and Bioethics (b) National Institute of Legal Medicine Bucharest, Dept. of Forensic Pathology *Corresponding author: Sos.Vitan Barzesti 9, 042122 Sector 4 Bucuresti, Romania, tel 0040723791072, e-mail: soraer@ gmail.com, [email protected] 4) National Institute of Legal Medicine Bucharest, Dept. of Forensic Pathology 5) Assist.Prof, (a) Carol Davila University of Medicine and Pharmacy, Bucharest, Romania (b) "Prof. Dr. C. C. Iliescu" Institute of Cardiovascular Diseases 15 M. Ceausu et al. Intraoperative death due to nodular amyloidosis cardiomyopathy associated with fat pulmonary embolism the deposition of immunoglobulin light chains (kappa or Histopathology investigation lambda), performed by monoclonal gammopathy. ATTR Material and methods amyloidosis is an autosomal dominant disorder caused Samples of myocardial tissue from two different by the amyloidogenic form of transthyretin, a plasma areas of the anterior wall of the left ventricle were taken protein synthesized in liver [7, 8]. for histopathology investigation. Specimens from brain, Other types of amyloidosis with possible lungs, liver, kidney and spleen were taken as well. cardiac involvement are: senile systemic amyloidosis The tissue samples were fixed in 10% neutral caused by the wild-type transthyretin, secondary buffered formalin (pH - 7) for 24–48 hours and paraffin amyloidosis after chronic systemic inflammation, and embedded. Sections were cut at 5 μm and stained with beta (2)-microglobulin amyloidosis after long-term standard HE, elastic van Gieson and Congo Red. Scharlach dialysis treatment [8]. If ATTR amyloidosis may be stain was performed in lung samples on frozen sections. indolent, untreated AL amyloidosis with clinical cardiac Immunohistochemistry for amyloid precursor involvement is a rapidly fatal disease. The management protein (APP, clone 3G12, dilution 1:50, producer decisions of cardiac amyloidosis are based on the Novocastra) was done on heart specimens, using sections underlying cause. Although treatment of senile systemic displayed on slides treated first with poly-L-lysine. IHC amyloidosis is largely supportive, the therapeutic was performed on 3 μm thick sections from formalin- approaches for AL amyloidosis include chemotherapy, fixed paraffin-embedded specimens, according to the autologous stem cell transplantation, and, rarely, cardiac indirect tristadial Avidin-Biotin-Complex method of Hsu transplantation [9]. The main causes of death in amyloid [15], modified by Bussolati and Gugliotta [16]. cardiomyopathy are restrictive cardiac insufficiency and Briefly, the procedure comprised: deparaffina- cardiac conduction disturbances, but thromboembolic tion in toluene and alcohol series, rehydration, washing disease or acute myocardial infarction are potential in phosphate buffer saline (PBS), blocking with normal causes as well [10-13]. serum, for 20 min, incubation with primary antibody for As AC is usually identifiable in older ages, and one hour, then with polymeric HRP-linker antibody con- is often associated with a longer evolution, it is rarely jugates (NovoLink Polymer Detection Systems, Novo- a considered a cause of sudden death. In monitored castra), washing in PBS and developing with 3.3'-DAB. patients with cardiac amyloidosis whose death was Antigen retrieval technique (heat induced epitope sudden (circumstance in which, even if the death is retrieval for paraffin sections) was done according to the sudden, it circumvolves the definition of sudden cardiac producer’s specifications. death), the most likely immediate cause of death was To ensure the reliability of the experimental electromechanical dissociation; ventricular fibrillation study, internal quality control of histopathologic and IHC appears in patients with a less severe heart failure [14]. We techniques were performed as a part of an implemented present a case in which a patient with cardiac amyloidosis and certified quality assurance system (ISO 9001/2008). died on the operating table, the direct cause of death a All slides were examined and photographed on trochanteric fracture causing fat pulmonary emboli, and a Zeiss AxioImager microscope (Gottingen, Germany). discuss the involvement of AC in thanatogenesys. Digital images acquired with Zeiss Axio Vision program have been processed and analyzed with ACDSee Pro CASE REPORT Photo Manager (Washington DC), running under Windows Vista. Clinical data. An 84 years old female patient, with a left RESULTS pertrochanteric fracture was admitted in the Orthopedics department. Personal history revealed coronary heart Macroscopic appearance revealed an old disease, essential hypertension, congestive heart ischemic stroke located in the left occipital area, partially failure class II NYHA, mitral regurgitation, aortic collapsed lungs, a myocardium with frequent waxy, tan disease, tricuspid regurgitation, secondary pulmonary nodules and small fibrotic areas (Figure 1), smooth heart hypertension, chronic atrial fibrillation, obesity, valves, first-second degree coronary atherosclerosis, dyslipidemia. Lab works at admission revealed a slightly stasis liver, kidney cysts and chronic pyelonephritis. elevated Quick time (13.6 sec), decreased potassium The microscopic study revealed interstitial (3.17 mmol/dL), increased fibrinogenemia (641 mg/dL). nodular deposits of a pink amorphous material The fracture was considered a candidate for open disseminated in the myocardium, not stainable with van reduction using a locked intramedullary fixation. During Gieson (Figure 2). surgery the patient suffered a respiratory arrest, which The nodular deposits stained ortochromatically was initially resuscitated but immediately after the patient with Congo Red (Figure 3) and showed green-apple suffered a cardiac arrest preceded by bradyasystole, birefringence in polarized light (Figure 4). IHC for irresponsive to CPR measures. APP (amyloid precursor protein) was intense positive 16 Romanian Journal of Legal Medicine Vol. XXI, No 1(2013) Figure 4. Green-apple birefringence of the amyloid under polarized light, 200x Figure 1. Gross appearance of cardiac amyloidosis: nodular, tan, waxy spots within the cardiac muscle. Inset - detail Figure 5. Intense IHC reaction for APP in nodular deposits, IHC, 400x Figure 2. Interstitial nodular deposits of amyloid (pink amorphous material) in myocardium, HE, 100x (left), which did not stain with van Gieson, VG, 100x (right) Figure 6. Pulmonary embolism with bone marrow in a medium size vessel in lung, HE, 100x (left); pulmonary embolism with lipids in capillaries in lung, Scharlach, 100x (right) in nodular deposits