Forensic Science International, 56 (1992) 195 - 199 Elsevier Scientific Publishers Ltd.
195
WIDESPREAD MYOCARDIAL AND PULMONARY BONE MARROW EMBOLISM FOLLOWING CARDIAC MASSAGE
JANUSZ DZII$CIOL, ANDRZEJ KEMONA, MARIA aRSKA, MA%GORZATA BARWIJUK, STANIS%AW SULKOWSKI, ZYGMUNT KOZIELEC and MAREK BALTAZIAK Department (Poland)
of Pathologieal
Anatomy, Divison of Endocrinology,
Medical Acao!emy, Bidtystok
(Received June 2Oth, 1992) (Accepted July 4th, 1992)
Summary Widespread fata1 massive bone marrow embolism of the coronary and the pulmonary arteries are described in a 71-year-old man with a respiratory disease. Cardiac massage was carried out during the cardiac arrest. In autopsy findings there were no fractures of the ribs or the sternum. The authors suggested that the cardiac massage was the most important predisposing factor for the bone marrow embolism. Key words: Bone marrow embolism; Cardiac massage
Introduction Bone marrow emboli (BME) are quite rare, commonly as result of trauma to bones containing red marrow. They are localised predominantly in the smal1 pulmonary arteries. Individual cases of BME have been observed in the vessels of other organs, including the coronary and the pulmonary arteries. Report of a Case A 7%year-old male was admitted to the clinic in a very poor general condition with a dyspnoea, cough, fever, sputum which was coloured slightly with blood and tarry stools. He had past history of ulcerous disease of the duodenum of 25 year duration and a basal cel1 carcinoma of nasal skin was diagnosed 2 years ago. Physical examination revealed bronchopneumonia, BP 110/70 mmHg and an irregular pulse rate of 105lmin. The radiograph of the chest showed focal postinflammatory lesions in the middle and upper lobes of the right lung. The left lung showed compensatory emphysema and the features of chronic pulmonary heart were seen. Resting electrocardiography revealed atria1 fibrillation with ventricular function of 106/min and myocardial ischaemia. Due to his bad genera1 condition endoscopy was not performed. Comespondence to: Janusz Dziqiof, Department ology, Medical Academy, Biafystok, Poland. 0379-0738/92/$05.00 0 1992 Elsevier Scientific Publishers Printed and Published in Ireland
Ireland Ltd.
of Pathological
Anatomy, Division of Endocrin-
196
Laboratory findings (metabolic-respiratory). mission. Resuscitation, cessful.
showed anaemia and decompensated mixed acidosis In spite of treatment, the patient died 2 days after adwhich included external cardiac massage, was unsuc-
Autopsy Findings An autopsy was performed 14 h after death. The following findings were noted: emphysema, mainly of the left lung, focal inflammatory and fibrous lesions, especially of the right lung; a slight myocardial hypertrophy and secondary anaemia of the internal organs. Arterial vessels demonstrated severe atherosclerosis. The heart muscle did not reveal focal lesions. There was also found chronic pyelonephritis and a peptic ulcer of 1.5 cm diameter. There was no evidente of mechanica1 trauma to the ribs and sternum following resuscitation. The microscopic picture revealed scattered BME in the vessels of the heart muscle and lungs. The embolie material consisted of haemopoietic and adipose tissue and in some of them fragments of bone trabeculae were seen. It was possible, using MGG histological staining method, to distinguish between individual development cel1 lines. The Gomori staining method revealed delicate reticular fibres. In the heart muscle including endocardium and epicardium, emboli were present in the smal1 and medium size arteries in large numbers (Figs. 1 and 2).
Fig. 1. Multiple bone marrow emboli in arterioles of myocardium-bone (hematoxylin-eosin, x 320).
marrow emboli in two arkries
Fig. 2. Higher magnification (hematoxylin-eosin, x 250).
of bone marrow embolus composed of fat and bloed-formative
c:ells
Fig. 3. Longitudinal section of myocardium artery showing bone marrow tissue embolus-fat cells and disintegrating hematopoietic elements (hematoxylin-eosin, x 100).
198
199
We did not observe any thrombotic lesions or endothelial reaction of the vessels in which emboli appeared. Occasionally, around the vessels with BME, smal1 foei of heart muscle necrosis were seen. The lumen of smal1 branches of the pulmonary arteries were narrowed due to BME which were present in al1 the lobes (Figs. 3 and 4). In some vessels one could observe smal1 bone trabeculae. Histopathological examination of bone marrow taken from the sternum, ilium and vertebrae did not reveal any pathological lesions. Comment The case reveals massive BME of the coronary and the pulmonary arteries. BME are easily recognizable after autopsy [ 1,5]. They occur mostly in the pulmonary arteries. They are uncommon in the other organs [ 2,4]. Usually, they occur after bone trauma or are due to vigorous external cardiac massage. In some cases, BME are present even when an autopsy does not reveal any trauma. They are probably due to microtraumas of bones, especially in elderly people with osteoporosis [ 1,5]. BME are attributed to a fall in blood pressure which causes slowing of perfusion and ischaemia of marrow. It follows shock of variable etiology. The barrier between haemopoietic tissue and vascular system is easily damaged. The anatomical structure of the bone marrow is responsible for this. It confirms the opinion that BME are attributed either to mechanical trauma or to primary or secondary carcinoma with a destruction of marrow tissue. As predisposing factors, steroid therapy and surgical intervention on the skeletal system are reported [ 6,8] . The clinical significante of BME has been discussed. Certain authors are of the opinion that BME does not have any clinical importante. Contrary opinions point to BME as a serious complication of the main disease which is in several cases the direct cause of death [ 1,3,5]. References 1 2 3 4 5 6 7 8
H. Arai, Pulmonary bone marrow embolism: A review of 350 necropsy cases. ActaPathd. Jp., (1979) 911-931. N.R. Gbatek and H.M. Zimmerman, Cerebral bone marrow embolism. Report of a case with observations on the genesis of traumatic fat embolism. Ar&. Pathol., 92 (1971) 112 - 118. 0. Having and O.P.N. Gruner, Pulmonary bone marrow embolism. A histological study of nonselected autopsy material. Acts Puthol. Microbiol. Scund., 81 (1973) 276-280. P.H. Kalina and R.J. Cambell, Marrow embolus to posterior ciliary vessel. Ah. Pathol. Lub. Med., 114 (1990) 979-980. A. Kemona, H.F. Nowak, J. Dzieciat; M. Sulik and S. Sulkowski, Pulmonary bone marrow embolism in non-selected autopsy material. Pathel. Pol., 40 (1989) 197- 206. J.K. Mason, Pulmonary fat and bone marrow embolism as an indication of ante mortem violente. Med. Soi. Law, 8 (1968) 200-208. K.S. Pyun and R.E. Kataenstein, Widespread bone marrow embolism with myocardial involvement. Arch. Pathol., 89 (1970) 378 - 381. H. Rappaport, M. Raum and J.B. Horrell, Bone marrow embolism. Am. J. Pathel., 27 (1951) 407 - 433.
195
WIDESPREAD MYOCARDIAL AND PULMONARY BONE MARROW EMBOLISM FOLLOWING CARDIAC MASSAGE
JANUSZ DZII$CIOL, ANDRZEJ KEMONA, MARIA aRSKA, MA%GORZATA BARWIJUK, STANIS%AW SULKOWSKI, ZYGMUNT KOZIELEC and MAREK BALTAZIAK Department (Poland)
of Pathologieal
Anatomy, Divison of Endocrinology,
Medical Acao!emy, Bidtystok
(Received June 2Oth, 1992) (Accepted July 4th, 1992)
Summary Widespread fata1 massive bone marrow embolism of the coronary and the pulmonary arteries are described in a 71-year-old man with a respiratory disease. Cardiac massage was carried out during the cardiac arrest. In autopsy findings there were no fractures of the ribs or the sternum. The authors suggested that the cardiac massage was the most important predisposing factor for the bone marrow embolism. Key words: Bone marrow embolism; Cardiac massage
Introduction Bone marrow emboli (BME) are quite rare, commonly as result of trauma to bones containing red marrow. They are localised predominantly in the smal1 pulmonary arteries. Individual cases of BME have been observed in the vessels of other organs, including the coronary and the pulmonary arteries. Report of a Case A 7%year-old male was admitted to the clinic in a very poor general condition with a dyspnoea, cough, fever, sputum which was coloured slightly with blood and tarry stools. He had past history of ulcerous disease of the duodenum of 25 year duration and a basal cel1 carcinoma of nasal skin was diagnosed 2 years ago. Physical examination revealed bronchopneumonia, BP 110/70 mmHg and an irregular pulse rate of 105lmin. The radiograph of the chest showed focal postinflammatory lesions in the middle and upper lobes of the right lung. The left lung showed compensatory emphysema and the features of chronic pulmonary heart were seen. Resting electrocardiography revealed atria1 fibrillation with ventricular function of 106/min and myocardial ischaemia. Due to his bad genera1 condition endoscopy was not performed. Comespondence to: Janusz Dziqiof, Department ology, Medical Academy, Biafystok, Poland. 0379-0738/92/$05.00 0 1992 Elsevier Scientific Publishers Printed and Published in Ireland
Ireland Ltd.
of Pathological
Anatomy, Division of Endocrin-
196
Laboratory findings (metabolic-respiratory). mission. Resuscitation, cessful.
showed anaemia and decompensated mixed acidosis In spite of treatment, the patient died 2 days after adwhich included external cardiac massage, was unsuc-
Autopsy Findings An autopsy was performed 14 h after death. The following findings were noted: emphysema, mainly of the left lung, focal inflammatory and fibrous lesions, especially of the right lung; a slight myocardial hypertrophy and secondary anaemia of the internal organs. Arterial vessels demonstrated severe atherosclerosis. The heart muscle did not reveal focal lesions. There was also found chronic pyelonephritis and a peptic ulcer of 1.5 cm diameter. There was no evidente of mechanica1 trauma to the ribs and sternum following resuscitation. The microscopic picture revealed scattered BME in the vessels of the heart muscle and lungs. The embolie material consisted of haemopoietic and adipose tissue and in some of them fragments of bone trabeculae were seen. It was possible, using MGG histological staining method, to distinguish between individual development cel1 lines. The Gomori staining method revealed delicate reticular fibres. In the heart muscle including endocardium and epicardium, emboli were present in the smal1 and medium size arteries in large numbers (Figs. 1 and 2).
Fig. 1. Multiple bone marrow emboli in arterioles of myocardium-bone (hematoxylin-eosin, x 320).
marrow emboli in two arkries
Fig. 2. Higher magnification (hematoxylin-eosin, x 250).
of bone marrow embolus composed of fat and bloed-formative
c:ells
Fig. 3. Longitudinal section of myocardium artery showing bone marrow tissue embolus-fat cells and disintegrating hematopoietic elements (hematoxylin-eosin, x 100).
198
199
We did not observe any thrombotic lesions or endothelial reaction of the vessels in which emboli appeared. Occasionally, around the vessels with BME, smal1 foei of heart muscle necrosis were seen. The lumen of smal1 branches of the pulmonary arteries were narrowed due to BME which were present in al1 the lobes (Figs. 3 and 4). In some vessels one could observe smal1 bone trabeculae. Histopathological examination of bone marrow taken from the sternum, ilium and vertebrae did not reveal any pathological lesions. Comment The case reveals massive BME of the coronary and the pulmonary arteries. BME are easily recognizable after autopsy [ 1,5]. They occur mostly in the pulmonary arteries. They are uncommon in the other organs [ 2,4]. Usually, they occur after bone trauma or are due to vigorous external cardiac massage. In some cases, BME are present even when an autopsy does not reveal any trauma. They are probably due to microtraumas of bones, especially in elderly people with osteoporosis [ 1,5]. BME are attributed to a fall in blood pressure which causes slowing of perfusion and ischaemia of marrow. It follows shock of variable etiology. The barrier between haemopoietic tissue and vascular system is easily damaged. The anatomical structure of the bone marrow is responsible for this. It confirms the opinion that BME are attributed either to mechanical trauma or to primary or secondary carcinoma with a destruction of marrow tissue. As predisposing factors, steroid therapy and surgical intervention on the skeletal system are reported [ 6,8] . The clinical significante of BME has been discussed. Certain authors are of the opinion that BME does not have any clinical importante. Contrary opinions point to BME as a serious complication of the main disease which is in several cases the direct cause of death [ 1,3,5]. References 1 2 3 4 5 6 7 8
H. Arai, Pulmonary bone marrow embolism: A review of 350 necropsy cases. ActaPathd. Jp., (1979) 911-931. N.R. Gbatek and H.M. Zimmerman, Cerebral bone marrow embolism. Report of a case with observations on the genesis of traumatic fat embolism. Ar&. Pathol., 92 (1971) 112 - 118. 0. Having and O.P.N. Gruner, Pulmonary bone marrow embolism. A histological study of nonselected autopsy material. Acts Puthol. Microbiol. Scund., 81 (1973) 276-280. P.H. Kalina and R.J. Cambell, Marrow embolus to posterior ciliary vessel. Ah. Pathol. Lub. Med., 114 (1990) 979-980. A. Kemona, H.F. Nowak, J. Dzieciat; M. Sulik and S. Sulkowski, Pulmonary bone marrow embolism in non-selected autopsy material. Pathel. Pol., 40 (1989) 197- 206. J.K. Mason, Pulmonary fat and bone marrow embolism as an indication of ante mortem violente. Med. Soi. Law, 8 (1968) 200-208. K.S. Pyun and R.E. Kataenstein, Widespread bone marrow embolism with myocardial involvement. Arch. Pathol., 89 (1970) 378 - 381. H. Rappaport, M. Raum and J.B. Horrell, Bone marrow embolism. Am. J. Pathel., 27 (1951) 407 - 433.
