case_images: PMC5775214_01
case_images: In panel (A), the gross appearance of the lesion, and in panel (B) the microscopic of the blood clot that was first found during dissecting the heart, consisting in fibrin and poor in cells. After removing the clot, a papillary multiple lesion was found, the base of which was in the wall of the ventricle (C,D).
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case_images: PMC5775214_01_fmed-04-00253-g001.jpg
case_images: F1
case_images: Tardieu's spots, a well-known sign of asphyxia. The silhouette of heart was preserved, and the coronary vessels were not occluded; but the thickness of the ventricles was increased, both in the left one (2.3 cm; normal 1.3-1.5 cm) and right one (1.3 cm; normal 0.3-0.5 cm), and in the septum (1 cm) and in their lumen a big blood clot was found (Figures 1A,B). After removing the clot, we found a papillary, whitish, multifocal lesion, the base of which was in the wall of the ventricle (Figures 1C,D).
case_images: (A) The ventricle hypertrophy (E/E 63x). (B-D) The papillary ventricular lesion consisted mainly in connective tissue, poor in cells [E/E 20x in (B), 10x in (C,D)]. (E) Collagen and elastic fibers (special stain. Sirius Red 10x). (F) The surface was positive for anti-FVIII (40x); and a diffuse, sparse positivity for anti-CD34 [20x in (G)] and anti-S-100 superficial and spars [20x in (I)] was found; few cells instead were positive for anti-Actin [40x in (H)].
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case_images: PMC5775214_01_fmed-04-00253-g002.jpg
case_images: F2
case_images: Histologically, in both the ventricles and the interventricular sept the number of muscle cells was increased, with an interposition of fibrous tissue confirming the cardiac hypertrophy (Figure 2A). Samples of the multiple papillary lesions were taken, and the hematoxylin and eosin stain (H&E) showed an extracellular fibrous matrix with elastic component and few cells interposed, while a single layer of cells covered the structure (Figures 2B-D). We performed histochemical special stains that confirmed the presence of mainly collagen and elastic fibers (Figure 2E). Immunohistochemistry showed a positivity for anti-CD34 and anti-S-100 in the whole lesion, positivity for anti-FVIII on the surface and focal positivity for actin (Figures 2F-I).
case_images: (A) Pulmonary emphysema (E/E 20x). (B-D) The alveoli were filled an effusion rich in protein and a rich infiltrate of eosinophil granulocytes too [E/E 63x in (B); 40x in (C)]. (D) The congestion of pulmonary vessels and proteinaceus aedema (E/E 40x).
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case_images: F3
case_images: Histology of the lungs showed an irregular emphysema (Figure 3A), congested vessels, and the hemorrhagic spots in pleura, typical aspects of asphyxia and hypoxia. Furthermore, the alveoli were filled by proteinaceous exudates with eosinophilic granulocytes and erythrocyte extravasation (Figures 3B-D).
case_images: More signs of asphyxia. (A) Brain edema (E/E 40x). (B) Congestion of subdural blood vessels (E/E 10x). (C) Edema and erythrocytes in the liver sinusoid (E/E 40x). (D) Congestion of kidney vessels (E/E 20x).
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case_images: PMC5775214_01_fmed-04-00253-g004.jpg
case_images: F4
case_images: Moreover, brain, liver, and multiorgan edema, congestion, and erhitrocyte extravasation were detected (Figures 4A-D).