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Diagnostic aspects for epidemic hemorrhage fever in legal medical autopsy: Report of 2 cases and review
Legal Medicine 11 (2009) S541–S543
Contents lists available at ScienceDirect
Legal Medicine journal homepage: www.elsevier.com/locate/legalmed
Case Report
Diagnostic aspects for epidemic hemorrhage fever in legal medical autopsy: Report of 2 cases and review Rui Zhao a,*, Bao-Li Zhu a,b, Da-Wei Guan a, Ru-Bo Li a, Guo-Hua Zhang a, Xu Wu a, De-wen Wang a a b
Department of Forensic Pathology, China Medical University School of Forensic Medicine, No. 92, Beier Road, Heping District, Shenyang 110001, Liaoning Province, PR China Department of Legal Medicine, Osaka City University Medical School, Asahi-machi 1-4-3, Abeno, Osaka 545-8585, Japan
a r t i c l e
i n f o
Article history: Received 17 December 2008 Accepted 8 January 2009 Available online 6 March 2009 Keywords: Epidemic hemorrhagic fever (EHF) Hemorrhagic fever with renal syndrome (HFRS) Hantavirus Forensic pathology
a b s t r a c t Epidemic hemorrhagic fever (EHF) is known also as hemorrhagic fever with renal syndrome (HFRS). Hantaviruses, a notorious cause of EHF is spreaded by rodents or biting insects, can cause epidemic hemorrhagic fever. This report describes two rare medico-legal autopsy cases died from epidemic hemorrhagic fever. The victims were two male individuals aged 34 years and 29 years. The medico-legal autopsies were requested for alleged medical negligence. In both cases, autopsy reveals lesions to kidneys and lungs with multiple organ hemorrhage and edema, indicative of the generalized capillary damage. On admission to hospital, both patients had the symptom of fever, lumbago, renal failure and recent outdoor activities. The laboratory diagnosis results indicating multiple organ dysfunction syndrome are also important for certificating of EHF. Though the ELISA-based detection of virus-specific IgM antibody which has the highest titers between 8 and 25d after onset of disease is positive in the 34-year-old case and negative in 29-year-old case, the pathological findings and clinical laboratory analysis suggested the both victims died of EHF. In addition, immunohistochemistry analysis for Hantavirus antigen in lung or in tubular cells and PCR having been used increasingly in recent years contribute to the diagnosis of Hantavirus infection. Ó 2009 Elsevier Ireland Ltd. All rights reserved.
1. Introduction Epidemic hemorrhagic fever, also called hemorrhagic fever with renal syndrome. Many arboviruses and the Hantaviruses, spreaded by rodents or biting insects or person-to-person transmission, can cause epidemic hemorrhagic fever. In China, it is caused mainly by Hantavirus. Because infection with some Hantavirus species may result in high morbidity and mortality rates and the victims are often involved in the medical malpractice, it is of particular importance to try to illustrate the effective diagnostic aspects in the view of forensic aspect. This report describes two rare medico-legal autopsy cases of death due to epidemic hemorrhagic fever. 2. Case report 2.1. Case history Case1 was a 34-year-old man. He had cold-like symptoms with a high fever, headache and lumbago for several days. Physical examination revealed that the patient was facial flushing and feb-
* Corresponding author. Tel.:+86 24 23256666 5415; fax: +86 24 23256666 5416. E-mail address: [email protected] (R. Zhao). 1344-6223/$ - see front matter Ó 2009 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.legalmed.2009.01.030
rile (temperature 39 °C). Laboratory finding revealed that WBC count 9.2 109/L, acute renal failure with deterioration of creatine (224 lmol/L), urinalysis disclosed proteinuria and the specific IgM antibody to EHF in blood was detected by enzyme-linked immunosorbent assay. Case2 is a 28-year-old man, suffered the same symptoms. Physical examination revealed that high fever, chilling, petechia on his face, chest and backside and carotic consciense, Laboratory indicated that WBC count 30 109/L and proteinuria, microscopic hematuria, urinary infection, Multiple Organ Failure and Disseminated Intravascular Coagulation. 2.2. Autopsy finding At autopsy, the palpebral conjunctivae were edematous and congestive with petechiae. In both the breast cavity and pericardial cavity, there were some reddish clear effusions. Numerous petechial hemorrhages diffused in the epicardium and endocardium. The lungs were dense, rubbery and heavy, showing multiple ecchymoses on the cut face and a degree of congestion, edema. The kidney was enlarged and congested on the cut face (Fig. 1A). Alimentary tract was filled with much deep red fluid. Ecchymosis was found in epiglottis. Pituitary was discovered hemorrhage (Fig. 1B) and wide range of hemorrhage was discovered at the site of injection. There was no evidence of other pathology or trauma.
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R. Zhao et al. / Legal Medicine 11 (2009) S541–S543
Fig. 1. (A) The kidney was enlarged and congested on the cut face in Case1. (B) Hemorrhage was discovered in pituitary in Case 2.
2.3. Histology finding In cases 1 and 2, focal microscopic hemorrhage and vascular congestion which indicative of injury of endothelium of capillaries in various organs, including brain, lung, cardiac interstitial and kidney interstitial, were observed. Kidney interstitial infiltrates with immune cells and interstitial hemorrhage (Fig. 2), pulmonary edema and interstitial hemorrhage were also seen (Fig. 3). Vascular thrombi and endothelium cell necrosis were also present in focal hemorrhage site. 3. Discussion Diagnosis of epidemic hemorrhagic fever is usually made on the basis of clinical, morphological and serologic findings. The clinical symptoms in a patient are fever, lumbago, renal failure, and recent outdoor activities. Laboratory findings of complete blood count differential can provide some clues for diagnosis, showing leukocytosis with a left shift and atypical lymphocytes are evident. Gross pathologic findings show that the lungs and kidney of patients are dense, rubbery and heavy. Histological findings revealed multi-
Fig. 2. Kidney interstitial infiltrates with immune cells and interstitial hemorrhage were discovered in both cases.
Fig. 3. Seriously pulmonary edema and interstitial hemorrhage were detected in both cases.
ple organ hemorrhage and congestion and generalized capillary damage, as well as acute tubulointerstital nephritis. ELISA, reverse transcriptase polymerase chain reaction (RT-PCR) for Hantavirus ribonucleic acid and immunohistochemistry (IHC) for Hantavirus antigen are used in confirming the diagnosis of EHF in China. Detections of EHF-specific IgM and IgG are common in clinics. In forensic practice, because of blood from cadaver only reflecting one phase of this disease, an IgM test whose highest titers are demonstrable between 8 and 25 d after onset of disease, which is often affected by postmortem change, is more important than IgG test. In fact, the most sensitive and potentially useful method for identification of viruses in postmortem investigations, Reverse transcriptase-PCR used increasingly in recent years can be used to detect Hantaviral RNA in fresh frozen lung/kidney tissue, blood clots or nucleated blood cells, but they have not yet become widely accepted as standard clinical laboratory tests no other than in forensic practice [1,2]. Immunohistochemistry (IHC) testing of formalin-fixed tissues or paraffin-embedded tissues, such as lung, kidney, lymph nodes, spleen, pancreas, pituitary, brain and liver, tubular cells, even endothelial cells in the capillaries of the myocardium and the endocardium, with specific monoclonal and polyclonal antibodies
R. Zhao et al. / Legal Medicine 11 (2009) S541–S543
can be used to detect Hantavirus antigens. The best antigen for the detection of HTV is the viral nucleocapsid (N) antigen which is uniformly recognized in patients with HTV infection [3]. The IHC testing is sensitive if only little time has passed after autopsy because it is reported that a decrease in positivity in the immunohistochemical method due to the influence of postmortem changes [4,5]. In summary, the diagnosis of death due to EHF should be supported by case history, laboratory finding and the pathologic findings with no evidence of other pathology or trauma or toxicosis.
Conflict of interest We declare that we have no financial and personal relationships with other people or organizations that can inappropriately influence our work, there is no professional or other personal interest conflict in the manuscript entitled.
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Acknowledgement We are thankful to the Sixth People’s Hospital of Shenyang for the laboratory detection. References [1] Aitichou M, Saleh SS, McElroy AK, Schmaljohn C, Ibrahim MS. Identification of Dobrava, Hantaan, Seoul, and Puumala viruses by one-step real-time RT-PCR. J Virol Methods 2005;124:21–6. [2] Moreli ML, Sousa RL, Figueiredo LT. Detection of Brazilian Hantavirus by reverse transcription polymerase chain reaction amplification of N gene in patients with Hantavirus cardiopulmonary syndrome. Mem Inst Oswaldo Cruz 2004;99:633–8. [3] Tai PW, Chen LC, Huang CH. Hanta hemorrhagic fever with renal syndrome: a case report and review. J Microbiol Immunol Infect 2005;38:221–3. [4] Muranyi W, Bahr U, Zeier M, van der Woude FJ. Hantavirus infection. J Am Soc Nephrol 2005;16:3669–79. [5] Fieguth A, Kleemann WJ, von Wasielewski R, Werner M, Tröger HD. Influence of postmortem changes on immunohistochemical reactions in skin. Int J Legal Med 1997;110:18–21.
Contents lists available at ScienceDirect
Legal Medicine journal homepage: www.elsevier.com/locate/legalmed
Case Report
Diagnostic aspects for epidemic hemorrhage fever in legal medical autopsy: Report of 2 cases and review Rui Zhao a,*, Bao-Li Zhu a,b, Da-Wei Guan a, Ru-Bo Li a, Guo-Hua Zhang a, Xu Wu a, De-wen Wang a a b
Department of Forensic Pathology, China Medical University School of Forensic Medicine, No. 92, Beier Road, Heping District, Shenyang 110001, Liaoning Province, PR China Department of Legal Medicine, Osaka City University Medical School, Asahi-machi 1-4-3, Abeno, Osaka 545-8585, Japan
a r t i c l e
i n f o
Article history: Received 17 December 2008 Accepted 8 January 2009 Available online 6 March 2009 Keywords: Epidemic hemorrhagic fever (EHF) Hemorrhagic fever with renal syndrome (HFRS) Hantavirus Forensic pathology
a b s t r a c t Epidemic hemorrhagic fever (EHF) is known also as hemorrhagic fever with renal syndrome (HFRS). Hantaviruses, a notorious cause of EHF is spreaded by rodents or biting insects, can cause epidemic hemorrhagic fever. This report describes two rare medico-legal autopsy cases died from epidemic hemorrhagic fever. The victims were two male individuals aged 34 years and 29 years. The medico-legal autopsies were requested for alleged medical negligence. In both cases, autopsy reveals lesions to kidneys and lungs with multiple organ hemorrhage and edema, indicative of the generalized capillary damage. On admission to hospital, both patients had the symptom of fever, lumbago, renal failure and recent outdoor activities. The laboratory diagnosis results indicating multiple organ dysfunction syndrome are also important for certificating of EHF. Though the ELISA-based detection of virus-specific IgM antibody which has the highest titers between 8 and 25d after onset of disease is positive in the 34-year-old case and negative in 29-year-old case, the pathological findings and clinical laboratory analysis suggested the both victims died of EHF. In addition, immunohistochemistry analysis for Hantavirus antigen in lung or in tubular cells and PCR having been used increasingly in recent years contribute to the diagnosis of Hantavirus infection. Ó 2009 Elsevier Ireland Ltd. All rights reserved.
1. Introduction Epidemic hemorrhagic fever, also called hemorrhagic fever with renal syndrome. Many arboviruses and the Hantaviruses, spreaded by rodents or biting insects or person-to-person transmission, can cause epidemic hemorrhagic fever. In China, it is caused mainly by Hantavirus. Because infection with some Hantavirus species may result in high morbidity and mortality rates and the victims are often involved in the medical malpractice, it is of particular importance to try to illustrate the effective diagnostic aspects in the view of forensic aspect. This report describes two rare medico-legal autopsy cases of death due to epidemic hemorrhagic fever. 2. Case report 2.1. Case history Case1 was a 34-year-old man. He had cold-like symptoms with a high fever, headache and lumbago for several days. Physical examination revealed that the patient was facial flushing and feb-
* Corresponding author. Tel.:+86 24 23256666 5415; fax: +86 24 23256666 5416. E-mail address: [email protected] (R. Zhao). 1344-6223/$ - see front matter Ó 2009 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.legalmed.2009.01.030
rile (temperature 39 °C). Laboratory finding revealed that WBC count 9.2 109/L, acute renal failure with deterioration of creatine (224 lmol/L), urinalysis disclosed proteinuria and the specific IgM antibody to EHF in blood was detected by enzyme-linked immunosorbent assay. Case2 is a 28-year-old man, suffered the same symptoms. Physical examination revealed that high fever, chilling, petechia on his face, chest and backside and carotic consciense, Laboratory indicated that WBC count 30 109/L and proteinuria, microscopic hematuria, urinary infection, Multiple Organ Failure and Disseminated Intravascular Coagulation. 2.2. Autopsy finding At autopsy, the palpebral conjunctivae were edematous and congestive with petechiae. In both the breast cavity and pericardial cavity, there were some reddish clear effusions. Numerous petechial hemorrhages diffused in the epicardium and endocardium. The lungs were dense, rubbery and heavy, showing multiple ecchymoses on the cut face and a degree of congestion, edema. The kidney was enlarged and congested on the cut face (Fig. 1A). Alimentary tract was filled with much deep red fluid. Ecchymosis was found in epiglottis. Pituitary was discovered hemorrhage (Fig. 1B) and wide range of hemorrhage was discovered at the site of injection. There was no evidence of other pathology or trauma.
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R. Zhao et al. / Legal Medicine 11 (2009) S541–S543
Fig. 1. (A) The kidney was enlarged and congested on the cut face in Case1. (B) Hemorrhage was discovered in pituitary in Case 2.
2.3. Histology finding In cases 1 and 2, focal microscopic hemorrhage and vascular congestion which indicative of injury of endothelium of capillaries in various organs, including brain, lung, cardiac interstitial and kidney interstitial, were observed. Kidney interstitial infiltrates with immune cells and interstitial hemorrhage (Fig. 2), pulmonary edema and interstitial hemorrhage were also seen (Fig. 3). Vascular thrombi and endothelium cell necrosis were also present in focal hemorrhage site. 3. Discussion Diagnosis of epidemic hemorrhagic fever is usually made on the basis of clinical, morphological and serologic findings. The clinical symptoms in a patient are fever, lumbago, renal failure, and recent outdoor activities. Laboratory findings of complete blood count differential can provide some clues for diagnosis, showing leukocytosis with a left shift and atypical lymphocytes are evident. Gross pathologic findings show that the lungs and kidney of patients are dense, rubbery and heavy. Histological findings revealed multi-
Fig. 2. Kidney interstitial infiltrates with immune cells and interstitial hemorrhage were discovered in both cases.
Fig. 3. Seriously pulmonary edema and interstitial hemorrhage were detected in both cases.
ple organ hemorrhage and congestion and generalized capillary damage, as well as acute tubulointerstital nephritis. ELISA, reverse transcriptase polymerase chain reaction (RT-PCR) for Hantavirus ribonucleic acid and immunohistochemistry (IHC) for Hantavirus antigen are used in confirming the diagnosis of EHF in China. Detections of EHF-specific IgM and IgG are common in clinics. In forensic practice, because of blood from cadaver only reflecting one phase of this disease, an IgM test whose highest titers are demonstrable between 8 and 25 d after onset of disease, which is often affected by postmortem change, is more important than IgG test. In fact, the most sensitive and potentially useful method for identification of viruses in postmortem investigations, Reverse transcriptase-PCR used increasingly in recent years can be used to detect Hantaviral RNA in fresh frozen lung/kidney tissue, blood clots or nucleated blood cells, but they have not yet become widely accepted as standard clinical laboratory tests no other than in forensic practice [1,2]. Immunohistochemistry (IHC) testing of formalin-fixed tissues or paraffin-embedded tissues, such as lung, kidney, lymph nodes, spleen, pancreas, pituitary, brain and liver, tubular cells, even endothelial cells in the capillaries of the myocardium and the endocardium, with specific monoclonal and polyclonal antibodies
R. Zhao et al. / Legal Medicine 11 (2009) S541–S543
can be used to detect Hantavirus antigens. The best antigen for the detection of HTV is the viral nucleocapsid (N) antigen which is uniformly recognized in patients with HTV infection [3]. The IHC testing is sensitive if only little time has passed after autopsy because it is reported that a decrease in positivity in the immunohistochemical method due to the influence of postmortem changes [4,5]. In summary, the diagnosis of death due to EHF should be supported by case history, laboratory finding and the pathologic findings with no evidence of other pathology or trauma or toxicosis.
Conflict of interest We declare that we have no financial and personal relationships with other people or organizations that can inappropriately influence our work, there is no professional or other personal interest conflict in the manuscript entitled.
S543
Acknowledgement We are thankful to the Sixth People’s Hospital of Shenyang for the laboratory detection. References [1] Aitichou M, Saleh SS, McElroy AK, Schmaljohn C, Ibrahim MS. Identification of Dobrava, Hantaan, Seoul, and Puumala viruses by one-step real-time RT-PCR. J Virol Methods 2005;124:21–6. [2] Moreli ML, Sousa RL, Figueiredo LT. Detection of Brazilian Hantavirus by reverse transcription polymerase chain reaction amplification of N gene in patients with Hantavirus cardiopulmonary syndrome. Mem Inst Oswaldo Cruz 2004;99:633–8. [3] Tai PW, Chen LC, Huang CH. Hanta hemorrhagic fever with renal syndrome: a case report and review. J Microbiol Immunol Infect 2005;38:221–3. [4] Muranyi W, Bahr U, Zeier M, van der Woude FJ. Hantavirus infection. J Am Soc Nephrol 2005;16:3669–79. [5] Fieguth A, Kleemann WJ, von Wasielewski R, Werner M, Tröger HD. Influence of postmortem changes on immunohistochemical reactions in skin. Int J Legal Med 1997;110:18–21.