The forensic spleen: Morphological, radiological, and toxicological investigations

Forensic Science International 297 (2019) 384–387

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The forensic spleen: Morphological, radiological, and toxicological investigations Cristian Palmierea,* , Camilla Tettamantib , Maria Pia Scarpellia , Rexson Tsec a b c

CURML, University Center of Legal Medicine, Chemin de la Vulliette 4, 1000 Lausanne 25, Switzerland DISSAL, Via De Toni 12, 16132 Genova, Italy Department of Forensic Pathology, LabPLUS, Auckland City Hospital, Auckland 1148, New Zealand

A R T I C L E I N F O

A B S T R A C T

Article history: Available online 22 February 2019

The spleen is only uncommonly investigated in the forensic setting. Thorough examinations are performed in some specific situations such as splenic trauma (including iatrogenic trauma from cardiopulmonary resuscitation attempts), anaphylaxis, drowning, and sepsis-related deaths. The aim of this review is to present the available literature focusing on a few selected splenic diseases as well as forensic investigations performed on the spleen in order to summarize the most frequent situations in which this routinely unexplored organ may merit more extensive examination. © 2019 Elsevier B.V. All rights reserved.

Keywords: Forensic pathology Autopsy Spleen Drowning Anaphylaxis

1. Introduction Postmortem investigations specifically focusing on the spleen are uncommon in the forensic setting and undoubtedly more systematic in clinical pathology [1]. Forensic pathologists frequently face spleen injuries typically occurring in the course of major trauma (i.e. traffic accidents and falls from high), though less dramatic spleen injuries may be occasionally observed from trivial trauma in a diseased spleen (such as post Epstein-Barr virus infection) or as a complication of resuscitation attempts [2–6]. In addition to basic autopsy and histology, radiological (postmortem computed tomography - CT), morphological (histochemistry and immunohistochemistry), toxicological, microbiological, and genetic (polymerase chain reaction - PCR) investigations focusing on the spleen have been proposed by several forensic researchers over the last years. These have proven to be of significant value in providing useful and complementary data in various situations [7–14]. The purpose of this article is to present an overview of the available forensic literature focusing on a few selected splenic disease processes and forensic investigations performed on the spleen, in order to identify and summarize the most current

DOI of original article: http://dx.doi.org/10.1016/j.forsciint.2018.08.012 * Corresponding author. E-mail address: [email protected] (C. Palmiere). http://dx.doi.org/10.1016/j.forsciint.2019.01.042 0379-0738/© 2019 Elsevier B.V. All rights reserved.

settings in which this routinely unexplored organ may merit more thorough examination. Pathological conditions seen in surgical pathology, such as neoplastic (leukaemia, lymphoma etc), will not be discussed in this paper and can be referred to in standard surgical pathology textbooks. 1.1. Anatomy and physiology The spleen is the largest organ in the human immune system, and is composed by two functionally distinct compartments, the white pulp (mostly consisting of lymphocytes) and the red pulp (containing venous sinuses, red blood cells as well as lymphocytes and macrophages). Main spleen functions encompass lymphocytes proliferation and differentiation, blood storage, and aged red blood cell clearing [1,15–20]. 1.2. Splenomegaly Splenomegaly can be defined as an abnormal enlargement of the organ and can be caused by enhanced splenic function, splenic infiltration, or splenic congestion (congestive splenomegaly) [10,19,20]. Enhanced splenic function may be observed in situations of pronounced sequestration of abnormal red blood cells (haemolytic anaemia) or increased immune activity in immunological disorders and/or chronic systemic infections. Splenic congestion may be due to blood flow blockage through the splenic vessels and pooling of blood in the splenic red pulp, thus leading to dilated veins and sinuses.

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Hepatic fibrosis/cirrhosis, chronic cardiac failure, splenic vein thrombosis and various obstructions in spleen-related circulation may be also responsible for congestive splenomegaly. Transient splenomegaly may be observed during systemic acute infections [15]. In the fetus, an enlarged spleen may be caused by fetal infections, anemia, hematological diseases, or metabolic disorders, and can be accompanied or not by hepatomegaly [21]. 1.3. Splenic trauma Major splenic trauma is frequently encountered in the forensic setting and usually follows high-energy impacts, such as following motor vehicle collisions. Splenic trauma may occasionally be the consequence of trivial injuries in a diseased organ. On the other hand, iatrogenic injury to the spleen may sometimes occur during cardiopulmonary resuscitation and surgery [3–6,22–25]. Spontaneous (non-traumatic) splenic rupture and non-traumatic subcapsular ruptured hematoma of the spleen with hemoperitoneum have been described in some situations of both clinical and forensic interest including infections, malignancy, metabolic disorders, as well as vascular and haematological diseases [26]. In adults, blunt trauma to the left lateral thorax may be responsible for spleen ruptures typically associated with rib fractures [27,28]. Analogously, in the paediatric population, blunt abdominal trauma due to road traffic accidents, contact sports, or abuse, may cause visceral injury that can potentially involve the spleen [29]. Another scenario is iatrogenic trauma from cardiopulmonary resuscitation attempts. Resuscitative procedures based on external chest compression may be responsible for unusual lesions or injuries of thoracic and/or abdominal organs, of which forensic pathologists must be aware in order to avoid misinterpretation of unexpected findings. Due to the anatomical situation, the left lobe of the liver is more commonly affected by cardiopulmonary resuscitation related trauma. Spleen or gastric ruptures caused by cardiopulmonary resuscitation attempts may nevertheless be observed, though more unfrequently [30]. On the other hand, anatomical abnormalities of the spleen or liver (i.e. when the organ’s position is higher than normal) may contribute to an increased risk of injury during cardiopulmonary resuscitation and should not underestimated [2,30–34]. Cardiopulmonary resuscitation-related hepatic and splenic injuries have been reported to potentially lead to fatal outcomes in individuals who were resuscitated (and/or following the Heimlich maneuver). Hence, some clinicians recommend that all patients who received cardiopulmonary resuscitation be examined for potential splenic trauma, which should be suspected also in situations of unexpected cardiovascular collapse following cardiopulmonary resuscitation [31,35]. In situations of abdominal trauma, postmortem CT sensitivity and specificity in showing visceral injuries are reported to be not ideal. Indeed, at unenhanced postmortem CT, only indirect signs may be observed possibly suggesting spleen injury or lesions involving the vessels [36]. 1.4. Anaphylaxis In situations of suspected IgE-mediated fatal anaphylaxis, splenic tissue samples should be systematically obtained at autopsy for histochemical and immunohistochemical investigations to demonstrate eosinophil infiltration and activated mast cells in the red pulp of the organ. Analogously, myocardium and coronary artery wall samples should be systematically collected at autopsy in situations of suspected anaphylaxis to investigate the presence of activated mast cells and eosinophils, as repeatedly highlighted by some research teams [8,9,37–41].

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1.5. Drowning The observation of a small, blood-depleted, dry spleen as a sign of drowning dates back to the 19th century [42]. In more recent times, Haffner et al. [43] performed a retrospective study of spleen findings in a series of cases of freshwater drowning compared to non-drowning controls and concluded that a small, dry spleen may indeed be noticed in cases of drowning, though inconstantly. Hadley and Fowler [44] reviewed spleen weight in a series of drowning cases compared to non-drowning control cases and concluded that the commonly reported autopsy finding of a small, blood-depleted spleen in drowning could be basically a postmortem phenomenon. Other authors have tried to increase the reliability of the postmortem diagnosis of drowning using spleen weight, though it was concluded that it was an unspecific parameter [45–47]. Vander Plaetsen et al. [10] investigated the diagnostic value of postmortem CT in corpses recovered from water compared with controls and noticed a lower radiological density in the spleen in drowning cases, possibly indicating a situation of haemodilution. Specific PCR-based methods for detecting picoplankton and diatom DNA in spleen tissue samples collected at autopsy to support the postmortem diagnosis of drowning has been proposed in recent years, among other authors, by Rutty et al. [11,12], and Racz et al. [13], with promising findings. 1.6. Sepsis Main reported splenic features during sepsis in the forensic literature have traditionally consisted of splenomegaly, reduced spleen consistency, muddy appearance of the organ, neutrophilic infiltrates, and parenchymal congestion [48,49]. However, more recent studies speculated that spleen softening in cases of suspected bacterial sepsis is a nonspecific finding of limited diagnostic value. Analogously, neutrophilic inflammatory infiltrates (so called acute splenitis) have not been found to be characteristic of bacterial sepsis in clinically diagnosed sepsis cases [49,50]. General bacteriological culture and PCR assay for specific infectious agents in postmortem biological fluids (peripheral and cardiac blood, cerebrospinal fluid, and pericardial fluid) and tissue samples (lung and spleen specimens) collected at autopsy are routinely performed in the forensic setting to confirm or rule out the presence of true antemortem bacterial infections possibly involved in the death [14,50,51]. 1.7. Postmortem CT findings Postmortem CT findings pertaining to the spleen were investigated among others by Okuma et al. [7], who noticed a positive correlation between the weight of the spleen measured during autopsy and the volume of the organ observable on postmortem CT, despite a systematic reduction in its volume on postmortem CT compared to antemortem CT findings. Though the weight of the spleen could be theoretically estimated from the volume of the organ measured on postmortem CT, the results obtained by these authors have led them to recommended utmost care when interpreting spleen postmortem CT findings in order to avoid underestimations or misinterpretations of reduced spleen volume as well as mistakes in normal versus pathological findings. 1.8. Toxicology Due to the richness of the spleen in blood, toxicological investigations using spleen tissue samples collected at autopsy

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might prove useful for analysis of compounds that bind to hemoglobin, such as carbon monoxide and cyanide [52,53]. As far as the postmortem distribution of some specific drugs (and metals) is concerned, numerous authors compared spleen concentrations of some analytes to those found in other fluids and tissues collected at autopsy, with varying results [54–64]. A further approach for collecting, among others, postmortem spleen tissue samples for toxicology has been described in a series of studies performed by Staeheli et al. [65–67], who combined the traditional sampling technique at autopsy with a CT-guided sampling technique prior to autopsy. 1.9. Genetic Though spleen tissue samples are not routinely collected for DNA-based identification, some authors evaluated the postmortem rate of DNA degradation obtained in spleen specimens and observed that spleen samples could theoretically be used for DNAbased identification up to five days postmortem [68,69]. 2. Conclusions The overview of the forensic literature presented herein allows some synthetic conclusions to be drawn (Table 1). A first consideration pertains to the fact that “traditional”, morphological, splenic observations described in drowning and sepsis-related deaths in the past (i.e. dry spleen and splenomegaly) would merit critical review and should be updated using modern (and at present more and more extensively diffused) postmortem radiological methods. This would allow traditional “macroscopic” findings observed at autopsy to be supported by radiological findings and, consequently, unspecific and inconstant macroscopic and radiological observations to be definitely considered of limited or no value for diagnostic purposes. A second important point to highlight is that the aforementioned postmortem radiological methods can now be combined with other complementary techniques and investigations that are more and more widespread used in the forensic setting (i.e. postmortem bacteriology/postmortem genetic using PCR probes). In this respect, traditional sampling techniques (collection during autopsy) might be complemented by alternative sampling techniques (collection during postmortem imaging), and more

Table 1 Summarizes the main forensic investigations that may be performed on the spleen. Situation of forensic interest

Forensic investigation

Parenchymal and vascular lesions: major trauma, spontaneous splenic rupture, non-traumatic subcapsular splenic ruptured hematoma, iatrogenic trauma from cardiopulmonary resuscitation Anaphylaxis

Postmortem CT – Postmortem angiography

Drowning

Sepsis

Intoxication

DNA-based identification

Histology Histochemistry Immunohistochemistry Postmortem CT PCR for picoplankton and diatom DNA (spleen CT-guided biopsies – sampling at autopsy) General bacteriological culture and specific PCR assay (spleen tissue samples) Spleen tissue samples (spleen CTguided biopsies – sampling at autopsy) Forensic genetic (spleen tissue samples)

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