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SA MEDIESE TYDSKRIF DEEL 66 3 NOVEMBER 1984 699

Pulmonary embolism due to hepatic



tIssue - a forensic vital sign?
A case report

J. J. MOAR

Histological examination of the liver revealed extensive paren-


chymal lacerations with diffuse ex.rravasation of erythrocytes
Summary into liver substance. Examination of a section of lung tissue
A case of pulmonary embolism due to hepatic tissue demonstrated a tissue plug lying free within a pulmonary vessel
occurring after trauma is presented. This finding may (Fig. I). It was easily identified as liver tissue, comprising large
be of forensic value in indicating the antemortem polyhedral cells with abundant eosinophilic cytoplasm and
nature of an injury by constituting evidence of an intra round nuclei (Fig. 2). Lipofuscin accumulation was noted within
vitam phenomenon. the cytoplasm and individual cells showed intense granular
autofluorescence due to the large numbers of mitochondria
S AIr lied J 1984; Ill: 699-700. characteristically present in hepatocytes (Fig. 3).

.:~ 1
,;
Pulmonary embolism following trauma is a well-recognized
event, .the embolus usually consisting of fat and haemopoietic
tissue or both. Occasional cases involving cerebral tissue emboliz-
ing to lung after trauma,' birth injury2-6 or a gunshot wound of
the brain 7 have also been reported. Pulmonary embolism due to
hepatic tissue, however, has generally been considered a rarity,
only 4 reports S- 11 having appeared in the English language
literarure during the period 1942-1971. Animal experiments 12 in
which liver lacerations were produced in dogs by closed blunt
abdominal trauma appeared to confIrm the rarity of the condition,
since no cases of pulmonary embolism by hepatic tissue were
observed among these animals.
The following case report describes a pulmonary embolism
due to hepatic tissue in a 25-year-old man who had fallen off a
train and who survived for 6 hours. This finding may be of use in
indicating the antemorrem nature of an injury, thus differen-
tiating it from a postmortem traumatic artefact.
Fig. 1. Section of lung tissue showing a tissue plug lying free within
a pulmonary vessel.
Case report
A 25-year-old Black man was admined to the casualty department
of Baragwanath Hospital, Johannesburg, after falling from a
train. Examination revealed an unconscious, areflexic patient
with no recordable· blood pressure, no spontaneous respiration
and numerous conrusions and lacerations over the right side of
the body and face. A maxillary fracture was present as well as a
ruptured liver. He was given 2 units of blood and intubated,
ventilated and resuscitated. In spite of these measures his
condition deteriorated rapidly, and he died 5 hours after
admission (6 hours after the accident).
At autopsy numerous conrusions and lacerations were noted
over the right side of the body as well as an extensive rupture of
the liver involving the right and left lobes including the caudate
and quadrate lobes. The peritoneal cavity contained 2600 ml of
blood. The spleen was undamaged. There were no further
fmdings of note on macroscopic examination.

Department of Forensic Medicine, University of the Wit-


watersrand, Johannesburg Fig. 2. Magnification of the tissue plug shown in Fig. 1 revealing
J. J. MOAR, M.B. CH.B., M.MED. (FORENSIC PATHOL) liver tissue comprising large polyhedral cells with abundant
eosinophilic cytoplasm and round nuclei.
700 SA MEDICAL JOURNAL VOLUME 66 3 NOVEMBER 1984

addition, a simple blow to a part of me body already altered by


postmortem lividity may rupture capillaries distended with
blood, squeezing some of this blood into tissue spaces and
thereby mimicking antemortem haemorrhage. Conversely, an
antemortem injury sustained when the blood pressure is close to
zero because of other fatal wounds may show little or no
haemorrhage.
The finding in this case, merefore, of an antemortem pheno-
menon corroborated by a documented period of patient survival
may suggest further grounds for study. Furthermore, this imra
vicam phenomenon occurred at some time during the 6-hour
survival period during which the age of an injury cannot be
accurately determined on histological grounds nor diff~rentiated
from a similar injury occurring either during the agonal' period or
shortly after death. (
This may therefore constitute an additional vital sign which
should be searched for in cases ofliver injury where doubt exists
Fig. 3. Intense granular autofluorescence characteristic of about the timing of injury; it may serve as corroborative evidence
hepatocytes from segments of the tissue plug noted within a of an antemortem event.
pulmonary vessel.

Discussion I sincerely thank Dr A. C. Paterson of the South African Instirute


for Medical Research for assistance wim me fluorescent microscopy,
The problem of determining the moment of death and differen- and Professor N. J. Schepers for his review of the manuscript.
tiating between antemortem and postmortem injuries has long
confronted the forensic pathologist. Tumerous avenues of
investigation have been pursued in the attempt to elucidate this
problem. These have ranged from biochemical investigations,
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