AUTOPSY #:
PATIENT NAME:
MR #:
DATE:
A-4832
Rebecca Arnold
0329415
12/09/20XX
This 4-year-old white female was admitted with bruises of a 2-week duration, fever of 1 week,
and nose bleeding of 1 day.
On admission, hemoglobin was 5.8, platelets 29,000, WBC 30,200 with 85% lymphoblasts.
Acute lymphoblastic leukemia with L! FAB classification was diagnosed after a bone marrow
aspiration and biopsy were performed. She received allopurinol for hyperuricemia with a uric
acid of 11.9 mg/dL (normal: 2.6-7.0). She was started on vancomycin for fevers. She was
transfused single-donor platelets, but experienced a hypersensitivity reaction with chills,
intercostal retractions, and nasal flaring with perioral cyanosis. Although the cyanosis improved
and the respiratory distress improved, she developed active bleeding from the bone marrow
aspiration site.
Shortly thereafter, the patient passed away, 2 days after her admission.
EXTERNAL EXAMINATION
The body is that of a well-developed, moderately nourished, pale female child. The body
measures 85 cm from crown to heel and weighs 15 kg. The facies are normal. The head is
covered by a lot of hair. The eyes or are normal size. There are no epicanthic folds. The external
ears show normal cartilaginous development; they are in their normal set location. The external
auditory canals are patent. The nasal passages are patent. The posterior choanal canal can be
probed. The nasal bridge is normal. The tongue is of normal size, and teeth are present. The
tongue is free of ulcers and exudate. The palate is normal. There is no peripheral
lymphadenopathy. The chest is symmetrical. The abdomen is slightly distended. Muscle
development is normal. The genitalia are those of a normal female child. The urethral meatus is
patent. The clitoris is not hypertrophied. The anus is patent. The back shows no scoliosis or
kyphosis. There are 5 normally formed digits on the hands and feet, which are free of edema and
cyanosis. The palm lines are examined and are not unusual. The nails are developed. The skin
shows pallor, petechiae, and ecchymosis.
INTERNAL EXAMINATION
The body is opened through the usual Y-shaped incision. Subcutaneous fat is 0.5 cm thick. The
umbilicus is removed en bloc with a wide skin margin.
ABDOMINAL CAVITY
The peritoneal cavity contains 50 mL of straw-colored, serosanguineous fluid. The abdominal
and pelvic organs are in their normal position. The kidneys are normally located.
THORACIC CAVITY
The great veins are flat. Each pleural space contains 20 mL of clear fluid, which is not cultured.
No adhesions are found.
(continued)
AUTOPSY REPORT
AUTOPSY #: A-4832
PATIENT NAME: Rebecca Arnold
MR #: 0329415
DATE: 12/09/20XX
Page 2
PERICARDIAL CAVITY
The pericardium is opened and contains no excess fluid. No adhesions are found. A blood culture
is taken.
ORGAN DESCRIPTION
CARDIOVASCULAR SYSTEM
HEART: The apex consists of the right/left ventricles. The aorta and pulmonary artery arise in
their normal relation to one another. The pulmonary veins enter the left atrium and no anomalous
veins are noted. The heart is opened along the normal blood-flow channels. No abnormal valves
are noted. The auricular appendage contains no clots or vegetations. The endocardium of the
right atrium is of normal thickness. The septum primum covers the foramen ovale adequately
and cannot be probed. The tricuspid valve consists of 3 normal, thin leaflets. The right ventricle
shows its usual trabecular muscles; the crista supraventricularis and outflow tract are normal.
The pulmonary valve consists of 3 cusps without thickening. The pulmonary artery cannot be
opened into the aorta. The main pulmonary artery measures 4.1 cm in circumference. The right
and left pulmonary arteries are identified. The left atrium receives 2 pulmonary veins from each
lung. The endocardium of the left atrium is thin. The mitral valve contains 2 normal leaflets,
inserted by normal, thin chordae tendineae onto the two papillary muscles. The mitral valve
contains 3 normal cusps. The myocardium of the left ventricle is mildly hypertrophied. The left
coronary artery arises from the left coronary cusps, and the right from the right. These pursue
their usual course.
MEASUREMENTS
OPEN CIRCUMFERENCE:
Tricuspid 6.2 cm
Pulmonic 4.1 cm
Right Ventricle 0.25 cm
Mitral 4.8 cm
Aortic 3.5 cm
Left Ventricle 1 cm
AORTA AND GREAT VESSELS: The aorta arises from the left ventricle, gives rise to 3 normal
branches, and descends along the left side of the vertebral column.
VEINS: The inferior vena cava, superior vena cava, renal veins, and hepatic vein are patent. The
splenic vein, inferior mesenteric, superior mesenteric, and portal veins are patent.
(continued)
AUTOPSY REPORT
AUTOPSY #: A-4832
PATIENT NAME: Rebecca Arnold
MR #: 0329415
DATE: 12/09/20XX
Page 3
RESPIRATORY SYSTEM
The larynx and trachea are free of webs, mucous plugs, foreign bodies, edema, and mucosal
lacerations.
LUNGS: The heart and lungs together weigh 310 g. The pleural surfaces are pale. The bronchial
tree is free of mucous plugs and exudate. The pulmonary parenchyma shows consolidation after
dissection. The pulmonary arterial tree is free of thromboemboli.
GASTROINTESTINAL SYSTEM
The oral cavity and esophagus are free of fibrinopurulent membranes, vesicular, ulcerations, and
other lesions. There is no tracheoesophageal fistula, enteric duplication, stenosis, atresia, webs,
or diverticula. The stomach is well rugated and free of ulcers. The mesentery is normally rotated.
The small intestine is collapsed. The duodenum, jejunum, ileum, and colon are intact and free of
serosal and mucosal lesions. The cecum and appendix are in the right lower quadrant. The colon
is normally attached to the posterior abdominal wall. No atresias are noted.
LIVER: Weighs 600 g. The capsule is transparent. The liver parenchyma is a normal brown-red
and cuts with increased resistance. The lobular pattern is normal.
GALLBLADDER AND BILE DUCTS: The gallbladder contains green bile. Bile stones are
absent. The mucosa is green. Bile can be expressed from the gallbladder into the duodenum. The
common duct and right and left hepatic ducts are present.
PANCREAS: The pancreas is cut longitudinally and the pancreatic duct is visualized. The
lobular pattern is normal. No necrosis is noted.
GENITOURINARY SYSTEM
The kidneys weigh 15 g together and are left attached to the pelvic organs and aorta. The renal
veins are opened and contain no thrombi. The renal arteries are normal. The kidneys show
normal lobulations. The capsules strip easily, revealing a smooth surface. On cut surface, the
corticomedullary junction is sharp. The parenchyma does not bulge from the cut surface. The
pyramids and papillae are normal. Pelves are smooth, and ureters arise from these and enter the
urinary bladder normally at the trigone. The bladder wall is not hypertrophied. The urethra is
opened, and no posterior urethral valves are noted. The uterus is normally formed. The ovaries
are unremarkable. The fallopian tubes are of average and uniform width.
HEMOLYMPHATIC SYSTEM
SPLEEN: The spleen weighs 145 g. The capsular surface is translucent and contains no
wrinkling, exudates, or fibrosis. Cut surface is red and deep purple-brown and consistency is
mushy.
LYMPH NODES: The lymph nodes from the cervical, periaortic, peripancreatic, axillary, and
inguinal areas are generally swollen.
(continued)
AUTOPSY REPORT
AUTOPSY #: A-4832
PATIENT NAME: Rebecca Arnold
MR #: 0329415
DATE: 12/09/20XX
Page 4
THYMUS: Weighs 6 g.
BONE MARROW: Red, moist, and ample.
ENDOCRINE SYSTEM
THYROID: The red-brown thyroid is normally placed in relation to the larynx. The weight of the
bilateral lobes of thyroid is 4 g.
ADRENALS: The adrenals together weigh 6g; cut surface shows a normal fetal and adult cortex.
MUSCULOSKELETAL SYSTEM
BONE: Two ribs are taken and bisected. The cartilage, epiphyses, and metaphyses are normal.
SKELETAL MUSCLES: Grossly normal.
JOINTS: Not remarkable.
CRANICAL CAVITY: The reflected scalp shows no evidence of contusion, hematoma, or other
lesion. The calvariae and bones at the base of the skull are not remarkable. No fractures or other
injuries are present. The dura mater and pia arachnoid and associated spaces are normal in
appearance. They are without hemorrhage or evidence of inflammation. The weight of the brain
is 1280 g. The cerebral hemispheres are symmetrical and normal in appearance. Cut sections of
the brain show symmetry and essentially normal structures throughout. The circle of Willis and
other intracranial vessels are normal. The pituitary gland is grossly normal. The pineal gland is
present.
SPINAL CORD AND VERTEBRAL COLUMN: Intact.
FINDINGS
I. RESPIRATORY SYSTEM
All lobes of lung show leukemic cell infiltration around the bronchioles or blood vessels. There
is edematous fluid accumulated in air spaces of the left lower lobe.
II. CARDIOVASCULAR SYSTEM
Leukemic cell infiltration with scattered aggregates in subepicardial adipose tissue is seen.
Myocardium and endocardium are not remarkable.
III. GASTROINTESTINAL SYSTEM
LIVER: Shows extensive leukemic cell infiltration within all portal areas, but the hepatic
architecture is well preserved. No bile stasis is seen. There was a proliferation of histiocytes with
ingested platelets. Red blood cells in dilated sinusoids are seen, which is consistent with
hemophagocytic syndrome. Atypical leukemic cells are seen infiltrated in the gastrointestinal
mucosa and submucosa.
(continued)
AUTOPSY REPORT
AUTOPSY #: A-4832
PATIENT NAME: Rebecca Arnold
MR #: 0329415
DATE: 12/09/20XX
Page 5
IV. GENITOURINARY SYSTEM
KIDNEYS: Bilateral kidneys show leukemic cell infiltration in the interstitum. Hemophagocytic
syndrome is seen with erythrophagocytosis or platelet phagocytosis in the renal tubules.
ADNEXA: Adnexa including uterus, ovaries, and fallopian tubes show leukemic cell infiltration.
Retroperitoneum and parametrium show hemorrhage admixed with a few atypical cells.
URINARY BLADDER: Shows hematoma formation.
V. HEMATOLOGICAL SYSTEM
SPLEEN: Shows extensive leukemic cell infiltration with congestion and hemorrhage.
Hemophagocytosis is seen, also.
BONE MARROW: Shows leukemic cell infiltration with hemophagocytosis.
VI. LYMPHATIC SYSTEM
All lymph nodes reveal atypical leukemic cell infiltration.
VII. ENDOCRINE SYSTEM
Thymus, adrenal glands, thyroid, and pancreas all show leukemic cell infiltration.
______________________________
Marvin L. Smith, MD
MLS/ps
D: 12/09/20XX
T: 12/13/20XX