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Short report
The impact of pulmonary bone component embolism: an autopsy study Matthias S Dettmer,1,2 Niels Willi,1 Thore Thiesler,1 Peter Ochsner,3 Gieri Cathomas1 1
Institute of Pathology Liestal, Cantonal Hospital Baselland, Liestal, Switzerland 2 Institute of Pathology, University of Bern, Bern, Switzerland 3 Department of Orthopedic Surgery, Cantonal Hospital Baselland, Liestal, Switzerland Correspondence to Dr Matthias S Dettmer, Institute of Pathology, University of Bern, Murtenstrasse 31, 3010 Bern, Switzerland; [email protected] MSD and NW contributed equally. Received 5 November 2013 Revised 6 December 2013 Accepted 10 December 2013 Published Online First 7 January 2014
ABSTRACT Aims Pulmonary bone marrow embolism (BME) and pulmonary bone fragment embolism (BFE) are two types of non-thrombotic pulmonary embolism (NTPE). While BME can be found consistently in autopsies, BFE is a rarely observed event. Both these conditions have bone lesions as source of embolism and are not considered to be causative for death. Methods A retrospective autopsy study was performed and lung whole tissue slides were reviewed for the presence of pulmonary embolism. Clinicopathological data were screened for osseous lesions considered as risk factors for BME and BFE. Results We reviewed 985 consecutive, unselected autopsies and identified 29 cases of BME (2.9%) and 5 cases of BFE (0.5%). Both conditions were mutually exclusive. While BME showed a significant association with costal fractures, BFE was significantly associated with osteomyelitis and previously performed femur nailing. There were between 1 and 346 bone emboli in BFE with a density ranging from 0.74 to 30.5 emboli/ cm2 with mean embolic diameter of 45.8±37.6 μm. In two patients, BFE contributed significantly to fatal outcome. Conclusions BME was associated with costal fractures, while BFE was associated with orthopaedic procedures and osteomyelitis. BFE can result in patient death. Both conditions appeared exclusively, indicating that although they originate from osseous lesions their underlying pathogenesis may likely be different.
INTRODUCTION
To cite: Dettmer MS, Willi N, Thiesler T, et al. J Clin Pathol 2014;67: 370–374. 370
Non-thrombotic pulmonary embolism (NTPE) is, in contrast to thrombotic pulmonary embolism, an uncommonly encountered cause of morbidity and mortality. NTPE is caused by different cell types, gas, fluids, foreign material and infectious agents. The effects are not purely mechanical but are also linked to the nature of the embolic agent. It often presents with uncharacteristic symptoms and signs and thus is clinically often not suspected.1 Pulmonary embolism of bone components (BCE) encompasses embolism of bone marrow (BME), of bone fragments (BFE) and embolism of fat. The latter does not necessarily originate in the bone marrow but can also arise from soft tissue laceration. BCE is considered a rare event and of minor clinical impact. Nevertheless, cases with a fatal outcome most often associated with underlying sickle cell disease have been reported.2–4 Trauma, resuscitative measures, orthopaedic surgical procedures, bone marrow transplantation and haemoglobinopathies have been considered risk factors for BCE.1
In prior publications, BME and BFE have been reported to occur in combination or were not properly separated.5 6 The aim of this retrospective study was to assess the incidence of BME and BFE in an autopsy cohort to evaluate their underlying disease and assess risk factors.
MATERIALS AND METHODS All adult autopsies performed at the Institute of Pathology of the Kantonsspital Baselland in Liestal, Switzerland, during the years 2002 to 2004 were reviewed. Routinely, from every patient one tissue sample from each pulmonary lobe had been taken during autopsy for histology and stained with H&E and Elastica-van Gieson (EvG). Additional specimens were taken in case of focal lesions. All lung slides were reviewed by one experienced pathologist (NW) for the presence of bone fragment emboli or bone marrow emboli. BME were defined as emboli comprising fat and/or bone marrow, whereas bone fragments within pulmonary arteries or arterioles were required for a diagnosis of BFE (figure 1). The number, size and area of embolised bone fragments were assessed and correlated with the total area of the lung tissue fragments. Microscopic measurements were performed with ‘Cell^A’ imaging software (Olympus Europe, Hamburg). The autopsy documentation charts including the final reports were reviewed, and the history of orthopaedic interventions with application of orthopaedic devices (such as total or partial replacement of hip and knee, dynamic hip screw, femoral nailing, open reduction and internal fixation (ORIF) of various sites) and the presence of bone lesions such as osteomyelitis, rib fractures, bone metastasis and vertebral sintering were recorded. Descriptive statistics, χ2 test and Mann–Whitney U test were calculated with SPSS 21 (IBM, Armonk, USA). Sample distribution was assessed with Kolmogorov–Smirnov test. p Values of
Short report
The impact of pulmonary bone component embolism: an autopsy study Matthias S Dettmer,1,2 Niels Willi,1 Thore Thiesler,1 Peter Ochsner,3 Gieri Cathomas1 1
Institute of Pathology Liestal, Cantonal Hospital Baselland, Liestal, Switzerland 2 Institute of Pathology, University of Bern, Bern, Switzerland 3 Department of Orthopedic Surgery, Cantonal Hospital Baselland, Liestal, Switzerland Correspondence to Dr Matthias S Dettmer, Institute of Pathology, University of Bern, Murtenstrasse 31, 3010 Bern, Switzerland; [email protected] MSD and NW contributed equally. Received 5 November 2013 Revised 6 December 2013 Accepted 10 December 2013 Published Online First 7 January 2014
ABSTRACT Aims Pulmonary bone marrow embolism (BME) and pulmonary bone fragment embolism (BFE) are two types of non-thrombotic pulmonary embolism (NTPE). While BME can be found consistently in autopsies, BFE is a rarely observed event. Both these conditions have bone lesions as source of embolism and are not considered to be causative for death. Methods A retrospective autopsy study was performed and lung whole tissue slides were reviewed for the presence of pulmonary embolism. Clinicopathological data were screened for osseous lesions considered as risk factors for BME and BFE. Results We reviewed 985 consecutive, unselected autopsies and identified 29 cases of BME (2.9%) and 5 cases of BFE (0.5%). Both conditions were mutually exclusive. While BME showed a significant association with costal fractures, BFE was significantly associated with osteomyelitis and previously performed femur nailing. There were between 1 and 346 bone emboli in BFE with a density ranging from 0.74 to 30.5 emboli/ cm2 with mean embolic diameter of 45.8±37.6 μm. In two patients, BFE contributed significantly to fatal outcome. Conclusions BME was associated with costal fractures, while BFE was associated with orthopaedic procedures and osteomyelitis. BFE can result in patient death. Both conditions appeared exclusively, indicating that although they originate from osseous lesions their underlying pathogenesis may likely be different.
INTRODUCTION
To cite: Dettmer MS, Willi N, Thiesler T, et al. J Clin Pathol 2014;67: 370–374. 370
Non-thrombotic pulmonary embolism (NTPE) is, in contrast to thrombotic pulmonary embolism, an uncommonly encountered cause of morbidity and mortality. NTPE is caused by different cell types, gas, fluids, foreign material and infectious agents. The effects are not purely mechanical but are also linked to the nature of the embolic agent. It often presents with uncharacteristic symptoms and signs and thus is clinically often not suspected.1 Pulmonary embolism of bone components (BCE) encompasses embolism of bone marrow (BME), of bone fragments (BFE) and embolism of fat. The latter does not necessarily originate in the bone marrow but can also arise from soft tissue laceration. BCE is considered a rare event and of minor clinical impact. Nevertheless, cases with a fatal outcome most often associated with underlying sickle cell disease have been reported.2–4 Trauma, resuscitative measures, orthopaedic surgical procedures, bone marrow transplantation and haemoglobinopathies have been considered risk factors for BCE.1
In prior publications, BME and BFE have been reported to occur in combination or were not properly separated.5 6 The aim of this retrospective study was to assess the incidence of BME and BFE in an autopsy cohort to evaluate their underlying disease and assess risk factors.
MATERIALS AND METHODS All adult autopsies performed at the Institute of Pathology of the Kantonsspital Baselland in Liestal, Switzerland, during the years 2002 to 2004 were reviewed. Routinely, from every patient one tissue sample from each pulmonary lobe had been taken during autopsy for histology and stained with H&E and Elastica-van Gieson (EvG). Additional specimens were taken in case of focal lesions. All lung slides were reviewed by one experienced pathologist (NW) for the presence of bone fragment emboli or bone marrow emboli. BME were defined as emboli comprising fat and/or bone marrow, whereas bone fragments within pulmonary arteries or arterioles were required for a diagnosis of BFE (figure 1). The number, size and area of embolised bone fragments were assessed and correlated with the total area of the lung tissue fragments. Microscopic measurements were performed with ‘Cell^A’ imaging software (Olympus Europe, Hamburg). The autopsy documentation charts including the final reports were reviewed, and the history of orthopaedic interventions with application of orthopaedic devices (such as total or partial replacement of hip and knee, dynamic hip screw, femoral nailing, open reduction and internal fixation (ORIF) of various sites) and the presence of bone lesions such as osteomyelitis, rib fractures, bone metastasis and vertebral sintering were recorded. Descriptive statistics, χ2 test and Mann–Whitney U test were calculated with SPSS 21 (IBM, Armonk, USA). Sample distribution was assessed with Kolmogorov–Smirnov test. p Values of
