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Dr. Andrew Rynne

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How is extracting and testing blood for post mortem done?

Answered by
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Dr. Vivek Chail

Radiologist

Practicing since :2002

Answered : 6508 Questions

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Posted on Tue, 5 Aug 2014 in X-ray, Lab tests and Scans
Question: Dear Dr XXXXXXX

Many thanks for the reply and information given.

Most of my general questions have been answered, the idea being to gain an overview of the medical situation.

My subscription ends 26 May so I will probably find a question every day or two until then.

In a reply you write;

"Urosepsis is an end result of uncontrolled cystitis and happens when the toxins have spread through blood to other areas and the patient shows generalized fever and sickness".

Is it possible to have "minor" urosepsis? What does "minor" mean? Early stages, under control of antibiotics? Can it be easily misdiagnosed as cystitis? What toxins are specifically associated with urosepsis?

Thanks again.

XXXX


Hello Dr XXXXXXX

I've contacted your colleague and I await his reply with interest.

I'll read the article link for your colleague that you gave me and will no doubt make a comment.

Thank you very much for your referral.

XXXX

Hello Dr XXXXXXX

My e-mail sent to Dr Madani was returned for technical problems? Could you check it?

Thanks.

Hello Dr XXXXXXX

I haven't heard from you for 3 days so there must be a problem..

I've checked the internet given address for Dr Madani and it is the same as the one given by yourself so I don't understand the problem. My letter should have reached him today and I hope to get a reply in the near future.

I've read the didactic article by Dr Madani and note that it is focused on longer term use of nitrofurantoin. Perhaps the shorter term adverse effects might also be of research interest though a longer term preventive use can't be ruled out I presume without doing High Resolution CT.

If I don't receive a reply from you before 26 May when my subscription expires (I suppose that I will have no reason to renew it...) I thank you for your excellent service. My XXXXX XXXXXXX e-mail address is YYYY@YYYY .

Thanking you again.

XXXXXX XXXXXXX (XXXXX)

Hello again Dr XXXXXXX

The communication got interrupted last time without saying than you but I gave you an excellent rating and comment.

I contacted Dr Madani but I haven't received a reply as yet.

You may recall that I was asking about nitrofurantoin and I also read Dr Madani's didactic article which was most useful.

I would like to ask about the possibility of extracting and testing blood post mortem.

Is it normal to have only 0.1 mL of blood for testing after five months at low temperature in the mortuary which I am told is insufficient for testing? After 1 month however the blood was 2 mL.

What does 0.1 mL mean?

Why is there less blood now than 5 months ago?

Is it still possible at 0.1 mL to test the enzyme tryptase for antibody reactions or high performance liquid chromatography for the concentration of this medication?

If not, are there any other more sensitive methods to suggest which are effective for testing nitrofurantoin at that concentration of blood?

Is it possible to test as above at the higher concentration of 2 mL?

Who are the world experts in this field?


I would much appreciate your thorough investigation as in the past of this question.

XXXXX


I would like to ask about the possibility of extracting and testing blood post mortem. Is it normal to have only 0.1 mL of blood for testing after five months at low temperature in the mortuary which I am told is insufficient for testing? After 1 month however the blood was 2 mL. What does 0.1 mL mean? Why is there less blood now than 5 months ago? Is it still possible at 0.1 mL to test the enzyme tryptase for antibody reactions or high performance liquid chromatography for the concentration of this medication? If not, are there any other more sensitive methods to suggest which are effective for testing nitrofurantoin at that concentration of blood? Is it possible to test as above at the higher concentration of 2 mL?
doctor
Answered by Dr. Vivek Chail 14 hours later
Brief Answer:
Test requirements are as below

Detailed Answer:
Hi XXXX
Glad to hear from you.

Your earlier queries (ones posted after my last reply) were not made available to me due to technical reasons. Sorry if you have had any difficulty but I have no control over it.

I have read through your latest query and would like to put forward my views. In testing for tryptase, the samples can be taken up to 24 hours after death. This test cannot be done after 5 months following death and the blood at present is altered and not suitable for testing. The problem is not with amount of blood but with the time of collection which is best within 24 hours after death up to 3 to 4 days when the cadaver is kept at 4 degrees C temperature withing 24 hours after death. After this the accuracy of the test decreases.

In my knowledge there is no such test to study the nitrofurantoin concentration of blood in the present case.

Hope your query is answered.
Do write back if you have any doubts.

Regards,
Dr.Vivek
Above answer was peer-reviewed by : Dr. Vinay Bhardwaj
doctor
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Follow up: Dr. Vivek Chail 1 hour later

Hello again Dr XXXXXXX

Thanks for the reply and information.

It is not necessarily the nitrofurantoin "concentration" that I wish to test but the presence of an antibody reaction so as to establish an adverse reaction last January which was very probable in this case.

The question I suppose is how long do antibodies exist in the blood after decease? Another healthcare doctor mentioned 3 months as being okay to trace an antibody reaction. Perhaps 5 months is okay too? Perhaps the doctor was referring to another enzyme than tryptase or another more advanced and sensitive method?

Also, is it possible to use the liquid chromatography test for nitrofurantoin with blood plasma and not just urine?

If the problem is not with the amount of blood but with the time why would a doctor make such a statement? The problem of time wasn't mentioned but the quantity of blood?

I would appreciate a prompt reply if possible because I have to discuss this matter.

Thanks.
doctor
Answered by Dr. Vivek Chail 8 hours later
Brief Answer:
Testing details

Detailed Answer:
Hi XXXXX
Thanks for writing back with an update.

Tyrptase is the most suitable enzyme to test for any hypersensitive reaction mediated through mast cells which may be triggered by any offending agent. There are tests to analyse tryptase and the one available commercially uses quantitative fluorescence immunoassay technique. The name of the test is IMMUNOCAP Tryptase, Phadia Laboratories, Uppsala, Sweden.

Concerning the time of collection, its usually best to take the sample 15 minutes to 3 hours after onset of allergy symptoms. For shipping, the specimen may be kept at room temperature up to 2 days. The specimen can be stored at 2-8°C if it is to undergo assay within 5 days following collection. If longer periods are expected, the sample should be stored at -20 to -70°C.

Regarding the amount of blood at least 0.2-0.5 mL of serum is required, meaning that at least 0.5-1 mL of blood needs to be collected. Please keep in mind that when we talk about blood its fresh blood and the blood in the deceased after 5 months may not be conforming to the standard testing samples.

It is important that you discuss with your doctor finer details about testing and then I can assist you with more information that you may require.

Hope your query is answered.
Do write back if you have any doubts.

Regards,
Dr.Vivek
Above answer was peer-reviewed by : Dr. Raju A.T
doctor
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Follow up: Dr. Vivek Chail 17 hours later

Hello Dr XXXXXXX

Thank you for your information.

I have writtten to the doctor about this and will discuss this question with you when I have a reply.

Another question concerns the doubt over a diagnosis of broncho-pneumonia made from two clinical impressions/signs.

a) The friability/fragility of one lobe.

b) purulent fluid in the lower lungs.

It seems that friability can be caused by other sources of infection other than pneumonia and fluid in the lungs is normal after a fatal cardiac arrest so I have been informed.

I visited my mother just a few hours before her decease and she was perfectly normal and she exhibited no signs of a chest infection in the days before that.

Just to check the diagnosis I asked the Coroner to do second level scientific tests - a biopsy etc but have not succeeded in this request up to now.

Given the five months that have passed since my mother's decease would a lung biopsy etc be able to confirm or not by scientific tesing the clinical impression/opinion of bronchpneumona ?

The same question might be asked of a brain tissue biopsy?

If so what tests would you recommend?

Thanks.

XXXX



doctor
Answered by Dr. Vivek Chail 10 hours later
Brief Answer:
Review of preserved visceral specimens

Detailed Answer:
Hi XXXX
Thanks for writing back with an update.

The first post mortem is the most important procedure to address any disagreements. Since its 5 months following death, certain changes may have occurred in both, lungs and brain which could mask findings or give wrong interpretations.

Its completely agreeable that the deceased was not having any symptoms of chest infection which were obvious to you at the time of meeting her hours before death. But keeping in mind her age and general condition in the last few months of her life, it cannot be said with certainty that she was free from any kind of respiratory infection.

I suggest that if any pathological visceral specimens of lungs and brain were preserved after the first post mortem, they may be reviewed again by different team of doctors.

Hope your query is answered.
Do write back if you have any doubts.

Regards,
Dr.Vivek
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Vivek Chail 29 hours later
Good morning Dr XXXXXXX

Thanks for the reply.

Would a blood test perhaps show up bacterial/antibody reaction to the broncho-pneumonia infection last January?

XXXXX
doctor
Answered by Dr. Vivek Chail 14 hours later
Brief Answer:
Tissue sampling techniques usually done

Detailed Answer:
Hi XXXXX
Thanks for writing back with an update.

A blood test to show up bacterial or antibody reaction to the broncho pneumonia infection last January is difficult to conceptualize. Studies have shown the diagnosis of etiology in severe pneumonia remains a challenging area. Postmortem lung tissue potentially increases the sensitivity of investigations for identification of causative pathogens in fatal cases of pneumonia and can confirm antemortem microbiological diagnoses. Tissue sampling allows assessment of histological patterns of disease and ancillary immunohistochemical or molecular diagnostic techniques. Blood tests are not available to confirm pneumonia.

Hope your query is answered.
Do write back if you have any doubts.

Regards,
Dr.Vivek
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Vivek Chail 19 hours later
Hello Dr XXXXXXX

Thanks for the information.

I haven't heard from the microbiologist about the 1 mL blood question/ nitrofurantoin test yet.

I have a practical question.

Dr Madani didn't contact me.

The Coroner belives the test are not in his remit.

Time is running out now and anything is worth a try.

I would appreciate it if you could recommend another doctor (or ask your hospital for a contact in the Manchester/Lancashire UK area if possible or anywhere in the UK) who might be able to extract some blood from my mother and and tissue for a lung biopsy and mediate the nitrofurantoin/biopsy analysis.

Thanks.

XXXXX

doctor
Answered by Dr. Vivek Chail 15 hours later
Brief Answer:
Links to Central XXXXXXX university hospital

Detailed Answer:
Hi XXXX XXXXXXX
Thanks for writing back with an update.

We do not have any direct alliance with hospitals in the UK.

I did a search based on your requirements and could find the relevant information on query based on attempting tests for blood and tissue analysis. This needs further discussion with the people directly involved in doing such tests due to the sensitive nature of the case.

The link to contacts in department of laboratory medicine in Central XXXXXXX University Hospitals is given below.

Please note that it is better to proceed through research hospitals.

http://www.cmft.nhs.uk/info-for-health-professionals/laboratory-medicine/laboratory-medicine-contacts

Hope your query is answered.
Do write back if you have any doubts.

Regards,
Dr.Vivek
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Vivek Chail 2 days later
Good afternoon Dr XXXXXXX

Thanks for the information.

I am in contact with the doctors again and hope to link some last minute research.

Do you know anything about that Swedish company test you mentioned? Is it more sensive than the standard assay tests to detect tryptase for example?

What happens in time to blood that reduces the optimum conditions for such testing?

Do the antibodies just disappear gradually? Does it depend on the blood consititution of the deceased therefore changing from person to person?

Thanks.

XXXX
doctor
Answered by Dr. Vivek Chail 11 hours later
Brief Answer:
Its a commercially approved test

Detailed Answer:

Hi XXXX XXXXXXX
Thanks for writing back with an update.

The Swedish company based tryptase test is approved by the FDA and I consider it as an acceptable test which is beneficial to many patients. The company product website is as given

http://www.phadia.com/da/Products/Allergy-testing-products/ImmunoCAP-Assays/ImmunoCAP-Tryptase/

Blood contains red blood cells, white blood cells and platelets as well as the serum which contains protein molecules including antibodies. After death the blood proteins undergo degeneration. After degeneration these antibodies lose their individual characteristics which makes it unsuitable for testing.

The antibodies slowly get degenerated and disappear. Since they are made of proteins and every individuals proteins are dictated by their genes, there is some variation in the decrease of antibody levels in the population.

Hope your query is answered.
Do write back if you have any doubts.

Regards,
Dr.Vivek
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Vivek Chail 39 hours later
Hello Dr XXXXXXX

Thanks for the information.

With regard to a possible allergic or adverse reaction to the medication nitrofurantoin is "anaphyslaxis" a common symptom/condition?

What is this condition?

What tests are available to identify this reaction/condition-anaphyslaxis?

What does this sentence mean "the appearances at the post mortem were those of bronchopneumonia and the changes I saw would not suggest anaphyslaxis".

What is the doctor specifically referring to medically when he uses the word "changes"?

Thanks

XXXXX

I'm not sure that I have another follow up question after your next reply so if I don't contact you again (which I might) thank you for your excellent and punctual service which has given me a bit of a specialised medical education helping me to deal with "medicospeak" .


doctor
Answered by Dr. Vivek Chail 9 hours later
Brief Answer:
Please find details below

Detailed Answer:
Hi XXXXX XXXXXXX
Thanks for writing back with an update.

An anaphylaxis is a sudden violent hypersensitive reaction with potential fatal outcomes. It is not commonly associated with nitrofurantoin use.

You can say that it is an extreme type of allergy reaction and usually involves sudden release of chemicals causing inflammation of the respiratory passage leading to respiratory failure if not controlled.

The tryptase test is useful in knowing if a person has had an anaphylaxis reaction.

In saying "the appearances at the post mortem were those of bronchopneumonia and the changes I saw would not suggest anaphyslaxis" the doctor probably intends to say that the post mortem changes in lungs do not support the features seen in anaphylaxis and are more likely to be indicative of infection and pneumonia in the deceased.

Hope your query is answered.
Do write back if you have any doubts.

Regards,
Dr.Vivek
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Vivek Chail 12 hours later
Hello Dr XXXXXXX

Thanks for the reply and information.

You state, "the tryptase test is useful in knowing whether a person has had an anaphylaxis reaction".

What result specifically would give the confirmation of such a reaction? How is it measured for example? What does it measure precisely?

Thanks.

XXXXX
doctor
Answered by Dr. Vivek Chail 18 hours later
Brief Answer:
Measures tryptase levels

Detailed Answer:
Hi Green XXXXXXX
Thanks for writing back with an update.

You are most welcome.

The detailed information on tryptase test specifies the following:

In healthy individuals the tryptase baseline levels have been reported to range approximately between 1–15 μg/l. Each individual has its own unique baseline level, which usually is stable over time. Some individuals with elevated baseline levels of tryptase, approximately >10 μg/l, are considered to be at increased risk for severe anaphylactic reaction.

Elevated levels of tryptase can usually be detected for up to 3 to 6 hours after the anaphylactic reaction. They return to normal within 12-14 hours after release.

In patients with systemic anaphylaxis levels of tryptase are, in general, persistently elevated above 20 μg/l

These are available as test kits.

Hope your query is answered.
Do write back if you have any doubts.

Regards,
Dr.Vivek
Above answer was peer-reviewed by : Dr. Ashwin Bhandari
doctor
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Follow up: Dr. Vivek Chail 2 hours later
Hello Dr XXXXXXX

Thanks for the information.

Does anaphylactic mean an extreme allergic reaction?

For example an adverse reaction to nitrofurantoin such as chest discomfort, some respiratory distress, malaise and anxiety when becoming more elevated and distressing can then be termed medically as anaphylactic ?

So in my mother's case if there had been an anaphylactic reaction- an extreme reaction if that is correct as a description, the blood collected in March or recently taken blood after 5 months wouldn't show that particular tryptase reaction?

Is tryptase an enzyme that is a marker for antibodies? Can antibodies be detected in other ways if the tryptase is so short lived?

As far as detecting antibodies to a possible adverse reaction to nitrofurantoin is concerned I have been led to believe by various medical opinion that this may still be possible after a few months and that each individual is unique in thsi respect..

Thanks.

XXXXX
doctor
Answered by Dr. Vivek Chail 18 hours later
Brief Answer:
Please find details below

Detailed Answer:
Hi XXXX XXXXXXX
Thanks for writing back with an update.

Anaphylaxis is an extreme allergic reaction which gives little time to realize what exactly is happening and by the time medical help is sought the patient can die.

The chances of the blood collected in March or after 5 months has a very low chance of testing positive for high levels of tryptase.

Anti tryptase found in the testing kit binds with tryptase in the patients blood and this is automatically analyzed for concentration of the tyrptase levels. The anti bodies to tryptase are made in the lab and this reacts with tryptase in the patients blood. This is a highly complex procedure and invloves various lab techniques.

Any antibody is made of proteins and if not stored properly in its native environment, proteins get denatured and destroyed. As proteins in an individual are coded by the DNA these may vary in stability among the population.

Hope your query is answered.
Do write back if you have any doubts.

Regards,
Dr.Vivek
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Vivek Chail 3 hours later
Hello Dr XXXXXXX

Thanks for the information.

Now I would like you to evaluate a diagnostic decisional process.

Please study the clinical case study below and answer (with reasons of course) why you believe scientific tests should or should not done to confirm or not the diagnostic "opinion" based on the symptoms, impressions and signs given;

The patient/the deceased was 95 at the point of death and died after a cardiac arrest. She had been physically healthy for her age.

Every few months a mild UTI infection was noted and treated with antibiotics.

The cause of death after an autopsy examination was determined as 1a bronchopneumonia (and 1b vascular dementia).

The signs of possible bronchopneumonia from the report are the firmness of the right lower lobe and its friableness.

However, the following pre-autopsy findings may be taken into account.

1) The deceased showed no signs of chest discomfort, pneumonia or bronchopneumonia in the period leading up to the day of decease.

2) No medication for a chest infection was therefore given in the week before the decease.

3) At 4 pm the day before the day of decease the next of kin reports that the deceased seemed perfectly normal.

4) Chest discomfort and breathing problems were noted in the early hours of the morning before the decease at 06.50.

5) The out-of-hours doctor at 03.00 the morning of the decease noted the following;

a) No abnormal signs were given by the stethoscope examination of the chest-no wheezing sound or harder to hear places of breathing.

b) the blood/saturation level was verbally reported at 03.00 as being normal. A later written report of the same time noted the blood/oxygen saturation level as 92% (normal is 95%-while sleeping 94% the literature consulted reports).

Given the information available should scientific testing be done - lung biopsy and blood testing to confirm or not the clinical impression of bronchopneumonia as being the primary cause of death?

Thanks.

XXXXX
doctor
Answered by Dr. Vivek Chail 16 hours later
Brief Answer:
Lung biopsy can confirm pneumonia

Detailed Answer:
Hi XXXX XXXXXXX
Thanks for writing back with an update.

Death due to suspected pneumonia in an elderly patient suffering from dementia is a very delicate situation. As such any patient over the age of 85 years may not present with typical signs and symptoms of pneumonia.

Clinical studies show that in most cases, if you look closely, you will find that the body is trying to mount an inflammatory response but is not completely successful. The patient may be feeling cold and shivering as the body tries to increase the temperature. The patient may have a decreased appetite as the body is trying hard to produce inflammatory chemicals. The patient may get slightly confused as the body is struggling to fight the infection.

This is even more difficult to evaluate in a patient with dementia as they may not express their problems and fever is not seen as in such patients. The actual symptoms vary and are unpredictable but you can put the pieces together and link them to the lungs and the failed inflammatory response.

Testing the blood may not show confirmatory results because of the failed inflammatory response.

Lung biopsy can confirm the presence of pneumonia in the deceased.

Hope your query is answered.
Do write back if you have any doubts.

Regards,
Dr.Vivek
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Vivek Chail 5 hours later
Hello Dr XXXXXXX

Thanks for the infomation.

The deceased was diagnosed not only with pneumonia but with broncho-pneumonia.

What are the signs of "broncho" in bronchopneumonia?

No pus on compression of the lung was noticed and noted as such?

No signs of a chest complaint up until the early hours of the day of decease. No medication. No auscultation abnormality. Deceased appeared in good health a few hours before decease. The deceased was actually able to speak about how she felt to an extent. Blood/oxygen saturation level normal three hours before the decease.


The full clinical signs on which the opinion is based in the PM report are;

1) Larynx and trachea are remarkable.
2) Small amount of pus in the airways to the left lower lobe.
3) Firm texture to the left lower lobe though no pus on expression.
4) Oedema in the lower lobes.
5) The right lobe lower lobe shows more diffuse firmness and is very soft and friable on compression.
6) Prominent areas of purulent membrane over the base of the left lower lobe.

Which of those signs might be consistent with bronchpneumonia? Can the signs mentioned be caused by another condition -signs such as firmness or friability or the amount of fluid in the lungs mentioned?

Is the medical OPINION of the pathologist (stated as such in the PM report ) and based on one or two signs scientifically INDUBITABLE in your OPINION reaching the reasonable standard of care expected of investigative medical science without the necessity scientific clinical testing and given the information provided?

In addition to the clinical impressions revealed should a scientific test such as a lung biopsy be authorised in these clinically reported circumstances?

Thanks.

XXXXX XXXXXXX

doctor
Answered by Dr. Vivek Chail 18 hours later
Brief Answer:
Findings are acceptable

Detailed Answer:
Hi XXXXX XXXXXXX
Thanks for writing back with an update.

Bronchopneumonia is differentiated from pneumonia or lobar pneumonia by its patchy distribution. It is usually seen in infants and older individuals (extremes of age).

As discussed earlier, in a 95 years old individual the onset and progression of disease may not be clinically pronounced. This is because of the inability of the cells in the body to put up a strong fight to the infection causing organisms. This is the reason for absence of fever and other inflammatory signs.

The below mentioned findings suggest bronchopneumonia

Small amount of pus in the airways to the left lower lobe.
Oedema in the lower lobes.
The right lobe lower lobe shows more diffuse firmness and is very soft and friable on compression.
Prominent areas of purulent membrane over the base of the left lower lobe.

Once there is little pus and purulent membrane then it is unlikely to be due to any other cause including anaphylaxis.

The findings are circumstantial and therefore acceptable keeping in mind the age and medical history of the deceased.

A final confirmation may however be made by doing lung biopsy.

Hope your query is answered.
Do write back if you have any doubts.

Regards,
Dr.Vivek
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Vivek Chail 6 hours later

Hello Dr XXXXXXX

re; definitive and conclusive diagnosis criteria that do not necessitate clinical scientific tests question/circumstantial findings

Thanks for the reply and information.

I would be very grateful if you could comment on.

1) Blood/oxygen saturation being normal three hours before the decease.

2) Auscultation result being normal.

3) The membrane identiflied and the normal occurance of fluid in the lungs post-fatal cardiac arrest which may have become infected. The autopsy was three weeks after the decease.


4) Can broncho-pneumonia develop from what appears to be a normal healthy state to the clinical condition itself in five and half hours or from the moment of some sort of activation/reaction? A change must have occurred in the body at about 1 am leading to decease at about 6.50 am.

and the last two important questions

5) Whether the four signs above that you mention in your reply are DEFINITIVE in the diagnosis that the cause of death was broncho-pneumonia? Could the signs be the result of another cause?

6) Are scientific tests necessary to conclude the expected steps in a scientific diagnosis that can be considered as definitive?

7) Could you specify what you mean by "the findings are circumstantial"?


What I would like to know is not whether a scientific clinical test COULD be done but whether the scientific test SHOULD be done ( perhaps because "the findings are circumstantial" as you state) as it is necessary in the scientific diagnostic process given the few clinical impressions given i.e. some fluid in the lungs, friableness of one lobe etc .

Thanks.

XXXXX XXXXXXX



doctor
Answered by Dr. Vivek Chail 20 hours later
Brief Answer:
Detailed answers given below

Detailed Answer:
Hi XXXXX XXXXXXX
Thanks for writing back with an update

Answers to each query is given below.

1) Blood/oxygen saturation being normal three hours before the decease.
Blood oxygen saturation SpO2 is only one of the factors involved in the functioning of the respiratory system. There are many other variables like arterial blood gases which give more detailed information on the actual transport of oxygen in the blood.

2) Auscultation result being normal.
Auscultation is a reflection of the heart function and in a 95 year old person it may not be able to appreciate subtle changes in heart beat due to aging changes in the heart.

3) The membrane identified and the normal occurrence of fluid in the lungs post-fatal cardiac arrest which may have become infected. The autopsy was three weeks after the decease.
There are certain changes which occur before death and are more pronounced just after death. I agree there will be changes due to decomposition (even when stored at below normal temperatures) and it may include fluid accumulation, but going by the findings of the pathologist, the lung changes are most likely to have occurred just before death and not the result of short duration decomposition which has happened in 3 weeks.


4) Can broncho-pneumonia develop from what appears to be a normal healthy state to the clinical condition itself in five and half hours or from the moment of some sort of activation/reaction? A change must have occurred in the body at about 1 am leading to decease at about 6.50 am.
Broncho pneumonia was already present for a day or more prior to death. The changes were not obvious to the attending staff and the immune system of the deceased was not strong enough to cause typical symptoms and signs of disease. This led to a situation of sudden death while everything looked apparently normal 6 hours earlier.

5) Whether the four signs above that you mention in your reply are DEFINITIVE in the diagnosis that the cause of death was broncho-pneumonia? Could the signs be the result of another cause?
With little pus and membrane formation, the findings of oedema and diffuse firmness with friability are definitive of death due to broncho pneumonia in an individual with weak immune response.

6) Are scientific tests necessary to conclude the expected steps in a scientific diagnosis that can be considered as definitive?
Scientific tests are not necessary and could be done. There is little to rethink about any other cause from the above mentioned findings. I still recall that the patient had vascular dementia and in old age, dementia and weak immune response together might have contributed to the delay in recognizing the deteriorating health of the deceased in the final hours preceding death.

7) Could you specify what you mean by "the findings are circumstantial"?
Circumstantial applies to the series of events which include atypical presentation of broncho pneumonia in a patient having dementia. Under these situations it is difficult to expect the deceased having high fever and toxic features in the hours before her demise.

I would not suggest any further scientific clinical tests as the findings are definitive in the current setting.

Hope your query is answered.
Do write back if you have any doubts.

Regards,
Dr.Vivek
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
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I have been told I have sinus bradycardia and am having symptoms of light headedness, fatigue , confusion, heart palpitations, pulse between 40 and 50 for 5 days. Should I go see my doctor or jusr see if it passes. Why would it get worse as I have...

doctor1 MD

Hi I'm worried that early repolarization can cause sudden death I've read so much about this online, I had it on my ECG I don't understand why doctors are not concerned

doctor1 MD

I am on metronidazole for giardia and med info said not to use propylene glycol, as if I knew what that was, and I started getting fluttery sensation in throat and down to chest like I had asthma . I brainstormed what it could be and looked into...