Autopsy Findings

A serosanguineous pleural effusion (300 ml) was present on the right. The heart was enlarged (380 g, normal 300 g). Look at each of the following photos and explain what has happened.

A. Valves were normal except for the pulmonic, which is shown here. Compare it with an example of a normal pulmonic valve below (B). One commissure is indicated at the arrow.

B. Normal pulmonic valve. Note the thin,translucent cusps and normal commissures.

C. The right lung weighed 1000 g and the left, 900 g (normal about 250 g apiece). The right had a fibrinous pleuritis. After distension with formalin and fixation, one slice from the left lung showed two yellowish lesions.

D. A slice of the right lower lobe showed two lesions.

Answer

Clinical summary Image 2

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Answers:

A. The pulmonic valve had large vegetations, about 2 cm in diameter, on each of 2 cusps. They were very friable, and one (on the leaflet to the right of the arrow) was dislodged before the photo was taken, revealing a hole, 5 x 3 mm in diameter (not shown), in the cusp. The vegetation that is present (anterior leaflet) obscures the commissure and has spread to the wall of the pulmonary artery. No pedunculated portion was present at autopsy. The valve leaflets are thickened, a congenital anomaly (see discussion).

C. The slice of lung shows two segmental pulmonary arteries that are occluded by thrombus. Note the airway next to the vessel near the center. No infarct or hemorrhage is present in the distal parenchyma. These two thrombi probably came from the pedunculated portions of the vegetations that were identified in the echocardiogram.

The slice of lung in D shows two cavities with thin walls. The larger abuts the pleura and may have been responsible for the parapneumonic effusion. Both cavities show small amounts of residual necrotic lung, which is dark in the smaller cavity and pale in the larger one. The cavitation is the result of pneumonia and ischemia caused by septic thromboemboli as in C. Note the pleuritis at the base (lower left).

D. Compare this slice with the radiograph taken four days previously. The larger, subpleural cavity seen here appears as a mass-like consolidation without cavitation on the radiograph.

The photos show typical consequences of right-sided infective endocarditis: cavitated, pneumonic infarcts and pulmonary emboli without infarction.

The liver (2200 g, normal 1500-1800 g) and spleen (320 g, normal 100 g) were enlarged. The kidneys were shrunken (R 75 g, L 92 g, normal 150 g each) from the chronic membranoproliferative glomerulonephritis. The brain was normal.

Clinical summary Image 2

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