Angela D. Levy

This study compared autopsy with postmortem multidetector computed tomography (MDCT) findings in charred remains. Seventeen consecutive male subjects (mean age, 29.4 years) who perished in a fire-related event resulting in charred remains underwent total body MDCT immediately prior to routine autopsy that included serum carboxyhemoglobin measurement. MDCT showed all thermal tissue changes (skin and subcutaneous fat loss, skeletal muscle retraction, pugilistic attitude, cortical fractures, bone and organ destruction, thermal epidural hematoma, and thermal amputation) and established all fracture patterns that were lethal, but autopsy added the fire as a contributory cause of death when there was carboxyhemoglobin elevation. MDCT had limited value in determination of lethal vascular and visceral injuries. MDCT is an effective complement to autopsy in the setting of charred remains and may serve to augment a limited autopsy. This may be particularly useful in mass casualty scenarios.

Tumors and tumorlike lesions that secondarily involve the mesothelial or submesothelial layers of the peritoneum are a diverse group of disorders that range in biologic behavior from benign to highly malignant. The anatomy of peritoneal ligaments and mesenteries and the normal circulation of peritoneal fluid dictate location and distribution of these diseases within the peritoneal cavity. Peritoneal carcinomatosis is the most common secondary tumor to affect the peritoneal cavity. When it arises from carcinomas of the gastrointestinal tract or ovary, the prognosis is grave. However, when low-grade mucinous adenocarcinoma of the appendix spreads to the peritoneal cavity, the consequence is typically pseudomyxoma peritonei, which is a clinical syndrome, characterized by recurrent and recalcitrant voluminous mucinous ascites due to surface growth on the peritoneum without significant invasion of underlying tissues. Carcinomas from elsewhere in the body, as well as lymphomas and sarcomas, may also produce diffuse peritoneal metastasis. Granulomatous peritonitis is the consequence of disseminated infection such as tuberculosis or histoplasmosis, foreign materials, or rupture of a tumor or hollow viscus. Finally, a group of benign miscellaneous conditions that range from common disorders such as endometriosis and splenosis to very rare conditions such as gliomatosis peritonei and melanosis may also affect the peritoneum diffusely. Secondary tumors and tumorlike lesions of the peritoneum have overlapping imaging features when compared with each other and primary peritoneal tumors. Knowledge of peritoneal anatomy, normal fluid circulation within the peritoneal cavity, and clinical and pathologic features of secondary peritoneal lesions is essential for identification of these lesions.

Primary peritoneal tumors are uncommon lesions that arise from the mesothelial or submesothelial layers of the peritoneum. Primary malignant mesothelioma, multicystic mesothelioma, primary peritoneal serous carcinoma, leiomyomatosis peritonealis disseminata, and desmoplastic small round cell tumor are the most prominent of these rare lesions. Primary malignant mesothelioma is a highly aggressive malignancy that occurs most commonly in older men and that has a strong association with high levels of asbestos exposure. It manifests most often as diffuse sheetlike or nodular thickening of the peritoneal surfaces, but it may occasionally be a localized mass. Multicystic mesothelioma occurs most frequently in women and has benign or indolent biologic behavior in the majority of patients. It is a multilocular cystic mass that arises from the pelvic peritoneal surfaces. Primary peritoneal serous carcinoma occurs almost exclusively in women. It is histologically identical to ovarian serous carcinoma and may be indistinguishable from metastatic ovarian carcinoma at imaging studies. Leiomyomatosis peritonealis disseminata is a rare, benign proliferative process that also occurs exclusively in women and is characterized by multiple smooth muscle nodules throughout the peritoneum. Desmoplastic small round cell tumor is a highly aggressive malignancy of unknown origin that occurs most often in the peritoneal cavity of young men. This unusual group of tumors is linked together by a common site of origin and imaging manifestations that mimic those of peritoneal carcinomatosis. Knowledge of the spectrum of imaging findings in this group of primary peritoneal tumors, along with their clinical and pathologic characteristics, is important in the evaluation of patients with diffuse peritoneal disease.

To retrospectively determine the multidetector computed tomographic (CT) virtual autopsy findings of death by drowning in comparison with autopsy findings. The institutional review board of the Armed Forces Institute of Pathology approved this HIPAA-compliant study and did not require informed consent by the next of kin. Total-body multidetector CT was performed, immediately prior to routine autopsy, in 28 consecutive male subjects (mean age, 24.2 years) who died of drowning and a control group of 12 consecutive male subjects (mean age, 50.8 years) who died of sudden death from atherosclerotic coronary artery disease. Images were evaluated for the presence of fluid and sediment in the paranasal sinuses and airways, mastoid air cell fluid, frothy fluid in the airways, pulmonary opacity (ground-glass opacity or airspace consolidation), interlobular septal thickening, and gastric distention and contents (fluid or sediment). Image findings were compared with findings from autopsy reports and photographs. All drowning subjects had fluid in the paranasal sinuses and mastoid air cells and had ground-glass opacity within the lungs. Twenty-six subjects (93%) had fluid in the subglottic trachea and main bronchi. Fourteen subjects (50%) had high-attenuation sediment in the subglottic airways. Frothy fluid in the airways was present in six subjects (21%). Twenty-five (89%) of the drowning subjects had pulmonary ground-glass opacity with septal lines, which was mild with apical and perihilar distribution in 12 subjects, severe and diffuse in nine, posterior and basilar in three, and limited to the apices in one (not assessed in three of 28 subjects because of decomposition). Control subjects showed mastoid cell fluid (25%), sinus fluid (83%), subglottic airway fluid (92%), and pulmonary ground-glass opacity (100%) but did not have evidence of frothy airway fluid or high-attenuation sediment in the airways. The multidetector CT finding of frothy airway fluid or high-attenuation airway sediment is highly suggestive of drowning; multidetector CT findings of pan sinus fluid, mastoid cell fluid, subglottic tracheal and bronchial fluid, and ground-glass opacity within the lung at multidetector CT are supportive of drowning in the appropriate scenario.