Dear Editor,

We read with great interest the original article by Bernardi et al. [1] in the December 2005 issue of the Journal. According to literature previously published, the authors believe that necroscopy is the standard method to determine the cause of death when investigating clinicopathological discrepancies and the epidemiology of disease. They reviewed the provisional and final reports of necropsies performed at their Institution in 2001 to check diagnostic changes between initial gross diagnosis and subsequent histological analysis in several organs. They found that microscopic examination has a major impact on macroscopic diagnosis, altering and refining previous diagnoses, especially in the lungs, liver and kidneys. Moreover Bernardi et al. [1] raise the question that, in routine necropsies, histological sampling increases costs and turnaround times, and consequently some pathologists believe that histology may not always be necessary.

We found their discussion of literature and interpretation of the data very pertinent and we wish to share with the authors and the readers our experience. We would like to stress out even further the necessity for the pathologist to realize the usefulness of histological analysis. Due to a misbelief that post mortem events alter morphology in such a way to prevent a correct diagnosis, some pathologists decide not to take samples for histology. Grellner and coll. [2] have systematically shown however that histological analysis is feasible and useful even when the exam is made of exhumed bodies months after burial. At the autopsy, the pathologist should first describe the macroscopic aspect of each organ and take samples of each visible lesion. A provisional diagnosis may be given while histology is pending but the diagnosis should be confirmed by histological analysis. It should be noted that a correct sampling by the pathologist must be performed to avoid forensic consequences from misdiagnosis.

Moreover pathologists should keep in mind that the classical pathological patterns are changing due to the effects of novel and more prompt interventions. In some cases alterations are identifiable only at a microscopic level. We would like to point out that the histological analysis of the heart sometimes is fundamental to determine the cause of death and date the event. This is especially important in such diseases as non- atherosclerotic coronary pathology [3-5]. In our own small experience an accurate histological examination allowed us to specify the chain of events which brought on unexpected sudden death [6,7].

In conclusion we are grateful to the authors for addressing such a relevant issue. Although it may appear time consuming and costly at first, a more complete assessment would reveal that the risk of misdiagnosis using macroscopic only analyses is relatively high, and an accurate assessment of the scenario using histological analysis assures the reliability of the findings, which is of particular relevance in forensic medicine. Moreover, the detailed analysis under the microscope is the access pathway to a different dimension where the pathologist sees not only the end event but he has insight of the pathophysiologic cascade of cellular and molecular events leading to the disease.

References

1. Bernardi FD, Saldiva PH, Mauad T. Histological examination has a major impact on macroscopic necropsy diagnoses. J Clin Pathol 2005;58:1261-4.

2. Grellner W, Glenewinkel F. Exhumations: synopsis of morphological and toxicological findings in relation to the postmortem interval. Survey on a 20-year period and review of the literature. Forensic Sci Int 1997;90:139- 59.

3. Corrado D, Basso C, Thiene G. Sudden cardiac death in young people with apparently normal heart. Cardiovasc Res 2001;50:399-408.

4. De Giorgio F, Abbate A, Vetrugno G, et al. Non-atherosclerotic coronary pathology causing sudden death. J Clin Pathol in press.

5. De Giorgio F, Abbate A, Capelli A, et al. Spontaneous rupture of coronary artery in HIV+ patient treated with HAART. Am J Forensic Med Pathol 2005;26:197.

6. De Giorgio F, Abbate A, Biondi-Zoccai GG, et al. Fatal choking due to amyloid infiltration of the laryngeal plexus. Virchows Arch. 2005;447:115-

7. De Giorgio F, Abbate A, Biondi-Zoccai GG, et al. An unusual cause of fatal pulmonary embolism. Int J Cardiol. in press.