Clinical History:

This 39-year-old white male suffered 53% third degree burns in an airplane accident at Cheyenne, Wyoming on 5/21/80.  Following stabilization, he was transported to the burn unit, otherwise the medical history was noncontributory.

On admission, the patient was alert, afebrile, and had good urine output.  Laryngeal edema was present on admission and this soon resulted in stridor.  In addition, bilateral pulmonary infiltrates appeared; those were thought secondary to inhalation of smoke.  The patient went into shock with rapidly deteriorating blood gases requiring intubation and PEEP.  Over the subsequent two weeks, the patient received two wound debridements with autologous skin grafts.  Fever developed and continued along with an elevated white count with left shift until death.

On 6/9/80, multiple resistant Pseudomonas was cultured from the burn sites.  Small amounts of blood were aspirated from the N-G tube and a platelet count revealed less than 25,000 platelets.  On 6/12/80, the patient experienced a sudden bradycardia and at 12:05 was pronounced dead.

Autopsy Findings:

Autopsy findings included full thickness burns of 60% of the body surface.  The heart weighed 270 grams. It's gross appearance is illustrated in Figure 1 and Figure 2 and its microscopic appearance is shown in Figure 3.  Coronary arteries were widely patent.

The lungs were both heavy, firm, and exuded large amounts of yellow cloudy fluid when cut. Bronchi were erythematous and contained red-tinged mucous.  Aside from focal pneumonia, the lungs appeared as in Figure 4.

The liver was heavier than normal and was red-brown with a prominent lobular pattern.  Blood oozed from the freshly cut surface.

The spleen was heavier than normal. It's cut surface is shown in Figure 5.

The kidneys were normal in weight.  The only abnormality was a lesion in the right lower pole that was similar to the lesion in the spleen.

The rest of the organs were unremarkable.

Questions:

1.  There are two abnormalities in Figure 1.  What are they? (one is also illustrated in Figure 2).

2.  Figure 3 shows the microscopic appearance of the pathologic valvular lesions illustrated in Figure 1 and Figure 2.  A Gram stain was negative (stain for bacterial organisms).  Give two pathogenetic explanations for these lesions that fit this case.  Which is more likely?  Why?

3. What complications might arise from the valvular lesions as suggested by Figure 5?

4.  Give the diagnoses corresponding to the description of the liver and the appearance of the right ventricle in Figure 1

5.  a) The history of smoke inhalation, shock, gram negative infection, and increasing respiratory failure (high O₂ exposure) suggest what pulmonary syndrome is part of this patient's demise (see histology on Figure 4).

    b) The low platelet count suggests what other syndrome often found in patients with tissue damage, septic shock, etc?