Department of Pathology
Medical Center Blvd
Winston-Salem, NC 27157
Phone: (336) 716-4311
Fax: (336) 716-7595
MEDICOLEGAL AUTOPSY REPORT
A. G. McDonald, M.D., Pathology
Tiffany Erin O'Neill , DO
Medical Record #:
NCBH Path #:
8/16/2014 (Age: 1)
Garry L. Wooten
Haywood County Medical Examiner
FINAL AUTOPSY DIAGNOSIS
I. Blunt force injuries of the head:
A. Contusions of the scalp, cheeks, and lip
B. Abrasions behind right ear, under the nose and on posterior neck
C. Subscalpular hemorrhage, left frontal
D. Subgaleal hemorrhages, left frontal and bilateral parietal
E. Subdural hematoma, right cerebrum and left cerebellum (40 mL); partially clotted
F. Subarachnoid hemorrhage, left parasagittal and optic chiasm
G. Cerebral edema and right medial temporal lobe herniation
1. Bilateral retinal hemorrhages
2. Bilateral optic nerve sheath hemorrhages
H. Diffuse hypoxic/ischemic injury with associated necrosis
II. Blunt force injuries of the torso:
A. Contusions of the chest and back
III. Blunt force injuries of the upper extremities:
A. Right arm:
1. Contusion of the shoulder
B. Left arm:
1. Contusions of the shoulder
IV. Blunt force injuries of the lower extremities:
A. Right leg:
1. Contusions of the thigh (anterior and posterior) and above ankle
B. Left leg:
1. Contusions of the thigh (anterior and posterior) and over calf
V. Mild, patchy, necrotizing bronchiolitis (likely due to respiratory syncytial virus (RSV))
***Electronically Signed Out By:
A. G. McDonald, M.D., Pathology***
Viral culture: nasopharyngeal:
1+ Coagulase negative Staphylococci
3+ Streptococci, alpha hemolytic; 2+ Saprophytic neisseria species
Body Fluid - blood:
Coagulase negative Staphylococci; Methicillin resistant Staphylococcus aureus; Streptococci, alpha
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Summary of Findings
The cause of death in this 18-month-old male, Kyler Presnell, is diffuse hypoxic/ischemic injury of the brain with necrosis due to
acute subdural hematoma due to blunt force injuries of the head.
Major findings at autopsy included contusions of the scalp with underlying hemorrhage; a right-sided, partially clotted subdural
hematoma (40 mL); and brain with subarachnoid hemorrhage, edema, right medial temporal lobe herniation, hypoxic/ischemic
injury and regions of necrosis. In addition there were multiple bruises/contusions of the arms, legs and torso. The retinal
hemorrhages and optic nerve sheath hemorrhages are likely secondary to the increase in intracranial pressure as a result of the
cerebral edema. A mild, patchy bronchiolitis with rare syncytial cell formation is present, most likely due to recent infection with
respiratory syncytial virus (RSV); however, despite RSV genetic material being detected in the nasopharyngeal specimen, a PCR
genetic test for RSV on the lung tissue was negative. The bronchiolitis is mild and patchy and did not cause or contribute to the
death. Postmortem bacterial cultures grew a mixture of organisms consistent with postmortem contamination. Postmortem
toxicology screening on aortic blood for a detectable carbon monoxide level and common substances of abuse is negative.
According to initial investigative reports, the decedent was found unresponsive and Emergency Medical Services was called. Upon
arrival to the scene, the emergency personnel noticed a strong kerosene odor and were initially concerned for a carbon
monoxide-related death due to a faulty heating unit in the residence. Per review of investigative materials provided by the County
Medical Examiner, Kyler had recently moved in with his paternal grandparents following the incarceration of his parents
(approximately 3 and ½ weeks prior to death). Due to the paternal grandmother’s work schedule, the child spent the majority of the
day with his disabled paternal grandfather. Kyler was reportedly put to bed in the pack-and-play in the living room around 21:00 by
his grandfather the night prior to his death. He was found by his grandparents in the pack-and-play unresponsive at around 04:20
the day of his death. Grandparents attempted resuscitation until medics arrived and declared Kyler dead on scene.
Per interview with the paternal grandfather on 2/2/2016, Kyler had no changes in his behavior the day prior to his death with
waking up at 07:30, being fed, playing until tired, napping at noon, waking at 14:00, eating and playing until bed time at 21:00. Per
the grandfather, the child was never out of his sight. When interviewed on 2/2/2016 and 2/11/2016, the paternal grandmother said
the only recent trauma she knew of was Kyler falling in pack-and-play “once” weeks ago, falling against a door several weeks ago,
and falling and hitting dumbbells a week prior to death. Both grandparents repeatedly denied knowing of or causing significant
head trauma. Paternal grandfather stated during his 2/2/2016 interview that “I’m pretty smart. It’s either her or me” while also
stating “I didn’t hurt this child and I know my wife didn’t hurt this child”. Aside from the paternal grandparents, the only caretaker in
the prior three and a 1/2 weeks was 20 days prior where Kyler was noted to be ambulating and fell three times, hitting his knees
and his bottom. Review of a jail visit video dated 1/28/2016 (3 days prior to death) showed Kyler to be acting age appropriate
(pointing to nose and hair when prompted, “talking” on the phone to his father) and without obvious external head trauma.
Review of the Kyler’s medical records indicates he was born at 37 weeks gestation with APGARs of 9 and 9. At 8 months of age
(4/27/2015), he was brought to Haywood Regional for a head contusion related to rolling off the bed. At his 10 month well-child
check (6/22/2015), he was noted to have a rash, cough and congestion and immunizations were administered. On 9/5/2015, Kyler
was taken to Haywood Regional for acute urticaria and was treated with steroids and diphenhydramine. When Kyler moved in with
his paternal grandparents, he reportedly had an upper respiratory tract infection that was being treated with oral antibiotics. No
documentation of easy bruising or bleeding is identified in Kyler’s medical history.
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Body Weight: 17 pounds
(Crown-Heel Length): 81 cm
(normal: 78 cm)
The body is that of a well-developed, well-nourished, Caucasian male
toddler appearing the stated age. Body identification includes an
identification tag on the right great toe and body bag.
The body is received clothed in a clean diaper, a white T-shirt and a
blue and white sock. No personal effects accompany the body.
Crown-Rump Length: 54 cm
Head Circumference: 48 cm
Chest Circumference: 41 cm
The body is cool to the touch. Rigor is absent in the extremities and jaw.
Diffuse, fixed, red-purple livor extends over the posterior surfaces of the
body, except in areas subject to pressure. The head is normally formed.
Scalp hair is blonde, curly, and 8 cm in length. The hair growth pattern
is normal. The anterior and posterior fontanelles are closed. The eyes
are normally formed. Indirect funduscopic examination of the eyes
demonstrates bilateral retinal hemorrhages. The irides are green. The
corneae are transparent. The sclerae and conjunctivae are pale. The
ears are normally formed and placed with the appropriate amount of
cartilage. The nose and lips are unremarkable. The deciduous teeth are
partially erupted and normal for age. The palate is intact and is neither
high nor arched. The neck is without masses and the larynx is in the
The thorax is symmetrical. The abdomen is not protuberant. The
extremities are bilaterally symmetrical with all digits present. Palmar
creases are unremarkable. The external genitalia are those of a normal
male toddler, with testes bilaterally in the scrotum, which is
appropriately rugated. The back and anus are unremarkable.
There are no identifying marks or scars.
Emergency resuscitation and/or medical therapy consists of
electrocardiogram pads on the chest and defibrillator pads on the chest
EVIDENCE OF INJURY
HEAD AND NECK
BLUNT FORCE INJURIES
Two red-blue contusions (½ x ¼-inch and ¼ x ¼-inch) are on the right
side of the forehead. A 3/8 x 1/8-inch, red-blue contusion is above the
right ear. A ¾ x 1/16-inch, red, linear abrasion behind the right ear. A 1/2
x ¼-inch, red-brown contusion is on the right cheek near the right corner
of the mouth. An additional ½ x ¼-inch contusion is near the center of
A 2 ½ x 1 ½ inch area of blue discoloration with three red-blue
contusions (up to 3/8 x ¼ inch) is on the left side of the forehead around
the temple region. Four red-brown contusions, up to ½ x 1/4-inch, are on
the left cheek. A 1/8 x 1/16 inch, red, circular abrasion is between the lip
and nose on the left side. A ¼ x ¼ inch red-blue contusion involves the
upper lip on the left side. Frenula are intact.
Internally, a 4 x 3 ½-inch area of subgaleal hemorrhages, ranging in size
from ¼ x ¼ inch up to 2 x ¾ inch, is over the bilateral parietal bones
posteriorly. A 7 ½ x 3-inch subscalpular hemorrhage and a 3 ½ x 2
½-inch subgaleal hemorrhage are over the left frontal aspect of the skull.
A 40 ml, partially clotted, subdural hemorrhage is over the right cerebral
hemisphere. A ½ x ½ inch subdural hemorrhage is over the left
A ¼ x 1/8 inch red, linear abrasion is on the back of the neck on the right
CHEST AND ABDOMEN
BLUNT FORCE INJURIES
Four red-brown contusions, ranging in size from 1/8 x 1/8 inch to ½ x
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¼-inch, are over the central chest, possibly related to cardiopulmonary
resuscitation. A ½ x ½ inch, red-brown contusion is on the upper back to
the right of midline. A 1/8 x 1/8 inch, red-blue contusion, is on the lower
back on the left side.
BLUNT FORCE INJURIES
A ¼ x ¼ inch, red-brown contusion is on the lateral shoulder.
Two red-brown contusions (1/8 x 1/8-inch and ½ x ¼-inch) are on the
BLUNT FORCE INJURIES
Three red-blue contusions, measuring ½ x ¼-inch each, are on the
anterior thigh. Two red-brown contusions (3/8 x 3/8-inch and ¼ x
¼-inch) are on the posterior thigh. A ¼ x ¼-inch, red-blue contusion is
above the ankle medially.
Three red-brown contusions, ranging in size from 1/8 x 1/8-inch to ½ x
¼-inch, are over the anterior thigh. Four red-brown contusions, ranging
in size from 1/8 x 1/8-inch to ½ x ¼-inch, are over the posterior thigh. A
1/8 x 1/8-inch, red-brown contusion is over the posterior calf.
Panniculus adiposus: 0.4 cm
No adhesions or abnormal collections of fluid are present in any of the
body cavities. All body organs are present in normal and anatomical
CENTRAL NERVOUS SYSTEM
See “Evidence of Injury” section above and Neuropathology section
Examination of the soft tissues of the neck, including strap muscles and
large vessels, reveals no abnormalities. The hyoid bone and larynx are
intact. The lingual mucosa is intact; the underlying firm red-brown
musculature is devoid of hemorrhage.
Heart weight: 37.7 gm
The pericardial surfaces are smooth, glistening and unremarkable; the
pericardial sac is free of significant fluid or adhesions. The shape and
size of the heart are not unusual. The coronary arteries arise normally,
follow the usual distribution and are widely patent. The chambers and
valves bear the usual size-position relationships and are unremarkable.
The left ventricle measures 0.6 cm in thickness and the right ventricle
0.1 cm. The myocardium is dark red-brown, firm, and unremarkable; the
atrial and ventricular septa are intact. The foramen ovale is appropriately
membrane protected. The pulmonary artery, the aorta and its major
branches arise normally, follow the usual course and are widely patent;
the ductus arteriosus is anatomically closed. The vena cava and its
major tributaries, and the pulmonary veins return to the heart in the
usual distribution and are free of thrombi.
Combined lung weight:
The upper airway is clear of debris and foreign material; the mucosal
surfaces are smooth, yellow-tan and unremarkable. The pleural surfaces
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are smooth, glistening and unremarkable. Lobar divisions are of the
usual configuration. The pulmonary parenchyma is dark red-purple,
exuding slight to moderate amounts of blood and frothy fluid; no focal
lesions are noted. The parietal pleura are stripped from the thoracic
cavity walls, revealing unremarkable soft tissue and bony structures
without hemorrhage and acute or remote bony trauma. The
intraparenchymal pulmonary arteries are normally developed, patent,
and without thrombus or embolus.
LIVER AND BILIARY SYSTEM
Liver weight: 250 gm
Bile volume: 3 mL
The hepatic capsule is smooth, glistening and intact, covering red-brown
parenchyma with no focal lesions noted. The gallbladder contains
green-yellow, slightly mucoid bile; the mucosa is velvety and
unremarkable. The extrahepatic biliary tree is patent. The portal vein
and its tributaries are unremarkable.
The esophagus is lined by gray-white, smooth mucosa. The gastric
mucosa is arranged in the usual rugal folds, and the lumen has 30 mL of
brown, partially digested food. The root and radius of the mesentery
bear the usual size-position relationship. The serosa of the small and
large bowel and appendix is unremarkable. The small bowel has yellow
fecal material and the large bowel and distal small bowel have dark
green fecal material. The pancreas has a normal gray-white, lobulated
appearance, and the ducts are unobstructed.
Right kidney: 22.9 gm
Left kidney: 23.9 gm
Urine volume: 75 mL
The cortical surfaces are smooth, red-brown, and lobulated. The cortex
is of normal thickness, and sharply delineated from the medullary
pyramids, which are red-purple to tan and unremarkable. The usual
complement of calyces is present without abnormality. The pelves and
ureters are unremarkable. The relationships at the trigone are
unremarkable. The urinary bladder mucosa is gray-tan and smooth. The
testes, prostate and seminal vesicles are infantile and unremarkable.
Spleen weight: 15.5 gm
The spleen has a smooth, intact capsule covering red-purple,
Thymus weight: 10 gm
moderately firm parenchyma; the lymphoid follicles are unremarkable.
The regional lymph nodes are unremarkable. The bone marrow is
red-purple and homogeneous, without evidence of focal abnormality.
The thymus has a normal, lobulated, tan-pink appearance without
Combined adrenal weight:
The pituitary, thyroid, and adrenal glands are unremarkable.
The axial and appendicular skeletons are unremarkable. The
musculature is well developed. The diaphragm is intact and in its proper
position. Postmortem radiographic studies demonstrate no definitive
acute or remote fractures.
Left ventricle, right ventricle, interventricular septum
Right lung, upper lobe
Right lung, middle lobe
Right lung, lower lobe
Left lung, upper lobe
Left lung, lower lobe
Spleen, left adrenal and kidney
Liver, right adrenal and kidney
Large bowel, small bowel
Thymus, testis, bladder
Gastroesophageal junction, pancreas
Page 5 of 9
12. Epiglottis, trachea and thyroid
The heart has no evidence of acute ischemic changes, myocarditis, or myofiber disarray.
The lungs have patchy foci of bronchiolitis with necroinflammatory debris, a patchy increase in interstitial chronic inflammation,
and a single syncytial cell concerning for viral cytopathic effect. No respiratory syncytial virus (RSV) genetic material is
identified via polymerase chain reaction (PCR) on frozen lung tissue.
The liver has no significant inflammation, no steatosis or cholestasis.
The kidneys have normally formed glomeruli and occasional, nonspecific intratubular calcifications. Occasional partial or
globally sclerotic glomeruli are seen beneath the renal capsule, consistent with physiologic subcapsular involution. There is no
significant inflammation or fibrosis.
The adrenals have extravasated red blood cells within the medulla.
The spleen has normal red pulp and white pulp containing germinal centers with an epithelioid appearance. No necrosis or
multi-nucleated cells are seen.
The bowel shows no inflammation and normal collections of ganglion cells.
The thymus shows lobules between fibrotic bands composed of thymocytes, epithelioreticular cells and Hassall’s corpuscles.
The testis shows normal seminiferous tubules that are appropriately developed for age.
The bladder shows normal urothelium with umbrella cells and no significant inflammation.
The pancreas contains normal islets cells and acini without inflammation.
The gastroesophageal junction section had a denuded epithelium. There is no significant inflammation in the muscularis.
The epiglottis shows stratified squamous epithelium with associated lymphoid aggregates and no significant inflammation.
The trachea has intraluminal vegetable material and respiratory epithelium without significant inflammation.
The thyroid has unremarkable epithelial cells surrounding colloid.
The rib shows normal cartilage and bone elements and trilineage hematopoiesis.
Date of Report:
DECEDENT: Kyler Presnell
Status of Report: Approved
Report Electronically Approved By: Justin Brower, PhD
SPECIMENS received from Anna Greene McDonald on 04-feb-2016
S160003063: 2.0 ml Blood
S160003063: 2.0 ml Blood
Page 6 of 9
Benzodiazepines ------------- None Detected LCMS
Carbon Monoxide----------------- Less than
Cocaine metabolite ---------- None Detected LCMS
Ethanol --------------------- None Detected
Gabapentin/Pregabalin ------- None Detected LCMS
Opiates/Opioids ------------- None Detected LCMS
Organic Bases --------------- None Detected
S160003064: 4.0 ml Blood
SOURCE: Femoral Vessel
S160003066: 30.0 ml Blood
SOURCE: Subdural Space
S160003067: 14.0 ml Urine
Accredited by the American Board of Forensic Toxicology, Inc.
The globes are of similar size measuring 2.2 cm in axial, vertical and horizontal dimensions. The right and left optic nerves
measure 1.3 cm and 1.1 cm, respectively. Both exhibit diffuse optic nerve sheath hemorrhage that is more concentrated at the
optic nerve-globe junction. The clear corneae measure 1.1 cm (horizontal) x 1.1 cm (vertical). The irides appear light brown and
lenses are crystalline. Upon sectioning the globes at the pars plana, the right fundus has 9 retinal hemorrhages over the posterior
pole extending past the equator. The hemorrhages are superficial and dot/blot along the vascular arcades of the posterior fundus.
Two subinternal limiting membrane hemorrhages are slightly larger measuring 1/3 to 1/2 disc diameter in size and are located past
the equator in the 12:00 and 2:00 position. A small amount of vitreous hemorrhage overlies the optic nerve disc. The left fundus
has 10-15 superficial, flame-shaped hemorrhages located around the optic disc, one above the superior temporal arcade, and
another at 6:00 about 4 disc diameters from the optic nerve head. The one above the superior temporal arcade is located about 5
disc diameters from the optic nerve. All of the hemorrhages on the left appear superficial and the largest is no more than 1/10 disc
diameter in size. Slight blurring of the optic disc margins is present, bilaterally.
The globes and corresponding optic nerves are similar histologically. The optic nerves have subarachnoid, subdural and
intra-dural extravasated blood. The intra-dural blood is most concentrated within the connective tissue surrounding the intra-dural
course of the retinal artery and vein. Scattered extravasated blood is within the adjacent adipose tissue. Retinal hemorrhages
involve all layers of the retina and are most numerous over the posterior fundus but occasional foci of extravasated blood are
adjacent to the ora serrata. No retinal necrosis or retinoschisis is present. A special stain for iron (Prussian blue) shows no
hemosiderin in the optic nerves or retinae.
Bilateral retinal hemorrhages
Bilateral optic nerve sheath hemorrhages
Page 7 of 9
Neuropathology Final Diagnosis
BRAIN, DURA, SPINAL CORD, AUTOPSY:
Fresh subdural hemorrhage, right.
Subarachnoid hemorrhage, left parasagittal and optic chiasm.
Cerebral edema with right medial temporal herniation.
Diffuse hypoxic/ischemic injury with associated necrosis.
Neuropathology Diagnosis Comment
The brain demonstrates diffuse hypoxic/ischemic injury with a non-uniform pattern of necrosis. The right cerebral hemisphere
demonstrates increased necrosis compared to the left in the following regions which are likely involved in or impinged upon by
the herniation of the right medial temporal lobe: right frontal cortex underlying the subdural hemorrhage, the right medial
temporal cortex, left midbrain, and left superior cerebellum. The bilateral orbital cortices/preoptic hypothalamic regions at the
base of the brain are also involved by necrosis.
***Electronically Signed Out***
A. G. McDonald, M.D., Pathology
Neuropathology Gross Description
The specimen consists of the brain with calvarial dura. The brain weighed 1100 grams in the formalin fixed state. The dura
demonstrates minimal possible hemorrhage without obvious subdural membranes. The superior sagittal sinus is patent. The
leptomeninges demonstrate subarachnoid hemorrhage over the left parasagittal region and around the optic chiasm. The cerebral
hemispheres are edematous, and are without significant atrophy, focal encephalomalacia, or mass lesions. Examination of the
base of the brain shows edema and dusky discoloration consistent with herniation of the right medial temporal lobe with no
herniation of the cerebellar tonsils. The bilateral orbital cortices appear dusky and necrotic. The arteries of the circle of Willis are in
the usual anatomic configuration and are patent. The cranial nerve stumps are of normal caliber and color. The exterior surfaces of
the brainstem and cerebellum demonstrate a dusky discoloration of the left superior cerebellum.
Coronal sections through the cerebral hemispheres show cortex which is continuous and of normal thickness. The right temporal
lobe, right frontal lobe, and bilateral orbital cortices appear necrotic and have a dusky discoloration, predominantly involving the
cortex. The white matter and central gray nuclei are unremarkable. The lateral and third ventricles are normal in size and shape
and are lined by smooth glistening ependyma. Transverse sections through the brainstem show a focal discoloration with possible
necrosis of the left side of the midbrain, and otherwise normal architecture of the gray and white matter. The substantia nigra and
locus ceruleus have a normal amount of pigment for age. The cerebral aqueduct is patent and the fourth ventricle is unremarkable.
Sections through the cerebellum show discoloration of the left superior cerebellum measuring 1.5 x 1.4 x 1 cm with otherwise
normal cortex, white matter and deep gray nuclei.
A portion of the spinal cord is available for examination. The spinal dura is without hemorrhages, exudates or mass lesions on the
epidural or subdural surface. The spinal leptomeninges are thin and translucent. The anterior and posterior spinal nerve roots are
of normal caliber and color. Transverse sections through the spinal cord show normal gray and white matter.
Summary of sections:
23- Clot – right parietal
24- Left superior cerebellar discoloration and uninvolved left cerebellum
28- Spinal cord
29- Right frontal discoloration
30- Right temporal
31- Left hippocampus
32- Right occipital
33- Bilateral orbital
34- Left basal ganglia
35, 36, 38 - Additional dura
37 – Discoloration near preoptic-anterior hypothalamic region
Page 8 of 9
39 – Leptomeninges from non-discolored areas
40 – Non-discolored right temporal lobe
41 – Discoloration in right temporal lobe
42 – Non-discolored cortex near basal ganglia
43 – Non-discolored cortex (probably frontal lobe)
Neuropathology Microscopic Description
Focal fresh subdural hemorrhage is present without evidence of fibroblast proliferation. The blood clot submitted from the right
parietal region demonstrates fresh blood with no evidence of organization. Acute necrosis with red neurons, infiltrating
intraparenchymal and perivascular neutrophils, and fresh, predominantly perivascular hemorrhage are present in the cerebellum,
midbrain, right frontal cortex/white matter, right temporal cortex, bilateral orbital cortices, and preoptic/anterior hypothalamic region.
Neutrophils are also noted within the meninges and within the Virchow-Robbins spaces in areas adjacent to the necrotic areas.
Small foci of neutrophils and extravasated red blood cells are noted within the meninges adjacent to the pons and medulla, and
macrophages and rare neutrophils are noted in the leptomeninges adjacent to grossly normal areas of cortex. Abundant red
neurons are noted in the hippocampus and rare red neurons are noted in the right occipital cortex and in other areas of the cortex
that appear grossly normal/non-discolored. A focal vascular calcification is noted in the basal ganglia. Sections of the spinal cord
Immunohistochemical stains for HSV1, HSV2, and VZV are performed on the bilateral orbital cortex, and are negative. The positive
immunohistochemical controls worked appropriately.
“These tests were developed and their performance characteristics determined by North Carolina Baptist Hospital, Molecular
Diagnostics Laboratory. They have not been cleared or approved by the U.S. Food and Drug Administration. The FDA has
determined that such clearance or approval is not necessary. These tests are used for clinical purposes. They should not be
regarded as investigational or for research. This laboratory is certified under the Clinical Laboratory Improvement Amendments of
1988 (CLIA) as qualified to perform high complexity clinical laboratory testing.”
Garry L. Wooten
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