Provisional anatomical diagnosis

Subendothelial infarction
Chronic leg ulcer
Acute gastric ulceration

History

Patient was referred with shortness of breath, pedal oedema, orthopnea and PND, also cellulitis of
the left lower leg.

PMH: IHD x5 with three previous admissions to Caura for CCF

Never had asthma, smoke

Obese patient
Cardiopulmonary distress
Left leg red oozing serous fluid
Ascites
Hepatic enlargement
Cellulitis left leg
Right heart failure

ECHO

Dilated cardiomyopathy EF<17%

X- ray no osteomyelitis
She was placed on Zinnacef IV, Gentamycin IV
She is responding with initial dobutamine infusion but decompensated and went into renal
failure.

CLINICAL DIAGNOSIS

1. Chronic dilated cardiomyopathy

2. Cellulitis left lower leg
3. Altered mental state

POST MORTEM EXAMINATION

External Appearances

An obese middle-aged female with icterus, leg oedema and a shallow healing ulcer on the lateral
aspect of the left leg (4x4cm). A sub umbilical median scar measuring 11cm long was present.

CVS

Pericardium: There were fibrinous exudates producing adhesions

Heart: Weight- 890g (Male 200-350g, Female 200-300g)

Myocardium: Thickness L.V 18mm RV5 5mm (LVH)

There is 4 chamber dilation with the ventricles most affected. The ventricular walls alaso appeared
thickened. The left ventricular endocardium was thickened and pale grey- including the papillary
muscles. There was congestion and intervening pallor in the subendocardial region over an areas
measuring 4x4cm.
Endocardium valves; Mild thickening present in the mitral and tricuspid valves

Coronary Arteries: The right coronary was patent with minimal atheroma. The origin (proximal 1cm)
of the LAD was calcified but occlusion was 30%. The left circumflex was patent.

Aorta: Severe atherosclerosis was present in the abdominal aorta

Stomach: Four gastric ulcers were present in the pylorus and antrum, the largest 3.5cm in diameter

Large intestine: Diverticular disease was present

Liver: 1540g ( 1100-1600)

Severe fatty changes with passive congestion was present throughout.

Histology

Sections of the left ventricle show patchy transmural fibrosis, which is maximal in the sub
endocardium and papillary muscles. There is ongoing necrosis in the subendocardial myocytes with
foci of chronic inflammation scattered throughout the wall of the ventricle. Blood vessels are
congested. There is also marked atypia of myocyte nuclei.

The lungs show congestion and pulmonary oedema. The liver shows marked congestive changes
with sclerosis of acini, particularly around hepatic venules. The kidneys show medullary changes but
no significant changes.

Sections of the stomach show acute ulceration extending to the muscle layers. There is no evidence
of malignancy.

CONCLUSION

The marked degree of dilatation of cardiac chambers and increased cardiac weight, along with some
histological features strongly indicate dilated cardiomyopathy. However there is evidence of
previous and recent myocardial infarction in the subendothelial region.

This would undoubtedly have aggravated the congestive cardiac failure