31
Forensic Lung Pathology
Michael A. Graham
Sudden and unexpected natural deaths and nonnatural
deaths may result from various pulmonary conditions.
Additionally, several nonpulmonary conditions of foren-
sic significance may be complicated by the development
of respiratory lesions. Certain situations with pulmonary
pathology are particularly likely to be critically scruti-
nized and may form the basis of allegations of medical
negligence, other personal injury liability, or wrongful
death.l
The forensic evaluation of lethal or nonlethal conditions
is essentially the same and conceptually differs little from
a clinician's approach to a patient with a similar condition
(Table 31.1). In some cases this diagnostic/investigative
process is quite broad, whereas in other cases the issues
are of very limited scope and the investigation may be
narrowly focused. The pathologist may playa critical role
in these evaluations, not only by addressing the above-
noted issues, but also by documenting pertinent findings
that other experts may rely on in formulating their opin-
ions; properly recognizing, collecting, preserving, and
transmitting physical evidence; and presenting findings
and opinions in appropriate legal forums.
The focus of many forensic evaluations is on establish-
ing the cause and manner of death. The elucidation of the
mechanism of death may also be of importance in some
cases. In other cases, the cause of disease or injury, timing
of lesions, establishing the presence or extent of lesions
and any response to therapy, evaluating modifying or
contributory factors to death or disability, or correlating
findings with antemortem activity or condition may be at
issue. As noted above, the process to arrive at these deter-
minations has the same components as a clinician's
approach to a patient: assessment of the history, physical
examination, and ancillary studies.
In fatalities, determinations of the cause of death,
manner of death, and mechanism of death are often
important. Commonly, there is confusion about the mean-
ings and use of these terms as they apply to medicolegal
death investigation and death certification.
1174
The cause of death is the disease or injury that begins
the unbroken pathophysiologic sequence leading to
death. The disease/injury that causes death at a particular
time is often referred to as the immediate cause of death.
The disease/injury that starts the unbroken chain of
medical events culminating in death is referred to as the
underlying cause of death. Proper recognition of the latter
is very important for death certification, epidemiology,
public policy, and the proper resolution of criminal justice
and civil liability issues. 2 The mechanism of death is the
nonspecific pathophysiologic alteration through which
the cause of death exerts its lethal influence. The manner
of death is a term peculiar to death certification that
describes how death came about-through natural causes,
homicide, suicide, or accident. 2 The determination of the
manner of death is heavily dependent on the investiga-
tion of the circumstances surrounding the death or, if
death is delayed, the illness or injury ultimately respon-
sible for death. In some cases the information will not
enable a clear determination to be made, and a classifica-
tion of undetermined may be warranted.
The most important determination of the manner of
death is to differentiate deaths due to natural conditions
from those stemming from some nonnatural manner. Any
case in which a nonnatural manner is contemplated must
be referred to the appropriate medicolegal authority,
medical or coroner, for review. It is important to remem-
ber that a "natural" disease may arise in a fashion that
merits a nonnatural manner of death (e.g., Yersinia pestis
pneumonia acquired as the result of an act of bioterror-
ism is homicide).
Pulmonary findings may also help resolve other medi-
colegal issues that may arise in a particular case. The sig-
nificance of any particular finding must always be
considered in the context of the issues being addressed.
The significance of a particular finding can be thought of
in medical/physiologic terms (i.e., what effect it has on
the person) or in forensic (investigative) terms (i.e., what
light it sheds on the nature, age, or cause of a disease/
31. Forensic Lung Pathology 1175

TABLE 31.1. Death investigation process

Examine
History
Circumstances surrounding, leading
Past history
Scene
Body
Ancillary tests
Interpret
Correlate

injury). The medical significance and the investigative sig-

nificance can be mutually exclusive; medically important
findings may be of minimal, if any, investigative help,
while a medically trivial finding may be the critical datum
in resolving an important investigative issue.
A variety of pulmonary lesions may be associated with
or cause sudden, unexpected death. Although there are a
variety of definitions of sudden death, the most com-
monly used refers to death occurring within 1 hour of the
onset of symptoms or signs. In addition to being sudden,
deaths coming under the jurisdiction of the medicolegal FIGURE 31.1. Acute epiglottitis. Swollen hyperemic epiglottis
with focal mucosal necrosis.
official, medical examiner/coroner, also are unexpected.
These conditions may result from primary natural disease
conditions or may arise during the course of or as sequelae
to some other underlying disease or injury. epiglottis is often markedly swollen and hyperemic (Fig.
31.1), whereas in adults epiglottitis is characterized by
more diffuse supraglottic swelling (Fig. 31.2). Microscopic
Sudden Unexpected Death examination demonstrates suppurative inflammation
that, in some cases, may be restricted to the deep central
Epiglottitis portions of the epiglottis (Fig. 31.3).

Acute epiglottitis is characterized by the abrupt onset of

a clinical complex often including sore throat, dysphagia,
high fever, "hot-potato" voice, drooling, and airway pro-
tective head and neck posturing. 3 The disease may prog-
ress very rapidly and cause sudden obstruction of the
airway. Death is typically caused by airway obstruction
or sepsis. Overall, mortality is less than 5%.
Haemophilus influenzae type b (Rib) is responsible for
causing most cases in children and adults. In the prevac-
cine era (Rib vaccine was introduced circa 1985 to 1992),
Rib was responsible for 75% to 90% of pediatric epiglot-
titis. 3 Currently, 25% to 32% of cases are caused by Rib.
A variety of other organisms, including Streptococcus
pneumoniae, are currently responsible for a significant
number of cases. 3 The clinical features of epiglottitis have
remained the same as before the vaccine was available. 3
Introduction of the vaccine has also changed the epide-
miology of epiglottitis. There has been a 95% decrease in
the incidence of Rib diseases. 4 In addition, the average
age of patients with epiglottitis has increased?
The gross appearance of the inflamed epiglottis differs
somewhat between children and adults. In children the FIGURE 31.2. Acute epiglottitis. Diffuse supraglottic swelling.