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First virtual autopsy in Saudi Arabia: A case report with literature review

Article in Journal of Forensic Radiology and Imaging · November 2014

DOI: 10.1016/j.jofri.2014.11.002

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 Journal of Forensic Radiology and Imaging 3 (2015) 76–79

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Journal of Forensic Radiology and Imaging

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Case report

First virtual autopsy in Saudi Arabia: A case report with literature review
Khaldoon Aljerian, Abdulrahman Alhawas, Sakher Alqahtani, Bartolomeu Golding,
Theeb Alkahtani n
King Saud University, Riyadh, Saudi Arabia

art ic l e i nf o a b s t r a c t

Article history: In this paper we document the first reported use of virtual autopsy tools in Saudi Received Arabia. The
Received 12 September 2014 subject was a female stillbirth who was subjected to a multi-detector CT Accepted scan, revealing
Received in revised form radiological findings consistent with the diagnosis of Available Online autosomal recessive polycystic
1 November 2014
kidney disease (ARPKD). This was later refuted by manual autopsy that diagnosed MCDK. More studies
Accepted 7 November 2014
Available online 18 November 2014
are required before a conclusion on the validity of virtual autopsy can be reached.
& 2014 Elsevier Ltd. All rights reserved.
Keywords:
Virtual autopsy
First case
Saudi Arabia
Islamic fatwa
Multicystic dysplastic kidney disease (MCDK)

1. Introduction ▪ To confirm the presence of infectious diseases that, if con-

Post-mortem examination (PME) is a procedure performed on a
cadaver, usually as a means of determining cause of death [1], but
also as a way of ensuring accurate record keeping of mortality
statistics [2], quality assurance in critical care units [3–5] and as an
assessment of medical diagnostics and care [6–8]. In Saudi Arabia,
the importance of PME is escalated as the majority of death
certificates are not accurate [9] and the rate of consanguinity is
very high [10–12] which has genetic implications for offspring
including birth defects [13–17].
In Islam, it is a religious requirement to bury the body
immediately after death [18]. This is why Muslims consider that
immediate burial is essential to comfort the deceased and many
times do not allow autopsy. As the Holy Qur'an and the Hadith
have not directly addressed the issue of autopsy [19], help was
sought of a fatwa which is a ruling on a point of Islamic law given
by a recognized authority [20] issued by the Islamic Committee to
know the indications of performing hospital or medico legal
autopsy.
The fatwa decreed that autopsies were allowed if the following
conditions were observed:
▪ When it is requested by a judge during criminal proceedings to
determine the cause of death of a victim when the latter is
deemed ambiguous or unclear.
n
Corresponding author.
firmed, may require preventative or containment measures to
avoid public health concerns.
▪ For teaching purposes in certified institutions such as Univer-
sities and colleges of medicine.
The other clauses of the fatwa narrate the ethical and moral
values of Islam, which are mandatory while dealing with human
dead bodies. Nonetheless, this fatwa clarifies the Islamic perspec-
tive of PME and recommends such an examination where needed.
In current days, Islam no longer conflicts with autopsy, but social
aspects matter more to the public view than religious facts [20].
But, even though hospital autopsy services are urgently
required, they are, as of yet, scarce in both private and government
healthcare institutions. However, current health concerns, such as
the MERS epidemic, have served to increase the demand of such
services due to the severe number of fatalities in a short period of
time. Faced with these issues, the medical community has been
compelled to question the reasons for the lack of availability of
PME and instigated the implementation of practical alternative.
Virtual autopsy PME by multi-slice computed tomography
(MSCT) and magnetic resonance imaging (MRI) [29], is an inno-
vative technique in forensic medicine that may be used as a part of
PME [21] or as an alternative tool to the classic forensic autopsy.
However, its use as an alternative to autopsy is yet in its nascent
phases [30] although several institutions worldwide have imple-
mented it in their medico-legal workflow [22]. Virtual autopsy is
expected not only to increase the rate of PMEs, but also to serve an
effective alternative to the classic autopsy in countries like Saudi

http://dx.doi.org/10.1016/j.jofri.2014.11.002
2212-4780/& 2014 Elsevier Ltd. All rights reserved.
 K. Aljerian et al. / Journal of Forensic Radiology and Imaging 3 (2015) 76–79 77

Arabia, which lack highly specialized pathologists and have socio-
cultural and religious barriers.
In this study, the first ever implementation, in Saudi Arabia, of
virtual autopsy tools for the diagnosis of cause of death is
documented and compared with a manual autopsy to confirm
the results. The objective was to help support virtual autopsy as an
accurate alternative for manual practices and thus a way to bypass
the barriers that exist in modern society.
2. Case description
numerous cysts [42]. Multicystic dysplastic kidney disease (MCDK)
was considered as there was also evidence parenchymal destruc-
tion [23]. However, as the condition was bilateral which is very
uncommon in MCDK, the suggestion was discarded.
Following this, a forensic pathologist, using standard dissection
and tissue analysis, conducted a manual autopsy with biopsy of
kidney tissue for laboratory analysis. The diagnosis was multicystic
dysplastic kidney disease (MCDK) as there was evidence of renal
dysplasia, which is not found in ARPKD [24], and large irregular
cyst masses (Fig. 2).

The deceased was a female stillbirth. Unfortunately, due to a

hospital misfiling, parental and pre-natal information could not be
obtained. Virtual autopsy was conducted to determine cause of
death after consent was obtained from the subject's parents. The
postmortem scan was performed by a General Electrical (GE) light
speed 16 multi-detector computerized tomography scan (MDCT),
manufactured by GE Healthcare (Milwaukee, WI, USA). The PMCT
specifications were 180 mAs, 120 kVp and a measured FOV of
50 cm. This was reconstructed to images of 0.625 mm slice
thickness at 1.375:1 Pitch. All images were exported to a dedicated
review workstation (Advantage workstation, version 4.5; GE
Healthcare, Milwaukee, WI) for further assessment. A qualified
radiologist then reviewed the findings. Needle biopsy was not
performed due to a lack of proper equipment.
When viewed by a qualified radiologist, the CT images revealed
significant enlargement of both kidneys with numerous bilateral
cystic hypodense lesions, mainly in peripheral areas, causing
destruction of normal renal parenchyma. The renal pelvis was
under-developed and there was also mild flank distention (Fig. 1).
These findings suggested the diagnosis of Autosomal Recessive
Polycystic kidney disease (ARPKD) which is characterized by
presenting bilaterally enlarged, diffusely hypodense kidneys with

Fig. 2. Images showing the (a) gross kidney structure with bilateral presentation
and (b) a histological section showing dysplastic ducts, immature tubules, abortive
glomeruli and disorganized nephrons, all of which are consistent with MCDK.

Fig. 1. (a) Coronal and (b) axial mid-abdomen crosssectional CT image showing
enlargement of both kidneys (indicated) with diffuse hypodensity. Numerous cysts Fig. 3. Image of the right side of the subjects face depicting the characteristic
in addition to an under-developed pelvicalyceal system are also in evidence. deformities of Potter's facies. A frontal image could not be obtained.
78 K. Aljerian et al. / Journal of Forensic Radiology and Imaging 3 (2015) 76–79
There was also evidence of Potter facies, with the fetus
exhibiting characteristic deformed facial features such as flattened
nose and low set ears, caused by insufficient renal function during
gestation, leading to reduced amniotic fluid (Fig. 3) [25].
3. Discussion
Postmortem macroscopical and histological examination is
the most accurate method of determining cause of death and
auditing accuracy of clinical diagnosis, diagnostic tests and
death certification [26]. Nevertheless, there has been a decline
in the rate of autopsy worldwide for decades, a fact that has
been widely documented [27–30,31–35]. Studies have shown
that the declining rate of non-coroner autopsies is caused by
the creation of bioethics laws [36], patients views on the prac-
tice which makes it difficult to obtain consent from relatives;
advances in modern diagnostic techniques [37,38], delay in
obtaining autopsy reports [39], concerns about disfigurement
and other cultural [40,41] or religious reasons. There is also a lack
of satisfactory knowledge about autopsies in relatives and clin-
icians [42,43]. We believe that using virtual autopsy can solve
most of these issues.
Our findings show that virtual autopsies can serve as a practical
means to counter this problem. Its execution was fast, taking no
more than 20 min to complete the scan, and required little in
technical expertise to accomplish.
This would help to avoid the need for prolonged preservation
of the body, which can be expensive and difficult in hot countries.
Furthermore, there was no physical tampering with the body or
treatment with any chemical that could mare its appearance. This
should serve to make it more acceptable in the public eye and not
causes any religious outcry on grounds of desecration or disrespect
of a loved-ones remains.
Furthermore, the resulting scans, being in digital form, did not
require any immediate attention and could be seen by a trained
radiologist as time allowed. This would help to ameliorate the
problem of short supply of medical professionals, as it would only
require a fraction of the time to analyze the results rather than
conduct extensive manual testing.
We are well aware that performing a biopsy simultaneously to
a virtual autopsy is advisable [44,45] and could have provided the
physical evidence required to make the accurate diagnoses
between MCDK and ARKP but, being a relatively new procedure
in SA, the equipment necessary was lacking. Considering this and
the fact that bilateral MCDK is rare, the misdiagnosis of ARPKD is
under stable.
This highlights the problem of using a virtual autopsy without
taking a biopsy or performing a manual autopsy. The lack of
physical data or samples could result in physicians misdiagnosing
a condition as they would draw conclusions based on past
experience or what they believe to be the most likely disease by
descriptions provided. This raises the question of how much of an
alternative a virtual autopsy is if it requires an invasive procedure
to be performed to be accurate, the very thing that needed to be
avoided.
4. Conclusion
There is a requirement for concerted effort on the part of
clinicians, pathologists, the public, and the government to resus-
citate and sustain the practice of autopsy in Saudi Arabia and
virtual autopsy can attain high public acceptability.
The procedure shows a relatively good degree of accuracy but it
may fail to stand on its own without the aid of minimal invasive
procedures (biopsies). However, the degree of invasiveness is
small and therefore still acceptable under cultural limitations.
Further studies would need to be conducted to determine if this
is indeed the case or simply the result of a very uncommon and
misleading condition.
4.1. Recommendation
Recommendations are divided into two sections, those pertain-
ing to the Saudi Arabia clinicians and those pertaining to any
generalized public.
Those directed at clinicians include:
 Comprehensive internal examination to reach the histological
diagnosis should be performed and its findings should be
compared with the diagnosis of virtual autopsy. We recom-
mend that more studies be conducted before any conclusions
on the validity of a virtual autopsy as an alternative tool for
manual autopsies can be reached.
 Virtual autopsy should be made essential in medical care,
education and research and, if warranted minimal invasive
procedures such as fine needle biopsy of suspected organ or
tissue may be subsequently performed to reach the cause
of death.
Recommendations for general audiences are
 Awareness of virtual autopsy alternatives should be promoted
to the public and training and encouragement to radiologists,
pathologists and other healthcare professional should be pro-
vided across Saudi Arabia.
 A unit of forensic radiology should be established at King Saud
University to flourish the scope of Victory in the country and to
broaden its role in medical education, clinical research and
healthcare quality assurance.
Acknowledgments
We would like to thank the College of Medicine of King Saud
University, Riyadh, for allowing us to use their facilities and
equipment for the present study. We would also like to thank
the department's staff for their help in running the equipment and
preparing the resulting imagery.
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