Endgames Picture Quiz

An unusual death in the community

BMJ 2013; 346 doi: https://doi.org/10.1136/bmj.f3667 (Published 26 June 2013) Cite this as: BMJ 2013;346:f3667
  1. Chris Johnson, specialist registrar,
  2. Shiv Koria, foundation year 1 doctor,
  3. David Fattah, consultant histopathologist
  1. 1Department of Histopathology, Northampton General Hospital, Northampton NN1 5BD, UK
  1. Correspondence to: C Johnson christopher.johnson{at}uhl-tr.nhs.uk

A 45 year old white man was found dead at home. The coroner was informed and requested an autopsy because the cause of death was not apparent. The patient had recently been under review by the respiratory team for poor respiratory function and patchy fibronodular lung changes. His history included osteomyelitis of the elbow, congenital kyphoscoliosis, and testicular seminoma, which had been treated with orchidectomy and chemotherapy.

At postmortem examination, the abdominal cavity contained copious pus covering the serosal aspect of the small bowel. There was an obvious perforation at the level of the mid-ileum, as well as three ulcers on the mucosal aspect of the ileum, one of which had perforated.

Widespread pale nodules measuring up to 5 mm each were noted throughout the parenchyma of both lungs and a small pale lesion was present in the left kidney. No abnormalities were seen in the cardiovascular, endocrine, or central nervous systems.

Histological sections of the small bowel (fig 1), lungs, liver, and kidney were taken for further analysis.

Fig 1 Histological section of the small bowel; original magnification ×4


  • 1 Describe the histological features of the section of the small bowel

  • 2 What are the main causes of granulomatous inflammation within the small intestine?

  • 3 What further investigations are appropriate if an infective cause is suspected?

  • 4 Suggest a suitable cause of death for completion of a death certificate

  • 5 What are the public health implications in this case?


1 Describe the histological features of the section of the small bowel

Short answer

The histological section shows widespread granulomatous inflammation within the submucosa and muscularis propria of the bowel. A Langhans giant cell can also be seen.

Long answer

The small bowel villi are not easily visible in this histological section of postmortem bowel because of autolysis as a result of decomposition. Inflammation can be seen within the submucosa and the muscularis propria. Caseous …

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