A 62-year-old male was hospitalized after suffering severe physical injuries in an argument with the neighbors. The patient was diagnosed with multiple fractures including a fracture in the right clavicle and second, third, and fourth ribs of the right chest wall. There was no past medical history of diabetes mellitus, hypertension, tuberculosis, or any chronic illness. No history of immunosuppressive therapy or steroid intake was evident. The patient was in severe respiratory distress at the time of admission, and an emergency tracheostomy was done. He was prescribed broad-spectrum antibiotics and parenteral nutrition, but there was no improvement in his medical condition, which later required mechanical ventilation. He died after 3 weeks of hospitalization, and a medicolegal autopsy was conducted to ascertain the cause of death. Heart, both lungs, and pieces of liver, spleen, and kidneys were sent for histopathological examination to determine the cause of death.
On gross examination, the heart weighed 350 g and measured 14 x 10 x 4 cm. On cut section, multiple gray-yellow plaques were seen in the left ventricular wall, the interventricular septum, and the apex regions (Figure 1A). The lungs weighed 850 g (right lung) and 660 g (left lung) and measured 18 x 16 x 12 cm and 17 x 16 x 13 cm, respectively. The cut surface of both lungs showed multiple gray-white necrotic areas (Figure 1B). The liver and spleen were grossly unremarkable. The kidneys weighed 150 g (right kidney) and 130 g (left kidney) and measured 10 x 5 x 2 cm and 9 x 5 x 2 cm; the cut surface showed grey-yellow necrotic areas (Figure 2).
Representative microsections examined from the left ventricular wall, the interventricular septum, and the apex of the heart showed infiltration by acute inflammatory infiltrate with focal areas of necrosis and the presence of branching septate hyphae with morphology resembling Aspergillus spp. Periodic acid-Schiff (PAS) and Gomori methenamine silver (GMS) stain of the fungus demonstrated the distinct dichotomous acute angle branching of septate hyphae with the orientation of the branches in a similar direction (Figure 3).
Representative microsections examined from lung specimens and kidney showed extensive multifocal areas of necrosis with acute and chronic inflammatory infiltrate, a few giant cells, and the presence of fungal hyphae with a morphology similar to Aspergillus spp. These fungal hyphae were again demonstrated with the help of PAS and GMS stains (Figure 4). Microsections examined from the liver and spleen were unremarkable. Thus, the post-mortem diagnosis was disseminated invasive aspergillosis.