Table 2.

Summary of comorbidities, recent procedures, and clinicopathological course in 18 patients with Multifocal or Localized HPE.

Case Age Sex	Comorbid Conditions and → Suspected Contributing Procedure(s)	Documented Clinical Cause of Death	Documented Cause(s) of Death on Original Autopsy	Documented Signs and Diagnoses (Final Month of Life)	Findings on Retrospective CP Review
Multifocal HPE (n=6)
1 73F	Hypertrophic cardiomyopathy; HTN; DM; CKD requiring HD → Hemodialysis; CVVH; Cardiac cath; CVC	Cardiac insufficiency	Per clinical history, probable cardiac insufficiency	■ Possible pneumonia ■ Pulmonary embolism ■ Vasculitis (p-ANCA +) ■ Lymphadenopathy ■ Sepsis with DIC, MODS	aMultiorgan failure; Widespread HPE; Hypertrophic cardiomyopathy
2 65M	Aortic stenosis requiring prior valve replacement; A. fib; HTN; DM; Recent cardioversion complicated by Clostridium difficile colitis → CVC	Respiratory insufficiency	Respiratory failure/DIC	■ Possible pneumonia ■ Hemoptysis ■ Decubitus ulcer ■ Sepsis with DIC, MODS	aMultiorgan failure; DIC; HPE; Scattered pulmonary and cerebral infarcts
3 64M	HTN; DM; CKD; A. fib; Ischemic cardiomyopathy; recent OHT (on immunosuppressive therapy) → CVC; ECMO; Hemodialysis; CVVH	Septic shock	Pneumonia; Septic shock; Peripheral pulmonary emboli noted	■ Mediastinitis ■ Groin infection ■ Pneumonia ■ Pulmonary embolism ■ Upper GI bleed ■ Acute PEA + SVT ■ Septic shock with MODS	a, bSeptic shock; Pneumonia; Pulmonary HPE; Pulmonary microinfarct
4 69M	CAD; prior CABG; HL; recent MVA w/ Brown Sequard syndrome complicated by empyema and sepsis → CVC	Sepsis; leptomeningitis; brainstem infarcts	Sepsis; leptomeningitis; brainstem infarcts	■ Leptomeningitis ■ Embolic stroke ■ A fib with RVR ■ DVT ■ Septic shock with DIC, MODS	Sepsis; Leptomeningitis; Brainstem infarcts; Pulmonary HPE
5 41M	Remote h/o aortic dissection s/p repair; HTN; hepatitis C; osteogenesis imperfecta; Presented to ED with acute diarrhea → CVC; Arterial Line; Hemodialysis	Septic shock; embolic stroke	Multiple embolic infarcts involving lungs, brain, kidneys, liver, spleen	■ Vasculitis (p-ANCA −) ■ Embolic stroke ■ Septic shock with DIC, MODS ■ Anoxic brain injury	cMultiple embolic infarcts involving lungs, brain, kidneys, liver, spleen secondary to septic emboli; Pulmonary HPE
6 59M	Abdominal liposarcoma requiring recent colectomy → PICC; CVC; Arterial line	Acute Pulmonary embolism	Acute pulmonary embolism due to foreign material	■ Pulmonary embolism ■ Sudden death	a,b,dAcute pulmonary embolism due to foreign material
Localized HPE (n=12)
7 57F	h/o breast CA; dilated cardiomyopathy; PFO; HTN; CKD; A. fib requiring warfarin; Admitted for cellulitis requiring IV Ab → CVC; Cardiac Cath	Nonischemic cardiomyopathy	Multiorgan failure associated with cardiomyopathy	■ Pulmonary embolism ■ Pneumonia ■ A fib with RVR ■ DVT ■ SIRS/shock with DIC, MODS	Multiorgan failure; Cardiomyopathy; Pulmonary HPE
8 21F	Morbid obesity; Admitted for spontaneous pneumothorax; complicated by pneumonia, empyema requiring IV Ab and R. lung wedge resection → CVC; ECMO	Pneumonia; sepsis; Cor pulmonale	Pneumonia; sepsis; DAD; Cor pulmonale	■ Pneumonia ■ Pulmonary embolism ■ Septic shock ■ Coagulopathy with DIC, MODS	bPneumonia; sepsis; DAD; Cor pulmonale; Pulmonary HPE
9 55M	Aortic regurgitation; aortic aneurysm; HTN; HL; CHF; Admitted for aortic valve replacement → Cardiac Bypass	Acute PEA	Acute PEA; Anoxic brain injury	■ Acute PEA ■ Anoxic brain injury	Acute PEA; Pulmonary HPE; Anoxic brain injury
10 65M	Rectal CA s/p recent resection; CAD; HTN; HL; Recent pneumonia requiring IV Ab → CVC; Arterial line	Acute pneumonia	Acute pneumonia	■ Resolving perineal wound ■ Acute pneumonia ■ Acute hypoxemia ■ Acute PEA	Acute pneumonia; Pulmonary HPE
11 61M	h/o CVA; MI; HTN; HL; CKD; Admitted for upper GI bleed/newly diagnosed signet ring CA (gastric) → CVC	Hemorrhagic shock; signet ring CA	Hemorrhagic shock; signet ring CA	■ GI hemorrhage/signet ring CA ■ Hemorrhagic shock ■ ARDS ■ MODS	Hemorrhagic shock; Signet ring CA; Pulmonary HPE
12 16M	Anomalous left coronary artery requiring surgical repair → ECMO; Swan-Ganz	Acute cardiac tamponade; Pneumonia	Acute cardiac tamponade; Pneumonia	■ Pulmonary hemorrhage ■ Pneumonia ■ Pulmonary embolism ■ Septic shock with MODS	Cardiac tamponade; Pneumonia; Pulmonary HPE
13 60M	h/o CAD; DM; HL; ESRD on HD; Aortic stenosis; Schizophrenia; Admitted for acute MI → Hemodialysis; CVC; IVC Filter	Cardiogenic shock	Cardiogenic shock	■ Cardiogenic shock ■ Pneumonia ■ DVT ■ MODS ■ Upper GI bleed	Cardiogenic shock; Pulmonary HPE
14 47F	Rheumatoid arthritis; nonischemic cardiomyopathy; Admitted for CHF →CVC; CVVH	Nonischemic cardiomyopathy	Nonischemic cardiomyopathy; Pneumonia	■ Cardiogenic shock ■ MODS	Nonischemic cardiomyopathy; Pneumonia; Pulmonary HPE
15 61M	COPD; esophageal ulcers; recent admission for cysturethroscopy; Readmitted for syncope → CVC; Pulmonary Angiography	Pulmonary thromboembolism	Pulmonary thromboembolism	■ Pulmonary thromboembolism	bPulmonary thromboembolism; Pulmonary HPE
16 48M	h/o Fournier's gangrene admitted for debridement → CVC	Septic shock	Septic shock; acute pulmonary hemorrhage	■ Pneumonia ■ Pulmonary Embolism ■ Urinary tract infection ■ Gastrointestinal bleed ■ Possible DVT ■ Septic shock with MODS	bSeptic shock, Acute pulmonary hemorrhage; PNA; Pulmonary HPE
17 35M	HTN; CAD; HL; Admitted for acute type A aortic dissection → ECMO	Acute aortic dissection	Acute aortic dissection	■ Acute MI ■ Acute aortic dissection ■ Anoxic brain injury ■ Cardiac tamponade ■ MODS	Acute aortic dissection; Scattered cerebral infarcts; Pulmonary HPE
18 71M	h/o CAD; A. Fib; HL; PVD; Recent cardiac cath/stenting Recent lower extremity vascular bypass surgery → CVC; Lower Extremity Bypass; CVVH	Septic shock; CHF	Septic shock; CHF	■ Septic shock ■ Rhabdomyolysis ■ Small bowel ischemia ■ MODS	Septic shock; CHF Pulmonary HPE

Abbreviations: A. Fib, atrial fibrillation; B/L, bilateral; CA, adenocarcinoma; CABG, coronary artery bypass graft; CAD, coronary artery disease; cardiac cath, cardiac catheterization; CKD, chronic kidney disease; CP, clinicopathological; CVA, cerebral vascular accident; CVC, central venous catheterization; CVVH, continuous veno-venous hemofiltration; DIC, disseminated intravascular coagulation; DM, diabetes mellitus type II; DVT, deep venous thrombosis; ECMO, extracorporeal membrane oxygenation; ESRD, end-stage renal disease; HD, hemodialysis; HL, hyperlipidemia; h/o, history of; HPE, hydrophilic polymer emboli; HTN, hypertension; HL, hyperlipidemia; IV Ab, intravenous antibiotics; IVH, intravenous hydration; LAD, lymphadenopathy; MI, myocardial infarction; MODS, multiple organ dysfunction syndrome; OHT, orthotopic heart transplantation; PE, pulmonary embolism; PEA, pulseless electrical activity; PFO, patent foramen ovale; PICC, peripherally inserted central catheter; PNA, bronchopneumonia; R., right; RUL, right upper lobe of lung; RUQ, right upper quadrant; RVR, rapid ventricular response; SIRS, systemic inflammatory response syndrome; s/p, status post; SVT, supraventricular tachycardia; VSD, ventricular septal defect.

^aHPE may have been a primary cause of morbidity

^b“Rule out pulmonary embolism” specified on autopsy request

^cScattered septic emboli were present, along with multifocal HPE

^dMechanism of death is inconclusive (in addition to HPE, rare intravascular plant material is identified)