Skin Subdural Hematoma

Circumscribed bleedings of the skin are a clinically well-known manifestation of DIC during the course of sepsis and are still apparent postmortem on the outer body surface (Figure 3.33). Sometimes these bleedings appear in a discreet petechial pattern, occasionally taking the shape of extensive, confluent hemorrhages.

Metastatic spread of septic microemboli may lead to circumscribed cutaneous bleedings in distinct locations (Figures 3.34 and 3.35) and must be differentiated from DIC-related skin bleedings that manifest usually over the entire body surface.

In sepsis-related deaths, jaundice of the skin, sclerae, and conjunctivae upon external examination of the body indicate liver failure complicating the septic disease state.

Fig. 3.34. Cutaneous bleedings on the inner aspects of the fingers due to metastatic spread of septic microemboli.
Septic Microemboli
Fig. 3.35. Septic microemboli totally occluding a small artery. The emboli originated from endocarditis of the mitral valve. Strong inflammatory cell infiltration in all vessel layers are seen (same case as Figure 3.34).

A rapid onset of body decomposition (impressively contrastive to the length of the preceding postmortem interval and to the ambient temperatures to which the corpse was exposed after death) seen as putrefactive skin alterations with a greenish skin discoloration, skin slippage, and outlining of the superficial veins of the chest and upper extremities is frequently found in individuals who suffered from infection or sepsis prior to death. The most rapid onset and course of postmortem putrefaction is seen in gas gangrene (clostridial myonecrosis). The typical presentation of gas gangrene at external examination is a gloomy, violaceous to reddish-brown discoloration of the skin with hemor-rhagic bullae formation (Figure 3.36). The skin appears tightened and shows palpable subcutaneous emphysema (crepitation). Clostridial gas gangrene is one of the most fulminant necrotizing infections affecting humans. Gas gangrene is not a disease of the past. Infection with Clostridium perfringens type A in devitalized tissue as a result of recent surgery or other trauma is the most common cause.

Putrefactive Bullae Postmortem
Fig. 3.36. Gas gangrene due to Clostridium difficile infection. Hemorrhagic bullae formation upon the skin is seen.

The proof of the portal of entry of the pathogenic organism often is difficult to establish because clostridial gas gangrene also may develop in the absence of trauma in individuals with underlying immunocompromise, malignancies, pancreatitis, cholecystitis, liver cirrhosis, diabetes mellitus, radiation colitis, or alcohol abuse.

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