18.- LARYNX AS TARGET ORGAN OF ANAPHYLACTIC REACTION IN AN ASTHMATIC PATIENT.Prof.Garfia.A

18.-FATAL OBSTRUCTIVE EDEMA OF THE ARITENOEPIGLOTTIC FOLDS FOLLOWING AN ANAPHYLACTIC REACTION IN A ASMATHIC PATIENT.

PROF.GARFIA.A

Fatal upper airway obstruction can occurs in children and in adults people. In young children is most commonly caused by inhaled foreing bodies, particularly due to food or toy parts. Much less frequently fatal compromise of the superior airway occurs due to an congenital malformation such as a lingual thyrod at the base of the tongue (see:http://www.forensic-histopathology-garfiaa.blogspot.com), from the same author), or a lingual thyroglossal duct cyst. Acquired lesions may also result in fatal airway narrowing and often involve an infectious etiology such as acute epiglottitis, or acute inflamation of a lingual tonsil. Many of these cases occurs in infancy and very early chilhood, although food aspiration, so called “cafe coronary death” may occur at any age. A special chapter in adults it is referred to deaths due to Anaphylactic Reactions after insect bites – wasp, hornets and bees- or deaths following drug administration sometimes difficult to diagnostised due to some drugs are drugs normally utilized againts the anaphylactic process, such as metilprednisolone or other corticoids which utilize “carboximethylcellulose” as disolvent.

CASE REPORT

A finnish man, 58 years old, with pathological antecedents of alergical illnes, arterial hypertension and bronchial asthma presented an undiagnosed clinical picture of pain in the right half of the face, accompanied by important facial and lingual edema. Soon after, the patient went to the Hospital Emergency Service and, after 3 hours, transferred to Intensive Care Unit, where he suffered cardiorespiratory arrest and die.

The medicament treatment guide was the following:

At Home

Urbason….60mg.i.v.

Amoxicillin..875 mg/12 hours.

Antihistamines…(unknown).

Few hours later the clinical picture suffers progresive worsening and the patient go to the Urgency Hospital Service.At the Hospital, the patient presented severe lingual and laringeal edema.The Medical team administrated:

Actocortin…300mg+

Urbason……40 mg, dissolved in a 100ml ampoule of physiological serum. After that, the patient presented a convulsive picture and cardiorespiratory arrest and was sended to the Critic Unit.The orotracheal intubation with a Sheridan tube number 6, was not possible.The patient received the following medication:

Adrenalin: two bolus of 20mg.

Atropine……3mg.

Salbutamol. 3mg

The patient went to cardiovascular arrest and die after 70 min. of cardiopulmonary resuscitation.

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PROF. GARFIA.A

Photo nº 1.-Macroscopical aspect of the larynx, posterior aspect. 
   To note the severe obstructive edema (arrows) of the arytenoepiglottic folds (stars) and the erasure of the cuneiform and corniculate tubercles of the right sidedue to the brutal suffocating edema, typical of the larynx anaphylactic response.The differential dignosis must be made with the infectious acute fatal epiglottitis, where the affectation of the inflamation affects, more specifically, to the epiglottical structures. Prof.Garfia.A

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PHOTO Nº 2. To show the microscopical aspect of the arytenoepiglottic folds.
Note that the inflamation is due to the edema with scanty cellular componente inside it. This is the second characteristic of the anaphylactic affectation of the larinx (anaphylactic target organ in asthmatic people). Ep=epithelium. Ed= edema.
Prof.Garfia.A

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PHOTO Nº 3.- To show the scanty cellular component (arrows) inside the edema in the anaphylactic reaction. Cells are, principally, leucocytes eosinophiles and plasma cells (the third characteristic of the laringeal anaphilactic reaction). Masson Trichrome-stain.Prof.Garfia.A