Department of Pathology

Medical Center Blvd

Winston-Salem, NC 27157
Phone: (336) 716-4311
Fax: (336) 716-7595

MEDICOLEGAL AUTOPSY REPORT

Pathologist:
Resident:
Autopsy Assistant:
Service:
Admitted:
Expired:
Autopsied:
Reported:
Attending Physician:

Medical
Examiner:

JERRI LYNN MCLEMORE , MD

Kenneth Long

Patient Name::
Medical Record #:
DOB/Age::
Race/Gender:

ECCLESTON, ELIZABETH ANN

NCBH Path #:

A16-462

12/9/2015 (Age: 3 m)
W/F

3/13/2016
3/15/2016
12/7/2016
Robert Carr Moffatt
Buncombe County Medical Examiner

FINAL AUTOPSY DIAGNOSIS

I. History of cardiac arrest, with resuscitation
A. Hypoxic-ischemic injury of the brain
B. Focal gastrointestinal mucosal necrosis
***Electronically Signed Out By:

JERRI LYNN MCLEMORE , MD***

jlm

Cultures:
Left Lung:
[Left Lower Lobe]: 1+ Stenotrophomonas maltophilia
Right Lung:
[Right Upper Lobe]: No growth
Viral culture: nasopharyngeal:
Negative
Summary of Findings
The cause of death is undetermined.
According to investigative reports, the infant was transported to a local hospital after allegedly being found unresponsive.
Cardiopulmonary resuscitation resulted in a return of pulse; however, the baby was diagnosed with global hypoxic-ischemic brain
injury. She was declared dead about 8 days after admission.
The mother initially reported that the baby had been fussy and was placed in a car seat, supine, with a cushion underneath her.
She was given a pacifier when she had become fussy again after which she quieted down. Allegedly, a short time later, the baby
was found unresponsive. The mother later stated that she had placed the baby prone on the cushion when the baby started crying
so that the baby would cry into the cushion, which the mother claimed she did for about 1 hour. The parents disappeared after
initial interviews with investigators, leaving behind a signed note with vague suicidal ideation. The parents were later found alive at
which time the mother claimed that they had tried to administer albuterol via an inhaler into the babys nose and mouth when they
found her unresponsive. The mother also claimed that the father had intentionally dropped the infant after she was found
unresponsive although no injuries were found at autopsy.
The infant was delivered vaginally at term without complications. The mother had late prenatal care. The parents had missed the
babys 2 month appointment and vaccinations.
Autopsy findings revealed non-specific changes of the brain and spinal cord due to injury from lack of blood flow prior to
resuscitation and the effects of prolonged ventilation after resuscitation. Additionally, no anatomic reason such as a congenital
defect to explain sudden incapacitation was present. No discrete traumatic injuries were present. Postmortem toxicologic analysis
was not performed because no appropriate antemortem specimens from around the time of admission to the hospital were
available.
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ECCLESTON, ELIZABETH ANN

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The changing stories by the parent(s) regarding the circumstances around the time the infant was found unresponsive are
worrisome. Concerns about a possible albuterol overdose based on one of the stories provided by the parents could not be proven
due to lack of appropriate specimens for toxicologic analysis; however, delivery of albuterol via an inhaler is not an effective mode
of delivery of this drug for an infant. The autopsy findings for this infant are non-specific for a specific etiology for the cardiac arrest;
however, the autopsy findings do not exclude intentional smothering as a cause of death.

EXTERNAL EXAMINATION
Body Weight: 8.38 pounds
Body Length (Crown-Heel
Length): 25.5 in
Crown-Rump Length: 17.25 in
Head Circumference: 17.125 in
Chest Circumference: 19 in
Abdominal Circumference: 18.5
in

A representative from Woodfin Police Department is present during the

autopsy.
The body is that of a well developed, edematous, white female infant
whose state age is approximately 3 months. Body identification includes
a toe tag and an identification bracelet around the left ankle.
The body is received unclothed. No personal effects accompany the
body.
The body is cool to touch. Rigor is present in all extremities and jaw but
assessment is hindered by the amount of subcutaneous edema present.
Diffuse, faint, red-purple livor extends over the posterior surfaces of the
body, except in areas subject to pressure.
The head is normally formed. Scalp hair is brown, wavy, and measures
about 1/4 inch in length. The hair growth pattern is normal with a thicker
layer of hair at the occiput. The anterior fontanelle is open and bulging.
The posterior fontanelle is closed. The eyes are normally formed.
Indirect funduscopic examination of the eyes demonstrates two and
three retinal hemorrhages in the left and right eyes, respectively. The
irides are darkly-colored. The corneae are slightly cloudy. The sclerae
and conjunctivae show a small cluster of 5 faint red petechiae on the
upper right palpebral conjunctiva and 2 red pinpoint petechiae on the
lower left palpebral conjunctiva. The ears are edematous, but normally
formed and placed with the appropriate amount of cartilage. The nose
and lips are unremarkable. The mouth is edentulous in keeping with the
age of the infant. The palate is intact and is neither high nor arched. The
neck is without masses and without webbing, and the larynx is in the
midline. The thorax is symmetrical. The abdomen is protuberant. The
extremities are bilaterally symmetrical with all digits present. Palmar
creases are unremarkable. The fingernails appear to have been
trimmed. Spotty, black ink smudges are on the fingerpads and
underneath the nails. Similar patches of black ink are on the soles of the
feet. The external genitalia are those of a normal female with intact
hymen and pooling of a small amount of serosanguineous fluid at the
posterior aspect of the vaginal os. The back and anus are
unremarkable.
Identifying marks and scars consist of a 3/4 inch oval brown macule on
the proximal anterior left lower leg. Emergency resuscitation and/or
medical therapy consists of endotracheal and nasogastric tubes, an port
over the central chest, intravenous catheters in the right foot, upper left
arm, and superolateral left parietal scalp, Foley catheter without bag,
and three black sutures at the base of the lateral right neck. Needle
puncture marks are on the superior anterior right frontal scalp,
superolateral left parietal scalp with blue contusion, antecubital fossae,
left and right inguinal regions, and anterior right lower leg. Puncture
marks are on the heels of the feet. A 1/4 inch oval red contusion is on
the lateral right neck under the ear and corresponds to the tape holding
the endotracheal tube in place. A red abraded contusion is on the lateral
right ankle/foot corresponding to tape holding the intravenous catheter in

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place.
Evidence given to the representative for Woodfin Police Department
during the autopsy includes a blood spot card, blood in a purple top
tube, pulled head hair, and a buccal swab.

EVIDENCE OF INJURY
HEAD AND NECK
A 1/8 inch red contusion with a cluster of 3 pinpoint red petechiae is on
the mucosa aspect of the midline upper lip. A pinpoint red petechial
contusion is on the midline lower lip mucosa.
CHEST AND ABDOMEN
None
UPPER EXTREMITIES
None
LOWER EXTREMITIES
None

INTERNAL EXAMINATION
BODY CAVITIES
Panniculus adiposus: 0.8 cm

CENTRAL NERVOUS SYSTEM

Brain weight: 560 gm

ECCLESTON, ELIZABETH ANN

Approximately 50 ml of yellow serous fluid are within each of the pleural

cavities. About 200 ml of similar fluid is within the peritoneal cavity. All
body organs are present in normal and anatomical position.
The dura mater and falx cerebri are intact. The leptomeninges are thin,
delicate and transparent. The cerebrospinal fluid is clear. In-situ, the
external surface and configuration of the brain are not unusual except
for marked edema with compression of the sulci and flattening of the
gyri; the gyral pattern is consistent with the stated age of the infant. The
cerebri are markedly soft. The structures at the base of the brain,
including cranial nerves and blood vessels, are intact and free of
abnormality. The cerebellum and brain stem are partially liquified due to
autolysis and degradation. Further examination of the brain is performed
with a neuropathologist after fixation of the tissue. A posterior spinal
cord dissection is performed. No subcutaneous hemorrhages are
present, and no intramuscular hemorrhage involves the muscles of the
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posterior neck or back. The spinal cord is unroofed with removal of the
spinous processes. The left cervical dorsal root ganglia are not
visualized, probably due to degradation of the tissue. The right cervical
dorsal root ganglia have scattered punctate dark purple hemorrhages
within some of the roots. The cervical spinal cord is markedly soft with
intraparenchymal blue-purple discoloration/hemorrhage. Further
dissection of the cord is performed after fixation with the
neuropathologist.
NECK
Examination of the soft tissues of the neck, including strap muscles and
large vessels, reveals no abnormalities. The hyoid bone and larynx are
intact. The lingual mucosa is intact; the underlying firm red-brown
musculature is devoid of hemorrhage.
CARDIOVASCULAR SYSTEM
Heart weight: 32.4 gm

RESPIRATORY SYSTEM
Lung weights: Right- 55.7 gm
Left- 46.2 gm

LIVER AND BILIARY SYSTEM

Liver weight: 198.8 gm
Bile volume: 5 ml

The pericardial surfaces are smooth, glistening and unremarkable; the

pericardial sac is free of significant fluid or adhesions. The shape and
size of the heart are not unusual. The coronary arteries arise normally,
follow the usual distribution and are widely patent. The chambers and
valves bear the usual size-position relationships and are unremarkable.
The myocardium is dark red-brown, firm, and unremarkable; the atrial
and ventricular septa are intact. The endocardial surface of the left
ventricle within the aortic outflow track has hemorrhage (flame
hemorrhages). The foramen ovale is appropriately membrane protected.
The pulmonary artery, the aorta and its major branches arise normally,
follow the usual course and are widely patent; the ductus arteriosus is
anatomically closed. The vena cava and its major tributaries, and the
pulmonary veins return to the heart in the usual distribution and are free
of thrombi.
The upper airway is clear of debris and foreign material; the mucosal
surfaces are smooth, yellow-tan and unremarkable. The pleural surfaces
are smooth, glistening and unremarkable. Lobar divisions are of the
usual configuration. The pulmonary parenchyma is dark red-purple,
exuding moderate amounts of blood and frothy fluid; no focal lesions are
noted. The parietal pleura are stripped from the thoracic cavity walls,
revealing unremarkable soft tissue and bony structures without
hemorrhage and acute or remote bony trauma. The intraparenchymal
pulmonary arteries are normally developed, patent, and without
thrombus or embolus.
The hepatic capsule is smooth, glistening and intact, covering red-brown
parenchyma with no focal lesions. The gallbladder contains dark green,
slightly mucoid bile; the mucosa is velvety and unremarkable. The
extrahepatic biliary tree is patent. The portal vein and its tributaries are
unremarkable.

ALIMENTARY TRACT
The esophagus is lined by gray-white, smooth mucosa. The gastric
mucosa is arranged in the usual rugal folds, and the lumen has
approximately 5 ml of slightly thick tan material. The root and radius of
the mesentery bear the usual size-position relationship. The serosa of
the small and large bowel and appendix is unremarkable. The pancreas
has a normal gray-white, lobulated appearance, and the ducts are
unobstructed.
GENITOURINARY TRACT
Right kidney: 37.6 gm
Left kidney: 44.0 gm
Urine volume: 0 ml

The cortical surfaces are smooth, red-brown, and lobulated. The cortex
is of normal thickness, and sharply delineated from the medullary
pyramids, which are red-purple to tan and unremarkable. The usual
complement of calyces is present without abnormality. The pelves, and
ureters are unremarkable. The relationships at the trigone are
unremarkable. The urinary bladder mucosa is gray-tan and smooth. The
uterus, fallopian tubes, ovaries, and vagina are infantile and
unremarkable.
RETICULOENDOTHELIAL SYSTEM
Spleen weight: 10.5 gm
The spleen has a smooth, intact capsule covering red-purple,
Thymus weight: 12.5 gm
moderately firm parenchyma; the lymphoid follicles are unremarkable.
ECCLESTON, ELIZABETH ANN

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The regional lymph nodes are unremarkable. The bone marrow is

red-purple and homogeneous, without focal abnormality. The thymus
has a normal, lobulated, tan-pink appearance without petechiae.
ENDOCRINE SYSTEM
Combined adrenal weight: 3.7
gm

The pituitary, thyroid, and adrenal glands are unremarkable.

MUSCULOSKELETAL SYSTEM
The axial and appendicular skeletons are unremarkable. The
musculature is well developed. The diaphragm is intact and in its proper
position. Postmortem radiographic studies demonstrate no remote or
acute bony trauma or abnormalities.

Block Summary:
1. Lung
2. Heart
3. Bone marrow
4. Epiglottis, ovary
5. Trachea, lung, spleen
6. Liver, pancreas
7. Thymus, small and large intestines
8. Uterus, trachea
9. Mesenteric lymph node, duodenum, kidney
Microscopic Description:
LUNGS- Sections show congestion, increased septal cellularity due to leukocytosis, prominent atelectasis, scattered
peribronchiolar lymphoid aggregates, and clusters of macrophages with sparse admixed neutrophils in many alveoli.
BONE MARROW- Section shows around 80% cellularity with trilineage maturation. Eosinophils and its precursors are
prominent.
INTESTINES- Sections show increased eosinophils within the colonic mucosa and submucosa and focal colonic mucosal
necrosis. Possible increased fibrosis involves the colonic submucosa. The small intestine has scattered eosinophils and possible
edema.
THYMUS- Section shows involution of the cortex.
KIDNEY- Section shows numerous red granular and proteinaceous tubular casts.
LIVER- Section shows loss of intrahepatocytic glycogen.

TOXICOLOGY
Toxicology Folder:
Date of Report:

T201602524
24-mar-2016

DECEDENT: Elizabeth Ann Eccleston

Status of Report: Approved
Report Electronically Approved By: Sandra Bishop-Freeman, PhD

No analyses requested, specimen(s) held.

===============================================================================
SPECIMENS received from Jerri L. McLemore on 24-mar-2016
S160007609:
SOURCE: Liver

Liver

ECCLESTON, ELIZABETH ANN

CONDITION: Postmortem
OBTAINED: 15-mar-2016
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ECCLESTON, ELIZABETH ANN

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_______________________________________________________________________________
S160007610:
SOURCE: Muscle

Muscle

CONDITION: Postmortem
OBTAINED: 15-mar-2016

_______________________________________________________________________________
S160007611: 2.0 ml Bile
SOURCE: Gall Bladder

CONDITION: Postmortem
OBTAINED: 15-mar-2016

_______________________________________________________________________________
S160007612:
SOURCE: Kidney

Kidney

CONDITION: Postmortem
OBTAINED: 15-mar-2016

_______________________________________________________________________________
S160007613:
Gastric Contents
SOURCE: Stomach

CONDITION: Postmortem
OBTAINED: 15-mar-2016

_______________________________________________________________________________
S160007614:
Other
SOURCE: Abdominal Cavity

CONDITION: Postmortem
OBTAINED: 15-mar-2016

_______________________________________________________________________________
Accredited by the American Board of Forensic Toxicology, Inc.
032416 17:02

*** END

OF

REPORT ***

OPHTHALMOLOGY EXAMINATION
Both globes are of similar size measuring 2.0 cm in axial, vertical and horizontal dimensions. The right and left optic nerves
measure 1.7 cm and 1.6 cm, respectively. Neither exhibits any optic nerve sheath hemorrhage or hemorrhage in the surrounding
fat. The clear corneae measure 1.0 cm (horizontal) x 0.9 cm (vertical). The irides appear brown and the lenses are crystalline.
Upon sectioning the globes at the pars plana, three superficial retinal hemorrhages are over the right posterior fundus, one just
below the fovea and another at the 12:00-1:00 position, about 2-3 disc diameters from the optic nerve head and a third in the 5:00
position, two disc diameters from the optic nerve head. All of these are minute and measure less than 1/10 disc diameter in size.
The left fundus has two superficial retinal hemorrhages, one at the 1:00 position and one at the 6:00 position. These are superficial
hemorrhages that measure less than 1/10 disc diameter in size. The one above the superior temporal arcade is located about two
disc diameters from the optic nerve head and the one at the 6:00 position is located about 1-2 disc diameter from the optic nerve
head. The optic disc margins appear sharp.
MICROSCOPIC DESCRIPTION:

Block Summary:
1. Right optic nerve
2. Right ciliary body, lens & cornea
3. Right retina
4. Right retina
5. Left optic nerve
6. Left ciliary body, lens & cornea
7. Left retina
8. Left retina
The optic nerves have no extravasated blood, hemosiderin-laden macrophages or inflammatory infiltrates. The ciliary bodies,
corneae and lenses are age-appropriate and have no abnormal findings. Both retinae have solitary foci of extravasated blood
within the nerve fiber layers.
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DIAGNOSIS:
Bilateral retinal hemorrhages

Neuropathology Final Diagnosis

BRAIN, DURA, AND SPINAL CORD, AUTOPSY:
Severe diffuse hypoxic/ischemic injury with necrosis, edema, vascular congestion, and extravasated blood in the
perivascular spaces and leptomeninges.
Spinal cord with no diagnostic abnormality.
Fresh subdural hemorrhage.

ks/5/24/2016

***Electronically Signed Out By JERRI LYNN MCLEMORE , MD***

KIMBERLY STOGNER-UNDERWOOD ,
MD

Neuropathology Gross Description

The specimen consists of the brain with calvarial dura. The brain weighed 560 grams in the fresh state and weighs
860 grams post-fixation. The dura has a focally granular texture with patchy red-brown staining. The superior sagittal
sinus contains a significant amount of clotted blood which is grossly consistent with post-mortem coagulation. A mild
collection of subarachnoid blood is present involving the base of the brain. Complete assessment of the cerebral
hemispheres is precluded by diffuse softening, and edema. Examination of the intact base of the brain shows no
apparent herniation of the medial temporal lobes or the cerebellar tonsils. The arteries of the circle of Willis are in the
usual anatomic configuration and are patent. The cranial nerve stumps are of normal caliber and color. The exterior
surfaces of the brainstem and cerebellum are unremarkable. Coronal sections through the cerebral hemispheres
show normal development of the cortex, white matter, and central gray nuclei in the areas available for assessment.
The periventricular white matter and region of the germinal matrix exhibit no abnormalities of texture or color.
The lateral and third ventricles are not able to be assessed secondary to softening and edema. Transverse sections through the
brainstem show normal architecture of the gray and white matter. Sections through the cerebellum show normal cortex, white
matter and deep gray nuclei.
The spinal cord (15 cm in length) is available for examination. The spinal dura is without hemorrhages, exudates or mass lesions
on the epidural or subdural surface. The spinal leptomeninges are thin and translucent. The anterior and posterior spinal nerve
roots are of normal caliber and color. Transverse sections through the spinal cord show normal gray and white matter.
Block Summary:
1)
2)
3)
4)
5)
6)
7)
8)
9)
10)
11)

Midbrain
Base of brain with subarachnoid hemorrhage
Right basal ganglia
Left thalamus
Right cerebral cortex
Left cerebral cortex
Pons
Right cerebellum
Spinal cord
Sagittal sinus
Dura

Neuropathology Microscopic Description

Sections of the brain demonstrate diffuse edema and red neurons in multiple regions of the brain. Vascular congestion is noted
with focal perivascular extravasated red blood cells both within the brain parenchyma and the leptomeninges. Sections of the
ECCLESTON, ELIZABETH ANN

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spinal cord demonstrate no diagnostic abnormality. No thrombus is noted in the sagittal sinus. Focal fresh blood is present on
the dura with no evidence of organization. Extravasated blood is also noted within the dura.

COPY TO:
Robert Carr Moffatt, MD

ECCLESTON, ELIZABETH ANN

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