Keywords:
Meningitis, autopsy - central nervous system - pneumonia - lung abscess
Palavras-chave:
Meningite - autópsia - sistema nervoso central - pneumonia - abscesso pulmonar
The history of Anatomical Pathology in the state of Paraná, southern Brazil, is linked to the development of the Universidade Federal do Paraná (UFPR). Officially founded in 1912, it was the first university in Brazil. The UFPR originated from the School of Arts and Industry founded by Antonio Mariano de Lima (Trás-os-Montes, Portugal, 1858 - Manaus, Brazil, 1942). Despite its apparent lack of success, the School of Arts and Industry produced important artists, such as João Zaco Paraná (1884-1961) and João Turin (1878- 1949), as well as giving rise to the UFPR. Many of the UFPR founders were faculty members of the School of Arts and Industries; among them Victor Ferreira do Amaral (1862-1953), who taught Anatomy classes and was its vice-director. He was the first dean of the UFPR, when it became a federal university[1].
The School of Medicine of the UFPR was founded by the physicians Victor do Amaral, Nilo Cairo (1874-929), Petit Carneiro (1876-1940), and Alfredo de Assis Gonçalves (1884-1984). In 1913, Pathology as a discipline and medical specialty was first taught by several nonpathologist professors under the name of Anatomical Pathology and Physiology[2],[3].
In 1935, Dr. Paulo de Queiroz Telles Tibiriçá (1903- ?) was hired by the UFPR from the University of São Paulo, where he specialized in Pathology. He was assigned to develop the Department of Anatomical Pathology and Physiology. He created a museum of anatomy specimens, microscope slide collections and organized clinicopathological meetings. The department was inaugurated on September 7, 1935[2],[3]; later, Professor Tibiriçá moved to the Universidade Federal do Rio Grande do Sul, Porto Alegre in 1944[4].
During these early years, autopsies were performed in the Santa Casa Hospital, where the UFPR medical students received training before the Hospital de Clínicas (HC-UFPR) was founded in 1961. The Department of Anatomical Pathology and Physiology moved to the HC-UFPR this same year[2],[3].
The objective of the present study was to identify and report the first central nervous system (CNS) clinical autopsy performed by the Department of Anatomical Pathology and Physiology of the UFPR. This study will contribute to the register and historical analysis of the evolution of Neuropathology in Brazil and South America.
METHODS
The autopsy report archives of the Department of Anatomical Pathology of the HC-UFPR were reviewed from 1951 onward. Other possible clinical anatomy interpretations, different from the one at the time, are reviewed and discussed.
RESULTS
In the archives of the Department of Anatomical Pathology and Physiology, of the HC-UFPR, there are a total of 13,986 autopsy examinations, performed between 1951 and 2014. This period includes autopsies performed before the foundation of the HC-UFPR.
The first autopsy performed by the Department of Anatomical Pathology and Physiology of the School of Medicine of the UFPR was performed on November 18, 1951 on a 32-year-old white widowed woman. The cause of death was pulmonary tuberculosis ([Figure 1]). The first adult CNS autopsy was no. 70, performed on April 23, 1952. The case was a 45-year-old white man who was married and had worked as a bill collector. The cause of death was acute purulent meningitis (bacterial meningitis) associated with lobar pneumonia with abscesses ([Figure 2]). Both autopsies were performed by Prof. Dr. Ruy Leal.
Figure 1 The first clinical autopsy performed by the Department of Anatomical Pathology of the School of Medicine of the UFPR, was performed on November 18, 1951, on a 32-year-old white widowed woman. The cause of death was pulmonary tuberculosis. The pathologist who signed was Prof. Dr. Ruy Leal. According to the World Health Organization, tuberculosis, while no longer among the 10 leading causes of death, still remained among the 15 leading causes worldwide in 2012[9].
Figure 2 The first adult CNS clinical autopsy report, autopsy no. 70, was performed on April 23, 1952. The cause of death was acute purulent meningitis associated with lobar pneumonia with abscesses. The pathologist who signed was Prof. Dr. Ruy Leal.
DISCUSSION
No records exist of autopsies performed in the UFPR during the early period (1913-1950). Autopsy services in other cities in Paraná state started in the 1960s and ’70s[3]; therefore, there is strong evidence that autopsy no. 70 was the first CNS clinical autopsy study performed in an anatomical pathology university laboratory in Paraná state, as well as in southern Brazil, as Professor Tibiriçá moved from the UFPR to the Universidade Federal do Rio Grande do Sul to organize the Anatomical Pathology service in the state of Rio Grande do Sul[4].
According with the autopsy report, this case was considered at the time, by Dr. Ruy Leal, as lobar pneumonia complicated by lung abscesses followed by meningitis; however, the etiologic agent was not identified. The main causes of pulmonary abscesses are anaerobic bacteria (46%), comprising Peptostreptococcus sp (12%), Fusobacterium nucleatum (5%), and Prevotella sp. (1%); while 11% are aerobic, comprising Staphylococcus aureus (4%), Klebsiella pneumoniae (3%), Streptococcus pneumoniae serotype 3 (1%), Pseudomonas aeruginosa; and polymicrobians (43%) (aerobic and anaerobic)[5]. Most lung abscesses are caused by aspiration of oral secretions in patients with impaired consciousness. The meningitis was secondary to septicemic dissemination of bacteria to the brain. Lung abscesses constantly seed bacteria into the bloodstream, increasing the patient's risk of brain infection and meningitis[6] ([Figure 3A]). Other possible interpretations are discussed in [Figure 3B and C].
Figure 3 Clinical anatomical interpretations of the autopsy report and possible etiologic agents. We do not have the clinical history of the patient to best interpret the autopsy report, so this is a speculative discussion. A. Interpretation considered at the time, by Dr. Ruy Leal, as lobar pneumonia complicated by lung abscesses followed by meningitis; the main causes of lung abscesses are anaerobic bacteria, complicated by meningitis. B. Another probable interpretation, communitarian bacterial meningitis caused by Streptococcus pneumoniae, based on the patient's age, complicated by impaired consciousness and aspiration pneumonia with abscesses. C. S. pneumoniae pneumonia, the main etiologic agent of lobar pneumonia, complicated by lung abscesses; followed by sepsis and dissemination of S. pneumoniae to the brain, and meningitis. This hypothesis is less probable. S. pneumoniae, as a cause of lung abscess occurs in only 1%[5].
Meningitis was first reported by Thomas Willis (1621-1675). Gaspard Vieusseux (1746-1814) and Andre Matthey (1778-1842) in Geneva, and Elisa North (1771-1843) from Massachusetts, described epidemics of meningococcal meningitis. William Mestrezat (1883-1929) and H. Houston Merritt (1902-1979) later compiled large series of CSF profiles in meningitis. Successful meningitis treatment began with the introduction of serum therapy for meningococcal meningitis by Georg Joachmann (1874-1915) in Germany, and Simon Flexner (1863-1946) in the United States. Antibiotic therapy began in the 20th century with use of sulfonamides by Francois Schwentker (1904-1954) and penicillin by Chester Keefer (1897-1972). Vaccination against meningitis debuted in the early 20th century and progressed to the development of vaccines against N. meningitidis and H. influenzae, which remain mainstays of modern Medicine[7].
Infectious diseases were the cause of death in both autopsies presented in this paper ([Figures 1] and [2]), consistent with the predominant causes of mortality in Brazil during this period. Mortality decreased significantly from the 1970s. While mortality from infectious and parasitic diseases has declined, mortality from chronic degenerative causes and injuries related to accidents and violence have increased[8] ([Figure 4]).
Figure 4 Proportional mortality according to causes among capital cities in Brazil, 1930-1999 (modified from Carmo et al.[8]).
In conclusion, we report on the earliest adult CNS autopsy case in the records of the Department of Anatomical Pathology and Physiology of the HC-UFPR, this being the first CNS clinical autopsy performed in the state of Paraná, with strong evidence that it was also the first in southern Brazil. The death was due to an infectious disease that was the main cause of death in Brazil in the 1950s.
