Fat Embolism and Severe Natural Disease: Challenges for Certification

Abstract

Detectable intravascular fat has been reported in up to 90% of patients with long bone fractures. However, the more clinically significant fat embolism syndrome (FES) is less common. Despite its common occurrence, determining the significance of fat embolism as a cause of death remains controversial; however, helpful objective criteria through a tiered approach have recently been proposed. Patients with coexisting natural disease and fat embolism present an additional challenge for interpretation. We present an illustrative 59-year-old woman with severe comorbidities who died 11 days following a femoral neck fracture and discuss how the use of special techniques to demonstrate embolic fat and published guidelines for diagnosis were helpful in death certification. The case also provides a beautiful morphologic illustration of the accumulation of lipid laden alveolar macrophages as intravascular fat is absorbed into the tissues over time. Such macrophages can also be clinically detected by bronchoalveolar lavage, which can provide some objective support for a clinically suspected diagnosis of fat embolism.