Professional Documents
Culture Documents
Medical
Examiner:
Patient Name::
Medical Record #:
DOB/Age::
Race/Gender:
PRESNELL, KYLER
NCBH Path #:
A16-201
8/16/2014 (Age: 1)
W/M
1/31/2016
2/1/2016
5/25/2016
Garry L. Wooten
Haywood County Medical Examiner
teo
Cultures:
Viral culture: nasopharyngeal:
Positive RSV
Left Lung:
1+ Coagulase negative Staphylococci
Right Lung:
3+ Streptococci, alpha hemolytic; 2+ Saprophytic neisseria species
Body Fluid - blood:
Coagulase negative Staphylococci; Methicillin resistant Staphylococcus aureus; Streptococci, alpha
hemolytic
PRESNELL, KYLER
Page 1 of 9
A16-201
PRESNELL, KYLER
Autopsy Report
A16-201
Summary of Findings
The cause of death in this 18-month-old male, Kyler Presnell, is diffuse hypoxic/ischemic injury of the brain with necrosis due to
acute subdural hematoma due to blunt force injuries of the head.
Major findings at autopsy included contusions of the scalp with underlying hemorrhage; a right-sided, partially clotted subdural
hematoma (40 mL); and brain with subarachnoid hemorrhage, edema, right medial temporal lobe herniation, hypoxic/ischemic
injury and regions of necrosis. In addition there were multiple bruises/contusions of the arms, legs and torso. The retinal
hemorrhages and optic nerve sheath hemorrhages are likely secondary to the increase in intracranial pressure as a result of the
cerebral edema. A mild, patchy bronchiolitis with rare syncytial cell formation is present, most likely due to recent infection with
respiratory syncytial virus (RSV); however, despite RSV genetic material being detected in the nasopharyngeal specimen, a PCR
genetic test for RSV on the lung tissue was negative. The bronchiolitis is mild and patchy and did not cause or contribute to the
death. Postmortem bacterial cultures grew a mixture of organisms consistent with postmortem contamination. Postmortem
toxicology screening on aortic blood for a detectable carbon monoxide level and common substances of abuse is negative.
According to initial investigative reports, the decedent was found unresponsive and Emergency Medical Services was called. Upon
arrival to the scene, the emergency personnel noticed a strong kerosene odor and were initially concerned for a carbon
monoxide-related death due to a faulty heating unit in the residence. Per review of investigative materials provided by the County
Medical Examiner, Kyler had recently moved in with his paternal grandparents following the incarceration of his parents
(approximately 3 and weeks prior to death). Due to the paternal grandmothers work schedule, the child spent the majority of the
day with his disabled paternal grandfather. Kyler was reportedly put to bed in the pack-and-play in the living room around 21:00 by
his grandfather the night prior to his death. He was found by his grandparents in the pack-and-play unresponsive at around 04:20
the day of his death. Grandparents attempted resuscitation until medics arrived and declared Kyler dead on scene.
Per interview with the paternal grandfather on 2/2/2016, Kyler had no changes in his behavior the day prior to his death with
waking up at 07:30, being fed, playing until tired, napping at noon, waking at 14:00, eating and playing until bed time at 21:00. Per
the grandfather, the child was never out of his sight. When interviewed on 2/2/2016 and 2/11/2016, the paternal grandmother said
the only recent trauma she knew of was Kyler falling in pack-and-play once weeks ago, falling against a door several weeks ago,
and falling and hitting dumbbells a week prior to death. Both grandparents repeatedly denied knowing of or causing significant
head trauma. Paternal grandfather stated during his 2/2/2016 interview that Im pretty smart. Its either her or me while also
stating I didnt hurt this child and I know my wife didnt hurt this child. Aside from the paternal grandparents, the only caretaker in
the prior three and a 1/2 weeks was 20 days prior where Kyler was noted to be ambulating and fell three times, hitting his knees
and his bottom. Review of a jail visit video dated 1/28/2016 (3 days prior to death) showed Kyler to be acting age appropriate
(pointing to nose and hair when prompted, talking on the phone to his father) and without obvious external head trauma.
Review of the Kylers medical records indicates he was born at 37 weeks gestation with APGARs of 9 and 9. At 8 months of age
(4/27/2015), he was brought to Haywood Regional for a head contusion related to rolling off the bed. At his 10 month well-child
check (6/22/2015), he was noted to have a rash, cough and congestion and immunizations were administered. On 9/5/2015, Kyler
was taken to Haywood Regional for acute urticaria and was treated with steroids and diphenhydramine. When Kyler moved in with
his paternal grandparents, he reportedly had an upper respiratory tract infection that was being treated with oral antibiotics. No
documentation of easy bruising or bleeding is identified in Kylers medical history.
EXTERNAL EXAMINATION
PRESNELL, KYLER
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A16-201
PRESNELL, KYLER
Body Weight: 17 pounds
Body Length
(Crown-Heel Length): 81 cm
(normal: 78 cm)
Autopsy Report
A16-201
Crown-Rump Length: 54 cm
Head Circumference: 48 cm
Chest Circumference: 41 cm
Abdominal Circumference:
36.5 cm
The body is cool to the touch. Rigor is absent in the extremities and jaw.
Diffuse, fixed, 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 blonde, curly, and 8 cm in length. The hair growth pattern
is normal. The anterior and posterior fontanelles are closed. The eyes
are normally formed. Indirect funduscopic examination of the eyes
demonstrates bilateral retinal hemorrhages. The irides are green. The
corneae are transparent. The sclerae and conjunctivae are pale. The
ears are normally formed and placed with the appropriate amount of
cartilage. The nose and lips are unremarkable. The deciduous teeth are
partially erupted and normal for age. The palate is intact and is neither
high nor arched. The neck is without masses and the larynx is in the
midline.
The thorax is symmetrical. The abdomen is not protuberant. The
extremities are bilaterally symmetrical with all digits present. Palmar
creases are unremarkable. The external genitalia are those of a normal
male toddler, with testes bilaterally in the scrotum, which is
appropriately rugated. The back and anus are unremarkable.
There are no identifying marks or scars.
Emergency resuscitation and/or medical therapy consists of
electrocardiogram pads on the chest and defibrillator pads on the chest
and back.
EVIDENCE OF INJURY
HEAD AND NECK
PRESNELL, KYLER
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A16-201
PRESNELL, KYLER
Autopsy Report
A16-201
LOWER EXTREMITIES
INTERNAL EXAMINATION
BODY CAVITIES
Panniculus adiposus: 0.4 cm
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: 37.7 gm
RESPIRATORY SYSTEM
Combined lung weight:
The upper airway is clear of debris and foreign material; the mucosal
surfaces are smooth, yellow-tan and unremarkable. The pleural surfaces
PRESNELL, KYLER
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A16-201
PRESNELL, KYLER
90.8 gm
Autopsy Report
A16-201
ALIMENTARY TRACT
GENITOURINARY TRACT
Right kidney: 22.9 gm
Left kidney: 23.9 gm
Urine volume: 75 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
testes, prostate and seminal vesicles are infantile and unremarkable.
RETICULOENDOTHELIAL SYSTEM
Spleen weight: 15.5 gm
The spleen has a smooth, intact capsule covering red-purple,
Thymus weight: 10 gm
moderately firm parenchyma; the lymphoid follicles are unremarkable.
The regional lymph nodes are unremarkable. The bone marrow is
red-purple and homogeneous, without evidence of focal abnormality.
The thymus has a normal, lobulated, tan-pink appearance without
petechiae.
ENDOCRINE SYSTEM
Combined adrenal weight:
4.8 gm
MUSCULOSKELETAL SYSTEM
BLOCK SUMMARY
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
PRESNELL, KYLER
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A16-201
PRESNELL, KYLER
Autopsy Report
A16-201
MICROSCOPIC DESCRIPTION
The heart has no evidence of acute ischemic changes, myocarditis, or myofiber disarray.
The lungs have patchy foci of bronchiolitis with necroinflammatory debris, a patchy increase in interstitial chronic inflammation,
and a single syncytial cell concerning for viral cytopathic effect. No respiratory syncytial virus (RSV) genetic material is
identified via polymerase chain reaction (PCR) on frozen lung tissue.
The liver has no significant inflammation, no steatosis or cholestasis.
The kidneys have normally formed glomeruli and occasional, nonspecific intratubular calcifications. Occasional partial or
globally sclerotic glomeruli are seen beneath the renal capsule, consistent with physiologic subcapsular involution. There is no
significant inflammation or fibrosis.
The adrenals have extravasated red blood cells within the medulla.
The spleen has normal red pulp and white pulp containing germinal centers with an epithelioid appearance. No necrosis or
multi-nucleated cells are seen.
The bowel shows no inflammation and normal collections of ganglion cells.
The thymus shows lobules between fibrotic bands composed of thymocytes, epithelioreticular cells and Hassalls corpuscles.
The testis shows normal seminiferous tubules that are appropriately developed for age.
The bladder shows normal urothelium with umbrella cells and no significant inflammation.
The pancreas contains normal islets cells and acini without inflammation.
The gastroesophageal junction section had a denuded epithelium. There is no significant inflammation in the muscularis.
The epiglottis shows stratified squamous epithelium with associated lymphoid aggregates and no significant inflammation.
The trachea has intraluminal vegetable material and respiratory epithelium without significant inflammation.
The thyroid has unremarkable epithelial cells surrounding colloid.
The rib shows normal cartilage and bone elements and trilineage hematopoiesis.
TOXICOLOGY
Toxicology Folder:
Date of Report:
T201601003
09-feb-2016
CONDITION: Postmortem
OBTAINED: 01-feb-2016
CONDITION: Postmortem
OBTAINED: 01-feb-2016
Page 6 of 9
A16-201
PRESNELL, KYLER
Autopsy Report
A16-201
CONDITION: Postmortem
OBTAINED: 01-feb-2016
_______________________________________________________________________________
S160003065:
SOURCE: Liver
Liver
CONDITION: Postmortem
OBTAINED: 01-feb-2016
_______________________________________________________________________________
S160003066: 30.0 ml Blood
SOURCE: Subdural Space
CONDITION: Postmortem
OBTAINED: 01-feb-2016
_______________________________________________________________________________
S160003067: 14.0 ml Urine
SOURCE:
CONDITION: Postmortem
OBTAINED: 01-feb-2016
_______________________________________________________________________________
Accredited by the American Board of Forensic Toxicology, Inc.
020916 16:00
*** END
OF
REPORT ***
OPHTHALMOLOGY EXAMINATION
The globes are of similar size measuring 2.2 cm in axial, vertical and horizontal dimensions. The right and left optic nerves
measure 1.3 cm and 1.1 cm, respectively. Both exhibit diffuse optic nerve sheath hemorrhage that is more concentrated at the
optic nerve-globe junction. The clear corneae measure 1.1 cm (horizontal) x 1.1 cm (vertical). The irides appear light brown and
lenses are crystalline. Upon sectioning the globes at the pars plana, the right fundus has 9 retinal hemorrhages over the posterior
pole extending past the equator. The hemorrhages are superficial and dot/blot along the vascular arcades of the posterior fundus.
Two subinternal limiting membrane hemorrhages are slightly larger measuring 1/3 to 1/2 disc diameter in size and are located past
the equator in the 12:00 and 2:00 position. A small amount of vitreous hemorrhage overlies the optic nerve disc. The left fundus
has 10-15 superficial, flame-shaped hemorrhages located around the optic disc, one above the superior temporal arcade, and
another at 6:00 about 4 disc diameters from the optic nerve head. The one above the superior temporal arcade is located about 5
disc diameters from the optic nerve. All of the hemorrhages on the left appear superficial and the largest is no more than 1/10 disc
diameter in size. Slight blurring of the optic disc margins is present, bilaterally.
Microscopic Description:
The globes and corresponding optic nerves are similar histologically. The optic nerves have subarachnoid, subdural and
intra-dural extravasated blood. The intra-dural blood is most concentrated within the connective tissue surrounding the intra-dural
course of the retinal artery and vein. Scattered extravasated blood is within the adjacent adipose tissue. Retinal hemorrhages
involve all layers of the retina and are most numerous over the posterior fundus but occasional foci of extravasated blood are
adjacent to the ora serrata. No retinal necrosis or retinoschisis is present. A special stain for iron (Prussian blue) shows no
hemosiderin in the optic nerves or retinae.
DIAGNOSES:
PRESNELL, KYLER
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A16-201
PRESNELL, KYLER
Autopsy Report
A16-201
ks/5/13/2016
Page 8 of 9
A16-201
PRESNELL, KYLER
Autopsy Report
A16-201
COPY TO:
Garry L. Wooten
PRESNELL, KYLER
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A16-201