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Chapter 15

Chapter 15

A Study of the Histological Localization of Dextran in Tissues of Korean Battle Casualties

Captain Austin L. Vickery, MC, USA

For several years there has been mounting interest and investigation in the field of synthetic plasma expanders. Dextran has been amongst the foremost of these substances under active experimental study and clinical application. There have now been many reports in the literature attesting to the efficacy of dextran as a relatively short-term blood volume expander.1-6 The fate of dextran after it has been infused has been carefully investigated by many methods. It has been shown that 25 to 50 per cent is lost in the urine during the first 24 hours, 5, 8, 12, 13, 15 and the presence of dextran has actually been demonstrated in kidney tissues of animals that had received it.11, 14 Other investigations have demonstrated that some of the injected dextran is actively metabolized as a carbohydrate.7, 10, 16, 17 Still other work indicates that some is stored for variable periods of time in the tissues; 9, 19, 20 tissue changes noted after dextran administration have been attributed to the effects of this material.6, 22-24 Most of these observations were made in animals that received large and repeated doses of dextran, but a few autopsy reports of humans who had received dextran described similar tissue changes, especially in the kidneys.6 Problems presented themselves concerning the nature of these changes and whether or not they were indicative of damage.

In 1952, a trial use of dextran in Korean battle casualties was undertaken by The Surgeon General's Office. Sixty-seven wounded soldiers in forward areas of the war zone received the substance and the results indicated a satisfactory expansion of the plasma volume. Further limited use of dextran in Korea under the aegis of the Surgical Research Team was approved and liaison with the Pathology Section of the 406th Medical General Laboratory was established for histopathological study of submitted tissues from such patients.

During the initial phase of this tissue study, three autopsies were studied of patients who had received dextran following battle wounds (406 MGL Nos. J-2836, J-2837 and J-2838). Two of these patients had received three units of dextran and one had five units. All three died of their severe wounds within relatively short times after wounding-7 hours, 11 hours and 28 hours. The tissues were fixed in the usual 10 per cent formalin at the 8055th MASH and then forwarded to the 406th Medical General Laboratory. On initial histological


198

examination of this material, no specific changes were observed referable to dextran. However, on reviewing the kidney sections, the tubular changes of epithelial swelling, granularity and vacuolization were recognized to some degree in all three patients. It was decided to apply the recently developed histochemical technic for the actual visualization of dextran in tissues, reported by Mowry, Longley and Millican21 in 1952; later improvements in the method were also adopted.20, 25 The basic feature of this development was recognition of the high solubility rate of dextran in aqueous solutions. By fixing tissues in absolute alcohol, processing without aqueous contact and then staining with the periodic acid-Schiff method for polysaccharides, these investigators were successful in staining dextran in tissue preparations.

In order to gain experience with this new technic, to verify the published data and to have histological material as a baseline for further studies on human autopsy material, a series of rats were given intravenous infusions of dextran.14 These studies confirmed the success of the published technic to delineate what is interpreted as dextran within tissues. Accordingly, the method was adopted for work on autopsy tissues of battle casualties who had received dextran.

From October 1952, until May 1953, a special series of 15 autopsies of patients who had received dextran was performed in Korea. All but one of these were done by Lieutenant Joseph G. Strawitz, MC, at a forward Surgical Hospital in conjunction with the Surgical Research Team's over-all project on the use of plasma expanders in the wounded soldier. Particular efforts were made to perform the post-mortem examinations at short intervals following death. Representative tissue blocks were fixed in absolute alcohol in addition to routine fixatives. These were sent to the 406th Medical General Laboratory in Tokyo. The alcohol-fixed material was processed and stained according to the modified Schiff technic of Mowry et al.20

The basis for the staining of polysaccharides in tissue with the Schiff method is that of a liberation of aldehyde groups (by oxidation of 1, 2 glycol linkages with periodic acid) and then a demonstration of free insoluble aldehyde groups by a specific aldehyde reagent (Schiff's reagent-fuchsin-sulfurous acid). The saccharides in tissues thus treated will stain rose-red to reddish-purple. Obviously this stain is not specific for dextran, for the PAS method colors many natural tissue carbohydrates. The element of confusion between the identity of these positively stained substances and dextran-related materials is largely obviated by the comparison of the tissue section with a consecutive serial control section, stained simultaneously in the same manner but having been exposed to water prior to staining.


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The dextran deposits, being highly soluble in water, are absent in the control section. The natural tissue saccharides (i. e., basement membranes, hyaline, colloid, mucin and glycogen) are not completely soluble in either water or alcohol and may appear stained in both sections. Consequently, it is necessary to compare the alcoholic-PAS-stained sections with corresponding aqueous controls, to be certain that what is interpreted as dextran in the former is absent (dissolved out) in the latter.

Before referring to the autopsy findings in this group of battle casualties, some of the aspects and problems relative to the histological identification of dextran should be mentioned. When material identified with dextran was seen in tissues, in the majority of instances, it appeared as discrete purplish-red granules of variable size and at times almost black. When large concentrations were present, the granularity was not observed but instead solid aggregates of very dark, reddish-black, homogeneous material were noted, as in the renal tubular lumina. At other times, particularly within liver and kidney cells, the entire cytoplasm presented a rose-red stain without actual granular aggregates. As with other histochemical procedures, varying degrees of success were sometimes encountered in a uniform employment of the stain by tissues which, at times, defied a rational explanation, particularly in identical sections of the same tissue. However, this difficulty was not in the order of seeing "dextran-stained material" as an artefact but rather a tendency for the dextran material sometimes to accept the stain in one area and not in another where there was no apparent reason for its also not being demonstrable. This patchy staining of dextran-containing tissues was likewise observed in the experimental rats14 where conditions for prompt fixation, etc., were ideal.

Observations

With the utilization of the noted histochemical technic the following general observations were made in the histological evaluation of dextran in 15 autopsies of severely wounded patients. It should be kept in mind, in the evaluation of these observations, that this series of patients represents a specialized group. The average time interval from the wound episode until death was about 39 hours, and the average time from the start of the last dextran infusion until death was approximately 17 hours.* However, as noted in Table 1, there were 12 patients whose last infusion was in progress within 12 hours of death. These figures indicate the short temporal range of the study and suggest appropriate considerations in the interpretation of the observations. 


*This average does not include Cases 5, 10 and 14, in which the infusions were given over prolonged periods.


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Table 1. Data on Dextran Infusion after Wounding

Case Number

Autopsy Number

Time from Wound Episode to Death (Hours)

Time from Start of Last Dextran Infusion to Death (Hours)

Total Amount Dextran Infused (ml.)

Wound Site

Histological Grade of Dextran in Kidneys

Shock Status

1

J-3198

16

6

1,000

Head

4

None

2

J-3199

32

4

2,000

Multiple

5

24 hours before death

3

J-3200

69

65

1,000

Extremities

2

Entire course

4

J-3315

40

4

1,500

Abdomen and Arm

5

During last 17 hours

5

J-3426

50

*47

4,500

Burns

2

None

6

J-3430

9

6

1,500

Head

5

During last few hours

7

J-3434

6

6

1,500

Extremities

4

Entire course

8

J-3548

6

1

1,500

Head and Hands

1

Entire course

9

J-3694

500

Head

0

(Died within hour of wound)

10

J-3760

17

*11

2,000

Abdomen

3

During last few hours

11

J-3761

4

4

500

Multiple

2

Died of hemorrhagic shock during operation

12

J-3793

106

93

1,500

Multiple

3

Intermittent entire course

13

J-3858

17

13

1,300

Chest

0

Terminal only

14

J-3859

42

*20

7,000

Multiple

5

During 12-hour period postop. None last 20 hours.

15

J-3860

167

5

1,500

Abdomen

4

Terminal 8 hours (approx.)

*Infusion given continuously until death in Cases 10 and 14, and until 5 hours before death in Case 5.

Histological Grading of Renal Dextran Content:

0-None.
1-Blood vessels only.
2-Patchy, minimal.
3-Patchy, moderate.
4-Diffuse, moderate.
5-Diffuse, marked.


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Kidney. Dextran deposits were seen more consistently in the kidney than in any other organ studied. Likewise, it was seen to appear in both blood vessels and parenchyma with relative rapidity. In patients receiving large amounts within a matter of a few hours prior to death, the microscopic picture was a dramatic one. The entire section displayed a deep red mahogany color, contrasting sharply with the light pinkish-red of the aqueous control section. Microscopically, the tubules contained large masses of dark positive-staining material within their lumens, often completely filling the tubule (Figs.1 and 2). These heavy aggregates of material were most common in the lower nephron and the collecting tubules. The tubular cells likewise showed a staining affinity, and this was most interesting in the proximal convoluted tubules. Here, aggregates of discrete, dextran-staining granules were seen within the cytoplasm of the cells, usually unassociated with intraluminal material (Figs. 3, 4, 5, and 6). This observation was likewise made in the rat experiments (Figs. 7 and 8), corroborating the published data of Mowry et al. in mice20 and is suggestive of tubular absorption or metabolism of dextran. The periglomerular spaces likewise contained granules or small clumps of the stained material.

FIGURE 1 (Case #2, Autopsy #J-3l99). Kidney section of a soldier who died 32 hours after wounding. He received a total of 2,000 ml. of dextran during the terminal 10 hours of life with the last 1,000 ml. starting 4 hours prior to death. In addition to the many aggregates of dextran in the tubular and glomerular space, the tubular cells show a marked staining affinity.

Periodic Acid Schiff (Mowry) X 120


202

FIGURE 2 (Case #2, Autopsy #J-3199). Another renal section of the same case illustrated in Figure 1. The tubular intraluminal and intracellular localization of the dextran is clearly shown. Note the large vein containing a dense concentration of dextran granules.

Periodic Acid Schiff (Mowry) X 120

In patients who received less dextran and/or at relatively long intervals prior to death, the material had a tendency to be distributed in a patchy or helter-skelter fashion in the kidney with a tendency to localize in isolated peripheral portions of the sections, principally in the convoluted tubules. This heterogeneous distribution, which was seen in other tissues as well, has seemed more likely to be an inherent and somewhat unpredictable feature of the fixation or staining technic than an accurate quantitative reflection of tissue dextran content. However, there appeared to be some degree of correlation between the amount of dextran administered, the time interval until death and the quantities seen in the microscopic sections. As noted in Table 1, an attempt was made to grade the relative amounts of dextran-staining material seen in the kidneys as a relatively crude index for rough correlative purposes with several other variables.

There was no sign of tissue damage, reaction or inflammatory cellular response noted in any of the kidney sections which could be related to the dextran. This was also true for the rat tissues, including those with multiple injections.

The routine H and E kidney sections showed the previously referred to tubular changes of cellular swelling: cytoplasmic vacuolization and


203

FIGURE 3 (Case #12, Autopsy #J-3793). Dextran granules within the cytoplasm of convoluted tubular cells, presenting a finely stippled appearance. This battle casualty received his last dextran infusion almost 4 days prior to death. The postoperative course was complicated by oliguria (lower nephron nephrosis) and intermittent hypotension.

Periodic Acid Schiff (Mowry) X 240

granularity and intraluminal, amorphous, eosinophilic material (Fig. 9). These findings seemed largely restricted to the convoluted portions of the nephron and, in particular, to the proximal segments where the brush border of the epithelium was often clearly defined. In some instances, the tubular epithelial swelling was quite striking, serving to delimit sharply the convoluted tubules from the adjacent parenchyma (Fig. 10). Efforts to correlate the histological degree of tubular cell swelling with the quantity of dextran administered and the time intervals involved were inconclusive as to a quantitative relationship. However, a rough direct relationship did exist between the amount of dextran seen in the kidney tissue and the amount of tubular swelling. The fact that tubular changes were recognized in all cases, representing a rather wide range of post-infusion intervals and dextran amounts, suggests that these alterations are readily produced and tend to disappear slowly. In none of these cases was there evidence of any degenerative sequences associated with this "nephrotic" picture.


204

FIGURE 4 (Case #11, Autopsy #J-3761). Kidney section from a soldier who received 500 ml. of dextran at the battalion aid station 30 minutes following multiple severe wounds. He died 4 hours later. Note the dextran aggregates and granules scattered about the tubular parenchyma both within the tubules and the cells.

Periodic Acid Schiff (Mowry) X 240

Spleen. Dextran deposits have been described in the splenic reticuloendothelial cells of mice within short intervals following infusions.20 In the series of rats studied at our laboratory similar evidence was obtained but the most definite identifications were made following multiple and prolonged periods of infusions. The photomicrograph (Fig. 12) is of such a spleen showing the intracellular dextran material circumferentially arranged around Malpighian corpuscles. No associated tissue changes were observed. It was, however, difficult to be certain about the demonstration of minute phagocytosed quantities in the early post-infusion periods. This was likewise true for the human autopsies. On first examination, no dextran-like material was identified but subsequent studies were suggestive of minimal focal phagocytosis; in no case were these deposits unequivocal. There was no recognizable evidence of any tissue reaction in the human spleen.

Liver. The evaluation of dextran within the liver is complicated by the natural presence of glycogen which, being insoluble in both alcohol and aqueous periodic acid-Schiff preparations, appears in both slides.


205

FIGURE 5 (Case #4, Autopsy #J-3315). This longitudinal view of renal tubules shows a rather diffuse sprinkling of dextran granules within the cellular cytoplasm. The cells also appear slightly swollen. This patient received extensive wounds and developed renal insufficiency. He died 41 hours after wounding. A Total of 1,500 ml. of dextran was administered; 500 ml. was given at the battalion aid station and the final 1,000 ml. was infused 4 hours before death.

Periodic Acid Schiff (Mowry) X 240

The dextran-staining material, however, is dissolved out in the aqueous control PAS section, and by careful comparison of both sections its presence can be detected. This was often quite difficult, particularly when the liver cells were laden with glycogen. Discrete phagocytosed granules of dextran-staining substance were also noted within occasional Kupffer cells of two patients with long survival periods between infusions and death. Similar localizations were seen in the rat studies where they were consistently noted in the animals receiving multiple injections over prolonged periods.

Lungs. The lungs of the autopsy cases presented a rather varied picture of dextran identification. The most common finding was that of aggregates of granules within the blood vessels and within alveolar capillaries. There appeared to be a direct relationship between the amount deposited and short intervals between dextran infusion and death. In several of the "short-interval" cases, a few particles were seen in the intra-alveolar spaces, sometimes intermixed with edema fluid (Figs. 13 and 14).


206

FIGURE 6 (Case #4, Autopsy #J-3315). This is a higher magnification of the bracketed zone of Figure 5. The intracellular dextran granules and the cellular swelling are well illustrated.

Periodic Acid Schiff (Mowry) X 820

FIGURE 7 (Rat #M-6627). Low-power view of the medullary portion of a rat kidney 1 hour following a 1 ml. intravenous infusion of dextran. Note the intense tubular concentration of the dark-staining dextran.

Periodic Acid Schiff (Mowry) X 46


207

FIGURE 8 (Rat #6627). Kidney section of a rat sacrificed 1 hour following a single 1 ml. intravenous infusion of dextran (see also Figure 7). The rapid appearance of dextran granules, not only in the distal tubular spaces but within the proximal convoluted cells, is well illustrated.

Periodic Acid Schiff (Mowry) X 230

Pancreas. The pancreatic parenchymal cells did not show any intracellular dextran-staining material. In a few cases, however, sprinklings of granules were noted in the interstitial tissue and peri-pancreatic fat.

Heart. Not uncommonly, the myocardial capillaries were loaded with the dextran granules. In only two cases, however, was there definite evidence of their presence in the stroma, and this was only patchy and light in density. The myocardial fibers, being loaded with glycogen granules, were difficult to assess without very close comparisons with the aqueous control sections. There did not, however, seem to be any localization of dextran within the muscle fibers.

Gastrointestinal Tract. Occasional sections of stomach and intestine were submitted with the autopsy material. No dextran was identified in their walls.

Brain. Tissue blocks from the brains of three patients were studied. Except for the occasional sprinkling of the dextran particles within blood vessels, none was noted.

Soft Tissues. Several of the autopsy cases plus two additional surgically removed specimens included samples of striated muscle, some obtained from wound sites, and also sections of skin. Two


208

FIGURE 9 (Case #14, Autopsy #J-3859). "Nephrotic" picture of renal tubular cellular swelling and vacuolization following dextran infusions. The characteristic amorphous intraluminal "casts" are also evident. This soldier suffered very severe wounds, and his postoperative course, despite vigorous therapy, was marked by persistent shock. He received 7,000 ml. of dextran over the 42-hour period of survival following injury.

Hematoxylin and Eosin X 235

muscle sections showed occasional foci of dextran-staining granules within the stroma. The skin sections were all interpreted as being negative save for one notable exception obtained from a severely burned patient, which will be referred to in the Discussion.

Earlier in this report, reference was made to comments by Johnston and co-workers on "overlapping" morphologic features of dextran-induced tubular changes and lower nephron nephrosis. Four of the patients in the present series had a clinical course and histopathologic picture of post-traumatic renal insufficiency (Cases 2, 3, 4 and 12). The kidneys of all four patients presented the typical convoluted tubular changes described above, in addition to the lesion of lower nephron nephrosis. There was no particular difficulty in distinguishing the one lesion from another. Each had histological characteristics distinctive enough to permit a differential diagnosis. The major features of the so-called "dextran-induced" tubular changes seen in both the routine H and E and Mowry PAS preparations were: the sharp confinement of the lesion to the convoluted tubules (and principally the proximal portions); a swollen appearance of the


209

FIGURE 10 (Case #14, Autopsy #J-3859). A low-power view of the section illustrated in Figure 9. Note the rather sharp confinement of the clear vascular swelling to the cells of the convoluted tubules.

Hematoxylin and Eosin X 100

tubular epithelium often with blurring of the precise cell borders; a tendency of the cell cytoplasm to be clear and finely granular; and the amorphous, eosinophilic, intraluminal material. The histological features of lower nephron nephrosis are well known and differ from these in: (a) the location of the principal alterations (mainly distal nephron instead of proximal convoluted tubules); (b) the presence of distinctive heme-type casts which generally are pigmented and coarsely granular tending to fill the lumina (in contrast to irregularly outlined islands of finely granular to wispy, strandlike masses); (c) the frequent association of tubular epithelial degenerative changes (as compared to none); and (d) the absence of impressive vacuolization and swelling of tubular cells (in contrast to their being the most conspicuous features in the other entity). Interestingly enough, in the patients with associated lower nephron nephrosis, granules of dextran material were occasionally seen dispersed in the heme-cast material (Fig. 11).

Miscellaneous Organs and Tissues. Dextran-stained material was sporadically seen in the interstitial tissue of such organs as bladder, thyroid, adrenal and testis (Fig. 15). As with the occasional focal


210

FIGURE 11 (Case #4, Autopsy #J-3315). Dextran aggregates and granules in renal tubules of a patient with post-traumatic renal insufficiency who was given 1,000 ml. of dextran 4 hours prior to death. Note the hook-shaped tubule in the center which contains a typical heme cast (the lightly staining amorphous material) in which are interspersed many irregularly-sized dextran granules.

Periodic Acid Schiff (Mowry) X 240

deposits seen in striated muscle stroma, there was no predictable consistency of these findings.

Discussion

An interpretation of histological observations in this series of 15 autopsies is limited in scope because of the relatively few cases, and because the time intervals involved, from dextran infusions until death, were short, often being only a matter of a few hours. Consequently, one of the major considerations in the evaluation of the effects of dextran on tissues, namely, the question of its possible storage in various cells or organs, can be surveyed only on the basis of such changes being evident very early.

This group of battle casualties presented some unusual considerations with reference to the normal renal clearance of dextran, for most of the patients had suffered periods of profound shock associated with their extensive injuries. The Surgical Research Team demonstrated, by dextran assays in the plasma and urine, the ability of non-oliguric, severely wounded patients to begin renal clearance of dextran within an hour after the start of the infusion. Likewise, the histological


211

FIGURE 12 (Rat #M-6633). Survey view of the spleen of a rat which had received bi-weekly dextran infusions (1 ml.) over a 2-month period and then was sacrificed a month following the last injection. Phagocytosed particles of dextran are seen within the reticuloendothelial cells about the periphery of the pale staining Malpighian corpuscles and have a circumferential distribution.

Periodic Acid Schiff (Mowry) X 48

studies revealed the presence of dextran-straining material within the kidneys in patients with the shortest survival times. In only two cases was no dextran identified in renal tissue. In one of these (Case 9), the soldier received a severe gunshot wound of the head and a unit of dextran was started within minutes at the battalion aid station. The patient died, however, within 20 minutes and it is doubtful if he received much of the infusion. The other case (Case 13) should have exhibited dextran in the kidneys; the failure of its demonstration was unexplainable except possibly on the basis of a technical error in tissue preparation.

There were four cases (Cases 2, 3, 4 and 12) that presented a particularly interesting renal study for they showed the pathologic findings of lower nephron nephrosis. One of these (Case 12), in fact, was submitted from the Renal Insufficiency Center where the patient had been under treatment for post-traumatic renal insufficiency. Although there are not available previous data on the actual demonstration of dextran in the human kidney, with particular reference to how long it may remain visualized after intravenous administration,


212

FIGURE 13 (Case #8, Autopsy #J-3548). Dextran granules within pulmonary alveolar spaces. This soldier received a severe penetrating head wound, associated with profound shock. He was given, in addition to blood, 1,500 ml. of dextran during the 1 hours' hospitalization before death. The presence of extravascular dextran particles in the alveoli may have resulted from the shock state. It was interesting to note that the kidney sections of this patient showed no dextran in the tubules, which fact also might be related to hypotension.

Periodic Acid Schiff (Mowry) X 190

two of these cases (Cases 2 and 12) with renal insufficiency suggested a lower excretory rate. They represented the longest intervals between dextran infusions and death in the entire series, 65 hours and 93 hours respectively. Past studies on the normal renal clearance of dextran and those of the Surgical Research Team on the severely wounded without oliguria indicated that after such intervals the great majority of the substance should have been excreted. The fact that it was still evident in the kidneys of these two patients may have been an abnormal manifestation related to the lower nephron nephrosis. Actual granules of dextran were seen intermixed with the tubular hemoglobin casts in these patients (Fig. 11).

An interesting corollary to these observations in renal failure cases was the data of Howard et al. on dextran assays in plasma and urine of the post-traumatic anuric soldier. These revealed a gradual disappearance of the substance in the plasma similar to that of a non-oliguric wounded man, despite renal failure.18 Rat studies of Bloom,


213

FIGURE 14 (Case #3, Autopsy #J-3200). Dextran particles intermixed with edema fluid in lung tissue of a casualty who suffered from shock throughout a 70-hour post-wound survival period. This observation is of particular interest because of the long time that lapsed (65 hours) after the last dextran infusion. The possibility is raised that this is a manifestation of extravascular immobilization of dextran in a patient with a protracted hypotensive course.

Periodic Acid Schiff (Mowry) X 240

quoted by Johnston and Lundy,10 showed a 68 per cent disappearance of dextran from the plasma in 24 hours in nephrectomized animals. Such observations as these strongly support the concept of dextran metabolism, and also indicate that the kidneys probably do not play an integral role in the metabolic process. The visualization of dextran particles in renal tubular cells, particularly in the proximal convoluted portions, most likely represents an absorption mechanism of dextran; and this process might be linked to its partial hydrolysis facilitating further metabolism elsewhere in the body.

Concerning the extravascular diffusion of dextran, comment has already been made on its visualization within the interstitial spaces of some organs, where it appeared free and not within phagocytes. Two cases deserve special attention in this regard. Case 8 was that of a Korean who received multiple penetrating wounds of the skull and hands and was admitted to the forward hospital in extremis. In addition to blood transfusions, he was given 1,500 ml. of dextran in the 1 hour and 15 minutes prior to death. Although only a minimal amount of dextran was found in the kidney tissue (within blood ves-


214

FIGURE 15 (Case #2, Autopsy #J-3199). A pool of dextran granules in the interstitial connective tissue of the thyroid. (There was no local neck trauma). This soldier suffered from marked postoperative shock, which probably was instrumental in causing this unusually prominent extravascular diffusion. A total of 2,000 ml. of dextran was administered during the 10 hours before death.

Periodic Acid Schiff (Mowry) X 240


 sels), there were areas of marked deposition of dextran-staining granules within pulmonary alveoli (Fig. 13). The dynamics of the transference of the substance from the vascular compartment to the intra-alveolar spaces can only be speculated upon. Similarly, whether the identified granules represent unaltered (unhydrolyzed dextran) is likewise unknown. Bollman26 performed experiments on the extravascular diffusion of dextran from blood in rabbits and determined that the amount of extravascular dextran was small and that, following hemorrhage, it had little influence on the mobilization of fluid available to the blood.

Another patient (Case 3) was of interest with regard to the possibility of the temporary immobilization of dextran in pulmonary edema fluid. This soldier suffered multiple penetrating wounds of the buttocks and extremities. Despite massive blood transfusions (15,500 ml. in 6 hours), the patient showed a picture of shock all through his 66-hour hospital course. He had also received 1,500 ml. of dextran in the early hours of post-wound treatment. Although there was an interval of about 64 hours from the dextran infusion until death, large amounts of dextran were seen in the lung air spaces associated with a marked degree of pulmonary edema fluid (Fig. 14).


215

One of the patients (Case 5) received severe burns. Second and third degree burns of 75 per cent of the body surface resulted from the explosion of an oil stove. This patient received 4,500 ml. of dextran during his 47-hour hospital course, which was administered continuously until 5 hours before death. The striking histological finding was a heavy concentration of dextran-staining granules in the skin. Throughout the sections of burned skin, these granules were distributed most prominently in the pools of extravasated fluid in the interstitial spaces of the damaged skin and extended fairly deep into the corium (Fig. 16). As previously noted, sections of skin of other patients failed to show any dextran material. This burn case is of interest because of the virtual absence of dextran identified in any of the organs except the skin. The kidney revealed only minimal amounts, patchy in distribution. Renal function remained good during the patient's course, in spite of which, the dextran contained in the burned skin was not mobilized.

As previously noted, the few specimens of striated muscle and skin obtained from the autopsy cases showed no evidence of dextran localization in the skin and only occasional foci within the interstitial tissue

FIGURE 16 (Case #5, Autopsy #J-3426). This is a section of severely burned skin. In addition to blood, 4,500 ml. of dextran was given over most of the 2-day survival period. Note the dispersion of fine granules in the edematous upper corium. The other organs were either negative for dextran or showed only small foci.

Periodic Acid Schiff (Mowry) X 230


216

of the muscle. In addition, surgical biopsies of both muscle and skin from amputation stumps were studied in two patients who had received dextran several hours previously in the course of treatment. None of these tissues showed evidence of dextran localization. They represented, however, soft tissue from the sites of surgical amputation and not from the actual areas of battle trauma.

Comments have already been made on the nephrotic-like tubular changes observed in kidneys following the administration of dextran. These were consistently present in all cases and, in some, appeared quite striking. These swollen, convoluted tubular cells in ordinary H and E sections presented such a distinctive picture that their recognition in the routine review of autopsy tissues was enough to warrant a strong suspicion that dextran had been administered. On consulting clinical records, this proved to be true in several cases. However, these tubular changes were unassociated with any cellular response or recognizable signs of local tissue reaction. As previous investigators have remarked, they appeared transient and reversible. The Mowry PAS-stained kidney sections correlated nicely with these observations; for in cases showing the most marked tubular epithelial swelling, dense concentrations of dextran-staining material were seen both intracellularly and intraluminally. Arthur Allen, in his textbook on the kidney,27 refers to the morphologic tubular sequences incident to infusions of hypertonic sugar solutions as giving the pathologic picture of "osmotic nephrosis," a transient effect. The dextran-induced changes seem quite identical to these.

Concerning the reticuloendothelial system as a storage site for dextran, the observations in this series of autopsies indicated no significant phagocytosis in either the spleen or liver. This may have been related to the short time intervals involved, and further studies on patients with longer survival times from infusion to death are needed to help answer the questions of dextran tissue storage. It might be emphasized that although experiments with mice20 and rats14 have shown definite evidence of phagocytosed dextran-staining material as long as 3 months following injection, the relative dextran dosage was high and the injections multiple. For instance, a 1 ml. dose of dextran to a 20 gm. mouse is roughly equivalent to an infusion of about 3,000 ml. to an average man. There seems little reason to suppose that the element of tissue storage of dextran in man will prove to be a significant factor. Even in animal studies with multiple large infusions and signs of phagocytosis in the reticuloendothelial body cells, no remarkable tissue changes or reactions have been recognized.14, 20


217

Summary

1. A study of the histological localization of dextran in autopsy tissues of 15 battle casualties in Korea was made.

2. A modified periodic acid Schiff staining method (Mowry) was used. Dextran was distinguished from glycogen by its solubility in water.

3. Dextran rapidly appears in the human kidney tissue and can be visualized in all portions of the nephron. Intracellular granules identified as dextran have been observed in the proximal convoluted tubules of humans and experimental rats, which suggests that dextran absorption and/or metabolism occurs in the kidney.

4. Granules of dextran were occasionally noted in the reticuloendothelial cells of human liver and spleen but these were too minute and scattered for interpretive significance. However, in the rat tissues (after multiple large infusions over a long time) definite and distinct focal phagocytosis was evident.

5. The appearance of dextran within hepatic cells apparently occurs shortly after infusion and is probably associated with a metabolic breakdown of the dextran molecules in this organ.

6. There was scant evidence in this survey of the diffusibility of dextran into tissue spaces except in association with abnormal physiologic states. Specific instances of the latter were cited and included dextran immobilized in the pulmonary edema fluid of those in shock and in the skin tissues of the severely burned.

7. A swelling of renal convoluted tubular cells was noted to be a consistent sequela of dextran therapy. This was correlated with intracellular dextran in the histochemical preparations. These changes were morphologically similar to those following hypertonic sugar infusion and appeared to be nontoxic and transient.

8. Four of the fifteen patients had symptoms of anuria and presented the pathologic findings of lower nephron nephrosis. These were discussed from the standpoints of the effects of anuria on dextran excretion and the significance of dextran in the parenchyma of the anuric kidney for extended periods following infusion.

9. None of the tissues studied (human or rat) showed any recognizable lesions or changes referable to dextran toxicity.

References

1. Lundy, J. S., Gray, H. K., and Craig, W. M.: Dextran in Supportive Therapy with Comments on Periston and Gelatin. Arch. Surg. 61: 55, 1950.

2. Meyer, L. M., Berlin, N. Y., Hyde, G. M., Parsons, R. J., and Whittington, B.: Changes in Blood Volume Following Administration of Dextran-Determined by P32 Labelled Red Cells. Surg., Gynec. & Obst. 94: 712, 1952.


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3. Wilson, J. S., Estes, E. H., Jr., Doyle, J. T., Bloom, W. L., and Warren, J. V.: The Use of Dextran in the Treatment of Blood Loss and Shock. Am. J. Med. Sci. 223: 364, 1952.

4. Raisz, L. G., and Pulaski, E. J.: A Comparison of Efficacy of Dextran, Oxypolygelatin, Plasma and Saline as Plasma Volume Expanders. Am. J. Physiol. 169: 475, 1952.

5. Amspacher, W. R., and Curreri, A. R.: Use of Dextran in Control of Shock Resulting from War Wounds. Arch. Surg. 66: 730, 1953.

6. Johnston, E. V., Bennett, W. A., Lundy, J. S., and Janes, J. M.: Use of Dextran (Macrodex) in Burns, Part II. Am. J. Surg. 85: 720, 1953.

7. Gropper, A. L., Raisz, L. G., and Amspacher, W. H.: Plasma Expanders. Surg., Gynec. & Obst. 95: 521, 1952.

8. Tarrow, A. B., and Pulaski, E. J.: Reactions in Man from Infusion with Dextran. Anesthesiology 14: 359, 1953.

9. Maycock, W. d'A.: Plasma Substitutes. Brit. Med. Bull. 10: 29, 1954.

10. Johnston, E. V., and Lundy, J. S.: Use of Dextran (Macrodex) in Burns, Part I. Am. J. Surg. 85: 713, 1953.

11. Hestrin, S., Shilo, M., and Feingold, D. S.: Infection-promoting Activity of Levan and Dextran as a Function of Degree of Polymerization. Brit. J. Exper. Path. 35: 107, 1954.

12. Ravdin, I. S.: Plasma Expanders. J. A. M. A. 150: 10, 1952.

13. Bloom, W. L.: Cited by Gropper, et al. (Reference 7).

14. Vickery, A. L.: Unpublished Data, 406th Med. Gen. Lab., Pathology Section.

15. Giebisch, G., and Lauson, D.: Renal Excretion and Volume Distribution of Various Dextrans. Fed. Proc. 13: 54, 1954.

16. Gray, I., Siiteri, P. K., and Pulaski, E. J.: Metabolism of Plasma Substitute. I. Dextran (Macrodex). Proc. Soc. Exper. Biol., N. Y. 77: 626, 1951.

17. Gray, I., and Highland, G. P.: Metabolism of Plasma Expanders Studied with Carbon 14-Labelled Dextran. Annual Report of Surgical Research Unit, Brooke Army Hospital, p. 15, 1952.

18. Howard, J. M., Frawley, J., Artz, C. P., and Sako, Y.: The Fate of Dextran and Modified Fluid Gelatin in Patients with Post-traumatic Renal Insufficiency. Surg., Gynec. & Obst. 100: 207, 1955. (Chapter 13, this volume).

19. Bull, J. P., Ricketts, C., Squire, J. R., et al.: Dextran as a Plasma Substitute. Lancet 1: 134, 1949.

20. Mowry, R. W., and Millican, C.: A Histochemical Study of the Distribution and Fate of Dextran in Tissues of the Mouse. Am. J. Path. 29: 523, 1953.

21. Mowry, R. W., Longley, J. B., and Millican, C.: Histochemical Demonstration of Intravenously Injected Dextran in Kidney and Liver of the Mouse. J. Lab. and Clin. Med. 39: 211, 1952.

22. Goldenberg, M., Crane, R. D., and Popper, H.: Effect of the Intravenous Administration of Dextran, A Macromolecular Carbohydrate, to Animals. Am J. Clin. Path. 17: 939, 1947.

23. Turner, F. P., Butler, B. C., Smith, M. E., and Scudder, J.: Dextran: An Experimental Plasma Substitute. Surg., Gynec. & Obst. 88: 661, 1949.

24. Persson, B. H.: Histochemical Studies on Fate of Parenterally Administered Dextran in Rabbits. Acta Soc. Med. Upsaliensis 57: 411, 1952.

25. Morwy, R. W.: Personal communication.

26. Bollman, J. L.: Extravascular Diffusion of Dextran from Blood. J. Lab. and Clin. Med. 41: 421, 1953.

27. Allen, A. C.: The Kidney, Medical and Surgical Diseases. Grune and Stratton, New York, 1951.

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