J Clin Pathol 1987;40:1206-1211

Islet cell necrosis in the neonatal pancreas: a report ofthree cases

P F ROBERTS

From the Department. of Histopathology, Norfolk and Northwich Hospital

SUMMARY Three cases of islet cell necrosis in neonates are reported. The association of this rare

condition with antepartum haemorrhage, anoxia, shock and intravascular coagulation are

discussed. The clinical and morphological appearances were compared with previous descriptions ofthis condition and an association with neonatal hypoglycaemia was made. There are several patho-physiological mechanisms which may be responsible for this unusual pattern of necrosis.

Neonatal islet cell necrosis is not described in moststandard textbooks of pathology and there have onlybeen a few reported cases.` 3

I describe three new cases in detail, discuss thefactors associated with this condition, and review pre-vious reports of descriptions of degenerative changesin the islets of Langerhans in the neonatal period.

Case reports

CASE 1A baby boy of 35 weeks' gestation was delivered bycaesarian section because of maternal pre-eclamptictoxaemia and placental abruption. At birth the infantweighted 2044 g and began breathing immediately.The Apgar score was 8 at one minute and 9 at fiveminutes, the skin was pink in air, and there was nointercostal recession. The pulse was 150/minute. At24 hours of age abdominal distention, large gastricaspirations, and hypothermia developed. The infantwas intubated and ventilated. Rectal bleeding devel-oped and an abdominal radiograph showed necro-tising enterocolitis. The haemoglobin concentrationwas 18-8 g/dl, white cell count 6-4 x 109/l, platelets262 x 109/1, serum sodium concentration 140mmol/l, serum potassium concentration 4-7 mmol/l,and serum urea concentration 3-7 mmol/l. Treatmentwas started with penicillin, netilmicin, and met-ronidazole. At 36 hours blood-stained diarrhoea per-sisted and was accompanied by hypotension (37/23mm Hg), with tachycardia (200/minute) and fever of

Accepted for publication 13 March 1987

38°C. At 72 hours of age anaemia and slight icterusdeveloped, and a small blood transfusion was given.At 80 hours of age a Dextrostix test showed a zeroblood glucose concentration, and the infant devel-oped a cardiac arrest and could not be resuscitated.During the course of the last 12 hours the pro-thrombin time and partial thromboplastin time wereprolonged. The platelet count fell to 141 x 109/l butno fibrin degradation products could be found. Theserum urea concentration rose to 6-8 mmol/l and thepotassium concentration to 6-7 mmol/l. Cultures ofblood samples were negative.At necropsy 30 hours after death the brain was con-

gested but showed no subependymal haemorrhage.The heart was normal with a patent ductus arteriosus.The lungs were uniformly dark red and solid. Thejejunum and ileum were dilated and purple with focalthinning of the wall and fibrinous exudate on theserosa, typical of necrotising enterocolitis. Focalulcers were seen in the colonic mucosa but there wereno perforations. The other organs appeared to benormal.

CASE 2A baby girl born after 39 weeks' gestation was deliv-ered by emergency caesarian section because ofunsuspected placenta praevia presenting with vaginalhaemorrhage and fetal bradycardia. At delivery theinfant weighed 348 g, and Apgar scores were 0 at oneminute, 0 at five minutes, and 2 at 10 minutes. Shewas immediately intubated, ventilated with oxygen,and given sodium bicarbonate, adrenalin, and cardiacmassage. Shortly afterwards spontaneous breathingstarted but the heart rate was less than 100/minute

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Islet cell necrosis in the neonatal pancreas 1207

Fig1At least eight n c islt wii a r te ofp s:. (;tl n oi.)

Fig I At least eight necrotic islets within acinar tissue ofpancreas. (Haematoxylin and eosin.)

Fig 2 Detail ofnecrotic islet to show eosinophilic necrosis ofcells with ghost like remains ofnuclei and residual viableendothelial cells. (Haematoxylin and eosin.)

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1208

and a Dextrostix test showed a zero blood glucoseconcentration. Four mls of 50% dextrose with dex-amethasone, blood transfusion, and frusemide were

given. At two hours the blood pressure fell, the heartrate dropped to 60/minute, and she was reintubated.At six hours convulsions developed and were treatedwith phenobarbitone. Hypotension persisted and at16 hours of age she died. Investigations included:haemoglobin concentration of 90 g/dl, white cellcount of 8-6 x 109/1, platelets at 94 x 109/l, serum

urea concentration of 1 7 mmol/l, and serum potas-sium concentration of 4-7 mmol/dl. At necropsy72 hours after death, the brain showed no evidence ofintracerebral haemorrhage. The lungs were pale andsolid with some purulent material in the bronchi andtrachea. The heart was pale with a patent ductus arte-riosus. The stomach showed haemorrhages in themucosa, and the small bowel was bluish-red withblood-stained contents. The colon was normal; no

perforation was seen. The liver showed mottled con-

gestion, and the adrenal glands showed segmentalareas of haemorrhage. Other organs were normal.

CASE 3A baby boy of 37 weeks' gestation and weight 3060 gwas delivered by caesarian section for failure oflabour to progress and was found to have shortlimbed dwarfism (spondylo-epiphyseal dysplasia con-

genita), which had been previously diagnosed byultrasound scan. The ribs and vertebral bodies were

poorly calcified, soft, and compressible and there wasa pronounced reduction in chest volume. At birth theApgar score was 7-8 and oxygen was required to keepthe skin pink. In view of the poor prognosis oxygenwas discontinued at two hours of age and he diedaged 12 hours.At necropsy six days after death, the brain showed

Robertsanoxic changes with dilatation of superficial capillar-ies. The lungs were blue, solid, and poorly aerated,and the ribs were softened and showed bulbous costalcartilages. The chest volume was reduced. The heartand great vessels were normal. The intra-abdominalviscera were normal.

Microscopic features

CASE 1

The colon and ileum showed an acute ischaemicenterocolitis with gas cysts in the submucosa, andfibrin thrombi in capillaries. No evidence of Hir-schsprung's disease was seen. The kidney showed no

tubular necrosis. The liver, heart, adrenals, testis andthymus showed anoxic haemorrhages but no necrosis.Fibrin thrombi were seen in splenic trabecular vessels.The lungs showed anoxic alveolar and septal hae-morrhage and fibrin thrombi in pulmonary arterybranches. No hyaline membrane was present. Thebrain contained a microscopic subependymal hae-morrhage in the region of the caudate nucleus. Thepancreas showed no abnormality of the exocrine ele-ments but about half (estimated by counting islets insections from each block) of the islets showed com-

plete eosinophilic necrosis, leaving only a ghost-likeoutline of the pre-existing endocrine cell cytoplasmand nucleus (figs 1 and 2).Gomori's aldehyde fuchsin stain showed smudgy

granules of B cells in the necrotic islets. No immu-noglobulin (IgM, IgG, IgA) deposits were detected inthe islet cells or in the capillary walls using a standardperoxidase-antiperoxidase method (Dakopatts) on

paraffin sections. In about one tenth of the overallnumber of islets there was incomplete necrosis char-acterised by pyknosis and karyorrhexis of nuclei andeosinophilia of cytoplasm. No viral inclusion bodies

Table Details ofcases reported to date

Source Gestation (weeks) Maternalfactors Delivery Weight (g)

1 40 Prolonged labour Cephalic vaginal 2994

2 42 Post-mature Vertex vaginal 3402

3 36 Placenta praevia rhesus incompatability Caesarian 2608

4 37 Road traffic accident Caesarian 3000

5 40 Ante-partum haemorrhage Caesarian Notknown

6 12 weeks post-partum Down's syndrome Not known Not known

7 35 Ante-partum haemorrhage toxaemia Caesarian 2044

8 39 Ante-partum haemorrhage vasa praevia Caesarian 3480

9 37 Prolonged labour Caesarian 3066

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Islet cell necrosis in the neonatal pancreas

k~~~~~~~~~~~~~~~~~~~~~~~~~---k ~~

If

Fig 3 Another islet showing incomplete necrosis with pyknotic, irregular nuclei and shrinkage ofcytoplasm. Changes are

particularly noticeable in left hemisphere. (Haematoxylin and eosin.)

were seen in the endocrine cells. The nuclei of thesedegenerate cells was often spindle or wedge shapedand as small as half the size of nearby unaffected isletcells. The cytoplasm was similarly reduced in amount(fig 3). These degenerative changes were presentthroughout the pancreas but the severity of thechanges seemed to be relatively uniform within lob-ules of pancreatic tissue.The capillary network of the islets was intact with

viable plump endothelial cells lining congested vascu-

lar channels which were free of fibrin thrombi. Therewas no exudation of fibrin in the islets and no

inflammatory reaction. Pancreatic interlobular veinswere dilated. No thrombi or interstitial haemorrhageswere seen in the exocrine tissue and no autolysis was

present.

CASE 2The ileum showed acute infarction with early necrosisof mucosa. Focal haemorrhagic congestion was seen

Microscopical ischaemic necrosisAge at death(hours) Apgar score Intravascular coagulation Renal Hepatic Intestinal Adrenal

8-5 Not done Not known + + +

9 Not done Notknown + +

11-5 Not done Notknown + + + +

48 Not done No + + +

26 0 (1 min), 1 (5 mins) No + + - -

72 Not done No + +

92 8 (I min), 9 (5 min) Yes - - +

16 0 (I min), 0 (15 min) Yes - - +

12 7 (1 min),-(5 min) No

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1210in the liver, adrenals, kidneys and spleen but nonecrosis was present, though there were fibrin depos-its in the hepatic and adrenal cortical sinusoids. Thelungs showed amniotic aspiration due to fetal dis-tress. The exocrine pancreas was normal. The endo-crine pancreas showed early necrosis in a little lessthan half of the islets, characterised by nuclear pyk-nosis and karyorrhexis and eosinophilic degenerationof cytoplasm. About one tenth showed completenecrosis. The appearances were otherwise identicalwith those of case 1.

CASE 3Anoxic haemorrhages were seen in the thymus andrenal cortex and medulla. Fetal squames were seen inlung alveoli. No adrenal haemorrhage or ischaemicchanges in the ileum and colon were seen. The pan-creas showed normal exocrine tissue, but about onethird of the islets showed eosinophilic degeneration ofthe cell cytoplasm with partial or complete loss ofnuclei. The appearances were otherwise identical withthose of case 1.

Discussion

Neonatal islet cell necrosis in the absence of frankpancreatitis, tumour or viral4' infections such asCoxsackie B5, Rubella, cytomegalovirus, andvaricella-zoster, is a rarely reported phenomenon.Only three previous reports document the condition.The first by Bernstein1 in 1958 described three neo-nates who developed anoxia in the perinatal periodand died within 32 hours of birth. One neonate waspremature and the other two were term deliveries.The islet cell necrosis was associated with renal tubalnecrosis in each case. Morphologically, the isletsshowed the same histological appearance as the threecases reported here. The exocrine tissue wasunaffected. No blood sugar concentrations wererecorded, although all three neonates had terminalconvulsions alternating with periods of flaccidity. Thesecond report by Emery and Bury2 described a surveyof 1000 necropsies on infants and children, of which40 showed haemorrhagic "lesions" of the isletsconsisting of dilated sinusoids and collapse and lossof islet cell cytoplasm with pyknosis of the nuclei.These cases resemble the early stages of my threeexamples of complete necrosis of the islet cells. Curi-ously, Emery and Bury recognised the "occasionalcase" in which there was complete coagulative necro-sis of the islets but failed to describe or include thecases in their survey. No blood sugar concentrationswere recorded in the affected infants. Their patientswith islet haemorrhagic lesions were stillborn or neo-nates surviving up to 28 days of age. There was apositive association with prematurity and stillbirth,

Roberts75% of cases occurring in stillbirths, and over 75% ofcases occurring in neonates of less than 37 weeks' ges-tation. The oldest case was found as late as 28 daysafter birth. No association was found with cyanoticattacks, convulsions, hyaline membrane disease, hae-morrhagic manifestations or maternal diabetes whencompared with other infants dying at the same age. Inthe stillbirths there was no association with maternaltoxaemia or hypertension. The third report3described three infants ranging in age from 1 day to 3months; two died from profound shock in a roadtraffic accident and placental abruption, respectively,and the third from congenital heart disease with heartfailure. The morphological features were identicalwith those of the three cases reported here. Theauthors reviewed 30 other neonatal and infantnecropsies in which there was clinical or morpho-logical evidence of shock and they were unable to findany additional examples of islet cell necrosis.

Excluding Emery and Bury's cases, the table sum-marises the salient features of the nine cases reportedto date. There is a common clinical picture of anoxiaand shock, often due to maternal factors such as pla-cental abruption. Two thirds of the infants were bornby caesarian section and none was less than 35 weeksgestation. Over half were born at full term. In eachcase the birth weight was consistent with the length ofgestation, and no clinically important growthretardation can have occurred. Microscopical exam-ination of other organs showed a variety of lesionsassociated with shock. No common pattern of tissuedamage could be identified, though renal tubularnecrosis and central hepatic necrosis were most oftenassociated.

It could be that the islet changes were attributableto post mortem autolysis. In the three cases reportedhere the necropsies were performed 30, 72 hours, andsix days after death, the bodies having been refrig-erated almost immediately. The tissues were well pre-served in all three cases, even after six days. Further-more, the proportion of islets showing necroticchange was inversely related to the interval afterdeath; autolysis therefore seems to be an unlikelyexplanation for these changes.

Hypoglycaemia was detected in two of the casescurrently described but was not estimated in the third.In the other two series the serum glucose concen-tration was not measured. No common pattern ofdrug ingestion or injection was seen in the mothers ofthe three cases I reported, either during pregnancy orin labour. The hypoglycaemia may have been a directresult of the extensive islet cell necrosis leading tosudden release of insulin from the damaged cells.Such a mechanism is well recognised in the earlyphase of diabetes mellitus6 induced by the experi-mental use of alloxan.

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Islet cell necrosis in the neonatal pancreas 1211

Haematological and microscopical evidence of dis-seminated intravascular coagulation was detected intwo of my cases but it was not seen in Seemayer'scases and it was not looked for in Bernstein's series.Emery and Bury's large scale survey of 1000

necropsies on infants and children showed anincidence of 4% of haemorrhagic lesions in the islets.The lesions they describe are similar to thosedescribed in this paper and may represent an earlyphase in development of frank necrosis. While anassociation with prematurity was noted, they wereunable to find a consistent link with any clinical fea-tures or any histological changes in other organs.Similarly, those cases discovered in stillbirths wereunassociated with any maternal factors which mayhave caused intrauterine anoxia. They concluded thatthe islet changes were physiological rather thanpathological and represented a form of involutionduring development. Further support for this hypoth-esis is seen in Seemayer's paper where he reviews30 cases of fatal shock in infancy and fails to findadditional examples of islet cell necrosis. He cites thisfinding, however, to support his contention that thecondition is a rare manifestation of shock rather thanto suggest an alternative mechanism for its develop-ment.

Additional support for a physiological mechanismfor cell necrosis can be found in the modern conceptof apoptosis.7 The combination of eosinophilicnecrosis of cytoplasm, shrinkage, and pyknosis ofnuclei, and lack of inflammatory response are thelight-microscopical hallmarks of apoptosis. Physio-logical apoptosis is well recognised in the fetal adrenalcortex, endometrium, female breast and corpusluteum; perhaps this is what we have been describingin the islets of Langerhans.Two conflicting theories on the development of

these lesions remain. The first is that neonatal shockleads to reduced haemoperfusion or anoxia which

causes selective necrosis of the islets. This necrosisdoes not affect the exocrine tissue even though itshares a common anatomical blood supply. Thehigher metabolic requirements of the islet tissue inresponse to shock may explain this phenomenon. Thesecond is that the necrosis is a florid physiologicalprocess akin to apoptosis and the presence of shockor anoxia is purely coincidental. On the evidence sofar, neither theory can be confidently substantiated. Itis difficult, however, to believe that a physiologicalphenomenon could lead to such widespread destruc-tion of endocrine cells. Furthermore, Seemayer citespersonal unpublished evidence of experimental,hypovolaemic induced necrosis of pancreatic islets inyoung rats. It is only by wider recognition of thisentity and further studies that progress can be madeinto the understanding of this rare condition.

References

1 Bernstein J. Renal tubular and pancreatic islet cell necrosis innewly born infants. Am J Dis Child 1958;96:705-10.

2 Emery JL, Bury HPR. Involuntary changes in the islets ofLangerhans in the foetus and newborn. Biol Neonate1964;6: 16-25.

2 Seemayer TA, Osborne C, De Chadarevian JP. Shock relatedinjury of pancreatic islets of Langerhans in newborn andyoung infants. Hum Pathol 1985;16:1231-4.

4 Jenson AB, Rosenberg HS, Notkins AL. Pancreatic islet celldamage in children with fatal viral infections. Lancet1980;ii:354-8.

5 Ahmad M, Abraham AA. Pancreatic ileitis with coxsackie virusB5 infection. Hum Pathol 1982;13:661-2.

6 Howel SL, Taylor KW. The acute pancreatic effect of Alloxan inthe rabbit. J Endocrinol 1967;37:421-7.

7 Kerr JFR, Bishop CJ, Searle J. Apoptosis. In: Recent advances inhistopathology, 12. Edinburgh: Churchill Livingstone,1985:1-15.

Requests for reprints to: Dr PF Roberts, ConsultantHistopathologist, Norfolk and Norwich Hospitals,Brunswick Road, Norwich, Norfolk NRI 3SR, England.

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