Postmortem artefacts in sudden cardiac death: A forensic case report

Abstract

Sudden cardiac death is a major forensic challenge because it can occur unexpectedly in apparently healthy individuals and postmortem artefacts may complicate interpretation. We report the case of a 28-year-old male who was found deceased, with autopsy revealing critical coronary artery blockages alongside insect-related postmortem artefacts. These artefacts initially mimicked antemortem injuries, but careful examination distinguished them from actual pathology. Comprehensive ancillary investigations including histopathological examination that confirmed the gross autopsy findings, and a full toxicological screen yielding negative results corroborated the diagnosis of coronary insufficiency as the cause of death. This case underscores the importance of meticulous autopsy protocols in recognising postmortem changes, preventing misdiagnosis, and ensuring accurate determination of the cause of death in suspected cases of sudden cardiac death.

Introduction

Sudden death (SD) or sudden cardiac death (SCD) is defined as an unexpected fatality occurring within 24 h of symptom onset, excluding non-cardiac causes such as advanced lung disease or severe trauma.^1,2 In young adults and athletes, hypertrophic cardiomyopathy is frequently implicated, though many cases show either no structural abnormality or coronary artery disease (CAD) on postmortem examination.^{3 –5} Such deaths are particularly striking when they occur in apparently healthy individuals during physical exertion, leading to ongoing debate about the utility of population screening programs. ⁶ Age also influences the underlying cause: in the 1–40-year group, primary arrhythmia syndromes are more frequent in pediatric victims, whereas cardiomyopathies predominate in young adults. ⁷ Alcohol consumption is another recognised factor, capable of precipitating supraventricular and ventricular dysrhythmias and significantly increasing cardiovascular risk. ⁸

Postmortem artefacts are alterations arising after death, unrelated to the individual’s physiological or pathological state, which may complicate forensic interpretation. ⁹ External changes such as discolouration, apparent injuries, or staining may raise suspicion of foul play if misinterpreted. Moreover, arthropods can significantly modify the condition of remains; for example, ant activity produces irregular superficial lesions, punctate defects, or loss of soft tissues, including eyelashes, that can mimic trauma.^10,11

The present case is distinct in describing SD in a young individual with no previously known cardiac disease, in whom autopsy revealed both coronary artery pathology and striking postmortem artefacts. It emphasises the importance of differentiating natural causes of SD from environmentally induced postmortem changes. It highlights the critical role of thorough autopsy, toxicological analysis and clear medico-legal communication in preventing misinterpretation.

Case presentation

A 28-year-old male was found deceased on a motorcycle in a forested area (Figure 1) and was referred for a medico-legal autopsy. He was discovered leaning forward over the handlebar, with the upper torso flexed and the face resting toward the headlamp area, while both lower limbs remained astride the motorcycle. The surrounding ground showed no significant evidence of disturbance, and there were no obvious signs of a struggle or roadway impact nearby. He was wearing a blue half-sleeved shirt and violet trousers, with whitish stains noted on the anterior surface of the shirt; these stains were non-haemorrhagic and appeared consistent with postmortem soiling.

Figure 1.

Body found leaning forward over the motorcycle, with no evidence of impact or scene disturbance.

External examination (Figure 2) showed postmortem artefactual changes more marked on the right side of the face, with smaller areas on the left extending from the eyebrows to the chin and adjoining neck. These consisted of superficial peeling of the epidermis with surface crusting and exposure of the teeth; the right external ear was also absent. Importantly, no vital reaction or haemorrhage was identified, and dissection did not reveal underlying bleeding. The superficial epithelial loss demonstrated irregular, scalloped margins compatible with early ant-feeding, a pattern commonly encountered in bodies exposed outdoors, although similar superficial changes may occur with other arthropod activity. The asymmetric distribution likely reflects arthropod access points, localised drying and environmental exposure rather than antemortem injury. The darker discolouration noted over the affected areas was attributed to postmortem hypostasis and drying rather than haemorrhage. Taken together, these features did not support antemortem facial trauma and were interpreted as postmortem arthropod scavenging artefacts.

Figure 2.

Superficial facial tissue loss with scalloped margins and absent right ear, without vital reaction consistent with arthropod postmortem artefacts.

Internal examination showed no evidence of haemorrhage or trauma in the neck structures, and the cranium, meninges, brain, vertebral column and spinal cord appeared normal. The heart weighed 375 g, with left ventricular wall thickness of ~2 cm, and revealed severe coronary atherosclerosis: the left anterior descending artery was occluded by about 80% near its origin. In contrast, the right coronary artery was narrowed by nearly 70% at its origin. The lungs were congested and edematous, while the liver, gall bladder, spleen, pancreas and both kidneys were also enlarged and clogged. The stomach contained partially digested food without unusual odour or foreign material, and the intestines showed no remarkable lesions. Other visceral organs, including the urinary bladder, adrenal glands and genitalia, were unremarkable.

Histological examination demonstrated pronounced myocyte hypertrophy with enlarged, hyperchromatic nuclei and mild interstitial fibrosis, without evidence of acute myocardial infarction, myocarditis or other inflammatory processes. These microscopic features corroborated the gross autopsy findings of chronic ischaemic heart disease with left ventricular hypertrophy. A comprehensive toxicological evaluation, including assays for alcohol, commonly encountered pesticides, sedative hypnotic agents, opioids, stimulant drugs, cannabinoids, volatile substances and routinely abused drugs, was conducted using immunoassay screening followed by GC-MS confirmation where applicable. All toxicological results were negative. The combined assessment of gross pathology, histology and toxicology substantiated coronary insufficiency secondary to severe coronary artery atherosclerosis with left ventricular hypertrophy as the cause of death. In a young individual, such ancillary investigations are critical for excluding hereditary cardiomyopathies, toxicological factors and acute ischaemic pathology.

Discussion

The ability to distinguish antemortem trauma from postmortem artefacts is fundamental in forensic pathology, as errors in interpretation can lead to serious judicial consequences and distress for the deceased’s relatives. In the present case, extensive facial lesions caused by ant activity mimicked traumatic injuries, underscoring the diagnostic challenges that arise when environmental factors alter postmortem appearances. Recognition of their postmortem origin was crucial to avoid misclassification as assault-related injuries.

Previous studies have highlighted this problem. Viero et al. ¹¹ demonstrated how insect activity, including fly artefacts, maggot trails and ant bites, can mimic vital injuries and misdirect investigations, stressing the importance of entomological awareness in forensic work. Similarly, Thejaswi et al. ¹⁰ reported medicolegal cases in which ant bites and discolourations were misinterpreted as assault or poisoning, leading to unwarranted suspicion against healthcare professionals. These findings closely parallel the present case, where careful assessment prevented false attribution of homicidal violence.

Campobasso et al. ¹² further emphasised that ant feeding not only produces serpiginous skin defects resembling abrasions but also alters decomposition dynamics by preying on fly larvae, complicating postmortem interval estimation. In our case, the absence of vital reaction in the lesions, combined with correlation to the scene findings, supported their identification as postmortem artefacts. Tatiya et al. ¹³ highlighted similar diagnostic dilemmas, demonstrating how postmortem changes can simulate antemortem events, such as aspiration, and reinforcing the role of histology in enhancing diagnostic certainty when macroscopic findings are ambiguous.

Beyond the artefacts, the autopsy revealed advanced CAD with critical occlusions, offering a natural explanation for SCD. As noted by Thiene ¹⁴ and Banner et al.,^15,16 autopsy remains central in elucidating the cause of SCD, particularly in young adults, where sudden natural deaths frequently raise suspicion of foul play.

In young individuals with advanced coronary atherosclerosis, particularly in the absence of known risk factors, an underlying familial lipid disorder such as familial hypercholesterolemia should be considered. Although genetic testing was not performed in this case, standard medico-legal practice includes informing the investigating authorities and relatives about the potential hereditary nature of premature CAD, with first-degree relatives advised to undergo cardiovascular evaluation and lipid profile screening through appropriate healthcare services. ¹⁷

Conclusion

This case shows how insect-related postmortem artefacts can resemble traumatic injuries and influence forensic interpretation. Although the facial lesions were most consistent with ant-feeding patterns, the involvement of other insects cannot be excluded, and careful evaluation is required. A complete autopsy supported by histology and toxicology confirmed coronary insufficiency due to severe coronary atherosclerosis with left ventricular hypertrophy as the cause of death. Such thorough assessment is especially important in young individuals to rule out hereditary or toxicological factors and to ensure accurate identification of natural disease (Supplemental Material).