IMAGES IN FORENSICS Post-mortem CT with macroscopic and microscopic correlation in a case of sudden death due to systemic sarcoidosis Jatin Bodwal 1,2 & Marc Napoleone 3 & Jayantha Herath 2 Accepted: 8 May 2020 # Springer Science+Business Media, LLC, part of Springer Nature 2020 Abstract We report a case of sudden death due to systemic sarcoidosis in a fifty-four year old male who was reportedly healthy. A computerized tomography (CT) scan was performed before the autopsy. It showed cardiomegaly with hilar and abdominal lymphadenopathy. The autopsy showed pale yellow plaque deposition on the heart surface which was infiltrating the myocar- dium. Histological examination of the heart, lungs, liver, and spleen showed extensive sarcoid granulomata which helped in establishing the cause of death. Keywords Sarcoidosis . Post-mortem CT . Sudden death Case report A man in his mid-fifties was found dead in the bed at his residence by his landlord. The deceased had been living at his friend’s house for the past 3 years and was reportedly healthy over the last few days to months prior to his death. He had a past medical history of hypertension, elevated cho- lesterol, and elevated prostatic surface antigen (PSA). There was no history of drug and alcohol abuse and his family his- tory was not known. Medications included only hypolipid- emic and anti-hypertensive drugs. The deceased’s body underwent a routine pre-autopsy CT and a post-mortem examination. CT images revealed an en- larged heart with bilateral symmetric hilar and right paratracheal lymphadenopathy in the thoracic region (Figs. 1 and 2). In the abdominal region lymph nodes in the porta hepatis and para-aortic regions were also enlarged (Fig. 3). CT images raised our suspicion towards the diagnosis of sarcoidosis. On external examination no significant findings were ob- served. At autopsy, the heart weight was enlarged and hypertrophied (560 g) with mild remodeling. Pale/yellow to white, plaque-like diffuse infiltrative disease was identified in the myocardium (Fig. 4a and b). The infiltrative process was diffusely present throughout the myocardium, involving the full thickness of all four chambers, extending to the ascending aorta and valves. These plaques predominantly involved the myocardium of the left ventricular free wall, followed by the septum, right ventricle, and atria. The myocardial wall thick- ness of the left ventricle and interventricular septum was 1.7 cm and the wall thickness of the right ventricle was 0.5 cm. Histological examination of the heart showed numerous non-necrotizing granulomata resembling the microscopic fea- tures of sarcoid granuloma associated with marked myocardi- al fibrosis and chronic inflammation (Figs. 5 and 6). The myocardium involvement of sarcoidosis revealed the presence of numerous lymphocytes located at the border zones around the granulomas. A dense band of fibroblasts and collagen fibers encased this aggregate of inflammatory cells; lungs, liver, kidneys, lymph nodes, spleen, and adrenal glands also showed numerous granulomata (Fig. 7a–c). Special stains for tuberculosis and fungus were negative. * Jatin Bodwal jatinfsm@gmail.com 1 Department of Forensic Medicine, Deen Dayal Upadhyay Hospital, Saheed Mangal Pandey Marg, Nanak Pura, Hari Nagar, New Delhi 110064, India 2 Department of Pathobiology and Laboratory Medicine, University of Toronto & Ontario Forensic Pathology Service, Toronto, Ontario, Canada 3 Department of Diagnostic Radiology, University of Toronto, Toronto, Ontario, Canada Forensic Science, Medicine and Pathology https://doi.org/10.1007/s12024-020-00259-8