Depending on the stage of the disease, autopsy findings of COVID-19 may include a spectrum of cardiopulmonary pathologies including alveolar hyaline membrane formation, vascular thrombosis, and intracardiac thrombi. Identification of a COVID-19 positive decedent in the absence of clinical history relies primarily on post-mortem nasopharyngeal (NP) or oropharyngeal (OP) swabs for real time polymerase chain reaction (RT-PCR). In the absence of definitive microbiology testing, post-mortem computed tomography (PMCT) may be a powerful adjunct tool for screening. Persistence of pathological changes may prolong physiological alterations and increase the risk of cardiopulmonary compromise. This current case outlines the forensic presentation, utilization of screening tools including PMCT, and the autopsy findings of a recent toxicology related sudden death case in the context of severe sequelae of COVID-19 pneumonia. This case demonstrates the limitation of NP and OP swabs in the post-mortem setting, the value of PMCT as an adjunct screening tool, and raises the consideration of COVID-19 sequelae as a potential contributing risk factors in sudden death cases in the community.

We report a case of a 39-year-old woman who died of fulminant pulmonary thromboembolism (PE). Autopsy showed classical findings of fulminant PE with occlusion of the bilateral main stem pulmonary arteries. Ancillary testing revealed inherited thrombophilia (Prothrombin 20,210 G > A and MTHFR 677 C > T mutation). Pre-autopsy postmortem computed tomography was used to test whether virtual imaging studies alone (virtual autopsy) would be sufficient to detect PE. Our studies show that computed tomography (CT) can differentiate antemortem clots from a postmortem clot in certain cases, particularly when combined with magnetic resonance imaging (MRI), which is superior in the assessment of soft tissue. We show that postmortem CT and MRI can aid in the diagnosis of pulmonary embolism by virtual autopsy, especially when used in conjunction.

Aortoenteric fistula (AEF) is an uncommon source of upper gastrointestinal (GI) tract hemorrhage, commonly occurring in persons with previous aortic surgery. Non-surgery related AEFs (primary AEFs) may occur in association with atherosclerotic lesions, infections, malignancies, or, rarely, result from penetrating/eroding foreign bodies. Given its rarity, primary AEF is not commonly considered in the pathologist's preliminary list of differential diagnoses at the commencement of an autopsy; however, the use of postmortem cross-sectional imaging may allow for the identification of primary AEF as a reasonable differential diagnoses prior to conventional autopsy. The current case outlines the forensic presentation, postmortem computed tomography (PMCT) features, and autopsy findings of a recent case of primary AEF resulting in lethal gastrointestinal hemorrhage. In such cases, PMCT features supporting primary AEF as the underlying cause of death include an atherosclerotic aneurysm abutting a segment of the GI tract with no definite soft tissue plane of separation, luminal GI contents of similar radiographic density to the aortic contents, lack of previous aortic surgery, and lack of a competing explanation for GI hemorrhage or a competing cause of death. Deaths from massive enteric hemorrhage without a medical history to suggest an underlying cause for the hemorrhage would fall under medicolegal jurisdiction and may, by examination of scene and circumstances alone, initially seem suspicious. This case demonstrates how PMCT could be used by a team of expert forensic radiologists and forensic pathologists to rapidly feedback vital information on the cause and manner of death to the criminal justice system.

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