Sudden death in water: Diagnostic challenges

The authors report a case of sudden death in a breath-holding diver and highlight the forensic diagnostic difficulties in opining the cause of sudden death in water. The autopsy showed increased thickness of the left ventricular wall with a distinct pattern of concentric hypertrophy, evident particularly in the subaortic interventricular septum. Histological examination revealed diffuse interstitial fibrosis and associated findings of multifocal myocyte disarray especially evident in the subaortic interventricular septum. The analysis and discussion of this case made it possible to attribute sudden death to a lethal arrhythmia following myocyte disarray and hypoxia caused by breath-holding, the triggering factor of apnea. This case demonstrates the importance of a thorough forensic investigation, particularly in histological terms, in subjects found dead in water, in order to ascertain the real cause of death, which may not be always ascribable to drowning.