A case-control autopsy series of liver pathology associated with novel coronavirus disease (COVID-19)

BACKGROUND

Although severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) responsible for coronavirus disease 2019 (COVID-19) is most well-known for causing pulmonary injury, a significant proportion of patients experience hepatic dysfunction. The mechanism by which SARS-CoV2 causes liver injury is not fully understood. The goal of this study was to describe the hepatic pathology in a large cohort of deceased patients with COVID-19 as compared to a control group of deceased patients without COVID-19.

METHODS

Consented autopsy cases at two institutions were searched for documentation of COVID-19 as a contributing cause of death. A group of consecutive consented autopsy cases during the same period, negative for SARS-CoV-2 infection, was used as a control group. The autopsy report and electronic medical records were reviewed for relevant clinicopathologic information. H&E-stained liver sections from both groups were examined for pertinent histologic features. Select cases underwent immunohistochemical staining for CD 68 and ACE2 and droplet digital polymerase chain reaction (ddPCR) assay for evaluation of SARS-CoV2 RNA.

RESULTS

48 COVID-19 positive patients (median age 73, M:F 3:1) and 40 COVID-19 negative control patients (median age 67.5, M:F 1.4:1) were included in the study. The COVID-19 positive group was significantly older and had a lower rate of alcoholism and malignancy, but there was no difference in other comorbidities. The COVID-19 positive group was more likely to have received steroids (75.6 % vs. 36.1 %, p < 0.001). Hepatic vascular changes were seen in a minority (10.6 %) of COVID-19 positive cases. When all patients were included, there were no significant histopathologic differences between groups, but when patients with chronic alcoholism were excluded, the COVID-19 positive group was significantly more likely to have steatosis (80.9 % vs. 50.0 %, p = 0.004) and lobular inflammation (45.7 % vs. 20.7 %, p = 0.03). Testing for viral RNA by ddPCR identified 2 of the 18 (11.1 %) COVID-19 positive cases to have SARS-CoV-2 RNA detected within the liver FFPE tissue.

CONCLUSIONS

The most significant findings in the liver of COVID-19 positive patients were mild lobular inflammation and steatosis. The high rate of steroid therapy in this population may be a possible source of steatosis. Hepatic vascular alterations were only identified in a minority of patients and did not appear to play a predominant role in COVID-19 mediated hepatic injury. Low incidence of SARS-CoV-2 RNA positivity in liver tissue in our cohort suggests hepatic injury in the setting of COVID-19 may be secondary in nature.

Suicide by Gaseous Displacement of Atmospheric Oxygen With Carbon Dioxide From Dry Ice Sublimation

ABSTRACT

Deaths from gaseous substances can occur from exposure to toxic gases or from accumulation of nontoxic gases that displace oxygen. We present a 38-year-old man with no known medical history, who was found deceased in a small bathroom with blankets and towels shoved under the door from the inside.At autopsy, the decedent was found to be in a moderate state of decomposition. There was mild pulmonary congestion, with no other significant findings. Standard postmortem toxicology on femoral blood was noncontributory.A search of the decedent's cell phone revealed statements and internet searches regarding carbon dioxide (CO 2 ) and asphyxia using dry ice. A journal entry also outlined a suicide plan using large amounts of dry ice, which was enacted by placing a laundry basket of dry ice into a bathtub containing water. Based on the investigation, the cause of death was determined to be asphyxia from displacement of oxygen with CO 2 .Dry ice sublimates into gaseous CO 2 , which quickly accumulates, with concentrations of 10% or more, rapidly becoming life-threatening. There are no pathognomonic autopsy findings seen in CO 2 -related asphyxia. In these circumstances, scene investigation is the most important factor in determining cause of death.

A Thrombectomy Model Based on Ex Vivo Whole Human Brains

BACKGROUND AND PURPOSE

The persistent challenges in thrombectomy for large-vessel occlusion, such as suboptimal complete recanalization and first-pass effect imply an insufficient understanding of the artery-clot-device interaction. In this study, we present a thrombectomy model using fresh human brains, which can capture the artery-clot-device interaction through concurrent transmural and angiographic visualizations.

MATERIALS AND METHODS

Fresh nonfrozen whole adult human brains were collected and connected to a customized pump system tuned to deliver saline flow at a physiologic flow rate and pressure. Angiography was performed to verify the flow in the anterior-posterior and vertebrobasilar circulations and collaterals. Large-vessel occlusion was simulated by embolizing a radiopaque clot analog. Thrombectomy was tested, and the artery-clot-device interactions were recorded by transmural and angiographic videos.

RESULTS

Baseline cerebral angiography revealed excellent penetration of contrast in the anterior-posterior and vertebrobasilar circulations without notable arterial cutoffs and with robust collaterals. Small branches (<0.5 mm) and perforating arteries were consistently opacified with good patency. Three device passes were performed to achieve recanalization, with failure modes including elongation, fragmentation, and distal embolization.

CONCLUSIONS

This model enables concurrent transmural and angiographic analysis of artery-clot-device interaction in a human brain and provides critical insights into the action mechanism and failure modes of current and upcoming thrombectomy devices.

Acute Kidney Injury in Severe COVID-19 Has Similarities to Sepsis-Associated Kidney Injury: A Multi-Omics Study

OBJECTIVE

To compare coronavirus disease 2019 (COVID-19) acute kidney injury (AKI) to sepsis-AKI (S-AKI). The morphology and transcriptomic and proteomic characteristics of autopsy kidneys were analyzed.

PATIENTS AND METHODS

Individuals 18 years of age and older who died from COVID-19 and had an autopsy performed at Mayo Clinic between April 2020 to October 2020 were included. Morphological evaluation of the kidneys of 17 individuals with COVID-19 was performed. In a subset of seven COVID-19 cases with postmortem interval of less than or equal to 20 hours, ultrastructural and molecular characteristics (targeted transcriptome and proteomics analyses of tubulointerstitium) were evaluated. Molecular characteristics were compared with archived cases of S-AKI and nonsepsis causes of AKI.

RESULTS

The spectrum of COVID-19 renal pathology included macrophage-dominant microvascular inflammation (glomerulitis and peritubular capillaritis), vascular dysfunction (peritubular capillary congestion and endothelial injury), and tubular injury with ultrastructural evidence of mitochondrial damage. Investigation of the spatial architecture using a novel imaging mass cytometry revealed enrichment of CD3⁺CD4⁺ T cells in close proximity to antigen-presenting cells, and macrophage-enriched glomerular and interstitial infiltrates, suggesting an innate and adaptive immune tissue response. Coronavirus disease 2019 AKI and S-AKI, as compared to nonseptic AKI, had an enrichment of transcriptional pathways involved in inflammation (apoptosis, autophagy, major histocompatibility complex class I and II, and type 1 T helper cell differentiation). Proteomic pathway analysis showed that COVID-19 AKI and to a lesser extent S-AKI were enriched in necroptosis and sirtuin-signaling pathways, both involved in regulatory response to inflammation. Upregulation of the ceramide-signaling pathway and downregulation of oxidative phosphorylation in COVID-19 AKI were noted.

CONCLUSION

This data highlights the similarities between S-AKI and COVID-19 AKI and suggests that mitochondrial dysfunction may play a pivotal role in COVID-19 AKI. This data may allow the development of novel diagnostic and therapeutic targets.

Expression of Immune Checkpoint Receptors in Placentae With Infectious and Non-Infectious Chronic Villitis

Pregnancy is an immunological paradox whereby maternal immunity accepts a genetically unique fetus (or fetuses), while maintaining protective innate and adaptive responses to infectious pathogens. This close contact between the genetically diverse mother and fetus requires numerous mechanisms of immune tolerance initiated by trophoblast cell signals. However, in a placental condition known as villitis of unknown etiology (VUE), there appears to be a breakdown in this tolerance allowing maternal cytotoxic T-cells to traffic into the placenta to destroy fetal villi. VUE is associated with several gestational complications and an increased risk of recurrence in a subsequent pregnancy, making it a significant obstetrical diagnosis. The cause of VUE remains unclear, but dysfunctional signaling through immune checkpoint pathways, which have a critical role in blunting immune responses, may play an important role. Therefore, using placental tissue from normal pregnancy (n=8), VUE (n=8) and cytomegalovirus (CMV) infected placentae (n=4), we aimed to identify differences in programmed cell death 1 (PD-1), programmed death ligand-1 (PD-L1), LAG3 and CTLA4 expression between these etiologies by immunohistochemistry (IHC). Results demonstrated significantly lower expression of PD-L1 on trophoblast cells from VUE placentae compared to control and CMV infection. Additionally, we observed significantly higher counts of PD-1+ (>100 cells/image) and LAG3+ (0-120 cells/image) cells infiltrating into the villi during VUE compared to infection and control. Minimal CTLA4 staining was observed in all placentae, with only a few Hofbauer cells staining positive. Together, this suggests that a loss of tolerance through immune checkpoint signaling may be an important mechanism leading to the activation and trafficking of maternal cells into fetal villi during VUE. Further mechanistic studies are warranted to understand possible allograft rejection more clearly and in developing effective strategies to prevent this condition from occurring in utero.

Cerebral Vascular Thrombosis Associated With Ulcerative Colitis and Primary Sclerosing Cholangitis

ABSTRACT

We report a case of a sudden death of a 23-year-old man with a history of ulcerative colitis and primary sclerosing cholangitis due to cerebral vascular thrombosis. He was found supine in bed with no signs of trauma or drug use. Three days before being found, he had complained of fever and excessive diarrhea. At autopsy, the brain was markedly edematous with diffuse subarachnoid hemorrhage over the left cerebral hemisphere. The vessels at the base of the brain were unremarkable, and there was no significant hemorrhage over the inferior surfaces. On sectioning, clotted blood was identified in the left frontal lobe and lateral ventricles. Microscopically, the left cerebral hemisphere showed extensive intraparenchymal hemorrhage, necrosis, and numerous thrombosed leptomeningeal vessels. Sections of the transverse and descending colon showed changes consistent with the history of ulcerative colitis.Cerebral venous and sinus thrombosis represents approximately 1% of all strokes and is a known rare complication associated with inflammatory bowel disease (IBD). Symptoms of cerebral venous thrombosis are highly variable and may manifest as headache, focal neurological deficits, seizure, or encephalopathy. In addition to acquired hypercoagulability risk factors patients develop during active disease flares (eg, dehydration), studies suggest that IBD itself represents an independent risk factor for thrombosis. It is important for the forensic pathologist to consider thrombotic complications, particularly those in the cerebral venous system, as potential manifestations of known or undiagnosed IBD.

COVID-19-Associated Nonocclusive Fibrin Microthrombi in the Heart

Supplemental Digital Content is available in the text.

Background:

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and its resultant clinical presentation, coronavirus disease 2019 (COVID-19), is an emergent cause of mortality worldwide. Cardiac complications secondary to this infection are common; however, the underlying mechanisms of such remain unclear. A detailed cardiac evaluation of a series of individuals with COVID-19 undergoing postmortem evaluation is provided, with 4 aims: (1) describe the pathological spectrum of the myocardium; (2) compare with an alternate viral illness; (3) investigate angiotensin-converting enzyme 2 expression; and (4) provide the first description of the cardiac findings in patients with cleared infection.

Methods:

Study cases were identified from institutional files and included COVID-19 (n=15: 12 active, 3 cleared), influenza A/B (n=6), and nonvirally mediated deaths (n=6). Salient information was abstracted from the medical record. Light microscopic findings were recorded. An angiotensin-converting enzyme 2 immunohistochemical H-score was compared across cases. Viral detection encompassed SARS-CoV-2 immunohistochemistry, ultrastructural examination, and droplet digital polymerase chain reaction.

Results:

Male sex was more common in the COVID-19 group (P=0.05). Nonocclusive fibrin microthrombi (without ischemic injury) were identified in 16 cases (12 COVID-19, 2 influenza, and 2 controls) and were more common in the active COVID-19 cohort (P=0.006). Four active COVID-19 cases showed focal myocarditis, whereas 1 case of cleared COVID-19 showed extensive disease. Arteriolar angiotensin-converting enzyme 2 endothelial expression was lower in COVID-19 cases than in controls (P=0.004). Angiotensin-converting enzyme 2 myocardial expression did not differ by disease category, sex, age, or number of patient comorbidities (P=0.69, P=1.00, P=0.46, P=0.65, respectively). SARS-CoV-2 immunohistochemistry showed nonspecific staining, whereas ultrastructural examination and droplet digital polymerase chain reaction were negative for viral presence. Four patients (26.7%) with COVID-19 had underlying cardiac amyloidosis. Cases with cleared infection had variable presentations.

Conclusions:

This detailed histopathologic, immunohistochemical, ultrastructural, and molecular cardiac series showed no definitive evidence of direct myocardial infection. COVID-19 cases frequently have cardiac fibrin microthrombi, without universal acute ischemic injury. Moreover, myocarditis is present in 33.3% of patients with active and cleared COVID-19 but is usually limited in extent. Histological features of resolved infection are variable. Cardiac amyloidosis may be an additional risk factor for severe disease.

The Spectrum of Histopathologic Findings in Lungs of Patients With Fatal Coronavirus Disease 2019 (COVID-19) Infection

Context.—

Respiratory failure appears to be the ultimate mechanism of death in most patients with severe coronavirus disease 2019 (COVID-19) infection. Studies of postmortem COVID-19 lungs largely report diffuse alveolar damage and capillary fibrin thrombi, but we have also observed other patterns.

Objective.—

To report demographic and radiographic features along with macroscopic, microscopic, and microbiologic postmortem lung findings in patients with COVID-19 infections.

Design.—

Patients with confirmed COVID-19 infection and postmortem examination (March 2020–May 2020) were included. Clinical findings were abstracted from medical records. Lungs were microscopically reviewed independently by 4 thoracic pathologists. Imaging studies were reviewed by a thoracic radiologist.

Results.—

Eight patients (7 men, 87.5%; median age, 79 years; range, 69–96 years) died within a median of 17 days (range, 6–100 days) from onset of symptoms. The median lung weight was 1220 g (range, 960–1760 g); consolidations were found in 5 patients (62.5%) and gross thromboemboli were noted in 1 patient (12.5%). Histologically, all patients had acute bronchopneumonia; 6 patients (75%) also had diffuse alveolar damage. Two patients (25%) had aspiration pneumonia in addition. Thromboemboli, usually scattered and rare, were identified in 5 patients (62.5%) in small vessels and in 2 of these patients also in pulmonary arteries. Four patients (50%) had perivascular chronic inflammation. Postmortem bacterial lung cultures were positive in 4 patients (50%). Imaging studies (available in 4 patients) were typical (n = 2, 50%), indeterminate (n = 1, 25%), or negative (n = 1, 25%) for COVID-19 infection.

Conclusions.—

Our study shows that patients infected with COVID-19 not only have diffuse alveolar damage but also commonly have acute bronchopneumonia and aspiration pneumonia. These findings are important for management of these patients.

Maternal T Cells in the Human Placental Villi Support an Allograft Response during Noninfectious Villitis

During human pregnancy, proinflammatory responses in the placenta can cause severe fetal complications, including growth restriction, preterm birth, and stillbirth. Villitis of unknown etiology (VUE), an inflammatory condition characterized by the infiltration of maternal CD8⁺ T cells into the placenta, is hypothesized to be secondary to either a tissue rejection response to the haploidentical fetus or from an undiagnosed infection. In this study, we characterized the global TCR β-chain profile in human T cells isolated from placentae diagnosed with VUE compared with control and infectious villitis-placentae by immunoSEQ. Immunosequencing demonstrated that VUE is driven predominantly by maternal T cell infiltration, which is significantly different from controls and infectious cases; however, these T cell clones show very little overlap between subjects. Mapping TCR clones to common viral epitopes (CMV, EBV, and influenza A) demonstrated that Ag specificity in VUE was equal to controls and significantly lower than CMV-specific clones in infectious villitis. Our data indicate VUE represents an allograft response, not an undetected infection. These observations support the development of screening methods to predict those at risk for VUE and the use of specific immunomodulatory therapies during gestation to improve outcomes in affected fetuses.

Suicidal Carbon Monoxide Poisoning by Formic and Sulfuric Acids

In 1987, a case report was published in the German journal Archiv für Kriminologie describing an apparently novel method of suicide in which the decedent produced a lethal amount of carbon monoxide by mixing formic acid and sulfuric acid. This method of chemical suicide remained obscure until 2003, when Dr. Philip Nitschke, a vocal supporter of assisted suicide, began promoting a homemade carbon monoxide generator which utilized this same chemical reaction. In 2006, he coauthored The Peaceful Pill Handbook, which provided further details about how the device worked. Pro-voluntary euthanasia organizations and online forums continue to provide information about this method, promoting it as painless and efficient. There have been nine case reports of suicides and attempted suicides using this chemical reaction, with five reported in Europe, three in the United States, and one in Taiwan. Two additional cases were reported in news articles that did not correspond to known case reports, indicating that this method of suicide is more common than the scientific literature would suggest. We present the case of a 44-year-old male who learned about this method of chemical suicide online and filmed the suicidal act while verbally recording carbon monoxide levels prior to losing consciousness.

Child Death Review: Past, Present, and Future

This article describes the current state of child death reviews (CDR) in the United States. The CDR process has evolved over almost 40 years from informal local meetings to a coordinated effort involving all 50 states. Child death review programs across the country vary in the level of financial and administrative support, legislation, and review processes. While there is still a long way to go in standardizing the practice between states, great strides have been made in data collection, education, and prevention initiatives.

Certification of Vehicular Hyperthermia Deaths in the Pediatric Population

The investigation of vehicular hyperthermia deaths in infants and children requires coordination between the autopsy, clinical history, and scene investigation. Unfortunately, autopsy findings can be limited or nonspecific, clinical history may be unavailable, and details concerning ambient temperature and vehicular temperature may be vague. In cases where hyperthermia is established as the cause of death, the certification of manner of death can be challenging and inconsistent among medical examiners. This article provides an overview of vehicular hyperthermia deaths and the certification of cause and manner of death in these cases.

Investigation of Sudden Unexpected Infant Deaths

The investigation of infant death is complex and requires synergy between multiple agencies including law enforcement, Child Protective Services, medicolegal death investigators, and forensic pathologists. Prior to the forensic pediatric autopsy, the death investigator must identify the types of death scenes involved (e.g., hospital, residence, daycare) and document the details of the scene. Interviews must be conducted with the caregivers and other family members (including doll reenactments), law enforcement, pediatricians, and emergency medical personnel. The forensic pathologist must be able to conduct a comprehensive pediatric forensic autopsy and be aware of the specific challenges related to cases of sudden unexpected infant deaths. This article provides an overview of infant death investigation, discussing the roles and responsibilities of the medicolegal death investigator and the forensic pathologist.

Justices of the Peace and Medicolegal Death Investigation: A Situation Unique to Texas

Death investigation throughout the United States is conducted by medical examiners, coroners, or combined systems, based on the laws of individual states. Larger counties in Texas employ medical examiners, but smaller counties rely on justices of the peace. Texas is unique in the use of justices of the peace in the place of county coroners. These justices have multiple responsibilities, including small claims courts, civil marriages, and inquests and death certification. In Texas counties with medical examiner offices, the justice of the peace relinquishes the responsibilities of death investigation and certification.

Intracranial Hemorrhage: Traumatic Fall versus Terminal Collapse

When approaching a case in which a decedent's body is on the ground, death investigators collect circumstantial, historical, and clinical (radiographic) information to infer whether the person fell to the ground and sustained a head injury or simply experienced a terminal collapse due to a natural event. We have observed that cases presenting as presumed accidental head trauma, some of which have diagnosed subdural hematomas, are sometimes proven to be of natural causes following autopsy. Autopsies sometimes demonstrate that either 1) the intracranial hemorrhage is intracerebral rather than subdural, 2) the subdural hemorrhage is an extension from an intracerebral hemorrhage, or 3) there is no intracranial hemorrhage at all. In each of these examples, the autopsy established that the manner of death is natural rather than accidental, as originally presumed at the outset of the investigation.

We performed a 5 year retrospective study on cases indicating intracranial hemorrhage in the cause of death statement in order to assess how often the cause and manner of death would have been incorrectly certified without an autopsy. We found that 6% of cases presumed at the time of initial investigation to represent falls with accidental head trauma (specifically, subdural hemorrhage) were proven by autopsy to represent intracranial hemorrhage of natural manner. Conversely, 7% of cases with intracranial hemorrhage that were presumed to be due to natural disease were proven by autopsy to represent accidental trauma.

Proper certification of manner of death has important legal implications which may be of critical importance to family members.

Extramedullary Cardiac Plasmacytoma

An 86 year old female presented to the emergency department with a one week history of leg swelling and recent weight gain. An echocardiogram revealed an 8.7 x 5 cm mass of the right atrium that appeared to be adherent to the atrial wall and filled over 90% of the volume of the right atrial chamber. The patient expired approximately one month later, and an autopsy limited to the heart and pericardial sac was requested. The autopsy confirmed the presence of a 9 cm mass involving the right atrium and completely encasing the right coronary artery. Microscopically the tumor was composed of sheets of plasma cells. Immunohisto-chemical studies showed that the cells were kappa light chain restricted, strongly positive for LCA and CD79a, and negative for CD138 and CD20. Given the gross and microscopic findings, the lesion was diagnosed as an extramedullary plasmacytoma of the heart.

An unusual suicidal death by automobile antenna: a case report

Worldwide, over one million people commit suicide every year. In the United States, the majority of these cases consist of gunshot wounds, hangings, and drug overdoses. Nevertheless, on rare occasions will individuals exhibit extraordinary creativity in how they decide to end their lives.

A decomposing white male was found lying beside his vehicle; blood was noted on the hood. Beneath the deceased's head was a copious amount of blood, and clutched within his right hand was a vehicle radio antenna. A search of a nearby storage shed uncovered drug paraphernalia and in the decedent's bedroom were two handwritten suicide notes. At autopsy, a defect was discovered in the right posterior oropharnyx. Immediately posterior to this injury were fractures of the right transverse processes and interarticular portions of the C2 and C3 vertebrae, with perforation of the right vertebral artery. No other injuries were noted externally. Radiographs of the head and neck showed no evidence of a projectile, and no corresponding exit defect was identified. Postmortem toxicology was positive for cocaine and methamphetamine.

We present a case report of a man under the influence of cocaine and methamphetamine employing a car antenna to cause self-inflicted, intraoral penetrating trauma to the cervical spine and right vertebral artery, resulting in exsanguination and his subsequent death.

Multifocal motor sensory demyelinating neuropathy: Inflammatory demyelinating polyradiculoneuropathy

The authors present two cases that provide the first autopsy findings in multifocal acquired demyelinating sensory and motor neuropathy (MADSAMN). Both cases documented multifocal but asymmetric demyelinating neuropathy with rare axonal degeneration. One case clearly documented an inflammatory polyradiculoplexoneuropathy, confirming the inflammatory nature of this neuropathy. This study showed that MADSAMN is an inflammatory demyelinating polyradiculoneuropathy that shares histologic features observed in chronic inflammatory demyelinating polyradiculoneuropathy and multifocal motor neuropathy (MMN), suggesting a similar immunopathogenesis for these entities.

Acute myocardial infarction in sickle cell anemia

Cardiovascular dysfunction consistent with ischemia has been observed during episodes of painful crisis and following periods of heavy physical exertion in individuals with sickle cell disease. Similar findings have been observed in other individuals while taking the alpha-adrenergic agonist pseudoephedrine. However, acute myocardial infarction is extremely rare. The authors describe a case of sudden death in a child with sickle cell disease due to acute myocardial infarction and suggest that heavy exertional stress and use of pseudoephedrine may have precipitated the event.

Suicidal hangings in jail using telephone cords

In a three month period of 2000, three suicide hanging deaths involving the use of telephone cords occurred in Texas jails and were autopsied at the Southwestern Institute of Forensic Sciences in Dallas. In each case, the telephone was located within the cell, allowing the prisoners unhindered access at any time. Because of these incidents, two of the jails shortened their receiver cords to a total length of 6-8 in. The telephones were otherwise unaltered, and are still in the same locations. The third jail replaced their entire phone with a cordless telephone. Despite the attention that these cases received, standards have not been set regarding the type or placement of telephones used within jail cells, and a fourth incident in 2002 underscores this ongoing problem. These three incidents highlight the need to provide telephones that, if placed within holding cells or other jail cells, do not provide a possible means of suicide.

Exsanguination by subclavian-esophageal fistula associated with a left subclavian aneurysm

Aortic aneurysms are a common autopsy finding, but aneurysms confined exclusively to the subclavian arteries are rare. When found, they are typically associated with trauma, surgery, or aberrant vessel distribution. Subclavian-esophageal fistula formation is also rare, with the vast majority being related to aberrant vessel distribution or esophageal foreign bodies. Dicle et al. first reported a subclavian-esophageal fistula associated with a non-aberrant subclavian artery aneurysm in 1999 (1). The following case would mark the second report of that phenomenon, and the first in the setting of a forensic autopsy.