The role of myocardial bridge of the left anterior descending artery in a sudden death of a ketamine and cannabis user. Addressing the uncertainties on the cause of death in a forensic pathologist's casework

In this case report, the role of a myocardial bridge of the left anterior descending artery (LAD) and recent use of cannabis in a sudden death of a drug user is discussed, also considering the relevance of histopathological pulmonary findings. A 37-year-old man with a history of drug abuse was found dead in his house. External and autoptic examination were performed, as well as histologic and toxicologic analyses of tissues, organs and body fluids samples. Autoptic examination revealed signs of previous endovenous drugs administration and a 0.5 cm deep intramyocardial bridging of a 1.5 cm long segment of the left anterior descending (LAD) artery. Histo-pathologic examination revealed the presence of diffuse alveolar hemorrhage and multiple alveolar macrophages containing brownish pigments. Toxicological analysis of post-mortem blood revealed recent use of ketamine (<0.5 ng/ml) and cannabis derivatives (8.8 ng/ml for THC and 2.2 ng/ml for 11-OH-THC) in a subject with a history of previous abuse of cocaine, MDMA, and ketamine, confirmed through hair analysis. The analysis of forensic literature, thoroughly examined in this paper, along with a comprehensive evaluation of all post-mortem data, indicates that cannabis likely contributed to the cause of death, in conjunction with myocardial bridging. This suggests a dual mechanism involving both cardiac and pulmonary factors. This case could add to the limited body of evidence in the literature and provide insights into the potential contributory role of cannabis in sudden deaths.