Histological insights into sudden, unexpected death due to tuberculosis: two autopsy case reports and review of the literature

We report two singular cases of sudden death in which the cause was advanced tuberculosis infection. In the first case, a 24-year-old man died suddenly following massive hemoptysis due to erosion of the pulmonary vessels. The second case involved a 29-year-old man who died unexpectedly from asphyxia secondary to hemoptysis caused by fibrocavitatory tuberculosis. Toxicological screening and HIV testing were negative in both cases. Medico-legal autopsy, combined with detailed histological examination, was essential to determine the exact cause of death.

Article

Dear Editor,

Although tuberculosis is a disease with millennia of evidence in both palaeopathology and art, it remains a cause of sudden and unexpected death in modern populations¹. Sudden deaths due to tuberculosis-related complications are more common in developing countries such as South Asia, Sub-Saharan Africa, and India, where high tuberculosis prevalence correlates with limited access to healthcare^2,3. Massive hemoptysis, the most significant pulmonary complication of tuberculosis, accounts for more than 50% of related deaths⁴ and is frequently associated with fibro-cavitation, bronchopulmonary tuberculosis with vessel erosion, aspiration of blood into the airways, or vascular anomalies such as Rasmussen’s aneurysms⁵.

Here, we report the pulmonary alterations in the unexpected sudden deaths of two young male immigrants whose deaths were associated with tuberculosis, to aid in identifying causes of death in cases of hemorrhage without a definitive pre-mortem diagnosis.

Case Reports

Case 1: A 24-year-old Romanian man died suddenly. Autopsy revealed increased lung weight (left lung 945 g, right lung 1050 g), tenacious pleural adhesions, and extensive perihilar lymphadenopathy. Lung parenchyma was extensively replaced by whitish nodules of varying sizes (Fig. 1A), which on section showed central caseous necrosis (white arrows, Fig. 1B) and cavitations with trabeculations and large necrotic hemorrhagic foci (yellow arrows, Fig. 1B). The bronchial lumen contained blood (Fig. 1C).

Histology (H&E staining) revealed numerous tuberculomas with central caseous necrosis (Fig. 1G), surrounded by a fibrotic wall containing Langhans giant cells, epithelioid histiocytes, and lymphocytes. Ziehl–Neelsen staining confirmed Mycobacterium tuberculosis bacilli (Fig. 1I). Tuberculomas were also observed in perihilar lymph nodes (Fig. 1L). The cause of death was attributed to massive hemoptysis, likely due to bronchial vessel erosion by the infection.

Case 2: A 29-year-old Indian man residing in Italy underwent autopsy revealing lung hepatization, bilateral pleural adhesions, and parenchyma replaced by nodular whitish solid formations, some with central cavitations. The tracheobronchial tree contained blood, and multiple tubercles were visible on the lung surfaces. Lung sections demonstrated caseating necrosis with cavitation (Fig. 1B,D,F). Histology showed markedly dilated alveoli, congested alveolar septal vessels, pulmonary edema, and parenchyma replaced by nodular formations with central caseous necrosis surrounded by fibrotic walls, Langhans giant cells, epithelioid histiocytes, and lymphocytes. Ziehl-Neelsen staining confirmed Mycobacterium tuberculosis bacilli (Fig. 5C). Cause of death was asphyxia due to hemoptysis secondary to fibrocavitatory tuberculosis. Microbiological testing confirmed tuberculosis infection.

In both cases, epidemiological investigation identified tuberculosis infection among cohabitants, who received appropriate antibiotic treatment.

Discussion

Sudden unexpected death (SUD) is defined as the unexpected death of an individual with no prior medical history, where a cause cannot be certified without autopsy. Pulmonary tuberculosis can present as bronchopneumonia and hemoptysis and may involve other vital organs. Tuberculosis rarely causes sudden death, except in rare cases of tuberculous myocarditis⁶.

The literature reports several cases of SUD due to hemoptysis in tuberculosis infection⁷. Tuberculosis-associated hemoptysis has been linked to healed tuberculosis with bronchiectasis in 17.3% of cases and active pulmonary disease in 15.4% of cases⁸. Pulmonary artery thrombosis near a tuberculous lesion, compensatory bronchial artery dilation, and vessel erosion by tuberculous lesions are primary causes of hemoptysis⁹.

In Case 1, external injury as a cause of hemorrhage was excluded; death was due to acute upper airway hemorrhage. Massive hemoptysis, likely from bronchial vessel erosion, caused hemorrhagic shock and cardiocirculatory arrest. Hemoptysis may be the first manifestation of significant respiratory disease and can lead to death via blood loss or asphyxiation¹⁰.

Case 2 involved asphyxia due to hemoptysis secondary to fibrocavitatory tuberculosis. Histological examination of the heart showed diffuse edema, wavy-shaped cardiomyocytes, myofibril reduction, sarcoplasmic depletion, and intercalated disc disruption, suggesting coexisting dilated cardiomyopathy.

Sudden death represents a challenge for forensic pathologists. In both cases, tuberculosis-associated hemoptysis was the cause of death, and autopsy was critical in reaching the diagnosis. Post-diagnosis, epidemiological investigation enabled treatment of cohabitants, preventing further spread. Tuberculosis screening strategies for migrants may help identify and treat undiagnosed cases, reducing public health risk.

CONFLICTS OF INTEREST STATEMENT

The authors declare no conflicts of interest.

FUNDING

None.

AUTHOR CONTRIBUTIONS

Conceptualisation: R.Z., M.N., G.M., A.M.; Methodology: G.T., M.S.; Software: F.B., F.L.; Validation: A.M., D.P.M., G.M.; Formal analysis: R.Z., M.N., G.M.; Investigation: G.T., F.L.; Data curation: M.S., F.B., D.P.M.; Writing – original draft: M.N., A.M., F.L.; Writing – review & editing: A.M., G.M., R.Z., M.N.; Visualisation: F.L., D.P.M.; Supervision: R.Z., A.M., M.N., G.M. All authors have read and approved the final manuscript.

ETHICAL CONSIDERATIONS

All procedures were conducted in accordance with institutional ethical standards and the 1964 Helsinki Declaration and its amendments. Case publication in anonymised form was authorised by the local prosecutor, and written informed consent was obtained from relatives. Formal ethical approval was not required.

History

Received: November 8, 2025

Accepted: April 1, 2026

Figures and tables

Figure 1. Macroscopic examination of lungs: case 1 (A,C,E): Lung parenchyma replaced by whitish nodules of varying sizes (A); sections show tuberculomas with central cavitation and caseous necrosis (white arrows) and necrotic hemorrhagic foci (yellow arrows) (B); communication of tuberculoma with bronchus (C). Case 2 (B,D,F): Lung parenchyma replaced by necrotic nodular formations with central cavitations. Histology: H&E staining shows nodular formations with central caseous necrosis (G) surrounded by fibrotic walls and Langhans giant cells, epithelioid histiocytes, and lymphocytes (H). Ziehl–Neelsen staining identifies M. tuberculosis bacilli (I). Tuberculomas also present in perihilar lymph nodes (L). Magnifications: G,L=10×; H=60×; I=100×.