Sudden cardiac testosterone-related death involving a young bodybuilder: autopsy, histopathological and toxicological findings

BackgroundAnabolic androgenic steroids (AASs) comprise a large group of synthetic derivatives of testosterone, designed to enhance anabolic properties while minimizing androgenic effects. In addition to their therapeutic applications, AASs are frequently abused by athletes, particularly bodybuilders, to enhance performance, promote muscle growth, and increase lean body mass due to their significant anabolic effects. Prolonged misuse and abuse of AASs can lead to multiple adverse effects, some of which may be fatal, particularly in the cardiovascular system.Case presentationThis report presents a case of sudden cardiac death (SCD) in a 28-year-old, apparently healthy male bodybuilder with a history of chronic AAS abuse. A complete autopsy, along with histological and toxicological analyses, was performed. The autopsy findings included pronounced muscle hypertrophy and hepatomegaly. Macroscopically, the left and right coronary arteries exhibited 75-80% luminal narrowing, and there was a moderate increase in left ventricular wall thickness. Histological examination of myocardial tissue revealed multifocal myocardial necrosis, areas of myocyte disarray with a star-like arrangement, focal colliquative myocytolysis (grade 1), small foci of mild interstitial and perivascular fibrosis in the myocardium of the left ventricular wall, and peliosis hepatis. Toxicological analysis demonstrated a urinary testosterone-to-epitestosterone (T/E) ratio of 38.7, confirming exogenous testosterone administration. In this case, the combined effects of vigorous physical training and intramuscular testosterone administration likely led to sympathetic nervous system activation, predisposing the individual to myocardial damage and subsequent SCD.ConclusionsIn cases of sudden death among apparently healthy bodybuilders, a thorough circumstantial investigation, along with comprehensive autopsy, histological, and toxicological analyses, is essential to confirm AAS abuse and identify the cardiac pathologies associated with these substances, which play a critical role in such fatalities.