Investigators described a forensic autopsy of a nearly drowned young man with cardiac papillary fibroelastoma who died because of a pulmonary inflammatory infiltration rich in granulocytes after intensive care.

This occurrence is rare but possible and should be kept in mind because a lung inflammatory infiltrate rich in eosinophilic granulocytes can be present in different pathological conditions and differential diagnoses are often difficult to do. Papillary fibroelastoma, also called fibropapilloma, or fibroelastic hamartoma, or Lambl’s excrescence, is a rare benign lesion of heart. It is the second most common primary cardiac neoplasm, accounting for 4.4–8% of all tumors of the heart.

The incidence is relatively low, but statistic dates are actually quite different from hospital to hospital. It is usually found accidentally in patients, either during magnetic resonance imaging, echocardiography, during cardiac surgery or autopsy. The lesion can be seen at any age (mean: 60 years). Papillary fibroelastomas can be either single or multiple, the latter possibility especially if it develops on a damaged tissue, with valvular or ventricular or atrium location.

Pulmonary eosinophilia is a rare condition but its diagnosis is challenging, because it can have the same diverse clinical and radiographic presentations seen in other common pulmonary conditions. Radiological manifestations show pulmonary infiltrates, characterized by foci of air-space consolidation and focal ground-glass opacities, can be seen in pulmonary eosinophilia of all causes.

In our case, at admission in the intensive care, imaging was negative as well as toxicology and laboratory finding. Peripheral eosinophilia was lacking, as pathological features associated did, like a granulomatous reaction that usually occurs in infections. This excluded a lung injury induced by pathogens or drugs.

Histopathology showed the alveoli filled by proteinaceous exudates with eosinophilic granulocytes without evidence of parasitosis or other clues for use of drugs such as amphetamine, heroin, or cocaine too, or IgE-mediated damage. This confirmed an acute lung injury with hypoxia-related eosinophils. This could be due to the recent drowning, as described in literature.

The diagnosis was a death by an eosinophilic pneumonia, which developed 36 h after nearly drowning in a subject with papillary fibroelastoma. This complicance is rare but possible. The case that are reporting is important to know pathologies that are not frequent and that can lead to death, and because the microscopic tests are often important in solving the cases that come in forensic setting. The fall in the sea was due to an accidental cardiac event and there was no crime of murder or suicide or professional misconduct by intensive care physicians.