Sudden unexpected death in infancy (SUDI) and myocarditis: State of the art and medico-legal implications. A systematic review

Sudden infant deaths should be recognized as a public health concern, and understanding their underlying causes is crucial to elucidate this still poorly understood phenomenon. Despite efforts and standardized diagnostic protocols including autopsies and laboratory tests, the causes of sudden infant death often remain unclear in the 75 % of the cases. The aim of this review is to analyze the available data on SUDI associated with myocarditis, offering forensic pathologists a comprehensive overview of this topic, with a particular focus not only on pathophysiological and clinical implications but also on medico-legal aspects. This systematic review included articles concerning SUDI related to myocarditis, in particular etiopathogenesis, diagnosis, consequences and medico-legal implications. The research was carried out on articles written in English published between January 1990 and December 2024. A total of 557 studies were found through the electronic search and 11 studies were included after cross-referenced research on the references of the examined full-text articles. A total of 31 studies were included in this systematic review. The study showed that a definitive diagnosis of myocarditis should only be established when all necessary criteria have been met, given the potential liability implications of asserting a specific cause of death in an infant condition that remains the subject of ongoing debate and research. To optimize this process, the inclusion of expert pediatric pathologists in multidisciplinary teams is strongly recommended to standardize analytical methods and guide autopsy, histological, and genetic examinations based on the unique characteristics of the pediatric population.