Dying with SARS-CoV-2 infection-an autopsy study of the first consecutive 80 cases in Hamburg, Germany

Carolin Edler, Ann Sophie Schröder, Martin Aepfelbacher, Antonia Fitzek, Axel Heinemann, Fabian Heinrich, Anke Klein, Felicia Langenwalder, Marc Lütgehetmann, Kira Meißner, Klaus Püschel, Julia Schädler, Stefan Steurer, Herbert Mushumba, Jan-Peter Sperhake, Carolin Edler, Ann Sophie Schröder, Martin Aepfelbacher, Antonia Fitzek, Axel Heinemann, Fabian Heinrich, Anke Klein, Felicia Langenwalder, Marc Lütgehetmann, Kira Meißner, Klaus Püschel, Julia Schädler, Stefan Steurer, Herbert Mushumba, Jan-Peter Sperhake

Abstract

Autopsies of deceased with a confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection can provide important insights into the novel disease and its course. Furthermore, autopsies are essential for the correct statistical recording of the coronavirus disease 2019 (COVID-19) deaths. In the northern German Federal State of Hamburg, all deaths of Hamburg citizens with ante- or postmortem PCR-confirmed SARS-CoV-2 infection have been autopsied since the outbreak of the pandemic in Germany. Our evaluation provides a systematic overview of the first 80 consecutive full autopsies. A proposal for the categorisation of deaths with SARS-CoV-2 infection is presented (category 1: definite COVID-19 death; category 2: probable COVID-19 death; category 3: possible COVID-19 death with an equal alternative cause of death; category 4: SARS-CoV-2 detection with cause of death not associated to COVID-19). In six cases, SARS-CoV-2 infection was diagnosed postmortem by a positive PCR test in a nasopharyngeal or lung tissue swab. In the other 74 cases, SARS-CoV-2 infection had already been known antemortem. The deceased were aged between 52 and 96 years (average 79.2 years, median 82.4 years). In the study cohort, 34 deceased were female (38%) and 46 male (62%). Overall, 38% of the deceased were overweight or obese. All deceased, except for two women, in whom no significant pre-existing conditions were found autoptically, had relevant comorbidities (in descending order of frequency): (1) diseases of the cardiovascular system, (2) lung diseases, (3) central nervous system diseases, (4) kidney diseases, and (5) diabetes mellitus. A total of 76 cases (95%) were classified as COVID-19 deaths, corresponding to categories 1-3. Four deaths (5%) were defined as non-COVID-19 deaths with virus-independent causes of death. In eight cases, pneumonia was combined with a fulminant pulmonary artery embolism. Peripheral pulmonary artery embolisms were found in nine other cases. Overall, deep vein thrombosis has been found in 40% of the cases. This study provides the largest overview of autopsies of SARS-CoV-2-infected patients presented so far.

Keywords: Autopsy; COVID-19; Coronavirus; Pulmonary embolism; SARS-CoV-2; Venous thromboembolic disease.

Conflict of interest statement

The authors declare that they have no conflict of interest.

Figures

Fig. 1
Fig. 1
a Heavy, congested lungs (case 52). b Patchy pleural surface with segmental hyperemia (case 2). c Cutting surface of the lung with alternating hyperemic and pale areas (case 5). d Lung surface with pleurisy (case 12). e Thrombosis of the deep veins of the lower extremity (case 4). f Pulmonary embolism (case 4)
Fig. 2
Fig. 2
(all H&E) a Lung: diffuse alveolar damage (case 2, × 80). b Lung: squamous metaplasia (case 4, × 50). c Lymphocytes in the wall of a small pulmonary artery (case 2, × 80). d Lung: hyaline membranes (case 5, × 80). e Purulent pneumonia (case 7, × 80). f Pharyngitis with predominant lymphoplasmacellular infiltrate (case 11, × 80)

References

    1. Robert Koch Institute (2020) Empfehlungen zum Umgang mit SARS-Cov-2-infizierten Verstorbenen. Verstorbene.html. Accessed 16 March 2020
    1. The Committee for Biological Agents (2020) Einstufung des SARS-CoV-2 in Risikogruppe 3 und Empfehlungen zur Labordiagnostik . Accessed 20 April 2020
    1. DGRM (2020) Joint statement of the German Society for Forensic Medicine and the Professional Association of German Forensic Doctors on the handling of deceased and living persons infected with SARS-CoV-2 in forensic medicine. . Accessed 20 April 2020
    1. DeRegCOVID (2020) Deutsches Register von COVID-19 Obduzierten Fällen. . Accessed 20 April 2020
    1. Barton LM, Duval EJ, Stroberg E, Ghosh S, Mukhopadhyay S. COVID-19 autopsies, Oklahoma, USA. Am J Clin Pathol. 2020;153:725–733. doi: 10.1093/ajcp/aqaa062.
    1. Pfefferle S, Reucher S, Nörz D, Lütgehetmann M (2020) Evaluation of a quantitative RT-PCR assay for the detection of the emerging coronavirus SARS-CoV-2 using a high throughput system. Euro Surveill 25(9). 10.2807/1560-7917.ES.2020.25.9.2000152
    1. Wichmann D, Sperhake JP, Lütgehetmann M, Steurer S, Edler C, Heinemann A, Heinrich F, Mushumba H, Kniep I, Schröder AS, Burdelski C, de Heer G, Nierhaus A, Frings D, Pfefferle S, Becker H, Bredereke-Wiedling H, de Weerth A, Paschen HR, Sheikhzadeh-Eggers S, Stang A, Schmiedel S, Bokemeyer C, Addo MM, Aepfelbacher M, Püschel K, Kluge S (2020) Autopsy findings and venous thromboembolism in patients with COVID-19 – a prospective cohort study. Ann Intern Med. 10.7326/M20-2003
    1. Puelles VG, Lütgehetmann M, Lindenmeyer MT, Sperhake JP, Wong MN, Allweiss L, Chilla S, Heinemann A, Wanner N, Liu S, Braun F, Lu S, Pfefferle S, Schröder AS, Edler C, Gross O, Glatzel M, Wichmann D, Wiech T, Kluge S, Pueschel K, Aepfelbacher M, Huber TB (2020) Multi-organ and renal tropism of SARS-CoV-2. NEJM. 10.1056/NEJMc2011400
    1. Molina DK, DiMaio VJ. Normal organ weights in men: part II-the brain, lungs, liver, spleen, and kidneys. Am J Forensic Med Pathol. 2012;33(4):368–372. doi: 10.1097/PAF.0b013e31823d29ad.
    1. Molina DK, DiMaio VJ. Normal organ weights in men: part II-the brain, lungs, liver, spleen, and kidneys. Am J Forensic Med Pathol. 2015;36(3):182–187. doi: 10.1097/PAF.0000000000000175.
    1. Schönamsgruber N, Schröder C, Edler C, Püschel K, Sperhake JP, Schröder AS. Quality of external post-mortem examination and quality of death certificates at the University Hospital in Hamburg. Rechtsmedizin. 2019;29:281–286. doi: 10.1007/s00194-019-0323-5.
    1. Ermenc B. Comparison of the clinical and post mortem diagnoses of the cause of death. Forensic Sci Int. 2000;114:117–119. doi: 10.1016/S0379-0738(00)00329-7.
    1. Robert Koch Institute (2020) ? Accessed 20 April 2020
    1. Robert Koch Institute (2020) . Accessed 20 April 2020
    1. Giannis D, Ziogas AI, Giannic P (2020) Coagulation disorders in coronavirus infected patients: COVID-19, SARS-CoV-1, MERS-CoV and lessons from the past. J Clin Virol:j.jcv.2020.104362
    1. Guan W, Ni Z, Hu Y, Liang C, et al. Clinical characteristics of coronavirus disease 2019 in China. N Engl J Med. 2020;382:1708–1720. doi: 10.1016/NEJMoa2002032.
    1. Han H, Yang L, Liu R, Liu F, Wu KL, Li J, Liu XH, Zhu CL (2020) Prominent changes in blood coagulation of patients with SARS-CoV-2 infection. Clin Chem Lab Med 0. 10.1515/cclm-2020-0188
    1. Varga Z, Flammer AJ, Steiger P, Haberecker M, Andermatt R, Zinkernagel AS, Mehra MR, Schuepbach RA, Ruschitzka F, Moch H. Endothelial cell infection and endotheliitis in COVID-19. Lancet. 2020;395:1417–1418. doi: 10.1016/S0140-6736(20)30937-5.

Source: PubMed

Sponsorzy i współpracownicy

Warunki medyczne

Interwencje lekowe

3
Subskrybuj