The autopsy debate during the COVID-19 emergency: the Italian experience

New autopsy technique in COVID-19 positive dead bodies: opening the thoracic cavity with an outlook to reduce aerosol spread

AIMS

After the advent of the COVID-19 pandemic, most countries have modified some of their health-related regulations. However, this has not been in the case of the postmortem of deceased because it has a legal aspect. Thus, the healthcare providers knowingly or unknowingly faced the threat of COVID-19 exposure from those dead bodies. To introduce an autopsy technique that reduces the droplet spreads, especially in those mortuaries where the biosafety mechanism is not highly equipped.

METHODS

The validity of the new incision was achieved through the calculation of the Scale Content Validity Index (SCVI) taking inputs from 17 forensic specialists. The subjects for the new technique were selected from the patients who were RTPCR positive for COVID-19 or clinically or radiologically showing features of COVID-19.

RESULTS

The dissection procedure was finalised by achieving the SCVI at 0.92. The chest cavity was approached through the abdominal cavity by opening the diaphragm and dissecting out the contents of the chest using a long blade knife.

CONCLUSIONS

The advantage of this approach is that the autopsy surgeon and pathologists do not have to open the chest cavity by dissecting the Sternum, and hence the chance of droplet infection becomes almost nil. This technique is complete, simple, less time-consuming and conducive for sample collection, and even reduces the possibility of body fluid seepage following a postmortem examination.

A Survey on forensic odontologists' activity in Italy during the COVID-19 pandemic

Few information on virus contagion at the beginning of the covid-19 pandemic led to severe restrictions in the dental and forensic activity in Italy, the introduction of procedural guidelines and implementation of preventive measures. A specific survey on Italian forensic odontologists (FOds) activity was conducted to investigate the COVD-19 pandemic impact on daily practices, the preventive measures adopted to manage the risks of contagion procedures performed on living and dead people and the possible peculiar cases that required the intervention of a medical examiner. A total of 122 FOds answered, mostly males over 46 years coming from northern Italy. The results highlight the lack of specific guidelines for the procedures on living people compared to those on the dead but the regulations for the daily clinical practice resulted more than sufficient: in fact, more than 80% of FOds adopted the preventive and safety measures provided for dental practices. The forensic activity significantly decreased during the initial period (more than 75%) and gradually normalized to pre-pandemic numbers in approximately 50% of cases after the implementation of the vaccination campaign. 13 cases of occupational contagion have been reported, most of them (more than 85%) in northern and central Italy. In two cases members of the dental staff sued the employer for responsibility in the contagion. The decrease of the overall ID activity during the pandemic time can be more likely attributed to the of the dental data than the real impact of the pandemic regulations. The use of telematic tools, such as teleconferences, for many procedures proved to be an important resource useful for application even in post-pandemic times.

Organ manifestations of COVID-19: what have we learned so far (not only) from autopsies?

The use of autopsies in medicine has been declining. The COVID-19 pandemic has documented and rejuvenated the importance of autopsies as a tool of modern medicine. In this review, we discuss the various autopsy techniques, the applicability of modern analytical methods to understand the pathophysiology of COVID-19, the major pathological organ findings, limitations or current studies, and open questions. This article summarizes published literature and the consented experience of the nationwide network of clinical, neuro-, and forensic pathologists from 27 German autopsy centers with more than 1200 COVID-19 autopsies. The autopsy tissues revealed that SARS-CoV-2 can be found in virtually all human organs and tissues, and the majority of cells. Autopsies have revealed the organ and tissue tropism of SARS-CoV-2, and the morphological features of COVID-19. This is characterized by diffuse alveolar damage, combined with angiocentric disease, which in turn is characterized by endothelial dysfunction, vascular inflammation, (micro-) thrombosis, vasoconstriction, and intussusceptive angiogenesis. These findings explained the increased pulmonary resistance in COVID-19 and supported the recommendations for antithrombotic treatment in COVID-19. In contrast, in extra-respiratory organs, pathological changes are often nonspecific and unclear to which extent these changes are due to direct infection vs. indirect/secondary mechanisms of organ injury, or a combination thereof. Ongoing research using autopsies aims at answering questions on disease mechanisms, e.g., focusing on variants of concern, and future challenges, such as post-COVID conditions. Autopsies are an invaluable tool in medicine and national and international interdisciplinary collaborative autopsy-based research initiatives are essential.

Radio-Histological Correlation of Lung Features in Severe COVID-19 Through CT-Scan and Lung Ultrasound Evaluation

Background

Patients with coronavirus disease 2019 (COVID-19) can develop severe bilateral pneumonia leading to respiratory failure. Lung histological samples were scarce due to the high risk of contamination during autopsies. We aimed to correlate histological COVID-19 features with radiological findings through lung ultrasound (LU)-guided postmortem core needle biopsies (CNBs) and computerized tomography (CT) scans.

Methodology

We performed an observational prospective study, including 30 consecutive patients with severe COVID-19. The thorax was divided into 12 explorations regions to correlate LU and CT-scan features. Histological findings were also related to radiological features through CNBs.

Results

Mean age was 62.56 ± 13.27 years old, with 96.7% male patients. Postmortem LU-guided CNBs were performed in 13 patients. Thirty patients were evaluated with both thoracic LU and chest CT scan, representing a total of 279 thoracic regions explored. The most frequent LU finding was B2-lines (49.1%). The most CT-scan finding was ground-glass opacity (GGO, 29%). Pathological CT-scan findings were commonly observed when B2-lines or C-lines were identified through LU (positive predictive value, PPV, 87.1%). Twenty-five postmortem echo-guided histological samples were obtained from 12 patients. Histological samples showed diffuse alveolar damage (DAD) (75%) and chronic interstitial inflammation (25%). The observed DAD was heterogeneous, showing multiple evolving patterns of damage, including exudative (33.3%), fibrotic (33.3%), and organizing (8.3%) phases. In those patients with acute or exudative pattern, two lesions were distinguished: classic hyaline membrane; fibrin "plug" in alveolar space (acute fibrinous organizing pneumonia, AFOP). C-profile was described in 33.3% and presented histological signs of DAD and lung fibrosis. The predominant findings were collagen deposition (50%) and AFOP (50%). B2-lines were identified in 66.7%; the presence of hyaline membrane was the predominant finding (37.5%), then organizing pneumonia (12.5%) and fibrosis (37.5%). No A-lines or B1-lines were observed in these patients.

Conclusion

LU B2-lines and C-profile are predominantly identified in patients with severe COVID-19 with respiratory worsening, which correspond to different CT patterns and histological findings of DAD and lung fibrosis.

Potentials of post-mortem CT investigations during SARS-COV-2 pandemic: a narrative review

In December 2019, a new coronavirus, SARS-COV-2, caused a cluster of cases of pneumonia in China, and rapidly spread across the globe. It was declared a pandemic by the World Health Organization on March 11th, 2020. Virtual autopsy by post-mortem CT (PMCT) and its ancillary techniques are currently applied in post-mortem examinations as minimally or non-invasive techniques with promising results. In this narrative review, we speculate on the potentials of PMCT and its ancillary techniques, as a viable investigation technique for analysis of suspected or confirmed SARS-COV-2 deaths. An online literature search was performed by using three prefix search terms (postmortem, post-mortem, post mortem) individually combined with the suffix radiology, imaging, computed tomography, CT and with the search terms ‘SARS-CoV-2’ and ‘COVID-19’ to identify papers about PMCT and its ancillary techniques in SARS-COV-2 positive cadavers. PMCT findings suggestive for pulmonary COVID-19 in deceased positive SARS-COV-2 infection are reported in the literature. PMCT ancillary techniques were never applied in such cases. PMCT imaging of the lungs has been proposed as a pre-autopsy screening method for SARS-COV-2 infection. Further studies are needed to ascertain the value of PMCT in determining COVID-19 as the cause of death without autopsy histopathological confirmation. We advocate the application of PMCT techniques in the study of ascertained or suspected SARS-COV-2 infected deceased individuals as a screening technique and as a method of post-mortem investigation, to augment the numbers of case examined and significantly reducing infection risk for the operators.

SARS-CoV-2 viral load and replication in postmortem examinations

We examined 29 autopsy cases (investigated between October 2020 and February 2021) whose postmortem swabs tested positive for SARS-CoV-2. Twenty-two of 29 cases died while hospitalized (H), while the remaining 7 cases were not hospitalized (NH). Since we included only cases in which the time since death was known (excluding unwitnessed NH deaths), the interval between death and postmortem swab(s) was registered, with a mean NH value of 5.50 days and a mean H value of 3.98 days. The mean age of NH was 65 years, while H were older (mean age: 73 years). Twenty-eight nasopharyngeal and 27 lungs postmortem swabs were obtained and real-time reverse transcriptase‒polymerase chain reaction assay for total and replicative SARS-CoV-2 RNA and mRNA detection was performed. Although the mean death-postmortem swabs interval was higher in NH than in H, the mean viral load of NH was higher than that of H (2.53 × 10¹¹ copies/mL vs 9.31 × 10⁸ copies/mL). In 13/29 cases (6 NH and 7 H), indicators of active replication were found. The relationship between the presence of replicative mRNA and death without hospitalization and that between the minimum cycle threshold value of SARS-CoV-2 RNA and the cycle threshold value of replicative SARS-CoV-2 mRNA were found to be statistically significant (with respective P values of 0.013 and 0.000). Therefore, especially in NH, full compliance with guidelines on biological safety in the autopsy room is essential, and no autopsy can be performed on infected cases in a structure that does not meet the established safety criteria.

Knowledge, attitude, and practice of forensic practitioners during COVID-19 pandemic in Arab countries

COVID-19 pandemic burdens forensic practice worldwide. The experience of crisis management is a lesson learned that guides future preparedness for similar casualties. Thus, the present study takes an in-depth look at the knowledge, attitude, and practice of forensic practitioners during the COVID-19 pandemic in the Arab world. A comprehensive questionnaire was adopted in compliance with optimum international standards for the management of deaths during the pandemic. The survey was electronically distributed in 13 Arab countries. The responses were received from 29 forensic practitioners from 11 countries. Total median knowledge, attitude, and practice scores of respondents constituted 37.9%, 74%, and 36.8% of optimum scores respectively. Regarding knowledge, better scores are related to risk assessment and routes of exposure to Coronavirus, whereas, least scores were related to ventilation and negative pressure system. Most of the participants had a positive attitude, 85.2% were concerned about proper management of COVID-19 deaths, and 77.8% trusted the decisions of their teams. Considering practice, better scores are related to forensic staff competence, whereas, least scores were related to the implementation of ideal safety measures. Participants described the management process as useful (52%), reliable (35%), high quality (21%), and cost-effective (17%), however, they expressed challenges as staff infection, limited resources, and infrastructure issues. This survey guides readjusting of procedures and future preparedness for similar disasters in the Arab world. This research adopted a questionnaire that could be used in initial and periodic assessments in any medicolegal institute worldwide. Also, it could support infrastructure projects and disaster management plans.

Cytokine storm and histopathological findings in 60 cases of COVID-19-related death: from viral load research to immunohistochemical quantification of major players IL-1β, IL-6, IL-15 and TNF-α

This study involves the histological analysis of samples taken during autopsies in cases of COVID-19 related death to evaluate the inflammatory cytokine response and the tissue localization of the virus in various organs. In all the selected cases, SARS-CoV-2 RT-PCR on swabs collected from the upper (nasopharynx and oropharynx) and/or the lower respiratory (trachea and primary bronchi) tracts were positive. Tissue localization of SARS-CoV-2 was detected using antibodies against the nucleoprotein and the spike protein. Overall, we tested the hypothesis that the overexpression of proinflammatory cytokines plays an important role in the development of COVID-19-associated pneumonia by estimating the expression of multiple cytokines (IL-1β, IL-6, IL-10, IL-15, TNF-α, and MCP-1), inflammatory cells (CD4, CD8, CD20, and CD45), and fibrinogen. Immunohistochemical staining showed that endothelial cells expressed IL-1β in lung samples obtained from the COVID-19 group (p < 0.001). Similarly, alveolar capillary endothelial cells showed strong and diffuse immunoreactivity for IL-6 and IL-15 in the COVID-19 group (p < 0.001). TNF-α showed a higher immunoreactivity in the COVID-19 group than in the control group (p < 0.001). CD8 + T cells where more numerous in the lung samples obtained from the COVID-19 group (p < 0.001). Current evidence suggests that a cytokine storm is the major cause of acute respiratory distress syndrome (ARDS) and multiple organ failure and is consistently linked with fatal outcomes.

Translational deep phenotyping of deaths related to the COVID-19 pandemic: protocol for a prospective observational autopsy study

INTRODUCTION

The COVID-19 pandemic is an international emergency with an extreme socioeconomic impact and a high mortality and disease burden. The COVID-19 outbreak is neither fully understood nor fully pictured. Autopsy studies can help understand the pathogenesis of COVID-19 and has already resulted in better treatment of patients. Structured and systematic autopsy of COVID-19-related deaths will enhance the mapping of pathophysiological pathways, not possible in the living. Furthermore, it provides an opportunity to envision factors translationally for the purpose of disease prevention in this and future pandemics. This is the protocol for an autopsy study that offers an umbrella for deep and diverse investigations of COVID-19-related deaths, including a systematic investigation of 'long' COVID-19 by means of extensive and systematic tissue sampling.

METHODS AND ANALYSIS

A COVID-19-specific autopsy algorithm has been created to cover all cases undergoing clinical or forensic autopsy in Denmark. The algorithm describes advanced tissue sampling and a translational analytical follow-up for deep phenotyping. The translational approach covers registry data, postmortem imaging, gross autopsy findings, microscopic organ changes, postmortem toxicology, postmortem biochemical investigation, microbiological profiling and immunological status at the time of death, and future research projects covering genetics and epigenetics on an organ level.

ETHICS AND DISSEMINATION

This study has been approved by the Regional Ethics Committee of the Region of Greater Copenhagen (No: H-20078436) and the Danish Data Protection Agency (No: 2002-54-1080). Next of kin gave informed consent to research. The study results will be published in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

This study is purely observational and, as such, does not meet the criteria of the International Committee of Medical Journal Editors for clinical trials; thus, there is no need for registration in a database of research trials, such as clinical trials. To facilitate cooperation in research, provide transparency on case recruitment for publications to come and to avoid unnecessary duplicate work, we nevertheless wish to publish our protocol.

Autopsies in pandemics - a perspective on barriers and benefits. Is it time for a revival?

Influenza virus and coronavirus pandemics regularly sweep the globe, at great cost of health and economy. Our aim was to conduct a PubMed search for autopsy studies on influenza and coronavirus to investigate the contribution of autopsies during pandemics, focussing on autopsy methods and procedures and the role of autopsy findings in pandemics. The retrieved autopsy studies generally relied on microscopy, polymerase chain reaction (PCR), immunostaining and electron microscopy. Most were small and reported on lung effects, including diffuse alveolar damage (DAD), pneumonia and tracheobronchitis. Antibiotic therapy has diminished a role for bacterial pneumonia, whereas obesity is an emerging risk factor. Autopsy studies have provided new insights into coronavirus disease 2019 (COVID-19) treatments like anti-coagulative therapy. Unfortunately, autopsies during pandemics are hampered by lack of guidelines, facilities and expertise for handling potentially infectious corpses and by widely varying recommendations for personal protective equipment and procedures. The Department of Forensic Pathology, at the Forensic Institute, at the University of Copenhagen in Denmark has, in collaboration with the Department of Pathology, Rigshospitalet, Copenhagen, initiated a prospective observational study on COVID-19-related deaths encompassing postmortem imaging, standardized autopsy procedures/reporting and extensive tissue sampling for histological, chemical, microbiological and genetic analysis. The study involves a diverse array of research groups at the University of Copenhagen, and the clinical field.

Persistence of SARS-CoV-2 in deceased patients and safe handling of infected bodies

This article analyzes the literature on SARS-CoV-2 persistence in the corpses of patients infected with COVID-19, possible routes of viral transmission from the bodies and biosafety measures to prevent the spread of the infection. SARS-CoV-2 persists for quite long in the tissues and bodily fluids of decedents with COVID-19 and on various surfaces. The longest viability of the virus is on stainless steel and plastic surfaces that come in contact with the infected body. Autopsies on decedents with COVID-19 must be performed at specially conditioned facilities. Medical and forensic pathologists and other mortuary workers must adhere to stringent biosafety requirements.

The handling of SARS-CoV-2 associated deaths - infectivity of the body

The body of a deceased with Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection is considered infectious. In this study, we present the results of infectivity testing of the body and testing of mortuary staff for SARS-CoV-2. We performed real-time quantitative polymerase chain reaction (RT-qPCR) for SARS-CoV-2 on 33 decedents with ante mortem confirmed SARS-CoV-2 infection. Swabs of the body surface from five different body regions and from the body bag or coffin were examined. A subset of the swabs was brought into cell culture. In addition, screening of 25 Institute of Legal Medicine (ILM) personnel for ongoing or past SARS-CoV-2 infection was performed at two different time points during the pandemic. Swabs from all locations of the body surface and the body environment were negative in cases of negative post mortem nasopharyngeal testing (n=9). When the post mortem nasopharyngeal swab tested positive (n=24), between 0 and 5 of the body surface swabs were also positive, primarily the perioral region. In six of the cases, the body bag also yielded a positive result. The longest postmortem interval with positive SARS-CoV-2 RT-qPCR at the body surface was nine days. In no case viable SARS-CoV-2 was found on the skin of the bodies or the body bags. One employee (autopsy technician) had possible occupational infection with SARS-CoV-2; all other employees were tested negative for SARS-CoV-2 RNA or antibody twice. Our data indicate that with adequate management of general safety precautions, transmission of SARS-CoV-2 through autopsies and handling of bodies is unlikely.

Histopathological features in fatal COVID-19 acute respiratory distress syndrome

Background

COVID-19 acute respiratory distress syndrome (ARDS) shares the common histological hallmarks with other forms of ARDS. However, the chronology of the histological lesions has not been well established.

Objective

To describe the chronological histopathological alterations in the lungs of patients with COVID-19 related ARDS.

Design

A prospective cohort study was carried out.

Setting

Intensive Care Unit of a tertiary hospital.

Patients

The first 22 consecutive COVID-19 deaths.

Measurements

Lung biopsies and histopathological analyses were performed in deceased patients with COVID-19 related ARDS. Clinical data and patient course were evaluated.

Results

The median patient age was 66 [63-74] years; 73% were males. The median duration of mechanical ventilation was 17 [8-24] days. COVID-19 induced pulmonary injury was characterized by an exudative phase in the first week of the disease, followed by a proliferative/organizing phase in the second and third weeks, and finally an end-stage fibrosis phase after the third week. Viral RNA and proteins were detected in pneumocytes and macrophages in a very early stage of the disease, and were no longer detected after the second week.

Limitation

Limited sample size.

Conclusions

The chronological evolution of COVID-19 lung histopathological lesions seems to be similar to that seen in other forms of ARDS. In particular, lung lesions consistent with potentially corticosteroid-sensitive lesions are seen.

Claimed medical malpractice in fatal SARS-CoV-2 infections: the importance of combining ante- and post-mortem radiological data and autopsy findings for correct forensic analysis

We present the case of an elderly woman who died from COVID-19 during the first wave of the pandemic. The physicians in charge of the patient were later accused of medical malpractice resulting in the death of the patient. The article reviews the comprehensive medico-legal investigations into this case that included an analysis of the medical history, clinical imaging, post-mortem imaging, autopsy, histopathology, and microbiology as well as an assessment of the medical knowledge regarding transmission of the SARS-CoV-2 virus and the management of COVID-19 at the time of the patient's death. The investigation resulted in a verdict of not guilty. This case highlights the value of clinical and post-mortem imaging as well as various challenges of medico-legal investigations of COVID-19 related deaths.

Histopathological features in fatal COVID-19 acute respiratory distress syndrome

BACKGROUND

COVID-19 acute respiratory distress syndrome (ARDS) shares the common histological hallmarks with other forms of ARDS. However, the chronology of the histological lesions has not been well established.

OBJECTIVE

To describe the chronological histopathological alterations in the lungs of patients with COVID-19 related ARDS.

DESIGN

A prospective cohort study was carried out.

SETTING

Intensive Care Unit of a tertiary hospital.

PATIENTS

The first 22 consecutive COVID-19 deaths.

MEASUREMENTS

Lung biopsies and histopathological analyses were performed in deceased patients with COVID-19 related ARDS. Clinical data and patient course were evaluated.

RESULTS

The median patient age was 66 [63-74] years; 73% were males. The median duration of mechanical ventilation was 17 [8-24] days. COVID-19 induced pulmonary injury was characterized by an exudative phase in the first week of the disease, followed by a proliferative/organizing phase in the second and third weeks, and finally an end-stage fibrosis phase after the third week. Viral RNA and proteins were detected in pneumocytes and macrophages in a very early stage of the disease, and were no longer detected after the second week.

LIMITATION

Limited sample size.

CONCLUSIONS

The chronological evolution of COVID-19 lung histopathological lesions seems to be similar to that seen in other forms of ARDS. In particular, lung lesions consistent with potentially corticosteroid-sensitive lesions are seen.

COVID-19 autopsies of Istanbul

Background/aims

The aim of this study is to share autopsy findings of COVID-19-positive cases and autopsy algorithms for safely handling of suspicious bodies during this pandemic.

Methods

COVID-19-positive cases of Istanbul Morgue Department were retrospectively analyzed. Sampling indications for PCR tests in suspicious deaths, macroscopic and microscopic findings obtained in cases with positive PCR tests were evaluated.

Results

In the morgue department, 345(25.8%) of overall 1336 autopsy cases were tested for COVID-19. PCR test was found positive in 26 cases. Limited autopsy procedure was performed in 7 cases, while the cause of death was determined by external examination in the remaining 19 cases. Male-to-female ratio was found 3.3:1 and mean age was 60.0 ± 13.6 among all PCR-positive cases. Cause of death was determined as viral pneumonia in fully autopsied cases. Most common findings were sticky gelatinous fluid in cavities and firm and swollen lungs, varying degrees of consolidation. In microscopy, diffuse alveolar epithelial damage, type-II pneumocyte hyperplasia, hyaline membrane formation, fibrinous exudate, and fibrinous plaques in the alveoli were the most common findings.

Conclusions

In COVID-19 autopsies, pulmonary findings were found to be prominent and the main pathology was pneumonia. Older age and findings of chronic diseases indicate that the cases were in the multirisk group in terms of COVID-19 mortality.

Safe Management Strategies in Clinical Forensic Autopsies of Confirmed COVID-19 Cases

To date, there is poor evidence on the transmission of infection in individuals handling the bodies of deceased persons infected with SARS-CoV-2 and in particular, during autopsies. The aim of this study was to demonstrate that when appropriate strategies are adopted autopsy is a safe procedure with a minimal infection risk for all subjects involved (pathologists, technical personnel, and others) when proper strategies are adopted. We performed 16 autopsies on cadavers of persons who had died with confirmed COVID-19 with different post-mortem intervals (PMI). To confirm the presence of SARS-CoV-2 RNA, for each autopsy, 2 swabs were sampled from lungs, while to evaluate environmental contamination, 11 swabs were taken at three different times: T0 (before autopsy), T1 (at the end of the autopsy, without removing the corpse), and T2 (after cleaning and disinfecting the autopsy room). Specifically, 2 swabs were sampled on face shields used by each pathologist, and 4 swabs were collected on the autopsy table; 4 swabs were also collected from walls and 1 from floor. Lung swabs confirmed the presence of SARS-CoV-2 RNA in all cases. Environmental swabs, collected at T0 and T2 were all negative, while swabs sampled at T1 were shown to be positive. Interestingly, no association was shown between PMI length and environmental contamination. Infection control strategies for safe management of clinical forensic autopsies of bodies with suspected or confirmed COVID-19 are also described.

Inexplicable COVID-19! Would pathological autopsy be the panacea?

SARS-CoV-2 has swamped the entire world, unfolding into a COVID-19 pandemic. Efforts are on to develop an understanding of the various aspects related to SARS-CoV-2 and COVID-19. A pathological autopsy can play a vital role in understanding the pathophysiology of the disease, which may be vital in evolving effective management strategies. Despite its significance in the present circumstances, only a limited number of pathological autopsies are being conducted worldwide. The paper stresses on the need for taking up pathological autopsies globally and discusses its present status and the way forward, along with international perspectives and recommendations for consideration of pathological autopsy. (www.actabiomedica.it)

Persistence of SARS-CoV-2 RNA in post-mortem swab 35 days after death: A case report

Post-mortem swabs for Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) RNA detection have been recommended by several Scientific Committees and Institutions as a standard procedure for post-mortem assessment of potential Coronavirus Disease-19 (COVID-19) related deaths. To date there is no data about the SARS-CoV-2 RNA detectability period in human bodies after death. The present case documents the persistence of SARS-CoV-2 RNA in the upper respiratory tract 35-days after death. Post-mortem swabs could be used as a valuable tool in preventive evaluation of the risks-benefits ratio associated with autopsy execution. SARS-CoV-2 RNA post-mortem detection could have a key diagnostic role in deaths lacking medical assistance, unattended deaths, and patients with multiple comorbidities. Based on the present report, staged post-mortem swabs should be performed even after a long post-mortem interval.

[Histopathological features due to the SARS-CoV-2]

The infection due to the SARS-CoV-2 leads lesions mainly observed at the respiratory tract level, but not exclusively. The analyses of these lesions benefited from different autopsy studies. Thus, these lesions were observed in different organs, tissues and cells. These observations allowed us to rapidly improve the knowledge of the pathophysiological mechanisms associated with this emergent infectious disease. The virus can be detected in formalin fixed paraffin embedded tissues using immunohistochemistry, in situ hybridization, molecular biology and/or electron microscopy approaches. However, many uncertainties are still present concerning the direct role of the SARS-CoV-2 on the different lesions observed in different organs, outside the lung, such as the heart, the brain, the liver, the gastrointestinal tract, the kidney and the skin. In this context, it is pivotal to keep going to increase the different tissue and cellular studies in the COVID-19 positive patients aiming to better understanding the consequences of this new infectious disease, notably considering different epidemiological and co-morbidities associated factors. This could participate to the development of new therapeutic strategies too. The purpose of this review is to describe the main histological and cellular lesions associated with the infection due to the SARS-CoV-2.

Preventive home therapy for symptomatic patients affected by COVID-19 and followed by teleconsultations

In this paper we present our experience on the treatment at home of Covid+ symptomatic patients. One hundred and eighty-two subjects (111 men and 71 women) aged from 32 to 71 years have been consecutively followed at home in telemedicine from 1st September to 24th December 2020. We were informed almost twice daily in morning and evening about body temperature, symptoms (cough, shortness of breath or difficulty breathing, fatigue, muscle of body aches, headache, loss of taste or smell, sore throat, congestion or runny nose, nausea and vomiting, diarrhea), oxygen saturation measured by digital pulse oximetry and blood pressure. Our protocol of treatment was based on early use of prednisone (25 mg in the morning and 12.5 mg in the afternoon) and low molecular weight heparin (4000 UI one or two times daily) initiated just after the positivity of molecular nasopharyngeal test (about 3-4 days as mean time after initiation of symptomatology and not after 7-8 days as suggested by other protocols) and oxygen therapy when necessary. Antibiotics such as azithromycin for six days was added. It is always recommended to associate lansoprazole 30 mg to prevent gastric hemorrhages and potassium and magnesium supplements. This treatment scheme was able to reduce the risk of hospitalization as only 4 patients needed to be admitted to the Hospital, and only two in subintensive department. After negativeness of molecular nasopharyngeal test, patients were invited for a thoracic computerized tomography and laboratory evaluation of d-dimer and other data of inflammation to show eventual lung interstitial involvement characteristic of COVID-19.

[Histological pulmonary features due to the Sars-CoV-2]

The histological lesions associated with an infection with the Sars-CoV-2 are mainly observed at the respiratory tract level, but not exclusively. Analyses of these lesions strongly beneficied from autopsic studies allowing us to improve the knowledge of the pathophysiology mechanisms of this emerging infectious disease. Cytological analyses, notably those obtained from broncho-alveolar lavages, poorly contribute to the Covid-19 diagnosis, but can be usefull for eliminate a couple of differential diagnoses. Although non specific, the lesions observed in the pulmonary parenchyma can be directly associated with the presence of the Sars-CoV-2 thanks to ancillary tools allowing its detection. Indeed, the presence of the virus can be detected using immunohistochemistry, in situ hybridization, molecular biology and/or electron microscopy approaches. Several uncertainties still exist concerning the direct role due to the Sars-CoV-2 in the observed lesions which can be due too to a cardiovascular failure and/or to the treatment(s) received in intensive care units. Thus, it is critical to keep going to increase our efforts for the tissue analyses, notably thanks to the autopsies of Covid-19 patients, in order to better understand the consequences of this infectious disease, and, particularly according the epidemiological factors and the different associated morbidities. An increased knowledge will participate to the further therapeutic strategies against the Covid-19. This review adresses the main histological lesions of the lung parenchyma currently described in patients infected by the Sars-CoV-2.

Perils of human remains examination in COVID-19 times

The novel coronavirus, SARS-CoV-2 has surged globally bringing the whole world virtually to a standstill. Due to its highly contagious nature, various guidelines, protocols and preventive strategies have been devised for the safety of healthcare workers during management of the living as well as the dead. However, guidelines and precautions to be followed during the examination of the human skeletal remains are largely lacking. The present communication intends to address the issue of safe handling of human remains during medicolegal investigations in the COVID-19 pandemic times.

Postmortem Swabs in the Severe Acute Respiratory Syndrome Coronavirus 2 Pandemic: Report on 12 Complete Clinical Autopsy Cases

CONTEXT.—

Clinical autopsies have historically provided a fundamental contribution in the definition of the clinicopathologic basis of infectious diseases. Even though we are witnessing the decline of the clinical autopsy, its importance remains unchanged as it is the most exhaustive way to investigate diseases. The identification of the virus in postmortem tissues is a fundamental step in the definition of its clinical features.

OBJECTIVE.—

To investigate the presence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in postmortem examination with swabs.

DESIGN.—

We performed postmortem swabs in 12 autopsy cases of patients with a clinical diagnosis of SARS-CoV-2-related pneumonia. Our protocol consisted of a rhinopharyngeal and a tracheal swab in order to search for the virus in the upper airways, and of 2 swabs on the parenchyma of each lung. We also performed a fifth swab on the parenchyma of both lungs in order to search for other viruses that could evolve in a clinical picture of interstitial pneumonia.

RESULTS.—

Overall, we found 9 of 12 cases had at least 1 postmortem swab positive for SARS-CoV-2. Moreover, we evaluated the time between the antemortem and postmortem swabs, the time between death and the postmortem swabs, and the time between the postmortem swabs and acceptance to the microbiology laboratory. Of note, we did not find a relationship between the results of the swabs and either the time elapsed from their collection or the time elapsed before their acceptance in the microbiology laboratory.

CONCLUSIONS.—

A thorough knowledge of the eventual persistence of pathogens in deaths related to infectious diseases is fundamental for the safety of the operators during the autopsy practice, especially when referring to emergent pathogens, such as SARS-CoV-2. Our study highlights the importance in performing multiple swabs in the postmortem examination, because SARS-CoV-2 swab positivity can be limited to only a single swab.

Autopsy Services and Emergency Preparedness of a Tertiary Academic Hospital Mortuary for the COVID-19 Public Health Emergency: The Yale Plan

Pathology Autopsy and Mortuary Services have been front and center in the severe acute respiratory syndrome coronavirus 2 (SARS-Co-V-2) pandemic. The sheer number of fatalities from the pandemic have been unlike any other in recent memory and needed the rapid creation of new protocols and paradigms to manage the situation. This required rapidly escalating mortuary capacity to manage the increased fatalities from the pandemic with the establishment of lines of communication and networking with governmental entities, institution of new policies for patient flow, and implementation of worker infection control and well-being plans. Autopsies also assumed a crucial role, both to provide insight into the pathomechanisms of a novel disease and to allow tissue retrieval necessary to power research directed towards finding a vaccine. We here outline the plan adopted by the Yale Autopsy and Mortuary Services, in alignment with the institutional mission of high-quality patient care, education, research and health care worker safety and well-being, as the Corona Virus Disease of 2019 (COVID-19) pandemic surged in Connecticut. In the early response phase, ensuring sufficient mortuary capacity necessarily took center stage. As we enter the recovery and plateau phase of the pandemic, setting up a process for a rapid and safe autopsy, that will meet educational and research needs while ensuring the safety of our workforce is being implemented.

Autopsies of COVID-19 deceased? Absolutely!

Autopsies are an essential tool for understanding new diseases. Against this background, it is incomprehensible why there is great reluctance worldwide to perform autopsies on COVID-19 deceased patients. The article provides an overview of the status of the autopsy series published worldwide and shows the path taken by the city of Hamburg in Germany, where autopsies are ordered by the health authorities in the interests of disease control. The risk of infection posed by SARS-CoV-2-positive deceased persons may be overestimated. The scientific benefit that can be drawn from experience with autopsies and further examination of tissue samples is immeasurable.

More than Pneumonia: Distinctive Features of SARS-Cov-2 Infection. From Autopsy Findings to Clinical Implications: A Systematic Review

Despite safety recommendations for the management of corpses with COVID-19 infection and the high number of deaths worldwide, the post-mortem investigation rate is extremely low as well as the scientific contributions describing the pathological features. The first results of post-mortem investigations provided interesting findings and contributed to promoting unexplored therapeutic approaches and new frontiers of research. A systematic review is provided with the aim of summarizing all autopsy studies up to February 2020 in which a complete post-mortem investigation in patients with COVID-19 disease was performed, focusing on histopathological features. We included case reports, case series, retrospective and prospective studies, letters to the editor, and reviews. A total of 28 studies fulfilled the inclusion criteria, producing a pooled dataset of 407 full autopsies. Analyzing the medical history data, only 12 subjects had died without any comorbidities (for 15 cases the data were not available). The post-mortem investigation highlighted that acute respiratory distress syndrome (ARDS) and multiple organ failure represent the main clinical features of COVID-19 disease, often leading to pulmonary thromboembolism and superimposed bronchopneumonia. The discussed data showed a strict relationship among the inflammatory processes, diffuse alveolar, and endothelial damage. In light of these results, the full autopsy can be considered as the gold standard to investigate unknown infections or pathogens resulting in death.

Validation of a composed COVID-19 chest radiography score: the CARE project

OBJECTIVES

The aim of this study was to validate a composed coronavirus disease 2019 (COVID-19) chest radiography score (CARE) based on the extension of ground-glass opacity (GG) and consolidations (Co), separately assessed, and to investigate its prognostic performance.

METHODS

COVID-19-positive patients referring to our tertiary centre during the first month of the outbreak in our area and with a known outcome were retrospectively evaluated. Each lung was subdivided into three areas and a three-grade score assessing the extension of GG and Co was used. The CARE was derived from the sum of the subscores. A mixed-model ANOVA with post hoc Bonferroni correction was used to evaluate whether differences related to the referring unit (emergency room, COVID-19 wards and intensive care unit (ICU)) occurred. Logistic regression analyses were used to investigate the impact of CARE, patients' age and sex on the outcome. To evaluate the prognostic performance of CARE, receiver operating characteristic curves were computed for the entire stay and at admission only.

RESULTS

A total of 1203 chest radiographs of 175 patients (120 males; mean age 67.81±15.5 years old) were examined. On average, each patient underwent 6.8±10.3 radiographs. Patients in ICU as well as deceased patients showed higher CARE scores (p<0.05, each). Age, Co and CARE significantly influenced the outcome (p<0.05 each). The CARE demonstrated good accuracy (area under the curve (AUC)=0.736) using longitudinal data as well as at admission only (AUC=0.740). A CARE score of 17.5 during hospitalisation showed 75% sensitivity and 69.9% specificity.

CONCLUSIONS

The CARE was demonstrated to be a reliable tool to assess the severity of pulmonary involvement at chest radiography with a good prognostic performance.

Histopathological findings and viral tropism in UK patients with severe fatal COVID-19: a post-mortem study

BACKGROUND

Severe COVID-19 has a high mortality rate. Comprehensive pathological descriptions of COVID-19 are scarce and limited in scope. We aimed to describe the histopathological findings and viral tropism in patients who died of severe COVID-19.

METHODS

In this case series, patients were considered eligible if they were older than 18 years, with premortem diagnosis of severe acute respiratory syndrome coronavirus 2 infection and COVID-19 listed clinically as the direct cause of death. Between March 1 and April 30, 2020, full post-mortem examinations were done on nine patients with confirmed COVID-19, including sampling of all major organs. A limited autopsy was done on one additional patient. Histochemical and immunohistochemical analyses were done, and histopathological findings were reported by subspecialist pathologists. Viral quantitative RT-PCR analysis was done on tissue samples from a subset of patients.

FINDINGS

The median age at death of our cohort of ten patients was 73 years (IQR 52-79). Thrombotic features were observed in at least one major organ in all full autopsies, predominantly in the lung (eight [89%] of nine patients), heart (five [56%]), and kidney (four [44%]). Diffuse alveolar damage was the most consistent lung finding (all ten patients); however, organisation was noted in patients with a longer clinical course. We documented lymphocyte depletion (particularly CD8-positive T cells) in haematological organs and haemophagocytosis. Evidence of acute tubular injury was noted in all nine patients examined. Major unexpected findings were acute pancreatitis (two [22%] of nine patients), adrenal micro-infarction (three [33%]), pericarditis (two [22%]), disseminated mucormycosis (one [10%] of ten patients), aortic dissection (one [11%] of nine patients), and marantic endocarditis (one [11%]). Viral genomes were detected outside of the respiratory tract in four of five patients. The presence of subgenomic viral RNA transcripts provided evidence of active viral replication outside the respiratory tract in three of five patients.

INTERPRETATION

Our series supports clinical data showing that the four dominant interrelated pathological processes in severe COVID-19 are diffuse alveolar damage, thrombosis, haemophagocytosis, and immune cell depletion. Additionally, we report here several novel autopsy findings including pancreatitis, pericarditis, adrenal micro-infarction, secondary disseminated mucormycosis, and brain microglial activation, which require additional investigation to understand their role in COVID-19.

FUNDING

Imperial Biomedical Research Centre, Wellcome Trust, Biotechnology and Biological Sciences Research Council.

Fibrotic progression and radiologic correlation in matched lung samples from COVID-19 post-mortems

Data on the pathology of COVID-19 are scarce; available studies show diffuse alveolar damage; however, there is scarce information on the chronologic evolution of COVID-19 lung lesions. The primary aim of the study is to describe the chronology of lung pathologic changes in COVID-19 by using a post-mortem transbronchial lung cryobiopsy approach. Our secondary aim is to correlate the histologic findings with computed tomography patterns. SARS-CoV-2-positive patients, who died while intubated and mechanically ventilated, were enrolled. The procedure was performed 30 min after death, and all lung lobes sampled. Histopathologic analysis was performed on thirty-nine adequate samples from eight patients: two patients (illness duration < 14 days) showed early/exudative phase diffuse alveolar damage, while the remaining 6 patients (median illness duration—32 days) showed progressive histologic patterns (3 with mid/proliferative phase; 3 with late/fibrotic phase diffuse alveolar damage, one of which with honeycombing). Immunohistochemistry for SARS-CoV-2 nucleocapsid protein was positive predominantly in early-phase lesions. Histologic patterns and tomography categories were correlated: early/exudative phase was associated with ground-glass opacity, mid/proliferative lesions with crazy paving, while late/fibrous phase correlated with the consolidation pattern, more frequently seen in the lower/middle lobes. This study uses an innovative cryobiopsy approach for the post-mortem sampling of lung tissues from COVID-19 patients demonstrating the progression of fibrosis in time and correlation with computed tomography features. These findings may prove to be useful in the correct staging of disease, and this could have implications for treatment and patient follow-up.

Innovative diagnostic approach and investigation trends in COVID19-A systematic review

A highly contagious viral infection emerged in Wuhan city; China had increased mortality with uncertain pathogenesis spreads throughout the world to become a pandemic. It is reported to be caused by a member of β coronaviruses and named it as COVID-19 by the World Health Organization (WHO). The disease is caused by a mutant strain of coronavirus SARS-COV-2 that affects the respiratory tract causing mild to severe respiratory tract illness. The clinical manifestation ranges from mild, moderate, severe and very severe signs and symptoms result in death due to severe hypoxia or multi-organ dysfunction. Also, the affected persons were capable of infecting others through various modes of transmission through respiratory droplets (aerosol spread). A definite investigation protocol has followed to diagnose COVID 19 disease but mainly confirmed with reverse transcription polymerase chain reaction. Computerized tomography scan plays a significant role in the diagnosis and prognosis of affected individuals. The major problem with COVID-19 is due to its novelty and lack of vaccination or treatment. This review focuses on the mutation, pathogenesis, various diagnostic tests adopted and autopsy findings in patients affected with COVID-19.

Histopathological findings and viral tropism in UK patients with severe fatal COVID-19: a post-mortem study

Background

Severe COVID-19 has a high mortality rate. Comprehensive pathological descriptions of COVID-19 are scarce and limited in scope. We aimed to describe the histopathological findings and viral tropism in patients who died of severe COVID-19.

Methods

In this case series, patients were considered eligible if they were older than 18 years, with premortem diagnosis of severe acute respiratory syndrome coronavirus 2 infection and COVID-19 listed clinically as the direct cause of death. Between March 1 and April 30, 2020, full post-mortem examinations were done on nine patients with confirmed COVID-19, including sampling of all major organs. A limited autopsy was done on one additional patient. Histochemical and immunohistochemical analyses were done, and histopathological findings were reported by subspecialist pathologists. Viral quantitative RT-PCR analysis was done on tissue samples from a subset of patients.

Findings

The median age at death of our cohort of ten patients was 73 years (IQR 52–79). Thrombotic features were observed in at least one major organ in all full autopsies, predominantly in the lung (eight [89%] of nine patients), heart (five [56%]), and kidney (four [44%]). Diffuse alveolar damage was the most consistent lung finding (all ten patients); however, organisation was noted in patients with a longer clinical course. We documented lymphocyte depletion (particularly CD8-positive T cells) in haematological organs and haemophagocytosis. Evidence of acute tubular injury was noted in all nine patients examined. Major unexpected findings were acute pancreatitis (two [22%] of nine patients), adrenal micro-infarction (three [33%]), pericarditis (two [22%]), disseminated mucormycosis (one [10%] of ten patients), aortic dissection (one [11%] of nine patients), and marantic endocarditis (one [11%]). Viral genomes were detected outside of the respiratory tract in four of five patients. The presence of subgenomic viral RNA transcripts provided evidence of active viral replication outside the respiratory tract in three of five patients.

Interpretation

Our series supports clinical data showing that the four dominant interrelated pathological processes in severe COVID-19 are diffuse alveolar damage, thrombosis, haemophagocytosis, and immune cell depletion. Additionally, we report here several novel autopsy findings including pancreatitis, pericarditis, adrenal micro-infarction, secondary disseminated mucormycosis, and brain microglial activation, which require additional investigation to understand their role in COVID-19.

Funding

Imperial Biomedical Research Centre, Wellcome Trust, Biotechnology and Biological Sciences Research Council.

"Tomorrow Never Dies": Recent Advances in Diagnosis, Treatment, and Prevention Modalities against Coronavirus (COVID-19) amid Controversies

The outbreak of novel coronavirus disease (2019-nCoV or COVID-19) is responsible for severe health emergency throughout the world. The attack of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is found to be responsible for COVID-19. The World Health Organization has declared the ongoing global public health emergency as a pandemic. The whole world fights against this invincible enemy in various capacities to restore economy, lifestyle, and safe life. Enormous amount of scientific research work(s), administrative strategies, and economic measurements are in place to create a successful step against COVID-19. Furthermore, differences in opinion, facts, and implementation methods laid additional layers of complexities in this battle against survival. Thus, a timely overview of the recent, important, and overall inclusive developments against this pandemic is a pressing need for better understanding and dealing with COVID-19. In this review, we have systematically summarized the epidemiological studies, clinical features, biological properties, diagnostic methods, treatment modalities, and preventive measurements related to COVID-19.

The Impact of the COVID-19 Pandemic and the Associated Belgian Governmental Measures on Cancer Screening, Surgical Pathology and Cytopathology

Introduction

The severe acute respiratory syndrome coronavirus 2 caused a pandemic of coronavirus disease 2019 (COVID-19). Unprecedented public health actions were introduced, including social distancing, travel restrictions and quarantine. The Belgian government announced a national emergency plan, thereby postponing all non-urgent medical consultations and operations. This report analyses the impact of these measures on cancer screening, through assessment of the workload of a laboratory for histopathology and cytopathology.

Methods

Data on monthly numbers of histological and cytological samples, immunohistochemistry and molecular tests were extracted from the laboratory information management system.

Results

The global histopathological and cytological workload was substantially reduced. The impact on oncology-related surgical procedures was rather limited. The anti-COVID-19 measures significantly diminished all screening-related samples, such as colon biopsies, breast biopsies and cervical cytology, and strongly reduced the number of samples related to “functional” pathology, such as thyroidectomies and gastric biopsies.

Conclusions

Since many health care interventions are reflected in the workload of a pathology laboratory, this study enabled us to identify areas for “deconfinement” health care actions. Our findings indicate that various areas in medicine were affected, but the impact seemed largest for cancer screening. Health care professionals should assure that consultations related to cancer screening are postponed instead of cancelled.