[Update on collaborative autopsy-based research in German pathology, neuropathology, and forensic medicine]

BACKGROUND

Autopsies are a valuable tool for understanding disease, including COVID-19.

MATERIALS AND METHODS

The German Registry of COVID-19 Autopsies (DeRegCOVID), established in April 2020, serves as the electronic backbone of the National Autopsy Network (NATON), launched in early 2022 following DEFEAT PANDEMIcs.

RESULTS

The NATON consortium's interconnected, collaborative autopsy research is enabled by an unprecedented collaboration of 138 individuals at more than 35 German university and non-university autopsy centers through which pathology, neuropathology, and forensic medicine autopsy data including data on biomaterials are collected in DeRegCOVID and tissue-based research and methods development are conducted. More than 145 publications have now emerged from participating autopsy centers, highlighting various basic science and clinical aspects of COVID-19, such as thromboembolic events, organ tropism, SARS-CoV‑2 detection methods, and infectivity of SARS-CoV-2 at autopsy.

CONCLUSIONS

Participating centers have demonstrated the high value of autopsy and autopsy-derived data and biomaterials to modern medicine. The planned long-term continuation and further development of the registry and network, as well as the open and participatory design, will allow the involvement of all interested partners.

COVID-19 lungs in post-mortem computed tomography

Post-mortem computed tomography (PMCT) is a rapid and noninvasive diagnostic tool for important contributions to the identification of pulmonary findings in the deceased with pneumonia, including cases of coronavirus disease 2019 (COVID-19). Although computed tomography (CT) shows a high sensitivity for pneumonia in living persons, it is relatively unspecific for COVID-19 pneumonia clinically. Typical CT findings for viral pneumonia therefore require confirmation by PCR tests (polymerase chain reaction tests), even if lung infections with severe acute respiratory syndrome coronavirus type 2 (SARS-CoV-2) show characteristic patterns, most frequently ground glass opacities (GGO) and a combination of GGO and air space consolidations.

In the consecutive autopsy series of SARS-CoV‑2 deaths from Hamburg, Germany, the most frequent cause of death was and still is COVID-19 pneumonia. Typical findings were frequently found in the PMCT in SARS-CoV-2-associated deaths, which were taken into account when classifying the death as COVID-19.

[The first COVID-19 hotspot in a retirement home in Hamburg]

Background

Coronavirus disease 2019 (COVID-19), a disease caused by the new coronavirus (SARS-CoV-2), is a particular threat to old people. At the end of March 2020, the first and so far largest outbreak of the disease occurred in a retirement home in Hamburg.

Methods

Analysis of procedures in dealing with a residential unit affected by SARS-CoV‑2, accommodating a risk group of 60 seniors with dementia is presented as well as a detailed presentation of post-mortem examination results of all 8 deceased tested positive for SARS-CoV‑2.

Results

Out of 60 residents, 39 were infected by SARS-CoV‑2. Due to preventive procedures it was possible to stop further spreading of the infection to other residential areas. In all 8 fatal cases, the autopsy diagnosis was death due to COVID-19. Autopsies revealed all COVID-19 patients to have a fatal (broncho)pneumonia and signs of relevant pre-existing cardiac, renal and pulmonary conditions in all cases. In 75% (n = 6) of the cases a fresh venous thrombosis was found. In 66.7% (n = 4) of the cases thrombotic events were combined with peripheral pulmonary artery thromboembolisms.

Conclusion

The cohort of SARS-CoV‑2 infected residents of a nursing home is characteristic for clinical and epidemiological features of the new coronavirus disease. Due to a centralized evaluation of all fatalities at the Institute of Legal Medicine in Hamburg, a detailed examination of all deceased positive for SARS-CoV‑2 was possible. Thereby, increased case fatality rates of approximately 20% could in all cases be assigned to a relevant number of pre-existing comorbidities of multiple organ systems, which was consistent with the clinical data available.

Autoerotic Deaths in Hamburg, Germany: Autoerotic accident or death from internal cause in an autoerotic setting? A retrospective study from 2004-2018

INTRODUCTION

Autoerotic deaths are rare events. The death scene is often bizarre and the death unexpected, thus often requiring forensic autopsies. Our analysis will provide an overview of the expected range of causes and manners of death in cases of autoerotic deaths.

METHODS

A retrospective analysis was carried out on all scientific and forensic autopsies and postmortem examinations performed at the Department of Legal Medicine in Hamburg, Germany, over the period of 2004-2018.

RESULTS

25 cases of autoerotic fatalities were identified over this 15-year-period or one to two cases per year, respectively. Autopsies were carried out on 23 of these cases. 16 (64%) of the cases involved autoerotic accidents and 7 (28%) from internal causes of death during an autoerotic act. Two cases had not undergone an autopsy. On average, those who were involved in autoerotic accidents had been younger in age (average age: 37 years) than the individuals who died from internal disease (average age: 61 years). Only one woman was involved. The most common cause of death in autoerotic accidents was strangulation (hanging: 8 cases, ligature strangulation: 1 case), followed by smothering of the respiratory tract (4 cases). Fatal intoxication was diagnosed in three of the cases. Fatalities with natural cause of death solely involved cardiovascular causes of death.

CONCLUSIONS

Autoerotic deaths involved a wide range of natural and non-natural causes of death. The reconstruction of such unusual cases and detection of non-natural fatalities requires thorough investigation of the scene of death as well as a postmortem external and internal examination including a chemical toxicological and blood alcohol analysis.

Application of ultrasonography to postmortem examination. Diagnosis of pericardial tamponade

In postmortem examination, it is difficult to diagnose pericardial tamponade in a dead body from the findings of conventional external examination alone. However, ultrasonography is a common diagnostic tool for pericardial tamponade in clinical practice. We studied the postmortem diagnosis of pericardial tamponade at external examination level by applying an ultrasonographic device. The ultrasonographic findings were compared with the conventional autopsy findings. Among 455 cases of forensic autopsy in Hamburg and Tokyo conducted within 5 days after death, we successfully diagnosed 11 cases of pericardial tamponade by ultrasound imaging prior to autopsy, and failed to diagnose pericardial tamponade in only two cases. In addition, 79 cases of external examination conducted at the Tokyo Medicinal Examiner's Office were also examined with ultrasonography, and we diagnosed three cases of pericardial tamponade and five cases of pericardial effusion. The differences in ultrasonographic findings between tamponade and effusion were relatively clear. Although autopsy provides definitive evidence for the cause of death, sometimes autopsy cannot be performed due to some social factors. In such cases, conventional external examination alone cannot establish a cause of death by pericardial tamponade, and application of diagnostic imaging technique will be helpful. While CT and/or MRI may provide more detailed information than ultrasound imaging, these techniques require special equipment, room and specialist, and most of all involves high cost, which is perhaps the most important consideration in the present atmosphere of medical cost containment. On the other hand, the ultrasonographic devices we use are compact, and can be used directly at the scene of death. Postmortem application of ultrasonography may be a valuable adjunct in the work of medical examiners and forensic pathologists.

Immunohistochemical detection of hemoglobin in frost erythema

Reddish discoloration of exposed skin areas, called frost erythema, is an important criterion for the diagnosis of fatal hypothermia. In the present study, we used immunohistochemistry in a prospective trial to show that on the molecular level, the correlate of frost erythema is hemoglobin without hemorrhage. Furthermore, we compared routine histological and immunohistochemical features of frost erythema, hematoma and livor mortis and established some criteria for their histological differentiation.

Application of compact ultrasound imaging device to postmortem diagnosis

In regions with low autopsy rates, forensic examiners often have to rely on external findings. Imaging techniques can assist the external examination and provide a more objective diagnosis. The SonoSite 180, a portable ultrasound device, was used for the examination of dead bodies. The influence of different degrees of decomposition was estimated. Even in cases with intestinal gas formation images of internal organs could be obtained with special techniques. Various pathological findings were detected by ultrasound and verified by autopsy (e.g. pericardial tamponade, cardiac hypertrophy, fatty liver, aortic aneurysm, metastatic liver, etc.). The experiences with the SonoSite 180 are promising. The device can be carried to the death scene or to the morgue and therefore serve as a valuable tool for medicolegal applications.

Post-mortem diagnosis and age estimation of infants' fractures

Detection and dating of infants' fractures plays an important role in the diagnosis of the battered child syndrome. Under this aspect three cases of infants with multiple fractures of different ages due to child abuse were evaluated post-mortem. Radiological findings were compared with the autopsy results, followed by contact radiography and histopathological assessment. Out of a total of 44 osseous lesions, 27 fractures were diagnosed by post-mortem skeletal survey, additionally 5 recent rib fractures were suspected, 4 of which were confirmed histologically and all were located paravertebrally. The fractures not detected radiologically were mostly recent rib fractures diagnosed or suspected at autopsy or by contact radiography and confirmed histologically. The histological investigation allowed a more precise dating of the fractures, particularly with reference to the early stages of fracture healing. Microscopic signs of fracture healing processes, such as periosteal thickening, osteoid production and calcification of soft callus tissue, can be detected earlier and quantified more accurately. In advanced stages of healing the osseous apposition rate can be measured semiquantitatively up to a certain extent. A scheme involving a careful external investigation, skeletal survey, autopsy, contact radiography and histology has been proven useful for diagnosing and dating infants' fractures.

[Postmortem bite injuries cause by a domestic cat]

A 70-year-old farmer was found dead in front of a barn. The emergency doctor did not note any significant findings at the external examination of the body. When the corpse was picked up by the undertaker, he noticed facial injuries. Several domestic cats were strolling around the barn at this time. External examination by a forensic pathologist revealed both sharp and crenated wound margins around the removed ear with punctured stabs adjacent to the mutilation. Further small perforating but not mutilating skin lesions were found also on other parts of the face. Given the typical morphology of the skin lesions and the observation of cats at the death scene, it is concluded that the injuries were inflicted by at least one domestic cat. In the forensic literature, reports on depredation of human corpses by cats are rare. To our knowledge, this is the first case report of outdoor cat depredation in the early postmortem interval. The case shows that domestic cats feed on human corpse even if other food is available.

Sudden death due to cerebrotendinous xanthomatosis confirmed by mutation analysis

A case of sudden death of a 52-year-old mentally retarded Caucasian male is described where the rectal temperature was 43.4 degrees C 3 h postmortem. The autopsy revealed cerebrotendinous xanthomatosis (CTX), a rare hereditary metabolic disorder, as the primary disease. The diagnosis was confirmed by postmortem identification of two mutations (compound heterozygosity for R237X and IVS6+1G-->A) in the sterol 27-hydroxylase (CYP27) gene. Both mutations have already been described in patients with CTX and can be considered the most likely cause of the disease. The pathomechanism of the excessive hyperthermia could not be completely elucidated.