A Postmortem Portrait of the Coronavirus Disease 2019 (COVID-19) Pandemic: A Large Multi-institutional Autopsy Survey Study

Abstract

Context: This study represents the largest compilation to date of clinical and postmortem data from decedents with coronavirus disease 2019 (COVID-19). It will augment previously published small series of autopsy case reports, refine clinicopathologic considerations, and improve the accuracy of future vital statistical reporting. Objective: To accurately reflect the pre-existing diseases and pathologic conditions of decedents with Sars-CoV-2 infection through autopsy. Design: Comprehensive data from 135 autopsy evaluations of COVID-19-positive decedents is presented, including histologic assessment. Postmortem examinations were performed by 36 pathologists at 19 medical centers or forensic institutions in the United States and Brazil. Data from each autopsy were collected through the online submission of multiple choice and openended survey responses. Results: Patients dying of or with COVID-19 had an average of 8.89 pathologic conditions documented at autopsy, spanning a combination of prior chronic disease and acute conditions acquired during hospitalization. Virtually all decedents were cited as having more than one preexisting condition, encompassing an average of 2.88 such diseases each. Clinical conditions during terminal hospitalization were cited 395 times for the 135 autopsied decedents and predominantly encompassed acute failure of multiple organ systems and/or impaired coagulation. Myocarditis was rarely cited. Conclusions: Cause-of-death statements in both autopsy reports and death certificates may not encompass the severity or spectrum of co-morbid conditions in those dying of or with COVID-19. If supported by additional research, this finding may have implications for public health decisions and reporting moving forward through the pandemic.

Cardiac pathology in COVID-19: a single center autopsy experience

“…Autopsy reports have described a varied prevalence of cardiac pathologies associated with COVID-19, including acute ischemia, myocarditis, pericarditis, cytokine storm and non-myocarditis inflammation, and microvascular injury with resultant thrombosis. 7 , 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 The discrepancy in these findings may be due to the absence of a predefined standard COVID-19 autopsy protocol. [7] In particular, while persistent myocardial inflammation has been of concern in COVID-19 survivors (with cardiac magnetic resonance imaging showing persistent myocardial inflammation in up to 60.0% of patients), [22] the prevalence of pathologically confirmed inflammatory infiltrates and/or myocarditis is much lower.…”

Over- and under-estimation of COVID-19 deaths

“…Many medical problems mentioned in free text are not entered in the electronic records’ problem list of COVID-19 patients [ 35 ]. Autopsies also find many more problems than are otherwise reported [ 36 ]. However, autopsies are exceedingly rare [ 37 ].…”

Impact of COVID‐19 in Liver Disease Progression

“…(1,33) The cytokine storm may also be implicated in the disseminated intravascular coagulation (DIC) and thrombocytopenia, which can worsen the DIC complications, as observed in COVID-19. (34) Patients with COVID-19 have exhibited endotheliitis in the liver, (35) fibrin microthrombi in liver sinusoids, (36,37) and activation of the complement system. (38) One report demonstrated that, in contrast to patients with mild COVID-19, patients with non-COVID-19 pneumonia did not exhibit elevated levels of AST, ALT, or GGT, (39) suggesting that patients with mild COVID-19 may have elevated liver damage markers independently of the presence of inflammation.…”