Autopsy Tool in Unknown Diseases: The Experience with Coronaviruses (SARS-CoV, MERS-CoV, SARS-CoV-2)

Abstract

In the last two decades, three unknown pathogens have caused outbreaks, generating severe global health concerns. In 2003, after nucleic acid genotyping, a new virus was named severe acute respiratory syndrome coronavirus (SARS-CoV). After nine years, another coronavirus emerged in the middle east and was named MERS-CoV (Middle East Respiratory Syndrome—Coronavirus). Finally, in December 2019, a new unknown coronavirus was isolated from a cluster of patients and was named SARS-CoV-2 (COVID-19, coronavirus disease 2019). This review aims to propose a complete overview of autopsy in the three coronaviruses over the past two decades, showing its pivotal role in the management of unknown diseases. A total of 116 studies fulfilled the inclusion criteria: 14 studies were collected concerning SARS-CoV (87 autopsy reports, from Asian and American countries), 2 studies for MERS-CoV (2 autopsy reports, from Middle-East Asian countries), and 100 studies on SARS-CoV-2 (930 autopsy reports). Analyzing the data obtained on COVID-19, based on the country criterion, a large number of post-mortem investigation were performed in European countries (580 reports), followed by American countries (251 reports). It is interesting to note that no data were found from the Oceanic countries, maybe because of the minor involvement of the outbreak. In all cases, autopsy provided much information about each unknown coronavirus. Despite advanced technologies in the diagnostic fields, to date, autopsy remains the gold standard method to understand the biological features and the pathogenesis of unknown infections, especially when awareness of a pathogen is restricted and the impact on the healthcare system is substantial. The knowledge gained through this technique may positively influence therapeutic strategies, ultimately reducing mortality.

COVID-19 Vaccine and Death: Causality Algorithm According to the WHO Eligibility Diagnosis

“…Therefore, other hypothesis should be explored to explain the observed adverse effects. First, the existence of undiagnosed SARS-CoV-2 infection should be excluded, considering that the coagulation problems are very similar to the COVID-19 patients [25,38,[53][54][55][56][57]. This hypothesis is excluded in the two reported cases, considering that we performed several molecular investigations in different tissue samples, including atypical tissues (i.e., intestine).…”

“…The lesson "to learn from the dead" [41] should be considered a rule and not only an opportunity to diagnose post-mortem unexplained deaths, especially when it is temporally related to vaccine administration. In these cases, the autopsy tool represents the gold standard method to gain all information about death [38]. The same approach could be useful in order to diagnose other morbid conditions in other disciplinary contexts (i.e., blood transfusion) [42].…”

“…In our opinion, it is important to stress the importance of the post-mortem investigation in the application of the algorithm. Autopsy is a fundamental diagnostic technique in cases of new or unfamiliar human pathologies [38]: in the same manner, it represents the gold standard method to clarify unknown diseases related to vaccine administration. In Italy, the Sicily Region with a specific act established a protocol to be applied in suspected cases of death ("Regional taskforce for the implementation of diagnostic findings and autopsy examinations in COVID-19 positive corpses or in the event of post-vaccination deaths") [27].…”

Post-Mortem Detection of SARS-CoV-2 RNA in Long-Buried Lung Samples

“…Since the SARS-CoV-2 outbreak was declared a pandemic by the WHO, the number of infections and related deaths has increased worldwide exponentially [ 19 ]. This has highlighted the importance of implementing shared guidelines for the management of COVID-19-positive and potentially infectious corpses [ 20 , 21 ]. Due to the huge amount of COVID-19 related-deaths, autopsies and confirmatory analyses could not be performed in all suspected cases immediately, therefore the scientific community has raised the question of whether confirmatory analyses could be performed on exhumed bodies after a long period of burial [ 22 ].…”

Sudden Death in Adults: A Practical Flow Chart for Pathologist Guidance

“…The mortality rate related to PE is high and it is due to the principal causes: pulmonary mainstream obstruction and liberation of vasoconstrictive mediators from the thrombi [ 53 ]. For example, pulmonary thromboembolism has been identified as one of the common clinical pictures of COVID-19, justifying SD in several subjects who died from SARS-CoV-2 infection [ 54 , 55 , 56 ]. Other clinical pictures of APE are: symptoms similar to acute respiratory distress syndrome (ARDS) [ 57 ]; fever syndrome with or without pseudopneumonia [ 58 ]; acute right heart failure/shock/hypotension (often with epigastric pain) [ 59 ]; left heart failure (with pulmonary congestion) [ 60 ]; chest pain similar to pleuritic syndrome with or without hemoptysis (with or without effusion) [ 61 ]; similar to acute coronary syndrome (ACS) (with or without chest pain) [ 62 ]; syncope [ 63 ]; complete atrioventricular (AV) block with idioventricular rhythm [ 49 ]; persistent or paroxysmal atrial fibrillation (AF), atrial flutter, atrial tachycardia [ 64 ]; paroxysmal supraventricular tachycardia (PSVT) [ 49 ]; DVT and silent PE [ 65 ]; platypnea-orthodeoxia [ 66 ]; abdominal pain without acute abdomen [ 64 ]; and delirium [ 67 ].…”