The clinical value of minimal invasive autopsy in COVID-19 patients

Abstract

Background Minimally invasive autopsy (MIA) is a validated and safe method to establish the cause of death (COD), mainly in low-resource settings. However, the additional clinical value of MIA in Coronavirus disease (COVID-19) patients in a high-resource setting is unknown. The objective was to assess if and how MIA changed clinical COD and contributing diagnoses in deceased COVID-19 patients. Methods and findings A prospective observational cohort from April to May 2020 in a 981-bed teaching hospital in the epicenter of the COVID-19 pandemic in Belgium was established. Patients who died with either PCR-confirmed or radiologically confirmed COVID-19 infection were consecutively included. MIA consisted of whole-body CT and CT-guided Tru-Cut® biopsies. Diagnostic modalities were clinical chart review, radiology, microbiology, and histopathology which were assessed by two independent experts per modality. MIA COD and contributing diagnoses were established during a multi-disciplinary meeting. Clinical COD (CCOD) and contributing diagnosis were abstracted from the discharge letter. The main outcomes were alterations in CCOD and contributing diagnoses after MIA, and the contribution of each diagnostic modality. We included 18 patients, of which 7 after intensive care unit hospitalization. MIA led to an alteration in 15/18 (83%) patients. The CCOD was altered in 5/18 (28%) patients. MIA found a new COD (1/5), a more specific COD (1/5), a less certain COD (1/5), or a contributing diagnosis to be the COD (2/5). Contributing diagnoses were altered in 14/18 (78%) patients: 9 new diagnoses, 5 diagnoses dismissed, 3 made more specific, and 2 made less certain. Overall, histopathology contributed in 14/15 (93%) patients with alterations, radiology and microbiology each in 6/15 (40%), and clinical review in 3/15 (20%). Histopathology was deemed the most important modality in 10 patients, radiology in two patients, and microbiology in one patient. Conclusion MIA, especially histological examination, can add valuable new clinical information regarding the cause of death in COVID-19 patients, even in a high-resource setting with wide access to premortem diagnostic modalities. MIA may provide important clinical insights and should be applied in the current ongoing pandemic. Trial registration Clinicaltrials.gov identifier: NCT04366882

Minimally Invasive Autopsy Practice in COVID-19 Cases: Biosafety and Findings

“…As in other MIAs conducted in adults in Mozambique [ 15 ] and Brazil [ 45 ], we successfully obtained the samples included in the study protocol. Contrary to several recent MIA studies in COVID-19 [ 35 , 44 , 46 ], our findings suggest that ultrasound or computed tomography guidance is not necessary to consistently and successfully obtain representative, high-quality samples [ 14 , 15 , 16 , 17 ].…”

“…Importantly, the findings of the MIA in COVID-19 deaths were comparable to those of the conventional autopsy performed on the same body. Indeed, the accumulated evidence shows that the performance of MIA in COVID-19 deaths [ 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 44 , 46 ] is almost identical to that of the complete autopsies [ 44 , 47 , 48 , 49 , 50 , 51 , 52 , 53 , 54 , 55 , 56 ]. In our study, four deaths were attributed to COVID-19, whereas two of the deaths were considered as caused by other conditions; in these two cases the SARS-CoV-2 infection was considered a comorbidity.…”

“…Notably, evidence on the safety of performing MIA in COVID-19 cases is limited. Indeed, most MIA studies on COVID-19 do not report the biosafety precautions undertaken during the procedure [ 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 ]. Recently, biosafety recommendations for performing ultrasound-guided MIAs have been published [ 44 ], but the reported conditions [ 44 ] included a negative air-pressure room which is frequently not available in middle and low-resource settings.…”

Postmortem radiologic and pathologic findings in COVID-19: The Toronto experience with pre-hospitalization deaths in the community

“…On a pathological basis, histological evidence of a viral pneumonitis pattern in addition to confirmation of the presence of the virus is required to establish the diagnosis. Similarly, as previously reported in the literature, so-called “radiologically confirmed” COVID-pneumonia is entirely insufficient to definitively conclude a death was the result of COVID-19 disease [18] . Reliable diagnosis of fatal COVID-19 can only be established by a combination of clinical, radiologic, microbiologic, and histopathologic correlation, with the latter 2 being of the most discerning diagnostic value.…”

Praktische Aspekte von COVID-19-Obduktionen

“…Minimal-invasive Autopsie (MIA) in einer etwas einfacheren Technik bereits erfolgreich angewendet [ 25 ], wobei Todesursachen mittels MIA mit vergleichbarer hoher Sicherheit wie mittels konventioneller Autopsie ermittelt werden konnten. Über erste positive Erfahrungen der minimal-invasiven Autopsie im Rahmen der COVID-19-Pandemie wurde bereits berichtet [ 26 , 27 ]. Einer der Vorteile der minimal-invasiven Verfahren ist die fehlende Aerosolbildung, sodass unter Einhaltung der spezifischen Sicherheitsvorkehrungen (siehe Tab.…”