Dying with SARS-CoV-2 infection-an autopsy study of the first consecutive 80 cases in Hamburg, Germany

Abstract

Autopsies of deceased with a confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection can provide important insights into the novel disease and its course. Furthermore, autopsies are essential for the correct statistical recording of the coronavirus disease 2019 (COVID-19) deaths. In the northern German Federal State of Hamburg, all deaths of Hamburg citizens with ante- or postmortem PCR-confirmed SARS-CoV-2 infection have been autopsied since the outbreak of the pandemic in Germany. Our evaluation provides a systematic overview of the first 80 consecutive full autopsies. A proposal for the categorisation of deaths with SARS-CoV-2 infection is presented (category 1: definite COVID-19 death; category 2: probable COVID-19 death; category 3: possible COVID-19 death with an equal alternative cause of death; category 4: SARS-CoV-2 detection with cause of death not associated to COVID-19). In six cases, SARS-CoV-2 infection was diagnosed postmortem by a positive PCR test in a nasopharyngeal or lung tissue swab. In the other 74 cases, SARS-CoV-2 infection had already been known antemortem. The deceased were aged between 52 and 96 years (average 79.2 years, median 82.4 years). In the study cohort, 34 deceased were female (38%) and 46 male (62%). Overall, 38% of the deceased were overweight or obese. All deceased, except for two women, in whom no significant pre-existing conditions were found autoptically, had relevant comorbidities (in descending order of frequency): (1) diseases of the cardiovascular system, (2) lung diseases, (3) central nervous system diseases, (4) kidney diseases, and (5) diabetes mellitus. A total of 76 cases (95%) were classified as COVID-19 deaths, corresponding to categories 1-3. Four deaths (5%) were defined as non-COVID-19 deaths with virus-independent causes of death. In eight cases, pneumonia was combined with a fulminant pulmonary artery embolism. Peripheral pulmonary artery embolisms were found in nine other cases. Overall, deep vein thrombosis has been found in 40% of the cases. This study provides the largest overview of autopsies of SARS-CoV-2-infected patients presented so far.

Keywords: Autopsy; COVID-19; Coronavirus; Pulmonary embolism; SARS-CoV-2; Venous thromboembolic disease.

Fig. 1

a Heavy, congested lungs (case 52). b Patchy pleural surface with segmental hyperemia (case 2). c Cutting surface of the lung with alternating hyperemic and pale areas (case 5). d Lung surface with pleurisy (case 12). e Thrombosis of the deep veins of the lower extremity (case 4). f Pulmonary embolism (case 4)

Fig. 2

(all H&E) a Lung: diffuse alveolar damage (case 2, × 80). b Lung: squamous metaplasia (case 4, × 50). c Lymphocytes in the wall of a small pulmonary artery (case 2, × 80). d Lung: hyaline membranes (case 5, × 80). e Purulent pneumonia (case 7, × 80). f Pharyngitis with predominant lymphoplasmacellular infiltrate (case 11, × 80)