Autopsy Findings in 32 Patients with COVID-19: A Single-Institution Experience

Abstract

Background: A novel coronavirus, SARS-CoV-2, was identified in Wuhan, China in late 2019. This virus rapidly spread around the world causing disease ranging from minimal symptoms to severe pneumonia, which was termed coronavirus disease (i.e., COVID). Postmortem examination is a valuable tool for studying the pathobiology of this new infection.

Methods: We report the clinicopathologic findings from 32 autopsy studies conducted on patients who died of COVID-19 including routine gross and microscopic examination with applicable special and immunohistochemical staining techniques.

Results: SARS-CoV-2 infection was confirmed by nasopharyngeal RT-PCR in 31 cases (97%) and by immunohistochemical staining for SARS-CoV-2 spike-protein in the lung in the remaining 1 case (3%). The ethnically diverse cohort consisted of 22 males and 10 females with a mean age of 68 years (range: 30-100). Patients most commonly presented with cough (17 [55%]), shortness of breath (26 [81%]), and a low-grade fever (17 [55%]). Thirty-one (97%) of the patients had at least 1 comorbidity (mean = 4). Twenty-eight patients (88%) had widespread thromboembolic disease, as well as diffuse alveolar damage (30 [94%]), diabetic nephropathy (17 [57%]) and acute tubular injury. Patterns of liver injury were heterogeneous, featuring 10 (36%) with frequent large basophilic structures in sinusoidal endothelium, and increased immunoblast-like cells in lymph nodes.

Conclusion: This series of autopsies from patients with COVID-19 confirms the observation that the majority of severely affected patients have significant pulmonary pathology. However, many patients also have widespread microscopic thromboses, as well as characteristic findings in the liver and lymph nodes.

Keywords: Acute respiratory distress syndrome; Autopsy; COVID-19; Thrombi.

Fig. 1

Multisystem microscopic thromboses were common including in the intracardiac arteries and arterioles (a, b; ×20 and ×40), highlighted by CD61 immunohistochemistry (c; ×20), in the lung with (d; ×20) or without (e; ×20) associated infarction and in other organs including the prostate (f; ×40).

Fig. 2

Liver showing steatosis and large, atypical basophilic sinusoidal structures as seen in 2 separate cases. a H&E, ×20. b PAS-D, ×20. c H&E, ×40. d PAS-D, ×40.

Fig. 3

Lymph nodes with preserved architecture (a; H&E, ×20), including intact follicles highlighted by CD3 (b; IHC, ×20), CD20 (c; IHC, ×20), and CD10 (d; IHC, ×20). The subcapsular and intraparenchymal sinuses contain large transformed cells with prominent nucleoli and amphophilic cytoplasm (e, f; H&E with oil immersion, ×100), which stain for CD20 (e, inset, IHC, ×60).

Fig. 4

Kidney showing prominent changes of diabetic nephropathy including mesangial diabetic glomerulosclerosis and extensive arteriolar hyalinosis (a; PAS, ×40), acute tubular necrosis (b; H&E, ×20), papillary necrosis (c; H&E, ×4), atheroembolic disease (d; PAS, ×20), glomerular thrombotic microangiopathy (e; H&E, ×40), and glomerular and arteriolar endothelial staining for C5b-9 (f; IHC, ×40).