New Mexico's COVID-19 Experience

Abstract

The 2019 novel coronavirus disease (COVID-19) has spread worldwide, infiltrating, infecting, and devastating communities in all locations of varying demographics. An overwhelming majority of published literature on the pathologic findings associated with COVID-19 is either from living clinical cohorts or from autopsy findings of those who died in a medical care setting, which can confound pure disease pathology. A relatively low initial infection rate paired with a high biosafety level enabled the New Mexico Office of the Medical Investigator to conduct full autopsy examinations on suspected COVID-19-related deaths. Full autopsy examination on the first 20 severe acute respiratory syndrome coronavirus 2-positive decedents revealed that some extent of diffuse alveolar damage in every death due to COVID-19 played some role. The average decedent was middle-aged, male, American Indian, and overweight with comorbidities that included diabetes, ethanolism, and atherosclerotic and/or hypertensive cardiovascular disease. Macroscopic thrombotic events were seen in 35% of cases consisting of pulmonary thromboemboli and coronary artery thrombi. In 2 cases, severe bacterial coinfections were seen in the lungs. Those determined to die with but not of severe acute respiratory syndrome coronavirus 2 infection had unremarkable lung findings.

FIGURE 1

Postmortem computed tomography findings in rapidly fatal community cases of COVID-19. The lung windows of PMCT scans in 2 rapidly fatal COVID-19 cases. Case 2: an 82-year-old woman with a history of essential hypertension who reported severe cough, backache, chest pain, and sore throat before death. Bilateral, ill-defined, mixed densities in a diffuse distribution are demonstrated in the axial plane (A) and in the coronal plane (B). Case 4: a 60-year-old man with uncontrolled diabetes mellitus and chronic ethanol abuse who reported fever, cough, sore throat, dyspnea, and chest discomfort before death. Diffuse consolidations in both lungs are demonstrated in the axial plane (C) and in the coronal plane (D).

FIGURE 2

Gross and microscopic findings of cardiopulmonary thrombotic events identified at autopsy. Representative gross and microscopic findings in 5 decedents found to have macroscopic cardiopulmonary thrombotic events. A, Case 3: firm, slippery, edematous lungs with a combined weight of 1360 g. Sectioning revealed numerous small-caliber thrombi. B, Case 6: gross examination of an edematous 870-g right lung revealed large-caliber pulmonary thromboemboli in the superior branches of the pulmonary arteries. C, Case 3: in the microscopic correlate additionally seen are a predominance of interstitial megakaryocytes (yellow arrows), as well as hyaline membranes (blue arrow; H&E, original magnification ×40). D, Case 5: coronary artery thrombus of the left circumflex coronary artery seen in a homeless man. E, Case 6: microscopically, pulmonary thromboemboli correlated with layered blood components within the arterial lumina (Lines of Zhan), characteristic of antemortem formation (H&E, ×2).

FIGURE 3

Comparison of microscopic lung findings in asymptomatic carriers with those with aggressive, symptomatic infections. Postmortem lung sections with no significant histology findings in decedents whose deaths were attributed to intoxication as compared with deaths attributed to COVID-19 infection, which are characterized by DAD. A, Case 8: low-power view of a decedent who died of fentanyl toxicity who incidentally tested positive for COVID-19 (H&E, original magnification ×2). B, Case 7: low-power view of the lungs of a chronic alcoholic who reported fever, cough, and feeling unwell before collapsing at home demonstrating congested intra-alveolar airspaces containing hyaline membranes, pulmonary edema, type II pneumocytes hyperplasia, macrophages, and fibrin (H&E, ×10). C, Case 9: high-power view of the lungs of a decedent who died of acute ethanol intoxication but tested positive for COVID-19 (H&E, ×40). D, Case 4: high-power view of extensive DAD with hyaline membrane formation, type II pneumocyte hyperplasia, pulmonary edema in a man with uncontrolled diabetes mellitus and chronic ethanolism who reported fever, cough, sore throat, dyspnea, and chest pain before death (H&E, ×40).

FIGURE 4

Two cases of coinfection with SARS-CoV-2 and S. pneumoniae. In 2 cases, decedents were positive both for COVID-19 infection and for a concomitant bacterial lung infection with S. pneumoniae. A, Case 13: diffuse intra-alveolar neutrophils with hyaline membrane formation (H&E, original magnification ×10). B, Case 13: intra-alveolar neutrophils and hyaline membranes with associated diplococci, intra-alveolar hemorrhage and fibrin, and coagulative necrosis (H&E, ×40). C, Case 19: sheets of intra-alveolar neutrophils (H&E, ×10). D. Case 19: sheets of neutrophils with coagulative necrosis (H&E, ×40).