Histopathological Evaluation of Deceased Persons in Lusaka, Zambia With or Without Coronavirus Disease 2019 (COVID-19) Infection: Results Obtained From Minimally Invasive Tissue Sampling

Abstract

Background: Although much has been learned about the pathophysiology of coronavirus disease 2019 (COVID-19) infections, pathology data from patients who have died of COVID-19 in low- and middle-income country settings remain sparse. We integrated minimally invasive tissue sampling (MITS) into an ongoing postmortem surveillance study of COVID-19 in deceased individuals of all ages in Lusaka, Zambia.

Methods: We enrolled deceased subjects from the University Teaching Hospital Morgue in Lusaka, Zambia within 48 hours of death. We collected clinical and demographic information, a nasopharyngeal swab, and core tissue biopsies from the lung, liver, and kidneys for pathologic analysis. Individuals were considered eligible for MITS if they had a respiratory syndrome prior to death or a COVID-19+ polymerase chain reaction (PCR) nasopharyngeal swab specimen. Samples were retested using quantitative reverse transcriptase PCR.

Results: From June to September 2020 we performed MITS on 29 deceased individuals. PCR results were available for 28/29 (96.5%) cases. Three had a COVID-19+ diagnosis antemortem, and 5 more were identified postmortem using the recommended cycle threshold cut-point <40. When expanding the PCR threshold to 40 ≤ cycle threshold (Ct) ≤ 45, we identified 1 additional case. Most cases were male and occurred in the community The median age at death was 47 years (range 40-64). Human immunodeficiency virus (HIV)/AIDS, tuberculosis, and diabetes were more common among the COVID-19+ cases. Diffuse alveolar damage and interstitial pneumonitis were common among COVID-19+ cases; nonspecific findings of hepatic steatosis and acute kidney injury were also prevalent in the COVID-19+ group. Vascular thrombi were rarely detected.

Conclusions: Lung abnormalities typical of viral pneumonias were common among deceased COVID-19+ individuals, as were nonspecific findings in the liver and kidneys. Pulmonary vascular thrombi were rarely detected, which could be a limitation of the MITS technique. Nonetheless, MITS offers a valuable alternative to open autopsy for understanding pathological changes due to COVID-19.

Keywords: COVID-19; autopsy; minimally invasive tissue sampling; pathology; postmortem.

Figure 1.

Lung demonstrating diffuse alveolar damage. A, Lung demonstrating the exudative phase, characterized by fluid accumulation in the alveolar spaces (asterisk) and early membrane formation (arrow). B, Lung demonstrating the organizing phase with interstitial proliferation of fibroblasts (asterisk).

Figure 2.

Four panels showing lung tissue with hematoxylin and eosin staining. A, Lung tissue at ×100 magnification. Areas of caseous necrosis (asterisk). B, Lung tissue at ×400 magnification. There is an area of pneumocyte hyperplasia (arrow) with lymphocytic infiltrate in the interstitium (asterisk). C, Lung tissue at ×400 magnification. There is a granuloma (asterisk) with a multinucleated giant cell (arrow). D, Lung tissue at ×400 magnification. There is an acute pneumonia with alveolar neutrophils (asterisk).

Figure 3.

Two panels showing liver tissue with hematoxylin and eosin staining at ×100 magnification. A, Areas of centrilobar hepatocyte dropout, necrosis (arrow). B, Steatosis (arrow) and areas of acute hepatitis (asterisk).

Figure 4.

Kidney tissue with hematoxylin and eosin staining at ×100 magnification with evidence of hyaline arteriolosclerosis (asterisk).

Figure 5.

Heart tissue with hematoxylin and eosin staining at ×100 magnification showing wavy coagulative necrosis of cardiomyocytes (asterisk).