COVID-19 autopsy in people who died in community settings: the first series

Abstract

Here, we report the pathological findings of nine complete autopsies of individuals who died in community settings in the UK, three of which were positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), three tested negative for SARS-CoV-2 but are likely false negatives, and three died of other respiratory infections. Autopsy revealed firm, consolidated lungs or lobar pneumonia. Histology of the lungs showed changes of diffuse alveolar damage with fibrin membrane formation, thickened alveolar walls and interstitium with lymphocytic infiltrate, and type 2 pneumocyte hyperplasia with shedding into the alveolar space. This series is the first in the world to describe autopsy findings in individuals dying suddenly in the community, not previously known to have COVID-19 infection, and the first autopsy series in the UK. During a time when testing in the UK is currently primarily offered to patients in hospital or symptomatic key workers, with limited testing available in community settings, it highlights the importance of testing for COVID-19 at autopsy. Two deaths occurred in care homes where a diagnosis of COVID-19 allowed the health protection team to provide support in that ‘closed setting’ to reduce the risks of onward transmission. This work highlights the need for frequent COVID-19 testing in the management of patients in community settings. Comprehensive virology and microbiology assessment is pivotal to correctly identify the cause of death, including those due to COVID-19 infection, and to derive accurate death statistics.

More than Pneumonia: Distinctive Features of SARS-Cov-2 Infection. From Autopsy Findings to Clinical Implications: A Systematic Review

“…The main immunohistochemical investigations concerned the lymphocellular population, macrophages, platelets, and megakaryocytes. Despite the involvement of cytokines and chemokines in the pathogenesis of COVID-19 disease, a panel for cytokines was proposed only in two studies [ 49 , 56 ]. A total of 12/32 studies completed the post-mortem investigation with electron microscopy [ 11 , 18 , 19 , 20 , 24 , 33 , 37 , 38 , 46 , 47 , 52 , 55 ].…”

“…Evidence of segmental or sub-segmental pulmonary emboli determining lobar infarction was also detected [ 11 , 19 , 20 , 39 ]. Vascular changes associated with proliferative and exudative diffuse alveolar damage with hyaline membrane deposition, necrosis of alveolar lining cells, TTF-1 positive type II pneumocytes hyperplasia with nucleomegaly, and prominent nucleoli alternatively combined with the accumulation of lymphocytes, macrophages, multinucleated giant cells were considered as distinctive features of COVID-19 infection [ 10 , 11 , 18 , 19 , 20 , 23 , 24 , 26 , 28 , 33 , 34 , 35 , 36 , 38 , 39 , 41 , 42 , 43 , 44 , 47 , 49 , 51 , 53 , 55 , 56 , 57 , 58 ]. Interstitial, peribronchiolar, and perivascular CD-3 positive T cells with a predominance of CD4 positive T cells over CD8-positive T cells were also described.…”

“…CD20-positive B lymphocytes were generally absent, suggesting that the immune response in lung parenchyma is mainly mediated by T lymphocytes [ 18 , 20 , 33 , 34 , 35 , 38 , 49 ]. In the study of Wang et al, lymphocytic infiltration accounted for the majority of CD20 positive B cells, whereas CD3 positive T cells made up a small proportion including CD4 positive T cells and CD8 positive T cells [ 56 ]. Fibrin thrombi associated with increased CD61 positive platelets and megakaryocytes in pre-capillary and post-capillary vessels without complete luminal obstruction were also observed in lung specimens collected from patients with COVID-19 [ 18 , 19 , 33 , 38 , 43 , 47 ].…”

“…Furthermore, perivascular and intra-alveolar ACE2-positive lymphocytes were recorded. A strong expression of chemokine and inflammatory cytokines (IL6, IL10, TNF-alpha) was observed when performed [ 56 ]. Prominent expression of the anti-viral antibodies on alveolar epithelial cells and on blood vessels was detected [ 56 , 60 , 61 ].…”

Histopathological findings in COVID-19 cases: A Systematic Review

“…(which was not certified by peer review) damage in 73 cases (25.8%), (13,20,24,26,32,34,46,48,58,60,62) squamous metaplasia in 68 cases (24%), (13,19,28,30,31,37,44,46,50,56,59,60,66) viral inclusion in 45 cases (15.9%), (13,25,29,31,48,54,60) serous exudation in 19 cases (6.7%), (46,48,51,58) fibrinoid vascular necrosis in 17 cases (6%), (19,26,44,49,53,60) and pulmonary embolism in 14 cases (4.9%). (28,29,40,49,54,57) (Appendix-3) 3.6 | Heart histopathological findings:…”