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

• Published in: International Journal of Legal Medicine 2020-07, Vol.134 (4), p.1275-1284
• Main Authors: Edler, Carolin, Schröder, Ann Sophie, Aepfelbacher, Martin, Fitzek, Antonia, Heinemann, Axel, Heinrich, Fabian, Klein, Anke, Langenwalder, Felicia, Lütgehetmann, Marc, Meißner, Kira, Püschel, Klaus, Schädler, Julia, Steurer, Stefan, Mushumba, Herbert, Sperhake, Jan-Peter
• Format: Article
• Language: English
• Subjects: Age Distribution; Aged; Aged, 80 and over; Alveolar Epithelial Cells - pathology; Autopsies; Autopsy; Betacoronavirus - genetics; Betacoronavirus - isolation & purification; Cardiovascular system; Central nervous system; Comorbidity; Coronavirus Infections - mortality; Coronavirus Infections - pathology; Coronaviruses; COVID-19; Cross Infection - mortality; Death; Diabetes mellitus; Embolisms; Exudates and Transudates; Fatalities; Female; Fibroblasts - pathology; Fibrosis - pathology; Forensic Medicine; Germany - epidemiology; Giant Cells - pathology; Humans; Infections; Kidney diseases; Lung - pathology; Male; Medical Law; Medicine; Medicine & Public Health; Megakaryocytes - pathology; Middle Aged; Nursing Homes - statistics & numerical data; Organ Size; Overweight - epidemiology; Pandemics; Pneumonia, Viral - mortality; Pneumonia, Viral - pathology; Polymerase Chain Reaction; Pulmonary arteries; Pulmonary Embolism - pathology; Pulmonary embolisms; Residential Facilities - statistics & numerical data; Respiratory diseases; SARS-CoV-2; Severe acute respiratory syndrome coronavirus 2; Sex Distribution; Thrombosis; Topical Collection on COVID-19; Travel-Related Illness; Venous Thrombosis - pathology; Viral diseases; Viruses
• ISSN: 0937-9827; 1437-1596
• DOI: 10.1007/s00414-020-02317-w

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.