Autopsy Findings and Venous Thromboembolism in Patients With COVID-19

Ann Intern Med. 2020 May 6;M20-2003. doi: 10.7326/M20-2003. Online ahead of print.


Background: The new coronavirus, severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), has caused more than 210 000 deaths worldwide. However, little is known about the causes of death and the virus's pathologic features.

Objective: To validate and compare clinical findings with data from medical autopsy, virtual autopsy, and virologic tests.

Design: Prospective cohort study.

Setting: Autopsies performed at a single academic medical center, as mandated by the German federal state of Hamburg for patients dying with a polymerase chain reaction-confirmed diagnosis of COVID-19.

Patients: The first 12 consecutive COVID-19-positive deaths.

Measurements: Complete autopsy, including postmortem computed tomography and histopathologic and virologic analysis, was performed. Clinical data and medical course were evaluated. Results: Median patient age was 73 years (range, 52 to 87 years), 75% of patients were male, and death occurred in the hospital (n = 10) or outpatient sector (n = 2). Coronary heart disease and asthma or chronic obstructive pulmonary disease were the most common comorbid conditions (50% and 25%, respectively). Autopsy revealed deep venous thrombosis in 7 of 12 patients (58%) in whom venous thromboembolism was not suspected before death; pulmonary embolism was the direct cause of death in 4 patients. Postmortem computed tomography revealed reticular infiltration of the lungs with severe bilateral, dense consolidation, whereas histomorphologically diffuse alveolar damage was seen in 8 patients. In all patients, SARS-CoV-2 RNA was detected in the lung at high concentrations; viremia in 6 of 10 and 5 of 12 patients demonstrated high viral RNA titers in the liver, kidney, or heart.

Limitation: Limited sample size.

Conclusion: The high incidence of thromboembolic events suggests an important role of COVID-19-induced coagulopathy. Further studies are needed to investigate the molecular mechanism and overall clinical incidence of COVID-19-related death, as well as possible therapeutic interventions to reduce it.

Primary funding source: University Medical Center Hamburg-Eppendorf.

Keywords: Autopsy; COVID-19; Computed axial tomography; Deep vein thrombosis; Kidneys; Liver; Lungs; Pulmonary diseases; Pulmonary embolism; Veins.