COVID-19 lungs in post-mortem computed tomography

Minimally Invasive Tissue Sampling via Post Mortem Ultrasound: A Feasible Tool (Not Only) in Infectious Diseases-A Case Report

In the past years the number of hospital autopsies have declined steadily, becoming almost excluded from medical training. Medicolegal (forensic) autopsies account for almost all autopsies, whereas hospital autopsies are becoming increasingly rare. Minimally invasive tissue sampling (MITS) using post mortem ultrasound offers the opportunity to increase the number of post mortem examinations in a clinical and even forensic context. MITS is a needle-based post mortem procedure that uses (radiological) imaging techniques to examine major organs of the body, acquire tissue samples and aspirate fluid from the body cavities or hollow organs. In this study, MITS was used to determine the presence of other co-existing diseases in a deceased infected 97-year-old woman with severe acute respiratory syndrome coronavirus 2. The examination of her body was carried out using ultrasound as an imaging tool and to gather ultrasound-guided biopsies as conventional autopsy was rejected by the next of kin. Ultrasound and histology identified an intravesical mass leading to an obstruction of the urinary outlet resulting in bilateral hydronephrosis and purulent pyelonephritis, which was unknown during her lifetime. Histopathological examination revealed the tumor mass to be a squamous cell carcinoma. This study has shown that MITS can be used to determine the cause of death and the presence of concomitant diseases in the infectious deceased.

Virtual autopsy in SARS-CoV-2 breakthrough infection: a case report

It is well documented that COVID-19 vaccines are effective tools for limiting the pandemic. Unfortunately, as is true for all vaccines, SARS-CoV-2 infection in vaccinated individuals is still possible.

We present an autopsy case of SARS-CoV-2 infection after vaccination (“breakthrough infection”) in an elderly man with several comorbidities where post-mortem CT scan was performed. The death was histologically attributed to cardio-respiratory arrest due to ischemic heart failure related to superinfected COVID-19 pneumonia and pre-existing comorbidities. For the first time in the literature, PMCT imaging related to a fatal, autopsy case of breakthrough SARS-CoV-2 infection is reported. PMCT of the lungs, in accordance with histopathological results, showed few signs of COVID-19 pneumonia, large area of consolidation in the right lower lobe, interpreted as bronco-pneumonic focus, and hypostasis.

These findings were well-correlated with the previously reported literature about both PMCT and clinical CT imaging of the lungs in non-vaccinated individuals with early COVID-19 pneumonia and about pulmonary clinical CT imaging in COVID-19 pneumonia in breakthrough SARS-COV-2 infections.

Further studies are needed to cover the whole spectrum of PMCT lung imaging in fatal breakthrough SARS-CoV-2 infection, however, this case represent a first step for exploring this difficult challenge during SARS-CoV-2 pandemic using virtual autopsy.

Analysis of the role of PMCT during the COVID-19 pandemic: a systematic review

Objectives

During COVID-19 pandemic PMCT has been proposed as a forensic investigation method. This systematic review is aimed to systematize evidence and peer-reviewed opinions reported during the first two years of pandemic, to evaluate the role of PMCT during the COVID-19 pandemic.

Materials and methods

An online literature search was performed to identify publications on PMCT during the COVID-19 pandemic between December 2019 and March 2022. For each publication included, the following data were collected: title and abstract, year of publication, type of article, number and type of individuals examined. The selected publications were also categorized based on PMCT findings, histopathological results, the comparison between PMCT and histopathological findings, cause of death and proposed role of PMCT during the pandemic.

Results

A total of 20 publications were included, mostly case reports (9/20). All cases examined included adults. The most frequent PMCT pattern in positive cases was diffuse mixed densities with prevalence of consolidations (pattern 1) (54%). In 97% of the cases where a comparison between PMCT and histological results was performed, a correspondence was found. In 82% of the cases the principal cause of death was COVID-19 pneumonia. PMCT has been proposed as a pre-autopsy screening tool in 62%, and as a method for augmenting post-mortem data in 50% of the papers reporting this issue.

Conclusion

This systematic review suggests that PMCT should be regarded as a highly valuable investigative technique for the forensic evaluation of deaths with ascertained or suspected COVID-19 pneumonia.

Organ manifestations of COVID-19: what have we learned so far (not only) from autopsies?

The use of autopsies in medicine has been declining. The COVID-19 pandemic has documented and rejuvenated the importance of autopsies as a tool of modern medicine. In this review, we discuss the various autopsy techniques, the applicability of modern analytical methods to understand the pathophysiology of COVID-19, the major pathological organ findings, limitations or current studies, and open questions. This article summarizes published literature and the consented experience of the nationwide network of clinical, neuro-, and forensic pathologists from 27 German autopsy centers with more than 1200 COVID-19 autopsies. The autopsy tissues revealed that SARS-CoV-2 can be found in virtually all human organs and tissues, and the majority of cells. Autopsies have revealed the organ and tissue tropism of SARS-CoV-2, and the morphological features of COVID-19. This is characterized by diffuse alveolar damage, combined with angiocentric disease, which in turn is characterized by endothelial dysfunction, vascular inflammation, (micro-) thrombosis, vasoconstriction, and intussusceptive angiogenesis. These findings explained the increased pulmonary resistance in COVID-19 and supported the recommendations for antithrombotic treatment in COVID-19. In contrast, in extra-respiratory organs, pathological changes are often nonspecific and unclear to which extent these changes are due to direct infection vs. indirect/secondary mechanisms of organ injury, or a combination thereof. Ongoing research using autopsies aims at answering questions on disease mechanisms, e.g., focusing on variants of concern, and future challenges, such as post-COVID conditions. Autopsies are an invaluable tool in medicine and national and international interdisciplinary collaborative autopsy-based research initiatives are essential.

Potentials of post-mortem CT investigations during SARS-COV-2 pandemic: a narrative review

In December 2019, a new coronavirus, SARS-COV-2, caused a cluster of cases of pneumonia in China, and rapidly spread across the globe. It was declared a pandemic by the World Health Organization on March 11th, 2020. Virtual autopsy by post-mortem CT (PMCT) and its ancillary techniques are currently applied in post-mortem examinations as minimally or non-invasive techniques with promising results. In this narrative review, we speculate on the potentials of PMCT and its ancillary techniques, as a viable investigation technique for analysis of suspected or confirmed SARS-COV-2 deaths. An online literature search was performed by using three prefix search terms (postmortem, post-mortem, post mortem) individually combined with the suffix radiology, imaging, computed tomography, CT and with the search terms ‘SARS-CoV-2’ and ‘COVID-19’ to identify papers about PMCT and its ancillary techniques in SARS-COV-2 positive cadavers. PMCT findings suggestive for pulmonary COVID-19 in deceased positive SARS-COV-2 infection are reported in the literature. PMCT ancillary techniques were never applied in such cases. PMCT imaging of the lungs has been proposed as a pre-autopsy screening method for SARS-COV-2 infection. Further studies are needed to ascertain the value of PMCT in determining COVID-19 as the cause of death without autopsy histopathological confirmation. We advocate the application of PMCT techniques in the study of ascertained or suspected SARS-COV-2 infected deceased individuals as a screening technique and as a method of post-mortem investigation, to augment the numbers of case examined and significantly reducing infection risk for the operators.

Postmortem CT pulmonary findings in SARS-CoV-2-positive cases: correlation with lung histopathological findings and autopsy results

Introduction/purpose

Postmortem computed tomography (PMCT) is a valuable tool for analyzing the death of patients with SARS-CoV-2 infection. The purpose of this study was to investigate the correlation between PMCT lung findings in autopsy cadavers positive for SARS-CoV-2 infection and the severity of COVID-19 lung disease by histopathological analysis.

Materials and methods

We reviewed chest PMCT findings, paying particular attention to the lung parenchyma, in 8 autopsy cases positive for SARS-CoV-2. Correlations between chest PMCT and histopathological findings were assessed. Clinical conditions and comorbidities were also recorded and discussed. The primary cause of death was finally considered.

Results

In 6/8 cases, pulmonary PMCT findings were massive consolidation (4/8) and bilateral diffuse mixed densities with a crazy-paving pattern (2/8). These cases showed severe pulmonary signs of COVID-19 at histopathological analysis. In the remaining 2/8 cases, pulmonary PMCT findings were scant antideclive ground-glass opacities in prevalent gradient densities attributed to hypostasis. In 4/8 cases with massive consolidations, important comorbidities were noted. In 6/8 cases with severe pulmonary histopathological signs of lung COVID-19, autopsy found that the cause of death was cardiorespiratory failure. In the remaining 2/8 cases, histopathological analysis revealed lung alterations due to edema and some signs of SARS-CoV-2 infection; the cause of death was not attributed to SARS-CoV-2 infection (Table 1).

Discussion and conclusion

Chest PMCT findings correlate with the severity of COVID-19 lung disease at histopathology examination. According to our results, there may also be a relationship between cause of death and PMCT findings in COVID-19, which must be critically analyzed considering clinical antemortem data.

Postmortem CT in decedents with SARS-CoV-2 infection. A single institution experience

Coronavirus disease 2019 (COVID-19) caused by SARS-CoV-2 produced a global pandemic with significant mortality. As autopsies are not routinely performed on all decedents with SARS-CoV-2 infection, postmortem CT (PMCT) may be valuable to provide additional information on the cause of death and risk factors known to be associated with an increased mortality in COVID-19. The purpose of this manuscript is to review the PMCT findings in a series of 42 decedents with SARS-CoV-2 infection from our institution. Retrospective analysis of 42 decedents who had a positive postmortem nasopharyngeal swab for SARS-CoV-2 and had a PMCT were included in this study. Images were reviewed for pulmonary findings seen in COVID-19 and other organ involvement. Of the 42 decedents, although the majority had imaging findings in the lungs that would be consistent with COVID-19 and acute respiratory distress syndrome, in 14% of the decedents the SARS-CoV-2 infection was likely coincidental and the PMCT findings suggested that they died from other pathology. Over half of the decedents that died from COVID-19 had PMCT findings of vascular disease. PMCT is useful to identify pulmonary and extra pulmonary findings in decedents with SARS-CoV-2 infection that can provide additional information, which may be useful for the forensic pathologist to help determine the underlying cause of death.

Supplemental data for this article are available online at

Molecular docking of SARS-COV-2 Spike epitope sequences identifies heterodimeric peptide-protein complex formation with human Zo-1, TLR8 and brain specific glial proteins

SARS-COV-2 infection causes severe respiratory tract illness leading to asphyxia and death. The onset of infection is associated with loss of smell, blurred vision, headache with bronchopulmonary symptoms. The clinical observations of neurological abnormalities lead us to address the question, does the virus enter into brain and what is the underlying mechanism of brain infection? The working hypothesis is, SARS-COV-2 Spike epitopes modify blood brain barrier and infect glial cells to induce brain inflammation in genetically diverse human population. The hypothesis is tested by determining binding or interacting ability of virus Spike epitope peptides M1Lys60 and Ala240Glu300 with human toll-like receptor 8 (TLR 8), brain targeted Vascular Cell adhesion Molecules (VCAM1) proteins, Zonula Occludens (ZO), glial cell specific protein NDRG2 and Apo- S100B. The molecular dynamic experiments are performed, and root mean square deviation (RMSD) values are determined for interactions between the Spike peptides and selected proteins. The observations demonstrate formation of heterodimeric complex between the epitope peptides and selected protein structures. The viral epitopes have ability to bind with HLA-DRB1 15:01, 07:01 or 03.01 alleles thus found immunogenic in nature. The observations altogether suggest entry of these Spike protein epitopes into human brain causes inflammation.

Use of post-mortem chest computed tomography in Covid-19 pneumonia

Background and aim

COVID-19 is an extremely challenging disease, both from a clinical and forensic point of view, and performing autopsies of COVID-19 deceased requires adequately equipped sectorial rooms and exposes health professionals to the risk of contagion. Among one of the categories that are most affected by SARS-Cov-2 infection are the elderly residents. Despite the need for prompt diagnoses, which are essential to implement all isolation measures necessary to contain the infection spread, deceased subjects in long-term care facilities are still are often diagnosed post-mortem. In this context, our study focuses on the use of post-mortem computed tomography for the diagnosis of COVID-19 infection, in conjunction with post-mortem swabs. The aim of this study was to assess the usefulness of post-mortem whole CT-scanning in identifying COVID-19 pneumonia as a cause of death, by comparing chest CT-findings of confirmed COVID-19 fatalities to control cases.

Materials and methods

The study included 24 deceased subjects: 13 subjects coming from long-term care facility and 11 subjects died at home. Whole body CT scans were performed within 48 h from death in all subjects to evaluate the presence and distribution of pulmonary abnormalities typical of COVID-19-pneumonia, including: ground-glass opacities (GGO), consolidation, and pleural effusion to confirm the post-mortem diagnosis.

Results

Whole-body CT scans was feasible and allowed a complete diagnosis in all subjects. In 9 (69%) of the 13 cases from long-term care facility the cause of death was severe COVID 19 pneumonia, while GGO were present in 100% of the study population.

Conclusion

In the context of rapidly escalating COVID-19 outbreaks, given that laboratory tests for the novel coronavirus is time-consuming and can be falsely negative, the post-mortem CT can be considered as a reliable and safe modality to confirm COVID-19 pneumonia. This is especially true for specific postmortem chest CT-findings that are rather characteristic of COVID-19 fatalities.