The evolution of pulmonary pathology in fatal COVID-19 disease: an autopsy study with clinical correlation
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ORIGINAL ARTICLE
The evolution of pulmonary pathology in fatal COVID-19 disease: an autopsy study with clinical correlation Hans Bösmüller 1 & Selina Traxler 1 & Michael Bitzer 2 & Helene Häberle 3 & Wolfgang Raiser 4 & Dominik Nann 1 & Leonie Frauenfeld 1 & Antonio Vogelsberg 1 & Karin Klingel 1 & Falko Fend 1 Received: 13 May 2020 / Revised: 28 May 2020 / Accepted: 21 June 2020 # The Author(s) 2020
Abstract The pandemia of coronavirus disease 2019 (COVID-19) has caused more than 355,000 confirmed deaths worldwide. However, publications on postmortem findings are scarce. We present the pulmonary findings in four cases of fatal COVID-19 with a spectrum of lung pathology reflecting disease course and duration, invasive therapies, and laboratory features. Early disease is characterized by neutrophilic, exudative capillaritis with microthrombosis and high levels of IL-1beta and IL-6. Later stages are associated with diffuse alveolar damage and ongoing intravascular thrombosis in small to medium-sized pulmonary vessels, occasionally with areas of infarction equivalents, accompanied by laboratory features of disseminated intravascular coagulation. In late stages, organizing pneumonia with extensive intra-alveolar proliferation of fibroblasts and marked metaplasia of alveolar epithelium can be observed. Viral RNA is encountered in the lung, with virus particles in endothelial cells and pneumocytes. In many patients, multi-organ failure with severe liver damage sets in finally, possibly as consequence of an early-onset proinflammatory cytokine storm and/or thrombotic microangiopathy. Keywords COVID-19 . Autopsy . Lung . Capillaritis . Microthrombosis
Introduction Since the outbreak of coronavirus disease 2019 (COVID-19) caused by the novel coronavirus SARS-CoV-2 in December 2019, almost 5.6 million people have been infected during the Karin Klingel and Falko Fend authors share senior authorship This article is part of the Topical Collection on Quality in Pathology Electronic supplementary material The online version of this article (https://doi.org/10.1007/s00428-020-02881-x) contains supplementary material, which is available to authorized users. * Hans Bösmüller [email protected] 1
Department of Pathology and Neuropathology, University Hospital Tübingen and Eberhard Karls University Tübingen, Liebermeisterstraße 8, 72076 Tübingen, Germany
2
Department of Internal Medicine I, University Hospital Tübingen, Tübingen, Germany
3
Department of Anaesthesiology, University Hospital Tübingen, Tübingen, Germany
4
Office for General Medicine, Tübingen, Germany
course of the pandemia so far, and more than 355,000 succumbed to the disease [1]. Severe pneumonitis advancing to acute respiratory distress syndrome (ARDS), frequently associated with multi-organ failure, has been observed as the main clinical feature in fatal cases, with a case fatality rate of 1–4% [2, 3]. Despite the massive scale of the pandemia, published data on autopsy findings are limited [4–8]. In addition to diffuse alveolar damage,
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