Is it COVID-19? The value of medicolegal autopsies during the first year of the COVID-19 pandemic

Abstract

ObjectivesWe describe the experience of a busy metropolitan medical examiner’s office in the United States and share our navigation of the COVID-19 autopsy decision-making process. We describe key gross and microscopic findings that, with appropriate laboratory testing, should direct a pathologist towards a COVID-19-related cause of death. Material and methodsWe performed a retrospective review of 258 suspected and/or confirmed COVID-19 associated deaths that occurred between March 5, 2020, and March 4, 2021. ResultsA total of 62 cases due to fatal COVID-19 were identified; autopsy findings included diffuse alveolar damage, acute bronchopneumonia and lobar pneumonia, and pulmonary thromboemboli. Nine additional decedents had a nasopharyngeal swab positive for SARS-CoV-2 and a cause of death unrelated to COVID-19. Forty-seven cases with COVID-19-like symptoms showed no laboratory or histopathologic evidence of SARS-CoV-2 infection; the most common causes of death in this group were hypertensive or atherosclerotic cardiovascular disease, complications of chronic alcoholism, and pulmonary thromboemboli unrelated to infection. ConclusionsThe clinical findings associated with COVID-19 are not specific; a broad differential diagnosis should be embraced when decedents present with cough or shortness of breath. An autopsy may be indicated to identify a cause of death unrelated to COVID-19.