Results from 12 patients who died of COVID-19 in Hamburg, Germany show that death in four of them was caused by a massive pulmonary embolism from a blood clot that traveled from the leg to a lung artery.
Autopsies are rarely routinely done in medical settings today. In the United States, states have their own criteria when autopsies should be performed, usually when a death is suspicious or there is a significant public health threat. Families, too, can request autopsies to confirm a cause of death.
The German autopsies back up findings from autopsies in the United States conducted in late spring when deaths from the virus began to wane. Physicians did report clotting in patients but not to the extent revealed in the autopsies.
“The clotting was not only in the large vessels but also in the smaller vessels,” researcher and pathologist Amy Rapkiewicz, M.D., told CNN July 10. “And this was dramatic because though we might have expected it in the lungs, we found it in almost every organ that we looked at in our autopsy study.”
The results of that study were reported in the Lancet journal, EClinical Medicine in June.
The study on the German autopsies was published in the Annals of Internal Medicine on May 6.
The Chicken or the Egg
The results raise at least one question: did the virus cause the clots or were the patients predisposed to clots, regardless of the infection?
“Virus in the clots may mean nothing in particular,” said Marilyn Singleton, M.D., J.D. a board-certified anesthesiologist and former president of the Association of American Physicians and Surgeons. “Maybe the virus is not housed in the clots—just created the conditions for the clots. There are so many people (including my husband several years ago) who get a pulmonary embolus for unknown reasons.”
Time for More Autopsies?
The results raise a second issue: with an unpredictable virus, should health agencies revise autopsy practices?
It is possible to get a reliable cause of death without an autopsy, Singleton says.
“[Doctors can determine the cause from] patient history, clinical findings, lab tests, toxicology, and imaging reports,” Singleton said.
“Autopsies are usually done when it is a surprise. With COVID, the actual mechanism of action at the cellular level would be great to know,” Singleton said. “The results of the cellular action at some point become non-specific to COVID, but generalized, out-of-control inflammatory reactions, such as the cytokine storm, or disseminated intravascular coagulation—well-known years before we ever heard of COVID.”
It is hard to use general autopsy practices in the current situation, Singleton says.
“People are trying to find out as much as they can about COVID, so they are probably asking more family members for autopsy permission,” Singleton said.
Autopsies, however, are not always an easy decision.
“My first death on the operating table was what we guessed was a massive pulmonary embolus in a healthy person,” Singleton said. “He was awake and talking (under spinal for a minor procedure) and he suddenly flatlined on the EKG. This was before pulse oximeters. We could not resuscitate him—a sign of a massive pulmonary embolus. The family refused autopsy.”
AnneMarie Schieber (firstname.lastname@example.org) is managing editor of Health Care News.