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What Has Been Learned About Coronavirus Through Recent Autopsies

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What Has Been Learned About Coronavirus Through Recent Autopsies

2020-07-01 22:38:37

By Laura Tucker, Staff writer; Image: Coronavirus research (Image source: Public domain)

 

Medical research has long been accomplished through autopsies, and it's no different with the novel coronavirus. From the time it first became a pandemic, it was so overwhelming to hospital systems that they didn't have time to solve anything. They were too busy trying to keep people alive.

Yet now some of the institutions that had many cases are releasing results of what they found in the autopsies of the people who died from COVID-19. While it's confirmed some things for doctors, it's also led to more questions.

It was confirmed that the organ under attack the most is the lungs, yet the virus was also found in the brain, kidneys, liver, gastrointestinal tract, spleen, and the endothelial cells that line blood vessels. There's also been clotting in organs in a significant number of cases.

Much of all that was expected — what wasn't was the findings relating to the brain and heart. "It's about what we are not seeing," said Mary Fowkes, an associate professor of pathology. She's on a team at Mount Sinai Health that has performed autopsies on 67 COVID-19 patients.

Fowkes expected to find the virus and/or inflammation in the brain because of the reports of neurological symptoms, but she didn't find much. Doctors were warning about a cardiac complication they believed was myocarditis. Autopsies have not turned up evidence of this, however.

It was also learned that there was oxygen deprivation of the brain and that blood clots may form early on in the disease. This could lead to a change in treatment.

New modeling showed that approximately 22 percent of the population, about 1.7 billion people throughout the world and 72 million in the United States, could become seriously ill if they become infected. Four percent of the people would require hospitalization.

To protect the pathologists from the virus and to avoid sending it throughout the air during the autopsies, they used special tools and then stored organs in a disinfecting solution for several weeks before studying them. Each organ is then sectioned and small amounts of tissue collected for studying.

An autopsy in New Orleans became public on April 10 and was one of the first. LSU Health had treated the 44-year-old man. Richard Vander Heide recalls finding hundreds or thousands of microclots when he cut the man's lung.

"I will never forget the day," he reported. "I said to the resident, 'This is very unusual.' I had never seen something like this."

Moving on to other patients, he saw the same thing. He published the paper online before submitting it to a journal to make sure the information could be seen by doctors earlier. The strategy worked. His findings influenced doctors and hospitals to start using blood thinners in their COVID-19 treatments.

Seventy-seven more lung autopsies were described in papers from Italy, a Mount Sinai Health study, an NYU Langone Health study, and a collaboration between Harvard Medical School and German researchers. These autopsies showed more of the same.

A study from Lancet's eClinicalMedicine this month showed abnormal clotting in the heart, kidney, and liver, along with the lungs of seven patients. The authors began to wonder if this was the cause of the multiple-organ failure in COVID-19 patients.

There were also significant findings with the heart. Initially, it was reported that up to 20 to 30 percent of COVID-19 patients appeared to have myocarditis, a fatal heart problem. The body attacks tissue, believing it's foreign, leaving dead zones in the heart. Myocyte muscle cells would be surrounded by infection-fighting lymphocyte cells. Normally, this condition is easy to find in autopsies, but in the autopsy samples being observed, lymphocytes were not surrounding the dead myocytes.

Fowkes and her colleague, Clare Bryce, saw "very mild" inflammation on the heart's surface, but it didn't appear to be myocarditis.

Amy Rapkiewicz noticed an abundance of megakaryocytes, a rare cell that produces platelets. These control clotting and are normally only found in bone marrow and lungs. Revisiting the lung samples, she found they had the megakaryocytes as well. "I could not remember a case before where we saw that," said Rapkiewicz. "It was remarkable they were in the heart."

Vander Heide of LSU reported findings on 10 patients and explained that "when you look at a COVID heart, you don't see what you'd expect." While a couple of the patients had gone into cardiac arrest, when he examined them, the primary damage was in the lungs and not the heart.

COVID-19's effects on the brain haven't been reported much, but that could be because it's particularly puzzling to the pathologists. Patients have reported neurological difficulties, including the loss of smell or taste, altered mental status, and strokes. An early study out of China showed 22 percent of patients had neurological issues. French researches reported 84 percent of patients in ICU had neurological problems. Even more were found in a UK study.

Neuropathologist Isaac Solomon, of Brigham and Women's Hospital in Boston, investigated whether COVID-19 was embedding itself in the brain. After studying key areas of the brain in 18 consecutive deaths, he found the virus only in some areas, and it wasn't clear whether they were dead remnants or active virus at the time of death. There were large amounts of damage from oxygen deprivation, however. He noted they were "very surprised."

If the virus isn't getting into the brain in large amounts, Solomon said that helps with developing drugs for it, as it gets more difficult when it's pervasive. This finding also showed the importance of getting patients on supplementary oxygen as quickly as possible.

He also notes his findings suggest damage had been happening over a longer period of time. This makes him question the effects on people who aren't that ill. "The big lingering question is what happens to people who survive COVID," he said. "Is there a lingering effect on the brain?"

The Mount Sinai Health team was also puzzled not to find much virus or inflammation in the brain. What they did find was a widespread appearance of tiny clots.

"Fowkes said, "If you have one blood clot in the brain, we see that all the time. But what we're seeing is, some patients are having multiple strokes in blood vessels that are in two or even three different territories."

Rapkiewicz, of NYU Langone Health, found damage to the lungs, kidneys, and liver, the same as what's been reported since nearly the beginning of the pandemic. Yet, it was off to her. She noticed some had far too many of a cell that's rarely found in those areas, something she'd never seen before. It seemed somewhat familiar.

She researched through history books and found a reference to a report in the 1960s of a patient with dengue fever, a mosquito-borne tropical disease. It appeared to destroy those cells which produce platelets, causing uncontrollable bleeding. COVID-19 saw that but with a more dangerous amplified effect that caused clotting.

It's too early to know how all these findings will translate into a change in treatment, according to Rapkiewicz. One of her first calls after her discovery was to cardiac specialist Jeffrey Berger at NYU, who runs a lab that focuses on platelets. He believes the autopsies suggest anti-platelet medications, in addition to blood thinners, may be helpful. 

"It's only one piece of a very big puzzle, and we have a lot more to learn, he said. "but if we can prevent significant complications, and if more patients can survive the infection, that changes everything."

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