Postmortem Examination of Patients With COVID-19 | Critical Care Medicine | JAMA | JAMA Network
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    9 Comments for this article
    Viral PCR in Pleural Fluid
    Anand Sundaralingam, MBBS, BSc, MRCP | Oxford University Hospitals
    Could the authors comment further on what proportion of the patients were found to be viral PCR positive in pleural fluid? Though pleural effusion appears to not be a prominent respiratory manifestation of Covid-19, the presence of viral PCR in pleural fluid may well represent a hazard to clinicians performing pleural procedures and may need to guide infection control policies.
    COVID-19 Post-Mortem Findings
    Arturo Tozzi, Pediatrician | University of Noth Texas
    In this intriguing paper, the Authors report acute and organizing diffuse alveolar damage as the predominant histopathologic finding in postmortem evaluation of 10 patients with COVID-19.  These data run counter to the not yet reviewed series of 38 cases described by Carsana et al. on MedRxiv (, who emphasize how the main relevant finding in COVID-19 deceased patients is the presence of platelet-fibrin thrombi in small arterial vessels.

    Arturo Tozzi
    Center for Nonlinear Science, University of North Texas, Denton, Texas, USA

    Carlo Venditti
    Ospedale Rummo, Benevento, Italy
    Re: Viral PCR in Pleural Fluid
    Rainer Claus, MD | Hematology and Oncology, Medical Faculty, University of Augsburg, Germany
    Thank you for your interesting and relevant comment. In the meantime, we have extended our cohort to 19 patients. Of those, 10 patients had clinically relevant pleural effusion and 5 patients were indeed found to be positive for SARS-CoV-2 by RT-PCR in the pleural fluid. Thus, pleural procedures might possibly be associated with an increased risk of infection.
    Daniel Goyal, MRCP, PhD | Gibraltar Health Authority
    The lack of autopsies in this new infection has been somewhat frustrating. These findings are very welcomed. And thanks for the concise descriptions. Emboli not seen! Not sure viral load was checked - which would be useful. And should we be reconsidering steroids?
    Postmortem examination on COVID-19, virus existance and note for preventive practice
    Viroj Wiwanitkit, MD | Dr DY Patil University, Pune, India
    The results from this report by Schaller on postmortem examination of patients with COVID-19 [1] hints at the possibility that SARS-CoV-2 might still exist in body after death, which could account for some unexplained deaths. Safety in postmortem examinations is an important clinical issue to be kept in mind for all practitioners [2 - 3]; it is unclear if we have sufficient protective practices at present.

    1. Schaller T, Hirschbühl K, Burkhardt K, et al Georg Postmortem Examination of Patients With COVID-19. JAMA. Published online May 21, 2020. doi:10.1001/jama.2020.8907
    2. Sriwijitalai W, Wiwanikit V. Corrigendum
    to "COVID-19 in Forensic Medicine Unit Personnel: Observation From Thailand" [J Forensic Legal Med 72 May 2020, 101964]
    J Forensic Leg Med . 2020 May;72:101967. doi: 10.1016/j.jflm.2020.101967.
    3. Sriwijitalai W, Wiwanikit V. COVID-19 in Forensic Medicine Unit Personnel: Observation From Thailand. J Forensic Leg Med. 2020 May;72:101964. doi: 10.1016/j.jflm.2020.101964
    Why No Testing of GI Specimens?
    Giovanni Ghirga, Pediatrician, Italy |
    Xiao showed that ACE2 protein, which has been proven to be a cell receptor for SARS-CoV-2, is abundantly expressed in the glandular cells of gastric, duodenal, and rectal epithelia, supporting the entry of SARS-CoV-2 into the host cells (1). Furthermore, in more than 20% of patients with SARS-CoV-2, it was observed that the test result for viral RNA remained positive in feces, even after test results for viral RNA in the respiratory tract converted to negative, indicating that the viral gastrointestinal infection and potential fecal-oral transmission can last even after viral clearance in the respiratory tract (1).

    In this
    paper specimens from lung, heart, liver, spleen, kidney, brain, pleural effusion, and cerebrospinal fluid (CSF) were assessed and we hoped specimens from gastric and intestinal epithelia would have been assessed.


    1) Hiao F, et al. Evidence for Gastrointestinal Infection of SARS-CoV-2. Gastroenterology. May 2020. Volume 158, Issue 6, Pages 1831–1833.e3
    Giovanni Ghirga, Pediatrician, Italy
    No Thromboembolic Events
    Vedat Aslan, MD | Antalya Education and Research Hospital
    No thrombosis in autopsy. So why are d-dimer levels so high in Covid-19 patients?

    I think fibrosis is the cause. In primary idıopathic pulmonary fibrosis (IPF) patients, D-dimer elevation is an important sign of prognosis. In Covid-19 patients, after extravasation of plasma into the interstitial space (capillary leak), fibrinogen in plasma interacts with fibronectin to cause fibrosis. Tissue plasminogen also starts to degrade this fibrosis and then D-dimer levels start to elevate. Autopsy findings also show this.
    Thrombosis can be the very late complication of Covid-19.
    post-mortem nasopharyngeal swabs
    Darrell Lewis, BASC, MD, FRCSC | Dalhousie University
    Thank you for your very important work. Could you please elaborate further on "SARS-CoV-2 was still detectable in the respiratory tracts of all patients"? Specifically, were the nasopharyngeal swabs performed post-mortem all positive? This has implications for post-mortem tissue donor screening. Thank you again.
    RE: Post-Mortem Nasopharyngeal Swabs
    Rainer Claus, MD | Hematology and Oncology, Medical Faculty, University of Augsburg, Germany
    Thank you very much for your comment. We performed nasopharyngeal, tracheal and bronchial swabs and tested for SARS-CoV-2 RNA by RT-PCR. From the 10 patients reported in the Research Letter, 9 were RT-PCR positive from nasopharyngeal swabs. 7 and 6 patients were positive from tracheal and bronchial swabs, respectively. Taken together, we could detect viral DNA in all of the patients at at least one site of the respiratory tract. It is remarkable that Ct values were considerably below 20 in some of the patients suggesting postmortem persistence of high viral burden.
    Research Letter
    May 21, 2020

    Postmortem Examination of Patients With COVID-19

    Author Affiliations
    • 1Institute of Pathology and Molecular Diagnostics, University Medical Center Augsburg, Augsburg, Germany
    • 2Department of Hematology and Clinical Oncology, University Medical Center Augsburg, Augsburg, Germany
    • 3Institute of Laboratory Medicine and Microbiology, University Medical Center Augsburg, Augsburg, Germany
    • 4Department of Gastroenterology, University Medical Center Augsburg, Augsburg, Germany
    JAMA. 2020;323(24):2518-2520. doi:10.1001/jama.2020.8907

    Approximately 15% of individuals affected by coronavirus disease 2019 (COVID-19) develop severe disease, and 5% to 6% are critically ill (respiratory failure and/or multiple organ dysfunction or failure).1,2 Severely ill and critically ill patients have a high mortality rate, especially with older age and coexisting medical conditions. Because there are still insufficient data on cause of death, we describe postmortem examinations in a case series of patients with COVID-19.

    Between April 4 and April 19, 2020, we conducted serial postmortem examinations in patients with proven severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection who died at the University Medical Center Augsburg (Germany). Autopsies were conducted according to published best practice.3 Specimens from lung, heart, liver, spleen, kidney, brain, pleural effusion, and cerebrospinal fluid (CSF) were assessed. Postmortem nasopharyngeal, tracheal, bronchial swabs, pleural effusion, and CSF were tested for SARS-CoV-2 by reverse transcriptase–polymerase chain reaction. This study was approved by the local institutional review board, and written informed consent was obtained from next of kin.