key: cord-1017495-nvhk45vp
authors: Hirschbühl, Klaus; Schaller, Tina; Kling, Elisabeth; Märkl, Bruno; Claus, Rainer
title: Autopsy of patients with COVID-19: A balance of fear and curiosity
date: 2020-05-31
journal: Pathol Res Pract
DOI: 10.1016/j.prp.2020.153039
sha: 59c0e1fb69de21d770b0c8005331c904a206f30a
doc_id: 1017495
cord_uid: nvhk45vp

nan

Keywords: COVID-19, SARS-CoV-2, autopsy, personal protective equipment (PPE)

Corona virus disease 2019 (COVID-19) disease has become pandemic since December 2019.

App. 15% of those affected undergo a severe disease and 5-6% are critical (respiratory failure, and/or multiple organ dysfunction/failure). COVID-19 pathogenesis is still not sufficiently understood. Thus, systematic examination is mandatory to comprehend extent and mechanisms of this novel disease. Autopsy is the only opportunity to macroscopically observe organs and take optimal samples for histological and molecular analyses. Thereby, autopsy is very likely superior over postmortem core needle biopsies. Consequently, several reports have recently demonstrated that autopsy based examinations generate important insights into the disease manifestations, the mechanisms of organ failure and the association with viral distribution [3, 4, 6] .

While most Coronavirinae belong to hazard group 2 (HG2), severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has recently been categorized as HG3 like the severe acute respiratory syndrome coronavirus (SARS-CoV) and the Middle East respiratory syndrome coronavirus (MERS-CoV), indicating that it can cause severe human disease and may be a serious hazard to contact persons. Thus, postmortem examinations in SARS-CoV-2 positive patients have to be considered high-risk infectious autopsies. Several publications and recommendations from official institutions (such as the Robert-Koch-Institut, Berlin, for Germany) have generated a debate about weighing risks and benefits of autopsies in COVID-main route of transmission is by respiratory droplets released from infected persons. This is not a major concern when handling human remains or performing postmortem procedures.

Transmission via surfaces appears less frequent and relevant. Taken together, evidence about the risk of getting infected during autopsies and workup of the specimens is lacking so far.

Here, we report our experience from a series of full autopsies (including brain autopsy) of 17 patients with proven SARS-CoV-2 infection and COVID-19 at the University Medical Center Augsburg [6]. The study was approved by the local institutional review board (approval number 2020-18, April 20, 2020). Autopsies were conducted always by the identical team of four trained physicians without technical assistance between April 4 and 28, 2020, according to recommendations and published best practice for managing cases with HG3 pathogens [1, 2] CDC, UK, RKI,. Personal protective equipment (PPE) used for all autopsies included a surgical scrub suit and rubber boots, a hat to protect hair, safety goggles and a clear visor to protect the face, an FFP3 mask for respiratory protection, a waterproof gown, additional forearm protection, a plastic apron, cut-resistant glass fibre reinforced protective gloves and double surgical gloves as illustrated in Figure 1 . PPE was disposed before leaving the autopsy suite. In summary, we describe an autopsy procedure applicable to cases of COVID-19 and provide first evidence that postmortem examinations can be conducted safely in those patients when applying appropriate PPE. This report is the first of its kind on analyses of autopsy personnel J o u r n a l P r e -p r o o f tested negative by RT-PCR and serology. Our observations indicate that the risk of SARS-CoV-2 infection during autopsy might be overestimated and restrictions on postmortem examinations could be reconsidered. However, a systematic risk assessment for full autopsy, workup and examination of the specimens is still not available and needs to be completed. This is of particular interest since different pathologists/working groups in a number of different countries follow different standard operating procedures for autopsy of COVID-19 patients ( Table 1) . Taken together, it appears to be common sense to protect autopsy personnel during the procedure in the same fashion as personnel on wards specific for SARS-CoV-2 positive patients.

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. 

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