COVID-19 - cause of death or associated disease: response from pathologists

Patients with COVID-19 die “of” or “with” the coronavirus. The pathologists who performed autopsies on these victims disagreed. Writes about this DW.

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Every evening, as in regular reports from the front, viewers are told how many currently infected with the SARS-CoV-2 coronavirus in their country, how many have recovered and how many have died.

But doctors in many countries affected by the pandemic are arguing about whether people who become infected die “from” or “with” COVID-19, or whether this disease is simply concomitant, and the cause of death is chronic illnesses. The answers, in theory, should come from autopsy results.

The Koch Institute was initially against autopsies

At the initial stage of the coronavirus epidemic in Germany, the state Robert Koch Institute (RKI), which coordinates the fight against infectious diseases in the country, for safety reasons did not recommend performing autopsies on deceased patients with SARS-CoV-2 in their bodies. Back in early April, the RKI strongly recommended on its website to “avoid examining internal organs, performing autopsies or other actions that cause aerosol leakage.”

Then the institute changed its mind, and its deputy director Lars Schaade at a press conference in Berlin even specifically pointed out the importance of opening autopsies as often as possible.

This is the only way to establish, he added, that coronavirus infects a lot more internal organs than it was possible to judge from the first data received from China.

However, from the very beginning, German morgues did not listen to the RKI recommendation, which the chairman of the Federal Union of German Pathologists, Karl Friedrich Bürrig, called “an unfortunate mistake.” For all modern infectious diseases, autopsies are very important to determine the course of the disease, including COVID-19, Burrig recalled.

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Hamburg forensic expert database

The most extensive database on this matter was compiled by Professor Klaus Püschel, director of the Institute of Forensic Medicine at the University Hospital of Hamburg.

“From the dead,” the professor is sure, “you can learn a lot to treat the living.”

From March 22 to April 11, he performed autopsies on 65 deceased patients diagnosed with COVID-19. Everyone, without exception, suffered from others in addition to this disease. Thus, 46 people were “lung patients” during their lifetime, 28 had diseases of other internal organs or transplanted organs, 10 suffered from diabetes or obesity, 10 had cancer, 16 had dementia (the total number is more than 65, since some patients had several diseases. — Ed.).

Now in Püschel’s database there is information from more than 100 autopsies, which confirm his initial conclusion: none of the deceased suffered exclusively from COVID-19. All had other ailments - cardiovascular diseases (in particular, they had suffered heart attacks), high blood pressure, atherosclerosis, diabetes, cancer, pulmonary or kidney failure, and cirrhosis of the liver.

Therefore, Klaus Püschel considers the fear of coronavirus to be exaggerated and says that COVID-19 “is not a particularly dangerous viral disease.” According to him, this virus must be taken seriously, but the hype around it, according to the professor, has caused unfounded fears among the population. Among the unjustified measures, he also considers the ban on saying goodbye to relatives of the dead.

“Although you shouldn’t kiss the dead,” says Püschel, “you can look at them and even touch them with your hands if you wash them after that.”

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Post-mortem studies in Italy and Switzerland

The data obtained by Püschel in Hamburg roughly correspond to the report of the Italian Ministry of Health, compiled not from the results of the autopsy, but from the medical histories of 1 deceased patients. 738% of them had at least one other disease in addition to COVID-96,4. The most common conditions were high blood pressure (19%), diabetes (70%) and cardiovascular disease (32%). The average age of deaths in Italy was 28 years, in Hamburg - 79.

All 20 patients who were autopsied after death by the chief pathologist at the Swiss University Hospital in Basel, Alexander Tzankov, were also hypertensive. In addition, most of them were overweight, two thirds had heart and vascular problems, and a third had diabetes.

But unlike Professor Klaus Puschel, Tsankov is not inclined to call COVID-19 a relatively harmless disease. If they had not become infected with a coronavirus, Tsankov recalled, these people would most likely be still alive now.

“Without COVID-19, these patients would have lived longer: maybe by an hour, maybe by a day, maybe by a week, and maybe by a year,” Tsankov noted.

David Horst, the chief pathologist of the Berlin Charite University Hospital, draws attention to this circumstance. The average age of dead patients with COVID-19 opened by him is 69 years old, but among them was one 45-year-old woman.

In an interview with the Berliner Zeitung newspaper, he confirmed that all the deceased he examined had chronic diseases during their lifetime: cardiovascular disease, hypertension, pulmonary insufficiency, and some were obese. But, Horst recalled, “such diseases are very common in Germany among people over 65 years of age, affecting every third person.”

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The Berlin pathologist notes that in most cases, these chronic diseases alone do not pose a serious threat to life. But in combination with coronavirus, they become extremely dangerous, especially for the elderly.

Answering the question of Berliner Zeitung about the most common complications caused by coronavirus, the expert named three. First, damage to the lungs, which begin to fill with fluid and as a result cease to enrich the body with oxygen. Secondly, bacteria quickly multiply in the affected lungs, which often leads to inflammatory processes and sepsis. Thirdly, this is a violation of the blood coagulation process, as a result of which blood clots form, causing a collapse of the cardiovascular system.

Regarding the debate about whether patients died “of” or “with” COVID-19, Horst insists on the “from” formulation. He confirms that all the deceased had one or another chronic illness, but not so serious as to die from it.

“I think it’s very important not to let the idea arise that the coronavirus is not dangerous because these people would have died anyway,” Horst said. “Without coronavirus, they would be alive right now.”

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