Discussion
In this report, we present an autopsy case of COVID-19 with anti-viral
and anti-inflammatory therapy. Pulmonary pathology revealed severe
hemorrhagic change, but the findings of DAD and subpleural fibrosis were
not so prominent. Autopsy findings of COVID-19 have been reported from
worldwide countries, including the United States13,
and those from Europe14-16, Asia12,
17, 18, and Africa19. No national differences have
been described, and most reports stated that DAD is a major cause of
respiratory failure, which is different from the present case.
Since this pandemic occurred, efforts have been made to overcome the
exaggerated host immune reactions, and a living WHO guideline on drugs
for COVID-19, for example, was repeatedly updated20.
Autopsy of the present case was performed in April, 2021 during the
4th pandemic wave in Japan, and the patient was
treated with anti-inflammatory therapy with dexamethasone and
tocilizumab. Thus, the absence of active DAD and severe fibrosis would
be due to the therapeutic effects. Subpleural fibrosis was also
restricted. Thus, we interpret that the direct cause of death was severe
hemorrhage, but not DAD.
The reason why severe hemorrhage occurred remain undetermined. In the
kidney, microvascular thrombosis was seen in the glomerular vessels,
resembling pathology of DIC, although the last platelet count was over
90,000/µl in the peripheral blood. The patient was also under
anticoagulation therapy with warfarin, due to permanent atrial
fibrillation. His PT-INR was kept between 1.8-3.8 in the last day. At
the autopsy, his stomach was filled with blood, and multiple ulceration
was seen accompanying candida colonies. In kidney, bacterial colonies
were also present with multiple abscess. Thus, co-infection may relate
to the systematic coagulation and fibrinolysis disorder, but it could
not be concluded.
In conclusion, we present the autopsy case of COVID-19 treated with
remdesivir, dexamethasone, and tocilizumab. The pulmonary pathology
suggested the therapeutic effect, but the cause of severe hemorrhage
remain unknown. Co-infection would be also a future issue in relation to
anti-inflammatory therapy for COVID-19. We hope our analysis contributes
to save the global lives from this pandemic disease.