AERZTE Steiermark | Juli/August 2020

20 ÆRZTE Steiermark  || 07/08|2020 FORSCHUNG Das Ausmaß der pulmonalen Kreislaufstörungen konnte nur durch eine systematische Aufarbeitung der Lungen entdeckt und dargestellt wer- den. Infolge der pulmona- len Gefäßverschlüsse kam es zur pulmonalen Hypertonie und zur konsekutiven Herz- insuffizienz. Zehn von elf Patienten hatten zur Throm- boseprophylaxe Antikoagu- das lymphatische System und in einigen Fällen auch das Pankreas betroffen sind. In der Lunge lassen sich neben Alveolarschäden sowie hy- alinen Membranen vor allem Mikro- und Makrothrombo- sen nachweisen. Zumindest Mikrothrombosen hatten sämtliche obduzierten Pa- tienten, einige auch solche in den größeren Gefäßen. Masern sind sehr ansteckend. Auch für Healthcareworker. Ohne Impfung erkranken 95 von 100 Menschen. Bei 10 von 100 Masern-Fällen ist mit schweren Folgeerkrankungen zu rechnen. Die Masern-Impfung schützt. Verlässlich. Bitte denken Sie an Ihren Impfschutz – und an den Ihrer MitarbeiterInnen! Gratis für Menschen jeden Alters! Fotolia Masern_inserat_mut_arzt.indd 1 10.03.2016 09:04:35 „Unsere Hypothese ist, dass die Ausbildung von Thromben in der Lunge durch die entzündlichen Veränderungen und die verlangsamte Blutzirkulation begünstigt wird.“ Sigurd Lax Pulmonary Arterial Thrombosis in COVID-19With Fatal Outcome: Results From a Prospective, Single-Center, Clinicopathologic Case Series SigurdF.Lax,MD,PhD;KristijanSkok,MD;PeterZechner,MD;HaraldH.Kessler,MD,PhD;NorbertKaufmann,MD; CamilloKoelblinger,MD;KlausVander,MD;UteBargfrieder,MD;andMichaelTrauner,MD,PhD Background: Coronavirus disease 2019 (COVID-19) caused by the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has rapidly become pandemic, with substantial mortality. Objective: To evaluate the pathologic changes of organ sys- tems and the clinicopathologic basis for severe and fatal outcomes. Design: Prospective autopsy study. Setting: Single pathology department. Participants: 11deceasedpatientswithCOVID-19(10ofwhom were selected at random for autopsy). Measurements: Systematic macroscopic, histopathologic, and viral analysis (SARS-CoV-2 on real-time polymerase chain reac- tion assay), with correlation of pathologic and clinical features, including comorbidities, comedication, and laboratory values. Results: Patients' age ranged from 66 to 91 years (mean, 80.5 years;8men,3women).Tenofthe11patientsreceivedprophy- lactic anticoagulant therapy; venous thromboembolism was not clinically suspected antemortem in any of the patients. Both lungs showed various stages of diffuse alveolar damage (DAD), includingedema,hyalinemembranes,andproliferationofpneu- mocytesandfibroblasts.Thrombosisofsmallandmid-sizedpul- monary arteries was found in various degrees in all 11 patients and was associated with infarction in 8 patients and broncho- pneumoniain6patients.Kupffercellproliferationwasseeninall patients, and chronic hepatic congestion in 8 patients. Other changes in the liver included hepatic steatosis, portal fibrosis, lymphocytic infiltrates and ductular proliferation, lobular choles- tasis, and acute liver cell necrosis, together with central vein thrombosis. Additional frequent findings included renal proxi- mal tubular injury, focal pancreatitis, adrenocortical hyperplasia, andlymphocytedepletionofspleenandlymphnodes.ViralRNA was detectable in pharyngeal, bronchial, and colonic mucosa but not bile. Limitation: The sample was small. Conclusion: COVID-19predominantlyinvolvesthelungs,caus- ing DAD and leading to acute respiratory insufficiency. Death may be caused by the thrombosis observed in segmental and subsegmentalpulmonaryarterialvesselsdespitetheuseofpro- phylactic anticoagulation. Studies are needed to further under- stand the thrombotic complications of COVID-19, together with therolesforstrictthrombosisprophylaxis,laboratory,andimag- ing studies and early anticoagulant therapy for suspected pul- monary arterial thrombosis or thromboembolism. Primary Funding Source: None. AnnInternMed. doi:10.7326/M20-2566 Annals.org Forauthor,article,anddisclosureinformation,seeendoftext. ThisarticlewaspublishedatAnnals.orgon14May2020. T he pandemic spread of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) causing coro- navirus disease 2019 (COVID-19) has, within a few months, led to a global health and economic crisis (1–3). COVID-19 is usually characterized by symptoms of acute respiratory infection, such as fever, headache, dry cough, and shortness of breath, but may show further symptoms involving the gastrointestinal tract (gastroenteritis-like, withvomitinganddiarrhea,orahepatitis-likepicture)and the central nervous system (most notably anosmia) (4–8). Only a small subset of infected individuals becomes se- verely ill, requiring intensive care and with risk for death, but this number may increase dramatically through the high transmission rate of the virus (8–10). Although ad- vanced age and certain comorbid conditions, such as di- abetes mellitus and cardiovascular diseases, have been identified as risk factors for adverse outcome and death, the individual clinical course can be highly unpredictable and dynamic, with rapid deterioration of the respiratory and hemodynamic condition (10–14). So far, very little is known about the pathologic findings underlying the clinical presentation of severe COVID-19. Only a few reports on surgical specimens and autopsy cases have been published over the past fewmonths,anddetailedinformationisstilllimited(15– 17) and was in part obtained by postmortem core bi- opsies (18, 19). More insights from autopsies have be- come available from the 2003 SARS-CoV-1 epidemic, showing that patients with fatal outcome predomi- nantly had diffuse alveolar damage characterized by edema, hyaline membranes, and proliferation of pneu- mocytes and fibroblasts (20). Nevertheless, the pattern of organ damage caused by SARS-CoV-2 and occurring in patients with COVID-19 is still incompletely under- stood. In light of the currently limited options for effec- tive antiviral treatment, it may be critical to better un- derstand the morphologic basis for severe and fatal COVID-19 outcomes (21). The aim of this detailed autopsy study was to un- ravel the clinicopathologic basis for adverse outcomes in patients with a fatal course of COVID-19 by evaluat- ing the gross and microscopic findings in correlation with their clinical phenotypes. We used a prospectively designed systematic approach to perform the autop- Annals of Internal Medicine O RIGINAL R ESEARCH Annals.org AnnalsofInternalMedicine ©2020AmericanCollegeofPhysicians 1