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Clev
Medical Educator

Physicians are faced with many challenges during the COVID-19 pandemic, one of which is accurate determination of cause of death. While the cause of death may seem obvious in individuals who test positive for SARS-CoV-2 and die after a febrile illness that evolves into respiratory failure, not all cases fit this stereotype. Since many patients with COVID-19 are elderly and have underlying medical conditions, other possibilities must be considered. When such individuals die with atypical symptoms or are not tested for SARS-CoV-2 prior to death, assessment of cause of death can be complicated. The key question then becomes: did the patient die from COVID-19 or with COVID-19? These two cases offer insights into the underlying pathology of COVID-19 and illustrate how autopsies can clarify the cause of death in some cases. Case 1- A 77-year-old man with fever and chills for six days. He was scheduled to see a physician the following week. On the day of his demise, he had been feeling extremely weak and had become increasingly short of breath. He was emergently transported to a hospital, but unfortunately suffered a cardiac arrest during transport and died soon after reaching the hospital. He was never ventilated. His history included hypertension, remote deep vein thrombosis and remote splenectomy. At the time of autopsy, the forensic pathologist performed a postmortem nasopharyngeal swab and lung swab, both of which were positive for SARS-CoV-2. Testing for influenza was negative. Autopsy revealed microscopic findings typical of severe viral infection, including diffuse alveolar damage (image 2) and chronic airway inflammation (image 1). We concluded that the cause of death was COVID-19.