Autopsy Findings and Venous Thromboembolism in Patients With COVID-19
Authors: Oleg Epelbaum
Journal: Annals of Internal Medicine (2020)

Letters15 December 2020Autopsy Findings and Venous Thromboembolism in Patients With COVID-19FREEOleg Epelbaum, MDOleg Epelbaum, MDNew York Medical College, Valhalla, New York (O.E.)Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/L20-1205 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail TO THE EDITOR:Wichmann and colleagues' case series from Germany (1) was a welcome addition to the growing literature on the postmortem pulmonary histologic characteristics of lung disease related to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), even though the finding of diffuse alveolar damage in terminal cases does little to illuminate the process in its earlier stages. However, I am concerned about the authors' emphasis on the aspect of venous thromboembolism (VTE) as it relates to their findings. This term appears in the title of their article and dominates the concluding paragraph. If assimilated without context by the clinical community, this extract from the study's results could further fuel the pervasive but unsubstantiated belief that coronavirus disease 2019 (COVID-19) is a uniquely hypercoagulable state.Case 1 in the study is a patient who had an out-of-hospital cardiac arrest, with pulmonary embolism (PE) found to be the likely cause. This is unsurprising: Well before the emergence of SARS-CoV-2, PE had been recognized as the most common non–cardioaortic cause of unsuccessfully resuscitated community arrests (2). The other 3 PE cases in the series were managed in the intensive care unit, and all of these patients were obese and mechanically ventilated. The authors did not mention whether these patients received appropriate VTE prophylaxis, which remains a global deficiency from which Germany is not exempt.The antemortem detection rate of incidental PE in general intensive care unit populations receiving mechanical ventilation can approach 20% (with obesity being a risk factor) and exceeds that figure in autopsy studies. However, this finding has not been linked to inferior outcomes clinically and has rarely been deemed a precipitant of death pathologically (3). Death with diffuse alveolar damage is almost universally accompanied by pulmonary vascular thrombosis (including macrovascular disease). As such, the mere presence of thrombi as reported in the series by Wichmann and colleagues should not be construed as a unique feature of SARS-CoV-2 lung disease when diffuse alveolar damage is present. Furthermore, SARS-CoV-2 hardly stands out from other viruses in regard to postmortem VTE. Patients in a study of 8 autopsies done on fatal H1N1 influenza cases had a higher percentage of PE (5 of 8 patients [63%]) than did those in Wichmann and colleagues' series (4 of 12 patients [33%]) (4).Although severe COVID-19 promotes hemostatic dysregulation, it is not the only critical illness to do so. Wichmann and colleagues' findings do not advance the theory that critically ill patients with COVID-19 are unusually predisposed to VTE and therefore merit an unprecedented approach to anticoagulation. Yet, the authors imply otherwise, invoking an international guidance document (5) as corroboration even though the document's expert author panel voted against routine empirical anticoagulation.References1. Wichmann D, Sperhake JP, Lütgehetmann M, et al. Autopsy findings and venous thromboembolism in patients with COVID-19. A prospective cohort study. Ann Intern Med. 2020;173:268-77. doi:10.7326/M20-2003 LinkGoogle Scholar2. Virkkunen I, Paasio L, Ryynänen S, et al. Pulseless electrical activity and unsuccessful out-of-hospital resuscitation: what is the cause of death? Resuscitation. 2008;77:207-10. [PMID: 18249482] doi:10.1016/j.resuscitation.2007.12.006 CrossrefMedlineGoogle Scholar3. Minet C, Lugosi M, Savoye PY, et al. Pulmonary embolism in mechanically ventilated patients requiring computed tomography: Prevalence, risk factors, and outcome. Crit Care Med. 2012;40:3202-8. [PMID: 23164766] doi:10.1097/CCM.0b013e318265e461 CrossrefMedlineGoogle Scholar4. Harms PW, Schmidt LA, Smith LB, et al. Autopsy findings in eight patients with fatal H1N1 influenza. Am J Clin Pathol. 2010;134:27-35. [PMID: 20551263] doi:10.1309/AJCP35KOZSAVNQZW CrossrefMedlineGoogle Scholar5. Bikdeli B, Madhavan MV, Jimenez D, et al; Global COVID-19 Thrombosis Collaborative Group, Endorsed by the ISTH, NATF, ESVM, and the IUA, Supported by the ESC Working Group on Pulmonary Circulation and Right Ventricular Function. COVID-19 and thrombotic or thromboembolic disease: implications for prevention, antithrombotic therapy, and follow-up: JACC state-of-the-art review. J Am Coll Cardiol. 2020;75:2950-73. [PMID: 32311448] doi:10.1016/j.jacc.2020.04.031 CrossrefMedlineGoogle Scholar Comments 0 Comments Sign In to Submit A Comment Author, Article, and Disclosure InformationAuthors: Oleg Epelbaum, MDAffiliations: New York Medical College, Valhalla, New York (O.E.)Disclosures: The author has disclosed no conflicts of interest. The form can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=L20-1205. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetailsSee AlsoAutopsy Findings and Venous Thromboembolism in Patients With COVID-19 Dominic Wichmann , Jan-Peter Sperhake , Marc Lütgehetmann , Stefan Steurer , Carolin Edler , Axel Heinemann , Fabian Heinrich , Herbert Mushumba , Inga Kniep , Ann Sophie Schröder , Christoph Burdelski , Geraldine de Heer , Axel Nierhaus , Daniel Frings , Susanne Pfefferle , Heinrich Becker , Hanns Bredereke-Wiedling , Andreas de Weerth , Hans-Richard Paschen , Sara Sheikhzadeh-Eggers , Axel Stang , Stefan Schmiedel , Carsten Bokemeyer , Marylyn M. Addo , Martin Aepfelbacher , Klaus Püschel , and Stefan Kluge Autopsy Findings and Venous Thromboembolism in Patients With COVID-19 Dominic Wichmann Metrics Cited byStem cells or their exosomes: which is preferred in COVID-19 treatment? 15 December 2020Volume 173, Issue 12 Page: 1029-1030 Keywords Autopsy COVID-19 Intensive care units Lungs Pulmonary diseases Pulmonary vascular diseases Thrombosis Vascular diseases Venous thromboembolism Ventilators ePublished: 15 December 2020 Issue Published: 15 December 2020 Copyright & PermissionsCopyright © 2020 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...