128 CMAAO CORONA FACTS and MYTH BUSTER Post Mortem of Lung

128 CMAAO CORONA FACTS and MYTH BUSTER Post Mortem of Lung

Dr K K Aggarwal

President CMAAO

950: Update on Covid-19

The Lancet Infectious Diseases, showed that the predominant pattern of lung lesions in patients with COVID-19 patients was diffuse alveolar damage.

Luca Carsana, Papa Giovanni XXIII Hospital, Bergamo, Italy, and colleagues analysed lung tissue samples from 38 patients who died from COVID-19 in 2 hospitals in northern Italy between February 29, 2020, and March 24, 2020.

A median of 7 tissue blocks were taken from each lung, selecting the most representative areas identified at macroscopic examination. To better characterise the inflammatory infiltrate, immunohistochemical staining was done on the most representative areas of randomly selected cases for inflammatory infiltrate and cellular components, including staining with antibodies against CD68, CD3, CD45, CD61, TTF1, p40, and Ki-67.

Lungs of all patients were heavy, congested, and oedematous, with patchy involvement. In all cases, histological examination revealed features corresponding to the exudative and early or intermediate proliferative phases of diffuse alveolar damage, which included capillary congestion (in all cases), necrosis of pneumocytes (in all cases), hyaline membranes (in 33 cases), interstitial and intra-alveolar oedema (in 37 cases), type 2 pneumocyte hyperplasia (in all cases), squamous metaplasia with atypia (in 21 cases), and platelet-fibrin thrombi (in 33 cases).

Hyaline membrane formation and pneumocyte atypical hyperplasia are frequent. Importantly, the presence of platelet-fibrin thrombi in small arterial vessels is consistent with coagulopathy, which appears to be common in patients with COVID-19 and should be one of the main targets of therapy.

The patients had a mean age of 69 years and most (87%) were male. Time spent in the intensive care unit or intermediate medical ward ranged from 1 day to 23 days. At the time of hospitalisation, all patients had clinical and radiological features of interstitial pneumonia. Of the 26 patients with available D-dimer results, all had high values (>10 × the upper reference limit). Mean time from symptom onset to death was 16 days.

Reference: https://www.nejm.org/doi/full/10.1056/NEJMc2019373

SOURCE: The New England Journal of Medicine and The Lancet Infectious Diseases

Why Follow The Post Mortem Report

In the last Consultant-cum-management Joint Meeting held at Moolchand Hospital, the Medical Director of the hospital issued a statement that as per the requirement of National Accreditation of Boards of Hospitals, it is the duty of the hospital to follow the autopsy report, if done, from the Police.

The duty of the hospital is not over by handing over the file to the Police, if the patient was treated in their hospital.

I can only explain it under two reasons, firstly, by following up of autopsy report, the hospital can correlate their findings, learn their mistakes and improve in their future protocols.

The second reason I can narrate by way of an example. Long time back, there was a murder of the wife of a senior resident in Anesthesia in our Hospital. On the complaint of the parents of the murdered girl, the hospital Anesthetist was arrested under the Dowry Death Act.   He remained in Tihar Jail for over a year when on humanitarian ground, one of our consultants visited Tihar Jail and looked at the file of the case of the doctor who in the past one year had not appeared in the court even once as every time there was a date and the court used to say ‘adjourned’.

When he looked at the file, the post mortem report had shown that the girl was raped before death as sperms were detected in her female sex organs and these sperms’ DNA did not match with that of the Anesthetist doctor.

The very next hearing the doctor was released for not being found guilty in the case. Had the hospital, followed post mortem report, the case would have been solved within the initial few dates.

In more than 30 years of my career, I have not seen any hospital following this but being a requirement of NABH recognition, I think it will not only updated by medical profession but save situations like this as stated above.