On February 17, 2020, a pathology report by Wang Fusheng, a member of the Chinese Academy of Sciences and professor of the Fifth Medical Center (302 Hospital) of the PLA General Hospital, was published in the internationally renowned medical journal The Lancet Respiratory Medicine.
The report noted that the deceased’s lungs showed diffuse alveolar damage and pulmonary transparent membrane formation, consistent with severe acute respiratory distress syndrome (ARDS) performance, and overall pathological manifestations of the lungs were similar to SARS and MERS.
The report, called Pathological findings of COVID-19 associated acute respiratory distress syndrome (COVID-19 with acute respiratory distress syndrome), is The world’s first documented pathological examination of patients who died of new coronary pneumonia.
Patient sittivation on 14th day of death
On January 27th, A team of academicians from Wang Fusheng performed a minimally invasive pathology examination – rather than a full autopsy – on a patient who died of new coronary pneumonia. Specifically, tissue samples obtained by the team through punctured remains (the same as the clinically used biopsy operation, but only after the patient’s death) were investigated for pathological characteristics of patients who died from severe infections of SARS-CoV-2 (new coronavirus). However, there are no pathology reports due to the difficulty of performing autopsies or biopsies.
Photo Source: Lancet Time Medicine
In the report, the author first describes the basic stake in the death (as shown in the following figure):
He visited Wuhan on January 8-12 and developed mild chills and dry cough on 14 January (day 1 of the disease), but has not been treated since, and has been working until 21 January;
On 21 January, he was admitted to a fever clinic for symptoms such as fever, chills, cough, fatigue and shortness of breath;
January 22 (day 9 of the disease) chest tablets showed multiple plaque shadows in both lungs, and the Beijing Municipal Center for Disease Control and Prevention confirmed the diagnosis by taking a pharynx swab specimen using a reverse real-time PCR test;
Transfer immediately to the isolation ward and give oxygen through the mask. Atomized inhalation interferon alpha-2b, oral lopinavir/litonavir as an antiviral treatment, intravenous dripmo moxisatopreventsine to prevent secondary infections. Given its severe respiratory distress and hypoxemia, the intravenous injection of methyl-strong pine dragons reduces inflammation in the lungs. After receiving medication, the body temperature was reduced from 39.0 c to 36.4 degrees C, but coughing, breathing difficulties and fatigue were still present;
On January 25 (12th of the disease), chest tablets showed a sexually soaked and diffuse mesh shadow in the patient’s lungs. Due to claustrophobia, patients repeatedly reject edgto support from the ICU, and have received high-flow nasal catheter oxygen therapy (HFNC), which gives oxygen concentrations of 60% and flow rate of 40 L/min;
On 26 January (13th onset), symptoms did not improve, although oxygen saturation remained above 95%;
On the afternoon of 27 January (14th of the disease), hypoxemia and respiratory distress worsened. Despite receiving HFNC (100% oxygen concentration, 40 L/min flow rate), blood oxygen saturation decreased to 60% and sudden cardiac arrest. The team immediately underwent invasive ventilation, chest compression and epinephrine injections, but unfortunately the rescue was unsuccessful. The patient died at 18:31 BST on 27 January.
Sampled patients with lung, liver, and heart tissue
The tissue sample was taken from the patient’s lungs (the right lung in the lower part A and the b part in the left lung), the liver (part C below), and the heart tissue (part D below). Histology checks show that:
Double-sided diffuse alveolar damage with cellular fiber mucus-like oozing. Double-pulmonary visible mononucleitis cells are immersed, mainly lymphocytes. Multinuclear cells, cytonuclear nuclei, parent-particle cytoplasm, nuclear kernels are obvious, viral cell lesions change, no obvious intranuclear or cytoplasm in-cell viral inclusions are found. The pathological characteristics of neo-coronary pneumonia are similar to SARS and MerS coronavirus infection;
The right lung tissue showed obvious loss of the alveoli epithelial and the formation of the pulmonary transparent membrane, indicating that he was suffering from severe acute respiratory distress syndrome;
Left lung tissue is presented as pulmonary edema with transparent membrane formation, showing early severe acute respiratory distress syndrome;
Liver samples showed moderate microvascular fat degeneration and mild active inflammation in the small liver lobe conduit area, indicating that the injury may have been caused by neo-coronavirus infection or drug-induced liver damage;
There are a small number of mononucleitist cells in the cardiomyocytes, but there is no other material damage to the heart tissue.
In addition, the team performed flow cytoma analysis of the patient’s peripheral blood (a biological technique used to count and sort tiny particles suspended in the fluid). Can be used to flow through the optical or electronic detector of a cell for continuous multiple parameter analysis), found that the number of peripheral blood CD4 and CD8 T cells significantly reduced, but its status is hyperactive, HLA-DR and CD38 double positive rate is high. Increased concentration of highly irritating CCR4 plus CCR6 plus Th17 in CD4 T cells.
At the same time, CD8 T cells contained high concentrations of cytotoxic particles, of which perforated protein-positive cells accounted for 31.6%, granuloprotein-positive cells accounted for 64.2%, and granuloly protein and perforated protein were positive cells accounted for 30.5%.
The results showed that overactivation of T cells was characterized by an increase in Th17 and high cytotoxicity of CD8T cells, which partly explained the patient’s severe immune damage.
Timely and appropriate use of glucocorticoids and ventilator support
Based on the above research analysis, the team concluded that:
Pneumonia progressed rapidly, and there were some differences between the two lungs;
Liver tissue showed moderate microvascular fat degeneration and mild small leaf activity, but there was no conclusive evidence that SARS-CoV-2 infection or drug-based liver injury were the cause;
SARS-CoV-2 infection may not directly damage the heart;
Lymphocytes reduction is a common feature in patients with new coronary pneumonia and may be a key factor associated with the severity and mortality of the disease.
At the same time, the team believes that although the conventional use of glucocorticoids to treat new coronary pneumonia is not recommended, according to the pathological manifestations of pulmonary edema and transparent membrane formation in the patient’s pathological examination, patients with severe illness should consider the timely and appropriate use of glucocorticoids and ventilator support to prevent ARDS progress.
There is no doubt that even if this report is not an atomic pathology report, it is important for us to understand the pathogenesis of new coronary pneumonia and to help health care providers improve their clinical treatment strategies.
It is worth mentioning that the autopsy of the remains of the new coronavirus has already begun. On February 16, 2020, the autopsy of the remains of two new crown pneumonia victims was successfully completed at Jinyintan Hospital in Wuhan City, with the consent of the patient’s family, as permitted by legal policy, and the pathology of the two bodies was sent for examination and pathological report is expected within 10 days.
As the experts said:
The pathology of the new coronary pneumonia obtained by anatomical is of great help to the exploration of the clinical pathological changes and disease mechanisms of patients with new coronary pneumonia, and can fundamentally explore the pathogenicity and lethality of the new coronary pneumonia, which can provide a basis for the future clinical treatment of critically ill patients.
I would like to thank the families of those who signed the consent form for the autopsy with grief, and we look forward to the early publication of the pathology reports of the two autopsies.
https://www.thelancet.com/journals/lanres/article/PIIS2213-2600 (20) 30076-X/fulltext