Conclusions
This study emphasis that diffuse alveolar damage and microvascular pulmonary thrombosis in SARS-CoV-2 patients is main pathologic finding of ARDS patients caused by either direct viral cytopathic effect or host immune and inflammatory reaction. These findings might describe severe hypoxemia in COVID-19 patients suffering ARDS.
Our data strongly indicates the role of appropriate oxygen support and anticoagulation therapy with strict monitoring.
References
  1. Lu R, Zhao X, Li J, Niu P, Yang B, Wu H, et al. Genomic characterization and epidemiology of 2019 novel coronavirus: implications for virus origins and receptor binding. The Lancet. 2020;395(10224):565–74. https://doi.org/10.1016/S0140-6736(20)30251-8.
  2. World Health Organization. Coronavirus disease (COVID-2019) situation reports. https://www.who.int/emergencies/diseases/ novel-coronavirus-2019/situation-reports. Accessed April 3, 2020.
  3. Wu Z, McGoogan JM. Characteristics of and important lessons from the coronavirus disease 2019 (COVID-19) outbreak in China: summary of a report of 72 314 cases from the Chinese Center for Disease Control and Prevention. JAMA. 2020; 323 (13): 1239-42.
  4. Guan W-J, Ni Z-Y, Hu Y, Liang W-H, Ou C-Q, He J-X, et al. Clinical Characteristics of Coronavirus Disease 2019 in China. N Engl J Med. 2020;382(18):1708-20
  5. Guo T, Fan Y, Chen M, Wu X, Zhang L, He T, et al. Cardiovascular Implications of Fatal Outcomes of Patients with Coronavirus Disease 2019 (COVID-19). JAMA Cardiol. 2020: e201017.
  6. Rotzinger, D.C.; Beigelman-Aubry, C.; von Garnier, C.; Qanadli, S.D. Pulmonary embolism in patients with COVID-19: Time to change the paradigm of computed tomography. Thromb. Res. 2020 , 190, 58–59.
  7. Grimes Z, Bryce C, Sordillo EM, Gordon RE, Reidy J, Paniz Mondolfi A, Fowkes M. Fatal pulmonary thromboembolism in SARS-CoV-2-infection. Cardiovasc Pathol 2020: In press.
  8. Thille AW, Esteban A, Ferna´ ndez-Segoviano P, Rodriguez JM, Aramburu JA, Vargas-Erra´ zuriz P, Mart´ın-Pellicer A, Lorente JA, Frutos-Vivar F. Chronology of histological lesions in acute respiratory distress syndrome with diffuse alveolar damage: a prospective cohort study of clinical autopsies. Lancet Respir Med 2013;1: 395–401.
  9. Xu Z, Shi L, Wang Y, Zhang J, Huang L, Zhang C, et al. Pathological findings of COVID-19 associated with acute respiratory distress syndrome. Lancet Respir Med. 2020;8: 420–2.
  10. Buja LM, Barth RF, Krueger GR, Brodsky SV, Hunter RL. The importance of the autopsy in medicine: perspectives of pathology colleagues. Academic pathology. 2019 Mar 8; 6:2374289519834041.
  11. Zhang H, Zhou P, Wei Y, et al. Histopathologic changes and SARS-Cov-2 immunostaining in the lung of a patient with COVID-19. Ann Intern Med. 2020 May 5;172(9):629-632.
  12. Barton LM, Duval EJ, Stroberg E, Ghosh S, Mukhopadhyay S. Covid-19 autopsies, oklahoma, usa. American Journal of Clinical Pathology. 2020 May 5;153(6):725-33.)
  13. Zhou F., Yu T., Du R. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. Lancet. 2020; 395: 1054 – 1062.
  14. Gattinoni L., Coppola S., Cressoni M., Busana M., Chiumello D. Covid-19 Does Not Lead to a “Typical” Acute Respiratory Distress Syndrome. Am J Respir Crit Care Med. March 2020 doi: 10.1164/rccm.202003-0817LE)
  15. Konopka KE, Wilson A, Myers JL. Postmortem Lung Findings in an Asthmatic with Coronavirus Disease 2019 (COVID-19). Chest. 2020 Apr 28. pii: S0012-3692 (20) 30775-3. doi: 10.1016/j.chest.2020.04.032.
  16. Levi M, van der Poll T. Coagulation and sepsis. Thromb Res 2017;149: 38–44.)
  17. Grimes Z, Bryce C, Sordillo EM, Gordon RE, Reidy J, Paniz Mondolfi A, Fowkes M. Fatal pulmonary thromboembolism in SARS-CoV-2-infection. Cardiovasc Pathol 2020: In press
  18. Carsana L, Sonzogni A, Nasr A, et al. Pulmonary post-mortem findings in a large series of COVID-19 cases from Northern Italy. medRxiv. 2020 Jan 1
  19. Chaturvedi S, Braunstein EM, Yuan X, Yu J, Alexander A, Chen H, Gavriilaki E, Alluri R, Streiff MB, Petri M, Crowther MA. Complement activity and complement regulatory gene mutations are associated with thrombosis in APS and CAPS. Blood, The Journal of the American Society of Hematology. 2020 Jan 23;135(4):239-51.
  20. Magro C, Mulvey JJ, Berlin D, Nuovo G, Salvatore S, Harp J, Baxter-Stoltzfus A, Laurence J. Complement associated microvascular injury and thrombosis in the pathogenesis of severe COVID-19 infection: A report of five cases. Translational Research. 2020 Apr 15.
  21. Su H, Yang M, Wan C, Yi LX, Tang F, Zhu HY, Yi F, Yang HC, Fogo AB, Nie X, Zhang C. Renal histopathological analysis of 26 postmortem findings of patients with COVID-19 in China. Kidney international. 2020 Apr 9.
Figure legends
Figure 1. Case 1: Axial CT images show diffuse ground glass opacity with some crazy paving and consolidation (a,b). A small amount of lungs is spared. CT severity score is 38/40 according to the system proposed by Yang R, Li X, Liu H, Zhen Y, Zhang X, Xiong Q, Luo Y, Gao C, Zeng W. Chest ct severity score: An imaging tool for assessing severe covid-19. Radiology: Cardiothoracic Imaging. 2020 Mar 30;2(2): e200047.
Figure 2. Case 2: Axial CT images of the lungs show extensive ground glass appearance in the lungs, mainly in the peripheral regions (a). Some crazy paving and consolidation is also present in addition to mild bilateral pleural effusion (b). CT severity score is 24/40 according to the system proposed by Yang R, Li X, Liu H, Zhen Y, Zhang X, Xiong Q, Luo Y, Gao C, Zeng W. Chest ct severity score: An imaging tool for assessing severe covid-19. Radiology: Cardiothoracic Imaging. 2020 Mar 30;2(2):e200047.
Fig 3. Lungs and renal pathologic findings in case 1.
Pathological manifestation of lung tissue, Diffuse alveolar damage in acute phase (A)
Note hyaline membrane (arrow) (B,C)
Intranuclear inclusion-like structures (D)
Morphologically acute tubular necrosis on renal biopsy showing attenuation of tubular epithelium (E)
Fig 4. Pathologic findings of lung tissue (a,b) Diffuse alveolar damage
Pathologic findings of liver tissue. Hepatic steatosis (C)