Bergamo's anatomopathologist: "After removing the lab coat, I no longer think of bad news"
Abstract
Importance. The analysis of lung tissues of patients with COVID-19 may help understand pathogenesis and clinical outcomes in this life-threatening respiratory illness. Objective. To determine the histological patterns in lung tissue of patients with severe COVID-19. Design and participants. Lungs tissues of 38 cases who died for COVID-19 in two hospital of Northern Italy were systematically analysed. Hematoxylin-eosin staining, immunohistochemistry for the inflammatory infiltrate and cellular components, electron microscopy were performed. Results. The features of the exudative and proliferative phases of Diffuse Alveolar Disease (DAD) were found: capillary congestion, necrosis of pneumocytes, hyaline membrane, interstitial oedema, pneumocyte hyperplasia and reactive atypia, platelet-fibrin thrombi. The inflammatory infiltrate was composed by macrophages in alveolar lumens and lymphocytes mainly in the interstitium. Electron microscopy revealed viral particles within cytoplasmic vacuoles of pneumocytes. Conclusions and relevance. The predominant pattern of lung lesions in COVID-19 patients is DAD, as described for the other two coronavirus that infect humans, SARS-CoV and MERS-CoV. Hyaline membrane formation and pneumocyte atypical hyperplasia are frequently found. The main relevant finding is the presence of platelet-fibrin thrombi in small arterial vessels; this important observation fits into the clinical context of coagulopathy which dominates in these patients and which is one of the main targets of therapy.
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Published on: 04/04/2020 09:42
by Federica Mochi
Work hours are no longer counted at the hospital in Bergamo. But in addition to the work of doctors and nurses who fight in the ward there is also that, painstaking, carried out in the laboratories of pathological anatomy. It is there that Andrea Gianatti , 55 years old, director of the pathological anatomy department of Pope John XXIII, who works with his team incessantly performs autopsy examinations on Covid-19 cases.
" Even the autopsy has now been adapted to the situation that has arisen - explains Gianatti all'Adnkronos - since the virus has characteristics that are not yet fully clarified. We have decided to take the maximum precautions for this hospital, which is well equipped. We have rooms that allow us to work safely and we approached a sort of minimally invasive autopsy. It means that we do not perform complete organ dissection but perform limited sampling with biopsies on parenchymal organs such as the heart, lungs and liver. In this way we are able to obtain enough tissue to evaluate the effects of the disease at a microscopic level, which will allow us to understand in the future how the virus acts when it spreads inside the body ".
Since the beginning of the emergency, Gianatti, together with his team, has performed fifty exams in the autopsy field . But, he warns, "it's a number in the making, given that the long wave of the deadly consequences of the disease will persist for a while." The doctor, together with all the hospital health staff, immediately rolled up his sleeves, putting himself on the field at 360 degrees: “Initially - he explains - we have given availability to rotation in the Covid department, therefore in the clinical setting, although not being specialists dedicated to clinical activity. We all responded to the call by making a small contribution in the department, but soon we understood that our specialist contribution was more important, so we created a mini task force dedicated to this activity ".
Despite the dramatic situation, Gianatti tries to hold on : "Being in contact with the worst terminal event - he observes - we do not have the evidence of the human aspect of the suffering of the patients, we see the conclusion. In the first phase it was very shocking because some images of the mortuary district reminded us of these war scenarios and we were not used to it. I think of the military caravans carrying the corpses, behind it there was a commitment from the heroic mortuary district. In some cases it was necessary to recycle a type of activity which we were not used to, such as the acceleration of the bureaucratic part, the opening of dedicated spaces inside the cold rooms, the need to reduce waiting times because the funeral was blocked. But this company managed to arm itself up to teeth also from this point of view ". Psychologically, his team is holding up well but "at the end of this story - he warns - in a moment of tranquility, there could be unexplored post-traumatic effects that will be monitored".
Many of his colleagues, meanwhile, have died fighting on the front line against this invisible enemy. Like the coroner who died yesterday in Brescia. The last of a long list. " If I am afraid of going to work? - he says -. We have received very precise indications on the need and on the ways in which to approach the suspect cases, paths have been made and indications have been given on personal protective equipment. Although there is a risk, I believe that for hospital specialists compliance with these rules greatly limits the possibility of contagion. This is our job: to face the disease in risky situations. We cannot exempt ourselves and unfortunately there can be negative events. Seeing the dedication with which everyone hospital specialists have done their job, any reticence is lost . "
Gianatti is confident that the work he is carrying out on the pathological anatomy he directs, thanks to the collection of post mortem samples, can be very formative for the reflections that can be made in the future on the effects of the disease on the organs. “I don't hide the fact that the activity is creating a great interest from an anatomo-clinical point of view - he explains - because we are building a wealth of information almost unique in the world. Even from the Chinese experience there are no data published in scientific literature on that type of approach to the disease, so it is a bit to go back to the history of medicine in which, from the autopsy study, information relating to the characteristics of the disease was initially built " .
But who is deciding when and whether to perform an autopsy on a suspected Codiv-19 case ? "A recommendation has been issued by our scientific society - says Gianatti - which has accepted the indications of the Coal of Atalanta, which in turn has given very restrictive indications on the modalities with which to carry out these findings. However, if you go to study in detail the documentation and if we refer to the WHO documentation, the required parameters are fulfilled by the structure and organizational method that we have in this company. So, when there was involvement with the medical colleagues we have deemed appropriate, with due caution, to join this autoptic activity without thinking much about it ".
There is also another thing that Gianatti does not think much about when he takes off his lab coat: the bad news . “I have two 21 and 13 year old children stuck in the house - he says - I filter everything, trying to report only the most encouraging news, so much they are already informed of what is happening. At least at home we try to limit a continuation of the work ".
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