Physicians are faced with many challenges during the COVID-1 | Figure 1

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Physicians are faced with many challenges during the COVID-19 pandemic, one of which is accurate determination of cause of death. While the cause of death may seem obvious in individuals who test positive for SARS-CoV-2 and die after a febrile illness that evolves into respiratory failure, not all cases fit this stereotype. Since many patients with COVID-19 are elderly and have underlying medical conditions, other possibilities must be considered. When such individuals die with atypical symptoms or are not tested for SARS-CoV-2 prior to death, assessment of cause of death can be complicated.

The key question then becomes: did the patient die from COVID-19 or with COVID-19?

These two cases offer insights into the underlying pathology of COVID-19 and illustrate how autopsies can clarify the cause of death in some cases.

Case 1- A 77-year-old man with fever and chills for six days. He was scheduled to see a physician the following week. On the day of his demise, he had been feeling extremely weak and had become increasingly short of breath. He was emergently transported to a hospital, but unfortunately suffered a cardiac arrest during transport and died soon after reaching the hospital. He was never ventilated. His history included hypertension, remote deep vein thrombosis and remote splenectomy. At the time of autopsy, the forensic pathologist performed a postmortem nasopharyngeal swab and lung swab, both of which were positive for SARS-CoV-2. Testing for influenza was negative. Autopsy revealed microscopic findings typical of severe viral infection, including diffuse alveolar damage (image 2) and chronic airway inflammation (image 1). We concluded that the cause of death was COVID-19.

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\ \ March 30, 2020\ A not yet peer-reviewed manuscript from the University of Nebraska Medical Center provides evidence of viral contamination in commonly used items, toilet facilities and air samples. Researchers studied thirteen covid-19 patients who were housed in the National Biocontainment Unit and National Quarantine Unit. All rooms were “negative pressure” rooms, which draw air in but not back out. In the study, cell phones (83%) were identified as substantial sources of contamination. Other contaminated sources included glasses and stool samples from toilets (of which 81% were positive for SARS-Cov-2). But most concerning is that SARS-Cov-2 particles were found in the air even at distances greater than six feet from patients and were found in the ambient air even when patients who were not coughing. Nasal oxygen tubes (cannulas), a device commonly used in hospitals was found to distribute the highest airborne concentrations of SARS-Cov-2. Although these are preliminary findings from only thirteen patients held in isolation, it is concerning that the SARS-Cov-2 virus may be aerosolized even in mildly ill patients, and without the provocation of so-called aerosolizing procedures (such as suctioning) which cause viral particles to be carried, briefly, in droplets in the air. While it is uncertain still how much is “too much” of the virus for an individual to inhale come in contact with, this study underscores the need for healthcare providers to wear the appropriate PPE around patients under investigation and covid-19 positive patients.\ Shared with permission from Brief19, a daily review of #covid-19 research and policy.](https://app.figure1.com/case-detail/4d4855c2-c3ac-43c9-9276-5cda22546a19)

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