Covid-19: Clinical autopsies a crying need

Around 300 BCE, Herophilus of Chalcedon performed the first autopsies on humans and animals and recorded his findings. Later, Antistius, a Roman physician performed a forensic autopsy on the body of Julius Caesar and determined that the sovereign had been stabbed twenty-three times and one of the wounds had perforated the aorta, resulting in the death of the Roman emperor

Autopsies can be performed for several reasons but very broadly, the reasons for performing an autopsy are two. In cases where the death is suspected to be an accident, homicide or suicide, an autopsy may be performed in order to determine the exact cause of death. Such autopsies are termed as medicolegal autopsies and often, the findings may have to be presented in a court of law.

The second category of autopsies are called clinical autopsies and are performed primarily for scientific advancement. The clinical autopsy is performed to ascertain the cause of the disease in cases where the diagnosis could not be established antemortem. It can also be used for scientific research to determine exactly how the patient died. Many lives can be saved if a clinical autopsy advances knowledge about the disease. The life of another patient with the same or a similar disease can be saved if the knowledge gained from the clinical autopsy is utilised to develop new treatment protocols. The common axiom used to justify the clinical autopsy is ‘The dead teach the living’ and this maxim holds true even today.

Unfortunately, there has been a tremendous decline in the number of clinical autopsies being performed in various institutes. This is a global phenomenon and it would be wrong to place the blame squarely on one institute or one country. The reasons for this decline are numerous, however, the most commonly quoted reason is that there is a belief that diagnostics are very advanced today and the clinical autopsy is not required to ascertain a diagnosis.

Sadly, this fact does not appear to be true. In a paper which I had published in 2013, it was seen that in an astonishing 9.3% of hospital deaths, there was a discrepancy between the antemortem and post mortem diagnosis. That is an enormously high figure and should humble the entire physician community.

About three decades ago, the pathologist had to rely on the gross and microscopic appearance of the tissues in order to establish a diagnosis. The organs were examined and small pieces of tissue were taken from the areas which appeared to be involved by the diseases. These tissue fragments were then processed using standard histological techniques and then examined under a microscope. This combination of ‘gross’ and ‘microscopic’ examination of the body organs was sufficient to arrive at a diagnosis in the majority of cases. In addition, today, we have a host of molecular biology technologies like genomics and proteomics. These technologies help us delve deep into the molecular biology of a disease. Today’s technology can tell us how an organism enters into a cell, the mechanism by which it causes the disease and finally, how it kills the patient.

This data accentuates the importance of the role of the autopsy in Covid-19 deaths. When the keywords ‘Autopsy’, ‘Covid-19’ and ‘Post-Mortem’ are typed into the PUBMED database, only 128 papers could be retrieved as on 9th July 2020. Out of these publications, barely 40 publications focus on the autopsy in cases of Covid-19 infections. Barely 10% of the studies focus on the molecular pathological aspects of the disease, which would be a key factor in determining the pathogenesis or the temporal profile of the disease.

Pathogenesis has a direct impact on treatment. If the profile of the disease is understood, it would be possible to develop means to treat the disease. I can provide a crude analogy if I compare the treatment of disease as synonymous with apprehending a gangster. If you know the favourite haunts of a gangster and his modus operandi, it would be possible to arrest him easily. Similarly, if the disruptive mechanism of a microorganism is known, it would be possible to intervene at certain points and treat the infection.

Everyone would agree that treatment is of utmost importance. Treatment of protocols in the present pandemic have been changing very frequently. Hydroxychloroquine, lopinavir and ritonavir were the flavours of the season. On the 4th of July, the World Health Organisation accepted the recommendation from the Solidarity Trial’s International Steering Committee and recommended that these drugs should not be used in the treatment of Covid-19 infections. Perhaps a lot of these ‘hit and miss’ treatment protocols stem from the fact that we are as yet, ignorant about the exact pathogenesis of the disease. This could easily be remedied by performing clinical autopsies, backed up by the latest molecular techniques which would identify the disease pathogenesis.

However, there are problems in performing autopsies in Covid-19 patients. Firstly, it will be necessary to obtain the consent of the next of kin before an autopsy is performed. Secondly, pathologists may not be willing to perform clinical autopsies on Covid-19 patients in spite of the guidelines which have been issued by various authorities and the fact that performing an autopsy is not necessarily the same as writing your own obituary.

Most certainly challenges remain, predominantly in the areas of logistics and sentiment. However, the advantages far outweigh the hazards. An insight into the pathogenesis of this disease would perhaps go a long way in framing treatment protocols and guiding humanity in preventing the spread of the disease.

(The writer is Senior Consultant, Surgical Pathology and Molecular Diagnostics, Neuberg Anand Reference Laboratory, Bengaluru)