What else in times of COVID-19? The role of minimally invasive autopsy for the differential diagnosis of acute respiratory failure in a case of kala-azar

ABSTRACT Visceral leishmaniasis (VL) is a chronic vector-borne zoonotic disease caused by trypanosomatids, considered endemic in 98 countries, mainly associated with poverty. About 50,000-90,000 cases of VL occur annually worldwide, and Brazil has the second largest number of cases in the world. The clinical picture of VL is fever, hepatosplenomegaly, and pancytopenia, progressing to death in 90% of cases due to secondary infections and multi-organ failure, if left untreated. We describe the case of a 25-year-old female who lived in the metropolitan area of Sao Paulo, who had recently taken touristic trips to several rural areas in Southeastern Brazil and was diagnosed post-mortem. During the hospitalization in a hospital reference for the treatment of COVID-19, the patient developed acute respiratory failure, with chest radiographic changes, and died due to refractory shock. The ultrasound-guided minimally invasive autopsy diagnosed VL (macrophages containing amastigote forms of Leishmania in the spleen, liver and bone marrow), as well as pneumonia and bloodstream infection by gram-negative bacilli.

Chronic exposure to cigarette smoke transiently worsens the disease course in a mouse model of pulmonary paracoccidioidomycosis

ABSTRACT Paracoccidioidomycosis (PCM) may present as an acute/subacute clinical form, characterized by a progressive disease arising from the airborne initial infection, or, most often, as an asymptomatic or subclinical infection that may manifest later during an individual's life, the chronic form. Epidemiological studies show the existence of a strong association between smoking and the development of the chronic form. Current evidence demonstrates that cigarette smoke (CS) has immunosuppressive properties that could be implicated in the increasing susceptibility to the chronic form of PCM. To address this issue, we developed a murine model of a non-progressive pulmonary form of PCM that was exposed to CS at a magnitude that mimicked a moderate smoker. The chronic CS exposure started after 2 weeks and lasted up until 20 weeks post-infection, with the aim of mimicking human natural history, since it is estimated that individuals from endemic areas are infected early in life. The control group consisted of infected but not CS-exposed mice. We assessed the lung fungal burden (colony forming units [CFU]) and the area affected by the granulomatous inflammatory response, fungal dissemination to spleen and liver, and, by immunohistochemistry, the presence of CD4 and CD8 lymphocytes, CD68 and MAC-2 macrophages, and IFN-γ, IL-10 and TNF expressing cells within the granulomatous response. We detected a CS effect as early as 2 weeks after exposure (four weeks post-infection) when the lung CFU of exposed animals was significantly higher than in their non-exposed counterparts. At 12 weeks, the CS-exposed animals presented a more severe disease, as witnessed by the persistent higher lung fungal load (although it did not reach statistical significance [ p = 0.054]), greater dissemination to other organs, greater affected area of the lung, decreased IFN-γ/IL-10 ratio, and higher TNF expression within the granulomas, compared with CS-non-exposed mice. The number of CD4 and CD8 lymphocytes infiltrating the granulomas was similar between both mice groups, but there was a decrease in the number of MAC-2+ macrophages. No difference was noted in the CD68+ macrophage number. However, the follow-up in week 20 showed that the immunological effects of exposure to CS ceased, with both CS and NCS mice showing the same infectious features, i.e., a trend for resolution of the infection. In conclusion, we show that chronic CS-exposure alters the course of the disease in an experimental model of subclinical pulmonary PCM, confirming the epidemiological link between CS-exposure and the chronic form of PCM. However, we also show that this effect is transitory, being detected between 4- and 12-weeks post-infection but not thereafter. The possible immune mechanisms that mediate this effect and the reasons for its transitory effect are discussed.

An autopsy study of the spectrum of severe COVID-19 in children: From SARS to different phenotypes of MIS-C

Background: COVID-19 in children is usually mild or asymptomatic, but severe and fatal paediatric cases have been described. The pathology of COVID-19 in children is not known; the proposed pathogenesis for severe cases includes immune-mediated mechanisms or the direct effect of SARS-CoV-2 on tissues. We describe the autopsy findings in five cases of paediatric COVID-19 and provide mechanistic insight into the mechanisms involved in the pathogenesis of the disease. Methods: Children and adolescents who died with COVID-19 between March 18 and August 15, 2020 were autopsied with a minimally invasive method. Tissue samples from all vital organs were analysed by histology, electron microscopy (EM), reverse-transcription polymerase chain reaction (RT-PCR) and immunohistochemistry (IHC). Findings: Five patients were included, one male and four female, aged 7 months to 15 years. Two patients had severe diseases before SARS-CoV-2 infection: adrenal carcinoma and Edwards syndrome. Three patients were previously healthy and had multisystem inflammatory syndrome in children (MIS-C) with distinct clinical presentations: myocarditis, colitis, and acute encephalopathy with status epilepticus. Autopsy findings varied amongst patients and included mild to severe COVID-19 pneumonia, pulmonary microthrombosis, cerebral oedema with reactive gliosis, myocarditis, intestinal inflammation, and haemophagocytosis. SARSCoV- 2 was detected in all patients in lungs, heart and kidneys by at least one method (RT-PCR, IHC or EM), and in endothelial cells from heart and brain in two patients with MIS-C (IHC). In addition, we show for the first time the presence of SARS-CoV-2 in the brain tissue of a child with MIS-C with acute encephalopathy, and in the intestinal tissue of a child with acute colitis. Interpretation: SARS-CoV-2 can infect several cell and tissue types in paediatric patients, and the target organ for the...(AU)

Salivary glands are a target for SARS-CoV-2: a source for salivacontamination

The ability of the new coronavirus SARS-CoV-2 to spread and contaminate is one of the determinants of the COVID-19 pandemic status. SARS-CoV-2 has been detected in saliva consistently, with similar sensitivity to that observed innasopharyngeal swabs. We conducted ultrasound-guided postmortem biopsies in COVID-19 fatal cases. Samples ofsalivary glands (SGs; parotid, submandibular, and minor) were obtained. We analyzed samples using RT-qPCR, immu-nohistochemistry, electron microscopy, and histopathological analysis to identify SARS-CoV-2 and elucidate qual-itative and quantitative viral proles in salivary glands. The study included 13 female and 11 male patients, with amean age of 53.12 years (range 8­83 years). RT-qPCR for SARS-CoV-2 was positive in 30 SG samples from18 patients (60% of total SG samples and 75% of all cases). Ultrastructural analyses showed spherical 70­100 nm viral particles, consistent in size and shape with the Coronaviridae family, in the ductal lining cell cytoplasm,acinar cells, and ductal lumen of SGs. There was also degeneration of organelles in infected cells and the presence of acluster of nucleocapsids, which suggests viral replication in SG cells. Qualitative histopathological analysis showedmorphologic alterations in the duct lining epithelium characterized by cytoplasmic and nuclear vacuolization, as wellas nuclear pleomorphism. Acinar cells showed degenerative changes of the zymogen granules and enlarged nuclei.Ductal epithelium and serous acinar cells showed intense expression of ACE2 and TMPRSS receptors. An anti-SARS-CoV-2 antibody was positive in 8 (53%) of the 15 tested cases in duct lining epithelial cells and acinar cellsof major SGs. Only two minor salivary glands were positive for SARS-CoV-2 by immunohistochemistry. Salivaryglands are a reservoir for SARS-CoV-2 and provide a pathophysiological background for studies that indicate theuse of saliva as a diagnostic method for COVID-19 and highlight this biological uid's role in spreading the disease.© 2021 The Pathological Society of Great Britain and Ireland. Published by John Wiley & Sons, Ltd.

Extended minimally invasive autopsy: Technical improvements for the investigation of cardiopulmonary events in COVID-19

OBJECTIVES: Ultrasound-guided minimally invasive autopsies (MIA-US) are an alternative to conventional autopsies and have been used in our institution to investigate the pathophysiology of COVID-19 since the beginning of the pandemic. Owing to the limitations of post-mortem biopsies for evaluating cardiopulmonary events involving large vessels, we continuously improved the technique during this period. Objectives: To demonstrate the usefulness of an extended MIA-US technique (EMIA-US) for the study of thoracic involvement in COVID-19. METHOD: US-guided percutaneous tissue sampling was combined with a small thoracic incision (≤5 cm), allowing for the sampling of larger tissue samples or even the entire organ (lungs and heart). RESULTS: EMIA-US was performed for eight patients who died of COVID-19 in 2021. We demonstrate cardiopulmonary events, mainly thromboembolism and myocardial infarction, that could be evaluated using EMIA-US. CONCLUSIONS: Minimally invasive image-guided post-mortem tissue sampling is a flexible and practical method to conduct post-mortem studies of human diseases, mainly in areas that do not have autopsy facilities or, alternatively, when autopsy is not possible owing to financial constraints, cultural and religious values, or for safety reasons, such as in the case of highly contagious infectious diseases. We present evidence that EMIA-US is feasible and can be used as an alternative to increase the accuracy of MIA-US in detecting cardiopulmonary events involving large vessels, which may not be assessed through post-mortem biopsies.

Time de resposta rápida e atendimento de paradas cardíacas extra-hospitalares / Rapid response Team and out-of-hospital cardiac arrest

Times de Resposta Rápida (TRR) são equipes multidisciplinares treinadas para atender indivíduos com intercorrências agudas e graves, incluindo parada cardiorrespiratória (PCR) súbita, nas unidades de internação. O objetivo deste trabalho é discutir as particularidades do emprego de um TRR hospitalar no atendimento de PCRs extra-hospitalares, utilizando a experiência do time do Instituto Central do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (ICHC-FMUSP) para elucidação. Metodologia: Estudo retrospectivo, descritivo, utilizando o banco de dados do TRR do ICHC-FMUSP. Foram levantados todos os casos classificados como PCR súbita atendidos em ambiente extra-hospitalar, nos anos de 2014 a 2016. Dados globais de cinco pacientes que evoluíram com alta hospitalar e nível neurológico preservado foram descritos e analisados em detalhes. Resultados: Entre 11 atendimentos, oito tiveram retorno da circulação espontânea (RCE) na cena (72,2%) e três morreram no local. Dos oito pacientes admitidos com vida no Departamento de Emergência, cinco tiveram alta hospitalar após o evento (45,5%). A média de tempo de resposta foi 3 ± 1,2 minutos e o intervalo chamada-choque foi de 7,25 ± 3,2 minutos. Os ritmos de parada foram fibrilação ventricular (80%) e atividade elétrica sem pulso (20%). Dois pacientes foram diagnosticados com doença coronariana grave e quatro receberam um cardiodesfibrilador implantável (CDI) para profilaxia secundária de morte súbita. Um paciente, entre os cinco que tiveram alta, faleceu em outro serviço. Conclusão: Apesar de pouco usual, o emprego de um TRR hospitalar no atendimento de PCRs extra-hospitalares pode ser benéfico. Os desfechos favoráveis provavelmente decorreram do treinamento da equipe e da rapidez na realização do atendimento. A investigação cardiológica dos sobreviventes identificou pacientes com doenças graves, que, portanto, mais se beneficiariam da assistência de um time especializado

Introduction: Rapid Response Teams (RRT) are multidisciplinary groups trained to treat individuals with severe and acute events, including sudden cardiac arrest (CA), in in-patient units. The aim of this report is to discuss the singularities of deploying a hospital RRT for out-of-hospital CA assistance, using the experience of the team at the Instituto Central of Hospital das Clínicas of the University of São Paulo School of Medicine (ICHC-FMUSP) as illustration. Methodology: A retrospective, descriptive analysis was conducted, using the RRT database of the ICHC-FMUSP. All cases classified as sudden CA treated outside of the hospital between 2014 and 2016 were surveyed. Global data for five patients who progressed to discharge from hospital free of neuro - logical impairment were described and analyzed in detail. Results: Of the 11 cases, 8 had return of spontaneous circulation (ROSC) at the scene (72.2%), and 3 died on site. Of the 8 patients admitted to the Emergency Department, 5 were discharged from the hospital after the event (45.5%). The average response time was 3±1.2minutes, and the call-to-shock time interval was 7.25±3.2minutes. The cardiac arrest rhythms were ventricular fibrillation (80%) and pulseless electrical activity (20%). Two patients were diagnosed with severe coronary disease and four received an implantable cardioverter-defibrillator (ICD) for secondary prophylaxis of sudden death. One patient, of the 5 discharged, died in another unit. Conclusion: Although unusual, the use of a hospital RRT for out-of-hospital CA assistance can be beneficial. The favorable outcomes likely resulted from the team's training and the speed with which the treatment was given. Cardiovascular evaluation of the survivors identified patents with severe diseases, which would, therefore, most benefit from the care of a specialized team

Fatal disseminated cytomegalovirus infection with necrotizing oophoritis in a patient with acquired immunodeficiency syndrome

Disseminated human cytomegalovirus (CMV) disease occurs mainly as a congenital infection and among immunocompromised hosts. Patients with acquired immunodeficiency syndrome (AIDS) are at increased risk for CMV infection, and the most prevalent clinical manifestation is retinitis, followed by colitis, esophagitis, pneumonitis, and encephalitis. CMV oophoritis is poorly described in the literature with some cases reported in patients with hematological or solid malignancies, bone marrow or solid organ transplantation, immunosuppressive therapy, and advanced AIDS cases. We report the case of a 61-year-old woman with a recent diagnosis of AIDS, which was associated with a wasting syndrome. The patient presented with abdominal pain, headache, cutaneous vesicular lesions on the abdomen, anemia, lymphopenia, and hyponatremia; she died suddenly on the fourth day of hospitalization. The autopsy was performed and demonstrated disseminated CMV infection with hemorrhagic encephalitis as the immediate cause of death. Additionally, pneumonitis, extensive adrenalitis, ulcerated enteritis, focal hepatitis, and necrotizing oophoritis were found.

The diagnosis of multiple opportunistic infections in advanced stage AIDS: when Ockham's Razor doesn't cut it

In the advanced stage of AIDS, the diagnosis of the opportunistic infections may be challenging due to the high risk of performing invasive diagnostic methods in a patient with a critical clinical condition, as well as the correct interpretation of the results of microbiological exams. One of the challenges for the diagnosis and treatment of the opportunistic infections is that they may occur concomitantly in the same patient and they may mimic each other, leading to a high discrepancy between clinical and autopsy diagnoses. We describe the case of a 52-year-old man who was hospitalized because of weight loss, anemia, cough, and hepatosplenomegaly. During the investigation, the diagnosis of AIDS was made, and the patient developed respiratory failure and died on the fourth day of hospitalization. At autopsy, disseminated non-tuberculosis mycobacteriosis was found, affecting mainly the organs of the reticuloendothelial system. Also, severe and diffuse pneumonia caused by multiple agents (Pneumocystis jirovecii, Histoplasma capsulatum, suppurative bacterial infection, non-tuberculosis mycobacteria, and cytomegalovirus) was seen in a morphological pattern that could be called "collision pneumonia." The lesson from this case, revealed by the autopsy, is that in advanced AIDS, patients often have multiple opportunistic infections, so the principle of Ockham's razor­that a single diagnosis is most likely the best diagnosis­fails in this clinical context.

Disseminated toxoplasmosis in a patient with advanced acquired immunodeficiency syndrome

Extracerebral toxoplasmosis, with pulmonary involvement and shock, is a rare form of toxoplasmosis in patients with advanced AIDS. It can mimic pneumocystosis, histoplasmosis, and disseminated tuberculosis, and should be considered in the differential diagnosis of causes of respiratory failure and fulminant disease in this group of individuals, especially in areas where the Toxoplasma gondii infection is highly prevalent and in those without proper use of antimicrobial prophylaxis. We report the case of a 46-year-old male patient who presented to the emergency department with uremia, requiring urgent dialysis. During the laboratorial investigation, the patient had confirmed HIV infection, with a low CD4+ peripheral T-cell count (74 cells/µL). During hospitalization, the patient presented drug-induced hepatitis due to trimethoprim/sulfamethoxazole in a prophylactic dose, requiring interruption of this medication. On the 55th day of hospitalization, the patient developed refractory shock and died. At the autopsy, disseminated toxoplasmosis with encephalitis and severe necrotizing pneumonia were diagnosed, with numerous tachyzoites in the areas of pulmonary necrosis.

Gastrointestinal cytomegalovirus disease in a patient with pemphigus vulgaris treated with corticosteroid and mycophenolate mofetil

Pemphigus vulgaris is an autoimmune disease characterized by the formation of suprabasal intra-epidermal blisters on the skin and mucosal surfaces. Infectious diseases are the main cause of death in patients with pemphigus due to the disrupture of the physiological skin barrier, immune dysregulation, and the use of immunosuppressive medications leaving the patient prone to acquire opportunistic infections. We report the case of a 67-year-old woman diagnosed with pemphigus vulgaris, who was irregularly taking prednisone and mycophenolate mofetil. She was hospitalized because of a 1-month history of watery diarrhea and oral ulcers. Unfortunately, the patient died suddenly on the ward. The autopsy revealed a bilateral saddle pulmonary embolism, Gram-positive cocci bronchopneumonia, and gastrointestinal cytomegalovirus infection, causing extensive gastrointestinal mucosal ulcers.

Patogenia do envolvimento esplênico na leptospirose grave com síndrome de choque séptico / The pathogeny of the splenic lesion in severe leptospirosis with septic shock syndrom

A leptospirose é a zoonose mais comum, distribuída em todas as regiões do mundo e causada por bactérias virulentas do gênero Leptospira spp. A apresentação clínica da leptospirose varia de uma doença febril inespecífica a quadros graves com insuficiência renal aguda, icterícia, hemorragias graves, choque cardiovascular e falência de múltiplos órgãos. Pouco se sabe sobre a resposta imune do hospedeiro e os mecanismos patogênicos associados com a leptospirose grave com hemorragia pulmonar e choque cardiovascular. O baço tem sido estudado e considerado nos últimos anos como um órgão essencial na fisiopatologia da sepse/choque séptico, uma vez que nele ocorre perda de células da imunidade, secundária à apoptose. Objetivos: descrever os achados histológicos e a resposta imune in situ do baço de pacientes falecidos por leptospirose com hemorragia pulmonar e choque refratário, comparando-os com dois grupos controles, um formado por pacientes falecidos por choque séptico causado por bactérias Gram-positivas/-negativas e um segundo, formado por vítimas de trauma. Metodologia: retrospectivamente, 11 baços de pacientes com leptospirose grave e 10 baços de pacientes com choque séptico foram obtidos por necrópsia e comparados com 12 baços de vítimas de trauma abdominal fechado (controles normais), obtidos por esplenectomia. Os achados histológicos da polpa vermelha e da polpa branca esplênica foram analisados por meio de escore semi-quantitativo. A reação de imunohistoquímica (IH) foi empregada para a marcação de células NK, S100+, CD68+, TCD4+, TCD8+ e CD20+, bem como para células expressando caspase-3, TNF, IFN, IL-1, IL-2r, IL-6, IL-12, IL-10, IL-4 e TGF. A contagem de células marcadas foi realizada utilizando-se gratículo sobre 10 campos da polpa vermelha e 10 campos da polpa branca, escolhidos aleatoriamente. IH também foi realizada nos baços dos casos de leptospirose para a detecção de antígenos de Leptospira spp. Resultados: os baços de pacientes do grupo...

Leptospirosis is the most common worldwide zoonosis caused by virulent bacteria from the genus Leptospira spp. The clinical presentation of leptospirosis ranges from unspecific febrile illness to severe forms with acute renal failure, jaundice, hemorrhages, shock and multi organ failure. Little is known about the hosts immune response and the pathogenic mechanisms involved in severe leptospirosis. In recent years the spleen has been considered a pivotal organ in the patophysiology of the sepsis/septic shock because immune cells are lost due to apoptosis in this organ Objectives: describe and compare the splenic histological features and the immune response in situ in patients who died of pulmonary hemorrhage and shock caused by leptospirosis, with spleens from patients who suffered from Grampositive/- negative septic shock and abdominal trauma. Methodology: in retrospect, 11 spleen tissue samples from patients with leptospirosis and 10 spleens from patients with septic shock were obtained by necropsy, and compared with 12 spleens obtained by splenectomy from patients with abdominal trauma. The histological features in the red pulp and white pulp were analyzed by a semi quantitative score. Immunohistochemistry (IH) methods for NK , S100+, CD68+, TCD4+, TCD8+, CD20+ cells, caspase-3, TNF, IFN, IL-1, IL-2r, IL-6, IL-12, IL- 10, IL-4 and TGF were carried out and the stained cells were counted using a grid scale in ten fields of red pulp and white pulp chosen randomly. Also, IH was performed for Leptospira antigens in the leptospirosis patients. Results: the trauma group was totally different from the leptospirosis and septic shock patients which demonstrated strong similarities in the histological analysis: diffuse congestion in the red pulp with a moderate to intense infiltration of plasma cells, and polymorph nuclear cells, and follicles with marked atrophy. The Leptospira antigen was positive in eight (72,7%) spleen tissue samples from the...