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Jonigk, Danny; Werlein, Christopher; Acker, Till; Aepfelbacher, Martin; Amann, Kerstin U.; Baretton, Gustavo; Barth, Peter; Bohle, Rainer M.; Büttner, Andreas; Buettner, Reinhard; Dettmeyer, Reinhard; Eichhorn, Philip; Elezkurtaj, Sefer; Esposito, Irene; Evert, Katja; Evert, Matthias; Fend, Falko; Gassler, Nikolaus; Gattenloehner, Stefan; Glatzel, Markus; Göbel, Heike; Gradhand, Elise; Hansen, Torsten; Hartmann, Arndt; Heinemann, Axel; Heppner, Frank L.; Hilsenbeck, Julia; Horst, David; Kamp, Jan C.; Mall, Gita; Maerkl, Bruno; Ondruschka, Benjamin; Pablik, Jessica; Pfefferle, Susanne; Quaas, Alexander; Radbruch, Helena; Röcken, Christoph; Rosenwald, Andreas; Roth, Wilfried; Rudelius, Martina; Schirmacher, Peter; Slotta-Huspenina, Julia; Smith, Kevin; Sommer, Linna; Stock, Konrad; Ströbel, Philipp; Strobl, Stephanie; Titze, Ulf; Weirich, Gregor; Weis, Joachim; Werner, Martin; Wickenhauser, Claudia; Wiech, Thorsten; Wild, Peter; Welte, Tobias; Stillfried, Saskia von and Boor, Peter (2022): Organ manifestations of COVID-19: what have we learned so far (not only) from autopsies? In: Virchows Archiv, Vol. 481, No. 2: pp. 139-159

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The use of autopsies in medicine has been declining. The COVID-19 pandemic has documented and rejuvenated the importance of autopsies as a tool of modern medicine. In this review, we discuss the various autopsy techniques, the applicability of modern analytical methods to understand the pathophysiology of COVID-19, the major pathological organ findings, limitations or current studies, and open questions. This article summarizes published literature and the consented experience of the nationwide network of clinical, neuro-, and forensic pathologists from 27 German autopsy centers with more than 1200 COVID-19 autopsies. The autopsy tissues revealed that SARS-CoV-2 can be found in virtually all human organs and tissues, and the majority of cells. Autopsies have revealed the organ and tissue tropism of SARS-CoV-2, and the morphological features of COVID-19. This is characterized by diffuse alveolar damage, combined with angiocentric disease, which in turn is characterized by endothelial dysfunction, vascular inflammation, (micro-) thrombosis, vasoconstriction, and intussusceptive angiogenesis. These findings explained the increased pulmonary resistance in COVID-19 and supported the recommendations for antithrombotic treatment in COVID-19. In contrast, in extra-respiratory organs, pathological changes are often nonspecific and unclear to which extent these changes are due to direct infection vs. indirect/secondary mechanisms of organ injury, or a combination thereof. Ongoing research using autopsies aims at answering questions on disease mechanisms, e.g., focusing on variants of concern, and future challenges, such as post-COVID conditions. Autopsies are an invaluable tool in medicine and national and international interdisciplinary collaborative autopsy-based research initiatives are essential.

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