The trajectory of COVID-19 cardiopulmonary disease: insights from an autopsy study of community-based, pre-hospital deaths


ERJ Open Research

Contributing to research themes:


Post-mortem examination of lung and heart tissue has been vital to developing an understanding of COVID-19 pathophysiology, however studies to date have almost uniformly used tissue obtained from hospital-based deaths where individuals have been exposed to major medical and pharmacological interventions.


In this study we investigated patterns of lung and heart injury from 46 community-based, pre-hospital COVID-19-attributable deaths who underwent autopsy.


The cohort comprised 22 females and 24 males, median age 64 years (range 19–91) at time of death with illness duration range 0–23 days. Comorbidities associated with poor outcomes in COVID-19 were represented with obesity (BMI>30 kg·m−2) in 19/46 cases (41.3%). Diffuse alveolar damage (DAD) in its early exudative phase was the most common pattern of lung injury, however significant heterogeneity was identified with bronchopneumonia, pulmonary oedema consistent with acute cardiac failure, pulmonary thromboembolism and microthombosis also identified and often in overlapping patterns. Review of clinical records and next of kin accounts suggested a combination of unexpectedly low symptom burden, rapidly progressive disease and psychosocial factors may have contributed to a failure of hospital presentation prior to death.


Identifying such advanced acute lung injury in community-based deaths is extremely unusual and raises the question why some with severe COVID-19 pneumonitis were not hospitalised. Multiple factors that include low symptom burden, rapidly progressive disease trajectories and psychosocial factors provide possible explanations.

Author list:


  1. Newcastle University Translational and Clinical Research Institute, Newcastle upon Tyne, UK
  2. Department of Cellular Pathology, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
  3. Innovation Methodology and Application Research Theme, Biosciences Institute, Newcastle University, Newcastle upon Tyne, UK
  4. Department of Infection and Tropical Medicine, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
  5. Institute of Transplantation, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK


Luke Milross MD1, Joaquim Majo PhD2, Julian Pulle MBChB2, Sam Hoggard MBChB2, Nigel Cooper MBBS2, Bethany Hunter BSc MRes3, Christopher JA Duncan DPhil1,4, Andrew Filby PhD3 and Andrew J. Fisher PhD FRCP1, 5,*.