LAUSR

As is widely known, a novel virus termed severe acute respiratory syndrome coronavirus 2 (SARS CoV-2) emerged in December 2019 in Wuhan, China, which soon spread across the globe, causing the most significant pandemic in recent years. This entity is now commonly known as coronavirus disease 2019 (COVID-19). The emergence of this virus has had an impact on all aspects of medicine, and forensic pathology is no exception. During the past year, since the variant first emerged, much knowledge has been gained about the pathology and management of this disease, prompting much in the way of sharing information both in published and online literature and through online seminars. The majority of what is currently known regarding the pathological changes associated with SARS-CoV-2 is from the work undertaken in the early days of the Wuhan outbreak. As the disease spread across the globe, several case reports and papers describing histopathological observations have been published. It is now well recognised that an important entity of this contagious disease is diffuse alveolar damage with macrophage activation, and during the course of 2020, a high incidence of prothrombotic states was observed, leading to pulmonary embolism. However, SARS-CoV-2 pathology is not limited to the respiratory tract, with cardiac, renal and neurological entities being described. What is clear is that our understanding of the pathological consequences of the infection is still evolving, and the emergence of new strains will almost certainly pose new findings from post-mortem studies. How does this translate to forensic pathology? Whether or not a decedent shows positivity to SARSCoV-2 poses little or indeed no difficulty in cases of traumatic homicide, for example a decedent who has SARS-CoV-2 positivity but who has received fatal injuries caused by sharp-force assault. Clearly, the decedent has died soon after injury infliction, and therefore the presence of a viral infection has no relevance as to the cause of death. However, homicide forms only a portion of modern forensic pathology work, and often a forensic pathologist is asked to perform a post-mortem examination on a decedent who is believed to have died following negligent care or historic injury or who has sustained a prolonged stay in hospital following injury causation from assault or road traffic incidents. These are the cases where a sound knowledge of the current arena regarding histopathology and, to a degree, pathophysiology is paramount. It is accepted that certain groups of individuals are more susceptible to the effects of the SARS-CoV-2 viral infection, irrespective of the circumstances leading to death. This becomes extremely important in cases whereby determining causal link involving historic injury is the requirement for the instruction of a forensic pathologist to perform a post-mortem examination. The general population as a whole is equally at risk of contracting SARS-CoV-2 viral infection, and as such, predisposing disability does not necessary increase such risk. Anecdotal accounts, case reports and population studies of previously well patients with no known comorbidities who had fatally succumbed to COVID-19 provide further difficulty in assessing the role of COVID-19, causal link and fatal outcome. One could argue, however, that the pre-existing condition, be that neglectful care resulting in significant decubitus ulcers and malnutrition, incapacity from previous neurological injury following assault or polytrauma from road traffic collision, places the decedent within the category designated as ‘high risk’, and they would therefore be more liable to a poorer prognosis and fatal outcome. A good understanding of the histopathology of COVID-19 will also assist the forensic pathologist in evaluating whether a positive ante-mortem or postmortem reverse transcription polymerase chain reaction (RT-PCR) result for SARS-CoV-2 has played an important role in the causation of death. Equally, pathologists conducting post-mortem examinations should be reminded of the importance of not relying upon a positive or indeed negative RT-PCR result. There should be a high suspicion of COVID-19-related pathology in those decedents where unexpected changes within the lungs are seen by either postmortem radiological or anatomical examination. A history of recent alteration in cognition, new-onset delirium or other neurological symptoms should prompt a thorough examination of the central nervous system by neuropathology to determine whether COVID-19related encephalitis is present. Cardiac lesions such as sudden-onset cardiac dysrhythmias or myocarditis Medicine, Science and the Law