The question of whether someone died from COVID-19 or with it has never been as straightforward as pandemic mortality tallies might suggest. Across the world, forensic pathologists have grappled with this distinction as SARS-CoV-2 intersected with chronic disease, aging bodies, and overwhelmed health systems. A new retrospective study from northeastern Romania offers a rare regional dataset that both corroborates and complicates the global picture — and underscores the enduring importance of the autopsy table in infectious disease research.
The study analyzes 279 forensic autopsies performed between 2020 and 2022 on individuals with confirmed SARS-CoV-2 infection. The work represents one of the few comprehensive forensic datasets from Eastern Europe spanning three consecutive pandemic years, and it integrates statistical analyses of comorbidities, clinical presentations, and pathological cause-of-death patterns in ways rarely applied in the forensic autopsy literature.
A Cohort Defined by Age, Comorbidity, and Respiratory Collapse
The demographic profile of the study cohort was broadly consistent with international findings: approximately two-thirds of decedents were male, deaths were concentrated in individuals aged 40 to 90 years, and most occurred within days of a positive SARS-CoV-2 test — reflecting the rapid clinical deterioration that characterized severe COVID-19. The rural-urban distribution was nearly equal, with 52% of cases from urban areas and 48% from rural communities. Deaths were concentrated in 2021, which accounted for half of all cases, with 36% in 2020 and 14% in 2022, tracking Romania’s pandemic wave pattern.
Across the 279 individuals, researchers recorded 694 comorbidities — an average of more than two per person. Cardiovascular disease was by far the most prevalent, appearing in 260 cases, followed by digestive, metabolic, cerebral, and psychiatric conditions. Statistical analysis confirmed a significant association between age and comorbidity type: cerebral conditions were most common in the oldest decedents (median age 78 years), while tumoral pathologies appeared in a notably younger subgroup (median age 56 years). Sex showed only a weak and statistically marginal association with comorbidity distribution, and neither sex nor age significantly predicted which clinical diagnosis or cause of death was recorded — a finding the authors attribute to the overall homogeneity of vulnerability in an elderly, multi-morbid population.
The leading causes of death were COVID-19 pneumonia, acute respiratory distress syndrome, and bronchopneumonia, frequently in combination with underlying chronic conditions. Thrombotic events, including pulmonary embolism and organ infarctions, contributed to mortality in a subset of cases. In a minority of individuals, trauma or unrelated diseases were the primary cause of death despite a positive SARS-CoV-2 result — a finding that illustrates precisely why the “from versus with” distinction carries medico-legal and epidemiological weight.
Regional Divergences From the International Record
Perhaps the most scientifically significant aspects of the study are the ways in which the autopsy findings diverged from those reported in German, Italian, French, and Japanese series. Diffuse alveolar damage, hyaline membrane formation, and intra-alveolar edema were consistent findings, aligning with the international literature. However, organized fibrinous thrombi in alveolar vessels — frequently described in German and Italian autopsy series — were absent in this cohort. Lymphomononuclear myocarditis, another feature commonly reported in those same European datasets, was also not identified.
The authors offer several explanations for these discrepancies: autopsy timing (often within 24 to 48 hours of death) may have limited the detectability of fibrin organization; regional differences in viral variant prevalence and comorbidity profiles may have altered inflammatory responses; and limited access to advanced histochemical and molecular techniques may have reduced sensitivity for subtle vascular or myocardial lesions. The study also noted that intra-alveolar rather than interstitial edema predominated — a distinction the authors flag as warranting further investigation.
Forensic Pathology as a Public Health and Security Asset
Cases were drawn from the Iași Institute of Legal Medicine autopsy registry and digital medical records, with inclusion requiring confirmed SARS-CoV-2 infection (antemortem or postmortem RT-PCR), complete necropsy data, and sufficient clinical documentation.
Key limitations include a significant gap in vaccination data, absent in approximately 85% of cases, which precludes assessment of immunization’s effect on pathological patterns or mortality. Selection bias is inherent: the dataset captures only forensic cases, not hospital deaths.
The study’s deeper contribution lies in its demonstration of what autopsy-based surveillance can and cannot deliver. Forensic pathology proved essential during the pandemic for distinguishing direct viral mortality from incidental infection, correcting mortality statistics, and characterizing the interaction between SARS-CoV-2 and chronic disease burden. Yet without standardized protocols, molecular confirmation, and vaccination data integrated into medico-legal records, regional datasets will continue to yield findings that are difficult to compare and interpret across borders.
Sources and further reading:
Diac MM et al. Necropsy Findings in Sars-CoV-2 Infections—A Retrospective Study from Iasi, Romania. COVID. 28 May 2026.