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1.
The new engl
and jour nal of medicine n engl j med nejm.org 1 From the Institute of Pathology and De- partment of Molecular Pathology, Helios University Clinic Wuppertal, University of Witten–Herdecke, Wuppertal (M.A.), the Institute of Functional and Clinical Anatomy, University Medical Center of the Johannes Gutenberg University Mainz, Mainz (M.A.), the Institute of Pathology (M.K., F.L., C.W., H.S., D.J.), the Depart- ment of Cardiothoracic, Transplantation, and Vascular Surgery (A.H.), and the Clin- ic of Pneumology (T.W.), Hannover Medi- cal School, and the German Center for Lung Research, Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH) (M.K., A.H., T.W., F.L., C.W., H.S., D.J.), Hannover — all in Germany; the Laboratory of Respiratory Diseases, BREATH, Department of Chron- ic Diseases, Metabolism, and Aging, KU Leuven, Leuven, Belgium (S.E.V., A.V.); the Institute of Pathology and Medical Genetics, University Hospital Basel, Basel, Switzerland (A.T.); and the Angiogenesis Foundation, Cambridge (W.W.L., V.W.L.), and the Laboratory of Adaptive and Re- generative Biology and the Division of Thoracic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Bos- ton (S.J.M.) — all in Massachusetts. Ad- dress reprint requests to Dr. Mentzer at the Division of Thoracic Surgery, Brigham and Women’s Hospital, Harvard Medical School, 75 Francis St., Boston, MA 02115, or at smentzer@bwh.harvard.edu. This article was published on May 21, 2020, at NEJM.org. DOI: 10.1056/NEJMoa2015432 Copyright © 2020 Massachusetts Medical Society. BACKGROUND Progressive respiratory failure is the primary cause of death in the coronavirus dis- ease 2019 (Covid-19) pandemic. Despite widespread interest in the pathophysiology of the disease, relatively little is known about the associated morphologic and molecular changes in the peripheral lung of patients who die from Covid-19. METHODS We examined 7 lungs obtained during autopsy from patients who died from Covid-19 and compared them with 7 lungs obtained during autopsy from patients who died from acute respiratory distress syndrome (ARDS) secondary to influenza A(H1N1) infection and 10 age-matched, uninfected control lungs. The lungs were studied with the use of seven-color immunohistochemical analysis, micro–computed tomographic imaging, scanning electron microscopy, corrosion casting, and direct multiplexed measurement of gene expression. RESULTS In patients who died from Covid-19–associated or influenza-associated respiratory failure, the histologic pattern in the peripheral lung was diffuse alveolar damage with perivascular T-cell infiltration. The lungs from patients with Covid-19 also showed distinctive vascular features, consisting of severe endothelial injury associ- ated with the presence of intracellular virus and disrupted cell membranes. Histo- logic analysis of pulmonary vessels in patients with Covid-19 showed widespread thrombosis with microangiopathy. Alveolar capillary microthrombi were 9 times as prevalent in patients with Covid-19 as in patients with influenza (P<0.001). In lungs from patients with Covid-19, the amount of new vessel growth — predomi- nantly through a mechanism of intussusceptive angiogenesis — was 2.7 times as high as that in the lungs from patients with influenza (P<0.001). CONCLUSIONS In our small series, vascular angiogenesis distinguished the pulmonary pathobiology of Covid-19 from that of equally severe influenza virus infection. The universality and clinical implications of our observations require further research to define. (Funded by the National Institutes of Health and others.) ABSTR ACT Pulmonary Vascular Endothelialitis, Thrombosis, and Angiogenesis in Covid-19 Maximilian Ackermann, M.D., Stijn E. Verleden, Ph.D., Mark Kuehnel, Ph.D., Axel Haverich, M.D., Tobias Welte, M.D., Florian Laenger, M.D., Arno Vanstapel, Ph.D., Christopher Werlein, M.D., Helge Stark, Ph.D., Alexandar Tzankov, M.D., William W. Li, M.D., Vincent W. Li, M.D., Steven J. Mentzer, M.D., and Danny Jonigk, M.D. Original Article The New England Journal of Medicine Downloaded from nejm.org by ROD STER on May 21, 2020. For personal use only. No other uses without permission. Copyright © 2020 Massachusetts Medical Society. All rights reserved.
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med nejm.org2 The new engl and jour nal of medicine I nfection with severe acute respira- tory syndrome coronavirus 2 (SARS-CoV-2) in humans is associated with a broad spectrum of clinical respiratory syndromes, ranging from mild upper airway symptoms to progressive life- threatening viral pneumonia.1,2 Clinically, patients with severe coronavirus disease 2019 (Covid-19) have labored breathing and progressive hypoxemia and often receive mechanical ventilatory support. Radiographically, peripheral lung ground-glass opacities on computed tomographic (CT) imaging of the chest fulfill the Berlin criteria for acute respiratory distress syndrome (ARDS).3,4 Histo- logically, the hallmark of the early phase of ARDS is diffuse alveolar damage with edema, hemor- rhage, and intraalveolar fibrin deposition, as de- scribed by Katzenstein et al.5 Diffuse alveolar damage is a nonspecific finding, since it may have noninfectious or infectious causes, including Middle East respiratory syndrome coronavirus (MERS-CoV),6 SARS-CoV,7 SARS-CoV-2,8-10 and influenza viruses.11 Among the distinctive features of Covid-19 are the vascular changes associated with the disease. With respect to diffuse alveolar damage in SARS- CoV7 and SARS-CoV-2 infection,8,12 the forma- tion of fibrin thrombi has been observed anec- dotally but not studied systematically. Clinically, many patients have elevated D-dimer levels, as well as cutaneous changes in their extremities sug- gesting thrombotic microangiopathy.13 Diffuse in- travascular coagulation and large-vessel throm- bosis have been linked to multisystem organ failure.14-16 Peripheral pulmonary vascular changes are less well characterized; however, vasculopathy in the gas-exchange networks, depending on its effect on the matching of ventilation and perfu- sion that results, could potentially contribute to hypoxemia and the effects of posture (e.g., prone positioning) on oxygenation.17 Despite previous experience with SARS-CoV18 and early experience with SARS-CoV-2, the mor- Figure 1. Lymphocytic Inflammation in a Lung from a Patient Who Died from Covid-19. The gross appearance of a lung from a patient who died from coronavirus disease 2019 (Covid-19) is shown in Panel A (the scale bar corresponds to 1 cm). The histopathological examination, shown in Panel B, revealed interstitial and perivascular predominantly lymphocytic pneumonia with multifocal endothelialitis (hematoxylin–eosin staining; the scale bar corre- sponds to 200 μm). A B C Figure 2. Microthrombi in the Interalveolar Septa of a Lung from a Patient Who Died from Covid-19. The interalveolar septum of this patient (Patient 4 in Table S1A in the Supplementary Appendix) shows slightly expanded alveolar walls with multiple fibrinous microthrombi (arrowheads) in the alveolar capillaries. Extravasated erythrocytes and a loose network of fi- brin can be seen in the intraalveolar space (hematoxy- lin–eosin staining; the scale bar corresponds to 50 μm). The New England Journal of Medicine Downloaded from nejm.org by ROD STER on May 21, 2020. For personal use only. No other uses without permission. Copyright © 2020 Massachusetts Medical Society. All rights reserved.
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med nejm.org 3 Pulmonary Vascular Endothelialitis in Covid-19 phologic and molecular changes associated with these infections in the peripheral lung are not well documented. Here, we examine the morpho- logic and molecular features of lungs obtained during autopsy from patients who died from Covid-19, as compared with those of lungs from patients who died from influenza and age-matched, uninfected control lungs. Methods Patient Selection and Workflow We analyzed pulmonary autopsy specimens from seven patients who died from respiratory failure caused by SARS-CoV-2 infection and compared them with lungs from seven patients who died from pneumonia caused by influenza A virus subtype H1N1 (A[H1N1]) — a strain associated with the 1918 and 2009 influenza pandemics. The lungs from patients with influenza were archived tissue from the 2009 pandemic and were chosen for the best possible match with respect to age, sex, and disease severity from among the autopsies performed at the Hannover Medical School. Ten lungs that had been donated but not used for transplantation served as unin- fected control specimens. The Covid-19 group consisted of lungs from two female and five male patients with mean (±SD) ages of 68±9.2 years and 80±11.5 years, respectively (clinical data are provided in Table S1A in the Supplementary Ap- pendix, available with the full text of this article at NEJM.org). The influenza group consisted of lungs from two female and five male patients Figure 3. Microvascular Alterations in Lungs from Patients Who Died from Covid-19. Panels A and B show scanning electron micrographs of microvascular corrosion casts from the thin-walled alveolar plexus of a healthy lung (Panel A) and the substantial architectural distortion seen in lungs injured by Covid-19 (Panel B). The loss of a clearly visible vessel hierarchy in the alveolar plexus is the result of new blood-vessel forma- tion by intussusceptive angiogenesis. Panel C shows the intussusceptive pillar localizations (arrowheads) at higher magnification. Panel D is a transmission electron micrograph showing ultrastructural features of endothelial cell de- struction and SARS-CoV-2 visible within the cell membrane (arrowheads) (the scale bar corresponds to 5 μm). RC denotes red cell. A RC RC RC RC B DC The New England Journal of Medicine Downloaded from nejm.org by ROD STER on May 21, 2020. For personal use only. No other uses without permission. Copyright © 2020 Massachusetts Medical Society. All rights reserved.
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med nejm.org4 The new engl and jour nal of medicine with mean ages of 62.5±4.9 years and 55.4±10.9 years, respectively. Five of the uninfected lungs were from female donors (mean age, 68.2±6.9 years), and five were from male donors (mean age, 79.2±3.3 years) (clinical data are provided in Table S1B). The study was approved by and con- ducted according to requirements of the ethics committees at the Hannover Medical School and the University of Leuven. There was no commer- cial support for this study. All lungs were comprehensively analyzed with the use of microCT, histopathological, and multi- plexed immunohistochemical analysis, transmis- sion and scanning electron microscopy, corrosion casting, and direct multiplexed gene-expression analysis, as described in detail in the Methods section in the Supplementary Appendix. Statistical Analysis All comparisons of numeric variables (including those in the gene-expression analysis) were con- ducted with Student’s t-test familywise error rates due to multiplicity set at 0.05 with the use of the Benjamini–Hochberg method of controlling false A Density of Intussusceptive Angiogenic Features AngiogenicFeatureCount B Density of Sprouting Angiogenic Features C Intussusceptive Angiogenic Features over Time R=0.81, P<0.001 R=–0.2, P=0.52 R=0.61, P=0.01 R=–0.43, P=0.19 D Sprouting Angiogenic Features over Time 0 25 50 75 100 AngiogenicFeatureCount 0 25 50 75 100 AngiogenicFeatureCount 0 25 50 75 100 AngiogenicFeatureCount 0 25 50 75 100 5 10 15 20 Hospitalization in Days 5 10 15 20 Hospitalization in Days Covid-19 Influenza A(H1N1) Controls NSIP P=0.008 P<0.001 The New England Journal of Medicine Downloaded from nejm.org by ROD STER on May 21, 2020. For personal use only. No other uses without permission. Copyright © 2020 Massachusetts Medical Society. All rights reserved.
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med nejm.org 5 Pulmonary Vascular Endothelialitis in Covid-19 discovery rates. Original P values are reported only for the tests that met the criteria for false discovery rates. All confidence intervals have been calculated on the basis of the t-distribution, as well. Additional details are provided in the Meth- ods section of the Supplementary Appendix. Results Gross Examination The mean (±SE) weight of the lungs from patients with proven influenza pneumonia was signifi- cantly higher than that from patients with proven Covid-19 (2404±560 g vs. 1681±49 g; P = 0.04). The mean weight of the uninfected control lungs (1045±91 g) was significantly lower than those in the influenza group (P = 0.003) and the Covid-19 group (P<0.001). Angiocentric Inflammation All lung specimens from the Covid-19 group had diffuse alveolar damage with necrosis of alveolar lining cells, pneumocyte type 2 hyperplasia, and linear intraalveolar fibrin deposition (Fig. 1). In four of seven cases, the changes were focal, with only mild interstitial edema. The remaining three cases had homogeneous fibrin deposits and marked interstitial edema with early intraalveo- lar organization. The specimens in the influenza group had florid diffuse alveolar damage with massive interstitial edema and extensive fibrin deposition in all cases. In addition, three speci- mens in the influenza group had focal organiz- ing and resorptive inflammation (Fig. S2). These changes were reflected in the much higher weight of the lungs from patients with influenza. Immunohistochemical analysis of angioten- sin-converting enzyme 2 (ACE2) expression, mea- sured as mean (±SD) relative counts of ACE2- positive cells per field of view, in uninfected control lungs showed scarce expression of ACE2 in alveolar epithelial cells (0.053±0.03) and capil- lary endothelial cells (0.066±0.03). In lungs from patients with Covid-19 and lungs from patients with influenza, the relative counts of ACE2-posi- tive cells per field of view were 0.25±0.14 and 0.35±0.15, respectively, for alveolar epithelial cells and 0.49±0.28 and 0.55±0.11, respectively, for en- dothelial cells. Furthermore, ACE2-positive lym- phocytes were not seen in perivascular tissue or in the alveoli of the control lungs but were pres- ent in the lungs in the Covid-19 group and the influenza group (relative counts of 0.22±0.18 and 0.15±0.09, respectively). (Details of counting are provided in Table S2.) In the lungs from patients with Covid-19 and patients with influenza, similar mean (±SD) num- bers of CD3-positive T cells were found within a 200-μm radius of precapillary and postcapillary vessel walls in 20 fields of examination per pa- tient (26.2±13.1 for Covid-19 and 14.8±10.8 for influenza). With the same field size used for ex- amination, CD4-positive T cells were more nu- merous in lungs from patients with Covid-19 than in lungs from patients with influenza (13.6±6.0 Figure 4 (facing page). Numeric Density of Features of Intussusceptive and Sprouting Angiogenesis in Lungs from Patients Who Died from Covid-19 or Influenza A(H1N1). Angiogenic features of sprouting and intussusceptive angiogenesis (intussusceptive pillars and sprouts, re- spectively) were counted per field of view in microvas- cular corrosion casts of lungs from patients with Cov- id-19 (red), lungs from patients with influenza A(H1N1) (blue), and control lungs (white). In Panels A and B, the numeric densities of angiogenic features are summa- rized as box plots for intussusceptive and sprouting an- giogenesis. The boxes reflect the interquartile range, and the whiskers indicate the range (up to 1.5 times the interquartile range). Outliers are denoted by singular points. A statistical comparison between lungs from patients Covid-19 and those from patients with influen- za and uninfected control lungs showed a significantly higher frequency of angiogenesis in the patients with Covid-19 lungs, especially intussusceptive angiogenesis (P values were calculated with Student’s t-test, con- trolled for the familywise error rate with a Benjamini– Hochberg false discovery rate threshold of 0.05). Pan- els C and D show a chronological comparison of intussusceptive and sprouting angiogenesis in lungs from patients with Covid-19 and lungs from patients with influenza A(H1N1) plotted as a function of the du- ration of hospitalization. The numbers shown are Pear- son correlation coefficients and P values (all displayed P values of 0.05 or lower also pass the false discovery rate threshold of 0.05). The median angiogenic feature count for each patient is displayed as one dot. The shaded areas encompassing the dotted linear regres- sion lines are smoothed 95% confidence intervals. As a reference for increased blood-vessel formation in lung diseases, intussusceptive and sprouting angiogenesis as found in end-stage nonspecific interstitial pneumo- nia (NSIP), a chronic interstitial lung disease, at the time of lung transplantation (a mean of 1650 days from first consultation to lung transplantation) are shown (purple box plots). Findings in healthy control lungs are also indicated (white box plots). The white and purple box plots are displayed in relation to the y axis but not the x axis (as indicated by vertical dashed lines). The New England Journal of Medicine Downloaded from nejm.org by ROD STER on May 21, 2020. For personal use only. No other uses without permission. Copyright © 2020 Massachusetts Medical Society. All rights reserved.
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med nejm.org6 The new engl and jour nal of medicine vs. 5.8±2.5, P=0.04), whereas CD8-positive T cells were less numerous (5.3±4.3 vs. 11.6±4.9, P=0.008). Neutrophils (CD15 positive) were sig- nificantly less numerous adjacent to the alveolar epithelial lining in the Covid-19 group than in the influenza group (0.4±0.5 vs. 4.8±5.2, P=0.002). A multiplexed analysis of inflammation-relat- ed gene expression examining 249 genes from the nCounter Inflammation Panel (NanoString Technologies) revealed similarities and differenc- es between the specimens in the Covid-19 group and those in the influenza group. A total of 79 inflammation-related genes were differentially regulated only in specimens from patients with Covid-19, whereas 2 genes were differentially regu- lated only in specimens from patients with influ- enza; a shared expression pattern was found for 7 genes (Fig. S1). Thrombosis and Microangiopathy The pulmonary vasculature of the lungs in the Covid-19 group and the influenza group was ana- lyzed with hematoxylin–eosin, trichrome, and immunohistochemical staining (as described in Figure 5. Relative Expression Analysis of Angiogenesis-Associated Genes in Lungs from Patients Who Died from Covid-19 or Influenza A(H1N1). RNA was isolated from sections sampled directly adjacent to those used for complementary histologic and immunohistochemical analyses. RNA was isolated with the Maxwell RNA extraction system (Promega) and, after quality control through Qubit analysis (ThermoFisher), was used for further analysis. During the NanoString procedure, individual copies of all RNA molecules were labeled with gene-specific bar codes and counted individually with the nCounter Analysis System (NanoString Technologies). The expression of angiogenesis-asso- ciated genes was measured with the NanoString nCounter PanCancer Progression panel (323 target genes annotated as relevant for an- giogenesis). The resulting gene-expression data were normalized to negative control lanes (arithmetic mean background subtraction), positive control lanes (geometric mean normalization factor), and all reference genes present on the panel (geometric mean normaliza- tion factor) with the use of nSolver Analysis Software, version 4.0. Shown in the Venn diagram are only genes that are statistically differ- entially expressed as compared with expression in controls in both disease groups (Student’s t-test, controlled for the familywise error rate with a Benjamini–Hochberg false discovery rate threshold of 0.05). Up-regulation and down-regulation of genes is indicated by col- ored arrowheads suffixed to the gene symbols (purple denotes up-regulation, red denotes down-regulation). Influenza A(H1N1) Covid-19 AAMP ADAM15 AKT1 ANGPTL4 APOH ATPIF1 CEACAM1 COL1A1 COL1A2 COL4A2 CXCL10 CYP1B1 ECM1 FGFR2 GPI GREM1 HGF HIF1A HMOX1 HRAS HSPB1 IGF1 IL6 KRAS MAP2K2 MMP14 MMP2 NOS3 NRCAM NRP1 NRP2 PDCL3 PLA2G2A PLAU PPP1R16B RUNX1 STAT1 THY1 TIMP1 TNFRSF1A TYMP VCAM1 VEGFA VHL WARS ADAM8 AGT ALDOA ANXA2P2 BMP7 C3AR1 CCBE1 CDC42 CLIC4 COL18A1 COL3A1 COL5A1 CTNNB1 CXCL13 CXCL8 ECSCR EIF2AK3 EPHA1 EPHB4 ERBB2 FGF2 FLT1 FN1 GPR56 ITGA2 ITGA5 ITGB1 ITGB8 MAP2K1 MAP3K7 MAPK1 MED1 MTDH NCL NF1 NR4A1 NRXN1 NRXN3 PDCD10 PDGFA PIK3CA PLA2G2D PLXDC1 PPP3R1 PTEN QKI RAF1 RAMP1 RBPJ ROCK1 ROCK2 RTN4 S1PR1 SERPINE1 SERPINF1 SERPING1 SNAI1 SPARC SRGN SRPK2 SULF1 TAL1 TFPI2 TGFBR2 THBS1 THBS2 TNFRSF12A VEGFC WNT5A AKT2 ALB BTG1 CALCRL CASP8 CHI3L1 CHP1 CIB1 EPAS1 EPHB3 LAMA4 LAMA5 MAPKAPK3 NFAT5 NOTCH1 PIK3CD PIK3R2 PNPLA6 PROK2 PTPRB RNH1 SPHK2 SRC SRF STAB1 ZFPM2 The New England Journal of Medicine Downloaded from nejm.org by ROD STER on May 21, 2020. For personal use only. No other uses without permission. Copyright © 2020 Massachusetts Medical Society. All rights reserved.
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med nejm.org 7 Pulmonary Vascular Endothelialitis in Covid-19 the Methods section of the Supplementary Ap- pendix). Analysis of precapillary vessels showed that in four of the seven lungs from patients with Covid-19 and four of the seven lungs from the patients with influenza, thrombi were consis- tently present in pulmonary arteries with a diam- eter of 1 mm to 2 mm, without complete lumi- nal obstruction (Figs. S3 and S5). Fibrin thrombi of the alveolar capillaries could be seen in all the lungs from both groups of patients (Fig. 2). Al- veolar capillary microthrombi were 9 times as prevalent in patients with Covid-19 as in patients with influenza (mean [±SD] number of distinct thrombi per square centimeter of vascular lumen area, 159±73 and 16±16, respectively; P = 0.002). Intravascular thrombi in postcapillary venules of less than 1 mm diameter were seen in lower num- bers in the lungs from patients with Covid-19 than in those from patients with influenza (12±14 vs. 35±16, P = 0.02). Two lungs in the Covid-19 group had involvement of all segments of the vasculature, as compared with four of the lungs in the influenza group; in three of the lungs in the Covid-19 group and three of the lungs in the influenza group, combined capillary and venous thrombi were found without arterial thrombi. The histologic findings were supported by three-dimensional microCT of the pulmonary specimens: the lungs from patients with Covid-19 and from patients with influenza showed nearly total occlusions of precapillary and postcapillary vessels. Angiogenesis We examined the microvascular architecture of the lungs from patients with Covid-19, lungs from patients with influenza, and uninfected control lungs with the use of scanning electron micros- copy and microvascular corrosion casting. The lungs in the Covid-19 group had a distorted vas- cularity with structurally deformed capillaries (Fig. 3). Elongated capillaries in the lungs from patients with Covid-19 showed sudden changes in caliber and the presence of intussusceptive pillars within the capillaries (Fig. 3C). Transmis- sion electron microscopy of the Covid-19 endo- thelium showed ultrastructural damage to the endothelium, as well as the presence of intracel- lular SARS-CoV-2 (Fig. 3D). The virus could also be identified in the extracellular space. In the lungs from patients with Covid-19, the density of intussusceptive angiogenic features (mean [±SE], 60.7±11.8 features per field) was significantly higher than that in lungs from pa- tients with influenza (22.5±6.9) or in uninfected control lungs (2.1±0.6) (P<0.001 for both com- parisons) (Fig. 4A). The density of features of conventional sprouting angiogenesis was also higher in the Covid-19 group than in the influ- enza group (Fig. 4B). When the pulmonary an- giogenic feature count was plotted as a function of the length of hospital stay, the degree of in- tussusceptive angiogenesis was found to in- crease significantly with increasing duration of hospitalization (P<0.001) (Fig. 4C). In contrast, the lungs from patients with influenza had less intussusceptive angiogenesis and no increase over time (Fig. 4C). A similar pattern was seen for sprouting angiogenesis (Fig. 4D). A multiplexed analysis of angiogenesis-related gene expression examining 323 genes from the nCounterPanCancerProgressionPanel(NanoString Technologies) revealed differences between the specimens from patients with Covid-19 and those from patients with influenza. A total of 69 angio- genesis-related genes were differentially regulat- ed only in the Covid-19 group, as compared with 26 genes differentially regulated only in the in- fluenza group; 45 genes had shared changes in expression (Fig. 5). Discussion In this study, we examined the morphologic and molecular features of seven lungs obtained dur- ing autopsy from patients who died from SARS- CoV-2 infection. The lungs from these patients were compared with those obtained during au- topsy from patients who had died from ARDS secondary to influenza A(H1N1) infection and from uninfected controls. The lungs from the patients with Covid-19 and the patients with in- fluenza shared a common morphologic pattern of diffuse alveolar damage and infiltrating perivas- cular lymphocytes. There were three distinctive angiocentric features of Covid-19. The first fea- ture was severe endothelial injury associated with intracellular SARS-CoV-2 virus and disrupted en- dothelial cell membranes. Second, the lungs from patients with Covid-19 had widespread vascular thrombosis with microangiopathy and occlusion of alveolar capillaries.12,19 Third, the lungs from patients with Covid-19 had significant new ves- sel growth through a mechanism of intussus- The New England Journal of Medicine Downloaded from nejm.org by ROD STER on May 21, 2020. For personal use only. No other uses without permission. Copyright © 2020 Massachusetts Medical Society. All rights reserved.
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med nejm.org8 The new engl and jour nal of medicine ceptive angiogenesis. Although our sample was small, the vascular features we identified are con- sistent with the presence of distinctive pulmonary vascular pathobiologic features in some cases of Covid-19. Our finding of enhanced intussusceptive angio- genesis in the lungs from patients with Covid-19 as compared with the lungs from patients with in- fluenza was unexpected. New vessel growth can occur by conventional sprouting or intussuscep- tive (nonsprouting) angiogenesis. The characteris- tic feature of intussusceptive angiogenesis is the presence of a pillar or post spanning the lumen of the vessel.20 Typically referred to as an intus- susceptive pillar, this endothelial-lined intravas- cular structure is not seen by light microscopy but is readily identifiable by corrosion casting and scanning electron microscopy.21 Although tissue hypoxia was probably a common feature in the lungs from both these groups of patients, we speculate that the greater degree of endothe- lialitis and thrombosis in the lungs from pa- tients with Covid-19 may contribute to the rela- tive frequency of sprouting and intussusceptive angiogenesis observed in these patients. The rela- tionship of these findings to the clinical course of Covid-19 requires further research to elucidate. A major limitation of our study is that the sample was small; we studied only 7 patients among the more than 320,000 people who have died from Covid-19, and the autopsy data also represent static information. On the basis of the available data, we cannot reconstruct the timing of death in the context of an evolving disease process. Moreover, there could be other factors that account for the differences we observed be- tween patients with Covid-19 and those with in- fluenza. For example, none of the patients in our study who died from Covid-19 had been treated with standard mechanical ventilation, whereas five of the seven patients who died from influ- enza had received pressure-controlled ventilation. Similarly, it is possible that differences in detect- able intussusceptive angiogenesis could be due to the different time courses of Covid-19 and in- fluenza. These and other unknown factors must be considered when evaluating our data.22 None- theless, our analysis suggests that this possibil- ity is unlikely, particularly since the degree of intussusceptive angiogenesis in the patients with Covid-19 increased significantly with increasing length of hospitalization, whereas in the patients with influenza it remained stable at a significantly lower level. Moreover, we have shown intussuscep- tive angiogenesis to be the predominant angio- genic mechanism even in late stages of chronic lung injury.21 ACE2 is an integral membrane protein that appears to be the host-cell receptor for SARS- CoV-2.23,24 Our data showed significantly greater numbers of ACE2-positive cells in the lungs from patients with Covid-19 and from patients with influenza than in those from uninfected con- trols. We found greater numbers of ACE2-posi- tive endothelial cells and significant changes in endothelial morphology, a finding consistent with a central role of endothelial cells in the vas- cular phase of Covid-19. Endothelial cells in the specimens from patients with Covid-19 showed disruption of intercellular junctions, cell swelling, and a loss of contact with the basal membrane. The presence of SARS-CoV-2 virus within the endothelial cells, a finding consistent with other studies,25 suggests that direct viral effects as well as perivascular inflammation may contribute to the endothelial injury. We report the presence of pulmonary intus- susceptive angiogenesis and other pulmonary vas- cular features in the lungs of seven patients who died from Covid-19. Additional work is needed to relate our findings to the clinical course in these patients. To aid others in their research, our full data set is available on the Vivli platform (https:// vivli.org/) and can be requested with the use of the following digital object identifier: https://doi .org/10.25934/00005576. Supported by grants (HL94567 and HL134229, to Drs. Ack- ermann and Mentzer) from the National Institutes of Health, a grant from the Botnar Research Centre for Child Health (to Dr. Tzankov), a European Research Council Consolidator Grant (XHale) (771883, to Dr. Jonigk), and a grant (KFO311, to Dr. Jonigk) from Deutsche Forschungsgemeinschaft (Project Z2). Disclosure forms provided by the authors are available with the full text of this article at NEJM.org. We thank Kerstin Bahr, Jan Hinrich Braesen, Peter Braubach, Emily Brouwer, Annette Mueller Brechlin, Regina Engelhardt, Jasmin Haslbauer, Anne Hoefer, Nicole Kroenke, Thomas Men- ter, Mahtab Taleb Naghsh, Christina Petzold, Vincent Schmidt, and Pauline Tittmann for technical support; Peter Boor of the German Covid-19 registry; and Lynnette Sholl, Hans Kreipe, Hans Michael Kvasnicka, and Jean Connors for helpful comments. Dr. Jonigk thanks Anita Swiatlak for her continued support. The New England Journal of Medicine Downloaded from nejm.org by ROD STER on May 21, 2020. For personal use only. No other uses without permission. Copyright © 2020 Massachusetts Medical Society. All rights reserved.
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