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Gawaz A, Schindler M, Hagelauer E, Blanchard G, Riel S, Vollert A, Gilliet M, Unterluggauer L, Stary G, Pospischil I, Hoetzenecker W, Fehrenbacher B, Schaller M, Guenova E, Forchhammer S. SARS-CoV-2-Induced Vasculitic Skin Lesions Are Associated with Massive Spike Protein Depositions in Autophagosomes. J Invest Dermatol 2024; 144:369-377.e4. [PMID: 37580012 DOI: 10.1016/j.jid.2023.07.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Revised: 07/21/2023] [Accepted: 07/24/2023] [Indexed: 08/16/2023]
Abstract
In patients infected with severe acute respiratory syndrome coronavirus 2, vasculopathic changes of the skin are associated with a severe prognosis. However, the pathogenesis of this vasculopathy is not conclusively clarified. In this study, 25 prospectively collected skin samples from patients with COVID-19-related skin lesions were examined for vasculopathic changes and, in case of vasculitis, were further analyzed with electron microscopy and immunohistochemistry. Vasculopathy was observed in 76% of all COVID-19-related inflammatory skin lesions. Visual endothelial changes without manifest leukocytoclastic vasculitis were found in 60% of the COVID-19-related skin lesions, whereas leukocytoclastic vasculitis was diagnosed in 16%. In the cases of vasculitis, there were extensive spike protein depositions in microvascular endothelial cells that colocalized with the autophagosome proteins LC3B and LC3C. The autophagy protein complex LC3-associated endocytosis in microvascular endothelial cells seems to be an important pathogenic factor for severe acute respiratory syndrome coronavirus 2-related vasculitis in the skin. On ultrastructural morphology, the vasculitic process was dominated by intracellular vesicle formation and endothelial cell disruption. Direct presence of severe acute respiratory syndrome coronavirus 2 particles in the skin was not observed. Therefore, our results suggest that instead of direct viral infection, dermal vasculitic lesions in COVID-19 are caused by severe acute respiratory syndrome coronavirus 2 spike protein deposition followed by endothelial damage with activation of autophagy.
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Affiliation(s)
- Andrea Gawaz
- Department of Dermatology, University Hospital Tübingen, Tübingen, Germany
| | - Michael Schindler
- Institute for Medical Virology and Epidemiology of Viral Diseases, University Hospital Tübingen, Tübingen, Germany
| | - Elena Hagelauer
- Institute for Medical Virology and Epidemiology of Viral Diseases, University Hospital Tübingen, Tübingen, Germany
| | - Gabriela Blanchard
- Department of Dermatology, Lausanne University Hospital (CHUV), Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
| | - Simon Riel
- Department of Dermatology, University Hospital Tübingen, Tübingen, Germany
| | - Anneli Vollert
- Department of Dermatology, University Hospital Tübingen, Tübingen, Germany
| | - Michel Gilliet
- Department of Dermatology, Lausanne University Hospital (CHUV), Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
| | | | - Georg Stary
- Department of Dermatology, Medical University of Vienna, Vienna, Austria
| | - Isabella Pospischil
- Department of Dermatology, Kepler University Hospital, Johannes Kepler University, Linz, Austria
| | - Wolfram Hoetzenecker
- Department of Dermatology, Kepler University Hospital, Johannes Kepler University, Linz, Austria
| | | | - Martin Schaller
- Department of Dermatology, University Hospital Tübingen, Tübingen, Germany
| | - Emmanuella Guenova
- Department of Dermatology, Lausanne University Hospital (CHUV), Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland; Department of Dermatology, Hospital 12 de Octubre, Medical school, University Complutense, Madrid, Spain.
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Arguinchona LM, Zagona-Prizio C, Joyce ME, Chan ED, Maloney JP. Microvascular significance of TGF-β axis activation in COVID-19. Front Cardiovasc Med 2023; 9:1054690. [PMID: 36684608 PMCID: PMC9852847 DOI: 10.3389/fcvm.2022.1054690] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Accepted: 12/09/2022] [Indexed: 01/09/2023] Open
Abstract
As 2023 approaches, the COVID-19 pandemic has killed millions. While vaccines have been a crucial intervention, only a few effective medications exist for prevention and treatment of COVID-19 in breakthrough cases or in unvaccinated or immunocompromised patients. SARS-CoV-2 displays early and unusual features of micro-thrombosis and immune dysregulation that target endothelial beds of the lungs, skin, and other organs. Notably, anticoagulation improves outcomes in some COVID-19 patients. The protein transforming growth factor-beta (TGF-β1) has constitutive roles in maintaining a healthy microvasculature through its roles in regulating inflammation, clotting, and wound healing. However, after infection (including viral infection) TGF-β1 activation may augment coagulation, cause immune dysregulation, and direct a path toward tissue fibrosis. Dysregulation of TGF-β signaling in immune cells and its localization in areas of microvascular injury are now well-described in COVID-19, and such events may contribute to the acute respiratory distress syndrome and skin micro-thrombosis outcomes frequently seen in severe COVID-19. The high concentration of TGF-β in platelets and in other cells within microvascular thrombi, its ability to activate the clotting cascade and dysregulate immune pathways, and its pro-fibrotic properties all contribute to a unique milieu in the COVID-19 microvasculature. This unique environment allows for propagation of microvascular clotting and immune dysregulation. In this review we summarize the physiological functions of TGF-β and detail the evidence for its effects on the microvasculature in COVID-19. In addition, we explore the potential role of existing TGF-β inhibitors for the prevention and treatment of COVID-19 associated microvascular thrombosis and immune dysregulation.
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Affiliation(s)
- Lauren M. Arguinchona
- School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Caterina Zagona-Prizio
- School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Megan E. Joyce
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Edward D. Chan
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, United States,Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, CO, United States,National Jewish Health, Denver, CO, United States
| | - James P. Maloney
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, United States,*Correspondence: James P. Maloney,
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Kiełbowski K, Wojtyś M, Kostopanagiotou K, Janowski H, Wójcik J. Association of major postoperative wound and anastomotic complications in thoracic surgery with COVID-19 infection ☆. Surg Open Sci 2022; 10:208-215. [PMCID: PMC9637540 DOI: 10.1016/j.sopen.2022.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Revised: 09/22/2022] [Accepted: 10/11/2022] [Indexed: 11/09/2022] Open
Abstract
Background One of the most uncommon manifestations of perioperative Covid-19 infection is impaired wound healing. The aim of this study is to present previously unreported observation of thoracotomy and esophageal anastomosis dehiscence in the course of Covid-19 infection after uncomplicated thoracic surgeries. Methods This is a single-center study describing unusual wound and anastomosis complications in COVID-19 patients after uncomplicated thoracic surgeries. Medical data was prospectively collected and retrospectively reviewed. All patients admitted to the hospital were symptom free and tested negative for COVID-19 infection preoperatively. Clinical courses were compared to a non-infected control group from historical data. Results The total of 14 patients were included. Study group involved 7 patients with major wound and anastomosis complications concurrent with COVID-19 infection. Control group was composed of 7 patients matched with the type of surgeries and treated before Coronavirus pandemic. Surgeries included lung transplantations, lung cancer surgeries and esophagectomies. The mean age of the study group was 65.7 years. Major wound and anastomosis complications occurred 13.6 days postoperatively while the mean time of Covid-19 detection was 21 days. The course of infection varied from mild to very severe which resulted in 3 deaths due to COVID-19 induced ARDS. The mean time of hospital stay was 40,9 days. There were no differences between both groups in baseline characteristics while hospitalization time was significantly longer in the study group. Conclusions COVID-19 infection should be included in differential diagnosis in postoperative patients with major wound or anastomosis complications.
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Affiliation(s)
- Kajetan Kiełbowski
- Department of Thoracic Surgery and Transplantation, Pomeranian Medical University, Szczecin, Poland
| | - Małgorzata Wojtyś
- Department of Thoracic Surgery and Transplantation, Pomeranian Medical University, Szczecin, Poland,Corresponding author at: Department of Thoracic Surgery and Transplantation, Pomeranian Medical University, Alfreda Sokołowskiego 11, 70-891 Szczecin, Poland
| | | | - Henryk Janowski
- Department of Thoracic Surgery and Transplantation, Pomeranian Medical University, Szczecin, Poland
| | - Janusz Wójcik
- Department of Thoracic Surgery and Transplantation, Pomeranian Medical University, Szczecin, Poland
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Singh R, Freeman EE. Viruses, Variants, and Vaccines: How COVID-19 Has Changed the Way We Look at Skin. CURRENT DERMATOLOGY REPORTS 2022; 11:289-312. [PMID: 36274754 PMCID: PMC9574791 DOI: 10.1007/s13671-022-00370-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/28/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Rhea Singh
- Department of Dermatology, Massachusetts General Hospital, Harvard Medical School, 50 Staniford St, Boston, MA 02114 USA
- Virginia Commonwealth University School of Medicine, Richmond, VA USA
| | - Esther E. Freeman
- Department of Dermatology, Massachusetts General Hospital, Harvard Medical School, 50 Staniford St, Boston, MA 02114 USA
- Medical Practice Evaluation Center, Mongan Institute, Massachusetts General Hospital, Boston, MA USA
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Bull BS, Hay KL, Herrmann PC. Fibrin Strands Will Grow from Soluble Fibrin and Hang Up in an In Vitro Microcirculatory Viscoelastic Model: Is This a Major Cause of COVID-19 Associated Coagulopathy? J Clin Med 2022; 11:jcm11082084. [PMID: 35456177 PMCID: PMC9031993 DOI: 10.3390/jcm11082084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 03/25/2022] [Accepted: 04/04/2022] [Indexed: 12/04/2022] Open
Abstract
Viscoelastic testing (VET) by both TEG and ROTEM has demonstrated hypercoagulability early in corona virus disease 2019 (COVID-19) associated coagulopathy (CAC). Additional VET studies demonstrated fibrinolytic shutdown late in a majority of severely ill COVID-19 patients with an associated elevation of d-dimer. Elevated d-dimer confirms that coagulation, followed by fibrinolysis, has occurred. These findings imply that, during CAC, three enzymes—thrombin, Factor XIIIa and plasmin—must have acted in sequence. However, limitations in standard VET analyses preclude exploration of the earliest phases of clot induction, as well as clot formation and clot dissolution in flowing blood. Herein, we describe a novel method illuminating aspects of this unexplored area. In addition, we created an in vitro blood flow model in which the interactions of thrombin, Factor XIII and plasmin with fibrinogen can be studied, allowing the determination of soluble fibrin (SF), the highly unstable form of fibrin that precedes the appearance of a visible clot. This model allows the determination of the SF level at which fibrin microclots begin to form.
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