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Magro C, Mulvey JJ, Berlin D, Nuovo G, Salvatore S, Harp J, Baxter-Stoltzfus A, Laurence J. Complement associated microvascular injury and thrombosis in the pathogenesis of severe COVID-19 infection: A report of five cases. Transl Res 2020. [PMID: 32299776 DOI: 10.1016/j.transl.2010.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Abstract
Acute respiratory failure and a systemic coagulopathy are critical aspects of the morbidity and mortality characterizing infection with severe acute respiratory distress syndrome-associated coronavirus-2, the etiologic agent of Coronavirus disease 2019 (COVID-19). We examined skin and lung tissues from 5 patients with severe COVID-19 characterized by respiratory failure (n= 5) and purpuric skin rash (n = 3). COVID-19 pneumonitis was predominantly a pauci-inflammatory septal capillary injury with significant septal capillary mural and luminal fibrin deposition and permeation of the interalveolar septa by neutrophils. No viral cytopathic changes were observed and the diffuse alveolar damage (DAD) with hyaline membranes, inflammation, and type II pneumocyte hyperplasia, hallmarks of classic acute respiratory distress syndrome, were not prominent. These pulmonary findings were accompanied by significant deposits of terminal complement components C5b-9 (membrane attack complex), C4d, and mannose binding lectin (MBL)-associated serine protease (MASP)2, in the microvasculature, consistent with sustained, systemic activation of the complement pathways. The purpuric skin lesions similarly showed a pauci-inflammatory thrombogenic vasculopathy, with deposition of C5b-9 and C4d in both grossly involved and normally-appearing skin. In addition, there was co-localization of COVID-19 spike glycoproteins with C4d and C5b-9 in the interalveolar septa and the cutaneous microvasculature of 2 cases examined. In conclusion, at least a subset of sustained, severe COVID-19 may define a type of catastrophic microvascular injury syndrome mediated by activation of complement pathways and an associated procoagulant state. It provides a foundation for further exploration of the pathophysiologic importance of complement in COVID-19, and could suggest targets for specific intervention.
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Affiliation(s)
- Cynthia Magro
- Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, New York
| | - J Justin Mulvey
- Department of Laboratory Medicine, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - David Berlin
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Weill Cornell Medicine, New York, New York
| | - Gerard Nuovo
- The Ohio State University Comprehensive Cancer Center, Columbus Ohio and Discovery Life Sciences, Powell, Ohio
| | - Steven Salvatore
- Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, New York
| | - Joanna Harp
- Department of Dermatology, Weill Cornell Medicine
| | | | - Jeffrey Laurence
- Department of Medicine, Division of Hematology and Medical Oncology, Weill Cornell Medicine, New York, New York.
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Magro C, Mulvey JJ, Berlin D, Nuovo G, Salvatore S, Harp J, Baxter-Stoltzfus A, Laurence J. Complement associated microvascular injury and thrombosis in the pathogenesis of severe COVID-19 infection: A report of five cases. Transl Res 2020; 220:1-13. [PMID: 32299776 PMCID: PMC7158248 DOI: 10.1016/j.trsl.2020.04.007] [Citation(s) in RCA: 1543] [Impact Index Per Article: 385.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Accepted: 04/09/2020] [Indexed: 02/06/2023]
Abstract
Acute respiratory failure and a systemic coagulopathy are critical aspects of the morbidity and mortality characterizing infection with severe acute respiratory distress syndrome-associated coronavirus-2, the etiologic agent of Coronavirus disease 2019 (COVID-19). We examined skin and lung tissues from 5 patients with severe COVID-19 characterized by respiratory failure (n= 5) and purpuric skin rash (n = 3). COVID-19 pneumonitis was predominantly a pauci-inflammatory septal capillary injury with significant septal capillary mural and luminal fibrin deposition and permeation of the interalveolar septa by neutrophils. No viral cytopathic changes were observed and the diffuse alveolar damage (DAD) with hyaline membranes, inflammation, and type II pneumocyte hyperplasia, hallmarks of classic acute respiratory distress syndrome, were not prominent. These pulmonary findings were accompanied by significant deposits of terminal complement components C5b-9 (membrane attack complex), C4d, and mannose binding lectin (MBL)-associated serine protease (MASP)2, in the microvasculature, consistent with sustained, systemic activation of the complement pathways. The purpuric skin lesions similarly showed a pauci-inflammatory thrombogenic vasculopathy, with deposition of C5b-9 and C4d in both grossly involved and normally-appearing skin. In addition, there was co-localization of COVID-19 spike glycoproteins with C4d and C5b-9 in the interalveolar septa and the cutaneous microvasculature of 2 cases examined. In conclusion, at least a subset of sustained, severe COVID-19 may define a type of catastrophic microvascular injury syndrome mediated by activation of complement pathways and an associated procoagulant state. It provides a foundation for further exploration of the pathophysiologic importance of complement in COVID-19, and could suggest targets for specific intervention.
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Affiliation(s)
- Cynthia Magro
- Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, New York
| | - J Justin Mulvey
- Department of Laboratory Medicine, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - David Berlin
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Weill Cornell Medicine, New York, New York
| | - Gerard Nuovo
- The Ohio State University Comprehensive Cancer Center, Columbus Ohio and Discovery Life Sciences, Powell, Ohio
| | - Steven Salvatore
- Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, New York
| | - Joanna Harp
- Department of Dermatology, Weill Cornell Medicine
| | | | - Jeffrey Laurence
- Department of Medicine, Division of Hematology and Medical Oncology, Weill Cornell Medicine, New York, New York.
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Barnes BJ, Adrover JM, Baxter-Stoltzfus A, Borczuk A, Cools-Lartigue J, Crawford JM, Daßler-Plenker J, Guerci P, Huynh C, Knight JS, Loda M, Looney MR, McAllister F, Rayes R, Renaud S, Rousseau S, Salvatore S, Schwartz RE, Spicer JD, Yost CC, Weber A, Zuo Y, Egeblad M. Targeting potential drivers of COVID-19: Neutrophil extracellular traps. J Exp Med 2020; 217:e20200652. [PMID: 32302401 PMCID: PMC7161085 DOI: 10.1084/jem.20200652] [Citation(s) in RCA: 1010] [Impact Index Per Article: 252.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 04/09/2020] [Accepted: 04/13/2020] [Indexed: 12/15/2022] Open
Abstract
Coronavirus disease 2019 (COVID-19) is a novel, viral-induced respiratory disease that in ∼10-15% of patients progresses to acute respiratory distress syndrome (ARDS) triggered by a cytokine storm. In this Perspective, autopsy results and literature are presented supporting the hypothesis that a little known yet powerful function of neutrophils-the ability to form neutrophil extracellular traps (NETs)-may contribute to organ damage and mortality in COVID-19. We show lung infiltration of neutrophils in an autopsy specimen from a patient who succumbed to COVID-19. We discuss prior reports linking aberrant NET formation to pulmonary diseases, thrombosis, mucous secretions in the airways, and cytokine production. If our hypothesis is correct, targeting NETs directly and/or indirectly with existing drugs may reduce the clinical severity of COVID-19.
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Affiliation(s)
- Betsy J. Barnes
- Center for Autoimmune, Musculoskeletal and Hematopoietic Diseases, The Feinstein Institutes for Medical Research & Departments of Molecular Medicine and Pediatrics, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY
| | | | | | - Alain Borczuk
- Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, NY
| | | | - James M. Crawford
- Department of Pathology and Laboratory Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, East Garden City, NY
| | | | | | - Caroline Huynh
- Division of Thoracic and Upper GI Surgery, Department of Surgery, Montreal, Canada
- Goodman Cancer Research Centre, McGill University, Montreal, Canada
| | - Jason S. Knight
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Massimo Loda
- Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, NY
| | - Mark R. Looney
- Department of Medicine, University of California, San Francisco, San Francisco, CA
| | - Florencia McAllister
- Department of Clinical Cancer Prevention, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Roni Rayes
- Division of Thoracic and Upper GI Surgery, Department of Surgery, Montreal, Canada
- Goodman Cancer Research Centre, McGill University, Montreal, Canada
| | | | - Simon Rousseau
- Department of Medicine, McGill University & The Research Institute of the McGill University Health Centre, Montreal, Canada
| | - Steven Salvatore
- Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, NY
| | - Robert E. Schwartz
- Division of Gastroenterology and Hepatology, Department of Medicine, Weill Cornell Medicine, New York, NY
| | - Jonathan D. Spicer
- Division of Thoracic and Upper GI Surgery, Department of Surgery, Montreal, Canada
- Goodman Cancer Research Centre, McGill University, Montreal, Canada
| | - Christian C. Yost
- Department of Pediatrics, Program in Molecular Medicine, University of Utah School of Medicine, Salt Lake City, UT
| | - Andrew Weber
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Northwell Health, Manhasset, NY
| | - Yu Zuo
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
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Halani SH, Yousefi S, Velazquez Vega J, Rossi MR, Zhao Z, Amrollahi F, Holder CA, Baxter-Stoltzfus A, Eschbacher J, Griffith B, Olson JJ, Jiang T, Yates JR, Eberhart CG, Poisson LM, Cooper LAD, Brat DJ. Multi-faceted computational assessment of risk and progression in oligodendroglioma implicates NOTCH and PI3K pathways. NPJ Precis Oncol 2018; 2:24. [PMID: 30417117 PMCID: PMC6219505 DOI: 10.1038/s41698-018-0067-9] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2018] [Revised: 09/18/2018] [Accepted: 09/24/2018] [Indexed: 12/22/2022] Open
Abstract
Oligodendrogliomas are diffusely infiltrative gliomas defined by IDH-mutation and co-deletion of 1p/19q. They have highly variable clinical courses, with survivals ranging from 6 months to over 20 years, but little is known regarding the pathways involved with their progression or optimal markers for stratifying risk. We utilized machine-learning approaches with genomic data from The Cancer Genome Atlas to objectively identify molecular factors associated with clinical outcomes of oligodendroglioma and extended these findings to study signaling pathways implicated in oncogenesis and clinical endpoints associated with glioma progression. Our multi-faceted computational approach uncovered key genetic alterations associated with disease progression and shorter survival in oligodendroglioma and specifically identified Notch pathway inactivation and PI3K pathway activation as the most strongly associated with MRI and pathology findings of advanced disease and poor clinical outcome. Our findings that Notch pathway inactivation and PI3K pathway activation are associated with advanced disease and survival risk will pave the way for clinically relevant markers of disease progression and therapeutic targets to improve clinical outcomes. Furthermore, our approach demonstrates the strength of machine learning and computational methods for identifying genetic events critical to disease progression in the era of big data and precision medicine.
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Affiliation(s)
| | - Safoora Yousefi
- Department of Biomedical Informatics, Emory University, Atlanta, GA USA
| | - Jose Velazquez Vega
- Department of Pathology and Laboratory Medicine, Emory University, Atlanta, GA USA
| | - Michael R. Rossi
- Department of Pathology and Laboratory Medicine, Emory University, Atlanta, GA USA
| | - Zheng Zhao
- Department of Neurosurgery, Tiantan Hospital, Capital Medical University, Beijing, China
| | - Fatemeh Amrollahi
- Department of Biomedical Informatics, Emory University, Atlanta, GA USA
| | - Chad A. Holder
- Department of Radiology, Emory University, Atlanta, GA USA
| | | | - Jennifer Eschbacher
- Department of Neuropathology, Barrow Neurological Institute, Phoenix, AZ USA
| | - Brent Griffith
- Department of Radiology, Henry Ford Health System, Detroit, MI USA
- Josephine Ford Cancer Institute, Henry Ford Health System, Detroit, MI USA
| | - Jeffrey J. Olson
- Emory University School of Medicine, Atlanta, GA USA
- Department of Neurosurgery, Emory University, Atlanta, GA USA
- Winship Cancer Institute, Emory University, Atlanta, GA USA
| | - Tao Jiang
- Department of Neurosurgery, Tiantan Hospital, Capital Medical University, Beijing, China
| | - Joseph R. Yates
- Divisions of Pathology, Ophthalmology, and Oncology, Johns Hopkins University School of Medicine, Baltimore, MD USA
| | - Charles G. Eberhart
- Divisions of Pathology, Ophthalmology, and Oncology, Johns Hopkins University School of Medicine, Baltimore, MD USA
| | - Laila M. Poisson
- Josephine Ford Cancer Institute, Henry Ford Health System, Detroit, MI USA
- Department of Public Health Sciences, Henry Ford Hospital Systems, Detroit, MI USA
| | - Lee A. D. Cooper
- Emory University School of Medicine, Atlanta, GA USA
- Department of Biomedical Informatics, Emory University, Atlanta, GA USA
- Winship Cancer Institute, Emory University, Atlanta, GA USA
- Department of Biomedical Engineering, Emory University/Georgia Institute of Technology, Atlanta, GA USA
| | - Daniel J. Brat
- Department of Pathology, Northwestern University Feinberg School of Medicine, Chicago, IL USA
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Baxter-Stoltzfus A, Sahu MB, Furman AC. Commentary on Excerpts From "The Purloined Letter". Acad Med 2018; 93:897. [PMID: 29846233 DOI: 10.1097/01.acm.0000535058.45766.12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Affiliation(s)
- Amelia Baxter-Stoltzfus
- A. Baxter-Stoltzfus is a fourth-year medical student, Emory University School of Medicine, Atlanta, Georgia; ORCID: http://orcid.org/0000-0003-1832-7493. M.B. Sahu is a fourth-year medical student, Emory University School of Medicine, Atlanta, Georgia; ORCID: http://orcid.org/0000-0001-8326-9475. A.C. Furman is professor of psychiatry and behavioral sciences and codirector, Lister Society, Emory University School of Medicine, Atlanta, Georgia; ; ORCID: http://orcid.org/0000-0001-9628-1406
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Halani SH, Yousefi S, Vega JEV, Baxter-Stoltzfus A, Olson JJ, Cooper L, Brat D. PATH-33. MARKERS AND MECHANISMS OF DISEASE PROGRESSION IN IDH-MUTANT ASTROCYTOMAS. Neuro Oncol 2017. [DOI: 10.1093/neuonc/nox168.723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Halani SH, Yousefi S, Baxter-Stoltzfus A, Amgad M, Vega JEV, Olson JJ, Cooper L, Brat DJ. 225 Markers and Mechanisms of Disease Progression in IDH-Mutant Astrocytomas. Neurosurgery 2017. [DOI: 10.1093/neuros/nyx417.225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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