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Ackermann M, Werlein C, Plucinski E, Leypold S, Kühnel MP, Verleden SE, Khalil HA, Länger F, Welte T, Mentzer SJ, Jonigk DD. The role of vasculature and angiogenesis in respiratory diseases. Angiogenesis 2024:10.1007/s10456-024-09910-2. [PMID: 38580869 DOI: 10.1007/s10456-024-09910-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 02/11/2024] [Indexed: 04/07/2024]
Abstract
In European countries, nearly 10% of all hospital admissions are related to respiratory diseases, mainly chronic life-threatening diseases such as COPD, pulmonary hypertension, IPF or lung cancer. The contribution of blood vessels and angiogenesis to lung regeneration, remodeling and disease progression has been increasingly appreciated. The vascular supply of the lung shows the peculiarity of dual perfusion of the pulmonary circulation (vasa publica), which maintains a functional blood-gas barrier, and the bronchial circulation (vasa privata), which reveals a profiled capacity for angiogenesis (namely intussusceptive and sprouting angiogenesis) and alveolar-vascular remodeling by the recruitment of endothelial precursor cells. The aim of this review is to outline the importance of vascular remodeling and angiogenesis in a variety of non-neoplastic and neoplastic acute and chronic respiratory diseases such as lung infection, COPD, lung fibrosis, pulmonary hypertension and lung cancer.
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Affiliation(s)
- Maximilian Ackermann
- Institute of Pathology, University Clinics of RWTH University, Aachen, Germany.
- Institute of Pathology and Molecular Pathology, Helios University Clinic Wuppertal, University of Witten/Herdecke, Witten, Germany.
- Institute of Anatomy, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany.
| | | | - Edith Plucinski
- Institute of Pathology, Hannover Medical School, Hannover, Germany
| | - Sophie Leypold
- Institute of Pathology, University Clinics of RWTH University, Aachen, Germany
| | - Mark P Kühnel
- Institute of Pathology, University Clinics of RWTH University, Aachen, Germany
- Member of the German Center for Lung Research (DZL), Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH), Hannover, Germany
| | - Stijn E Verleden
- Antwerp Surgical Training, Anatomy and Research Centre (ASTARC), University of Antwerp, Antwerp, Belgium
| | - Hassan A Khalil
- Division of Thoracic and Cardiac Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, USA
- Laboratory of Adaptive and Regenerative Biology, Brigham & Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Florian Länger
- Institute of Pathology, University Clinics of RWTH University, Aachen, Germany
| | - Tobias Welte
- Member of the German Center for Lung Research (DZL), Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH), Hannover, Germany
- Department of Respiratory Medicine, Hannover Medical School, Hannover, Germany
| | - Steven J Mentzer
- Division of Thoracic and Cardiac Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, USA
- Laboratory of Adaptive and Regenerative Biology, Brigham & Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Danny D Jonigk
- Institute of Pathology, University Clinics of RWTH University, Aachen, Germany
- Member of the German Center for Lung Research (DZL), Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH), Hannover, Germany
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2
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Kloc A, Campbell KS, Espinoza YAU. Detection of Parvovirus B19 genome in human heart tissue samples. BMC Res Notes 2023; 16:239. [PMID: 37775826 PMCID: PMC10542668 DOI: 10.1186/s13104-023-06527-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 09/21/2023] [Indexed: 10/01/2023] Open
Abstract
OBJECTIVE Identifying viral genomes in human heart tissues is critical for disease diagnosis and assessment of cardiovascular damage. Human heart tissue samples obtained during a biopsy procedure are routinely used to test for the presence of viruses, as guided by clinical manifestations and prognosis. Furthermore, heart tissue samples obtained post-mortem or during a cardiac transplant procedure serve as a valuable research tool, as they allow for an in-depth assessment of cardiac pathology that can aid in our understanding of molecular pathways associated with disease. Because viral nucleic acid constitutes only a small portion of each sample's genetic material, appropriate methods are necessary for positive viral genome identification. RESULTS Snap-frozen heart tissue samples obtained either post-mortem or during a cardiac transplant procedure were used to develop conditions for detection of Parvovirus B19. Briefly, total DNA was isolated from the heart tissue under varying conditions. A PCR-based assay with Parvovirus B19 specific primers was implemented to detect the presence of the viral genome, followed by Sanger Sequencing. The mechanical disruption of the heart tissue, as well as the cardiac tissue processing methods, had a significant effect on the DNA quality and the ability to detect the Parvovirus B19 genome.
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Affiliation(s)
- Anna Kloc
- Department of Biology and Environmental Science, University of New Haven, West Haven, CT, USA.
| | - Kenneth S Campbell
- Saha Cardiovascular Research Center, University of Kentucky College of Medicine, Lexington, KY, USA
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Karev V, Starshinova AY, Glushkova A, Kudlay D, Starshinova A. Features of Myocarditis: Morphological Differential Diagnosis in Post-COVID-19 Children. Diagnostics (Basel) 2023; 13:2499. [PMID: 37568863 PMCID: PMC10417761 DOI: 10.3390/diagnostics13152499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Revised: 07/17/2023] [Accepted: 07/24/2023] [Indexed: 08/13/2023] Open
Abstract
Myocarditis is characterized by dysfunction and destruction of cardiomyocytes, infiltrative inflammation, and development of fibrosis. Late diagnosis of myocarditis has been a serious global health problem, especially due to the spread of a new coronavirus infection. The aim of this review is to identify differences between myocarditis of viral etiology, including SARS-CoV-2 lesions, based on instrumental and pathomorphological findings. MATERIAL AND METHODS We analyzed publications covering the period from December 2019 to May 2023, published in publicly accessible international databases ("Medline", "PubMed", "Scopus"), with queries for the keywords "myocarditis", "children", "cardiovascular inflammation", "COVID-19", "SARS-CoV-2", "severe acute respiratory syndrome coronavirus 2", "differential diagnosis". RESULTS It was found that no unambiguous morphological criteria for the diagnosis of myocarditis coupled to SARS-CoV-2 lesions were identified. However, the detected histopathological changes such as virus-associated degeneration, apoptosis, cardiomyocyte necrosis, moderate interstitial hyperemia, myocardial tissue oedema, and capillary endothelial cell dysfunction were the major markers of SARS-CoV-2 infection. CONCLUSION It is necessary further reconsider morphological criteria to diagnose SARS-CoV-2-caused myocarditis, rather than solely relying on detecting viral RNA by PCR as the sole evidence-based criterion. Similar issues accompany diagnostics of myocardial lesions associated with other viral infections. Evidence for an etiological diagnosis of myocarditis can be provided by a comprehensive analysis of the diagnostic criteria obtained, confirming virus exposure, followed by development of distinct clinical symptoms, MRI and CT changes, and morphological criteria.
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Affiliation(s)
- Vadim Karev
- Children’s Clinical Research Center for Infectious Diseases, St. Petersburg 194100, Russia;
- Almazov National Medical Research Centre, St. Petersburg 197341, Russia
| | | | - Anzhela Glushkova
- Medical Faculty, Pavlov First Saint Petersburg State Medical University, St. Petersburg 197022, Russia;
| | - Dmitry Kudlay
- Department of Pharmacology, Institute of Pharmacy, I.M. Sechenov First Moscow State Medical University, Moscow 119991, Russia;
- Institute of Immunology FMBA of Russia, Moscow 115478, Russia
| | - Anna Starshinova
- Almazov National Medical Research Centre, St. Petersburg 197341, Russia
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4
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Werlein C, Ackermann M, Stark H, Shah HR, Tzankov A, Haslbauer JD, von Stillfried S, Bülow RD, El-Armouche A, Kuenzel S, Robertus JL, Reichardt M, Haverich A, Höfer A, Neubert L, Plucinski E, Braubach P, Verleden S, Salditt T, Marx N, Welte T, Bauersachs J, Kreipe HH, Mentzer SJ, Boor P, Black SM, Länger F, Kuehnel M, Jonigk D. Inflammation and vascular remodeling in COVID-19 hearts. Angiogenesis 2023; 26:233-248. [PMID: 36371548 PMCID: PMC9660162 DOI: 10.1007/s10456-022-09860-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 10/13/2022] [Indexed: 11/13/2022]
Abstract
A wide range of cardiac symptoms have been observed in COVID-19 patients, often significantly influencing the clinical outcome. While the pathophysiology of pulmonary COVID-19 manifestation has been substantially unraveled, the underlying pathomechanisms of cardiac involvement in COVID-19 are largely unknown. In this multicentre study, we performed a comprehensive analysis of heart samples from 24 autopsies with confirmed SARS-CoV-2 infection and compared them to samples of age-matched Influenza H1N1 A (n = 16), lymphocytic non-influenza myocarditis cases (n = 8), and non-inflamed heart tissue (n = 9). We employed conventional histopathology, multiplexed immunohistochemistry (MPX), microvascular corrosion casting, scanning electron microscopy, X-ray phase-contrast tomography using synchrotron radiation, and direct multiplexed measurements of gene expression, to assess morphological and molecular changes holistically. Based on histopathology, none of the COVID-19 samples fulfilled the established diagnostic criteria of viral myocarditis. However, quantification via MPX showed a significant increase in perivascular CD11b/TIE2 + -macrophages in COVID-19 over time, which was not observed in influenza or non-SARS-CoV-2 viral myocarditis patients. Ultrastructurally, a significant increase in intussusceptive angiogenesis as well as multifocal thrombi, inapparent in conventional morphological analysis, could be demonstrated. In line with this, on a molecular level, COVID-19 hearts displayed a distinct expression pattern of genes primarily coding for factors involved in angiogenesis and epithelial-mesenchymal transition (EMT), changes not seen in any of the other patient groups. We conclude that cardiac involvement in COVID-19 is an angiocentric macrophage-driven inflammatory process, distinct from classical anti-viral inflammatory responses, and substantially underappreciated by conventional histopathologic analysis. For the first time, we have observed intussusceptive angiogenesis in cardiac tissue, which we previously identified as the linchpin of vascular remodeling in COVID-19 pneumonia, as a pathognomic sign in affected hearts. Moreover, we identified CD11b + /TIE2 + macrophages as the drivers of intussusceptive angiogenesis and set forward a putative model for the molecular regulation of vascular alterations.
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Affiliation(s)
- Christopher Werlein
- Institute of Pathology, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hannover, Germany
| | - Maximilian Ackermann
- Institute of Pathology and Department of Molecular Pathology, Helios University Clinic Wuppertal, University of Witten/Herdecke, Wuppertal, Germany
- Institute of Functional and Clinical Anatomy, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Helge Stark
- Institute of Pathology, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hannover, Germany
- Member of the German Center for Lung Research (DZL), Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH), Hannover, Germany
| | - Harshit R Shah
- Institute of Pathology, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hannover, Germany
- Member of the German Center for Lung Research (DZL), Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH), Hannover, Germany
| | - Alexandar Tzankov
- Institute of Medical Genetics and Pathology, University Hospital Basel, Basel, Switzerland
| | | | | | | | - Ali El-Armouche
- Institute of Pharmacology and Toxicology, Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Stephan Kuenzel
- Institute of Pharmacology and Toxicology, Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- Department of Dermatology, Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Jan Lukas Robertus
- Department of Histopathology, Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - Marius Reichardt
- Institute for X-Ray Physics, University of Göttingen, Göttingen, Germany
| | - Axel Haverich
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Anne Höfer
- Institute of Pathology, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hannover, Germany
- Member of the German Center for Lung Research (DZL), Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH), Hannover, Germany
| | - Lavinia Neubert
- Institute of Pathology, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hannover, Germany
- Member of the German Center for Lung Research (DZL), Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH), Hannover, Germany
| | - Edith Plucinski
- Institute of Pathology, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hannover, Germany
- Member of the German Center for Lung Research (DZL), Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH), Hannover, Germany
| | - Peter Braubach
- Institute of Pathology, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hannover, Germany
- Member of the German Center for Lung Research (DZL), Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH), Hannover, Germany
| | - Stijn Verleden
- Department of Thoracic Medicine, Antwerp University Hospital, Antwerp, Belgium
| | - Tim Salditt
- Institute for X-Ray Physics, University of Göttingen, Göttingen, Germany
- Cluster of Excellence 'Multiscale Bioimaging: From Molecular Machines to Networks of Excitable Cells' (MBExC), University of Göttingen, Göttingen, Germany
| | - Nikolaus Marx
- Department of Internal Medicine I, University Hospital Aachen, Aachen, Germany
| | - Tobias Welte
- Member of the German Center for Lung Research (DZL), Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH), Hannover, Germany
- Clinic of Pneumology, Hannover Medical School, Hannover, Germany
| | - Johann Bauersachs
- Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Hans-Heinrich Kreipe
- Institute of Pathology, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hannover, Germany
| | - Steven J Mentzer
- Laboratory of Adaptive and Regenerative Biology, Brigham and Women's Hospital, Harvard Medical School, Boston, USA
- Division of Thoracic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, USA
| | - Peter Boor
- Institute of Pathology, RWTH University of Aachen, Aachen, Germany
- Institute of Pathology and Department of Nephrology, RWTH University of Aachen, Aachen, Germany
| | - Stephen M Black
- Department of Cellular Biology and Pharmacology Translational Medicine, Florida International University, Florida, USA
| | - Florian Länger
- Institute of Pathology, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hannover, Germany
- Member of the German Center for Lung Research (DZL), Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH), Hannover, Germany
| | - Mark Kuehnel
- Institute of Pathology, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hannover, Germany
- Member of the German Center for Lung Research (DZL), Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH), Hannover, Germany
| | - Danny Jonigk
- Institute of Pathology, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hannover, Germany.
- Member of the German Center for Lung Research (DZL), Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH), Hannover, Germany.
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5
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Zhang X, Wang J, Huang X, Zhu Y, Zhu Y, Tang L, Cai H, Fang X, Huang L. Case Report: Parvovirus B19 infection complicated by hemophagocytic lymphohistiocytosis in a heart-lung transplant patient. Front Immunol 2023; 14:1099468. [PMID: 36825017 PMCID: PMC9941661 DOI: 10.3389/fimmu.2023.1099468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 01/26/2023] [Indexed: 02/10/2023] Open
Abstract
Immunosuppressed patients can contract parvovirus B19, and some may experience hemophagocytic lymphohistiocytosis (HLH). Herein, we describe the first report of hemophagocytic lymphohistiocytosis in a heart-lung transplant patient with concomitant parvovirus B19 infection. The patient was treated with intravenous immune globulin (IVIG) and the features of HLH were remission. This instance emphasizes the significance of parvovirus B19 monitoring in transplant patients with anemia; if HLH complicates the situation, IVIG may be an adequate remedy. Finally, a summary of the development in diagnosing and managing parvovirus B19 infection complicated by HLH is provided.
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Affiliation(s)
- Xuewu Zhang
- Department of Critical Care Units, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Department of Hematology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China.,Zhejiang Provincial Key Laboratory of Hematopoietic Malignancy, Zhejiang University, Hangzhou, Zhejiang, China
| | - Jingxia Wang
- Department of Infectious Diseases, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Xiaohan Huang
- Department of Nephrology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yue Zhu
- Department of Critical Care Units, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yijing Zhu
- Department of Hematology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Lingling Tang
- Department of Infectious Diseases, Shulan (Hangzhou) Hospital, Zhejiang Shuren University of Shulan International Medical College, Hangzhou, China
| | - Hongliu Cai
- Department of Critical Care Units, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Key Laboratory of Clinical Evaluation Technology for Medical Devices of Zhejiang Province, Hangzhou, China
| | - Xueling Fang
- Department of Critical Care Units, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Lingtong Huang
- Department of Critical Care Units, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
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6
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Badrinath A, Bhatta S, Kloc A. Persistent viral infections and their role in heart disease. Front Microbiol 2022; 13:1030440. [PMID: 36504781 PMCID: PMC9730422 DOI: 10.3389/fmicb.2022.1030440] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Accepted: 11/02/2022] [Indexed: 11/25/2022] Open
Abstract
Viral infections are the culprit of many diseases, including inflammation of the heart muscle, known as myocarditis. Acute myocarditis cases have been described in scientific literature, and viruses, such as parvovirus B19, coxsackievirus B3, or more recently, SARS-CoV-2, were the direct cause of cardiac inflammation. If not treated, myocarditis could progress to dilated cardiomyopathy, which permanently impairs the heart and limits a person's lifespan. Accumulated evidence suggests that certain viruses may persist in cardiac tissue after the initial infection, which could open up the door to reactivation under favorable conditions. Whether this chronic infection contributes to, or initiates, cardiac damage over time, remains a pressing issue in the field of virus-induced heart pathology, and it is directly tied to patients' treatment. Previously, large case studies found that a few viruses: parvovirus B19, coxsackievirus, adenovirus, human herpesvirus 6, cytomegalovirus and Epstein-Barr virus, are most commonly found in human endomyocardial biopsy samples derived from patients experiencing cardiac inflammation, or dilated cardiomyopathy. SARS-CoV-2 infection has also been shown to have cardiovascular consequences. This review examines the role of viral persistence in cardiac inflammation and heart disease, and discusses its implications for patients' outcomes.
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7
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Jonigk D, Werlein C, D. Lee P, Kauczor HU, Länger F, Ackermann M. Pulmonary and Systemic Pathology in COVID-19—Holistic Pathological Analyses. DEUTSCHES ARZTEBLATT INTERNATIONAL 2022; 119:429-435. [PMID: 35698804 PMCID: PMC9549895 DOI: 10.3238/arztebl.m2022.0231] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 03/22/2022] [Accepted: 05/10/2022] [Indexed: 01/26/2023]
Abstract
BACKGROUND The COVID-19 pandemic is the third worldwide coronavirus-associated disease outbreak in the past 20 years. Lung involvement, with acute respiratory distress syndrome (ARDS) in severe cases, is the main clinical feature of this disease; the cardiovascular system, the central nervous system, and the gastrointestinal tract can also be affected. The pathophysiology of both pulmonary and extrapulmonary organ damage was almost completely unknown when the pandemic began. METHODS This review is based on pertinent publications retrieved by a selective search concerning the structural changes and pathophysiology of COVID-19, with a focus on imaging techniques. RESULTS Immunohistochemical, electron-microscopic and molecular pathological analyses of tissues obtained by autopsy have improved our understanding of COVID-19 pathophysiology, including molecular regulatory mechanisms. Intussusceptive angiogenesis (IA) has been found to be a prominent pattern of damage in the affected organs of COVID-19 patients. In IA, an existing vessel changes by invagination of the endothelium and formation of an intraluminal septum, ultimately giving rise to two new lumina. This alters hemodynamics within the vessel, leading to a loss of laminar flow and its replacement by turbulent, inhomogeneous flow. IA, which arises because of ischemia due to thrombosis, is itself a risk factor for the generation of further microthrombi; these have been detected in the lungs, heart, liver, kidneys, brain, and placenta of COVID-19 patients. CONCLUSION Studies of autopsy material from various tissues of COVID-19 patients have revealed ultrastructural evidence of altered microvascularity, IA, and multifocal thrombi. These changes may contribute to the pathophysiology of post-acute interstitial fibrotic organ changes as well as to the clinical picture of long COVID.
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Affiliation(s)
- Danny Jonigk
- Institute of Pathology, Hannover Medical School, Hannover, Germany
- German Center for Lung Research (DZL), Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH), Hannover site, Hannover, Germany
- *Institut für Pathologie, Medizinische Hochschule Hannover Carl-Neuberg-Straße 1, 30625 Hannover, Germany
| | | | - Peter D. Lee
- Department of Mechanical Engineering, Faculty of Engineering Science, University College London, London, UK
| | - Hans-Ulrich Kauczor
- Department of Diagnostic and Interventional Radiology, Heidelberg University Hospital, Heidelberg, Germany
- Translational Lung Research Center Heidelberg, Heidelberg University Hospital, Heidelberg, Germany
| | - Florian Länger
- Institute of Pathology, Hannover Medical School, Hannover, Germany
- German Center for Lung Research (DZL), Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH), Hannover site, Hannover, Germany
| | - Maximilian Ackermann
- Institute of Pathology and Molecular Pathology, Helios University Hospital Wuppertal, University Hospital of Witten-Herdecke, Wuppertal, Germany
- Institute of Functional and Clinical Anatomy, University Medical Center Mainz, Mainz, Germany
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8
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Epicardial and microvascular coronary artery spasm in biopsy-proven viral myocarditis. Int J Cardiol 2022; 360:1-4. [DOI: 10.1016/j.ijcard.2022.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 04/16/2022] [Accepted: 05/04/2022] [Indexed: 11/05/2022]
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9
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Jonigk D, Werlein C, Acker T, Aepfelbacher M, Amann KU, Baretton G, Barth P, Bohle RM, Büttner A, Büttner R, Dettmeyer R, Eichhorn P, Elezkurtaj S, Esposito I, Evert K, Evert M, Fend F, Gaßler N, Gattenlöhner S, Glatzel M, Göbel H, Gradhand E, Hansen T, Hartmann A, Heinemann A, Heppner FL, Hilsenbeck J, Horst D, Kamp JC, Mall G, Märkl B, Ondruschka B, Pablik J, Pfefferle S, Quaas A, Radbruch H, Röcken C, Rosenwald A, Roth W, Rudelius M, Schirmacher P, Slotta-Huspenina J, Smith K, Sommer L, Stock K, Ströbel P, Strobl S, Titze U, Weirich G, Weis J, Werner M, Wickenhauser C, Wiech T, Wild P, Welte T, von Stillfried S, Boor P. Organ manifestations of COVID-19: what have we learned so far (not only) from autopsies? Virchows Arch 2022; 481:139-159. [PMID: 35364700 PMCID: PMC8975445 DOI: 10.1007/s00428-022-03319-2] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 03/22/2022] [Accepted: 03/25/2022] [Indexed: 01/08/2023]
Abstract
The use of autopsies in medicine has been declining. The COVID-19 pandemic has documented and rejuvenated the importance of autopsies as a tool of modern medicine. In this review, we discuss the various autopsy techniques, the applicability of modern analytical methods to understand the pathophysiology of COVID-19, the major pathological organ findings, limitations or current studies, and open questions. This article summarizes published literature and the consented experience of the nationwide network of clinical, neuro-, and forensic pathologists from 27 German autopsy centers with more than 1200 COVID-19 autopsies. The autopsy tissues revealed that SARS-CoV-2 can be found in virtually all human organs and tissues, and the majority of cells. Autopsies have revealed the organ and tissue tropism of SARS-CoV-2, and the morphological features of COVID-19. This is characterized by diffuse alveolar damage, combined with angiocentric disease, which in turn is characterized by endothelial dysfunction, vascular inflammation, (micro-) thrombosis, vasoconstriction, and intussusceptive angiogenesis. These findings explained the increased pulmonary resistance in COVID-19 and supported the recommendations for antithrombotic treatment in COVID-19. In contrast, in extra-respiratory organs, pathological changes are often nonspecific and unclear to which extent these changes are due to direct infection vs. indirect/secondary mechanisms of organ injury, or a combination thereof. Ongoing research using autopsies aims at answering questions on disease mechanisms, e.g., focusing on variants of concern, and future challenges, such as post-COVID conditions. Autopsies are an invaluable tool in medicine and national and international interdisciplinary collaborative autopsy-based research initiatives are essential.
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Affiliation(s)
- Danny Jonigk
- Institute of Pathology, Hannover Medical School, Hannover, Germany.
| | | | - Till Acker
- Institute of Neuropathology, University Hospital Giessen and Marburg, Giessen, Germany
| | - Martin Aepfelbacher
- Institute of Medical Microbiology, Virology, and Hygiene, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Kerstin U Amann
- Department of Nephropathology, University Hospital Erlangen-Nürnberg, Erlangen, Germany
| | - Gustavo Baretton
- Department of Pathology, University Hospital Dresden, Dresden, Germany
| | - Peter Barth
- Gerhard Domagk Institute of Pathology, University Hospital Münster, Münster, Germany
| | - Rainer M Bohle
- Department of Pathology, University Hospital Saarland Homburg, Homburg, Germany
| | - Andreas Büttner
- Institute of Forensic Medicine, University Medical Center Rostock, Rostock, Germany
| | - Reinhard Büttner
- Department of Pathology, University Hospital Cologne, Cologne, Germany
| | - Reinhard Dettmeyer
- Department of Legal Medicine, University Hospital Giessen and Marburg, Giessen, Germany
| | - Philip Eichhorn
- Department of Pathology, University Hospital Erlangen-Nürnberg, Erlangen, Germany
| | - Sefer Elezkurtaj
- Department of Pathology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Irene Esposito
- Department of Pathology, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Katja Evert
- Department of Pathology, University Hospital Regensburg, Regensburg, Germany
| | - Matthias Evert
- Department of Pathology, University Hospital Regensburg, Regensburg, Germany
| | - Falko Fend
- Department of Pathology, University Hospital Tübingen, Tübingen, Germany
| | - Nikolaus Gaßler
- Department of Pathology, University Hospital Jena, Jena, Germany
| | - Stefan Gattenlöhner
- Department of Pathology, University Hospital Giessen and Marburg, Giessen, Germany
| | - Markus Glatzel
- Institute of Neuropathology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Heike Göbel
- Department of Pathology, University Hospital Cologne, Cologne, Germany
| | - Elise Gradhand
- Senckenberg Institute of Pathology, University Hospital Frankfurt, Frankfurt, Germany
| | - Torsten Hansen
- Department of Pathology, University Hospital OWL of the Bielefeld University, Campus Lippe, Detmold, Germany
| | - Arndt Hartmann
- Department of Pathology, University Hospital Erlangen-Nürnberg, Erlangen, Germany
| | - Axel Heinemann
- Department of Legal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Frank L Heppner
- Department of Neuropathology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany.,German Center for Neurodegenerative Diseases (DZNE) Berlin, Berlin, Germany.,Cluster of Excellence, NeuroCure, Berlin, Germany
| | - Julia Hilsenbeck
- Department of Pathology, University Hospital Dresden, Dresden, Germany
| | - David Horst
- Department of Pathology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Jan C Kamp
- Department of Respiratory Medicine, Hannover Medical School, Hannover, Germany
| | - Gita Mall
- Department of Legal Medicine, University Hospital Jena, Jena, Germany
| | - Bruno Märkl
- General Pathology and Molecular Diagnostics, University Hospital Augsburg, Augsburg, Germany
| | - Benjamin Ondruschka
- Institute of Legal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jessica Pablik
- Department of Pathology, University Hospital Dresden, Dresden, Germany
| | - Susanne Pfefferle
- Institute of Medical Microbiology, Virology, and Hygiene, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Alexander Quaas
- Department of Pathology, University Hospital Cologne, Cologne, Germany
| | - Helena Radbruch
- Department of Neuropathology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Christoph Röcken
- Department of Pathology, University Hospital Schleswig-Holstein, Kiel, Germany
| | | | - Wilfried Roth
- Department of Pathology, University Medical Center Mainz, Mainz, Germany
| | - Martina Rudelius
- Institute of Pathology, Ludwig-Maximilians-Universität Munich, Munich, Germany
| | - Peter Schirmacher
- Department of Pathology, Heidelberg University Hospital, Heidelberg, Germany
| | - Julia Slotta-Huspenina
- Department of Pathology, TUM School of Medicine of Technical University of Munich, Munich, Germany
| | - Kevin Smith
- Senckenberg Institute of Pathology, University Hospital Frankfurt, Frankfurt, Germany
| | - Linna Sommer
- Department of Pathology, University Hospital Dresden, Dresden, Germany
| | - Konrad Stock
- Department of Nephrology, TUM School of Medicine of Technical University of Munich, Munich, Germany
| | - Philipp Ströbel
- Department of Pathology, University Medical Center Göttingen, Göttingen, Germany
| | - Stephanie Strobl
- Department of Pathology, University Medical Center Mainz, Mainz, Germany
| | - Ulf Titze
- Department of Pathology, University Hospital OWL of the Bielefeld University, Campus Lippe, Detmold, Germany
| | - Gregor Weirich
- Department of Pathology, TUM School of Medicine of Technical University of Munich, Munich, Germany
| | - Joachim Weis
- Department of Neuropathology, University Hospital RWTH Aachen, Aachen, Germany
| | - Martin Werner
- Institute for Surgical Pathology, Medical Center, University of Freiburg, Freiburg, Germany
| | - Claudia Wickenhauser
- Department of Pathology, University Hospital Halle (Saale), Halle (Saale), Germany
| | - Thorsten Wiech
- Department of Pathology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Peter Wild
- Senckenberg Institute of Pathology, University Hospital Frankfurt, Frankfurt, Germany
| | - Tobias Welte
- Department of Respiratory Medicine, Hannover Medical School, Hannover, Germany
| | | | - Peter Boor
- Institute of Pathology, University Hospital RWTH Aachen, Aachen, Germany. .,Department of Nephrology and Immunology, University Hospital RWTH Aachen, Aachen, Germany.
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10
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Reichardt M, Moller Jensen P, Andersen Dahl V, Bjorholm Dahl A, Ackermann M, Shah H, Länger F, Werlein C, Kuehnel MP, Jonigk D, Salditt T. 3D virtual histopathology of cardiac tissue from Covid-19 patients based on phase-contrast X-ray tomography. eLife 2021; 10:e71359. [PMID: 34930527 PMCID: PMC8747495 DOI: 10.7554/elife.71359] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Accepted: 12/10/2021] [Indexed: 11/29/2022] Open
Abstract
For the first time, we have used phase-contrast X-ray tomography to characterize the three-dimensional (3d) structure of cardiac tissue from patients who succumbed to Covid-19. By extending conventional histopathological examination by a third dimension, the delicate pathological changes of the vascular system of severe Covid-19 progressions can be analyzed, fully quantified and compared to other types of viral myocarditis and controls. To this end, cardiac samples with a cross-section of 3.5mm were scanned at a laboratory setup as well as at a parallel beam setup at a synchrotron radiation facility the synchrotron in a parallel beam configuration. The vascular network was segmented by a deep learning architecture suitable for 3d datasets (V-net), trained by sparse manual annotations. Pathological alterations of vessels, concerning the variation of diameters and the amount of small holes, were observed, indicative of elevated occurrence of intussusceptive angiogenesis, also confirmed by high-resolution cone beam X-ray tomography and scanning electron microscopy. Furthermore, we implemented a fully automated analysis of the tissue structure in the form of shape measures based on the structure tensor. The corresponding distributions show that the histopathology of Covid-19 differs from both influenza and typical coxsackie virus myocarditis.
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Affiliation(s)
- Marius Reichardt
- Institut für Röntgenphysik, Georg-August-Universität Göttingen, Friedrich-Hund-PlatzGöttingenGermany
| | | | | | | | - Maximilian Ackermann
- Institute of Anatomy and Cell Biology, University Medical Center of the Johannes Gutenberg-University MainzMainzGermany
| | - Harshit Shah
- Medizinische Hochschule Hannover (MHH)HannoverGermany
- Deutsches Zentrum für Lungenforschung (DZL), Hannover (BREATH)HannoverGermany
| | - Florian Länger
- Medizinische Hochschule Hannover (MHH)HannoverGermany
- Deutsches Zentrum für Lungenforschung (DZL), Hannover (BREATH)HannoverGermany
| | | | - Mark P Kuehnel
- Medizinische Hochschule Hannover (MHH)HannoverGermany
- Deutsches Zentrum für Lungenforschung (DZL), Hannover (BREATH)HannoverGermany
| | - Danny Jonigk
- Medizinische Hochschule Hannover (MHH)HannoverGermany
- Deutsches Zentrum für Lungenforschung (DZL), Hannover (BREATH)HannoverGermany
| | - Tim Salditt
- Institut für Röntgenphysik, Georg-August-Universität Göttingen, Friedrich-Hund-PlatzGöttingenGermany
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11
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Hang W, Chen C, Zhang XA, Wang DW. Endothelial dysfunction in COVID-19 calls for immediate attention: the emerging roles of the endothelium in inflammation caused by SARS-CoV-2. Front Med 2021; 15:638-643. [PMID: 33748924 PMCID: PMC7982315 DOI: 10.1007/s11684-021-0831-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 10/14/2020] [Indexed: 12/22/2022]
Abstract
The COVID-19 pandemic has caused numerous deaths around the world. A growing body of evidence points to the important role of overwhelming inflammatory responses in the pathogenesis of COVID-19 and the effectiveness of anti-inflammation therapy against COVID-19 is emerging. In addition to affecting the lungs, COVID-19 can be a severe systemic inflammatory disease that is related to endothelial dysfunction. We are calling for closer attention to endothelial dysfunction in COVID-19 not only for fully revealing the pathogenic mechanism of COVID-19 but also for properly adjusting the strategy of clinical intervention.
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Affiliation(s)
- Weijian Hang
- Division of Cardiology, Department of Internal Medicine, and Hubei Key Laboratory of Genetics and Molecular Mechanisms of Cardiological Disorders, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Chen Chen
- Division of Cardiology, Department of Internal Medicine, and Hubei Key Laboratory of Genetics and Molecular Mechanisms of Cardiological Disorders, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Xin A Zhang
- Department of Physiology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, 73104, USA
| | - Dao Wen Wang
- Division of Cardiology, Department of Internal Medicine, and Hubei Key Laboratory of Genetics and Molecular Mechanisms of Cardiological Disorders, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China.
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12
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Abstract
Viral respiratory diseases constitute the most common reasons for hospitalization with more than half of all acute illnesses worldwide. Progressive respiratory failure with pronounced diffuse alveolar damage has been identified as the primary cause of death in COVID-19. COVID-19 pneumonia shares common histopathological hallmarks with influenza (H1N1)-related ARDS, like diffuse alveolar damage (DAD) with edema, hemorrhage, and intra-alveolar fibrin deposition. The lungs with COVID-19 pneumonia revealed perivascular inflammation, an endothelial injury, microangiopathy, and an aberrant blood vessel neoformation by intussusceptive angiogenesis. While this pronounced angiocentric inflammation is likely be found - to varying degrees - in numerous other organs, e.g., the heart, COVID-19 is hypothesized to be not just a pulmonary, but rather a systemic "vascular disease."
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13
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Hang W, Chen C, Seubert JM, Wang DW. Fulminant myocarditis: a comprehensive review from etiology to treatments and outcomes. Signal Transduct Target Ther 2020; 5:287. [PMID: 33303763 PMCID: PMC7730152 DOI: 10.1038/s41392-020-00360-y] [Citation(s) in RCA: 57] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 09/14/2020] [Accepted: 09/17/2020] [Indexed: 12/15/2022] Open
Abstract
Fulminant myocarditis (FM) is characterized by a rapid progressive decline in cardiac function and a high mortality rate. Since the first report of FM patients in the 1980s, several clinical trials and research studies have been published increasing our knowledge regarding FM. Currently, the diagnosis of FM depends on various techniques including electrocardiography, echocardiography, endomyocardial biopsy, and cardiac magnetic resonance. The development of mechanical circulation support (MCS) devices and progress in our understanding of the pathophysiological mechanisms underlying FM, treatment regimens have evolved from simple symptomatic treatment to a life support-based comprehensive treatment approach. The core mechanism underlying the development of FM is the occurrence of an inflammatory cytokine storm. This review provides a comprehensive account of the current understanding of FM pathophysiology and knowledge regarding its etiology, pathophysiology, treatments, and outcomes.
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Affiliation(s)
- Weijian Hang
- Division of Cardiology, Department of Internal Medicine, and Hubei Key Laboratory of Genetics and Molecular Mechanisms of Cardiological Disorders, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Chen Chen
- Division of Cardiology, Department of Internal Medicine, and Hubei Key Laboratory of Genetics and Molecular Mechanisms of Cardiological Disorders, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - John M Seubert
- Faculty of Pharmacy and Pharmaceutical Sciences University of Alberta, Edmonton, Alberta, T6G 2E1, Canada.
| | - Dao Wen Wang
- Division of Cardiology, Department of Internal Medicine, and Hubei Key Laboratory of Genetics and Molecular Mechanisms of Cardiological Disorders, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China.
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14
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Ackermann M, Mentzer SJ, Kolb M, Jonigk D. Inflammation and intussusceptive angiogenesis in COVID-19: everything in and out of flow. Eur Respir J 2020; 56:13993003.03147-2020. [PMID: 33008942 PMCID: PMC7530910 DOI: 10.1183/13993003.03147-2020] [Citation(s) in RCA: 68] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 08/28/2020] [Indexed: 12/20/2022]
Affiliation(s)
- Maximilian Ackermann
- Institute of Pathology and Molecular Pathology, Helios University Clinic Wuppertal, University of Witten/Herdecke, Wuppertal, Germany .,Institute of Functional and Clinical Anatomy, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Steven J Mentzer
- Laboratory of Adaptive and Regenerative Biology, Harvard Medical School, Brigham and Women's Hospital, Boston, MA, USA
| | - Martin Kolb
- Firestone Institute for Respiratory Health, Research Institute at St Joseph's Healthcare, Dept of Medicine, McMaster University, Hamilton, ON, Canada
| | - Danny Jonigk
- Institute of Pathology, Hannover Medical School, Hannover, Germany.,Member of the German Center for Lung Research (DZL), Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH), Hannover, Germany
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15
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Intussusceptive angiogenesis in Covid-19: hypothesis on the significance and focus on the possible role of FGF2. Mol Biol Rep 2020; 47:8301-8304. [PMID: 32920756 PMCID: PMC7486971 DOI: 10.1007/s11033-020-05831-7] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Revised: 09/01/2020] [Accepted: 09/07/2020] [Indexed: 12/12/2022]
Abstract
The interest on the role of angiogenesis in the pathogenesis and progression of human interstitial lung diseases is growing, with conventional sprouting (SA) and non-sprouting intussusceptive angiogenesis (IA) being differently represented in specific pulmonary injury patterns. The role of viruses as key regulators of angiogenesis is known for several years. A significantly enhanced amount of new vessel growth, through a mechanism of IA, has been reported in lungs of patients who died from Covid-19; among the angiogenesis-related genes, fibroblast growth factor 2 (FGF2) was found to be upregulated. These findings are intriguing. FGF2 plays a role in some viral infections: the upregulation is involved in the MERS-CoV-induced strong apoptotic response crucial for its highly lytic replication cycle in lung cells, whereas FGF2 is protective against the acute lung injury induced by H1N1 influenza virus, improving the lung wet-to-dry weight ratio. FGF2 plays a role also in regulating IA, acting on pericytes (crucial for the formation of intraluminal pillars), and endothelium, and FGF2-induced angiogenesis may be promoted by inflammation and hypoxia. IA is a faster and probably more efficient process than SA, able to modulate vascular remodeling through pruning of redundant or inefficient blood vessels. We can speculate that IA might have the function of restoring a functional vascular plexus consequently to extensive endothelialitis and alveolar capillary micro-thrombosis observed in Covid-19. Anti-Vascular endothelial growth factor (anti-VEGF) strategies are currently investigated for treatment of severe and critically ill Covid-19 patients, but also FGF2, and its expression and/or signaling, might represent a promising target.
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16
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Affiliation(s)
- Thomas F Lüscher
- Professor of Cardiology, Imperial College and Director of Research, Education & Development, Royal Brompton and Harefield Hospitals London, UK.,Professor and Chairman, Center for Molecular Cardiology, University of Zurich, Switzerland.,Editor-in-Chief, EHJ Editorial Office, Zurich Heart House, Hottingerstreet 14, 8032 Zurich, Switzerland
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