Probes for INS

We report postmortem cardio-pulmonary findings including detection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in formalin-fixed paraffin embedded tissue in 12 patients with COVID-19. The 5 women and 7 men (median age: 73 years; range 35-96) died 6-38 days after onset of symptoms (median: 14.5 days). Eight patients received mechanical ventilation. Ten patients showed diffuse alveolar damage (DAD), 7 as exudative and 3 as proliferative/organizing DAD. One case presented as acute fibrinous and organizing pneumonia. Seven patients (58%) had acute bronchopneumonia, 1/7 without associated DAD and 1/7 with aspergillosis and necrotic bronchitis. Microthrombi were present in 5 patients, only in exudative DAD. Reverse transcriptase quantitative PCR detected high virus amounts in 6 patients (50%) with exudative DAD and symptom-duration ≤14 days, supported by immunohistochemistry and in-situ RNA hybridization (RNAscope). The 6 patients with low viral copy levels were symptomatic for ≥15 days, comprising all cases with organizing DAD, the patient without DAD and one exudative DAD. We show the high prevalence of DAD as a reaction pattern in COVID-19, the high number of overlying acute bronchopneumonia, and high-level pulmonary virus detection limited to patients who died ≤2 weeks after onset of symptoms, correlating with exudative phase of DAD.

Loss of kidney function is a common feature of COVID-19 infection, but serum creatinine (SCr) is not a sensitive or specific marker of kidney injury. We tested whether molecular biomarkers of tubular injury measured at hospital admission were associated with AKI in those with COVID-19 infection.This is a prospective cohort observational study consisting of 444 consecutive SARS-CoV-2 patients enrolled in the Columbia University Emergency Department at the peak of New York's pandemic (March-April 2020). Urine and blood were collected simultaneously at hospital admission (median time: day 0, IQR 0-2 days) and urine biomarkers analyzed by ELISA and by a novel dipstick. Kidney biopsies were probed for biomarker RNA and for histopathologic acute tubular injury (ATI) scores.Admission uNGAL was associated with AKI diagnosis (267±301 vs. 96±139 ng/mL, P < 0.0001) and staging; uNGAL levels >150ng/mL demonstrated 80% specificity and 75% sensitivity to diagnose AKI-stage 2-3. Admission uNGAL quantitatively associated with prolonged AKI, dialysis, shock, prolonged hospitalization, and in-hospital death, even when admission SCr was not elevated. The risk of dialysis increased almost 4-fold per standard deviation of uNGAL independently of baseline SCr, co-morbidities, and proteinuria [OR(95%CI): 3.59 (1.83-7.45), P < 0.001]. In COVID-19 kidneys, NGAL mRNA expression broadened in parallel with severe histopathological injury (ATI). Conversely, low uNGAL levels at admission ruled out stage 2-3 AKI (NPV 0.95, 95%CI: 0.92-0.97) and the need for dialysis (NPV: 0.98, 95%CI: 0.96-0.99)). While proteinuria and uKIM-1 implicated tubular injury, neither were diagnostic of AKI stages.In COVID-19 patients, uNGAL quantitatively associated with histopathological injury (ATI), the loss of kidney function (AKI), and the severity of patient outcomes.

Pregnant individuals infected with SARS-CoV-2 have higher rates of ICU admission, oxygen requirement, need for mechanical ventilation and death than non-pregnant individuals. Increased COVID-19 disease severity may be associated with increased risk for viremia and placental infection. Maternal SARS-CoV-2 infection is also associated with pregnancy complications such as preeclampsia and preterm birth, that can be either placentally-mediated or reflected in the placenta. Maternal viremia followed by placental infection may lead to maternal-fetal transmission (vertical), which affects 1-3% of exposed newborns. However, there is no agreed-upon or standard definition of placental infection. NIH/NICHD convened a group of experts to propose a working definition of placental infection to inform ongoing studies of SARS-CoV-2 during pregnancy. Experts recommended that placental infection be defined using techniques that allow virus detection and localization in placental tissue by one or more of the following methods: in-situ hybridization with anti-sense probe (detects replication) and/or a sense probe (detects viral genome or immunohistochemistry to detect viral nucleocapsid (N) or spike (S) proteins. If the above methods are not possible, RT-PCR detection and/or quantification of viral RNA in placental homogenates, or electron microscopy are alternative approaches. A graded classification for the likelihood of placental infection as definitive, probable, possible, and unlikely was proposed. Manuscripts reporting placental infection should describe the sampling method (location and number of samples collected), method of preservation of tissue, and detection technique. Recommendations were made for the handling of the placenta, examination, and sampling, as well as the use of validated reagents and sample protocols (included as appendices).