ENDOTHELIAL CELLS AND BLOOD VESSELS – CRITICAL TARGETS FOR COVID-19-INDUCED TISSUE INJURY AND SPREAD TO DISTANT ORGANS. UNDERLYING MECHANISMS INCLUDE ENDOTHELIAL DYSFUNCTION AND INJURY

Endothelial cells (ECs) lining the blood vessels of all organs express the SARS-CoV2 receptor. In the absence of preexisting tissue damage, the virus would need to pass through the ECs to blood vessels to infect other tissues. Thus, EC are a target for SARS-CoV-2 infection and a conduit for viral dissemination to distant organs. We hypothesized that ECs infection and/ or injury are the mechanisms of COVID-19 pathology and multi-organ dissemination and injury. Methods: Human studies: We used lung, heart, kidney, and small bowel specimens obtained during autopsies (n=5) from COVID-19 patients and uninfected subjects. Studies: 1) histologic evaluation of endothelial damage and endotheliitis, 2) immunohistochemistry for vWF, PAI-1, VCAM-1, & ICAM-1. Studies in cultured human microvascular ECs (HMVECs): We cultured lung and cardiac HMVECs in the presence or absence of SARSCoV- 2 S1 and/or S2 protein (10 ng/ml) for 0 - 24 hr. Studies:1) cell viability and proliferation;2) angiogenesis on Matrigel and cell migration;3) mitochondrial membrane potential (MMP);4) RNA seq analysis;5) Western blotting for vWF, PAI-1, VCAM-1, and ICAM-1. We examined the protective effect of melatonin, Coenzyme Q10 and nerve growth factor on S1/S2 protein induced HMVEC cell damage. Results: Histopathologic examination revealed presence of endothelial abnormalities and endotheliitis with marked presence of inflammatory cells in vessel wall & lumen, and fibrinous microthrombi) in lung, heart & kidney in autopsy specimens of COVID-19 patients. Immunostaining visualized increased vWF, PAI-1, VCAM- 1, & ICAM-1 in COVID-19. In in vitro study, S1 and S2 proteins induced endothelial injury, reduced angiogenesis and phosphorylated/activated Erk and Akt proteins in cultured HMVECs. Treatment of HMVECs for 1 & 4 hours with S2 but not S1 protein increased ICAM-1 levels by 1.4- to 1.8-fold (P < 0.001). RNA Seq analysis showed that treatment of HMVECs with S1 and S2 proteins upregulated VCAM-1, ICAM-1 and E-selectin mRNA in cultured HMVECs. Melatonin, Coenzyme Q10 and NGF stimulated angiogenesis in HMVECs by 2.4-, 1.3-&1.4-fold (all P < 0.001). Conclusions: 1) Significant endothelial abnormalities, blood vessel damage and endotheliitis are present in lung, heart and kidney autopsy specimens of COVID-19 patients, 2) There is increased expression of vWF, PAI-1, VCAM-1, and ICAM- 1 in lung, heart, and kidney specimens of COVID-19 patients, 3) Treatment of cultured HMVECs with SARS-CoV-2 S1 and S2 proteins upregulates VCAM-1, ICAM-1 and Eselectin expression, 4) SARS-CoV-2 S1 and S2 proteins induce endothelial injury in cultured HMVECs, and 5) melatonin, Coenzyme Q10 and NGF stimulated EC function. These studies uncovered novel mechanism – endothelial dysfunction underlying SARS-CoV-2 and identified melatonin, Coenzyme Q10 and NGF as potential drugs for treatment of COVID- 19-induced EC injury

On-Line Project-Based Learning on Healthcare Technologies Against Epidemic Diseases: A COVID-19 Case Study

Quality technical education on healthcare technologies is still inaccessible to young adults in low-resource settings due to high costs, low-tech environments, and gaps in learning materials. The online and open-source collaborative Project-Based Learning (PBL) methodology intends to introduce early-career engineers into the development of healthcare technologies by allowing students from all around the world, regardless of background or place of origin, to engage in collaborative design methods, the use of open-source resources and learning experiences from experts in the field. This paper discusses a case study in which the aforementioned methodology was implemented, the "COVID-19 Innovation Competition and Design Bootcamp 2020", which brought together 105 participants from 22 countries, mostly in Africa, to conceptualize the design of 10 medical devices in two weeks for an integral management of the COVID-19 pandemic that is applicable to other infectious disease outbreaks. The presented experience demonstrates that highly formative virtual PBL experiences can be carried out, in a cost-effective way and in connection with real societal needs, for which remarkable solutions can be found, by virtue of multidisciplinary and international cooperation. Our findings demonstrate that even if it is difficult to reach the degree of project completion achievable with longer-term and on-site design-build experiences, on-line PBL has been shown to promote students' professional skills in an effective way.

Isolated EBV-induced acute hepatitis in the absence of infectious mononucleosis

Introduction: Epstein-Barr virus (EBV) is a globally prevalent herpesvirus with an estimated 90-95% seropositivity rate worldwide. It is most known for causing infectious mononucleosis characterized by the classic triad of fever, pharyngitis, and lymphadenopathy. Hepatitis is a common manifestation seen in 90% of cases;however, isolated acute hepatitis in the absence of infectious mononucleosis is a rare clinical presentation. Case Description/Methods: An 18-year-old female with no medical history presented with fevers, fatigue, myalgia, and headache ongoing for one week. She had been evaluated previously with recommendations for supportive care for an unspecified viral illness. Workup at the time had been negative for urine hCG, COVID-19, heterophile antibody, Lyme disease, and bacteremia. However, symptoms worsened with the development of nausea, vomiting, and darkening of her urine. Prior to this, patient had been in her normal state of health without sick contacts, travel history, animal exposures, risky sexual practices, or substance use. Exam revealed cervical lymphadenopathy and hepatosplenomegaly. Labs showed normal leukocyte count 8.4 thou/cmm with differential significant for reactive lymphocytosis 19% and bandemia 8%. Liver function tests were abnormal with elevated total bilirubin 3.8 mg/dL, AST 366 U/L, ALT 460 U/L, ALP 562 U/L. Synthetic function was intact. Hepatic ultrasound was unrevealing. Extensive infectious workup revealed acute EBV infection with serologies showing positive VCA IgM Ab 74.3 U/mL, negative VCA IgG Ab 11.9 U/mL, negative EA Ab < 5 U/mL, negative EBNA Ab < 3 U/mL. Patient was managed supportively with improved symptoms. She was instructed to avoid physical contact sports for one month upon discharge. Discussion: Clinically significant EBV induced hepatitis is a rare entity seen in < 5% of cases. Nevertheless, it is important to consider EBV as a causative pathogen of acute hepatitis. Heterophile antibody or Monospot test is the diagnostic test of choice with a sensitivity of 85% and a specificity of 100%;however, false negatives can occur especially early in the disease course. EBV serology has an improved sensitivity of 97% with a comparable specificity of 94%. As such, follow-up serology is necessary especially if clinical suspicion is high. While no specific EBV targeted therapies exist, it is important to identify it given the potential complications, including splenic rupture, airway obstruction, malignancies, lymphoproliferative disorders, among others.

THE UNFORUNATE SEEDING OF TESTICULAR CHORIOCARCINOIMA FOLLOWING THE FONTAN PROCEDURE

TOPIC: Lung Cancer TYPE: Medical Student/Resident Case Reports INTRODUCTION: The Fontan procedure is a palliative surgical procedure performed in children ages 2-4 years old with hypoplastic right heart syndrome by relocating the inferior vena cava from the right atrium to the right pulmonary artery to complete the Fontan circuit[1][2]. This circuit allows for normalization of arterial saturation and abolishment of chronic volume overload at the cost of decreased cardiac output.[1] This adjustment allows for almost all venous blood to return to heart through the right pulmonary artery[3]. We present a case below in a patient with hypoplastic right heart treated with the Fontan procedure who was later diagnosed with testicular choriocarcinoma with hematogenous metastasis through the right pulmonary artery. CASE PRESENTATION: An 18-year-old male with a past medical history of heterotaxia, hypoplastic right heart treated with Fontan palliation and Kawashima surgery initially presented for persistent, worsening dyspnea. On further questioning the patient reported an active lifestyle but over the past several weeks had begun to develop dyspnea with limited ambulation and persistent cough. On presentation, the patient was found to be in acute hypoxic respiratory failure. Computed tomography (CT) imaging of the chest, abdomen and pelvis showed a new large right retroperitoneal mass causing hydronephrosis as well as innumerable right sided pulmonary nodules concerning for metastatic disease. Biopsy of the retroperitoneal mass revealed germ cell tumor, with choriocarcinoma heavily present in the tissue. The patient underwent MRI of the brain for staging, which subsequently revealed numerous embolic strokes. He was started on a chemotherapy regimen of etoposide, ifosfamide, and cisplatin;however, his course was complicated by COVID-19 infection which caused further deterioration in his respiratory status. He unfortunately passed away from respiratory failure. DISCUSSION: In this case, the Fontan procedure provided the patient with excellent oxygenation as the patient was able to exercise and live relatively unbound by his complex cardiovascular history. However, this procedure served as the conduit that allowed his testicular choriocarcinoma to hematogenously spread and predominately seed his right lung. Hospitalization was further complicated by active COVID-19 infection and in concert with his poor lung status, the patient passed. CONCLUSIONS: This case highlights the unique anatomy and physiology of patients treated with the Fontan circulation. This life saving surgery performed in early childhood unfortunately served as the conduit for hematogenously spread of choriocarcinoma. As a consequence of the surgery, the right pulmonary artery receives all the venous return which then allowed the malignancy to spread predominately to the right lung. REFERENCE #1: Gewillig M. The Fontan Circulation. Heart. 2005;91:839-846 REFERENCE #2: Kutty S, Jacobs M, Thompson R, Danford D. Fontan Circulation of Next Generation: Why It's Necessary, What It May Look Like. JAHA. 2020;9:e01 3691 REFERENCE #3: Cowgill LD. The Fontan Procedure: A Historical Review. Ann Thoracic Surgery. 1991;51:1026-30 DISCLOSURES: No relevant relationships by Arjan Ahluwalia, source=Web Response No relevant relationships by Martin Delatorre, source=Web Response No relevant relationships by Kaitlyn Musco, source=Web Response No relevant relationships by Alina Zhu, source=Web Response