Lymphatic coagulation and neutrophil extracellular traps in lung-draining lymph nodes of COVID-19 decedents.

ABSTRACT

Clinical manifestations of severe COVID-19 include coagulopathies that are exacerbated by the formation of neutrophil extracellular traps (NETs). Here, we report that pulmonary lymphatic vessels, which traffic neutrophils and other immune cells to the lung-draining lymph node (LDLN), can also be blocked by fibrin clots in severe COVID-19. Immunostained tissue sections from COVID-19 decedents revealed widespread lymphatic clotting not only in the lung, but notably in the LDLN, where the extent of clotting correlated with the presence of abnormal, regressed, or missing germinal centers. it strongly correlated with the presence of intralymphatic NETs. In mice, TNFα induced intralymphatic fibrin clots, and this could be inhibited by DNAse 1, which degrades NETs. In vitro, TNF induced lymphatic endothelial cell upregulation of ICAM-1 and CXCL8 among other neutrophil-recruiting factors as well as thrombomodulin downregulation. Furthermore, in decedents, lymphatic clotting in LDLNs. In a separate cohort of hospitalized patients, serum levels of MPO-DNA (a NET marker) inversely correlated with antiviral antibody titers, but D-dimer levels, indicative of blood thrombosis, did not correlate with either. In fact, patients with high MPO-DNA but low D-dimer levels generated poor anti-viral antibody titers. This study introduces lymphatic coagulation in lungs and LDLNs as a clinical manifestation of severe COVID-19 and suggests the involvement of NETosis of lymphatic-trafficking neutrophils. It further suggests that lymphatic clotting may correlate with impaired formation or maintenance of germinal centers necessary for robust antiviral antibody responses, although further studies are needed to determine whether and how lymphatic coagulation impacts adaptive immune responses.