key: cord-0872672-965gc3n6 authors: Pietsch, Heiko; Escher, Felicitas; Aleshcheva, Ganna; Baumeier, Christian; Morawietz, Lars; Elsaesser, Albrecht; Schultheiss, Heinz-Peter title: Proof of SARS-CoV-2 Genomes in Endomyocardial Biopsy with Latency After Acute Infection date: 2020-10-09 journal: Int J Infect Dis DOI: 10.1016/j.ijid.2020.10.012 sha: fbdadb716c49c9d620c50b979779786136c7eaf7 doc_id: 872672 cord_uid: 965gc3n6 Emergence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has reached pandemic level. Cardiovascular complications in COVID-19 have been reported frequently, however, evidence for causal relationship has not been established. We describe detection of SARS-CoV-2 viral genomes in a patient with heart failure symptoms investigating endomyocardial biopsy following a latent period of four weeks after onset of pulmonary symptoms. Viral infection was accompanied by myocardial inflammation indicating infection of the heart muscle. Since December 2019, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) quickly became a worldwide health emergency and has reached pandemic level (Zhu et al. 2020 ). The SARS-CoV-2 disease 2019 (COVID-19) has alarmed not only the pulmonologists as COVID-19 manifests mainly as a respiratory disease, but also clinicians of other disciplines. Clinical reports have confirmed cardiac involvement during COVID-19 (Inciardi et al. 2020; Madjid et al. 2020) . SARS-CoV-2 is an enveloped RNA virus that binds to its target cell via a viral envelope-anchored spike protein and the putative host receptor angiotensin-converting enzyme 2 (ACE2). Besides other tissue and cell types, ACE2 is highly expressed in vascular endothelial cells and in heart muscle cells (Liu et al. 2020) . Previous work from our group identified SARS-CoV-2 genomes by PCR in the myocardium of COVID-19 patients affected by intramyocardial inflammation (Escher et al. 2020) . Presence of viral genomes in the heart of COVID-19 patients was also verified in autopsy studies without an association with myocarditis in fulminant stages (Lindner et al. 2020) . Cardiotropism of SARS-CoV-2 was confirmed in J o u r n a l P r e -p r o o f vitro, but might occur after a latent period following acute infection of the respiratory tract in vivo (Sharma et al. 2020) . To investigate the presence of SARS-CoV-2 as a potentially cardiotropic virus with a possible latency until detection in the myocardium, real-time reverse transcription polymerase chain reaction (RT-qPCR) was performed in endomyocardial biopsies (EMBs). EMBs were analyzed in the Institute for Cardiac Diagnostics and Therapy, Berlin, Germany by histology, immunohistology, and molecular biology (Schultheiss et al. 2019) . In a COVID-19 affected patient, SARS-CoV-2-RNA was detected in RNA extracted from EMB tissue using RT-qPCR indicating endomyocardial infection (SARS-CoV2 E-gene specific RT-qPCR; sample Ct-value = 33.4 ± 1.9; positive control Ct-value = 35.9 ± 0.5; Fig.1 ) (TIB Molbiol, Berlin, Germany). This was an otherwise healthy 59-year-old woman of Caucasian race, admitted to the intensive care unit with severe acute respiratory syndrome. Dyspnea, neither fever nor cough, was the only symptom corresponding to a typical clinical picture of acute heart failure. The first clinical contact was on February 17 th , 2020. At that time, the clinical experiences with COVID-19 in Germany were scarce and therefore COVID-19 was not suspected as differential diagnosis. Throat swab specimens tested negative for respiratory syncytial virus and influenza A and B virus. Blood tests revealed elevated levels of markers of myocyte injury (high-sensitivity troponin T level of 83.6 pg/ml and creatine kinase-MB level of 125-43 U/L), which remained positive during the first days of her hospitalization. Transthoracic echocardiography showed a severe diastolic dysfunction III with an increased wall thickness (interventricular septum, 14 mm) and minimal pericardial effusion. After respiratory improvement, coronary artery disease could be excluded and due to progressive heart failure symptoms, EMB was carried out by left ventricular catheterization four weeks after onset of pulmonary symptoms. In addition to positive proof of SARS-CoV-2-RNA, Although subgenomic SARS-CoV-2-RNA indicating replicative infection has been detected to date only in the respiratory tract, viral genomes were detectable in other organs, such as kidneys, liver, skin, eyes, and nervous system of infected individuals Wolfel et al. 2020 ). Presence of SARS-CoV-2 genomes in EMBs indicates that SARS-CoV-2 is potentially able to infect the heart muscle. A recently published report identified viral particles in interstitial cytopathic macrophages in EMB of a COVID-19 cardiogenic shock patient by electron microscopy (Tavazzi et al. 2020) . Herewith, we validated the direct cardiac involvement associated with intramyocardial inflammation as a complication in a patient affected by . In this study, we were able to show that virus positivity in the heart is still present after a latent period of four weeks after onset of pulmonary symptoms. During the present study, J o u r n a l P r e -p r o o f it was not possible to determine the exact cell type being susceptible to SARS-CoV-2 infection within the myocardium. Elevated histopathological and systemic parameters of myocardial inflammation in the absence of signs of necrosis indicates that cardiac disfunction and myocyte hypertrophy might be caused by ischemic conditions resulting from damage to intramural vessels and small capillaries (Varga et al. 2020) . Limitations in EMB sample size did allow for conclusive histopathological evaluation of capillary damage by using specific endothelial cell markers in the present study. However, CD11b + -macrophage infiltration was more pronounced in the surrounding areas of capillaries. A follow-up EMB revealed a significant reduction of inflammatory cell infiltration and tested negative for SARS-CoV-2-RNA, implicating viral clearance in the myocardium. The present results suggest, that successful detection of SARS-CoV-2 genomes in the heart during the course of infection might only be possible in a temporally restricted phase. The long-term effect of COVID-19 in the heart muscle needs to be investigated and one may speculate that further cardiac complications in the progression of COVID-19 following viral clearance may result from abundant inflammatory reaction or induction of auto-immune processes (Galeotti and Bayry 2020) . This EMB-based finding should prompt the clinician to continue cardiac surveillance after pulmonary infection identifying SARS-CoV-2 as a potential new causative agent in the development of heart failure. Since COVID-19 was not suspected initially, specifically preserved blood samples corresponding to the date of catheterization to allow for systemic molecular testing of SARS-CoV-2 genomes were not available. EMB is limited in sample size, thus amount of isolated RNA was not sufficient for SARS-CoV-2 genome in depth analysis targeting different regions or sequencing of viral genome. However, high sensitivity and specificity of the used PCR J o u r n a l P r e -p r o o f systems to detect SARS-CoV-2 genomes have been demonstrated recently ). This study did not receive any funding. The patient gave permission and informed consent for the publication of this case report. HP, FE, GA, CB, LM, and HPS report personal fees from IKDT Berlin outside the submitted work. No other relationships/conditions/circumstances that present a potential conflict of interest relevant to the work. The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. Detection of 2019 novel coronavirus (2019-nCoV) by real-time RT-PCR. Euro Surveill Bull Eur sur les Mal Transm = Eur Commun Dis Bull Detection of viral SARS-CoV-2 genomes and histopathological changes in endomyocardial biopsies. 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