Severe Acute Respiratory Syndrome Coronavirus 2 Vasculopathy in a Syrian Golden Hamster Model

Clinical evidence of vascular dysfunction and hypercoagulability as well as pulmonary vascular damage and microthrombosis are frequently reported in severe cases of human coronavirus disease 2019 (COVID-19). Syrian golden hamsters recapitulate histopathologic pulmonary vascular lesions reported in patients with COVID-19. Herein, special staining techniques and transmission electron microscopy further define vascular pathologies in a Syrian golden hamster model of human COVID-19. The results show that regions of active pulmonary inflammation in severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection are characterized by ultrastructural evidence of endothelial damage with platelet marginalization and both perivascular and subendothelial macrophage infiltration. SARS-CoV-2 antigen/RNA was not detectable within affected blood vessels. Taken together, these findings suggest that the prominent microscopic vascular lesions in SARS-CoV-2–inoculated hamsters likely occur due to endothelial damage followed by platelet and macrophage infiltration.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in humans varies from asymptomatic to severe respiratory disease, progressing to acute respiratory distress syndrome, multiorgan dysfunction, and death in a subset of patients. As the pandemic has progressed, there have been increasing reports documenting clinical evidence of coagulation abnormalities (coagulopathy) and microscopic indicators of pulmonary vascular damage (vasculopathy), including endotheliitis, defined as subendothelial leukocyte infiltration with lifting and/or damage to endothelial cells, 1 vasculitis, and microthrombosis associated with severe cases of coronavirus disease 2019 . 2e5 Syrian golden hamsters (Mesocricetus auratus) are naturally susceptible to SARS-CoV-2 and closely recapitulate the clinical, virological, and histopathologic features of human  Herein, a Syrian golden hamster model was used to define SARS-CoV-2einduced vasculopathies, which have not been fully characterized in this animal model. Hamsters show regions of active SARS-CoV-2einduced pulmonary inflammation that exhibit ultrastructural evidence of endothelial damage with detachment from the underlying basement membrane, platelet marginalization, and marked perivascular and subendothelial mononuclear inflammation composed primarily of macrophages. At 3 to 6 or 7 days post inoculation (dpi), SARS-CoV-2 antigen/RNA was not detectable within affected blood vessels. These findings suggest that the microscopic vascular lesions in SARS-CoV-2einoculated hamsters occur not primarily due to direct viral infection of the endothelium, but rather due to indirect endothelial damage with loss of endothelial attachment and vascular compromise followed by platelet and macrophage infiltration.

Materials and Methods
Hamsters, Viral Inoculation, and Euthanasia All hamster experiments were conducted under protocol number 21868, approved by the University of California, Davis, Institutional Animal Care and Use Committee. Infectious virus was handled in certified animal biosafety level 3 laboratory spaces in compliance with approved institutional biological use authorization number R2813. University of California, Davis, is accredited by the Association for Assessment and Accreditation of Laboratory Animal Care, and all work adhered to the NIH Guide for the Care and Use of Laboratory Animals. 12 Two experiments, each using 8-to 10-weekeold male and female Syrian golden hamsters, were performed [experiment 1, N Z 15 (8 males and 7 females); experiment 2, N Z 8 (4 males and 4 females)]; the animals were from Charles River Laboratories (Wilmington, MA) and were acclimated for up to 7 days at 22 C to 25 C and a 12:12-hours light/dark cycle. Rodent chow with 18% protein content and sterile bottled water were provided ad libitum for the duration of the experiment.
SARS-CoV-2/human/USA/CA-CZB-59X002/2020 (Gen-Bank, https://www.ncbi.nlm.nih.gov/nuccore/MT394528; accession number MT394528, data available to public) from a 2020 patient with COVID-19 in Northern California was passaged twice in Vero-E6 (ATCC, Manassas, VA) cells to achieve a titer of 2.2 Â 10 7 plaque-forming units (PFUs)/mL and stored at À80 C. Randomly selected hamsters from experiment 1 and experiment 2 were anesthetized with isoflurane and administered 30 mL of phosphate-buffered saline (PBS; Thermo Fisher Scientific, Waltham, MA) [experiment 1, N Z 4 (2 males and 2 females); experiment 2, N Z 2 (1 male and 1 female)] or SARS-CoV-2 diluted in PBS at a dose of 10 4 PFUs [experiment 1, N Z 11 (6 males and 5 females); experiment 2, N Z 6 (3 males and 3 females)] intranasally by a hanging drop over both nares. Hamsters were monitored daily for clinical signs through the experimental end point and euthanized if weight loss exceeded 20% or if they appeared moribund. Hamsters were anesthetized daily with isoflurane, weighed, and throat swabbed (Puritan; Thermo Fisher Scientific). Swabs were vortexed in 400 mL of Dulbecco's modified Eagle's medium (Thermo Fisher Scientific) and stored at À80 C. Before euthanasia, whole blood was collected via submandibular vein puncture, allowed to clot at room temperature for >10 minutes, and centrifuged for 5 minutes at 8000 Â g. Serum was also stored at À80 C. Following humane euthanasia by isoflurane overdose and cervical dislocation, hamsters were perfused with cold sterile PBS, and a necropsy was performed. Tissues were divided and processed for virology assays and histopathology. Lung was homogenized in 1 to 10 mL/mg Dulbecco's modified Eagle's medium with a sterile glass bead using a TissueLyser (Qiagen, Germantown, MD) at 30 Hz for 4 minutes, centrifuged at 10,000 Â g for 5 minutes, and stored at À80 C.

Plaque Assays
Infectious SARS-CoV-2 was detected from thawed hamster samples and remaining inocula immediately after inoculation using Vero cell plaque assays. Briefly, samples were serially diluted 10-fold in Dulbecco's modified Eagle's medium with 1% bovine serum albumin (both from Thermo Fisher Scientific) starting at an initial dilution of 1:8. The 12-well plates of confluent Vero CCL-81 cells (ATCC) were inoculated with 125 mL of each dilution and incubated at 37 C and 5% CO 2 for 1 hour. After incubation, each cell monolayer was overlaid with 0.5% agarose (Invitrogen, Carlsbad, CA) diluted in Dulbecco's modified Eagle's medium with 5% fetal bovine serum and 1Â antibiotic-antimycotic (both from Thermo Fisher Scientific) and incubated for 3 days at 5% CO 2 and 37 C. Cell monolayers were then fixed with 4% formalin for 30 minutes, agar plugs were gently removed, and viable cells were stained for 10 minutes with 0.05% crystal violet (Sigma, St. Louis, MO) in 20% ethanol, then rinsed with water. Plaques were counted and viral titers were recorded as the reciprocal of the highest dilution where plaques were noted (PFUs per swab, mg tissue, or mL inoculum).

Necropsy Tissue Processing and Histopathology
At necropsy, lung was inflated, and tissues were fixed for 48 hours at room temperature with a 10-fold volume of 10% neutral-buffered formalin (Thermo Fisher Scientific). A subset of tissues, including lung, brain, liver, spleen, heart, peripheral lymph nodes, eye, and nasal cavity, was embedded in paraffin, thin sectioned (4 mm thick), and stained routinely with hematoxylin and eosin. Hematoxylin and eosinestained slides were scanned to Â40 magnification using an Aperio slide scanner (Leica Biosystems, Deer Park, IL) with a magnification doubler and a resolution of 0.25 mm/pixel. Image files were uploaded on a Leica hosted web-based site, and a board-certified veterinary anatomic pathologist (E.E.B.) blindly evaluated sections for SARS-CoV-2einduced histologic lesions. For immunofluorescence, fixed tissue was cryoprotected by rinsing overnight in PBS at 4 C, followed by transfer into 30% sucrose (Thermo Fisher Scientific) in 1Â PBS for a second night, frozen over dry ice in Andwin Scientific Tissue-Tek cryomolds filled with Tissue-plus OCT compound, wrapped in parafilm (all from Thermo Fisher Scientific), and stored at À20 C.

In Situ Hybridization
Colorimetric in situ hybridization was performed according to the manufacturer's instructions, using the RNAscope 2.5 HD Red Reagent Kit (Advanced Cell Diagnostics, Newark,

Transmission Electron Microscopy
Lung tissues from two experiment 1 SARS-CoV-2einoculated hamsters (one each at 3 dpi and 6 dpi) and two experiment 2 SARS-CoV-2einoculated hamsters (one each at 3 dpi and 6 dpi) were evaluated by transmission electron microscopy (TEM

Validation of the Model
The experimental design is summarized in Supplemental Figure S1A. Briefly, two groups of hamsters (experiment 1, N Z 11; experiment 2, N Z 6) were inoculated intranasally with SARS-CoV-2 Alpha (B.1.1.7) or mock inoculated (experiment 1, N Z 4; experiment 2, N Z 2) with Dulbecco's PBS on day 0, monitored daily for weight loss and clinical disease and to swab the oropharyngeal cavity, and euthanized on 3, 6, or 7 dpi. A dose of 10 4 PFUs was chosen because previous studies modeling human COVID-19 in Syrian golden hamsters have shown that SARS-CoV-2 inoculum doses ranging from 10 3 to 10 5.6 PFUs reproducibly infect all animals and produce similar infectious lung and tracheal titers and lung and spleen inflammation scores. 6e9, 13,14 Herein, SARS-CoV-2einoculated hamsters from experiments 1 and 2 showed similar trends in body weight and recovery of infectious virus from the respiratory tract. A subset of experiment 1 and 2 hamsters inoculated with SARS-CoV-2 exhibited mild weight loss from 2 to 3 dpi (Supplemental Figure S1B), although none reached euthanasia criteria (loss of 20% of day 0 weight) or displayed clinical signs of illness. In both experiments, infectious virus was recovered from the upper respiratory tract between 1 and 3 dpi and from the lung at 3 dpi (Supplemental Figure S1, C and D). Most hamsters did not become viremic, although infectious virus was detected in the plasma of one female hamster from experiment 1, which also had a low infectious virus titer in the duodenum at 3 dpi. Otherwise, infectious virus was not detected in other hamster tissues. Overall, SARS-CoV-2einoculated hamsters developed nonlethal infection with infectious virus recoverable until 3 dpi from the upper airway and lung. All hamsters inoculated with SARS-CoV-2 developed moderate to severe microscopic pulmonary lesions (Figure 1). No significant microscopic abnormalities were noted in the Syrian Golden Hamsters Inoculated with SARS-CoV-2 Develop Progressive Broncho-Interstitial Pneumonia with Prominent Vascular Lesions SARS-CoV-2einduced airway disease and pneumonia in two independent experimental groups of hamsters were assessed using two methods. First, ImageJ was used to quantify the approximate lung surface area exhibiting microscopic lesions consistent with COVID-19 (defined as inflammation, necrosis, hemorrhage, and/or edema visible at subgross magnification) as a proxy for the overall extent and severity of pulmonary lesions. Next, pathologic lesions specifically affecting pulmonary vasculature were scored according to the criteria outlined in Supplemental Table S1. Both scores were significantly higher in SARS-CoV-2einoculated hamsters when compared with uninfected controls ( Figure 1A). Experiment 1 and 2 SARS-CoV-2einoculated hamsters exhibited a progressive increase in the extent and severity of lung lesions from 3 to 7 dpi (Figure 1). At 3 dpi, there was patchy neutrophilic and histiocytic inflammation centered on large airways (bronchitis and bronchiolitis), as well as variable bronchiolar epithelial and alveolar septal necrosis with replacement by fibrin, hemorrhage, edema, necrotic debris, numerous neutrophils, and macrophages, and scattered multinucleated syncytial cells ( Figure 1C) that was absent from uninfected control hamsters ( Figure 1B). By 6 dpi, lesions progressed to widespread necrotizing broncho-interstitial pneumonia ( Figure 1D). Reparative changes, consisting of bronchiolar epithelial hyperplasia ( Figure 1D) and type II pneumocyte hyperplasia, were also common by 6 dpi. Vascular lesions, including marked perivascular cuffing and subendothelial mononuclear inflammatory cell infiltration (endotheliitis) with variable transmigration of the vessel wall, were noted frequently at both time points (Figure 1, C and D); however, necrotizing vasculitis and thrombosis were not prominent features. These histologic features are consistent with published data from hamster models, 6e10 including lesions reported in association with emerging SARS-CoV-2 variants. 15,16

Pulmonary Subendothelial Inflammation in SARS-CoV-2eInoculated Hamsters Is Characterized by Endothelial Damage with Macrophage and Platelet Infiltration
Immunohistochemistry, immunofluorescence, in situ hybridization, and TEM were used to further characterize foci Vasculopathy in Hamsters with SARS-CoV-2 The American Journal of Pathologyajp.amjpathol.org of endotheliitis identified on hematoxylin and eosinestained slides. Immunohistochemistry staining with antibodies against von Willebrand factor/factor 8 (endothelial cells) (Figure 2A), Iba1 (macrophages), CD3 (T lymphocytes), and CD79a (B lymphocytes) revealed that, at 3, 6, and 7 dpi, the mononuclear cells adhered to the endothelial surface or infiltrating subendothelial vascular layers were consistent primarily with macrophages ( Figure 2B). There were also low numbers of T lymphocytes ( Figure 2C) and few B lymphocytes ( Figure 2D). Internal immunohistochemistry controls are shown in Supplemental Figure S2. Immunofluorescence antibodies against SARS-CoV-2 nucleocapsid protein demonstrated viral antigen in hamster terminal bronchiolar epithelium, type I pneumocytes, and, less commonly, alveolar macrophages at 3 dpi (Figure 3, AeC). Anti-endothelial cell antibody CD31 (green) highlighted endothelial cells lining a small pulmonary artery ( Figure 3A). Green anti-platelet antibody (CD41) localized along the arteriolar endothelium ( Figure 3B), indicating areas of platelet marginalization, which were not present in the mock-inoculated hamster. The presence of intracytoplasmic green signal within mononuclear cells (Figure 3, B and C) was consistent with platelet phagocytosis by macrophages. Viral nucleocapsid protein was not identified within or near blood vessels (Figure 3, AeC) or within a mock-inoculated hamster. In situ hybridization was used to assess the cellular tropism of SARS-CoV-2 in the hamster respiratory tract (Figure 3, DeL), where positive cells demonstrated intracytoplasmic red signal. Overall, SARS-CoV-2 RNA was observed primarily at 3 dpi ( Figure 3) within bronchial/bronchiolar epithelial cells, type I and II pneumocytes, and (less frequently) alveolar macrophages, where it corresponded with areas of inflammation. Notably, viral RNA was not identified within or associated with the pulmonary vasculature (Figure 3, F, I, and L).
Ultrastructurally, there was evidence of endothelial activation and injury in the pulmonary vasculature of SARS-CoV-2einoculated hamsters in both experimental replicates, particularly at 6 dpi. Activated endothelial cells bulged into the vascular lumen ( Figure 4A), often with  Figure 4A). These features were corroborated by the corresponding light microscopic images (Figure 4, E and F), which also exhibited endothelial bulging into the lumen and subintimal infiltration of mononuclear cells ( Figure 4C) with endothelial cytoplasmic vacuolation ( Figure 4E). There were no viral particles noted within or associated with affected endothelial cells. Taken together, these results are suggestive of vascular endothelial damage with mononuclear subendothelial inflammation and infiltration of platelets into areas of active pulmonary infection and inflammation.

Discussion
The histopathologic pulmonary lesions reported here, including moderate to severe broncho-interstitial pneumonia and alveolar damage with prominent perivascular and subendothelial inflammation, are comparable with the limited published autopsy data available from patients with severe COVID-19, 2,17e19 although hyaline membranes and

Vasculopathy in Hamsters with SARS-CoV-2
The American Journal of Pathologyajp.amjpathol.org vasculitis with microthrombi (also frequently reported in humans) were not significant features in these hamsters. This disparity may reflect the timing of disease progression, the presence of comorbidities, and/or other host-specific factors. In vivo hamster studies employ healthy animals and are terminated by 10 to 14 dpi. 6e9 In contrast, human autopsy data largely derive from hospitalized patients with severe COVID-19 exacerbated by comorbidities and extensive exposure to medications, with a median duration between symptom onset and death exceeding 15 days. 20,21 Supporting this hypothesis, lung specimens from two patients with pulmonary adenocarcinoma retrospectively diagnosed with SARS-CoV-2 infection also lacked hyaline membranes and microthrombi, presumably because COVID-19 was an unexpected, ancillary diagnosis and the lobectomies happened to capture the acute stage of disease. 19 TEM and special staining techniques demonstrated that endotheliitis in SARS-CoV-2einoculated hamsters is associated with endothelial cell damage, characterized by marked cytoplasmic vacuolation with thickened irregular basement membranes, platelet marginalization, and infiltration of macrophages. In contrast, previously documented cases of noneCOVID-19eassociated endotheliitis, including hepatic sinusoidal endotheliitis associated with acute cellular rejection of liver allografts 1 and corneal endotheliitis secondary to herpes viral infection or corneal graft rejection, 22 tend to be lymphocytic in nature. These findings are consistent with published data; Allnoch et al 23 recently reported similar histopathologic, immunohistochemical, and ultrastructural findings in SARS-CoV-2einoculated Syrian golden hamsters.
Both direct and indirect mechanisms of endothelial damage have been implicated in the pathogenesis of COVID-19einduced vasculopathy. 3,5 In vitro studies have identified viral antigen and/or RNA within endothelial cells, 24,25 particularly senescent endothelial cells. 25 In autopsy tissues, virus-like particles have been identified ultrastructurally within endothelial cells. 2,26e29 Notably, studies utilizing molecular techniques to identify endothelial viral antigen or RNA 2,30 generally fail to exclude staining of vascular support cells, such as pericytes and vascular smooth muscle cells, which are closely associated with the endothelium and express the SARS-CoV-2 receptor angiotensin-converting enzyme 2. 31e33 Overall, attempts to localize viral antigen/RNA to endothelial cells have been largely unsuccessful, equivocal, 26,28,34e37 or only possible at early time points, where it associates with a lack of viral replication or endothelial damage. 25 Additional studies report that endothelial cells do not express high levels of angiotensin-converting enzyme 2 and that they are capable of only low levels of viral replication, even when exposed to high titers of SARS-CoV-2. 33,38 Furthermore, the ultrastructural studies described above are underlined by a collective lack of reproducibility, 39 and critics have suggested that some of the viral particles reported in the literature may actually be subcellular organelles, such as coated vesicles. 40,41 Perturbations of vascular support cells may also contribute to COVID-19eassociated coagulopathy, as in vitro exposure of human pericytes to SARS-CoV-2 spike protein resulted in dysfunctional pericyte signaling, secretion of proinflammatory cytokines, and endothelial cell death. 31,32 Together, these data and ours support an indirect mechanism of SARS-CoV-2einduced vascular damage in hamsters.
Although the pathogenesis of SARS-CoV-2einduced vascular damage has yet to be defined, existing data suggest that dysregulation of the systemic immune response may play a significant role. Systemic inflammation generates cross talk between platelets, endothelial cells, and leukocytes, ultimately resulting in endothelial damage, platelet hyperactivation, parallel activation of the coagulation cascade, and thrombosis. 42 The so-called cytokine storm 5,43 produces a self-amplifying loop, where activated endothelial cells promote leukocyte and platelet adherence, microvascular obstruction, extensive vascular inflammation, and subsequent production and release of toxic reactive oxygen species and proinflammatory cytokines, including IL-6, IL-1b (a key cytokine associated with endothelial dysfunction), and tumor necrosis factor-a. Rodent models of pulmonary infection/inflammation (including SARS-CoV-2) have demonstrated a correlation between increased proinflammatory mediators and decreased aquaporins (which are transmembrane proteins important in paracellular fluid exchange), leading to postulation that pulmonary vascular alterations and perivascular edema may result in loss of CoV-2einoculated hamsters. AeC: IFA with antibodies against SARS-CoV-2 nucleocapsid protein (NP; red) at 3 days post inoculation (dpi) shows the presence of viral antigen (arrowheads) within hamster terminal bronchiolar epithelium (AeC), alveolar septa (B), and, less commonly, alveolar macrophages (B and C). A: Antieendothelial cell antibody CD31 (green) highlights endothelial cells lining a small pulmonary artery, which lacks red SARS-CoV-2 NP signal. B and C: Anti-platelet antibody CD41 (green) highlights platelet marginalization along the arteriolar endothelium (double-headed arrow; B), and the presence of intracytoplasmic green signal within mononuclear cells (B and C) is consistent with platelet phagocytosis by alveolar macrophages (arrows). AeC: Viral NP is not associated with pulmonary vessels. DeL: Distribution of SARS-CoV-2 RNA-positive cells in ISH-labeled sections of lung. Cells labeled by riboprobe in situ hybridization stain red. DeF: Lung from uninfected hamster is negative for ISH signal. G and H: In lung sections from a SARS-CoV-2einoculated hamster euthanized at 3 dpi, SARS-CoV-2 RNA is most prominent within airways, extending from mainstem bronchi to bronchiolar epithelial cells of smaller airways and multifocally into type I and II pneumocytes of peribronchiolar alveolar septa. J and K: In lung sections from a SARS-CoV-2einoculated hamster euthanized at 6 dpi, the number of positive cells has decreased dramatically, with scattered signal in pneumocytes lining alveolar septa, and occasional weak signal remaining in airway epithelial cells. F, I, and L: No signal is identified within pulmonary vessels. DAPI binds DNA. Scale bars: 20 mm (AeC, E, F, H, I, K, and L); 1 mm (D, G, and J). A, arteriole; B, bronchiole; vRNA, viral RNA. endothelial cell integrity and loosening of intercellular junctions. 23,44 The end result of these dynamic, multifaceted, and often overlapping processes is a procoagulant, proinflammatory state characterized by increased vascular permeability, further production of proinflammatory cytokines and coagulation factors, and activation of platelets and leukocytes. 45 Activated platelets release vasoactive, hemostatic, and inflammatory mediators, trigger the coagulation cascade, and provide a procoagulant surface for secondary hemostasis, 46,47 exacerbating the existing inflammatory milieu and generating a hypercoagulable state and clinical signs of impaired coagulation.
In addition, high levels of complement component C3a in patients with severe COVID-19 are associated with differentiation/degranulation of cytotoxic T cells and subsequent endothelial injury. 48 Cytokines (eg, IL-8), complement components (eg, C5a), and activated platelets can additionally induce release of neutrophil extracellular traps (NETs), scaffolds of extracellular DNA with attached histones, neutrophil granule proteins, and antimicrobial Figure 4 Transmission electron microscopic (TEM) and corresponding light-microscopic images of hamster pulmonary blood vessels 6 days after inoculation (dpi) with SARS-CoV-2. AeD: TEM images. E and F: Hematoxylin and eosin (H&E)estained light microscopic images corresponding with TEM images. A: Activated endothelial cells (ECs) lining a small pulmonary arteriole and bulging into the vascular lumen with a subintimal lymphocyte (L; red circle). B: Activated venular endothelial cell with frond-like filopodia (arrows). C and D: Damaged, degenerating endothelial cells with marked cytoplasmic vacuolation (asterisks; C and D), resulting in partial detachment from the underlying, thickened basal lamina (C). E: Small pulmonary arteriole exhibiting endothelial bulging into the lumen with subintimal infiltration of mononuclear cells (black circles; corresponds with A). F: Endothelial cell cytoplasmic vacuolation (black arrowheads; corresponding with C and D). F: Inset: Higher-magnification view of endothelial cytoplasmic vacuolation (from black boxed area). Scale bars: 5 mm (A); 2 mm (B, C, and F, inset); 1 mm (D); 20 mm (E and F, main image). N, neutrophil; RBC, red blood cell. ajp.amjpathol.org -The American Journal of Pathology peptides that function to trap, immobilize, and/or kill pathogens 5,49,50 and are also known to induce the formation of immunologically mediated microthrombi (immunothrombosis). 49 Notably, Becker et al 11 recently demonstrated the presence of NETosis markers, but not viral antigen, associated with microscopic vascular lesions in a hamster model of COVID-19. A human cohort study similarly reported elevated serum markers for NETosis, microscopic evidence of extensive neutrophil-platelet infiltration, and NET-containing pulmonary microthrombi in patients with severe COVID-19. 49 This precarious clinical situation is exacerbated by both aging and preexisting cardiovascular risk factors, such as obesity, hypertension, and diabetes, 5 which are also known to prime platelets for hyperreactivity. 46 Immune dysregulation, resulting in excessive production of proinflammatory cytokines, endothelial damage, and platelet hyperactivation, is a plausible driving force behind the hypercoagulable state and microthrombosis observed in some patients with COVID-19. Although this was an observational study, these findings, particularly the lack of viral association with inflamed vessels, and published data 5,11,30,46,51e53 collectively support a primarily indirect mechanism linking inflammation and hypercoagulability in severe cases of COVID-19. Although further study regarding viral effects on pericytes and endotheliumplatelet-leukocyte interactions is necessary to fully understand the pathogenesis of SARS-CoV-2eassociated coagulopathy, our results suggest that novel therapeutics targeting the dysregulated immune system (ie, cytokine production or NETosis) may prove to be effective medical countermeasures against COVID-19. To our knowledge, this is the first use of TEM and special histologic staining techniques to demonstrate endothelial damage with marginalization of activated platelets and lack of viral association with affected blood vessels in regions of active pulmonary SARS-CoV-2 infection in a Syrian golden hamster model of human COVID-19.