Clinicopathologic, Immunohistochemical, and Ultrastructural Findings of a Fatal Case of Middle East Respiratory Syndrome Coronavirus Infection in the.

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Clinicopathologic, Immunohistochemical, and Ultrastructural Findings of a Fatal Case of Middle East Respiratory Syndrome Coronavirus Infection in the United Arab Emirates, April 2014 Dianna L. Ng, Farida Al Hosani, M. Kelly Keating, Susan I. Gerber, Tara L. Jones, Maureen G. Metcalfe, Suxiang Tong, Ying Tao, Negar N. Alami, Lia M. Haynes, Mowafaq Ali Mutei, Laila Abdel-Wareth, Timothy M. Uyeki, David L. Swerdlow, Maha Barakat, Sherif R. Zaki The American Journal of Pathology Volume 186, Issue 3, Pages 652-658 (March 2016) DOI: 10.1016/j.ajpath.2015.10.024 Copyright © 2016 American Society for Investigative Pathology Terms and Conditions

Figure 1 CXR images. A: CXR at initial ED visit shows small left-sided opacity. B: CXR at second ED visit, with increase of left-sided opacity. C: Portable CXR 1 day after admission with substantial progression of the opacity. CXR, chest X-ray; ED, emergency department. The American Journal of Pathology 2016 186, 652-658DOI: (10.1016/j.ajpath.2015.10.024) Copyright © 2016 American Society for Investigative Pathology Terms and Conditions

Figure 2 Histopathology of lung from MERS-CoV patient. A: Pulmonary edema. B: Diffuse alveolar damage, including prominent hyaline membrane formation (arrow). C: Alveolar fibrin deposits, type 2 pneumocyte hyperplasia, and thickened alveolar septa involved by edema and a mixed inflammatory infiltrate. D–F: Immunostaining of MERS-CoV antigen in pneumocytes (Ab 1511; D, arrow), a multinucleated syncytial cell (Ab 1511; E, arrow), and a binucleated cell (Ab 1514; F, arrow). G: Moderate lymphocytic inflammation of the submucosal glands. H: Magnified from the boxed area in G. Submucosal glands with focal areas of necrosis (arrow). I: Immunostaining of MERS-CoV antigen in necrotic foci of submucosal glands (arrow; Ab 1512). Original magnification: ×5 (A); ×20 (B–D); ×75 (E); ×100 (F); ×10 (G); ×40 (H); ×63 (I). Ab, antibody; MERS-CoV, Middle East respiratory syndrome coronavirus. The American Journal of Pathology 2016 186, 652-658DOI: (10.1016/j.ajpath.2015.10.024) Copyright © 2016 American Society for Investigative Pathology Terms and Conditions

Figure 3 Immunohistochemical and ultrastructural localization of MERS-CoV and associated histologic findings. A: MERS-CoV and cytokeratin antigens in pneumocytes (arrow); red stain, MERS-CoV; brown stain, cytokeratin. B: MERS-CoV antigens in pneumocytes (arrowhead) and CD68 antigens in macrophages (arrow); red stain, CD68; brown stain, MERS-CoV. C: MERS-CoV and surfactant antigens in type 2 pneumocytes (arrow); red stain, surfactant; brown stain, MERS-CoV. D: MERS-CoV and DPP4 in pneumocytes (arrow); red stain, DPP4; brown stain, MERS-CoV. E: Fragmented pneumocyte infected with MERS-CoV, hyaline membrane (arrowhead) present. F: Magnified from the boxed area in E. MERS-CoV virions dispersed as single particles (arrow) or in clusters within membrane-bound vesicles (arrowhead). Spherical and pleomorphic particles ranged in size from 50 to 150 nm diameter. Scale bars: 2 μm (E); 500 nm (F). Original magnification: ×100 (A and C); ×63 (B); ×75 (D). DPP4, dipeptidyl peptidase 4; MERS-CoV, Middle East respiratory syndrome coronavirus. The American Journal of Pathology 2016 186, 652-658DOI: (10.1016/j.ajpath.2015.10.024) Copyright © 2016 American Society for Investigative Pathology Terms and Conditions