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Guloyan V, Oganesian B, Baghdasaryan N, Yeh C, Singh M, Guilford F, Ting YS, Venketaraman V. Glutathione Supplementation as an Adjunctive Therapy in COVID-19. Antioxidants (Basel) 2020; 9:antiox9100914. [PMID: 32992775 PMCID: PMC7601802 DOI: 10.3390/antiox9100914] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 09/14/2020] [Accepted: 09/20/2020] [Indexed: 01/08/2023] Open
Abstract
Morbidity and mortality of coronavirus disease 2019 (COVID-19) are due in large part to severe cytokine storm and hypercoagulable state brought on by dysregulated host-inflammatory immune response, ultimately leading to multi-organ failure. Exacerbated oxidative stress caused by increased levels of interleukin (IL)-6 and tumor necrosis factor α (TNF-α) along with decreased levels of interferon α and interferon β (IFN-α, IFN-β) are mainly believed to drive the disease process. Based on the evidence attesting to the ability of glutathione (GSH) to inhibit viral replication and decrease levels of IL-6 in human immunodeficiency virus (HIV) and tuberculosis (TB) patients, as well as beneficial effects of GSH on other pulmonary diseases processes, we believe the use of liposomal GSH could be beneficial in COVID-19 patients. This review discusses the epidemiology, transmission, and clinical presentation of COVID-19 with a focus on its pathogenesis and the possible use of liposomal GSH as an adjunctive treatment to the current treatment modalities in COVID-19 patients.
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Affiliation(s)
- Vika Guloyan
- College of Osteopathic Medicine of the Pacific, Western University of Health Sciences, Pomona, CA 91766-1854, USA; (V.G.); (B.O.); (N.B.); (C.Y.); (Y.-S.T.)
| | - Buzand Oganesian
- College of Osteopathic Medicine of the Pacific, Western University of Health Sciences, Pomona, CA 91766-1854, USA; (V.G.); (B.O.); (N.B.); (C.Y.); (Y.-S.T.)
| | - Nicole Baghdasaryan
- College of Osteopathic Medicine of the Pacific, Western University of Health Sciences, Pomona, CA 91766-1854, USA; (V.G.); (B.O.); (N.B.); (C.Y.); (Y.-S.T.)
| | - Christopher Yeh
- College of Osteopathic Medicine of the Pacific, Western University of Health Sciences, Pomona, CA 91766-1854, USA; (V.G.); (B.O.); (N.B.); (C.Y.); (Y.-S.T.)
| | - Manpreet Singh
- Department of Emergency Medicine, St Barnabas Hospital, Bronx, NY 10457, USA;
| | | | - Yu-Sam Ting
- College of Osteopathic Medicine of the Pacific, Western University of Health Sciences, Pomona, CA 91766-1854, USA; (V.G.); (B.O.); (N.B.); (C.Y.); (Y.-S.T.)
| | - Vishwanath Venketaraman
- College of Osteopathic Medicine of the Pacific, Western University of Health Sciences, Pomona, CA 91766-1854, USA; (V.G.); (B.O.); (N.B.); (C.Y.); (Y.-S.T.)
- Correspondence: ; Tel.: +1-909-706-3736; Fax: +1-909-469-5698
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602
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Jain S, Jain S, Sharma SK. Tocilizumab in COVID-19: finding the optimal route and dose. LANCET RHEUMATOLOGY 2020; 2:e738-e739. [PMID: 32964209 PMCID: PMC7498201 DOI: 10.1016/s2665-9913(20)30334-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Siddharth Jain
- Division of Clinical Immunology and Rheumatology, Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - Sanjay Jain
- Division of Clinical Immunology and Rheumatology, Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - Shefali Khanna Sharma
- Division of Clinical Immunology and Rheumatology, Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
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603
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Hakim NN, Chi J, Olazagasti C, Liu JM. Secondary hemophagocytic lymphohistiocytosis versus cytokine release syndrome in severe COVID-19 patients. Exp Biol Med (Maywood) 2020; 246:5-9. [PMID: 32972235 DOI: 10.1177/1535370220962043] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
IMPACT STATEMENT Severe COVID-19 associated pneumonia and acute respiratory distress syndrome has recently been described with life-threatening features of cytokine storm and loosely referred to as hemophagocytic lymphohistiocytosis (HLH) or macrophage activation syndrome (MAS). Although a recent report indicated favorable responses to the interleukin-1 receptor antagonist, anakinra in eight patients with COVID-19 secondary HLH diagnosed using the HScore calculation, others have suggested that the diagnosis of secondary HLH is uncommon and that the use of the HScore has limited value in guiding immunomodulatory therapy for COVID-19. Here, we provide additional perspective on this important controversy based upon comparisons between 14 COVID-19 cytokine storm patients and 10 secondary HLH patients seen immediately prior to the pandemic. We hypothesize that identification of HLH may relate to the severity or timing of cytokine release and suggest distinguishing between cytokine release syndrome and secondary HLH, reserving the latter term for cases fulfilling diagnostic criteria.
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Affiliation(s)
- Nausheen N Hakim
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Monter Cancer Center, Lake Success, NY 11042, USA
| | - Jeffrey Chi
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Monter Cancer Center, Lake Success, NY 11042, USA
| | - Coral Olazagasti
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Monter Cancer Center, Lake Success, NY 11042, USA
| | - Johnson M Liu
- Division of Hematology, Department of Medicine, Maine Medical Center, Portland, ME 04102, USA
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604
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Rubsamen R, Burkholz S, Massey C, Brasel T, Hodge T, Wang L, Herst C, Carback R, Harris P. Anti-IL-6 Versus Anti-IL-6R Blocking Antibodies to Treat Acute Ebola Infection in BALB/c Mice: Potential Implications for Treating Cytokine Release Syndrome. Front Pharmacol 2020; 11:574703. [PMID: 33071786 PMCID: PMC7538647 DOI: 10.3389/fphar.2020.574703] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2020] [Accepted: 08/31/2020] [Indexed: 12/15/2022] Open
Abstract
Cytokine release syndrome (CRS) is known to be a factor in morbidity and mortality associated with acute viral infections including those caused by filoviruses and coronaviruses. IL-6 has been implicated as a cytokine negatively associated with survival after filovirus and coronavirus infection. However, IL-6 has also been shown to be an important mediator of innate immunity and important for the host response to an acute viral infection. Clinical studies are now being conducted by various researchers to evaluate the possible role of IL-6 blockers to improve outcomes in critically ill patients with CRS. Most of these studies involve the use of anti-IL-6R monoclonal antibodies (α-IL-6R mAbs). We present data showing that direct neutralization of IL-6 with an α-IL-6 mAb in a BALB/c Ebolavirus (EBOV) challenge model produced a statistically significant improvement in outcome compared with controls when administered within the first 24 h of challenge and repeated every 72 h. A similar effect was seen in mice treated with the same dose of α-IL-6R mAb when the treatment was delayed 48 h post-challenge. These data suggest that direct neutralization of IL-6, early during the course of infection, may provide additional clinical benefits to IL-6 receptor blockade alone during treatment of patients with virus-induced CRS.
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Affiliation(s)
- Reid Rubsamen
- Flow Pharma Inc., Pleasant Hill, CA, United States.,Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, United States
| | | | - Christopher Massey
- Department of Microbiology and Immunology, University of Texas Medical Branch, Galveston, TX, United States
| | - Trevor Brasel
- Department of Microbiology and Immunology, University of Texas Medical Branch, Galveston, TX, United States
| | - Tom Hodge
- Flow Pharma Inc., Pleasant Hill, CA, United States
| | - Lu Wang
- Flow Pharma Inc., Pleasant Hill, CA, United States
| | | | | | - Paul Harris
- Department of Medicine, Columbia University, New York, NY, United States
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605
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Martínez-Sanz J, Muriel A, Ron R, Herrera S, Pérez-Molina JA, Moreno S, Serrano-Villar S. Effects of tocilizumab on mortality in hospitalized patients with COVID-19: a multicentre cohort study. Clin Microbiol Infect 2020; 27:238-243. [PMID: 32979572 PMCID: PMC7510451 DOI: 10.1016/j.cmi.2020.09.021] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 09/06/2020] [Accepted: 09/15/2020] [Indexed: 01/16/2023]
Abstract
Objectives Tocilizumab has been proposed as a candidate therapy for patients with severe coronavirus disease 2019 (COVID-19), especially among those with higher systemic inflammation. We investigated the association between receipt of tocilizumab and mortality in a large cohort of hospitalized patients. Methods In this cohort study of patients hospitalized with COVID-19 in Spain, the primary outcome was time to death and the secondary outcome time to intensive care unit (ICU) admission or death. We used inverse probability weighting to fit marginal structural models adjusted for time-varying covariates to determine the causal relationship between receipt of tocilizumab and outcome. Results Data from 1229 patients were analysed, with 261 patients (61 deaths) in the tocilizumab group and 969 patients (120 deaths) in the control group. In the adjusted marginal structural models, a significant interaction between receipt of tocilizumab and high C-reactive protein (CRP) levels was detected. Tocilizumab was associated with decreased risk of death (adjusted hazard ratio 0.34, 95% confidence interval 0.16–0.72, p 0.005) and ICU admission or death (adjusted hazard ratio 0.39, 95% confidence interval 0.19–0.80, p 0.011) among patients with baseline CRP >150 mg/L but not among those with CRP ≤150 mg/L. Exploratory subgroup analyses yielded point estimates that were consistent with these findings. Conclusions In this large observational study, tocilizumab was associated with a lower risk of death or ICU admission or death in patients with higher CRP levels. While the results of ongoing clinical trials of tocilizumab in patients with COVID-19 will be important to establish its safety and efficacy, our findings have implications for the design of future clinical trials.
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Affiliation(s)
- Javier Martínez-Sanz
- Department of Infectious Diseases, Hospital Universitario Ramón y Cajal, Facultad de Medicina, Universidad de Alcalá, IRYCIS, Spain.
| | - Alfonso Muriel
- Clinical Biostatistic Unit, Hospital Universitario Ramón y Cajal, Departamento de Enfermería y Fisioterapia, Universidad de Alcalá, IRYCIS, CIBERESP, Madrid, Spain
| | - Raquel Ron
- Department of Infectious Diseases, Hospital Universitario Ramón y Cajal, Facultad de Medicina, Universidad de Alcalá, IRYCIS, Spain
| | - Sabina Herrera
- Department of Infectious Diseases, Hospital Universitario Ramón y Cajal, Facultad de Medicina, Universidad de Alcalá, IRYCIS, Spain
| | - José A Pérez-Molina
- Department of Infectious Diseases, Hospital Universitario Ramón y Cajal, Facultad de Medicina, Universidad de Alcalá, IRYCIS, Spain
| | - Santiago Moreno
- Department of Infectious Diseases, Hospital Universitario Ramón y Cajal, Facultad de Medicina, Universidad de Alcalá, IRYCIS, Spain
| | - Sergio Serrano-Villar
- Department of Infectious Diseases, Hospital Universitario Ramón y Cajal, Facultad de Medicina, Universidad de Alcalá, IRYCIS, Spain.
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606
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Efficacy of corticosteroid treatment for hospitalized patients with severe COVID-19: a multicentre study. Clin Microbiol Infect 2020; 27:105-111. [PMID: 32971254 PMCID: PMC7506332 DOI: 10.1016/j.cmi.2020.09.014] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 09/01/2020] [Accepted: 09/06/2020] [Indexed: 12/15/2022]
Abstract
Objective To assess the efficacy of corticosteroids in patients with coronavirus disease 2019 (COVID-19). Methods A multicentre observational study was performed from 22 February through 30 June 2020. We included consecutive adult patients with severe COVID-19, defined as respiratory rate ≥30 breath per minute, oxygen saturation ≤93% on ambient air or arterial partial pressure of oxygen to fraction of inspired oxygen ≤300 mm Hg. We excluded patients being treated with other immunomodulant drugs, receiving low-dose corticosteroids and receiving corticosteroids 72 hours after admission. The primary endpoint was 30-day mortality from hospital admission. The main exposure variable was corticosteroid therapy at a dose of ≥0.5 mg/kg of prednisone equivalents. It was introduced as binomial covariate in a logistic regression model for the primary endpoint and inverse probability of treatment weighting using the propensity score. Results Of 1717 patients with COVID-19 evaluated, 513 were included in the study, and of these, 170 (33%) were treated with corticosteroids. During hospitalization, 166 patients (34%) met the criteria of the primary outcome (60/170, 35% in the corticosteroid group and 106/343, 31% in the noncorticosteroid group). At multivariable analysis corticosteroid treatment was not associated with lower 30-day mortality rate (adjusted odds ratio, 0.59; 95% confidence interval (CI), 0.20–1.74; p 0.33). After inverse probability of treatment weighting, corticosteroids were not associated with lower 30-day mortality (average treatment effect, 0.05; 95% CI, −0.02 to 0.09; p 0.12). However, subgroup analysis revealed that in patients with PO2/FiO2 < 200 mm Hg at admission (135 patients, 52 (38%) treated with corticosteroids), corticosteroid treatment was associated with a lower risk of 30-day mortality (23/52, 44% vs. 45/83, 54%; adjusted odds ratio, 0.20; 95% CI, 0.04–0.90; p 0.036). Conclusions The effect of corticosteroid treatment on mortality might be limited to critically ill COVID-19 patients.
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607
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Canham MA, Campbell JDM, Mountford JC. The use of mesenchymal stromal cells in the treatment of coronavirus disease 2019. J Transl Med 2020; 18:359. [PMID: 32958009 PMCID: PMC7503434 DOI: 10.1186/s12967-020-02532-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 09/15/2020] [Indexed: 02/06/2023] Open
Abstract
More than seven months into the coronavirus disease -19 (COVID-19) pandemic, infection from the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) has led to over 21.2 million cases and resulted in over 760,000 deaths worldwide so far. As a result, COVID-19 has changed all our lives as we battle to curtail the spread of the infection in the absence of specific therapies against coronaviruses and in anticipation of a proven safe and efficacious vaccine. Common with previous outbreaks of coronavirus infections, SARS and Middle East respiratory syndrome, COVID-19 can lead to acute respiratory distress syndrome (ARDS) that arises due to an imbalanced immune response. While several repurposed antiviral and host-response drugs are under examination as potential treatments, other novel therapeutics are also being explored to alleviate the effects on critically ill patients. The use of mesenchymal stromal cells (MSCs) for COVID-19 has become an attractive avenue down which almost 70 different clinical trial teams have ventured. Successfully trialled for the treatment of other conditions such as multiple sclerosis, osteoarthritis and graft versus host disease, MSCs possess both regenerative and immunomodulatory properties, the latter of which can be harnessed to reduce the severity and longevity of ARDS in patients under intensive care due to SARS-CoV-2 infection.
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Affiliation(s)
- Maurice A Canham
- Tissues, Cells & Advanced Therapeutics, Scottish National Blood Transfusion Service, The Jack Copland Centre, 52 Research Avenue North, Edinburgh, EH14 4BE, UK.
| | - John D M Campbell
- Tissues, Cells & Advanced Therapeutics, Scottish National Blood Transfusion Service, The Jack Copland Centre, 52 Research Avenue North, Edinburgh, EH14 4BE, UK
| | - Joanne C Mountford
- Tissues, Cells & Advanced Therapeutics, Scottish National Blood Transfusion Service, The Jack Copland Centre, 52 Research Avenue North, Edinburgh, EH14 4BE, UK
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608
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Giesen N, Sprute R, Rüthrich M, Khodamoradi Y, Mellinghoff SC, Beutel G, Lueck C, Koldehoff M, Hentrich M, Sandherr M, von Bergwelt-Baildon M, Wolf HH, Hirsch HH, Wörmann B, Cornely OA, Köhler P, Schalk E, von Lilienfeld-Toal M. Evidence-based management of COVID-19 in cancer patients: Guideline by the Infectious Diseases Working Party (AGIHO) of the German Society for Haematology and Medical Oncology (DGHO). Eur J Cancer 2020; 140:86-104. [PMID: 33068941 PMCID: PMC7505554 DOI: 10.1016/j.ejca.2020.09.009] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 08/20/2020] [Accepted: 09/02/2020] [Indexed: 01/08/2023]
Abstract
Since its first detection in China in late 2019 the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and the associated infectious disease COVID-19 continue to have a major impact on global healthcare and clinical practice. Cancer patients, in particular those with haematological malignancies, seem to be at an increased risk for a severe course of infection. Deliberations to avoid or defer potentially immunosuppressive therapies in these patients need to be balanced against the overarching goal of providing optimal antineoplastic treatment. This poses a unique challenge to treating physicians. This guideline provides evidence-based recommendations regarding prevention, diagnostics and treatment of SARS-CoV-2 infection and COVID-19 as well as strategies towards safe antineoplastic care during the COVID-19 pandemic. It was prepared by the Infectious Diseases Working Party (AGIHO) of the German Society for Haematology and Medical Oncology (DGHO) by critically reviewing the currently available data on SARS-CoV-2 and COVID-19 in cancer patients applying evidence-based medicine criteria.
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Affiliation(s)
- Nicola Giesen
- Department of Haematology and Oncology, Internal Medicine V, University Hospital Heidelberg, Heidelberg, Germany.
| | - Rosanne Sprute
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, Excellence Center for Medical Mycology (ECMM), Center for Integrated Oncology (CIO ABCD), German Centre for Infection Research, Partner Site Bonn-Cologne, Cologne, Germany; University of Cologne, Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), Cologne, Germany
| | - Maria Rüthrich
- Department of Haematology and Medical Oncology, Clinic for Internal Medicine II, University Hospital Jena, Jena, Germany; Leibniz Institute for Natural Product Research and Infection Biology, Hans Knöll Institute, Jena, Germany
| | - Yascha Khodamoradi
- Department of Internal Medicine, Infectious Diseases, Goethe University Frankfurt, Frankfurt Am Main, Germany
| | - Sibylle C Mellinghoff
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, Excellence Center for Medical Mycology (ECMM), Center for Integrated Oncology (CIO ABCD), German Centre for Infection Research, Partner Site Bonn-Cologne, Cologne, Germany; University of Cologne, Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), Cologne, Germany
| | - Gernot Beutel
- Department for Haematology, Haemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany; Working Party Intensive Care in Haematologic and Oncologic Patients (iCHOP) of the German Society of Haematology and Medical Oncology (DGHO)
| | - Catherina Lueck
- Department for Haematology, Haemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany; Working Party Intensive Care in Haematologic and Oncologic Patients (iCHOP) of the German Society of Haematology and Medical Oncology (DGHO)
| | - Michael Koldehoff
- Working Party Intensive Care in Haematologic and Oncologic Patients (iCHOP) of the German Society of Haematology and Medical Oncology (DGHO); Department of Bone Marrow Transplantation, West German Cancer Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Marcus Hentrich
- Department of Medicine III - Haematology/Oncology, Red Cross Hospital, Munich, Germany
| | - Michael Sandherr
- Specialist Clinic for Haematology and Oncology, Medical Care Center Penzberg, Penzberg, Germany
| | - Michael von Bergwelt-Baildon
- Working Party Intensive Care in Haematologic and Oncologic Patients (iCHOP) of the German Society of Haematology and Medical Oncology (DGHO); Department of Internal Medicine III, LMU University Hospital, DKTK Partner Site Munich, BZKF Partner Site Munich, CCC-Munich, Munich, Germany
| | - Hans-Heinrich Wolf
- Department of Haematology, Oncology and Haemostaseology, Internal Medicine III, Südharzklinikum, Nordhausen, Germany
| | - Hans H Hirsch
- Transplantation & Clinical Virology, Department Biomedicine (Haus Petersplatz), University of Basel, Basel, Switzerland; Clinical Virology, Laboratory Medicine, University Hospital Basel, Basel, Switzerland; Infectious Diseases & Hospital Epidemiology, University Hospital Basel, Basel, Switzerland
| | - Bernhard Wörmann
- Division of Haematology, Oncology and Tumor Immunology, Department of Medicine, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Oliver A Cornely
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, Excellence Center for Medical Mycology (ECMM), Center for Integrated Oncology (CIO ABCD), German Centre for Infection Research, Partner Site Bonn-Cologne, Cologne, Germany; University of Cologne, Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), Cologne, Germany
| | - Philipp Köhler
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, Excellence Center for Medical Mycology (ECMM), Center for Integrated Oncology (CIO ABCD), German Centre for Infection Research, Partner Site Bonn-Cologne, Cologne, Germany; University of Cologne, Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), Cologne, Germany
| | - Enrico Schalk
- Working Party Intensive Care in Haematologic and Oncologic Patients (iCHOP) of the German Society of Haematology and Medical Oncology (DGHO); Department of Haematology and Oncology, Medical Center, Otto-von-Guericke University Magdeburg, Magdeburg, Germany
| | - Marie von Lilienfeld-Toal
- Department of Haematology and Medical Oncology, Clinic for Internal Medicine II, University Hospital Jena, Jena, Germany; Leibniz Institute for Natural Product Research and Infection Biology, Hans Knöll Institute, Jena, Germany
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609
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Streicher C, Engalenc X, Gaudin M, Vignaud G, Daulange A, Abraham B. Could Tocilizumab be an Attractive Therapeutic Option for Elderly Patients with Severe COVID-19? A Case Report. Clin Drug Investig 2020; 40:1085-1088. [PMID: 32951190 PMCID: PMC7502217 DOI: 10.1007/s40261-020-00969-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Affiliation(s)
- Caroline Streicher
- Unité de préparation et de contrôle pharmaceutique (UPCP), Centre Hospitalier de Brive La Gaillarde, 1 boulevard du Dr Verlhac, 19312, Brive la Gaillarde Cedex, France.
| | - Xavier Engalenc
- Médecine interne et Maladies infectieuses, Centre Hospitalier de Brive La Gaillarde, 1 boulevard du Dr Verlhac, 19312, Brive la Gaillarde Cedex, France
| | - Marion Gaudin
- Médecine interne et Maladies infectieuses, Centre Hospitalier de Brive La Gaillarde, 1 boulevard du Dr Verlhac, 19312, Brive la Gaillarde Cedex, France
| | - Guillaume Vignaud
- Médecine interne et Maladies infectieuses, Centre Hospitalier de Brive La Gaillarde, 1 boulevard du Dr Verlhac, 19312, Brive la Gaillarde Cedex, France
| | - Annick Daulange
- Unité de préparation et de contrôle pharmaceutique (UPCP), Centre Hospitalier de Brive La Gaillarde, 1 boulevard du Dr Verlhac, 19312, Brive la Gaillarde Cedex, France
| | - Bruno Abraham
- Médecine interne et Maladies infectieuses, Centre Hospitalier de Brive La Gaillarde, 1 boulevard du Dr Verlhac, 19312, Brive la Gaillarde Cedex, France
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610
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Abstract
Introduction In clinical trial for the Ebola virus, the broad-spectrum anti-viral agent remdesivir was shown to have a good safety profile. Remdesivir is now being tested in severe COVID-19. Areas covered The Gilead Sciences SIMPLE trial suggests that the short-term use of remdesivir probably does not increase mortality dramatically or have serious short-term toxicity when used to treat severe COVID-19. The Adaptive COVID-19 treatment trials (ACTT1) trial showed that remdesivir may shorten recovery and decrease mortality in severe COVID-19 without increasing adverse effects. Expert opinion It seems to me that we have learnt very little from the SIMPLE trial, and this would be predicted from a trial that has no control or placebo group. The results of ACTT1 were reported early after an interim analysis showed that a higher than expected number of recoveries had occurred. There was an indication that remdesivir may be reducing mortality, but this was no statistical significance. The trial is continuing, and the final data are eagerly awaited to determine whether remdesivir is a game-changing remedy or a ripple in the ongoing search for a medicine for the treatment of COVID-19.
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Affiliation(s)
- Sheila A Doggrell
- Faculty of Health, Queensland University of Technology , Brisbane, Australia
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611
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Effective treatment of severe acute pancreatitis and COVID-19 pneumonia with tocilizumab. GASTROENTEROLOGY REVIEW 2020; 15:267-272. [PMID: 33005274 PMCID: PMC7509907 DOI: 10.5114/pg.2020.99042] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Accepted: 08/24/2020] [Indexed: 02/06/2023]
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612
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The Association of Inflammatory Cytokines in the Pulmonary Pathophysiology of Respiratory Failure in Critically Ill Patients With Coronavirus Disease 2019. Crit Care Explor 2020; 2:e0203. [PMID: 33063041 PMCID: PMC7515615 DOI: 10.1097/cce.0000000000000203] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Supplemental Digital Content is available in the text. Objectives: The majority of coronavirus disease 2019 mortality and morbidity is attributable to respiratory failure from severe acute respiratory syndrome coronavirus 2 infection. The pathogenesis underpinning coronavirus disease 2019-induced respiratory failure may be attributable to a dysregulated host immune response. Our objective was to investigate the pathophysiological relationship between proinflammatory cytokines and respiratory failure in severe coronavirus disease 2019. Design: Multicenter prospective observational study. Setting: ICU. Patients: Critically ill patients with coronavirus disease 2019 and noncoronavirus disease 2019 critically ill patients with respiratory failure (ICU control group). Interventions: Daily measurement of serum inflammatory cytokines. Measurements and Main Results: Demographics, comorbidities, clinical, physiologic, and laboratory data were collected daily. Daily serum samples were drawn for measurements of interleukin-1β, interleukin-6, interleukin-10, and tumor necrosis factor-α. Pulmonary outcomes were the ratio of Pao2/Fio2 and static lung compliance. Twenty-six patients with coronavirus disease 2019 and 22 ICU controls were enrolled. Of the patients with coronavirus disease 2019, 58% developed acute respiratory distress syndrome, 62% required mechanical ventilation, 12% underwent extracorporeal membrane oxygenation, and 23% died. A negative correlation between interleukin-6 and Pao2/Fio2 (rho, –0.531; p = 0.0052) and static lung compliance (rho, –0.579; p = 0.033) was found selectively in the coronavirus disease 2019 group. Diagnosis of acute respiratory distress syndrome was associated with significantly elevated serum interleukin-6 and interleukin-1β on the day of diagnosis. Conclusions: The inverse relationship between serum interleukin-6 and Pao2/Fio2 and static lung compliance is specific to severe acute respiratory syndrome coronavirus 2 infection in critically ill patients with respiratory failure. Similar observations were not found with interleukin-β or tumor necrosis factor-α.
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613
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d'Arminio Monforte A, Tavelli A, Bai F, Tomasoni D, Falcinella C, Castoldi R, Barbanotti D, Mulè G, Allegrini M, Tesoro D, Tagliaferri G, Mondatore D, Augello M, Cona A, Ancona G, Gazzola L, Iannotti N, Tincati C, Viganò O, De Bona A, Bini T, Cozzi-Lepri A, Marchetti G. The importance of patients' case-mix for the correct interpretation of the hospital fatality rate in COVID-19 disease. Int J Infect Dis 2020; 100:67-74. [PMID: 32950738 PMCID: PMC7497732 DOI: 10.1016/j.ijid.2020.09.037] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 08/31/2020] [Accepted: 09/13/2020] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVE We aimed to document data on the epidemiology and factors associated with clinical course leading to death of patients hospitalised with COVID-19. METHODS Prospective observational cohort study on patients hospitalised with COVID-19 disease in February-24th/May-17th 2020 in Milan, Italy. Uni-multivariable Cox regression analyses were performed. Death's percentage by two-weeks' intervals according to age and disease severity was analysed. RESULTS A total of 174/539 (32.3%) patients died in hospital over 8228 person-day follow-up; the 14-day Kaplan-Meier probability of death was 29.5% (95%CI: 25.5-34.0). Older age, burden of comorbidities, COVID-19 disease severity, inflammatory markers at admission were independent predictors of increased risk, while several drug-combinations were predictors of reduced risk of in-hospital death. The highest fatality rate, 36.5%, occurred during the 2nd-3rd week of March, when 55.4% of patients presented with severe disease, while a second peak, by the end of April, was related to the admission of older patients (55% ≥80 years) with less severe disease, 30% coming from long-term care facilities. CONCLUSIONS The unusual fatality rate in our setting is likely to be related to age and the clinical conditions of our patients. These findings may be useful to better allocate resources of the national healthcare system, in case of re-intensification of COVID-19 epidemics.
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Affiliation(s)
- Antonella d'Arminio Monforte
- Clinic of Infectious Diseases, Department of Health Science, ASST Santi Paolo e Carlo, University of Milan, Milan, Italy.
| | - Alessandro Tavelli
- Clinic of Infectious Diseases, Department of Health Science, ASST Santi Paolo e Carlo, University of Milan, Milan, Italy
| | - Francesca Bai
- Clinic of Infectious Diseases, Department of Health Science, ASST Santi Paolo e Carlo, University of Milan, Milan, Italy
| | - Daniele Tomasoni
- Clinic of Infectious Diseases, Department of Health Science, ASST Santi Paolo e Carlo, University of Milan, Milan, Italy
| | - Camilla Falcinella
- Clinic of Infectious Diseases, Department of Health Science, ASST Santi Paolo e Carlo, University of Milan, Milan, Italy
| | - Roberto Castoldi
- Clinic of Infectious Diseases, Department of Health Science, ASST Santi Paolo e Carlo, University of Milan, Milan, Italy
| | - Diletta Barbanotti
- Clinic of Infectious Diseases, Department of Health Science, ASST Santi Paolo e Carlo, University of Milan, Milan, Italy
| | - Giovanni Mulè
- Clinic of Infectious Diseases, Department of Health Science, ASST Santi Paolo e Carlo, University of Milan, Milan, Italy
| | - Marina Allegrini
- Clinic of Infectious Diseases, Department of Health Science, ASST Santi Paolo e Carlo, University of Milan, Milan, Italy
| | - Daniele Tesoro
- Clinic of Infectious Diseases, Department of Health Science, ASST Santi Paolo e Carlo, University of Milan, Milan, Italy
| | - Gianmarco Tagliaferri
- Clinic of Infectious Diseases, Department of Health Science, ASST Santi Paolo e Carlo, University of Milan, Milan, Italy
| | - Debora Mondatore
- Clinic of Infectious Diseases, Department of Health Science, ASST Santi Paolo e Carlo, University of Milan, Milan, Italy
| | - Matteo Augello
- Clinic of Infectious Diseases, Department of Health Science, ASST Santi Paolo e Carlo, University of Milan, Milan, Italy
| | - Andrea Cona
- Clinic of Infectious Diseases, Department of Health Science, ASST Santi Paolo e Carlo, University of Milan, Milan, Italy
| | - Giuseppe Ancona
- Clinic of Infectious Diseases, Department of Health Science, ASST Santi Paolo e Carlo, University of Milan, Milan, Italy
| | - Lidia Gazzola
- Clinic of Infectious Diseases, Department of Health Science, ASST Santi Paolo e Carlo, University of Milan, Milan, Italy
| | - Nathalie Iannotti
- Clinic of Infectious Diseases, Department of Health Science, ASST Santi Paolo e Carlo, University of Milan, Milan, Italy
| | - Camilla Tincati
- Clinic of Infectious Diseases, Department of Health Science, ASST Santi Paolo e Carlo, University of Milan, Milan, Italy
| | - Ottavia Viganò
- Clinic of Infectious Diseases, Department of Health Science, ASST Santi Paolo e Carlo, University of Milan, Milan, Italy
| | - Anna De Bona
- Clinic of Infectious Diseases, Department of Health Science, ASST Santi Paolo e Carlo, University of Milan, Milan, Italy
| | - Teresa Bini
- Clinic of Infectious Diseases, Department of Health Science, ASST Santi Paolo e Carlo, University of Milan, Milan, Italy
| | - Alessandro Cozzi-Lepri
- Centre for Clinical Research, Epidemiology, Modelling and Evaluation, Institute for Global Health, University College London, London, UK
| | - Giulia Marchetti
- Clinic of Infectious Diseases, Department of Health Science, ASST Santi Paolo e Carlo, University of Milan, Milan, Italy
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614
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Tremblay D, Seah C, Schneider T, Bhalla S, Feld J, Naymagon L, Wang B, Patel V, Jun T, Jandl T, Rahman F, Liu STH, Aberg JA, Bouvier N. Convalescent Plasma for the Treatment of Severe COVID-19 Infection in Cancer Patients. Cancer Med 2020; 9:8571-8578. [PMID: 32945149 PMCID: PMC7537286 DOI: 10.1002/cam4.3457] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 08/20/2020] [Accepted: 08/23/2020] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Patients with malignancy are particularly vulnerable to infection with Severe Acute Respiratory Disease-Coronavirus-2 (SARS-CoV-2) given their immunodeficiency secondary to their underlying disease and cancer-directed therapy. We report a case series of patients with cancer who received convalescent plasma, an investigational therapy for severe Coronavirus Disease 2019 (COVID-19). METHODS Patients with cancer were identified who received convalescent plasma. Enrolled patients had confirmed COVID-19 with severe or life-threatening disease and were transfused with convalescent plasma from donors with a SARS-CoV-2 anti-spike antibody titer of ≥ 1:320 dilution. Oxygen requirements and clinical outcomes of interests were captured as well as laboratory parameters at baseline and 3 days after treatment. RESULTS We identified 24 patients with cancer, 14 of whom had a hematological malignancy, who were treated with convalescent plasma. Fifteen patients (62.5%) were on cancer-directed treatment at the time of COVID-19 infection. After a median of hospital duration of 9 days, 13 patients (54.2%) had been discharged home, 1 patient (4.2%) was still hospitalized, and 10 patients had died (41.7%). Non-intubated patients, particularly those on nasal cannula alone, had favorable outcomes. Three mild febrile non-hemolytic transfusion reactions were observed. C-reactive protein significantly decreased after 3 days of treatment, while other laboratory parameters including ferritin and D-dimer remained unchanged. CONCLUSIONS Convalescent plasma may be a promising therapy in cancer patients with COVID-19.
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Affiliation(s)
- Douglas Tremblay
- Division of Hematology and Medical Oncology, Icahn School of Medicine at Mount Sinai, Tisch Cancer Institute, New York, NY, USA
| | - Carina Seah
- Graduate School of Biomedical Science, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Thomas Schneider
- Department of Pathology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Sheena Bhalla
- Division of Hematology and Medical Oncology, Icahn School of Medicine at Mount Sinai, Tisch Cancer Institute, New York, NY, USA
| | - Jonathan Feld
- Division of Hematology and Medical Oncology, Icahn School of Medicine at Mount Sinai, Tisch Cancer Institute, New York, NY, USA
| | - Leonard Naymagon
- Division of Hematology and Medical Oncology, Icahn School of Medicine at Mount Sinai, Tisch Cancer Institute, New York, NY, USA
| | - Bo Wang
- Division of Hematology and Medical Oncology, Icahn School of Medicine at Mount Sinai, Tisch Cancer Institute, New York, NY, USA
| | - Vaibhav Patel
- Division of Hematology and Medical Oncology, Icahn School of Medicine at Mount Sinai, Tisch Cancer Institute, New York, NY, USA
| | - Tomi Jun
- Division of Hematology and Medical Oncology, Icahn School of Medicine at Mount Sinai, Tisch Cancer Institute, New York, NY, USA
| | - Thomas Jandl
- Division of Hematology and Medical Oncology, Icahn School of Medicine at Mount Sinai, Tisch Cancer Institute, New York, NY, USA
| | - Farah Rahman
- Division of Infectious Diseases, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Sean T H Liu
- Division of Infectious Diseases, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Judith A Aberg
- Division of Infectious Diseases, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Nicole Bouvier
- Division of Infectious Diseases, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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615
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Guaraldi G, Milic J, Cozzi-Lepri A, Pea F, Mussini C. Tocilizumab in COVID-19: finding the optimal route and dose - Authors' reply. LANCET RHEUMATOLOGY 2020; 2:e739-e740. [PMID: 32964210 PMCID: PMC7498220 DOI: 10.1016/s2665-9913(20)30333-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Giovanni Guaraldi
- Department of Infectious Diseases, Azienda Ospedaliero-Universitaria Policlinico of Modena, Modena 41124, Italy.,Department of Surgical, Medical, Dental and Morphological Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Jovana Milic
- Department of Surgical, Medical, Dental and Morphological Sciences, University of Modena and Reggio Emilia, Modena, Italy.,Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Modena, Italy
| | - Alessandro Cozzi-Lepri
- Centre for Clinical Research, Epidemiology, Modelling and Evaluation, Institute for Global Health, University College London, London, UK
| | - Federico Pea
- Institute of Clinical Pharmacology, Azienda Ospedaliero-Universitaria Santa Maria Della Misericordia, University of Udine, Udine, Italy
| | - Cristina Mussini
- Department of Infectious Diseases, Azienda Ospedaliero-Universitaria Policlinico of Modena, Modena 41124, Italy.,Department of Surgical, Medical, Dental and Morphological Sciences, University of Modena and Reggio Emilia, Modena, Italy
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616
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Levin JM, Oprea TI, Davidovich S, Clozel T, Overington JP, Vanhaelen Q, Cantor CR, Bischof E, Zhavoronkov A. Artificial intelligence, drug repurposing and peer review. Nat Biotechnol 2020; 38:1127-1131. [DOI: 10.1038/s41587-020-0686-x] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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617
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Abstract
The recent emergence of the coronavirus disease 19 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in China is now a global health emergency. The transmission of SARS-CoV-2 is mainly via human-to-human contact. This virus is expected to be of zoonotic origin and has a high genome identity to that of bat derived SARS-like coronavirus. Various stringent measures have been implemented to lower person-to-person transmission of COVID-19. Particular observations and attempts have been made to reduce transmission in vulnerable populations, including older adults, children, and healthcare providers. This novel CoV enters the cells through the angiotensin-converting enzyme 2 (ACE2) receptor. There is a higher risk of COVID-19 infection among those with preexisting cardiovascular diseases (CVD), and it has been connected with various direct and indirect complications, including myocarditis, acute myocardial injury, venous thromboembolism, and arrhythmias. This article summarizes the various cardiovascular complications and mechanisms responsible for the same with COVID-19 infection. For the benefit of the scientific community and public, the effect of COVID-19 on major vital organs such as the kidneys, liver, and intestines has been briefly discussed. In this review, we also discuss drugs in different stages of clinical trials and their associated complications, as well as the details of vaccines in various stages of development.
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618
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Campbell CM, Guha A, Haque T, Neilan TG, Addison D. Repurposing Immunomodulatory Therapies against Coronavirus Disease 2019 (COVID-19) in the Era of Cardiac Vigilance: A Systematic Review. J Clin Med 2020; 9:E2935. [PMID: 32932930 PMCID: PMC7565788 DOI: 10.3390/jcm9092935] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 09/07/2020] [Accepted: 09/08/2020] [Indexed: 01/08/2023] Open
Abstract
The ongoing coronavirus disease 2019 (COVID-19) pandemic has resulted in efforts to identify therapies to ameliorate adverse clinical outcomes. The recognition of the key role for increased inflammation in COVID-19 has led to a proliferation of clinical trials targeting inflammation. The purpose of this review is to characterize the current state of immunotherapy trials in COVID-19, and focuses on associated cardiotoxicities, given the importance of pharmacovigilance. The search terms related to COVID-19 were queried in ClinicalTrials.gov. A total of 1621 trials were identified and screened for interventional trials directed at inflammation. Trials (n = 226) were fully assessed for the use of a repurposed drug, identifying a total of 141 therapeutic trials using a repurposed drug to target inflammation in COVID-19 infection. Building on the results of the Randomized Evaluation of COVID-19 Therapy (RECOVERY) trial demonstrating the benefit of low dose dexamethasone in COVID-19, repurposed drugs targeting inflammation are promising. Repurposed drugs directed at inflammation in COVID-19 primarily have been drawn from cancer therapies and immunomodulatory therapies, specifically targeted anti-inflammatory, anti-complement, and anti-rejection agents. The proposed mechanisms for many cytokine-directed and anti-rejection drugs are focused on evidence of efficacy in cytokine release syndromes in humans or animal models. Anti-complement-based therapies have the potential to decrease both inflammation and microvascular thrombosis. Cancer therapies are hypothesized to decrease vascular permeability and inflammation. Few publications to date describe using these drugs in COVID-19. Early COVID-19 intervention trials have re-emphasized the subtle, but important cardiotoxic sequelae of potential therapies on outcomes. The volume of trials targeting the COVID-19 hyper-inflammatory phase continues to grow rapidly with the evaluation of repurposed drugs and late-stage investigational agents. Leveraging known clinical safety profiles and pharmacodynamics allows swift investigation in clinical trials for a novel indication. Physicians should remain vigilant for cardiotoxicity, often not fully appreciated in small trials or in short time frames.
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Affiliation(s)
- Courtney M. Campbell
- Cardio-Oncology Program, Division of Cardiology, Department of Internal Medicine, The Ohio State University Medical Center, Columbus, OH 43210, USA;
| | - Avirup Guha
- Harrington Heart and Vascular Institute, Case Western Reserve University, Cleveland, OH 44106, USA;
| | - Tamanna Haque
- Division of Hematology/Oncology, Department of Internal Medicine, The Ohio State University Medical Center, Columbus, OH 43210, USA;
| | - Tomas G. Neilan
- Cardio-Oncology Program, Division of Cardiology, Department of Internal Medicine, Massachusetts General Hospital, Boston, MA 02144, USA;
| | - Daniel Addison
- Cardio-Oncology Program, Division of Cardiology, Department of Internal Medicine, The Ohio State University Medical Center, Columbus, OH 43210, USA;
- Division of Cancer Prevention and Control, Department of Internal Medicine, College of Medicine, The Ohio State University, Columbus, OH 43210, USA
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619
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Strongyloides infection manifested during immunosuppressive therapy for SARS-CoV-2 pneumonia. Infection 2020; 49:539-542. [PMID: 32910321 PMCID: PMC7481762 DOI: 10.1007/s15010-020-01522-4] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 09/01/2020] [Indexed: 02/07/2023]
Abstract
Background SARS-CoV-2 pandemic has posed formidable public health and clinical challenges. The use of immunosuppressive agents, such as high dose corticosteroids and cytokine inhibitors (e.g., Tocilizumab) has been suggested to contrast the hyperinflammatory process involved in the pathogenesis of the severe disease, with conflicting evidence. Among the drawbacks of immunosuppressive therapy, the risk of reactivation of latent infections, including parasitic infestations, is to be considered. Case presentation We report a case of a 59-year-old Italian patient treated with high dose intravenous dexamethasone and two intravenous doses of Tocilizumab for interstitial bilateral pneumonia associated with SARS-CoV-2 infection who developed itching, abdominal pain, and an increased eosinophil count. Stool examination confirmed the presence of S. stercoralis larvae. The patient was treated with a 4-day course of Ivermectin with full recovery. Discussion We report the first case of S. stercoralis infection following an 11-day treatment with high-dose steroids and Tocilizumab for severe COVID-19. Clinicians should be aware of the risk of strongyloidiasis as a complication of the treatment for severe COVID-19.
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620
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Atallah B, El Nekidy W, Mallah SI, Cherfan A, AbdelWareth L, Mallat J, Hamed F. Thrombotic events following tocilizumab therapy in critically ill COVID-19 patients: a Façade for prognostic markers. Thromb J 2020; 18:22. [PMID: 32922212 PMCID: PMC7479301 DOI: 10.1186/s12959-020-00236-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 08/26/2020] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Hospitals in the Middle East Gulf region have experienced an influx of COVID-19 patients to their medical wards and intensive care units. The hypercoagulability of these patients has been widely reported on a global scale. However, many of the experimental treatments used to manage the various complications of COVID-19 have not been widely studied in this context. The effect of the current treatment protocols on patients' diagnostic and prognostic biomarkers may thus impact the validity of the algorithms adopted. CASE PRESENTATION In this case series, we report four cases of venous thromboembolism and 1 case of arterial thrombotic event, in patients treated with standard or intensified prophylactic doses of unfractionated heparin or low molecular weight heparin at our institution. Tocilizumab has been utilized as an add-on therapy to the standard of care to treat patients with SARS-CoV-2 associated acute respiratory distress syndrome, in order to dampen the hyperinflammatory response. It is imperative to be aware that this drug may be masking the inflammatory markers (e.g. IL6, CRP, fibrinogen, and ferritin), without reducing the risk of thrombotic events in this population, creating instead a façade of an improved prognostic outcome. However, the D-dimer levels remained prognostically reliable in these cases, as they were not affected by the drug and continued to be at the highest level until event occurrence. CONCLUSIONS In the setting of tocilizumab therapy, traditional prognostic markers of worsening infection and inflammation, and thus potential risk of acute thrombosis, should be weighed carefully as they may not be reliable for prognosis and may create a façade of an improved prognostic outcome insteasd. Additionally, the fact that thrombotic events continued to be observed despite decrease in inflammatory markers and the proactive anticoagulative approach adopted, raises more questions about the coagulative mechanisms at play in COVID-19, and the appropriate management strategy.
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Affiliation(s)
- Bassam Atallah
- Department of Pharmacy Services, Cleveland Clinic Abu Dhabi, Al Maryah Island, Abu Dhabi, United Arab Emirates
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH USA
| | - Wasim El Nekidy
- Department of Pharmacy Services, Cleveland Clinic Abu Dhabi, Al Maryah Island, Abu Dhabi, United Arab Emirates
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH USA
| | - Saad I. Mallah
- School of Medicine, Royal College of Surgeons in Ireland–Bahrain, Al Sayh, Bahrain
| | - Antoine Cherfan
- Department of Pharmacy Services, Cleveland Clinic Abu Dhabi, Al Maryah Island, Abu Dhabi, United Arab Emirates
| | - Laila AbdelWareth
- Department of Clinical Pathology, Cleveland Clinic Abu Dhabi, Al Maryah Island, Abu Dhabi, United Arab Emirates
| | - Jihad Mallat
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH USA
- Critical Care Institute, Cleveland Clinic Abu Dhabi, Al Maryah Island, Abu Dhabi, United Arab Emirates
- Normandy University, UNICAEN ED 497, Caen, France
| | - Fadi Hamed
- Critical Care Institute, Cleveland Clinic Abu Dhabi, Al Maryah Island, Abu Dhabi, United Arab Emirates
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621
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Rendeiro AF, Casano J, Kyriakos Vorkas C, Singh H, Morales A, DeSimone RA, Ellsworth GB, Soave R, Kapadia SN, Saito K, Brown CD, Hsu J, Kyriakides C, Chiu S, Cappelli L, Teresa Cacciapuoti M, Tam W, Galluzzi L, Simonson PD, Elemento O, Salvatore M, Inghirami G. Longitudinal immune profiling of mild and severe COVID-19 reveals innate and adaptive immune dysfunction and provides an early prediction tool for clinical progression. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2020:2020.09.08.20189092. [PMID: 32935114 PMCID: PMC7491529 DOI: 10.1101/2020.09.08.20189092] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
With a rising incidence of COVID-19-associated morbidity and mortality worldwide, it is critical to elucidate the innate and adaptive immune responses that drive disease severity. We performed longitudinal immune profiling of peripheral blood mononuclear cells from 45 patients and healthy donors. We observed a dynamic immune landscape of innate and adaptive immune cells in disease progression and absolute changes of lymphocyte and myeloid cells in severe versus mild cases or healthy controls. Intubation and death were coupled with selected natural killer cell KIR receptor usage and IgM+ B cells and associated with profound CD4 and CD8 T cell exhaustion. Pseudo-temporal reconstruction of the hierarchy of disease progression revealed dynamic time changes in the global population recapitulating individual patients and the development of an eight-marker classifier of disease severity. Estimating the effect of clinical progression on the immune response and early assessment of disease progression risks may allow implementation of tailored therapies.
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Affiliation(s)
- André F Rendeiro
- Institute of Computational Biomedicine, Weill Cornell Medicine, New York, NY, USA
- Caryl and Israel Englander Institute for Precision Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Joseph Casano
- Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Charles Kyriakos Vorkas
- Division of Infectious Diseases, Department of Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Harjot Singh
- Division of Infectious Diseases, Department of Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Ayana Morales
- Division of Infectious Diseases, Department of Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Robert A DeSimone
- Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Grant B Ellsworth
- Division of Infectious Diseases, Department of Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Rosemary Soave
- Division of Infectious Diseases, Department of Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Shashi N Kapadia
- Division of Infectious Diseases, Department of Medicine, Weill Cornell Medicine, New York, NY, USA
- Department of Population Health Sciences, Weill Cornell Medicine, New York, NY, USA
| | - Kohta Saito
- Division of Infectious Diseases, Department of Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Christopher D Brown
- Division of Infectious Diseases, Department of Medicine, Weill Cornell Medicine, New York, NY, USA
| | - JingMei Hsu
- Division of Hematology/Oncology, Department of Medicine Weill Cornell Medicine, New York, NY, 10065, USA
| | - Christopher Kyriakides
- Department of Rehabilitation Medicine at NYU Grossman School of Medicine New York, NY, USA
| | - Steven Chiu
- Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Luca Cappelli
- Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, NY, USA
| | | | - Wayne Tam
- Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Lorenzo Galluzzi
- Caryl and Israel Englander Institute for Precision Medicine, Weill Cornell Medicine, New York, NY, USA
- Department of Radiation Oncology, Weill Cornell Medical College, New York, NY, USA
- Sandra and Edward Meyer Cancer Center, New York, NY, USA
- Department of Dermatology, Yale School of Medicine, New Haven, CT, USA
| | - Paul D Simonson
- Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Olivier Elemento
- Institute of Computational Biomedicine, Weill Cornell Medicine, New York, NY, USA
- Caryl and Israel Englander Institute for Precision Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Mirella Salvatore
- Department of Population Health Sciences, Weill Cornell Medicine, New York, NY, USA
- Division of Public Health Programs, Department of Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Giorgio Inghirami
- Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, NY, USA
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622
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Ji P, Chen J, Golding A, Nikolov NP, Saluja B, Ren YR, Sahajwalla CG. Immunomodulatory Therapeutic Proteins in COVID-19: Current Clinical Development and Clinical Pharmacology Considerations. J Clin Pharmacol 2020; 60:1275-1293. [PMID: 32779201 PMCID: PMC7436618 DOI: 10.1002/jcph.1729] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Accepted: 08/07/2020] [Indexed: 01/08/2023]
Abstract
The coronavirus disease 2019 (COVID‐19) pandemic caused by infection with SARS‐CoV‐2 has led to more than 600 000 deaths worldwide. Patients with severe disease often experience acute respiratory distress characterized by upregulation of multiple cytokines. Immunomodulatory biological therapies are being evaluated in clinical trials for the management of the systemic inflammatory response and pulmonary complications in patients with advanced stages of COVID‐19. In this review, we summarize the clinical pharmacology considerations in the development of immunomodulatory therapeutic proteins for mitigating the heightened inflammatory response identified in COVID‐19.
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Affiliation(s)
- Ping Ji
- Division of Inflammation and Immune Pharmacology, Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland, USA
| | - Jianmeng Chen
- Division of Inflammation and Immune Pharmacology, Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland, USA
| | - Amit Golding
- Division of Rheumatology and Transplant Medicine, Office of Immunology and Inflammation, Office of New Drugs, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland, USA
| | - Nikolay P Nikolov
- Division of Rheumatology and Transplant Medicine, Office of Immunology and Inflammation, Office of New Drugs, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland, USA
| | - Bhawana Saluja
- Division of Inflammation and Immune Pharmacology, Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland, USA
| | - Yunzhao R Ren
- Division of Inflammation and Immune Pharmacology, Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland, USA
| | - Chandrahas G Sahajwalla
- Division of Inflammation and Immune Pharmacology, Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland, USA
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623
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Ladani AP, Loganathan M, Danve A. Managing rheumatic diseases during COVID-19. Clin Rheumatol 2020; 39:3245-3254. [PMID: 32895747 PMCID: PMC7476772 DOI: 10.1007/s10067-020-05387-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 08/28/2020] [Accepted: 08/31/2020] [Indexed: 12/18/2022]
Abstract
Rheumatology practice, during Coronavirus Disease 2019 (COVID-19) pandemic, has faced multifaceted challenges. Rheumatologists routinely prescribe immunosuppressant medications to their patients with multisystem autoimmune rheumatic diseases who are concerned about the increased risk of acquiring COVID-19 infection and are anxious to know if they should continue or hold these medications. Rheumatologists are often inundated by calls from their patients and physician colleagues caring for COVID-19 patients in hospitals, about how to manage the immunosuppression. Physicians face the challenging task of keeping up with the most up-to-date information on COVID-19. There are uncertainties about the mode of spread, clinical features, management options as well as long-term complications of COVID-19. Data are rapidly evolving and different studies on treatment options are showing contradictory results. It is known that viral illnesses can trigger a flare-up of underlying rheumatic disease that was previously in remission. To further complicate the scenario, some of the immunosuppressants have shown to have antiviral properties. This has created dilemma in the light of current COVID-19 crisis, as whether to continue or stop the immunosuppressive agents which could be essential to prevent complications of the rheumatic diseases including organ failure but also there is concern about acquiring COVID-19 or developing serious infection. Until we get an effective vaccine, immunosuppressant management for rheumatic diseases as well as other autoimmune diseases and transplants will pose difficult questions. This article is an attempt to review and understand COVID-19 and its impact on the immune system with special emphasis on managing medications used for autoimmune rheumatic diseases. We have provided general guidance about decision making, in regards to the immunosuppressive agents used in rheumatology practice with an understanding that this may change in near future.
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Affiliation(s)
- Amit P Ladani
- Department of Medicine, Division of Rheumatology, West Virginia University, 600 Suncrest Town Center, Morgantown, WV, 26505, USA.
| | - Muruga Loganathan
- Department of Behavior Medicine and Psychiatry, West Virginia University, Morgantown, WV, USA
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624
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Esposito S, Gnocchi M, Gagliardi M, Affanni P, Veronesi L, Colucci ME, Neglia C, Argentiero A, Principi N. Therapeutic strategies against COVID-19. ACTA BIO-MEDICA : ATENEI PARMENSIS 2020; 91:e2020038. [PMID: 32921732 PMCID: PMC7716986 DOI: 10.23750/abm.v91i3.10450] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Accepted: 08/17/2020] [Indexed: 12/15/2022]
Abstract
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a novel coronavirus that mainly affects the upper and lower respiratory tract and is responsible for extremely different degrees of disease, ranging from flu-like symptoms to atypical pneumonia that may evolve to acute respiratory distress syndrome and, ultimately, death. No specific therapy for SARS-CoV-2 has yet been identified, but since the beginning of the outbreak, several pre-existing therapeutics have been reconsidered for the treatment of infected patients. The aim of this article is to discuss current therapeutics against SARS-CoV-2. A literature review was performed using PubMed, collecting data from English-language articles published until June 20th, 2020. Literature analysis showed that with the acquisition of more in-depth knowledge on the characteristics of SARS-CoV-2 and the pathogenesis of the different clinical manifestations, a more rationale use of available drugs has become possible. However, the road to defining which drugs are effective and which schedules of administration must be used to maximize efficacy and minimize adverse events is still very long. To date, it is only clear that no drug can alone cope with all the problems posed by SARS-CoV-2 infection and effective antivirals and inflammatory drugs must be given together to reduce COVID-19 clinical manifestations. Moreover, choice of therapy must always be tailored on clinical manifestations and, when they occur, drugs able to fight coagulopathy and venous thromboembolism that may contribute to respiratory deterioration must be prescribed.
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Affiliation(s)
| | - Margherita Gnocchi
- Pediatric Clinic, Pietro Barilla Children's Hospital, Department of Medicine and Surgery, University of Parma, Parma, Italy.
| | - Martina Gagliardi
- Pediatric Clinic, Pietro Barilla Children's Hospital, Department of Medicine and Surgery, University of Parma, Parma, Italy.
| | - Paola Affanni
- Department of Medicine and Surgery, University of Parma, Italy.
| | - Licia Veronesi
- Department of Medicine and Surgery, University of Parma, Italy.
| | | | - Cosimo Neglia
- Pediatric Clinic, Pietro Barilla Children's Hospital, Department of Medicine and Surgery, University of Parma, Parma, Italy.
| | - Alberto Argentiero
- Pediatric Clinic, Pietro Barilla Children's Hospital, Department of Medicine and Surgery, University of Parma, Parma, Italy.
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625
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Talotta R, Robertson E. Autoimmunity as the comet tail of COVID-19 pandemic. World J Clin Cases 2020; 8:3621-3644. [PMID: 32953841 PMCID: PMC7479552 DOI: 10.12998/wjcc.v8.i17.3621] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2020] [Revised: 07/29/2020] [Accepted: 08/26/2020] [Indexed: 02/05/2023] Open
Abstract
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection can give rise to different clinical manifestations that are directly related to viral tissue damage or indirectly induced by the antiviral immune response. Hyper-activation of the immune system in an attempt to eradicate the infection may trigger autoimmunity. Several immune-mediated disorders have been described in SARS-CoV-2-infected individuals. These include cutaneous rashes and vasculitis, autoimmune cytopenia, anti-phospholipid syndrome, central or peripheral neuropathy, myositis and myocarditis. On the other hand, rheumatic patients were reported to have similar coronavirus disease 2019 (COVID-19) incidence, morbidity and mortality rates compared to general population. This opinion review will summarize the crucial immunologic steps which occur during SARS-CoV-2-infection that may link autoimmunity to COVID-19 and provides an opportunity for further discussion regarding this association.
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Affiliation(s)
- Rossella Talotta
- Department of Clinical and Experimental Medicine, Rheumatology Unit, AOU “Gaetano Martino”, University of Messina, Messina 98100, Italy
| | - Erle Robertson
- Department of Otorhinolaryngology-Head and Neck Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19014, United States
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626
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Najafi S, Rajaei E, Moallemian R, Nokhostin F. The potential similarities of COVID-19 and autoimmune disease pathogenesis and therapeutic options: new insights approach. Clin Rheumatol 2020; 39:3223-3235. [PMID: 32885345 PMCID: PMC7471540 DOI: 10.1007/s10067-020-05376-x] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 08/23/2020] [Accepted: 08/27/2020] [Indexed: 12/29/2022]
Abstract
Abstract Cytokine pathways and their signaling disorders can be the cause of onset and pathogenesis of many diseases such as autoimmune diseases and COVID-19 infection. Autoimmune patients may be at higher risk of developing infection due to the impaired immune responses, the use of immunosuppressive drugs, and damage to various organs. Increased secretion of inflammatory cytokines and intolerance of the patient’s immune system to COVID-19 infection are the leading causes of hospitalization of these patients. The content used in this paper has been taken from English language articles (2005–2020) retrieved from the PubMed database and Google Scholar search engine using “COVID-19,” “Autoimmune disease,” “Therapeutic,” “Pathogenesis,” and “Pathway” keywords. The emergence of COVID-19 and its association with autoimmune disorders is a major challenge in the management of these diseases. The results showed that the use of corticosteroids in the treatment of autoimmune diseases can make diagnosis and treatment of COVID-19 more challenging by preventing the fever. Due to the common pathogenesis of COVID-19 and autoimmune diseases, the use of autoimmune drugs as a possible treatment option could help control the virus. Key Points • Inflammatory cytokines play an essential role in the pathogenesis of COVID-19 • ACE2 dysfunctions are related to the with COVID-19 and autoimmune diseases • The use autoimmune diseases drugs can be useful in treating COVID-19
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Affiliation(s)
- Sahar Najafi
- Thalassemia & Hemoglobinopathy Research Center, Health Research Institute, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Elham Rajaei
- Golestan Hospital Clinical Research Development Unit, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Rezvan Moallemian
- State Key Laboratory of Microbial Metabolism, Joint International Research Laboratory of Metabolic & Developmental Sciences, Sheng Yushou Center of Cell Biology and Immunology, School of Life Science and Biotechnology, Shanghai Jiao Tong University, Shanghai, 200240, China
| | - Forough Nokhostin
- Internal medicine, Faculty of Medicine, Ahvaz Jundishapur University of Medical Science, Ahvaz, Iran.
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627
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Zhou L, Huntington K, Zhang S, Carlsen L, So EY, Parker C, Sahin I, Safran H, Kamle S, Lee CM, Lee CG, Elias JA, Campbell KS, Naik MT, Atwood WJ, Youssef E, Pachter JA, Navaraj A, Seyhan AA, Liang O, El-Deiry WS. Natural Killer cell activation, reduced ACE2, TMPRSS2, cytokines G-CSF, M-CSF and SARS-CoV-2-S pseudovirus infectivity by MEK inhibitor treatment of human cells. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2020:2020.08.02.230839. [PMID: 32793908 PMCID: PMC7418728 DOI: 10.1101/2020.08.02.230839] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/14/2023]
Abstract
COVID-19 affects vulnerable populations including elderly individuals and patients with cancer. Natural Killer (NK) cells and innate-immune TRAIL suppress transformed and virally-infected cells. ACE2, and TMPRSS2 protease promote SARS-CoV-2 infectivity, while inflammatory cytokines IL-6, or G-CSF worsen COVID-19 severity. We show MEK inhibitors (MEKi) VS-6766, trametinib and selumetinib reduce ACE2 expression in human cells. In some human cells, remdesivir increases ACE2-promoter luciferase-reporter expression, ACE2 mRNA and protein, and ACE2 expression is attenuated by MEKi. In serum-deprived and stimulated cells treated with remdesivir and MEKi we observed correlations between pRB, pERK, and ACE2 expression further supporting role of proliferative state and MAPK pathway in ACE2 regulation. We show elevated cytokines in COVID-19-(+) patient plasma (N=9) versus control (N=11). TMPRSS2, inflammatory cytokines G-CSF, M-CSF, IL-1α, IL-6 and MCP-1 are suppressed by MEKi alone or with remdesivir. We observed MEKi stimulation of NK-cell killing of target-cells, without suppressing TRAIL-mediated cytotoxicity. Pseudotyped SARS-CoV-2 virus with a lentiviral core and SARS-CoV-2 D614 or G614 SPIKE (S) protein on its envelope infected human bronchial epithelial cells, small airway epithelial cells, or lung cancer cells and MEKi suppressed infectivity of the pseudovirus. We show a drug class-effect with MEKi to stimulate NK cells, inhibit inflammatory cytokines and block host-factors for SARS-CoV-2 infection leading also to suppression of SARS-CoV-2-S pseudovirus infection of human cells. MEKi may attenuate SARS-CoV-2 infection to allow immune responses and antiviral agents to control disease progression.
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Affiliation(s)
- Lanlan Zhou
- Brown Experimentalists Against COVID-19 (BEACON) Group, Brown University, Providence, RI, 02912
- Laboratory of Translational Oncology and Experimental Cancer Therapeutics, Warren Alpert Medical School, Brown University, Providence, RI, 02912
- Department of Pathology and Laboratory medicine, Warren Alpert Medical School, Brown University, Providence, RI, 02912
- The Joint Program in Cancer Biology, Brown University and Lifespan Health System, Providence, RI, 02912
- Cancer Center at Brown University, Warren Alpert Medical School, Brown University, Providence, RI, 02912
- Warren Alpert Medical School, Brown University, Providence, RI, 02912
| | - Kelsey Huntington
- Brown Experimentalists Against COVID-19 (BEACON) Group, Brown University, Providence, RI, 02912
- Laboratory of Translational Oncology and Experimental Cancer Therapeutics, Warren Alpert Medical School, Brown University, Providence, RI, 02912
- The Joint Program in Cancer Biology, Brown University and Lifespan Health System, Providence, RI, 02912
- Cancer Center at Brown University, Warren Alpert Medical School, Brown University, Providence, RI, 02912
- Pathobiology Graduate Program, Brown University, Providence, RI, 02912
- Warren Alpert Medical School, Brown University, Providence, RI, 02912
| | - Shengliang Zhang
- Brown Experimentalists Against COVID-19 (BEACON) Group, Brown University, Providence, RI, 02912
- Laboratory of Translational Oncology and Experimental Cancer Therapeutics, Warren Alpert Medical School, Brown University, Providence, RI, 02912
- Department of Pathology and Laboratory medicine, Warren Alpert Medical School, Brown University, Providence, RI, 02912
- The Joint Program in Cancer Biology, Brown University and Lifespan Health System, Providence, RI, 02912
- Cancer Center at Brown University, Warren Alpert Medical School, Brown University, Providence, RI, 02912
- Warren Alpert Medical School, Brown University, Providence, RI, 02912
| | - Lindsey Carlsen
- Brown Experimentalists Against COVID-19 (BEACON) Group, Brown University, Providence, RI, 02912
- Laboratory of Translational Oncology and Experimental Cancer Therapeutics, Warren Alpert Medical School, Brown University, Providence, RI, 02912
- The Joint Program in Cancer Biology, Brown University and Lifespan Health System, Providence, RI, 02912
- Cancer Center at Brown University, Warren Alpert Medical School, Brown University, Providence, RI, 02912
- Pathobiology Graduate Program, Brown University, Providence, RI, 02912
- Warren Alpert Medical School, Brown University, Providence, RI, 02912
| | - Eui-Young So
- The Joint Program in Cancer Biology, Brown University and Lifespan Health System, Providence, RI, 02912
- Cancer Center at Brown University, Warren Alpert Medical School, Brown University, Providence, RI, 02912
- Hematology-Oncology Division, Department of Medicine, Lifespan Health System and Warren Alpert Medical School, Brown University, Providence, RI, 02912
| | - Cassandra Parker
- Brown Experimentalists Against COVID-19 (BEACON) Group, Brown University, Providence, RI, 02912
- Laboratory of Translational Oncology and Experimental Cancer Therapeutics, Warren Alpert Medical School, Brown University, Providence, RI, 02912
- The Joint Program in Cancer Biology, Brown University and Lifespan Health System, Providence, RI, 02912
- Cancer Center at Brown University, Warren Alpert Medical School, Brown University, Providence, RI, 02912
- Department of Surgery, Lifespan Health System and Warren Alpert Medical School, Brown University, Providence, RI, 02912
- Warren Alpert Medical School, Brown University, Providence, RI, 02912
| | - Ilyas Sahin
- Brown Experimentalists Against COVID-19 (BEACON) Group, Brown University, Providence, RI, 02912
- Laboratory of Translational Oncology and Experimental Cancer Therapeutics, Warren Alpert Medical School, Brown University, Providence, RI, 02912
- The Joint Program in Cancer Biology, Brown University and Lifespan Health System, Providence, RI, 02912
- Cancer Center at Brown University, Warren Alpert Medical School, Brown University, Providence, RI, 02912
- Hematology-Oncology Division, Department of Medicine, Lifespan Health System and Warren Alpert Medical School, Brown University, Providence, RI, 02912
- Warren Alpert Medical School, Brown University, Providence, RI, 02912
| | - Howard Safran
- The Joint Program in Cancer Biology, Brown University and Lifespan Health System, Providence, RI, 02912
- Cancer Center at Brown University, Warren Alpert Medical School, Brown University, Providence, RI, 02912
- Hematology-Oncology Division, Department of Medicine, Lifespan Health System and Warren Alpert Medical School, Brown University, Providence, RI, 02912
- Warren Alpert Medical School, Brown University, Providence, RI, 02912
| | - Suchitra Kamle
- The Joint Program in Cancer Biology, Brown University and Lifespan Health System, Providence, RI, 02912
- Cancer Center at Brown University, Warren Alpert Medical School, Brown University, Providence, RI, 02912
- Department of Molecular Microbiology and Immunology, Brown University, Providence, RI, 02912
- Warren Alpert Medical School, Brown University, Providence, RI, 02912
| | - Chang-Min Lee
- The Joint Program in Cancer Biology, Brown University and Lifespan Health System, Providence, RI, 02912
- Cancer Center at Brown University, Warren Alpert Medical School, Brown University, Providence, RI, 02912
- Department of Molecular Microbiology and Immunology, Brown University, Providence, RI, 02912
- Warren Alpert Medical School, Brown University, Providence, RI, 02912
| | - Chun Geun Lee
- The Joint Program in Cancer Biology, Brown University and Lifespan Health System, Providence, RI, 02912
- Cancer Center at Brown University, Warren Alpert Medical School, Brown University, Providence, RI, 02912
- Department of Molecular Microbiology and Immunology, Brown University, Providence, RI, 02912
- Warren Alpert Medical School, Brown University, Providence, RI, 02912
| | - Jack A. Elias
- The Joint Program in Cancer Biology, Brown University and Lifespan Health System, Providence, RI, 02912
- Cancer Center at Brown University, Warren Alpert Medical School, Brown University, Providence, RI, 02912
- Department of Molecular Microbiology and Immunology, Brown University, Providence, RI, 02912
- Warren Alpert Medical School, Brown University, Providence, RI, 02912
| | - Kerry S. Campbell
- Blood Cell and Development Program, Fox Chase Cancer Center, Philadelphia, PA, 19111
| | - Mandar T. Naik
- Warren Alpert Medical School, Brown University, Providence, RI, 02912
- Department of Molecular Pharmacology, Physiology and Biotechnology, Warren Alpert Medical School, Brown University, Providence, RI, 02912
| | - Walter J. Atwood
- The Joint Program in Cancer Biology, Brown University and Lifespan Health System, Providence, RI, 02912
- Cancer Center at Brown University, Warren Alpert Medical School, Brown University, Providence, RI, 02912
- Warren Alpert Medical School, Brown University, Providence, RI, 02912
- Department of Molecular Biology, Cell Biology, and Biochemistry, Warren Alpert Medical School, Brown University, Providence, RI, 02912
| | | | | | - Arunasalam Navaraj
- Brown Experimentalists Against COVID-19 (BEACON) Group, Brown University, Providence, RI, 02912
- Laboratory of Translational Oncology and Experimental Cancer Therapeutics, Warren Alpert Medical School, Brown University, Providence, RI, 02912
- Department of Pathology and Laboratory medicine, Warren Alpert Medical School, Brown University, Providence, RI, 02912
- The Joint Program in Cancer Biology, Brown University and Lifespan Health System, Providence, RI, 02912
- Cancer Center at Brown University, Warren Alpert Medical School, Brown University, Providence, RI, 02912
- Warren Alpert Medical School, Brown University, Providence, RI, 02912
| | - Attila A. Seyhan
- Brown Experimentalists Against COVID-19 (BEACON) Group, Brown University, Providence, RI, 02912
- Laboratory of Translational Oncology and Experimental Cancer Therapeutics, Warren Alpert Medical School, Brown University, Providence, RI, 02912
- Department of Pathology and Laboratory medicine, Warren Alpert Medical School, Brown University, Providence, RI, 02912
- The Joint Program in Cancer Biology, Brown University and Lifespan Health System, Providence, RI, 02912
- Cancer Center at Brown University, Warren Alpert Medical School, Brown University, Providence, RI, 02912
- Warren Alpert Medical School, Brown University, Providence, RI, 02912
| | - Olin Liang
- The Joint Program in Cancer Biology, Brown University and Lifespan Health System, Providence, RI, 02912
- Cancer Center at Brown University, Warren Alpert Medical School, Brown University, Providence, RI, 02912
- Hematology-Oncology Division, Department of Medicine, Lifespan Health System and Warren Alpert Medical School, Brown University, Providence, RI, 02912
- Warren Alpert Medical School, Brown University, Providence, RI, 02912
| | - Wafik S. El-Deiry
- Brown Experimentalists Against COVID-19 (BEACON) Group, Brown University, Providence, RI, 02912
- Laboratory of Translational Oncology and Experimental Cancer Therapeutics, Warren Alpert Medical School, Brown University, Providence, RI, 02912
- Department of Pathology and Laboratory medicine, Warren Alpert Medical School, Brown University, Providence, RI, 02912
- The Joint Program in Cancer Biology, Brown University and Lifespan Health System, Providence, RI, 02912
- Cancer Center at Brown University, Warren Alpert Medical School, Brown University, Providence, RI, 02912
- Pathobiology Graduate Program, Brown University, Providence, RI, 02912
- Hematology-Oncology Division, Department of Medicine, Lifespan Health System and Warren Alpert Medical School, Brown University, Providence, RI, 02912
- Warren Alpert Medical School, Brown University, Providence, RI, 02912
- Correspondence:
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628
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Roomi S, Ullah W, Ahmed F, Farooq S, Sadiq U, Chohan A, Jafar M, Saddique M, Khanal S, Watson R, Boigon M. Efficacy of Hydroxychloroquine and Tocilizumab in Patients With COVID-19: Single-Center Retrospective Chart Review. J Med Internet Res 2020; 22:e21758. [PMID: 32784192 PMCID: PMC7470234 DOI: 10.2196/21758] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 07/31/2020] [Accepted: 08/04/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND During the initial phases of the COVID-19 pandemic, there was an unfounded fervor surrounding the use of hydroxychloroquine (HCQ) and tocilizumab (TCZ); however, evidence on their efficacy and safety have been controversial. OBJECTIVE The purpose of this study is to evaluate the overall clinical effectiveness of HCQ and TCZ in patients with COVID-19. We hypothesize that HCQ and TCZ use in these patients will be associated with a reduction in in-hospital mortality, upgrade to intensive medical care, invasive mechanical ventilation, or acute renal failure needing dialysis. METHODS A retrospective cohort study was performed to determine the impact of HCQ and TCZ use on hard clinical outcomes during hospitalization. A total of 176 hospitalized patients with a confirmed COVID-19 diagnosis was included. Patients were divided into two comparison groups: (1) HCQ (n=144) vs no-HCQ (n=32) and (2) TCZ (n=32) vs no-TCZ (n=144). The mean age, baseline comorbidities, and other medications used during hospitalization were uniformly distributed among all the groups. Independent t tests and multivariate logistic regression analysis were performed to calculate mean differences and adjusted odds ratios with 95% CIs, respectively. RESULTS The unadjusted odds ratio for patients upgraded to a higher level of care (ie, intensive care unit) (OR 2.6, 95% CI 1.19-5.69; P=.003) and reductions in C-reactive protein (CRP) level on day 7 of hospitalization (21% vs 56%, OR 0.21, 95% CI 0.08-0.55; P=.002) were significantly higher in the TCZ group compared to the control group. There was no significant difference in the odds of in-hospital mortality, upgrade to intensive medical care, need for invasive mechanical ventilation, acute kidney failure necessitating dialysis, or discharge from the hospital after recovery in both the HCQ and TCZ groups compared to their respective control groups. Adjusted odds ratios controlled for baseline comorbidities and medications closely followed the unadjusted estimates. CONCLUSIONS In this cohort of patients with COVID-19, neither HCQ nor TCZ offered a significant reduction in in-hospital mortality, upgrade to intensive medical care, invasive mechanical ventilation, or acute renal failure needing dialysis. These results are similar to the recently published preliminary results of the HCQ arm of the Recovery trial, which showed no clinical benefit from the use of HCQ in hospitalized patients with COVID-19 (the TCZ arm is ongoing). Double-blinded randomized controlled trials are needed to further evaluate the impact of these drugs in larger patient samples so that data-driven guidelines can be deduced to combat this global pandemic.
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Affiliation(s)
- Sohaib Roomi
- Jefferson Health Abington, Abington, PA, United States
| | - Waqas Ullah
- Jefferson Health Abington, Abington, PA, United States
| | - Faizan Ahmed
- Jefferson Health Abington, Abington, PA, United States
| | - Soban Farooq
- King Edward Medical University, Lahore, Pakistan
| | - Usama Sadiq
- Jefferson Health Abington, Abington, PA, United States
| | - Asad Chohan
- Newark Beth Israel Medical Center, Newark, NJ, United States
| | - Munnam Jafar
- Jefferson Health Abington, Abington, PA, United States
| | | | | | - Robert Watson
- Jefferson Health Abington, Abington, PA, United States
| | - Margot Boigon
- Jefferson Health Abington, Abington, PA, United States
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629
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Potere N, Di Nisio M, Cibelli D, Scurti R, Frattari A, Porreca E, Abbate A, Parruti G. Response to: 'Correspondence on 'Interleukin-6 blockade with subcutaneous tocilizumab in severe COVID-19 pneumonia and hyperinflammation: a case-control study' by Potere et al' by Buckley. Ann Rheum Dis 2020; 81:e195. [PMID: 32873552 DOI: 10.1136/annrheumdis-2020-218715] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2020] [Accepted: 08/11/2020] [Indexed: 01/11/2023]
Affiliation(s)
- Nicola Potere
- Department of Medical, Oral and Biotechnological Sciences, Università degli Studi Gabriele d'Annunzio, Chieti, Italy.,VCU Pauley Heart Center, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Marcello Di Nisio
- Department of Medicine and Ageing Sciences, Università degli Studi Gabriele d'Annunzio, Chieti-Pescara, Italy.,Department of Vascular Medicine, Academic Medical Center, Amsterdam, The Netherlands
| | | | - Rosa Scurti
- Geriatric Medicine Unit, Pescara General Hospital, Pescara, Italy
| | | | - Ettore Porreca
- Department of Medical, Oral and Biotechnological Sciences, Università degli Studi Gabriele d'Annunzio, Chieti, Italy
| | - Antonio Abbate
- VCU Pauley Heart Center, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Giustino Parruti
- Infectious Diseases Unit, Pescara General Hospital, Pescara, Italy
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630
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Agbuduwe C, Basu S. Haematological manifestations of COVID-19: From cytopenia to coagulopathy. Eur J Haematol 2020; 105:540-546. [PMID: 32663356 PMCID: PMC7404736 DOI: 10.1111/ejh.13491] [Citation(s) in RCA: 55] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 07/08/2020] [Accepted: 07/09/2020] [Indexed: 01/08/2023]
Abstract
Emerging data from the management of patients with coronavirus disease 2019 (COVID‐19) suggests multi‐systemic involvement, including the hemopoietic system. The haematological manifestations of COVID‐19 include blood count anomalies notably lymphopenia and neutrophilia which are of prognostic significance. Hyperferritinemia and elevated lactate dehydrogenase have also been associated with increased mortality. Furthermore, there is considerable evidence of a distinct coagulopathy associated with COVID‐19 characterised by elevated D‐dimers and an increased risk of thrombotic events. This comprehensive review summarises the latest evidence from published studies and discusses the implications of the various haematological manifestations of COVID‐19 with a view to guiding clinical management and risk stratification in this rapidly evolving pandemic.
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Affiliation(s)
| | - Supratik Basu
- University of Wolverhampton, Wolverhampton, UK.,New Cross Hospital, Wolverhampton, UK
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631
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Podlasin RB, Kowalska JD, Pihowicz A, Wojtycha-Kwaśnica B, Thompson M, Dyda T, Czeszko-Paprocka H, Horban A. How to follow-up a patient who received tocilizumab in severe COVID-19: a case report. Eur J Med Res 2020; 25:37. [PMID: 32854774 PMCID: PMC7450912 DOI: 10.1186/s40001-020-00438-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2020] [Accepted: 08/19/2020] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND COVID-19 is characterized by fast deterioration in the mechanism of cytokine storm. Therefore, treatment with immunomodulating agents should be initiated as soon as hyperinflammation is established. Evidence for the use of tocilizumab (TCZ) in COVID-19 is emerging, but the drug in this setting is used "off label" with limited data on both effectiveness and safety. Therefore, Hospital for Infectious Diseases in Warsaw established a Standard Operating Procedure (SOP) for the use of TCZ in severe COVID-19 cases. CASE PRESENTATION Here, we present a case of 27-year-old, otherwise healthy man, who was successfully treated with chloroquine, azithromycin, tocilizumab and a standard of care. Initially the magnitude of lung devastation, clinical deterioration and the need for mechanical ventilation suggested unfavorable prognosis. However, we observed complete regression in radiological changes and rapid clinical improvement. Irrespective of this, patient's serum interleukin 6 and aminotransferases remained elevated even after a month from treatment. CONCLUSIONS An overlapping effect of hyperinflammation, hypoxic organ injury and drug-related toxicity warrants a long-term follow-up for COVID-19 survivors. In addition, residual IL-6 receptors blockage may mask new infections. A standardized approach to follow-up for COVID-19 survivors is urgently needed. Current and future research should also investigate the impact of experimental therapies on lung tissue healing and regeneration, as well as long-term treatment toxicities.
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Affiliation(s)
| | - Justyna D Kowalska
- Department of Adults' Infectious Diseases, Medical University of Warsaw, Warsaw, Poland.
| | - Andrzej Pihowicz
- Intensive Care Unit, Hospital for Infectious Diseases in Warsaw, Warsaw, Poland
| | - Beata Wojtycha-Kwaśnica
- Department of Diagnostic Imaging, Hospital for Infectious Diseases in Warsaw, Warsaw, Poland
| | | | - Tomasz Dyda
- Molecular Diagnostics Laboratory, Hospital for Infectious Diseases in Warsaw, Warsaw, Poland
| | - Hanna Czeszko-Paprocka
- Central Analytical Laboratory, Hospital for Infectious Diseases in Warsaw, Warsaw, Poland
| | - Andrzej Horban
- Department of Adults' Infectious Diseases, Medical University of Warsaw, Warsaw, Poland
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632
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Treatment with tocilizumab or corticosteroids for COVID-19 patients with hyperinflammatory state: a multicentre cohort study (SAM-COVID-19). Clin Microbiol Infect 2020; 27:244-252. [PMID: 32860964 PMCID: PMC7449935 DOI: 10.1016/j.cmi.2020.08.010] [Citation(s) in RCA: 78] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Revised: 08/05/2020] [Accepted: 08/09/2020] [Indexed: 01/13/2023]
Abstract
Objectives The objective of this study was to estimate the association between tocilizumab or corticosteroids and the risk of intubation or death in patients with coronavirus disease 19 (COVID-19) with a hyperinflammatory state according to clinical and laboratory parameters. Methods A cohort study was performed in 60 Spanish hospitals including 778 patients with COVID-19 and clinical and laboratory data indicative of a hyperinflammatory state. Treatment was mainly with tocilizumab, an intermediate-high dose of corticosteroids (IHDC), a pulse dose of corticosteroids (PDC), combination therapy, or no treatment. Primary outcome was intubation or death; follow-up was 21 days. Propensity score-adjusted estimations using Cox regression (logistic regression if needed) were calculated. Propensity scores were used as confounders, matching variables and for the inverse probability of treatment weights (IPTWs). Results In all, 88, 117, 78 and 151 patients treated with tocilizumab, IHDC, PDC, and combination therapy, respectively, were compared with 344 untreated patients. The primary endpoint occurred in 10 (11.4%), 27 (23.1%), 12 (15.4%), 40 (25.6%) and 69 (21.1%), respectively. The IPTW-based hazard ratios (odds ratio for combination therapy) for the primary endpoint were 0.32 (95%CI 0.22–0.47; p < 0.001) for tocilizumab, 0.82 (0.71–1.30; p 0.82) for IHDC, 0.61 (0.43–0.86; p 0.006) for PDC, and 1.17 (0.86–1.58; p 0.30) for combination therapy. Other applications of the propensity score provided similar results, but were not significant for PDC. Tocilizumab was also associated with lower hazard of death alone in IPTW analysis (0.07; 0.02–0.17; p < 0.001). Conclusions Tocilizumab might be useful in COVID-19 patients with a hyperinflammatory state and should be prioritized for randomized trials in this situation.
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633
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Guaraldi G, Meschiari M, Milic J, Cozzi-Lepri A, Mussini C. Tocilizumab for severe COVID-19 pneumonia - Authors' reply. LANCET RHEUMATOLOGY 2020; 2:e660-e661. [PMID: 32838326 PMCID: PMC7431126 DOI: 10.1016/s2665-9913(20)30285-x] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- Giovanni Guaraldi
- Department of Infectious Diseases, Azienda Ospedaliero-Universitaria Policlinico of Modena, Modena 41124, Italy
- Department of Surgical, Medical, Dental and Morphological Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Marianna Meschiari
- Department of Infectious Diseases, Azienda Ospedaliero-Universitaria Policlinico of Modena, Modena 41124, Italy
| | - Jovana Milic
- Department of Surgical, Medical, Dental and Morphological Sciences, University of Modena and Reggio Emilia, Modena, Italy
- Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Modena, Italy
| | - Alessandro Cozzi-Lepri
- Centre for Clinical Research, Epidemiology, Modelling and Evaluation, Institute for Global Health, University College London, London, UK
| | - Cristina Mussini
- Department of Infectious Diseases, Azienda Ospedaliero-Universitaria Policlinico of Modena, Modena 41124, Italy
- Department of Surgical, Medical, Dental and Morphological Sciences, University of Modena and Reggio Emilia, Modena, Italy
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634
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Affiliation(s)
- Brian J Lipworth
- Scottish Centre for Respiratory Research, Ninewells Hospital and Medical School, Dundee, Scotland, UK
| | - Rory Chan
- Scottish Centre for Respiratory Research, Ninewells Hospital and Medical School, Dundee, Scotland, UK
| | - Chris RuiWen Kuo
- Scottish Centre for Respiratory Research, Ninewells Hospital and Medical School, Dundee, Scotland, UK
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635
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Affiliation(s)
- Salvatore Piano
- Unit of Internal Medicine and Hepatology, Department of Medicine, University and Hospital of Padova, Padova 35100, Italy
| | - Roberto Vettor
- Unit of Internal Medicine and Hepatology, Department of Medicine, University and Hospital of Padova, Padova 35100, Italy
| | - Paolo Angeli
- Unit of Internal Medicine and Hepatology, Department of Medicine, University and Hospital of Padova, Padova 35100, Italy
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636
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Affiliation(s)
- Jean-Jacques Mourad
- Department of Internal Medicine, Groupe Hospitalier Paris Saint-Joseph, Paris 75014, France
| | - Philippe Azria
- Department of Internal Medicine, Groupe Hospitalier Paris Saint-Joseph, Paris 75014, France
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637
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De Biasi S, Lo Tartaro D, Meschiari M, Gibellini L, Bellinazzi C, Borella R, Fidanza L, Mattioli M, Paolini A, Gozzi L, Jaacoub D, Faltoni M, Volpi S, Milić J, Sita M, Sarti M, Pucillo C, Girardis M, Guaraldi G, Mussini C, Cossarizza A. Expansion of plasmablasts and loss of memory B cells in peripheral blood from COVID-19 patients with pneumonia. Eur J Immunol 2020; 50:1283-1294. [PMID: 32910469 DOI: 10.1002/eji.202048838] [Citation(s) in RCA: 81] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 07/09/2020] [Accepted: 07/23/2020] [Indexed: 12/23/2022]
Abstract
Studies on the interactions between SARS-CoV-2 and humoral immunity are fundamental to elaborate effective therapies including vaccines. We used polychromatic flow cytometry, coupled with unsupervised data analysis and principal component analysis (PCA), to interrogate B cells in untreated patients with COVID-19 pneumonia. COVID-19 patients displayed normal plasma levels of the main immunoglobulin classes, of antibodies against common antigens or against antigens present in common vaccines. However, we found a decreased number of total and naïve B cells, along with decreased percentages and numbers of memory switched and unswitched B cells. On the contrary, IgM+ and IgM- plasmablasts were significantly increased. In vitro cell activation revealed that B lymphocytes showed a normal proliferation index and number of dividing cells per cycle. PCA indicated that B-cell number, naive and memory B cells but not plasmablasts clustered with patients who were discharged, while plasma IgM level, C-reactive protein, D-dimer, and SOFA score with those who died. In patients with pneumonia, the derangement of the B-cell compartment could be one of the causes of the immunological failure to control SARS-Cov2, have a relevant influence on several pathways, organs and systems, and must be considered to develop vaccine strategies.
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Affiliation(s)
- Sara De Biasi
- Department of Medical and Surgical Sciences for Children and Adults, University of Modena and Reggio Emilia School of Medicine, Modena, Italy
| | - Domenico Lo Tartaro
- Department of Medical and Surgical Sciences for Children and Adults, University of Modena and Reggio Emilia School of Medicine, Modena, Italy
| | - Marianna Meschiari
- Infectious Diseases Clinics, AOU Policlinico and University of Modena and Reggio Emilia, Modena, Italy
| | - Lara Gibellini
- Department of Medical and Surgical Sciences for Children and Adults, University of Modena and Reggio Emilia School of Medicine, Modena, Italy
| | - Caterina Bellinazzi
- Department of Medical and Surgical Sciences for Children and Adults, University of Modena and Reggio Emilia School of Medicine, Modena, Italy
| | - Rebecca Borella
- Department of Medical and Surgical Sciences for Children and Adults, University of Modena and Reggio Emilia School of Medicine, Modena, Italy
| | - Lucia Fidanza
- Department of Medical and Surgical Sciences for Children and Adults, University of Modena and Reggio Emilia School of Medicine, Modena, Italy
| | - Marco Mattioli
- Department of Medical and Surgical Sciences for Children and Adults, University of Modena and Reggio Emilia School of Medicine, Modena, Italy
| | - Annamaria Paolini
- Department of Medical and Surgical Sciences for Children and Adults, University of Modena and Reggio Emilia School of Medicine, Modena, Italy
| | - Licia Gozzi
- Department of Medical and Surgical Sciences for Children and Adults, University of Modena and Reggio Emilia School of Medicine, Modena, Italy
| | - Dina Jaacoub
- Infectious Diseases Clinics, AOU Policlinico and University of Modena and Reggio Emilia, Modena, Italy
| | - Matteo Faltoni
- Infectious Diseases Clinics, AOU Policlinico and University of Modena and Reggio Emilia, Modena, Italy
| | - Sara Volpi
- Infectious Diseases Clinics, AOU Policlinico and University of Modena and Reggio Emilia, Modena, Italy
| | - Jovana Milić
- Infectious Diseases Clinics, AOU Policlinico and University of Modena and Reggio Emilia, Modena, Italy
| | - Marco Sita
- Department of Anesthesia and Intensive Care, AOU Policlinico and University of Modena and Reggio Emilia, Modena, Italy
| | - Mario Sarti
- Clinical Microbiology Unit, AOU Policlinico, Modena, Italy
| | - Carlo Pucillo
- Laboratory of Immunology, Department of Medicine, University of Udine, Udine, Italy
| | - Massimo Girardis
- Department of Anesthesia and Intensive Care, AOU Policlinico and University of Modena and Reggio Emilia, Modena, Italy
| | - Giovanni Guaraldi
- Infectious Diseases Clinics, AOU Policlinico and University of Modena and Reggio Emilia, Modena, Italy
| | - Cristina Mussini
- Infectious Diseases Clinics, AOU Policlinico and University of Modena and Reggio Emilia, Modena, Italy
| | - Andrea Cossarizza
- Department of Medical and Surgical Sciences for Children and Adults, University of Modena and Reggio Emilia School of Medicine, Modena, Italy.,National Institute for Cardiovascular Research, Bologna, Italy
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638
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Perlin DS, Zafir-Lavie I, Roadcap L, Raines S, Ware CF, Neil GA. Levels of the TNF-Related Cytokine LIGHT Increase in Hospitalized COVID-19 Patients with Cytokine Release Syndrome and ARDS. mSphere 2020; 5:e00699-20. [PMID: 32817460 PMCID: PMC7426176 DOI: 10.1128/msphere.00699-20] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2020] [Accepted: 08/03/2020] [Indexed: 02/07/2023] Open
Abstract
Many coronavirus disease 2019 (COVID-19) patients demonstrate lethal respiratory complications caused by cytokine release syndrome (CRS). Multiple cytokines have been implicated in CRS, but levels of tumor necrosis factor superfamily 14 (TNFSF14) (LIGHT) have not been previously measured in this setting. In this study, we observed significantly elevated serum LIGHT levels in hospitalized COVID-19 patients compared to healthy age- and gender-matched control patients. The assay detected bioavailable LIGHT unbound to the inhibitor Decoy receptor-3 (DcR3). Bioavailable LIGHT levels were elevated in patients both on and off ventilatory support, with a trend toward higher levels in patients requiring mechanical ventilation. In hospitalized patients over the age of 60, who exhibited a mortality rate of 82%, LIGHT levels were significantly higher (P = 0.0209) in those who died than in survivors. As previously reported, interleukin 6 (IL-6) levels were also elevated in these patients, with significantly (P = 0.0076) higher levels observed in patients who died than in survivors, paralleling the LIGHT levels. Although attempts to block IL-6 binding to its receptor have shown limited success in COVID-19 CRS, neutralization of LIGHT may prove to be more effective owing to its more central role in regulating antiviral immune responses. The findings presented here demonstrate that LIGHT is a cytokine which may play an important role in COVID-19 patients presenting with acute respiratory distress syndrome (ARDS) and CRS and suggest that LIGHT neutralization may be beneficial to COVID-19 patients.
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Affiliation(s)
- David S Perlin
- Hackensack Meridian Health Center for Discovery and Innovation, Nutley, New Jersey, USA
| | | | | | - Shane Raines
- 2b Analytics, LLC, Wallingford, Pennsylvania, USA
| | - Carl F Ware
- Laboratory of Molecular Immunology, Sanford Burnham Prebys Medical Discovery Institute, La Jolla, California, USA
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639
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Potere N, Di Nisio M, Rizzo G, La Vella M, Polilli E, Agostinone A, Spacone A, Di Carlo S, Costantini A, Abbate A, Porreca E, Parruti G. Low-dose subcutaneous tocilizumab to prevent disease progression in patients with moderate COVID-19 pneumonia and hyperinflammation. Int J Infect Dis 2020; 100:421-424. [PMID: 32768701 PMCID: PMC7406468 DOI: 10.1016/j.ijid.2020.07.078] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 07/04/2020] [Accepted: 07/23/2020] [Indexed: 12/24/2022] Open
Abstract
Aim This study aimed to evaluate the safety and efficacy profile of low-dose tocilizumab (TCZ), to prevent disease progression, subcutaneously administered to patients with moderate COVID-19 pneumonia and hyperinflammation. Methods Clinical characteristics and outcomes were retrospectively analysed of patients – with laboratory-confirmed bilateral COVID-19 pneumonia, hyperinflammation (C-reactive protein (CRP) ≥20 mg/dL), no hypoxaemia (oxygen saturation >90%), and no contraindications to TCZ – who were treated with subcutaneous TCZ (324 mg) administered within 48 h from hospitalization on top of standard of care (SOC). They were compared with matched controls treated with SOC only before TCZ was available at the institution. Clinical data were available for all patients until death or until day 35 for those discharged from hospital. Findings Ten consecutive patients (six males, median age 55 years) treated with TCZ on top of SOC, and ten patients (six males, median age 56 years) treated with SOC only were included. TCZ was well-tolerated with no clinically relevant adverse events. TCZ was associated with a reduction in CRP at day 1 (–50%, IQR –28 to –80) and day 3 (–89%, IQR –79 to –96; p = 0.005 for within-group), whereas there was no significant change in CRP values in the SOC group (p < 0.001 for between-group comparisons at both time points). TCZ resulted in a parallel improvement in oxygenation, as assessed by the ratio of partial pressure of oxygen to fraction of inspired oxygen (P/F) ratio, which increased at day 1 (+11%, IQR +6 to +16; p = 0.005 for within-group and p = 0.006 for between-group comparisons), and day 3 (+23%, IQR +16 to +34; p = 0.005 for within-group and p = 0.003 for between-group comparisons). None of the TCZ-treated patients had disease progression, defined as requirement of oxygen therapy or mechanical ventilation, whereas progression occurred in five (50%) patients among the SOC group. Conclusions Low-dose subcutaneous TCZ may be a safe and promising therapeutic option administered on top of SOC to prevent disease progression in hospitalised patients with moderate COVID-19 and hyperinflammation.
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Affiliation(s)
- Nicola Potere
- Department of Medical, Oral and Biotechnological Sciences, 'G. D'Annunzio' University, Chieti, Italy; VCU Pauley Heart Center, Virginia Commonwealth University, Richmond VA, USA
| | - Marcello Di Nisio
- Department of Medicine and Ageing Sciences, 'G. D'Annunzio' University, Chieti-Pescara, Italy; Department of Vascular Medicine, Academic Medical Center, Amsterdam, The Netherlands
| | - Giulia Rizzo
- Department of Medical, Oral and Biotechnological Sciences, 'G. D'Annunzio' University, Chieti, Italy
| | - Matteo La Vella
- Department of Medical, Oral and Biotechnological Sciences, 'G. D'Annunzio' University, Chieti, Italy
| | - Ennio Polilli
- Unit of Clinical Pathology, Pescara General Hospital, Pescara, Italy
| | | | | | - Silvio Di Carlo
- Respiratory Medicine Unit, Pescara General Hospital, Pescara, Italy
| | | | - Antonio Abbate
- VCU Pauley Heart Center, Virginia Commonwealth University, Richmond VA, USA
| | - Ettore Porreca
- Department of Medical, Oral and Biotechnological Sciences, 'G. D'Annunzio' University, Chieti, Italy
| | - Giustino Parruti
- Infectious Diseases Unit, Pescara General Hospital, Pescara, Italy.
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640
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Kaddoura M, AlIbrahim M, Hijazi G, Soudani N, Audi A, Alkalamouni H, Haddad S, Eid A, Zaraket H. COVID-19 Therapeutic Options Under Investigation. Front Pharmacol 2020; 11:1196. [PMID: 32848795 PMCID: PMC7424051 DOI: 10.3389/fphar.2020.01196] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 07/22/2020] [Indexed: 12/15/2022] Open
Abstract
Since its emergence in China in December 2019, COVID-19 has quickly spread around the globe causing a pandemic. Vaccination or the development of herd immunity seems the only way to slow down the spread of the virus; however, both are not achievable in the near future. Therefore, effective treatments to mitigate the burden of this pandemic and reduce mortality rates are urgently needed. Preclinical and clinical studies of potential antiviral and immunomodulatory compounds and molecules to identify safe and efficacious therapeutics for COVID-19 are ongoing. Two compounds, remdesivir, and dexamethasone have been so far shown to reduce COVID-19-associated death. Here, we provide a review of the potential therapeutic agents being considered for the treatment and management of COVID-19 patients.
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Affiliation(s)
- Malak Kaddoura
- Department of Experimental Pathology, Immunology & Microbiology, Faculty of Medicine, American University of Beirut, Beirut, Lebanon
- Center for Infectious Disease Research, Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | - Malak AlIbrahim
- Department of Experimental Pathology, Immunology & Microbiology, Faculty of Medicine, American University of Beirut, Beirut, Lebanon
- Center for Infectious Disease Research, Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | - Ghina Hijazi
- Department of Experimental Pathology, Immunology & Microbiology, Faculty of Medicine, American University of Beirut, Beirut, Lebanon
- Center for Infectious Disease Research, Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | - Nadia Soudani
- Department of Experimental Pathology, Immunology & Microbiology, Faculty of Medicine, American University of Beirut, Beirut, Lebanon
- Center for Infectious Disease Research, Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | - Amani Audi
- Department of Experimental Pathology, Immunology & Microbiology, Faculty of Medicine, American University of Beirut, Beirut, Lebanon
- Center for Infectious Disease Research, Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | - Habib Alkalamouni
- Department of Experimental Pathology, Immunology & Microbiology, Faculty of Medicine, American University of Beirut, Beirut, Lebanon
- Center for Infectious Disease Research, Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | - Salame Haddad
- Department of Experimental Pathology, Immunology & Microbiology, Faculty of Medicine, American University of Beirut, Beirut, Lebanon
- Center for Infectious Disease Research, Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | - Ali Eid
- Department of Pharmacology and Toxicology, Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | - Hassan Zaraket
- Department of Experimental Pathology, Immunology & Microbiology, Faculty of Medicine, American University of Beirut, Beirut, Lebanon
- Center for Infectious Disease Research, Faculty of Medicine, American University of Beirut, Beirut, Lebanon
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641
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Dastan F, Saffaei A, Haseli S, Marjani M, Moniri A, Abtahian Z, Abedini A, Kiani A, Seifi S, Jammati H, Hashemian SMR, Pourabdollah Toutkaboni M, Eslaminejad A, Heshmatnia J, Sadeghi M, Nadji SA, Dastan A, Baghaei P, Varahram M, Yousefian S, Salamzadeh J, Tabarsi P. Promising effects of tocilizumab in COVID-19: A non-controlled, prospective clinical trial. Int Immunopharmacol 2020; 88:106869. [PMID: 32889241 PMCID: PMC7402206 DOI: 10.1016/j.intimp.2020.106869] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 07/31/2020] [Accepted: 07/31/2020] [Indexed: 01/08/2023]
Abstract
The pathophysiology of SARS-CoV-2 infection may be attributed to cytokine release syndrome. In this syndrome, interleukin 6 is released after the activation of the inflammatory cascade. The mortality rate in the current study was 16%. Tocilizumab may be a promising agent to decrease the mortality rate in severe or critical SARS-CoV-2 infection.
Background The clinical presentation of SARS-CoV-2 infection ranges from mild symptoms to severe complications, including acute respiratory distress syndrome. In this syndrome, inflammatory cytokines are released after activation of the inflammatory cascade, with the predominant role of interleukin (IL)-6. The aim of this study was to evaluate the effects of tocilizumab, as an IL-6 antagonist, in patients with severe or critical SARS-CoV-2 infection. Methods In this prospective clinical trial, 76 patients with severe or critical SARS-CoV-2 infection were evaluated for eligibility, and ultimately, 42 patients were included. Tocilizumab was administered at a dose of 400 mg as a single dose via intravenous infusion. Primary outcomes included changes in oxygenation support, need for invasive mechanical ventilation, and death. Secondary outcomes included radiological changes in the lungs, IL-6 plasma levels, C-reactive protein levels, and adverse drug reactions. The data were analyzed using SPSS software. Results Of the 42 included patients, 20 (48%) patients presented the severe infection stage and 22 (52%) were in the critical stage. The median age of patients was 56 years, and the median IL-6 level was 28.55 pg/mL. After tocilizumab administration, only 6 patients (14%) required invasive ventilation. Additionally, 35 patients (83.33%) showed clinical improvement. By day 28, a total of 7 patients died (6 patients in the critical stage and 1 patient in the severe stage). Neurological adverse effects were observed in 3 patients. Conclusions Based on the current results, tocilizumab may be a promising agent for patients with severe or critical SARS-CoV-2 infection, if promptly initiated during the severe stage.
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Affiliation(s)
- Farzaneh Dastan
- Department of Clinical Pharmacy, School of Pharmacy, Shahid Beheshti University of Medical Sciences, Tehran, Iran; Chronic Respiratory Diseases Research Center (CRDRC), National Research Institute of Tuberculosis and Lung Diseases (NRITLD), Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Ali Saffaei
- Student Research Committee, Department of Clinical Pharmacy, School of Pharmacy, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Sara Haseli
- Chronic Respiratory Diseases Research Center (CRDRC), National Research Institute of Tuberculosis and Lung Diseases (NRITLD), Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Majid Marjani
- Clinical Tuberculosis and Epidemiology Research Center, National Research Institute of Tuberculosis and Lung Diseases (NRITLD), Masih Daneshvari Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Afshin Moniri
- Virology Research Center, National Research Institute of Tuberculosis and Lung Diseases (NRITLD), Masih Daneshvari Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Zahra Abtahian
- Clinical Tuberculosis and Epidemiology Research Center, National Research Institute of Tuberculosis and Lung Diseases (NRITLD), Masih Daneshvari Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Atefeh Abedini
- Chronic Respiratory Diseases Research Center (CRDRC), National Research Institute of Tuberculosis and Lung Diseases (NRITLD), Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Arda Kiani
- Tracheal Diseases Research Center, National Research Institute of Tuberculosis and Lung Diseases (NRITLD), Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Sharareh Seifi
- Chronic Respiratory Diseases Research Center (CRDRC), National Research Institute of Tuberculosis and Lung Diseases (NRITLD), Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Hamidreza Jammati
- Chronic Respiratory Diseases Research Center (CRDRC), National Research Institute of Tuberculosis and Lung Diseases (NRITLD), Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Seyed Mohammad Reza Hashemian
- Chronic Respiratory Diseases Research Center (CRDRC), National Research Institute of Tuberculosis and Lung Diseases (NRITLD), Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mihan Pourabdollah Toutkaboni
- Lung Transplant Research Center, National Research Institute of Tuberculosis and Lung Diseases (NRITLD), Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Alireza Eslaminejad
- Chronic Respiratory Diseases Research Center (CRDRC), National Research Institute of Tuberculosis and Lung Diseases (NRITLD), Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Jalal Heshmatnia
- Chronic Respiratory Diseases Research Center (CRDRC), National Research Institute of Tuberculosis and Lung Diseases (NRITLD), Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mohsen Sadeghi
- Chronic Respiratory Diseases Research Center (CRDRC), National Research Institute of Tuberculosis and Lung Diseases (NRITLD), Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Seyed Alireza Nadji
- Virology Research Center, National Research Institute of Tuberculosis and Lung Diseases (NRITLD), Masih Daneshvari Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Alireza Dastan
- Ernest and Julio Gallo Management Program, School of Engineering, University of California, Merced, CA, United States
| | - Parvaneh Baghaei
- Clinical Tuberculosis and Epidemiology Research Center, National Research Institute of Tuberculosis and Lung Diseases (NRITLD), Masih Daneshvari Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mohammad Varahram
- Chronic Respiratory Diseases Research Center (CRDRC), National Research Institute of Tuberculosis and Lung Diseases (NRITLD), Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Sahar Yousefian
- Department of Clinical Pharmacy, School of Pharmacy, Shahid Beheshti University of Medical Sciences, Tehran, Iran; Chronic Respiratory Diseases Research Center (CRDRC), National Research Institute of Tuberculosis and Lung Diseases (NRITLD), Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Jamshid Salamzadeh
- Department of Clinical Pharmacy, School of Pharmacy, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Payam Tabarsi
- Clinical Tuberculosis and Epidemiology Research Center, National Research Institute of Tuberculosis and Lung Diseases (NRITLD), Masih Daneshvari Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
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642
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Winthrop KL, Mariette X. To immunosuppress: whom, when and how? That is the question with COVID-19. Ann Rheum Dis 2020; 79:1129-1131. [PMID: 32753413 PMCID: PMC7456547 DOI: 10.1136/annrheumdis-2020-218694] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 07/29/2020] [Accepted: 07/29/2020] [Indexed: 12/15/2022]
Affiliation(s)
- Kevin L Winthrop
- Divisions of Infectious Diseases and Public Health, Oregon Health and Sciences University, Portland, Oregon, USA
| | - Xavier Mariette
- Rheumatology, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Paris-Sud, Hôpital Bicêtre, Le Kremlin Bicêtre, France.,Université Paris-Sud, Center for Immunology of Viral Infections and Autoimmune Diseases (IMVA), Institut pour la Santé et la Recherche Médicale (INSERM) UMR 1184, Université Paris-Saclay, Le Kremlin Bicêtre, France
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Montesarchio V, Parrela R, Iommelli C, Bianco A, Manzillo E, Fraganza F, Palumbo C, Rea G, Murino P, De Rosa R, Atripaldi L, D'Abbraccio M, Curvietto M, Mallardo D, Celentano E, Grimaldi AM, Palla M, Trojaniello C, Vitale MG, Million-Weaver SL, Ascierto PA. Outcomes and biomarker analyses among patients with COVID-19 treated with interleukin 6 (IL-6) receptor antagonist sarilumab at a single institution in Italy. J Immunother Cancer 2020; 8:e001089. [PMID: 32784217 PMCID: PMC7418768 DOI: 10.1136/jitc-2020-001089] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/17/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND The inflammatory pathology observed in severe COVID-19 disease caused by the 2019 novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is characterized by elevated serum levels of C reactive protein (CRP) and cytokines, including interferon gamma, interleukin 8 (IL-8), and interleukin 6 (IL-6). Initial reports from the outbreak in Italy, China and the USA have provided anecdotal evidence of improved outcomes with the administration of anti-IL-6 agents, and large-scale trials evaluating these therapies are ongoing. STUDY DESCRIPTION In this retrospective case series, clinical outcomes and correlates of response to treatment with the IL-6 receptor antagonist sarilumab are described for 15 patients with COVID-19 from a single institution in Southern Italy. Among 10 patients whose symptoms improved after sarilumab treatment, rapid decreases in CRP levels corresponded with clinical improvement. Lower levels of IL-6 at baseline as well as lower neutrophil to lymphocyte ratio as compared with patients whose COVID-19 did not improve with treatment were associated with sarilumab-responsive disease. CONCLUSIONS This observation may reflect a possible clinical benefit regarding early intervention with IL-6-modulatory therapies for COVID-19 and that CRP could be a potential biomarker of response to treatment.
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Affiliation(s)
- Vincenzo Montesarchio
- Department of Medical Oncology, Azienda Ospedaliera dei Colli-Monaldi Hospital, Napoli, Italy
| | - Roberto Parrela
- Department of Infectious Diseases and Infectious Diseases Emergencies, Azienda Ospedaliera dei Colli-Cotugno Hospital, Napoli, Italy
| | - Chiara Iommelli
- Department of Medical Oncology, Azienda Ospedaliera dei Colli-Monaldi Hospital, Napoli, Italy
| | - Antonella Bianco
- Department of Medical Oncology, Azienda Ospedaliera dei Colli-Monaldi Hospital, Napoli, Italy
| | - Elio Manzillo
- Department of Infectious Diseases and Infectious Diseases Emergencies, Azienda Ospedaliera dei Colli-Cotugno Hospital, Napoli, Italy
| | - Fiorentino Fraganza
- Critical Area Department, Azienda Ospedaliera dei Colli-Cotugno and Monaldi Hospital, Napoli, Italy
| | - Cristiana Palumbo
- Department of Health Services, Azienda Ospedaliera dei Colli-Cotugno and Monaldi Hospital, Napoli, Italy
| | - Gaetano Rea
- Department of Health Services, Azienda Ospedaliera dei Colli-Cotugno and Monaldi Hospital, Napoli, Italy
| | - Patrizia Murino
- Critical Area Department, Azienda Ospedaliera dei Colli-Cotugno and Monaldi Hospital, Napoli, Italy
| | - Rosanna De Rosa
- Critical Area Department, Azienda Ospedaliera dei Colli-Cotugno and Monaldi Hospital, Napoli, Italy
| | - Luigi Atripaldi
- Department of Health Services, Azienda Ospedaliera dei Colli-Cotugno and Monaldi Hospital, Napoli, Italy
| | - Maurizio D'Abbraccio
- Department of Infectious Diseases and Infectious Diseases Emergencies, Azienda Ospedaliera dei Colli-Cotugno Hospital, Napoli, Italy
| | - Marcello Curvietto
- Department of Melanoma, Cancer Immunotherapy and Development Therapeutics, Istituto Nazionale Tumori IRCCS Fondazione Pascale, Napoli, Campania, Italy
| | - Domenico Mallardo
- Department of Melanoma, Cancer Immunotherapy and Development Therapeutics, Istituto Nazionale Tumori IRCCS Fondazione Pascale, Napoli, Campania, Italy
| | - Egidio Celentano
- Epidemiology and Biostatistics Unit, Istituto Nazionale Tumori IRCCS Fondazione Pascale, Napoli, Campania, Italy
| | - Antonio Maria Grimaldi
- Department of Melanoma, Cancer Immunotherapy and Development Therapeutics, Istituto Nazionale Tumori IRCCS Fondazione Pascale, Napoli, Campania, Italy
| | - Marco Palla
- Department of Melanoma, Cancer Immunotherapy and Development Therapeutics, Istituto Nazionale Tumori IRCCS Fondazione Pascale, Napoli, Campania, Italy
| | - Claudia Trojaniello
- Department of Melanoma, Cancer Immunotherapy and Development Therapeutics, Istituto Nazionale Tumori IRCCS Fondazione Pascale, Napoli, Campania, Italy
| | - Maria Grazia Vitale
- Department of Melanoma, Cancer Immunotherapy and Development Therapeutics, Istituto Nazionale Tumori IRCCS Fondazione Pascale, Napoli, Campania, Italy
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Buckley LF, Wohlford GF, Ting C, Alahmed A, Van Tassell BW, Abbate A, Devlin JW, Libby P. Role for Anti-Cytokine Therapies in Severe Coronavirus Disease 2019. Crit Care Explor 2020; 2:e0178. [PMID: 32832913 PMCID: PMC7419062 DOI: 10.1097/cce.0000000000000178] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
The causative agent for coronavirus disease 2019, severe acute respiratory syndrome coronavirus 2, appears exceptional in its virulence and immunopathology. In some patients, the resulting hyperinflammation resembles a cytokine release syndrome. Our knowledge of the immunopathogenesis of coronavirus disease 2019 is evolving and anti-cytokine therapies are under active investigation. This narrative review summarizes existing knowledge of the immune response to coronavirus infection and highlights the current and potential future roles of therapeutic strategies to combat the hyperinflammatory response of patients with coronavirus disease 2019. DATA SOURCES Relevant and up-to-date literature, media reports, and author experiences were included from Medline, national newspapers, and public clinical trial databases. STUDY SELECTION The authors selected studies for inclusion by consensus. DATA EXTRACTION The authors reviewed each study and selected approrpriate data for inclusion through consensus. DATA SYNTHESIS Hyperinflammation, reminiscent of cytokine release syndromes such as macrophage activation syndrome and hemophagocytic lymphohistiocytosis, appears to drive outcomes among adults with severe coronavirus disease 2019. Cytokines, particularly interleukin-1 and interleukin-6, appear to contribute importantly to such systemic hyperinflammation. Ongoing clinical trials will determine the efficacy and safety of anti-cytokine therapies in coronavirus disease 2019. In the interim, anti-cytokine therapies may provide a treatment option for adults with severe coronavirus disease 2019 unresponsive to standard critical care management, including ventilation. CONCLUSIONS This review provides an overview of the current understanding of the immunopathogenesis of coronavirus disease 2019 in adults and proposes treatment considerations for anti-cytokine therapy use in adults with severe disease.
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Affiliation(s)
- Leo F Buckley
- Department of Pharmacy Services, Brigham and Women's Hospital, Boston, MA
| | - George F Wohlford
- Department of Pharmacotherapy and Outcomes Science, Virginia Commonwealth University, Richmond, VA
| | - Clara Ting
- Department of Pharmacy Services, Brigham and Women's Hospital, Boston, MA
| | - Abdullah Alahmed
- Department of Pharmacy Services, Brigham and Women's Hospital, Boston, MA
- Department of Pharmacy Practice, Qassim University, Buraydah, Saudi Arabia
| | - Benjamin W Van Tassell
- Department of Pharmacotherapy and Outcomes Science, Virginia Commonwealth University, Richmond, VA
| | - Antonio Abbate
- Division of Cardiology, Virginia Commonwealth University, Richmond, VA
| | - John W Devlin
- School of Pharmacy, Northeastern University, Boston, MA
| | - Peter Libby
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA
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645
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Manfredi A, Luppi F, Cassone G, Vacchi C, Salvarani C, Sebastiani M. Pathogenesis and treatment of idiopathic and rheumatoid arthritis-related interstitial pneumonia. The possible lesson from COVID-19 pneumonia. Expert Rev Clin Immunol 2020; 16:751-770. [PMID: 32722946 PMCID: PMC7594185 DOI: 10.1080/1744666x.2020.1803064] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Accepted: 07/27/2020] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Main clinical manifestations of SARS-CoV-2 infection are characterized by fever, dyspnea, and interstitial pneumonia, frequently evolving in acute respiratory distress syndrome (ARDS). AREAS COVERED Features of coronavirus disease 2019 (COVID-19) presents some common points with interstitial lung disease (ILD) both idiopathic and related to rheumatoid arthritis (RA), typically characterized by a chronic progression over time and possibly complicated by acute exacerbation (AE). The study of common pathogenetic mechanisms, such as the involvement of toll-like receptor 4, could contribute to the knowledge and treatment of idiopathic and RA-ILD. Moreover, hyperinflammation, mainly characterized by increase of effector T-cells and inflammatory cytokines, and activation of coagulation cascade, observed in COVID-19 related ARDS have been already shown in patients with AE of idiopathic and RA-ILD. A literature search was performed in PubMed, Embase, Scopus, and Web of Science, together with a manual search in COVID-resource centers of the main journals. EXPERT OPINION Despite the uncertainty about pathogenetic aspects about COVID-19- pneumonia, it could be a possible model for other forms of ILD and AE. The great amount of data from studies on COVID-19 could be helpful in proposing safe therapeutic approaches for RA-ILD, in understanding pathogenesis of usual interstitial pneumonia and to develop new therapeutic strategies for AE.
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Affiliation(s)
- A Manfredi
- Rheumatology Unit, University of Modena and Reggio Emilia, Azienda Ospedaliero-Universitaria Policlinico Di Modena, Modena, Italy
| | - F Luppi
- Department of Medicine and Surgery, University of Milan Bicocca, Respiratory Unit, San Gerardo Hospital, ASST Monza, Monza, Italy
| | - G Cassone
- Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Modena, Italy
- Rheumatology Unit, Santa Maria Hospital, IRCCS, Reggio Emilia, Italy
| | - C Vacchi
- Rheumatology Unit, University of Modena and Reggio Emilia, Azienda Ospedaliero-Universitaria Policlinico Di Modena, Modena, Italy
- Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Modena, Italy
| | - C Salvarani
- Rheumatology Unit, University of Modena and Reggio Emilia, Azienda Ospedaliero-Universitaria Policlinico Di Modena, Modena, Italy
- Rheumatology Unit, Santa Maria Hospital, IRCCS, Reggio Emilia, Italy
| | - M Sebastiani
- Rheumatology Unit, University of Modena and Reggio Emilia, Azienda Ospedaliero-Universitaria Policlinico Di Modena, Modena, Italy
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646
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Jung E, Romero R, Yeo L, Diaz-Primera R, Marin-Concha J, Para R, Lopez AM, Pacora P, Gomez-Lopez N, Yoon BH, Kim CJ, Berry SM, Hsu CD. The fetal inflammatory response syndrome: the origins of a concept, pathophysiology, diagnosis, and obstetrical implications. Semin Fetal Neonatal Med 2020; 25:101146. [PMID: 33164775 PMCID: PMC10580248 DOI: 10.1016/j.siny.2020.101146] [Citation(s) in RCA: 95] [Impact Index Per Article: 23.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The fetus can deploy a local or systemic inflammatory response when exposed to microorganisms or, alternatively, to non-infection-related stimuli (e.g., danger signals or alarmins). The term "Fetal Inflammatory Response Syndrome" (FIRS) was coined to describe a condition characterized by evidence of a systemic inflammatory response, frequently a result of the activation of the innate limb of the immune response. FIRS can be diagnosed by an increased concentration of umbilical cord plasma or serum acute phase reactants such as C-reactive protein or cytokines (e.g., interleukin-6). Pathologic evidence of a systemic fetal inflammatory response indicates the presence of funisitis or chorionic vasculitis. FIRS was first described in patients at risk for intraamniotic infection who presented preterm labor with intact membranes or preterm prelabor rupture of the membranes. However, FIRS can also be observed in patients with sterile intra-amniotic inflammation, alloimmunization (e.g., Rh disease), and active autoimmune disorders. Neonates born with FIRS have a higher rate of complications, such as early-onset neonatal sepsis, intraventricular hemorrhage, periventricular leukomalacia, and death, than those born without FIRS. Survivors are at risk for long-term sequelae that may include bronchopulmonary dysplasia, neurodevelopmental disorders, such as cerebral palsy, retinopathy of prematurity, and sensorineuronal hearing loss. Experimental FIRS can be induced by intra-amniotic administration of bacteria, microbial products (such as endotoxin), or inflammatory cytokines (such as interleukin-1), and animal models have provided important insights about the mechanisms responsible for multiple organ involvement and dysfunction. A systemic fetal inflammatory response is thought to be adaptive, but, on occasion, may become dysregulated whereby a fetal cytokine storm ensues and can lead to multiple organ dysfunction and even fetal death if delivery does not occur ("rescued by birth"). Thus, the onset of preterm labor in this context can be considered to have survival value. The evidence so far suggests that FIRS may compound the effects of immaturity and neonatal inflammation, thus increasing the risk of neonatal complications and long-term morbidity. Modulation of a dysregulated fetal inflammatory response by the administration of antimicrobial agents, anti-inflammatory agents, or cell-based therapy holds promise to reduce infant morbidity and mortality.
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Affiliation(s)
- Eunjung Jung
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services (NICHD/NIH/DHHS), Bethesda, MD, and Detroit, MI, USA; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI, USA
| | - Roberto Romero
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services (NICHD/NIH/DHHS), Bethesda, MD, and Detroit, MI, USA; Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA; Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, MI, USA; Center for Molecular Medicine and Genetics, Wayne State University, Detroit, MI, USA; Detroit Medical Center, Detroit, MI, USA; Department of Obstetrics and Gynecology, Florida International University, Miami, FL, USA.
| | - Lami Yeo
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services (NICHD/NIH/DHHS), Bethesda, MD, and Detroit, MI, USA; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI, USA
| | - Ramiro Diaz-Primera
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services (NICHD/NIH/DHHS), Bethesda, MD, and Detroit, MI, USA; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI, USA
| | - Julio Marin-Concha
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services (NICHD/NIH/DHHS), Bethesda, MD, and Detroit, MI, USA; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI, USA
| | - Robert Para
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services (NICHD/NIH/DHHS), Bethesda, MD, and Detroit, MI, USA; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI, USA
| | - Ashley M Lopez
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services (NICHD/NIH/DHHS), Bethesda, MD, and Detroit, MI, USA; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI, USA
| | - Percy Pacora
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services (NICHD/NIH/DHHS), Bethesda, MD, and Detroit, MI, USA; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI, USA
| | - Nardhy Gomez-Lopez
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services (NICHD/NIH/DHHS), Bethesda, MD, and Detroit, MI, USA; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI, USA; Department of Biochemistry, Microbiology and Immunology, Wayne State University School of Medicine, Detroit, MI, USA
| | - Bo Hyun Yoon
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services (NICHD/NIH/DHHS), Bethesda, MD, and Detroit, MI, USA; Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Chong Jai Kim
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services (NICHD/NIH/DHHS), Bethesda, MD, and Detroit, MI, USA; Department of Pathology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Stanley M Berry
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services (NICHD/NIH/DHHS), Bethesda, MD, and Detroit, MI, USA; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI, USA
| | - Chaur-Dong Hsu
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services (NICHD/NIH/DHHS), Bethesda, MD, and Detroit, MI, USA; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI, USA; Department of Physiology, Wayne State University School of Medicine, Detroit, MI, USA
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647
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Jain S, Sharma SK. Rational use of tocilizumab in COVID-19. Ann Rheum Dis 2020; 81:e213. [DOI: 10.1136/annrheumdis-2020-218519] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2020] [Revised: 07/11/2020] [Accepted: 07/15/2020] [Indexed: 12/13/2022]
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648
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Potere N, Di Nisio M, Cibelli D, Scurti R, Frattari A, Porreca E, Abbate A, Parruti G. Response to: 'Rational use of tocilizumab in COVID-19' by Jain and Sharma. Ann Rheum Dis 2020; 81:e215. [PMID: 32737108 DOI: 10.1136/annrheumdis-2020-218626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Accepted: 07/25/2020] [Indexed: 11/04/2022]
Affiliation(s)
- Nicola Potere
- Department of Medical, Oral and Biotechnological Sciences, Università degli Studi Gabriele d'Annunzio, Chieti, Italy.,VCU Pauley Heart Center, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Marcello Di Nisio
- Department of Medicine and Ageing Sciences, Università degli Studi Gabriele d'Annunzio, Chieti-Pescara, Italy.,Department of Vascular Medicine, Amsterdam UMC Location AMC, Amsterdam, North Holland, Netherlands
| | | | - Rosa Scurti
- Geriatric Medicine Unit, Pescara General Hospital, Pescara, Italy
| | | | - Ettore Porreca
- Department of Medical, Oral and Biotechnological Sciences, Università degli Studi Gabriele d'Annunzio, Chieti, Italy
| | - Antonio Abbate
- VCU Pauley Heart Center, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Giustino Parruti
- Infectious Diseases Unit, Pescara General Hospital, Pescara, Italy
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649
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Capecchi PL, Lazzerini PE. Targeting IL-6 in COVID-19. Response to: ‘Rational use of tocilizumab in COVID-19’ by Jain and Sharma. Ann Rheum Dis 2020; 81:e214. [DOI: 10.1136/annrheumdis-2020-218627] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Accepted: 07/22/2020] [Indexed: 01/14/2023]
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650
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Loganathan S, Athalye SN, Joshi SR. Itolizumab, an anti-CD6 monoclonal antibody, as a potential treatment for COVID-19 complications. Expert Opin Biol Ther 2020; 20:1025-1031. [DOI: 10.1080/14712598.2020.1798399] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Subramanian Loganathan
- Clinical Sciences, Clinical Development and Medical Affairs, Biocon Biologics India Ltd, Bengaluru, India
| | - Sandeep N. Athalye
- Clinical Sciences, Clinical Development and Medical Affairs, Biocon Biologics India Ltd, Bengaluru, India
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