Gender susceptibility to COVID-19: a review of the putative role of sex hormones and X chromosome

Outcome of SARS-CoV-2 Infection in 121 Patients with Inborn Errors of Immunity: A Cross-Sectional Study

PURPOSE

There is still scarce data on SARS-CoV-2 infection in patients with Inborn Errors of Immunity (IEI) and many unresolved questions. We aimed to describe the clinical outcome of SARS-CoV-2 infection in Brazilian IEI patients and identify factors influencing the infection.

METHODS

We did a cross-sectional, multicenter study that included patients of any age affected by IEI and SARS-CoV-2 infection. The variables studied were sex, age, type of IEI, comorbidities (number and type), treatment in use for IEI, clinical manifestations and severity of SARS-CoV-2 infection.

RESULTS

121 patients were included: 55.4% female, ages from six months to 74 yo (median age = 25.1 yo). Most patients had predominantly antibody deficiency (n = 53). The infection was mostly asymptomatic (n = 21) and mild (n = 66), and one child had multisystem inflammatory syndrome (MIS-C). We could not observe sex-related susceptibility, and there was a weak correlation between age and severity of infection. The number of comorbidities was higher in severe cases, particularly bronchiectasis and cardiopathy. There were no severe cases in hereditary angioedema patients. Six patients aged 2 to 74 years died, three of them with antibody deficiency.

CONCLUSION

The outcome was mild in most patients, but the Case Fatality Ratio was higher than in the general population. However, the type of IEI was not a determining factor for severity, except for complement deficiencies linked to milder COVID-19. The severity of SARS-CoV-2 infection seems to be more related to older age, a higher number of comorbidities and type of comorbidities (bronchiectasis and cardiopathy).

Elderly Male With Cardiovascular-Related Comorbidities Has a Higher Rate of Fatal Outcomes: A Retrospective Study in 602 Patients With Coronavirus Disease 2019

Elderly with comorbidities have shown a higher rate of fatal outcomes when suffering coronavirus disease 2019 (COVID-19). However, a delineation of clinical significances of hematologic indices and underlying comorbidities in the progression and outcome of COVID-19 remains undefined. Six hundred two COVID-19 patients with established clinical outcomes (discharged or deceased) from Hankou Hospital of Wuhan, China between January 14, 2020 and February 29, 2020 were retrospectively analyzed. Of the 602 patients with COVID-19, 539 were discharged and 63 died in the hospital. The deceased group showed higher leukocyte and neutrophil counts but lower lymphocyte and platelet counts. Longer activated partial thromboplastin time (APTT) and prothrombin time (PT), as well as higher D-dimer and C-reactive protein levels, were found in non-survivors. Our observations suggest that these parameters could serve as potential predictors for the fatal outcome and in the discharged group. A higher neutrophil count and D-dimer level but lower lymphocyte were associated with a longer duration of hospitalization. A multivariable Cox regression analysis showed that higher neutrophil count, prolonged PT, and low lymphocyte count were risk factors for patients with COVID-19. Also, we found an association of lower lymphocyte count and higher C-reactive protein levels with the elderly group and those with cardiovascular-related comorbidities. The significantly different hematologic profiles between survivors and non-survivors support that distinct hematologic signatures in COVID-19 patients will dictate different outcomes as a prognostic marker for recovery or fatality. Lymphopenia and aggressive inflammatory response might be major causes for fatal outcomes in the elderly male and especially those with cardiovascular-related comorbidities.

SARS-CoV-2 vs. human gametes, embryos and cryopreservation

The COVID-19 pandemic, caused by the SARS-CoV-2 virus, is an unprecedented global situation, and all countries have adopted their own measurements to mitigate the spread of the virus in the first as well as in the subsequent waves of infection. All measures, especially in the first wave of the pandemic, were in combination with recommendations provided by professional and scientific organizations. Similar measures were applied to specific procedures, such as the management of infertility, including in vitro fertilization-embryo transfer (IVF-ET) treatments. Although there is no clear scientific evidence yet that the SARS-CoV-2 may exert negative effects on IVF outcome, especially at the early stages, several clinical reports indicate that the virus may impact male fertility through specific receptors presented at the somatic cells of the testis and used by the virus in order to gain entry to the respective cells. Nevertheless, it is not unreasonable to suspect that the virus may affect sperm function as well as oocyte performance directly through specific receptors or indirectly through other signaling pathways. Despite the good practice of IVF laboratory techniques, culture media may also be contaminated during equilibration when airborne virus's particles can contaminate culture media from an already infected embryology area or staff. Furthermore, although there is no clinical evidence, liquid nitrogen could be a route of infection for gametes and embryos when it has been contaminated during production or transportation. Therefore, cryopreservation of gametes and embryos must be virus-free. This communication aims to provide some aspects of the possible impact of the virus on gametes and embryos and how it may affect the cryopreservation procedures.Abbreviations: ACE2: angiotensin- converting enzyme 2; ART: assisted reproductive technology; ASRM: American Society for Reproductive Medicine; CDC: Centers for Disease Control and Prevention; COVID-19: coronavirus disease 2019; ESHRE: European Society of Human Reproduction and Embryology; ET: embryo transfer; FSH: follicle stimulating hormone; IFFS: International Federation of Fertility Societies; IVF: in vitro fertilization; LH: luteinizing hormone; LN: liquid nitrogen; SARS-CoV-2: severe acute respiratory syndrome coronavirus 2; T: testosterone; WHO: World Health Organization.

Genetic and epigenetic factors associated with increased severity of Covid-19

Since December 2019, a new form of severe acute respiratory syndrome (SARS) from a novel strain of coronavirus (SARS coronavirus 2 [SARS-CoV-2]) has been spreading worldwide. The disease caused by SARS-CoV-2 was named Covid-19 and declared as a pandemic by the World Health Organization in March 2020. Clinical symptoms of Covid-19 range from common cold to more severe disease defined as pneumonia, hypoxia, and severe respiratory distress. In the next stage, disease can become more critical with respiratory failure, sepsis, septic shock, and/or multiorgan failure. Outcomes of Covid-19 indicate large gaps between the male-female and the young-elder groups. Several theories have been proposed to explain variations, such as gender, age, comorbidity, and genetic factors. It is likely that mixture of genetic and nongenetic factors interplays between virus and host genetics and determines the severity of disease outcome. In this review, we aimed to summarize current literature in terms of potential host genetic and epigenetic factors that associated with increased severity of Covid-19. Several studies indicated that the genetic variants of the SARS-CoV-2 entry mechanism-related (angiotensin-converting enzymes, transmembrane serine protease-2, furin) and host innate immune response-related genes (interferons [IFNs], interleukins, toll-like receptors), and human leukocyte antigen, ABO, 3p21.31, and 9q34.2 loci are critical host determinants related to Covid-19 severity. Epigenetic mechanisms also affect Covid-19 outcomes by regulating IFN signaling, angiotensin-converting enzyme-2, and immunity-related genes that particularly escape from X chromosome inactivation. Enhanced understanding of host genetic and epigenetic factors and viral interactions of SARS-CoV-2 is critical for improved prognostic tools and innovative therapeutics.

A tissue- and gender-specific regulation of the SARS-CoV-2 receptor ACE2 by p53 in pigs

The current COVID-19 pandemic is caused by infections with the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). A sex-bias has been observed, with increased susceptibility and mortality in male compared to female patients. The gene for the SARS-CoV-2 receptor ACE2 is located on the X chromosome. We previously generated TP53 mutant pigs that exhibit a sex-specific patho-phenotype due to altered regulation of numerous X chromosome genes. In this study, we explored the effect of p53 deficiency on ACE2 expression in pigs. First, we identified the p53 binding site in the ACE2 promoter and could show its regulatory effect on ACE2 expression by luciferase assay in porcine primary kidney fibroblast cells. Later, quantitative PCR and western blot showed tissue- and gender-specific expression changes of ACE2 and its truncated isoform in p53-deficient pigs. We believe these findings will broaden the knowledge on ACE2 regulation and COVID-19 susceptibility.

Overview of COVID-19 Disease: Virology, Epidemiology, Prevention Diagnosis, Treatment, and Vaccines

Coronaviruses belong to the “Coronaviridae family”, which causes various diseases, from the common cold to SARS and MERS. The coronavirus is naturally prevalent in mammals and birds. So far, six human-transmitted coronaviruses have been discovered. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was first reported in December 2019 in Wuhan, China. Common symptoms include fever, dry cough, and fatigue, but in acute cases, the disease can lead to severe shortness of breath, hypoxia, and death. According to the World Health Organization (WHO), the three main transmission routes, such as droplet and contact routes, airborne transmission and fecal and oral for COVID-19, have been identified. So far, no definitive curative treatment has been discovered for COVID-19, and the available treatments are only to reduce the complications of the disease. According to the World Health Organization, preventive measures at the public health level such as quarantine of the infected person, identification and monitoring of contacts, disinfection of the environment, and personal protective equipment can significantly prevent the outbreak COVID-19. Currently, based on the urgent needs of the community to control this pandemic, the BNT162b2 (Pfizer), mRNA-1273 (Moderna), CoronaVac (Sinovac), Sputnik V (Gamaleya Research Institute, Acellena Contract Drug Research, and Development), BBIBP-CorV (Sinofarm), and AZD1222 (The University of Oxford; AstraZeneca) vaccines have received emergency vaccination licenses from health organizations in vaccine-producing countries. Vasso Apostolopoulos, Majid Hassanzadeganroudsari

Polycystic ovary syndrome: Pathways and mechanisms for possible increased susceptibility to COVID-19

In 75% of women with polycystic ovary syndrome (PCOS), insulin action is impaired. In obesity, visceral adipose tissue becomes dysfunctional: Chronic inflammation is favored over storage, contributing to the development of metabolic complications. PCOS, metabolic syndrome (MetSy) and non-alcoholic fatty liver disease (NAFLD) apparently share common pathogenic factors; these include abdominal adiposity, excess body weight and insulin resistance. Alterations in the gut microbiome have been noted in women with PCOS compared to controls; these may lead to deterioration of the intestinal barrier, increased gut mucosal permeability and immune system activation, hyperinsulinemia and glucose intolerance, which hamper normal ovarian function and follicular development (all being hallmarks of PCOS). It has been proposed that PCOS may entail higher susceptibility to coronavirus disease 2019 (COVID-19) via its associated comorbidities (NAFLD, obesity, MetSy and alterations in the gut microbiome). Studies have found an association between acute respiratory distress syndrome (seen in severe cases of COVID-19) and the intestinal microbiome. Furthermore, apparently, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) can gain entry to the gastrointestinal tract via locally-expressed angiotensin converting enzyme type 2 receptors. Excess body weight is associated with more severe COVID-19 and increased mortality. Although robust links between SARS-CoV-2 infection and PCOS/NAFLD/gut microbiome/metabolic consequences are yet to be confirmed, it seems that strategies for adapting the intestinal microbiome could help reduce the severity of COVID-19 in women with PCOS with or without NAFLD, MetSy or obesity.

A comprehensive evaluation of early potential risk factors for disease aggravation in patients with COVID-19

The 2019 Coronavirus Disease (COVID-19) has become an unprecedented public crisis. We retrospectively investigated the clinical data of 197 COVID-19 patients and identified 88 patients as disease aggravation cases. Compared with patients without disease aggravation, the aggravation cases had more comorbidities, including hypertension (25.9%) and diabetes (20.8%), and presented with dyspnoea (23.4%), neutrophilia (31.5%), and lymphocytopenia (46.7%). These patients were more prone to develop organ damage in liver, kidney, and heart (P < 0.05). A multivariable regression analysis showed that advanced age, comorbidities, dyspnea, lymphopenia, and elevated levels of Fbg, CTnI, IL-6, and serum ferritin were significant predictors of disease aggravation. Further, we performed a Kaplan–Meier analysis to evaluate the prognosis of COVID-19 patients, which suggested that 64.9% of the patients had not experienced ICU transfers and survival from the hospital.

COVID-19-Considerations for the Female Athlete

The SARS CoV-2 virus (COVID-19) caused the whole sporting calendar to be paused. As we embark on the challenge of navigating through the return to play (RTP) process, there is a necessity to consider the needs of all athletes. This commentary specifically considers recommendations and requirements for the female athlete with a physiological emphasis during and following the COVID-19 pandemic, however, it will be relevant for any similar future scenarios that may present. It is important to acknowledge that there remain many unknowns surrounding COVID-19 and the female athlete both in the short- and long-term.

Angiotensin-converting enzyme 2 and COVID-19: patients, comorbidities, and therapies

On March 11, 2020, the World Health Organization declared coronavirus disease 2019 (COVID-19) a pandemic, and the reality of the situation has finally caught up to the widespread reach of the disease. The presentation of the disease is highly variable, ranging from asymptomatic carriers to critical COVID-19. The availability of angiotensin-converting enzyme 2 (ACE2) receptors may reportedly increase the susceptibility and/or disease progression of COVID-19. Comorbidities and risk factors have also been noted to increase COVID-19 susceptibility. In this paper, we hereby review the evidence pertaining to ACE2's relationship to common comorbidities, risk factors, and therapies associated with the susceptibility and severity of COVID-19. We also highlight gaps of knowledge that require further investigation. The primary comorbidities of respiratory disease, cardiovascular disease, renal disease, diabetes, obesity, and hypertension had strong evidence. The secondary risk factors of age, sex, and race/genetics had limited-to-moderate evidence. The tertiary factors of ACE inhibitors and angiotensin II receptor blockers had limited-to-moderate evidence. Ibuprofen and thiazolidinediones had limited evidence.

The Impact of SARS-CoV-2 Infection on the Development of Neurodegeneration in Multiple Sclerosis

The novel coronavirus disease 2019 (COVID-19) pandemic, caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), remains a global challenge. Currently, there is some information on the consequences of COVID-19 infection in multiple sclerosis (MS) patients, as it is a newly discovered coronavirus, but its far-reaching effects on participation in neurodegenerative diseases seem to be significant. Recent cases reports showed that SARS-CoV-2 may be responsible for initiating the demyelination process in people who previously had no symptoms associated with any nervous system disorders. It is presently known that infection of SARS-CoV-2 evokes cytokine storm syndrome, which may be one of the factors leading to the acute cerebrovascular disease. One of the substantial problems is the coexistence of cerebrovascular disease and MS in an individual's life span. Epidemiological studies showed an enhanced risk of death rate from vascular disabilities in MS patients of approximately 30%. It has been demonstrated that patients with severe SARS-CoV-2 infection usually show increased levels of D-dimer, fibrinogen, C-reactive protein (CRP), and overactivation of blood platelets, which are essential elements of prothrombotic events. In this review, the latest knowledge gathered during an ongoing pandemic of SARS-CoV-2 infection on the neurodegeneration processes in MS is discussed.

Assessment of Post-COVID-19 Quality of Life Using the Quality of Life Index

BACKGROUND

COVID-19 has impacted many aspects of peoples' quality of life (QOL).

AIM

To assess the QOL of post-COVID-19 cases and determine their associated sociodemographic attributes.

METHODS

A cross-sectional community-based study targeted recovered COVID-19 cases using an online questionnaire. An Arabic version of the Quality of Life Index (QLI) was evaluated for reliability and validity using Cronbach's alpha and Spearman's product moment tests, respectively. Descriptive analysis, Mann-Whitney U, Kruskal-Wallis H, and Spearman correlation tests were used to investigate the relationships between QOL and study independent variables, including sociodemographic characteristics, time since infection, intention for vaccination, perception of the influence of COVID-19 on general health, history of hospitalization, and history of chronic illness. Subgroups were compared using a Student's t-test for normally distributed data and the Wilcoxon rank-sum test or the Kruskal-Wallis test for non-normally distributed data.

RESULTS

In a sample of 449 respondents, the total QLI score was 22.64 ± 4.36; for subscales, it ranged from 20.86 ± 5.04 to 24.99 ± 4.74. Males had significantly higher health and functioning subscale (HFSUB) scores compared to females (p = 0.033). Employed cases had significantly higher social and economic subscale (SOCSUB) scores than unemployed cases (p = 0.000). Married people reported significantly higher family subscale (FAMSUB) scores (p = 0.000) than unmarried people. People who believe that their general health was affected by COVID-19 had significantly lower HFSUB and psychological and spiritual subscale (PSPSUB) scores (p = 0.000 and p = 0.021, respectively). Individuals with a history of hospital admissions scored lower on PSPSUB (p = 0.000). Age was significantly associated with both SOCSUB (p = 0.006) and FAMSUB (p = 0.040).

CONCLUSION

Sociodemographic attributes of people with a history of COVID-19 revealed significant differences in some QOL domains, as measured by the Arabic version of the generic QLI. History of hospitalization and beliefs about COVID-19's impact on general health negatively influenced individual's HFSUB and PSPSUB.

Evidence for treatment with estradiol for women with SARS-CoV-2 infection

BACKGROUND

Given that an individual's age and gender are strongly predictive of coronavirus disease 2019 (COVID-19) outcomes, do such factors imply anything about preferable therapeutic options?

METHODS

An analysis of electronic health records for a large (68,466-case), international COVID-19 cohort, in 5-year age strata, revealed age-dependent sex differences. In particular, we surveyed the effects of systemic hormone administration in women. The primary outcome for estradiol therapy was death. Odds ratios (ORs) and Kaplan-Meier survival curves were analyzed for 37,086 COVID-19 women in two age groups: pre- (15-49 years) and peri-/post-menopausal (> 50 years).

RESULTS

The incidence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection is higher in women than men (by about + 15%) and, in contrast, the fatality rate is higher in men (about + 50%). Interestingly, the relationships between these quantities are linked to age: pre-adolescent girls and boys had the same risk of infection and fatality rate, while adult premenopausal women had a significantly higher risk of infection than men in the same 5-year age stratum (about 16,000 vs. 12,000 cases). This ratio changed again in peri- and postmenopausal women, with infection susceptibility converging with men. While fatality rates increased continuously with age for both sexes, at 50 years, there was a steeper increase for men. Thus far, these types of intricacies have been largely neglected. Because the hormone 17ß-estradiol influences expression of the human angiotensin-converting enzyme 2 (ACE2) protein, which plays a role in SARS-CoV-2 cellular entry, propensity score matching was performed for the women's sub-cohort, comparing users vs. non-users of estradiol. This retrospective study of hormone therapy in female COVID-19 patients shows that the fatality risk for women > 50 years receiving estradiol therapy (user group) is reduced by more than 50%; the OR was 0.33, 95% CI [0.18, 0.62] and the hazard ratio (HR) was 0.29, 95% CI [0.11,0.76]. For younger, pre-menopausal women (15-49 years), the risk of COVID-19 fatality is the same irrespective of estradiol treatment, probably because of higher endogenous estradiol levels.

CONCLUSIONS

As of this writing, still no effective drug treatment is available for COVID-19; since estradiol shows such a strong improvement regarding fatality in COVID-19, we suggest prospective studies on the potentially more broadly protective roles of this naturally occurring hormone.