COVID-19 in immunocompromised patients: A systematic review of cancer, hematopoietic cell and solid organ transplant patients

Outcomes of COVID-19 in children with cancer – Report from the Indian Pediatric Oncology Group (InPOG) COVID-19 registry in India

Introduction

The clinical outcomes of COVID-19 infection in children with cancer have been variable worldwide. Therefore, we aimed to collect data from all regions in India through a national collaborative study and identify factors that cause mortality directly related to COVID-19 infection.

Methods

Data was collected prospectively on children across India on cancer therapy and diagnosed with COVID-19 infections from 47 centers from April 2020 to October 2021. Information was recorded on the demographics, the number of children that required intervention, and the outcome of the infection. In addition, we analyzed the impact of the delta variant in 2021.

Results

A total of 659 children were studied, of whom 64% were male and 36% were female. The data from the eastern region was sparse, and this was a collection bias. COVID-19 infection was predominantly seen in children less than five years. The delta variant had a higher impact in the southern region, and this was statistically significant. Of the 659 children, 30 children died (4.5%), however only 7 of the deaths were directly attributed to COVID-19 infection (1%).

Conclusion

The study reports the largest nationally representative cohort of children with cancer and COVID-19 to date in India. We identified demographic and clinical factors associated with increased all-cause mortality in patients with cancer. Complete characterization of the cohort has provided further insights into the effects of COVID-19 on cancer outcomes. The low mortality allows us to recommend that specific cancer treatments be continued without delays in therapy.

Hematopoietic stem cell transplant in two pediatric patients testing positive for SARS-CoV-2: A case report

BACKGROUND

The SARS-CoV-2 pandemic brought challenges to all areas of medicine. In pediatric bone marrow transplant (BMT), one of the biggest challenges was determining how and when to transplant patients infected with SARS-CoV-2 while mitigating the risks of COVID-related complications.

METHODS

Our joint adult and pediatric BMT program developed protocols for performing BMT during the pandemic, including guidelines for screening and isolation. For patients who tested positive for SARS-CoV-2, the general recommendation was to delay BMT for at least 14 days from the start of infection and until symptoms improved and the patient twice tested negative by polymerase chain reaction (PCR). However, delaying BMT in patients with malignancy increases the risk of relapse.

RESULTS

We opted to transplant two SARS-CoV-2 persistently PCR positive patients with leukemia at high risk of relapse. One patient passed away early post-BMT of a transplant-related complication. The other patient is currently in remission and doing well.

CONCLUSION

These cases demonstrate that when the risk associated with delaying BMT is high, it may be reasonable to proceed to transplant in pediatric leukemia patients infected with SARS-CoV-2.

Risk Factors for Severe COVID-19 and Hospital Admission in Patients With Inborn Errors of Immunity - Results From a Multicenter Nationwide Study

Despite the progress in the understanding how COVID-19 infection may impact immunocompromised patients, the data on inborn errors of immunity (IEI) remain limited and ambiguous. Therefore, we examined the risk of severe infection course and hospital admission in a large cohort of patients with IEI. In this multicenter nationwide retrospective survey-based trial, the demographic, clinical, and laboratory data were collected by investigating physicians from 8 national referral centers for the diagnosis and treatment of IEI using a COVID-19-IEI clinical questionnaire. In total, 81 patients with IEI (including 16 with hereditary angioedema, HAE) and confirmed SARS-CoV-2 infection were enrolled, and were found to have a 2.3-times increased (95%CI: 1.44–3.53) risk ratio for hospital admission and a higher mortality ratio (2.4% vs. 1.7% in the general population). COVID-19 severity was associated with the presence of clinically relevant comorbidities, lymphopenia, and hypogammaglobulinemia, but not with age or BMI. No individuals with HAE developed severe disease, despite a hypothesized increased risk due to perturbed bradykinin metabolism. We also demonstrated a high seroconversion rate in antibody-deficient patients and the safety of anti-spike SARS CoV-2 monoclonal antibodies and convalescent plasma. Thus, IEI except for HAE, represent significant risk factors for a severe COVID-19. Therefore, apart from general risk factors, immune system dysregulation may also be involved in the poor outcomes of COVID-19. Despite the study limitations, our results support the findings from previously published trials.

Coronavirus disease 2019 in immunocompromised patients: a comprehensive review of coronavirus disease 2019 in hematopoietic stem cell recipients

PURPOSE OF REVIEW

Immunocompromised patients are notably vulnerable to severe coronavirus disease 2019. This review summarizes COVID-19 features and outcomes in autologous and allogeneic hematopoietic stem cell transplantation (HSCT) recipients.

RECENT FINDINGS

Recent findings suggest that HSCT recipients exhibit a high burden of comorbidities and COVID-19 clinical features almost similar to the general COVID population. Furthermore, HSCT recipients exhibit a protracted SARS-CoV-2 shedding, prolonging duration of symptoms and promoting the generation of highly mutated viruses. Last, most of studies report a higher COVID-19 mortality in HSCT recipients, mainly driven by age, comorbidities, time from transplantation, and immunosuppression because of both treatments and underlying hematological malignancy.

SUMMARY

Further studies are warranted to determine the proper impact of HSCT-related immune disorders on COVID-19 outcomes, and to evaluate specific treatments and vaccination strategy in this high-risk population. Taken together, those findings emphasize the need for more rigorous surveillance and preemptive measures for all HSCT recipients.

SARS-CoV-2 Vaccines: Safety and Immunogenicity in Solid Organ Transplant Recipients and Strategies for Improving Vaccine Responses

Purpose of Review

While solid organ transplant (SOT) recipients are at the highest risk for severe complications and increased mortality from COVID19 disease, their vaccination against SARS-CoV-2 remains challenging due to fear of immune-mediated adverse events and suboptimal immune response. Our current review is aimed to summarize current knowledge about the safety and efficacy of SARS-CoV-2 vaccines, describe factors that are correlated with immune response, and discuss strategies to improve vaccine immunogenicity in SOT recipients.

Recent Findings

SARS-CoV-2 vaccines are safe in SOT recipients and not related to rejection or other major adverse events. The immune response to two doses of vaccine is suboptimal and correlated to age and magnitude of immunosuppression. Administration of a third vaccine dose brings to significant amplification of immune response.

Summary

This review strengthens the existing recommendation of vaccination by three doses of vaccine in all SOT recipients and completion of vaccination before transplantation if possible.

Vulnerability to SARS-CoV-2 infection and disease: ripping the curl after the storm

SARS-CoV-2 infection now seems to have entered the announced endemic phase. The population's immunity is increasingly more robust, thanks to successive vaccination and booster campaigns, and the almost inevitable exposure and re-exposure to the virus itself, which has truly served as a natural immunizing mechanism. On the other hand, the genetic drift of the virus is leading it to become another catarrhal agent, as are the other endemic human coronaviruses. However, it should not be lost sight of that there are still segments of the population with susceptibility to severe COVID, who will be candidates to continue receiving vaccine boosters or antiviral drugs in the initial stages of infection.

Comparison of Clinical Outcome between Immunocompetent and Immunocompromised Children Aged 1 to 12 Years Admitted with Acute COVID-19 Infection – A Retrospective Review

The pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has created havoc in adults and children. Immunocompromised children are considered a high-risk group for the extreme manifestation of coronavirus disease 2019 (COVID-19) infection. There are conflicting reports on the outcome of SARS-CoV-2 disease in immunocompromised children. We aimed to find the difference in clinical outcomes of COVID-19 infection between immunocompetent and immunocompromised children. This includes a retrospective chart review of children admitted with COVID-19 infection in a tertiary care pediatric hospital in Northern India from March 1, 2021, to May 31, 2021. There were 35 COVID-19-positive children aged 1 to 12 years admitted during the study period. The study participants were divided into two groups: immunocompetent and immunocompromised patients. The clinical features, laboratory parameters, treatment needs, and outcomes in both groups were compared. Among 35 patients enrolled, 17 were immunocompromised and 18 were immunocompetent. The median duration of hospital stay, clinical features, laboratory parameters, severity of illness, treatment needs, and outcomes were comparable between the two groups. Immunocompromised children are not at a higher risk of severe COVID-19 manifestation compared to immunocompetent children.

Psychological distress and resilience in a multicentre sample of adolescents and young adults with cancer during the COVID-19 pandemic

Understanding impact of the coronavirus pandemic (COVID-19) on Adolescents and Young Adults (AYA) with cancer is important to inform care. Online survey of 16-24 year olds receiving cancer treatment at eight cancer centres in the UK. We measured: self-perceived increased anxiety since COVID-19, impact of COVID-19 on treatment, life and relationships, PHQ-8, GAD and the two-item Connor-Davidson Resilience Scale (CD-RISC). 112 AYA participated. 59.8% had previous mental health difficulties. 78.6% reported COVID-19 having a significant impact on life. 79% reported experiencing increased anxiety since COVID-19.43.4% had moderate-severe PHQ-8 scores and 37.1% GADS-7 scores. Impact on life was associated with moderate-severe PHQ-8 scores (OR 5.23, 95% CI 1.65-16.56, p < 0.01), impact on relationships with moderate-severe GADS-7 and PHQ-8 score (OR 2.89, 95% CI 1.11-7.54, p = 0,03; OR 3.54, 95% CI 2.32-15.17, p < 0.01; OR 2.42, 95% CI 1.11-5.25, p =0.03). Greater resilience was associated with lower mod-severe GADS-7and PHQ-8 scores (OR 0.58, 95% CI 0.41-0.81, p < 0.01; OR 0.55 95% CI 0.4-0.72, p < 0.01; OR 0.52, 95% CI 0.38-0.69, p < 0.01). We found high levels of psychological distress. Perceived impact of COVID-19 on relationships and life was predictive of poorer mental health, with resilience a protective factor.

Recent review of COVID-19 management: diagnosis, treatment and vaccination

The idiopathic Coronavirus disease 2019 (COVID-19) pandemic outbreak caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has reached global proportions; the World Health Organization (WHO) declared it as a public health emergency during the month of January 30, 2020. The major causes of the rise of new variants of SARS-CoV-2 are genetic mutations and recombination. Some of the variants with high infection and transmission rates are termed as variants of concern (VOCs) like currently Omicron variants. Pregnant women, aged people, and immunosuppressed and compromised patients constitute the most susceptible human population to the SARS-CoV-2 infection, especially to the new evolving VOCs. To effectively manage the pathological condition of infection, the focus should be directed towards prevention and prophylactic approach. In this narrative review, we aimed to analyze the current scenario of COVID-19 management and discuss the treatment and prevention strategies. We also focused on the complications prevalent during the COVID-19 and post-COVID period and to discuss the novel approaches developed for mitigation of the global pandemic. We have also emphasized on the COVID-19 management approaches for the special population including children, pregnant women, aged groups, and immunocompromised patients. We conclude that the advancements in therapeutic and pharmacological domains have provided opportunities to develop and design novel diagnosis, treatment, and prevention strategies. New advanced techniques such as RT-LAMP, RT-qPCR, High-Resolution Computed Tomography, etc., efficiently diagnose patients with SARS-CoV-2 infection. In the case of treatment options, new drugs like paxlovid, combinations of β-lactum drugs and molnupiravir are found to be effective against even the new emerging variants. In addition, vaccination is an essential approach to prevent the infection or to reduce its severity. Vaccines for against COVID-19 from Comirnaty by Pfizer-BioNTech, SpikeVax by Moderna, and Vaxzevria by Oxford-AstraZeneca are approved and used widely. Similarly, numerous vaccines have been developed with different percentages of effectiveness against VOCs. New developments like nanotechnology and AI can be beneficial in providing an efficient and reliable solution for the suppression of SARS-CoV-2. Public health concerns can be efficiently treated by a unified scientific approach, public engagement, and better diagnosis.

Influence of chronic corticosteroids and calcineurin inhibitors on COVID-19 clinical outcomes: Analysis of a nationwide registry

OBJECTIVES

To analyze whether subgroups of immunosuppressive (IS) medications confer different outcomes in COVID-19.

METHODS

Multicenter retrospective cohort of consecutive immunosuppressed patients (ISP) hospitalized with COVID-19 from March to July 2020. The primary outcome was in-hospital mortality. A propensity score-matched (PSM) model comparing ISP and non-ISP was planned, as well as specific PSM models comparing individual IS medications associated with mortality.

RESULTS

Out of 16,647 patients, 868 (5.2%) were on chronic IS therapy prior to admission and were considered ISP. In the PSM model, ISP had greater in-hospital mortality (OR 1.25, 95%CI 0.99-1.62), which was related to a worse outcome associated with chronic corticoids (OR 1.89, 95%CI 1.43-2.49). Other IS drugs had no repercussion on mortality risk (including calcineurin inhibitors (CNI), OR 1.19, 95% CI 0.65-2.20). In the pre-planned specific PSM model within patients on chronic IS treatment before admission, corticosteroids were associated with an increased risk of mortality (OR 2.34, 95%CI 1.43-3.82).

CONCLUSIONS

Chronic IS therapies pose a heterogeneous group of drugs with different risk profiles for severe COVID-19 and death. Chronic systemic corticosteroid is associated with increased mortality. On the contrary, CNI and other IS treatments prior to admission do not seem to convey different outcomes.

Stem Cells Therapy for COVID-19: A Systematic Review and Meta-Analysis

Introduction: Vaccination seems to be a good solution for preventing and controlling coronavirus disease (COVID-19) pandemic, but still there are some challenges in COVID-19 vaccination. Investigating new therapeutic options for COVID-19 is necessary. The current study aimed to evaluate the safety and efficacy of stem cells in treating patients with COVID-19.

Methods: We reviewed the relevant scientific literature published up to April 1, 2021. The pooled risk ratio (RR) with 95% CI was assessed using a fixed or random-effect model. We considered P < 0.05 as statistically significant for publication bias. Data were analyzed by Comprehensive Meta-Analysis software, Version 2.0 (Biostat, Englewood, NJ).

Results: After reviewing 1,262 records, we identified 10 studies that met the inclusion criteria. The analysis showed that stem cell therapy could significantly reduce the mortality rate (RR 0.471, 95% CI: 0.270–0.821) and morbidity (RR 0.788, 95% CI: 0.626–0.992) in patients with COVID-19; compared with the control group.

Conclusions: The present study suggests that stem cell therapy has a remarkable effect on reducing mortality and morbidity of patients with COVID-19. Further large-scale studies are needed to approve these results. Defining a protocol for stem cell therapy in patients with COVID-19 can lead to achieving the best clinical outcomes.

Is pregnancy a risk factor for in-hospital mortality in reproductive-aged women with SARS-CoV-2 infection? A nationwide retrospective observational cohort study

Objective

To examine the effect of pregnancy on coronavirus disease 2019 (COVID‐19) ‐related in‐hospital mortality in women of reproductive age (between 15 and 45 years), with severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) infection confirmed with polymerase chain reaction tests, adjusted for factors such as co‐infection and intervention that were not considered in existing literature.

Methods

Data gathered from a nationwide database in Brazil were analyzed using multivariate logistic regression and multivariate Cox regression. Adjusted odds ratios and hazard ratios of independent factors associated with in‐hospital death were calculated.

Results

A total of 97 712 women were included in the study. After the adjustment for sociodemographic factors, epidemiologic characteristics, pre‐existing medical conditions, and intervention, pregnant women were found to be associated with lower risk for in‐hospital mortality as well as longer survival time compared with non‐pregnant women. When covariates of intervention were omitted from the analysis, pregnancy did not appear to be a significant factor associated with mortality.

Conclusion

With the adjustment for intervention that was shown to be an independent factor associated with mortality, pregnancy appeared to have a favorable effect on SARS‐CoV‐2 infection. Given the immunosuppressed state of pregnancy, this finding is in line with the hypothetical protective role of a weaker immune response that inhibits the production of proinflammatory cytokine.

COVID-19 in renal transplant recipients and general population: a comparative study of clinical, laboratory, and radiological features, severity, and outcome

INTRODUCTION

Coronavirus disease 2019 (COVID-19), a novel disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has led to millions of deaths worldwide. Kidney transplant recipients (KTRs) are a fragile population due to their immunosuppressed status. However, there are limited studies available comparing this population with the general population regarding clinical symptoms, and laboratory and imaging features as well as disease severity and clinical outcomes.

METHODS

A total of 24 KTRs and 40 patients from the general population (control group) were enrolled after applying exclusion criteria. Clinical symptoms, laboratory values, and lung involvement patterns in high-resolution computed tomography (HRCT) were compared between KTRs with COVID-19 and their counterparts from the general population. Moreover, the category of disease severity and adverse outcomes such as intensive care unit (ICU) admission, mechanical ventilation (MV), and mortality rate were also compared between these two groups.

RESULTS

Hypertension was significantly higher among KTRs. Dyspnea was significantly more among the control group (P = 0.045). There was no significant difference in the rest of clinical symptoms (P > 0.05). There was no significant difference in CT features as well, except pleural effusion, which was more prevalent in the control group. A lower absolute lymphocytic count (ALC) and platelet count were observed in KTRs. Renal transplant recipients (RTRs) had a higher elevation in creatinine level than their counterparts. The ICU admission, MV, duration of hospital stay, and mortality as adverse outcomes were not significantly different between the KTR and control groups.

CONCLUSION

In conclusion, there was no significant difference in the severity and risk of adverse outcomes, including MV, ICU admission, and mortality between KTRs under chronic immunosuppression and the control group.

The impact of COVID-19 in children post hematopoietic stem cell transplantation: Experience from a pediatric transplant unit in India

Hematopoietic stem cell transplantation (HSCT) has been particularly challenging during the COVID-19 pandemic. We aimed to analyse the impact of infection with COVID-19 in children post-HSCT and describe the clinical syndromes and the disease manifestations in this cohort. Patients and methods: Children who underwent HSCT between January 2019 to June 2021 and acquired COVID-19 infection were included in the study. The symptomatic children were hospitalized for supportive care. Asymptomatic children were treated in home isolation with azithromycin and zinc supplements. Children who were on immunosuppressants were continued on it. Results: A total of 9/265 children who underwent HSCT in the study period were diagnosed with COVID-19, the incidence being 3.3%. The cycle threshold value in all children was low (≤17), indicating a profound viremia. All children had cytopenia, four had hyponatremia, and two had grade 2 cytokine release syndrome. The severity of the disease was mild in 5 children, moderate in 1 child, and severe in 3 children. Post COVID sequelae included ARDS (n = 1), MIS-C and DVT (n = 1), rhinocerebral rhizopus infection (n = 1). Three children with severe infection died, two due to multiorgan dysfunction and one due to fungal infection. Conclusion: The presence of GVHD, opportunistic fungal infection, and hyponatremia help predict a severe course and mortality in children post HSCT who are diagnosed to have COVID-19 infection. Prophylaxis for mucormycosis in high-risk children with GVHD is an essential aspect of management.

SARS-CoV-2 in children with cancer or after haematopoietic stem cell transplant: An analysis of 131 patients

PURPOSE

There are limited data on SARS-CoV-2 (COVID-19) infection in children with cancer or after haematopoietic stem cell transplant (HSCT). We describe the severity and outcomes of SARS-COV-2 in these patients and identify factors associated with severe disease.

METHODS

This was a multinational, observational study of children (aged <19 years) with cancer or HSCT and SARS-CoV-2 confirmed by polymerase chain reaction. COVID-19 was classified as asymptomatic, mild, moderate, severe or critical (≥1 organ support). Exact polytomous regression was used to determine the relationship between clinical variables and disease severity.

RESULTS

One hundred and thirty-one patients with COVID-19 across 10 countries were identified (median age 8 years). Seventy-eight (60%) had leukaemia/lymphoma, 48 (37%) had solid tumour and five had primary immunodeficiency and HSCT. Fever (71%), cough (47%) and coryza (29%) were the most frequent symptoms. The median duration of detectable virus was 16 days (range, 1-79 days). Forty-nine patients (37%) were hospitalised for COVID-19 symptoms, and 15 (11%) required intensive care unit-level care. Chemotherapy was delayed/modified in 35% of patients. COVID-19 was asymptomatic in 32% of patients, mild in 47%, moderate in 8%, severe in 4% and critical in 9%. In 124 patients (95%), a full recovery was documented, and four (3%) died due to COVID-19. Any comorbidity (odds ratio, 2.94; 95% confidence interval [CI], 1.81-5.21), any coinfection (1.74; 95% CI 1.03-3.03) and severe baseline neutropenia (1.82; 95% CI 1.13-3.09) were independently and significantly associated with increasing disease severity.

CONCLUSION

Although most children with cancer had asymptomatic/mild disease, 13% had severe COVID-19 and 3% died. Comorbidity, coinfection and neutropenia may increase the risk of severe disease. Our data may help management decisions in this vulnerable population.

SARS-CoV-2 persistence in immunocompromised children

OBJECTIVES

We evaluated the length of time immunocompromised children (ICC) remain positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), identified factors associated with viral persistence, and determined cycle threshold (C_T ) values of children with viral persistence as a surrogate of viral load.

METHODS

We conducted a retrospective cohort study of ICC at a pediatric hospital from March 2020 to March 2021. Immunocompromised status was defined as primary, secondary, or acquired due to medical comorbidities/immunosuppressive treatment. The primary outcome was time to first of two consecutive negative SARS-CoV-2 polymerase chain reaction (PCR) tests at least 24 hours apart. Testing of sequential clinical specimens from the same subject was conducted using the Centers for Disease Control (CDC) 2019-nCoV real-time reverse transcriptase (RT)-PCR Diagnostic Panel assay. Descriptive statistics, Kaplan-Meier curve median event times and log-rank tests were used to compare outcomes between groups.

RESULTS

Ninety-one children met inclusion criteria. Median age was 15.5 years (interquartile range [IQR] 8-18), 64% were male, 58% were White, and 43% were Hispanic/Latinx. Most (67%) were tested in outpatient settings and 58% were asymptomatic. The median time to two negative tests was 42 days (IQR 25.0-55.0), with no differences in median time by illness presentation or level of immunosuppression. Seven children had more than one sample available for repeat testing, and five of seven (71%) children had initial C_T values of <30 (moderate to high viral load); four children had C_T values of <30, 3-4 weeks later, suggesting persistent moderate to high viral loads.

CONCLUSIONS

Most ICC with SARS-CoV-2 infection had mild disease, with prolonged viral persistence >6 weeks and moderate to high viral load.

Severe acute respiratory syndrome coronavirus 2 infection in the stem cell transplant recipient - clinical spectrum and outcome

PURPOSE OF REVIEW

Focusing on large multicenter cohorts reported over the last months, this review aims at summarizing the available evidence by July 2021 on the impact of coronavirus disease 2019 (COVID-19) on hematopoietic stem cell transplant (HSCT) recipients in terms of epidemiology, clinical features, and outcome.

RECENT FINDINGS

The incidence of COVID-19 in institutional cohorts varied according to different regions and study periods from 0.4% to 8.3%. Clinical presentation was overall comparable to other immunocompromised hosts and the general population. Microbiologically confirmed superinfection occurred in 13-25% of recipients, with most episodes due to hospital-acquired bacteria and few reported cases of COVID-19-associated aspergillosis. Prolonged nasopharyngeal severe acute respiratory syndrome coronavirus 2 shedding has been demonstrated for as long as 210 days. Mortality rates were similar across studies (14.8-28.4%) and did not markedly differ from those observed in nontransplant hematological patients during the first wave. Older age and shorter time from transplantation were associated with mortality, as well as underlying disease status and amount of immunosuppression. No outcome differences were found in most studies between allogeneic and autologous procedures.

SUMMARY

Considerable advances have been achieved in the characterization of COVID-19 in the HSCT population, although uncertainties remain in the optimal therapeutic management.

Progress in the Diagnosis and Treatment of COVID-19 in Children: A Review

Coronavirus disease 2019 (COVID-19) has been circulating in many countries around the world, characterized by long incubation period, strong infectivity, strong variability, high population susceptibility and diversified transmission methods. Its causative agent is severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Compared with adult patients, the clinical manifestations of COVID-19 in children are often dominated by mild or asymptomatic infections, but children are also important virus carriers and play an important role in the transmission of the virus. In addition, some children will show excessive inflammatory response and experience serious complications such as multisystem inflammatory syndrome in children (MIS-C). At present, the research on COVID-19 in children is still imperfect. This article will review epidemiological characteristics, the mechanism of action, variant characteristics, clinical manifestations, auxiliary examinations and treatment of children with COVID-19, in order to provide help for the diagnosis, treatment and research of children with COVID-19.

Clinical experience of coronavirus disease 2019 in hematopoietic cell transplant and chimeric antigen receptor T-cell recipients

PURPOSE OF REVIEW

To discuss the clinical experience of coronavirus disease 2019 (COVID-19) in hematopoietic cell transplant and chimeric antigen receptor T-cell therapy recipients over the past year and to identify key knowledge gaps for future research.

RECENT FINDINGS

Immunocompromised individuals and those with chronic health conditions are especially susceptible to infections, which have had a disproportionate impact on health outcomes during the COVID-19 pandemic. Several studies have evaluated the clinical characteristics and outcomes of transplant and cellular therapy (TCT) recipients who developed COVID-19. Age, sex, comorbid conditions, and social determinants of health are important predictors of the risk of severe acute respiratory syndrome coronavirus 2 infection and of the eventual severity of the disease. Various treatment approaches have been investigated over the last year. The paradigm of management strategies continues to evolve as more experience is accumulated.

SUMMARY

In this review, we summarize some important findings as they relate to the clinical characteristics of TCT recipients who develop COVID-19. We also discuss some treatment approaches that are currently recommended and opine on vaccination in this population.

Methotrexate as a safe immunosuppressive agent during the COVID-19 pandemic

Background

During the ongoing COVID-19 pandemic, immunocompromised patients are at a higher risk of severe infection, since the immune system has an important role in defeating this disease. This study compares the severity of COVID-19 in patients taking methotrexate with the severity of their family members’ illness as patients with normal immune system function.

Methods

A total of 35 participants, including 14 patients taking methotrexate and 21 patients with normal immune function, entered this study, and the indicators of COVID-19 severity were compared between these two groups.

Results

The case group, who were on methotrexate therapy, had significantly less severe COVID-19 based on their symptoms, including fever (p = 0.000) and cough and dyspnea (p = 0.01) as well as in terms of COVID-19 severity indicators such as pulmonary involvement (p = 0.001), ferritin level (p = 0.001), white blood cell count (p = 0.008) and CRP level (p = 0.006), compared to the control group. There was a significant correlation between taking methotrexate and lower severity in COVID-19 disease.

Conclusion

The present findings demonstrated that methotrexate does not predispose patients to severe COVID-19; on the contrary, patients taking methotrexate may experience a milder disease, possibly due to their reduced severe inflammatory reactions as a result of inhibited TNFα, lowered IL6, and increased T regulatory cells. According to these findings, methotrexate appears to be a suitable treatment option for patients who need immunosuppressive medications during the COVID-19 pandemic.

Clinical characteristics and prognosis of immunosuppressed inpatients with COVID-19 in Japan

Introduction

We aimed to analyze the clinical characteristics and outcomes of immunosuppressed inpatients with coronavirus disease 2019 (COVID-19).

Methods

In this observational study, we utilized a large nationwide registry of hospitalized patients with COVID-19 in Japan. Patients’ baseline characteristics and outcomes were compared according to the immunosuppressed states of the patients. The impact of different therapeutic agents on the clinical courses of the patients was evaluated.

Results

Data of 14,760 patients were included, and 887 (5.9%) were immunosuppressed. The immunosuppressed state of the patient resulted from solid tumor (43.3%, n = 384), chemotherapy within 3 months (15.6%, n = 138), collagen disease (16.9%, n = 150), use of immunosuppressive agents (16.0%, n = 142), and metastatic solid tumor (13.5%, n = 120). Immunosuppressed patients were older and had a higher severity of illness at admission and during hospitalization than non-immunosuppressed patients. The mortality rates for major diseases causing immunosuppression were as follows: solid tumor, 12.5% (48/384; P < 0.001; relative risk [RR], 3.41); metastatic solid tumor, 31.7% (38/120; P < 0.001; RR, 8.43); leukemia, 23.1% (9/39; P < 0.001; RR, 5.87); lymphoma, 33.3% (20/60; P < 0.001; RR, 8.63); and collagen disease, 15.3% (23/150; P < 0.001; RR 3.97). Underlying diseases with high mortality rates were not necessarily associated with high rates of invasive supportive care.

Conclusions

The prognosis of immunosuppressed COVID-19 inpatients varied according to the different immunosuppressed states. Multiple factors, including the severity of the underlying diseases, might have affected their invasive supportive care indications.

Recent Advances of COVID-19 Modeling Based on Regenerative Medicine

Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) has caused a pandemic since December 2019 that originated in Wuhan, China. Soon after that, the world health organization declared Coronavirus disease-2019 a global health concern. SARS-CoV-2 is responsible for a lethal respiratory infection as well as the involvement of other organs due to its large tropism spectrum such as neurologic, cardiovascular, endocrine, gastrointestinal, and renal systems. Since the behavior of the virus is not fully understood, a new manifestation of the infection is revealed every day. In order to be able to design more efficient drugs and vaccines to treat the infection, finding out the exact mechanism of pathogenicity would be necessary. Although there have been some big steps toward understanding the relevant process, there are still some deficiencies in this field. Accordingly, regenerative medicine (RM), can offer promising opportunities in discovering the exact mechanisms and specific treatments. For instance, since it is not always possible to catch the pathophysiology mechanisms in human beings, several modeling methods have been introduced in this field that can be studied in three main groups: stem cell-based models, organoids, and animal models. Regarding stem cell-based models, induced pluripotent stem cells are the major study subjects, which are generated by reprogramming the somatic stem cells and then directing them into different adult cell populations to study their behavior toward the infection. In organoid models, different cell lines can be guided to produce a 3D structure including liver, heart, and brain-like platforms. Among animal models, mice are the most common species in this field. However, in order for mice models to be permissive to the virus, angiotensin-converting enzyme 2 receptors, the main receptor involved in the pathogenicity of the virus, should be introduced to the host cells through different methods. Here, the current known mechanism of SARS-CoV-2 infection, different suggested models, the specific response toward different manipulation as well as challenges and shortcomings in each case have been reviewed. Finally, we have tried to provide a quick summary of the present available RM-based models for SARS-CoV-2 infection, as an essential part of developing drugs, for future therapeutic goals.

The Interplay between Housing Environmental Attributes and Design Exposures and Psychoneuroimmunology Profile-An Exploratory Review and Analysis Paper in the Cancer Survivors' Mental Health Morbidity Context

Adult cancer survivors have an increased prevalence of mental health comorbidities and other adverse late-effects interdependent with mental illness outcomes compared with the general population. Coronavirus Disease 2019 (COVID-19) heralds an era of renewed call for actions to identify sustainable modalities to facilitate the constructs of cancer survivorship care and health care delivery through physiological supportive domestic spaces. Building on the concept of therapeutic architecture, psychoneuroimmunology (PNI) indicators-with the central role in low-grade systemic inflammation-are associated with major psychiatric disorders and late effects of post-cancer treatment. Immune disturbances might mediate the effects of environmental determinants on behaviour and mental disorders. Whilst attention is paid to the non-objective measurements for examining the home environmental domains and mental health outcomes, little is gathered about the multidimensional effects on physiological responses. This exploratory review presents a first analysis of how addressing the PNI outcomes serves as a catalyst for therapeutic housing research. We argue the crucial component of housing in supporting the sustainable primary care and public health-based cancer survivorship care model, particularly in the psychopathology context. Ultimately, we illustrate a series of interventions aiming at how housing environmental attributes can trigger PNI profile changes and discuss the potential implications in the non-pharmacological treatment of cancer survivors and patients with mental morbidities.

The development of biologics to target SARS-CoV2: Treatment potential of antibodies in patient groups with poor immune response

Development of novel antibodies to combat the novel SARS-CoV-2 virus is ongoing. Importantly, particular subgroups are more prone to severe disease, namely patients with poor immune responses. This includes cancer patients with solid and haematological disease, solid organ transplant (SOT) patients and those with congenital or acquired immunodeficiency. Outcomes for patients with poor immune responses receiving antibody therapy for underlying disease and SARS-CoV-2 severe infection are undergoing investigation. The objective of this study was to perform a search on patients with poor immune responses with severe SARS-CoV-2 infection, to assess if antibody therapy is beneficial in such populations. We performed searches using PubMED and medrXiv up to May 2021 of patients with solid and hematologic malignancy, SOT patients and acquired or congenital immunodeficiency. The primary outcome was to assess if antibody therapy was included during SARS-CoV-2 infection and the clinical outcomes of such treatment in this population. Here we find that there is a repurposing of monoclonal antibodies to target cytokine release syndrome, along with the use of convalescent plasma (CP). Despite CP demonstrating promising results, we reiterate evidence that CP forces mutational escape and subsequent variant development. Repurposing of antibody therapies (such as Tocilizumab) proved effective, especially in SOT patients. This also potentially opens an avenue for the use of anti-SARS-CoV-2 spike protein neutralizing monoclonal antibodies; however, studies have yet to focus on patients with poor immune responses as a subpopulation.

Coronavirus disease 2019 in children

PURPOSE OF REVIEW

Over the course of the coronavirus disease 2019 (COVID-19) pandemic, it has become clear that the clinical features, epidemiology, and outcomes of COVID-19 are distinct in children relative to adults. In this review, we will present recent pediatric studies informing our current understanding of COVID-19 in children, and review pediatric considerations surrounding disease transmission, currently available therapies, and vaccination.

RECENT FINDINGS

Recent studies have shed light on the clinical epidemiology of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in children, identifying a high prevalence of asymptomatic and mild infections, with severe COVID-19 infrequently reported. Several adult clinical trials have informed the use of remdesivir, anti-SARS-CoV-2 monoclonal antibodies, dexamethasone, and tocilizumab in the management of COVID-19. Associations between underlying comorbid medical conditions and severe outcomes, as well as transmission dynamics of SARS-CoV-2 in children, are complex and warrant further study. Finally, highly efficacious vaccines are available for adults and adolescents, with pediatric trials ongoing.

SUMMARY

Children generally fare well with acute COVID-19 infection, though critical illness is possible. Future research should focus on clarifying the role of children in SARS-CoV-2 transmission and optimal prevention strategies, particularly in the school setting, as well as evaluating pediatric vaccine candidates.

The Immunology of SARS-CoV-2 Infection and Vaccines in Solid Organ Transplant Recipients

Since its outbreak in December 2019, the coronavirus disease 2019 (COVID-19) pandemic, caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), led to an enormous rise in scientific response with an excess of COVID-19-related studies on the pathogenesis and potential therapeutic approaches. Solid organ transplant (SOT) recipients are a heterogeneous population with long-lasting immunosuppression as a joining element. Immunocompromised patients are a vulnerable population with a high risk of severe infections and an increased infection-related mortality rate. It was postulated that the hyperinflammatory state due to cytokine release syndrome during severe COVID-19 could be alleviated by immunosuppressive therapy in SOT patients. On the other hand, it was previously established that T cell-mediated immunity, which is significantly weakened in SOT recipients, is the main component of antiviral immune responses. In this paper, we present the current state of science on COVID-19 immunology in relation to solid organ transplantation with prospective therapeutic and vaccination strategies in this population.

Mycotic infection prevalence among patients undergoing bronchoalveolar lavage with search of SARS-CoV-2 after two negative nasopharyngeal swabs

The evidence that severe coronavirus disease 2019 (COVID-19) is a risk factor for development of mycotic respiratory infection with an increased mortality is rising. Immunosuppressed are among the most susceptible patients andAspergillusspecies is the most feared superinfection. In this study we evaluated mycotic isolation prevalence on bronchoalveolar lavage (BAL) of patients who underwent bronchoscopy in search of severe acute respiratory coronavirus 2 (SARS-CoV-2) RNA. Moreover, we described the clinical characteristics and main outcomes of these patients. We included 118 patients, 35.9% of them were immunosuppressed for different reasons: in 23.7% we isolated SARS-CoV-2 RNA, in 33.1% we identified at least one mycotic agent and both in 15.4%. On BAL we observed in three casesAspergillusspp, in six casesPneumocystisand in 32Candidaspp. The prevalence of significant mold infection was 29.3% and 70.7% of cases were false positive or clinically irrelevant infections. In-hospital mortality of patients with fungal infection was 15.3%. The most frequent computed tomography (CT) pattern, evaluated with the Radiological Society of North America consensus statement, among patients with a mycotic pulmonary infection was the atypical one (p< 0.0001). Mycotic isolation on BAL may be interpreted as an innocent bystander, but its identification could influence the prognosis of patients, especially in those who need invasive investigations during the COVID-19 pandemic; BAL plays a fundamental role in resolving clinical complex cases, especially in immunosuppressed patients independently from radiological features, without limiting its role in ruling out SARS-CoV-2 infection.

COVID-19 Severity and Mortality in Solid Organ Transplantation: Differences between Liver, Heart, and Kidney Recipients

The infection by the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) can generate a wide spectrum of clinical manifestations ranging from asymptomatic to severe respiratory and systemic disease with coagulation disorder named coronavirus disease 2019 (COVID-19). Patients with comorbidities have been identified as risk groups for severe COVID-19, also having a higher death risk. Previous reports have conflicting results regarding if solid organ transplant recipients present an increased risk for COVID-19. Nevertheless, previous investigations failed to distinguish between different organs received or made a longitudinal investigation on those patients. We recruited 39 solid organ transplant recipients: 25 kidney transplant recipients, 7 heart transplant recipients, and 7 liver transplant recipients and 25 age-matched non-transplant COVID-19 patients without comorbidities (control group) and compared daily laboratory data in addition to performing survival analysis. Heart and kidney transplant recipients presented an increase in several COVID-19 severity-associated biomarkers, such as neutrophil-to-lymphocyte ratio and thrombocytopenia, in comparison to the control group and liver transplant recipients. Heart and kidney transplant recipients also presented an increase in the need for intensive care and invasive mechanical ventilation during the disease’s course. Importantly, heart and kidney transplant recipients presented a higher mortality rate in comparison to liver transplant recipients and non-transplant recipients. In our cohort, heart and kidney transplant recipients presented a difference in clinical characteristics and survival rate in comparison to liver transplant recipients. Further investigation involving immune response to SARS-CoV-2 in solid organ recipients should consider and separate patients according to the organ grafted.

Vaccination and their importance for lung transplant recipients in a COVID-19 world

INTRODUCTION

Lung transplant patients are immunocompromised because of the medication they receive to prevent rejection, and as a consequence are susceptible to (respiratory) infections. Adequate vaccination strategies, including COVID-19 vaccination, are therefore needed to minimize infection risks.

AREAS COVERED

The international vaccination guidelines for lung transplant patients are reviewed, including the data on immunogenicity and effectivity of the vaccines. The impact on response to vaccination of the various categories of immunosuppressive drugs, used in the posttransplant period, on response to vaccination is described. A number of immunosuppressive and/or anti-inflammatory drugs also is used for controlling the immunopathology of severe COVID-19. Current available COVID-19 vaccines, both mRNA or adenovirus based are recommended for lung transplant patients.

EXPERT OPINION

In order to improve survival and quality of life, infections of lung transplant patients should be prevented by vaccination. When possible, vaccination should start already during the pre-transplantation period when the patient is on the waiting list. Booster vaccinations should be given post-transplantation, but only when immunosuppression has been tapered. Vaccine design based on mRNA technology could allow the design of an array of vaccines against other respiratory viruses, offering a better protection for lung transplant patients.

COVID-19 and Progesterone: Part 2. Unraveling High Severity, Immunity Patterns, Immunity grading, Progesterone and its potential clinical use

Severely ill COVID–19 (Corona Virus Disease of 2019) patients have a hyperinflammatory condition with a high concentration of pro-inflammatory cytokines termed the cytokine storm. This milieu is reported to cause acute lung injury, oxygen deprivation, multiorgan damage, critical illness, and often death. Post SARS–CoV–2 (Severe Acute Respiratory Syndrome Coronavirus 2) infection, the fight between the invading virus and the host's immune system would either terminate in recovery, with eradication of the infection and regulation of the immune system; or there would be a continuation of immune attacks even after the virus has been cleared, leading to immune dysregulation and disease. This outcome is chiefly dependent on two factors: (1) the patient's immune response, and (2) sufficiency plus efficiency of the regulator(s). Concerning the first, the present research introduces a framework based on different types of immune responses to SARS–CoV–2 along with known disease examples, and how this relates to varying clinical outcomes and treatment needs for COVID–19 patients. About the second factor of ‘regulator(s)’, part 1 of the manuscript described in depth the regulatory role of progesterone in COVID–19. The present study investigates five immunity patterns and the status of the regulatory hormone progesterone with respect to the two established demographic risk factors for COVID–19 high-severity: male sex, and old age. The study evaluates the status of progesterone as a credible determinant of immune regulation and dysregulation. It duly relates the immunity patterns to clinical outcomes and evinces indications for clinical use of progesterone in COVID–19. It proposes a clear answer to the question: "why are males and old patients most likely to have critical illness due to COVID–19?" The study highlights clinical domains for the use of progesterone in COVID–19. Part 2 of this research introduces the concept of immunity patterns and immunity grading. These concepts herewith provided for the clinical course of COVID–19 also apply to other hyperinflammatory conditions. Possible clinical applications of progesterone to treat critically ill COVID–19 patients will open an avenue for hormonal treatments of infections and other immune-related diseases.

Operational challenges in the COVID era: Asymptomatic infections and vaccination timing

The coronavirus disease 2019 (COVID‐19) pandemic has created unprecedented challenges for solid organ transplant programs. While transplant activity has largely recovered, appropriate management of deceased donor candidates who are asymptomatic but have positive nucleic acid testing (NAT) for SARS‐CoV‐2 is unclear, as this result may reflect active infection or prolonged viral shedding. Furthermore, candidates who are unvaccinated or partially vaccinated continue to receive donor offers. In the absence of robust outcomes data, transplant professionals at US adult kidney transplant centers were surveyed (February 13, 2021 to April 29, 2021) to determine community practice (N: 92 centers, capturing 41% of centers and 57% of transplants performed). The majority (97%) of responding centers declined organs for asymptomatic NAT+ patients without documented prior infection. However, 32% of centers proceed with kidney transplant in NAT+ patients who were at least 30 days from initial diagnosis with negative chest imaging. Less than 7% of programs reported inactivating patients who were unvaccinated or partially vaccinated. In conclusion, despite national recommendations to wait for negative testing, many centers are proceeding with kidney transplant in patients with positive SARS‐CoV‐2 NAT results due to presumed viral shedding. Furthermore, few centers are requiring COVID‐19 vaccination prior to transplantation at this time.

Immunomodulation as a Potent COVID-19 Pharmacotherapy: Past, Present and Future

In the first year of its appearance, the 2019 coronavirus disease (COVID-19) has affected more than 150 million individuals and killed 3 million people worldwide. The pandemic has also triggered numerous global initiatives to tackle the newly emerging disease, including the development of SARS-CoV-2 vaccines and the attempt to discover potential pharmacological therapies. Nonetheless, despite the success of SARS-CoV-2 vaccine development, COVID-19 therapy remains challenging. Several repurposed drugs that were documented to be useful in small clinical trials have been shown to be ineffective in larger studies. Additionally, the pathophysiology of SARS-CoV-2 infection displayed the predominance of hyperinflammation and immune dysregulation in inducing multiorgan damage. Therefore, the potential benefits of both immune modulation and suppression in COVID-19 have been extensively discussed. Here, we reviewed the roles of immunomodulation as potential COVID-19 pharmacological modalities based on the existing data and proposed several new immunologic targets to be tested in the foreseeable future.

Tocilizumab in COVID-19: Factors Associated With Mortality Before and After Treatment

Tocilizumab (TCZ) has been administered in SARS-CoV-2 pneumonia but the factors associated with mortality before and after treatment remain unclear. Cox regression models were used to estimate the predictors of time to death in a cohort of hospitalized patients with COVID-19 receiving TCZ. In addition, the mean differences between discharged and deceased patients in laboratory parameters measured before and 3, 6 and 9 days after TCZ administration were estimated with weighted generalized estimation equations. The variables associated with time to death were immunosuppression (Hazard Ratio-HR 3.15; 95% confidence interval-CI 1.17, 8.51), diabetes mellitus (HR 2.63; 95% CI 1.23-5.64), age (HR 1.05; 95% CI 1.02-1.09), days since diagnosis until TCZ administration (HR 1.05, 95% CI 1.00-1.09), and platelets (HR 0.27; 95% CI: 0.11, 0.69). In the post-TCZ analysis and compared to discharged patients, deceased patients had more lactate dehydrogenase (p = 0.013), troponin I (p = 0.013), C-reactive protein (p = 0.013), neutrophils (p = 0.024), and fewer platelets (p = 0.013) and lymphocytes (p = 0.013) as well as a lower average PaO₂/FiO₂ ratio. In conclusion, in COVID-19 diagnosed patients receiving TCZ, early treatment decreased the risk of death, while age, some comorbidities and baseline lower platelet counts increased that risk. After TCZ administration, lower platelet levels were again associated with mortality, together with other laboratory parameters.

COVID-19-related myocarditis post-heart transplantation

This report describes the first heart transplantation recipient with acute biventricular heart failure symptoms caused by a post-myocarditis state, late after a severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. No other viral pathogens could be detected. Computed tomography angiography did not show cardiac allograft vasculopathy, and myocardial biopsy demonstrated no clinically relevant rejection. Subsequent cardiovascular magnetic resonance imaging revealed extensive epicardial delayed enhancement without myocardial edema. Heart failure medication was initiated and an implantable cardioverter defibrillator was implanted (due to non-sustained ventricular tachycardias), leading to a partial recovery of the ejection fraction. Further studies are needed to investigate the number of heart transplant recipients with myocardial damage after a SARS-CoV-2 infection.

Graft injury and re-transplantation in liver transplant patients with COVID-19

This article discusses the current scene of liver transplantation (LT) in light of the impact of COVID-19, with particular emphasis on the possibility of graft injury and re-transplantation in LT patients infected with SARS-CoV-2. A major concern is whether such patients experience a more severe form of disease which may lead to a higher risk of acute, irreversible liver injury. If this is serious, it may necessitate re-transplantation. This article aims to raise awareness in this relatively under-researched domain. More studies are required to evaluate this issue since it has strong implications in healthcare resource allocation and clinical decision-making. Several potential research directions are proposed, including the possibility of prolonging bridging therapy for non-urgent LT cases: patients with hepatocellular carcinoma; and whether hepatoprotective agents play a role in liver-sparing during SARS-CoV-2 infection. There is also substantial discussion of the relevance of lung injury in LT patients with COVID-19 since it is not uncommon regarding the high expression of ACE2 receptors in the lungs, and that lung injury remains the major cause of death in patients with chronic liver disease.