151
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Nizami S, Arunasalam K, Green J, Cook J, Lawrence CB, Zarganes-Tzitzikas T, Davis JB, Di Daniel E, Brough D. Inhibition of the NLRP3 inflammasome by HSP90 inhibitors. Immunology 2020; 162:84-91. [PMID: 32954500 PMCID: PMC7730016 DOI: 10.1111/imm.13267] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 08/25/2020] [Accepted: 09/09/2020] [Indexed: 12/19/2022] Open
Abstract
Excessive and dysregulated inflammation is known to contribute to disease progression. HSP90 is an intracellular chaperone known to regulate inflammatory processes including the NLRP3 inflammasome and secretion of the pro‐inflammatory cytokine interleukin(IL)‐1β. Here, primarily using an in vitro inflammasome ASC speck assay, and an in vivo model of murine peritonitis, we tested the utility of HSP90 inhibitors as anti‐inflammatory molecules. We report that the HSP90 inhibitor EC144 effectively inhibited inflammatory processes including priming and activation of NLRP3 in vitro and in vivo. A specific inhibitor of the β HSP90 isoform was ineffective suggesting the importance of the α isoform in inflammatory signalling. EC144 inhibited IL‐1β and IL‐6 in vivo when administered orally, and was brain‐penetrant. These data suggest that HSP90 inhibitors may be useful for targeting inflammation in diverse diseases that are worsened by the presence of inflammation.
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Affiliation(s)
- Sohaib Nizami
- Alzheimer's Research UK Oxford Drug Discovery Institute, University of Oxford, Oxford, UK
| | - Kanisa Arunasalam
- Alzheimer's Research UK Oxford Drug Discovery Institute, University of Oxford, Oxford, UK
| | - Jack Green
- Division of Neuroscience and Experimental Psychology, School of Biological Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK.,Lydia Becker Institute of Immunology and Inflammation, University of Manchester, Manchester, UK
| | - James Cook
- Division of Neuroscience and Experimental Psychology, School of Biological Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK.,Lydia Becker Institute of Immunology and Inflammation, University of Manchester, Manchester, UK
| | - Catherine B Lawrence
- Division of Neuroscience and Experimental Psychology, School of Biological Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK.,Lydia Becker Institute of Immunology and Inflammation, University of Manchester, Manchester, UK
| | | | - John B Davis
- Alzheimer's Research UK Oxford Drug Discovery Institute, University of Oxford, Oxford, UK
| | - Elena Di Daniel
- Alzheimer's Research UK Oxford Drug Discovery Institute, University of Oxford, Oxford, UK
| | - David Brough
- Division of Neuroscience and Experimental Psychology, School of Biological Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK.,Lydia Becker Institute of Immunology and Inflammation, University of Manchester, Manchester, UK
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152
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Cheng L, Li H, Li L, Liu C, Yan S, Chen H, Li Y. Ferritin in the coronavirus disease 2019 (COVID-19): A systematic review and meta-analysis. J Clin Lab Anal 2020; 34:e23618. [PMID: 33078400 PMCID: PMC7595919 DOI: 10.1002/jcla.23618] [Citation(s) in RCA: 177] [Impact Index Per Article: 44.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2020] [Revised: 09/21/2020] [Accepted: 09/24/2020] [Indexed: 12/15/2022] Open
Abstract
Objective The coronavirus disease 2019 (COVID‐19) has rapidly developed into a pandemic. Increased levels of ferritin due to cytokine storm and secondary hemophagocytic lymphohistiocytosis were found in severe COVID‐19 patients. Therefore, the aim of this study was to determine the role of ferritin in COVID‐19. Methods Studies investigating ferritin in COVID‐19 were collected from PubMed, EMBASE, CNKI, SinoMed, and WANFANG. A meta‐analysis was performed to compare the ferritin level between different patient groups: non‐survivors versus survivors; more severe versus less severe; with comorbidity versus without comorbidity; ICU versus non‐ICU; with mechanical ventilation versus without mechanical ventilation. Results A total of 52 records involving 10 614 COVID‐19‐confirmed patients between December 25, 2019, and June 1, 2020, were included in this meta‐analysis, and 18 studies were included in the qualitative synthesis. The ferritin level was significantly increased in severe patients compared with the level in non‐severe patients [WMD 397.77 (95% CI 306.51‐489.02), P < .001]. Non‐survivors had a significantly higher ferritin level compared with the one in survivors [WMD 677.17 (95% CI 391.01‐963.33), P < .001]. Patients with one or more comorbidities including diabetes, thrombotic complication, and cancer had significantly higher levels of ferritin than those without (P < .01). Severe acute liver injury was significantly associated with high levels of ferritin, and its level was associated with intensive supportive care, including ICU transfer and mechanical ventilation. Conclusions Ferritin was associated with poor prognosis and could predict the worsening of COVID‐19 patients.
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Affiliation(s)
- Linlin Cheng
- Department of Clinical Laboratory, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Haolong Li
- Department of Clinical Laboratory, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Liubing Li
- Department of Clinical Laboratory, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Chenxi Liu
- Department of Clinical Laboratory, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Songxin Yan
- Department of Clinical Laboratory, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Haizhen Chen
- Department of Clinical Laboratory, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China.,Department of Clinical Laboratory, The First Hospital of Jilin University, Jilin, China
| | - Yongzhe Li
- Department of Clinical Laboratory, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
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153
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The Lazarus effect of very high-dose intravenous anakinra in severe non-familial CNS-HLH. LANCET RHEUMATOLOGY 2020; 2:e736-e738. [PMID: 33083789 PMCID: PMC7561319 DOI: 10.1016/s2665-9913(20)30361-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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154
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Penman SL, Kiy RT, Jensen RL, Beoku‐Betts C, Alfirevic A, Back D, Khoo SH, Owen A, Pirmohamed M, Park BK, Meng X, Goldring CE, Chadwick AE. Safety perspectives on presently considered drugs for the treatment of COVID-19. Br J Pharmacol 2020; 177:4353-4374. [PMID: 32681537 PMCID: PMC7404855 DOI: 10.1111/bph.15204] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Revised: 07/09/2020] [Accepted: 07/10/2020] [Indexed: 02/06/2023] Open
Abstract
Intense efforts are underway to evaluate potential therapeutic agents for the treatment of COVID-19. In order to respond quickly to the crisis, the repurposing of existing drugs is the primary pharmacological strategy. Despite the urgent clinical need for these therapies, it is imperative to consider potential safety issues. This is important due to the harm-benefit ratios that may be encountered when treating COVID-19, which can depend on the stage of the disease, when therapy is administered and underlying clinical factors in individual patients. Treatments are currently being trialled for a range of scenarios from prophylaxis (where benefit must greatly exceed risk) to severe life-threatening disease (where a degree of potential risk may be tolerated if it is exceeded by the potential benefit). In this perspective, we have reviewed some of the most widely researched repurposed agents in order to identify potential safety considerations using existing information in the context of COVID-19.
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Affiliation(s)
- Sophie L. Penman
- MRC Centre for Drug Safety Science, Department of Pharmacology and TherapeuticsUniversity of LiverpoolLiverpoolUK
| | - Robyn T. Kiy
- MRC Centre for Drug Safety Science, Department of Pharmacology and TherapeuticsUniversity of LiverpoolLiverpoolUK
| | - Rebecca L. Jensen
- MRC Centre for Drug Safety Science, Department of Pharmacology and TherapeuticsUniversity of LiverpoolLiverpoolUK
| | | | - Ana Alfirevic
- MRC Centre for Drug Safety Science, Department of Pharmacology and TherapeuticsUniversity of LiverpoolLiverpoolUK
| | - David Back
- MRC Centre for Drug Safety Science, Department of Pharmacology and TherapeuticsUniversity of LiverpoolLiverpoolUK
| | - Saye H. Khoo
- MRC Centre for Drug Safety Science, Department of Pharmacology and TherapeuticsUniversity of LiverpoolLiverpoolUK
| | - Andrew Owen
- MRC Centre for Drug Safety Science, Department of Pharmacology and TherapeuticsUniversity of LiverpoolLiverpoolUK
| | - Munir Pirmohamed
- MRC Centre for Drug Safety Science, Department of Pharmacology and TherapeuticsUniversity of LiverpoolLiverpoolUK
| | - B. Kevin Park
- MRC Centre for Drug Safety Science, Department of Pharmacology and TherapeuticsUniversity of LiverpoolLiverpoolUK
| | - Xiaoli Meng
- MRC Centre for Drug Safety Science, Department of Pharmacology and TherapeuticsUniversity of LiverpoolLiverpoolUK
| | - Christopher E. Goldring
- MRC Centre for Drug Safety Science, Department of Pharmacology and TherapeuticsUniversity of LiverpoolLiverpoolUK
| | - Amy E. Chadwick
- MRC Centre for Drug Safety Science, Department of Pharmacology and TherapeuticsUniversity of LiverpoolLiverpoolUK
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155
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Chen LYC, Hoiland RL, Stukas S, Wellington CL, Sekhon MS. Confronting the controversy: interleukin-6 and the COVID-19 cytokine storm syndrome. Eur Respir J 2020; 56:2003006. [PMID: 32883678 PMCID: PMC7474149 DOI: 10.1183/13993003.03006-2020] [Citation(s) in RCA: 141] [Impact Index Per Article: 35.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2020] [Accepted: 08/24/2020] [Indexed: 12/15/2022]
Abstract
The concept of coronavirus disease 2019 (COVID-19)-related cytokine storm syndrome (COVID-CSS) emerged early in the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic to explain why some patients exposed to this virus become critically ill with acute respiratory distress syndrome, multi-organ failure, and death. A seminal study from Wuhan, China reported higher serum concentrations of inflammatory cytokines in patients requiring critical care compared to those with milder disease, and the authors postulated that “cytokine storm was associated with disease severity” [1]. Hypercytokinaemic immune dysregulation in COVID-19 is known as cytokine storm syndrome. Interleukin-6 levels ≥80 pg·mL−1 predict an increased risk of respiratory failure and death, and immunomodulatory therapy is an area of urgent investigation. https://bit.ly/3jq3uJ4
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Affiliation(s)
- Luke Y C Chen
- Division of Hematology, Dept of Medicine, University of British Columbia, Vancouver, BC, Canada
- Centre for Health Education Scholarship, University of British Columbia, Vancouver, BC, Canada
| | - Ryan L Hoiland
- Dept of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, BC, Canada
- Dept of Cellular and Physiological Sciences, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Sophie Stukas
- Dept of Pathology and Laboratory Medicine, International Collaboration on Repair Discoveries, School of Biomedical Engineering, Djavad Mowafaghian Centre for Brain Health, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Cheryl L Wellington
- Dept of Pathology and Laboratory Medicine, International Collaboration on Repair Discoveries, School of Biomedical Engineering, Djavad Mowafaghian Centre for Brain Health, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Mypinder S Sekhon
- Division of Critical Care Medicine, Dept of Medicine, University of British Columbia, Vancouver, BC, Canada
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156
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Wahezi DM, Lo MS, Rubinstein TB, Ringold S, Ardoin SP, Downes KJ, Jones KB, Laxer RM, Pellet Madan R, Mudano AS, Turner AS, Karp DR, Mehta JJ. American College of Rheumatology Guidance for the Management of Pediatric Rheumatic Disease During the COVID-19 Pandemic: Version 1. Arthritis Rheumatol 2020; 72:1809-1819. [PMID: 32705780 PMCID: PMC7404941 DOI: 10.1002/art.41455] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 07/21/2020] [Indexed: 12/16/2022]
Abstract
Objective To provide clinical guidance to rheumatology providers who treat children with pediatric rheumatic disease (PRD) in the context of the coronavirus disease 2019 (COVID‐19) pandemic. Methods The task force, consisting of 7 pediatric rheumatologists, 2 pediatric infectious disease physicians, 1 adult rheumatologist, and 1 pediatric nurse practitioner, was convened on May 21, 2020. Clinical questions and subsequent guidance statements were drafted based on a review of the queries posed by the patients as well as the families and healthcare providers of children with PRD. An evidence report was generated and disseminated to task force members to assist with 3 rounds of asynchronous, anonymous voting by email using a modified Delphi approach. Voting was completed using a 9‐point numeric scoring system with predefined levels of agreement (categorized as disagreement, uncertainty, or agreement, with median scores of 1–3, 4–6, and 7–9, respectively) and consensus (categorized as low, moderate, or high). To be approved as a guidance statement, median vote ratings were required to fall into the highest tertile for agreement, with either moderate or high levels of consensus. Results The task force drafted 33 guidance statements, which were voted upon during the second and third rounds of voting. Of these 33 statements, all received median vote ratings within the highest tertile of agreement and were associated with either moderate consensus (n = 6) or high consensus (n = 27). Statements with similar recommendations were combined, resulting in 27 final guidance statements. Conclusion These guidance statements have been generated based on review of the available literature, indicating that children with PRD do not appear to be at increased risk for susceptibility to SARS–CoV‐2 infection. This guidance is presented as a “living document,” recognizing that the literature on COVID‐19 is rapidly evolving, with future updates anticipated.
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Affiliation(s)
- Dawn M Wahezi
- Children's Hospital at Montefiore and Albert Einstein College of Medicine, New York, New York
| | - Mindy S Lo
- Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Tamar B Rubinstein
- Children's Hospital at Montefiore and Albert Einstein College of Medicine, New York, New York
| | | | - Stacy P Ardoin
- Nationwide Children's Hospital and Ohio State University, Columbus, Ohio
| | - Kevin J Downes
- Children's Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Karla B Jones
- Nationwide Children's Hospital and Ohio State University, Columbus, Ohio
| | - Ronald M Laxer
- University of Toronto and The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Rebecca Pellet Madan
- New York University Grossman School of Medicine and Hassenfeld Children's Hospital, New York, New York
| | | | - Amy S Turner
- American College of Rheumatology, Atlanta, Georgia
| | - David R Karp
- University of Texas Southwestern Medical Center, Dallas
| | - Jay J Mehta
- Children's Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
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157
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Muller R, Briantais A, Faucher B, Borentain P, Nafati C, Blasco V, Gregoire E, Bernit E, Seguier J, Meunier B, Harlé JR, Ebbo M, Schleinitz N. Acute severe hepatitis in adult-onset Still's disease: case report and comprehensive review of a life-threatening manifestation. Clin Rheumatol 2020; 40:2467-2476. [PMID: 32955629 DOI: 10.1007/s10067-020-05383-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 08/27/2020] [Accepted: 08/31/2020] [Indexed: 10/23/2022]
Abstract
Acute severe hepatitis is a rare complication of adult-onset Still's disease (AOSD). This condition is poorly characterized. We performed a review of the medical literature to describe clinical, biological, pathological, and treatment characteristics from AOSD patients with acute severe hepatitis. Their characteristics were compared with AOSD patients without severe hepatitis. Twenty-one cases were collected including a new case reported here. Patients with severe hepatitis were mostly young adults with a median age of 28 years (range: 20 to 55 years). Overall, patients with severe hepatitis had less arthritis, macular rash, sore throat, lymphadenopathy, or splenomegaly than patients without severe hepatitis. Cytopenia was more frequent in case of severe hepatitis. Most patients were treated with steroids, and the use of biotherapies has increased over the last decade. Despite treatment, 49% of patients required liver transplantation and 24% died. Key Points • Acute severe hepatitis in adult-onset Still's disease (AOSD) is associated with liver transplantation and/or death in, respectively, 43% and 24% of cases. • Severe hepatitis is the inaugural manifestation of AOSD in half of cases. Diagnosis is difficult when extra-hepatic clinical manifestations are lacking. • The mechanism of hepatic necrosis in AOSD with severe hepatitis is unknown. Liver biopsy is not specific and should not delay treatment initiation.
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Affiliation(s)
- Romain Muller
- Service de médecine interne, Aix Marseille Université, APHM, Hôpital La Timone, Marseille, France
| | - Antoine Briantais
- Service de médecine interne, Aix Marseille Université, APHM, Hôpital La Timone, Marseille, France
| | - Benoit Faucher
- Service de médecine interne, Aix Marseille Université, APHM, Hôpital La Timone, Marseille, France
| | - Patrick Borentain
- Service d'hépato-gastro-entérologie, Aix Marseille Université, APHM, Hôpital La Timone, Marseille, France
| | - Cyril Nafati
- Réanimation polyvalente et des pathologies du foie, Aix Marseille Université, APHM, Hôpital La Timone, Marseille, France
| | - Valery Blasco
- Réanimation polyvalente et des pathologies du foie, Aix Marseille Université, APHM, Hôpital La Timone, Marseille, France
| | - Emilie Gregoire
- Service de chirurgie digestive, Aix Marseille Université, APHM, Hôpital La Timone, Marseille, France
| | - Emmanuelle Bernit
- Service de médecine interne, Aix Marseille Université, APHM, Hôpital La Timone, Marseille, France
| | - Julie Seguier
- Service de médecine interne, Aix Marseille Université, APHM, Hôpital La Timone, Marseille, France
| | - Benoit Meunier
- Service de médecine interne, Aix Marseille Université, APHM, Hôpital La Timone, Marseille, France
| | - Jean-Robert Harlé
- Service de médecine interne, Aix Marseille Université, APHM, Hôpital La Timone, Marseille, France
| | - Mikael Ebbo
- Service de médecine interne, Aix Marseille Université, APHM, Hôpital La Timone, Marseille, France
| | - Nicolas Schleinitz
- Service de médecine interne, Aix Marseille Université, APHM, Hôpital La Timone, Marseille, France.
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158
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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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159
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Jamilloux Y, Gerfaud-Valentin M, Sève P. Intravenous anakinra for cytokine storm syndromes. THE LANCET RHEUMATOLOGY 2020; 2:e521-e522. [PMID: 32838314 PMCID: PMC7373384 DOI: 10.1016/s2665-9913(20)30225-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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160
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Martis N, Audemard-Verger A. Intravenous anakinra for cytokine storm syndromes. THE LANCET. RHEUMATOLOGY 2020; 2:e522. [PMID: 38273616 DOI: 10.1016/s2665-9913(20)30219-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Accepted: 06/22/2020] [Indexed: 01/27/2024]
Affiliation(s)
- Nihal Martis
- Medical Intensive Care Unit and Internal Medicine Department, University Hospital of Nice, 06200 Nice, France; Côte d'Azur University, Nice, France.
| | - Alexandra Audemard-Verger
- Internal Medicine Department, University Hospital of Tours, Tours, France; University of Tours, Tours, France
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161
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Abstract
The number of people infected with SARS-CoV-2, and sadly dying from COVID-19, has exploded, and so the amount of literature on the novel coronavirus and the disease it causes has increased proportionately. The case numbers in some countries are beyond the epidemic peak, but the uncertainty about a second wave keeps politicians and societies under pressure. Appropriate decision-making and winning support from the population depends on precise scientific information rather than leaving the field to scaremongers of all proveniences. This mini-review is an update of earlier reports (Brüssow, Microb Biotechnol 2020a;13:607; Brüssow, Microb Biotechnol 2020b; https://doi.org/10.1111/1751-7915.13592).
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Affiliation(s)
- Harald Brüssow
- Department of BiosystemsLaboratory of Gene TechnologyKU LeuvenLeuvenBelgium
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162
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Tanner T, Wahezi DM. Hyperinflammation and the utility of immunomodulatory medications in children with COVID-19. Paediatr Respir Rev 2020; 35:81-87. [PMID: 32792288 PMCID: PMC7387280 DOI: 10.1016/j.prrv.2020.07.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Accepted: 07/21/2020] [Indexed: 01/08/2023]
Abstract
The rapid spread of SARS-CoV-2 infection globally coupled with the relatively high case-fatality rate has led to immediate need for therapeutic intervention to prevent and treat COVID-19 disease. There is accumulating evidence that morbidity and mortality in COVID-19 may be exacerbated by a dysregulated host immune response resulting in significant hyperinflammation and cytokine release. The aim of this review is to describe the basis for the immune dysregulation caused by SARS-CoV-2 infection and to examine current investigations into immunomodulatory therapies aimed at targeting the excessive host immune response.
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Affiliation(s)
- Tamara Tanner
- Division of Pediatric Rheumatology, Children's Hospital at Montefiore, 3415 Bainbridge Ave, Bronx, NY, 10467, United States.
| | - Dawn M Wahezi
- Division of Pediatric Rheumatology, Children's Hospital at Montefiore, 3415 Bainbridge Ave, Bronx, NY, 10467, United States.
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163
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Clark KEN, Collas O, Lachmann H, Singh A, Buckley J, Bhagani S. Safety of intravenous anakinra in COVID-19 with evidence of hyperinflammation, a case series. Rheumatol Adv Pract 2020; 4:rkaa040. [PMID: 32964179 PMCID: PMC7454860 DOI: 10.1093/rap/rkaa040] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 07/07/2020] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVES Anakinra is a selective IL-1 inhibitor, which has been used in the context of secondary haemophagocytic lymphohistiocytosis. Although usually given in the s.c. form, previous anecdotal reports have emphasized its utility when given i.v. Our aim is to report our experience on the beneficial effects of anakinra i.v. in patients with SARS-CoV-2 and evidence of hyperinflammation. METHODS We report four patients with severe COVID-19 infection requiring intensive care admission and ventilatory support. RESULTS All four patients showed evidence of deterioration, with hyperferritinaemia and increasing oxygen requirements and with superadded bacterial infections. Upon commencement of anakinra i.v., there was subsequent improvement in the patients clinically, with reduction in ventilatory support and inotropic support, and biochemically, with rapid improvement in inflammatory markers. CONCLUSION Anakinra is safe to use i.v. in patients with COVID-19 and evidence of superadded bacterial infection. Although its utility has not been confirmed in a randomized trial, current research in the COVID-19 pandemic aims to establish the utility of immunosuppression, including IL-1 blockade, on the outcomes of patients with moderate to severe disease. Our case series supports its use in patients with severe, life-threatening COVID-19 and evidence of hyperinflammation.
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Affiliation(s)
- Kristina E N Clark
- Department for Rheumatology and Connective Tissue Diseases, University College London
| | - Oliver Collas
- Department of Intensive Care, Royal Free Hospital London NHS Foundation Trust
| | - Helen Lachmann
- UK National Amyloidosis Centre, University College London
| | | | | | - Sanjay Bhagani
- Department of Infectious Diseases, Royal Free Hospital London NHS Foundation Trust, London, UK
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164
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Papa-Gobbi R, Bueno A, Serradilla J, Talayero P, Stringa P, Pascual-Miguel B, Alcolea-Sánchez A, González-Sacristan R, Andrés AM, López-Santamaría M, Rumbo M, Ramos-Boluda E, Hernández-Oliveros F. Novel coronavirus (SARS-CoV-2) infection in a patient with multivisceral transplant. Transpl Infect Dis 2020; 23:e13430. [PMID: 32741047 PMCID: PMC7435537 DOI: 10.1111/tid.13430] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 07/17/2020] [Accepted: 07/20/2020] [Indexed: 01/19/2023]
Affiliation(s)
- Rodrigo Papa-Gobbi
- Transplant Group, La Paz University Hospital Health Research Institute (IdiPAZ), Madrid, Spain
| | - Alba Bueno
- Transplant Group, La Paz University Hospital Health Research Institute (IdiPAZ), Madrid, Spain.,Department of Pediatric Surgery, La Paz University Hospital, Madrid, Spain
| | - Javier Serradilla
- Transplant Group, La Paz University Hospital Health Research Institute (IdiPAZ), Madrid, Spain.,Department of Pediatric Surgery, La Paz University Hospital, Madrid, Spain
| | - Paloma Talayero
- Department of Immunology, 12 de Octubre University Hospital, Madrid, Spain
| | - Pablo Stringa
- Institute for Immunological and Pathophysiological Studies (IIFP), School of Exact Sciences, National University of La Plata, National Council of Scientific and Technical Research (CONICET), La Plata, Argentine
| | - Bárbara Pascual-Miguel
- Translational Research in Pediatric Oncology, Hematopoietic Transplantation & Cell Therapy, Hospital La Paz Institute for Health Research (IdiPAZ), Madrid, Spain
| | | | | | - Ane M Andrés
- Transplant Group, La Paz University Hospital Health Research Institute (IdiPAZ), Madrid, Spain.,Department of Pediatric Surgery, La Paz University Hospital, Madrid, Spain
| | | | - Martín Rumbo
- Institute for Immunological and Pathophysiological Studies (IIFP), School of Exact Sciences, National University of La Plata, National Council of Scientific and Technical Research (CONICET), La Plata, Argentine
| | | | - Francisco Hernández-Oliveros
- Transplant Group, La Paz University Hospital Health Research Institute (IdiPAZ), Madrid, Spain.,Department of Pediatric Surgery, La Paz University Hospital, Madrid, Spain
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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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166
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Mehta P, Porter JC, Manson JJ, Isaacs JD, Openshaw PJM, McInnes IB, Summers C, Chambers RC. Therapeutic blockade of granulocyte macrophage colony-stimulating factor in COVID-19-associated hyperinflammation: challenges and opportunities. THE LANCET. RESPIRATORY MEDICINE 2020; 8:822-830. [PMID: 32559419 PMCID: PMC7834476 DOI: 10.1016/s2213-2600(20)30267-8] [Citation(s) in RCA: 94] [Impact Index Per Article: 23.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Revised: 05/29/2020] [Accepted: 06/01/2020] [Indexed: 01/19/2023]
Abstract
The COVID-19 pandemic is a global public health crisis, with considerable mortality and morbidity exerting pressure on health-care resources, including critical care. An excessive host inflammatory response in a subgroup of patients with severe COVID-19 might contribute to the development of acute respiratory distress syndrome (ARDS) and multiorgan failure. Timely therapeutic intervention with immunomodulation in patients with hyperinflammation could prevent disease progression to ARDS and obviate the need for invasive ventilation. Granulocyte macrophage colony-stimulating factor (GM-CSF) is an immunoregulatory cytokine with a pivotal role in initiation and perpetuation of inflammatory diseases. GM-CSF could link T-cell-driven acute pulmonary inflammation with an autocrine, self-amplifying cytokine loop leading to monocyte and macrophage activation. This axis has been targeted in cytokine storm syndromes and chronic inflammatory disorders. Here, we consider the scientific rationale for therapeutic targeting of GM-CSF in COVID-19-associated hyperinflammation. Since GM-CSF also has a key role in homoeostasis and host defence, we discuss potential risks associated with inhibition of GM-CSF in the context of viral infection and the challenges of doing clinical trials in this setting, highlighting in particular the need for a patient risk-stratification algorithm.
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Affiliation(s)
- Puja Mehta
- Centre for Inflammation and Tissue Repair, Division of Medicine, University College London, London, UK; Department of Rheumatology, University College London Hospital, London, UK
| | - Joanna C Porter
- Centre for Inflammation and Tissue Repair, Division of Medicine, University College London, London, UK
| | - Jessica J Manson
- Department of Rheumatology, University College London Hospital, London, UK
| | - John D Isaacs
- Institute of Cellular Medicine, Newcastle University, Newcastle, UK
| | - Peter J M Openshaw
- National Heart and Lung Institute, Faculty of Medicine, Imperial College London, London, UK
| | - Iain B McInnes
- Institute of Infection, Immunity and Inflammation, University of Glasgow, Glasgow, UK
| | | | - Rachel C Chambers
- Centre for Inflammation and Tissue Repair, Division of Medicine, University College London, London, UK.
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168
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Opoka-Winiarska V, Grywalska E, Roliński J. Could hemophagocytic lymphohistiocytosis be the core issue of severe COVID-19 cases? BMC Med 2020; 18:214. [PMID: 32664932 PMCID: PMC7360379 DOI: 10.1186/s12916-020-01682-y] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 06/25/2020] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND COVID-19, a disease caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), commonly presents as fever, cough, dyspnea, and myalgia or fatigue. Although the majority of patients with COVID-19 have mild symptoms, some are more prone to serious outcomes, including pneumonia, acute respiratory distress syndrome (ARDS), and even death. Hemophagocytic lymphohistiocytosis (HLH) is a severe, life-threatening inflammatory syndrome associated with intense cytokine release (also known as a "cytokine storm"). Similar to COVID-19, HLH is characterized by aggressive course leading to multi-organ failure. MAIN TEXT The purpose of this review article is to draw attention to the possibility of the complication of HLH in patients with the severe course of COVID-19. Indeed, some of the clinical characteristics observed in the more severe cases of COVID-19 are reminiscent of secondary HLH (which can be triggered by infections, malignancies, rheumatological diseases, or autoimmune/immunodeficiency conditions). The pathogenesis of SARS-CoV-2 infection also suggests that HLH or a similar hyperinflammatory syndrome is the cause of the severe course of the infection. CONCLUSION The pathogenesis and clinical symptoms of severe COVID-19 indicate that an increased inflammatory response corresponding to HLH is occurring. Therefore, patients with severe COVID-19 should be screened for hyperinflammation using standard laboratory tests to identify those for whom immunosuppressive therapy may improve outcomes.
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Affiliation(s)
- Violetta Opoka-Winiarska
- Department of Paediatric Pulmonology and Rheumatology, Medical University of Lublin, Gębali 6, 20-093, Lublin, Poland.
| | - Ewelina Grywalska
- Department of Clinical Immunology and Immunotherapy, Medical University of Lublin, Chodzki 4a Street, 20-093, Lublin, Poland.,Department of Clinical Immunology, St. John's Cancer Hospital, K. Jaczewskiego 7 St, 20-090, Lublin, Poland
| | - Jacek Roliński
- Department of Clinical Immunology and Immunotherapy, Medical University of Lublin, Chodzki 4a Street, 20-093, Lublin, Poland.,Department of Clinical Immunology, St. John's Cancer Hospital, K. Jaczewskiego 7 St, 20-090, Lublin, Poland
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169
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Seffer MT, Cottam D, Forni LG, Kielstein JT. Heparin 2.0: A New Approach to the Infection Crisis. Blood Purif 2020; 50:28-34. [PMID: 32615569 PMCID: PMC7445380 DOI: 10.1159/000508647] [Citation(s) in RCA: 59] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Accepted: 05/11/2020] [Indexed: 11/22/2022]
Abstract
In April 2020, the US Food and Drug Administration granted emergency use authorization for certain medical devices to be used in patients with coronavirus disease 2019 (COVID-19). This included extracorporeal blood purification devices. This narrative review will give a brief overview regarding some of the extracorporeal devices that could be used to treat COVID-19 patients, including the Seraph® 100 Microbind® Affinity Blood Filter, produced by ExThera Medical (Martinez, CA, USA), first licensed in the European Economic Area in 2019. The Seraph® 100 contains ultrahigh molecular weight polyethylene beads with end point-attached heparin and is approved for the reduction of pathogens from the bloodstream either as a single agent or as an adjunct to conventional anti-infective agents. Bacteria, viruses, fungi, and toxins have been shown to bind to the immobilized heparin in a similar way to the interaction with heparan sulfate on the cell surface. This binding is nonreversible and as such, the pathogens are removed from the bloodstream. In this review, we describe the pathophysiological basis and rationale for using heparin for pathogen removal from the blood as well as exploring the technology behind the adaptation of heparin to deprive it of its systemic anticoagulant activity. In addition, we summarize the in vitro data as well as the available preclinical testing and published clinical reports. Finally, we discuss the enormous potential of this technology in an era of increasing antibiotic resistance and high mortality associated with sepsis and consider the application of this as a possible treatment option for COVID-19.
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Affiliation(s)
- Malin-Theres Seffer
- Medical Clinic V, Nephrology
- Rheumatology
- Blood Purification, Academic Teaching Hospital Braunschweig, Braunschweig, Germany.,Microbial Proteomics, Helmholtz Centre for Infection Research, Braunschweig, Germany
| | - Daniel Cottam
- Intensive Care Unit, Royal Surrey Hospital NHS Foundation Trust, Guildford, United Kingdom
| | - Lui G Forni
- Intensive Care Unit, Royal Surrey Hospital NHS Foundation Trust, Guildford, United Kingdom.,Department of Clinical & Experimental Medicine, School of Biosciences & Medicine, University of Surrey, Guildford, United Kingdom
| | - Jan T Kielstein
- Medical Clinic V, Nephrology
- Rheumatology
- Blood Purification, Academic Teaching Hospital Braunschweig, Braunschweig, Germany,
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170
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Nasonov EL. IMMUNOPATHOLOGY AND IMMUNOPHARMACOTHERAPY OF CORONAVIRUS DISEASE 2019 (COVID-19): FOCUS ON INTERLEUKIN 6. RHEUMATOLOGY SCIENCE AND PRACTICE 2020. [DOI: 10.14412/1995-4484-2020-245-261] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
The Coronavirus Disease 2019 (COVID-19) pandemic has drawn closer attention than ever before to the problems of the immunopathology of human diseases, many of which have been reflected when studying immune-mediated inflammatory rheumatic diseases (IIRDs). The hyperimmune response called a cytokine storm, the pathogenetic subtypes of which include hemophagocytic lymphohistiocytosis, macrophage activation syndrome, and cytokine release syndrome, is among the most serious complications of IIRDs or treatment for malignant neoplasms and may be a stage of COVID-19 progression. A premium is placed to interleukin-6 (IL-6) in the spectrum of cytokines involved in the pathogenesis of the cytokine storm syndrome. The clinical introduction of monoclonal antibodies (mAbs) that inhibit the activity of this cytokine (tocilizumab, sarilumab, etc.) is one of the major advances in the treatment of IIRDs and critical conditions within the cytokine storm syndrome in COVID-19. The review discusses data on the clinical and prognostic value of IL-6 and the effectiveness of anti-IL-6 receptor and anti-IL-6 mAbs, as well as prospects for personalized therapy of the cytokine storm syndrome in COVID-19.
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Affiliation(s)
- E. L. Nasonov
- V.A. Nasonova Research Institute of Rheumatology; I.M. Sechenov First Moscow State Medical University (Sechenov University), Ministry of Health of Russia
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171
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Song Y, Ye Y, Su SH, Stephens A, Cai T, Chung MT, Han M, Newstead MW, Frame D, Singer BH, Kurabayashi K. A Digital Protein Microarray for COVID-19 Cytokine Storm Monitoring. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2020:2020.06.15.20131870. [PMID: 32587979 PMCID: PMC7310633 DOI: 10.1101/2020.06.15.20131870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/23/2023]
Abstract
Despite widespread concern for cytokine storms leading to severe morbidity in COVID-19, rapid cytokine assays are not routinely available for monitoring critically ill patients. We report the clinical application of a machine learning-based digital protein microarray platform for rapid multiplex quantification of cytokines from critically ill COVID-19 patients admitted to the intensive care unit (ICU) at the University of Michigan Hospital. The platform comprises two low-cost modules: (i) a semi-automated fluidic dispensing/mixing module that can be operated inside a biosafety cabinet to minimize the exposure of technician to the virus infection and (ii) a 12-12-15 inch compact fluorescence optical scanner for the potential near-bedside readout. The platform enabled daily cytokine analysis in clinical practice with high sensitivity (<0.4pg/mL), inter-assay repeatability (~10% CV), and near-real-time operation with a 10 min assay incubation. A cytokine profiling test with the platform allowed us to observe clear interleukin-6 (IL-6) elevations after receiving tocilizumab (IL-6 inhibitor) while significant cytokine profile variability exists across all critically ill COVID-19 patients and to discover a weak correlation between IL-6 to clinical biomarkers, such as Ferritin and CRP. Our data revealed large subject-to-subject variability in a patient's response to anti-inflammatory treatment for COVID-19, reaffirming the need for a personalized strategy guided by rapid cytokine assays.
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172
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Ehrenreich H, Weissenborn K, Begemann M, Busch M, Vieta E, Miskowiak KW. Erythropoietin as candidate for supportive treatment of severe COVID-19. Mol Med 2020; 26:58. [PMID: 32546125 PMCID: PMC7297268 DOI: 10.1186/s10020-020-00186-y] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Accepted: 06/08/2020] [Indexed: 02/07/2023] Open
Abstract
In light of the present therapeutic situation in COVID-19, any measure to improve course and outcome of seriously affected individuals is of utmost importance. We recap here evidence that supports the use of human recombinant erythropoietin (EPO) for ameliorating course and outcome of seriously ill COVID-19 patients. This brief expert review grounds on available subject-relevant literature searched until May 14, 2020, including Medline, Google Scholar, and preprint servers. We delineate in brief sections, each introduced by a summary of respective COVID-19 references, how EPO may target a number of the gravest sequelae of these patients. EPO is expected to: (1) improve respiration at several levels including lung, brainstem, spinal cord and respiratory muscles; (2) counteract overshooting inflammation caused by cytokine storm/ inflammasome; (3) act neuroprotective and neuroregenerative in brain and peripheral nervous system. Based on this accumulating experimental and clinical evidence, we finally provide the research design for a double-blind placebo-controlled randomized clinical trial including severely affected patients, which is planned to start shortly.
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Affiliation(s)
- Hannelore Ehrenreich
- Clinical Neuroscience, Max Planck Institute of Experimental Medicine, Göttingen, Germany.
| | | | - Martin Begemann
- Clinical Neuroscience, Max Planck Institute of Experimental Medicine, Göttingen, Germany
- Department of Psychiatry & Psychotherapy, University Medical Center, Göttingen, Germany
| | - Markus Busch
- Center of Internal Medicine, Hannover Medical School, Hannover, Germany
| | - Eduard Vieta
- Institute of Neuroscience, University of Barcelona, IDIBAPS, CIBERSAM, Barcelona, Spain
| | - Kamilla W Miskowiak
- Psychiatric Centre Copenhagen, University Hospital, Rigshospitalet, Copenhagen, Denmark.
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173
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González-Gay MA, Mayo J, Castañeda S, Cifrián JM, Hernández-Rodríguez J. Tocilizumab: from the rheumatology practice to the fight against COVID-19, a virus infection with multiple faces. Expert Opin Biol Ther 2020; 20:717-723. [PMID: 32406282 PMCID: PMC7441755 DOI: 10.1080/14712598.2020.1770222] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Miguel A González-Gay
- Division of Rheumatology and Epidemiology, Genetics and Atherosclerosis Research Group on Systemic Inflammatory Diseases, Hospital Universitario Marqués de Valdecilla, IDIVAL , Santander, Spain.,University of Cantabria , Santander, Spain.,Cardiovascular Pathophysiology and Genomics Research Unit, School of Physiology, Faculty of Health Sciences, University of the Witwatersrand , Johannesburg, South Africa
| | - José Mayo
- Infectious Diseases Unit, Galdakao-Usansolo Hospital , Galdakao, Bizkaia, Spain
| | - Santos Castañeda
- Rheumatology Division, Hospital de La Princesa, IIS-Princesa, Cátedra UAM-Roche, EPID Future, Universidad Autónoma de Madrid (UAM) , Madrid, Spain
| | - José M Cifrián
- Division of Pneumology, Hospital Universitario Marqués de Valdecilla, IDIVAL , Santander, Spain
| | - José Hernández-Rodríguez
- Vasculitis Research Unit and Clinical Unit of Autoinflammatory Diseases, Department of Autoimmune Diseases, Hospital Clínic of Barcelona, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS) , Barcelona, Spain
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174
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Abstract
Background Coronaviruses can induce the production of interleukin (IL)-1β, IL-6, tumour necrosis factor, and other cytokines implicated in autoinflammatory disorders. It has been postulated that anakinra, a recombinant IL-1 receptor antagonist, might help to neutralise the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-related hyperinflammatory state, which is considered to be one cause of acute respiratory distress among patients with COVID-19. We aimed to assess the off-label use of anakinra in patients who were admitted to hospital for severe forms of COVID-19 with symptoms indicative of worsening respiratory function. Methods The Ana-COVID study included a prospective cohort from Groupe Hospitalier Paris Saint-Joseph (Paris, France) and a historical control cohort retrospectively selected from the Groupe Hospitalier Paris Saint-Joseph COVID cohort, which began on March 18, 2020. Patients were included in the prospective cohort if they were aged 18 years or older and admitted to Groupe Hospitalier Paris Saint-Joseph with severe COVID-19-related bilateral pneumonia on chest x-ray or lung CT scan. The other inclusion criteria were either laboratory-confirmed SARS-CoV-2 or typical lung infiltrates on a lung CT scan, and either an oxygen saturation of 93% or less under oxygen 6 L/min or more, or aggravation (saturation ≤93% under oxygen 3 L/min) with a loss of 3% of oxygen saturation in ambient air over the previous 24 h. The historical control group of patients had the same inclusion criteria. Patients in the anakinra group were treated with subcutaneous anakinra (100 mg twice a day for 72 h, then 100 mg daily for 7 days) as well as the standard treatments at the institution at the time. Patients in the historical group received standard treatments and supportive care. The main outcome was a composite of either admission to the intensive care unit (ICU) for invasive mechanical ventilation or death. The main analysis was done on an intention-to-treat basis (including all patients in the anakinra group who received at least one injection of anakinra). Findings From March 24 to April 6, 2020, 52 consecutive patients were included in the anakinra group and 44 historical patients were identified in the Groupe Hospitalier Paris Saint-Joseph COVID cohort study. Admission to the ICU for invasive mechanical ventilation or death occurred in 13 (25%) patients in the anakinra group and 32 (73%) patients in the historical group (hazard ratio [HR] 0·22 [95% CI 0·11–0·41; p<0·0001). The treatment effect of anakinra remained significant in the multivariate analysis (HR 0·22 [95% CI 0·10–0·49]; p=0·0002). An increase in liver aminotransferases occurred in seven (13%) patients in the anakinra group and four (9%) patients in the historical group. Interpretation Anakinra reduced both need for invasive mechanical ventilation in the ICU and mortality among patients with severe forms of COVID-19, without serious side-effects. Confirmation of efficacy will require controlled trials. Funding Groupe Hospitalier Paris Saint-Joseph.
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175
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Meneghel A, Martini G, Amigoni A, Pettenazzo A, Padalino M, Zulian F. Case Report: Life-Threatening Macrophage Activation Syndrome With Fulminant Myocarditis Successfully Rescued by High Dose Intravenous Anakinra. Front Pediatr 2020; 8:635080. [PMID: 33537271 PMCID: PMC7848179 DOI: 10.3389/fped.2020.635080] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Accepted: 12/22/2020] [Indexed: 01/20/2023] Open
Abstract
Macrophage activation syndrome (MAS) is a rare, potentially life-threatening, condition triggered by infections or flares in rheumatologic and neoplastic diseases. The mainstay of treatment includes high dose corticosteroids, intravenous immunoglobulins and immunosuppressive drugs although, more recently, a more targeted approach, based on the use of selective cytokines inhibitors, has been reported. We present the case of a two-year-old boy with 1-month history of high degree fever associated with limping gait, cervical lymphadenopathy and skin rash. Laboratory tests showed elevation of inflammatory markers and ferritin. By exclusion criteria, systemic onset Juvenile Idiopathic Arthritis (sJIA) was diagnosed and steroid therapy started. A couple of weeks later, fever relapsed and laboratory tests were consistent with MAS. He was promptly treated with high doses intravenous methylprednisolone pulses and oral cyclosporin A. One day later, he developed an acute myocarditis and a systemic capillary leak syndrome needing intensive care. Intravenous Immunoglobulin and subcutaneous IL-1-antagonists Anakinra were added. On day 4, after an episode of cardiac arrest, venous-arterial extracorporeal membrane oxygenation (VA-ECMO) was started. Considering the severe refractory clinical picture, we tried high dose intravenous Anakinra (HDIV-ANA, 2 mg/Kg q6h). This treatment brought immediate benefit: serial echocardiography showed progressive resolution of myocarditis, VA-ECMO was gradually decreased and definitively weaned off in 6 days and MAS laboratory markers improved. Our case underscores the importance of an early aggressive treatment in refractory life-threatening sJIA-related MAS and adds evidence on safety and efficacy of HDIV-ANA particularly in acute myocarditis needing VA-ECMO support.
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Affiliation(s)
- Alessandra Meneghel
- Pediatric Rheumatology Unit, Department of Women's and Children's Health, University Hospital of Padua, Padua, Italy
| | - Giorgia Martini
- Pediatric Rheumatology Unit, Department of Women's and Children's Health, University Hospital of Padua, Padua, Italy
| | - Angela Amigoni
- Pediatric Intensive Care Unit, Department of Women's and Children's Health, University Hospital of Padua, Padua, Italy
| | - Andrea Pettenazzo
- Pediatric Intensive Care Unit, Department of Women's and Children's Health, University Hospital of Padua, Padua, Italy
| | - Massimo Padalino
- Pediatric and Congenital Cardiac Surgery, Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Padua, Italy
| | - Francesco Zulian
- Pediatric Rheumatology Unit, Department of Women's and Children's Health, University Hospital of Padua, Padua, Italy
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