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Mellor-Pita S, Tutor-Ureta P, Velasco P, Plaza A, Diego I, Vázquez-Comendador J, Vionnet AP, Durán-del Campo P, Moreno-Torres V, Vargas JA, Castejon R. IgA Anti-β2-Glycoprotein I Antibodies as Markers of Thrombosis and Severity in COVID-19 Patients. Viruses 2024; 16:1071. [PMID: 39066233 PMCID: PMC11281419 DOI: 10.3390/v16071071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2024] [Revised: 06/27/2024] [Accepted: 07/01/2024] [Indexed: 07/28/2024] Open
Abstract
Patients with COVID-19 may develop a hypercoagulable state due to tissue and endothelial injury, produced by an unbalanced immune response. Therefore, an increased number of thromboembolic events has been reported in these patients. The aim of this study is to investigate the presence of antiphospholipid antibodies (aPL) in COVID-19 patients, their role in the development of thrombosis and their relationship with the severity of the disease. In this retrospective study, serum samples from 159 COVID-19 patients and 80 healthy donors were analysed for the presence of aPL. A total of 29 patients (18.2%) and 14 healthy donors (17.5%) were positive for aPL. Nineteen COVID-19 patients (12%) but no healthy donor presented a positive percentage of the IgA isotype aPL. IgA anti-β2-glycoprotein I antibodies (anti-β2GPI) were the most frequent type (6.3%) in patients but was not detected in any healthy donor. The positivity of this antibody was found to be significantly elevated in patients with thromboembolic events (25% vs. 5%, p = 0.029); in fact, patients with positive IgA anti-β2GPI had an incidence of thrombosis over six times higher than those who had normal antibody concentrations [OR (CI 95%) of 6.67 (1.5-30.2), p = 0.014]. Additionally, patients with moderate-severe disease presented a higher aPL positivity than patients with mild disease according to the Brescia (p = 0.029) and CURB-65 (p = 0.011) severity scales. A multivariate analysis showed that positivity for IgA anti-β2GPI is significantly associated with disease severity measured by CURB-65 [OR (CI 95%) 17.8 (1.7-187), p = 0.0016]. In conclusion, COVID-19 patients have a significantly higher positive percentage of the IgA isotype aPL than healthy donors. IgA anti-β2GPI antibodies were the most frequently detected aPL in COVID-19 patients and were associated with thrombosis and severe COVID-19 and are thus proposed as a possible marker to identify high-risk patients.
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Affiliation(s)
- Susana Mellor-Pita
- Systemic Autoimmune Diseases Unit, Department of Internal Medicine, IDIPHIM (Puerta de Hierro University Hospital Research Institute), Hospital Universitario Puerta de Hierro Majadahonda, 28222 Madrid, Spain; (S.M.-P.); (P.T.-U.); (P.V.); (I.D.); (J.V.-C.); (P.D.-d.C.); (V.M.-T.); (J.A.V.)
- Department of Medicine, Facultad de Medicina, Universidad Autónoma de Madrid, 28029 Madrid, Spain
| | - Pablo Tutor-Ureta
- Systemic Autoimmune Diseases Unit, Department of Internal Medicine, IDIPHIM (Puerta de Hierro University Hospital Research Institute), Hospital Universitario Puerta de Hierro Majadahonda, 28222 Madrid, Spain; (S.M.-P.); (P.T.-U.); (P.V.); (I.D.); (J.V.-C.); (P.D.-d.C.); (V.M.-T.); (J.A.V.)
- Department of Medicine, Facultad de Medicina, Universidad Autónoma de Madrid, 28029 Madrid, Spain
| | - Paula Velasco
- Systemic Autoimmune Diseases Unit, Department of Internal Medicine, IDIPHIM (Puerta de Hierro University Hospital Research Institute), Hospital Universitario Puerta de Hierro Majadahonda, 28222 Madrid, Spain; (S.M.-P.); (P.T.-U.); (P.V.); (I.D.); (J.V.-C.); (P.D.-d.C.); (V.M.-T.); (J.A.V.)
| | - Aresio Plaza
- Department of Immunology, Hospital Universitario Puerta de Hierro Majadahonda, 28222 Madrid, Spain; (A.P.); (A.P.V.)
| | - Itziar Diego
- Systemic Autoimmune Diseases Unit, Department of Internal Medicine, IDIPHIM (Puerta de Hierro University Hospital Research Institute), Hospital Universitario Puerta de Hierro Majadahonda, 28222 Madrid, Spain; (S.M.-P.); (P.T.-U.); (P.V.); (I.D.); (J.V.-C.); (P.D.-d.C.); (V.M.-T.); (J.A.V.)
| | - José Vázquez-Comendador
- Systemic Autoimmune Diseases Unit, Department of Internal Medicine, IDIPHIM (Puerta de Hierro University Hospital Research Institute), Hospital Universitario Puerta de Hierro Majadahonda, 28222 Madrid, Spain; (S.M.-P.); (P.T.-U.); (P.V.); (I.D.); (J.V.-C.); (P.D.-d.C.); (V.M.-T.); (J.A.V.)
| | - Ana Paula Vionnet
- Department of Immunology, Hospital Universitario Puerta de Hierro Majadahonda, 28222 Madrid, Spain; (A.P.); (A.P.V.)
| | - Pedro Durán-del Campo
- Systemic Autoimmune Diseases Unit, Department of Internal Medicine, IDIPHIM (Puerta de Hierro University Hospital Research Institute), Hospital Universitario Puerta de Hierro Majadahonda, 28222 Madrid, Spain; (S.M.-P.); (P.T.-U.); (P.V.); (I.D.); (J.V.-C.); (P.D.-d.C.); (V.M.-T.); (J.A.V.)
| | - Víctor Moreno-Torres
- Systemic Autoimmune Diseases Unit, Department of Internal Medicine, IDIPHIM (Puerta de Hierro University Hospital Research Institute), Hospital Universitario Puerta de Hierro Majadahonda, 28222 Madrid, Spain; (S.M.-P.); (P.T.-U.); (P.V.); (I.D.); (J.V.-C.); (P.D.-d.C.); (V.M.-T.); (J.A.V.)
| | - Juan Antonio Vargas
- Systemic Autoimmune Diseases Unit, Department of Internal Medicine, IDIPHIM (Puerta de Hierro University Hospital Research Institute), Hospital Universitario Puerta de Hierro Majadahonda, 28222 Madrid, Spain; (S.M.-P.); (P.T.-U.); (P.V.); (I.D.); (J.V.-C.); (P.D.-d.C.); (V.M.-T.); (J.A.V.)
- Department of Medicine, Facultad de Medicina, Universidad Autónoma de Madrid, 28029 Madrid, Spain
| | - Raquel Castejon
- Systemic Autoimmune Diseases Unit, Department of Internal Medicine, IDIPHIM (Puerta de Hierro University Hospital Research Institute), Hospital Universitario Puerta de Hierro Majadahonda, 28222 Madrid, Spain; (S.M.-P.); (P.T.-U.); (P.V.); (I.D.); (J.V.-C.); (P.D.-d.C.); (V.M.-T.); (J.A.V.)
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Wang C, Jiang H, Chen S, Zhao Y, Li J, Huang C, Zhou Y, Wang Q, Tian X, Li M, Zeng X, Zhao Y, Wu C, Zhao J. Exploring the impact of acute viral exposure on clinical characteristics and antibody profiles in antiphospholipid syndrome: a study in CAPSTONE. Clin Exp Med 2024; 24:130. [PMID: 38888664 PMCID: PMC11189343 DOI: 10.1007/s10238-024-01400-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2024] [Accepted: 06/10/2024] [Indexed: 06/20/2024]
Abstract
The relationship between antiphospholipid syndrome (APS) and acute viral infection, such as SARS-CoV-2, is unclear. This study aims to assess symptoms, antiphospholipid antibody (aPL) fluctuations, and complication risks in APS patients infected with SARS-CoV-2. APS patients from Peking Union Medical College Hospital during the COVID-19 outbreak (October-December 2022) were included. Age- and gender-matched APS patients without infection served as controls. Data on demographics, symptoms, treatments, and serum aPL levels were analyzed. Of 234 APS patients, 107 (45.7%) were infected with SARS-CoV-2. Typical symptoms included high fever (81.3%), cough/expectoration (70.1%), and pharyngalgia (52.3%). Age- and gender-based matching selected 97 patients in either infected or uninfected group. After infection, anti-β-2-glycoprotein I-IgG (aβ2GP1-IgG) increased from 4.14 to 4.18 AU/ml, aβ2GP1-IgM decreased from 9.85 to 7.38 AU/ml, and anticardiolipin-IgA (aCL-IgA) significantly increased with a median remaining at 2.50 APLU/ml. Lupus anticoagulants and other aPLs remained stable. Arterial thrombosis incidence increased from 18 (18.6%) to 21 (21.6%), while venous thrombosis incidence did not change. Additionally, 7 (6.5%) patients presented either new-onset or worsening thrombocytopenia, characterized by a significant decline in platelet count (no less than 10 × 109/L) within two weeks of SARS-CoV-2 infection, all of which recovered within 2 weeks. Acute SARS-CoV-2 infection may induce or worsen thrombocytopenia but does not substantially increase thrombotic events in APS. The process of SARS-CoV-2 infection was related to mild titer fluctuation of aβ2GP1-IgG, aβ2GP1-IgM and aCL-IgA in APS patients, necessitating careful monitoring and management.
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Affiliation(s)
- Chuhan Wang
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Beijing, 100730, China
| | - Hui Jiang
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Beijing, 100730, China
| | - Siyun Chen
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Beijing, 100730, China
| | - Yuan Zhao
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Beijing, 100730, China
| | - Jun Li
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Beijing, 100730, China
| | - Can Huang
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Beijing, 100730, China
- National Clinical Research Center of Dermatologic and Immunologic Diseases (NCRC-DID), Beijing, 100730, China
- Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, 100730, China
- State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Beijing, 100730, China
| | - Yangzhong Zhou
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Beijing, 100730, China
- National Clinical Research Center of Dermatologic and Immunologic Diseases (NCRC-DID), Beijing, 100730, China
- Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, 100730, China
- State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Beijing, 100730, China
| | - Qian Wang
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Beijing, 100730, China
- National Clinical Research Center of Dermatologic and Immunologic Diseases (NCRC-DID), Beijing, 100730, China
- Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, 100730, China
- State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Beijing, 100730, China
| | - Xinping Tian
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Beijing, 100730, China
- National Clinical Research Center of Dermatologic and Immunologic Diseases (NCRC-DID), Beijing, 100730, China
- Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, 100730, China
- State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Beijing, 100730, China
| | - Mengtao Li
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Beijing, 100730, China
- National Clinical Research Center of Dermatologic and Immunologic Diseases (NCRC-DID), Beijing, 100730, China
- Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, 100730, China
- State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Beijing, 100730, China
| | - Xiaofeng Zeng
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Beijing, 100730, China
- National Clinical Research Center of Dermatologic and Immunologic Diseases (NCRC-DID), Beijing, 100730, China
- Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, 100730, China
- State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Beijing, 100730, China
| | - Yan Zhao
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Beijing, 100730, China
- National Clinical Research Center of Dermatologic and Immunologic Diseases (NCRC-DID), Beijing, 100730, China
- Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, 100730, China
- State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Beijing, 100730, China
| | - Chuancong Wu
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Beijing, 100730, China.
- Department of Rheumatology and Immunology, Affiliated Qingyuan Hospital, The Sixth Clinical Medical School, Guangzhou Medical University, Qingyuan People's Hospital, Qingyuan, 511518, Guangdong, China.
| | - Jiuliang Zhao
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Beijing, 100730, China.
- National Clinical Research Center of Dermatologic and Immunologic Diseases (NCRC-DID), Beijing, 100730, China.
- Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, 100730, China.
- State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Beijing, 100730, China.
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Mahroum N, Habra M, Alrifaai MA, Shoenfeld Y. Antiphospholipid syndrome in the era of COVID-19 - Two sides of a coin. Autoimmun Rev 2024:103543. [PMID: 38604461 DOI: 10.1016/j.autrev.2024.103543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Revised: 04/08/2024] [Accepted: 04/08/2024] [Indexed: 04/13/2024]
Abstract
In addition to the respiratory symptoms associated with COVID-19, the disease has consistently been linked to many autoimmune diseases such as systemic lupus erythematous and antiphospholipid syndrome (APS). APS in particular was of paramount significance due to its devastating clinical sequela. In fact, the hypercoagulable state seen in patients with acute COVID-19 and the critical role of anticoagulant treatment in affected individuals shed light on the possible relatedness between APS and COVID-19. Moreover, the role of autoimmunity in the assumed association is not less important especially with the accumulated data available regarding the autoimmunity-triggering effect of SARS-CoV-2 infection. This is furtherly strengthened at the time patients with COVID-19 manifested antiphospholipid antibodies of different types following infection. Additionally, the severe form of the APS spectrum, catastrophic APS (CAPS), was shown to have overlapping characteristics with severe COVID-19 such as cytokine storm and multi-organ failure. Interestingly, COVID vaccine-induced autoimmune phenomena described in the medical literature have pointed to an association with APS. Whether the antiphospholipid antibodies were present or de novo, COVID vaccine-induced vascular thrombosis in certain individuals necessitates further investigations regarding the possible mechanisms involved. In our current paper, we aimed to focus on the associations mentioned, their implications, importance, and consequences.
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Affiliation(s)
- Naim Mahroum
- International School of Medicine, Istanbul Medipol University, Istanbul, Turkey.
| | - Mona Habra
- International School of Medicine, Istanbul Medipol University, Istanbul, Turkey
| | | | - Yehuda Shoenfeld
- Zabludowicz Center for autoimmune diseases, Sheba Medical Center, Ramat-Gan, Israel; Reichman University, Herzliya, Israel
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4
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de Groot PG. The mystery of autoantibodies solved? Blood 2024; 143:1065-1066. [PMID: 38512263 DOI: 10.1182/blood.2023023637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/22/2024] Open
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Rodriguez-Pintó I, Espinosa G, Cervera R. What we know and what we don't know about catastrophic antiphospholipid syndrome. Rheumatology (Oxford) 2024; 63:SI46-SI53. [PMID: 38320593 DOI: 10.1093/rheumatology/kead556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 08/16/2023] [Indexed: 02/08/2024] Open
Abstract
Catastrophic antiphospholipid syndrome (CAPS) is a severe condition with high mortality. Since its description in 1992, an important effort has been made to improve and disseminate knowledge on CAPS. Most of our current knowledge comes from the studies performed using the CAPS Registry, a database created in 2000 to gather as many cases as possible in order to better define this disease. It has demonstrated that this condition has multiple faces and is often triggered by a precipitating factor that leads to a thrombotic microangiopathy and cytokine storm involving almost any organ of the body. Analysis of the CAPS Registry has also shown that patients receiving anticoagulation, glucocorticoids and plasma exchange and/or IVIG have a better prognosis. However, there are still many unresolved questions. In this review we summarize what is known and what is still a matter of research in this condition.
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Affiliation(s)
- Ignasi Rodriguez-Pintó
- Autoimmune Diseases Unit, Hospital Universitari Mútua de Terrassa, Terrassa, Catalonia, Spain
| | - Gerard Espinosa
- Department of Autoimmune Diseases, Reference Centre for Systemic Autoimmune Diseases (UEC, CSUR) of the Catalan and Spanish Health Systems/Member of ERN-ReCONNET, Hospital Clínic, Barcelona, Catalonia, Spain
| | - Ricard Cervera
- Department of Autoimmune Diseases, Reference Centre for Systemic Autoimmune Diseases (UEC, CSUR) of the Catalan and Spanish Health Systems/Member of ERN-ReCONNET, Hospital Clínic, Barcelona, Catalonia, Spain
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Costa Oliveira D, Assis JG, Linhares F, Carrola P. Anticardiolipin Antibody Determination to Guide Q Fever Treatment. Cureus 2024; 16:e51840. [PMID: 38327944 PMCID: PMC10847898 DOI: 10.7759/cureus.51840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/06/2024] [Indexed: 02/09/2024] Open
Abstract
Query (Q) fever is a worldwide infectious disease with acute and chronic manifestations caused by Coxiella burnetii. The clinical manifestations are so variable that the disease is often only diagnosed if systematically considered as a differential diagnosis. Here, we present a case of a 39-year-old man who lived in a countryside house, with cattle and sheep in his field, with acute Q fever hepatitis with the typical granulomatous arrangement in the liver biopsy. The diagnosis was confirmed by polymerase chain reaction (PCR) assay in a serum sample and the presence of phase II antibodies. Anticardiolipin antibody (aCL) determination at diagnosis of acute Q fever and during follow-up was made to persecute early identification and to guide the treatment and prophylaxis of possible complications, such as endocarditis.
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Affiliation(s)
- Diogo Costa Oliveira
- Intensive Care Unit, Centro Hospitalar de Trás-os-Montes e Alto Douro, Vila Real, PRT
| | - José Guilherme Assis
- Internal Medicine, Centro Hospitalar de Trás-os-Montes e Alto Douro, Vila Real, PRT
| | - Fernanda Linhares
- Internal Medicine, Centro Hospitalar de Trás-os-Montes e Alto Douro, Vila Real, PRT
| | - Paulo Carrola
- Internal Medicine, Centro Hospitalar de Trás-os-Montes e Alto Douro, Vila Real, PRT
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Rachkovska A, Krenytska D, Karbovskyy V, Raksha N, Halenova T, Vovk T, Savchuk O, Ostapchenko L. A study of fibrinolytic system components in donor groups depending on various titers of circulating anti-SARS-CoV-2 IgG in the bloodstream. Blood Coagul Fibrinolysis 2023; 34:439-445. [PMID: 37577922 DOI: 10.1097/mbc.0000000000001248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/15/2023]
Abstract
The fibrinolytic system plays an important role in controlling blood coagulation at each stage, from thrombin generation to fibrin clot cleavage. Currently, long-term multiorgan dysfunction post-coronavirus disease 2019 (COVID-19) may include coagulation disorders. Little information is available about the potential causes of post-COVID-19 coagulopathy, but one of them may be subpopulation IgG produced by the immune system against SARS-CoV-2. This article describes the changes in the main parameters of the fibrinolytic system in donors with various titers of anti-SARS-CoV-2 IgG, which is part of a complex study of the hemostasis system in these donor groups. We determined the most significant parameters of the fibrinolytic system, such as potential activity and amount of plasminogen and tissue plasminogen activator (tPA), amount of plasminogen activator inhibitor-1 (PAI-1), inhibitory potentials of α-2-antiplasmin, α-1-antitrypsin, α-2-macroglobulin in the blood plasma of donor groups. The obtained results represent the maximum and minimum values of measurement parameters among donor groups with titers of anti-SARS-CoV-2 IgG at least 10 ± 3 Index (S/C), and their statistical differences from the reference point [donor group with titer of anti-SARS-CoV-2 IgG 0 Index (S/C)]. We established the changes in fibrinolytic parameters depending on the titers of anti-SARS-CoV-2 IgG. One conclusion can be drawn from this: anti-SARS-CoV-2 IgG population may influence coagulation in the post-COVID-19 period. Further research in-vitro and in-vivo experimental models using selected and purified IgG may confirm our previous findings.
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Dima A, Popescu DN, Moroti R, Stoica E, State G, Negoi F, Berza IA, Parvu M. Antiphospholipid Antibodies Occurrence in Acute SARS-CoV-2 Infection without Overt Thrombosis. Biomedicines 2023; 11:biomedicines11051241. [PMID: 37238912 DOI: 10.3390/biomedicines11051241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Revised: 04/12/2023] [Accepted: 04/19/2023] [Indexed: 05/28/2023] Open
Abstract
We sought to determine the prevalence of antiphospholipid antibodies (aPLs) and their correlation with COVID-19 severity (in terms of clinical and laboratory parameters) in patients without thrombotic events during the early phase of infection. This was a cross-sectional study with the inclusion of hospitalized COVID-19 patients from a single department during the COVID-19 pandemic (April 2020-May 2021). Previous known immune disease or thrombophilia along with long-term anticoagulation and patients with overt arterial or venous thrombosis during SARS-CoV-2 infection were excluded. In all cases, data on four criteria for aPL were collected, namely lupus anticoagulant (LA), IgM and IgG anticardiolipin antibodies (aCL), as well as IgG anti-β2 glycoprotein I antibodies (aβ2GPI). One hundred and seventy-nine COVID-19 patients were included, with a mean age of 59.6 (14.5) years and a sex ratio of 0.8 male: female. LA was positive in 41.9%, while it was strongly positive in 4.5%; aCL IgM was found in 9.5%, aCL IgG in 4.5%, and aβ2GPI IgG in 1.7% of the sera tested. Clinical correlation: LA was more frequently expressed in severe COVID-19 cases than in moderate or mild cases (p = 0.027). Laboratory correlation: In univariate analysis, LA levels were correlated with D-dimer (p = 0.016), aPTT (p = 0.001), ferritin (p = 0.012), C-reactive protein (CRP) (p = 0.027), lymphocyte (p = 0.040), and platelet (p < 0.001) counts. However, in the multivariate analysis, only the CRP levels correlated with LA positivity: OR (95% CI) 1.008 (1.001-1.016), p = 0.042. LA was the most common aPL identified in the acute phase of COVID-19 and was correlated with infection severity in patients without overt thrombosis.
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Affiliation(s)
- Alina Dima
- Department of Rheumatology, Colentina Clinical Hospital, 020125 Bucharest, Romania
| | | | - Ruxandra Moroti
- Department of Infectious Diseases, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania
- Department of Infectious Diseases, National Institute for Infectious Diseases Matei Bals, 021105 Bucharest, Romania
| | - Elisabeta Stoica
- Department of Infectious Diseases, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania
| | - Georgiana State
- Department of Rheumatology, Colentina Clinical Hospital, 020125 Bucharest, Romania
| | - Florentina Negoi
- Department of Rheumatology, Colentina Clinical Hospital, 020125 Bucharest, Romania
| | - Ioana Adriana Berza
- Department of Rheumatology, Colentina Clinical Hospital, 020125 Bucharest, Romania
| | - Magda Parvu
- Department of Rheumatology, Colentina Clinical Hospital, 020125 Bucharest, Romania
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Abstract
Antiphospholipid syndrome (APS) is a thrombo-inflammatory disease propelled by circulating autoantibodies that recognize cell surface phospholipids and phospholipid binding proteins. The result is an increased risk of thrombotic events, pregnancy morbidity, and various other autoimmune and inflammatory complications. Although antiphospholipid syndrome was first recognized in patients with lupus, the stand alone presentation of antiphospholipid syndrome is at least equally common. Overall, the diagnosis appears to affect at least one in 2000 people. Studies of antiphospholipid syndrome pathogenesis have long focused on logical candidates such as coagulation factors, endothelial cells, and platelets. Recent work has shed light on additional potential therapeutic targets within the innate immune system, including the complement system and neutrophil extracellular traps. Vitamin K antagonists remain the mainstay of treatment for most patients with thrombotic antiphospholipid syndrome and, based on current data, appear superior to the more targeted direct oral anticoagulants. The potential role of immunomodulatory treatments in antiphospholipid syndrome management is receiving increased attention. As for many systemic autoimmune diseases, the most important future direction is to more precisely identify mechanistic drivers of disease heterogeneity in pursuit of unlocking personalized and proactive treatments for patients.
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Affiliation(s)
- Jason S Knight
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - D Ware Branch
- James R. and Jo Scott Research Chair, Department of Obstetrics and Gynecology, University of Utah Health and Intermountain Healthcare, Salt Lake City, Utah, USA
| | - Thomas L Ortel
- Division of Hematology, Departments of Medicine and Pathology, Duke University, Durham, North Carolina, USA
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Root-Bernstein R. From Co-Infections to Autoimmune Disease via Hyperactivated Innate Immunity: COVID-19 Autoimmune Coagulopathies, Autoimmune Myocarditis and Multisystem Inflammatory Syndrome in Children. Int J Mol Sci 2023; 24:ijms24033001. [PMID: 36769320 PMCID: PMC9917907 DOI: 10.3390/ijms24033001] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 01/21/2023] [Accepted: 01/23/2023] [Indexed: 02/05/2023] Open
Abstract
Neutrophilia and the production of neutrophil extracellular traps (NETs) are two of many measures of increased inflammation in severe COVID-19 that also accompany its autoimmune complications, including coagulopathies, myocarditis and multisystem inflammatory syndrome in children (MIS-C). This paper integrates currently disparate measures of innate hyperactivation in severe COVID-19 and its autoimmune complications, and relates these to SARS-CoV-2 activation of innate immunity. Aggregated data include activation of Toll-like receptors (TLRs), nucleotide-binding oligomerization domain (NOD) receptors, NOD leucine-rich repeat and pyrin-domain-containing receptors (NLRPs), retinoic acid-inducible gene I (RIG-I) and melanoma-differentiation-associated gene 5 (MDA-5). SARS-CoV-2 mainly activates the virus-associated innate receptors TLR3, TLR7, TLR8, NLRP3, RIG-1 and MDA-5. Severe COVID-19, however, is characterized by additional activation of TLR1, TLR2, TLR4, TLR5, TLR6, NOD1 and NOD2, which are primarily responsive to bacterial antigens. The innate activation patterns in autoimmune coagulopathies, myocarditis and Kawasaki disease, or MIS-C, mimic those of severe COVID-19 rather than SARS-CoV-2 alone suggesting that autoimmunity follows combined SARS-CoV-2-bacterial infections. Viral and bacterial receptors are known to synergize to produce the increased inflammation required to support autoimmune disease pathology. Additional studies demonstrate that anti-bacterial antibodies are also required to account for known autoantigen targets in COVID-19 autoimmune complications.
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Capozzi A, Riitano G, Recalchi S, Manganelli V, Longo A, Falcou A, De Michele M, Garofalo T, Pulcinelli FM, Sorice M, Misasi R. Antiphospholipid antibodies in patients with stroke during COVID-19: A role in the signaling pathway leading to platelet activation. Front Immunol 2023; 14:1129201. [PMID: 36936925 PMCID: PMC10017527 DOI: 10.3389/fimmu.2023.1129201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 02/09/2023] [Indexed: 03/06/2023] Open
Abstract
Background Several viral and bacterial infections, including COVID-19, may lead to both thrombotic and hemorrhagic complications. Previously, it has been demonstrated an "in vitro" pathogenic effect of "antiphospholipid" antibodies (aPLs), which are able to activate a proinflammatory and procoagulant phenotype in monocytes, endothelial cells and platelets. This study analyzed the occurrence of aPL IgG in patients with acute ischemic stroke (AIS) during COVID-19, evaluating the effect of Ig fractions from these patients on signaling and functional activation of platelets. Materials and methods Sera from 10 patients with AIS during COVID-19, 10 non-COVID-19 stroke patients, 20 COVID-19 and 30 healthy donors (HD) were analyzed for anti-cardiolipin, anti-β2-GPI, anti-phosphatidylserine/prothrombin and anti-vimentin/CL antibodies by ELISA. Platelets from healthy donors were incubated with Ig fractions from these patients or with polyclonal anti-β2-GPI IgG and analyzed for phospho-ERK and phospho-p38 by western blot. Platelet secretion by ATP release dosage was also evaluated. Results We demonstrated the presence of aPLs IgG in sera of patients with AIS during COVID-19. Treatment with the Ig fractions from these patients or with polyclonal anti-β2-GPI IgG induced a significant increase of phospho-ERK and phospho-p38 expression. In the same vein, platelet activation was supported by the increase of adenyl nucleotides release induced by Ig fractions. Conclusions This study demonstrates the presence of aPLs in a subgroup of COVID-19 patients who presented AIS, suggesting a role in the mechanisms contributing to hypercoagulable state in these patients. Detecting these antibodies as a serological marker to check and monitor COVID-19 may contribute to improve the risk stratification of thromboembolic manifestations in these patients.
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Affiliation(s)
- Antonella Capozzi
- Department of Experimental Medicine, “Sapienza” University of Rome, Rome, Italy
| | - Gloria Riitano
- Department of Experimental Medicine, “Sapienza” University of Rome, Rome, Italy
| | - Serena Recalchi
- Department of Experimental Medicine, “Sapienza” University of Rome, Rome, Italy
| | - Valeria Manganelli
- Department of Experimental Medicine, “Sapienza” University of Rome, Rome, Italy
| | - Agostina Longo
- Department of Experimental Medicine, “Sapienza” University of Rome, Rome, Italy
| | - Anne Falcou
- Emergency Department, “Sapienza” University of Rome, Rome, Italy
| | | | - Tina Garofalo
- Department of Experimental Medicine, “Sapienza” University of Rome, Rome, Italy
| | - Fabio M. Pulcinelli
- Department of Experimental Medicine, “Sapienza” University of Rome, Rome, Italy
| | - Maurizio Sorice
- Department of Experimental Medicine, “Sapienza” University of Rome, Rome, Italy
- *Correspondence: Maurizio Sorice,
| | - Roberta Misasi
- Department of Experimental Medicine, “Sapienza” University of Rome, Rome, Italy
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12
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Tsukamoto Y, Sugimoto T, Umeda M, Kato T, Hiura Y, Morita K, Ariyoshi K. A Patient with Severe Fever with Thrombocytopenia Syndrome, Activated Partial Thromboplastin Time Prolongation, and Transient Antiphospholipid Antibodies. Intern Med 2022. [PMID: 36476549 PMCID: PMC10400393 DOI: 10.2169/internalmedicine.0782-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
A prolonged activated partial thromboplastin time (APTT) is observed in patients with severe fever with thrombocytopenia syndrome (SFTS) and is one of the risk factors for severe disease. The mechanism underlying a prolonged APTT is largely unknown. The presence of antiphospholipid (aPL) antibodies in various viral infections has been documented but never reported in a patient with SFTS. We herein report the first SFTS patient with APTT prolongation and concurrent transiently positive aPL antibodies (lupus anticoagulants and anticardiolipin antibodies) with no coagulation factor deficiency.
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Affiliation(s)
- Yutaka Tsukamoto
- Department of Clinical Medicine, Institute of Tropical Medicine, Nagasaki University, Japan
| | - Takashi Sugimoto
- Department of Clinical Medicine, Institute of Tropical Medicine, Nagasaki University, Japan
| | - Masataka Umeda
- Department of Immunology and Rheumatology, Nagasaki University Graduate School of Biomedical Sciences, Japan
- Department of General Medicine, Nagasaki University Graduate School of Biomedical Sciences, Japan
| | - Takeharu Kato
- Department of Hematology, Nagasaki University Hospital, Japan
| | - Yukari Hiura
- Department of Dermatology, Hiura Hospital, Japan
| | - Kouichi Morita
- Department of Virology, Institute of Tropical Medicine, Nagasaki University, Japan
| | - Koya Ariyoshi
- Department of Clinical Medicine, Institute of Tropical Medicine, Nagasaki University, Japan
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13
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Serrano M, Espinosa G, Serrano A, Cervera R. COVID-19 and the antiphospholipid syndrome. Autoimmun Rev 2022; 21:103206. [PMID: 36195247 PMCID: PMC9527199 DOI: 10.1016/j.autrev.2022.103206] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Accepted: 09/28/2022] [Indexed: 01/08/2023]
Abstract
Coronavirus disease 2019 (COVID-19) has resulted in a global pandemic. Most COVID-19 patients are asymptomatic or have flu-like symptoms. However, around 15% of the patients may have severe disease, including unilateral or bilateral pneumonia with acute respiratory distress syndrome and progressive hypoxemia that may require mechanical ventilation assistance. A systemic inflammatory response syndrome occurs in the most severe forms of COVID-19, with multiorgan involvement which can be life threatening caused by a cytokine storm. Although what best characterizes COVID-19 are the manifestations of the respiratory system, it has been shown that it also acts at the cardiovascular level, producing coagulation abnormalities, which causes thrombotic events mainly in the arteries/arterioles, microcirculation and venous system, and potentially increased mortality risk. This multiorgan vascular disease overlaps with other known microangiopathies, such as thrombotic microangiopathy or paroxysmal nocturnal hemoglobinuria, where complement overactivation plays an important role in the pathophysiology of thrombosis. Furthermore, coagulopathy secondary to COVID-19 occurs in the context of an uncontrolled inflammatory response, reminiscent of APS, especially in its catastrophic form. This review summarizes the current knowledge regarding the relationship between COVID-19 and the APS.
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Affiliation(s)
- Manuel Serrano
- Department of Immunology, Healthcare Research Institute I+12, Hospital 12 de Octubre, Madrid, Spain
| | - Gerard Espinosa
- Department of Autoimmune Diseases, Hospital Clínic, Insititut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Universitat de Barcelona, Barcelona, Catalonia, Spain
| | - Antonio Serrano
- Department of Immunology, Healthcare Research Institute I+12, Hospital 12 de Octubre, Madrid, Spain
| | - Ricard Cervera
- Department of Autoimmune Diseases, Hospital Clínic, Insititut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Universitat de Barcelona, Barcelona, Catalonia, Spain,Corresponding author at: Servei de Malalties Autoimmunes, Hospital Clínic, Villarroel, 170, 08036 Barcelona, Catalonia, Spain
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14
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Zeng H, Cai M, Xue H, Xie W, Long X. Prevalence and coagulation correlation of anticardiolipin antibodies in patients with COVID-19. Medicine (Baltimore) 2022; 101:e31040. [PMID: 36254008 PMCID: PMC9575396 DOI: 10.1097/md.0000000000031040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
We aimed to determine prevalence and characteristics of anticardiolipin antibodies (ACLs) and its correlations with laboratory coagulation variables in patients with coronavirus disease 2019 (COVID-19). We retrospectively analyzed the prevalence of serum ACLs and its correlation with coagulative laboratory variables in 87 patients with COVID-19. ACLs were detected in 13/21 (61.91%) critically ill patients, and 21/66 (31.82%) in non-critically ill patients. For ACLs, IgA, and IgG were the most common types. The prevalence of IgG in critical ill patients was much higher than that in non-critical patients with odd ratio = 2.721. And the levels of all isotypes of ACLs in critically ill patients were much higher than those in non-critically ill patients. Correlation analysis showed that activated partial thromboplastin time and thrombin time had weak correlation with ACLs-IgG (R = 0.308, P = .031; R = 0.337, P = .018, respectively). Only the prevalence of ACLs-IgG shows a significant difference when compared critically ill patients with non-critically ill patients. ACLs do not seem to have a clear correlation with thrombosis occurred in COVID-19 patients.
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Affiliation(s)
- Hui Zeng
- Center of Clinical Laboratory, Hangzhou Ninth People’s Hospital, Hangzhou, Zhejiang, China
- Department of Laboratory Medicine, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, China
| | - Meihong Cai
- Department of Dermatology, Wuhan Wuchang Hospital, Wuchang Hospital Affiliated to Wuhan University of Science and Technology, Wuhan, Hubei, China
| | - Han Xue
- Department of Laboratory Medicine, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, China
| | - Wen Xie
- Department of Laboratory Medicine, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, China
| | - Xinghua Long
- Department of Laboratory Medicine, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, China
- * Correspondence: Xinghua Long, Department of Laboratory Medicine, Zhongnan Hospital of Wuhan University, 169 Donghu Road, Wuhan, Hubei 430071, China (e-mail: )
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15
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Abstract
The presence of thrombotic events in COVID-19 patients has been described since the beginning of the pandemic. This association has been confirmed in most of the reported studies. Autopsy reports have shown that most thromboses are located in the lung, although they have also been observed in other organs such as the skin and kidneys. SARS-CoV2 infection induces a generalized prothrombotic state, which is attributed to a combination of factors such as hypoxia, excess cellular apoptosis, and mainly to overactivation of the immune system. Among immune-mediated prothrombotic situations, antiphospholipid syndrome (APS) stands out. Recurrent thrombotic events are observed in APS in the presence of antiphospholipid antibodies (aPL). There are numerous studies that report high prevalence of aPL in patients with COVID-19 infection. However, the results show discrepancies in the data on the prevalence of aPL, and its role in the pathogenesis of thrombosis in these patients. This could be due to the heterogeneity of the detection procedures for aPL or to transient elevations of non-pathogenic aPL levels in the context of infection. In this review we try to clarify the role of aPL in COVID-19 infection, and attempt to answer the question of whether it is a coagulopathy of its own, or secondary to APS.
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16
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Anticardiolipin Autoantibodies as Useful Biomarkers for the Prediction of Mortality in Septic Patients. J Immunol Res 2022; 2022:9775111. [PMID: 35685432 PMCID: PMC9174012 DOI: 10.1155/2022/9775111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Revised: 03/30/2022] [Accepted: 05/11/2022] [Indexed: 11/17/2022] Open
Abstract
Background. The detection of antiphospholipid antibodies (aPL) is of interest because of their importance in the pathogenesis of arterial or venous thrombosis. They could be a “second hit” of an inflammatory event such as infection. The aim of our study was to assess the performance of antiphospholipid antibody biomarker to predict in-hospital mortality in intensive care unit (ICU) septic patients. Methods. We conducted a prospective single-center observational study including consecutive critically ill septic adults admitted to the intensive care unit. Clinical and laboratory data including enzyme-linked immunosorbent assay for antiphospholipid antibodies (anticardiolipin (aCL), antiphosphatidylserine (aPS)) were obtained. Blood samples were collected on days 1, 3, 5, 8, and 10 of hospitalization. The primary study endpoint was ICU mortality defined as death before ICU discharge. Secondary end points included correlation between SOFA score and biological parameters. Results. A total of 53 patients were enrolled. 18.8% of patients were aPL positive. In-hospital mortality rate was 60%. Multivariate analysis showed that age and aCL at days 3 and 5 along with SOFA at day 3 were independent outcome predictors. A significant positive correlation existed between SOFA at days 3, 5, and 8 and antiphospholipid antibody concentrations. Conclusions. Our data showed that antiphospholipid was useful biomarkers for the prediction of mortality in critically ill septic patients. We found a positive correlation between SOFA score and antiphospholipid antibodies.
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17
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Serrano M, Espinosa G, Serrano A, Cervera R. Antigens and Antibodies of the Antiphospholipid Syndrome as New Allies in the Pathogenesis of COVID-19 Coagulopathy. Int J Mol Sci 2022; 23:ijms23094946. [PMID: 35563337 PMCID: PMC9102661 DOI: 10.3390/ijms23094946] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 04/21/2022] [Accepted: 04/26/2022] [Indexed: 01/27/2023] Open
Abstract
High prevalence of both criteria and extra-criteria antiphospholipid antibodies (aPL) has been reported in COVID-19 patients. However, the differences in aPL prevalence decreased when an age-matched control group was included. The association of aPL with thrombotic events in COVID-19 is very heterogeneous. This could be influenced by the fact that most of the studies carried out were conducted on small populations enriched with elderly patients in which aPL was measured only at a single point and they were performed with non-standardized assays. The few studies that confirmed aPL in a second measurement showed that aPL levels hardly changed, with the exception of the lupus anticoagulant that commonly reduced. COVID-19 coagulopathy is an aPL-independent phenomenon closely associated with the onset of the disease. Thrombosis occurs later in patients with aPL presence, which is likely an additional prothrombotic factor. B2-glycoprotein deficiency (mainly aPL antigen caused both by low production and consumption) is very common during the SARS-CoV2 infection and has been associated with a greater predisposition to COVID-19 complications. This could be a new prothrombotic mechanism that may be caused by the blockage of its physiological functions, the anticoagulant state being the most important.
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Affiliation(s)
- Manuel Serrano
- Department of Immunology, Healthcare Research Institute I+12, Hospital 12 de Octubre, 28041 Madrid, Spain;
| | - Gerard Espinosa
- Department of Autoimmune Diseases, Hospital Clínic, Insititut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Universitat de Barcelona, 08036 Barcelona, Spain; (G.E.); (R.C.)
| | - Antonio Serrano
- Department of Immunology, Healthcare Research Institute I+12, Hospital 12 de Octubre, 28041 Madrid, Spain;
- Correspondence: or
| | - Ricard Cervera
- Department of Autoimmune Diseases, Hospital Clínic, Insititut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Universitat de Barcelona, 08036 Barcelona, Spain; (G.E.); (R.C.)
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18
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Wiwanitkit V. Antiphospholipid antibody syndrome and dengue fever. MEDICAL JOURNAL OF DR. D.Y. PATIL VIDYAPEETH 2022. [DOI: 10.4103/mjdrdypu.mjdrdypu_443_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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19
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Emadi-Baygi M, Ehsanifard M, Afrashtehpour N, Norouzi M, Joz-Abbasalian Z. Corona Virus Disease 2019 (COVID-19) as a System-Level Infectious Disease With Distinct Sex Disparities. Front Immunol 2021; 12:778913. [PMID: 34912345 PMCID: PMC8667725 DOI: 10.3389/fimmu.2021.778913] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Accepted: 11/11/2021] [Indexed: 01/08/2023] Open
Abstract
The current global pandemic of the Severe Acute Respiratory Syndrome CoronaVirus 2 (SARS-CoV-2) causing COVID-19, has infected millions of people and continues to pose a threat to many more. Angiotensin-Converting Enzyme 2 (ACE2) is an important player of the Renin-Angiotensin System (RAS) expressed on the surface of the lung, heart, kidney, neurons, and endothelial cells, which mediates SARS-CoV-2 entry into the host cells. The cytokine storms of COVID-19 arise from the large recruitment of immune cells because of the dis-synchronized hyperactive immune system, lead to many abnormalities including hyper-inflammation, endotheliopathy, and hypercoagulability that produce multi-organ dysfunction and increased the risk of arterial and venous thrombosis resulting in more severe illness and mortality. We discuss the aberrated interconnectedness and forthcoming crosstalks between immunity, the endothelium, and coagulation, as well as how sex disparities affect the severity and outcome of COVID-19 and harm men especially. Further, our conceptual framework may help to explain why persistent symptoms, such as reduced physical fitness and fatigue during long COVID, may be rooted in the clotting system.
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Affiliation(s)
- Modjtaba Emadi-Baygi
- Department of Genetics, Faculty of Basic Sciences, Shahrekord University, Shahrekord, Iran
| | - Mahsa Ehsanifard
- Department of Genetics, Faculty of Basic Sciences, Shahrekord University, Shahrekord, Iran
| | - Najmeh Afrashtehpour
- Department of Genetics, Faculty of Basic Sciences, Shahrekord University, Shahrekord, Iran
| | - Mahnaz Norouzi
- Department of Research and Development, Erythrogen Medical Genetics Lab, Isfahan, Iran
| | - Zahra Joz-Abbasalian
- Clinical Laboratory, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran
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20
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Liu Y. Correspondence on 'Anticardiolipin and other antiphospholipid antibodies in critically ill COVID-19 positive and negative patients' by Trahtemberg et al. Ann Rheum Dis 2021:annrheumdis-2021-221711. [PMID: 34810196 DOI: 10.1136/annrheumdis-2021-221711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Accepted: 10/20/2021] [Indexed: 11/04/2022]
Affiliation(s)
- Yudong Liu
- The Key Laboratory of Geriatrics, Beijing Institute of Geriatrics, Beijing Hospital, National Center of Gerontology, National Health Commission, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
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21
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Chidharla A, Syed SB, Chatterjee T, Tarantino MD. A Case Report of COVID-Associated Catastrophic Antiphospholipid Syndrome Successfully Treated with Eculizumab. J Blood Med 2021; 12:929-933. [PMID: 34744467 PMCID: PMC8566005 DOI: 10.2147/jbm.s324873] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 09/28/2021] [Indexed: 12/16/2022] Open
Abstract
Antiphospholipid syndrome (APS) is an autoimmune disorder characterized by multiple episodes of venous and arterial thromboses or recurrent fetal losses in the presence of antiphospholipid antibodies against β2GP1, frequently accompanied by moderate thrombocytopenia. Catastrophic APS (CAPS) is a severe manifestation of APS. COVID-19 may have an intense hypercoagulable state in critically ill patients. SARS-CoV2 may potentiate pathogenic APS effects, including the activation of endothelial cells, monocytes, platelets, and complement, resulting in a proinflammatory state and prothrombotic events. The endothelial tropism of SARS-CoV2 may also modify the clinical presentation of COVID-19 in susceptible individuals and trigger flares of underlying vascular diseases. We report a case of a 64-year-old woman with a history of triple-positive APS who had multiple thrombotic and bleeding episodes after being found to have a COVID-19 infection temporally associated with CAPS development that was successfully treated with eculizumab, preventing further macro- and microvascular thrombotic events at 1 month follow-up. Our case highlights the need for more research regarding the mechanism by which COVID-19 may potentiate APS and lead to the development of CAPS.
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Affiliation(s)
- Anusha Chidharla
- Department of Medical Oncology, Kansas University Cancer Center, Kansas, KS, USA
| | - Salman B Syed
- Department of Internal Medicine, University of Illinois College of Medicine, Peoria, IL, USA
| | - Tulika Chatterjee
- Department of Internal Medicine, University of Illinois College of Medicine, Peoria, IL, USA
| | - Michael D Tarantino
- Department of Hematology, Bleeding and Clotting Disorders Institute, Peoria, IL, USA
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22
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Meroni PL, Borghi MO. Antiphospholipid Antibody Assays in 2021: Looking for a Predictive Value in Addition to a Diagnostic One. Front Immunol 2021; 12:726820. [PMID: 34621272 PMCID: PMC8490700 DOI: 10.3389/fimmu.2021.726820] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Accepted: 09/01/2021] [Indexed: 12/22/2022] Open
Abstract
Antiphospholipid antibodies (aPL) are mandatory for the diagnosis but are also a risk factor for the antiphospholipid syndrome (APS) clinical manifestations. Lupus anticoagulant (LA), anticardiolipin (aCL), and anti-beta2 glycoprotein I (β2GPI) assays are the formal laboratory classification/diagnostic criteria. Additional nonclassification assays have been suggested; among them, antiphosphatidylserine-prothrombin (aPS/PT) and antidomain 1 β2GPI antibodies are the most promising ones although not yet formally accepted. aPL represent the example of a laboratory test that moved from dichotomous to quantitative results consistent with the idea that reporting quantitative data offers more diagnostic/prognostic information for both vascular and obstetric manifestations. Although the general rule is that the higher the aPL titer, the higher the test likelihood ratio, there is growing evidence that this is not the case for persistent low titers and obstetric events. LA displays the highest diagnostic/prognostic power, although some isolated LAs are apparently not associated with APS manifestations. Moreover, isotype characterization is also critical since IgG aPL are more diagnostic/prognostic than IgA or IgM. aPL are directed against two main autoantigens: β2GPI and PT. However, anti-β2GPI antibodies are more associated with the APS clinical spectrum. In addition, there is evidence that anti-β2GPI domain 1 antibodies display a stronger diagnostic/prognostic value. This finding supports the view that antigen and even epitope characterization represents a further step for improving the assay value. The strategy to improve aPL laboratory characterization is a lesson that can be translated to other autoantibody assays in order to improve our diagnostic and prognostic power.
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Affiliation(s)
- Pier Luigi Meroni
- Istituto Auxologico Italiano, IRCCS, Immunorheumatology Research Laboratory, Milan, Italy
| | - Maria Orietta Borghi
- Istituto Auxologico Italiano, IRCCS, Immunorheumatology Research Laboratory, Milan, Italy.,Department of Clinical Science and Community Health, University of Milan, Milan, Italy
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23
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Massaro G, Lecis D, Martuscelli E, Chiricolo G, Sangiorgi GM. Clinical Features and Management of COVID-19–Associated Hypercoagulability. Card Electrophysiol Clin 2021; 14:41-52. [PMID: 35221084 PMCID: PMC8556574 DOI: 10.1016/j.ccep.2021.10.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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24
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Abstract
Many skin manifestations of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection reflect activation of cutaneous and systemic immune responses involving effector pathways of both the innate and adaptive arms of the immune system. This article reviews evidence from the recent clinical and scientific literature that informs the current understanding of the consequences of coronavirus disease 2019 (COVID-19)-induced immune cell activation, as relevant to dermatology. Topics include the clinical consequences of autoantibody production in patients with COVID-19, immunologic evidence for chilblains as a manifestation of SARS-CoV-2 infection, and the relationship between type I interferons and COVID-19 disease severity.
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Affiliation(s)
- Antonia E Gallman
- Department of Microbiology and Immunology, University of California, San Francisco, San Francisco, CA, USA; Medical Scientist Training Program, University of California, San Francisco, 513 Parnassus Avenue, Room HSE1001A, San Francisco, CA 94143, USA
| | - Marlys S Fassett
- Department of Microbiology and Immunology, University of California, San Francisco, San Francisco, CA, USA; Department of Dermatology, University of California, San Francisco, 513 Parnassus Avenue, Room HSE1001E, San Francisco, CA 94143, USA.
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25
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Trahtemberg U, Rottapel R, Dos Santos CC, Slutsky AS, Baker A, Fritzler MJ. Anticardiolipin and other antiphospholipid antibodies in critically ill COVID-19 positive and negative patients. Ann Rheum Dis 2021; 80:1236-1240. [PMID: 33903092 PMCID: PMC8076626 DOI: 10.1136/annrheumdis-2021-220206] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Revised: 03/16/2021] [Accepted: 04/07/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND Reports of severe COVID-19 being associated with thrombosis, antiphospholipid antibodies (APLA), and antiphospholipid syndrome have yielded disparate conclusions. Studies comparing patients with COVID-19 with contemporaneous controls of similar severity are lacking. METHODS 22 COVID-19+ and 20 COVID-19- patients with respiratory failure admitted to intensive care were studied longitudinally. Demographic and clinical data were obtained from the day of admission. APLA testing included anticardiolipin (aCL), anti-β2glycoprotien 1 (β2GP1), antidomain 1 β2GP1 and antiphosphatidyl serine/prothrombin complex. Antinuclear antibodies (ANAs) were detected by immunofluorescence and antibodies to cytokines by a commercially available multiplexed array. Analysis of variance was used for continuous variables and Fisher's exact test was used for categorical variables with α=0.05 and the false discovery rate at q=0.05. RESULTS APLAs were predominantly IgG aCL (48%), followed by IgM (21%) in all patients, with a tendency towards higher frequency among the COVID-19+. aCL was not associated with surrogate markers of thrombosis but IgG aCL was strongly associated with worse disease severity and higher ANA titres regardless of COVID-19 status. An association between aCL and anticytokine autoantibodies tended to be higher among the COVID-19+. CONCLUSIONS Positive APLA serology was associated with more severe disease regardless of COVID-19 status. TRIAL REGISTRATION NUMBER NCT04747782.
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Affiliation(s)
| | - Robert Rottapel
- Departments of Medicine and Immunology, University of Toronto, Toronto, Ontario, Canada
- Division of Rheumatology, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Claudia C Dos Santos
- Critical Care, St Michael's Hospital, Toronto, Ontario, Canada
- Keenan Centre for Biomedical Research, Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Arthur S Slutsky
- Keenan Centre for Biomedical Research, Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Andrew Baker
- Critical Care, St Michael's Hospital, Toronto, Ontario, Canada
- Keenan Centre for Biomedical Research, Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Marvin J Fritzler
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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Moroșan D, Șerban A, Trifan C, Encica S, Pop S, Șerban TC, Rednic S, Damian L. Frenemies within: An Endocarditis Case in Behçet's Disease. J Pers Med 2021; 11:728. [PMID: 34442371 PMCID: PMC8402229 DOI: 10.3390/jpm11080728] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 07/14/2021] [Accepted: 07/25/2021] [Indexed: 01/05/2023] Open
Abstract
A 57-year female patient diagnosed with Behçet's disease, on azathioprine, was noticed to have at a routine examination antinuclear and antiphospholipid antibodies. An overlapping lupus-like syndrome was diagnosed; hydroxychloroquine and aspirin were added. Three years later, the patient presented with dyspnea and sweating, with no fever. A cardiac bruit was noted; a giant vegetation was detected by echocardiography. Laboratory revealed severe thrombocytopenia, antiphospholipid antibodies and low complement. Blood cultures were positive for Abiotrophia defectiva serology and also revealed a chronic Coxiella burnetii infection. Antibiotic therapy, low-dose anticoagulation and control of the underlying disease mildly improved the platelet count, which fully recovered only after cardiac valve replacement. However, the Behçet's disease, initially quiescent, flared after the therapy of infections. We discuss potential links between Behçet's disease and the occurrence of antinuclear and antiphospholipid antibodies and Coxiella endocarditis in this setting. We also highlight the differences between the endocarditis in Behçet's disease, antiphospholipid syndrome, Coxiella burnetii and Abiotrophia defectiva infection, respectively. Intracellular infections may modify the presentation of autoimmune diseases. Confounding clinical features of Coxiella persistent infection and non-bacterial thrombotic endocarditis in Behçet's disease warrant further insight.
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Affiliation(s)
- Diana Moroșan
- Department of Rheumatology, “Iuliu Hatieganu” University of Medicine and Pharmacy Cluj-Napoca, 8 Victor Babeș St., 400012 Cluj-Napoca, Romania; (D.M.); (S.R.)
| | - Adela Șerban
- Department of Cardiology, “Iuliu Hatieganu” University of Medicine and Pharmacy Cluj-Napoca, 8 Victor Babeș St., 400012 Cluj-Napoca, Romania;
- Department of Cardiology, “Niculae Stancioiu” Heart Institute Cluj-Napoca, 19-21, Calea Moților St., 400001 Cluj-Napoca, Romania;
| | - Cătălin Trifan
- Department of Cardiovascular Surgery, “Niculae Stancioiu” Heart Institute Cluj-Napoca, 19-21, Calea Moților St., 400001 Cluj-Napoca, Romania;
| | - Svetlana Encica
- Department of Pathology, “Niculae Stancioiu” Heart Institute Cluj-Napoca, 19-21, Calea Moților St., 400001 Cluj-Napoca, Romania
| | - Sorin Pop
- 1st Internal Medicine Department, Emergency Clinical County Hospital Cluj, 3-5 Clinicilor St., 400006 Cluj-Napoca, Romania;
| | - Tudor Costinel Șerban
- Department of Cardiology, “Niculae Stancioiu” Heart Institute Cluj-Napoca, 19-21, Calea Moților St., 400001 Cluj-Napoca, Romania;
| | - Simona Rednic
- Department of Rheumatology, “Iuliu Hatieganu” University of Medicine and Pharmacy Cluj-Napoca, 8 Victor Babeș St., 400012 Cluj-Napoca, Romania; (D.M.); (S.R.)
- Department of Rheumatology, Centre for Rare Musculoskeletal Autoimmune and Autoinflammatory Diseases, Emergency Clinical County Hospital Cluj, 2-4 Clinicilor St., 400006 Cluj-Napoca, Romania;
| | - Laura Damian
- Department of Rheumatology, Centre for Rare Musculoskeletal Autoimmune and Autoinflammatory Diseases, Emergency Clinical County Hospital Cluj, 2-4 Clinicilor St., 400006 Cluj-Napoca, Romania;
- CMI Reumatologie Dr. Damian, 6-8 P. Maior St., 400002 Cluj-Napoca, Romania
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Perdan-Pirkmajer K, Žigon P, Boc A, Podovšovnik E, Čučnik S, Mavri A, Rotar Ž, Ambrožič A. The Predictive Value of the aCL and Anti-β2GPI at the Time of Acute Deep Vein Thrombosis-A Two-Year Prospective Study. Biomedicines 2021; 9:biomedicines9080901. [PMID: 34440105 PMCID: PMC8389571 DOI: 10.3390/biomedicines9080901] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2021] [Accepted: 07/23/2021] [Indexed: 11/16/2022] Open
Abstract
Antiphospholipid syndrome (APS) is an important cause of deep vein thrombosis (DVT). According to current APS classification criteria, APS cannot be confirmed until 24 weeks after DVT. This time frame results in frequent discontinuation of anticoagulant treatment before APS is diagnosed. Therefore, the aim of our study was to evaluate the potential predictive value of anticardiolipin (aCL) and anti-β2glycoprotein I (anti-β2GPI) before discontinuation of anticoagulation therapy. Patients with newly diagnosed DVT were included into a 24-month prospective study. All patients received anticoagulant therapy. aCL and anti-β2GPI were determined at inclusion and every four weeks for the first 24 weeks and then one and two years after inclusion. APS was confirmed in 24/221 (10.9%) patients. At the time of acute DVT 20/24 (83.3%), APS patients had positive aCL and/or anti-β2GPI. Two patients had low aCL levels and two were negative at the time of acute DVT but later met APS criteria due to lupus anticoagulant (LA). Our data indicate that negative aCL and/or anti-β2GPI at the time of acute DVT make further aPL testing unnecessary; however, LA should be determined after discontinuation of anticoagulant therapy. Positive aCL and/or anti-β2GPI at the time of acute DVT have a strong positive predictive value for APS and may support therapeutic decisions.
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Affiliation(s)
- Katja Perdan-Pirkmajer
- Department of Rheumatology, University Medical Centre Ljubljana, SI-1000 Ljubjana, Slovenia; (K.P.-P.); (P.Ž.); (S.Č.); (Ž.R.)
- Division for Internal Medicine, Faculty of Medicine, University of Ljubljana, SI-1000 Ljubljana, Slovenia;
| | - Polona Žigon
- Department of Rheumatology, University Medical Centre Ljubljana, SI-1000 Ljubjana, Slovenia; (K.P.-P.); (P.Ž.); (S.Č.); (Ž.R.)
- Faculty of Mathematics, Natural Sciences and Information Technologies, University of Primorska, SI-6000 Koper, Slovenia
| | - Anja Boc
- Faculty of Medicine, Institute of Anatomy, University of Ljubljana, SI-1000 Ljubljana, Slovenia;
- Department of Vascular Diseases, University Medical Centre Ljubljana, SI-1000 Ljubljana, Slovenia
| | - Eva Podovšovnik
- Faculty of Tourism Studies, University of Primorska, SI-6000 Portorož, Slovenia;
| | - Saša Čučnik
- Department of Rheumatology, University Medical Centre Ljubljana, SI-1000 Ljubjana, Slovenia; (K.P.-P.); (P.Ž.); (S.Č.); (Ž.R.)
- Faculty of Pharmacy, University of Ljubljana, SI-1000 Ljubljana, Slovenia
| | - Alenka Mavri
- Division for Internal Medicine, Faculty of Medicine, University of Ljubljana, SI-1000 Ljubljana, Slovenia;
- Department of Vascular Diseases, University Medical Centre Ljubljana, SI-1000 Ljubljana, Slovenia
| | - Žiga Rotar
- Department of Rheumatology, University Medical Centre Ljubljana, SI-1000 Ljubjana, Slovenia; (K.P.-P.); (P.Ž.); (S.Č.); (Ž.R.)
- Division for Internal Medicine, Faculty of Medicine, University of Ljubljana, SI-1000 Ljubljana, Slovenia;
| | - Aleš Ambrožič
- Department of Rheumatology, University Medical Centre Ljubljana, SI-1000 Ljubjana, Slovenia; (K.P.-P.); (P.Ž.); (S.Č.); (Ž.R.)
- Correspondence:
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28
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Gil-Etayo FJ, Garcinuño S, Lalueza A, Díaz-Simón R, García-Reyne A, Pleguezuelo DE, Cabrera-Marante O, Rodriguez-Frias EA, Perez-Rivilla A, Serrano M, Serrano A. Anti-Phospholipid Antibodies and COVID-19 Thrombosis: A Co-Star, Not a Supporting Actor. Biomedicines 2021; 9:biomedicines9080899. [PMID: 34440103 PMCID: PMC8389622 DOI: 10.3390/biomedicines9080899] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 07/19/2021] [Accepted: 07/23/2021] [Indexed: 12/25/2022] Open
Abstract
Background: COVID-19 clinical features include a hypercoagulable state that resembles the antiphospholipid syndrome (APS), a disease characterized by thrombosis and presence of antiphospholipid antibodies (aPL). The relationship between aPL-presence and the appearance of thrombi as well as the transience or permanence of aPL in COVID-19 patients is not sufficiently clear. Methods: A group of 360 COVID-19 patients were followed-up for 6 months. Classic aPL, anti-B2GPI IgA, anti-phosphatidylserine/prothrombin IgG/M and anti-SARS-CoV-2 antibodies were determined at acute phase and >12 weeks later. The reference group included 143 healthy volunteers of the same age-range distribution. Results: aPL prevalence was similar in COVID-19 patients and the reference population. aPL presence in both determinations was significantly associated with thrombosis (OR: 2.33 and 3.71), strong agreement being found for classic aPL and anti-B2GPI IgA (Weighted kappa: 0.85–0.91). Thrombosis-associated aPL occurred a median of 17 days after hospital admission (IQR: 6–28) vs. 4 days for the rest (IQR: 3–7). Although anti-SARS-CoV-2 antibodies levels increased during convalescence, aPL hardly changed. Conclusions: Most COVID-19 patients would carry these aPL before the infection. At least two mechanisms could be behind thrombosis, early immune-dysregulation-mediated thrombosis after infection and belated-aPL-mediated thrombosis, with SARS-CoV-2 behaving as a second hit.
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Affiliation(s)
- Francisco Javier Gil-Etayo
- Department of Immunology, Hospital Universitario 12 de Octubre, 28041 Madrid, Spain; (F.J.G.-E.); (D.E.P.); (O.C.-M.); (E.A.R.-F.)
| | - Sara Garcinuño
- Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), 28041 Madrid, Spain;
| | - Antonio Lalueza
- Department of Internal Medicine, Hospital Universitario 12 de Octubre, 28041 Madrid, Spain; (A.L.); (R.D.-S.); (A.G.-R.)
| | - Raquel Díaz-Simón
- Department of Internal Medicine, Hospital Universitario 12 de Octubre, 28041 Madrid, Spain; (A.L.); (R.D.-S.); (A.G.-R.)
| | - Ana García-Reyne
- Department of Internal Medicine, Hospital Universitario 12 de Octubre, 28041 Madrid, Spain; (A.L.); (R.D.-S.); (A.G.-R.)
| | - Daniel Enrique Pleguezuelo
- Department of Immunology, Hospital Universitario 12 de Octubre, 28041 Madrid, Spain; (F.J.G.-E.); (D.E.P.); (O.C.-M.); (E.A.R.-F.)
| | - Oscar Cabrera-Marante
- Department of Immunology, Hospital Universitario 12 de Octubre, 28041 Madrid, Spain; (F.J.G.-E.); (D.E.P.); (O.C.-M.); (E.A.R.-F.)
| | - Edgard Alfonso Rodriguez-Frias
- Department of Immunology, Hospital Universitario 12 de Octubre, 28041 Madrid, Spain; (F.J.G.-E.); (D.E.P.); (O.C.-M.); (E.A.R.-F.)
| | - Alfredo Perez-Rivilla
- Department of Microbiology, Hospital Universitario 12 de Octubre, 28041 Madrid, Spain;
| | - Manuel Serrano
- Department of Immunology, Hospital Universitario Clínico San Carlos, 28041 Madrid, Spain;
| | - Antonio Serrano
- Department of Immunology, Hospital Universitario 12 de Octubre, 28041 Madrid, Spain; (F.J.G.-E.); (D.E.P.); (O.C.-M.); (E.A.R.-F.)
- Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), 28041 Madrid, Spain;
- Department of Epidemiology, Biomedical Research Centre Network for Epidemiology and Public Health (CIBERESP), 28029 Madrid, Spain
- Correspondence: ; Tel.: +34-659-496-544
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Favaloro EJ, Henry BM, Lippi G. Is Lupus Anticoagulant a Significant Feature of COVID-19? A Critical Appraisal of the Literature. Semin Thromb Hemost 2021; 48:55-71. [PMID: 34130341 DOI: 10.1055/s-0041-1729856] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
The term "lupus anticoagulant (LA)" identifies a form of antiphospholipid antibodies (aPLs) causing prolongation of clotting tests in a phospholipid concentration-dependent manner. LA is one of the laboratory criteria identified in patients with antiphospholipid (antibody) syndrome (APS). The presence of LA in patients with APS represents a significant risk factor for both thrombosis and pregnancy morbidity. There have been several reports of similarities between some of the pathophysiological features of COVID-19 and APS, in particular the most severe form, catastrophic APS. There have also been many reports identifying various aPLs, including LA, in COVID-19 patients. Accordingly, a very pertinent question arises: "Is LA a feature of COVID-19 pathology?" In this review, we critically appraise the literature to help answer this question. We conclude that LA positivity is a feature of COVID-19, at least in some patients, and potentially those who are the sickest or have the most severe infection. However, many publications have failed to appropriately consider the many confounders to LA identification, being assessed using clot-based assays such as the dilute Russell viper venom time, the activated partial thromboplastin time (aPTT), and the silica clotting time. First, most patients hospitalized with COVID-19 are placed on anticoagulant therapy, and those with prior histories of thrombosis would possibly present to hospital already on anticoagulant therapy. All anticoagulants, including vitamin K antagonists, heparin (both unfractionated heparin and low-molecular-weight heparin), and direct oral anticoagulants affect these clot-based assays. Second, C-reactive protein (CRP) is highly elevated in COVID-19 patients, and also associated with severity. CRP can also lead to false-positive LA, particularly with the aPTT assay. Third, persistence of aPL positivity (including LA) is required to identify APS. Fourth, those at greatest risk of thrombosis due to aPL are those with highest titers or multiple positivity. Most publications either did not identify anticoagulation and/or CRP in their COVID-19 cohorts or did not seem to account for these as possible confounders for LA detection. Most publications did not assess for aPL persistence, and where persistence was checked, LA appeared to represent transient aPL. Finally, high titer aPL or multiple aPL positivity were in the minority of COVID-19 presentations. Thus, at least some of the reported LAs associated with COVID-19 are likely to be false positives, and the relationship between the detected aPL/LA and COVID-19-associated coagulopathy remains to be resolved using larger and better studies.
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Affiliation(s)
- Emmanuel J Favaloro
- Department of Haematology, Sydney Centres for Thrombosis and Haemostasis, Institute of Clinical Pathology and Medical Research (ICPMR), NSW Health Pathology, Westmead Hospital, Westmead, New South Wales, Australia.,School of Biomedical Sciences, Charles Sturt University, Wagga Wagga, New South Wales, Australia
| | - Brandon Michael Henry
- Cardiac Intensive Care Unit, The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Giuseppe Lippi
- Section of Clinical Biochemistry, University of Verona, Verona, Italy
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30
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Favaloro EJ, Henry BM, Lippi G. COVID-19 and Antiphospholipid Antibodies: Time for a Reality Check? Semin Thromb Hemost 2021; 48:72-92. [PMID: 34130340 DOI: 10.1055/s-0041-1728832] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Antiphospholipid antibodies (aPL) comprise a panel of autoantibodies that reflect a potential prothrombotic risk in several autoimmune conditions, most notably antiphospholipid (antibody) syndrome (APS). aPL can be divided into those that form part of the laboratory criteria for APS, namely, lupus anticoagulant (LA), as well as anticardiolipin antibodies (aCL) and anti-β2-glycoprotein I antibodies (aβ2GPI) of the immunoglobulin G and M classes, and those that form a group considered as "noncriteria antibodies." The noncriteria antibodies include, for example, antiphosphatidylserine antibodies (aPS), antiprothrombin antibodies (aPT), and antiphosphatidylserine/prothrombin complex antibodies (aPS/PT). COVID-19 (coronavirus disease 2019) represents a prothrombotic disorder, and there have been several reports of various aPL being present in COVID-19 patients. There have also been similarities drawn between some of the pathophysiological features of COVID-19 and APS, in particular, the most severe form, catastrophic APS (CAPS). In this review, we critically appraise the literature on aPL and COVID-19. This is a companion piece to a separate review focused on LA. In the current review, we primarily concentrate on the so-called solid phase identifiable aPL, such as aCL and aβ2GPI, but also reflect on noncriteria aPL. We conclude that aPL positivity may be a feature of COVID-19, at least in some patients, but in general, identified "solid-phase" aPL are of low titer and not able to be well-linked to the thrombotic aspects of COVID-19. Also, most publications did not assess for aPL persistence, and where persistence was checked, the findings appeared to represent transient aPL. Importantly, high-titer aPL or multiple aPL positivity (including double, triple) were in the minority of COVID-19 presentations, and thus discount any widespread presence of APS, including the most severe form CAPS, in COVID-19 patients.
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Affiliation(s)
- Emmanuel J Favaloro
- Department of Haematology, Sydney Centres for Thrombosis and Haemostasis, Institute of Clinical Pathology and Medical Research (ICPMR), NSW Health Pathology, Westmead Hospital, Westmead, NSW, Australia.,School of Biomedical Sciences, Charles Sturt University, Wagga Wagga, NSW, Australia
| | - Brandon Michael Henry
- Cardiac Intensive Care Unit, The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Giuseppe Lippi
- Section of Clinical Biochemistry, University of Verona, Verona, Italy
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31
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Rangaswamy C, Mailer RK, Englert H, Konrath S, Renné T. The contact system in liver injury. Semin Immunopathol 2021; 43:507-517. [PMID: 34125270 PMCID: PMC8202222 DOI: 10.1007/s00281-021-00876-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 05/27/2021] [Indexed: 01/18/2023]
Abstract
Coagulation is controlled by a delicate balance of prothrombotic and antithrombotic mechanisms, to prevent both excessive blood loss from injured vessels and pathologic thrombosis. The liver plays a pivotal role in hemostasis through the synthesis of plasma coagulation factors and their inhibitors that, in addition to thrombosis and hemostasis, orchestrates an array of inflammatory responses. As a result, impaired liver function has been linked with both hypercoagulability and bleeding disorders due to a pathologic balance of pro- and anticoagulant plasma factors. At sites of vascular injury, thrombus propagation that finally may occlude the blood vessel depends on negatively charged biopolymers, such as polyphosphates and extracellular DNA, that provide a physiological surface for contact activation of coagulation factor XII (FXII). FXII initiates the contact system that drives both the intrinsic pathway of coagulation, and formation of the inflammatory mediator bradykinin by the kallikrein–kinin system. Moreover, FXII facilitates receptor-mediated signalling, thereby promoting mitogenic activities, angiogenesis, and neutrophil stimulation with implications for liver diseases. Here, we summarize current knowledge on the FXII-driven contact system in liver diseases and review therapeutic approaches to target its activities during impaired liver function.
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Affiliation(s)
- Chandini Rangaswamy
- Institute of Clinical Chemistry and Laboratory Medicine (O26), University Medical Center Hamburg-Eppendorf, Martinistrasse 52, D-20246, Hamburg, Germany
| | - Reiner K Mailer
- Institute of Clinical Chemistry and Laboratory Medicine (O26), University Medical Center Hamburg-Eppendorf, Martinistrasse 52, D-20246, Hamburg, Germany
| | - Hanna Englert
- Institute of Clinical Chemistry and Laboratory Medicine (O26), University Medical Center Hamburg-Eppendorf, Martinistrasse 52, D-20246, Hamburg, Germany
| | - Sandra Konrath
- Institute of Clinical Chemistry and Laboratory Medicine (O26), University Medical Center Hamburg-Eppendorf, Martinistrasse 52, D-20246, Hamburg, Germany
| | - Thomas Renné
- Institute of Clinical Chemistry and Laboratory Medicine (O26), University Medical Center Hamburg-Eppendorf, Martinistrasse 52, D-20246, Hamburg, Germany.
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32
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Talotta R, Robertson ES. Antiphospholipid antibodies and risk of post-COVID-19 vaccination thrombophilia: The straw that breaks the camel's back? Cytokine Growth Factor Rev 2021; 60:52-60. [PMID: 34090785 PMCID: PMC8159713 DOI: 10.1016/j.cytogfr.2021.05.001] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 05/24/2021] [Indexed: 12/12/2022]
Abstract
Antiphospholipid antibodies (aPLs), present in 1–5 % of healthy individuals, are associated with the risk of antiphospholipid syndrome (APS), which is the most common form of acquired thrombophilia. APLs may appear following infections or vaccinations and have been reported in patients with COronaVIrus Disease-2019 (COVID-19). However, their association with COVID-19 vaccination is unclear. Notably, a few cases of thrombocytopenia and thrombotic events resembling APS have been reported to develop in recipients of either adenoviral vector- or mRNA-based COVID-19 vaccines. The aim of this review is therefore to speculate on the plausible role of aPLs in the pathogenesis of these rare adverse events. Adenoviral vector-based vaccines can bind platelets and induce their destruction in the reticuloendothelial organs. Liposomal mRNA-based vaccines may instead favour activation of coagulation factors and confer a pro-thrombotic phenotype to endothelial cells and platelets. Furthermore, both formulations may trigger a type I interferon response associated with the generation of aPLs. In turn, aPLs may lead to aberrant activation of the immune response with participation of innate immune cells, cytokines and the complement cascade. NETosis, monocyte recruitment and cytokine release may further support endothelial dysfunction and promote platelet aggregation. These considerations suggest that aPLs may represent a risk factor for thrombotic events following COVID-19 vaccination, and deserve further investigations.
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Affiliation(s)
- Rossella Talotta
- Rheumatology Unit, Department of Clinical and Experimental Medicine, University of Messina, AOU "Gaetano Martino", via Consolare Valeria 1, 98124, Messina, Italy.
| | - Erle S Robertson
- Department of Otorhinolaryngology-Head and Neck Surgery, Perelman School of Medicine, University of Pennsylvania, 3610 Hamilton Walk, 201E JP, Philadelphia, PA, 19104, USA.
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33
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Costa-Filho RC, Castro-Faria HC, Mengel J, Pelajo-Machado M, Martins MA, Leite ÉT, Mendonça-Filho HT, de Souza TDACB, Bello GB, Leite JPG. Should COVID-19 be branded to viral thrombotic fever? Mem Inst Oswaldo Cruz 2021; 116:e200552. [PMID: 33950107 PMCID: PMC8103775 DOI: 10.1590/0074-02760200552] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 04/01/2021] [Indexed: 12/17/2022] Open
Abstract
Coronaviruses can cause a diverse array of clinical manifestations, from fever with symptoms of the common cold to highly lethal severe acute respiratory syndrome (SARS) and middle east respiratory syndrome (MERS). SARS-CoV-2, the coronavirus discovered in Hubei province, China, at the end of 2019, became known worldwide for causing coronavirus disease 2019 (COVID-19). Over one year's time period, the scientific community has produced a large bulk of knowledge about this disease and countless reports about its immune-pathological aspects. This knowledge, including data obtained in postmortem studies, points unequivocally to a hypercoagulability state. However, the name COVID-19 tells us very little about the true meaning of the disease. Our proposal is more comprehensive; it intends to frame COVID-19 in more clinical terminology, making an analogy to viral haemorrhagic fever (VHF). Thus, we found irrefutable evidence in the current literature that COVID-19 is the first viral disease that can be branded as a viral thrombotic fever. This manuscript points out that SARS-CoV-2 goes far beyond pneumonia or SARS. COVID-19 infections promote remarkable interactions among the endothelium, coagulation, and immune response, building up a background capable of promoting a "thrombotic storm," much more than a "cytokine storm." The importance of a viral protease called main protease (Mpro) is highlighted as a critical component for its replication in the host cell. A deeper analysis of this protease and its importance on the coagulation system is also discussed for the first time, mainly because of its similarity with the thrombin and factor Xa molecules, as recently pointed out by structural comparison crystallographic structures.
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Affiliation(s)
- Rubens Carmo Costa-Filho
- Hospital Pró-Cardíaco, Américas Serviços Médicos, United-Health Group, Rio de Janeiro, RJ, Brasil
| | - Hugo Caire Castro-Faria
- Fundação Oswaldo Cruz-Fiocruz, Instituto Oswaldo Cruz, Laboratório de Imunofarmacologia, Rio de Janeiro, RJ, Brasil
| | - José Mengel
- Fundação Oswaldo Cruz-Fiocruz, Instituto Oswaldo Cruz, Laboratório de Imunologia Clínica, Rio de Janeiro, RJ, Brasil
- Centro Universitário Arthur Sá Earp Neto, Faculdade de Medicina de Petrópolis, Petrópolis, RJ, Brasil
| | - Marcelo Pelajo-Machado
- Fundação Oswaldo Cruz-Fiocruz, Instituto Oswaldo Cruz, Laboratório de Patologia, Rio de Janeiro, RJ, Brasil
| | - Marco Aurélio Martins
- Fundação Oswaldo Cruz-Fiocruz, Instituto Oswaldo Cruz, Laboratório de Inflamação, Rio de Janeiro, RJ, Brasil
| | | | | | | | - Gonzalo Bentacor Bello
- Fundação Oswaldo Cruz-Fiocruz, Instituto Oswaldo Cruz, Laboratório de AIDS e Imunologia Molecular, Rio de Janeiro, RJ, Brasil
| | - José Paulo Gagliardi Leite
- Fundação Oswaldo Cruz-Fiocruz, Instituto Oswaldo Cruz, Laboratório de Virologia Comparada e Ambiental, Rio de Janeiro, RJ, Brasil
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34
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Endothelial dysfunction and immunothrombosis as key pathogenic mechanisms in COVID-19. Nat Rev Immunol 2021; 21:319-329. [PMID: 33824483 PMCID: PMC8023349 DOI: 10.1038/s41577-021-00536-9] [Citation(s) in RCA: 536] [Impact Index Per Article: 178.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/09/2021] [Indexed: 02/07/2023]
Abstract
Coronavirus disease 2019 (COVID-19) is a clinical syndrome caused by infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Patients with severe disease show hyperactivation of the immune system, which can affect multiple organs besides the lungs. Here, we propose that SARS-CoV-2 infection induces a process known as immunothrombosis, in which activated neutrophils and monocytes interact with platelets and the coagulation cascade, leading to intravascular clot formation in small and larger vessels. Microthrombotic complications may contribute to acute respiratory distress syndrome (ARDS) and other organ dysfunctions. Therapeutic strategies aimed at reducing immunothrombosis may therefore be useful. Several antithrombotic and immunomodulating drugs have been proposed as candidates to treat patients with SARS-CoV-2 infection. The growing understanding of SARS-CoV-2 infection pathogenesis and how it contributes to critical illness and its complications may help to improve risk stratification and develop targeted therapies to reduce the acute and long-term consequences of this disease. Here, the authors propose that SARS-CoV-2 induces a prothrombotic state, with dysregulated immunothrombosis in lung microvessels and endothelial injury, which drive the clinical manifestations of severe COVID-19. They discuss potential antithrombotic and immunomodulating drugs that are being considered in the treatment of patients with COVID-19.
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Cappel MA, Cappel JA, Wetter DA. Pernio (Chilblains), SARS-CoV-2, and COVID Toes Unified Through Cutaneous and Systemic Mechanisms. Mayo Clin Proc 2021; 96:989-1005. [PMID: 33714595 PMCID: PMC7826004 DOI: 10.1016/j.mayocp.2021.01.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Revised: 01/05/2021] [Accepted: 01/13/2021] [Indexed: 12/14/2022]
Abstract
Pernio or chilblains is characterized by erythema and swelling at acral sites (eg, toes and fingers), typically triggered by cold exposure. Clinical and histopathologic features of pernio are well described, but the pathogenesis is not entirely understood; vasospasm and a type I interferon (IFN-I) immune response are likely involved. During the coronavirus disease 2019 (COVID-19) pandemic, dermatologists have observed an increase in pernio-like acral eruptions. Direct causality of pernio due to COVID-19 has not been established in many cases because of inconsistent testing methods (often negative results) for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). However, a form of COVID-19‒associated pernio (also called COVID toes) is probable because of increased occurrence, frequently in young patients with no cold exposure or a history of pernio, and reports of skin biopsies with positive SARS-CoV-2 immunohistochemistry. PubMed was searched between January 1, 2020, and December 31, 2020 for publications using the following keywords: pernio, chilblain, and acral COVID-19. On the basis of our review of the published literature, we speculate that several unifying cutaneous and systemic mechanisms may explain COVID-19‒associated pernio: (1) SARS-CoV-2 cell infection occurs through the cellular receptor angiotensin-converting enzyme 2 mediated by transmembrane protease serine 2, subsequently affecting the renin-angiotensin-aldosterone system with an increase in the vasoconstricting, pro-inflammatory, and prothrombotic angiotensin II pathway. (2) Severe acute respiratory syndrome coronavirus 2 cell infection triggers an immune response with robust IFN-I release in patients predisposed to COVID-19‒associated pernio. (3) Age and sex discrepancies correlated with COVID-19 severity and manifestations, including pernio as a sign of mild disease, are likely explained by age-related immune and vascular differences influenced by sex hormones and genetics, which affect susceptibility to viral cellular infection, the renin-angiotensin-aldosterone system balance, and the IFN-I response.
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Key Words
- ace2, angiotensin-converting enzyme 2
- adam17, a disintegrin and metalloproteinase 17
- ang, angiotensin
- ang1-7, angiotensin-(1-7)
- angii, angiotensin ii
- at1r, angiotensin type 1 receptor
- at2r, angiotensin type 2 receptor
- covid-19, coronavirus disease 2019
- hif-1α, hypoxia-inducible factor 1α
- ifn, interferon
- ifn-i, type i interferon
- ifn-α, interferon α
- il, interleukin
- mxa, myxovirus resistance protein a
- no, nitric oxide
- nsp, nonstructural protein
- pcr, polymerase chain reaction
- pdc, plasmacytoid dendritic cell
- raas, renin-angiotensin-aldosterone system
- s1, spike protein 1
- s2, spike protein 2
- sars-cov, severe acute respiratory syndrome coronavirus
- sars-cov-2, severe acute respiratory syndrome coronavirus 2
- th17, helper t cell 17
- tlr7, toll-like receptor 7
- tmprss2, transmembrane protease serine 2
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Affiliation(s)
- Mark A Cappel
- Gulf Coast Dermatopathology Laboratory, Dermatology Associates of Tampa Bay, Tampa, FL
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Dieudonné Y, Guffroy A, Poindron V, Sprauel PS, Martin T, Korganow AS, Gies V. B cells in primary antiphospholipid syndrome: Review and remaining challenges. Autoimmun Rev 2021; 20:102798. [PMID: 33722752 DOI: 10.1016/j.autrev.2021.102798] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2020] [Accepted: 01/03/2021] [Indexed: 02/03/2023]
Abstract
It is now widely accepted that antiphospholipid antibodies (aPL) have direct pathogenic effects and that B cells, notably through aPL production, play a key role in the development of antiphospholipid syndrome (APS). Recent findings strengthened the implication of B cells with the description of specific B cell phenotype abnormalities and inborn errors of immunity involving B cell signaling in APS patients. In addition, it has been shown in preclinical models that cross-reactivity between APS autoantigens and mimotopes expressed by human gut commensals can lead to B cell tolerance breakdown and are sufficient for APS development. However, B cell targeting therapies are surprisingly not as effective as expected in APS compared to other autoimmune diseases. Elucidation of the B cell tolerance breakdown mechanisms in APS patients may help to develop and guide the use of novel therapeutic agents that target B cells or specific immune pathway.
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Affiliation(s)
- Yannick Dieudonné
- Université de Strasbourg, INSERM UMR - S1109, F-67000 Strasbourg, France; Hôpitaux Universitaires de Strasbourg, Department of Clinical Immunology and Internal Medicine, National Reference Center for Systemic Autoimmune Diseases (CNR RESO), Tertiary Center for Primary Immunodeficiencies, F-67000 Strasbourg, France; Université de Strasbourg, Faculty of Medicine, F-67000 Strasbourg, France.
| | - Aurélien Guffroy
- Université de Strasbourg, INSERM UMR - S1109, F-67000 Strasbourg, France; Hôpitaux Universitaires de Strasbourg, Department of Clinical Immunology and Internal Medicine, National Reference Center for Systemic Autoimmune Diseases (CNR RESO), Tertiary Center for Primary Immunodeficiencies, F-67000 Strasbourg, France; Université de Strasbourg, Faculty of Medicine, F-67000 Strasbourg, France
| | - Vincent Poindron
- Université de Strasbourg, INSERM UMR - S1109, F-67000 Strasbourg, France; Hôpitaux Universitaires de Strasbourg, Department of Clinical Immunology and Internal Medicine, National Reference Center for Systemic Autoimmune Diseases (CNR RESO), Tertiary Center for Primary Immunodeficiencies, F-67000 Strasbourg, France; Université de Strasbourg, Faculty of Medicine, F-67000 Strasbourg, France
| | - Pauline Soulas Sprauel
- Université de Strasbourg, INSERM UMR - S1109, F-67000 Strasbourg, France; Hôpitaux Universitaires de Strasbourg, Department of Clinical Immunology and Internal Medicine, National Reference Center for Systemic Autoimmune Diseases (CNR RESO), Tertiary Center for Primary Immunodeficiencies, F-67000 Strasbourg, France; Université de Strasbourg, Faculty of Pharmacy, F-67400 Illkirch, France
| | - Thierry Martin
- Université de Strasbourg, INSERM UMR - S1109, F-67000 Strasbourg, France; Hôpitaux Universitaires de Strasbourg, Department of Clinical Immunology and Internal Medicine, National Reference Center for Systemic Autoimmune Diseases (CNR RESO), Tertiary Center for Primary Immunodeficiencies, F-67000 Strasbourg, France; Université de Strasbourg, Faculty of Medicine, F-67000 Strasbourg, France
| | - Anne-Sophie Korganow
- Université de Strasbourg, INSERM UMR - S1109, F-67000 Strasbourg, France; Hôpitaux Universitaires de Strasbourg, Department of Clinical Immunology and Internal Medicine, National Reference Center for Systemic Autoimmune Diseases (CNR RESO), Tertiary Center for Primary Immunodeficiencies, F-67000 Strasbourg, France; Université de Strasbourg, Faculty of Medicine, F-67000 Strasbourg, France
| | - Vincent Gies
- Université de Strasbourg, INSERM UMR - S1109, F-67000 Strasbourg, France; Hôpitaux Universitaires de Strasbourg, Department of Clinical Immunology and Internal Medicine, National Reference Center for Systemic Autoimmune Diseases (CNR RESO), Tertiary Center for Primary Immunodeficiencies, F-67000 Strasbourg, France; Université de Strasbourg, Faculty of Pharmacy, F-67400 Illkirch, France
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Nasonov EL. Coronavirus disease 2019 (COVID-19) and autoimmunity. RHEUMATOLOGY SCIENCE AND PRACTICE 2021. [DOI: 10.47360/1995-4484-2021-5-30] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The coronavirus 2019 pandemic (coronavirus disease, COVID-19), etiologically related to the SARS-CoV-2 virus (severe acute respiratory syndrome coronavirus-2), has once again reawakened healthcare professionals’ interest towards new clinical and conceptual issues of human immunology and immunopathology. An unprecedented number of clinical trials and fundamental studies of epidemiology, virology, immunology and molecular biology, of the COVID-19 clinical course polymorphism and pharmacotherapy have been conducted within one year since the outbreak of 2019 pandemic, bringing together scientists of almost all biological and physicians of almost all medical specialties. Their joint efforts have resulted in elaboration of several types of vaccines against SARS-CoV-2 infection and, in general, fashioning of more rational approaches to patient management. Also important for COVID-19 management were all clinical trials of biologics and “targeted” anti-inflammatory drugs modulating intracellular cytokine signaling, which have been specifically developed for treatment immune-mediated inflammatory rheumatic disease (IMIRDs) over the past 20 years. It became obvious after a comprehensive analysis of the entire spectrum of clinical manifestations and immunopathological disorders in COVID-19 is accompanied by a wide range of extrapulmonary clinical and laboratory disorders, some of which are characteristic of IMIRDs and other autoimmune and auto-in-flammatory human diseases. All these phenomena substantiated the practice of anti-inflammatory drugs repurposing with off-label use of specific antirheumatic agents for treatment of COVID-19. This paper discusses potential use of glucocorticoids, biologics, JAK inhibitors, etc., blocking the effects of pro-inflammatory cytokines for treatment of 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 of the Ministry of Health Care of Russian Federation (Sechenov University)
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Lou M, Yuan D, Liao S, Tong L, Li J. Potential mechanisms of cerebrovascular diseases in COVID-19 patients. J Neurovirol 2021; 27:35-51. [PMID: 33534131 PMCID: PMC7856859 DOI: 10.1007/s13365-021-00948-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 12/31/2020] [Accepted: 01/14/2021] [Indexed: 01/08/2023]
Abstract
Since the outbreak of coronavirus disease 2019 (COVID-19) in 2019, it is gaining worldwide attention at the moment. Apart from respiratory manifestations, neurological dysfunction in COVID-19 patients, especially the occurrence of cerebrovascular diseases (CVD), has been intensively investigated. In this review, the effects of COVID-19 infection on CVD were summarized as follows: (I) angiotensin-converting enzyme 2 (ACE2) may be involved in the attack on vascular endothelial cells by severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), leading to endothelial damage and increased subintimal inflammation, which are followed by hemorrhage or thrombosis; (II) SARS-CoV-2 could alter the expression/activity of ACE2, consequently resulting in the disruption of renin-angiotensin system which is associated with the occurrence and progression of atherosclerosis; (III) upregulation of neutrophil extracellular traps has been detected in COVID-19 patients, which is closely associated with immunothrombosis; (IV) the inflammatory cascade induced by SARS-CoV-2 often leads to hypercoagulability and promotes the formation and progress of atherosclerosis; (V) antiphospholipid antibodies are also detected in plasma of some severe cases, which aggravate the thrombosis through the formation of immune complexes; (VI) hyperglycemia in COVID-19 patients may trigger CVD by increasing oxidative stress and blood viscosity; (VII) the COVID-19 outbreak is a global emergency and causes psychological stress, which could be a potential risk factor of CVD as coagulation, and fibrinolysis may be affected. In this review, we aimed to further our understanding of CVD-associated COVID-19 infection, which could improve the therapeutic outcomes of patients. Personalized treatments should be offered to COVID-19 patients at greater risk for stroke in future clinical practice.
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Affiliation(s)
- Manxue Lou
- Department of Neurology, Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400010, China
| | - Dezhi Yuan
- Department of Neurology, First Affiliated Hospital of Army Medical University (Chongqing Southwest Hospital), Chongqing, 400038, China
- Department of Neurology, People's Hospital of Shapingba District, Chongqing, 400038, China
| | - Shengtao Liao
- Department of Gastroenterology, Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400010, China
| | - Linyan Tong
- Department of Neurology, Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400010, China
| | - Jinfang Li
- Department of Neurology, Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400010, China.
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Devaux CA, Camoin-Jau L, Mege JL, Raoult D. Can hydroxychloroquine be protective against COVID-19-associated thrombotic events ? JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2021; 54:37-45. [PMID: 33500211 PMCID: PMC7783458 DOI: 10.1016/j.jmii.2020.12.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 12/15/2020] [Accepted: 12/24/2020] [Indexed: 02/06/2023]
Abstract
Although SARS-CoV-2 is considered a lung-tropic virus, severe COVID-19 is not just a viral pulmonary infection, clinically it is a multi-organ pathology with major coagulation abnormalities and thromboembolism events. Recently, antiphospholipid (aPL) antibodies were found increased in a large number of COVID-19 patients. Elevated aPL have been well documented in antiphospholipid syndrome (APS), a systemic autoimmune disorder characterized by recurrent venous or arterial thrombosis and/or obstetrical morbidity. Among treatment regimen of APS, hydroxychloroquine (HCQ) is one of the molecules proposed in the primary prevention of thrombosis and obstetrical morbidity in those patients. Due to its antithrombotic properties documented in APS therapy, HCQ could be considered a good candidate for the prevention of thrombotic events in COVID-19 patients in association with anticoagulant and its repurposing deserves further evaluation.
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Affiliation(s)
- Christian A Devaux
- Aix-Marseille Univ, IRD, APHM, MEPHI, IHU-Méditerranée Infection, Marseille, France; CNRS, Marseille, France.
| | - Laurence Camoin-Jau
- Aix-Marseille Univ, IRD, APHM, MEPHI, IHU-Méditerranée Infection, Marseille, France; Laboratoire D'Hématologie, Hôpital de La Timone, APHM, Boulevard Jean- Moulin, 13005, Marseille, France
| | - Jean-Louis Mege
- Aix-Marseille Univ, IRD, APHM, MEPHI, IHU-Méditerranée Infection, Marseille, France
| | - Didier Raoult
- Aix-Marseille Univ, IRD, APHM, MEPHI, IHU-Méditerranée Infection, Marseille, France
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García-Ortega A, de la Rosa D, Oscullo G, Castillo-Villegas D, López-Reyes R, Martínez-García MÁ. Coagulation disorders and thromboembolic disease in COVID-19: review of current evidence in search of a better approach. J Thorac Dis 2021; 13:1239-1255. [PMID: 33717596 PMCID: PMC7947499 DOI: 10.21037/jtd-20-3062] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
The new severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has been an unprecedented global health problem, causing more than 20 million infections and more than 900,000 deaths (September 2020). The SARS-CoV-2 infection, known as COVID-19, has various clinical presentations, from asymptomatic or mild catarrhal processes to severe pneumonia that rapidly progresses to acute respiratory distress syndrome (ARDS) and multiple organ failure. In the last few months, much scientific literature has been devoted to descriptions of different aspects of the coagulation disorders and arterial and venous thrombotic complications associated with COVID-19, particularly venous thromboembolism (VTE). These studies have revealed that SARS-CoV-2 could lead to a prothrombotic state reflecting the high cumulative incidence of associated thrombotic events, particularly in patients admitted to intensive care units (ICUs). As regards the coagulopathy observed in association with SARS-CoV-2 infection, the mechanisms that activate coagulation have been hypothesized as being linked to immune responses, through the release of pro-inflammatory mediators that interact with platelets, stimulate the expression of tissue factor, induce an upregulation of plasminogen activator inhibitor-1, suppress the fibrinolytic system and lead to endothelial dysfunction, triggering thrombogenesis. D-dimer elevation has been recognized as a useful biomarker of poor prognosis, although the best cut-off point for predicting VTE in COVID-19 patients has still not been clarified. This review will try to update all the available scientific information on this important topic with enormous clinical and therapeutic implications.
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Affiliation(s)
- Alberto García-Ortega
- Pneumology Department, Hospital Universitario and Politécnico La Fe, 46026 Valencia, Spain.,Medical Research Institute Hospital La Fe (IISLAFE), 46026 Valencia, Spain
| | - David de la Rosa
- Pneumology Department, Hospital Universitario Santa Creu i Sant Pau, 08041 Barcelona, Spain
| | - Grace Oscullo
- Pneumology Department, Hospital Universitario and Politécnico La Fe, 46026 Valencia, Spain.,Medical Research Institute Hospital La Fe (IISLAFE), 46026 Valencia, Spain
| | | | - Raquel López-Reyes
- Pneumology Department, Hospital Universitario and Politécnico La Fe, 46026 Valencia, Spain
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Kwok YFR, Asti D, Mudduluru BM, Skaradinskiy Y. Catastrophic antiphospholipid syndrome post-Epstein-Barr virus infection: a case report. Hematol Transfus Cell Ther 2020; 44:419-421. [PMID: 33358683 PMCID: PMC9477760 DOI: 10.1016/j.htct.2020.09.153] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 09/02/2020] [Accepted: 09/19/2020] [Indexed: 11/17/2022] Open
Affiliation(s)
| | - Divya Asti
- Staten Island University Hospital, Staten Island, NY, United States
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Im JH, Chung MH, Lee HJ, Kwon HY, Baek JH, Jang JH, Lee JS. Splenic infarction and infectious diseases in Korea. BMC Infect Dis 2020; 20:915. [PMID: 33267828 PMCID: PMC7708890 DOI: 10.1186/s12879-020-05645-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Accepted: 11/22/2020] [Indexed: 01/20/2023] Open
Abstract
Background The spleen contains immune cells and exhibits a pattern of infarction different from other organs; as such, splenic infarction (SI) may provide important clues to infection. However, the nature of the relationship between SI and infectious disease(s) is not well understood. Accordingly, this retrospective study investigated the relationship between SI and infection. Methods Hospital records of patients with SI, who visited Inha University Hospital (Incheon, Republic of Korea) between January 2008 and December 2018, were reviewed. Patient data regarding clinical presentation, causative pathogens, risk factors, and radiological findings were collected and analyzed. Results Of 353 patients with SI, 101 with infectious conditions were enrolled in this study, and their data were analyzed to identify associations between SI and infection. Ten patients were diagnosed with infective endocarditis (IE), and 26 exhibited bacteremia without IE. Twenty-seven patients experienced systemic infection due to miscellaneous causes (negative result on conventional automated blood culture), including the following intracellular organisms: parasites (malaria [n = 12], babesiosis [n = 1]); bacteria (scrub typhus [n = 5]); viruses (Epstein–Barr [n = 1], cytomegalovirus [n = 1]); and unidentified pathogen[s] (n = 7). Splenomegaly was more common among patients with miscellaneous systemic infection; infarction involving other organs was rare. Thirty-eight patients had localized infections (e.g., respiratory, intra-abdominal, or skin and soft tissue infection), and most (35 of 38) had other risk factors for SI. Conclusions In this study, various infectious conditions were found to be associated with SI, and intracellular organisms were the most common causative pathogens. Further studies are needed to examine other possible etiologies and the underlying pathophysiological mechanisms.
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Affiliation(s)
- Jae Hyoung Im
- Division of Infectious Diseases, Department of Internal Medicine, Inha University School of Medicine, Incheon, 22212, Republic of Korea
| | - Moon-Hyun Chung
- Department of Internal Medicine, Seogwipo Medical Center, Jeju-do, Republic of Korea
| | - Hye-Jin Lee
- Translation Research Center, Inha University School of Medicine, Incheon, Republic of Korea
| | - Hea Yoon Kwon
- Division of Infectious Diseases, Department of Internal Medicine, Inha University School of Medicine, Incheon, 22212, Republic of Korea
| | - Ji Hyeon Baek
- Division of Infectious Diseases, Department of Internal Medicine, Inha University School of Medicine, Incheon, 22212, Republic of Korea
| | - Ji-Hun Jang
- Department of Hospital Medicine, Inha University School of Medicine, Incheon, 22212, Republic of Korea.
| | - Jin-Soo Lee
- Division of Infectious Diseases, Department of Internal Medicine, Inha University School of Medicine, Incheon, 22212, Republic of Korea.
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Dorsolateral medullary infarction during skin infection by Stenotrophomonas maltophilia in a patient with triple antiphospholipid antibody positivity: a case-based review. Clin Rheumatol 2020; 40:2965-2971. [PMID: 33155156 PMCID: PMC7643724 DOI: 10.1007/s10067-020-05489-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2020] [Revised: 10/20/2020] [Accepted: 10/28/2020] [Indexed: 02/06/2023]
Abstract
Thrombotic events are the most frequent causes of death in patients with antiphospholipid syndrome (APS). Previous studies have reported infection to be the most important trigger of thrombosis in APS, with molecular mimicry considered to be a major mechanism. Although timely management of infections has been recommended in patients with high suspicion of infection, anti-infective therapy would not take effect in a short time due to the dilemma in determining the origins of infection, especially in patients undergoing immunosuppressive therapy. Here, we describe a 26-year-old patient with systemic lupus erythematosus with triple antiphospholipid antibody positivity who had a stroke involving her dorsolateral medulla, despite timely anti-infective treatment within the context of skin infection caused by Stenotrophomonas maltophilia. To the best of our knowledge, it is the first report about the association between Stenotrophomonas maltophilia infection and thrombotic complications in APS. Thus, solely focusing on anti-infective therapy by the current recommendation for the management of APS may be insufficient within the context of infection; early initiation of effective anticoagulation should also be suggested until the anti-infective therapy becomes effective, especially in patients with high-risk antiphospholipid antibody profiles, in whom the potential benefit would outweigh the risk of bleeding.
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Aguirre-Alastuey ME, Suárez-Díaz S, Rodríguez-Jerez F, Coto-Hernández R, Caminal-Montero L. Venous thrombosis in a systemic lupus erythematosus patient with antiphospholipid antibodies coinciding with mild Covid-19. Lupus 2020; 30:172-174. [PMID: 33092468 DOI: 10.1177/0961203320967407] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
| | | | | | - Rubén Coto-Hernández
- Systemic Autoinmmune Diseases Unit, Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Hospital Universitario Central de Asturias, Oviedo, Spain
| | - Luis Caminal-Montero
- Systemic Autoinmmune Diseases Unit, Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Hospital Universitario Central de Asturias, Oviedo, Spain
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Xiao M, Zhang Y, Zhang S, Qin X, Xia P, Cao W, Jiang W, Chen H, Ding X, Zhao H, Zhang H, Wang C, Zhao J, Sun X, Tian R, Wu W, Wu D, Ma J, Chen Y, Zhang D, Xie J, Yan X, Zhou X, Liu Z, Wang J, Du B, Qin Y, Gao P, Lu M, Hou X, Wu X, Zhu H, Xu Y, Zhang W, Li T, Zhang F, Zhao Y, Li Y, Zhang S. Antiphospholipid Antibodies in Critically Ill Patients With COVID-19. Arthritis Rheumatol 2020; 72:1998-2004. [PMID: 32602200 PMCID: PMC7361932 DOI: 10.1002/art.41425] [Citation(s) in RCA: 110] [Impact Index Per Article: 27.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Accepted: 06/25/2020] [Indexed: 12/20/2022]
Abstract
OBJECTIVE Coagulopathy is one of the characteristics observed in critically ill patients with coronavirus disease 2019 (COVID-19). Antiphospholipid antibodies (aPLs) contribute to coagulopathy, though their role in COVID-19 remains unclear. This study was undertaken to determine the prevalence and characteristics of aPLs in patients with COVID-19. METHODS Sera collected from 66 COVID-19 patients who were critically ill and 13 COVID-19 patients who were not critically ill were tested by chemiluminescence immunoassay for anticardiolipin antibodies (aCLs), anti-β2 -glycoprotein I (anti-β2 GPI) (IgG, IgM, and IgA), and IgG anti-β2 GPI-domain 1 (anti-β2 GPI-D1) and IgM and IgG anti-phosphatidylserine/prothrombin (anti-PS/PT) antibodies were detected in the serum by enzyme-linked immunosorbent assay. RESULTS Of the 66 COVID-19 patients in critical condition, aPLs were detected in 31 (47% ). Antiphospholipid antibodies were not present among COVID-19 patients who were not in critical condition. The IgA anti-β2 GPI antibody was the most commonly observed aPL in patients with COVID-19 and was present in 28.8% (19 of 66) of the critically ill patients, followed by IgA aCLs (17 of 66, or 25.8%) and IgG anti-β2 GPI (12 of 66, or 18.2%). For multiple aPLs, IgA anti-β2 GPI + IgA aCLs was the most common antibody profile observed (15 of 66, or 22.7%), followed by IgA anti-β2 GPI + IgA aCL + IgG anti-β2 GPI (10 of 66, or 15.2%). Antiphospholipid antibodies emerge ~35-39 days after disease onset. A dynamic analysis of aPLs revealed 4 patterns based on the persistence or transient appearance of the aPLs. Patients with multiple aPLs had a significantly higher incidence of cerebral infarction compared to patients who were negative for aPLs (P = 0.023). CONCLUSION Antiphospholipid antibodies were common in critically ill patients with COVID-19. Repeated testing demonstrating medium to high titers of aPLs and the number of aPL types a patient is positive for may help in identifying patients who are at risk of developing cerebral infarction. Antiphospholipid antibodies may be transient and disappear within a few weeks, but in genetically predisposed patients, COVID-19 may trigger the development of an autoimmune condition similar to the antiphospholipid syndrome (APS), referred to as "COVID-19-induced APS-like syndrome." Long-term follow-up of COVID-19 patients who are positive for aPLs would be of great importance in understanding the pathogenesis of this novel coronavirus.
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Affiliation(s)
- Meng Xiao
- Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Yan Zhang
- Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Shulan Zhang
- Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Xuzhen Qin
- Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Peng Xia
- Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Wei Cao
- Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Wei Jiang
- Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Huan Chen
- Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Xin Ding
- Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Hua Zhao
- Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Hongmin Zhang
- Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Chunyao Wang
- Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Jing Zhao
- Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Xuefeng Sun
- Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Ran Tian
- Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Wei Wu
- Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Dong Wu
- Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Jie Ma
- Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Yu Chen
- Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Dong Zhang
- Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Jing Xie
- Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Xiaowei Yan
- Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Xiang Zhou
- Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Zhengyin Liu
- Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Jinglan Wang
- Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Bin Du
- Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Yan Qin
- Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Peng Gao
- Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Minya Lu
- Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Xin Hou
- Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Xian Wu
- Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Huadong Zhu
- Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Yingchun Xu
- Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Wen Zhang
- Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Taisheng Li
- Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Fengchun Zhang
- Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Yongqiang Zhao
- Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Yongzhe Li
- Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Shuyang Zhang
- Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
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46
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Abstract
Severe Acute Respiratory Syndrome-Coronavirus-2 is responsible for the current pandemic that has led to more than 10 million confirmed cases of Coronavirus Disease-19 (COVID-19) and over 500,000 deaths worldwide (4 July 2020). Virus-mediated injury to multiple organs, mainly the respiratory tract, activation of immune response with the release of pro-inflammatory cytokines, and overactivation of the coagulation cascade and platelet aggregation leading to micro- and macrovascular thrombosis are the main pathological features of COVID-19. Empirical multidrug therapeutic approaches to treat COVID-19 are currently used with extremely uncertain outcomes, and many others are being tested in clinical trials. Acetylsalicylic acid (ASA) has both anti-inflammatory and antithrombotic effects. In addition, a significant ASA-mediated antiviral activity against DNA and RNA viruses, including different human coronaviruses, has been documented. The use of ASA in patients with different types of infections has been associated with reduced thrombo-inflammation and lower rates of clinical complications and in-hospital mortality. However, safety issues related both to the risk of bleeding and to that of developing rare but serious liver and brain damage mostly among children (i.e., Reye's syndrome) should be considered. Hence, whether ASA might be a safe and reasonable therapeutic candidate to be tested in clinical trials involving adults with COVID-19 deserves further attention. In this review we provide a critical appraisal of current evidence on the anti-inflammatory, antithrombotic, and antiviral effects of ASA, from both a pre-clinical and a clinical perspective. In addition, the potential benefits and risks of use of ASA have been put in the context of the adult-restricted COVID-19 population.
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47
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Hasan Ali O, Bomze D, Risch L, Brugger SD, Paprotny M, Weber M, Thiel S, Kern L, Albrich WC, Kohler P, Kahlert CR, Vernazza P, Bühler PK, Schüpbach RA, Gómez-Mejia A, Popa AM, Bergthaler A, Penninger JM, Flatz L. Severe COVID-19 is associated with elevated serum IgA and antiphospholipid IgA-antibodies. Clin Infect Dis 2020; 73:e2869-e2874. [PMID: 32997739 PMCID: PMC7543315 DOI: 10.1093/cid/ciaa1496] [Citation(s) in RCA: 59] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 09/29/2020] [Indexed: 01/15/2023] Open
Abstract
Background Severe coronavirus disease 2019 (COVID-19) frequently entails complications that bear similarities to autoimmune diseases. To date, there is little data on possible IgA-mediated autoimmune responses. Here, we aim to determine whether COVID-19 is associated with a vigorous total IgA response and if IgA antibodies are associated with complications of severe illness. Since thrombotic events are frequent in severe COVID-19 and resemble hypercoagulation of antiphospholipid syndrome (APS), our approach focused on antiphospholipid antibodies (aPL). Methods In this retrospective cohort study clinical data and aPL from 64 patients with COVID-19 were compared from three independent tertiary hospitals (one in Liechtenstein, two in Switzerland). Samples were collected from April 9 th to May 1 st, 2020. Results Clinical records of 64 patients with COVID-19 were reviewed and divided into a cohort with mild illness (mCOVID) (41%), a discovery cohort with severe illness (sdCOVID) (22%) and a confirmation cohort with severe illness (scCOVID) (38%). Total IgA, IgG and aPL were measured with clinical diagnostic kits. Severe illness was significantly associated with increased total IgA (sdCOVID, P=0.01; scCOVID, p-value<0.001), but not total IgG. Among aPL, both cohorts with severe illness significantly correlated with elevated anti-Cardiolipin IgA (sdCOVID and scCOVID, p-value<0.001), anti-Cardiolipin IgM (sdCOVID, P=0.003; scCOVID, P<0.001), and anti-Beta2 Glycoprotein-1 IgA (sdCOVID and scCOVID, P<0.001). Systemic lupus erythematosus was excluded from all patients as a potential confounder. Conclusions Higher total IgA and IgA-aPL were consistently associated with severe illness. These novel data strongly suggest that a vigorous antiviral IgA-response, possibly triggered in the bronchial mucosa, induces systemic autoimmunity.
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Affiliation(s)
- Omar Hasan Ali
- Department of Medical Genetics, Life Sciences Institute, University of British Columbia, Vancouver, Canada.,Department of Dermatology, University Hospital Zurich, Zurich, Switzerland.,Institute of Immunobiology, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - David Bomze
- Institute of Immunobiology, Kantonsspital St. Gallen, St. Gallen, Switzerland.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Lorenz Risch
- Labormedizinisches Zentrum Dr. Risch, Vaduz, Liechtenstein.,Center of Laboratory Medicine, University Institute of Clinical Chemistry, University of Bern, Bern, Switzerland
| | - Silvio D Brugger
- Department of Infectious Diseases and Hospital Hygiene, University Hospital Zurich, Zurich, Switzerland
| | - Matthias Paprotny
- Department of General Internal Medicine, Landesspital Liechtenstein, Vaduz, Liechtenstein
| | - Myriam Weber
- Department of General Internal Medicine, Landesspital Liechtenstein, Vaduz, Liechtenstein
| | - Sarah Thiel
- Department of General Internal Medicine, Landesspital Liechtenstein, Vaduz, Liechtenstein
| | - Lukas Kern
- Department of Pulmonology, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Werner C Albrich
- Division of Infectious Diseases and Hospital Epidemiology, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Philipp Kohler
- Division of Infectious Diseases and Hospital Epidemiology, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Christian R Kahlert
- Division of Infectious Diseases and Hospital Epidemiology, Kantonsspital St. Gallen, St. Gallen, Switzerland.,Department of Infectious Diseases and Hospital Epidemiology, Children's Hospital of Eastern Switzerland, St. Gallen, Switzerland
| | - Pietro Vernazza
- Division of Infectious Diseases and Hospital Epidemiology, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Philipp K Bühler
- Institute of Intensive Care Medicine, University Hospital Zurich, Zurich, Switzerland
| | - Reto A Schüpbach
- Institute of Intensive Care Medicine, University Hospital Zurich, Zurich, Switzerland
| | - Alejandro Gómez-Mejia
- Department of Infectious Diseases and Hospital Hygiene, University Hospital Zurich, Zurich, Switzerland
| | - Alexandra M Popa
- Research Center for Molecular Medicine of the Austrian Academy of Sciences, Vienna, Austria
| | - Andreas Bergthaler
- Research Center for Molecular Medicine of the Austrian Academy of Sciences, Vienna, Austria
| | - Josef M Penninger
- Department of Medical Genetics, Life Sciences Institute, University of British Columbia, Vancouver, Canada.,IMBA, Institute of Molecular Biotechnology of the Austrian Academy of Sciences, Vienna, Austria
| | - Lukas Flatz
- Department of Dermatology, University Hospital Zurich, Zurich, Switzerland.,Institute of Immunobiology, Kantonsspital St. Gallen, St. Gallen, Switzerland.,Department of Dermatology, Kantonsspital St. Gallen, St. Gallen, Switzerland.,Department of Oncology and Hematology, Kantonsspital St. Gallen, St. Gallen, Switzerland
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48
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Deep Vein Thrombosis and Pulmonary Embolism in the Setting of Mycoplasma Infection. Case Rep Med 2020; 2020:8708417. [PMID: 32963546 PMCID: PMC7490632 DOI: 10.1155/2020/8708417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 08/26/2020] [Accepted: 09/01/2020] [Indexed: 11/17/2022] Open
Abstract
Thirteen-year-old female twins presented one week apart with documented Mycoplasma pneumoniae respiratory infection. Each developed venous thrombosis and pulmonary emboli in association with transient self-limited para-infectious anti-phospholipid antibodies. Comprehensive evaluation revealed no identifiable genetic prothrombotic variables. Both children recovered after receiving antibiotics and anticoagulation therapy. Thrombotic complications associated with Mycoplasma pneumoniae infections are rare, particularly in children; the occurrence of this complication in identical twins has not been previously reported.
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49
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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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50
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Nasonov EL, Beketova TV, Reshetnyak TM, Lila AM, Ananieva LP, Lisitsyna TA, Soloviev SK. Coronavirus disease 2019 (COVID-19) and immune-mediated inflammatory rheumatic diseases: at the crossroads of thromboinflammation and autoimmunity. RHEUMATOLOGY SCIENCE AND PRACTICE 2020. [DOI: 10.47360/1995-4484-2020-353-367] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Inflammation and coagulation are key basic mechanism of protection against all potentially pathogenic mechanical and biological factors targeting human organism from inner and outer environment. On the other hand, uncontrolled inflammation results in hypercoagulation, inhibition of anticoagulation and alteration of mechanisms responsible for resolution of inflammation, while production of “procoagulant” mediators (thrombin, tissue factor and others), activation of platelets and of vascular endothelial cells maintains inflammation. All factors taken together serve as the basis for a pathological process called thromboinflammation or immunothrombosis. Currently thromboinflammation is considered in the broad sense as a universal pathogenetic mechanism of numerous widespread acute and chronic conditions, including immune-mediated (autoimmune) inflammatory rheumatic diseases, oftentimes complicated by severe irreversible damage to vital organs. Thromboinflammation gained specific attention during СОVID-19 (coronavirus disease 2019) pandemic, caused by SARS-Cov-2 (severe acute respiratory syndrome Coronavirus-2). COVID-19 is considered currently as systemic thromboinflammation syndrome, manifesting via generalized thrombosis of arterial and venous macro- and microvasculature, termed as COVID-19-coagulopathy. The paper discusses common pathogenetic coagulopathy mechanisms in COVID-19 and immune-mediated (autoimmune) inflammatory rheumatic diseases (IMRDs), associated with overproduction of antiphospholipid antibodies, activation of the complement system, and dis-regulated synthesis of proinflammatory cytokines, etc. Delineating the autoimmune subtype of thromboinflammation, identification of genetic (i.e., genes encoding the complement system and others) and molecular-biologic biomarkers associated with higher occurrence of COVID-19-coagulopathy are the most relevant undertakings for the current practice. Gaining insights into mechanisms of thromboinflammation and converting them into potential pharmacotherapies of IMDs would facilitate and accelerate the drafting of effective therapeutic strategies for COVID-19.
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Affiliation(s)
- E. L. Nasonov
- VA Nasonova Research Institute of Rheumatology;
I.M. Sechenov First Moscow State Medical University, MOH (Sechenov University)
| | | | - T. M. Reshetnyak
- VA Nasonova Research Institute of Rheumatology;
Russian Medical Academy of Continuing Prefessional Education, Ministry of Health of Russia
| | - A. M. Lila
- VA Nasonova Research Institute of Rheumatology
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