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Focosi D, McConnell S, Sullivan DJ, Casadevall A. Analysis of SARS-CoV-2 mutations associated with resistance to therapeutic monoclonal antibodies that emerge after treatment. Drug Resist Updat 2023; 71:100991. [PMID: 37572569 DOI: 10.1016/j.drup.2023.100991] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 07/18/2023] [Accepted: 07/30/2023] [Indexed: 08/14/2023]
Abstract
The mutation rate of the Omicron sublineage has led to baseline resistance against all previously authorized anti-Spike monoclonal antibodies (mAbs). Nevertheless, in case more antiviral mAbs will be authorized in the future, it is relevant to understand how frequently treatment-emergent resistance has emerged so far, under different combinations and in different patient subgroups. We report the results of a systematic review of the medical literature for case reports and case series for treatment-emergent immune escape, which is defined as emergence of a resistance-driving mutation in at least 20% of sequences in a given host at a given timepoint. We identified 32 publications detailing 216 cases that included different variants of concern (VOC) and found that the incidence of treatment emergent-resistance ranged from 10% to 50%. Most of the treatment-emergent resistance events occurred in immunocompromised patients. Interestingly, resistance also emerged against cocktails of two mAbs, albeit at lower frequencies. The heterogenous therapeutic management of those cases doesn't allow inferences about the clinical outcome in patients with treatment-emergent resistance. Furthermore, we noted a temporal correlation between the introduction of mAb therapies and a subsequent increase in SARS-CoV-2 sequences across the globe carrying mutations conferring resistance to that mAb, raising concern as to whether these had originated in mAb-treated individuals. Our findings confirm that treatment-emergent immune escape to anti-Spike mAbs represents a frequent and concerning phenomenon and suggests that these are associated with mAb use in immunosuppressed hosts.
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Affiliation(s)
- Daniele Focosi
- North-Western Tuscany Blood Bank, Pisa University Hospital, Italy.
| | - Scott McConnell
- Department of Molecular Microbiology and Immunology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA
| | - David J Sullivan
- Department of Molecular Microbiology and Immunology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA
| | - Arturo Casadevall
- Department of Molecular Microbiology and Immunology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA
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Casadevall A, Focosi D. SARS-CoV-2 variants resistant to monoclonal antibodies in immunocompromised patients constitute a public health concern. J Clin Invest 2023; 133:e168603. [PMID: 36919696 PMCID: PMC10014096 DOI: 10.1172/jci168603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/16/2023] Open
Abstract
COVID-19 in immunocompromised hosts has emerged as a difficult therapeutic management problem. Immunocompromised hosts mount weak responses to SARS-CoV-2 and manifest infection outcomes ranging from severe disease to persistent infection. Weakened immune systems mean greater viral loads and increased opportunities for viral evolution. Gupta, Konnova, et al. report the emergence of resistant SARS-CoV-2 variants in immunocompromised patients after monoclonal antibody (mAb) therapy. mAbs target only a single determinant in the viral Spike protein, which is a weakness of such therapy when treating a mutagenic and variable virus. Hence, the emergence of mAb resistance could have been anticipated, but its documentation is important because it has major public health implications, since such resistant variants have the potential to spread and escape vaccine immunity. For immunocompromised patients, these findings suggest the need for combination therapy with antiviral drugs and the use of polyclonal antibody preparations such as convalescent plasma.
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Affiliation(s)
- Arturo Casadevall
- Department of Molecular Microbiology and Immunology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Daniele Focosi
- North-Western Tuscany Blood Bank, Pisa University Hospital, Pisa, Italy
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Dioverti V, Boghdadly ZE, Shahid Z, Waghmare A, Abidi MZ, Pergam S, Boeckh M, Dadwal S, Kamboj M, Seo S, Chemaly RF, Papanicolaou GA. Revised Guidelines for Coronavirus Disease 19 Management in Hematopoietic Cell Transplantation and Cellular Therapy Recipients (August 2022). Transplant Cell Ther 2022; 28:810-821. [PMID: 36103987 PMCID: PMC9464362 DOI: 10.1016/j.jtct.2022.09.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Accepted: 09/05/2022] [Indexed: 01/17/2023]
Abstract
This document is intended as a guide for diagnosis and management of Coronavirus Disease 2019 (COVID-19), caused by the virus SARS-CoV-2, in adult and pediatric HCT and cellular therapy patients. This document was prepared using available data and with expert opinion provided by members of the (ASTCT) Infectious Diseases Special Interest Group (ID-SIG) and is an update of pervious publication. Since our original publication in 2020, the NIH and IDSA have published extensive guidelines for management of COVID-19 which are readily accessible ( NIH Guidelines , IDSA Guidelines ). This update focuses primarily on issues pertaining specifically to HCT/cellular therapy recipients. Information provided in this manuscript may change as new information becomes available.
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Affiliation(s)
- Veronica Dioverti
- Assistant Professor of Medicine, Johns Hopkins University, Baltimore, Maryland.
| | - Zeinab El Boghdadly
- Assistant Professor of Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Zainab Shahid
- Attending physician, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Alpana Waghmare
- Associate Professor of Pediatrics, University of Washington, Seattle, Washington; Fred Hutchinson Cancer Center, Seattle, Washington
| | - Maheen Z Abidi
- Assistant Professor of Medicine, University of Colorado, Denver, Colorado
| | - Steven Pergam
- Professor, Fred Hutchinson Cancer Research Center, Associate Professor, University of Washington, Seattle, Washington
| | - Michael Boeckh
- Fred Hutchinson Cancer Center, Seattle, Washington; Professor of Medicine, University of Washington, Seattle, Washington
| | | | - Mini Kamboj
- Associate Professor of Medicine, Weill Cornell Medical College, New York, New York; Memorial Sloan Kettering Cancer Center, New York, New York
| | - Susan Seo
- Memorial Sloan Kettering Cancer Center, New York, New York; Professor of Clinical Medicine, Weill Cornell Medical College, New York, New York
| | - Roy F Chemaly
- Professor of Medicine, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Genovefa A Papanicolaou
- Memorial Sloan Kettering Cancer Center, New York, New York; Professor of Medicine, Weill Cornell Medical College, New York, New York
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Simons LM, Ozer EA, Gambut S, Dean TJ, Zhang L, Bhimalli P, Schneider JR, Mamede JI, Ison MG, Karmali R, Gordon LI, Lorenzo-Redondo R, Hultquist JF. De novo emergence of SARS-CoV-2 spike mutations in immunosuppressed patients. Transpl Infect Dis 2022; 24:e13914. [PMID: 35899968 PMCID: PMC9353292 DOI: 10.1111/tid.13914] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 06/21/2022] [Accepted: 06/30/2022] [Indexed: 12/26/2022]
Abstract
BACKGROUND The continuing evolution of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) variants with decreased susceptibility to neutralizing antibodies is of clinical importance. Several spike mutations associated with immune escape have evolved independently in association with different variants of concern (VOCs). How and when these mutations arise is still unclear. We hypothesized that such mutations might arise in the context of persistent viral replication in immunosuppressed hosts. METHODS Nasopharyngeal specimens were collected longitudinally from two immunosuppressed patients with persistent SARS-CoV-2 infection. Plasma was collected from these same patients late in disease course. SARS-CoV-2 whole genome sequencing was performed to assess the emergence and frequency of mutations over time. Select Spike mutations were assessed for their impact on viral entry and antibody neutralization in vitro. RESULTS Our sequencing results revealed the intrahost emergence of spike mutations that are associated with circulating VOCs in both immunosuppressed patients (del241-243 and E484Q in one patient, and E484K in the other). These mutations decreased antibody-mediated neutralization of pseudotyped virus particles in cell culture, but also decreased efficiency of spike-mediated cell entry. CONCLUSIONS These observations demonstrate the de novo emergence of SARS-CoV-2 spike mutations with enhanced immune evasion in immunosuppressed patients with persistent infection. These data suggest one potential mechanism for the evolution of VOCs and emphasize the importance of continued efforts to develop antiviral drugs for suppression of viral replication in hospitalized settings.
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Affiliation(s)
- Lacy M. Simons
- Department of Medicine, Division of Infectious Diseases, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- Center for Pathogen Genomics and Microbial Evolution, Northwestern University Havey Institute for Global Health, Chicago, IL, USA
| | - Egon A. Ozer
- Department of Medicine, Division of Infectious Diseases, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- Center for Pathogen Genomics and Microbial Evolution, Northwestern University Havey Institute for Global Health, Chicago, IL, USA
| | - Stephanie Gambut
- Department of Microbial Pathogens and Immunity, Rush University Medical Center, Chicago, IL, USA
| | - Taylor J. Dean
- Department of Medicine, Division of Infectious Diseases, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- Center for Pathogen Genomics and Microbial Evolution, Northwestern University Havey Institute for Global Health, Chicago, IL, USA
| | - Li Zhang
- Department of Microbial Pathogens and Immunity, Rush University Medical Center, Chicago, IL, USA
| | - Pavan Bhimalli
- Department of Microbial Pathogens and Immunity, Rush University Medical Center, Chicago, IL, USA
| | - Jeffrey R. Schneider
- Department of Microbial Pathogens and Immunity, Rush University Medical Center, Chicago, IL, USA
| | - João I. Mamede
- Department of Microbial Pathogens and Immunity, Rush University Medical Center, Chicago, IL, USA
| | - Michael G. Ison
- Department of Medicine, Division of Infectious Diseases, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- Department of Surgery, Division of Organ Transplantation, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Reem Karmali
- Department of Medicine, Division of Hematology and Oncology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- Robert H. Lurie Comprehensive Cancer Center, Chicago, IL, USA
| | - Leo I. Gordon
- Department of Medicine, Division of Hematology and Oncology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Ramon Lorenzo-Redondo
- Department of Medicine, Division of Infectious Diseases, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- Center for Pathogen Genomics and Microbial Evolution, Northwestern University Havey Institute for Global Health, Chicago, IL, USA
| | - Judd F. Hultquist
- Department of Medicine, Division of Infectious Diseases, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- Center for Pathogen Genomics and Microbial Evolution, Northwestern University Havey Institute for Global Health, Chicago, IL, USA
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Hentzien M, Owen A, Strub-Wourgaft N, Pérez-Casas C, Trøseid M, Calmy A. Rethinking treatment paradigms for the deployment of SARS-CoV-2 antiviral drugs on the shifting landscape of new variants. Front Microbiol 2022; 13:998287. [PMID: 36312942 PMCID: PMC9597299 DOI: 10.3389/fmicb.2022.998287] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 09/26/2022] [Indexed: 11/26/2023] Open
Affiliation(s)
- Maxime Hentzien
- HIV/AIDS Unit, Infectious Diseases Division, Geneva University Hospitals, Geneva, Switzerland
| | - Andrew Owen
- Centre of Excellence in Long-acting Therapeutics (CELT), University of Liverpool, Liverpool, United Kingdom
| | - Nathalie Strub-Wourgaft
- COVID Response and Pandemic Preparedness Director, Drugs for Neglected Diseases Initiative (DNDi), Geneva, Switzerland
| | | | - Marius Trøseid
- Section of Clinical Immunology and Infectious Diseases, Oslo University Hospital, Oslo, Norway
| | - Alexandra Calmy
- HIV/AIDS Unit, Infectious Diseases Division, Geneva University Hospitals, Geneva, Switzerland
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Martín-Díaz RM, Cabrejas-Ugartondo J, Iglesias-López M, Chulvi-Calvo B, Vélez-Rodriguez D. Persistently positive PCR SARS-CoV-2 at low cycle threshold in an immunosuppressed patient. Braz J Infect Dis 2022; 26:102696. [PMID: 36037848 PMCID: PMC9393159 DOI: 10.1016/j.bjid.2022.102696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 07/15/2022] [Accepted: 08/05/2022] [Indexed: 12/27/2022] Open
Abstract
We describe the very prolonged course of the disease in an immunosuppressed patient with persistently positive PCR against SARS-CoV-2 with low cycle threshold for at least 114 days.
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Affiliation(s)
- Rosa-María Martín-Díaz
- Sureste Hospital, Department of Internal Medicine, Arganda del Rey, Madrid, Spain,Corresponding Author.
| | | | - Mar Iglesias-López
- Sureste Hospital, Department of Continuity Care, Arganda del Rey, Madrid, Spain
| | - Beatriz Chulvi-Calvo
- Sureste Hospital, Department of Internal Medicine, Arganda del Rey, Madrid, Spain
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