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Alonzi T, Aiello A, Sali M, Delogu G, Villella VR, Raia V, Nicastri E, Piacentini M, Goletti D. Multiple antimicrobial and immune-modulating activities of cysteamine in infectious diseases. Biomed Pharmacother 2024; 178:117153. [PMID: 39024833 DOI: 10.1016/j.biopha.2024.117153] [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: 06/05/2024] [Revised: 07/11/2024] [Accepted: 07/12/2024] [Indexed: 07/20/2024] Open
Abstract
Infectious diseases are a major threat to global health and cause millions of deaths every year, particularly in developing countries. The emergence of multidrug resistance challenges current antimicrobial treatments, inducing uncertainty in therapeutic protocols. New compounds are therefore necessary. A drug repurposing approach could play a critical role in developing new treatments used either alone or in combination with standard therapy regimens. Herein, we focused on cysteamine, an aminothiol endogenously synthesized by human cells during the degradation of coenzyme-A, which is a drug approved for the treatment of nephropathic cystinosis. Cysteamine influences many biological processes due to the presence of the highly reactive thiol group. This review provides an overview of cysteamine-mediated effects on different viruses, bacteria and parasites, with a particular focus on infections caused by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2), Mycobacterium tuberculosis, non-tuberculous mycobacteria (NTM), and Pseudomonas aeruginosa. Evidences for a potential use of cysteamine as a direct antimicrobial agent and/or a host-directed therapy, either alone or in combination with other antimicrobial drugs, are described.
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Affiliation(s)
- Tonino Alonzi
- Translational Research Unit, National Institute for Infectious Diseases Lazzaro Spallanzani-IRCCS, Rome, Italy
| | - Alessandra Aiello
- Translational Research Unit, National Institute for Infectious Diseases Lazzaro Spallanzani-IRCCS, Rome, Italy
| | - Michela Sali
- Dipartimento di Scienze Biotecnologiche di Base, Cliniche Intensivologiche e Perioperatorie, Università Cattolica del Sacro Cuore, Rome, India; Dipartimento di Scienze di Laboratorio ed Ematologiche, Fondazione Policlinico Universitario A. Gemelli, IRCCS; Rome, Italy
| | - Giovanni Delogu
- Dipartimento di Scienze Biotecnologiche di Base, Cliniche Intensivologiche e Perioperatorie, Università Cattolica del Sacro Cuore, Rome, India; Mater Olbia Hospital, Olbia, Italy
| | - Valeria Rachela Villella
- CEINGE, Advanced Biotechnologies Franco Salvatore, Naples, Italy; Department of Molecular Medicine and Medical Biotechnologies, University of Naples Federico II, Naples, Italy
| | - Valeria Raia
- Pediatric Unit, Department of Translational Medical Sciences, Regional Cystic Fibrosis Center, Federico II University Naples, Naples, Italy
| | - Emanuele Nicastri
- Clinical Division of Infectious Diseases, National Institute for Infectious Diseases Lazzaro Spallanzani-IRCCS, Rome, Italy
| | - Mauro Piacentini
- Department of Biology, University of Rome "Tor Vergata", Rome, Italy; Cell Biology and Electron Microscopy Unit, National Institute for Infectious Diseases Lazzaro Spallanzani-IRCCS, Rome, Italy
| | - Delia Goletti
- Translational Research Unit, National Institute for Infectious Diseases Lazzaro Spallanzani-IRCCS, Rome, Italy.
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Ishihara Y, Naruse H, Fujigaki H, Murakami R, Ando T, Sakurai K, Uehara K, Shimomae K, Sakaguchi E, Hattori H, Sarai M, Ishii J, Fujii R, Ito H, Saito K, Izawa H. Humoral and Cellular Response Induced by Primary Series and Booster Doses of mRNA Coronavirus Disease 2019 Vaccine in Patients with Cardiovascular Disease: A Longitudinal Study. Vaccines (Basel) 2024; 12:786. [PMID: 39066424 PMCID: PMC11281625 DOI: 10.3390/vaccines12070786] [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: 06/04/2024] [Revised: 07/07/2024] [Accepted: 07/15/2024] [Indexed: 07/28/2024] Open
Abstract
Preexisting cardiovascular disease (CVD) is a pivotal risk factor for severe coronavirus disease 2019 (COVID-19). We investigated the longitudinal (over 1 year and 9 months) humoral and cellular responses to primary series and booster doses of mRNA COVID-19 vaccines in patients with CVD. Twenty-six patients with CVD who received monovalent mRNA COVID-19 vaccines were enrolled in this study. Peripheral blood samples were serially drawn nine times from each patient. IgG against the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) spike receptor-binding domain (RBD) was measured using an enzyme-linked immunosorbent assay. The numbers of interferon-γ-releasing cells in response to SARS-CoV-2 peptides were measured using an enzyme-linked immunospot assay. The RBD-IgG titers increased 2 weeks after the primary series and booster vaccination and waned 6 months after vaccination. The S1-specific T cell responses in patients aged < 75 years were favorable before and after booster doses; however, the Omicron BA.1-specific T cell responses were poor. These results suggest that regular vaccination is useful to maintain long-term antibody levels and has implications for booster dose strategies in patients with CVD. Additional booster doses, including Omicron variant-adapted mRNA vaccines, may be recommended for patients with CVD, regardless of age.
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Affiliation(s)
- Yuya Ishihara
- Department of Clinical Laboratory, Fujita Health University Hospital, Toyoake 470-1192, Japan;
| | - Hiroyuki Naruse
- Department of Clinical Pathophysiology, Fujita Health University Graduate School of Health Sciences, Toyoake 470-1192, Japan; (E.S.); (H.H.)
| | - Hidetsugu Fujigaki
- Department of Advanced Diagnostic System Development, Fujita Health University Graduate School of Health Sciences, Toyoake 470-1192, Japan; (H.F.); (K.S.)
| | - Reiko Murakami
- Institute for Glyco-Core Research, Gifu University, Yanagido, Gifu 501-1193, Japan;
| | - Tatsuya Ando
- Department of Joint Research Laboratory of Clinical Medicine, Fujita Health University School of Medicine, Toyoake 470-1192, Japan; (T.A.); (K.S.); (H.I.)
| | - Kouhei Sakurai
- Department of Joint Research Laboratory of Clinical Medicine, Fujita Health University School of Medicine, Toyoake 470-1192, Japan; (T.A.); (K.S.); (H.I.)
| | - Komei Uehara
- Department of Preventive Medical Sciences, Fujita Health University Graduate of Health Sciences, Toyoake 470-1192, Japan; (K.U.); (K.S.)
| | - Koki Shimomae
- Department of Preventive Medical Sciences, Fujita Health University Graduate of Health Sciences, Toyoake 470-1192, Japan; (K.U.); (K.S.)
| | - Eirin Sakaguchi
- Department of Clinical Pathophysiology, Fujita Health University Graduate School of Health Sciences, Toyoake 470-1192, Japan; (E.S.); (H.H.)
| | - Hidekazu Hattori
- Department of Clinical Pathophysiology, Fujita Health University Graduate School of Health Sciences, Toyoake 470-1192, Japan; (E.S.); (H.H.)
| | - Masayoshi Sarai
- Department of Cardiology, Fujita Health University School of Medicine, Toyoake 470-1192, Japan; (M.S.); (J.I.); (H.I.)
| | - Junnichi Ishii
- Department of Cardiology, Fujita Health University School of Medicine, Toyoake 470-1192, Japan; (M.S.); (J.I.); (H.I.)
| | - Ryosuke Fujii
- Department of Medical Sciences, Fujita Health University School of Medicine, Toyoake 470-1192, Japan;
| | - Hiroyasu Ito
- Department of Joint Research Laboratory of Clinical Medicine, Fujita Health University School of Medicine, Toyoake 470-1192, Japan; (T.A.); (K.S.); (H.I.)
| | - Kuniaki Saito
- Department of Advanced Diagnostic System Development, Fujita Health University Graduate School of Health Sciences, Toyoake 470-1192, Japan; (H.F.); (K.S.)
| | - Hideo Izawa
- Department of Cardiology, Fujita Health University School of Medicine, Toyoake 470-1192, Japan; (M.S.); (J.I.); (H.I.)
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3
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Eviatar T, Pappo A, Freund T, Friedlander Y, Elkayam O, Hagin D, Heshin-Bekenstein M. Cellular immune response to the anti-SARS-CoV-2 BNT162b2 mRNA vaccine in pediatric autoimmune inflammatory rheumatic disease patients and controls. Clin Exp Immunol 2024; 217:167-172. [PMID: 38767466 PMCID: PMC11239557 DOI: 10.1093/cei/uxae044] [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: 02/23/2024] [Revised: 04/03/2024] [Accepted: 05/18/2024] [Indexed: 05/22/2024] Open
Abstract
This paper aims to compare the cellular immune response to the SARS-CoV-2 BNT162b2 vaccine of pediatric patients with autoimmune inflammatory rheumatic disease (pAIIRD) and healthy controls. A prospective longitudinal study was conducted between April 2021 and December 2022 at the Tel Aviv Medical Center. Children <18 years, with pediatric-onset AIIRD and healthy controls, who have received at least two doses of the BNT162b2 vaccine, were included. Humoral response was evaluated by serum levels of anti-SARS-CoV-2 receptor-binding domain antibodies. Cellular response was evaluated by flow cytometry, measuring IFNγ and TNFα production by CD4+ T cells following stimulation with SARS-CoV-2 Spike peptide mix. The study included 20 pAIIRD patients and 11 controls. The mean age of participants was 12.6 ± 2.94 years, with 58.1% females. The cellular response to the BNT162b2 vaccine was statistically similar in both groups. However, the humoral response was statistically lower in pAIIRD compared with the healthy control group. There was no statistically significant correlation between the humoral response and cellular response. During the study period, 43.75% of AIIRD children and 72.7% of controls had a breakthrough COVID-19 infection (P = 0.48). Bivariate models examining the effect of the cellular response and presence of an AIIRD on breakthrough infections found no effect. Compared with healthy controls, pAIIRD demonstrated similar cellular responses. Patients showed reduced humoral response compared with healthy adolescents, but similar breakthrough infection rates. These findings may support the importance of the cellular response in protecting against COVID-19 infections.
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Affiliation(s)
- Tali Eviatar
- Rheumatology Department, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- School of Medicine, Faculty of Medical and Health Sciences, Tel Aviv University, Tel Aviv, Israel
| | - Adi Pappo
- Pediatric Rheumatology Unit, Schneider Children’s Hospital, Petach Tikva, Israel
| | - Tal Freund
- School of Medicine, Faculty of Medical and Health Sciences, Tel Aviv University, Tel Aviv, Israel
- Department of Allergy and Clinical Immunology, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel
| | | | - Ori Elkayam
- Rheumatology Department, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- School of Medicine, Faculty of Medical and Health Sciences, Tel Aviv University, Tel Aviv, Israel
| | - David Hagin
- School of Medicine, Faculty of Medical and Health Sciences, Tel Aviv University, Tel Aviv, Israel
- Department of Allergy and Clinical Immunology, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Merav Heshin-Bekenstein
- School of Medicine, Faculty of Medical and Health Sciences, Tel Aviv University, Tel Aviv, Israel
- Pediatric Rheumatology Service, Dana Children’s Hospital of Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
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4
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Klinmalai C, Srisala S, Sahakijpicharn T, Apiwattanakul N. Monitoring of adaptive immune responses in healthcare workers who received a Coronavirus disease 2019 vaccine booster dose. Health Sci Rep 2024; 7:e2250. [PMID: 39015422 PMCID: PMC11250167 DOI: 10.1002/hsr2.2250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2024] [Revised: 06/26/2024] [Accepted: 07/01/2024] [Indexed: 07/18/2024] Open
Abstract
Background and Aims Coronavirus disease 2019 (COVID-19) has become a global pandemic and led to increased mortality and morbidity. Vaccines against the etiologic agent; severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) were approved for emergency use on different platforms. In the early phase of the pandemic, Thai healthcare workers (HCWs) received CoronaVac, an inactivated vaccine, as the first vaccine against SARS-CoV-2, followed by ChAdOx1 nCoV-19, a viral vector-based vaccine, or BNT162b2, an mRNA vaccine, as a booster dose. This preliminary study evaluated the immunogenicity of ChAdOx1 nCoV-19 and BNT162b2 as a booster dose in HCWs who previously received two doses of CoronaVac. Methods Ten HCW participants received ChAdOx1 nCoV-19 and another 10 HCWs received BNT162b2 as a booster dose after two doses of CoronaVac. Anti-RBD IgG, neutralizing antibodies (NAb), and cellular immunity, including interferon-gamma (IFN-γ)-releasing CD4, CD8, double negative T cells, and NK cells, were measured at 3 and 5 months after the booster dose. Results There was no significant difference in anti-RBD IgG levels at 3 and 5 months between the two different types of booster vaccine. The levels of anti-RBD IgG and NAb were significantly decreased at 5 months. HCWs receiving BNT162b2 had significantly higher NAb levels than those receiving ChAdOx1 nCoV-19 at 5 months after the booster dose. IFN-γ release from CD4 T cells was detected at 3 months with no significant difference between the two types of booster vaccines. However, IFN-γ-releasing CD4 T cells were present at 5 months in the ChAdOx1 nCoV-19 group only. Conclusion ChAdOx1 nCoV-19 or BNT162b2 can be used as a booster dose after completion of the primary series primed by inactivated vaccine. Although the levels of immunity decline at 5 months, they may be adequate during the first 3 months after the booster dose.
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Affiliation(s)
- Chompunuch Klinmalai
- Department of Paediatrics, Faculty of Medicine Ramathibodi HospitalMahidol UniversityBangkokThailand
| | - Supanart Srisala
- Research Center, Faculty of Medicine Ramathibodi HospitalMahidol UniversityBangkokThailand
| | - Thiantip Sahakijpicharn
- Department of Paediatrics, Faculty of Medicine Ramathibodi HospitalMahidol UniversityBangkokThailand
| | - Nopporn Apiwattanakul
- Department of Paediatrics, Faculty of Medicine Ramathibodi HospitalMahidol UniversityBangkokThailand
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5
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Vita S, D’Abramo A, Coppola A, Farroni C, Iori AP, Faraglia F, Sette A, Grifoni A, Lindestam Arlehamn C, Bibas M, Goletti D, Nicastri E. Combined antiviral therapy as effective and feasible option in allogenic hematopoietic stem cell transplantation during SARS-COV-2 infection: a case report. Front Oncol 2024; 14:1290614. [PMID: 38414746 PMCID: PMC10896944 DOI: 10.3389/fonc.2024.1290614] [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: 09/07/2023] [Accepted: 01/29/2024] [Indexed: 02/29/2024] Open
Abstract
Here we describe the case of a 51 years old Italian woman with acute lymphoblastic leukemia who underwent to hematopoietic stem cell transplantation (HSCT) during SARS-COV-2 infection. She presented a prolonged COVID-19 successfully treated with dual anti SARS-COV-2 antiviral plus monoclonal antibody therapy.
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Affiliation(s)
- Serena Vita
- Clinical Department, National Institute for Infectious Diseases ‘Lazzaro Spallanzani’ Istituti di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Alessandra D’Abramo
- Clinical Department, National Institute for Infectious Diseases ‘Lazzaro Spallanzani’ Istituti di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Andrea Coppola
- Clinical Department, National Institute for Infectious Diseases ‘Lazzaro Spallanzani’ Istituti di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Chiara Farroni
- Clinical Department, National Institute for Infectious Diseases ‘Lazzaro Spallanzani’ Istituti di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Anna Paola Iori
- Policlinico Umberto I, Sapienza University of Rome, Rome, Italy
| | - Francesca Faraglia
- Clinical Department, National Institute for Infectious Diseases ‘Lazzaro Spallanzani’ Istituti di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Alessandro Sette
- Center for Infectious Disease and Vaccine Research, La Jolla Institute for Immunology (LJI), La Jolla, CA, United States
| | - Alba Grifoni
- Center for Infectious Disease and Vaccine Research, La Jolla Institute for Immunology (LJI), La Jolla, CA, United States
| | - Cecilia Lindestam Arlehamn
- Center for Infectious Disease and Vaccine Research, La Jolla Institute for Immunology (LJI), La Jolla, CA, United States
| | - Michele Bibas
- Clinical Department, National Institute for Infectious Diseases ‘Lazzaro Spallanzani’ Istituti di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Delia Goletti
- Clinical Department, National Institute for Infectious Diseases ‘Lazzaro Spallanzani’ Istituti di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Emanuele Nicastri
- Clinical Department, National Institute for Infectious Diseases ‘Lazzaro Spallanzani’ Istituti di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
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6
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Martínez-Fleta P, Vicente-Rabaneda EF, Triguero-Martínez A, Roy-Vallejo E, Uriarte-Ecenarro M, Gutiérrez-Rodríguez F, Quiroga-Colina P, Romero-Robles A, Montes N, García-Castañeda N, Mejía-Abril GP, García-Vadillo JA, Llorente-Cubas I, Villagrasa JR, Serra López-Matencio JM, Ancochea J, Urzainqui A, Esparcia-Pinedo L, Alfranca A, de la Fuente H, García-Vicuña R, Sánchez-Madrid F, González-Álvaro I, Castañeda S. Beneficial effect of temporary methotrexate interruption on B and T cell responses upon SARS-CoV-2 vaccination in patients with rheumatoid arthritis or psoriatic arthritis. NPJ Vaccines 2024; 9:21. [PMID: 38291047 PMCID: PMC10827732 DOI: 10.1038/s41541-024-00805-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 01/02/2024] [Indexed: 02/01/2024] Open
Abstract
B and T cell responses were evaluated in patients with rheumatoid arthritis (RA) or psoriatic arthritis (PsA) after 1 or 2 weeks of methotrexate (MTX) withdrawal following each COVID-19 vaccine dose and compared with those who maintained MTX. Adult RA and PsA patients treated with MTX were recruited and randomly assigned to 3 groups: MTX-maintenance (n = 72), MTX-withdrawal for 1 week (n = 71) or MTX-withdrawal for 2 weeks (n = 73). Specific antibodies to several SARS-CoV-2 antigens and interferon (IFN)-γ and interleukin (IL)-21 responses were assessed. MTX withdrawal in patients without previous COVID-19 was associated with higher levels of anti-RBD IgG and neutralising antibodies, especially in the 2-week withdrawal group and with higher IFN-γ secretion upon stimulation with pools of SARS-CoV-2 S peptides. No increment of RA/PsA relapses was detected across groups. Our data indicate that two-week MTX interruption following COVID-19 vaccination in patients with RA or PsA improves humoral and cellular immune responses.
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Affiliation(s)
- Pedro Martínez-Fleta
- Department of Immunology, Hospital Universitario de La Princesa IIS-Princesa (Instituto de Investigación Sanitaria del Hospital Universitario de La Princesa), Madrid, Spain
| | - Esther F Vicente-Rabaneda
- Department of Rheumatology, Hospital Universitario de La Princesa IIS-Princesa (Instituto de Investigación Sanitaria del Hospital Universitario de La Princesa), Madrid, Spain
| | - Ana Triguero-Martínez
- Department of Rheumatology, Hospital Universitario de La Princesa IIS-Princesa (Instituto de Investigación Sanitaria del Hospital Universitario de La Princesa), Madrid, Spain
| | - Emilia Roy-Vallejo
- Department of Internal Medicine, Hospital Universitario de La Princesa IIS-Princesa (Instituto de Investigación Sanitaria del Hospital Universitario de La Princesa), Madrid, Spain
| | - Miren Uriarte-Ecenarro
- Department of Rheumatology, Hospital Universitario de La Princesa IIS-Princesa (Instituto de Investigación Sanitaria del Hospital Universitario de La Princesa), Madrid, Spain
| | - Francisco Gutiérrez-Rodríguez
- Department of Rheumatology, Hospital Universitario de La Princesa IIS-Princesa (Instituto de Investigación Sanitaria del Hospital Universitario de La Princesa), Madrid, Spain
| | - Patricia Quiroga-Colina
- Department of Rheumatology, Hospital Universitario de La Princesa IIS-Princesa (Instituto de Investigación Sanitaria del Hospital Universitario de La Princesa), Madrid, Spain
| | - Ana Romero-Robles
- Department of Rheumatology, Hospital Universitario de La Princesa IIS-Princesa (Instituto de Investigación Sanitaria del Hospital Universitario de La Princesa), Madrid, Spain
| | - Nuria Montes
- Department of Rheumatology, Hospital Universitario de La Princesa IIS-Princesa (Instituto de Investigación Sanitaria del Hospital Universitario de La Princesa), Madrid, Spain
| | - Noelia García-Castañeda
- Department of Rheumatology, Hospital Universitario de La Princesa IIS-Princesa (Instituto de Investigación Sanitaria del Hospital Universitario de La Princesa), Madrid, Spain
| | - Gina P Mejía-Abril
- Clinical Pharmacology Department, Hospital Universitario de La Princesa, Instituto Teófilo Hernando, Instituto de Investigación Sanitaria La Princesa (IP), Universidad Autónoma de Madrid (UAM), Madrid, Spain
| | - Jesús A García-Vadillo
- Department of Rheumatology, Hospital Universitario de La Princesa IIS-Princesa (Instituto de Investigación Sanitaria del Hospital Universitario de La Princesa), Madrid, Spain
- Department of Medicine, Universidad Autónoma de Madrid (UAM), Madrid, Spain
| | - Irene Llorente-Cubas
- Department of Rheumatology, Hospital Universitario de La Princesa IIS-Princesa (Instituto de Investigación Sanitaria del Hospital Universitario de La Princesa), Madrid, Spain
| | - José R Villagrasa
- Department of Preventive Medicine, Hospital Universitario de La Princesa IIS-Princesa (Instituto de Investigación Sanitaria del Hospital Universitario de La Princesa), Madrid, Spain
| | - José M Serra López-Matencio
- Department of Hospital Pharmacy, Hospital Universitario de La Princesa IIS-Princesa (Instituto de Investigación Sanitaria del Hospital Universitario de La Princesa), Madrid, Spain
| | - Julio Ancochea
- Department of Medicine, Universidad Autónoma de Madrid (UAM), Madrid, Spain
- Department of Pneumology, Hospital Universitario de La Princesa IIS-Princesa (Instituto de Investigación Sanitaria del Hospital Universitario de La Princesa), Madrid, Spain
- Cátedra UAM-Roche, EPID-Future, Department of Medicine, Universidad Autónoma de Madrid (UAM), Madrid, Spain
- Centro de Investigación en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III (ISCIII), Madrid, Spain
| | - Ana Urzainqui
- Department of Immunology, Hospital Universitario de La Princesa IIS-Princesa (Instituto de Investigación Sanitaria del Hospital Universitario de La Princesa), Madrid, Spain
| | - Laura Esparcia-Pinedo
- Department of Immunology, Hospital Universitario de La Princesa IIS-Princesa (Instituto de Investigación Sanitaria del Hospital Universitario de La Princesa), Madrid, Spain
| | - Arantzazu Alfranca
- Department of Immunology, Hospital Universitario de La Princesa IIS-Princesa (Instituto de Investigación Sanitaria del Hospital Universitario de La Princesa), Madrid, Spain
- Department of Medicine, Universidad Autónoma de Madrid (UAM), Madrid, Spain
- CIBER Cardiovascular CIBERCV, Madrid, Spain
| | - Hortensia de la Fuente
- Department of Immunology, Hospital Universitario de La Princesa IIS-Princesa (Instituto de Investigación Sanitaria del Hospital Universitario de La Princesa), Madrid, Spain
- CIBER Cardiovascular CIBERCV, Madrid, Spain
| | - Rosario García-Vicuña
- Department of Rheumatology, Hospital Universitario de La Princesa IIS-Princesa (Instituto de Investigación Sanitaria del Hospital Universitario de La Princesa), Madrid, Spain
- Department of Medicine, Universidad Autónoma de Madrid (UAM), Madrid, Spain
| | - Francisco Sánchez-Madrid
- Department of Immunology, Hospital Universitario de La Princesa IIS-Princesa (Instituto de Investigación Sanitaria del Hospital Universitario de La Princesa), Madrid, Spain
- Department of Medicine, Universidad Autónoma de Madrid (UAM), Madrid, Spain
- CIBER Cardiovascular CIBERCV, Madrid, Spain
| | - Isidoro González-Álvaro
- Department of Rheumatology, Hospital Universitario de La Princesa IIS-Princesa (Instituto de Investigación Sanitaria del Hospital Universitario de La Princesa), Madrid, Spain.
| | - Santos Castañeda
- Department of Rheumatology, Hospital Universitario de La Princesa IIS-Princesa (Instituto de Investigación Sanitaria del Hospital Universitario de La Princesa), Madrid, Spain.
- Cátedra UAM-Roche, EPID-Future, Department of Medicine, Universidad Autónoma de Madrid (UAM), Madrid, Spain.
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7
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Benoit JM, Breznik JA, Ang JC, Bhakta H, Huynh A, Cowbrough B, Baker B, Heessels L, Lodhi S, Yan E, Ewusie J, Nazy I, Bramson J, Miller MS, Bernatsky S, Larché MJ, Bowdish DME. Immunomodulatory drugs have divergent effects on humoral and cellular immune responses to SARS-CoV-2 vaccination in people living with rheumatoid arthritis. Sci Rep 2023; 13:22846. [PMID: 38129594 PMCID: PMC10739702 DOI: 10.1038/s41598-023-50263-5] [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: 07/12/2023] [Accepted: 12/18/2023] [Indexed: 12/23/2023] Open
Abstract
Understanding the efficacy of SARS-CoV-2 vaccination in people on immunosuppressive drugs, including those with rheumatoid arthritis (RA), is critical for their protection. Vaccine induced protection requires antibodies, CD4+ T cells, and CD8+ T cells, but it is unclear if these are equally affected by immunomodulatory drugs. Here, we determined how humoral and cellular SARS-CoV-2 vaccination responses differed between people with RA and controls, and which drug classes impacted these responses. Blood was collected from participants with RA on immunomodulatory drugs and controls after their second, third, and fourth SARS-CoV-2 vaccinations. Receptor binding domain (RBD)-specific antibodies were quantified by ELISA. Spike-specific memory T cells were quantitated using flow cytometry. Linear mixed models assessed the impact of age, sex, and immunomodulatory drug classes on SARS-CoV-2 vaccination responses. Compared to non-RA controls (n = 35), participants with RA on immunomodulatory drugs (n = 62) had lower anti-RBD IgG and spike-specific CD4+ T cell levels, but no deficits in spike-specific CD8+ T cells, following SARS-CoV-2 vaccination. Use of costimulation inhibitors was associated with lower humoral responses. JAK inhibitors were associated with fewer spike-specific CD4+ T cells. Participants with RA on immunomodulatory drugs mounted weaker responses to SARS-CoV-2 vaccination, with different drug classes impacting the cellular and humoral compartments.
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Affiliation(s)
- Jenna M Benoit
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- McMaster Immunology Research Centre, Hamilton, ON, Canada
- Firestone Institute of Respiratory Health, St. Joseph's Healthcare, Hamilton, ON, Canada
| | - Jessica A Breznik
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- McMaster Immunology Research Centre, Hamilton, ON, Canada
- McMaster Institute for Research on Aging, McMaster University, Hamilton, ON, Canada
| | - Jann C Ang
- Department of Biochemistry, McMaster University, Hamilton, ON, Canada
| | - Hina Bhakta
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Angela Huynh
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Braeden Cowbrough
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- McMaster Immunology Research Centre, Hamilton, ON, Canada
| | - Barbara Baker
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Lauren Heessels
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Sumiya Lodhi
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Elizabeth Yan
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Joycelyne Ewusie
- Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, Hamilton, ON, Canada
| | - Ishac Nazy
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Jonathan Bramson
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- McMaster Immunology Research Centre, Hamilton, ON, Canada
| | - Matthew S Miller
- McMaster Immunology Research Centre, Hamilton, ON, Canada
- Department of Biochemistry, McMaster University, Hamilton, ON, Canada
| | - Sasha Bernatsky
- Department of Medicine, McGill University, Montreal, QC, Canada
| | - Maggie J Larché
- Department of Medicine, McMaster University, Hamilton, ON, Canada.
- McMaster Immunology Research Centre, Hamilton, ON, Canada.
| | - Dawn M E Bowdish
- Department of Medicine, McMaster University, Hamilton, ON, Canada.
- McMaster Immunology Research Centre, Hamilton, ON, Canada.
- Firestone Institute of Respiratory Health, St. Joseph's Healthcare, Hamilton, ON, Canada.
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8
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da Silva Antunes R, Weiskopf D, Sidney J, Rubiro P, Peters B, Arlehamn CSL, Grifoni A, Sette A. The MegaPool Approach to Characterize Adaptive CD4+ and CD8+ T Cell Responses. Curr Protoc 2023; 3:e934. [PMID: 37966108 PMCID: PMC10662678 DOI: 10.1002/cpz1.934] [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] [Indexed: 11/16/2023]
Abstract
Epitopes recognized by T cells are a collection of short peptide fragments derived from specific antigens or proteins. Immunological research to study T cell responses is hindered by the extreme degree of heterogeneity of epitope targets, which are usually derived from multiple antigens; within a given antigen, hundreds of different T cell epitopes can be recognized, differing from one individual to the next because T cell epitope recognition is restricted by the epitopes' ability to bind to MHC molecules, which are extremely polymorphic in different individuals. Testing large pools encompassing hundreds of peptides is technically challenging because of logistical considerations regarding solvent-induced toxicity. To address this issue, we developed the MegaPool (MP) approach based on sequential lyophilization of large numbers of peptides that can be used in a variety of assays to measure T cell responses, including ELISPOT, intracellular cytokine staining, and activation-induced marker assays, and that has been validated in the study of infectious diseases, allergies, and autoimmunity. Here, we describe the procedures for generating and testing MPs, starting with peptide synthesis and lyophilization, as well as a step-by-step guide and recommendations for their handling and experimental usage. Overall, the MP approach is a powerful strategy for studying T cell responses and understanding the immune system's role in health and disease. © 2023 Wiley Periodicals LLC. Basic Protocol 1: Generation of peptide pools ("MegaPools") Basic Protocol 2: MegaPool testing and quantitation of antigen-specific T cell responses.
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Affiliation(s)
- Ricardo da Silva Antunes
- Center for Infectious Disease and Vaccine Research, La Jolla Institute for Immunology (LJI); La Jolla, CA, USA
| | - Daniela Weiskopf
- Center for Infectious Disease and Vaccine Research, La Jolla Institute for Immunology (LJI); La Jolla, CA, USA
| | - John Sidney
- Center for Infectious Disease and Vaccine Research, La Jolla Institute for Immunology (LJI); La Jolla, CA, USA
| | - Paul Rubiro
- Center for Infectious Disease and Vaccine Research, La Jolla Institute for Immunology (LJI); La Jolla, CA, USA
| | - Bjoern Peters
- Center for Infectious Disease and Vaccine Research, La Jolla Institute for Immunology (LJI); La Jolla, CA, USA
- Department of Medicine, Division of Infectious Diseases and Global Public Health, University of California, San Diego (UCSD), La Jolla, CA, USA
| | | | - Alba Grifoni
- Center for Infectious Disease and Vaccine Research, La Jolla Institute for Immunology (LJI); La Jolla, CA, USA
| | - Alessandro Sette
- Center for Infectious Disease and Vaccine Research, La Jolla Institute for Immunology (LJI); La Jolla, CA, USA
- Department of Medicine, Division of Infectious Diseases and Global Public Health, University of California, San Diego (UCSD), La Jolla, CA, USA
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9
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Dudley HM, O'Mara M, Auma A, Gong J, Ross Y, Gurevich N, Carbone S, Reihs A, Nguyen Y, McComsey GA, Cao Y, Balazs AB, Gordesky L, Payne M, Singer N, Kostadinova L, Wilson B, Zidar DA, King CL, Canaday DH, Shive CL, Mattar MM, Anthony DD. Rheumatoid arthritis and older age are associated with lower humoral and cellular immune response to primary series COVID-19 mRNA vaccine. Vaccine 2023; 41:6112-6119. [PMID: 37659895 DOI: 10.1016/j.vaccine.2023.08.033] [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] [Received: 04/20/2023] [Revised: 08/09/2023] [Accepted: 08/14/2023] [Indexed: 09/04/2023]
Abstract
OBJECTIVE People with autoimmune disease have worse COVID-19 infection-related outcomes, lower antibody responses to COVID-19 vaccine, and higher rates of breakthrough infection. Immunosuppressive medications used to treat rheumatoid arthritis (RA) are associated with lower COVID-19 vaccine responses, though independent contributions of comorbidities, T-cell immunity, and age are less clear. We sought to test the hypothesis that RA, immunosuppressive medications used to treat RA, and older age, contribute to reduced B and T cell response to COVID-19 vaccine. METHODS We evaluated serum samples, taken the day of 1st vaccine dose, the day of 2nd dose, 2-6 weeks after 2nd dose, 7-12 weeks after 2nd dose, 13-24 weeks after 2nd dose, and 2-6 weeks after the 3rd dose, for anti-spike IgG and neutralizing antibody levels to Wuhan and Omicron BA.1 and peripheral blood mononuclear cells (PBMC) for spike-specific IFN-γ and IL-2 production by ELISPOT assay in 46 RA and 101 non-autoimmune control participants before and after the primary series COVID-19 mRNA vaccination. RESULTS RA participants had lower spike-specific IgG and Wuhan-strain neutralizing antibody levels 2-6 weeks compared to controls after the second dose of primary vaccine series. Neutralizing antibody levels against Omicron BA.1 were low in both groups. IFN-γ production correlated with Wuhan neutralizing antibody levels, while older age negatively correlated with spike-specific IL-2, IFN-γ and IgG. Lower antibody levels were associated with older age, RA status, and medication usage, while lower T cell responses were associated primarily with older age. CONCLUSIONS These data indicate lower COVID-19 mRNA vaccine-induced antibody levels in persons with RA compared to individuals without RA, likely partially attributable to immune suppressive medications. At the same time, older age is associated with lower antibody and cellular immune response to COVID-19 vaccines.
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Affiliation(s)
- Holly M Dudley
- Department of Molecular Biology, Case Western Reserve University School of Medicine, Cleveland, OH, United States; Cleveland Veterans Affairs Medical Center, Cleveland, OH, United States; Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, OH, United States; The MetroHealth System, Cleveland, OH, United States
| | - Megan O'Mara
- Cleveland Veterans Affairs Medical Center, Cleveland, OH, United States; Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, OH, United States
| | - Ann Auma
- Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, OH, United States
| | - Jenny Gong
- Cleveland Veterans Affairs Medical Center, Cleveland, OH, United States; Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, OH, United States; The MetroHealth System, Cleveland, OH, United States
| | - Yael Ross
- Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, OH, United States; The MetroHealth System, Cleveland, OH, United States
| | - Natalie Gurevich
- Cleveland Veterans Affairs Medical Center, Cleveland, OH, United States; Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, OH, United States
| | - Sarah Carbone
- Cleveland Veterans Affairs Medical Center, Cleveland, OH, United States
| | - Alex Reihs
- Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, OH, United States
| | - Ynez Nguyen
- Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, OH, United States
| | - Grace A McComsey
- Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, OH, United States
| | - Yi Cao
- Ragon Institute of MGH, MIT and Harvard, Cambridge, MA, United States
| | | | - Larraine Gordesky
- Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, OH, United States; The MetroHealth System, Cleveland, OH, United States
| | - Michael Payne
- Department of Global Health, Case Western Reserve University School of Medicine, Cleveland, OH, United States
| | - Nora Singer
- Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, OH, United States; The MetroHealth System, Cleveland, OH, United States
| | - Lenche Kostadinova
- Cleveland Veterans Affairs Medical Center, Cleveland, OH, United States; Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, OH, United States
| | - Brigid Wilson
- Cleveland Veterans Affairs Medical Center, Cleveland, OH, United States
| | - David A Zidar
- Cleveland Veterans Affairs Medical Center, Cleveland, OH, United States; Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, OH, United States; Department of Global Health, Case Western Reserve University School of Medicine, Cleveland, OH, United States; Department of Pathology, Case Western Reserve University School of Medicine, Cleveland, OH, United States
| | - Christopher L King
- Cleveland Veterans Affairs Medical Center, Cleveland, OH, United States; Department of Global Health, Case Western Reserve University School of Medicine, Cleveland, OH, United States
| | - David H Canaday
- Cleveland Veterans Affairs Medical Center, Cleveland, OH, United States; Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, OH, United States
| | - Carey L Shive
- Cleveland Veterans Affairs Medical Center, Cleveland, OH, United States; Department of Pathology, Case Western Reserve University School of Medicine, Cleveland, OH, United States
| | - Maya M Mattar
- Cleveland Veterans Affairs Medical Center, Cleveland, OH, United States; Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, OH, United States
| | - Donald D Anthony
- Cleveland Veterans Affairs Medical Center, Cleveland, OH, United States; Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, OH, United States; The MetroHealth System, Cleveland, OH, United States
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10
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Aiello A, Najafi-Fard S, Goletti D. Initial immune response after exposure to Mycobacterium tuberculosis or to SARS-COV-2: similarities and differences. Front Immunol 2023; 14:1244556. [PMID: 37662901 PMCID: PMC10470049 DOI: 10.3389/fimmu.2023.1244556] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 07/31/2023] [Indexed: 09/05/2023] Open
Abstract
Tuberculosis (TB), caused by Mycobacterium tuberculosis (Mtb) and Coronavirus disease-2019 (COVID-19), whose etiologic agent is severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), are currently the two deadliest infectious diseases in humans, which together have caused about more than 11 million deaths worldwide in the past 3 years. TB and COVID-19 share several aspects including the droplet- and aerosol-borne transmissibility, the lungs as primary target, some symptoms, and diagnostic tools. However, these two infectious diseases differ in other aspects as their incubation period, immune cells involved, persistence and the immunopathological response. In this review, we highlight the similarities and differences between TB and COVID-19 focusing on the innate and adaptive immune response induced after the exposure to Mtb and SARS-CoV-2 and the pathological pathways linking the two infections. Moreover, we provide a brief overview of the immune response in case of TB-COVID-19 co-infection highlighting the similarities and differences of each individual infection. A comprehensive understanding of the immune response involved in TB and COVID-19 is of utmost importance for the design of effective therapeutic strategies and vaccines for both diseases.
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Affiliation(s)
| | | | - Delia Goletti
- Translational Research Unit, National Institute for Infectious Diseases Lazzaro Spallanzani- Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
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11
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Petrone L, Sette A, de Vries RD, Goletti D. The Importance of Measuring SARS-CoV-2-Specific T-Cell Responses in an Ongoing Pandemic. Pathogens 2023; 12:862. [PMID: 37513709 PMCID: PMC10385870 DOI: 10.3390/pathogens12070862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Revised: 06/19/2023] [Accepted: 06/20/2023] [Indexed: 07/30/2023] Open
Abstract
Neutralizing antibodies are considered a correlate of protection against SARS-CoV-2 infection and severe COVID-19, although they are not the only contributing factor to immunity: T-cell responses are considered important in protecting against severe COVID-19 and contributing to the success of vaccination effort. T-cell responses after vaccination largely mirror those of natural infection in magnitude and functional capacity, but not in breadth, as T-cells induced by vaccination exclusively target the surface spike glycoprotein. T-cell responses offer a long-lived line of defense and, unlike humoral responses, largely retain reactivity against the SARS-CoV-2 variants. Given the increasingly recognized role of T-cell responses in protection against severe COVID-19, the circulation of SARS-CoV-2 variants, and the potential implementation of novel vaccines, it becomes imperative to continuously monitor T-cell responses. In addition to "classical" T-cell assays requiring the isolation of peripheral blood mononuclear cells, simple whole-blood-based interferon-γ release assays have a potential role in routine T-cell response monitoring. These assays could be particularly useful for immunocompromised people and other clinically vulnerable populations, where interactions between cellular and humoral immunity are complex. As we continue to live alongside COVID-19, the importance of considering immunity as a whole, incorporating both humoral and cellular responses, is crucial.
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Affiliation(s)
- Linda Petrone
- Translational Research Unit, National Institute for Infectious Diseases “Lazzaro Spallanzani”-IRCCS, 00149 Rome, Italy;
| | - Alessandro Sette
- Center for Infectious Disease and Vaccine Research, La Jolla Institute for Immunology (LJI), La Jolla, CA 92037, USA;
- Department of Medicine, Division of Infectious Diseases and Global Public Health, University of California, San Diego (UCSD), La Jolla, CA 92037, USA
| | - Rory D. de Vries
- Department Viroscience, Erasmus University Medical Center, 3015CN Rotterdam, The Netherlands;
| | - Delia Goletti
- Translational Research Unit, National Institute for Infectious Diseases “Lazzaro Spallanzani”-IRCCS, 00149 Rome, Italy;
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12
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Grifoni A, Alonzi T, Alter G, Noonan DM, Landay AL, Albini A, Goletti D. Impact of aging on immunity in the context of COVID-19, HIV, and tuberculosis. Front Immunol 2023; 14:1146704. [PMID: 37292210 PMCID: PMC10246744 DOI: 10.3389/fimmu.2023.1146704] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 05/11/2023] [Indexed: 06/10/2023] Open
Abstract
Knowledge of aging biology needs to be expanded due to the continuously growing number of elderly people worldwide. Aging induces changes that affect all systems of the body. The risk of cardiovascular disease and cancer increases with age. In particular, the age-induced adaptation of the immune system causes a greater susceptibility to infections and contributes to the inability to control pathogen growth and immune-mediated tissue damage. Since the impact of aging on immune function, is still to be fully elucidated, this review addresses some of the recent understanding of age-related changes affecting key components of immunity. The emphasis is on immunosenescence and inflammaging that are impacted by common infectious diseases that are characterized by a high mortality, and includes COVID-19, HIV and tuberculosis.
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Affiliation(s)
- Alba Grifoni
- Center for Infectious Disease and Vaccine Research, La Jolla Institute for Immunology (LJI), La Jolla, CA, United States
| | - Tonino Alonzi
- Translational Research Unit, National Institute for Infectious Diseases “Lazzaro Spallanzani”-IRCCS, Rome, Italy
| | - Galit Alter
- Ragon Institute of Massachusetts General Hospital (MGH), Massachusetts Institute of Technology (MIT), and Harvard, Cambridge, MA, United States
| | - Douglas McClain Noonan
- Istituto Di Ricovero e Cura a Carattere Scientifico (IRCCS) MultiMedica, Milan, Italy
- Immunology and General Pathology Laboratory, Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy
| | - Alan L. Landay
- Department of Internal Medicine, Rush Medical College, Chicago, IL, United States
| | | | - Delia Goletti
- Translational Research Unit, National Institute for Infectious Diseases “Lazzaro Spallanzani”-IRCCS, Rome, Italy
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13
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Alicandro G, Orena BS, Rosazza C, Cariani L, Russo M, Zatelli M, Badolato R, Gramegna A, Blasi F, Daccò V. Humoral and cell-mediated immune responses to BNT162b2 vaccine against SARS-CoV-2 in people with cystic fibrosis. Vaccine 2023:S0264-410X(23)00590-X. [PMID: 37263872 DOI: 10.1016/j.vaccine.2023.05.041] [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: 03/23/2023] [Revised: 04/26/2023] [Accepted: 05/16/2023] [Indexed: 06/03/2023]
Abstract
People with cystic fibrosis (pwCF) were considered to be clinically vulnerable to COVID-19 and were therefore given priority in the vaccination campaign. Vaccines induced a humoral response in these patients that was comparable to the response observed among the general population. However, the role of the cell-mediated immune response in providing long-term protection against SARS-CoV-2 in pwCF has not yet been defined. In this study, humoral (antibody titre) and cell-mediated immune responses (interferon-γ release) to the BNT162b2 vaccine were measured at different time points, from around 6-8 months after the 2nd dose and up to 8 months after the 3rd dose, in 118 CF patients and 26 non-CF subjects. Subjects were sampled between November 2021 and September 2022 and followed-up for breakthrough infection through October 2022. pwCF mounted a cell-mediated response that was similar to that observed in non-CF subjects. Low antibody titres (<1st quartile) were associated with a higher risk of breakthrough infection (HR: 2.39, 95 % CI: 1.17-4.88), while there was no significant association with low INF-γ levels (<0.3 IU/mL) (HR: 1.38, 95 % CI: 0.64-2.99). Further studies are needed in subgroup of pwCF receiving immunosuppressive therapy, such as organ transplant recipients. This data is important for tailoring vaccination strategies for this clinically vulnerable population.
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Affiliation(s)
- G Alicandro
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Cystic Fibrosis Center, Milan, Italy; Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - B S Orena
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Microbiology Unit, Milan, Italy
| | - C Rosazza
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Cystic Fibrosis Center, Milan, Italy
| | - L Cariani
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Microbiology Unit, Milan, Italy
| | - M Russo
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Cystic Fibrosis Center, Milan, Italy
| | - M Zatelli
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Microbiology Unit, Milan, Italy
| | - R Badolato
- Department of Pediatrics, ASST Spedali Civili, Brescia, Italy; Department of Clinical and Experimental Sciences, University of Brescia, ASST Spedali Civili, Brescia, Italy
| | - A Gramegna
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy; Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Respiratory Unit and Cystic Fibrosis Adult Center, Milan, Italy
| | - F Blasi
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy; Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Respiratory Unit and Cystic Fibrosis Adult Center, Milan, Italy
| | - V Daccò
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Cystic Fibrosis Center, Milan, Italy.
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14
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Del Mastro A, Picascia S, D'Apice L, Trovato M, Barba P, Di Biase I, Di Biase S, Laccetti M, Belli A, Amato G, Di Muro P, Credendino O, Picardi A, De Berardinis P, Del Pozzo G, Gianfrani C. Booster Dose of SARS-CoV-2 mRNA Vaccine in Kidney Transplanted Patients Induces Wuhan-Hu-1 Specific Neutralizing Antibodies and T Cell Activation but Lower Response against Omicron Variant. Viruses 2023; 15:v15051132. [PMID: 37243218 DOI: 10.3390/v15051132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 04/29/2023] [Accepted: 05/08/2023] [Indexed: 05/28/2023] Open
Abstract
Kidney transplanted recipients (KTR) are at high risk of severe SARS-CoV-2 infection due to immunosuppressive therapy. Although several studies reported antibody production in KTR after vaccination, data related to immunity to the Omicron (B.1.1.529) variant are sparse. Herein, we analyzed anti-SARS-CoV-2 immune response in seven KTR and eight healthy controls after the second and third dose of the mRNA vaccine (BNT162b2). A significant increase in neutralizing antibody (nAb) titers were detected against pseudoviruses expressing the Wuhan-Hu-1 spike (S) protein after the third dose in both groups, although nAbs in KTR were lower than controls. nAbs against pseudoviruses expressing the Omicron S protein were low in both groups, with no increase after the 3rd dose in KTR. Reactivity of CD4+ T cells after boosting was observed when cells were challenged with Wuhan-Hu-1 S peptides, while Omicron S peptides were less effective in both groups. IFN-γ production was detected in KTR in response to ancestral S peptides, confirming antigen-specific T cell activation. Our study demonstrates that the 3rd mRNA dose induces T cell response against Wuhan-Hu-1 spike peptides in KTR, and an increment in the humoral immunity. Instead, humoral and cellular immunity to Omicron variant immunogenic peptides were low in both KTR and healthy vaccinated subjects.
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Affiliation(s)
- Andrea Del Mastro
- AORN A. Cardarelli-Internal Medicine Division 1-Immunology Unit, 80131 Naples, Italy
| | - Stefania Picascia
- Institute of Biochemistry and Cell Biology, Italian National Council of Research, 80131 Naples, Italy
| | - Luciana D'Apice
- Institute of Biochemistry and Cell Biology, Italian National Council of Research, 80131 Naples, Italy
| | - Maria Trovato
- Institute of Biochemistry and Cell Biology, Italian National Council of Research, 80131 Naples, Italy
| | - Pasquale Barba
- Institute of Biochemistry and Cell Biology, Italian National Council of Research, 80131 Naples, Italy
| | | | | | - Marco Laccetti
- AORN A. Cardarelli-Internal Medicine Division 1-Immunology Unit, 80131 Naples, Italy
| | - Antonello Belli
- AORN A. Cardarelli-Clinical Pathology Division, 80131 Naples, Italy
| | - Gerardino Amato
- AORN A. Cardarelli-Clinical Pathology Division, 80131 Naples, Italy
| | - Potito Di Muro
- AORN A. Cardarelli-Nephrology and Dialysis Unit, 80131 Naples, Italy
| | - Olga Credendino
- AORN A. Cardarelli-Nephrology and Dialysis Unit, 80131 Naples, Italy
| | - Alessandra Picardi
- AORN A. Cardarelli-Molecular Biology Laboratory-Hematology and HSC Transplantation Unit, 80131 Naples, Italy
| | | | - Giovanna Del Pozzo
- Institute of Genetics and Biophysics, Italian National Council of Research, 80131 Naples, Italy
| | - Carmen Gianfrani
- Institute of Biochemistry and Cell Biology, Italian National Council of Research, 80131 Naples, Italy
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15
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Aiello A, Coppola A, Ruggieri S, Farroni C, Altera AMG, Salmi A, Vanini V, Cuzzi G, Petrone L, Meschi S, Lapa D, Bettini A, Haggiag S, Prosperini L, Galgani S, Quartuccio ME, Bevilacqua N, Garbuglia AR, Agrati C, Puro V, Tortorella C, Gasperini C, Nicastri E, Goletti D. Longitudinal characterisation of B and T-cell immune responses after the booster dose of COVID-19 mRNA-vaccine in people with multiple sclerosis using different disease-modifying therapies. J Neurol Neurosurg Psychiatry 2023; 94:290-299. [PMID: 36522154 PMCID: PMC10086471 DOI: 10.1136/jnnp-2022-330175] [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] [Received: 08/19/2022] [Accepted: 12/01/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND The decline of humoral response to COVID-19 vaccine led to authorise a booster dose. Here, we characterised the kinetics of B-cell and T-cell immune responses in patients with multiple sclerosis (PwMS) after the booster dose. METHODS We enrolled 22 PwMS and 40 healthcare workers (HCWs) after 4-6 weeks from the booster dose (T3). Thirty HCWs and 19 PwMS were also recruited 6 months (T2) after the first dose. Antibody response was measured by anti-receptor-binding domain (RBD)-IgG detection, cell-mediated response by an interferon (IFN)-γ release assay (IGRA), Th1 cytokines and T-cell memory profile by flow cytometry. RESULTS Booster dose increased anti-RBD-IgG titers in fingolimod-treated, cladribine-treated and IFN-β-treated patients, but not in ocrelizumab-treated patients, although antibody titres were lower than HCWs. A higher number of fingolimod-treated patients seroconverted at T3. Differently, T-cell response evaluated by IGRA remained stable in PwMS independently of therapy. Spike-specific Th1-cytokine response was mainly CD4+ T-cell-mediated, and in PwMS was significantly reduced (p<0.0001) with impaired IL-2 production compared with HCWs at T3. In PwMS, total Th1 and IFN-γ CD4+ T-cell responders to spike protein were increased from T2 to T3.Compared with HCWs, PwMS presented a higher frequency of CD4+ and CD8+ terminally differentiated effector memory cells and of CD4+ effector memory (TEM) cells, independently of the stimulus suggesting the association of this phenotype with MS status. CD4+ and CD8+ TEM cell frequency was further increased at T3 compared with T2. CONCLUSIONS COVID-19 vaccine booster strengthens humoral and Th1-cell responses and increases TEM cells in PwMS.
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Affiliation(s)
- Alessandra Aiello
- Translational Research Unit, National Institute for Infectious Diseases Lazzaro Spallanzani Institute for Hospitalization and Care Scientific, Rome, Italy
| | - Andrea Coppola
- Translational Research Unit, National Institute for Infectious Diseases Lazzaro Spallanzani Institute for Hospitalization and Care Scientific, Rome, Italy
| | - Serena Ruggieri
- Department of Human Neurosciences, University of Rome La Sapienza, Rome, Italy.,Neuroimmunology Unit, Santa Lucia Foundation Institute for Hospitalization and Care Scientific, Rome, Italy
| | - Chiara Farroni
- Translational Research Unit, National Institute for Infectious Diseases Lazzaro Spallanzani Institute for Hospitalization and Care Scientific, Rome, Italy
| | - Anna Maria Gerarda Altera
- Translational Research Unit, National Institute for Infectious Diseases Lazzaro Spallanzani Institute for Hospitalization and Care Scientific, Rome, Italy
| | - Andrea Salmi
- Translational Research Unit, National Institute for Infectious Diseases Lazzaro Spallanzani Institute for Hospitalization and Care Scientific, Rome, Italy
| | - Valentina Vanini
- Translational Research Unit, National Institute for Infectious Diseases Lazzaro Spallanzani Institute for Hospitalization and Care Scientific, Rome, Italy.,Unità Operativa Semplice (UOS) Professioni Sanitarie Tecniche, National Institute for Infectious Diseases Lazzaro Spallanzani Institute for Hospitalization and Care Scientific, Rome, Italy
| | - Gilda Cuzzi
- Translational Research Unit, National Institute for Infectious Diseases Lazzaro Spallanzani Institute for Hospitalization and Care Scientific, Rome, Italy
| | - Linda Petrone
- Translational Research Unit, National Institute for Infectious Diseases Lazzaro Spallanzani Institute for Hospitalization and Care Scientific, Rome, Italy
| | - Silvia Meschi
- Laboratory of Virology, National Institute for Infectious Diseases Lazzaro Spallanzani Institute for Hospitalization and Care Scientific, Rome, Italy
| | - Daniele Lapa
- Laboratory of Virology, National Institute for Infectious Diseases Lazzaro Spallanzani Institute for Hospitalization and Care Scientific, Rome, Italy
| | - Aurora Bettini
- Laboratory of Virology, National Institute for Infectious Diseases Lazzaro Spallanzani Institute for Hospitalization and Care Scientific, Rome, Italy
| | - Shalom Haggiag
- Department of Neurosciences, San Camillo Forlanini Hospital, Rome, Italy
| | - Luca Prosperini
- Department of Neurosciences, San Camillo Forlanini Hospital, Rome, Italy
| | - Simonetta Galgani
- Department of Neurosciences, San Camillo Forlanini Hospital, Rome, Italy
| | | | - Nazario Bevilacqua
- Clinical Division of Infectious Diseases, National Institute for Infectious Diseases Lazzaro Spallanzani Institute for Hospitalization and Care Scientific, Rome, Italy
| | - Anna Rosa Garbuglia
- Laboratory of Virology, National Institute for Infectious Diseases Lazzaro Spallanzani Institute for Hospitalization and Care Scientific, Rome, Italy
| | - Chiara Agrati
- Cellular Immunology Laboratory, National Institute for Infectious Diseases Lazzaro Spallanzani Institute for Hospitalization and Care Scientific, Rome, Italy.,Department of Pediatric Hematology and Oncology, Bambino Gesu Pediatric Hospital, Rome, Italy
| | - Vincenzo Puro
- UOC Emerging Infections and Centro di Riferimento AIDS (CRAIDS), National Institute for Infectious Diseases Lazzaro Spallanzani Institute for Hospitalization and Care Scientific, Rome, Italy
| | - Carla Tortorella
- Department of Neurosciences, San Camillo Forlanini Hospital, Rome, Italy
| | - Claudio Gasperini
- Department of Neurosciences, San Camillo Forlanini Hospital, Rome, Italy
| | - Emanuele Nicastri
- Clinical Division of Infectious Diseases, National Institute for Infectious Diseases Lazzaro Spallanzani Institute for Hospitalization and Care Scientific, Rome, Italy
| | - Delia Goletti
- Translational Research Unit, National Institute for Infectious Diseases Lazzaro Spallanzani Institute for Hospitalization and Care Scientific, Rome, Italy
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16
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Wang S, Li J, Wang S, Ye Y, Li M, Liu Y, Chen B, Lai Y, Li L, Zhuang L, Peng S, Yang N, Zhang H, Xiao H. Impacts of delta and omicron variants on inactivated SARS-CoV-2 vaccine-induced T cell responses in patients with autoimmune diseases and healthy controls. Clin Transl Med 2023; 13:e1171. [PMID: 36639826 PMCID: PMC9839884 DOI: 10.1002/ctm2.1171] [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] [Received: 08/16/2022] [Revised: 12/24/2022] [Accepted: 12/28/2022] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection causes coronavirus disease 2019 (COVID-19), which is still devastating economies and communities globally. The increasing infections of variants of concern (VOCs) in vaccinated population have raised concerns about the effectiveness of current vaccines. Patients with autoimmune diseases (PAD) under immunosuppressant treatments are facing higher risk of infection and potentially lower immune responses to SARS-CoV-2 vaccination. METHODS Blood samples were collected from PAD or healthy controls (HC) who finished two or three doses of inactivated vaccines. Spike peptides derived from wild-type strain, delta, omicron BA.1 were utilised to evaluate T cell responses and their cross-recognition of delta and omicron in HC and PAD by flow cytometry and ex vivo IFNγ-ELISpot. RESULTS We found that inactivated vaccine-induced spike-specific memory T cells were long-lasting in both PAD and HC. These spike-specific T cells were highly conserved and cross-recognized delta and omicron. Moreover, a third inactivated vaccine expanded spike-specific T cells that responded to delta and omicron spike peptides substantially in both PAD and HC. Importantly, the polyfunctionality of spike-specific memory T cells was preserved in terms of cytokine and cytotoxic responses. Although the extent of T cell responses was lower in PAD after two-dose, T cell responses were boosted to a greater magnitude in PAD by the third dose, bringing comparable spike-specific T cell immunity after the third dose. CONCLUSION Inactivated vaccine-induced spike-specific T cells remain largely intact against delta and omicron variants. This study expands our understanding of inactivated vaccine-induced T cell responses in PAD and HC, which could have important indications for vaccination strategy.
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Affiliation(s)
- Shuyi Wang
- Department of Rheumatologythe First Affiliated HospitalSun Yat‐sen UniversityGuangzhouChina
| | - Jin Li
- Department of Rheumatologythe First Affiliated HospitalSun Yat‐sen UniversityGuangzhouChina
| | - Shuang Wang
- Department of Rheumatologythe First Affiliated HospitalSun Yat‐sen UniversityGuangzhouChina
| | - Yujin Ye
- Department of Rheumatologythe First Affiliated HospitalSun Yat‐sen UniversityGuangzhouChina
| | - Mengyuan Li
- Department of Rheumatologythe First Affiliated HospitalSun Yat‐sen UniversityGuangzhouChina
| | - Yihao Liu
- Clinical Trials Unitthe First Affiliated HospitalSun Yat‐sen UniversityGuangzhouChina
| | - Binfeng Chen
- Department of Rheumatologythe First Affiliated HospitalSun Yat‐sen UniversityGuangzhouChina
| | - Yimei Lai
- Department of Rheumatologythe First Affiliated HospitalSun Yat‐sen UniversityGuangzhouChina
| | - Liubing Li
- Department of Laboratory MedicineThe First Affiliated Hospital of Sun Yat‐sen UniversityGuangzhouChina
| | - Lili Zhuang
- Department of Rheumatologythe First Affiliated HospitalSun Yat‐sen UniversityGuangzhouChina
| | - Sui Peng
- Clinical Trials Unitthe First Affiliated HospitalSun Yat‐sen UniversityGuangzhouChina
| | - Niansheng Yang
- Department of Rheumatologythe First Affiliated HospitalSun Yat‐sen UniversityGuangzhouChina
| | - Hui Zhang
- Department of Rheumatologythe First Affiliated HospitalSun Yat‐sen UniversityGuangzhouChina,Institue of Precision Medicinethe First Affiliated HospitalSun Yat‐sen UniversityGuangzhouChina
| | - Haipeng Xiao
- Department of Endocrinologythe First Affiliated HospitalSun Yat‐sen UniversityGuangzhouChina
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17
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Huang Y, Shin JE, Xu AM, Yao C, Joung S, Wu M, Zhang R, Shin B, Foley J, Mahov SB, Modes ME, Ebinger JE, Driver M, Braun JG, Jefferies CA, Parimon T, Hayes C, Sobhani K, Merchant A, Gharib SA, Jordan SC, Cheng S, Goodridge HS, Chen P. Evidence of premature lymphocyte aging in people with low anti-spike antibody levels after BNT162b2 vaccination. iScience 2022; 25:105209. [PMID: 36188190 PMCID: PMC9510055 DOI: 10.1016/j.isci.2022.105209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Revised: 08/22/2022] [Accepted: 09/22/2022] [Indexed: 11/26/2022] Open
Abstract
SARS-CoV-2 vaccines have unquestionably blunted the overall impact of the COVID-19 pandemic, but host factors such as age, sex, obesity, and other co-morbidities can affect vaccine efficacy. We identified individuals in a relatively healthy population of healthcare workers (CORALE study cohort) who had unexpectedly low peak anti-spike receptor binding domain (S-RBD) antibody levels after receiving the BNT162b2 vaccine. Compared to matched controls, "low responders" had fewer spike-specific antibody-producing B cells after the second and third/booster doses. Moreover, their spike-specific T cell receptor (TCR) repertoire had less depth and their CD4+ and CD8+T cell responses to spike peptide stimulation were less robust. Single cell transcriptomic evaluation of peripheral blood mononuclear cells revealed activation of aging pathways in low responder B and CD4+T cells that could underlie their attenuated anti-S-RBD antibody production. Premature lymphocyte aging may therefore contribute to a less effective humoral response and could reduce vaccination efficacy.
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Affiliation(s)
- Yapei Huang
- Women’s Guild Lung Institute, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
| | - Juliana E. Shin
- Board of Governors Regenerative Medicine Institute, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
- Research Division of Immunology in the Department of Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
| | - Alexander M. Xu
- Board of Governors Regenerative Medicine Institute, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
- Division of Hematology and Cellular Therapy, Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
| | - Changfu Yao
- Women’s Guild Lung Institute, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
- Board of Governors Regenerative Medicine Institute, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
| | - Sandy Joung
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
| | - Min Wu
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
| | - Ruan Zhang
- Comprehensive Transplant Center, Transplant Immunology Laboratory, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
| | - Bongha Shin
- Comprehensive Transplant Center, Transplant Immunology Laboratory, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
| | - Joslyn Foley
- Board of Governors Regenerative Medicine Institute, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
- Division of Hematology and Cellular Therapy, Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
| | - Simeon B. Mahov
- Board of Governors Regenerative Medicine Institute, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
- Division of Hematology and Cellular Therapy, Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
| | - Matthew E. Modes
- Women’s Guild Lung Institute, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
| | - Joseph E. Ebinger
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
| | - Matthew Driver
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
| | - Jonathan G. Braun
- Research Division of Immunology in the Department of Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
- F. Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
- Department of Pathology and Laboratory Medicine, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
| | - Caroline A. Jefferies
- Research Division of Immunology in the Department of Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
- Department of Medicine, Division of Rheumatology, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
| | - Tanyalak Parimon
- Women’s Guild Lung Institute, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
| | - Chelsea Hayes
- Department of Pathology and Laboratory Medicine, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
| | - Kimia Sobhani
- Department of Pathology and Laboratory Medicine, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
| | - Akil Merchant
- Board of Governors Regenerative Medicine Institute, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
- Division of Hematology and Cellular Therapy, Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
| | - Sina A. Gharib
- Computational Medicine Core at Center for Lung Biology, Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, WA 98109, USA
| | - Stanley C. Jordan
- Comprehensive Transplant Center, Transplant Immunology Laboratory, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
| | - Susan Cheng
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
| | - Helen S. Goodridge
- Board of Governors Regenerative Medicine Institute, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
- Research Division of Immunology in the Department of Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
| | - Peter Chen
- Women’s Guild Lung Institute, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
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18
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Stahl D, tho Pesch C, Brück C, Esser RL, Thiele J, Di Cristanziano V, Kofler DM. Reduced humoral response to a third dose (booster) of SARS-CoV-2 mRNA vaccines by concomitant methotrexate therapy in elderly patients with rheumatoid arthritis. RMD Open 2022; 8:rmdopen-2022-002632. [PMID: 36216409 PMCID: PMC9556739 DOI: 10.1136/rmdopen-2022-002632] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/25/2022] [Indexed: 11/07/2022] Open
Abstract
Background Several health authorities recommend a third (booster) vaccination to protect patients with rheumatic and musculoskeletal diseases from severe COVID-19. Methotrexate has been shown to reduce the efficacy of the first and second dose of SARS-CoV-2 mRNA vaccines. So far, it remains unknown how concomitant methotrexate affects the efficacy of a COVID-19 booster vaccination. Methods We compared the humoral immune response to SARS-CoV-2 vaccination in 136 patients with rheumatoid arthritis (RA) treated with methotrexate and/or biological or targeted synthetic (b/tsDMARDs). IgG targeting the receptor binding domain (RBD) of SARS-CoV-2 spike protein was measured at a median of 52.5 (range 2–147) days after a third dose of the SARS-CoV-2 mRNA vaccines BNT162b2 or mRNA-1273. Results Anti-RBD IgG was significantly reduced in elderly patients receiving concomitant treatment with methotrexate as compared with elderly patients receiving monotherapy with b/tsDMARDs or methotrexate (64.8 (20.8, 600.3) binding antibody units per mL (BAU/mL) vs 1106.0 (526.3, 4965.2) BAU/mL vs 1743.8 (734.5, 6779.6) BAU/mL, median (IQR), p<0.001, Kruskal-Wallis test). In younger patients (< 64.5 years), concomitant methotrexate had no significant impact on the humoral immune response. Conclusions Concomitant methotrexate increases the risk of an insufficient humoral immune response to SARS-CoV-2 vaccination in elderly patients with RA. Pausing methotrexate during the third vaccination period may be considered for this group of patients.
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Affiliation(s)
- David Stahl
- Department I of Internal Medicine, University of Cologne, Koln, Germany,Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Cologne, Germany
| | - Carola tho Pesch
- Department I of Internal Medicine, University of Cologne, Koln, Germany
| | - Carolin Brück
- Department I of Internal Medicine, University of Cologne, Koln, Germany
| | - Ruth L Esser
- Department I of Internal Medicine, University of Cologne, Koln, Germany
| | - Jan Thiele
- Department I of Internal Medicine, University of Cologne, Koln, Germany
| | | | - David M Kofler
- Department I of Internal Medicine, University of Cologne, Koln, Germany,Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Cologne, Germany
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19
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Roseti L, Grigolo B. COVID-19 and rheumatic diseases: A mini-review. Front Med (Lausanne) 2022; 9:997876. [PMID: 36226148 PMCID: PMC9548696 DOI: 10.3389/fmed.2022.997876] [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: 07/19/2022] [Accepted: 09/12/2022] [Indexed: 11/13/2022] Open
Abstract
Joint pain and arthralgia can be manifestations of COVID-19, and studies evaluating long COVID symptoms identified the persistence of these disorders. Moreover, some case reports highlighted the development of new inflammatory arthritis in patients with COVID-19, suggesting a possible relation. Viral infections and rheumatic diseases share a documented relationship; they have been associated with genetic and environmental risk factors responsible for some of them. There is crosstalk between viruses and the immune system during the development of several rheumatic diseases. Moreover, infections may participate in the pathogenesis of autoimmune rheumatic diseases and contribute to patient mortality. Therefore, it is crucial to provide a clearer insight into the interaction between viral infections and rheumatic diseases. Here, we provide a mini-review of the current literature with the aim of shedding light on the relationship between COVID-19 and rheumatic or musculoskeletal diseases, which is still unclear. Specifically, we examined several aspects: risk for the rheumatic population of acquiring the virus or developing severe symptoms, similarities of COVID-19 and arthritis, the possible rheumatic consequence of COVID-19, of rheumatic drugs and vaccines, and COVID-19 prevention in rheumatic patients through vaccination.
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20
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Najafi-Fard S, Petruccioli E, Farroni C, Petrone L, Vanini V, Cuzzi G, Salmi A, Altera AMG, Navarra A, Alonzi T, Nicastri E, Palmieri F, Gualano G, Carlini V, Noonan DM, Albini A, Goletti D. Evaluation of the immunomodulatory effects of interleukin-10 on peripheral blood immune cells of COVID-19 patients: Implication for COVID-19 therapy. Front Immunol 2022; 13:984098. [PMID: 36148228 PMCID: PMC9486547 DOI: 10.3389/fimmu.2022.984098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Accepted: 08/11/2022] [Indexed: 12/03/2022] Open
Abstract
Objective Several therapies with immune-modulatory functions have been proposed to reduce the overwhelmed inflammation associated with COVID-19. Here we investigated the impact of IL-10 in COVID-19, through the ex-vivo assessment of the effects of exogenous IL-10 on SARS-CoV-2-specific-response using a whole-blood platform. Methods Two cohorts were evaluated: in “study population A”, plasma levels of 27 immune factors were measured by a multiplex (Luminex) assay in 39 hospitalized “COVID-19 patients” and 29 “NO COVID-19 controls” all unvaccinated. In “study population B”, 29 COVID-19 patients and 30 NO COVID-19-Vaccinated Controls (NO COVID-19-VCs) were prospectively enrolled for the IL-10 study. Whole-blood was stimulated overnight with SARS-COV-2 antigens and then treated with IL-10. Plasma was collected and used for ELISA and multiplex assay. In parallel, whole-blood was stimulated and used for flow cytometry analysis. Results Baseline levels of several immune factors, including IL-10, were significantly elevated in COVID-19 patients compared with NO COVID-19 subjects in “study population A”. Among them, IL-2, FGF, IFN-γ, and MCP-1 reached their highest levels within the second week of infection and then decreased. To note that, MCP-1 levels remained significantly elevated compared with controls. IL-10, GM-CSF, and IL-6 increased later and showed an increasing trend over time. Moreover, exogenous addition of IL-10 significantly downregulated IFN-γ response and several other immune factors in both COVID-19 patients and NO COVID-19-VCs evaluated by ELISA and a multiplex analysis (Luminex) in “study population B”. Importantly, IL-10 did not affect cell survival, but decreased the frequencies of T-cells producing IFN-γ, TNF-α, and IL-2 (p<0.05) and down-modulated HLA-DR expression on CD8+ and NK cells. Conclusion This study provides important insights into immune modulating effects of IL-10 in COVID-19 and may provide valuable information regarding the further in vivo investigations.
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Affiliation(s)
- Saeid Najafi-Fard
- Translational Research Unit, National Institute for Infectious Diseases Lazzaro Spallanzani- Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Elisa Petruccioli
- Translational Research Unit, National Institute for Infectious Diseases Lazzaro Spallanzani- Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Chiara Farroni
- Translational Research Unit, National Institute for Infectious Diseases Lazzaro Spallanzani- Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Linda Petrone
- Translational Research Unit, National Institute for Infectious Diseases Lazzaro Spallanzani- Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Valentina Vanini
- Translational Research Unit, National Institute for Infectious Diseases Lazzaro Spallanzani- Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
- Department of Epidemiology and Preclinical Research, UOS Professioni Sanitarie Tecniche National Institute for Infectious Diseases Lazzaro Spallanzani-Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Gilda Cuzzi
- Translational Research Unit, National Institute for Infectious Diseases Lazzaro Spallanzani- Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Andrea Salmi
- Translational Research Unit, National Institute for Infectious Diseases Lazzaro Spallanzani- Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Anna Maria Gerarda Altera
- Translational Research Unit, National Institute for Infectious Diseases Lazzaro Spallanzani- Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Assunta Navarra
- Clinical Epidemiology Unit, National Institute for Infectious Disease Lazzaro Spallanzani-Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Tonino Alonzi
- Translational Research Unit, National Institute for Infectious Diseases Lazzaro Spallanzani- Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Emanuele Nicastri
- Clinical Division of Infectious Diseases, National Institute for Infectious Diseases Lazzaro Spallanzani-Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Fabrizio Palmieri
- Respiratory Infectious Diseases Unit, National Institute for Infectious Diseases Lazzaro Spallanzani-Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Gina Gualano
- Respiratory Infectious Diseases Unit, National Institute for Infectious Diseases Lazzaro Spallanzani-Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Valentina Carlini
- Unit of Molecular Pathology, Biochemistry and Immunology, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) MultiMedica, Milan, Italy
| | - Douglas McClain Noonan
- Unit of Molecular Pathology, Biochemistry and Immunology, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) MultiMedica, Milan, Italy
- Immunology and General Pathology Laboratory, Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy
| | - Adriana Albini
- European Institute of Oncology IEO-Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Milan, Italy
- *Correspondence: Adriana Albini, ; Delia Goletti,
| | - Delia Goletti
- Translational Research Unit, National Institute for Infectious Diseases Lazzaro Spallanzani- Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
- *Correspondence: Adriana Albini, ; Delia Goletti,
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21
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Aiello A, Coppola A, Vanini V, Petrone L, Cuzzi G, Salmi A, Altera AMG, Tortorella C, Gualano G, Gasperini C, Scolieri P, Beccacece A, Vita S, Bruzzese V, Lorenzetti R, Palmieri F, Nicastri E, Goletti D. Accuracy of QuantiFERON SARS-CoV-2 research use only assay and characterization of the CD4 + and CD8 + T cell-SARS-CoV-2 response: comparison with a homemade interferon-γ release assay. Int J Infect Dis 2022; 122:841-849. [PMID: 35878802 PMCID: PMC9307287 DOI: 10.1016/j.ijid.2022.07.049] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 07/18/2022] [Accepted: 07/18/2022] [Indexed: 01/25/2023] Open
Abstract
OBJECTIVES In this study, we aimed to characterize the SARS-CoV-2-specific T cell response detected by the QuantiFERON SARS-CoV-2 research use only assay in terms of accuracy and T cell subsets involved compared with a homemade interferon (IFN)-γ release assay (IGRA). METHODS We evaluated T cell response by the standardized QuantiFERON SARS-CoV-2 tubes (antigen [Ag]1 and Ag2) and a homemade IGRA quantifying IFN-γ response to SARS-CoV-2 spike peptides (homemade-IGRA-SPIKE test). We evaluated the T cell subsets mediating the specific response using flow cytometry. RESULTS We prospectively enrolled 66 individuals: COVID-19 or post-COVID-19 subjects and NO-COVID-19-vaccinated subjects, including healthy donors and immunocompromised subjects. The standardized kit detected 62.1% (41/66) of T cell responders. Ag2 tube showed a higher IFN-γ quantitative and qualitative response. Ag1 tube response was mainly mediated by CD4+ T cells; Ag2 tube response was mediated by CD4+ and CD8+ T cells. The homemade-IGRA-SPIKE test detected a higher number of responders (52/66, 78.8%) than the QuantiFERON SARS-CoV-2 assay (P = 0.056). The response was found in both T cell subsets, although a higher magnitude and response rate was observed in the CD4+ T cell subset. CONCLUSION The QuantiFERON SARS-CoV-2 response is mediated by CD4+ and CD8+ T cells. A lower number of responders is found compared with the homemade-IGRA-SPIKE test, likely because of the different peptide composition.
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Affiliation(s)
- Alessandra Aiello
- Translational Research Unit, National Institute for Infectious Diseases Lazzaro Spallanzani-IRCCS, Rome, Italy
| | - Andrea Coppola
- Translational Research Unit, National Institute for Infectious Diseases Lazzaro Spallanzani-IRCCS, Rome, Italy
| | - Valentina Vanini
- Translational Research Unit, National Institute for Infectious Diseases Lazzaro Spallanzani-IRCCS, Rome, Italy,Unità Operativa Semplice (UOS) Professioni Sanitarie Tecniche, National Institute for Infectious Diseases Lazzaro Spallanzani-IRCCS, Rome, Italy
| | - Linda Petrone
- Translational Research Unit, National Institute for Infectious Diseases Lazzaro Spallanzani-IRCCS, Rome, Italy
| | - Gilda Cuzzi
- Translational Research Unit, National Institute for Infectious Diseases Lazzaro Spallanzani-IRCCS, Rome, Italy
| | - Andrea Salmi
- Translational Research Unit, National Institute for Infectious Diseases Lazzaro Spallanzani-IRCCS, Rome, Italy
| | - Anna Maria Gerarda Altera
- Translational Research Unit, National Institute for Infectious Diseases Lazzaro Spallanzani-IRCCS, Rome, Italy
| | - Carla Tortorella
- Department of Neurosciences, San Camillo Forlanini Hospital, Rome, Italy
| | - Gina Gualano
- Respiratory Infectious Diseases Unit, National Institute for Infectious Diseases Lazzaro Spallanzani-IRCCS, Rome, Italy
| | - Claudio Gasperini
- Department of Neurosciences, San Camillo Forlanini Hospital, Rome, Italy
| | - Palma Scolieri
- UOC di Medicina e Rete Reumatologica, Nuovo Regina Margherita Hospital, Rome, Italy
| | - Alessia Beccacece
- Clinical Division of Infectious Diseases, National Institute for Infectious Diseases Lazzaro Spallanzani-IRCCS, Rome, Italy
| | - Serena Vita
- Clinical Division of Infectious Diseases, National Institute for Infectious Diseases Lazzaro Spallanzani-IRCCS, Rome, Italy
| | - Vincenzo Bruzzese
- UOC di Medicina e Rete Reumatologica, Nuovo Regina Margherita Hospital, Rome, Italy
| | - Roberto Lorenzetti
- UOC di Gastroenterologia ASL Roma1, Nuovo Regina Margherita, Rome, Italy
| | - Fabrizio Palmieri
- Respiratory Infectious Diseases Unit, National Institute for Infectious Diseases Lazzaro Spallanzani-IRCCS, Rome, Italy
| | - Emanuele Nicastri
- Clinical Division of Infectious Diseases, National Institute for Infectious Diseases Lazzaro Spallanzani-IRCCS, Rome, Italy
| | - Delia Goletti
- Translational Research Unit, National Institute for Infectious Diseases Lazzaro Spallanzani-IRCCS, Rome, Italy,Corresponding author: Translational Research Unit of the Research Department, National Institute for Infectious Diseases, Padiglione del Vecchio, Room 39, Via Portuense 292, Rome 00149, Italy. Tel.: +39 06 55170 906; fax: +39 06 5582 825
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22
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Aiello A, Grossi A, Meschi S, Meledandri M, Vanini V, Petrone L, Casetti R, Cuzzi G, Salmi A, Altera AM, Pierelli L, Gualano G, Ascoli Bartoli T, Castilletti C, Agrati C, Girardi E, Palmieri F, Nicastri E, Di Rosa E, Goletti D. Coordinated innate and T-cell immune responses in mild COVID-19 patients from household contacts of COVID-19 cases during the first pandemic wave. Front Immunol 2022; 13:920227. [PMID: 35967321 PMCID: PMC9364317 DOI: 10.3389/fimmu.2022.920227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Accepted: 06/30/2022] [Indexed: 01/08/2023] Open
Abstract
Objective To better define the immunopathogenesis of COVID-19, the present study aims to characterize the early immune responses to SARS-CoV-2 infection in household contacts of COVID-19 cases. In particular, innate, T- and B-cell specific responses were evaluated over time. Methods Household contacts of COVID-19 cases screened for SARS−CoV−2 infection by nasopharyngeal swab for surveillance purposes were enrolled (T0, n=42). Of these, 28 subjects returned for a follow-up test (T1). The innate response was assessed by detecting a panel of soluble factors by multiplex-technology in plasma samples. Cell-mediated response was evaluated by measuring interferon (IFN)-γ levels by ELISA in plasma harvested from whole-blood stimulated with SARS−CoV−2 peptide pools, including spike (S), nucleocapsid (N) and membrane (M) proteins. The serological response was assessed by quantifying anti-Receptor-Binding-Domain (RBD), anti-Nucleocapsid (N), whole virus indirect immunofluorescence, and neutralizing antibodies. Results At T0, higher levels of plasmatic IFN-α, IL-1ra, MCP-1 and IP-10, and lower levels of IL-1β, IL-9, MIP-1β and RANTES were observed in subjects with positive swab compared to individuals with a negative one (p<0.05). Plasmatic IFN-α was the only cytokine detectable in subjects with positive SARS-CoV-2 swabs with high accuracy for swab score positivity (0.93, p<0.0001). Among subjects with positive swabs, significant negative correlations were found among the RT-PCR cycle threshold values reported for genes S and N and IFN-α or IP-10 levels. At T0, the IFN-γ T-cell specific response was detected in 50% (5/10) of subjects with positive swab, while anti-RBD/anti-N antibodies showed a positivity rate of 10% (1/10). At T1, the IFN-γ T-cell specific response was detected in most of the confirmed-infection subjects (77.8%, 7/9), whereas the serological response was still observed in a minority of them (44.4%, 4/9). Overall, the swab test showed a moderate concordance with the T-cell response (78.6%, k=0.467), and a scarce concordance with the serological one (72.9%, k=0.194). Conclusions Plasmatic IFN-α and the IFN-γ T-cell specific response appear early even in the absence of seroconversion, and show a greater positivity rate than the serological response in household contacts with positive swab.
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Affiliation(s)
- Alessandra Aiello
- Translational Research Unit, National Institute for Infectious Diseases Lazzaro Spallanzani-IRCCS, Rome, Italy
| | - Adriano Grossi
- Local Public Health Office, Azienda Sanitaria Locale (ASL) Roma 1, Rome, Italy
| | - Silvia Meschi
- Laboratory of Virology, National Institute for Infectious Diseases Lazzaro Spallanzani-IRCCS, Rome, Italy
| | - Marcello Meledandri
- Unità Operativa Complessa (UOC) Microbiology and Virology, Azienda Sanitaria Locale (ASL) Roma 1-San Filippo Neri Hospital, Rome, Italy
| | - Valentina Vanini
- Translational Research Unit, National Institute for Infectious Diseases Lazzaro Spallanzani-IRCCS, Rome, Italy
- Unità Operativa Semplice (UOS) Professioni Sanitarie Tecniche, National Institute for Infectious Diseases Lazzaro Spallanzani-IRCCS, Rome, Italy
| | - Linda Petrone
- Translational Research Unit, National Institute for Infectious Diseases Lazzaro Spallanzani-IRCCS, Rome, Italy
| | - Rita Casetti
- Laboratory of Cellular Immunology, National Institute for Infectious Diseases Lazzaro Spallanzani-IRCCS, Rome, Italy
| | - Gilda Cuzzi
- Translational Research Unit, National Institute for Infectious Diseases Lazzaro Spallanzani-IRCCS, Rome, Italy
| | - Andrea Salmi
- Translational Research Unit, National Institute for Infectious Diseases Lazzaro Spallanzani-IRCCS, Rome, Italy
| | - Anna Maria Altera
- Translational Research Unit, National Institute for Infectious Diseases Lazzaro Spallanzani-IRCCS, Rome, Italy
| | - Luca Pierelli
- Unità Operativa Complessa (UOC) Transfusion Medicine and Stem Cell, San Camillo Forlanini Hospital, Rome, Italy
| | - Gina Gualano
- Respiratory Infectious Diseases Unit, National Institute for Infectious Diseases Lazzaro Spallanzani-IRCCS, Rome, Italy
| | - Tommaso Ascoli Bartoli
- Clinical Division of Infectious Diseases, National Institute for Infectious Diseases Lazzaro Spallanzani-IRCCS, Rome, Italy
| | - Concetta Castilletti
- Laboratory of Virology, National Institute for Infectious Diseases Lazzaro Spallanzani-IRCCS, Rome, Italy
| | - Chiara Agrati
- Laboratory of Cellular Immunology, National Institute for Infectious Diseases Lazzaro Spallanzani-IRCCS, Rome, Italy
| | - Enrico Girardi
- Clinical Epidemiology, National Institute for Infectious Diseases Lazzaro Spallanzani-IRCCS, Rome, Italy
| | - Fabrizio Palmieri
- Respiratory Infectious Diseases Unit, National Institute for Infectious Diseases Lazzaro Spallanzani-IRCCS, Rome, Italy
| | - Emanuele Nicastri
- Clinical Division of Infectious Diseases, National Institute for Infectious Diseases Lazzaro Spallanzani-IRCCS, Rome, Italy
| | - Enrico Di Rosa
- Local Public Health Office, Azienda Sanitaria Locale (ASL) Roma 1, Rome, Italy
| | - Delia Goletti
- Translational Research Unit, National Institute for Infectious Diseases Lazzaro Spallanzani-IRCCS, Rome, Italy
- *Correspondence: Delia Goletti,
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