Challenges in the management of patients with systemic light chain (AL) amyloidosis during the COVID-19 pandemic

Impact of SARS-CoV-2 infection in patients with cardiac amyloidosis: Results of a multicentre registry

BACKGROUND

Descriptions on impact of SARS-CoV-2 infection in patients with cardiac amyloidosis (CA) are lacking. Our aim was to describe the prognosis of those patients.

METHODS

Retrospective observational study of unvaccinated patients with CA who developed SARS-CoV-2 infection enrolled in eleven centres (March 2020 to May 2021). Descriptive analysis of basal characteristics, hospitalization, mortality, and severe clinical course was performed. Comparisons to a population-based control group were made.

RESULTS

Forty-one patients were identified. Most patients had wild-type transthyretin CA (61%) and were on NYHA Class II-III (80.5%). CA patients were commonly hospitalized (73.2%) and those were more symptomatic than outpatients (p=0.035). The 24.4% of CA patients died as consequence of SARS-CoV-2 infection. Patients with CA had an increased risk of hospitalization [OR 6.23 (3.05-12.74), p<0.001] and mortality [OR 2.18 (1.01-4.68), p=0.047] when compared to control population after adjustment by age and sex. After a medium follow-time of 311 days, 41.5% of the CA cohort died.

CONCLUSIONS

SARS-CoV-2 infection is associated with high mortality and hospitalization rates in patients with CA, which exceed that expected by their sex and advanced age.

Pathomorphological Features of the Novel Coronavirus Disease in Patients with Systemic Amyloidosis

Amyloidosis is one of the rare systemic illnesses characterized by the deposition of amyloid fibrils in various organs and tissues. There is a common point between COVID-19 and systemic amyloidosis regarding the multiorgan involvement in the pathological process which leads to a heightened risk for severe morbidity and mortality in amyloidosis patients who contracted COVID-19. We performed a pathomorphological analysis of the autopsy records of 22 patients who had COVID-19 and pre-existing systemic amyloidosis. The premortem diagnosis of systemic amyloidosis was established in 55% of patients, and in other 45% of cases, amyloidosis was found at autopsy. Based on the results of immunohistochemical amyloid typing, amyloid A (AA) amyloidosis was detected in 23%, amyloid light chain (AL) lambda in 32%, AL kappa-in 9%, and transthyretin (ATTR) amyloidosis-in 36% of observations. Immunohistochemical staining with an antibody against SARS-CoV-2 Spike (S) protein revealed positive immune reactions in type II alveolocytes in 59% of deceased persons. The analysis of autopsy findings indicates that patients with systemic amyloidosis are more likely to experience an aggressive clinical course of COVID-19 which leads to a multiorgan failure and a higher risk of fatal outcome.

COVID-19 Infection and Vaccination and Its Relation to Amyloidosis: What Do We Know Currently?

Amyloidosis is a complex disorder characterized by deposited insoluble fibrillar proteins which misfold into β-pleated sheets. The pathogenesis of amyloidosis can vary but can be the result of immune dysregulation that occurs from sustained high inflammatory states, often known as AA amyloidosis. Multi-organ involvement including hepatic, gastrointestinal, renal, cardiac and immunological pathological manifestations has been observed amongst individuals presenting with amyloidosis. The recent global pandemic of severe acute respiratory syndrome coronavirus 2, also referred to as coronavirus 2019 (COVID-19), has been shown to be associated with multiple health complications, many of which are similar to those seen in amyloidosis. Though COVID-19 is recognized primarily as a respiratory disease, it has since been found to have a range of extra-pulmonary manifestations, many of which are observed in patients with amyloidosis. These include features of oxidative stress, chronic inflammation and thrombotic risks. It is well known that viral illnesses have been associated with the triggering of autoimmune conditions of which amyloidosis is no different. Over the recent months, reports of new-onset and relapsed disease following COVID-19 infection and vaccination have been published. Despite this, the exact pathophysiological associations of COVID-19 and amyloidosis remain unclear. We present a scoping review based on our systematic search of available evidence relating to amyloidosis, COVID-19 infection and COVID-19 vaccination, evaluating current perspectives and providing insight into knowledge gaps that still needs to be addressed going forward.

Changing paradigm in the treatment of amyloidosis: From disease-modifying drugs to anti-fibril therapy

Cardiac amyloidosis is a rare, debilitating, and usually fatal disease increasingly recognized in clinical practice despite patients presenting with non-specific symptoms of cardiomyopathy. The current standard of care (SoC) focuses on preventing further amyloid formation and deposition, either with anti-plasma cell dyscrasia (anti-PCD) therapies in light-chain (AL) amyloidosis or stabilizers of transthyretin (TTR) in transthyretin amyloidosis (ATTR). The SoC is supplemented by therapies to treat the complications arising from organ dysfunction; for example, heart failure, arrhythmia, and proteinuria. Advancements in treatments have improved patient survival, especially for those whose disease is detected and for whom treatment is initiated at an early stage. However, there still are many unmet medical needs, particularly for patients with severe disease for whom morbidity and mortality remain high. There currently are no approved treatments to reverse amyloid infiltration and deplete the amyloid fibrils already deposited in organs, which can continue to cause progressive dysfunction. Anti-fibril therapies aimed at removing the deposited fibrils are being investigated for safety and efficacy in improving outcomes for patients with severe disease. However, there is no clinical evidence yet that removing deposited amyloid fibrils will improve organ function, thereby improving quality of life or extending life. Nevertheless, anti-fibril therapies are actively being investigated in clinical trials to evaluate their ability to complement and synergize with current SoC.

Amyloidosis and COVID-19: experience from an amyloid program in Canada

Severe acute respiratory syndrome coronavirus (SARS-CoV2) and associated COVID-19 infection continue to impact patients globally. Patients with underlying health conditions are at heightened risk of adverse outcomes from COVID-19; however, research involving patients with rare health conditions remains scarce. The amyloidoses are a rare grouping of protein deposition diseases. Light-chain and transthyretin amyloidosis are the most common disease forms, often present with systemic involvement of vital organs including the heart, nerves, kidneys, and GI tracts of affected individuals. The Amyloidosis Program of Calgary examined 152 ATTR patients and 103 AL patients analyzing rates of vaccination, COVID-19 testing, infection outcomes, influence referrals, and excess deaths. Results showed 15 total PCR-confirmed COVID-19 infections in the tested population of amyloid patients, with a higher frequency of infections among patient with AL compared to the ATTR cohort (26.2% vs 5.1%). Four patients (26.6%) required hospital admission for COVID-19 infection, 2 ATTR, and 2 AL patients. Of the confirmed cases, 1 (0.07%) unvaccinated ATTR patient died of a COVID-19 infection. An excess of deaths was found in both the ATTR and AL cohorts when comparing pre-pandemic years 2018 and 2019 to the pandemic years of 2020 and 2021. The finding suggests that amyloidosis patients are likely at a high risk for severe COVID-19 infection and mortality, especially those of advanced age, those on an active treatment with chemotherapy, and those with concomitant B-cell or plasma cell disorder. The impact of virtual healthcare visits and pandemic measures on the excess of deaths observed requires further research.

Evaluation of miRNA 223/125a and COBLL1 Expressions and ROR-1 Levels as Reliable Markers in B- chronic Lymphocytic Leukemia

BACKGROUND

miRNA 223 /125a and Cordon-bleu Protein Like 1 (COBLL1) are novel biomarkers that can predict prognosis and guide treatment decisions in patients with chronic lymphocytic leukemia (CLL). Also, there is a growing interest in CLL monitoring based on flow cytometry of receptor tyrosine kinase-like orphan receptor-1 (ROR-1).  Objective: This study aimed to evaluate the relationship between miRNA 223 /125a and COBLL1 expressions and ROR-1 expression in patients with CLL. Also, the study evaluated the relationship between the expression of these biomarkers with tumor staging and cancer progression.

METHODS

Our study included 40 patients newly diagnosed with B-CLL. In peripheral blood (PB), miRNA 223/125a and COBLL1 expressions were detected by real-time polymerase chain reaction (real-time PCR) and ROR-1 percentage was detected by flow cytometry before and after treatment.  Results: High level of COBLL1 expression was statistically significantly associated with high ROR-1 percentage expression (P= 0.03). However, a high level of miRNA 223/125a expression was statistically significantly associated with low ROR-1 percentage expression (P=0.002). The sensitivity and specificity of ROR-1 as a predictor of high WBCs count after treatment were 96.6 and 81.1%, respectively. There was a statistically significant reduction of ROR-1 percentage after treatment compared to before treatment (P <0.001).

CONCLUSION

ROR-1 percentage expression can be considered a possible prognostic predictor in CLL along with miRNA 223/125a and COBLL1 expressions. This can be explained by the significant correlation between ROR-1 and the studied molecular biomarkers; miRNA 223/125a and COBLL1. In addition, there was a significantly higher ROR-1 percentage in patients with higher WBC counts. Moreover, there was a significant reduction in ROR-1 percentage after treatment.

Anaesthetic challenges in the spine surgery of a young Asian man with lumbar amyloidosis

Primary amyloidosis is a rare systemic disorder often associated with multiple organ dysfunction. The most common form, light chain amyloidosis, has an estimated age-adjusted incidence of 5.1-12.8 cases per million person-years. Spine involvement is extremely uncommon. We present the case of a young Asian man with newly diagnosed amyloidosis involving the lumbar spine among multiple organs with a pathological vertebral fracture that required urgent spine surgery. We believe this is the first reported case to discuss the perianaesthetic challenges in the management of lumbar spine amyloidosis.

Characterization by Quantitative Serum Proteomics of Immune-Related Prognostic Biomarkers for COVID-19 Symptomatology

The COVID-19 pandemic caused by SARS-CoV-2 challenges the understanding of factors affecting disease progression and severity. The identification of prognostic biomarkers and physiological processes associated with disease symptoms is relevant for the development of new diagnostic and therapeutic interventions to contribute to the control of this pandemic. To address this challenge, in this study, we used a quantitative proteomics together with multiple data analysis algorithms to characterize serum protein profiles in five cohorts from healthy to SARS-CoV-2-infected recovered (hospital discharge), nonsevere (hospitalized), and severe [at the intensive care unit (ICU)] cases with increasing systemic inflammation in comparison with healthy individuals sampled prior to the COVID-19 pandemic. The results showed significantly dysregulated proteins and associated biological processes and disorders associated to COVID-19. These results corroborated previous findings in COVID-19 studies and highlighted how the representation of dysregulated serum proteins and associated BPs increases with COVID-19 disease symptomatology from asymptomatic to severe cases. The analysis was then focused on novel disease processes and biomarkers that were correlated with disease symptomatology. To contribute to translational medicine, results corroborated the predictive value of selected immune-related biomarkers for disease recovery [Selenoprotein P (SELENOP) and Serum paraoxonase/arylesterase 1 (PON1)], severity [Carboxypeptidase B2 (CBP2)], and symptomatology [Pregnancy zone protein (PZP)] using protein-specific ELISA tests. Our results contributed to the characterization of SARS-CoV-2–host molecular interactions with potential contributions to the monitoring and control of this pandemic by using immune-related biomarkers associated with disease symptomatology.

Preliminary Analysis of the Therapeutic Mechanism of Feiluoning in Convalescent Patients With COVID-19

Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome-coronavirus 2 (SARS-CoV-2), is often accompanied by injury to pulmonary function and pulmonary fibrosis. Feiluoning (FLN) is a new Chinese medicine prescription which is available for the treatment of severe and critical convalescence of COVID-19 patients. FLN also has a positive effect on pulmonary function injury and pulmonary fibrosis. We explored the potential mechanism of FLN’s effect on the convalescent treatment of COVID-19. According to the pharmacodynamic activity parameters, we screened the active chemical constituents of FLN by comparing the Traditional Chinese Medicine Systems Pharmacology Database and Analysis Platform. The Uniprot database was used to querying the corresponding target genes, and Cytoscape 3.6.1 was used to construct a herb-compound-target network. Protein interaction analysis, target gene function enrichment analysis, and signal pathway analysis were performed using the STRING, DAVID, and Kyoto Encyclopedia of Genes and Genomes pathway databases. Molecular docking was used to predict the binding capacity of the core compound with COVID-19 hydrolase 3 Cl and angiotensin-converting enzyme 2 (ACE2). The herb-compound-target network was successfully constructed and key targets identified, including prostaglandin G/H synthase 2, estrogen receptor 1, heat shock protein HSP 90, and androgen receptor. The major affected metabolic pathways were pathways in cancer, pancreatic cancer, nonsmall cell lung cancer, and toll-like receptor signaling. The core compounds of FLN, including quercetin, luteolin, kaempferol, and stigmasterol, could strongly bind to COVID-19 3 Cl hydrolase, and other compounds, including 7-O-methylisomucronulatol and medicocarpin, could strongly bind to ACE2. Thus, it is predicted that FLN has the characteristics of a multicomponent, multitarget, and multichannel overall control compound. FLN’s mechanism of action in the treatment of COVID-19 may be associated with the regulation of inflammation and immune-related signaling pathways, and the influence of COVID-19 3 Cl hydrolase binding ability.

The impact of COVID-19 in the management of AL amyloidosis and Immunoglobulin Deposition Disease: A single-center experience

Introduction

Patients with AL amyloidosis and immunoglobulin deposition diseases (IDD) are vulnerable during the COVID‐19 pandemic due to the immune compromise from the plasma cell disorder and therapy‐related immune defects. We describe a local experience in providing care for patients with AL amyloidosis and IDD.

Method

Patient treatment and disease status since the beginning of the pandemic on March 11, 2020, as declared by WHO, were collected and analyzed.

Results

Ninety‐six patients with AL amyloidosis and IDD were included. Four patients with IDD and 22 patients with systemic AL amyloidosis were receiving treatment during the pandemic. Since the pandemic, patients’ treatments were discontinued if they achieved VGPR or better postinduction. Seven patients discontinued all treatment after achieving VGPR, and others required treatment modifications. 28 patients have been tested for COVID‐19, and all tests have been negative. Three patients died since the pandemic, two from organ complications of systemic AL amyloidosis and one from an unrelated cause.

Conclusion

The management of AL amyloidosis and IDD must be individualized on the clinical characteristics, centers’ access to care under the pandemic restrictions, and the epidemiological aspects of the outbreak.

Cancer or COVID-19? A Review of Guidelines for Safe Cancer Care in the Wake of the Pandemic

In the wake of the COVID-19 pandemic, due to reasons beyond control, health care workers have struggled to deliver treatment for the patients with cancer. The concern for otherwise healthy patients with curable cancers that require timely intervention or therapy is the risk of contracting COVID-19 may outweigh the benefits of cancer treatment. Lack of international guidelines leaves health care providers with a case-to-case approach for delivering optimal cancer care in the wake of the pandemic. Transition to telemedicine has somewhat bridged the gap for in-office visits, but there is a continuing challenge of delays in cancer screening or significant decline of new diagnoses of cancers due to the pandemic. We aim to propose a balance in risk from treatment delay versus risks from COVID-19 with emphasis on treatment modality (surgery, radiation, and systemic therapy) as well as supportive care for cancer patients, and therefore have reviewed the publications and recommendations from international societies and study groups available as of October 2020.