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Haunhorst S, Dudziak D, Scheibenbogen C, Seifert M, Sotzny F, Finke C, Behrends U, Aden K, Schreiber S, Brockmann D, Burggraf P, Bloch W, Ellert C, Ramoji A, Popp J, Reuken P, Walter M, Stallmach A, Puta C. Towards an understanding of physical activity-induced post-exertional malaise: Insights into microvascular alterations and immunometabolic interactions in post-COVID condition and myalgic encephalomyelitis/chronic fatigue syndrome. Infection 2024:10.1007/s15010-024-02386-8. [PMID: 39240417 DOI: 10.1007/s15010-024-02386-8] [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: 08/12/2024] [Accepted: 08/28/2024] [Indexed: 09/07/2024]
Abstract
BACKGROUND A considerable number of patients who contracted SARS-CoV-2 are affected by persistent multi-systemic symptoms, referred to as Post-COVID Condition (PCC). Post-exertional malaise (PEM) has been recognized as one of the most frequent manifestations of PCC and is a diagnostic criterion of myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS). Yet, its underlying pathomechanisms remain poorly elucidated. PURPOSE AND METHODS In this review, we describe current evidence indicating that key pathophysiological features of PCC and ME/CFS are involved in physical activity-induced PEM. RESULTS Upon physical activity, affected patients exhibit a reduced systemic oxygen extraction and oxidative phosphorylation capacity. Accumulating evidence suggests that these are mediated by dysfunctions in mitochondrial capacities and microcirculation that are maintained by latent immune activation, conjointly impairing peripheral bioenergetics. Aggravating deficits in tissue perfusion and oxygen utilization during activities cause exertional intolerance that are frequently accompanied by tachycardia, dyspnea, early cessation of activity and elicit downstream metabolic effects. The accumulation of molecules such as lactate, reactive oxygen species or prostaglandins might trigger local and systemic immune activation. Subsequent intensification of bioenergetic inflexibilities, muscular ionic disturbances and modulation of central nervous system functions can lead to an exacerbation of existing pathologies and symptoms.
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Affiliation(s)
- Simon Haunhorst
- Department of Sports Medicine and Health Promotion, Friedrich-Schiller-University Jena, Wöllnitzer Straße 42, 07749, Jena, Germany
- Center for Interdisciplinary Prevention of Diseases Related to Professional Activities, Jena, Germany
| | - Diana Dudziak
- Institute of Immunology, Jena University Hospital/ Friedrich-Schiller-University Jena, Jena, Germany
| | - Carmen Scheibenbogen
- Institute of Medical Immunology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt Universität Zu Berlin, and Berlin Institute of Health (BIH), Berlin, Germany
| | - Martina Seifert
- Institute of Medical Immunology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt Universität Zu Berlin, and Berlin Institute of Health (BIH), Berlin, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany
| | - Franziska Sotzny
- Institute of Medical Immunology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt Universität Zu Berlin, and Berlin Institute of Health (BIH), Berlin, Germany
| | - Carsten Finke
- Department of Neurology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Berlin, Germany
| | - Uta Behrends
- Children's Hospital, School of Medicine, Technical University of Munich, Munich, Germany
- German Center for Infection Research (DZIF), Berlin, Germany
- AGV Research Unit Gene Vectors, Helmholtz Munich (HMGU), Munich, Germany
| | - Konrad Aden
- Institute of Clinical Molecular Biology, Kiel University and University Medical Center Schleswig-Holstein, Campus Kiel, Kiel, Germany
- Department of Internal Medicine I, Kiel University and University Medical Center Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Stefan Schreiber
- Department of Internal Medicine I, Kiel University and University Medical Center Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Dirk Brockmann
- Center Synergy of Systems, TU Dresden University of Technology, Dresden, Germany
| | - Paul Burggraf
- mHealth Pioneers GmbH, Körtestraße 10, 10967, Berlin, Germany
| | - Wilhelm Bloch
- Department for Molecular and Cellular Sports Medicine, Institute for Cardiovascular Research and Sports Medicine, German Sport University Cologne, Cologne, Germany
| | - Claudia Ellert
- , Landarztnetz Lahn-Dill, Wetzlar, Germany
- Initiative Long COVID Deutschland, Lemgo, Germany
| | - Anuradha Ramoji
- Institute of Physical Chemistry (IPC) and Abbe Center of Photonics (ACP), Member of the Leibniz Centre for Photonics in Infection Research (LPI), Friedrich-Schiller-University Jena, Jena, Germany
- Leibniz Institute of Photonic Technology, Member of Leibniz Health Technologies, Member of the Leibniz Centre for Photonics in Infection Research (LPI), Jena, Germany
| | - Juergen Popp
- Institute of Physical Chemistry (IPC) and Abbe Center of Photonics (ACP), Member of the Leibniz Centre for Photonics in Infection Research (LPI), Friedrich-Schiller-University Jena, Jena, Germany
- Leibniz Institute of Photonic Technology, Member of Leibniz Health Technologies, Member of the Leibniz Centre for Photonics in Infection Research (LPI), Jena, Germany
| | - Philipp Reuken
- Department for Internal Medicine IV (Gastroenterology, Hepatology and Infectious Diseases), Jena University Hospital, Jena, Germany
| | - Martin Walter
- Department of Psychiatry and Psychotherapy, Jena Center for Mental Health, Jena University Hospital, Jena, Germany
- German Center for Mental Health (DZPG), Partner Site Jena, Jena, Germany
| | - Andreas Stallmach
- Department for Internal Medicine IV (Gastroenterology, Hepatology and Infectious Diseases), Jena University Hospital, Jena, Germany
| | - Christian Puta
- Department of Sports Medicine and Health Promotion, Friedrich-Schiller-University Jena, Wöllnitzer Straße 42, 07749, Jena, Germany.
- Department for Internal Medicine IV (Gastroenterology, Hepatology and Infectious Diseases), Jena University Hospital, Jena, Germany.
- Center for Sepsis Control and Care (CSCC), Jena University Hospital/Friedrich-Schiller-University Jena, Jena, Germany.
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Shaw RJ, Abrams ST, Badu S, Toh CH, Dutt T. The Highs and Lows of ADAMTS13 Activity. J Clin Med 2024; 13:5152. [PMID: 39274365 PMCID: PMC11396319 DOI: 10.3390/jcm13175152] [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: 06/18/2024] [Revised: 08/20/2024] [Accepted: 08/28/2024] [Indexed: 09/16/2024] Open
Abstract
Severe deficiency of ADAMTS13 (<10 iu/dL) is diagnostic of thrombotic thrombocytopenic purpura (TTP) and leads to accumulation of ultra-large vWF multimers, platelet aggregation, and widespread microthrombi, which can be life-threatening. However, the clinical implications of a low ADAMTS13 activity level are not only important in an acute episode of TTP. In this article, we discuss the effects of low ADAMTS13 activity in congenital and immune-mediated TTP patients not only at presentation but once in a clinical remission. Evidence is emerging of the clinical effects of low ADAMTS13 activity in other disease areas outside of TTP, and here, we explore the wider impact of low ADAMTS13 activity on the vascular endothelium and the potential for recombinant ADAMTS13 therapy in other thrombotic disease states.
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Affiliation(s)
- Rebecca J Shaw
- Liverpool University Hospitals NHS Foundation Trust, Liverpool L7 8YE, UK
- Clinical Infection, Microbiology and Immunology, Institute of Infection, Veterinary & Ecological Sciences, University of Liverpool, Ronald Ross Building, 8 West Derby Street, Liverpool L69 7BE, UK
| | - Simon T Abrams
- Clinical Infection, Microbiology and Immunology, Institute of Infection, Veterinary & Ecological Sciences, University of Liverpool, Ronald Ross Building, 8 West Derby Street, Liverpool L69 7BE, UK
| | - Samuel Badu
- Liverpool University Hospitals NHS Foundation Trust, Liverpool L7 8YE, UK
| | - Cheng-Hock Toh
- Liverpool University Hospitals NHS Foundation Trust, Liverpool L7 8YE, UK
- Clinical Infection, Microbiology and Immunology, Institute of Infection, Veterinary & Ecological Sciences, University of Liverpool, Ronald Ross Building, 8 West Derby Street, Liverpool L69 7BE, UK
| | - Tina Dutt
- Liverpool University Hospitals NHS Foundation Trust, Liverpool L7 8YE, UK
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3
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Yanai H, Adachi H, Hakoshima M, Katsuyama H, Sako A. The Significance of Endothelial Dysfunction in Long COVID-19 for the Possible Future Pandemic of Chronic Kidney Disease and Cardiovascular Disease. Biomolecules 2024; 14:965. [PMID: 39199353 PMCID: PMC11352301 DOI: 10.3390/biom14080965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2024] [Revised: 07/23/2024] [Accepted: 08/06/2024] [Indexed: 09/01/2024] Open
Abstract
Various symptoms have been reported to persist beyond the acute phase of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, which is referred to as long coronavirus disease 19 (long COVID-19). Over 65 million individuals suffer from long COVID-19. However, the causes of long COVID-19 are largely unknown. Since long COVID-19 symptoms are observed throughout the body, vascular endothelial dysfunction is a strong candidate explaining the induction of long COVID-19. The angiotensin-converting enzyme 2 (ACE2), the entry receptor for SARS-CoV-2, is ubiquitously expressed in endothelial cells. We previously found that the risk factors for atherosclerotic cardiovascular disease (ASCVD) and a history of ASCVD raise the risk of severe COVID-19, suggesting a contribution of pre-existing endothelial dysfunction to severe COVID-19. Here, we show a significant association of endothelial dysfunction with the development of long COVID-19 and show that biomarkers for endothelial dysfunction in patients with long COVID-19 are also crucial players in the development of ASCVD. We consider the influence of long COVID-19 on the development of chronic kidney disease (CKD) and ASCVD. Future assessments of the outcomes of long COVID-19 in patients resulting from therapeutic interventions that improve endothelial function may imply the significance of endothelial dysfunction in the development of long COVID-19.
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Affiliation(s)
- Hidekatsu Yanai
- Department of Diabetes, Endocrinology and Metabolism, National Center for Global Health and Medicine Kohnodai Hospital, 1-7-1 Kohnodai, Ichikawa 272-8516, Chiba, Japan; (H.A.); (M.H.); (H.K.)
| | - Hiroki Adachi
- Department of Diabetes, Endocrinology and Metabolism, National Center for Global Health and Medicine Kohnodai Hospital, 1-7-1 Kohnodai, Ichikawa 272-8516, Chiba, Japan; (H.A.); (M.H.); (H.K.)
| | - Mariko Hakoshima
- Department of Diabetes, Endocrinology and Metabolism, National Center for Global Health and Medicine Kohnodai Hospital, 1-7-1 Kohnodai, Ichikawa 272-8516, Chiba, Japan; (H.A.); (M.H.); (H.K.)
| | - Hisayuki Katsuyama
- Department of Diabetes, Endocrinology and Metabolism, National Center for Global Health and Medicine Kohnodai Hospital, 1-7-1 Kohnodai, Ichikawa 272-8516, Chiba, Japan; (H.A.); (M.H.); (H.K.)
| | - Akahito Sako
- Department of General Medicine, National Center for Global Health and Medicine Kohnodai Hospital, 1-7-1 Kohnodai, Ichikawa 272-8516, Chiba, Japan;
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4
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Shafqat A, Masters MC, Tripathi U, Tchkonia T, Kirkland JL, Hashmi SK. Long COVID as a disease of accelerated biological aging: An opportunity to translate geroscience interventions. Ageing Res Rev 2024; 99:102400. [PMID: 38945306 DOI: 10.1016/j.arr.2024.102400] [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: 04/21/2024] [Revised: 06/12/2024] [Accepted: 06/27/2024] [Indexed: 07/02/2024]
Abstract
It has been four years since long COVID-the protracted consequences that survivors of COVID-19 face-was first described. Yet, this entity continues to devastate the quality of life of an increasing number of COVID-19 survivors without any approved therapy and a paucity of clinical trials addressing its biological root causes. Notably, many of the symptoms of long COVID are typically seen with advancing age. Leveraging this similarity, we posit that Geroscience-which aims to target the biological drivers of aging to prevent age-associated conditions as a group-could offer promising therapeutic avenues for long COVID. Bearing this in mind, this review presents a translational framework for studying long COVID as a state of effectively accelerated biological aging, identifying research gaps and offering recommendations for future preclinical and clinical studies.
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Affiliation(s)
- Areez Shafqat
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia.
| | - Mary Clare Masters
- Division of Infectious Diseases, Northwestern University, Chicago, IL, USA
| | - Utkarsh Tripathi
- Robert and Arlene Kogod Center on Aging, Mayo Clinic, Rochester, MN, USA
| | - Tamara Tchkonia
- Robert and Arlene Kogod Center on Aging, Mayo Clinic, Rochester, MN, USA; Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, MN, USA
| | - James L Kirkland
- Robert and Arlene Kogod Center on Aging, Mayo Clinic, Rochester, MN, USA; Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, MN, USA; Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Shahrukh K Hashmi
- Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA; Research and Innovation Center, Department of Health, Abu Dhabi, UAE; College of Medicine and Health Sciences, Khalifa University, Abu Dhabi, United Arab Emirates
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5
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Hamlin RE, Pienkos SM, Chan L, Stabile MA, Pinedo K, Rao M, Grant P, Bonilla H, Holubar M, Singh U, Jacobson KB, Jagannathan P, Maldonado Y, Holmes SP, Subramanian A, Blish CA. Sex differences and immune correlates of Long COVID development, persistence, and resolution. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2024:2024.06.18.599612. [PMID: 38948732 PMCID: PMC11212991 DOI: 10.1101/2024.06.18.599612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/02/2024]
Abstract
Sex differences have been observed in acute COVID-19 and Long COVID (LC) outcomes, with greater disease severity and mortality during acute infection in males and a greater proportion of females developing LC. We hypothesized that sex-specific immune dysregulation contributes to the pathogenesis of LC. To investigate the immunologic underpinnings of LC development and persistence, we used single-cell transcriptomics, single-cell proteomics, and plasma proteomics on blood samples obtained during acute SARS-CoV-2 infection and at 3 and 12 months post-infection in a cohort of 45 patients who either developed LC or recovered. Several sex-specific immune pathways were associated with LC. Specifically, males who would develop LC at 3 months had widespread increases in TGF-β signaling during acute infection in proliferating NK cells. Females who would develop LC demonstrated increased expression of XIST, an RNA gene implicated in autoimmunity, and increased IL1 signaling in monocytes at 12 months post infection. Several immune features of LC were also conserved across sexes. Both males and females with LC had reduced co-stimulatory signaling from monocytes and broad upregulation of NF-κB transcription factors. In both sexes, those with persistent LC demonstrated increased LAG3, a marker of T cell exhaustion, reduced ETS1 transcription factor expression across lymphocyte subsets, and elevated intracellular IL-4 levels in T cell subsets, suggesting that ETS1 alterations may drive an aberrantly elevated Th2-like response in LC. Altogether, this study describes multiple innate and adaptive immune correlates of LC, some of which differ by sex, and offers insights toward the pursuit of tailored therapeutics.
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Affiliation(s)
- Rebecca E Hamlin
- Department of Medicine, Stanford University School of Medicine; Stanford, CA, USA
| | - Shaun M Pienkos
- Department of Medicine, Stanford University School of Medicine; Stanford, CA, USA
| | - Leslie Chan
- Department of Medicine, Stanford University School of Medicine; Stanford, CA, USA
- Stanford Immunology Program, Stanford University School of Medicine; Stanford, CA, USA
| | - Mikayla A Stabile
- Department of Medicine, Stanford University School of Medicine; Stanford, CA, USA
| | - Kassandra Pinedo
- Department of Medicine, Stanford University School of Medicine; Stanford, CA, USA
| | - Mallika Rao
- Stanford Center for Clinical Research, Stanford University; Stanford, CA, USA
| | - Philip Grant
- Department of Medicine, Stanford University School of Medicine; Stanford, CA, USA
| | - Hector Bonilla
- Department of Medicine, Stanford University School of Medicine; Stanford, CA, USA
| | - Marisa Holubar
- Department of Medicine, Stanford University School of Medicine; Stanford, CA, USA
| | - Upinder Singh
- Department of Medicine, Stanford University School of Medicine; Stanford, CA, USA
- Department of Microbiology and Immunology, Stanford University School of Medicine; Stanford, CA, USA
| | - Karen B Jacobson
- Department of Medicine, Stanford University School of Medicine; Stanford, CA, USA
| | - Prasanna Jagannathan
- Department of Medicine, Stanford University School of Medicine; Stanford, CA, USA
- Department of Microbiology and Immunology, Stanford University School of Medicine; Stanford, CA, USA
| | - Yvonne Maldonado
- Department of Pediatrics, Stanford University School of Medicine; Stanford, CA, USA
| | - Susan P Holmes
- Department of Statistics, Stanford University; Stanford, CA, USA
| | - Aruna Subramanian
- Department of Medicine, Stanford University School of Medicine; Stanford, CA, USA
| | - Catherine A Blish
- Department of Medicine, Stanford University School of Medicine; Stanford, CA, USA
- Stanford Medical Scientist Training Program, Stanford University School of Medicine; Stanford, CA, USA
- Chan Zuckerberg Biohub; San Francisco, CA, USA
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6
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Hunt BJ, Kuehn R, Fox T, Carson A, Scandrett K, Davey Smith G, Garner P. Challenging the current hypothesis that thrombosis is responsible for the post-COVID-19 condition. Res Pract Thromb Haemost 2024; 8:102442. [PMID: 38903154 PMCID: PMC11186963 DOI: 10.1016/j.rpth.2024.102442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Revised: 05/03/2024] [Accepted: 05/07/2024] [Indexed: 06/22/2024] Open
Abstract
People with the post-COVID-19 condition suffer symptoms that persist beyond 12 weeks following acute COVID-19 infection. Fatigue, shortness of breath, and cognitive dysfunction ("brain fog") are common. Scientists, clinicians, and patients debate the pathophysiology. One pathophysiological hypothesis is that prothrombotic changes associated with acute COVID-19 persist, causing clots that lead to symptoms. This theory, arising from a research team in South Africa and supported by a paper in Nature Medicine, has been widely disseminated on social media and entered the public narrative as a cause of the post-COVID-19 condition. We describe the development of this theory, examine the findings of a Cochrane review that critically appraises the "microclot" beliefs, and critically appraise the influential study relating clotting biomarkers to cognitive deficits. We conclude the inferences for the hypothesis are not based on evidence, unlicensed use of antithrombotic medication is not justified, and apheresis should not be considered outside of a well-designed clinical trial.
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Affiliation(s)
| | - Rebecca Kuehn
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Tilly Fox
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Alan Carson
- Department of Neuropsychiatry, University of Edinburgh, Edinburgh, United Kingdom
| | - Katie Scandrett
- Institute of Applied Research, University of Birmingham, Birmingham, United Kingdom
| | - George Davey Smith
- Medical Research Council Integrative Epidemiology Unit, University of Bristol, Bristol, United Kingdom
| | - Paul Garner
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
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Gheorghita R, Soldanescu I, Lobiuc A, Caliman Sturdza OA, Filip R, Constantinescu – Bercu A, Dimian M, Mangul S, Covasa M. The knowns and unknowns of long COVID-19: from mechanisms to therapeutical approaches. Front Immunol 2024; 15:1344086. [PMID: 38500880 PMCID: PMC10944866 DOI: 10.3389/fimmu.2024.1344086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Accepted: 02/14/2024] [Indexed: 03/20/2024] Open
Abstract
The coronavirus disease 2019 (COVID-19) pandemic caused by SARS-CoV-2 has been defined as the greatest global health and socioeconomic crisis of modern times. While most people recover after being infected with the virus, a significant proportion of them continue to experience health issues weeks, months and even years after acute infection with SARS-CoV-2. This persistence of clinical symptoms in infected individuals for at least three months after the onset of the disease or the emergence of new symptoms lasting more than two months, without any other explanation and alternative diagnosis have been named long COVID, long-haul COVID, post-COVID-19 conditions, chronic COVID, or post-acute sequelae of SARS-CoV-2 (PASC). Long COVID has been characterized as a constellation of symptoms and disorders that vary widely in their manifestations. Further, the mechanisms underlying long COVID are not fully understood, which hamper efficient treatment options. This review describes predictors and the most common symptoms related to long COVID's effects on the central and peripheral nervous system and other organs and tissues. Furthermore, the transcriptional markers, molecular signaling pathways and risk factors for long COVID, such as sex, age, pre-existing condition, hospitalization during acute phase of COVID-19, vaccination, and lifestyle are presented. Finally, recommendations for patient rehabilitation and disease management, as well as alternative therapeutical approaches to long COVID sequelae are discussed. Understanding the complexity of this disease, its symptoms across multiple organ systems and overlapping pathologies and its possible mechanisms are paramount in developing diagnostic tools and treatments.
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Affiliation(s)
- Roxana Gheorghita
- Victor Babes University of Medicine and Pharmacy, Timisoara, Romania
- Department of Biomedical Sciences, College of Medicine and Biological Science, University of Suceava, Suceava, Romania
| | - Iuliana Soldanescu
- Integrated Center for Research, Development and Innovation for Advanced Materials, Nanotechnologies, Manufacturing and Control Distributed Systems (MANSiD), University of Suceava, Suceava, Romania
| | - Andrei Lobiuc
- Department of Biomedical Sciences, College of Medicine and Biological Science, University of Suceava, Suceava, Romania
| | - Olga Adriana Caliman Sturdza
- Department of Biomedical Sciences, College of Medicine and Biological Science, University of Suceava, Suceava, Romania
- Suceava Emergency Clinical County Hospital, Suceava, Romania
| | - Roxana Filip
- Department of Biomedical Sciences, College of Medicine and Biological Science, University of Suceava, Suceava, Romania
- Suceava Emergency Clinical County Hospital, Suceava, Romania
| | - Adela Constantinescu – Bercu
- Department of Biomedical Sciences, College of Medicine and Biological Science, University of Suceava, Suceava, Romania
- Institute of Cardiovascular Science, Hemostasis Research Unit, University College London (UCL), London, United Kingdom
| | - Mihai Dimian
- Integrated Center for Research, Development and Innovation for Advanced Materials, Nanotechnologies, Manufacturing and Control Distributed Systems (MANSiD), University of Suceava, Suceava, Romania
- Department of Computer, Electronics and Automation, University of Suceava, Suceava, Romania
| | - Serghei Mangul
- Department of Clinical Pharmacy, USC Alfred E. Mann School of Pharmacy and Pharmaceutical Sciences, University of Southern California, Los Angeles, CA, United States
- Department of Quantitative and Computational Biology, USC Dornsife College of Letters, Arts and Sciences, University of Southern California (USC), Los Angeles, CA, United States
| | - Mihai Covasa
- Department of Biomedical Sciences, College of Medicine and Biological Science, University of Suceava, Suceava, Romania
- Department of Basic Medical Sciences, Western University of Health Sciences, College of Osteopathic Medicine, Pomona, CA, United States
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Valencia I, Lumpuy-Castillo J, Magalhaes G, Sánchez-Ferrer CF, Lorenzo Ó, Peiró C. Mechanisms of endothelial activation, hypercoagulation and thrombosis in COVID-19: a link with diabetes mellitus. Cardiovasc Diabetol 2024; 23:75. [PMID: 38378550 PMCID: PMC10880237 DOI: 10.1186/s12933-023-02097-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Accepted: 12/14/2023] [Indexed: 02/22/2024] Open
Abstract
Early since the onset of the COVID-19 pandemic, the medical and scientific community were aware of extra respiratory actions of SARS-CoV-2 infection. Endothelitis, hypercoagulation, and hypofibrinolysis were identified in COVID-19 patients as subsequent responses of endothelial dysfunction. Activation of the endothelial barrier may increase the severity of the disease and contribute to long-COVID syndrome and post-COVID sequelae. Besides, it may cause alterations in primary, secondary, and tertiary hemostasis. Importantly, these responses have been highly decisive in the evolution of infected patients also diagnosed with diabetes mellitus (DM), who showed previous endothelial dysfunction. In this review, we provide an overview of the potential triggers of endothelial activation related to COVID-19 and COVID-19 under diabetic milieu. Several mechanisms are induced by both the viral particle itself and by the subsequent immune-defensive response (i.e., NF-κB/NLRP3 inflammasome pathway, vasoactive peptides, cytokine storm, NETosis, activation of the complement system). Alterations in coagulation mediators such as factor VIII, fibrin, tissue factor, the von Willebrand factor: ADAMST-13 ratio, and the kallikrein-kinin or plasminogen-plasmin systems have been reported. Moreover, an imbalance of thrombotic and thrombolytic (tPA, PAI-I, fibrinogen) factors favors hypercoagulation and hypofibrinolysis. In the context of DM, these mechanisms can be exacerbated leading to higher loss of hemostasis. However, a series of therapeutic strategies targeting the activated endothelium such as specific antibodies or inhibitors against thrombin, key cytokines, factor X, complement system, the kallikrein-kinin system or NETosis, might represent new opportunities to address this hypercoagulable state present in COVID-19 and DM. Antidiabetics may also ameliorate endothelial dysfunction, inflammation, and platelet aggregation. By improving the microvascular pathology in COVID-19 and post-COVID subjects, the associated comorbidities and the risk of mortality could be reduced.
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Affiliation(s)
- Inés Valencia
- Molecular Neuroinflammation and Neuronal Plasticity Research Laboratory, Hospital Universitario Santa Cristina, IIS Hospital Universitario de La Princesa, 28009, Madrid, Spain.
| | - Jairo Lumpuy-Castillo
- Laboratory of Diabetes and Vascular Pathology, IIS-Fundación Jiménez Díaz, 28040, Madrid, Spain
- Spanish Biomedical Research Centre On Diabetes and Associated Metabolic Disorders (CIBERDEM) Network, Madrid, Spain
| | - Giselle Magalhaes
- Department of Pharmacology, School of Medicine, Universidad Autónoma de Madrid, 28029, Madrid, Spain
| | - Carlos F Sánchez-Ferrer
- Department of Pharmacology, School of Medicine, Universidad Autónoma de Madrid, 28029, Madrid, Spain
- Vascular Pharmacology and Metabolism (FARMAVASM), IdiPAZ, Madrid, Spain
| | - Óscar Lorenzo
- Laboratory of Diabetes and Vascular Pathology, IIS-Fundación Jiménez Díaz, 28040, Madrid, Spain.
- Spanish Biomedical Research Centre On Diabetes and Associated Metabolic Disorders (CIBERDEM) Network, Madrid, Spain.
| | - Concepción Peiró
- Department of Pharmacology, School of Medicine, Universidad Autónoma de Madrid, 28029, Madrid, Spain.
- Vascular Pharmacology and Metabolism (FARMAVASM), IdiPAZ, Madrid, Spain.
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9
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Philippe A, Günther S, Rancic J, Cavagna P, Renaud B, Gendron N, Mousseaux E, Hua-Huy T, Reverdito G, Planquette B, Sanchez O, Gaussem P, Salmon D, Diehl JL, Smadja DM. VEGF-A plasma levels are associated with impaired DLCO and radiological sequelae in long COVID patients. Angiogenesis 2024; 27:51-66. [PMID: 37526809 DOI: 10.1007/s10456-023-09890-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 07/21/2023] [Indexed: 08/02/2023]
Abstract
BACKGROUND Long COVID, also known as post-acute sequelae of COVID-19 (PASC), is characterized by persistent clinical symptoms following COVID-19. OBJECTIVE To correlate biomarkers of endothelial dysfunction with persistent clinical symptoms and pulmonary function defects at distance from COVID-19. METHODS Consecutive patients with long COVID-19 suspicion were enrolled. A panel of endothelial biomarkers was measured in each patient during clinical evaluation and pulmonary function test (PFT). RESULTS The study included 137 PASC patients, mostly male (68%), with a median age of 55 years. A total of 194 PFTs were performed between months 3 and 24 after an episode of SARS-CoV-2 infection. We compared biomarkers evaluated in PASC patients with 20 healthy volunteers (HVs) and acute hospitalized COVID-19 patients (n = 88). The study found that angiogenesis-related biomarkers and von Willebrand factor (VWF) levels were increased in PASC patients compared to HVs without increased inflammatory or platelet activation markers. Moreover, VEGF-A and VWF were associated with persistent lung CT scan lesions and impaired diffusing capacity of the lungs for carbon monoxide (DLCO) measurement. By employing a Cox proportional hazards model adjusted for age, sex, and body mass index, we further confirmed the accuracy of VEGF-A and VWF. Following adjustment, VEGF-A emerged as the most significant predictive factor associated with persistent lung CT scan lesions and impaired DLCO measurement. CONCLUSION VEGF-A is a relevant predictive factor for DLCO impairment and radiological sequelae in PASC. Beyond being a biomarker, we hypothesize that the persistence of angiogenic disorders may contribute to long COVID symptoms.
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Affiliation(s)
- Aurélien Philippe
- University Paris Cité, Innovative Therapies in Hemostasis, INSERM, 75006, Paris, France
- Hematology Department, AP-HP.Centre, Université Paris Cité, Georges Pompidou European Hospital, 75015, Paris, France
| | - Sven Günther
- University Paris Cité, Innovative Therapies in Hemostasis, INSERM, 75006, Paris, France
- Unité d'Explorations Fonctionnelles Respiratoires et du Sommeil, AP-HP, Georges Pompidou European Hospital, 75015, Paris, France
| | - Jeanne Rancic
- University Paris Cité, Innovative Therapies in Hemostasis, INSERM, 75006, Paris, France
| | - Pauline Cavagna
- Pharmacy Department, Pitié-Salpêtrière Hospital, AP-HP Sorbonne University, Paris, France
- Université Paris Cité, INSERM, PARCC, 75015, Paris, France
| | - Bertrand Renaud
- Unité d'Explorations Fonctionnelles Respiratoires et du Sommeil, AP-HP, Georges Pompidou European Hospital, 75015, Paris, France
| | - Nicolas Gendron
- University Paris Cité, Innovative Therapies in Hemostasis, INSERM, 75006, Paris, France
- Hematology Department, AP-HP.Centre, Université Paris Cité, Georges Pompidou European Hospital, 75015, Paris, France
| | - Elie Mousseaux
- Paris-Cardiovascular Research Center INSERM 970, Université de Paris, Paris, France
- Department of Radiology, Georges Pompidou European Hospital, 75015, Paris, France
| | - Thông Hua-Huy
- Unité d'Explorations Fonctionnelles Respiratoires et du Sommeil, AP-HP, Georges Pompidou European Hospital, 75015, Paris, France
| | - Guillaume Reverdito
- Paris-Cardiovascular Research Center INSERM 970, Université de Paris, Paris, France
- Department of Radiology, Georges Pompidou European Hospital, 75015, Paris, France
| | - Benjamin Planquette
- University Paris Cité, Innovative Therapies in Hemostasis, INSERM, 75006, Paris, France
- Respiratory Diseases Department, AP-HP.Centre, Université Paris Cité, Georges Pompidou European Hospital, 75015, Paris, France
| | - Olivier Sanchez
- University Paris Cité, Innovative Therapies in Hemostasis, INSERM, 75006, Paris, France
- Respiratory Diseases Department, AP-HP.Centre, Université Paris Cité, Georges Pompidou European Hospital, 75015, Paris, France
| | - Pascale Gaussem
- University Paris Cité, Innovative Therapies in Hemostasis, INSERM, 75006, Paris, France
- Hematology Department, AP-HP.Centre, Université Paris Cité, Georges Pompidou European Hospital, 75015, Paris, France
| | - Dominique Salmon
- Infectious Diseases and Immunology Department, AP-HP. Centre, Université Paris Cité, Hôtel-Dieu Hospital, 75004, Paris, France
| | - Jean-Luc Diehl
- University Paris Cité, Innovative Therapies in Hemostasis, INSERM, 75006, Paris, France
- Intensive Care Unit, AP-HP. Centre Université Paris Cité, Georges Pompidou European Hospital, 75015, Paris, France
| | - David M Smadja
- University Paris Cité, Innovative Therapies in Hemostasis, INSERM, 75006, Paris, France.
- Hematology Department, AP-HP.Centre, Université Paris Cité, Georges Pompidou European Hospital, 75015, Paris, France.
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10
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Neave L, Thomas M, de Groot R, Doyle AJ, Singh D, Adams G, David AL, Maksym K, Scully M. Alterations in the von Willebrand factor/ADAMTS-13 axis in preeclampsia. J Thromb Haemost 2024; 22:455-465. [PMID: 37926193 DOI: 10.1016/j.jtha.2023.10.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 10/07/2023] [Accepted: 10/25/2023] [Indexed: 11/07/2023]
Abstract
BACKGROUND Preeclampsia is a gestational hypertensive disorder characterized by maternal endothelial activation and increased ratio of soluble fms-like tyrosine kinase-1 (sFlt-1) inhibitor to placental growth factor (PlGF). The von Willebrand factor (VWF)/ADAMTS-13 axis is of interest because of the underlying endothelial activation and clinical overlap with pregnancy-associated thrombotic thrombocytopenic purpura. OBJECTIVES To assess VWF, ADAMTS-13, and VWF/ADAMTS-13 ratio in preeclampsia and look for associations with sFlt-1/PlGF ratio and clinical features. METHODS Thirty-four preeclampsia cases and 48 normal pregnancies were assessed in a case-control study. Twelve normal pregnancies in women with a history of preeclampsia formed an additional comparator group. VWF antigen (VWF:Ag) and VWF activity (VWF:Ac [VWF:glycoprotein IbM]) were measured via automated immunoturbidimetric assay, ADAMTS-13 activity was measured via fluorescence resonance energy transfer-VWF73 assay, and sFlt-1 and PlGF were measured via enzyme-linked immunosorbent assay. RESULTS VWF:Ag was higher in preeclampsia than in normal pregnancy (median, 3.07 vs 1.87 IU/mL; P < .0001). ADAMTS-13 activity was slightly lower (median, 89.6 vs 94.4 IU/dL; P = .02), with no severe deficiencies. Significant elevations in VWF:Ac were not observed in preeclampsia, resulting in reduced VWF:Ac/VWF:Ag ratios (median, 0.77 vs 0.97; P < .0001). VWF:Ag/ADAMTS-13 ratios were significantly higher in preeclampsia (median, 3.42 vs 2.06; P < .0001), with an adjusted odds ratio of 19.2 for a ratio of >2.7 (>75th centile of normal pregnancy). Those with a history of preeclampsia had similar ratios to normal pregnant controls. VWF:Ag/ADAMTS-13 and sFlt-1/PlGF were not correlated. However, percentage reduction in platelets correlated positively with VWF:Ac (P = .01), VWF:Ac/VWF:Ag ratio (P = .004), and sFlt-1/PlGF ratio (P = .01). CONCLUSION The VWF/ADAMTS-13 axis is significantly altered in preeclampsia. Further investigation of potential clinical utility is warranted.
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Affiliation(s)
- Lucy Neave
- Department of Clinical Haematology, University College London Hospitals NHS Foundation Trust, London, United Kingdom; Haemostasis Research Unit, University College London, London, United Kingdom.
| | - Mari Thomas
- Department of Clinical Haematology, University College London Hospitals NHS Foundation Trust, London, United Kingdom; National Institute for Health and Care Research University College London Hospital/University College London Biomedical Research Centre, London, United Kingdom
| | - Rens de Groot
- Institute of Cardiovascular Science, University College London, London, United Kingdom
| | - Andrew J Doyle
- Department of Clinical Haematology, University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | - Deepak Singh
- Special Coagulation, Health Services Laboratories, London, United Kingdom
| | - George Adams
- Department of Haematology, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Anna L David
- Elizabeth Garrett Anderson Institute for Women's Health, University College London, London, United Kingdom
| | - Katarzyna Maksym
- Elizabeth Garrett Anderson Institute for Women's Health, University College London, London, United Kingdom
| | - Marie Scully
- Department of Clinical Haematology, University College London Hospitals NHS Foundation Trust, London, United Kingdom; National Institute for Health and Care Research University College London Hospital/University College London Biomedical Research Centre, London, United Kingdom
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11
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Wacks M, Wortley E, Gregorowski A, Segal TY, Whittaker E. Fifteen-minute consultation: Managing post-COVID-19 syndrome (long COVID) in children and young people. Arch Dis Child Educ Pract Ed 2024; 109:29-34. [PMID: 37080731 DOI: 10.1136/archdischild-2022-324950] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 02/28/2023] [Indexed: 04/22/2023]
Abstract
Post-COVID-19 syndrome is a new condition that can have a major impact on the physical and mental well-being of children and young people, affecting their ability to access activities including education. Paediatricians and general practitioners need to be able to assess and manage patients with this condition; making the diagnosis, excluding serious pathology, managing comorbidities and accessing appropriate management are crucial. This 15 minute consultation presents an approach to history taking, examination, investigations, management principles and referrals.
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Affiliation(s)
| | - Elizabeth Wortley
- Paediatrics, University College London Hospitals NHS Foundation Trust, London, UK
| | - Anna Gregorowski
- Paediatric and Adolescent Department, University College London Hospitals NHS Foundation Trust, London, UK
| | - Terry Y Segal
- Paediatrics, University College London Hospitals NHS Foundation Trust, London, UK
| | - Elizabeth Whittaker
- Paediatric Infectious Diseases, Imperial College Healthcare NHS Trust, London, UK
- Section of Paediatric Infectious Diseases, Imperial College, London, UK
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12
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Johnston R, Sonnappa S, Goddings AL, Whittaker E, Segal TY. A review of post COVID syndrome pathophysiology, clinical presentation and management in children and young people. Paediatr Respir Rev 2024:S1526-0542(24)00003-4. [PMID: 38423894 DOI: 10.1016/j.prrv.2024.01.002] [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: 01/15/2024] [Accepted: 01/15/2024] [Indexed: 03/02/2024]
Abstract
Post Covid Syndrome (PCS) is a complex multi-system disorder with a spectrum of presentations. Severity ranges from mild to very severe with variable duration of illness and recovery. This paper discusses the difficulties defining and describing PCS. We review the current understanding of PCS, epidemiology, and predisposing factors. We consider potential mechanisms including viral persistence, clotting dysfunction and immunity. We review presentation and diagnosis and finally consider management strategies including addressing symptom burden, rehabilitation, and novel therapies.
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Affiliation(s)
- Rebecca Johnston
- Paediatric and Adolescent Division, University College London Hospitals NHS Foundation Trust, London, UK
| | - Samatha Sonnappa
- Department of Paediatric Respiratory Medicine, Royal Brompton Hospital, London, UK
| | - Anne-Lise Goddings
- Paediatric and Adolescent Division, University College London Hospitals NHS Foundation Trust, London, UK; UCL Great Ormond Street Institute of Child Health, London, UK
| | - Elizabeth Whittaker
- Department of Paediatric Infectious Diseases, Imperial College Healthcare NHS Trust, UK; Section of Paediatric Infectious Diseases, Imperial College London, UK
| | - Terry Y Segal
- Paediatric and Adolescent Division, University College London Hospitals NHS Foundation Trust, London, UK.
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13
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Constantinescu-Bercu A, Lobiuc A, Căliman-Sturdza OA, Oiţă RC, Iavorschi M, Pavăl NE, Șoldănescu I, Dimian M, Covasa M. Long COVID: Molecular Mechanisms and Detection Techniques. Int J Mol Sci 2023; 25:408. [PMID: 38203577 PMCID: PMC10778767 DOI: 10.3390/ijms25010408] [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: 11/28/2023] [Revised: 12/25/2023] [Accepted: 12/26/2023] [Indexed: 01/12/2024] Open
Abstract
Long COVID, also known as post-acute sequelae of SARS-CoV-2 infection (PASC), has emerged as a significant health concern following the COVID-19 pandemic. Molecular mechanisms underlying the occurrence and progression of long COVID include viral persistence, immune dysregulation, endothelial dysfunction, and neurological involvement, and highlight the need for further research to develop targeted therapies for this condition. While a clearer picture of the clinical symptomatology is shaping, many molecular mechanisms are yet to be unraveled, given their complexity and high level of interaction with other metabolic pathways. This review summarizes some of the most important symptoms and associated molecular mechanisms that occur in long COVID, as well as the most relevant molecular techniques that can be used in understanding the viral pathogen, its affinity towards the host, and the possible outcomes of host-pathogen interaction.
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Affiliation(s)
- Adela Constantinescu-Bercu
- Department of Biomedical Sciences, Faculty of Medicine and Biological Sciences, “Ştefan cel Mare” University of Suceava, 720229 Suceava, Romania; (A.C.-B.); (O.A.C.-S.); (M.I.); (N.-E.P.); (M.C.)
| | - Andrei Lobiuc
- Department of Biomedical Sciences, Faculty of Medicine and Biological Sciences, “Ştefan cel Mare” University of Suceava, 720229 Suceava, Romania; (A.C.-B.); (O.A.C.-S.); (M.I.); (N.-E.P.); (M.C.)
| | - Olga Adriana Căliman-Sturdza
- Department of Biomedical Sciences, Faculty of Medicine and Biological Sciences, “Ştefan cel Mare” University of Suceava, 720229 Suceava, Romania; (A.C.-B.); (O.A.C.-S.); (M.I.); (N.-E.P.); (M.C.)
- Suceava Emergency Clinical County Hospital, 720224 Suceava, Romania
| | - Radu Cristian Oiţă
- Integrated Center for Research, Development and Innovation for Advanced Materials, Nanotechnologies, Manufacturing and Control Distributed Systems (MANSiD), Ştefan cel Mare University of Suceava, 720229 Suceava, Romania; (R.C.O.); (I.Ș.); (M.D.)
| | - Monica Iavorschi
- Department of Biomedical Sciences, Faculty of Medicine and Biological Sciences, “Ştefan cel Mare” University of Suceava, 720229 Suceava, Romania; (A.C.-B.); (O.A.C.-S.); (M.I.); (N.-E.P.); (M.C.)
| | - Naomi-Eunicia Pavăl
- Department of Biomedical Sciences, Faculty of Medicine and Biological Sciences, “Ştefan cel Mare” University of Suceava, 720229 Suceava, Romania; (A.C.-B.); (O.A.C.-S.); (M.I.); (N.-E.P.); (M.C.)
| | - Iuliana Șoldănescu
- Integrated Center for Research, Development and Innovation for Advanced Materials, Nanotechnologies, Manufacturing and Control Distributed Systems (MANSiD), Ştefan cel Mare University of Suceava, 720229 Suceava, Romania; (R.C.O.); (I.Ș.); (M.D.)
| | - Mihai Dimian
- Integrated Center for Research, Development and Innovation for Advanced Materials, Nanotechnologies, Manufacturing and Control Distributed Systems (MANSiD), Ştefan cel Mare University of Suceava, 720229 Suceava, Romania; (R.C.O.); (I.Ș.); (M.D.)
- Department of Computers, Electronics and Automation, Ştefan cel Mare University of Suceava, 720229 Suceava, Romania
| | - Mihai Covasa
- Department of Biomedical Sciences, Faculty of Medicine and Biological Sciences, “Ştefan cel Mare” University of Suceava, 720229 Suceava, Romania; (A.C.-B.); (O.A.C.-S.); (M.I.); (N.-E.P.); (M.C.)
- Department of Basic Medical Sciences, College of Osteopathic Medicine, Western University of Health Sciences, Pomona, CA 91711, USA
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14
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Koleničová V, Vňuková MS, Anders M, Fišerová M, Raboch J, Ptáček R. A Review Article on Exercise Intolerance in Long COVID: Unmasking the Causes and Optimizing Treatment Strategies. Med Sci Monit 2023; 29:e941079. [PMID: 37897034 PMCID: PMC10619330 DOI: 10.12659/msm.941079] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 07/20/2023] [Indexed: 10/29/2023] Open
Abstract
There is a growing body of research on SARS-CoV-2 (PASC), previously known as the post-COVID syndrome, a chronic condition characterized by symptoms that persist after SARS-CoV-2 infection. Among these symptoms, feelings of physical exhaustion and prolonged fatigue are particularly prevalent and can significantly impact patients' quality of life. These symptoms are associated with reduced overall physical capacity, decreased daily physical activity, malaise after intense training, and intolerance to physical activity (IFA). IFA, described as a reduced ability to perform physical activities typical for the patient's age, can often lead to a sedentary lifestyle. Prolonged physical inactivity can cause deterioration in the overall physical condition and disrupt mitochondrial function, triggering a vicious cycle of gradual symptom worsening. The underlying causes of PASC remain unclear; however, several biochemical mechanisms have been discussed to explain the body's energy depletion, and a multidisciplinary approach that combines physical and cognitive rehabilitation and lifestyle interventions such as exercise and diet modifications has been suggested to improve the overall health and well-being of PASC patients. This critical review aims to review the existing research on the possible causes and links among chronic fatigue, reduced physical activity, and exercise intolerance in patients with PASC. Further research into the underlying causes and treatment of PASC and the importance of developing individualized treatment is needed to address each patient's unique health requirements.
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15
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Connors JM, Ariëns RAS. Uncertainties about the roles of anticoagulation and microclots in postacute sequelae of severe acute respiratory syndrome coronavirus 2 infection. J Thromb Haemost 2023; 21:2697-2701. [PMID: 37495081 DOI: 10.1016/j.jtha.2023.07.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 07/13/2023] [Accepted: 07/14/2023] [Indexed: 07/28/2023]
Abstract
Three years after the start of the pandemic, approaches to the prevention and treatment of acute COVID-19 have been established. However, postacute sequelae of SARS-CoV-2 infection (PASC) is now the focus of current investigations searching for the etiology of the symptoms and developing diagnostic and treatment strategies, as up to 10% of those with acute COVID-19 will go on to develop PASC, a significant public health burden. Some have suggested that ongoing microvascular thrombosis and microclots may play a role in the persistent sequelae of COVID-19 infection. Treatments are being given to address the presumed role of thrombosis in PASC, and some suggest that randomized controlled trials of anticoagulants in patients with PASC should be performed. In this Forum article, we focus on findings from patients with PASC that have led to the suggestion of using anticoagulants and discuss alternative considerations.
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Affiliation(s)
- Jean M Connors
- Hematology Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.
| | - Robert A S Ariëns
- Discovery and Translational Science Department, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, UK
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16
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Altmann DM, Whettlock EM, Liu S, Arachchillage DJ, Boyton RJ. The immunology of long COVID. Nat Rev Immunol 2023; 23:618-634. [PMID: 37433988 DOI: 10.1038/s41577-023-00904-7] [Citation(s) in RCA: 113] [Impact Index Per Article: 113.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/02/2023] [Indexed: 07/13/2023]
Abstract
Long COVID is the patient-coined term for the disease entity whereby persistent symptoms ensue in a significant proportion of those who have had COVID-19, whether asymptomatic, mild or severe. Estimated numbers vary but the assumption is that, of all those who had COVID-19 globally, at least 10% have long COVID. The disease burden spans from mild symptoms to profound disability, the scale making this a huge, new health-care challenge. Long COVID will likely be stratified into several more or less discrete entities with potentially distinct pathogenic pathways. The evolving symptom list is extensive, multi-organ, multisystem and relapsing-remitting, including fatigue, breathlessness, neurocognitive effects and dysautonomia. A range of radiological abnormalities in the olfactory bulb, brain, heart, lung and other sites have been observed in individuals with long COVID. Some body sites indicate the presence of microclots; these and other blood markers of hypercoagulation implicate a likely role of endothelial activation and clotting abnormalities. Diverse auto-antibody (AAB) specificities have been found, as yet without a clear consensus or correlation with symptom clusters. There is support for a role of persistent SARS-CoV-2 reservoirs and/or an effect of Epstein-Barr virus reactivation, and evidence from immune subset changes for broad immune perturbation. Thus, the current picture is one of convergence towards a map of an immunopathogenic aetiology of long COVID, though as yet with insufficient data for a mechanistic synthesis or to fully inform therapeutic pathways.
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Affiliation(s)
- Daniel M Altmann
- Department of Immunology and Inflammation, Imperial College London, Hammersmith Hospital, London, UK.
| | - Emily M Whettlock
- Department of Infectious Disease, Imperial College London, Hammersmith Hospital, London, UK
| | - Siyi Liu
- Department of Immunology and Inflammation, Imperial College London, Hammersmith Hospital, London, UK
- Department of Infectious Disease, Imperial College London, Hammersmith Hospital, London, UK
| | - Deepa J Arachchillage
- Centre for Haematology, Department of Immunology and Inflammation, Imperial College London, Hammersmith Hospital, London, UK
- Department of Haematology, Imperial College Healthcare NHS Trust, London, UK
| | - Rosemary J Boyton
- Department of Infectious Disease, Imperial College London, Hammersmith Hospital, London, UK
- Lung Division, Royal Brompton and Harefield Hospitals, Guy's and St Thomas' NHS Foundation Trust, London, UK
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17
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Greistorfer T, Jud P. Pathophysiological Aspects of COVID-19-Associated Vasculopathic Diseases. Thromb Haemost 2023; 123:931-944. [PMID: 37172941 DOI: 10.1055/s-0043-1768969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Abstract
Since the beginning of coronavirus disease 2019 (COVID-19) pandemic, numerous data reported potential effects on the cardiovascular system due to infection by severe acute respiratory syndrome-coronavirus 2 (SARS-CoV-2), which may lead to COVID-19-associated vasculopathies during the acute phase and measurable vascular changes in the convalescent phase. Infection by SARS-CoV-2 seems to have specific direct and indirect effects on the endothelium, immune and coagulation systems thus promoting endothelial dysfunction, immunothrombosis, and formation of neutrophil extracellular traps although the exact mechanisms still need to be elucidated. This review represents a recent update of pathophysiological pathways of the respective three major mechanisms contributing to COVID-19 vasculopathies and vascular changes and includes clinical implications and significance of outcome data.
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Affiliation(s)
- Thiemo Greistorfer
- Division of Angiology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Philipp Jud
- Division of Angiology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
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18
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Hawley HB. Long COVID: Clinical Findings, Pathology, and Endothelial Molecular Mechanisms. Am J Med 2023:S0002-9343(23)00539-9. [PMID: 37704072 DOI: 10.1016/j.amjmed.2023.08.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 05/29/2023] [Accepted: 08/08/2023] [Indexed: 09/15/2023]
Abstract
Persistence of COVID-19 symptoms may follow severe acute respiratory syndrome coronavirus 2 infection. The incidence of long COVID increases with the severity of acute disease, but even mild disease can be associated with sequelae. The symptoms vary widely, with fatigue, shortness of breath, and cognitive dysfunction the most common. Abnormalities of multiple organs have been documented, and histopathology has revealed widespread microthrombi. Elevated levels of complement are present in acute COVID-19 patients and may persist at lower levels in long COVID. Evidence supports complement activation, with endotheliopathy-associated disease as the molecular mechanism causing both acute and long COVID.
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Affiliation(s)
- H Bradford Hawley
- Department of Medicine, Wright State University Boonshoft School of Medicine, Dayton, Ohio.
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19
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Nicolai L, Kaiser R, Stark K. Thromboinflammation in long COVID-the elusive key to postinfection sequelae? J Thromb Haemost 2023; 21:2020-2031. [PMID: 37178769 PMCID: PMC10174338 DOI: 10.1016/j.jtha.2023.04.039] [Citation(s) in RCA: 19] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 03/18/2023] [Accepted: 04/10/2023] [Indexed: 05/15/2023]
Abstract
Long COVID is a public health emergency affecting millions of people worldwide, characterized by heterogeneous symptoms across multiple organ systems. Here, we discuss the current evidence linking thromboinflammation to postacute sequelae of COVID-19. Studies have found persistence of vascular damage with increased circulating markers of endothelial dysfunction, coagulation abnormalities with heightened thrombin generation capacity, and abnormalities in platelet counts in postacute sequelae of COVID-19. Neutrophil phenotype resembles acute COVID-19 with an increase in activation and Neutrophil Extracellular Trap formation. These insights are potentially linked by elevated platelet-neutrophil aggregate formation. This hypercoagulable state in turn can lead to microvascular thrombosis, evidenced by microclots and elevated D-dimer in the circulation as well as perfusion abnormalities in the lungs and brains of patients with long COVID. Also, COVID-19 survivors experience an increased rate of arterial and venous thrombotic events. We discuss 3 important, potentially intertwined hypotheses that might contribute to thromboinflammation in long COVID: lasting structural changes, most prominently endothelial damage, caused during initial infection; a persistent viral reservoir; and immunopathology driven by a misguided immune system. Finally, we outline the necessity for large, well-characterized clinical cohorts and mechanistic studies to clarify the contribution of thromboinflammation to long COVID.
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Affiliation(s)
- Leo Nicolai
- Department of Medicine I, University Hospital, LMU Munich, Munich, Germany; DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance, Germany.
| | - Rainer Kaiser
- Department of Medicine I, University Hospital, LMU Munich, Munich, Germany; DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance, Germany
| | - Konstantin Stark
- Department of Medicine I, University Hospital, LMU Munich, Munich, Germany; DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance, Germany
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Boccatonda A, Campello E, Simion C, Simioni P. Long-term hypercoagulability, endotheliopathy and inflammation following acute SARS-CoV-2 infection. Expert Rev Hematol 2023; 16:1035-1048. [PMID: 38018136 DOI: 10.1080/17474086.2023.2288154] [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: 07/06/2023] [Accepted: 11/22/2023] [Indexed: 11/30/2023]
Abstract
INTRODUCTION both symptomatic and asymptomatic SARS-CoV-2 infections - coined Coronavirus disease 2019 (COVID-19) - have been linked to a higher risk of cardiovascular events after recovery. AREAS COVERED our review aims to summarize the latest evidence on the increased thrombotic and cardiovascular risk in recovered COVID-19 patients and to examine the pathophysiological mechanisms underlying the interplay among endothelial dysfunction, inflammatory response and coagulation in long-COVID. We performed a systematic search of studies on hypercoagulability, endothelial dysfunction and inflammation after SARS-CoV-2 infection. EXPERT OPINION endothelial dysfunction is a major pathophysiological mechanism responsible for most clinical manifestations in COVID-19. The pathological activation of endothelial cells by a virus infection results in a pro-adhesive and chemokine-secreting phenotype, which in turn promotes the recruitment of circulating leukocytes. Cardiovascular events after COVID-19 appear to be related to persistent immune dysregulation. Patients with long-lasting symptoms display higher amounts of proinflammatory molecules such as tumor necrosis factor-α, interferon γ and interleukins 2 and 6. Immune dysregulation can trigger the activation of the coagulation pathway. The formation of extensive microclots in vivo, both during acute COVID-19 and in long-COVID-19, appears to be a relevant mechanism responsible for persistent symptoms and cardiovascular events.
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Affiliation(s)
- Andrea Boccatonda
- Internal Medicine, Bentivoglio Hospital, AUSL Bologna, Bentivoglio, Italy
| | - Elena Campello
- General Medicine and Thrombotic and Hemorrhagic Diseases Unit, Department of Medicine, University Hospital of Padova, Padova, Italy
| | - Chiara Simion
- General Medicine and Thrombotic and Hemorrhagic Diseases Unit, Department of Medicine, University Hospital of Padova, Padova, Italy
| | - Paolo Simioni
- General Medicine and Thrombotic and Hemorrhagic Diseases Unit, Department of Medicine, University Hospital of Padova, Padova, Italy
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21
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Wang S, Farland LV, Gaskins AJ, Mortazavi J, Wang YX, Tamimi RM, Rich-Edwards JW, Zhang D, Terry KL, Chavarro JE, Missmer SA. Association of laparoscopically-confirmed endometriosis with long COVID-19: a prospective cohort study. Am J Obstet Gynecol 2023; 228:714.e1-714.e13. [PMID: 36972892 PMCID: PMC10101545 DOI: 10.1016/j.ajog.2023.03.030] [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: 11/04/2022] [Revised: 02/07/2023] [Accepted: 03/20/2023] [Indexed: 03/29/2023]
Abstract
BACKGROUND Women are at greater risk than men of developing chronic inflammatory conditions and "long COVID." However, few gynecologic health risk factors for long COVID-19 have been identified. Endometriosis is a common gynecologic disorder associated with chronic inflammation, immune dysregulation, and comorbid presentation with autoimmune and clotting disorders, all of which are pathophysiological mechanisms proposed for long COVID-19. Therefore, we hypothesized that women with a history of endometriosis may be at greater risk of developing long COVID-19. OBJECTIVE This study aimed to investigate the association between history of endometriosis before SARS-CoV-2 infection and risk of long COVID-19. STUDY DESIGN We followed 46,579 women from 2 ongoing prospective cohort studies-the Nurses' Health Study II and the Nurses' Health Study 3-who participated in a series of COVID-19-related surveys administered from April 2020 to November 2022. Laparoscopic diagnosis of endometriosis was documented prospectively in main cohort questionnaires before the pandemic (1993-2020) with high validity. SARS-CoV-2 infection (confirmed by antigen, polymerase chain reaction, or antibody test) and long-term COVID-19 symptoms (≥4 weeks) defined by the Centers for Disease Control and Prevention were self-reported during follow-up. Among individuals with SARS-CoV-2 infection, we fit Poisson regression models to assess the associations between endometriosis and risk of long COVID-19 symptoms, with adjustment for potential confounding variables (demographics, body mass index, smoking status, history of infertility, and history of chronic diseases). RESULTS Among 3650 women in our sample with self-reported SARS-CoV-2 infections during follow-up, 386 (10.6%) had a history of endometriosis with laparoscopic confirmation, and 1598 (43.8%) reported experiencing long COVID-19 symptoms. Most women were non-Hispanic White (95.4%), with a median age of 59 years (interquartile range, 44-65). Women with a history of laparoscopically-confirmed endometriosis had a 22% greater risk of developing long COVID-19 (adjusted risk ratio, 1.22; 95% confidence interval, 1.05-1.42) compared with those who had never been diagnosed with endometriosis. The association was stronger when we defined long COVID-19 as having symptoms for ≥8 weeks (risk ratio, 1.28; 95% confidence interval, 1.09-1.50). We observed no statistically significant differences in the relationship between endometriosis and long COVID-19 by age, infertility history, or comorbidity with uterine fibroids, although there was a suggestive trend indicating that the association may be stronger in women aged <50 years (<50 years: risk ratio, 1.37; 95% confidence interval, 1.00-1.88; ≥50 years: risk ratio, 1.19; 95% confidence interval, 1.01-1.41). Among persons who developed long COVID-19, women with endometriosis reported on average 1 additional long-term symptom compared with women without endometriosis. CONCLUSION Our findings suggest that those with a history of endometriosis may be at modestly increased risk for long COVID-19. Healthcare providers should be aware of endometriosis history when treating patients for signs of persisting symptoms after SARS-CoV-2 infection. Future studies should investigate the potential biological pathways underlying these associations.
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Affiliation(s)
- Siwen Wang
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA.
| | - Leslie V Farland
- Department of Epidemiology and Biostatistics, Mel and Enid Zuckerman College of Public Health, The University of Arizona, Tucson, AZ
| | - Audrey J Gaskins
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Jasmine Mortazavi
- Department of Obstetrics, Gynecology and Reproductive Biology, College of Human Medicine, Michigan State University, Grand Rapids, MI
| | - Yi-Xin Wang
- Department of Environmental Health, Harvard T.H. Chan School of Public Health, Boston, MA
| | - Rulla M Tamimi
- Population Health Sciences, Weill Cornell Medicine, New York, NY
| | - Janet W Rich-Edwards
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA; Division of Women's Health, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Dan Zhang
- Women's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Kathryn L Terry
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA; Department of Obstetrics, Gynecology, and Reproductive Biology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Jorge E Chavarro
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA; Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA
| | - Stacey A Missmer
- Department of Obstetrics, Gynecology and Reproductive Biology, College of Human Medicine, Michigan State University, Grand Rapids, MI
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22
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Vassiliou AG, Vrettou CS, Keskinidou C, Dimopoulou I, Kotanidou A, Orfanos SE. Endotheliopathy in Acute COVID-19 and Long COVID. Int J Mol Sci 2023; 24:8237. [PMID: 37175942 PMCID: PMC10179170 DOI: 10.3390/ijms24098237] [Citation(s) in RCA: 20] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 04/28/2023] [Accepted: 04/30/2023] [Indexed: 05/15/2023] Open
Abstract
The pulmonary endothelium is a highly regulated organ that performs a wide range of functions under physiological and pathological conditions. Since endothelial dysfunction has been demonstrated to play a direct role in sepsis and acute respiratory distress syndrome, its role in COVID-19 has also been extensively investigated. Indeed, apart from the COVID-19-associated coagulopathy biomarkers, new biomarkers were recognised early during the pandemic, including markers of endothelial cell activation or injury. We systematically searched the literature up to 10 March 2023 for studies examining the association between acute and long COVID-19 severity and outcomes and endothelial biomarkers.
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Affiliation(s)
- Alice G. Vassiliou
- First Department of Critical Care Medicine & Pulmonary Services, School of Medicine, National and Kapodistrian University of Athens, Evangelismos Hospital, 106 76 Athens, Greece; (C.S.V.); (C.K.); (I.D.); (A.K.)
| | | | | | | | | | - Stylianos E. Orfanos
- First Department of Critical Care Medicine & Pulmonary Services, School of Medicine, National and Kapodistrian University of Athens, Evangelismos Hospital, 106 76 Athens, Greece; (C.S.V.); (C.K.); (I.D.); (A.K.)
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23
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van den Berg J, Haslbauer JD, Stalder AK, Romanens A, Mertz KD, Studt JD, Siegemund M, Buser A, Holbro A, Tzankov A. Von Willebrand factor and the thrombophilia of severe COVID-19: in situ evidence from autopsies. Res Pract Thromb Haemost 2023; 7:100182. [PMID: 37333991 PMCID: PMC10192064 DOI: 10.1016/j.rpth.2023.100182] [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: 10/13/2022] [Revised: 04/29/2023] [Accepted: 05/08/2023] [Indexed: 06/20/2023] Open
Abstract
Background COVID-19 is accompanied by a hypercoagulable state and characterized by microvascular and macrovascular thrombotic complications. In plasma samples from patients with COVID-19, von Willebrand factor (VWF) levels are highly elevated and predictive of adverse outcomes, especially mortality. Yet, VWF is usually not included in routine coagulation analyses, and histologic evidence of its involvement in thrombus formation is lacking. Objectives To determine whether VWF, an acute-phase protein, is a bystander, ie, a biomarker of endothelial dysfunction, or a causal factor in the pathogenesis of COVID-19. Methods We compared autopsy samples from 28 patients with lethal COVID-19 to those from matched controls and systematically assessed for VWF and platelets by immunohistochemistry. The control group comprised 24 lungs, 23 lymph nodes, and 9 hearts and did not differ significantly from the COVID-19 group in age, sex, body mass index (BMI), blood group, or anticoagulant use. Results In lungs, assessed for platelets by immunohistochemistry for CD42b, microthrombi were more frequent in patients with COVID-19 (10/28 [36%] vs 2/24 [8%]; P = .02). A completely normal pattern of VWF was rare in both groups. Accentuated endothelial staining was found in controls, while VWF-rich thrombi were only found in patients with COVID-19 (11/28 [39%] vs 0/24 [0%], respectively; P < .01), as were NETosis thrombi enriched with VWF (7/28 [25%] vs 0/24 [0%], respectively; P < .01). Forty-six percent of the patients with COVID-19 had VWF-rich thrombi, NETosis thrombi, or both. Trends were also seen in pulmonary draining lymph nodes (7/20 [35%] vs 4/24 [17%]; P = .147), where the overall presence of VWF was very high. Conclusion We provide in situ evidence of VWF-rich thrombi, likely attributable to COVID-19, and suggest that VWF may be a therapeutic target in severe COVID-19.
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Affiliation(s)
- Jana van den Berg
- Department of Hematology, University Hospital Basel, Basel, Switzerland
| | - Jasmin D Haslbauer
- Department of Pathology, Institute of Medical Genetics and Pathology, University Hospital Basel, Basel, Switzerland
- Department of Pathology, Cantonal Hospital Baselland, Liestal, Switzerland
| | - Anna K Stalder
- Department of Pathology, Institute of Medical Genetics and Pathology, University Hospital Basel, Basel, Switzerland
| | - Anna Romanens
- Department of Oncology, Cantonal Hospital Baselland, Liestal, Switzerland
| | - Kirsten D Mertz
- Department of Pathology, Cantonal Hospital Baselland, Liestal, Switzerland
| | - Jan-Dirk Studt
- Department of Medical Oncology and Hematology, University Hospital Zürich, Zürich, Switzerland
| | - Martin Siegemund
- Intensive Care Unit, Department of Acute Medicine, University Hospital, Basel, Switzerland
| | - Andreas Buser
- Department of Hematology, University Hospital Basel, Basel, Switzerland
- Regional Blood Transfusion Service, Swiss Red Cross, Basel, Switzerland
| | - Andreas Holbro
- Department of Hematology, University Hospital Basel, Basel, Switzerland
- Regional Blood Transfusion Service, Swiss Red Cross, Basel, Switzerland
| | - Alexandar Tzankov
- Department of Pathology, Institute of Medical Genetics and Pathology, University Hospital Basel, Basel, Switzerland
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24
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Wang S, Huang T, Weisskopf MG, Kang JH, Chavarro JE, Roberts AL. Multidimensional Sleep Health Prior to SARS-CoV-2 Infection and Risk of Post-COVID-19 Condition. JAMA Netw Open 2023; 6:e2315885. [PMID: 37252741 PMCID: PMC10230315 DOI: 10.1001/jamanetworkopen.2023.15885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Accepted: 04/15/2023] [Indexed: 05/31/2023] Open
Abstract
Importance The association of multiple healthy sleep dimensions with post-COVID-19 condition (PCC), also known as long COVID, has not been investigated. Objective To examine whether multidimensional sleep health before and during the COVID-19 pandemic, prior to SARS-CoV-2 infection, was associated with the risk of PCC. Design, Setting, and Participants This prospective cohort study (2015-2021) included Nurses' Health Study II participants who reported testing positive (n = 2303) for SARS-CoV-2 infection in a substudy series of COVID-19-related surveys (n = 32 249) between April 2020 and November 2021. After exclusion for incomplete information about sleep health and nonresponse to a question about PCC, 1979 women were included in the analysis. Exposures Sleep health was measured both before (June 1, 2015, to May 31, 2017) and early (April 1 to August 31, 2020) in the COVID-19 pandemic. Prepandemic sleep score was defined according to 5 dimensions: morning chronotype (assessed in 2015), 7 to 8 hours of sleep per day, low insomnia symptoms, no snoring, and no frequent daytime dysfunction (all assessed in 2017). On the first COVID-19 substudy survey (returned between April and August 2020), average daily sleep duration and sleep quality for the past 7 days were queried. Main Outcomes and Measures SARS-CoV-2 infection and PCC (≥4 weeks of symptoms) were self-reported during 1 year of follow-up. Comparisons were examined between June 8, 2022, and January 9, 2023, using Poisson regression models. Results Of the 1979 participants reporting SARS-CoV-2 infection (mean [SD] age, 64.7 [4.6] years; 1979 [100%] female; and 1924 [97.2%] White vs 55 [2.8%] other races and ethnicities), 845 (42.7%) were frontline health care workers, and 870 (44.0%) developed PCC. Compared with women who had a prepandemic sleep score of 0 or 1 (least healthy), those who scored 5 (most healthy) had a 30% lower risk of developing PCC (multivariable-adjusted relative risk, 0.70; 95% CI, 0.52-0.94; P for trend <.001). Associations did not differ by health care worker status. No or little daytime dysfunction prepandemic and good sleep quality during the pandemic were independently associated with a lower risk of PCC (relative risk, 0.83 [95% CI, 0.71-0.98] and 0.82 [95% CI, 0.69-0.99], respectively). Results were similar when PCC was defined as having 8 or more weeks of symptoms or as having ongoing symptoms at the time of PCC assessment. Conclusions and Relevance The findings indicate that healthy sleep measured prior to SARS-CoV-2 infection, both before and during the COVID-19 pandemic, may be protective against PCC. Future research should investigate whether interventions on sleep health may prevent PCC or improve PCC symptoms.
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Affiliation(s)
- Siwen Wang
- Department of Nutrition, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Tianyi Huang
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Marc G. Weisskopf
- Department of Environmental Health, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Jae H. Kang
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Jorge E. Chavarro
- Department of Nutrition, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
- Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Andrea L. Roberts
- Department of Environmental Health, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
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25
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Van der Feltz-Cornelis CM, Moriarty AS, Strain WD. Neurological Dysfunction in Long COVID Should Not Be Labelled as Functional Neurological Disorder. Viruses 2023; 15:783. [PMID: 36992491 PMCID: PMC10059786 DOI: 10.3390/v15030783] [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: 03/01/2023] [Accepted: 03/17/2023] [Indexed: 03/22/2023] Open
Abstract
There have been suggestions that Long COVID might be purely functional (meaning psychological) in origin. Labelling patients with neurological dysfunction in Long COVID as having functional neurological disorder (FND) in the absence of proper testing may be symptomatic of that line of thought. This practice is problematic for Long COVID patients, as motor and balance symptoms have been reported to occur in Long COVID frequently. FND is characterized by the presentation of symptoms that seem neurological but lack compatibility of the symptom with a neurological substrate. Although diagnostic classification according to the ICD-11 and DSM-5-TR is dependent predominantly on the exclusion of any other medical condition that could account for the symptoms, current neurological practice of FND classification allows for such comorbidity. As a consequence, Long COVID patients with motor and balance symptoms mislabeled as FND have no longer access to Long COVID care, whereas treatment for FND is seldom provided and is ineffective. Research into underlying mechanisms and diagnostic methods should explore how to determine whether motor and balance symptoms currently diagnosed as FND should be considered one part of Long COVID symptoms, in other words, one component of symptomatology, and in which cases they correctly represent FND. Research into rehabilitation models, treatment and integrated care are needed, which should take into account biological underpinnings as well as possible psychological mechanisms and the patient perspective.
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Affiliation(s)
| | - Andrew S. Moriarty
- Department of Health Sciences, Hull York Medical School, (HYMS), University of York, York YO10 5DD, UK
| | - William David Strain
- Diabetes and Vascular Medicine Research Centre, Institute of Biomedical and Clinical Science, College of Medicine and Health, University of Exeter, Exeter EX2 5AX, UK
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26
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Wang S, Li Y, Yue Y, Yuan C, Kang JH, Chavarro JE, Bhupathiraju SN, Roberts AL. Adherence to Healthy Lifestyle Prior to Infection and Risk of Post-COVID-19 Condition. JAMA Intern Med 2023; 183:232-241. [PMID: 36745445 PMCID: PMC9989904 DOI: 10.1001/jamainternmed.2022.6555] [Citation(s) in RCA: 25] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Accepted: 12/04/2022] [Indexed: 02/07/2023]
Abstract
Importance Few modifiable risk factors for post-COVID-19 condition (PCC) have been identified. Objective To investigate the association between healthy lifestyle factors prior to SARS-CoV-2 infection and risk of PCC. Design, Setting, and Participants In this prospective cohort study, 32 249 women in the Nurses' Health Study II cohort reported preinfection lifestyle habits in 2015 and 2017. Healthy lifestyle factors included healthy body mass index (BMI, 18.5-24.9; calculated as weight in kilograms divided by height in meters squared), never smoking, at least 150 minutes per week of moderate to vigorous physical activity, moderate alcohol intake (5 to 15 g/d), high diet quality (upper 40% of Alternate Healthy Eating Index-2010 score), and adequate sleep (7 to 9 h/d). Main Outcomes and Measures SARS-CoV-2 infection (confirmed by test) and PCC (at least 4 weeks of symptoms) were self-reported on 7 periodic surveys administered from April 2020 to November 2021. Among participants with SARS-CoV-2 infection, the relative risk (RR) of PCC in association with the number of healthy lifestyle factors (0 to 6) was estimated using Poisson regression and adjusting for demographic factors and comorbidities. Results A total of 1981 women with a positive SARS-CoV-2 test over 19 months of follow-up were documented. Among those participants, mean age was 64.7 years (SD, 4.6; range, 55-75); 97.4% (n = 1929) were White; and 42.8% (n = 848) were active health care workers. Among these, 871 (44.0%) developed PCC. Healthy lifestyle was associated with lower risk of PCC in a dose-dependent manner. Compared with women without any healthy lifestyle factors, those with 5 to 6 had 49% lower risk (RR, 0.51; 95% CI, 0.33-0.78) of PCC. In a model mutually adjusted for all lifestyle factors, BMI and sleep were independently associated with risk of PCC (BMI, 18.5-24.9 vs others, RR, 0.85; 95% CI, 0.73-1.00, P = .046; sleep, 7-9 h/d vs others, RR, 0.83; 95% CI, 0.72-0.95, P = .008). If these associations were causal, 36.0% of PCC cases would have been prevented if all participants had 5 to 6 healthy lifestyle factors (population attributable risk percentage, 36.0%; 95% CI, 14.1%-52.7%). Results were comparable when PCC was defined as symptoms of at least 2-month duration or having ongoing symptoms at the time of PCC assessment. Conclusions and Relevance In this prospective cohort study, pre-infection healthy lifestyle was associated with a substantially lower risk of PCC. Future research should investigate whether lifestyle interventions may reduce risk of developing PCC or mitigate symptoms among individuals with PCC or possibly other postinfection syndromes.
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Affiliation(s)
- Siwen Wang
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Yanping Li
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Yiyang Yue
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Changzheng Yuan
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Zhejiang University School of Public Health, Hangzhou, China
| | - Jae Hee Kang
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Jorge E. Chavarro
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Shilpa N. Bhupathiraju
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Andrea L. Roberts
- Department of Environmental Health, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
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27
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Constantinescu-Bercu A, Kessler A, de Groot R, Dragunaite B, Heightman M, Hillman T, Price LC, Brennan E, Sivera R, Vanhoorelbeke K, Singh D, Scully M. Analysis of thrombogenicity under flow reveals new insights into the prothrombotic state of patients with post-COVID syndrome. J Thromb Haemost 2023; 21:94-100. [PMID: 36695401 PMCID: PMC9773628 DOI: 10.1016/j.jtha.2022.10.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 10/10/2022] [Accepted: 10/24/2022] [Indexed: 01/11/2023]
Abstract
BACKGROUND Post-COVID syndrome (PCS) affects millions of people worldwide, causing a multitude of symptoms and impairing quality of life months or even years after acute COVID-19. A prothrombotic state has been suggested; however, underlying mechanisms remain to be elucidated. OBJECTIVES To investigate thrombogenicity in PCS using a microfluidic assay, linking microthrombi, thrombin generation, and the von Willebrand factor (VWF):a Disintegrin and Metalloproteinase with a Thrombospondin Type 1 motif, member 13 (ADAMTS13) axis. METHODS Citrated blood was perfused through microfluidic channels coated with collagen or an antibody against the VWF A3 domain, and thrombogenicity was monitored in real time. Thrombin generation assays were performed and α(2)-antiplasmin, VWF, and ADAMTS13 activity levels were also measured. RESULTS We investigated thrombogenicity in a cohort of 21 patients with PCS with a median time following symptoms onset of 23 months using a dynamic microfluidic assay. Our data show a significant increase in platelet binding on both collagen and anti-VWF A3 in patients with PCS compared with that in controls, which positively correlated with VWF antigen (Ag) levels, the VWF(Ag):ADAMTS13 ratio (on anti-VWF A3), and inversely correlated with ADAMTS13 activity (on collagen). Thrombi forming on collagen presented different geometries in patients with PCS vs controls, with significantly increased thrombi area mainly attributable to thrombi length in the patient group. Thrombi length positively correlated with VWF(Ag):ADAMTS13 ratio and thrombin generation assay results, which were increased in 55.5% of patients. α(2)-Antiplasmin levels were normal in 89.5% of patients. CONCLUSION Together, these data present a dynamic assay to investigate the prothrombotic state in PCS, which may help unravel the mechanisms involved and/or establish new therapeutic strategies for this condition.
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Affiliation(s)
- Adela Constantinescu-Bercu
- Institute of Cardiovascular Science, Haemostasis Research Unit, University College London (UCL), London, United Kingdom.
| | - Anna Kessler
- Department of Respiratory Medicine, University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | - Rens de Groot
- Institute of Cardiovascular Science, Haemostasis Research Unit, University College London (UCL), London, United Kingdom
| | - Bertina Dragunaite
- Institute of Cardiovascular Science, Haemostasis Research Unit, University College London (UCL), London, United Kingdom
| | - Melissa Heightman
- Department of Respiratory Medicine, University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | - Toby Hillman
- Department of Respiratory Medicine, University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | - Laura C Price
- Department of Respiratory Medicine, University College London Hospitals NHS Foundation Trust, London, United Kingdom; National Pulmonary Hypertension Service, Royal Brompton Hospital, London, United Kingdom
| | - Ewan Brennan
- Department of Respiratory Medicine, University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | - Raphael Sivera
- Institute of Cardiovascular Science, Haemostasis Research Unit, University College London (UCL), London, United Kingdom
| | - Karen Vanhoorelbeke
- Laboratory for Thrombosis Research, Katholieke Universiteit Leuven Campus Kulak Kortrijk, Kortrijk, Belgium
| | - Deepak Singh
- Special Coagulation, Health Services Laboratories, London, United Kingdom
| | - Marie Scully
- Institute of Cardiovascular Science, Haemostasis Research Unit, University College London (UCL), London, United Kingdom; Department of Haematology, University College London Hospitals National Health Service Foundation Trust, London, United Kingdom
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28
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Zhang Q, Ye Z, McGowan P, Jurief C, Ly A, Bignotti A, Yada N, Zheng XL. Effects of convalescent plasma infusion on the ADAMTS13-von Willebrand factor axis and endothelial integrity in patients with severe and critical COVID-19. Res Pract Thromb Haemost 2023; 7:100010. [PMID: 36531671 PMCID: PMC9744678 DOI: 10.1016/j.rpth.2022.100010] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Revised: 10/28/2022] [Accepted: 10/30/2022] [Indexed: 01/13/2023] Open
Abstract
Background Convalescent plasma infusion (CPI) was given to patients with COVID-19 during the early pandemic with mixed therapeutic efficacy. However, the impacts of CPI on the ADAMTS13-von Willebrand factor (VWF) axis and vascular endothelial functions are not known. Objectives To determine the impacts of CPI on the ADAMTS13-VWF axis and vascular endothelial functions. Methods Sixty hospitalized patients with COVID-19 were enrolled in the study; 46 received CPI and 14 received no CPI. Plasma ADAMTS13 activity, VWF antigen, endothelial syndecan-1, and soluble thrombomodulin (sTM) were assessed before and 24 hours after treatment. Results Patients with severe and critical COVID-19 exhibited significantly lower plasma ADAMTS13 activity than the healthy controls. Conversely, these patients showed a significantly increased VWF antigen. This resulted in markedly reduced ratios of ADAMTS13 to VWF in these patients. The levels of plasma ADAMTS13 activity in each patient remained relatively constant throughout hospitalization. Twenty-four hours following CPI, plasma ADAMTS13 activity increased by ∼12% from the baseline in all patients and ∼21% in those who survived. In contrast, plasma levels of VWF antigen varied significantly over time. Patients who died exhibited a significant reduction of plasma VWF antigen from the baseline 24 hours following CPI, whereas those who survived did not. Furthermore, patients with severe and critical COVID-19 showed significantly elevated plasma levels of syndecan-1 and sTM, similar to those found in patients with immune thrombotic thrombocytopenic purpura. Both syndecan-1 and sTM levels were significantly reduced 24 hours following CPI. Conclusion Our results demonstrate the relative deficiency of plasma ADAMTS13 activity and endothelial damage in patients with severe and critical COVID-19, which could be modestly improved following CPI therapy.
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Affiliation(s)
- Quan Zhang
- Department of Pathology and Laboratory Medicine, The University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Zhan Ye
- Department of Pathology and Laboratory Medicine, The University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Paul McGowan
- Department of Pathology and Laboratory Medicine, The University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Christopher Jurief
- Department of Pathology and Laboratory Medicine, The University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Andrew Ly
- Department of Pathology and Laboratory Medicine, The University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Antonia Bignotti
- Department of Pathology and Laboratory Medicine, The University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Noritaka Yada
- Department of Pathology and Laboratory Medicine, The University of Kansas Medical Center, Kansas City, Kansas, USA
| | - X. Long Zheng
- Department of Pathology and Laboratory Medicine, The University of Kansas Medical Center, Kansas City, Kansas, USA
- Institute of Reproductive and Developmental Sciences, The University of Kansas Medical Center, Kansas City, Kansas, USA
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29
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Jing H, Wu X, Xiang M, Liu L, Novakovic VA, Shi J. Pathophysiological mechanisms of thrombosis in acute and long COVID-19. Front Immunol 2022; 13:992384. [PMID: 36466841 PMCID: PMC9709252 DOI: 10.3389/fimmu.2022.992384] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Accepted: 10/27/2022] [Indexed: 08/02/2023] Open
Abstract
COVID-19 patients have a high incidence of thrombosis, and thromboembolic complications are associated with severe COVID-19 and high mortality. COVID-19 disease is associated with a hyper-inflammatory response (cytokine storm) mediated by the immune system. However, the role of the inflammatory response in thrombosis remains incompletely understood. In this review, we investigate the crosstalk between inflammation and thrombosis in the context of COVID-19, focusing on the contributions of inflammation to the pathogenesis of thrombosis, and propose combined use of anti-inflammatory and anticoagulant therapeutics. Under inflammatory conditions, the interactions between neutrophils and platelets, platelet activation, monocyte tissue factor expression, microparticle release, and phosphatidylserine (PS) externalization as well as complement activation are collectively involved in immune-thrombosis. Inflammation results in the activation and apoptosis of blood cells, leading to microparticle release and PS externalization on blood cells and microparticles, which significantly enhances the catalytic efficiency of the tenase and prothrombinase complexes, and promotes thrombin-mediated fibrin generation and local blood clot formation. Given the risk of thrombosis in the COVID-19, the importance of antithrombotic therapies has been generally recognized, but certain deficiencies and treatment gaps in remain. Antiplatelet drugs are not in combination with anticoagulant treatments, thus fail to dampen platelet procoagulant activity. Current treatments also do not propose an optimal time for anticoagulation. The efficacy of anticoagulant treatments depends on the time of therapy initiation. The best time for antithrombotic therapy is as early as possible after diagnosis, ideally in the early stage of the disease. We also elaborate on the possible mechanisms of long COVID thromboembolic complications, including persistent inflammation, endothelial injury and dysfunction, and coagulation abnormalities. The above-mentioned contents provide therapeutic strategies for COVID-19 patients and further improve patient outcomes.
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Affiliation(s)
- Haijiao Jing
- Department of Hematology, The First Hospital, Harbin Medical University, Harbin, China
| | - Xiaoming Wu
- Department of Hematology, The First Hospital, Harbin Medical University, Harbin, China
| | - Mengqi Xiang
- Department of Hematology, The First Hospital, Harbin Medical University, Harbin, China
| | - Langjiao Liu
- Department of Hematology, The First Hospital, Harbin Medical University, Harbin, China
| | - Valerie A. Novakovic
- Department of Research, VA Boston Healthcare System, Harvard Medical School, Boston, MA, United States
| | - Jialan Shi
- Department of Hematology, The First Hospital, Harbin Medical University, Harbin, China
- Department of Research, VA Boston Healthcare System, Harvard Medical School, Boston, MA, United States
- Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, United States
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30
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Fogarty H, Ward SE, Townsend L, Karampini E, Elliott S, Conlon N, Dunne J, Kiersey R, Naughton A, Gardiner M, Byrne M, Bergin C, O'Sullivan JM, Martin‐Loeches I, Nadarajan P, Bannan C, Mallon PW, Curley GF, Preston RJS, Rehill AM, Baker RI, Cheallaigh CN, O'Donnell JS. Sustained VWF-ADAMTS-13 axis imbalance and endotheliopathy in long COVID syndrome is related to immune dysfunction. J Thromb Haemost 2022; 20:2429-2438. [PMID: 35875995 PMCID: PMC9349977 DOI: 10.1111/jth.15830] [Citation(s) in RCA: 39] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 06/28/2022] [Accepted: 07/19/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Prolonged recovery is common after acute SARS-CoV-2 infection; however, the pathophysiological mechanisms underpinning Long COVID syndrome remain unknown. VWF/ADAMTS-13 imbalance, dysregulated angiogenesis, and immunothrombosis are hallmarks of acute COVID-19. We hypothesized that VWF/ADAMTS-13 imbalance persists in convalescence together with endothelial cell (EC) activation and angiogenic disturbance. Additionally, we postulate that ongoing immune cell dysfunction may be linked to sustained EC and coagulation activation. PATIENTS AND METHODS Fifty patients were reviewed at a minimum of 6 weeks following acute COVID-19. ADAMTS-13, Weibel Palade Body (WPB) proteins, and angiogenesis-related proteins were assessed and clinical evaluation and immunophenotyping performed. Comparisons were made with healthy controls (n = 20) and acute COVID-19 patients (n = 36). RESULTS ADAMTS-13 levels were reduced (p = 0.009) and the VWF-ADAMTS-13 ratio was increased in convalescence (p = 0.0004). Levels of platelet factor 4 (PF4), a putative protector of VWF, were also elevated (p = 0.0001). A non-significant increase in WPB proteins Angiopoietin-2 (Ang-2) and Osteoprotegerin (OPG) was observed in convalescent patients and WPB markers correlated with EC parameters. Enhanced expression of 21 angiogenesis-related proteins was observed in convalescent COVID-19. Finally, immunophenotyping revealed significantly elevated intermediate monocytes and activated CD4+ and CD8+ T cells in convalescence, which correlated with thrombin generation and endotheliopathy markers, respectively. CONCLUSION Our data provide insights into sustained EC activation, dysregulated angiogenesis, and VWF/ADAMTS-13 axis imbalance in convalescent COVID-19. In keeping with the pivotal role of immunothrombosis in acute COVID-19, our findings support the hypothesis that abnormal T cell and monocyte populations may be important in the context of persistent EC activation and hemostatic dysfunction during convalescence.
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Affiliation(s)
- Helen Fogarty
- Irish Centre for Vascular Biology, School of Pharmacy and Biomolecular SciencesRoyal College of Surgeons in IrelandDublinIreland
| | - Soracha E. Ward
- Irish Centre for Vascular Biology, School of Pharmacy and Biomolecular SciencesRoyal College of Surgeons in IrelandDublinIreland
| | - Liam Townsend
- Department of Infectious DiseasesSt James's HospitalDublinIreland
- Department of Clinical Medicine, School of Medicine, Trinity Translational Medicine InstituteTrinity College DublinDublinIreland
| | - Ellie Karampini
- Irish Centre for Vascular Biology, School of Pharmacy and Biomolecular SciencesRoyal College of Surgeons in IrelandDublinIreland
| | - Stephanie Elliott
- Irish Centre for Vascular Biology, School of Pharmacy and Biomolecular SciencesRoyal College of Surgeons in IrelandDublinIreland
| | - Niall Conlon
- Department of Clinical Medicine, School of Medicine, Trinity Translational Medicine InstituteTrinity College DublinDublinIreland
- Department of ImmunologySt James's HospitalDublinIreland
| | - Jean Dunne
- Department of ImmunologySt James's HospitalDublinIreland
| | - Rachel Kiersey
- Department of ImmunologySt James's HospitalDublinIreland
| | | | - Mary Gardiner
- Department of ImmunologySt James's HospitalDublinIreland
| | - Mary Byrne
- National Coagulation CentreSt James's HospitalDublinIreland
| | - Colm Bergin
- Department of Infectious DiseasesSt James's HospitalDublinIreland
- Department of Clinical Medicine, School of Medicine, Trinity Translational Medicine InstituteTrinity College DublinDublinIreland
| | - Jamie M. O'Sullivan
- Irish Centre for Vascular Biology, School of Pharmacy and Biomolecular SciencesRoyal College of Surgeons in IrelandDublinIreland
| | | | | | - Ciaran Bannan
- Department of Infectious DiseasesSt James's HospitalDublinIreland
| | - Patrick W. Mallon
- Centre for Experimental Pathogen Host ResearchUniversity College DublinDublinIreland
- St Vincent's University HospitalDublinIreland
| | - Gerard F. Curley
- Department of Anaesthesia and Critical CareRoyal College of Surgeons in IrelandDublinIreland
| | - Roger J. S. Preston
- Irish Centre for Vascular Biology, School of Pharmacy and Biomolecular SciencesRoyal College of Surgeons in IrelandDublinIreland
- National Children's Research CentreOur Lady's Children's Hospital CrumlinDublinIreland
| | - Aisling M. Rehill
- Irish Centre for Vascular Biology, School of Pharmacy and Biomolecular SciencesRoyal College of Surgeons in IrelandDublinIreland
| | - Ross I. Baker
- Western Australia Centre for Thrombosis and Haemostasis, Perth Blood InstituteMurdoch UniversityPerthWestern AustraliaAustralia
- Irish‐Australian Blood Collaborative (IABC) NetworkDublinIreland
| | - Cliona Ni Cheallaigh
- Department of Infectious DiseasesSt James's HospitalDublinIreland
- Department of Clinical Medicine, School of Medicine, Trinity Translational Medicine InstituteTrinity College DublinDublinIreland
| | - James S. O'Donnell
- Irish Centre for Vascular Biology, School of Pharmacy and Biomolecular SciencesRoyal College of Surgeons in IrelandDublinIreland
- National Coagulation CentreSt James's HospitalDublinIreland
- National Children's Research CentreOur Lady's Children's Hospital CrumlinDublinIreland
- Irish‐Australian Blood Collaborative (IABC) NetworkDublinIreland
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31
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Izzo R, Trimarco V, Mone P, Aloè T, Capra Marzani M, Diana A, Fazio G, Mallardo M, Maniscalco M, Marazzi G, Messina N, Mininni S, Mussi C, Pelaia G, Pennisi A, Santus P, Scarpelli F, Tursi F, Zanforlin A, Santulli G, Trimarco B. Combining L-Arginine with vitamin C improves long-COVID symptoms: The LINCOLN Survey. Pharmacol Res 2022; 183:106360. [PMID: 35868478 PMCID: PMC9295384 DOI: 10.1016/j.phrs.2022.106360] [Citation(s) in RCA: 37] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Revised: 07/17/2022] [Accepted: 07/18/2022] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Recent evidence suggests that oxidative stress and endothelial dysfunction play critical roles in the pathophysiology of COVID-19 and Long-COVID. We hypothesized that a supplementation combining L-Arginine (to improve endothelial function) and Vitamin C (to reduce oxidation) could have favorable effects on Long-COVID symptoms. METHODS We designed a survey (LINCOLN: L-Arginine and Vitamin C improves Long-COVID), assessing several symptoms that have been associated with Long-COVID to be administered nationwide to COVID-19 survivors; the survey also included effort perception, measured using the Borg scale. Patients receiving the survey were divided in two groups, with a 2:1 ratio: the first group included patients that received L-Arginine + Vitamin C, whereas the second group received a multivitamin combination (alternative treatment). RESULTS 1390 patients successfully completed the survey. Following a 30-day treatment in both groups, the survey revealed that patients in the L-Arginine + Vitamin C treatment arm had significantly lower scores compared to patients who had received the multivitamin combination. There were no other significant differences between the two groups. When examining effort perception, we observed a significantly lower value (p < 0.0001) in patients receiving L-Arginine + Vitamin C compared to the alternative-treatment arm. CONCLUSIONS Our survey indicates that the supplementation with L-Arginine + Vitamin C has beneficial effects in Long-COVID, in terms of attenuating its typical symptoms and improving effort perception.
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Affiliation(s)
- Raffaele Izzo
- Department of Advanced Biomedical Sciences, Federico II University, Naples, Italy
| | - Valentina Trimarco
- Department of Neuroscience, Reproductive Sciences and Dentistry, Federico II University, Naples, Italy
| | - Pasquale Mone
- Department of Medicine, Albert Einstein College of Medicine, New York, NY, USA
| | | | | | | | | | | | | | | | | | - Simone Mininni
- Associazione Scientifica Interdisciplinare Aggiornamento Medico (ASIAM), Florence, Italy
| | - Chiara Mussi
- Department of Biomedical and Metabolic Sciences and Neuroscience, University of Modena and Reggio Emilia, Modena, Italy
| | - Girolamo Pelaia
- Department of Health Science, Magna Graecia University, Catanzaro, Italy
| | | | | | | | | | | | - Gaetano Santulli
- Department of Advanced Biomedical Sciences, Federico II University, Naples, Italy; Department of Medicine, Albert Einstein College of Medicine, New York, NY, USA.
| | - Bruno Trimarco
- Department of Advanced Biomedical Sciences, Federico II University, Naples, Italy
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32
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Owen A, Patel JM, Parekh D, Bangash MN. Mechanisms of Post-critical Illness Cardiovascular Disease. Front Cardiovasc Med 2022; 9:854421. [PMID: 35911546 PMCID: PMC9334745 DOI: 10.3389/fcvm.2022.854421] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 06/22/2022] [Indexed: 11/13/2022] Open
Abstract
Prolonged critical care stays commonly follow trauma, severe burn injury, sepsis, ARDS, and complications of major surgery. Although patients leave critical care following homeostatic recovery, significant additional diseases affect these patients during and beyond the convalescent phase. New cardiovascular and renal disease is commonly seen and roughly one third of all deaths in the year following discharge from critical care may come from this cluster of diseases. During prolonged critical care stays, the immunometabolic, inflammatory and neurohumoral response to severe illness in conjunction with resuscitative treatments primes the immune system and parenchymal tissues to develop a long-lived pro-inflammatory and immunosenescent state. This state is perpetuated by persistent Toll-like receptor signaling, free radical mediated isolevuglandin protein adduct formation and presentation by antigen presenting cells, abnormal circulating HDL and LDL isoforms, redox and metabolite mediated epigenetic reprogramming of the innate immune arm (trained immunity), and the development of immunosenescence through T-cell exhaustion/anergy through epigenetic modification of the T-cell genome. Under this state, tissue remodeling in the vascular, cardiac, and renal parenchymal beds occurs through the activation of pro-fibrotic cellular signaling pathways, causing vascular dysfunction and atherosclerosis, adverse cardiac remodeling and dysfunction, and proteinuria and accelerated chronic kidney disease.
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Affiliation(s)
- Andrew Owen
- Department of Critical Care, Queen Elizabeth Hospital, University Hospitals Birmingham, Birmingham, United Kingdom
- Birmingham Acute Care Research Group, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, United Kingdom
| | - Jaimin M. Patel
- Department of Critical Care, Queen Elizabeth Hospital, University Hospitals Birmingham, Birmingham, United Kingdom
- Birmingham Acute Care Research Group, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, United Kingdom
| | - Dhruv Parekh
- Department of Critical Care, Queen Elizabeth Hospital, University Hospitals Birmingham, Birmingham, United Kingdom
- Birmingham Acute Care Research Group, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, United Kingdom
| | - Mansoor N. Bangash
- Department of Critical Care, Queen Elizabeth Hospital, University Hospitals Birmingham, Birmingham, United Kingdom
- Birmingham Acute Care Research Group, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, United Kingdom
- *Correspondence: Mansoor N. Bangash
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