High-dose intravenous immunoglobulins might modulate inflammation in COVID-19 patients

Reduction in ACE2 expression in peripheral blood mononuclear cells during COVID-19 - implications for post COVID-19 conditions

BACKGROUND

Severe COVID-19 is uncommon, restricted to 19% of the total population. In response to the first virus wave (alpha variant of SARS-CoV-2), we investigated whether a biomarker indicated severity of disease and, in particular, if variable expression of angiotensin converting enzyme 2 (ACE2) in blood might clarify this difference in risk and of post COVID -19 conditions (PCC).

METHODS

The IRB-approved study compared patients hospitalized with severe COVID-19 to healthy controls. Severe infection was defined requiring oxygen or increased oxygen need from baseline at admission with positive COVID-19 PCR. A single blood sample was obtained from patients within a day of admission. ACE2 RNA expression in blood cells was measured by an RT-PCR assay. Plasma ACE1 and ACE2 enzyme activities were quantified by fluorescent peptides. Plasma TIMP-1, PIIINP and MMP-9 antigens were quantified by ELISA. Data were entered into REDCap and analyzed using STATA v 14 and GraphPad Prism v 10.

RESULTS

Forty-eight patients and 72 healthy controls were recruited during the pandemic. ACE2 RNA expression in peripheral blood mononuclear cells (PBMC) was rarely detected acutely during severe COVID-19 but common in controls (OR for undetected ACE2: 12.4 [95% CI: 2.62-76.1]). ACE2 RNA expression in PBMC did not determine plasma ACE1 and ACE2 activity, suggesting alternative cell-signaling pathways. Markers of fibrosis (TIMP-1 and PIIINP) and vasculopathy (MMP-9) were additionally elevated. ACE2 RNA expression during severe COVID-19 often responded within hours to convalescent plasma. Analogous to oncogenesis, we speculate that potent, persistent, cryptic processes following COVID-19 (the renin-angiotensin system (RAS), fibrosis and vasculopathy) initiate or promote post-COVID-19 conditions (PCC) in susceptible individuals.

CONCLUSIONS

This work elucidates biological and temporal plausibility for ACE2, TIMP1, PIIINP and MMP-9 in the pathogenesis of PCC. Intersection of these independent systems is uncommon and may in part explain the rarity of PCC.

Intravenous immunoglobulins (IVIG) in severe/critical COVID-19 adult patients

The coronavirus disease 2019 (COVID-19) pandemic has become a huge obstacle to the health system due to the high rate of contagion. It is postulated that intravenous immunoglobulins (IVIG) can lower the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-related inflammation and prevent the development of acute respiratory distress syndrome (ARDS). The main advantages of IVIG treatment might be targeting cytokine storm in severe and critical COVID-19 by influences on complement, innate immune cells, effector T-cells, and Tregs. Randomized clinical trials (RCTs) and non-RCTs evaluating the safety and efficacy of IVIG in patients with severe/critical COVID-19 were performed. It seems that early administration of high-dose IVIG (in the acceleration phase of the disease) in severe or especially critical COVID-19 may be an effective therapeutic option, but there are no strong data to use it routinely. The results regarding mortality reduction are inconclusive. Additionally, IVIG treatment carries a risk of complications that should be considered when initiating treatment. However, given the COVID-19 mortality rate and limited therapeutic options, the use of IVIG is worth considering. This review summarizes the development and highlights recent advances in treatment with IVIG of severe/critically ill COVID-19 patients.

Benefits of high-dose intravenous immunoglobulin on mortality in patients with severe COVID-19: An updated systematic review and meta-analysis

Background

The clinical benefits of high-dose intravenous immunoglobulin (IVIg) in treating COVID-19 remained controversial.

Methods

We systematically searched databases up to February 17, 2022, for studies examining the efficacy of IVIg compared to routine care. Meta-analyses were conducted using the random-effects model. Subgroup analysis, meta-regression, and trial series analysis w ere performed to explore heterogeneity and statistical significance.

Results

A total of 4,711 hospitalized COVID-19 patients (1,925 IVIg treated and 2786 control) were collected from 17 studies, including five randomized controlled trials (RCTs) and 12 cohort studies. The application of IVIg was not associated with all-cause mortality (RR= 0.89 [0.63, 1.26], P= 0.53; I² = 75%), the length of hospital stays (MD= 0.29 [-3.40, 6.44] days, P= 0.88; I2 = 96%), the needs for mechanical ventilation (RR= 0.93 ([0.73, 1.19], P= 0.31; I2 = 56%), or the incidence of adverse events (RR= 1.15 [0.99, 1.33], P= 0.06; I2 = 20%). Subgroup analyses showed that overall mortality among patients with severe COVID-19 was reduced in the high-dose IVIg subgroup (RR= 0.33 [0.13, 0.86], P= 0.02, I² = 68%; very low certainty).

Conclusions

Results of this study suggest that severe hospitalized COVID-19 patients treated with high-dose IVIg would have a lower risk of death than patients with routine care.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021231040, identifier CRD42021231040.

COVID-19 Related Myocarditis in Adults: A Systematic Review of Case Reports

Despite the progress of its management, COVID-19 maintains an ominous condition which constitutes a threat, especially for the susceptible population. The cardiac injury occurs in approximately 30% of COVID-19 infections and is associated with a worse prognosis. The clinical presentation of cardiac involvement can be COVID-19-related myocarditis. Our review aims to summarise current evidence about that complication. The research was registered at PROSPERO (CRD42022338397). We performed a systematic analysis using five different databases, including i.a. MEDLINE. Further, the backward snowballing technique was applied to identify additional papers. Inclusion criteria were: full-text articles in English presenting cases of COVID-19-related myocarditis diagnosed by the ESC criteria and patients over 18 years old. The myocarditis had to occur after the COVID-19 infection, not vaccination. Initially, 1588 papers were screened from the database search, and 1037 papers were revealed in the backward snowballing process. Eventually, 59 articles were included. Data about patients' sex, age, ethnicity, COVID-19 confirmation technique and vaccination status, reported symptoms, physical condition, laboratory and radiological findings, applied treatment and patient outcome were investigated and summarised. COVID-19-related myocarditis is associated with the risk of sudden worsening of patients' clinical status, thus, knowledge about its clinical presentation is essential for healthcare workers.

Efficacy of Glucocorticoid plus Intravenous Immunoglobulin in Children with Immunoglobulin-Insensitive Kawasaki Disease

This study mainly analyzes the clinical effect of glucocorticoid (GC) plus intravenous immunoglobulin (IVIG) in treating children with immunoglobulin (Ig)-insensitive Kawasaki disease (KD). From September 2013 to November 2021, 86 Ig-insensitive KD children were selected, including 46 children (observation group, Obs) treated with GC plus IVIG, and 40 children (control group, Con) treated with IVIG. The symptom (fever and fever) resolution time, inflammatory factors (C-reactive protein, CRP; procalcitonin, PCT; interleukin-6, IL-6), immune indicators (CD3+, CD4+, CD8+ T lymphocytes CD3+, CD4+, and CD4+/CD8+), and incidence of adverse reactions were compared between the groups. The results identified shorter fever and rash resolution time in Obs compared with Con. The posttreatment CRP, PCT, IL-6, and CD8+ and the incidence of adverse events reduced notably in Obs and were lower than Con, while CD3+, CD4+, and CD4+/CD8+ elevated statistically and were higher than that of Con. Our results indicate that GC plus IVIG can significantly promote symptom resolution, alleviate inflammatory response, and improve immune function in children with Ig-insensitivity KD, with favorable safety and clinical promotion value.

Efficacy of intravenous immunoglobulin in the treatment of a COVID-19 patient

Introduction. Diabetes mellitus patients represent vulnerable group of people who are prone to getting infected with severe acute respiratory syndrome corona virus 2 (SARS-CoV-2). The virus has a high binding affinity to angiotensin-converting enzyme 2 receptor which allows efficient host cell entering, prolonged virus retention and possibility of insulin resistance and ketoacidosis development. Case outline. We describe a case of a 20-year-old patient with a past medical history of type-1 diabetes mellitus who presented with bilateral COVID-19 pneumonia. Initially treatment with polyvitamin therapy, corticosteroids, tocilizumab and convalescent plasma did not improve the patient condition, but might have led to the worsening of underlying disease, high blood glucose level and ketoacidosis. Patient developed a rapid progression of the disease and severe pneumonia that required intubation and mechanical ventilation. Intravenous immunoglobulin (IVIg) has been administrated in order to suppress a hyperactive immune response through its immunomodulatory effect. Forty-eight hours later respiratory gas exchange had been improved, almost complete regression of changes in the lungs have been seen, normalization of metabolic and gas exchange parameters have been detected. After 14 days in the hospital the patient was discharged home in good general condition. Conclusion. COVID-19 complicated by diabetes mellitus leads to a poor outcome of the disease, but antiviral and anti-inflammatory activity of IVIg suggests that they may be useful therapeutic agent and in the case of COVID-19. In the presented case, the application of IVIg very fast led to an improvement in the patient?s condition.

Immune dysfunction in COVID-19 and judicious use of antirheumatic drugs for the treatment of hyperinflammation

In the Wuhan province of China, almost two years ago, in December 2019, the novel Coronavirus 2019 has caused a severe involvement of the lower respiratory tract leading to an acute life-threatening respiratory syndrome, coronavirus disease-19 (COVID-19). Subsequently, coronavirus 2 (SARS-CoV-2) rapidly spread to the entire world causing a pandemic and affected every single person on earth either directly or indirectly with destroying all facets of social life and economy. Since the announcement of COVID-19 as a global pandemic, we have witnessed tremendous scientific work on all aspects of COVID-19 across the globe, which has never been witnessed before. The most remarkable achievement would be the introduction of vaccines, which provide protection from the severe infection and is the only premise for the control of disease. However, despite the tremendous work, the number of treatments either antiviral or immunomodulatory for infected patients are considerably limited, yet disease is causing substantial morbidity and mortality. COVID-19 follows heterogenous disease course among infected individuals, and dysregulated immune system is primarily responsible for the worse outcomes. Immune deficiency, being on corticosteroids for inflammatory diseases, delayed interferon response and advanced age adversely influence prognosis with impairing viral clearance. On the other hand, exuberant immune response with features of cytokine storm is the leading cause of death, which can be alleviated by use of either general immunosuppression with corticosteroids or selective neutralization of potent pro-inflammatory cytokines such as interleukin (IL)-1 and IL-6. Herein, we summarized the potential effective immunomodulatory treatments emphasizing in which patient population it is the most suitable, which dose should be administered, and which is the most appropriate timepoint to administer the drug during the course of the disease.