Investigation of Blood Plasma Viral Nucleocapsid Antigen as a Marker of Active Severe Acute Respiratory Syndrome Coronavirus 2 Omicron Variant Infection

Background

Nasopharyngeal qualitative reverse-transcription polymerase chain reaction (RT-PCR) is the gold standard for diagnosis of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, but it is not practical or sufficient in every clinical scenario due to its inability to distinguish active from resolved infection. Alternative or adjunct testing may be needed to guide isolation precautions and treatment in patients admitted to the hospital.

Methods

We performed a single-center, retrospective analysis of residual clinical specimens and medical record data to examine blood plasma nucleocapsid antigen as a candidate biomarker of active SARS-CoV-2. Adult patients admitted to the hospital or presenting to the emergency department with SARS-CoV-2 ribonucleic acid (RNA) detected by RT-PCR from a nasopharyngeal swab specimen were included. Both nasopharyngeal swab and a paired whole blood sample were required to be available for analysis.

Results

Fifty-four patients were included. Eight patients had positive nasopharyngeal swab virus cultures, 7 of whom (87.5%) had concurrent antigenemia. Nineteen (79.2%) of 24 patients with detectable subgenomic RNA and 20 (80.0%) of 25 patients with N2 RT-PCR cycle threshold ≤ 33 had antigenemia.

Conclusions

Most individuals with active SARS-CoV-2 infection are likely to have concurrent antigenemia, but there may be some individuals with active infection in whom antigenemia is not detectable. The potential for high sensitivity and convenience of a blood test prompts interest in further investigation as a screening tool to reduce reliance on nasopharyngeal swab sampling and as an adjunct diagnostic test to aid in clinical decision making during the period after acute coronavirus disease 2019.

Nucleocapsid antigenemia in patients receiving anti-CD20 therapy with protracted COVID-19

Immunocompromised patients with prolonged coronavirus disease 2019 symptoms present diagnostic and therapeutic challenges. We measured viral nucleocapsid antigenemia in 3 patients treated with anti-CD20 immunotherapy who acquired severe acute respiratory syndrome coronavirus 2 infection and experienced protracted symptoms. Our results support nucleocapsid antigenemia as a marker of persistent infection and therapeutic response.

Galectins: An Ancient Family of Carbohydrate Binding Proteins with Modern Functions

Galectins are a large family of carbohydrate binding proteins with members in nearly every lineage of multicellular life. Through tandem and en-mass genome duplications, over 15 known vertebrate galectins likely evolved from a single common ancestor extant in pre-chordate lineages. While galectins have divergently evolved numerous functions, some of which do not involve carbohydrate recognition, the vast majority of the galectins have retained the conserved ability to bind variably modified polylactosamine (polyLacNAc) residues on glycans that modify proteins and lipids on the surface of host cells and pathogens. In addition to their direct role in microbial killing, many proposed galectin functions in the immune system and cancer involve crosslinking glycosylated receptors and modifying signaling pathways or sensitivity to antigen from the outside in. However, a large body of work has uncovered intracellular galectin functions mediated by carbohydrate- and non-carbohydrate-dependent interactions. In the cytoplasm, galectins can tune intracellular kinase and G-protein-coupled signaling cascades important for nutrient sensing, cell cycle progression, and transformation. Particularly, but interconnected pathways, cytoplasmic galectins serve the innate immune system as sensors of endolysosomal damage, recruiting and assembling the components of autophagosomes during intracellular infection through carbohydrate-dependent and -independent activities. In the nucleus, galectins participate in pre-mRNA splicing perhaps through interactions with non-coding RNAs required for assembly of spliceosomes. Together, studies of galectin function paint a picture of a functionally dynamic protein family recruited during eons of evolution to regulate numerous essential cellular processes in the context of multicellular life.

Determinants of Neutralizing Antibody Response After SARS CoV-2 Vaccination in Patients With Myeloma

PURPOSE

Vaccine-induced neutralizing antibodies (nAbs) play a critical role in protection from SARS CoV-2. Patients with B-cell malignancies including myeloma are at increased risk of COVID-19-related mortality and exhibit variable serologic response to the vaccine. The capacity of vaccine-induced antibodies in these patients to neutralize SARS CoV-2 or its variants is not known.

METHODS

Sera from 238 patients with multiple myeloma (MM) undergoing SARS CoV-2 vaccination were analyzed. Antibodies against the SARS CoV-2 spike receptor-binding domain (RBD) and viral nucleocapsid were measured to detect serologic response to vaccine and environmental exposure to the virus. The capacity of antibodies to neutralize virus was quantified using pseudovirus neutralization assay and live virus neutralization against the initial SARS CoV-2 strain and the B1.617.2 (Delta) variant.

RESULTS

Vaccine-induced nAbs are detectable at much lower rates (54%) than estimated in previous seroconversion studies in MM, which did not monitor viral neutralization. In 33% of patients, vaccine-induced antispike RBD antibodies lack detectable neutralizing capacity, including against the B1.617.2 variant. Induction of nAbs is affected by race, disease, and treatment-related factors. Patients receiving mRNA1273 vaccine (Moderna) achieved significantly greater induction of nAbs compared with those receiving BNT162b2 (Pfizer; 67% v 48%, P = .006).

CONCLUSION

These data show that vaccine-induced antibodies in several patients with MM lack detectable virus-neutralizing activity. Vaccine-mediated induction of nAbs is affected by race, disease, vaccine, and treatment characteristics. These data have several implications for the emerging application of booster vaccines in immunocompromised hosts.

371. Estimating SARS-CoV-2 Seroprevalence from Spent Blood Samples, January–March 2021

Background

Measuring SARS-CoV-2 antibody prevalence in spent samples at serial time points can determine seropositivity in a diverse pool of individuals to inform understanding of trends as vaccinations are implemented.

Methods

Blood samples collected for clinical testing and then discarded ("spent samples") were obtained from the clinical laboratory of a medical center in Atlanta. A convenience sample of spent samples from both inpatients (medical/surgical floors, intensive care, obstetrics) and outpatients (clinics and ambulatory surgery) were collected one day per week from January-March 2021. Samples were matched to clinical data from the electronic medical record. In-house single dilution serological assays for SARS-CoV-2 receptor binding domain (RBD) and nucleocapsid (N) antibodies were developed and validated using pre-pandemic and PCR-confirmed COVID-19 patient serum and plasma samples (Figure 1). ELISA optical density (OD) cutoffs for seroconversion were chosen using receiver operating characteristic analysis with areas under the curve for all four assays greater than 0.95 after 14 days post symptom onset. IgG profiles were defined as natural infection (RBD and N positive) or vaccinated (RBD positive, N negative).

Figure 1. Nucleocapsid serology assay validation

Single dilution serological assays for SARS-CoV-2 nucleocapsid antibodies were validated using pre-pandemic and PCR-confirmed COVID-19 patient serum and plasma samples. ELISA optical density (OD) cutoffs for seroconversion were chosen using receiver operating characteristic (ROC) analysis with areas under the curve (AUC) for all four assays greater than 0.95 after 14 days post symptom onset.

Results

A total of 2406 samples were collected from 2132 unique patients. Median age was 58 years (IQR 40-70), with 766 (36%) ≥ 65 years. The majority were female (1173, 55%), and 1341 (63%) were Black. Median Elixhauser comorbidity index was 5 (IQR 2-9). 210 (9.9%) patients ever had SARS-CoV-2 detected by PCR, and 191 (9.0%) received a COVID-19 vaccine within the health system. Nearly half (1186/2406, 49.3%) of samples were collected from inpatient units, 586 (24.4%) from outpatient labs, 403 (16.8%) from the emergency department, and 231 (9.6%) from infusion centers. Overall, 17.0% had the IgG natural infection profile, while 16.2% had a vaccination profile. Prevalence estimates for IgG due to natural infection ranged from 24.0% in week 2 to 9.7% in week 5, and for IgG due to vaccine from 4.4% in week 2 to 32.0% in week 6 (Table, Figure 2).

Table. SARS-CoV-2 antibody seropositivity by week of sample collection for spent routine blood chemistry samples.

RBD = receptor binding domain. N = nucleocapsid. Seropositivity defined by enzyme-linked immunoassay (ELISA) optical density cutoffs selected using receiver operating characteristic analysis with areas under the curve (AUC) for all four assays greater than 0.95 after 14 days post symptom onset. IgG defined as positive if both RBD and N seropositive.

Figure 2. RBD and Nucleocapsid seropositivity to differentiate natural infection vs. vaccination by week of sample collection.

RBD = receptor binding domain. N = nucleocapsid. Seropositivity defined by enzyme-linked immunoassay (ELISA) optical density cutoffs selected using receiver operating characteristic analysis with areas under the curve (AUC) for all four assays greater than 0.95 after 14 days post symptom onset.

Conclusion

Estimated SARS-CoV-2 IgG seroprevalence among patients at a medical center from January-March 2021 was 17% by natural infection, and 16% by vaccination. Weekly trends likely reflect community spread and vaccine uptake.

Disclosures

Daniel Graciaa, MD, MPH, MSc, Critica, Inc (Consultant)

Longitudinal assessment of SARS-CoV-2 nucleocapsid antigenemia in patients hospitalized with COVID-19

While RT-PCR tests of nasopharyngeal swabs remain the gold standard for the detection of SARS-CoV-2 infection and monitoring of COVID-19 disease progression, measurement of nucleocapsid antigenemia in serum and plasma samples is an underexplored alternative proxy for disease severity. To explore the dynamics of nucleocapsid antigenemia, we measured levels of nucleocapsid antigen using a highly sensitive Single Molecule Array (Simoa) assay in 817 serially collected serum and plasma samples from 93 PCR-confirmed COVID-19 patients for whom symptom onset date could be extracted by chart review. In a subset of these individuals (n=13), we measured seroconversion by titering for receptor binding domain (RBD) specific IgG, IgA, and IgM. A model of exponential decay was fit to data from individuals with high resolution daily sampling (N=34), from which the half-life of SARS-CoV-2 nucleocapsid in serum was determined. Mean nucleocapsid half-life in this group of patients was 1.17 days (SD=0.82). Nucleocapsid levels were significantly higher in the first 10 days following symptom onset in patients who died compared to those with a milder disease course (p=0.004). Further, mortality was associated with a trend toward longer nucleocapsid half-life (1.51 days vs. 0.79 days) (p=0.10). In patients who had both antibody and antigenemia data available, antibody response was temporally linked to antigen decay, reaching peak levels as antigen was cleared from the blood. Our data identify SARS-CoV-2 nucleocapsid antigenemia as a potential diagnostic tool for acute COVID-19 disease and an early biomarker associated with disease severity.

Are We Forgetting About IgA? A Re-examination of Coronavirus Disease 2019 Convalescent Plasma

BACKGROUND

While convalescent plasma (CP) may benefit patients with COVID-19, fundamental questions remain regarding its efficacy, including the components of CP that may contribute to its therapeutic effect. Most current serological evaluation of CP relies on examination of total immunoglobulin or IgG-specific anti-SARS-CoV-2 antibody levels. However, IgA antibodies, which also circulate and are secreted along the respiratory mucosa, represent a relatively uncharacterized component of CP.

STUDY DESIGN AND METHODS

Residual samples from patients and CP donors were assessed for IgM, IgG, and IgA anti-SARS-CoV-2 antibody titers against the receptor-binding domain responsible for viral entry. Symptom onset was obtained by chart review.

RESULTS

Increased IgA anti-SARS-CoV-2 antibody levels correlated with clinical improvement and viral clearance in an infant with COVID-19, prompting a broader examination of IgA levels among CP donors and hospitalized patients. Significant heterogeneity in IgA levels was observed among CP donors, which correlated weakly with IgG levels or the results of a commonly employed serological test. Unlike IgG and IgM, IgA levels were also more likely to be variable in hospitalized patients and this variability persisted in some patients >14 days following symptom onset. IgA levels were also less likely to be sustained than IgG levels following subsequent CP donation.

CONCLUSIONS

IgA levels can be very heterogenous among CP donors and hospitalized patients and do not necessarily correlate with commonly employed testing platforms. Examining isotype levels in CP and COVID-19 patients may allow for a tailored approach when seeking to fill specific gaps in humoral immunity.

Cell-intrinsic MAVS promotes antigen specific CD8+ T cell proliferation and mitochondrial metabolism

Mitochondrial antiviral signaling protein (MAVS), the central adaptor protein for RIG-I like receptor (RLR) signaling, is essential for promoting innate immunity against RNA virus infections. MAVS is ubiquitously expressed, however its function in T cells is less clear. Using a mouse model of West Nile virus (WNV) infection, we find that MAVS is required in a cell-intrinsic manner for promoting antigen-specific CD8+ T cell accumulation. Through adoptive transfer experiments, we find that MAVS positively regulates cell cycle genes and promotes entry into proliferation in antigen-specific CD8+ T cells. Mechanistically, knockout of MAVS leads to dysregulated metabolic transcriptional profiles and decreased mitochondrial potential in vivo. Furthermore, we determined that CD8+ T cell receptor stimulation promotes oxidative phosphorylation in a MAVS-dependent manner to facilitate entry into proliferation. Our findings identify a non-canonical role for MAVS as a positive regulator of mitochondrial respiration and proliferation in CD8+ T cells during viral infection.

Generation and Use of Recombinant Galectins

Galectins are soluble carbohydrate binding proteins that can bind β-galactose-containing glycoconjugates by means of a conserved carbohydrate recognition domain (CRD). In mammalian systems, galectins have been shown to mediate very important roles in innate and adaptive immunity as well as facilitating host-pathogen relationships. Many of these studies have relied on purified recombinant galectins to uncover key features of galectin biology. A major limitation to this approach is that certain recombinant galectins purified using standard protocols are easily susceptible to loss of glycan-binding activity. As a result, biochemical studies that employ recombinant galectins can be misleading if the overall activity of a galectin remains unknown in a given assay condition. This article examines fundamental considerations when purifying galectins by lactosyl-sepharose and nickel-NTA affinity chromatography using human galectin-4N and -7 as examples, respectively. As other approaches are also commonly applied to galectin purification, we also discuss alternative strategies to galectin purification, using human galectin-1 and -9 as examples. © 2021 Wiley Periodicals LLC. Basic Protocol 1: Purification of galectins using lactosyl-sepharose affinity chromatography Basic Protocol 2: Purification of human galectin-7 using a nickel-NTA affinity chromatography column Alternate Protocol 1: Iodoacetamide alkylation of free sulfhydryls on galectin-1 Alternate Protocol 2: Purification of human galectin-9 using lactosyl-sepharose column chromatography.

An automated approach to determine antibody endpoint titers for COVID-19 by an enzyme-linked immunosorbent assay

While a variety of therapeutic options continue to emerge for COVID-19 treatment, convalescent plasma (CP) has been used as a possible treatment option early in the pandemic. One of the most significant challenges with CP therapy, however, both when defining its efficacy and implementing its approach clinically, is accurately and efficiently characterizing an otherwise heterogenous therapeutic treatment. Given current limitations, our goal is to leverage a SARS antibody testing platform with a newly developed automated endpoint titer analysis program to rapidly define SARS-CoV-2 antibody levels in CP donors and hospitalized patients. A newly developed antibody detection platform was used to perform a serial dilution enzyme-linked immunosorbent assay (ELISA) for immunoglobulin (Ig)G, IgM, and IgA SARS-CoV-2 antibodies. Data were then analyzed using commercially available software, GraphPad Prism, or a newly developed program developed in Python called TiterScape, to analyze endpoint titers. Endpoint titer calculations and analysis times were then compared between the two analysis approaches. Serial dilution analysis of SARS-CoV-2 antibody levels revealed a high level of heterogeneity between individuals. Commercial platform analysis required significant time for manual data input and extrapolated endpoint titer values when the last serial dilution was above the endpoint cutoff, occasionally producing erroneously high results. By contrast, TiterScape processed 1008 samples for endpoint titer results in roughly 14 minutes compared with the 8 hours required for the commercial software program analysis. Equally important, results generated by TiterScape and Prism were highly similar, with differences averaging 1.26 ± 0.2 percent (mean ± SD). The pandemic has created unprecedented challenges when seeking to accurately test large numbers of individuals for SARS-CoV-2 antibody levels with a rapid turnaround time. ELISA platforms capable of serial dilution analysis coupled with a highly flexible software interface may provide a useful tool when seeking to define endpoint titers in a high-throughput manner. Immunohematology 2021;37:33-43. While a variety of therapeutic options continue to emerge for COVID-19 treatment, convalescent plasma (CP) has been used as a possible treatment option early in the pandemic. One of the most significant challenges with CP therapy, however, both when defining its efficacy and implementing its approach clinically, is accurately and efficiently characterizing an otherwise heterogenous therapeutic treatment. Given current limitations, our goal is to leverage a SARS antibody testing platform with a newly developed automated endpoint titer analysis program to rapidly define SARS-CoV-2 antibody levels in CP donors and hospitalized patients. A newly developed antibody detection platform was used to perform a serial dilution enzyme-linked immunosorbent assay (ELISA) for immunoglobulin (Ig)G, IgM, and IgA SARS-CoV-2 antibodies. Data were then analyzed using commercially available software, GraphPad Prism, or a newly developed program developed in Python called TiterScape, to analyze endpoint titers. Endpoint titer calculations and analysis times were then compared between the two analysis approaches. Serial dilution analysis of SARS-CoV-2 antibody levels revealed a high level of heterogeneity between individuals. Commercial platform analysis required significant time for manual data input and extrapolated endpoint titer values when the last serial dilution was above the endpoint cutoff, occasionally producing erroneously high results. By contrast, TiterScape processed 1008 samples for endpoint titer results in roughly 14 minutes compared with the 8 hours required for the commercial software program analysis. Equally important, results generated by TiterScape and Prism were highly similar, with differences averaging 1.26 ± 0.2 percent (mean ± SD). The pandemic has created unprecedented challenges when seeking to accurately test large numbers of individuals for SARS-CoV-2 antibody levels with a rapid turnaround time. ELISA platforms capable of serial dilution analysis coupled with a highly flexible software interface may provide a useful tool when seeking to define endpoint titers in a high-throughput manner. Immunohematology 2021;37:33–43.

Complement Inhibition in Severe COVID-19 Acute Respiratory Distress Syndrome

Most children with COVID-19 have asymptomatic or mild illness. Those who become critically ill suffer from acute respiratory distress syndrome (ARDS) and acute kidney injury (AKI). The rapid deterioration of lung function has been linked to microangiopathic and immune-mediated processes seen in the lungs of adult patients with COVID-19. The role of complement-mediated acute lung injury is supported by animal models of SARS-CoV, evaluation of lung tissue in those who died from COVID-19 and response of COVID-19 ARDS to complement inhibition. We present a summary of a child with COVID-19 disease treated with convalescent plasma and eculizumab and provide a detailed evaluation of the inflammatory pathways.

Role of complement in alloimmunization and hyperhemolysis

PURPOSE OF REVIEW

The purpose of this review is to summarize the role of complement in regulating the removal of a target alloantigen following an incompatible red blood cell (RBC) transfusion, the formation of alloantibodies following RBC alloantigen exposure, and the development of hyperhemolysis in patients with sickle cell disease (SCD).

RECENT FINDINGS

Recent studies demonstrate that complement can accelerate alloantibody-mediated removal of target alloantigens from the RBC surface following incompatible transfusion. Complement also influences alloantigen availability during developing alloimmune responses and serves as a unique mediator of CD4 T-cell-independent alloantibody formation following RBC alloantigen exposure. Finally, alternative complement pathway activation appears to play a key role in the development of acute hemolytic episodes in patients with SCD, providing a potential druggable target to prevent acute complications in patients with this disease.

SUMMARY

Recent studies suggest that complement can regulate a wide variety of processes germane to hematology, from transfusion complications to baseline hemolysis in patients with SCD. As the role of complement in various disease processes becomes more fully understood, the ability to leverage recently developed complement modulating drugs will only continue to enhance providers' ability to favorably intervene in many hematological diseases.

Serum pooling for rapid expansion of anti-SARS-CoV-2 antibody testing capacity

Objectives

Examine possible pooling strategies designed to expand SARS-CoV-2 serological testing capacity.

Methods

Negative pools were assessed to determine optimal optical density (OD) cutoffs, followed by spiking weak or strong positive samples to assess initial assay performance. Samples were then randomly subjected to pool and individual testing approaches.

Results

Single positive specimens consistently converted pools of 5, 10, or 20 into positive outcomes. However, weaker IgG-positive samples failed to similarly convert pools of 50 to a positive result. In contrast, a stronger individual positive sample converted all pools tested into positive outcomes. Finally, examination of 150 samples configured into pools of 5, 10, 20 or 50 accurately predicted the presence of positive or negative specimens within each pool.

Conclusions

These results suggest that pooling strategies may allow expansion of serological testing capacity. While limitations exist, such strategies may aid in large-scale epidemiological screening or identification of optimal convalescent plasma donors.

Fc Gamma Receptors and Complement Component 3 Facilitate Anti-fVIII Antibody Formation

Anti-factor VIII (fVIII) alloantibodies, which can develop in patients with hemophilia A, limit the therapeutic options and increase morbidity and mortality of these patients. However, the factors that influence anti-fVIII antibody development remain incompletely understood. Recent studies suggest that Fc gamma receptors (FcγRs) may facilitate recognition and uptake of fVIII by recently developed or pre-existing naturally occurring anti-fVIII antibodies, providing a mechanism whereby the immune system may recognize fVIII following infusion. However, the role of FcγRs in anti-fVIII antibody formation remains unknown. In order to define the influence of FcγRs on the development of anti-fVIII antibodies, fVIII was injected into WT or FcγR knockout recipients, followed by evaluation of anti-fVIII antibodies. Anti-fVIII antibodies were readily observed following fVIII injection into FcγR knockouts, with similar anti-fVIII antibody levels occurring in FcγR knockouts as detected in WT mice injected in parallel. As antibodies can also fix complement, providing a potential mechanism whereby anti-fVIII antibodies may influence anti-fVIII antibody formation independent of FcγRs, fVIII was also injected into complement component 3 (C3) knockout recipients in parallel. Similar to FcγR knockouts, C3 knockout recipients developed a robust response to fVIII, which was likewise similar to that observed in WT recipients. As FcγRs or C3 may compensate for each other in recipients only deficient in FcγRs or C3 alone, we generated mice deficient in both FcγRs and C3 to test for potential antibody effector redundancy in anti-fVIII antibody formation. Infusion of fVIII into FcγRs and C3 (FcγR × C3) double knockouts likewise induced anti-fVIII antibodies. However, unlike individual knockouts, anti-fVIII antibodies in FcγRs × C3 knockouts were initially lower than WT recipients, although anti-fVIII antibodies increased to WT levels following additional fVIII exposure. In contrast, infusion of RBCs expressing distinct alloantigens into FcγRs, C3 or FcγR × C3 knockout recipients either failed to change anti-RBC levels when compared to WT recipients or actually increased antibody responses, depending on the target antigen. Taken together, these results suggest FcγRs and C3 can differentially impact antibody formation following exposure to distinct alloantigens and that FcγRs and C3 work in concert to facilitate early anti-fVIII antibody formation.

CD8+ T cell intrinsic MAVS promotes antigen-specific responses and mitochondrial metabolism during West Nile Virus neuroinvasive disease

West Nile Virus (WNV) is an arbovirus of the Flaviviridae family that causes annual outbreaks of encephalitis across North America. RIG-I like receptor (RLR) signaling through the central adaptor Mitochondrial antiviral signaling protein (MAVS) is essential for promoting immunity against WNV infection. While MAVS has been associated with type I interferon (IFN) induction during virus infection, here we describe a novel, cell-intrinsic role for MAVS in regulating antigen-specific CD8+ T cell responses. MAVS is expressed in CD8+ T cells and remains constant during the differentiation of CD8+ T cells. Generation of an effective CD8+ T cell response against WNV is essential for limiting virus replication in neurons, mitigating pathology in the brain, and protecting against lethal outcome. To understand how MAVS impacts CD8+ T cell responses during WNV infection, we utilized the WNV mouse model and adoptively co-transferred WT and Mavs−/− CD8+ T cells into congenically marked WT mice. We found that compared to WT cells, Mavs−/− antigen-specific CD8+ T cells displayed reduced accumulation of antigen-specific CD8+ T cells, reduced IFN-γ production and reduced formation of memory precursor cells during virus infection. At the peak of brain infection, Mavs−/− antigen-specific CD8+ T cells displayed highly divergent transcriptomes, including altered metabolic profiles, compared to WT CD8+ T cells. Further mechanistic studies found that after TCR stimulation of CD8+ T cells, MAVS promotes oxidative respiration and remodeling of mitochondrial morphology. Our findings identify a novel, non-canonical role for MAVS in the regulation of antigen-specific CD8+ T cell responses and mitochondrial function during neuroinvasive viral infection.