Web seminar for Maharashtra University of Health Sciences

COVID-19: : A review of the current situation and a trip into the eye of the cytokine storm

Associate professor in Immunology University of Montpellier, France

Dr. Franck Mennechet

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Severe acute respiratory syndrome coronavirus 2 (Sars-COV-2)

coronavirus disease 2019 (COVID-19)

positive-sense single-stranded RNA virus

The disease was first identified in December 2019 in Wuhan, China

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Simonnet A et al. Obesity 2020

Obesity

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MERS-Cov, Infected asymptomatic

Why the hell are we locking down for?

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Is the Sars-COV-2 mutating?

SARS-CoV-2 seems to mutate about 4 times more slowly than the flu.

Mutations can reveal how the Sars-COV-2 moves, but they’re easy to over interpret

As the outbreak unfolds, we expect to see more and more diversity.

https://doi.org/10.1093/nsr/nwaa036

Not a "mutation" but "an evolution" of the virus

(Peter Forster et al., PNAS 2020)

Recent phylogenetic analysis of COVID-19 strains that are currently spreading around the world that reveals 3 central variants of the virus (A, B and C)

Observations provided evidence of the genetic diversity and rapid evolution of Sars-COV-2

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What is the current situation in india?

April 22nd 2020 ????? Confirmed cases ??? Death

Rajasthan becomes first Indian state to conduct Covid-19 rapid testing

case-fatality ratio: 3,31%

COVID-19 Dashboard by the Center for Systems Science and Engineering (CSSE) at Johns Hopkins University (JHU)

Part of the population has tuberculosis (2.8 million) and respiratory issues, associated to high rates of smoking and air pollution in India

Hannah Monica Yesudian Dias et al., Indian J Med Res. 2018

March 23th, India confines itself to try to stop COVID-19 spread

The first case of the Covid-19 pandemic in India was reported on January 30th

India plans to significantly increase its COVID-19 screening capacity

March 13th ICMR, published full-genome sequences of the first two SARS-CoV-2 viruses from India

Pragya D Yadav et al, Indian JMR 2020

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The control of COVID-19 relies primarily on a country's public health capacity (detection, prevention, surveillance and treatment)

Because “we cannot fight a fire with our eyes blindfolded”

the WHO has called for countries to "test any suspected case".

COVID-19 diagnosis: How and what to do?

However, if high-quality diagnostic technologies are available for SARS-CoV-2 in most developed countries, they are neither, unsustainable, accessible nor affordable in low incomes countries

Who is strongly recommending COVID-19 diagnosis with combinations strategies

Molecular disagnosis Serological disagnosis

qPCR ELISA / Quick test

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Siatka c et al., Horiba Medical 2020 9

-A complex expensive methodology which involves equipments and many steps (takes times)

Early diagnosis : high viral loads were recorded in patients who were hospitalized shortly after first symptom

https://www.who.int/news-room/commentaries/detail/advice-on-the-use-of-point-of-care-immunodiagnostic-tests-for-covid-19

-qPCR tests can be defective if specimens are not properly collected (20% false negative)

Some people confirmed COVID-19 by qPCR had weak, late or absent antibody responses

Zhao et al., Clinical Infectious Diseases, 2020

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Molecular disagnostic

qPCR

Detection of the viral genome by qPCR appears as the gold standard to detect viruses in respiratory secretions.

« open adaptive system » available

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Serological disagnosis

ELISA/Quick IgM/IgG

IgM D8-10 & IgG D10-12 After first symptoms

Low-cost and quick test (10 mins; 8 EUR for the Biosynex © system ) Imperative for late hospitalized patients with undetectable viral load by molecular approaches. Health care providers will be confronted to patients whose travel or exposure history make them "patients under investigation" (PUI) for the disease.

Despite number of tests on the market they are not always very reliable Serological detection is possible only 5 days after the first symptoms.

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Clinical and biochemical features of COVID-19 patients

Li-sheng Wang et al., Inter Journal of Antim Agents 2020

There are already some evidences that COVID-19 can cause damage to tissues and organs other than the lung. 36.4% patients had neurological manifestations. 50% of COVID-19 patients have arrhythmia, acute heart injury, impaired renal function, and abnormal liver function at admission

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Clinical features of COVID-19 patients in Wuhan, China (n=41) or on meta‐analysis from Chinese patients (n=1994 on 10 studies)

All patients ICU patients

Chaolin Huang et al., Lancet 2020

Fever (88.5%) Cough (68.6%) Myalgia or fatigue (35.8%) Expectoration (28.2%) Dyspnea (21.9%) Headache or dizziness (12.1%) Diarrhea (4.8%) Nausea and vomiting (3.9%)

Long‐Quan Li et al, J of Med Virol

DOI: 10.1002/jmv.25757

Major symptoms

Minor symptoms

Radiographic evidence of pneumonia (75%)

https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-guidance-management-patients.html 13

Lymphocytopenia (LYM) (35%-83%) Increase C‐reactive protein (CRP) (44.3%-86%) Increase of lactic dehydrogenase (LDH) (28.3%) leukocytopenia (29.4%)

Laboratory examination

Long‐Quan Li et al, J of Med Virol 2020

Hypoalbuminemia (ALB) (9% -42%) Thrombocytopenia (5%-36%) Increase Creatine kinase (CK) (8%-32%) Increase Ferritin & IL-6

Yingxia Liu et al., China Science 2020

Huipeng Ge et al., Eu J of Clinl Mi & Inf D 2020

Nanshan Chen et al., The Lancet 2020

(https://doi.org/10.1016/j.cca.2020.03.004)

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Meta‐Analysis

Minor

Major

C‐reactive protein (CRP)

https://doi.org/10.1016/j.medmal.2020.03.007

CRP levels were positively correlated with the diameter of lung lesion and severe presentation

CRP levels are correlated with the level of inflammation, and its concentration level is not affected by factors such as age, sex, and physical condition

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Yingxia Liu et al., China Science 2020

ALB, LYM (%), NEU(%) and CRP were highly linked to viral lead and lung injury (ARDS)

C‐reactive protein (CRP)

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meta‐analysis

C‐reactive protein (CRP) & Lymphopenia

Siatka c et al., Horiba Medical 2020

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Age and SARS-CoV-2-specific NAb levels correlated with CRP levels of patients on the time admission 18

Antibody-dependent enhancement (ADE)?

C‐reactive protein (CRP)

Could additional tests decrease the false negative rate of the RT-PCR?

-Recommends testing CRP and procalcitonin (PCT): COVID19: Normal PCT and elevated CRP Correlating CRP it to prognosis and disease severity -Lymphocyte counts IL6 and IL10 testing (helpful to assess the risk of progression to severe condition) -Chest X-ray

Chinese, Italian, England guidance, & CDC

-Recommends performing routine haematology and biochemistry laboratory testing

WHO guidance

Helping for the diagnosis!

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In some patients, severe cytokine storms, is also an important cause of death

Respiratory failure from acute respiratory distress syndrome (ARDS) is the leading cause of mortality

Patients with critical illness had high plasma levels of inflammatory makers, suggesting potential immune dysregulation

The cytokine Storm: What is it?

Rudragouda Channappanavar et al., Semin Immunopathol. 2017

ALI: Acute Lung Injury 20

COVID-19

About 15% of the confirmed cases progress to the severe phase

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The cytokine Storm: What is it?

Thevarajan I et al, Nature Medicine, 2020

Tfh Cells

RIG1 MDA5 TLR-3,7,8,9

ACE2

Xiaowei Li et al., Journal of Pharmaceutical Analysis 2020

22 Kindler E & Thiel., Cell Host & Microbes Preview 2016

SARS-CoV and IFN: Too Little, Too Late

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immune response is required to eliminate the virus and to preclude disease progression to severe stages.

(Incubation and nonsevere stages)

(Yufang Shi et al., Cell Death & Differentiation 2020)

The host should be in good general health and an appropriate genetic background (e.g. HLA)

The cytokine release syndrome (CRS) affect patients with severe conditions

Because lymphopenia: CRS mediated mostly by Natural Immunity

Early Stage Severe stage

Boost the immun response Block the immun response

Studies have shown that the levels of inflammatory cytokines may be related to the severity of the disease, and an important cause of death

cytokine storm syndrome

Cov19 infection or even SRAS infections in general, have been reported to induce increased serum concentrations of proinflammatory cytokines (Wong CK et al., Clin Exp

Immunol. 2004)

It has been also reported that elevated inflammatory mediators play a crucial role in fatal pneumonia caused by pathogenic human coronaviruses such as SARS and MERS (Rudragouda Channappanavar et al., Semin Immunopathol. 2017)

The cytokine Storm: What is it?

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The “cytokine storm” in viral infections The “cytokine storm” in viral infections

IL1, IL6, IL,8, IL12, IL-17, IL-15, IFNγ, IFNa, IP10/CCL10, MIG/CXCL9 and MCP1/CCL2

Wong CK, et al., Clin Exp Immunol 2004; Rudragouda Channappanavar et al., Semin Immunopathol 2017; Mahallaw wet al., Cytokine 2018

Sras-COV Mers-COV

IL-6, IL-8, IL-10, MIP-1β/CCL4 and IFN-γ (Wang, Z. et al. PNAS 2014) H7N9

IP10/CCL10, MCP1/CCL2 , MIP1a/CCL3

IFN-γ, IL-8, IL-9, IL-17, IL-6, TNF-α, IL-15, IL-12p70

Early response Mild patients

H1N1

IL-15, IL-12p70, IL-6 Critical illness (J F Bermejo-Martin et al., BMC 2009)

Hospitalized

Influenza

For Sras-CoV-2, patient who did not experience complications of respiratory failure, only minimal pro-inflammatory cytokines and chemokines were found in the serum, even when symptomatic (Irani Thevarajan, Mature Medicine 2020)

Cytokine storms: Dengue - Zika

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IL-1b, IL1-Ra, IFNγ, IL-7, IL-4, IL-6, IL-8, IL-9, IL-10, GCSF, GMCSF, IP10/CXCL10,

MCP1/CCL2, MIP1a/CCL3, MIP1b/CCL4, PDGF, TNFα

IL5, IL12p70, IL15, Eotaxin, and RANTES/CCL5

IL2, IL7, IL10, GCSF, IP10/CXCL10,

MCP1/CCL2, IL6 MIP1a/CCL3, and

TNFα Sras-CO

V-2

Healthy Infected Infected (ICU)

Suxin Wan et al, MedRxiv 2020

Chaolin Huang et al. The lancet 2020

COVID-19: The “eye” of the cytokine storm COVID-19: The “eye” of the cytokine storm

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Thevarajan I et al, Nature Medicine, 2020

IP-10/CXCL10, MCP3/CCL7 and

IL-1ra

IFN-γ, IL-1ra, IL-2ra, IL-6, IL-10, IL-18, HGF, MCP-3/CCL7, MIG/CXCL9, M-CSF, G-CSF,

MIP1a/CCL3 CTACK/CCL27, IP-10/CXCL10

Healthy Infected Infected (ICU)

(Yang Yand et al. MedRxiv, 2020)

COVID-19: The eye of the cytokine storm COVID-19: The eye of the cytokine storm

(n=41)

GROa/CXCL1, MIP2-a/CXCL2, CXCL6, CXCL8, IP10/CXCL10, MCP-1/CCL2, MIP-1a/CCL3 and MIP1b/CCL4.

Xiong Yong et al., Emerging Microbes and Infections 2020

BAF

IL-2 Rc, IL-6, IL-8, IL-10, and TNFα. (undetectable concentrations of IL-1β)

Deceased patients (n=113) Tao Chen et al., BMJ 2020

The cytokine storm is a key factor in determining the clinical course of extrapulmonary multiple-organ failure

The serum levels of cytokines are significantly increased in patients with ARDS, and correlated with mortality rate

COVID-19 causes TH1 inflammatory cytokine storm in some patients with sever cases, that leads to ARDS or extrapulmonary multiple-organ failure. CXCL10 and TNFa could be a key biomarkers (Serum or BAF) for COVID-19 exacerbation & death prognostic. (@-TNFa treatment?)

COVID-19: The eye of the cytokine storm COVID-19: The eye of the cytokine storm

Not for COVID-19 diagnosis!

Biomarkers to evaluate COVID-19 severity

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IFN-γ, IL-10, MCP-3/CCL7, MIP1a/CCL3, IP-10/CXCL10 Sras-COV-2 Infection

IP-10/CXCL10 – TNFa-IL6? COVID-19 Severity/death ho

spit

aliz

ed

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Prepare for the worst & Hope for the best Be safe!

The proportion of the population that has been infected (and recovered) by SRAS-COV 2 is a critical measure to inform on a population level when and how social distancing interventions can be relaxed

What is the current seroprevalence? What is the current seroprevalence?

Seroprevalence in « Hot Spots populations» of the epidemic is currently between 1% to 14%

Could the summer bring an end to COVID-19?

N’Djamena, Chad

The number of cases detected in a country depends on multiple factors (testing, population density, health policies and facilities… and air

Life transmission of the flu goes down to very low levels during the summer

90% of the COVID-19 cases have been recorded in countries within a temperature range of 3°C to 17°C

The lower number of cases in tropical countries might be due to warm-humid conditions, under which the spread of the virus might be slower

Viral transmission seems lower in countries with higher temperature (Singapore, India, Taiwan, Qatar…)

basic reproduction number: R0: 2.43 to 3.10 Marco D'Arienzo et al., , Biosafety and Health, 2020

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