The dysregulated innate immune response in severe COVID-19 pneumonia that could drive poorer outcome

Mathieu Blot, Jean-Baptiste Bour, Jean Pierre Quenot, Abderrahmane Bourredjem, Maxime Nguyen, Julien Guy, Serge Monier, Marjolaine Georges, Audrey Large, Auguste Dargent, Alexandre Guilhem, Suzanne Mouries-Martin, Jeremy Barben, Belaid Bouhemad, Pierre-Emmanuel Charles, Pascal Chavanet, Christine Binquet, Lionel Piroth, LYMPHONIE study group, Pascal Andreu, François Aptel, Marie Labruyère, Sébastien Prin, Guillaume Beltramo, Philippe Bonniaud, Philip Bielefeld, Hervé Devilliers, Bernard Bonnotte, Marielle Buisson, Alain Putot, Mathieu Blot, Jean-Baptiste Bour, Jean Pierre Quenot, Abderrahmane Bourredjem, Maxime Nguyen, Julien Guy, Serge Monier, Marjolaine Georges, Audrey Large, Auguste Dargent, Alexandre Guilhem, Suzanne Mouries-Martin, Jeremy Barben, Belaid Bouhemad, Pierre-Emmanuel Charles, Pascal Chavanet, Christine Binquet, Lionel Piroth, LYMPHONIE study group, Pascal Andreu, François Aptel, Marie Labruyère, Sébastien Prin, Guillaume Beltramo, Philippe Bonniaud, Philip Bielefeld, Hervé Devilliers, Bernard Bonnotte, Marielle Buisson, Alain Putot

Abstract

Background: Although immune modulation is a promising therapeutic avenue in coronavirus disease 2019 (COVID-19), the most relevant targets remain to be found. COVID-19 has peculiar characteristics and outcomes, suggesting a unique immunopathogenesis.

Methods: Thirty-six immunocompetent non-COVID-19 and 27 COVID-19 patients with severe pneumonia were prospectively enrolled in a single center, most requiring intensive care. Clinical and biological characteristics (including T cell phenotype and function and plasma concentrations of 30 cytokines) and outcomes were compared.

Results: At similar baseline respiratory severity, COVID-19 patients required mechanical ventilation for significantly longer than non-COVID-19 patients (15 [7-22] vs. 4 (0-15) days; p = 0.0049). COVID-19 patients had lower levels of most classical inflammatory cytokines (G-CSF, CCL20, IL-1β, IL-2, IL-6, IL-8, IL-15, TNF-α, TGF-β), but higher plasma concentrations of CXCL10, GM-CSF and CCL5, compared to non-COVID-19 patients. COVID-19 patients displayed similar T-cell exhaustion to non-COVID-19 patients, but with a more unbalanced inflammatory/anti-inflammatory cytokine response (IL-6/IL-10 and TNF-α/IL-10 ratios). Principal component analysis identified two main patterns, with a clear distinction between non-COVID-19 and COVID-19 patients. Multivariate regression analysis confirmed that GM-CSF, CXCL10 and IL-10 levels were independently associated with the duration of mechanical ventilation.

Conclusion: We identified a unique cytokine response, with higher plasma GM-CSF and CXCL10 in COVID-19 patients that were independently associated with the longer duration of mechanical ventilation. These cytokines could represent the dysregulated immune response in severe COVID-19, as well as promising therapeutic targets. ClinicalTrials.gov: NCT03505281.

Keywords: Acute respiratory distress syndrome; COVID-19; CXCL10; GM-CSF; Immune response; Mechanical ventilation; Pneumonia.

Conflict of interest statement

we declare no competing interests.

Figures

Fig. 1
Fig. 1
Box plot showing plasma concentrations of cytokines in non-COVID-19 and COVID-19 patients. Plasma concentration of cytokines was measured within 48 h of hospitalization in 36 non-COVID-19 and 27 COVID-19 patients with severe pneumonia. For each cytokine, p-values from both Student t and Wilcoxon-Mann–Whitney U tests are indicated and the difference was considered significant if at least one was < 0.05. CCL C–C motif chemokine ligand, COVID-19 coronavirus disease 2019, IL interleukin, GM-CSF Granulocyte–macrophage colony-stimulating factor, TNF tumor necrosis factor, TGF transforming growth factor (LYMPHONIE study, 2018–2020)
Fig. 2
Fig. 2
Immune-suppression phenotype and inflammatory/anti-inflammatory balance in COVID-19 and non-COVID-19 patients. Boxplot showing cytokine production (IFN-γ (a), IL-1β (b), IL-6 (c), TNF-α (d)) of blood leukocytes on ex vivo stimulation (CD3/TLR7-8 agonists), using a standardized test (QuantiFERON Monitor®) within 48 h of hospitalization in non-COVID-19 (n = 36) and COVID-19 (n = 27) patients. As a reference, the test was performed in 7 non-infected control patients included in the Pneumochondrie study (NCT03955887) [24]. Boxplot depicting IL-6:IL10 (d) and TNF-α:IL-10 ratios in non-COVID-19 and COVID-19 patients. COVID-19 coronavirus disease 2019, IL interleukin, TNF tumor necrosis factor, WBS whole blood stimulation (LYMPHONIE study, 2018–2020)
Fig. 3
Fig. 3
Two-dimensional score plot of principal component analysis according to pneumonia etiology. Principal component analysis (PCA) was used to identify potentially significant patterns of 65 variables (clinical (n = 8), biological (n = 12), plasma cytokines (n = 30), cytokine production on ex vivo stimulation (n = 15)) from 63 patients with severe pneumonia (non-COVID-19 (n = 36), COVID-19 (n = 27)). Factors 1 and 4 were used to build a two-dimensional score plot of PCA and COVID-19 patients (red circles) and non-COVID-19 patients (bacterial (blue triangles), mixed (blue diamonds), viral (grey crosses) and other non-documented severe community acquired pneumonia (grey Xs)) were represented. (LYMPHONIE study, 2018-2020)

References

    1. Grasselli G, Zangrillo A, Zanella A, Antonelli M, Cabrini L, Castelli A, et al. Baseline characteristics and outcomes of 1591 patients infected with SARS-CoV-2 admitted to ICUs of the Lombardy Region Italy. JAMA. 2020;323(16):1574–1581. doi: 10.1001/jama.2020.5394.
    1. Giamarellos-Bourboulis EJ, Netea MG, Rovina N, Akinosoglou K, Antoniadou A, Antonakos N, et al. Complex immune dysregulation in COVID-19 patients with severe respiratory failure. Cell Host Microbe. 2020;27(6):992-1000.e3. doi: 10.1016/j.chom.2020.04.009.
    1. Minejima E, Bensman J, She RC, Mack WJ, Tuan Tran M, Ny P, et al. A dysregulated balance of proinflammatory and anti-inflammatory host cytokine response early during therapy predicts persistence and mortality in Staphylococcus aureus bacteremia. Crit Care Med. 2016;44(4):671–679. doi: 10.1097/CCM.0000000000001465.
    1. McElvaney OJ, McEvoy N, McElvaney OF, Carroll TP, Murphy MP, Dunlea DM, et al. Characterization of the inflammatory response to severe COVID-19 illness. Am J Respir Crit Care Med. 2020;202(6):812–821. doi: 10.1164/rccm.202005-1583OC.
    1. Sims JT, Krishnan V, Chang C-Y, Engle SM, Casalini G, Rodgers GH, et al. Characterization of the cytokine storm reflects hyperinflammatory endothelial dysfunction in COVID-19. J Allergy Clin Immunol. 2020;S0091–6749(20):31242-2.
    1. Del Valle DM, Kim-Schulze S, Huang H-H, Beckmann ND, Nirenberg S, Wang B, et al. An inflammatory cytokine signature predicts COVID-19 severity and survival. Nat Med. 2020;26(10):1636–1643. doi: 10.1038/s41591-020-1051-9.
    1. Carvelli J, Demaria O, Vély F, Batista L, Benmansour NC, Fares J, et al. Association of COVID-19 inflammation with activation of the C5a-C5aR1 axis. Nature. 2020 doi: 10.1038/s41586-020-2600-6.
    1. RECOVERY Collaborative Group. Horby P, Lim WS, Emberson JR, Mafham M, Bell JL, et al. Dexamethasone in Hospitalized Patients with Covid-19 - Preliminary Report. N Engl J Med. 2020 doi: 10.1056/NEJMoa2021436.
    1. Hue S, Beldi-Ferchiou A, Bendib I, Surenaud M, Fourati S, Frapard T, et al. Uncontrolled innate and impaired adaptive immune responses in patients with COVID-19 ARDS. Am J Respir Crit Care Med. 2020 doi: 10.1164/rccm.202005-1885OC.
    1. Sinha P, Matthay MA, Calfee CS. Is a « Cytokine Storm » Relevant to COVID-19? JAMA Intern Med. 2020;180(9):1152–1154. doi: 10.1001/jamainternmed.2020.3313.
    1. Chen LYC, Hoiland RL, Stukas S, Wellington CL, Sekhon MS. Confronting the controversy: interleukin-6 and the COVID-19 cytokine storm syndrome. Eur Respir J. 2020;56(4):2003006. doi: 10.1183/13993003.03006-2020.
    1. Blot M, Bourredjem A, Binquet C, Piroth L. Is Interleukin 6 the right target in COVID-19 severe pneumonia? Am J Respir Crit Care Med. 2020 doi: 10.1164/rccm.202007-2924LE.
    1. Leisman DE, Ronner L, Pinotti R, Taylor MD, Sinha P, Calfee CS, et al. Cytokine elevation in severe and critical COVID-19: a rapid systematic review, meta-analysis, and comparison with other inflammatory syndromes. Lancet Respir Med. 2020;S2213–2600(20):30404–30405.
    1. Remy KE, Mazer M, Striker DA, Ellebedy AH, Walton AH, Unsinger J, et al. Severe immunosuppression and not a cytokine storm characterize COVID-19 infections. JCI Insight. 2020;5(17):e140329. doi: 10.1172/jci.insight.140329.
    1. Hadjadj J, Yatim N, Barnabei L, Corneau A, Boussier J, Smith N, et al. Impaired type I interferon activity and inflammatory responses in severe COVID-19 patients. Science. 2020;369(6504):718–724. doi: 10.1126/science.abc6027.
    1. Channappanavar R, Fehr AR, Vijay R, Mack M, Zhao J, Meyerholz DK, et al. Dysregulated type I interferon and inflammatory monocyte-macrophage responses cause lethal pneumonia in SARS-CoV-infected mice. Cell Host Microbe. 2016;19(2):181–193. doi: 10.1016/j.chom.2016.01.007.
    1. Blot M, Jacquier M, Manoha C, Piroth L, Charles P-E, Pneumochondrie study group Alveolar SARS-CoV-2 viral load is tightly correlated with severity in COVID-19 ARDS. Clin Infect Dis. 2020 doi: 10.1093/cid/ciaa1172.
    1. Vincent JL, Moreno R, Takala J, Willatts S, De Mendonça A, Bruining H, et al. The SOFA (Sepsis-related Organ Failure Assessment) score to describe organ dysfunction/failure. On behalf of the Working Group on Sepsis-Related Problems of the European Society of Intensive Care Medicine. Intensive Care Med. 1996;22(7):707‑10.
    1. Le Gall JR, Lemeshow S, Saulnier F. A new simplified acute physiology score (SAPS II) based on a European/North American multicenter study. JAMA. 1993;270(24):2957–2963. doi: 10.1001/jama.1993.03510240069035.
    1. Fine MJ, Auble TE, Yealy DM, Hanusa BH, Weissfeld LA, Singer DE, et al. A prediction rule to identify low-risk patients with community-acquired pneumonia. N Engl J Med. 1997;336(4):243–250. doi: 10.1056/NEJM199701233360402.
    1. ARDS Definition Task Force, Ranieri VM, Rubenfeld GD, Thompson BT, Ferguson ND, Caldwell E, et al. Acute respiratory distress syndrome: the Berlin Definition. JAMA. 2012;307(23):2526‑33.
    1. Santagostino A, Garbaccio G, Pistorio A, Bolis V, Camisasca G, Pagliaro P, et al. An Italian national multicenter study for the definition of reference ranges for normal values of peripheral blood lymphocyte subsets in healthy adults. Haematologica. 1999;84(6):499–504.
    1. Troussard X, Vol S, Cornet E, Bardet V, Couaillac J-P, Fossat C, et al. Full blood count normal reference values for adults in France. J Clin Pathol. 2014;67(4):341–344. doi: 10.1136/jclinpath-2013-201687.
    1. Blot M, Jacquier M, Aho Glele L-S, Beltramo G, Nguyen M, Bonniaud P, et al. CXCL10 could drive longer duration of mechanical ventilation during COVID-19 ARDS. Crit Care. 2020;24(1):632. doi: 10.1186/s13054-020-03328-0.
    1. Sainani KL. Introduction to principal components analysis. PM R. 2014;6(3):275–278. doi: 10.1016/j.pmrj.2014.02.001.
    1. Cattell RB. The Scree Test For The Number Of Factors. Multivariate Behav Res. 1966;1(2):245–276. doi: 10.1207/s15327906mbr0102_10.
    1. Cattell RB, Vogelmann S. A Comprehensive Trial Of The Scree And Kg Criteria For Determining The Number Of Factors. Multivariate Behav Res. 1977;12(3):289–325. doi: 10.1207/s15327906mbr1203_2.
    1. Durbin J, Watson GS. Testing for serial correlation in least squares regression. II. Biometrika. 1951;38(1–2):159–178. doi: 10.1093/biomet/38.1-2.159.
    1. White H. A heteroskedasticity-consistent covariance matrix estimator and a direct test for heteroskedasticity. Econometrica. 1980;48(4):817–838. doi: 10.2307/1912934.
    1. Bhatraju PK, Ghassemieh BJ, Nichols M, Kim R, Jerome KR, Nalla AK, et al. Covid-19 in Critically Ill Patients in the Seattle Region-Case Series. N Engl J Med. 2020;382(21):2012–2022. doi: 10.1056/NEJMoa2004500.
    1. Gattinoni L, Coppola S, Cressoni M, Busana M, Rossi S, Chiumello D. COVID-19 Does Not Lead to a « Typical » Acute Respiratory Distress Syndrome. Am J Respir Crit Care Med. 2020;201(10):1299–1300. doi: 10.1164/rccm.202003-0817LE.
    1. Maggi E, Canonica GW, Moretta L. COVID-19: unanswered questions on immune response and pathogenesis. J Allergy Clin Immunol. 2020;146(1):18–22. doi: 10.1016/j.jaci.2020.05.001.
    1. Lang FM, Lee KM-C, Teijaro JR, Becher B, Hamilton JA. GM-CSF-based treatments in COVID-19: reconciling opposing therapeutic approaches. Nat Rev Immunol. 2020;20(8):507-514.
    1. Stanley E, Lieschke GJ, Grail D, Metcalf D, Hodgson G, Gall JA, et al. Granulocyte/macrophage colony-stimulating factor-deficient mice show no major perturbation of hematopoiesis but develop a characteristic pulmonary pathology. Proc Natl Acad Sci USA. 1994;91(12):5592–5596. doi: 10.1073/pnas.91.12.5592.
    1. Zhou Y, Fu B, Zheng X, Wang D, Zhao C, Qi Y, et al. Aberrant pathogenic GM-CSF + T cells and inflammatory CD14 + CD16 + monocytes in severe pulmonary syndrome patients of a new coronavirus. bioRxiv. 2020;2020.02.12.945576.
    1. Mehta P, Porter JC, Manson JJ, Isaacs JD, Openshaw PJM, McInnes IB, et al. Therapeutic blockade of granulocyte macrophage colony-stimulating factor in COVID-19-associated hyperinflammation: challenges and opportunities. Lancet Respir Med. 2020;8(8):822–830. doi: 10.1016/S2213-2600(20)30267-8.
    1. Oliviero A, de Castro F, Coperchini F, Chiovato L, Rotondi M. COVID-19 Pulmonary and Olfactory Dysfunctions: Is the Chemokine CXCL10 the Common Denominator? Neuroscientist. 2020;1073858420939033.
    1. Wong CK, Lam CWK, Wu AKL, Ip WK, Lee NLS, Chan IHS, et al. Plasma inflammatory cytokines and chemokines in severe acute respiratory syndrome. Clin Exp Immunol. 2004;136(1):95–103. doi: 10.1111/j.1365-2249.2004.02415.x.
    1. Yang Y, Shen C, Li J, Yuan J, Wei J, Huang F, et al. Plasma IP-10 and MCP-3 levels are highly associated with disease severity and predict the progression of COVID-19. J Allergy Clin Immunol. 2020;146(1):119-127.e4. doi: 10.1016/j.jaci.2020.04.027.
    1. Lev S, Gottesman T, Levin GS, Lederfein D, Berkov E, Diker D, et al. Real-time IP-10 measurements as a new tool for inflammation regulation within a clinical decision support protocol for managing severe COVID-19 patients. medRxiv. 22 juill 2020;2020.07.21.20158782.
    1. Ichikawa A, Kuba K, Morita M, Chida S, Tezuka H, Hara H, et al. CXCL10-CXCR3 enhances the development of neutrophil-mediated fulminant lung injury of viral and nonviral origin. Am J Respir Crit Care Med. 2013;187(1):65–77. doi: 10.1164/rccm.201203-0508OC.
    1. Brands X, Haak BW, Klarenbeek AM, Otto NA, Faber DR, Lutter R, et al. Concurrent immune suppression and hyperinflammation in patients with community-acquired pneumonia. Front Immunol. 2020;11:796. doi: 10.3389/fimmu.2020.00796.
    1. Neumann C, Scheffold A, Rutz S. Functions and regulation of T cell-derived interleukin-10. Semin Immunol. 2019;44:101344. doi: 10.1016/j.smim.2019.101344.
    1. Sterner RM, Sakemura R, Cox MJ, Yang N, Khadka RH, Forsman CL, et al. GM-CSF inhibition reduces cytokine release syndrome and neuroinflammation but enhances CAR-T cell function in xenografts. Blood. 2019;133(7):697–709. doi: 10.1182/blood-2018-10-881722.

Source: PubMed

Patrocinadores y Colaboradores

Condiciones médicas

Intervenciones de drogas

3
Suscribir