key: cord-0841098-qiey2pw7 authors: Devarajan, Asokan; Vaseghi, Marmar title: Hydroxychloroquine Can Potentially Interferes with Immune Function in COVID-19 patients: Mechanisms and Insights date: 2020-11-30 journal: Redox Biol DOI: 10.1016/j.redox.2020.101810 sha: fdec16d8d77b35b35e2c5cd81407b284cf0ca67e doc_id: 841098 cord_uid: qiey2pw7 The recent global pandemic due to COVID-19 is caused by a corona family virus, SARS-CoV-2 (Severe Acute Respiratory Syndrome Coronavirus 2). Despite rigorous efforts worldwide to control the spread and human to human transmission of this virus, incidence and death due to COVID-19 continue to rise. Several drugs have been tested for treatment of COVID-19, including hydroxychloroquine. While a number of studies have shown that hydroxychloroquine can prolong QT interval, potentially increasing risk of ventricular arrhythmias and Torsade de Pointes, its effects on immune cell function have not been extensively examined. In the current review, an overview of coronaviruses, viral entry and pathogenicity, immunity upon coronavirus infection, and current therapy options for COVID-19 are briefly discussed. Further based on preclinical studies, we provide evidence that i) hydroxychloroquine impairs autophagy, which leads to accumulation of damaged/oxidized cytoplasmic constituents and interferes with cellular homeostasis, ii) this impaired autophagy in part reduces antigen processing and presentation to immune cells and iii) inhibition of endosome-lysosome system acidification by hydroxychloroquine not only impairs the phagocytosis process, but also potentially alters pulmonary surfactants in the lungs. Therefore, it is likely that hydroxychloroquine treatment may in fact impair host immunity in response to SARS-CoV-2, especially in elderly patients or those with co-morbidities. Further, this review provides a rationale for developing and selecting antiviral drugs and includes a brief review of traditional strategies combined with new drugs to combat COVID-19. Currently, there are no proven antiviral medications/therapies available for COVID-19, and treatment guidelines for COVID-19 vary between countries. The WHO guidelines are, in general, recommending supportive care with management of symptoms, and advise caution with pregnant women, pediatric patients, and patients who have significant co-morbidities. In the current review, an overview of coronaviruses, viral entry and pathogenicity, immunity upon coronavirus infection, and current therapeutic options for COVID-19 are briefly discussed. We provide preclinical evidence suggesting that hydroxychloroquine (HCQ)/chloroquine (CQ) interferes with host immune function and impacts the in vivo immune response to SARS-CoV-2, especially in the elderly and patients with co-morbidities, providing insight as to its lack of clinical efficacy against SARS-CoV-2, 4 despite promising ex vivo data. Coronaviruses (CoVs) are the largest group of viruses belonging to the Nidovirales order and Coronaviridae family. Coronaviridae is further divided into two subfamilies, Coronavirinae and Torovirinae. The alpha, beta, gamma, and delta coronaviruses belong to Coronavirinae. There are seven coronaviruses that infect humans and have been identified since the mid-1960s. They consist of 1) 229E (alpha coronavirus), 2) NL63 (alpha coronavirus), 3) OC43 (beta coronavirus), 4) HKU1 (beta coronavirus), 5) MERS-CoV (the beta coronavirus), 6) SARS-CoV (the beta coronavirus) and 7) SARS-CoV2 (the beta coronavirus COVID-19) 5, 6, 7 . Figure 1 depicts the coronavirus structure and genome. Coronaviruses contain an RNA genome with a molecular weight of ∼30 kb. This genome consist of a 5′ cap structure with a 3′ poly (A) tail, which allows translation of viral proteins including the i) spike (S), ii) membrane (M), iii) J o u r n a l P r e -p r o o f 4 envelope (E) and iv) nucleocapsid (N) proteins. The homotrimer of S protein has a molecular weight of 150 kDa, with N-linked glycosylation which forms the spike-like structure on the surface of the virus (3). The M protein has a molecular weight of 25-30 kDa, which has 3 transmembrane domains and gives the viron its shape. The E protein is present in small quantities within the virion, has a molecular weight of approximately 8-12 kDa, facilitates assembly and release of the virus, and also has ion channel activity. Another structural protein, the hemagglutinin-esterase, is present in a subset of β-coronaviruses, binds with sialic acids on the surface of glycoproteins, and also has acetyl-esterase activity 7, 8 . The virus initially binds to the host cell's receptor via the S protein, and more specifically, the S1 domain/subunit of S protein. Depending on the type of coronavirus, the receptor-binding domains (RBD) within the S1 subunit/region can vary 9 . The S-protein-receptor interaction governs the tissue tropism of the virus. As seen in table 1 host cells receptors also vary depending on the type of coronavirus 7 . For example, angiotensin-converting enzyme 2 (ACE2) serves as the receptor for the SARS-CoV and HCoV-NL63, whereas dipeptidylpeptidase 4 serves as the receptor for MERS-CoV. Subsequently, the virus enters the cytosol by acid-dependent proteolytic cleavage of the S protein, primarily by the protease cathepsin, though other proteases can play this role. Finally, fusion of the viral and host cellular membranes occur in the acidified endosome of the host cell, ultimately releasing the viral genome into the cytoplasm. Following replication and assembly, virions are transported to the cell surface in vesicles and released by exocytosis 7 . Upon viral infection with the SARS-CoV, the APC process the viral antigen and present the processed antigen to the T-cells by MHC class 1 10, 11 . Antigen presentation activates humoral and cellular immunity responses by B and T cells, respectively. The antibody profiles against the SARS-CoV2 virus have a typical pattern of IgM and IgG production. Predominantly, S and N specific antibodies are produced. The SARS-specific IgM antibodies disappear at the end of week 12, whereas the IgG antibodies can last for a long time, suggesting that the IgG antibodies may have a protective role 12, 13 . From infection to onset of symptomatic illness generally occurs within 12 days. The clinical symptoms of COVID-19 are heterogeneous and range from mild flu-like symptoms to rapidly developing acute respiratory distress syndrome (ARDS), respiratory failure, sepsis driven cardiac injury and arrhythmias, J o u r n a l P r e -p r o o f 5 septic shock, and multiple organ failure, which can eventually cause death 14, 15, 16, 17 . The most common symptoms of COVID-19 are fever, cough, headache, fatigue, shortness of breath and leukopenia. Nausea and diarrhea can also occur, but are observed less commonly. Currently, the detection of SARS-CoV-2 viral RNA is the primary method for diagnosis of COVID-19. A secondary treatment strategy aims to reduce the inflammatory reponse that occurs in COVID-19 and is the cause of significantly morbitity and motraltiy. Tocilizumab (TCZ) specifically binds to soluble and membrane-bound IL-6 receptors (IL-6R), leading to the reduction of IL-6 mediated pro-inflammatory signaling. TCZ treatment improved clinical status such as hypoxemia and severity of CT lung imaging findings in severe COVID-19 patients in a small observational study 29, 33 . A retrospective study suggested that TCZ treatment reduced inflammatory markers, such as IL6 and C-reactive protein, in moderate-to-critically ill COVID-19 patients 29 . Further, different retrospective cohort studies have revealed that TCZ treatment significantly reduced the duration of vasopressor support in hypoxic COVID-19 patients compared to patients who did not receive TCZ 29 . However, Roche's phase III clinical trial of TCZ failed to show improvements in recovery or mortality when used alone for treatment of COVID 19 34 . On the other hand, a non-randomized study evaluating the benefit methylprednisolone (a steroid) followed by TCZ treatment (in case of insufficient improvement) compared to historical controls showed accelerated respiratory recovery, decreased hospital mortality rates, and reduced invasive mechanical ventilation in COVID-19-associated cytokine storm syndrome 35 . Therefore, the role of TCZ at this point in time in treatment of COVID-19 is unclear. Finally, dexamethasone, a different steroid, has also been used to reduce the inflammatory response in COVID-19 pateints. A recent study suggests that COVID-19 patients who have received dexamethasone had a lower incidence of death as compared to usual care 36 . Deficiency of ACE2 expression/activity increases angiotensin II levels, which further triggers interstitial fibrosis, endothelial dysfunction, inflammation, obesity-associated hypertension, and coagulation. In a lung injury model, spike protein of SARS-CoV was shown to downregulate ACE2 levels, which lead to further deterioration of lung function, an effect that was ameliorated by angiotensin-receptor blocker medications 56 . HCQ and CQ have been reported to reduce the glycosylation of ACE2 in host cells, which is essential for its activity 57, 58, 59 . In addition, by interfereing with endocytosis, HCQ and CQ can inhibit pulmonary surfactant production. Pulmonary surfactants are macromolecules secreted by exocytosis of lamellar bodies and recycled via endocytosis by type II alveolar epithelial cells. These macromolecules are critical in controlling the alveolar surface tesnsion to maintain optimal gas exchanage and prevent alveolar collapse at end-expriation 60, 61 . It is also important to note that for treatment of COVID-19, HCQ and CQ cytotoxic and viral replication inhibition assays were tested with only one type of cell line (Vero, kidney cell line) 42 HCQ, and at times, CQ, are used for treatment of rheumatoid arthritis and malaria, and their use is well supported by pre-clinical studies 84, 85 . However, unlike COVID-19, rheumatoid arthritis (RA) is an autoimmune disease characterized by synovial inflammation and joint destruction. HCQ is used to suppresses immune cell function 86 . Underlying lung and other organ dysfunction/failure is not commonly associated with RA, as it in COVID-19, in whom notable heart and lung injury as well as secondary lymphoid organs damage have been reported, 87 and therefore, results observed in treatment of RA are not directly applicable COVID-19. Of note, HCQ has been reported to increase risk of heart failure in patients with rheumatoid arthritis 88 . A recent multicenter, retrospective study of HCQ for treatment of rheumatoid arthritris demonstrate that although HCQ had no excess risk of severe adverse events in patients acutely, long term treatment was associated with excess of cardiovascular mortality 89 . It has been also reported that administration of CQ and its analogues long-term causes adverse effects on vision, including keratopathy and retinopathy in patient with rheumatoid arthritis 91, 92 . Finally, CQ treatment is associated with ototoxicity, including sensorineural hearing loss, tinnitus, and cochleovestibular manifestations 93 Both HCQ and CQ are also used to treat malaria. In this setting, HCQ and CQ alkalinize the food vacuoles in the plasmodium parasite, which eventually blocks the digestive mechanisms may be important to alleviate the oxidative burst that is formed during phagocytic processes thereby preventing organs injury and cell death 105 . 106, 107, 108 . 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