key: cord-0854847-agnnywut authors: Tan, Cuiyan; Zheng, Xiaobin; Sun, Fengfei; He, Jianzhong; Shi, Honglei; Chen, Meizhu; Tu, Changli; Huang, Yiying; Wang, Zhenguo; Liang, Yingjian; Wu, Jian; liu, Ye; Liu, Jing; Huang, Jin title: Hypersensitivity may be involved in severe COVID‐19 date: 2021-10-09 journal: Clin Exp Allergy DOI: 10.1111/cea.14023 sha: 56a8c24a46f6c4ed9817cfb2d9e50c3b97a8448c doc_id: 854847 cord_uid: agnnywut BACKGROUND: Deaths attributed to Coronavirus Disease 2019 (COVID‐19) are mainly due to severe hypoxemic respiratory failure. Although the inflammatory storm has been considered the main pathogenesis of severe COVID‐19, hypersensitivity may be another important mechanism involved in severe cases, which have a perfect response to corticosteroids (CS). METHOD: We detected the serum level of anti‐SARS‐CoV‐2–spike S1 protein‐specific IgE (SP‐IgE) and anti‐SARS‐CoV‐2 nucleocapsid protein‐specific IgE (NP‐IgE) in COVID‐19. Correlation of levels of specific IgE and clinical severity were analysed. Pulmonary function test and bronchial provocation test were conducted in early convalescence of COVID‐19. We also obtained histological samples via endoscopy to detect the evidence of mast cell activation. RESULT: The levels of serum SP‐IgE and NP‐IgE were significantly higher in severe cases, and were correlated with the total lung severity scores (TLSS) and the PaO(2)/FiO(2) ratio. Nucleocapsid protein could be detected in both airway and intestinal tissues, which was stained positive together with activated mast cells, binded with IgE. Airway hyperresponsiveness (AHR) exists in the early convalescence of COVID‐19. After the application of CS in severe COVID‐19, SP‐IgE and NP‐IgE decreased, but maintained at a high level. CONCLUSION: Hypersensitivity may be involved in severe COVID‐19. respiratory distress. On the contrary, coagulopathy in multiple vascular territories may account for severity in COVID-19, either related to a systemic immunopathology. 5 As some data reported, referred to the clinical manifestation and lung CT performance, it is probably that the hypoxic respiratory failure caused by COVID-19 may be related to hypersensitivity within the lungs. 6 Mast cells (MCs) are activated by SARS-CoV-2. 7 Although only recently recognized, MC activation syndrome (MCAS), usually due to acquired MC clonality, is a chronic multisystem disorder with inflammatory and allergic themes, and an estimated prevalence of 17%. 8 Mast cells may react to viruses in collaboration with other cells and lung autopsy findings from patients that died from the coronavirus disease that emerged in 2019 showed accumulation of mast cells in the lungs that was thought to be the cause of pulmonary oedema, inflammation and thrombosis. 9 CD63 is an important surface marker of activated human blood-derived MCs. 10, 11 We herein detected the anti-SARS-CoV-2 specific immunoglobulin E (IgE) and CD63+ cells after infection. 12 The IgG antibody titres rise from day 10 onwards to reach a peak whose height is likely to be influenced, on a case-bycase basis, by disease severity and virus load. 13 IgA serum concentrations peaked 3 weeks after symptom onset but persisted for several more weeks in saliva, and serum IgA was more potent than IgG in neutralizing SARS-CoV-2. 14 However, the dynamic feature of IgE after SARS-CoV-2 infection is still unknown. Our team successfully managed 102 COVID-19 cases. Among these patients, 27 developed hypoxemic respiratory failure, but no deaths occurred. 15 We retrospectively reviewed our cases and conducted a study to investigate the pathophysiology of COVID-19. We found that various COVID-19-related clinical features, from as severe as near-fatal hypoxemic respiratory failure to as mild as gastrointestinal discomfort, might be due to hypersensitivity reactions. As the treatment for COVID-19-related hypoxemic respiratory failure, we compared specific IgE, total lung severity scores (TLSS), and the arterial oxygen tension to inspiratory oxygen concentration ratio (PaO 2 /FiO 2 ) before and after administration of pulse methylprednisolone, and found the fast improved clinical manifestation and above index, which might suppress not only inflammatory storm but also the hypersensitivity reactions. There are few studies about pulmonary function in patients with Hypersensitivity may be involved in severe COVID-19. Chest CT was performed in all subjects using 1-mm slice thickness CT on a UCT 760 scanner (United Imaging; Shanghai, China). CT images were read by two experienced specialists with over five years of experience, and were evaluated for the presence or absence of the following findings: ground-glass opacity, centrilobular nodules and high-density linear or strip shadows. The distribution of lung lobes involved was described as subpleural, central, random or diffuse. 18 Total lung severity scores (TLSS) are assessed as previously reported. 18 First, each of the five lung lobes was assessed for degree of involvement and classified as none (0%), minimal (1%-25%), mild (26%-50%), moderate (51%-75%) or severe (76%-100%). Then, no involvement corresponded to a lobe score of 0, minimal to a lobe score of 1, mild to a lobe score of 2, moderate to a lobe score of 3, and severe to a lobe score of 4. Subsequently, the total lung severity score was calculated by summing the five lobe scores (range of possible scores, 0-20). In addition, the severity of COVID-19 was assessed by PaO 2 / FiO 2 and respiratory dysfunction was defined as PaO 2 / FiO 2 less than 300 mm Hg. All biological specimens used in this study were acquired from the specimen bank of our hospital with the approval of the participants. The sera and tissues from COVID-19 patients were obtained during hospitalization and stored at -80°C and in liquid nitrogen, respectively. Sera of the control group were obtained for routine health screening several months prior to the COVID-19 outbreak. We developed an enzyme-linked immunosorbent assay (ELISA) system to measure the levels of anti-SARS-CoV-2 IgE antibodies in the serum of all participants. The ELISA is a common method in the detection of specific IgE in clinical practice. 19 However, there lacks a specific IgE kit of SARS-COV-2. We developed an indirect ELISA system to detect sera anti-SARS-CoV-2 spike protein antibody and anti-SARS-CoV-2 N protein antibody. Checkerboard titration was used to determine the optimal antigen coating concentration, serum dilution and peroxidase-conjugate secondary antibody working dilution. Good repeatability was showed in the experiment. We tried to determine a cut-off value by the detection of sera from negative control individuals (detailed information in Figure S3 ). However, because of the small sample of the control group, it may cause some bias of the result. Therefore, instead of using a "positive" or "negative" in the paper when comparing the specific IgE between groups, we would like to compare their exact value. The procedure of ELISA was as follows: The presence of SARS-CoV-2 in nasal and pharyngeal swab specimens was detected by real-time PCR assays approved by the China Food and Drug Administration. Carl Zeiss MicroImaging). At last, the immunofluorescent staining results in specimens were observed by a confocal microscope. Partial subjects underwent a standard pulmonary function test and bronchial provocation test 3 months after discharge (Master Screen; Jaeger). Body plethysmography, spirometry and impulse Statistical analysis was performed using Statistical Package for Social Science (SPSS) Version 13.0 (SPSS, Inc). The data of normal distribution were shown as the mean ±standard deviation (SD). Continuous variables were compared using an independent sample t-test, whereas the rank-sum test was used for nonparametric data. The categorical variables were expressed as count (percentage) and compared using the chi-square test. The associations between the specific IgE and TLSS, or PaO 2 /FiO 2 ratio were analysed by Pearson correlation coefficient. All statistical tests were two-tailed. Statistical significance was taken as p < .05. Further analysis showed that the significant associations between Bronchoscopy was performed on a patient with severe hypoxemic respiratory failure receiving mechanical ventilation, and bronchial mucosa tissues were obtained. Intestinal endoscopy was performed on selected patients with gastrointestinal symptoms, and intestinal mucosa tissues were obtained. As shown in Figure 2 Notably, each of the 16 critically ill patients experienced clinically significant improvements in the lung oxygenation index after each administration of systemic corticosteroids and these 16 patients all recovered without any complications. 15 Our experience is that a patient with an oxygenation index of 150 mm Hg or less should receive methylprednisolone (MP) at a dose of 4-8 mg/kg/day to block the hypersensitivity reaction in the lungs. Among these 16 patients treated with corticosteroids, we had tested SP-IgE and NP-IgE in succession. Our results indicated that the application of corticosteroids significantly decreased specific-IgE (Figure 3 ), at the same time increased the PaO 2 /FiO 2 ratio ( Figure S1 ). We found that the level of anti-SARS-CoV-2-specific IgE antibodies decreased significantly after corticosteroids, but were still higher than healthy controls in the recovery period ( Figure S2 ). In addition, we did not find the effect of corticosteroids application on SARS-CoV-2 clearance. During the follow up of COVID-19 patients, we found chest tight- The ongoing COVID-19 outbreak has caused global disruption, with great concern for the mortality rate. There is an urgent need to The risk of asthma from a severe viral infection is well documented. 40 The two major pathogens linked to asthma pathogenesis, i.e. respiratory syncytial virus and rhinovirus, are both known to potently induce the production of IgE in humans. 41, 42 It appears that IgE may act as a signalling molecule for lung conventional dendritic cells (DCs). Once an effective adaptive immune response has been generated, virus-specific IgE will be produced, bind to the conventional DCs, and be cross-linked by viral antigen. 43 (FcεRIα) expression. 44 These results support a potential mechanism that allergic sensitization is associated with increased susceptibility to virus-induced asthma exacerbations. We noticed some articles focus on the use of omalizumab in COVID-19 patients who have to co-exist asthma or urticaria. The application of omalizumab can prevent exacerbation of asthma and even the existence of pneumonia during SARS-CoV-2 infection, 45 and also alleviate symptoms of exacerbated urticarial rash and angioedema due to COVID-19 in a patient with chronic spontaneous urticaria. 46 As a recombinant human anti-IgE antibody, omalizumab is originally designed to reduce sensitivity to allergens and blocks IgE binding to FcεRI. The excellent response to omalizumab may give evidence to how IgE work on COVID-19. Glucocorticoids are well-established as the first-line therapy for type Ⅰ hypersensitivity reactions and are also effective for inhibiting the inflammatory storm. It is reported that COVID-19-associated CSS could be treated with high-dose of methylprednisolone. The use of glucocorticoids may accelerate respiratory recovery, lower hospital mortality and reduce the likelihood of invasive mechanical ventilation in COVID-19-associated CSS. 47 The same phenomenon was observed by our team. 15 In our study, we found that timely and The study has several limitations. First, due to the difference in the progression of COVID-19 between patients, it is hard to determine an appropriate time to measure IgE, TLSS and PaO 2 /FiO 2 ratio. Therefore, these patients were examined two weeks later, after admission and CS use. Second, the sample size of our study remains small. Third, some studies also found that previous allergic history (such as asthma, atopic rhinitis and allergic dermatitis) has little effect on the occurrence and severity of COVID-19, 36,48 which need further research. Although our data suggested that IgE could be used to evaluate the severity of COVID-19, more research is required to validate our findings. In addition, limited data were available and the usefulness of specific IgE in predicting mortality remains unknown. However, this research may have a good application prospect. In COVID-19 patients, anti-SARS-CoV-2-specific IgE, which mediated activated mast cells in the bronchial and intestinal mucosa, had been detected and significant correlations with the severity of patients were found. After the application of CS in severe COVID-19, anti-SARS-CoV-2-specific IgE decreased but was maintained at a high level in early convalescence, which maybe is the reason for airway hyperresponsiveness (AHR) in these patients partly. Overall, our study indicated that hypersensitivity might be involved in severe COVID-19. Not applicable. The authors of this manuscript declare no relationships with any companies whose products or services might be related to the subject matter of the article. Jin Huang and Jing Liu had full access to all of the data in the study and took responsibility for the integrity of the data and the accuracy of the data analysis, including and especially any adverse effects. Cuiyan Tan ChiCTR2000032895, Jing Liu. All data published here are under the consent for publication. The datasets generated and analysed during the present study are available from the corresponding author on a reasonable request. COVID-19 Weekly Epidemiological Update, Data as received by WHO from national authorities, as of Coronavirus in China The role of IL-6 and other mediators in the cytokine storm associated with SARS-CoV-2 infection Reduction and Functional Exhaustion of T Cells in Patients With Coronavirus Disease 2019 (COVID-19) Coagulopathy and Antiphospholipid Antibodies in Patients with Covid-19 COVID-19, A Clinical Syndrome Manifesting as Hypersensitivity Pneumonitis Mast cell and eosinophil activation are associated With COVID-19 and TLR-mediated viral inflammation: implications for an anti-siglec-8 antibody Covid-19 hyperinflammation and post-Covid-19 illness may be rooted in mast cell activation syndrome Cytokine storm syndrome in SARS-CoV-2 infections: a functional role of mast cells Mast cell activation test in the diagnosis of allergic disease and anaphylaxis Antibody responses to SARS-CoV-2 in patients with COVID-19 Antibody Responses to SARS-CoV-2 in Patients With Novel Coronavirus Disease IgA dominates the early neutralizing antibody response to SARS-CoV-2 Successful use of methylprednisolone for treating severe COVID-19 Abnormal pulmonary function in COVID-19 patients at time of hospital discharge Impact of coronavirus disease 2019 on pulmonary function in early convalescence phase Chest CT Findings in Coronavirus Disease-19 (COVID-19): Relationship to Duration of Infection Highly sensitive ELISA-based assay for quantification of allergen-specific IgE antibody levels Successful Sequential Treatment for Severe Asthma Coexisting COVID-19 via Budesonide/Glycopyrrolate/Formoterol Fumarate Impulse oscillometry: interpretation and practical applications Utility of impulse oscillometry in young children with asthma Impulse oscillometry provides an effective measure of lung dysfunction in 4-year-old children at risk for persistent asthma Comparison of the efficacy of salmeterol/fluticasone propionate combination in Japanese and Caucasian asthmatics Covid-19 autopsies Autopsy findings and venous thromboembolism in patients with COVID-19: a prospective cohort study Vander Heide RS. Pulmonary and cardiac pathology in Covid-19: the first autopsy series from New Orleans. MedRxiv Novel insights on the pulmonary vascular consequences of COVID-19 Kawasaki-like diseases and thrombotic coagulopathy in COVID-19: delayed over-activation of the STING pathway? Megakaryocytes and platelet-fibrin thrombi characterize multi-organ thrombosis at autopsy in COVID-19: A case series Interferon and cytokine responses to SARScoronavirus infection Mast cells in alveolar septa of COVID-19 patients: a pathogenic pathway that may link interstitial edema to immunothrombosis Potential association of mast cells with coronavirus disease 2019 Janeway's immunobiology. Garland science Immune Alterations in a Patient with SARS-CoV-2-Related Acute Respiratory Distress Syndrome Is asthma protective against COVID-19? Interferon at the crossroads of allergy and viral infections Dysregulated Type I Interferon and Inflammatory Monocyte-Macrophage Responses Cause Lethal Pneumonia in SARS-CoV-Infected Mice Reciprocal regulatory effects of IFN-gamma and IL-4 on the in vitro development of human Th1 and Th2 clones Viral induction of a chronic asthma phenotype and genetic segregation from the acute response Predictive value of respiratory syncytial virus-specific IgE responses for recurrent wheezing following bronchiolitis Early-life respiratory viral infections, atopic sensitization, and risk of subsequent development of persistent asthma Induction of highaffinity IgE receptor on lung dendritic cells during viral infection leads to mucous cell metaplasia Enhanced plasmacytoid dendritic cell antiviral responses after omalizumab COVID-19 in a patient with severe asthma treated with Omalizumab Chronic spontaneous urticaria exacerbation in a patient with COVID-19: rapid and excellent response to omalizumab Historically controlled comparison of glucocorticoids with or without tocilizumab versus supportive care only in patients with COVID-19-associated cytokine storm syndrome: results of the CHIC study Clinical characteristics of 182 pediatric COVID-19 patients with different severities and allergic status