key: cord-0918772-g260stg0 authors: XU, Bo; FAN, Cun-yu; WANG, An-lu; ZOU, Yi-long; YU, Yi-han; HE, Cong; XIA, Wen-guang; ZHANG, Ji-xian; MIAO, Qing title: Suppressed T cell-mediated immunity in patients with COVID-19: a clinical retrospective study in Wuhan, China date: 2020-04-18 journal: J Infect DOI: 10.1016/j.jinf.2020.04.012 sha: 34bb7c0b70a65346092067f7c0983de1f92ef5e2 doc_id: 918772 cord_uid: g260stg0 Abstract Importance An ongoing outbreak of COVID-19 has exhibited significant threats around the world. We found a significant decrease of T lymphocyte subsets and an increase of inflammatory cytokines of hospitalized patients with COVID-19 in clinical practice. Methods We conducted a retrospective, single-center observational study of in-hospital adult patients with confirmed COVID-19 in Hubei Provincial Hospital of traditional Chinese and Western medicine (Wuhan, China) by Mar 1, 2020. Demographic, clinical, laboratory information, especially T lymphocyte subsets and inflammatory cytokines were reported. For patients who died or discharge from hospital, the associations of T lymphocyte subsets on admission were evaluated by univariate logistic regression with odds ratios (ORs) and 95% confidence intervals (CIs), warning values to predict in-hospital death were assessed by Receiver Operator Characteristic (ROC) curves. Results A total of 187 patients were enrolled in our study from Dec 26, 2019 to Mar 1, 2020, of whom 145 were survivors (discharge= 117) or non-survivors (in-hospital death=28). All patients exhibited a significant drop of T lymphocyte subsets counts with remarkably increasing concentrations of SAA, CRP, IL-6, and IL-10 compared to normal values. The median concentrations of SAA and CRP in critically-ill patients were nearly 4- and 10-fold than those of mild-ill patients, respectively. As the severity of COVID-19 getting worse, the counts of T lymphocyte drop lower.28 patients died in hospital, the median lymphocyte, CD3+ T-cell, CD4+ T-cell, CD8+ T-cell and B-cell were significantly lower than other patients. Lower counts (/uL) of T lymphocyte subsets lymphocyte (<500), CD3+T-cell (<200), CD4+ T-cell (<100), CD8+ T-cell (<100) and B-cell (<50) were associated with higher risks of in-hospital death of CIVID-19. The warning values to predict in-hospital death of lymphocyte, CD3+ T-cell, CD4+ T-cell, CD8+ T-cell, and B-cell were 559, 235, 104, 85 and 82, respectively. Conclusion We find a significant decrease of T lymphocyte subset is positively correlated with in-hospital death and severity of illness. The decreased levels of T lymphocyte subsets reported in our study were similar with SARS but not common among other virus infection, which may be possible biomarkers for early diagnosis of COVID-19. Our findings may shed light on early warning of high risks of mortality and help early intervention and treatment of COVID-19. An ongoing outbreak of novel coronavirus disease COVID-19 has exhibited significant threats to international health and economy. COVID-19 caused by the virus SARS-Cov-2 1 . The most likely ecological reservoirs for SARS-Cov-2 are bats 2 , but it is believed that the virus transmitted from animal to human by some intermediated animal host. In China, the first case of COVID-19 was reported in Wuhan, Hubei province at Dec,2019 3 . The first series of patients in Wuhan with conformed COVID-19 worked or lived around the local Huanan seafood wholesale market 4 , selling wild animals as well. Shortly after that, infected patients exploded without contact history of the market 5 . The number of COVID-19 globally were 76769 till Feb 21, 2020, including 75569 patients in China 6 . Unfortunately, no target treatment for this virus has been proved until now. We cannot totally know of this virus and its related diseases COVID-19. Therefore, this severe infectious disease garnered great research interest. Previous clinical studies revealed the epidemiological and clinical characteristics of infected patients of special population 7 or series cases [8] [9] [10] [11] . They focused on general clinical characteristics and laboratory results of patients with confirmed COVID-19. Meanwhile, several studies reported the damaged immunity system caused by SARS-Cov-2 and a significant decrease of lymphocyte in blood routine examination. But no research focused on the T lymphocyte subsets in COVID-19. In a general way, immune system is the first to be affected with virus infection. It has been confirmed that coronavirus infectious diseases such as severe acute respiratory (SARS) and Middle East respiratory syndromes (MERS) play important roles in immunity system injury. The T-cell and B-cell immunity may predict the disease severe level of coronavirus infection as well as the clinical outcomes 12 . T lymphocyte plays a vital role in cell-mediated and humoral immunity 13 . T lymphocyte includes CD3+ T cells, Dec 26, 2019 to now, we included over hundreds of patients with conformed COVID-19. We are one of the hospitals which primary diagnosed and treated COVID-19 patients and reported this new infectious disease to Chinese Center for Disease Control and Prevention (CDC) at first. In clinical practice, we find that most patients showed significant changes of T lymphocyte subset and several inflammatory cytokines. Therefore, we are interested in the relationship between T lymphocyte subset and in-hospital death and severity of illness among hospitalized patients with COVID-19. In this study, we focus on the suppressed T lymphocyte subsets and increased inflammatory cytokines. Furthermore, we measured the association of T lymphocyte subsets and in-hospital death as well as the severity of COVID-19. For this retrospective, single-center observational study, we included patients from Dec 26, We reviewed clinical records, laboratory findings, T lymphocyte subsets, chest CT scans, severity of illness, in-hospital death for continuing 187 patients with confirmed COVID-19. All information was obtained and curated with a customized data collection form. Two clinical investigators (XU and FAN) independently reviewed the data collection forms to verify data accuracy. We extract information of 187 patients of confirmed COVID-19, including demographic data, medical history, severity of illness, clinical symptoms, signs laboratory parameters on different time points, supporting therapy (anti-virus, antibiotics, immune stimulants and respiratory support), survival states of patients. The admission time of included patients was between Dec. 26, 2019 and Mar 1, 2020. Maternal throat swab samples were collected and tested for SARS-CoV-2 of our hospital laboratory department and CDC in Wuhan, Hubei, following WHO guidelines for qRT-PCR. Positive confirmatory cases of COVID-19 infection were defined as those with a positive test result. Routine blood examinations were complete blood count, coagulation profile, serum biochemical tests (including renal and liver function, creatine kinase and electrolytes), T lymphocyte subsets CD3+ T-cell, CD4+ T-cell (CD3 + CD4 + ), CD8+ T-cell (CD3 + CD8 + ), B-cell (CD3 -CD19 + ) and NK-cell (CD3 -(CD16+CD56) + ), myocardial enzymes, interleukin-6 (IL-6), IL-1β, IL-10, serum amyloid A (SAA) and c-reactive protein (CRP). T lymphocyte subsets were measured by the flow cytometry. Chest computed tomographic (CT) scans were done for all inpatients. Frequency of examinations were determined by the physician in charge. The severity levels of COVID-2019 are measured as follows: c. multi-organs failure, need transport to intensive care unit (ICU). The continuous data was presented as median with interquartile rage (IQR), and categorical data was present as frequencies with percentages. The severity of illness was categorized with mild, severe and critically ill. Clinical data were classified and analyzed according to in-hospital death and severity of illness. We adopted Mann-Whitney U test, χ 2 test or Fisher exact test to compare differences between groups. To measure the possible association of T lymphocyte subsets with in-hospital death, we reported odd ratios (ORs) and 95% confidence intervals (CIs) which were generated by univariate logistic regression. Considering the total numbers of in-hospital death (n=28) in our study, we did not adopt multivariable analysis for reasons of potential overfitting. The possible warning values of T lymphocyte subsets counts were assessed by Receiver Operator Characteristic (ROC) curves. The area under the ROC curve (AUC), specificity and sensitivity were all reported. All reported statistics of the data were two sided with a significant difference of 5%, and CIs were reported as two sided 95% CIs. Statistical analysis of the data performed in R v3.6.1 software (http://www.R-project.org). In this study, a total of 187 patients were enrolled, including 103 (55%) males and 84 (45%) All patients were treated in separation. All patients received antivirus treatment, including (Table1-1) The Table 2 ). In critically-ill patients, the median counts of lymphocyte, CD3+ T-cell, CD4+ T-cell, and CD8+ T-cell were almost decreased to a third of median counts of mild-ill patients, which is equal to nearly half of median counts of severe-ill patients (P<0.001). (Table 1 -2 and Figure 2B ) Figure 2C ). Meanwhile, we measured the concentrations of SAA, CRP and cytokines including IL-6 and IL-10 in plasma which were produced by T cells. With the severity of illness getting worse, the concentrations of SAA, CRP and IL-10 getting much higher (P<0.001) (Figure 4 ). To be specific, the median concentration of SAA in critically-ill was nearly 4-fold to mild-ill patients. And the median concentration of CRP in critically-ill patients was nearly 10-fold to mild-ill patients. The concentrations of IL-6 and IL-10 in COVID-19 patients were higher than normal values ( Figure 4 ). We adopted univariate logistic regression to measure the OR with 95% CI of potential association of T lymphocyte subsets with in-hospital death (Table 3) . 145 patients in our study discharged or died in hospital (had outcomes). We found lower T lymphocyte subsets levels were associated with higher risk of in-hospital death. P=0.034). Furthermore, we categorized T lymphocyte subsets into different groups based on their counts. We found lower T lymphocyte subsets lymphocyte (<500/uL), CD3+T-cell (<200/uL), CD4+ T-cell (<100/uL), CD8+ T-cell (<100/uL) and B-cell (<50/uL) counts were exhibit significantly higher risk of in-hospital death. (Table 3 ). We adopted ROC curve to find the warning values of T lymphocyte subsets lymphocyte, (Table 3 ) In this study, all patients, especially in severe-ill and critically-ill including dead patients, The study has several limitations. First, we adopted this research in a retrospective method, which may limit the strength and reliability of our results. Second, all enrolled patients were from one central with inevitable selective bias. Third, not all laboratory tests were done in all patients, including IL-1β, IL-6 and IL-10. Therefore, we did not assess the association of these cytokines with in-hospital death. Fourth, considering our limited sample size, we did not include other potential risk factors such as gender and age into multivariate logistic regression to assess the risk factors of T lymphocyte subsets. This may limit the interpretations of our results. However, since we are the first hospital to admit COVID-19 patients and reported it to Chinese CDC, we believe our study population and findings are representative and reliable. To our knowledge, this is the first clinical study to exhibit significant suppressed T cell We declare no competing interests. Wen-guang XIA and Ji-xian ZHANG had the idea for and designed the study and had full access to all of the data in the study. Bo XU and Cun-yu FAN take responsibility for the integrity of the data. Qing MIAO and An-lu WANG take responsibility of accuracy of the data analysis. An-lu WANG and other authors drafted the paper and did the analysis. All authors critically revised the manuscript for important intellectual content and gave final approval for the version to be published. Bo XU and Cun-yu FAN collected the data. All authors agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. 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