key: cord-0949962-lnws9tzu authors: Liu, Wang-Da; Chang, Sui-Yuan; Lan, Ting-Yuan; Lin, Yen-Chun; Kao, Jui-Hung; Liao, Chun-Hua; Tsai, Ming-Jui; Kuo, Po-Hsien; Huang, Yu-Shan; Wang, Jann-Tay; Sheng, Wang-Huei; Hsieh, Song-Chou; Chiang, Bor-Luen; Chen, Yee-Chun; Chang, Shan-Chwen title: Experience of the Use of Hydroxychloroquine on Patients with COVID-19: A Perspective on Viral Load and Cytokine Kinetics date: 2020-08-25 journal: J Formos Med Assoc DOI: 10.1016/j.jfma.2020.08.022 sha: 36c4c35c8715d9feecf604049cd88498935dfbe1 doc_id: 949962 cord_uid: lnws9tzu Abstract Until now, there are no approved treatment against COVID-19. Hydroxychloroquine (HCQ) was hypothesized to be active against SARS-CoV2 via antiviral and anti-inflammatory effect; however, HCQ for COVID-19 in clinical use remained debating. In this preliminary report, we presented six patients with mild to moderate COVID-19. They were treated with HCQ for 14 days from the day of COVID-19 diagnosis. Serial viral load from respiratory specimens were performed every other day. Cytokine profile was checked before HCQ initiation and on the 14th day of HCQ treatment. All patients receiving HCQ completed 14-day course without complication. Among the six patients, the mean duration from symptom onset to last detectable viral load was 34 ± 12 days, which was similar to those without specific treatment in previous reports. Low level of interferon-gamma was noted in all patients of different stage of infection and three patients had elevation of IL-17 level. Prolonged virus shedding is still observed regardless HCQ. The impact of HCQ on cytokine kinetics remained unclear; however, IL-17 could be an inflammatory marker for disease status monitor and a potential therapeutic target. Coronavirus disease 2019 (COVID-19) has caused catastrophic pandemics since late 2019, with clinical features from asymptomatic infection to multiorgan failure owing to cytokine storm. Until now, there are no approved treatments against COVID-19, while many drugs have been hypothesized to be active via antiviral or anti-inflammatory effect. 1 Hydroxychloroquine (HCQ) was theoretically to be actively against SARS-CoV-2 via interfering with the glycosylation of ACE2, blocking virus/cell fusion and inhibiting lysosomal activity by increasing intracellular pH level, and have anti-inflammatory effect by inhibiting the production and release of TNF and IL- 6. 2 Animal studies had demonstrated HCQ can efficiently inhibit SARS-CoV-2 infection in vitro, along with its anti-inflammatory function. 3 However, a previous retrospective study revealed that treatment with hydroxychloroquine, azithromycin, or both was not associated with significantly lower in-hospital mortality among COVID-19 patients. 4 Until now, efficacy of HCQ against SARS-CoV-2 infection remained debating. Besides, associated discussion of viral load kinetics after HCQ treatment is rare. Here we present six patients of mild to moderate COVID-19, with comprehensive virology and cytokine data. Between January 2020 and April 2020, there were 17 confirmed cases of COVID-19 hospitalized at National Taiwan University Hospital. They were confirmed through reverse transcription-polymerase chain reaction (RT-PCR) test of SARS-CoV-2 envelope (E), nucleocapsid (N), and RNA-dependent RNA polymerase (RdRp) gene. Six of them were prescribed with HCQ upon admission, with a loading dose of 400mg twice daily for the first seven days, and followed by 200mg twice daily for another seven days. Azithromycin was not given due to potential cardiac toxicity in the context of co-administration with HCQ. During hospitalization, blood tests for hemogram, C-reactive protein, ferritin were checked twice per week, including the period of HCQ treatment. Cytokine profile was checked before HCQ initiation and on the 14 th day of HCQ treatment. Chest radiograph were arranged once per week. Sputum, nasal swab and throat swab specimens were collected for examinations of SARS-CoV-2 RT-PCR every other day. Plasmid DNA containing the SARS-CoV-2 targeted E gene, was used to construct the standard curve to estimate the SARS-CoV-2 viral load by real-time RT-PCR tests. The demographic features of the patients are presented in the Table. Most of them were young female. All patients had mild respiratory symptoms before J o u r n a l P r e -p r o o f admission. None of them had respiratory distress. Initially, no leukocytosis or elevated C-reactive protein level was noted. At presentation, only one patient (Case 1) had fever (38.3℃) with chills, and her chest radiography revealed increasing infiltration over bilateral lung fields. The other five patients had normal chest X-ray image upon admission. Fever and airway symptoms of all six patients resolved within a week after admission. No new subjective discomfort, including nausea, abdominal pain, diarrhea or palpitation, was complained during HCQ therapy. All patients were discharged without complication after three consecutive sets of negative RT-PCR results from sputum, nasal swab and throat swab specimens. Virology data from upper and lower airway specimens are presented in Figure. Those with more serious symptoms and admitted in the early stage of clinical symptoms tend to have higher viral loads of sputum specimens (Case 1-3, >10 5 copies/mL), compared with those who were admitted in their late stage of infection. (Case 4-6, <10 3 copies/mL). Of Case 1, 2 and 3, viral load from upper airway specimens showed a decrease of 2 logs or more within seven days after starting HCQ treatment. Among the six patients, the mean duration from symptom onset to last detectable viral load was 34 ± 12 days. All six patients were found to have extremely low titers of interferon-gamma (IFN-γ) upon admission and on the 14 th day of HCQ therapy. Most of the cytokines we J o u r n a l P r e -p r o o f checked upon admission were in low titers or undetectable; except for Case 5, who was admitted 14 days after initial symptom onset and was found to have a high IL-17 level. Three of the six patients were found to have mildly elevated IL-17 level after 14-day HCQ treatment. Mild elevated IL-6 level was observed in four of six patients upon their admission, and all patients had low level or undetectable IL-6 after HCQ treatment. Our study echoes the finding that the administration of HCQ is not associated with acceleration of virus clearance. Among our patients, three with initial higher viral load showed a decrease of 2 logs or more in their viral loads within seven days after starting HCQ treatment, which was similar to previous reports of patients without any antiviral or antiinflammation medications. 7 11 Our study demonstrated the immune response was impaired not only found in type I and III interferon, but also found in type II interferon. Our case series demonstrated our experience of HCQ use in patients with mild to moderate COVID-19. Prolonged virus shedding is still observed regardless of HCQ. The impact of HCQ on cytokine kinetics remained unclear; however, IL-17 could be an inflammatory marker for disease status monitor and a potential therapeutic target. LDH, lactate dehydrogenase; CK, creatine kinase; IL, interleukin; IFN-γ, interferon gamma; TNF, tumor necrosis factor * SARS-CoV-2 specific IgG could be detected from the serum sampled upon admission. Prescribing COVID-19 treatments: what we should never forget A review on possible modes of actions of Chloroquine/ Hydroxychloroquine: Repurposing against SAR-COV-2 (COVID 19) pandemic Hydroxychloroquine, a less toxic derivative of chloroquine, is effective in inhibiting SARS-CoV-2 infection in vitro Association of Treatment With Hydroxychloroquine or Azithromycin With In-Hospital Mortality in Patients With COVID-19 in New York State Hydroxychloroquine in patients with mainly mild to moderate coronavirus disease 2019: open label, randomised controlled trial Prolonged virus shedding even after seroconversion in a patient with COVID-19 Virological assessment of hospitalized patients with COVID-2019 Could IL-17 represent a new therapeutic target for the treatment and/or management of COVID-19-related respiratory syndrome Hydroxychloroquine Inhibits the Differentiation of Th17 Cells in Systemic Lupus Erythematosus Imbalanced Host Response to SARS-CoV-2 Drives Development of COVID-19 This study is supported by National Taiwan University Hospital TOP DOWN Project (NO. 109-P13 and NO. 109-P14).