ABSTRACT
Background: The pathogenesis of neuropsychiatric symptoms persisting months after acute SARS-CoV-2 infection is poorly understood. We examined clinical and laboratory parameters in participants with post-acute COVID-19 neuropsychiatric symptom to assess for systemic and nervous system immune perturbations. Methods: Participants with a history of laboratory confirmed COVID-19 and ongoing neurologic symptoms were enrolled in an observational study that collected medical history;detailed post-COVID symptom survey;and paired cerebrospinal fluid (CSF) and blood. In addition to standard clinical labs, neopterin and anti-SARS-CoV-2 antibodies (anti-spike, RBD, and nucleocapsid) were measured by ELISA. Non-parametric tests were used to compare CSF and blood findings between the post-COVID participants and pre-COVID-19 era healthy controls. Results: Post-COVID participants (n=27) and controls (n=21) were similar in age (median 51 and 46 years), but there was a greater proportion of females (67% vs 24%;p=0.004) and white participants in the post-COVID cohort (63% vs 24%;p=0.04). The post-COVID study visit was a median of 264 days (IQR 59-332) after acute COVID-19 symptom onset. 35% were hospitalized during their acute illness;12% required intensive care. 33% had previously been treated with medications for mental health conditions. The most frequent neuropsychiatric symptoms were cognitive impairment (67%), mood symptoms (67%), headache (56%), and neuropathy (41%). Blood c-reactive protein, T cell count, and T cell subset frequency (CD4% and CD8%) were similar between groups, while D-dimer was higher in the post-COVID cohort (median 0.48 vs 0.27 mg/L;p = 0.019) (Figure). CSF WBC, protein, neopterin, and CSF/blood albumin ratio were similar between the groups;the frequency of CSF lymphocytes was lower in the post-COVID cohort (p = 0.05) (Figure 1). Antibodies against at least one SARS-CoV-2 antigen were detected in 7/10 CSF and 8/9 blood samples in the post-COVID CSF (antibody reactivity range 1.5 to 55-fold greater than to control antigens). Conclusion: In this small cohort of post-COVID participants with neurologic symptoms, we found limited differences in CSF and blood markers when compared to pre-pandemic healthy controls. Deeper immunophenotyping in a larger number of participants may provide greater insight into subtle differences. The presence of anti-SARS-CoV-2 antibodies in CSF months after acute infection warrants further investigation.
ABSTRACT
Cancer patients display immunomodulation related to malignancy and anti-cancer therapies, but how these factors impact COVID-19 remains unknown. To investigate immune responses in cancer patients with COVID-19, we undertook a prospective case-control study, enrolling hospitalized solid tumor patients with acute COVID-19, as well as age-, gender-, and comorbidity-matched COVID-19 patients without cancer as controls. Using biospecimens collected during hospitalization, we performed virologic measurements as well as in-depth immunophenotyping of cellular, antibody and cytokine responses. We enrolled 17 cancer patients (cases) admitted to Yale-New Haven Hospital between March 15 and June 30, 2020 with COVID-19, as well as 17 matched non-cancer patients (controls) admitted with COVID-19. No significant differences were observed between cases and controls based on patient characteristics (age, gender, race, co-morbidities, smoking history, days from symptom onset to COVID-19 diagnosis) or outcomes (COVID-19 severity, length of hospital stay, rate of intubation or mortality). The most common primary tumor sites were lung (4/17) and gastrointestinal (4/17);all cases had received cancer-directed therapy within 6 months of COVID-19 diagnosis, with 13/17 receiving treatment less than 1 month prior to hospitalization. Three of 17 cases had received immune checkpoint inhibitor therapies. Despite having similar SARS-CoV-2 viral RNA loads at the time of COVID-19 diagnosis when compared with controls, cancer cases had increased viral RNA abundance during hospitalization, suggesting slower clearance. Antibody responses against SARS-CoV-2 were preserved in cancer cases, with cases displaying similar levels of IgM and IgG antibodies directed against SARS-CoV-2 epitopes compared to controls. Cytokine profiling revealed higher plasma levels of CCL3, IL1A and CXCL12 in cancer cases compared to controls. Using flow cytometric immunophenotyping, we found that innate immune and non-T cell adaptive immune parameters were similar between cases and controls hospitalized with COVID-19. However, among cancer cases on conventional therapies, T cell lymphopenia was more profound, and these cases demonstrated higher levels of CD8+ exhausted (CD8+CD45RA-PD1+TIM3+ ), CD8+GranzymeB+ and CD4+CD38+HLA-DR+ and CD8+CD38+HLA-DR+ activated T cells when compared with controls;interestingly, these differences were not observed in patients who had received immune checkpoint inhibition. Thus, we found reduced viral RNA clearance and specific alterations in T cell and cytokine responses in cancer patients hospitalized with COVID-19 compared with matched controls with COVID-19. This dysregulated T cell response in cancer patients, which may reflect immune modulation due to chronic antigen stimulation as well as cancer therapies, may lead to altered virologic and clinical outcomes in this population.
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Background. Streptococcus pneumoniae (pneumococcus) is a common colonizer of the upper respiratory tract and can progress to cause invasive and mucosal disease. Additionally, infection with pneumococcus can complicate respiratory viral infections (influenza, respiratory syncytial virus, etc.) by exacerbating the initial disease. Limited data exist describing the potential relationship of SARS-CoV-2 infection with pneumococcus and the role of co-infection in influencing COVID-19 severity. Methods. Inpatients and healthcare workers testing positive for SARS-CoV-2 during March-August 2020 were tested for pneumococcus through culture-enrichment of saliva followed by RT-qPCR (to identify carriage) and for inpatients only, serotype-specific urine antigen detection (UAD) assays (to identify pneumococcal pneumonia). A multinomial multivariate regression model was used to examine the relationship between pneumococcal detection and COVID-19 severity. Results. Among the 126 subjects who tested positive for SARS-CoV-2, the median age was 62 years;54.9% of subjects were male;88.89% were inpatients;23.5% had an ICU stay;and 13.5% died. Pneumococcus was detected in 17 subjects (13.5%) by any method, including 5 subjects (4.0%) by RT-qPCR and 12 subjects (13.6%) by UAD. Little to no bacterial growth was observed on 21/235 culture plates. Detection by UAD was associated with both moderate and severe COVID-19 disease while RT-qPCR detection in saliva was not associated with severity. None of the 12 individuals who were UAD-positive died. Conclusion. Pneumococcal pneumonia (as determined by UAD) continues to occur during the ongoing pandemic and may be associated with more serious COVID-19 outcomes. Detection of pneumococcal carriage may be masked by high levels of antibiotic use. Future studies should better characterize the relationship between pneumococcus and SARS-CoV-2 across all disease severity levels.
ABSTRACT
Background: One third of COVID-19 patients develop significant neurological symptoms, yet SARS-CoV-2 is rarely detected in central nervous system (CNS) tissue, suggesting a potential role for parainfectious processes, including neuroimmune responses. Methods: We examined immune parameters in CSF and blood samples from a cohort of hospitalized patients with COVID-19 and significant neurological complications (n=6), compared to SARS-CoV-2 uninfected controls (Fig1A). Immune cells were characterized by single cell RNA and repertoire sequencing. Intrathecal antibodies were assessed for anti-viral and auto-reactivity by ELISA, mouse brain immunostaining, phage display, and IP-MS. Results: Through single cell and parallel cytokine analyses of CSF and paired plasma, we found divergent T cell responses in the CNS compartment, including increased levels of IL-1B and IL-12-associated innate and adaptive immune cell activation (Fig1B). We found evidence of clonal expansion of B cells in the CSF, with B cell receptor sequences that were unique from those observed in peripheral blood B cells (Fig1C), suggesting a divergent intrathecal humoral response to SARS-CoV-2. Indeed, all COVID-19 cases examined had anti-SARS-antibodies. Next, we directly examined whether CSF resident antibodies targeted self-antigens and found a significant burden of CNS autoimmunity, with the CSF from most patients recognizing neural self-antigens. COVID-19 CSF produced immunoreactive staining of specific anatomic regions of the brain including cortical neurons, olfactory bulb, thalamus, and cerebral vasculature. Finally, we produced a panel of monoclonal antibodies from patients' CSF and peripheral blood, and show that these target both anti-viral and anti-neural antigens-including one CSF-derived mAb specific for the spike protein that also recognizes neural tissue (Fig1D). Conclusion: This immune survey reveals evidence of a compartmentalized and self-reactive immune response in the CNS in COVID-19 patients with neurologic symptoms. We identified both innate and adaptive anti-viral immune responses, as well as humoral autoimmunity that appears to be unique to the CNS during SARS-CoV-2 infection. These data suggest a potential role for autoimmunity in contributing to neurological symptoms, and merit further investigation to the potential role of autoantibodies in post-acute COVID-19 neurological symptoms.
ABSTRACT
Background: Public health emergencies increase stress, anxiety, and fear, and older adults and those with pre-existing conditions may be especially vulnerable. We used a survey-based pilot study to explore the psychosocial impact of COVID-19 on older PLWH and correlate the level of COVID-19 related distress with baseline HIV disease metrics. Methods: Participants were PLWH > age 50 who had previously (2017-2020) enrolled in the HARC HIV biorepository study at Yale. 48 PLWH were contacted and 22 participated in this study, conducted Aug-Sep 2020. An 8-part survey was administered to inquire about COVID-19 exposure, financial distress, medication adherence/medical follow-up, social support, substance use, and mood symptoms (Table 1). Cross-sectional analysis was performed on results at the time of survey administration, and longitudinal analysis was performed to compare anxiety (GAD-7), alcohol/drug use (ASSIST), and depression (CES-D) to baseline values obtained pre-pandemic (median 1.3 years prior). Results: Participant demographics are reported in Table 1. 2 participants reported having been diagnosed with COVID-19, 1 of whom had a known COVID-19 positive contact. 68% of participants were retired and reported no changes to their work due to COVID-19, and most reported moderate (4.1 on scale of 0-7) financial distress. Most reported excellent medication adherence, with 77% reporting no missed doses. 95% stated they felt “very well supported” by their primary HIV care providers, with 18% saying their care was improved during COVID-19. Only 18% felt their care was “somewhat worse.” Most participants also scored highly on the social support scale, with an average score of 11 out of 14. There were no significant differences between pre-pandemic and current scores for anxiety, alcohol/drug use, and depression, and there was no correlation between baseline HIV metrics and current level of distress. However, there was an association between COVID-19-associated worsening in GAD-7 score and a history of substance use disorder (p = 0.02). Conclusion: These results suggest that overall, most participants were doing well with excellent medication adherence and no significant changes in scores for anxiety, depression, and substance use, but that older PLWH with a history of substance use disorder had a greater risk for increased anxiety during COVID- 19. These findings can help identify groups who may be the most at-risk to experience distress from a second wave of COVID-19 and put support measures in place.
ABSTRACT
Background: Smell loss has been recognized as an important, and potentially early, sign of COVID-19. However, to date smell loss has only been assessed in retrospective, COVID+ cohorts, and largely through self-report. The objective of this study was to implement a daily standardized behavioral test of smell sensitivity in healthcare workers (HCW) to capture changes in smell sensitivity over time and to assess whether these changes occur prior to positive COVID test. Methods: The study enrolled 500 high-risk COVID-negative HCW during the COVID-19 epidemic in Connecticut, beginning March 28, 2020 (80% F, mean age 38, 58% nurses). Initially, HCW received a daily symptom questionnaire with parosmia screening questions. On April 23 we introduced the “Jiffy”, a daily at-home psychophysical test of smell sensitivity, where olfactory stimuli are sampled and rated for perceived intensity. SARS-CoV-2 infection was tested every three days by PCR of nasopharyngeal swabs or saliva Results: Of the first 500 enrolled HCW, 376 HCW (75%) completed the Jiffy 4528 times (mean 12 times/HCW). 17/500 HCW (3.4%) had a COVID+ test, of which 9/17 (53%) reported smell loss through the Jiffy or the daily symptom survey. 6/9 (67%) reported smell loss that preceded or was concurrent with a COVID+ test. 8/17 COVID+ HCW completed the Jiffy, with 5/8 (63%) reporting reductions in smell versus 42/368 (11%) COVID- HCW (OR=13, 95% CI: 2.4-85, p=.001). COVID+ HCW rated their greatest reduction in smell sensitivity as slight (40%) and severe (60%), versus slight (88%) and moderate (12%) in COVID- HCW. 16/17 COVID+ HCW completed a daily symptom survey (mean 14 times/HCW), with 8/16 (50%) ever reporting parosmia versus 90/466 (19%) of COVID- HCW (OR=4.2, 95% CI: 1.3-13, p=.007). Overall, parosmia was the first reported symptom in 3/13 (23%) COVID+ HCW who reported symptoms. Conclusion: We conducted a prospective study of smell testing in a population at high risk for COVID-19 using two parallel approaches. Our results demonstrate the feasibility of at-home smell testing for assessing parosmia during COVID-19, in some cases even prior to a positive PCR result. Given the urgent need for widespread, lowcost, non-invasive testing for COVID-19, we are now developing an easy-to-use app to distribute this survey more widely to high-risk populations. (Table Presented).
ABSTRACT
Background: Initial CDC recommendations for passive monitoring of COVID-19 related symptoms among staff may not be sufficient in preventing the introduction and transmission of SARS-CoV-2 in healthcare settings. We therefore implemented active monitoring for SARS-CoV-2 infection in healthcare workers (HCWs) at an academic medical center during the COVID-19 epidemic in northeast US. Methods: We recruited a cohort of HCWs at Yale New Haven Hospital who worked in COVID-19 units and did not have COVID-19 related symptoms between March 28 and June 1, 2020. During follow-up, participants provided daily information on symptoms by responding to a web-based questionnaire, self-administered nasopharyngeal (NP) and saliva specimens every 3 days, and blood specimens every 14 days. We performed SARS-CoV-2 RT-PCR and an anti-spike protein IgM and IgG ELISA to identify virological and serological-confirmed infection, respectively. Results: We enrolled 525 (13%) amongst 4,136 HCW of whom daily information on symptoms and NP, saliva, and blood specimens were obtained for 66% (of 13208), 42% (or 1977), 44% (of 2071) and 65% (of 1099), respectively, of the follow-up measurement points. We identified 16 (3.0% of 525) HCWs with PCR-confirmed SARS-CoV-2 infection and an additional 12 (2.3% of 525) who were not tested by PCR or had negative PCR results but had serological evidence of infection. The overall cumulative incidence of SARS-CoV-2 infection was 5.3% (28 of 525) amongst HCWs. Cases were not identified by hospital protocols for passive staff self-monitoring for symptoms. Amongst 16 PCR-confirmed cases, 9 (56%) of the 16 PCR-confirmed HCW had symptoms during or after the date of initial detection. We did not identify an epidemiological link between the 28 confirmed cases. Conclusion: We found that a significant proportion (5.3%) of HCWs were infected with SARS-CoV-2 during the COVID-19 epidemic. In the setting of universal PPE use, infections were possibly acquired in the community rather than stemming from patient-HCW or HCW-HCW transmission. Passive monitoring of symptoms is inadequate in preventing introductions of SARS-CoV-2 into the healthcare setting due to asymptomatic and oligosymptomatic presentations.