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Introduction: The novel Coronavirus (SARS-CoV-2), responsible for severe acute respiratory syndrome, has emerged as a threat to humans since December 2019, and the search for a better understanding of the pathophysiology of coronavirus disease 2019 (COVID-19) and its definitive treatment is still in progress. Objective(s): To evaluate the plasma pro- and anti-inflammatory cytokines in COVID-19 patients and their associations with the disease severity and outcome. Method(s): Reverse-Transcriptase Polymerase Chain Reaction (RT-PCR)-confirmed COVID-19 unvaccinated patients at the Hospital de Clinicas (HC), UNICAMP, Campinas, SP, were enrolled. Clinical and laboratory data were extracted from the medical records, and the plasma cytokines levels were quantified using LUMINEX and ELISA. Result(s): There were 154 COVID-19 patients (99 survivors and 55 non-survivors) with male:female of 1.4:1, and a median age of 60 years. The non-survivors were older than survivors (65 vs. 55 years, p < 0.0001);and coronary artery disease and autoimmunity, disease severity, and oxygen therapy, intensive care, and intubation were associated with mortality. Non-survivors had higher leukocyte and neutrophil counts, and RDW and lower lymphocyte count at diagnosis. Non-survivors had higher levels of pro-inflammatory (TNF-alpha, IL-6, IFN-gamma, CCL3, IL-17/IL-17A, IL-8, G-CSF, CCL2/MCP-1) and anti-inflammatory (IL-1ra and IL-27) cytokines, but lower TGF-beta levels than the survivors. TNF-alpha levels were positively correlated with all studied cytokines except TGF-beta, while TGF-beta levels were negatively correlated with TNF-alpha, IL-6, CCL3, G-CSF, and IL-27. IL-27 levels were significantly correlated with all the cytokines except IL-37 and IL-17E. More than half (55.2%) of our patients had severe COVID-19, 18.8% had moderate, 16.2% had critical, 5.2% had mild, and 4.5% were asymptomatic. Majority of the patients (68.2%) required ICU care and had higher TNF-alpha, IL-6, IL-8, IL-17, CCL3, CCL2, IL-1ra, and IL-27 than others. 59.7% of the patients required endotracheal intubation and had higher TNF-alpha, IL-6, IL-8, CCL3, CCL2, and IL-1ra than those who did not have intubation. TNF-alpha, IL-6, and IL-8 had the highest Area Under the Receiver Operating Characteristics (AUROC) curve, sensitivity, and specificity for predicting mortality in these COVID-19 patients. Discussion and conclusion: The altered levels of pro- and anti-inflammatory cytokines support the role of SARS-CoV-2 in inducing cytokine storm, and higher concentrations seen in the deceased patients meant a more severe storm. Also, the increased leukocytes and neutrophils in our patients could have led to the release of reactive oxygen species, and end-organ damage, thus leading to poor outcomes. This study showed that the levels of these cytokines could be used as markers of mortality in COVID-19. It is possible to suggest that TNF, IL-6, and IL-8 levels at diagnosis could be efficient predictors of fatal outcomes in COVID-19 patients. If properly measured at diagnosis, these markers could be useful for triaging and predicting the outcome of COVID-19, thus guiding the treatment of the COVID-19. Funding(s): CNPq (#190374/2017-9), CAPES, FAPESP and FAEPEX (#338619). Copyright © 2022
ABSTRACT
Background/objective: The severity and outcome of COVID-19 are determined by the level of overstimulation of the immune response, age, and comorbidities in the patients infected by severe acute respiratory syndrome coronavirus type 2 (SARS-CoV-2). Lymphopenia is the most consistent finding that characterizes the hemogram in COVID-19 patients. We evaluated the hemogram and compared the lymphocyte count (LC),neutrophil-lymphocyte ratio (NLR), and platelet-lymphocyte ratio (PLR) at diagnosis in COVID-19 patients hospitalized at the Clinical Hospital of the State University of Campinas (UNICAMP), Campinas, São Paulo, Brazil. Methods: In this retrospective study, we reviewed the medical notes of 320 adult hospitalized patients with PCR-confirmed COVID-19 at the Clinical Hospital of UNICAMP, Campinas, from March 2020 to March 2021. The hemogram (performed using automated counter-XN 9000™, Sysmex, Japan) at COVID-19 diagnosis was analyzed, and NLR and PLR were calculated. The primary outcomes were discharge (n = 257 patients who recovered from the disease and were discharged from the hospital), and death (n = 63 those who died during treatment). Statistical analyses were performed using SPSS (version 22). Unpaired data of deceased and discharged COVID-19 patients were compared using Mann-Whitney tests. All results were significant if p < 0.05 or except otherwise stated. Results: Compared to the 257 discharged patients, the 63 deceased patients were older 56.0 vs 64.7 ys respectively, p = 0.000), the males are more in each group and the duration of hospitalization was not different (18.6 vs 19.7 days respectively, p = 0.12). The leukocyte (8.89 ± 4.50 vs 10.37 ± 7.03, p = 0.289) and platelet counts (227.00 ± 91.15 vs 197.79 ± 97.47, p = 0.119) were not significantly different in the two groups, the hematocrit was higher in the discharged than in the deceased patients (38.84 ± 6.86 vs 35.89 ± 8.57, p = 0.021). The LC was lower in the deceased (0.81 ± 0.59 × 103 vs 1.09 ± 0.80x103/μL, p = 0.002), and negatively correlated with the age of the patients(r = -0.145, p=0.009 at a significant level of 0.01). The deceased group had a higher NLR (17.52 ± 19.20 vs 10.06 ± 12.31, p < 0.001) and PLR (366.32 ± 275.03 vs 319.23 ± 331.54, p = 0.047) higher than the discharged group, and both parameters were strongly correlated (r = 0.734, p < 0.001 significant level of 0.01). One hundred and thirty-eight (53.7%) of the discharged patients and 45 (71.4%) of the deceased had LC of < 1.0 × 103/μL. The LC is associated with the disease outcome (χ2 = 6.498, df = 1, p = 0.011), and the odds for a deceased to have a lymphopenia is 1.9 times that for the discharged patients [OR = 1.87 (95% CI = 1.135-3.085). Discussion: Though lymphopenia is consistent in COVID-19, the cause is unclear. Acute recruitment of lymphocytes to the site of infection (mainly the lung) may explain this, thus the lymphopenia may worsen and the LRs will be elevated with the increasing severity of COVID-19. The negative correlation of LC with age and higher odds of lymphopenia in the deceased patients suggest that LC and the LRs at diagnosis could be easily accessible and useful predictors of severity and mortality in these patients. Conclusion: Our study supports that lymphopenia is negatively associated with mortality in COVID-19 patients and that the deceased patients have elevated NLR and PLR at diagnosis. These parameters are easily derived from the hemogram and could be utilized as affordable and accessible predictors of outcomes in patients with COVID-19.
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Background: Brazil became the South American epicenter for coronavirus disease (COVID-19) soon after the first case was diagnosed in February 2020 with the highest infection rate occurring in the state of Sao Paulo. COVID-19 is characterized by marked thrombo-inflammation mechanisms, and neutrophil-lymphocyte ratio (NLR) among many clinical and laboratory data, is becoming an inflammatory marker of severity and mortality of COVID-19. We evaluated the serial weekly lymphocyte ratios, which are easily derivable from the routine blood counts, in the survivors and non-survivors of COVID-19 at the Clinical Hospital of University of Campinas (UNICAMP), Campinas, Sao Paulo, Brazil, from time of diagnosis to the 3 rd week of care. This hospital is one of the referral centers for COVID-19 patients in this state. Methods: In this retrospective study, we reviewed the medical notes of 320 adults hospitalized patients with PCR-confirmed COVID-19 at the Clinical Hospital of UNICAMP, from March 2020 to March 2021. The serial weekly hematological parameters (analyzed using automated counter - XN 9000™, Sysmex, Japan) from the time of diagnosis were analyzed and lymphocytes ratios (neutrophil-lymphocyte, NLR, platelet-lymphocyte PLR, and monocyte-lymphocyte MLR) were calculated. The survivors (n=257) were those who recovered from the disease and were discharged from the hospital, while the non-survivors (n=63) were those who died in the course of treatment. Statistical analyses were performed using SPSS (version 22). Unpaired data of Survivors and Non-survivors with COVID-19 were compared using Mann-Whitney tests. Repeated measures were compared within and between groups using univariate and multivariate tests in general linear models. All results were considered significant if p<0.05. Results: Of the 320 patients, 257 (80.3%) were survivors and had lower mean age than the non-survivors (57.73 vs 64.65 years, p<0.001). At diagnosis, the non-survivors had a lower lymphocyte count (p=0.002), basophil count (p=0.049), and hematocrit (p=0.021) than the survivors, Table 1. We used general linear models for repeated measures and corrected for the patients who did not stay long enough to have a complete series of blood counts, Figure 1 A-G. Multivariate tests between the survivor and non-survivor groups showed significant variations with serial weekly lymphocyte count (p<0.001), neutrophil count (P=0.005), NLR (p=0.009), MLR (p=0.010), and PLR (p=0.035) but not with the weekly monocyte count (p=0.352) and platelet count (p=0.505). The NLR was higher and PLR was lower in the non-survivors at diagnosis (p<0.001 and p=0.047 respectively), both were higher in the 2 nd week post-diagnosis (p<0.001 and 0.043 respectively), and in the 3 rd week (p<0.001 and p=0.043 respectively) (Figure 1D and E). The MLR was not significantly different at diagnosis but became elevated in the following two weeks post-diagnosis (p=0.09, p=0.022, and p<0.001 respectively) (Figure 1F). Conclusions: The non-survivors were older and their NLR and MLR tend to increase from the time of diagnosis while their PLR tend to decrease after the 2 nd week post-COVID-19 diagnosis and treatment. On the other hand, all three ratios significantly decrease in the survivors. While neutrophilia and lymphopenia improved in the survivor, they worsen in non-survivors. These cells may have contributed towards the recovery by ameliorating the inflammatory response in survivors, and death by worsening the response in non-survivors of COVID-19. This study shows that serial lymphocyte count, neutrophil count, NLR, PLR, and MLR could serve as good and easily accessible markers of outcomes in patients with COVID-19 and could be used for monitoring of response to treatment. [Formula presented] Disclosures: Costa: Novartis: Consultancy.
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Background: Although initially considered at higher risk for severe presentations of COVID-19, observational studies with SCD patients have mostly pointed to clinical severity similar to the general population. However, the level of vulnerability of these individuals to become infected and the determinants for their contagion are still uncertain. Aims: To assess the prevalence of SARS-Cov-2 antibodies in SCD patients followed at a Brazilian center and its correlation with phenotypic and socioeconomic determinants. Methods: A questionnaire was applied regarding demographics, socioeconomic status, use of Hydroxyurea, working status and income, COVID-19 symptoms, and the perceptions about social isolation measures. Blood samples were taken for chemoluminescence IgG (anti-N) and IgM (anti-S) anti-SARS-CoV-2 tests (Abbott Architect™, Ireland);specific neutralizing antibody titers were accessed observing the cytopathic effect in cells incubated with patient serum-virus mixture. Results: From Jul/20 to Jan/21, 214 serological tests were performed on135 patients (86% of SCD patients registered at the center): 82 HbSS (61%), 41HbSC (30%), 8Sβ+ (6%), 4Sβ0 (3%);57% male and median age 42 (19-74). 66% were using Hydroxyurea and 4% were on chronic transfusion. In the analyzed period, 61 (45%) patients had vasoocclusive crises;37 (27%) had symptoms suggestive of COVID-19, but only 2 patients had a positive PCR for SARS-Cov-2. When questioned, only12% of patients did not consider themselves vulnerable to infection, and only17% believed that individual and collective protection measures were expendable. In fact, 91% stated that they were able to adopt basic social distance measures, with 76% reporting cancellation of social events and 64% managed to reduce the use of public transport, but only 44% could work or study remotely. Regarding serological evaluation, 57 patients (42%) were tested more than1 time during this period: 46 with 2 tests,11 with ≥ 3 tests. Among all patients,15 had positive results: 9 IgG/IgM+ and 6 IgG+ only, therefore with an overall seroprevalence of11%. Seroconversion was documented for only1 patient during the study period and, interestingly, with no signs and symptoms of infection. Moreover, 2 patients lost positivity for IgG 3 months after the initial positive test. The search for functionally neutralizing antibodies resulted in 9 patients with low titers (□1:40) and only 3 patients with remarkably high titers (≥1:640). There were no correlations between test positivity and education, income, number of household contacts and maintenance of work outside the home;however, serological positivity was associated with older age (40.3 x 22.9, p<.001) and regular use of public transport (Fisher exact test, p=0.02). Only1 patient in this cohort needed hospitalization for COVID-19, including mechanical ventilation and exchange transfusions, but was discharged after14 days Summary/Conclusion: These data attest to the effectiveness of social distancing instructions given to patients in our SCD clinic throughout the pandemic, considering the low overall positivity and only1 seroconversion during the study period. The fact that only1 patient in our center had severe disease agrees with other reports showing less severity for SCD than initially expected. In fact, the transient positivity of serological tests and the low levels of functional neutralizing antibodies in SCD patients may indicate the acquisition of protective immune responses that are not dependent on antibodies and that still need to be better evaluated.