A Case Report of Acute Lymphoblastic Leukaemia (ALL)/Lymphoblastic Lymphoma (LBL) Following the Second Dose of Comirnaty®: An Analysis of the Potential Pathogenic Mechanism Based on of the Existing Literature (preprint)

In this report we describe the case of a healthy, young, athletic woman who developed acute lymphoblastic leukaemia (ALL)/lymphoblastic lymphoma (LBL) after receiving the second dose of the Pfizer/BioNTech modified mRNA (modRNA) COVID-19 genetic vaccine (marketed as Comirnaty®). The first dose of the genetic vaccine did not appear to illicit any noticeable side effects, but within 24 hours of the second dose the patient suffered widespread and intensifying bone pain, fever, vomiting, and general malaise. Due to the persistence of the symptoms, the patient underwent a series of tests and examinations including a full laboratory workup, a consult with a clinical immunologist and rheumatologist, a Positron Emission Tomography (PET) imaging, as well as an osteomedullary biopsy. These together led to a definitive diagnosis of ALL. A time interval of 16 weeks from the second vaccination to the diagnosis of cancer was noted. Several similar cases with identical pathology which developed after the modRNA COVID-19 vaccination, are described in case reports in the scientific literature. The massive and indiscriminate use of genetic vaccines to fight COVID-19 is raising serious concerns about their safety and about the technology platform as a whole for this purpose. Growing evidence is accumulating regarding the biodistribution and persistence of the modRNA which can reach, thanks to the lipid nanoparticles, a multitude of tissues and organs of the body, including the bone marrow and other blood-forming organs and tissues. Moreover, there is evidence that the modRNA vaccines display a particular tropism for the bone marrow, influencing the immune system at multiple levels and being able to trigger not only autoimmune-based pathologies, but also neoplastic mechanisms. The aim of this article is to assess, on the basis of the available scientific literature, the risk of developing haematopoietic cancers after modRNA vaccination, and to investigate the potential genetic mechanisms involved in the pathogenesis of disease.

Importance of standard precautions to febrile neutropenia prevention in patients with cancer during COVID 19 outbreak (preprint)

Purpose Intensive cytotoxic chemotherapy increases the risk of infection in patients with cancer by inducing bone marrow suppression and mucosal injury. Febrile neutropenia (FN) is the most important clinical adverse event in patients with cancer who receiving cytotoxic chemotherapy. To prevent FN, prophylactic antibiotics, colony stimulating factors (CSFs) and also standard precautions including hand and respiratory hygiene are generally recommended but the exact effect of non-pharmacologic intervention such as standard precaution has not been clearly proven in the clinical setting. we aimed to compare the incidence of FN between pre-coronavirus disease 19 (COVID 19) era versus post-COVID 19 era.Material and methods We retrospectively enrolled patients with breast cancer who received adjuvant adriamycin and cyclosphosphamide (AC) chemotherapy at Jeju national university hospital.Results In total, 149 patients well enrolled, including 94 who received AC chemotherapy in pre-COVDI 19 era and 55 who received at post-COVID 19 era. Sixteen (10.7%) patients experienced the FN. Fourteen events (14.9%) and two events (3.6%) were occurred in pre-COVID 19 and post-COVDI 19 era, respectively. The post-COVID 19 era was the only risk factor for FN. (p = 0.032)Conclusion We found an association between FN occurrence and COVID 19 outbreak; thus, providing indirect evidence of the importance of non-pharmacological measure to reduce FN risk in patients with cancer. Further research is required to confirm the standard precautions for FN prevention in patients with cancer.

A prospective, single-center, randomized phase 2 trial of etoposide in severe COVID-19 (preprint)

The systemic inflammatory response seen in patients with severe COVID-19 shares many similarities with the changes observed in hemophagocytic lymphohistiocytosis (HLH); a disease characterized by excessive immune activation. Many patients with severe COVID qualify for a diagnosis of HLH. Etoposide, an inhibitor of topoisomerase II is used to control inflammation in HLH. This randomized, open-label, single center phase II trial attempted to determine whether etoposide can be used to blunt the inflammatory response in severe COVID. This trial was closed early after eight patients were randomized. This underpowered trial did not meet its primary endpoint of improvement in pulmonary status by two categories on an 8 point ordinal scale of respiratory function. There were not significant differences in secondary outcomes including overall survival at 30 days, cumulative incidence of grade 2 through 4 adverse events during hospitalization, duration of hospitalization, duration of ventilation and improvement in oxygenation or paO2/FIO2 ratio or improvement in inflammatory markers associated with cytokine storm. A high rate of grade 3 myelosuppression was noted in this critically ill population despite dose reduction, a toxicity which will limit future attempts to explore the utility of etoposide for virally-driven cytokine storm or HLH.

Prevalence of phalangeal bone marrow edema on MRI before and during the COVID-19 pandemic and correlation with chilblain skin lesions.

OBJECTIVE: The purpose of this study is to establish the prevalence bone marrow edema of the phalanges of the feet and hands before and during the COVID-19 pandemic on MRI studies and correlate with clinically chilblain skin lesions and epidemiological data. METHODS: This observational retrospective study. In patients with confirmed bone marrow edema of the phalanges, epidemiological data and clinical findings were collected, including the history of current or remote COVID-19 infection and vaccination status. The two-proportion test was used to compare the frequency of bone marrow edema in the phalanges before and during the pandemic, and the comparison between the categories variables was performed using the one-proportion test. RESULTS: Of the total of 7215 patients, only 20 presented isolated bone marrow edema of the digits in MRI studies; 2 (0.05%) were found two years before the pandemic's beginning, and 18 (0.64%) after the pandemic's onset, demonstrating an increase of 13-fold in this period. 16 were women with a mean age of 40.3 years and 4 were men with a mean age of 53.5 years. The most frequently reported clinical symptoms by the patients were pain (85.0%), and erythema of the skin (45.0%). Of the 18 patients found after the pandemic's onset, only 27.8% had COVID-19 infections confirmed by RT-PCR before the imaging study, and all cases were mild. CONCLUSION: This study demonstrated a significant increase in the prevalence of bone marrow edema of the phalanges after the onset of the COVID-19 pandemic, particularly in middle-aged and younger women.

Total-Body Multiparametric PET Quantification of 18F-FDG Delivery and Metabolism in the Study of COVID-19 Recovery (preprint)

Conventional whole-body 18F-FDG PET imaging provides a semi-quantitative evaluation of overall glucose metabolism without gaining insight into the specific transport and metabolic steps. Here we demonstrate the ability of total-body multiparametric 18F-FDG PET to quantitatively evaluate glucose metabolism using macroparametric quantification and assess specific glucose delivery and phosphorylation processes using microparametric quantification for studying recovery from coronavirus disease 2019 (COVID-19). Methods: The study included thirteen healthy subjects and twelve recovering COVID-19 subjects within eight weeks of confirmed diagnosis. Each subject had a dynamic 18F-FDG scan on the uEXPLORER total-body PET/CT system for one hour. Semiquantitative standardized uptake value (SUV) and SUV ratio relative to blood (SUVR) were calculated for regions of interest (ROIs) in different organs to measure glucose utilization. Tracer kinetic modeling was performed to quantify microparametric rate constants K1 and k3 that characterize 18F-FDG blood-to-tissue delivery and intracellular phosphorylation, respectively, and a macroparameter Ki that represents 18F-FDG net influx rate. Statistical tests were performed to examine differences between the healthy controls and recovering COVID-19 subjects. Impact of COVID-19 vaccination was investigated. We further generated parametric images to confirm the ROI-based analysis. Results: We detected no significant difference in lung SUV but significantly higher lung SUVR and Ki in the recovering COVID-19 subjects, indicating an improved sensitivity of kinetic quantification for detecting the difference in glucose metabolism. A significant difference was also observed in the lungs with the phosphorylation rate k3, but not with the delivery rate K1, which suggests it is glucose phosphorylation, not glucose delivery, that drives the observed difference of glucose metabolism in the lungs. Meanwhile, there was no or little difference in bone marrow metabolism measured with SUV, SUVR and Ki, but a significant increase in bone-marrow 18F-FDG delivery rate K1 in the COVID-19 group (p<0.05), revealing a difference of glucose delivery in this immune-related organ. The observed differences were lower or similar in vaccinated COVID-19 subjects as compared to unvaccinated ones. The organ ROI-based findings were further supported by parametric images. Conclusions: Higher lung glucose metabolism and bone-marrow glucose delivery were observed with total-body multiparametric 18F-FDG PET in recovering COVID-19 subjects as compared to healthy subjects, which suggests continued inflammation due to COVID-19 during the early stages of recovery. Total-body multiparametric PET of 18F-FDG delivery and metabolism can provide a more sensitive tool and more insights than conventional static whole-body 18F-FDG imaging to evaluate metabolic changes in systemic diseases such as COVID-19.

First-in-human immunoPET imaging of COVID-19 convalescent patients using dynamic total-body PET and a CD8-targeted minibody (preprint)

With the majority of CD8+ T cells residing and functioning in tissue, not blood, developing noninvasive methods for in vivo quantification of their biodistribution and kinetics in humans offers the means for studying their key role in adaptive immune response and memory. This study is the first report on using positron emission tomography (PET) dynamic imaging and compartmental kinetic modeling for in vivo measurement of whole-body biodistribution of CD8+ T cells in human subjects. For this, a 89Zr-labeled minibody with high affinity for human CD8 (89Zr-Df-Crefmirlimab) was used with total-body PET in healthy subjects (N=3) and in COVID-19 convalescent patients (N=5). The high detection sensitivity, total-body coverage, and the use of dynamic scans enabled the study of kinetics simultaneously in spleen, bone marrow, liver, lungs, thymus, lymph nodes, and tonsils, at reduced radiation doses compared to prior studies. Analysis and modeling of the kinetics was consistent with T cell trafficking effects expected from immunobiology of lymphoid organs, suggesting early uptake in spleen and bone marrow followed by redistribution and delayed increasing uptake in lymph nodes, tonsils, and thymus. Tissue-to-blood ratios from the first 7 h of CD8-targeted imaging showed significantly higher values in the bone marrow of COVID-19 patients compared to controls, with an increasing trend between 2 and 6 months post-infection, consistent with net influx rates obtained by kinetic modeling and flow cytometry analysis of peripheral blood samples. These results provide the platform for using dynamic PET scans and kinetic modelling to study total-body immunological response and memory.

SARS-CoV2 mRNA-vaccination-induced Immunological Memory in Human Non-Lymphoid and Lymphoid Tissues (preprint)

Tissue-resident lymphocytes provide organ-adapted protection against invading pathogens. Whereas their biology has been examined in great detail in various infection models, their generation and functionality in response to vaccination has not been comprehensively analyzed in humans. We therefore studied SARS-CoV2 mRNA-vaccine-specific T cells in surgery specimens of kidney, liver, lung, bone marrow and spleen in comparison to paired blood samples from largely virus-naive individuals. As opposed to lymphoid tissues, non-lymphoid organs harbored significantly elevated frequencies of Spike-specific CD4+ T cells compared to paired peripheral blood showing hallmarks of tissue residency and an expanded memory pool. Organ-derived, vaccine-specific T helper (Th) cells were characterized by increased portions of multifunctional cells over those detected in blood. Single-cell RNA sequencing revealed functional rather than organ-specific clusters of Spike-reactive Th cells, indicating similar diversification programs across tissues. T cell receptor (TCR) repertoire analysis indicated that the TCR sequence is a major determinant of transcriptomic state in tissue-resident, vaccine-specific CD4+ T cells. In summary, our data demonstrate that SARS-CoV2 vaccination entails acquisition of tissue memory and residency features in organs distant from the inoculation site, thereby contributing to our understanding of how local tissue protection might be accomplished.

Cellular and Humoral Immunity and Infection Responses to SARS-CoV-2:Immune Biomolecular Mechanisms by Case Study within SARS-CoV-2 Pathogenesis and Other Infections (preprint)

The coronavirus 2019 (COVID-19) pandemic was caused by a positive sense single-stranded RNA (ssRNA) severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). However, other human coronaviruses (hCoVs) exist, of which Middle East Respiratory Syndrome (MERS) and SARS-CoV (SARS) showed higher mortality rates without causing a pandemic. As of December 2022, SARS-CoV-2 has resulted in over 6.6 million deaths worldwide through an array of acute to chronic pathologies. Historical pandemics include smallpox and influenza with efficacious therapeutics utilized to reduce overall disease burden. Therefore, immune system process analysis is required to compare innate and adaptive immune system interactions. Lymphatic system organs include bone marrow and thymus using a network of nodes throughout which white blood cells traverse glycolipid membranes utilizing cytokines and chemokine gradients that affect cell development, differentiation, proliferation, and migration processes as well as genetic factors affecting cell receptor expression. Innate processes involve antigen-presenting cells and B lymphocyte cellular responses to pathogens relevant to other viral and bacterial infections but also in oncogenic diseases. Such processes utilize cluster of differentiation (CD) marker expression, major histocompatibility complexes (MHC), pleiotropic interleukins (IL) and chemokines. The adaptive immune system consists of Natural Killer (NK) and T cells. Other viruses are also contributory to cancer including human papillomavirus (cervical carcinoma ), Epstein-Barr virus (EBV) ( lymphoma), hepatitis B and C (hepatocellular carcinoma) and human T cell leukemia virus-1 (adult T-cell leukemia). Bacterial infections also increase the risk of developing cancer( e.g. H. pylori). Therefore, as the above factors can cause both morbidity and mortality along-side being transmitted within clinical and community settings, it is appropriate to now examine advances in single cell sequencing, FACS analysis and many other laboratory techniques that allow insights into discoveries of newer cell types. These developments offer improved clarity and understanding that over-lap with known autoimmune conditions that could be affected by innate B cell or T cell responses to SARS-CoV-2 infection. Thus, this review quantifies and outlines the nature of specific receptors and proteins relevant to clinical laboratories and medical research by documenting both innate and adaptive immune system cells within current coronavirus immunology case study data and other pathologies to date.

Current Landscape of Mesenchymal Stem Cell Therapy in COVID Induced Acute Respiratory Distress Syndrome (preprint)

The severe acute respiratory syndrome coronavirus 2 outbreak in Chinas Hubei area in late 2019 has now created a global pandemic that has spread to over 150 countries. In most people, COVID 19 is a respiratory infection that produces fever, cough, and shortness of breath. Patients with severe COVID 19 may develop ARDS. MSCs can come from a number of places, such as bone marrow, umbilical cord, and adipose tissue. Because of their easy accessibility and low immunogenicity, MSCs were often used in animal and clinical research. In recent studies, MSCs have been shown to decrease inflammation, enhance lung permeability, improve microbial and alveolar fluid clearance, and accelerate lung epithelial and endothelial repair. Furthermore, MSC-based therapy has shown promising outcomes in preclinical studies and phase 1 clinical trials in sepsis and ARDS. In this paper, we posit the therapeutic strategies using MSC and dissect how and why MSC therapy is a potential treatment option for COVID 19 induced ARDS. We cite numerous promising clinical trials, elucidate the potential advantages of MSC therapy for COVID 19 ARDS patients, examine the detriments of this therapeutic strategy and suggest possibilities of subsequent research.

Coronavirus disease 2019 and vaccination in patients with Shwachman-Diamond syndrome.

Because they can experience neutropenia due to bone marrow failure, patients with Shwachman-Diamond syndrome (SDS) carry increased risk for serious infections compared with the general population; however, there has been a paucity of data on the incidence and severity of coronavirus disease 2019 (COVID-19) in patients with SDS. We compiled results from a survey distributed to participants in the SDS Registry in May-June 2021. In this report, we describe the characteristics and outcomes of patients with SDS who had COVID-19. Patients reported a short clinical course without significant complications or cytopenias. Additionally, COVID-19 vaccines were well tolerated with minor side effects.

Macrophage Activation Syndrome in Two Infants with Multisystem Inflammatory Syndrome in Children (preprint)

Multisystem inflammatory syndrome in children (MIS-C) associated with SARS-CoV-2 infection with clinical features of Kawasaki-like disease was reported in various pediatric centers in late April 2020. Currently, cases have increased throughout the world with a range of manifestations from less to greater severity. However, hemophagocytosis has not been described in patients with MIS-C. We describe two infants diagnosed with MIS-C who presented Macrophage Activation Syndrome (MAS) with hemophagocytosis documented in the bone marrow. MIS-C can be complicated with MAS, the key features for diagnosis are splenomegaly, hypofibrinogenemia, hypertriglyceridemia and bone marrow hemophagocytosis. Cytokine storm and MAS in MIS-C may represent part of the spectrum of the disease and HScore could be of value in order to give timely and aggressive treatment.

Is Karachi Knocking at Herd Immunity? A Possible Reason for Decline in SARS-CoV-2 Infections (preprint)

Background: There is a sharp decline in newSARS-CoV-2 cases in Karachi from July onwards; most of them were asymptomatic. Seroconversion rates vary markedly in different countries. Herd immunity for this virus is considered to be at 60-70%. Previously, 36% of seropositivity was reported in the adult population of Karachi in July this year. The current study was conducted to report if seroprevalence has reached the threshold of herd immunity.Methods: This was a prospective cross-sectional study conducted in the first and second weeks of September 2020 at the National Institute of Blood disease and Bone Marrow Transplantation Hospital (NIBD), Karachi, Pakistan. Blood samples were collected from different segments of the population of Karachi workforce/community. An anti-SARS-CoV-2 test was performed using ECLIA from Roche Diagnostics International.Results: A total of 2404 subjects’ blood samples were received from healthcare workers, the industrial workforce, and healthy blood donors. Seroprevalence in industrial workers was highest (70%) as compared to healthcare workers (40%). Overall seropositivity in males (39%) was higher than females (16%). Blood donors (all males) showed a seropositivity of 37.8%. The co-morbid state was not significantly associated with seropositivity (p-value >0.05). Total cases of antibody-positive were 1322 of 2100 (55 %).Conclusion: Our results confirmed the current seroprevalence of 55% in the adult population in Karachi. There was a sharp rise from 36% reported previously in July. This rise coincided with a sharp decline in new reported COVID cases. We can conclude that we are approaching the target of herd immunity in Karachi.

Effect of underlying comorbidities on the infection and severity of COVID-19 in South Korea (preprint)

ABSTRACT Background: The coronavirus disease (COVID-19) pandemic is an emerging threat worldwide. It is still unclear how comorbidities affect the risk of infection and severity of COVID-19. Methods: A nationwide retrospective case-control study of 65,149 individuals, aged 18 years or older, whose medical cost for COVID-19 testing were claimed until April 8, 2020. The diagnosis of COVID-19 and severity of COVID-19 infection were identified from the reimbursement data using diagnosis codes and based on whether respiratory support was used, respectively. Odds ratios were estimated using multiple logistic regression, after adjusting for age, sex, region, healthcare utilization, and insurance status. Results: The COVID-19 group (5,172 of 65,149) was younger and showed higher proportion of females. 5.6% (293 of 5,172) of COVID-19 cases were severe. The severe COVID-19 group had older patients and a higher male ratio than the non-severe group. Cushing syndrome (Odds ratio range (ORR) 2.059-2.358), chronic renal disease (ORR 1.292-1.604), anemia (OR 1.132), bone marrow dysfunction (ORR 1.471-1.645), and schizophrenia (ORR 1.287-1.556) showed significant association with infection of COVID-19. In terms of severity, diabetes (OR 1.417, 95% CI 1.047-1.917), hypertension (OR 1.378, 95% CI 1.008-1.883), heart failure (ORR 1.562-1.730), chronic lower respiratory disease (ORR 1.361-1.413), non-infectious lower digestive system disease (ORR 1.361-1.418), rheumatoid arthritis (ORR 1.865-1.908), substance use (ORR 2.790-2.848), and schizophrenia (ORR 3.434-3.833) were related with severe COVID-19. Conclusions: We identified several comorbidities associated with COVID-19. Health care workers should be more careful when diagnosing and treating COVID-19 when the patient has the above-mentioned comorbidities. Keywords: COVID-19, SARS-CoV-2, Comorbidity, Risk factor, Severity

An Investigation of the Expression of 2019 Novel Coronavirus Cell Receptor Gene ACE2 in a Wide Variety of Human Tissues (preprint)

Background: The 2019 novel coronavirus (2019-nCoV) has affected more than 72,000 people worldwide and caused more than 1,800 deaths so far. 2019-nCoV uses the angiotensinconverting enzyme 2 (ACE2) as the cell receptor to invade the human host and primarily causes pneumonia. Thus, ACE2 is the key to understanding the mechanism of 2019-nCoV infection. Methods: We compared ACE2 expression levels across 31 human normal tissues, between males and females, and between younger (ages <= 49 years) and older (ages > 49 years) persons in these tissues. We also investigated the correlations between ACE2 expression and immune signatures in various tissues. Results: ACE2 expression levels were the highest in small intestine, testis, kidney, heart, thyroid, and adipose tissue, and were the lowest in blood, spleen, bone marrow, brain, blood vessel, and muscle. In lungs, colon, liver, bladder, and adrenal gland, ACE2 showed the medium expression levels. ACE2 was not differentially expressed between males and females and between younger and older persons in any tissue. In skin, digestive system, brain, and blood vessel, ACE2 expression levels were positively associated with immune signatures in both males and females. In thyroid and lungs, ACE2 expression levels were positively and negatively associated with immune signatures in males and females, respectively.Conclusions: Our data provide potential cues for the 2019-nCoV epidemic may infect other tissues outside lungs, affect males and females and young and old persons equally, and old age and male are associated with higher mortality risk for 2019-nCoV infection.