ALTERED PLASMA CYTOKINE CONCENTRATIONS ARE ASSOCIATED WITH THE CLINICAL SEVERITY OF PATIENTS WITH COVID-19

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

To evaluate the plasma pro- and anti-inflammatory cytokines in COVID-19 patients and their associations with the disease severity and outcome.

Methods

Reverse-Transcriptase Polymerase Chain Reaction (RT-PCR)-confirmed COVID-19 unvaccinated patients at the Hospital de Clínicas (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.

Results

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-α, IL-6, IFN-γ, CCL3, IL-17/IL-17A, IL-8, G-CSF, CCL2/MCP-1) and anti-inflammatory (IL-1ra and IL-27) cytokines, but lower TGF-β levels than the survivors. TNF-α levels were positively correlated with all studied cytokines except TGF-β, while TGF-β levels were negatively correlated with TNF-α, 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-α, 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-α, IL-6, IL-8, CCL3, CCL2, and IL-1ra than those who did not have intubation. TNF-α, 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

CNPq (#190374/2017-9), CAPES, FAPESP and FAEPEX (#338619).

Endothelial Nitric Oxide Synthase (eNOS) Gene Polymorphisms and Markers of Hemolysis, Inflammation and Endothelial Dysfunction in Brazilian Sickle Cell Anemia Patients

The impaired bioavailability of endogenous nitric oxide (NO) in sickle cell anemia (SCA) may be influenced by polymorphisms in the endothelial nitric oxide synthase gene (eNOS). We compared allelic/genotypic frequencies of the eNOS polymorphisms T-786C, VNTR4a/b and G894T between 89 adult SCA patients and 100 healthy controls, and investigated the relationship between these SNPs and markers of hemolysis [lactate dehydrogenase (LDH), indirect bilirubin (IB) and reticulocyte counts], inflammation [interleukins IL-1β, IL-6, IL-8, Tumor Necrosis Factor (TNF-α) and C-reactive protein (CRP)] and endothelial dysfunction (ED) [soluble vascular cell adhesion molecule-1 (sVCAM-1), soluble intercellular adhesion molecule-1 (sICAM-1), soluble L-selectin (sL-selectin), von Willebrand Factor (vWF) antigen and D-dimers] in the patients. The frequencies of the mutant -786C allele and -786C/C genotype were significantly higher in patients (p = 0.02 and p = 0.04, respectively) but not significantly correlated with the markers. For VNTR4a/b and G894T, the allelic/genotypic frequencies did not statistically differ between patient and control groups. Patients carrying the 4a allele and those with the 894G/G genotype showed a significant decrease in IB (p = 0.02 and p = 0.04, respectively), and only patients with the 4a allele exhibited reduced IL-1β (p = 0.01). The correlation profiles between markers of inflammation and ED significantly differed between patients carrying the mutant alleles and those with wild-type genotypes. This appears to be the first report on the relationship between eNOS gene polymorphisms and markers of hemolysis, inflammation and ED in Brazilian SCA patients. Our results indicate that the SNPs analyzed may influence the phenotypic variability of these patients.

Evaluation of sociodemographic, clinical, and laboratory markers of sickle leg ulcers among young nigerians at a tertiary health institution

Background

Sickle leg ulcer (SLU) is a chronic and debilitating complication of sickle cell disease (SCD) associated with huge physical and psychosocial discomfort. The occurrence of SLU has remained steady despite successful preventive strategies and advances in SCD care. Although multifactorial factors have been implicated in SLU, these are not fully understood, and data on how these relate to young Nigerian SCD patients are scanty.

Aims

This study aims to evaluate the sociodemographic, clinical, and laboratory markers of SLU in a young Nigerian SCD cohort.

Patients and Methods

This study involved 109 young SCD patients and 67 healthy peers. The sociodemographic and laboratory parameters of the participants were examined in addition to the evaluation of the SCD cohort for SLU.

Results

Only the HbSS patients had SLU. This was found in six of them giving a prevalence of 5.9% (6/101). Their median age was 17, range 14-21 years. There was a preceding history of trauma in 4 (66.7%), and this included a case of traditional scarifications for local therapeutic purposes. Two of the three (66.7%) males with SLU also had priapism (P = 0.0132). Patients with SLU were older, had less frequent bone pain crises, and significantly belonged to the low socioeconomic class (P < 0.05). Although patients with SLU had relatively higher lactate dehydrogenase, platelet count, aspartate transaminase, bilirubin, white blood cell, and lower Hb concentration and HbF, these did not attain statistical significance (P > 0.05).

Conclusion

This study confirms that SLU is common among young SCD patients with HbSS genotype, low socioeconomic background, and older age. It also suggests that SLU could be more related to hemolysis-associated SCD phenotypes among the patients.

Fracture of the talar neck associated with a compression fracture of the calcaneocuboid joint in a 5-year-old child: a case report

OBJECTIVE

The objectives of this present case study are to report a rare combination of a displaced talar neck fracture with a compression fracture of the calcaneocuboid joint in a 5-year-old child and to describe its radiological features, surgical treatment and clinical outcome. A 5-year-old male boy was injured in a car accident in which his left foot underwent one of the tires. On arrival at the hospital, a displaced talar neck fracture associated both with a cuboid fracture and compression of the articular surface of the cuboid at the calcaneocuboid join was identified. Fractures were fixed surgically. Leg was protected with a below-knee plaster split immobilization and non-weight-bearing for 5 weeks. After that period, the patient initiated a rehabilitation protocol with active and passive motion exercises.

DISCUSSION

Fractures and fracture dislocations at the mid-tarsal joint have an important impact on the global foot function because malunion can result in post-traumatic arthritis and three-dimensional deformities of the foot. If a cuboid compression fracture is not reduced properly, it can result in the shortening of the lateral column with the development of an abduction, pronation and flat foot deformity. A talar neck fracture, if unreduced, can result in medial column displacement and rotational dislocation of the talar head, leading to a subluxation in the talonavicular joint with severe restriction of foot function. With early surgical treatment and open reduction and internal fixation, our patient recovered from the accident without having symptoms of pain, avascular necrosis, postoperative foot deformities or neurovascular deficits.

CONCLUSIONS

The combination of a displaced talar neck fracture with a compression fracture of the calcaneocuboid joint in children usually requires correct diagnoses and early treatment with anatomic reduction and internal fixation to prevent severe post-traumatic deformities.

LEVEL OF EVIDENCE

V.

Cytomegalovirus (CMV) genotype in allogeneic hematopoietic stem cell transplantation

Background

Based on sequence variation in the UL55 gene that encodes glycoprotein B (gB), human cytomegalovirus (CMV) can be classified into four gB genotypes. Previous studies have suggested an association between CMV gB genotype and clinical outcome in patients who underwent an allogeneic hematopoietic stem cell transplant (HSCT). The goals of this study were identify patients with active infection caused by CMV in recipients of HSCT; determine the prevalence of CMV genotypes in the study group; correlate genotype with CMV disease, acute GVHD and overall survival.

Methods

The diagnosis of active CMV infection after allogeneic HSCT was detected by antigenemia (AGM) and/or nested-PCR (N-PCR). Positive samples from patients with active CMV infection were submitted to genotyping using N-PCR to amplify a region of UL55, followed by restriction analysis based on HinfI and RsaI digestion. Real-time PCR (qPCR) was used to determine the viral load during active CMV infection and antiviral treatment.

Results

Sixty-three allogeneic HSCT recipients were prospectively evaluated; 49/63 (78%) patients were infected with CMV genotypes – gB1 19/49 (39%), gB2 17/49 (35%), gB3 3/49 (6%), gB4 7/49 (14%) – and 3 (6%) had mixed CMV genotypes (gB1 + gB3, gB1 + gB4 and gB2 + gB4). Characterized by gastrointestinal disease, CMV disease occurred in 3/49 (6.1%) patients, who had CMV gB3 genotype. These gB3 genotype patients presented an increasing AGM number, mean 125 (± 250) (P = 0.70), and qPCR copies/ml, mean 37938 (SD ± 50542) (P = 0.03), during antiviral treatment, when compared with other CMV genotypes. According to CMV genotypes, stratified overall survival was 55% for gB1, 43% for gB2; 0% for gB3 and 57% for gB4 (P = 0.03).

Conclusions

One of the restrictions of the presented study was the low number of CMV gB sub-cohorts). However, we demonstrated that the frequency of active CMV infection in this HSCT population was high, and the most prevalent genotype in these patients with active CMV infection was gB1 and gB2 genotype (74%). In Brazil, HSCT recipients seem to carry mainly gB1 and gB2 CMV genotype.

A new β⁰-thalassemia frameshift mutation [β 48 (-T)] in a Uruguayan family

We describe here a new frameshift mutation of β-thalassemia in a Uruguayan family with Italian ancestry [β48 (-T); HBB:c.146delT]. This frameshift results in formation of premature stop codon (TGA) 40 bp downstream and in a short unstable product that is degraded in the cell.

Influence of eNOS gene polymorphism on cardiometabolic parameters in response to physical training in postmenopausal women

The health-promoting effects of exercise training (ET) are related to nitric oxide (NO) production and/or its bioavailability. The objective of this study was to determine whether single nucleotide polymorphism of the endothelial NO synthase (eNOS) gene at positions -786T>C, G894T (Glu298Asp) and at the variable number of tandem repeat (VNTR) Intron 4b/a would interfere with the cardiometabolic responses of postmenopausal women submitted to physical training. Forty-nine postmenopausal women were trained in sessions of 30-40 min, 3 days a week for 8 weeks. Genotypes, oxidative stress status and cardiometabolic parameters were then evaluated in a double-blind design. Both systolic and diastolic blood pressure values were significantly reduced after ET, which was genotype-independent. However, women without eNOS gene polymorphism at position -786T>C (TT genotype) and Intron 4b/a (bb genotype) presented a better reduction of total cholesterol levels (-786T>C: before = 213 ± 12.1, after = 159.8 ± 14.4, Δ = -24.9% and Intron 4b/a: before = 211.8 ± 7.4, after = 180.12 ± 6.4 mg/dL, Δ = -15%), and LDL cholesterol (-786T>C: before = 146.1 ± 13.3, after = 82.8 ± 9.2, Δ = -43.3% and Intron 4b/a: before = 143.2 ± 8, after = 102.7 ± 5.8 mg/dL, Δ = -28.3%) in response to ET compared to those who carried the mutant allele. Superoxide dismutase activity was significantly increased in trained women whereas no changes were observed in malondialdehyde levels. Women without eNOS gene polymorphism at position -786T>C and Intron 4b/a showed a greater reduction of plasma cholesterol levels in response to ET. Furthermore, no genotype influence was observed on arterial blood pressure or oxidative stress status in this population.

Clinical and genetic risk factors for moderate hyperbilirubinemia in Brazilian newborn infants

OBJECTIVE

To identify clinical and genetic risk factors for moderate hyperbilirubinemia during the first week of life.

STUDY DESIGN

Using univariate and multivariate multiple regression analyses, the RR for clinical factors, the African variant of glucose-6-phosphate dehydrogenase (G6PD) deficiency (G202A/A376G), and (TA)(n) UGT1A1 polymorphisms were established in a cohort of 608 Brazilian newborn infants. Hyperbilirubinemia was monitored until 134.5 ± 49.8 h of life (IQR, 111.0 to 156.7). The dependent variable was total bilirubinemia (TB) ≥12.9 mg per 100 ml estimated by transcutaneous or plasma bilirubin measurements.

RESULT

The African variant of G6PD deficiency and (TA)(7)/(TA)(7) and (TA)(7)/(TA)(8) polymorphisms present in 6.1 and 12.0% of newborns, respectively, were not risk factors for moderate hyperbilirubinemia. Coexpression of G6DP deficiency and UGT1A1 polymorphisms occurred in 0.49% of the subjects. Independent clinical predictors for TB≥ 12.9 mg per 100 ml were gestational age <38 weeks and reference curve percentiles >P40th.

CONCLUSION

In this study, G6PD deficiency and UGT1A1 gene promoter polymorphisms were not risk factors for moderate hyperbilirubinemia. Genetic factors may vary considerably in importance among different populations.

Hb Indianapolis [beta112 (G14) Cys-->Arg] as the probable cause of moderate hemolytic anemia and renal damage in a Brazilian patient

Hemoglobin (Hb) Indianapolis [beta112 (G14) Cys-->Arg] is a rare and slightly unstable beta-globin variant. All carriers described to date were clinically normal with only mild reticulocytosis. We report here a case of a Brazilian patient in whom hemolytic anemia and acute renal failure were probably caused by the presence of this variant.

Hb Florida: a novel elongated C-terminal beta-globin variant causing dominant beta-thalassemia phenotype

We report here a new frameshift mutation in exon 3 of the beta-globin gene, a single nucleotide deletion (-C) in between codons 140/141 (GCC/CTG-->GCC/TG), found in an 8-year-old Argentinean girl with clinical picture of thalassemia intermedia. It leads to a beta-chain that is elongated to 156 amino acids [(141)Trp-Pro-Thr-Ser-Ile-Thr-Lys-Leu-Ala-Phe-Leu-Leu-Ser-Asn-Phe-(156)Tyr-COOH]. The resulting hemoglobin, which we named Hb Florida, was not detected in peripheral blood; however, erythroid hyperplasia and dyserythropoiesis with large inclusion bodies on methyl violet staining were observed in bone marrow, suggesting that this is a hyperunstable variant producing a dominant beta-thalassemia phenotype, since the other beta-allele was completely normal.