"Actionable" host genetic markers for repurposing "add-on therapy" in COVID-19

Background/Objectives: COVID-19 still represents a lifethreatening disease in individuals with a specific genetic background. We successfully applied a new Machine Learning method on WES data to extract a set of coding variants relevant for COVID- 19 severity. We aim to identify personalized add-on therapy. Method(s): A subset of identified variants, "actionable" by repurposed drugs, were functionally tested by in vitro and in vivo experiments. Result(s): Males with either rare loss of function variants in the TLR7 gene or L412F polymorphism in the TLR3 gene benefit from IFN-gamma, which is specifically defective in activated PBMCs, restoring innate immunity. Females heterozygous for rare variants in the ADAMTS13 gene and males with D603N homozygous polymorphism in the SELP gene benefit from Caplacizumab, which reduces vWF aggregation and thrombus formation. Males with either the low-frequency gain of function variant T201M in CYP19A1 gene or with poly-Q repeats >=23 in the AR gene benefit from Letrozole, an aromatase inhibitor, which restores normal testosterone levels, reducing inflammation and which rescues male golden hamsters from severe COVID-19. Conclusion(s): By adding these commonly used drugs to standard of care of selected patients, the rate of intubation is expected to decrease consistently, especially in patients with high penetrance rare genetic markers, mitigating the effect of the pandemic with a significant impact on the healthcare system.

Hypogammaglobulinemia after Rituximab Treatment in an Italian Real-Life Cohort of Iim

Background. Rituximab (RTX) is a chimeric monoclonal antibody that binds the CD20 molecule on the surface of B cells and leads to B cell depletion. RTX is recommended by the European League Against Rheumatism (EULAR) as off-label in patients affected by idiopathic inflammatory myopathies (IIM). The real-world experience has shown that hypogammaglobulinemia occurring early after anti-CD20 treatment can be multifactorial (active disease, effect of other drugs) and usually transient, with a minimal increase in the risk of infections. The present study aimed to analyse the differences in the rate of RTX-associated hypogammaglobulinemia in a cohort of IIM patients in clinical practice, as well as the onset of major infections and its correlation with hypogammaglobulinemia. Methods. Patients followed at Rheumatology Unit of Siena University Hospital from January 2020 to September 2021 were retrospectively enrolled. Inclusion criteria were as follows: fulfilment of disease-specific classification criteria 2017 EULAR criteria and /or Peter and Bohan criteria for dermatomyositis (DM) and polymyositis (PM), positivity of anti-synthetase antibody and typical clinical features for anti-synthetase syndrome (ASS) and the measurement of serum Ig levels at the time of RTX administration (maximum 2 weeks before) (T0) and 6 (T1) to 12 (T2) months later, consistently with previous studies. Ig serum levels, measured by standard nephelometry (normal ranges: IgG 700-1600 mg/dL, IgM 40-240 mg/dL, IgA 70-400 mg/dL) were assessed as part of routine clinical care. Hypogammaglobulinemia was defined as moderate (serum IgG <600 mg/dL) and severe (IgG <400 mg/dL), as previously reported. Results. Seven patients (mean+/-SD, 57.3+/-19.7 years;7 female) were enrolled. Three of them had diagnosis of DM, three ASS and one PM. Two patients showed MDA5-positivity, two JO1-positivity, one TIF1-gamma-positivity, one PL7-positivity and the other one PM/Scl-positivity. All patients had at least two organs involved, and 4 out of 7 (57%) suffered from interstitial lung disease. Before starting RTX treatment, three and four patients underwent at least one and two synthetic immunosuppressants. All patients underwent low dosage of corticosteroids, and four patients underwent concomitant synthetic immunosuppressants (2 hydroxychloroquine and 2 MTX). IgG concentrations were statically lower at T2 compared to those at baseline (p=0.0391). None of them showed severe hypogammaglobulinemia. Similarly, IgM concentration significantly decreased at T2 compared to those at baseline (p=0.0078). Two patients showed major infections and two patients had paucisymptomatic COVID-19 (one of them had twice). Corticosteroids dosages were inversely correlated with IgG T2 concentrations (p=0.040, r=-0.919). Conclusion. Hypogammaglobulinemia following RTX is uncommon in IIM and is more likely in patients with high glucocorticoids, immunosuppressants and CYC exposure. IgG monitoring at least 6 months after RTX treatment may be useful in stratifying patients to identify those who require closer monitoring. These results shine a spotlight for increased awareness of the role of immunoglobulin measurement before maintenance doses of RTX.

RELAPSES of IDIOPATHIC INFLAMMATORY MYOPATHIES after VACCINATION AGAINST COVID19: A REAL-LIFE ITALIAN STUDY

Background: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccination plays a crucial role as pivotal strategies to curb the coronavirus dis-ease-19 (COVID-19) pandemic. Despite the mass-scale vaccination, literature data about the incidence of disease fares in IIM patients are still not reported as well as the immunological condition. Objectives: The present study aimed to describe the clinical status of patients affected by IIM after vaccination against COVID19 in order to assess the number of relapses or immune-mediated reactions in a cohort of Italian patients with such disease. Methods: We included all patients affected by IIM and followed by Myositis Clinic, Rheumatology and Respiratory Diseases Units, Siena University Hospital, Bari University Hospital, Policlinico Umberto I, Sapienza University, Rome, and Policlinico Paolo Giaccone, Palermo. Inclusion criteria were a recent (<3 months) clinical and serological assessment before the survey and a defnite diagnosis of dermatomyosi-tis, polymyositis and anti-synthetase syndrome. All patients underwent a telephone survey in order to establish their clinical status and potential relapses after vaccination. Results: A total of 119 IIM patients (median, IQR 58 (47-66) years;32 males) were consecutively enrolled. Fifty had a diagnosis of DM, 39 had PM and 30 had ASS. The median months of disease duration was 79.62±83.98. According to number of organs involvement, forty-two had only one, 45 had two organs involvement, 20 had three, 11 had four and one had five. The majority of them received two doses of COVID-19 vaccine, except four patients who refused the vaccination: 94 (78.9%) Cominarty, 16 (13.4%) Moderna, 5 (0.04%) AZ. Seven (0.06%) patients had fare after vaccination, the majority of them were mild except one major with three organs involved and one life-threatening with systemic involvement. In order to understand or predict the effect of demographic and clinical features on the fare development after vaccination, a logistic regression analysis was performed. The goodness-of-ft statistics showed a Chi2 associated with the Log ratio (L.R.) of 0.045. From the probability associated with the Chi-square tests, the Type II analysis showed the variable that most influences the development of fare was the number of organs involved (p=0.047). Sixty-eight patients received the third dose of COVID-19 vaccination: 51 (75%) Cominarty and 17 (25%) Moderna. Only one (0.01%) patient (the same who had life-threatening fare with systemic involvement after two doses) had fare after third dose and eventually died. Conclusion: Vaccines against SARS-CoV2 have provided, both in registratory studies and in preliminary real-life evidence, an overall good efficacy and safety. Nevertheless, only scanty data are available for rheumatic patients in general and the ones affected by IIM in particular. To the best of our knowledge, ours represent the largest cohort of IIM patients in which immunogenicity of anti-SARS-CoV2 vaccine was assessed. In line with real-life data from other diseases, we found a non-statistically signifcant risk of relapse in our patients, which occurred seldom, usually mild and in patients with a more severe and aggressive course of disease.

A multidisciplinary multicenter study evaluating risk factors, prevalence and characteristics of post-COVID-19 interstitial lung syndrome pcoils

Backgrounds: Available data indicate that a large minority of patients with COVID-19 develop ARDS, and pulmonary fibrosis is a recognized sequela of ARDS. However, the long-term pulmonary consequences of COVID-19 remain speculative. The aim of this study is to evaluate risk factors, prevalence and characteristics of POST-COVID-19 interstitial lung changes, with the unique opportunity to evaluate radiologic and pathologic correlations using HRCT and transbronchial lung cryobiopsy specimens.Methods: Here we present the preliminary data on HRCT features of POST-COVID-19 ILD. Data were collected at the time of the first interim analysis (28/11/2020) of the PCOILS trial: a prospective, multicenter national study involving 12 Italian centers (Fig 1). We collected data of consecutively hospitalized patients at baseline and then at 6 (+/-1) months after hospital discharge. HRCT changes at 6 months involving more than 5% of the total lung volume were considered significant. Patients with significant HRCT changes will undergo BAL and/or cryobiopsy and a subsequent follow-up with HRCT and lung function evaluation at 12(+/-1) and 18 (+/-1) months.Results: At the time of the present interim analysis, 524 patients from 9 centers were enrolled (enrollment is still ongoing and will end on January 31st, 2021). Median age was 67 years (range 18-87), 330 were males (62.9%). HRCT changes were detected in 333 participants (63.5%), and in 219 (41.7%) were considered significant. 118 cases (22.5%) showed fibrotic changes including the following HRCT patterns: 7 (1.3%) probable UIP, 45 (8.5%) NSIP (with or without OP), 38 (7.2%) indeterminate, 28 (5.3%) fibrotic consolidations. Among the remaining 101 (19.2%) non fibrotic cases the radiologists described: 11 (2%) NSIP-OP, 15 (2.8%) indeterminate, 67 (12.7%) pure ground glass, 8 (1.5%) consolidations all suspected for lung cancer. Conclusions: This preliminary analysis confirms that after COVID-19 infection a large minority of patients develops interstitial lung changes mostly with NSIP-OP, indeterminate features or ground glass. The hypothesis that post-COVID-19 interstitial changes and interstitial lung diseases may share common risk factors, pathogenetic mechanisms and disease behaviour warrants further evaluations. .

Prognostic bioindicators in severe COVID-19 patients.

BACKGROUND: Severe acute respiratory syndrome caused by novel coronavirus 2 (SARS-CoV-2) emerged in Wuhan (China) in December 2019. Here we evaluated a panel of biomarkers to phenotype patients and to define the role of immuno-inflammatory mediators as biomarkers of severity. MATERIALS AND METHODS: Serum samples were obtained from 24 COVID-19 patients on admission to hospital, before any treatment or infusion of intravenous steroids or invasive ventilation. KL-6 IL-6 and C-peptide were measured by chemiluminescent enzyme immunoassay. IL-6 assay was validated for accuracy and precision. The validity of variables used to distinguish severe from mild-to-moderate patients was assessed by areas under curves (AUC) of the receiver operating characteristic (ROC) and logistic regression was performed to combine parameters of the two groups. RESULTS: In the severe group, IL-6, CRP and KL-6 concentrations were significantly higher than in mild-to-moderate patients. KL-6, IL-6 and CRP concentrations were directly correlated with each other. ROC curve analysis of the logistic regression model including IL-6, KL-6 and CRP showed the best performance with an AUC of 0.95. CONCLUSIONS: Besides corroborating previous reports of over-expression of IL-6 in severe COVID-19 patients requiring mechanical ventilation, analytical determination of other mediators showed that IL-6 concentrations were correlated with those of KL-6 and CRP. The combination of these three prognostic bioindicators made it possible to distinguish severe COVID-19 patients with poor prognosis from mild-to-moderate patients.

Immune-inflammatory biomarkers' panel for severe COVID-19 patients

Background: Severe acute respiratory syndrome caused by novel coronavirus 2 (SARS-CoV-2) emerged in Wuhan (China) in December 2019. This study aimed to evaluate a panel of biomarkers in order to better phenotype population and to define the role of mediators as biomarkers of severity.Materials and methods: Serum samples were obtained from 24 COVID-19 patients at the hospital admission before any treatments and infusion of intravenous steroids or invasive ventilation. KL-6 IL-6 and C peptide were measured with CLEIA methods. IL-6 assays were validated for accuracy and precision. The validity of variables used to distinguish severe from mild-to-moderate group was assessed by areas under curves (AUC) in the receiver operating characteristic (ROC) and a logistic regression was performed to combine parameters between the two groups.Results: In severe group, IL-6 CRP and KL-6 concentrations were significantly increased than mild-to-moderate patients. Moreover KL-6, IL-6 and CRP biomarkers resulted directly correlated. In the logistic regression, ROC curve analysis of the model comprise IL-6, KL-6 and CRP reported the best performance with an AUC 0,95. Conclusions: On corroborating previous reports on IL-6 over-expression in severe COVID 19 patients requiring mechanical ventilation, the analytical determination of other mediators showed that IL-6 concentrations are correlated with those of KL-6 and CRP. The combination of three prognostic bioindicators allowed to discriminate between severe COVID-19 patients with poor prognosis from mild-tomoderate patients.