Role of Vitamin D, ACE2 and the Proteases as TMPRSS2 and Furin on SARS-CoV-2 Pathogenesis and COVID-19 Severity.

BACKGROUND: COVID-19, the 21st century pandemic disease caused by SARS-CoV-2, has shown a wide clinical spectrum ranging from asymptomatic to deadly serious pneumonia. OBJECTIVE: In our study, the relationship between the pathogenesis and clinical severity of COVID-19 and vitamin D, ACE2, Furin and TMPRSS2 was investigated. METHODS: Serum 25(OH)D, 1,25(OH)2D and ACE2 protein were measured in 85 COVID-19 cases, divided into 5 groups, according to disease severity, from asymptomatic to severe and including a healthy control group. Expression levels of ACE2, VDR, TMPRSS2 and Furin mRNAs in PBMC were also measured. The relationship of the parameters within each group, the severity of the disease and the effect on the patients' fate were investigated. RESULTS: Statistically significant differences were found between the severity of COVID-19 and all study parameters, except for serum 25(OH)D. A strong negative correlation was found between serum ACE2 protein, 1,25(OH)2D, and ACE2 mRNA, and disease severity, length of hospital stay and death/survival rate. Vitamin D deficiency increased the death risk by 5.6-fold (95% CI 0.75-41.47), and the levels of 1,25(OH)2D lower than 1 ng/mL increased the risk of death by 3.8-fold (95% CI 1.07-13.30). CONCLUSION: This study suggests that vitamin D supplementation could be beneficial in the treatment and/or prevention of COVID-19.

Myelosuppression and acute hematological complications of sulfur mustard exposure in victims of chemical terrorism.

Sulfur mustard (SM) is a vesicant chemical warfare agent. Recent studies reported alleged use of SM by non-state actors in Syria and Iraq. It has been shown that SM induced immunological and hematological complications. The aim of this study was to determine acute toxic effects of SM exposure on hematological parameters. Blood samples from a group of Syrian exposed to SM in 2016 were taken daily during the follow-up of the patients in intensive care unit. Initial leukocytosis was observed in all patients (100%) on the first 48 h after exposure. Following leukocytosis, isolated lymphopenia was observed in all patients (100%) between 2nd and 4th days. A decrease in hemoglobin level was noted in five patients (62.5%) between 4th and 5th days. Thrombocytopenia was observed in 75% of patients between 4th and 6th days for mild cases and between 9th and 11th days for severe cases. Three patients (37.5%) developed distinct leucopenia/neutropenia on 11th and 12th days. It was observed that human exposure to high dose of SM has direct toxic effect on hematological cells and bone marrow. New strategies on treatment of SM-induced myelosuppression could reduce the effects of hematological complications and could increase the survival rate in these patients.

Optimized Gas Chromatography-Tandem Mass Spectrometry for 1,1'-sulfonylbis[2-(methylthio) ethane] Quantification in Human Urine.

Sulfur mustard (SM) which is a bifunctional alkylating vesicant is one of the mostly used chemical warfare agent in First World War and the Iran-Iraq War. ß-Lyase metabolites of SM especially 1,1'-sulfonylbis[2-(methylthio)ethane] (SBMTE) is an unequivocal biomarker of the exposure. An optimized gas chromatography-tandem mass spectrometry method was developed and validated for the retrospective detection of SBMTE in human urine. Urine samples were treated with acidic titanium trichloride to reduce ß-lyase metabolites to the single analyte SBMTE. After neutralization and precipitation, SBMTE was extracted from urine by C8 solid-phase extraction cartridge and analyzed in the multiple-reaction monitoring mode. The lower limit of quantification was 1 ng/mL with relative standard deviation of <10%. Acceptable intra-day and inter-day precisions and accuracies were obtained. The developed method was successfully measured various levels of SBMTE which could be used as the forensic evidence of such a chemical attack.

Acute intensive care unit management of mustard gas victims: the Turkish experience.

PURPOSE: Sulphur mustard (SM) is an highly toxic and vesicant chemical weapon that was used in various military conflicts several times in the history. The severity of ocular, dermal, and pulmonary symptoms that may appear following a characteristic asymptomatic period are depending on the SM concentration and exposure duration. The aim of this study is to present the clinical features and share the intensive care unit (ICU) experiences for the medical management of mustard gas victims. MATERIALS AND METHODS: Thirteen Free Syrian Army soldiers near Al-Bab region of North Syria were reportedly exposed to oily blackish smoke with garlic smell due to the explosion of a trapped bomb without causing any blast or thermal effect on 26th November 2016. None of them wore any chemical protective suits or gas masks during explosion. Since they observed skin lesions including bullous formation next day, they were admitted to the Turkish Field Hospital at the Turkish - Syrian border and then evacuated to the State Hospital of Gaziantep Province, Turkey for further management. Eight victims who were very close to point of explosion suffered burning eyes, sore throat, dry cough and dyspnoea after the chemical attack. RESULTS: On admission to hospital, all cases had conjunctivitis, hoarseness and bullae on various body areas. Blepharospasm and opacity were found in 8 patients and 5 of them had corneal erosions and periorbital oedema. Temporary loss of vision in 4 cases lasted for 24 h. Multiple fluid-filled blisters were observed especially on the scalp, neck, arms and hands, where direct skin exposure to the agent occurred. A definitive clinical care and infection prophylaxis measures along with the burn treatment and bronchodilators for respiratory effects were applied in ICU. Two patients received granulocyte-colony-stimulating factor due to the SM-mediated bone marrow suppression on the 16th day of exposure and one of them died because of necrotic bronchial pseudomembrane obstruction resulting in cardiopulmonary arrest. CONCLUSIONS: SM was first used during the First World War and it is still considered one of the major chemical weapons recently used by non-state actors in Syria and Iraq. In case of SM exposure, medical treatment of SM-induced lesions is symptomatic because no antidote or causal therapy does exist even though SM is very well known for over 100 years. However, clinical management in intensive care medicine of SM victims have improved since the 1980s, this study which is one of the largest recent SM-exposed case series since that time is important for the contribution to the clinical experience.

Evaluation of Gamma-Radiation Inactivation of a Bioterrorism Agent, Bacillus anthracis Spores, on Different Materials.

Decontamination of suspected packages, such as sealed envelopes, liquids and tools that are likely contaminated with biological agents is of great importance. In this study, we aimed to determine the gamma radiation dose required for the decontamination of paper, fabric and liquid materials without causing any damage to the structure of these materials. Each study group included 11 pieces of paper, fabric and sterile saline contaminated with 0.8 × 105 virulent Bacillus anthracis (B. anthracis) spores. These specimens were exposed to doses of 5.49, 11.58, 17.21, 21.75, 27 and 33.1 kilogray (kGy) of gamma radiation from a cobalt-60 source. After irradiation of all the samples, a viability assessment of the B. anthracis spores was performed. It was found that full decontamination was achieved with 11.58 kGy on the paper samples and 17.21 kGy on the fabric and liquid samples. It was concluded that a dose of 20 kGy of gamma radiation may be recommended for the inactivation of B. anthracis for some surfaces when especially sensitive and valuable materials cannot be wet decontaminated were exposed. In addition, serologic and molecular assays of the suspected packets can be performed for forensic purposes without damaging existing evidence in a bioterror incident.

Antimicrobial susceptibility and molecular subtyping of 55 Turkish Bacillus anthracis strains using 25-loci multiple-locus VNTR analysis.

Anthrax, which is caused by the bacterium Bacillus anthracis, is one of the oldest documented infectious diseases in both livestock and humans. The differentiation of B. anthracis strains is difficult because of their highly homogeneous genomes. We used multiple-locus variable-number tandem repeat analysis (MLVA) with 25 markers to genotype 55 B. anthracis isolates from 16 distinct regions of Turkey. The antimicrobial susceptibility of the isolates was investigated using the agar dilution method. An eight-loci MLVA assay revealed six unique genotypes (G(K)13, G(K)27, G(K)35, G(K)43, G(K)44, and G(K)61). However, the 25-loci MLVA was more discriminatory, revealing the presence of ten genotypes instead of six. The additional genotypes resulted from the split of four subtypes: G(K)35 (b and c), G(K)43 (a and f), G(K)44 (d and e), and G(K)61 (i and j). All of the Turkish B. anthracis isolates were susceptible to ciprofloxacin, levofloxacin, tigecycline, linezolid, and vancomycin. One isolate was resistant to penicillin and to doxycycline. A total of 34 isolates were susceptible, 20 isolates were partially susceptible, and one isolate was resistant to erythromycin. None of the isolates exhibited susceptibility to cefotaxime. A total of 53 isolates were susceptible to gentamicin, and two were resistant. The genotypes G(K)35 (n=24), G(K)44 (n=13), and G(K)43 (n=10) were the most prevalent in 10, 6, and 5 regions, respectively, of the total 16 provinces. The B. anthracis isolates collected from these regions implied that the movement of B. anthracis is a result of the increased transportation of livestock and the resultant cross contamination.

Comparison of real-time polymerase chain reaction and conventional polymerase chain reaction methods for the rapid identification of Bacillus anthracis.

Bacillus anthracis spores have been shown to be one of the most effective biological weapons. For the rapid detection of B. anthracis spores, several genetic markers, including chromosomal and plasmid-based sequences, were studied with polymerase chain reaction (PCR) methods. In the present study, a method using a primer/probe set based on the pXO1-encoded pag gene for the detection of B. anthracis was tested in addition to culture. Eight pathological samples (four blood-immersed cotton specimens, two spleen tissue specimens, and two blood smears) with confirmed positive results for anthrax were used. All samples were suspended in saline solution and fixed with Gram and Giemsa stains for examination of colony and capsule formation. Amplicons were analyzed on 2% agarose gels with the classic PCR method. For real-time PCR, a fluorescently labeled TaqMan probe was used with a Smartcycler. Positive smear and cotton samples were confirmed with the standard culture and real-time PCR methods, but the same samples were found to be negative with the classic PCR method. A spleen sample known to be positive for B. anthracis was found to be negative with the culture method because of possible contamination with Proteus-type bacteria.

Comparative sporicidal effects of disinfectants after release of a biological agent.

Because of spore formation, Bacillus anthracis is considered the most resistant biological warfare agent known. The present study aimed to assess and compare well-known decontamination routes to inactivate the spores on daily-use environmental tools contaminated previously. To simulate the agent, Bacillus atrophaeus was used. Various environmental samples (such as tile, fabric clothing, wood, protective suit, glass, paper, soil, water, plastic, and metal) that may be contaminated after a biological incident were used as test carriers and inoculated with B. atrophaeus. Sodium hypochlorite, free chlorine, autoclaving, ethylene oxide, hydrogen peroxide, ultraviolet irradiation, and boiling decontaminated the samples. Glutaraldehyde (2%) and free chlorine solution (10,000 mg/L) were also found to be effective in decontaminating the samples and are recommended as alternatives to the use of sodium hypochlorite solution. Soil, tile, paper, and metal were determined to be the most difficult materials to decontaminate. It was concluded that 5% hypochlorite adjusted with acetic acid might also be used for decontamination. Decontamination strategies to reduce contamination of the environment by biological warfare agents need to be applied to mitigate the number of victims, in terms of prominent characteristics like cost-effectiveness and user-friendliness.

Chemical release at the airport and lessons learned from the medical perspective.

The risk of massive exposure to toxic chemical substances including chemical weapons or industrial chemicals has increased especially during the last century due to the development in industry and chemistry science. This paper aims to describe a real chemical release event and further exposures to personnel working at the Esenboga Airport, Ankara, Turkey, and to give lessons learned. This chemical release was noticed firstly by airport staff giving symptoms including nausea, vomiting, irritation of eyes, itching and rinorrhea. First responders from civil defense unit and a group of health staff including NBC First-aid and Rescue Team gave response to the incident. The increasing number of exposed or suspected cases transferred to hospital were isolated in Emergency Department (ED) following the decontamination at the airport. Due to the characteristic odour and the growing number of the victims, the releasing agent was considered to be likely cyanide or sulfur mustard. Because of the panic amongst the workers, the number of the exposed (real or suspected) people increased up to about 40 and were kept under observation in ED of the hospital. The chromotographic analysis revealed that the agent contained diallyl disulfide, an organo-sulfur compound present at very high concentrations in pure garlic oil. Blood results showed no cyanide and the isolation were terminated. Along with the lessons learned, incident showed that the health facilities should be prepared against such deliberate or accidental mass casualties.

Minimal change disease in a patient receiving IFN-alpha therapy for chronic hepatitis C virus infection.

Chronic hepatitis C virus (HCV) infection is associated with several extrahepatic syndromes. The principal types of renal disorders associated with chronic HCV infection are cryoglobulinemia or noncryoglobulinemic membranoproliferative glomerulonephritis (MPGN). Interferon-alpha (IFN-alpha) may precipitate or exacerbate the occurrence of MPGN. Our patient was a 32-year-old man who tested positive for HCV in July 1997. The patient was treated with IFN-alpha in another medical center for 6 months because his liver biopsy showed chronic active hepatitis. In December 1998, he applied to our clinic for a follow-up examination. The level of aspartate aminotransferase (AST) was 44 U/L, and that of alanine aminotransferase (ALT) was 69 U/L. HCV RNA was positive in serum, and chronic HCV infection was detected by liver biopsy. IFN-alpha therapy (5 million U/day) was administered for 6 months longer. In May 1999, the patient came to our polyclinic with edema of the feet and legs. We detected proteinuria, serum cholesterol of 269 mg/dl, AST of 50 U/L, ALT of 41 U/L, serum total protein of 3.4 g/dl, serum albumin of 1.2 g/dl, positive cryoglobulin, and urine protein of 9.84 g/day. Cryoglobulinemic MPGN was suspected and kidney biopsy was performed, resulting in a diagnosis of minimal change disease (MCD).