A wide spectrum of clinical manifestations has become a hallmark of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) COVID-19 pandemic, although the immunological underpinnings of diverse disease outcomes remain to be defined. We performed detailed characterization of B cell responses through high-dimensional flow cytometry to reveal substantial heterogeneity in both effector and immature populations. More notably, critically ill patients displayed hallmarks of extrafollicular B cell activation and shared B cell repertoire features previously described in autoimmune settings. Extrafollicular activation correlated strongly with large antibody-secreting cell expansion and early production of high concentrations of SARS-CoV-2-specific neutralizing antibodies. Yet, these patients had severe disease with elevated inflammatory biomarkers, multiorgan failure and death. Overall, these findings strongly suggest a pathogenic role for immune activation in subsets of patients with COVID-19. Our study provides further evidence that targeted immunomodulatory therapy may be beneficial in specific patient subpopulations and can be informed by careful immune profiling.

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Antibodies are a principal determinant of immunity for most RNA viruses and have 54 promise to reduce infection or disease during major epidemics. The novel 55 coronavirus SARS-CoV-2 has caused a global pandemic with millions of infections 56 and hundreds of thousands of deaths to date 1,2 . In response, we used a rapid 57 antibody discovery platform to isolate hundreds of human monoclonal antibodies 58 (mAbs) against the SARS-CoV-2 spike (S) protein. We stratify these mAbs into five 59 major classes based on their reactivity to subdomains of S protein as well as their 60 cross-reactivity to SARS-CoV. Many of these mAbs inhibit infection of authentic 61 SARS-CoV-2 virus, with most neutralizing mAbs recognizing the receptor-binding 62 domain (RBD) of S. This work defines sites of vulnerability on SARS-CoV-2 S and 63 demonstrates the speed and robustness of new antibody discovery methodologies. 64 65 Human mAbs to the viral surface spike (S) glycoprotein mediate immunity to other 66 betacoronaviruses including SARS-CoV 3-7 and Middle East respiratory syndrome 67 (MERS) 8-17 . Because of this, we and others have hypothesized that human mAbs may 68 have promise for use in prophylaxis, post-exposure prophylaxis, or treatment of SARS-69 CoV-2 infection 18 . MAbs can neutralize betacoronaviruses by several mechanisms 70 including blocking of attachment of the S protein RBD to a receptor on host cells (which 71 for SARS-CoV and SARS-CoV-2 1 is angiotensin-converting enzyme 2 [ACE2]) 12 . We 72 hypothesized that the SARS-CoV-2 S protein would induce diverse human neutralizing 73 antibodies following natural infection. While antibody discovery usually takes months 74 to years, there is an urgent need to both characterize the human immune response to 75 SARS-CoV-2 infection and to develop potential medical countermeasures. Using Zika 76 virus as a simulated pandemic pathogen and leveraging recent technological advances 77in synthetic genomics and single-cell sequencing, we recently isolated hundreds of 78 was not certified by peer review) is the author/funder. All rights reserved. No reuse allowed without permission.

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Human antibody-secreting cells (ASC) in peripheral blood are found after vaccination or infection but rapidly apoptose unless they migrate to the bone marrow (BM). Yet, elements of the BM microenvironment required to sustain long-lived plasma cells (LLPC) remain elusive. Here, we identify BM factors that maintain human ASC > 50 days in vitro. The critical components of the cell-free in vitro BM mimic consist of products from primary BM mesenchymal stromal cells (MSC), a proliferation-inducing ligand (APRIL), and hypoxic conditions. Comparative analysis of protein–protein interactions between BM-MSC proteomics with differential RNA transcriptomics of blood ASC and BM LLPC identify two major survival factors, fibronectin and YWHAZ. The MSC secretome proteins and hypoxic conditions play a role in LLPC survival utilizing mechanisms that downregulate mTORC1 signaling and upregulate hypoxia signatures. In summary, we identify elements of the BM survival niche critical for maturation of blood ASC to BM LLPC.