Cytokine Release Syndrome in COVID-19 Patients, A New Scenario for an Old Concern: The Fragile Balance between Infections and Autoimmunity

Abstract

On 7 January 2020, researchers isolated and sequenced in China from patients with severe pneumonitis a novel coronavirus, then called SARS-CoV-2, which rapidly spread worldwide, becoming a global health emergency. Typical manifestations consist of flu-like symptoms such as fever, cough, fatigue, and dyspnea. However, in about 20% of patients, the infection progresses to severe interstitial pneumonia and can induce an uncontrolled host-immune response, leading to a life-threatening condition called cytokine release syndrome (CRS). CRS represents an emergency scenario of a frequent challenge, which is the complex and interwoven link between infections and autoimmunity. Indeed, treatment of CRS involves the use of both antivirals to control the underlying infection and immunosuppressive agents to dampen the aberrant pro-inflammatory response of the host. Several trials, evaluating the safety and effectiveness of immunosuppressants commonly used in rheumatic diseases, are ongoing in patients with COVID-19 and CRS, some of which are achieving promising results. However, such a use should follow a multidisciplinary approach, be accompanied by close monitoring, be tailored to patient's clinical and serological features, and be initiated at the right time to reach the best results. Autoimmune patients receiving immunosuppressants could be prone to SARS-CoV-2 infections; however, suspension of the ongoing therapy is contraindicated to avoid disease flares and a consequent increase in the infection risk.

Psychological Distress in Patients with Autoimmune Arthritis during the COVID-19 Induced Lockdown in Italy

“…Mental health status was measured using the Depression, Anxiety, and Stress Scale (DASS-21), a standardized and validated scale already used in chronic arthritis patients, as well as in previous research related to SARS and COVID-19 [43,44]. The total depression subscale score was divided into normal (0-9), mild depression (10)(11)(12), moderate depression (13)(14)(15)(16)(17)(18)(19)(20), severe depression (21-27), and extremely severe depression (28)(29)(30)(31)(32)(33)(34)(35)(36)(37)(38)(39)(40)(41)(42). The total anxiety subscale score was divided into normal (0-6), mild anxiety (7-9), moderate anxiety (10)(11)(12)(13)(14), severe anxiety (15)(16)(17)(18)(19), and extremely severe anxiety .…”

“…The total anxiety subscale score was divided into normal (0-6), mild anxiety (7-9), moderate anxiety (10)(11)(12)(13)(14), severe anxiety (15)(16)(17)(18)(19), and extremely severe anxiety . The total stress subscale score was divided into normal (0-10), mild stress (11-18), moderate stress (19)(20)(21)(22)(23)(24)(25)(26), severe stress (27)(28)(29)(30)(31)(32)(33)(34), and extremely severe stress (35)(36)(37)(38)(39)(40)(41)(42).…”

Cardiovascular Complications of COVID-19: Pharmacotherapy Perspective

“…An approved therapy for patients with COVID-19 has yet to emerge; however, there are some medications used in the treatment of SARS-CoV-2 infection globally. They include hydroxychloroquine/chloroquine, which has immunomodulatory effects and can inhibit viral fusion; lopinavir/ritonavir, which is an antiretroviral agent and can block virus replication; dexamethasone as an anti-inflammatory agent; remdesivir, which is an inhibitor of RNA synthesis; and lastly passive immunotherapeutic agents such as tocilizumab, sarilumab, canakinumab, and anakinra [ 6 ]. Although not yet approved by any regulatory agencies, remdesivir has shown evidence of shortened time to recovery among patients with COVID-19 [ 7 ].…”

Cytokine storm in COVID-19: Potential therapeutics for immunomodulation

“…COVID-19 infections, it has been reported that cytokine profiles confirm the increased levels of interleukin-1β (IL-1β), IL-2, IL-6, IL-8, tumour necrosis factor-α or TNF-α and some chemokines. 19,20 These elevated levels of cytokines and chemokines confirm the sHLH syndrome in COVID-19 patients. Major clinical manifestations of sHLH include unremitting fever, enlarged liver, liver dysfunction, cytopenias, neurologic dysfunction, and multiorgan failure.…”