Coronavirus disease-2019 (COVID-19), caused by the novel severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), has lead to a global pandemic with a rising toll in infections and deaths. Better understanding of its pathogenesis will greatly improve the outcomes and treatment of affected patients. Here we compared the inflammatory and cardiovascular disease-related protein cargo of circulating large and small extracellular vesicles (EVs) from 84 hospitalized patients infected with SARS-CoV-2 with different stages of disease severity. Our findings reveal significant enrichment of proinflammatory, procoagulation, immunoregulatory and tissueremodelling protein signatures in EVs, which remarkably distinguished symptomatic COVID-19 patients from uninfected controls with matched comorbidities and delineated those with moderate disease from those who were critically ill. Specifically, EN-RAGE, followed by TF and IL-18R1, showed the strongest correlation with disease severity and length of hospitalization. Importantly, EVs from COVID-19 patients induced apoptosis of pulmonary microvascular endothelial cells in the order of disease severity. In conclusion, our findings support a role for EVs in the pathogenesis of COVID-19 disease and underpin the development of EV-based approaches to predicting disease severity, determining need for patient hospitalization and identifying new therapeutic targets.
K E Y WO R D S endothelial injury, inflammation, SARS-CoV-2, thrombosis
INTRODUCTIONThe coronavirus disease-2019 (COVID-19) caused by the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) (Dashboard WCDC-2020; Wu et al., 2020) is marked by endothelial dysfunction and dysregulated immune responses (Huertas et al., 2020). Like the SARS-CoV pathogen that led to epidemics in 2002 and 2003, SARS-CoV-2 enters cells via binding of its spike protein to angiotensin converting enzyme 2 (ACE2) receptors. ACE2 receptors are abundantly present in pulmonary alveolar type II and endothelial cells, thereby making the lungs and pulmonary vasculature susceptible to SARS-CoV-2-induced inflammation and injury (Zhao et al., 2020). Further, alveolar capillary micro-thrombi and endothelial damage with evidence of intracellular virus have been noted on post-mortem analysis of infected lungs (Ackermann et al., 2020). While there is growing evidence that endothelial injury, vascular remodelling and coagulopathy are key consequences of COVID-19 infection, it remains unclear how the virus induces these changes. Extracellular vesicles (EVs) carry proteins, coding and non-coding RNA, DNA fragments and lipids, which facilitate cross-talk between cells. The transfer of EV cargo plays aThis is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited.