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| Mechanisms involved in SARS-CoV-2 / COVID-19 |
It has been clear since the SARS epidemic of 2003 that coronavirus diseases caused by SARS-CoV infections are thromboinflammatory diseases. As of March 2020, when SARS-CoV-2 was politically (finally) declared a pandemic, COVID-19 was still treated like a main pulmonary disease. Reseachers have been pointing out that the underlying mechanisms are characterized by hyperinflammation, hypercoagulation, complement cascades and dysregulation of the Renin-Angiotensin-Aldosterone System, ultimately leading to thromboembolic events in multiple organs (MOF), stroke and post-COVID systemic diseases, such as Guillain-Barré and cardiomyopathy.
To provide a view into the complexity of COVID-19, I share with you the most prominent research papers on the mechanisms and pathogenicity of SARS-CoV-2. Some of the research papers of the biggest relevance for COVID-19 complications are as old as 60 years. This is why the paradigm should be that "Lots of the mechanisms causing COVID-19 are well-known, but we have to find the best practices to treat its complications".
I only refer to verified and reviewed research and scientific viewpoint papers citing verified references. If paper has already been peer reviewed but still awaitens the editory process (early release), I will mention this. To retrieve these papers from the PubMed/NCBI and Wiley database, I narrowed my search process to combinations of "SARS-CoV-2", "Thrombosis", "Pulmonary embolism", "Complement" and "Coagulation".
ACE and ACE2
Angiotensin Converting Enzyme defects in shock: implications for future therapy, Critical Care 22, Art. No. 274 (2018);
ADAM17
TMPRSS2 and ADAM17 Cleave ACE2 Differentially and Only Proteolysis by TMPRSS2 Augments Entry Driven by the SARS-Coronavirus Spike Protein, Journal of Virology, January 2014 Vol. 88, No. 2, P1293-1307;
Aquaporins
Aquaporin-mediated transport, Pathway R-HSA-445717, PubChem, 08 July 2020;
ARDS
Radiological findings from 81 patients with COVID-19 pneumonia in Wuhan, China: a descriptive study, Lancet Infectious Diseases Vol. 20, Issue 4, P425-434;
The evolving role of the Renin-angiotensin system in ARDS, Critical Care 21, Art. No. 329 (2017);
Asymptomatic SARS-CoV-2 Infection
Natural History of Asymptomatic SARS-CoV-2 Infection, NEJM 2020; 383:885-886, August 27, 2020;
B- and T-cell immunological memory (CD4+ and CD8+)
COVID-19 and the Path to Immunity, JAMA, September 11, 2020;
Depletion of CD4 and CD8 Positive T Cells Impairs Venous Thrombus Resolution in Mice, MDPI International Journal of Molecular Sciences 2020 March;21(5): 1650;
Call for better screening
Pathophysiological Basis and Rationale for Early Outpatient Treatment of SARS-CoV-2 (COVID-19) Infection, The American Journal of Medicine, August 06, 2020;
Cardiovascular complications
Outcomes of Cardiovascular MRI in Patients Recently Recovered from COVID-19 (coronavirus causes myocardial inflammation independent of preexisting conditions), JAMA Cardiology, July 27, 2020;
Coagulation
Immunothrombotic Dysregulation in COVID-19 Pneumonia is Associated with Respiratory Failure and Coagulopathy, Journal of Circulation, 28 July 2020;
Coagulation biomarkers are independent predictors of increased oxygen requirements in COVID-19, Journal of Thrombosis and Haemostasis, 17 August 2020;
Coagulation parameters and venous thromboembolism in patients with and without COVID-19 admitted to the Emergency Department for acute respiratory insufficiency, Thrombosis Research Vol. 196, P209-212, December 2020;
Complement
Association of COVID-19 inflammation with activation of the C5a-C5aR1 axis, Nature 2020, 29 July 2020;
COVID-19: A collision of complement, coagulation and inflammatory pathways, Journal of Thrombosis and Haemostasis Vol. 18, Issue 9, September 2020, P2110-2117;
Comparative tropism and transmission (profiling of SARS-CoV-2)
Distinct conformational states of SARS-CoV-2 Spike protein, Science 21 July 2020;
Coronavirus surprise from cryo-EM data, Wiley Analytical Science, 22 July 2020;
Single-Cell Sequencing of Peripheral Mononuclear Cells Reveals Distinct Immune Response Landscapes of COVID-19 and Influenza Patients, Immunity Vol. 53, Issue 3, 15 September 2020, P685-696;
Enhanced Binding of SARS-CoV-2 Spike Protein Receptor by Distal Polybasic Cleavage Site, ACS Nano 2020, 14, 8, 10616-10623;
Enhanced receptor binding of SARS-CoV-2 through networks of hydrogen-bonding and hydrophobic interactions, Proceedings of the National Academy of Sciences of the US (PNAS) June 23, 2020 117 (25), 13967-13974;
Pathogenicity, Transmission, Diagnosis and Treatment of COVID-19, JAMA 2020;324(8):782-793;
Risk of Ischemic Strole in Patients with COVID-19 vs. Patients With Influenza, JAMA Neurology, July 2, 2020;
Central Nervous System (CNS) complications
A case of malignant cerebral infarction associated with COVID-19 infection, British Journal of Neurosurgery, 05 August 2020;
Critical Care
Association of Noninvasive Oxygenation Strategies with All-Cause Mortality in Adults with Acute Hypoxemic Respiratory Failure: A Systematic Review and Analysis, JAMA 2020;324(1):57-67;
Anti Xa activity after high dose Low Molecular Weight Heparin (LMWH) thrombosis prophypaxis in COVID-19 patients at the IC Unit, Thrombosis Research Vol. 196, P1-3, December 01, 2020;
Impact of implementation of an individualised thromboprophylaxis protocol in critically ill ICU patients with COVID-19: A longitudinal controlled before and after study, Thrombosis Research Vol. 194, October 2020, P209-215;
Scientific and Standardization Committee communication: Clinical guidance on the diagnosis, prevention and treatment of Venous Thromboembolism (VTE) in hospitalized patients with COVID-19, Journal of Thrombosis and Haemostasis Vol. 18, Issue 8, August 2020, P1859-1865;
Inaccuracy of point-of-care international normalized ratio in Rivaroxaban-treated patients, Annals of Pharmacotherapy Vol. 47, Issue 9, September 1, 2013;
How I treat recurrent Venous Thromboembolism in patients receiving anticoagulant therapy, Blood Vol. 129, Issue 25, June 22, 2017;
Deep Vein Thrombosis (DVT)
Deep vein thrombosis in SARS-CoV-2 pneumonia-affected patients within standard care units: Exploring a submerged portion of the iceberg, Thrombosis Research Vol. 194, October 2020, P216-219;
Incidence of deep vein thrombosis among non-ICU patients hospitalized for COVID-19 despite pharmacological thromboprophylaxis, Journal of Thrombosis and Haemostasis Vol. 18, Issue 9, September 2020;
DIC (Disseminated Intravascular Coagulopathy) and differentiations of DIC
Clotting abnormalities in critically ill COVID-19 patients are inconsistent with overt Disseminated Intravascular Coagulation, Thrombosis Research Vol. 196, P272-275, December 01, 2020;
Higher procoagulatory potential but lower DIC score in COVID-19 ARDS patients compared to non-COVID-19 ARDS patients, Thrombosis Research Vol. 196, P186-192, December 01, 2020;
Endothelialitis/Endotheliitis
Pulmonary Vascular Endothelialitis, Thrombosis and Angiogenesis in COVID-19, New England Journal of Medicine (NEJM) 2020; 383:120-128, July 9, 2020;
Fibrinolysis
Fibrinolytic abnormalities in ARDS and versatility of thrombolytic drugs to treat COVID-19, Journal of Thrombosis and Haemostasis Vol. 18, Issue 7, July 2020;
Hypofibrinolytic state and high thrombin generation may play a major role in SARS-CoV-2 associated thrombosis, Journal of Thrombosis and Haemostasis Vol. 18, Issue 9, September 2020;
Interferons (IFN)
Role of IFN-γ responsiveness in CD8 T cell-mediated viral clearance and demyelination in coronavirus-infected mice, Journal of Neuroimmunology 2008 February; 194(1): 18-26;
Type I and Type III Interferons- Induction, Signaling, Evasion and Application to combat COVID-19, Cell Host & Microbe Vol. 27, Issue 6, p870-878, June 10, 2020;
Megakaryocytes
Megakaryocytes and platelet-fibrin thrombi characterize multi-organ thrombosis at autopsy in COVID-19: A case series, EClinicalMedicine Vol. 24, 100434, July 01, 2020;
Monocytes
Monocyte activation in systemic COVID-19 infection: Assay and rationale, EBioMedicine Vol. 59, 102964, September 01, 2020;
Neutrophils and NETs (& platelet interaction)
Immunothrombosis in severe COVID-19, EBioMedicine Vol. 59, 102942, September 01, 2020;
Pathogenicity of SARS-CoV-2: PROS1 and PL proteins
Identification of the antithrombotic protein S as a potential target of the SARS-CoV-2 palpain-like protease, Thrombosis Research Vol. 196, P257-259, December 01, 2020;
Pathogenicity of SARS-CoV-2: RNA and Spike protein
Circulating endothelial progenitors are increased in COVID-19 patients and correlate with SARS-CoV-2 RNA in severe cases, Journal of Thrombosis and Haemostasis, 06 August 2020;
Cleavage of spike protein of SARS coronavirus by protease factor Xa is associated with viral infectivity, Biochemical and Biophysical Research Communications 2007, July 20; 359(1): 174-179;
Platelets
Intravascular Platelet Aggregation in the Heart Induced by Norepinephrine, Journal of Circulation, 1972;46:698-708;
Platelet protein S limits venous but not arterial thrombosis propensity by controlling coagulation in the thrombus, Blood Vol. 135, Issue 22, May 28, 2020;
Pulmonary Embolism
Subsegmental Thrombus in COVID-19 Pneumonia: Immunothrombosis or Pulmonary Embolism? Data Analysis of Hospitalized Patients with Coronavirus Disease, Heart, Lung and Circulation, 24 August 2020;
Late Pulmonary Embolism after COVID-19 Pneumonia Despite Adequate Rivaroxaban Treatment, European Journal of Case Reports in Internal Medicine Vol. 7, No. 7, June 18, 2020;
Pyroptosis
Inflammasomes and Pyroptosis as Therapeutic Targets for COVID-19, The Journal of Immunology Vol. 205, Issue 2, 15 July 2020, P307-312;
RAAS (Renin-Angiotensin-Aldosterone) - KKS (Kallikrein-Kinin), Angiotensins and Bradykinin
Involvement of bradykinin B1 and B2 receptors in human PMN elastase release and increase in endothelial cell monolayer permeability, Immunopharmacology, 1996 June;33(1-3):325-9;
The Renin-Angiotensin System: An integrated view of lung disease and coagulopathy in COVID-19 and therapeutic implications, Journal of Experimental Medicine (2020) 217 (8):e20201000;
The evolving role of the Renin-angiotensin system in ARDS, Critical Care 21, Art. No. 329 (2017);
Stroke (and prevalence in young people due to SARS-CoV-2 infection)
Acute cerebral stroke with multiple infarctions and COVID-19, France, 2020, CDC Research Vol. 26, No. 9, September 2020;
A case of malignant cerebral infarction associated with COVID-19 infection, British Journal of Neurosurgery, 05 August 2020;
COVID-19 related stroke in young individuals, Lancet Neurology Vol. 19, Issue 9, P713-715, September 01, 2020;
Risk of Ischemic Strole in Patients with COVID-19 vs. Patients With Influenza, JAMA Neurology, July 2, 2020;
Stroke as a complication and prognostic factor of COVID-19, Neurologia Vol. 35, Issue 5, June 2020, P318-322;
Mechanisms of Stroke in COVID-19, Cerebrovascular Diseases Vol. 49, No. 4, September 2020;
Systemic diseases following SARS-CoV-2 infection
Autoimmune and inflammatory diseases following COVID-19, Nature Reviews Rheumatology 16, 413-414(2020);
Thrombosis
Arterial Mesentric Thrombosis as a Complication of SARS-CoV-2 Infection, European Journal of Case Reports in Internal Medicine 2020; 7(5): 001690;
Multisystemic Infarctions in COVID-19: Focus on the Spleen, European Journal of Case Reports in Internal Medicine 2020; 7(7): 001747;
Clotting abnormalities in critically ill COVID-19 patients are inconsistent with overt Disseminated Intravascular Coagulation, Thrombosis Research Vol. 196, P272-275, December 01, 2020;
Asymptomatic Deep Vein Thrombosis (DVT) in critically ill COVID-19 patients despite therapeutic levels of anti-Xa activity, Thrombosis Research Vol. 196, P268-271, December 01, 2020;
Extensive pulmonary perfusion defects compatible with microthrombosis and thromboembolic disease in severe COVID-19 pneumonia, Thrombosis Research Vol. 196, P135-137, December 01, 2020;
Systemic thromboemboli in patients with COVID-19 may result from paradoxical embolization, Thrombosis Research Vol. 196, P206-208, December 01, 2020;
Circulating endothelial progenitors are increased in COVID-19 patients and correlate with SARS-CoV-2 RNA in severe cases, Journal of Thrombosis and Haemostasis, 06 August 2020;
Thromboembolic events and apparent heparin resistance in patients infected with SARS-CoV-2, International Journal of Laboratory Hematology 2020 June;42:19-20;
Treatment/therapeutic options for treating COVID
Treatment of patients with acute Deep Vein Thrombosis and/or pulmonary embolism: efficacy and safety of non-VKA oral anti-coagulants in selected populations, Thrombosis Research Vol. 134, Issue 2, p227-233, August 01, 2014;
Ig-like ACE2 protein therapeutics: a revival in development during a pandemic, Journal of mAbs (antibodies) Vol. 12, Issue 1, December 2020;
Therapeutic blockade of granulocyte macrophage colony-stimulating factor (GM-CSF) in COVID-19 associated hyperinflammation: challenges and opportunities, Lancet Respiratory Medicine Vol. 8, Issue 8, p822-830, August 2020;
Fibrinolytic abnormalities in ARDS and versatility of thrombolytic drugs to treat COVID-19, Journal of Thrombosis and Haemostasis Vol. 18, Issue 7, July 2020;
Dynamic changes in fibrinogen and D-dimer levels in COVID-19 patients on nafamostat mesylate, Journal of Thrombosis and Thrombolysis 2020, 12 September 2020 (note: trial from Tokyo Hospital, coagulation dynamics might differ in non-Asian people);
Kallikrein-kinin blockade in patients with COVID-19 to prevent ARDS, Radboud UMC, April 27, 2020;
Accumulating evidence suggests anti-TNF therapy needs to be given trial priority in COVID-19 treatment, Lancet Rheumatology, September 04, 2020;
GM-CSF Blockade during Chimeric Antigen Receptor T Cell Therapy Reduces Cytokine Release Syndrome and Neurotoxicity and May Enhance Their Effector Functions, ASH Blood Vol. 132, November 29, 2018;
GM-CSF Neutralization With Lenzilumab in Severe COVID-19 Pneumonia: A Case-Control Study, Mayo Clinic Proceedings, 03 September 2020;
Effect of Dexamethasone on Days Alive and Ventilator-Free in Patients With Moderate or Severe ARDS and COVID-19: the CoDEX Randomized Clinical Trial, JAMA, September 2, 2020;
Effect of Hydrocortisone Among Critically Ill Patients With COVID-19: A Randomized Clinial Trial, JAMA, September 2, 2020;
The Role of Anticoagulation in COVID-19 Induced Hypercoagulability, Current Cardiology Reports 22, Art. No. 53(2020);
Viral load and antibody responses
Temporal profiles of viral load in posterior oropharyngeal saliva samples and serum antibody responses during infection by SARS-CoV-2: an observational cohort study, Lancet Infectious Diseases Vol. 20, Issue 5, P565-574;
