Secondary hemophagocytic lymphohistiocytosis versus cytokine release syndrome in severe COVID-19 patients

COVID-19 or SARS-CoV-2 infection can lead to severe acute respiratory distress syndrome/pneumonia with features of cytokine storm reminiscent of secondary hemophagocytic lymphohistiocytosis (HLH), which can be diagnosed by the calculated HScore. Recent reports have suggested favorable responses to the interleukin-1 receptor antagonist, anakinra in patients with COVID-19 associated secondary HLH. In our single institution study, we compared 14 COVID-19 cytokine storm patients with 10 secondary HLH patients seen immediately prior to the pandemic (non-COVID-19), to determine whether diagnostic features of secondary HLH were typically seen in COVID-19 patients presenting with cytokine storm. Although most of our COVID-19 patients did not fulfill diagnostic criteria for HLH, we hypothesize that identification of HLH may relate to the severity or timing of cytokine release. Based on our observations, we would suggest distinguishing between cytokine release syndrome and secondary HLH, reserving the latter term for cases fulfilling diagnostic criteria.Impact statementSevere COVID-19 associated pneumonia and acute respiratory distress syndrome has recently been described with life-threatening features of cytokine storm and loosely referred to as hemophagocytic lymphohistiocytosis (HLH) or macrophage activation syndrome (MAS). Although a recent report indicated favorable responses to the interleukin-1 receptor antagonist, anakinra in eight patients with COVID-19 secondary HLH diagnosed using the HScore calculation, others have suggested that the diagnosis of secondary HLH is uncommon and that the use of the HScore has limited value in guiding immunomodulatory therapy for COVID-19. Here, we provide additional perspective on this important controversy based upon comparisons between 14 COVID-19 cytokine storm patients and 10 secondary HLH patients seen immediately prior to the pandemic. We hypothesize that identification of HLH may relate to the severity or timing of cytokine release and suggest distinguishing between cytokine release syndrome and secondary HLH, reserving the latter term for cases fulfilling diagnostic criteria.     

Distribution of extravascular lung water after acute smoke inhalation

Anesthetized dogs with thoracotomy were injected with Evans blue dye and were exposed acutely (5 min) to wood smoke inhalation. Thin slices from freeze-dried samples were photographed and assessed for periarterial and perivenous cuff area and for blue coloration with a score of 0 to 5. Bloodless extravascular lung water (EVLW) was also measured. The smoke-exposed animals were compared with controls and with animals exposed to alloxan or to high-pressure-induced pulmonary edema. EVLW at 2 h after smoke (6.46 +/- 0.80) was above control value (4.30 +/- 0.63) but not different from the alloxan (6.13 +/- 0.70) or high-pressure (6.88 +/- 1.30) groups. Despite the similarity in EVLW in the edematous lungs, there were marked differences in the intensity of blue color and size of cuffing around arteries and veins: the smoke, alloxan, and high-pressure groups had blue color scores of 1.0 +/- 0.1, 2.9 +/- 0.3, and 0.3 +/- 0.1, respectively. These scores indicated a large increase in microvascular permeability to proteins in the alloxan group, a moderate increase in the smoke group, and minimal change in the high-pressure group. The perivascular cuff area was largest in the alloxan group and moderate in the smoke and high-pressure groups. The cuff area was higher for arteries than for veins in all groups except the 0.5-h smoke group. We conclude that smoke inhalation causes a moderate increase in permeability and EVLW compared with alloxan. The extravascular lung water accumulates preferentially around the arteries, but the size of the perivascular cuff is not similar for all causes of pulmonary edema.     

Functional heterogeneity correlates with structural heterogeneity of breast carcinoma acid-soluble glycoproteins

Patients with malignant tumors, specifically with metastatic breast carcinoma (BCa), are immunosuppressed and have defective lymphocyte responsiveness to antigenic and mitogenic stimulation. The present study examined the role of perchloric acid (PCA)-soluble glycoproteins and their oligosaccharide moieties from tumor cells and from sera of patients with metastatic BCa. Sera from 15 patients and from age-matched healthy adults were examined for immunoregulatory glycoproteins. BCa tissue was obtained from 9 of the 15 patients. The PCA extracts from tumor tissue were resolved into six (GP-I to GP-VI), and from serum into three (GP-II, GP-IV, and GP-V), BCa-associated glycoproteins. After alkaline borohydride treatment, six groups of BCa-associated oligosaccharides were obtained. Peripheral blood mononuclear (MNC) and natural killer (NK) cells were obtained from patients with metastatic BCa and from age-matched healthy adults. These were used as effector cells in the well-established 4-hr cytotoxicity assay. The results indicated that interleukin 2 (IL-2) significantly (P less than 0.001) enhanced the cytotoxic activities of MNC and NK cells from healthy adults, but it had a nonsignificant effect on MNC and NK cells from patients with metastatic BCa. The BCa-associated glycoproteins and their oligosaccharides varied in their effects on MNC and NK cells from both the healthy adults and the patients with metastatic BCa. IL-2 activated MNC cytotoxic activity against BCa cells. GP-I, GP-II, GP-III, and GP-IV inhibited MNC inherent cytotoxicity and blocked MNC stimulation by IL-2, GP-IV fraction had a statistically nonsignificant effect, whereas GP-V enhanced both MNC inherent and IL-2-activated cytotoxic activities. Oligosaccharides obtained from PCA extracts of BCa tissue and by alkaline borohydride treatment differentially bound and inhibited a series of monoclonal antibodies raised against BCa-associated glycoproteins. These results indicated that the oligosaccharide moieties of the BCa-associated glycoproteins modulate recognition of the BCa cells by the effector cells.     

Obesity and Long-Term Clinical and Economic Outcomes in Coronary Artery Disease Patients

Objective: Obesity is an important risk factor for coronary artery disease (CAD); however, its effect on acute coronary syndrome (ACS) patients’ long-term clinical and economic outcomes has not been quantified. We assessed the impact of increasing body mass index (BMI) on 10-year outcomes for ACS patients. Research Methods and Procedures: ACS patients with significant CAD receiving an initial cardiac catheterization at Duke University Medical Center between 1986 and 1997 were included. Patients with a BMI < 18.5 kg/m² were excluded; the remaining patients were classified by BMI as normal, overweight, obese, or very obese. Medical costs were estimated from a prior ACS clinical trial with costs adjusted to 1997 dollars and discounted at 3% per annum. Results: There were 9405 patients with data available for analysis. Follow-up was complete on >95% of patients. Patients who were obese at baseline increased from 20% to 33% between 1986 and 1997. Increased BMI was associated with younger age, multi-morbidity, and less severe CAD at baseline. It was also associated with more clinical events, higher cumulative inpatient medical costs, and significant differences in unadjusted survival at 10 years. However, it was not associated with differences in 10-year survival after adjusting for baseline characteristic differences. Discussion: Obese ACS pateints are younger and are hospitalized more frequently during the first 10 years of their illness than are non-obese patients. They also incur higher cumulative inpatient medical costs, especially the very obese. These findings highlight the opportunities for therapeutic benefit that aggressive weight management and secondary prevention may provide this population.     

Detection of granulocyte reactive oxygen species formation in whole blood using flow cytometry.

We have developed a technique for analysis of granulocyte reactive oxygen species formation in whole blood using flow cytometry and two color immunofluorescence. This technique relies upon the use of specific fluorescent dye (LDS-751) to stain nucleated cells, eliminating erythrocytes from analysis. Using LDS-751, forward angle light scatter, and 90 degrees side scatter, a granulocyte gate, monocyte gate, and lymphocyte gate were identified. Analysis with multiple FITC conjugated monoclonal antibodies demonstrated greater than 95% purity of a flow cytometrically identified granulocyte population in whole blood without physical manipulation of the blood. Utilizing 2'7' dichlorofluorescein diacetate (DCFH-DA), we were able to measure granulocyte intracellular reactive oxygen species production. Dose response curves were obtained for the effect of granulocyte agonists phorbol myristate acetate, FMLP, and heat fixed Staphylococcus aureus on reactive oxygen species production. The techniques described in this paper should be useful for measuring granulocyte activation in vivo with flow cytometry.     

Isoelectric focusing of lateral muscle myogen and haemoglobins of two species of Mugilidae

1. The myogen protein patterns of lateral muscle of Liza ramada (Risso) and Chelon labrosus (Risso), revealed by isoelectric focusing, are reported. Specific differences are noted both in the white and in the red muscle (where they are more evident). 2. Red muscle shows the presence of a chromoprotein, found to be myoglobin, with a pI characteristic for the species. 3. Blood haemoglobins were examined with the same technique and also found to be species specific.