COVID-19 and immunocompromised conditions: Ongoing challenging issue

Abstract

One of the most serious complications of COVID-19 is the development of uncontrolled production of cytokines that poses a major factor contributing to COVID-19 morbidity and mortality. The exact effect of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection on clinical and biochemical course of in patients with underlying immune compromised conditions is not well known with recent available data. The present letter aimed to draw attention to COVID-19 in immune deficiency.

Dear editor,

The important event in COVID-19 is depletion of antiviral defenses as well as exaggerated inflammatory response. ¹ One of the most serious complications of COVID-19 is the development of uncontrolled production of cytokines that poses a major factor contributing to COVID-19 morbidity and mortality. ² Cytokine storm, as a warning sign of COVID-19 escalation, characterized by rapid proliferation and over activation of T cells, macrophages, natural killer cells, and substantially releases of inflammatory cytokines and chemokines.^3,4

In the most severe cases of COVID-19, the prognosis can be markedly worsened by these pro inflammatory cytokines include IL-1, IL-6, IL-12, IFN-γ, and TNF-α.^3,5

There is limited data about COVID-19 and immunocompromised conditions. ⁶ The exact effect of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection on clinical and biochemical course of in patients with underlying immune compromised conditions is not well known with recent available data. Regarding the rapid spread of SARS-CoV-2 infection and unknown behavior of this disease especially in immune deficiency conditions, there are debates regarding management of these patients during the COVID-19 pandemic.^7,8

Since accurate prediction of course of COVID-19 especially in immunosuppressive patients will be essential to improve patient survival, the present letter aimed to draw attention to COVID-19 in immune deficiency.

In one hand immunosuppressive drugs could be harmful in the initial phase of COVID-19 that the host immune response is necessary to inhibit viral replication^6,9 and in the other hand, immunocompromised conditions include primary immune deficiency and secondary immune suppression issues (e.g. Post-organ transplantation and immunosuppressive therapy), might have a beneficial effect in the cytokine release storm phase of COVID-19. ¹⁰

In immunocompromised conditions during the development of COVID-19, due to impaired immune defenses from both underlying disease and treatment, there is an immune alternance process that may weaken the patient’s immune system and an attenuated inflammatory response may not associated with development of cytokine storm and severe clinical outcomes of COVID-19 due to suppression of some pathway of cellular or humeral response of immune system.^5,6,11,12

Overall, use of immunosuppressive agents have anti-inflammatory in various degree that influence the concentration, distribution and function of peripheral leukocytes, the activity of B and T lymphocytes, and the number and activity of neutrophils. ¹³ Alternation of these factors can be contributed in control of an exaggerated immune response of the host that preventing to the principal severe clinical manifestations of COVID-19 (i.e. respiratory and multi-organ failure). ¹³

Although the net effect of immunosuppressive drugs in patients with COVID-19 is unclear,^10,14 based on current data, patients taking biologic medications may not be at higher risk for severe disease. ⁹ So it could be hypothesized that although immunosuppressive drugs can be inhibit the host immune response against the virus, it can prevent cytokine release storm phase of COVID-19 as well. ⁶

Another important issue in these issue is the possibility of immunocompromised patients with COVID-19 and needing emergency surgery including acute abdominal conditions. The cytokine storm may be even more prominent in the patients with acute abdomen and these may pose challenge in immunocompromised conditions such as intra-abdominal infections. Laparoscopy versus open surgery is also an important question for this particular subset of patients.^15–17

Further experimentation is required to understand the changes in the immune response in COVID-19 infection and the mechanisms of abnormal cytokine expression in immunosuppressive conditions.