Comments for:
Abstract
The widespread presence of autoantibodies in acute infection with SARS-CoV-2 is increasingly recognized, but the prevalence of autoantibodies in non–SARS-CoV-2 infections and critical illness has not yet been reported. We profiled IgG autoantibodies in 267 patients from 5 independent cohorts with non–SARS-CoV-2 viral, bacterial, and noninfectious critical illness. Serum samples were screened using Luminex arrays that included 58 cytokines and 55 autoantigens, many of which are associated with connective tissue diseases (CTDs). Samples positive for anti-cytokine antibodies were tested for receptor blocking activity using cell-based functional assays. Anti-cytokine antibodies were identified in > 50% of patients across all 5 acutely ill cohorts. In critically ill patients, anti-cytokine antibodies were far more common in infected versus uninfected patients. In cell-based functional assays, 11 of 39 samples positive for select anti-cytokine antibodies displayed receptor blocking activity against surface receptors for Type I IFN, GM-CSF, and IL-6. Autoantibodies against CTD-associated autoantigens were also commonly observed, including newly detected antibodies that emerged in longitudinal samples. These findings demonstrate that anti-cytokine and autoantibodies are common across different viral and nonviral infections and range in severity of illness.
Authors
Allan Feng, Emily Y. Yang, Andrew Reese Moore, Shaurya Dhingra, Sarah Esther Chang, Xihui Yin, Ruoxi Pi, Elisabeth K.M. Mack, Sara Völkel, Reinhard Geßner, Margrit Gündisch, Andreas Neubauer, Harald Renz, Sotirios Tsiodras, Paraskevi C. Fragkou, Adijat A. Asuni, Joseph E. Levitt, Jennifer G. Wilson, Michelle Leong, Jennifer H. Lumb, Rong Mao, Kassandra Pinedo, Jonasel Roque, Christopher M. Richards, Mikayla Stabile, Gayathri Swaminathan, Maria L. Salagianni, Vasiliki Triantafyllia, Wilhelm Bertrams, Catherine A. Blish, Jan E. Carette, Jennifer Frankovich, Eric Meffre, Kari Christine Nadeau, Upinder Singh, Taia T. Wang, Eline T. Luning Prak, Susanne Herold, Evangelos Andreakos, Bernd Schmeck, Chrysanthi Skevaki, Angela J. Rogers, Paul J. Utz
Controlled studies with standardized methodologies are needed to determine the etiology and pathogenicity of autoantibodies in COVID-19.
Submitter: Claudia dos Santos | claudia.dossantos@unityhealth.to
Authors: Claudia dos Santos, Uriel Trahtemberg MD, PhD; Marvin J Fritzler MD, PhD
University of Toronto
Published April 4, 2023
The historical link of autoimmunity to the development of AAB during viral diseases and critical illnesses is well documented (1-3). Feng et al used custom, research-grade arrays and other assays to detect a wide range of autoantibodies in COVID-19, other acute respiratory and influenza diseases, control individuals with known autoimmune disease and known blocking autoantibodies, as well as healthy controls (4). We commend Feng et al. for their important observations, the breadth of AAB analytics, and the analysis of samples from different conditions and sources. However, we beg to differ on the statement in the Abstract that “…the prevalence of autoantibodies in non–SARS-CoV-2 infections and critical illness has not yet been reported.” In 2021 we published two manuscripts on anti-phospholipid antibodies (5) and a broader spectrum of AAB (6); our data was also the topic of a subsequent reviews (2, 3). We studied critically ill COVID-19 patients, comparing them to a contemporaneous cohort of non-COVID patients with a respiratory presentation of similar severity in the ICU. In communication with the authors of Feng et al, it is apparent that our publications were accidentally overlooked, given the difficulty of keeping abreast of the fast-developing literature on COVID-19 and autoimmunity (2).
In our studies we aimed to determine if any of the autoimmune biomarkers found were unique to SARS-CoV2 infection and COVID-19, or if they were merely a reflection of an acute inflammatory respiratory illness. We found that 1) the prevalence of ANA on HEp-2 substrates was 68% among COVID-19 patients and 60% among similarly ill, non-COVID-19 control patients; 2) both cohorts showed a marked variety of HEp-2 staining patterns; 3) no differences between the two cohorts in 22 AAB associated with autoimmune diseases; and 4) no correlation between the development of anti-COVID-19 antibodies and the 22 AAB panel longitudinally, over 5 time points (6). Another difference is our use of FDA- and Health Canada-approved assays whereas Feng et al used research grade, laboratory developed tests (LDT). Hence, translation of AAB findings to everyday clinical practice is limited. Indeed, LDTs are undergoing international reassessment (7).
In contrast to our studies and the current study of Feng et al. (4), most publications on this topic used healthy volunteers, patients that are not critically ill, or COVID-19 patients of milder severity as controls. To derive insight into the specific role of SARS-CoV-2 in the induction of autoimmunity and autoimmune diseases, we argued that non-COVID-19 patients with respiratory diseases of similar severity should be used as comparators and to a great extent the study of Feng et al has remarkably broadened these observations. Finally, notwithstanding the many reports of a broad spectrum of autoimmune phenomena associated COVID-19, to our knowledge, the literature has not provided compelling evidence that the autoantibodies associated with COVID-19 causes systemic autoimmune rheumatic diseases.
References
1. Burbelo PD, Seam N, Groot S, Ching KH, Han BL, Meduri GU, et al. Rapid induction of autoantibodies during ARDS and septic shock. J Transl Med. 2010;8:97.
2. Damoiseaux J, Dotan A, Fritzler MJ, Bogdanos DP, Meroni PL, Roggenbuck D, et al. Autoantibodies and SARS-CoV2 infection: The spectrum from association to clinical implication: Report of the 15th Dresden Symposium on Autoantibodies. Autoimmun Rev. 2022;21(3):103012.
3. Fritzler MJ. In: Shoenfeld YD, A. ed. Future of Autoimmunity Research: Autoimmunity, COVID-19, Post-COVID-19 Syndrome and COVID-19 Vaccinaiton. London: Academic Press; 2023:1-10.
4. Feng A, Yang EY, Moore AR, Dhingra S, Chang SE, Yin X, et al. Autoantibodies are highly prevalent in non-SARS-CoV-2 respiratory infections and critical illness. JCI Insight. 2023;8(3).
5. Trahtemberg U, Rottapel R, Dos Santos CC, Slutsky AS, Baker A, and Fritzler MJ. Anticardiolipin and other antiphospholipid antibodies in critically ill COVID-19 positive and negative patients. Ann Rheum Dis. 2021;80(9):1236-40.
6. Trahtemberg U, Fritzler MJ, and On behalf of the C-cotLBiLIsg. COVID-19-associated autoimmunity as a feature of acute respiratory failure. Intensive Care Med. 2021;47(7):801-4.
7. Spitzenberger F, Patel J, Gebuhr I, Kruttwig K, Safi A, and Meisel C. Laboratory-Developed Tests: Design of a Regulatory Strategy in Compliance with the International State-of-the-Art and the Regulation (EU) 2017/746 (EU IVDR [In Vitro Diagnostic Medical Device Regulation]). Ther Innov Regul Sci. 2022;56(1):47-64.
Reply to dos Santos, et al.
Submitter: PJ Utz | pjutz@stanford.edu
Authors: PJ Utz, Chrysanthi Skevaki, and Angela Rogers, on behalf of the authors.
Published April 4, 2023
We thank the authors for bringing to our attention their excellent study on autoantibodies in SARS-CoV-2 positive and negative patients entitled “COVID-19-associated autoimmunity as a feature of acute respiratory failure.” (1) The authors should be commended for collecting and studying samples from the earliest days of the pandemic. We likely missed this reference because the title suggested a focus on only SARS-CoV-2, while our JCI Insight paper (2) focused on patients hospitalized with infections other than SARS-CoV-2, comparing with ICU patients who did not have evidence of infection. Our JCI Insight paper followed on our initial Nature Communications paper (3) which studied only COVID-19. Combined, our two papers characterized samples from over 400 patients and 70 healthy controls from 9 different cohorts and 3 different countries. Honest mistakes happen with citations, including with our own studies during the pandemic (4-6). As we shared in previous email correspondence, we sincerely apologize for failing to cite the authors’ studies and will work hard to avoid such mistakes going forward.
On a separate note, it is disappointing that the authors have chosen a title to their response that implies that our methodology is not rigorous, particularly when our results and the reports of the authors are largely congruent (1, 7)). Large-scale, “unstandardized” protein arrays using novel methodologies have been instrumental in studying SARS-CoV-2 (8). Importantly, some of our assays have been validated by clinical-grade assays, including ANA, SARS-CoV-2 nucleocapsid IgG, and anti-Ro (3, 9). The authors fail to note that with the exception of Figure 3, Panel B, widely-available, standardized assays do not yet exist for measuring autoantibodies against a majority of analytes in the main figures (2), including antibodies to many cytokines, chemokines, growth factors and receptors (8). Moreover, we rigorously developed multiple cytokine blocking assays, taking into account our own prior publications (5, 10) and those from other experts (11-15). We are unaware of commercial reference labs, including the lab used by the authors, that measure receptor blocking activities as clinical-grade assays.
Finally, we agree with the authors’ statement that “there is no compelling evidence that the autoantibodies associated with COVID-19 cause systemic autoimmune rheumatic diseases.” We have neither claimed nor implied this in our paper. Nevertheless, a recent article has shown an association between SARS-CoV-2 infection and development of autoimmunity (16). Much work needs to be done in this area, including work by talented investigators, including the authors.
References
1. Trahtemberg U, Fritzler MJ, and On behalf of the C-cotLBiLIsg. COVID-19-associated autoimmunity as a feature of acute respiratory failure. Intensive Care Med. 2021;47(7):801-4.
2. Feng A, Yang EY, Moore AR, Dhingra S, Chang SE, Yin X, et al. Autoantibodies are highly prevalent in non-SARS-CoV-2 respiratory infections and critical illness. JCI Insight. 2023;8(3).
3. Chang SE, Feng A, Meng W, Apostolidis SA, Mack E, Artandi M, et al. New-onset IgG autoantibodies in hospitalized patients with COVID-19. Nat Commun. 2021;12(1):5417.
4. Choi MY, Clarke AE, Buhler K, Jung M, Mathew H, Zhang M, Cardwell FS, Waldhauser H, and Fritzler MJ. Cytokine autoantibodies in SARS-CoV-2 prepandemic and intrapandemic samples from an SLE cohort. Lupus Sci Med. 2022;9(1).
5. Price JV, Haddon DJ, Kemmer D, Delepine G, Mandelbaum G, Jarrell JA, et al. Protein microarray analysis reveals BAFF-binding autoantibodies in systemic lupus erythematosus. J Clin Invest. 2013;123(12):5135-45.
6. Sarantopoulos S, and Su MA. BAFF-ling autoantibodies. J Clin Invest. 2013;123(12):5006-8.
7. Trahtemberg U, Rottapel R, Dos Santos CC, Slutsky AS, Baker A, and Fritzler MJ. Anticardiolipin and other antiphospholipid antibodies in critically ill COVID-19 positive and negative patients. Ann Rheum Dis. 2021;80(9):1236-40.
8. Wang EY, Mao T, Klein J, Dai Y, Huck JD, Jaycox JR, et al. Diverse functional autoantibodies in patients with COVID-19. Nature. 2021;595(7866):283-8.
9. Ayoglu B, Donato M, Furst DE, Crofford LJ, Goldmuntz E, Keyes-Elstein L, et al. Characterising the autoantibody repertoire in systemic sclerosis following myeloablative haematopoietic stem cell transplantation. Ann Rheum Dis. 2023.
10. Rosenberg JM, Maccari ME, Barzaghi F, Allenspach EJ, Pignata C, Weber G, et al. Neutralizing Anti-Cytokine Autoantibodies Against Interferon-alpha in Immunodysregulation Polyendocrinopathy Enteropathy X-Linked. Front Immunol. 2018;9:544.
11. Bastard P, Gervais A, Le Voyer T, Rosain J, Philippot Q, Manry J, et al. Autoantibodies neutralizing type I IFNs are present in ~4% of uninfected individuals over 70 years old and account for ~20% of COVID-19 deaths. Sci Immunol. 2021;6(62).
12. Bastard P, Michailidis E, Hoffmann HH, Chbihi M, Le Voyer T, Rosain J, et al. Auto-antibodies to type I IFNs can underlie adverse reactions to yellow fever live attenuated vaccine. J Exp Med. 2021;218(4).
13. Bastard P, Orlova E, Sozaeva L, Levy R, James A, Schmitt MM, et al. Preexisting autoantibodies to type I IFNs underlie critical COVID-19 pneumonia in patients with APS-1. J Exp Med. 2021;218(7).
14. Bastard P, Rosen LB, Zhang Q, Michailidis E, Hoffmann HH, Zhang Y, et al. Autoantibodies against type I IFNs in patients with life-threatening COVID-19. Science. 2020;370(6515).
15. Patel SY, Ding L, Brown MR, Lantz L, Gay T, Cohen S, et al. Anti-IFN-gamma autoantibodies in disseminated nontuberculous mycobacterial infections. J Immunol. 2005;175(7):4769-76.
16. Tesch F, Ehm F, Vivirito A, Wende D, Batram M, Loser F, et al. Incident autoimmune diseases in association with a SARS-CoV-2 infection: A matched cohort study. medRxiv. 2023:2023.01.25.23285014.
