COVID-19 patients share common, corticosteroid-independent features of impaired host immunity to pathogenic molds

Patients suffering from coronavirus disease-2019 (COVID-19) are susceptible to deadly secondary fungal infections such as COVID-19-associated pulmonary aspergillosis and COVID-19-associated mucormycosis. Despite this clinical observation, direct experimental evidence for severe acute respiratory syndrome coronavirus type 2 (SARS-CoV-2)-driven alterations of antifungal immunity is scarce. Using an ex-vivo whole blood stimulation assay, we challenged blood from twelve COVID-19 patients with Aspergillus fumigatus and Rhizopus arrhizus antigens and studied the expression of activation, maturation, and exhaustion markers, as well as cytokine secretion. Compared to healthy controls, T-helper cells from COVID-19 patients displayed increased expression levels of the exhaustion marker PD-1 and weakened A. fumigatus - and R. arrhizus -induced activation. While baseline secretion of proinflammatory cytokines was massively elevated, whole blood from COVID-19 patients elicited diminished release of T-cellular (e.g., IFN-γ, IL-2) and innate immune cell-derived (e.g., CXCL9, CXCL10) cytokines in response to A. fumigatus and R. arrhizus antigens. Additionally, samples from COVID-19 patients showed deficient granulocyte activation by mold antigens and reduced fungal killing capacity of neutrophils. These features of weakened anti-mold immune responses were largely decoupled from COVID-19 severity, the time elapsed since diagnosis of COVID-19, and recent corticosteroid uptake, suggesting that impaired anti-mold defense is a common denominator of the underlying SARS-CoV-2 infection. Taken together, these results expand our understanding of the immune predisposition to post-viral mold infections and could inform future studies of immunotherapeutic strategies to prevent and treat fungal superinfections in COVID-19 patients

Development of functional immunoassays to study human host responses to the opportunistic pathogen AspergillusAspergillus fumigatusfumigatus

Aspergillus fumigatus ist ein opportunistisches fungales Humanpathogen, das ein breites Erkrankungsspektrum von der invasiven Aspergillose (IA) in immunkompromittierten Patienten bis zu einer Reihe von Hypersensitivitätserkrankungen in immunkompetenten Individuen hervorrufen kann. Die Diagnostik für A. fumigatus assoziierte Krankheitsbilder beruht auf mehreren diagnostischen Tests, die auch in ihrer Kombination oft zu späten und unzuverlässigen Diagnosen führen, was wiederum zu einer suboptimalen Patientenversorgung, erhöhter Mortalität und gesteigerten Kosten für das Gesundheitssystem führt. Es besteht daher die unbedingte Notwendigkeit, neue und bessere diagnostische Tests zur Detektion von A. fumigatus zu entwickeln. T Zell Assays sind vielversprechende, innovative diagnostische Tests, die bereits für andere Infektionskrankheiten in der Routinediagnostik eingesetzt werden. Erste Versuche wurden bereits unternommen, diese Assays auch für A. fumigatus assoziierte Erkrankungen einzusetzen. Die gängigsten, auf mononukleären Zellen des peripheren Blutes (PBMC)-basierten T Zell Assays sind der Enzyme-linked Immunosorbent Assay (ELISA), Enzyme-linked Immuno Spot Assay (ELISPOT) und die Durchflusszytometrie. Das Ziel dieser Dissertation war die Entwicklung eines klinisch einsetzbaren T-Zell-Assays für A. fumigatus assoziierte Erkrankungen. Die in der Literatur beschriebenen Assays zeigten in unseren Experimenten bei der Anwendung für mykologische Fragestellungen eine hohe Suszeptibilität gegenüber bereits kurzen präanalytischen Lagerzeiten und Krykonservierung, was einen klinischen Einsatz erschwerte. Wir entwickelten deshalb einen Vollblut basierten ELISA (VB-ELISA) mit dualer Kostimulation (α-CD28 und α-CD49d), hoher Reproduzierbarkeit und verbesserter Robustheit gegenüber präanalytischen Einflussfaktoren. Der VB ELISA konnte hohe Differenzen zwischen Typ 1 T Helferzellen (Th1) , Th2 und Th17 Zytokinkonzentrationen bei Patienten mit Aspergillus assoziierten Hypersensitivitätskrankheitsbildern und Kontrollpatienten feststellen. Um zu testen, ob dieser Anstieg auf die Erkrankung zurückzuführen ist oder auch bei hoher Aspergillus-Umweltexposition vorzufinden ist, wurde der Assay in Aspergillus exponierten gesunden ökologischen Landwirten getestet. In dieser Gruppe fanden wir ebenfalls eine erhöhte Th1 und Th2 Expansion und Zytokinsekretion gegenüber gesunden Kontrollspendern, jedoch wurde nur ein geringer Anstieg des Th17 Signalzytokines IL-17 detektiert. Die Detektion von IL-17 im VB-ELISA in Kombination mit anderen Zytokinmarkern ist daher ein vielversprechender Biomarker für die Diagnose von A. fumigatus assoziierten Hypersensitivitätserkrankungen. Neben diesen Hypersensitivitätserkrankungen haben wir den VB-ELISA auch in immunkompromittierten Patienten nach allogener Stammzelltransplantation (alloSZT), einer Hochrisikogruppe für die IA und die durch das humane Cytomegalovirus (HCMV) ausgelöste Zytomegalie, evaluiert. Während in unserer monozentrischen Pilotstudie aufgrund der geringen Inzidenz keine Evaluation an IA-Patienten erfolgen konnte, wurde mittels VB-ELISA eine hohe Konkordanz der HCMV-spezifischen T Zell Antwort mit der HCMV Serologie sowie eine vergleichbare Leistung zum ELISPOT, dem am häufigsten eingestetzen Assay für diese Fragestellung, festgestellt. Zusammenfassend haben wir mit dem VB ELISA einen vielversprechenden und breitflächig im Spektrum A. fumigatus assoziierter Erkrankungen einsetzbaren T Zell Assay entwickelt, der in der Zukunft in großen Studien mit klar definierten Patientenkohorten getestet werden sollte. Auf Grund von Daten aus Folgestudien, die auf dieser Arbeit basieren, ist des Weiteren davon auszugehen, dass der VB-ELISA auf Grund seiner Stärken potenziell in einer Vielzahl von Anwendungsgebieten und Pathogenen (eine Folgestudie mit SARS-CoV-2 wurde vor kurzem veröffentlicht) universell eingesetzt werden kann. Neben der Immundiagnostik für diverse Infektionserkrankungen könnte der Assay außerdem für T Zell Antworten auf Vakzinierungen und Immuntherapien, in vivo Experimente und in vitro Toxizitätstests verwendet werden.Aspergillus fumigatus is an opportunistic human pathogen, which is the cause of a wide disease spectrum. The spectrum ranges from invasive Aspergillosis (IA) in immunocompromised patients to diverse hypersensitivity diseases in immunocompetent individuals. Diagnostic assays of A. fumigatus have to be combined for efficient detection and still lead to unreliable and late diagnosis, resulting in suboptimal patient care, increased mortality and public health costs. There is, therefore, a great need to develop novel diagnostics for the detection of A. fumigatus. T-cell assays are promising, innovative diagnostic assays, which are used in routine diagnostics for certain infectious diseases. First affords have been made to adapt T-cell assays for the diagnosis of A. fumigatus-associated diseases. The most common T-cell assays are based on the isolation and stimulation of peripheral blood mononuclear cell (PBMC) and relay on Enzyme-linked Immunosorbent Assay (ELISA), Enzyme-Linked Immuno Spot Assay (ELISPOT) and flow cytometry as their read-out platforms. The aim of this dissertation was to develop a clinically feasible T-cell assay for A. fumigatus-associated diseases. We were able to demonstrate that all of these assays have high susceptibility towards pre-analytic factors like cryopreservation and shortly extended pre-analytic blood storage periods, hampering clinical feasibility. Thus, we developed a whole blood based ELISA (WB-ELISA) with dual co-stimulation (α-CD28 and α-CD49d), which showed high reproducibility, increased robustness towards pre-analytic factors and increased cytokine read-outs. The WB-ELISA was able to quantify large differences of T helper cell 1 (Th1), Th2 and Th17 cytokine concentrations in patients suffering from Aspergillus-associated hypersensitivity diseases compared to healthy controls. To analyze, whether these increased cytokine concentrations were the result of the pathology or could also be found in heavily Aspergillus-exposed individuals, we examined cytokine concentration in heavily Aspergillus-exposed organic farmers. We quantified increased Th1 and Th2 cytokine concentrations, however, we only found a minimal increase in the Th17 signal cytokine IL-17. Interleukin (IL)-17 (most likely in combination with other cytokines) is therefore a promising potential biomarker for the diagnosis of Aspergillus-associated hypersensitivity diseases. In addition to Aspergillus-associated hypersensitivity diseases, we tested the feasibility of the WB ELISA in immunocompromised patients after allogeneic stem cell transplantation (alloSCT). These patients are at high-risk for infections like IA as well as cytomegalovirus (CMV) disease, which is caused by CMV. Although, IA-specific evaluation could not be conducted, due to the low IA-incidence in these patients, the WB-ELISA showed high concordance of HCMV-specific T-cell responses with HCMV-serology as well as comparable performance to the ELISPOT, a commonly used T-cell assay for HCMV, in alloSCT patients. In conclusion, the successful development of the WB-ELISA has led to a promising and widely applicable T-cell assay for Aspergillus-associated diseases. In the future, the WB-ELISA should be evaluated in larger, multi-centric studies in well-defined patient cohorts suffering from Aspergillus-associated diseases. Furthermore, the WB-ELISA might be useful for a wide range of areas and pathogens (a follow-up study in COVID-19 patients was recently published). Besides the use in the immune diagnostics of infectious diseases, the WB-ELISA might also be applicable in the quantification of T-cell responses in vaccination- and immune therapy studies, in-vivo experiments and in-vitro toxicity testing

[Diabetes mellitus in coronary bypass surgery: risks and chances. Treatment concepts for a particularly challenging group of patients]

A steady increase in the numbers of diabetic patients in coronary surgery has been recorded over the last years. The causes for these rises are seen mainly in the general demographic development in the western industrialized nations, the epidemic progress and wide spread of diabetes mellitus, and changes in assignment behavior. In the following, the specific risk profile of diabetic coronary patients in heart surgery and tried and tested treatment concepts for this particularly challenging group of patients with reference to most recent study results will be presented. Particularly the peculiarities of coronary heart disease in diabetic patients, the choice of the revascularization method, different operative strategies for diabetic patients with coronary heart disease, and challenges faced at the cardiac surgery intensive care unit are discussed in detail

Immunomodulation as a Therapy for <i>Aspergillus</i> Infection: Current Status and Future Perspectives

Invasive aspergillosis (IA) is the most serious life-threatening infectious complication of intensive remission induction chemotherapy and allogeneic stem cell transplantation in patients with a variety of hematological malignancies. Aspergillus fumigatus is the most commonly isolated species from cases of IA. Despite the various improvements that have been made with preventative strategies and the development of antifungal drugs, there is an urgent need for new therapeutic approaches that focus on strategies to boost the host&#8217;s immune response, since immunological recovery is recognized as being the major determinant of the outcome of IA. Here, we aim to summarize current knowledge about a broad variety of immunotherapeutic approaches against IA, including therapies based on the transfer of distinct immune cell populations, and the administration of cytokines and antibodies

T-Cell Immune Surveillance in Allogenic Stem Cell Transplant Recipients: Are Whole Blood–Based Assays Ready to Challenge ELISPOT?

We compared the feasibility of 4 cytomegalovirus (CMV)- and Aspergillus-reactive T-cell immunoassay protocols in allogenic stem cell transplant recipients. While enzyme-linked immunospot performed best overall, logistically advantageous whole blood–based assays performed comparably in patients with less severe lymphocytopenia. CMV-induced interferon-gamma responses correlated strongly across all protocols and showed high concordance with serology