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ACUTE AUTOIMMUNE REACTION: AN OBSCURE MECHANISM OF COVID-19-RELATED MYOCARDIAL INJURY ?
Kenan YALTA, MD a
Ertan YETKIN, MD b
Gokay TAYLAN, MD a
Tulin YALTA, MD c
a Trakya University, Cardiology Department, Edirne, TURKEY
b Istinye University, Liv Hospital, Cardiology Department, Istanbul, TURKEY
c Trakya University, Pathology Department, Edirne, TURKEY
Corresponding Author: Kenan YALTA Trakya University, Cardiology Department, Edirne, TURKEY
Email- firstname.lastname@example.org, email@example.com Phone: 00905056579856
Acute myocardial injury has been suggested as an important prognostic factor in Covid-19 patients (1-3). In their recently published article (1), Wei JF, et al. have demonstrated a significant association of acute myocardial injury (defined as elevation of high sensitive troponin-T (hs-TnT) levels) with older age, pre-existing cardiovascular disease, disease severity (and hence; general frailty) and adverse prognosis in Covid-19 patients . The authors have principally attributed this injury to certain factors including systemic inflammation, hypoxemia and direct myocardial invasion by the viral agent (1). However, as described below, an acute autoimmune reaction triggered by the virus might also be considered as an alternative mechanism of myocardial injury par...
Acute myocardial injury has been suggested as an important prognostic factor in Covid-19 patients (1-3). In their recently published article (1), Wei JF, et al. have demonstrated a significant association of acute myocardial injury (defined as elevation of high sensitive troponin-T (hs-TnT) levels) with older age, pre-existing cardiovascular disease, disease severity (and hence; general frailty) and adverse prognosis in Covid-19 patients . The authors have principally attributed this injury to certain factors including systemic inflammation, hypoxemia and direct myocardial invasion by the viral agent (1). However, as described below, an acute autoimmune reaction triggered by the virus might also be considered as an alternative mechanism of myocardial injury particularly in a specific subgroup of Covid-19 patients, and might have potential implications:
Firstly; autoimmune myocardial injury in Covid-19 patients might, paradoxically, be considered as a sign of immunocompetence, and might more likely emerge in apparently healthy and relatively young patients, yet; with a genetic propensity for autoimmune diseases. Moreover, occurence of this phenomenon might not necessarilly be associated with pulmonary disease severity as well. Within this context, potential autoimmune reaction in Covid-19 patients might be susbstantiated by a recent report suggesting a potential link between covid-19 infection and Kawasaki disease (KD) (4) (a multisystemic disease renowned for its genetic and potentially autoimmune basis (5)). Moreover, autoimmunity was recently suggested to account for the evolution of interstitial pneumonia in genetically susceptible covid-19 patients (6). Accordingly, we would like to have information regarding co-existing autoimmune diseases (that might create a proclivity for autoimmune myocardial injury) particularly in those with elevated hs-TnT in the study (1)
Secondly; covid-19-related autoimmune myocardial injury might be due to a variety of molecular mechanisms (including cross reaction, bystander activation, etc. in genetically susceptible subjects (7)), and might be expected to arise particularly during the late course or even after convalescence period of the infection. Importantly, this autoimmune reaction should not be confused with another late presenting phenomenon namely ‘cytokine release syndrome’ (CRS) (2,3) that is well known to arise more likely in fragile subjects (with a deficiency of early cellular immune response to combat the virus), and has a poor prognosis. Accordingly, we wonder whether there were very late presentations of acute myocardial injury (suggestive of an autoimmune reaction) in the study (1).
Thirdly; the degree and extent of autoimmune reaction, if any, to the viral pathogen (possibly also involving other organ systems including vascular structures, etc.) might exclusively determine the prognosis in Covid-19 cases with minimal or no pulmonary findings. In particular, myocardial involvement might be expected to be transient and mild (as analogous to the setting of other acute autoimmune conditions including KD (5)). However, certain immunomodulatory strategies (similar to those in KD (5)) might speed up myocardial recovery, and might improve the prognosis in particular cases suffering acute heart failure.
In summary, autoimmune myocardial injury in covid-19 patients might serve as an important; yet overlooked mechanism of elevated cardiac biomarkers , particularly in apparently healthy and robust subjects regardless of their pulmonary disease severity. However, further implications of this phenomenon still needs to be established in the clinical setting.
Conflict of Interest: None
1- Wei JF, Huang FY, Xiong TY, et al. Acute myocardial injury is common in patients with covid-19 and impairs their prognosis. Heart. 2020 Apr 30. pii: heartjnl-2020-317007. doi: 10.1136/heartjnl-2020-317007. [Epub ahead of print].
2- Cheng R, Leedy D. COVID-19 and acute myocardial injury: the heart of the matter or an innocent bystander ? Heart. 2020 Apr 30. pii: heartjnl-2020-317025. doi: 10.1136/heartjnl-2020-317025. [Epub ahead of print].
3- Kang Y, Chen T, Mui D, et al. Cardiovascular manifestations and treatment considerations in covid-19. Heart. 2020 Apr 30. pii: heartjnl-2020-317056. doi: 10.1136/heartjnl-2020-317056. [Epub ahead of print].
4- Jones VG, Mills M, Suarez D, et al. COVID-19 and Kawasaki disease: Novel virus and novel case. Hosp Pediatr. doi.10.1542/hpeds.2020-0123
5- McCrindle BW, Rowley AH, Newburger JW, et al. American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee of the Council on Cardiovascular Disease in the Young; Council on Cardiovascular and Stroke Nursing; Council on Cardiovascular Surgery and Anesthesia; and Council on Epidemiology and Prevention. Diagnosis, Treatment, and Long-Term Management of Kawasaki Disease: A Scientific Statement for Health Professionals From the American Heart Association. Circulation. 2017; 135(17): e927-e999.
6- Caso F, Costa L, Ruscitti P , et al. Could Sars-coronavirus-2 trigger autoimmune and/or autoinflammatory mechanisms in genetically predisposed subjects? Autoimmun Rev. 2020 May;19(5):102524. doi: 10.1016/j.autrev.2020.102524. Epub 2020 Mar 24.
7- Smatti MK, Cyprian FS, Nasrallah GK, et al. Viruses and Autoimmunity: A Review on the Potential Interaction and Molecular Mechanisms. Viruses. 2019 Aug 19;11(8). pii: E762. doi: 10.3390/v11080762.