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Inflammatory profiles across the spectrum of disease reveal a distinct role for GM-CSF in severe COVID-19

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Science Immunology  10 Mar 2021:
Vol. 6, Issue 57, eabg9873
DOI: 10.1126/sciimmunol.abg9873
  • Fig. 1 Plasma mediators at the time of study enrollment demonstrated a broad exaggerated immune response in patients hospitalized with COVID-19.

    Clustered heatmap of 33 immune mediators in plasma samples collected from patients hospitalized with COVID-19 at the time of study enrolment. Missing mediator data were imputed and values were scaled within each mediator. Rows and columns were split by K-means clustering. Each patients’ column is additionally annotated with data on disease outcome (“Severity”) as one of the following outcome groups: not requiring oxygen support (‘3′, n=132), requiring oxygen via face mask or nasal prongs (‘4’, n=106), requiring non-invasive ventilation or high-flow nasal canulae oxygen (‘5′, n=79), requiring invasive mechanical ventilation (‘6/7’, n=85) or fatal disease (‘8’, n=69). Columns are additionally annotated with patient age, sex and duration of illness at the time of sample collection (“Onset”).

  • Fig. 2 Antiviral, coagulation, and inflammation associated mediators distinguished severity groups early in disease.

    Plasma samples from the time of study enrolment were analyzed for levels of the antiviral cytokines (A) IFN-α, (B) IFN-γ, and (C) the interferon-induced chemokine CXCL10 in healthy control (HC, n=15), patients with COVID-19 not requiring hospitalization (‘1/2’, n=39), and hospitalized patients with COVID-19 that would: not require oxygen support (‘3′, IFN-α n=32, other mediators n=132), require an oxygen face mask (‘4’, IFN-α n=23, other mediators n=106), require non-invasive ventilation or high-flow nasal cannulae (‘5′, IFN-α n=19, other mediators n=79), require invasive mechanical ventilation (‘6/7’, IFN-α n=19, other mediators n=85) or progress to fatal disease (‘8’, IFN-α n=14, other mediators n=69). Mediators associated with coagulation and endothelial injury were also quantified in these plasma samples; (D) D-dimer, (E) Angiopoietin-2, and (F) von-Willebrand factor A2 (vWF-A2). Similarly, mediators associated with inflammation were quantified: (G) IL-6; (H) GM-CSF; and (I) EN-RAGE/S100A12. Violin plots display medians (solid lines) and interquartile ranges (dashed lines). Data were analyzed for statistical significance using Kruskal-Wallis tests with Dunn’s tests for multiple comparisons between all groups. *P<0.05, **P<0.01, ***P<0.001, ****P<0.0001.

  • Fig. 3

    Plasma mediators in COVID-19 were coordinated around IL-6 and GM-CSF and influenced by age. (A) Correlogram of the association between plasma mediator levels at the time of enrolment in all patients hospitalized with COVID-19 (n=465). (B) Network analysis showing the mediator-to-mediator correlation profile. Nodes represent mediators and the coloring of edges between nodes represents the Spearman correlation coefficient (RS) connecting them. (C) Inflammatory mediator levels within an outcome group, stratified as those ≥ or < than 70 years of age. Data in panel a were analyzed using Spearman’s rank correlations with correction for multiple testing; significant correlations are denoted by a circle, the color of which denotes the Spearman’s R value. Data in panel C were analyzed using Mann-Whitney U tests with P-value adjustment for false discovery rate. Violin plots display medians (solid lines) and interquartile ranges (dashed lines).

  • Fig. 4 Longitudinal analysis of plasma mediator levels demonstrated a progressive immune response and an exaggerated inflammatory signature in fatal COVID-19.

    Plasma levels of (A) IFN-γ, (B) CXCL10, (C) Angiopoietin-2, (D) D-dimer, (E) GM-CSF, and (F) EN-RAGE/S100A12 over the course of disease in patients with fatal COVID-19. Plasma mediator levels of (G) IL-2, (H) IL-6, (I) GM-CSF, (J) D-dimer, and (K) von-Willebrand factor A2 (vWF-A2) within the first 4 days of symptom onset in patients in severity groups 6/7 or 8 (“Severe”, n=22) and groups 3, 4, or 5 (“Moderate”, n=54). Linear regressions with 95% confidence intervals are shown in panels A-F. Data in panels G-K were analyzed for statistical significance using Mann-Whitney U tests, where solid lines denote the median values and dashed lines denote the interquartile ranges.

  • Fig. 5

    GM-CSF and IL-1α were elevated in fatal COVID-19 relative to influenza. (A) Median Z-scores for each mediator between healthy controls (HC, n=15) and patients with fatal influenza (n=20) or fatal COVID-19 (severity 8, n=69). (B) Levels of IL-6, GM-CSF, IL-1α, IL-1β, Thrombomodulin, and vWF-A2 in plasma samples from patients with fatal influenza or COVID-19. Data were analyzed for statistical significance using Mann-Whitney tests with between groups. ***P<0.001, ****P<0.0001.

Supplementary Materials

  • immunology.sciencemag.org/cgi/content/full/6/57/eabg9873/DC1

    Fig. S1 – Routine laboratory parameters, HScores and 4C mortality scores on admission for included hospitalized patients with COVID-19.

    Fig. S2 – Principal component analysis of all mediator values from the time of recruitment.

    Fig. S3 – Plasma mediators at the time of enrolment in patients hospitalized with COVID-19.

    Fig. S4 – Age, but not sex, is associated with differences in plasma cytokine levels within COVID-19 disease severity groups.

    Fig. S5 – Plasma mediator levels over time.

    Fig. S6 – Elevated mediator levels are apparent in the first days of symptoms in Severe COVID-19.

    Fig. S7 – Distinct inflammatory profiles between fatal influenza and COVID-19.

    Fig. S8 – GM-CSF is not elevated in fatal influenza.

    Table S1 – Patient characteristics, vital signs and routine laboratory parameters on admission for included hospitalized patients with COVID-19

    Table S2 – Clinical characteristics of COVID-19 patient groups identified by clustering of plasma mediator values

    Table S3 – Clinical characteristics of patients with fatal influenza

    Table S4 – Multiple linear regression of GM-CSF levels, disease status and demographic variables between patients with fatal COVID-19 and influenza

    Table S5 – Raw data file (excel spreadsheet)

    The ISARIC4C investigators

  • The PDF file includes:

    • Fig. S1. Routine laboratory parameters, HScores and 4C mortality scores on admission for included hospitalized patients with COVID-19.
    • Fig. S2. Principal component analysis of all mediator values from the time of recruitment.
    • Fig. S3. Plasma mediators at the time of enrolment in patients hospitalized with COVID-19.
    • Fig. S4. Age, but not sex, is associated with differences in plasma cytokine levels within COVID-19 disease severity groups.
    • Fig. S5. Plasma mediator levels over time.
    • Fig. S6. Elevated mediator levels are apparent in the first days of symptoms in Severe COVID-19.
    • Fig. S7. Distinct inflammatory profiles between fatal influenza and COVID-19.
    • Fig. S8. GM-CSF is not elevated in fatal influenza.
    • Table S1. Patient characteristics, vital signs and routine laboratory parameters on admission for included hospitalized patients with COVID-19.
    • Table S2. Clinical characteristics of COVID-19 patient groups identified by clustering of plasma mediator values
    • Table S3. Clinical characteristics of patients with fatal influenza.
    • Table S4. Multiple linear regression of GM-CSF levels, disease status and demographic variables between patients with fatal COVID-19 and influenza.
    • The ISARIC4C investigators

    [Download PDF]

    Other Supplementary Material for this manuscript includes the following:

    • Table S5. Raw data file (excel spreadsheet).

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