Therefore, based on the possible therapeutic properties of NO, H2S and CO, a novel NSAIDs with ability to release one or more of those gaseous messengers have been synthesized. Until now, both preclinical and clinical studies have shown promising effects with respect to the anti-inflammatory potency as well as GI-safety of these novel NSAIDs. This review provides an overview of the gaseous mediators-based NSAIDs along with their mechanisms of action, with special emphasis on possible implications for GI mucosal defense mechanisms.Non-steroidal anti-inflammatory drugs (NSAIDs) represent one of the most widely used classes of drugs and play a pivotal role in the therapy of numerous inflammatory diseases. However, the adverse effects of these drugs, especially when applied chronically, frequently affect gastrointestinal (GI) tract, resulting in ulceration and bleeding, which constitutes a significant limitation in clinical practice. On the other hand, it has been recently discovered that gaseous mediators nitric oxide (NO), hydrogen sulfide (H Non-steroidal anti-inflammatory drugs (NSAIDs), such as aspirin, ketoprofen, naproxen, indomethacin and others, represent one of the most commonly prescribed medications with a wide spectrum of therapeutic effects. Due to their potent analgesic, anti-inflammatory and antipyretic properties they are commonly used to suppress pain, inflammation as well as fever associated with inflammatory diseases including for instance rheumatoid arthritis and osteoarthritis . Additio2 and PGE2, are mainly produced via activity of COX-1 and contribute to the maintenance of gastric mucosal barrier , which were expected to reduce PGs synthesis on the inflammation site, while remaining without such effect in gastric mucosa and thus preserving the potent anti-inflammatory activity with markedly decreased GI-toxicity . However2S) or carbon monoxide (CO) were shown to be involved in the maintenance of GI integrity, to exhibit gastroprotective action, to accelerate ulcer healing and to modulate gastric blood flow and gastro-duodenal secretion. All three molecules were shown to interact each other within GI tract. H2S-, NO- or CO-releasing pharmacological tools and chemicals were reported to prevent gastric mucosa against the damage induced by exposure of GI-mucosa to stress, ischemia/reperfusion, and the mucosal injury caused by pharmacological agents and drugs such as alendronate or aspirin and other NSAIDs. Therefore, over recent years novel H2S-, NO- or CO-releasing derivatives of NSAIDs were synthetized , hydrogen sulfide  and proton pump inhibitors (PPIs), both potent acid secretion suppressors have been clinically recommended in prevention of NSAIDs-induced gastric damage , expressed in the neurons of central and peripheral nervous system,•endothelial (eNOS) located in both endothelial cells and platelets,•inducible (iNOS), which is expressed in endothelial cells, smooth vascular muscle, neutrophils and macrophages.NO is a gaseous mediator involved in the regulation of numerous physiological pathways including those responsible for the homeostasis of the GI tract. NO is endogenously produced within esophageal, gastric and intestinal mucosa diabetes mellitus, hypertension and arteriosclerosis. Moreover, it has been shown that the pharmacologic inhibition of NO-synthase impaired the healing rate of gastric ulcers  was developed by chemically binding a NO-releasing moiety with the parent drug . ImportaThese promising results obtained in pre-clinical animal studies provided significant evidence to further explore the assessment of NCX-4016 and nitronaproxen (naproxcinod) in humans. NCX-4016 completed phase 1 clinical trial and entered phase 2, however the further development of this novel NO-NSAID was terminated due to the detected genotoxicity . Naproxcdiabetes mellitus. Similarly, in another report NCX-4016 treatment in the group of diabetic rats resulted in significantly reduced vascular endothelium damage   . Additioammation . , H2S-releasing diclofenac (ATB-337 and ACS-15), H2S-releasing ketoprofen (ATB-352) and H2S-releasing aspirin (ATB-340 and ACS-14). Administration of ATB-337 evoked approximately 90% less intestinal damage, when compared to native diclofenac  decreased the gastric lesions formation induced by aspirin administration and restored H2S plasma level, which was substantially reduced in rats subjected to acetylsalicylic acid. Also, H2S-releasing ketoprofen (ATB-352) reduced the inflammation and concomitant bone resorption in rats in experimental model of periodontitis. This effect was accompanied by a significantly diminished incidence of gastric lesions as compared to rats pretreated with classic ketoprofen  - constitutive HMOX-2 highly expressed in brain and testes, and inducible isoform HMOX-1 , reported to be activated in response to various stressful stimuli such as LPS, inflammatory cytokines or oxidative stress and plays a crucial role in the maintenance of cellular homeostasis  were developed to provide safe, manageable way of delivering physiologically efficient quantities of exogenous CO to various tissues and organs. The range of CORMs reported so far is wide and comprises the most investigated ones [Mn2(CO)10] (CORM-1), tricarbonyldichlororuthenium (II) dimer [Ru(CO)3Cl2]2 (CORM-2) and tricarbonylchloro (glycinato)ruthenium (II) (CORM-3) . Numerou2S pathway  and attenuated gastric mucosal lipid peroxidation when compared to aspirin administered alone . In anot pathway . Interes pathway . Despite pathway . It was Despite the initial focus on GI adverse effects of NSAIDs, their deleterious impact on cardiac, vascular and renal systems has gained increasing attention, especially when coxibs were introduced and their serious cardiovascular adverse effects were detected. Subsequent studies have confirmed that the widespread use of NSAIDs may be associated with harmful cardiovascular and renal complications including hypertension, myocardial infarction, heart failure as well as acute kidney injury and chronic kidney disease . Importain vivo in a model of acute myocardial ischemia as well as in vitro based on the model of ischemia/reperfusion myocardial injury, while control treatment with aspirin showed only little or no protection  and salicylic acid (ACS-21) in modulation of pathological changes related to metabolic syndrome induced by glutathione (GSH) depletion in rats. ACS-14 and ACS-2 but not classic aspirin, significantly restored endothelial dysfunction in aortic tissue and markedly reduced accompanying hypertension along with hyperinsulinemia, most probably in mechanisms dependent on H2S release (2S-releasing naproxen, ATB-346, did not produce significant change in arterial blood pressure or heart rate (2S could affect blood pressure under physiological and pathological conditions.It has been recently demonstrated that also CO and Hoperties . Rossoni release . On the art rate . Similarart rate . Thus, fex vivo, leading to significant vasodilatation with the involvement of potassium channels and guanylate cyclase activity (in vivo in rats has been noticed, suggesting possible use of CO-donating compounds as alternative therapy for hypertension (2S-NSAIDs, GYY4137 as chemical donor slowly liberating H2S, and CORMs against myocardial injury induced by ischemia/reperfusion (2S level (2S-releasing NSAIDs could be considered as therapeutic agents against atherosclerotic vascular lesions. On the other hand, the clinical implementation of CORMs may by limited due to the risk of cardiomyopathy (Interestingly, CO-releasing molecules, CORMs, have been also pointed out as potential antihypertensive agents. Preclinical studies demonstrated that treatment with CORM-3 induced relaxation of precontracted aortic rings activity . Additiortension . This sertension . Also, nerfusion . It is aerfusion . This da2S level . Thus, imyopathy . Therefo2S-releasing ATB-346 71. Furthermore, 2S have been recognized as protective factors within renal system. Yet, further studies may confirm and support these conclusions. On the other hand, CO-releasing CORM-A1 applied to healthy mice notably increased renal blood flow, as compared to control group (As it has been mentioned above, chronic treatment with NSAIDs also increases the risk of various forms of kidney injury and concomitant reduction in renal perfusion, secondary to decreased PGs biosynthesis . Howeverol group . Noteworol group . In spitol group . CO-releOvercoming the toxicity of NSAIDs, particularly the well-known GI adverse effects, still remains a target for further studies revolving around different preventive strategies including NSAIDs conjugated with gaseous mediators as one of the most interesting and promising groups. Animal studies as well as clinical trials concerning the efficacy and safety of these novel compounds have shown encouraging results, giving a solid background to prompt the further investigation. These novel NSAIDs or NSAIDs combined with CORMs were shown to modulate several molecular pathways ..2S-NSAIDs but also CO donors applied in combination with NSAIDs have been proven to retain the anti-inflammatory activity of their parent drugs, however, with markedly reduced gastrotoxicity and also importantly, with reduced intestinal toxicity, both become subjects of rising clinical underestimated concern (Both NO-NSADs and H concern . The inc


With the distinguished color-tunable CPOA, the multicolor CPL displays and visual RTP detection of ultraviolent light wavelength are successfully constructed. These results not only provide a new paradigm for realization of multicolor-tunable CPOA materials in single-component molecular systems, but also offer new opportunities for expanding the applicability of CPL and RTP materials for diversified applications.Circularly polarized organic afterglow (CPOA) with both long-lived room-temperature phosphorescence (RTP) and circularly polarized luminescence (CPL) is currently attracting great interest, but the development of multicolor-tunable CPOA in a single-component material remains a formidable challenge. Here, we report an efficient strategy to achieve multicolor CPOA molecules through chiral clusterization by implanting chirality center into non-conjugated organic cluster. Owing to excitation-dependent emission of clusters, highly efficient and significantly tuned CPOA emissions from blue to yellowish-green with dissymmetry factor over 2.3 × 10 Circularly polarized organic afterglow (CPOA) with both long-lived room-temperature phosphorescence and circularly polarized luminescence is attracting great interest, but the development of multicolor-tunable CPOA in a single-component material remains challenging. Here, the authors report a strategy to achieve multicolor CPOA through chiral clusterization by inserting a chirality center into a non-conjugated organic cluster. Especially, the pleochroism of chiral luminescent materials can empower multiplexing confidentiality for multilevel data encoding and encryption7; the multicolor CPL materials with stimuli-response attributes are idea emissive mediums for brilliant liquid crystal and stereoscopic display8; high sensitivity and spatial resolution luminescence sensors for biological analytes and object identification could also be gifted by employing polychromatic chiral molecules as optical marker recognition9. In these applications, multicolor-tunable CPL emissions are highly desired, but can be only realized in multicomponent material systems on the basis of various design methods including multicomponent supramolecular assembly11, chemical additive induced excited state modulation14 and solvation effect enabled structural color change15, etc. Nevertheless, it remains a daunting challenge to develop efficient multicolor-tunable CPL emission from a single-component material system with the capability to dynamically and selectively respond to the changes of physical parameters of external stimuli such as electrical and magnetic fields, pressure, and optical input16.Circularly polarized luminescent (CPL) materials with efficient emission dissymmetry factor  and suppress non-radiative decay of triplet excitons, and to boost efficient chirality transfer from chiral groups to chromophores simultaneously for the realization of CPOA materials with lifetime over 100 ms. Nonetheless, the afterglow emission colors of CPOA materials are limited to fixed emission colors, mostly in yellow or yellowish-green under ambient conditions24; it is rather difficult to develop multicolor-tunable CPOA materials due to the complicated chirality transfer between the chiral unit and the RTP emission group for CPL as well as the inefficient RTP color tuning for multicolor emission, especially in a molecule. To the best of our knowledge, the CPOA material showing multicolor-tunable CPL emission from a single-component molecule system has not yet been reported.Circularly polarized organic afterglow (CPOA) with both the ultralong-lived triplet excited state for room-temperature phosphorescence (RTP) and efficient CPL features is an amazing type of luminance that has emerged as a hot research topic recently because of the distinguished photophysical phenomena in various remarkable applications26. Inspired by the flexible chiral chain engineering to realize CPOA in a single-component purely organic small molecule, we suspect that the color-tunable CPOA can be also designed by implanting the chiral chain into a single-component cluster crystal. Indeed, through a large number of in-plane and interlayer molecular interactions and the dense in-plane and interlayer non-covalent bond network to support the formation of varied emission species and suppression of the non-radiative transition of excitons  light. Based on the spectacular feature of the color-tunable CPOA molecules, multicolor CPL displays and visual RTP detection of UV light were successfully established. These findings in purposefully constructing multicolor CPOA with the on-demand color-tuning ability through the elaborate molecular design by chiral clusterization would provide a promising platform for the exploration of single-component smart CPL and RTP materials.Here, we propose an efficient strategy to realize color-tunable CPOA from a single-component non-conjugated molecule by chiral clusterization. Specially, the non-conjugate cluster shows size-dependent clusterization-triggered emission (CTE) via through-space conjugation (TSC) for efficient excitation-dependent color-tunable organic afterglow emission due to the presence of varied luminescent centers with different cluster sizes Fig. 25,26. Inons Fig. 27–29, eftrans−1,2-diamidocyclohexane core and two succinic acid arms  promoted by the nitrogen (N) atoms to accelerate the production of triplet excitons. Meanwhile, bearing the carbonyls (C=O) and intra/intermolecular bonding sites, the succinic acid unit can remarkably boost the ISC process and more importantly33, establish strong non-covalent bond interactions between different molecules to form interlocked molecular system for the suppression of non-radiative decay and formation of varied clusters with different sizes. In addition, benefitting from the multiple heteroatoms and varied clusters, TSC originated from the orbital overlap of  and  can be effectively conferred to endow tunable triplet energy levels in different clusters34. As a proof of concept, with the molecular design strategy, the enantiomers of -DAACH, and -DAACH were facilely synthesized by a one-step amidation reaction between trans-/-diamidocyclohexane and succinic anhydride. This one-step reaction enables high yields up to 88% and the resultant molecules were systematically characterized by nuclear magnetic resonance (NMR) spectra, high-resolution mass spectra (HRMS), matrix-assisted laser desorption/ionization time of flight mass spectrometer (MALDI-TOF MS) and thermal physical properties -DAACH and -DAACH, showing long-lived emissions ranging from blue to yellowish-green with moderate |gely Fig. . The chiely Fig. . The almely Fig. . The excely Fig. , the graely Fig. -19 and cely Fig.  upon exc35. As shown in Fig. 26. Meanwhile, the transient emission decay images of -DAACH and -DAACH powders verified that this color-tunable emission is quite stable over time under the excitation by different wavelengths  spectra were further monitored. The SSPL of -DAACH is also excitation-dependent, exhibiting slight hypochromatic shift for varied colors from sky-blue to blue and tunable quantum yields when the excitation wavelength was changed from 260 to 360 nm -DAACH were conducted39. These intense intermolecular interactions were also theoretically identified by the independent gradient model (IGM) analysis40, exhibiting a large IGM isosurface between adjacent molecules in both dimers, trimers, and tetramers -DAACH adopted hairpin-shaped conformation in crystal Fig. , showing41. From the simulated excited state energy levels, there are only five triplet states showing singlet and triplet splitting energy (∆EST) lower than 0.37 eV for enabling possible ISC in -DAACH monomer according to the energy gap law -DAACH single crystal. From the simulation results, the highest occupied molecular orbital (HOMO) and the lowest unoccupied molecular orbital (LUMO) Fig.  were sepmer Fig. , respectmer Fig. . Accordimer Fig. .Fig. 4MeTo testify the universality of this chiral clusterization strategy in constructing single-component color-tunable CPOA materials, other two pairs of enantiomers of /-DAPCH and L/D-serine were explored. Indeed, /-DAPCH demonstrate superb excitation-dependent CPOA properties, showing tunable emission color ranging from 410 to 530 nm -DAACH and -DAACH powders, respectively. With the excitation wavelength changing from 254 to 365 nm, the OA images of “COO” were correspondingly changed from blue to yellowish-green, demonstrating the success in achieving multicolor CPOA displays -DAACH and -DAACH powders in fabricating multicolor CPL displays and visual UV color chart under ambient conditions Fig. 35. As deays Fig. , top. Moays Fig. , bottom.ays Fig. .trans-1, 2-diamidocyclohexane, and succinic acid containing multiple heteroatoms can not only yield efficient CPL emission and diverse CTE emission species but also boost efficient ISC and strong non-covalent intermolecular interactions to promote the generation of triplet excitons and suppression of non-radiative decay for efficient RTP. More importantly, owing to the spectacular chiral clusterization effects, dynamically selective response to the excitation wavelength for color-tunable CPOA emission was observed in the single-component molecular clusters. With the changing of excitation wavelength from 240 to 360 nm, the two enantiomers of -DAACH and -DAACH exhibited excellent color-tunable CPOA spanning from blue (~470 nm) to yellowish-green (~530 nm) with |glum | values higher than 2.3 × 10−3 and lifetime up to 587 ms. Taking advantage of the spectacular excitation-dependent color-tunable CPOA molecules, multicolor CPL displays and visual UV color charts were successfully constructed. The realization of multicolor-tunable CPOA emission from a single-component chiral cluster crystal through a one-stone-two-birds approach could afford fundamental and vital design clues for the exploration of smart multicolor CPL and RTP functional materials, shedding important light on the construction of multifunctional and high-performance new-concept organic molecules for advanced optoelectronic applications.In summary, we have succeeded in achieving color-tunable CPOA from a single-component chiral cluster crystal through chiral clusterization. The direct linkage between the chirality center of Unless otherwise noted, all reagents were purchased from Aldrich and Acros and used without additional purification. The molecular structures of the as-synthesized phosphorescent molecules were characterized by single-crystal X-ray diffraction, NMR spectroscopy, HRMS, and MALDI-TOF MS (see the Supplementary Information).nth singlet state (Sn) and the n-th triplet state (Tn) states were calculated at the TD-DFT method of B3LYP/6-31 G level based on the monomer and selected aggregates extracted from the single-crystal. Frontier molecular orbital distributions were calculated based on the monomer and selected aggregates extracted from the single-crystal at M06-2X/cc-pVTZ.The steady-state UV absorption data were collected on a Jasco V-750 spectrophotometer. The intrinsic circularly polarized luminescence (CPL) spectra were investigated using a JASCO CPL-300 spectrometer. The circular dichroism (CD) spectra were measured on a JASCO J-810 circular dichroism spectrometer. The fluorescence spectra, phosphorescence spectra, kinetic measurements, lifetimes of the room-temperature phosphorescence (RTP) were measured using an Edinburgh FLS980 fluorescence spectrophotometer equipped with a xenon arc lamp (Xe900), laser, and a microsecond (μs) flash-lamp (uF900), respectively. All the data of these single-crystal structures were collected on a Bruker SMART APEX (II)-CCD at 100 K. The photos and supporting videos were recorded by Nikon D90. The TD-DFT calculations were performed with the Gaussian 09 program. All the computational models were built from single-crystal structures without further geometry optimization. The excitation energy of the Supplementary InformationPeer Review File


Brain DWI MRI increased signal intensities corresponding to similar location of 99mTc-ECD brain SPECT/CT. In this case, we reported the pattern of decreased rCBF may correlate to rapidly progressive dementia and associated neurodegenerative symptoms of the highly suspected sCJD patient.Sporadic Creutzfeldt-Jakob disease (sCJD) is a rapidly-progressive dementing illness, the challenge of diagnosis during life. We presented a 78-year-old woman reported stupor, right facial palsy, and fluctuations in consciousness.


The novel coronavirus disease 2019 (COVID-19) has represented an overwhelming challenge for worldwide health systems. Patients with cancer are considered at higher risk for severe COVID-19 and increased mortality in case of infection. Although data on the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccination in patients with cancer are limited, there is enough evidence supporting anti-infective vaccination in general in patients with active cancer, or with history of previous malignancy. Subjects with classic Kaposi’s sarcoma (KS) represent a small subset of cancer patients, which should be considered at heightened risk for infections due to several factors including age, and impaired immune function status. Several cases of human herpesviruses reactivation among critically ill COVID-19 patients have been described. Moreover, in case of severe infection and treatment with immunomodulating agents, patients with CKS are exposed at significant risk of viral reactivation and disease progression. Considering the baseline clinical risk factors of patients with CKS, and the complex interplay of the two viral agents, SARS-CoV-2 vaccination should be strongly recommended among patients with KS. KS represents an interesting field to study the interactions among chronic viral infections, SARS-CoV-2 and the host’s immune system. Prospective observational studies are needed to provide more insights on vaccine activity and safety among patients with cancer, optimal vaccine schedules, potential interactions with antineoplastic therapies, and other comorbidities including chronic viral infections. The novel coronavirus disease 2019 (COVID-19) has represented an overwhelming challenge for worldwide health systems ,4. TheseRecently, considerable efforts have been put into developing safe and effective vaccines against SARS-CoV-2 . The maiAlthough data on SARS-CoV-2 vaccination in patients with cancer are extremely limited , there iSeveral guidelines have been promptly implemented in order to include indications on COVID-19 vaccination in patients with cancer . At the However, there might be significant differences for severe COVID-19 among cancer patients regarding underlying tumor , and type of systemic treatment  ,19. SpecSubjects with classic Kaposi’s sarcoma (CKS) represent a small subset of cancer patients, which should be considered at heightened risk for infections due to several factors including age, and impaired immune function status . Kaposi’Overall, these evidences suggest that patients with CKS may be at high risk of COVID-19. Moreover, in case of severe infection and treatment with immunomodulating drugs  1/2 inhibitor, baricitinib) , patient


Coronavirus disease 2019 (COVID-19) is an infectious disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Several cardiovascular complications of COVID-19 have been described in clinical studies. While those with pre-existing cardiovascular disease seem to have worse outcomes, growing evidence suggests that COVID-19 itself can cause myocardial injury, arrhythmia, and heart failure. We report a case of a 27-year-old male with no known comorbidities who presented with nausea, vomiting and non-radiating substernal chest pressure without respiratory symptoms in May of 2020. Laboratory findings showed elevated cardiac biomarkers and electrocardiogram showed diffuse ST-segment elevation. Coronary angiography revealed normal coronaries but findings suggestive of cardiogenic shock. Reverse transcription polymerase chain reaction for SARS-CoV-2 returned positive. He was treated for fulminant myopericarditis and cardiogenic shock with remdesivir, steroid, inotropes and vasopressors but rapidly deteriorated and went into cardiac arrest and was unable to be resuscitated despite multiple rounds of cardiopulmonary resuscitation. Fulminant myopericarditis is a rare complication of COVID-19 with high mortality that requires early recognition, treatment and a transfer to a tertiary facility with advanced cardiac services. Coronavirus disease 2019 (COVID-19) is an infectious disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The first case of COVID-19 was reported in Wuhan, China, in December 2019 and it was declared a global pandemic on March 11, 2020, by the World Health Organization (WHO) . We pres2. Initial laboratory tests showed mild leukocytosis, negative urine toxicology, and elevated troponin I and B-type natriuretic peptide (BNP). The electrocardiogram (EKG) showed diffuse ST-segment elevation without reciprocal ST changes , pulmonary artery pulsatility index of 0.5 , cardiac power output of 0.4 W, and pulmonary artery saturation of 46%   and pulse oximetry of 100% SaOs Figure . He was s Figure . Chest xs Figure . The pat) Figure . His clinical presentation was suggestive of FM with cardiogenic shock. Sputum was collected and examined for 18 viral nucleic acids related to the respiratory tract, but all returned negative. The RT-PCR assay of the nasopharyngeal swab returned positive for SARS-CoV-2. Echocardiogram revealed ejection fraction of 15% with severely depressed right ventricular systolic function. The patient was started on remdesivir, methylprednisolone, inotropic support with dobutamine and milrinone drip, but his condition continued to decline requiring intubation, pressor support with norepinephrine, epinephrine and admission to the intensive care unit. Circulatory assistance devices with peripheral venous-arterial extracorporeal membrane oxygenation (va-ECMO), percutaneous left ventricular assist device (LVAD) or intra-aortic balloon pump (IABP) were considered along with a transfer to an advanced facility, but unfortunately the patient became progressively hypotensive and went into pulseless electrical activity (PEA) arrest and was unable to be resuscitated despite multiple rounds of cardiopulmonary resuscitation (CPR).SARS-CoV-2 is an enveloped, positive-sense single-stranded ribonucleic acid (sRNA) that enters the human host cell by binding to angiotensin-converting enzyme 2 (ACE2) ,5. The AClinical presentations of COVID-19-induced myocarditis or myopericarditis vary widely. It can manifest itself in different ways, from mild symptoms such as fatigue, dyspnea including chest pain and moderate ventricular dysfunction to life-threatening arrhythmia and serious heart failure requiring mechanical circulatory support . DiagnosIn our case, we observed an increase in cardiac biomarkers for myocardial injury with ST-segment elevation on EKG and marked systolic dysfunction in the echocardiogram and patent coronary vessels. CMR was not done due to acute illness and neither was EMB due to lack of consent during coronary angiography. Due to a lack of clinical trials that provide good scientific evidence in cases of COVID-19-related fulminant myopericarditis, and the uncertainty of COVID-19 treatment with hydroxychloroquine and azithromycin in the early stages of the pandemic, these drugs were not used, but the patient received steroid in addition to remdesevir, inotropes, and pressure support. While the use of circulatory assist device was being considered, along with a potential transfer to a high-level center, the patient went into PEA arrest and was unable to be resuscitated despite multiple rounds of CPR.Even though respiratory failure is the cardinal form of severe COVID-19 infection, this case highlights the importance of understanding the lethal cardiac complication of COVID-19 infection, its presentation, diagnosis, and treatment. Myocardial injury can present with variable clinical manifestation. Fulminant myopericarditis is a rare life-threatening condition that requires immediate attention. During this pandemic, frontline health care providers’ education and awareness of this condition is crucial to increase timely access to adequately resourced facilities, including a transfer to a tertiary center with specialized cardiac team if necessary, to avoid multiorgan failure and to tailor specific therapy as early as possible in the disease process.


The prevalence of primary liver cancer is rapidly rising all around the world. Hepatocellular carcinoma (HCC) is the most common type of primary liver cancer. Unfortunately, the traditional treatment methods to cure HCC showed poor efficacy in patients who are not candidates for liver transplantation. Until recently, tyrosine kinase inhibitors (TKIs) were the front-line treatment for unresectable liver cancer. However, rapidly emerging new data has drastically changed the landscape of HCC treatment. The combination treatment of atezolizumab plus bevacizumab (immunotherapy plus anti-VEGF) was shown to provide superior outcomes and has become the new standard first-line treatment for unresectable or metastatic HCC. Currently, ongoing clinical trials with immune checkpoint blockade (ICB) have focused on assessing the benefit of antibodies against programmed cell death 1 (PD-1), programmed cell death-ligand 1 (PD-L1), and cytotoxic T-lymphocyte- associated antigen 4 (CTLA-4) as monotherapies or combination therapies in patients with HCC. In this review, we briefly discuss the mechanisms underlying various novel immune checkpoint blockade therapies and combination modalities along with recent/ongoing clinical trials which may generate innovative new treatment approaches with potential new FDA approvals for HCC treatment in the near future. Hepatocellular carcinoma (HCC) is a primary malignant disease of the liver. Primary liver cancer is the seventh most common malignancy and the second most frequent cancer-related death worldwide . The majUntil recently, tyrosine-kinase inhibitors (TKIs) like oral sorafenib were the most common gold-standard treatment for advanced HCC. However, the IMbrave150 trial NCT03434379) demonstrated that atezolizumab combined with bevacizumab resulted in better overall survival (OS) and progression-free survival (PFS), effectively replacing sorafenib as a new standard first-line treatment for advanced HCC, particularly for those with near normal liver function 34379 dem. Ramucirvia activating tumor-specific immune responses and disrupting immune tolerance. Developments in this field have led to many FDA approvals of immune checkpoint inhibitors (ICI) as primary treatment options for several different solid and hematologic malignancies , namely dendritic cells (DCs) and liver-specific APCs. These complex antigen presentation mechanisms require multiple costimulatory signals to achieve T-cell activation and clonal expansion. Meanwhile, APCs also produce additional signals for immune checkpoint molecules, limiting T cell hyperactivation. These suppressive signals from immune checkpoint molecules have an active role in maintaining tolerance and preventing unwanted immune responses. Malignant tumor environments disrupt normal suppressive signals and cause T-cell exhaustion, characterized by high expression of immune checkpoint molecules, impaired cytotoxicity, and low levels of effector cytokines, leading to chronic hyporesponsive immunity . Since iversus placebo in the second-line setting. Unfortunately, the HR for OS  and PFS  did not reach prespecified statistical plan  cells, mononuclear cells, and dendritic cells . PD-1 incal plan .Anti-PD-L1 antibodies, durvalumab and avelumab, are currently undergoing active assessment in clinical trials. Durvalumab showed 10.3% ORR in Phase I/II study of advanced HCC patients following prior treatment with sorafenib (NCT01693562) . In a siCTLA-4 is mainly expressed by Tregs, activated T cells, and NK cells . CTLA-4 via inhibition of T-cell infiltration due to diminished permeability of tumor vessels  trial compared the efficacy of atezolizumab plus bevacizumab combination with sorafenib therapy in first line setting in 501 patients with advanced HCC. Atezolizumab plus bevacizumab showed significantly better OS at 12 months than sorafenib (67.2% vs. 54.6% respectively). Also, median PFS was 6.8 months in the combination arm while 4.3 months in sorafenib group  . Also, c4379 triaIn vitro and in vivo preclinical studies of pembrolizumab plus lenvatinib combinations decreased TGF-ß and IL-10 by suppressing tumor-associated macrophages, Tregs, and related tumor microenvironment constituents . They reported that the avelumab plus axitinib combination showed antitumor activity (ORR: 31.8% [95% CI: 13.9-54.9%] per mRECIST for HCC) and was associated with a manageable toxicity profile . Other ctituents . PreclinPatients who received immunotherapy may develop immune-related adverse events (irAEs) due to their critical roles in self-tolerance. While a general perception is that ICI related to toxicities are milder than traditional cytotoxic and molecular targeted anticancer agents, some ICI-induced autoimmune conditions can be lethal, particularly if not immediately recognized . The mosSecond-generation immunotherapies such as TIM-3, LAG-3, and killer cell immunoglobulin-like receptor (KIR) are still in the relatively early stages of clinical development for advanced solid tumors . CombiniWith the development of cancer immunotherapy, the combination strategies are becoming prevalent. Moreover, immune-related adverse events (irAEs) occurred more frequently, showing a different pattern from single-agent therapy. In recent years, anti-PD-1 and anti-CTLA-4 antibodies combinations have been extensively studied, showing higher response rates than single-agent therapy. Previous studies showed that both the incidence and severity of irAEs increase with the combination of anti-CTLA-4 and anti-PD-1 therapy –56. A phTo date, there are no immunotherapy combinations related to specific irAEs; however, the incidence of serious irAEs is higher than monotherapies. For grade 2 or above irAES, ASCO, and National Comprehensive Cancer Network (NCCN) practice guidelines suggest treatment interruption, close monitoring, supportive management , 60.HCC is the second most frequent cause of cancer-related death worldwide, with limited therapeutic options. The immune system has an important and complex role in the pathogenesis of the HCC. Since the discovery of immune checkpoint proteins and development of their inhibitors, the treatment algorithms for HCC have dramatically changed and represent promising opportunities for patients. While ICIs have demonstrated promising results, efficacy remains limited for most patients and future improvements can only come through rigorous scientific investigations. We believe that ICIs will play an essential future role in the therapeutic interventions for patients with HCC, with the realization of improved clinical outcomes for all.All authors contributed to the article and approved the submitted version. The corresponding author is responsible for submitting a competing financial interest statement on behalf of all authors of the paper.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


The emergence and rapid proliferation of Coronavirus Disease-2019, throughout the past year, has put an unprecedented strain on the global schema of health infrastructure and health economy. The time-sensitive agenda of identifying the virus in humans and delivering a vaccine to the public constituted an effort to flatten the statistical curve of viral spread as it grew exponentially. At the forefront of this effort was an exigency of developing rapid and accurate diagnostic strategies. These have emerged in various forms over the past year—each with strengths and weaknesses. To date, they fall into three categories: (1) those isolating and replicating viral RNA in patient samples from the respiratory tract , (2) those detecting the presence of viral proteins  and serology-based exams identifying antibodies to the virus in whole blood and serum. The latter vary in their detection of immunoglobulins of known prevalence in early-stage and late-stage infection. With this review, we delineate the categories of testing measures developed to date, analyze the efficacy of collecting patient specimens from diverse regions of the respiratory tract, and present the up and coming technologies which have made pathogen identification easier and more accessible to the public. The illness now known as Coronavirus Disease-2019, or COVID-19, was first described in mid-December 2019 when the Wuhan health authorities detected a cluster of cases of atypical pneumonia [ORF1), envelope (env), nucleocapsid (N), spike (S) and RNA-dependent RNA polymerase (RdRp) genes. However, mutations across these regions may impact diagnostic performance by affecting specific oligo-binding sites and affecting test sensitivity. Even though SARS-CoV-2 possesses proofreading capacity which makes transcription and replication less prone to mutations, mutational events still occur. Thus, continuous genomic monitoring and target (primer/probe) optimization is key for diagnostic performance.Coronaviruses are enveloped, positive-sense, single-stranded RNA viruses . A part Throughout the pandemic, the populations who meet criteria for testing have evolved as the testing capacity has expanded. Initially, only patients with symptoms compatible with COVID-19 who had traveled to Wuhan, China, were eligible to be tested. As the pandemic progressed and local community transmission was recognized, rapid diagnosis of potentially SARS-CoV-2-infected individuals became crucial in order to cut off chains of transmission, and the requirement for travel was eliminated. As more diagnostic assays became available, screening of potentially exposed but asymptomatic patients became more widespread. Screening in facilities such as nursing homes and other communal living settings has become an indication for testing . The InfNasopharyngeal (NP) swabs are the preferred specimen for direct detection of SARS-CoV-2 according to both the World Health Organization (WHO) and the Centers for Disease Control and Prevention (CDC) guidelines.However, several significant barriers are associated with collection of NP swab specimens for SARS-CoV-2 detection, including the requirement for collection by a trained provider, the use of personal protective equipment (PPE) due to triggering of reflex cough/sneeze during collection, patient discomfort, and potential harm, including a case of a Cerebral Spinal Fluid (CSF) leak due to improper collection ,12. AddiSaliva is another alternative specimen type that has been considered for SARS-CoV-2 diagnostic testing. Advantages of this specimen type include ease of collection, minimal patient discomfort, and improved safety for both patients and providers. As collection of saliva does not provoke a cough/sneeze reflex, guidelines do not require special provider PPE for aerosol exposure. Furthermore, since flocked collection swabs and transport media are not required, reliance on the material supply chain is minimized. In an initial proof of concept, To et al. collected saliva from known positive patients and demonstrated that SARS-CoV-2 could be detected in specimens collected from 11 of the 12 tested . Wyllie SARS-CoV-2 can also be detected in lower respiratory specimens, although reports from different investigators are contradictory regarding diagnostic sensitivity, perhaps influenced by stage of disease or other patient characteristics. Possible lower tract specimens include sputum, tracheal aspirates and bronchoalveolar lavage (BAL). Tracheal aspirates are much simpler to obtain in intubated patients; however, unlike BAL fluid, the viscosity of the specimens vary. However, BAL has the disadvantage of requiring an invasive procedure. Some studies have suggested that lower respiratory tract specimens may be persistently positive longer than upper tract specimens. In a case reported from Thailand, a patient whose NP and oropharyngeal swab specimens had twice tested negative was diagnosed by RT-PCR detection of SARS-CoV-2 in a bronchoalveolar lavage (BAL) specimen collected on hospital day 8 . One potUnderstanding SARS-CoV-2 viral dynamics in the respiratory system may help to better guide specimen collection. However, studies addressing SARS-CoV-2 tissue distribution and dynamics are still scarce. Viral loads are known to differ amongst sample types, being higher in respiratory samples at early stages of the disease. For example, a meta-analysis comparing 3442 respiratory samples, including 1299 nasopharyngeal swabs, 1083 oropharyngeal swabs and 1060 sputum samples, indicated that sputum (71% positive samples) was far more sensitive than oropharyngeal swabs (54%) or nasopharyngeal swabs (43%), although when stratified by time since onset of symptoms, sensitivity was diminished for all three specimens types the later in the disease course the specimens were collected . InteresOnce the site of sample collection has been determined, the next consideration is the collection device and transport conditions. Traditionally, samples collected for viral testing are transported in viral transport media (VTM), which contains a mix of Hanks balance salt solution, antibiotics, antifungals, and a PH indicator. At the onset of the pandemic, these were in short supply. Many centers tested using saline or phosphate buffered saline (PBS) as transport media and found these performed as well as VTM ,25. It iDetection of the presence of viral RNA using NAAT has become the mainstay of SARS-CoV-2 diagnosis with real-time polymerase chain reaction (RT-PCR) being the most common NAAT method currently employed . RT-PCR In the U.S., multiple commercial assays are now marketed  and seveAssay selection relies on several factors, including availability of reagents, cost, throughput and performance characteristics . VariousOne potential advantage of RT-PCR-based tests is the ability to generate a cycle threshold (Ct) value. Ct values have been suggested as a surrogate for viral load ,72. The Disadvantages of PCR testing include the need for specialized and costly reagents, expensive laboratory instrumentation, and highly skilled laboratory personnel. Processing large numbers of specimens is time-consuming and even with automation of many processing steps can take a prolonged period of time to generate results ,76. One Transcription-mediated amplification is an alternate type of NAAT testing that forms the basis for the APTIMA assay performed on the high-throughput Panther platform. After hybridizing the viral RNA to a T7 promoter primer, it is reverse-transcribed into a complementary cDNA. The target RNA strand is subsequently degraded by RNAse H, leaving a single-stranded cDNA that includes the T7 promoter. An additional primer is used to generate a double-stranded DNA. T7 RNA polymerase then transcribes the ds-DNA into RNA amplicons, which can then restart the process, allowing this exponential amplification . Its perOther NAAT methods that have been considered for SARS-CoV-2 test manufacturing include reverse transcriptase loop-mediated isothermal amplification (RT-LAMP), nicking endonuclease amplification reaction (NEAR), and Recombinase Polymerase Amplification (RPA) . The incFinally, there has been much interest in use of innovative technologies such as clustered regularly interspaced short palindromic repeats (CRISPR) , SpecifiSARS-CoV-2 genetic variability has become a pressing issue, particularly in the context of the worldwide emergence of variants of concern and the potential to affect diagnostic performance. Of note, early in the pandemic, Artesi et al. reported on a recurrent mutation at position 26,340 of SARS-CoV-2 associated with dropout of the E gene on the Roche cobas SARS-CoV-2 Test . More reEven though the impact of variants on test performance is currently predicted to be low, laboratories should monitor routinely for target failure. This also highlights the importance of incorporating redundancy by targeting more than one target of the viral genome in order to decrease the likelihood of false negative results.The need for rapid, accurate diagnosis to facilitate appropriate implementation of respiratory isolation measures and patient management has led to the development of point of care testing (POCT); however, there have been concerns with the performance of these tests in some clinical settings. There are currently six rapid point-of-care (POC) NAATs that have received emergency use authorization (EUA) by US Food and Drug Administration (FDA) for point of care use to detect SARS-CoV-2: the Cue COVID-19 test, Abbott ID NOW, Cepheid Xpert Xpress SARS-CoV-2 test, Roche Cobas SARS-CoV-2 & Influenza A/B on the Cobas Liat System, Mesa BioTech Accula SARS-CoV-2 and BioFire Respiratory Panel 2.1-EZ.Hansen et al. compared results from 357 nasopharyngeal swabs tested on the cobas SARS-CoV-2 & Influenza A/B Assay run on the Laboratory in a tube (LIAT) instrument to the Roche cobas SARS-CoV-2 Test. The overall agreement was found to be 98.6% (352/357); the positive percent agreement for SARS-CoV-2 was 100% (162/162) and the negative percent agreement was 97.4% 190/195) . Althoug/195 . AlRapid antigen tests (RATs), which detect the presence of viral proteins, are another form of POCT . Most ofSerologic testing is an important tool at the population level, since establishing seroprevalence can enhance understanding of the epidemiology of COVID-19 and assist in public health planning. For an individual, serology can help establish potential susceptibility to infection or may be used as an adjunct to PCR testing for diagnosis, particularly when patients present late in the course of illness when the virus may no longer be detectable . For symAt present, serology is not recommended to assess the response to COVID-19 vaccination. Since vaccines induce antibodies to specific viral protein targets, post-vaccination serologic test results will be negative in persons if the test used does not detect antibodies induced by the vaccine . As for Serologic testing assays can be broadly divided into three main categories: detection of total antibodies, detection of specific antibody subclasses , and detection of neutralizing antibodies (nAbs) using qualitative or semi-quantitative methods . DetectiSeveral available serologic assays were compared directly by the National SARS-CoV-2 serology assay evaluation group, including four commercial and one home-brew serologic assay: the SARS-CoV-2 IgG assay (Abbott), Liaison SARS-CoV-2 S1/S2 IgG assay (Diasorin), Elecsys Anti-SARS-CoV-2 assay (Roche), SARS-CoV-2 total assay (Siemens) and the Oxford Immunoassay. The results for 976 pre-pandemic blood samples and 536 samples from patients with confirmed SARS-CoV-2 infection, collected > 20 days after symptom onset, were evaluated. All five assays demonstrated a sensitivity and specificity of >90%, with a sensitivity of >98% for specimens obtained > 30 days after symptom onset . SimilarThe diversity of molecular assays targeting different SARS-CoV-2 genes has enhanced diagnosis capacity and precise identification of SARS-CoV-2 infections. However, the accumulation of nucleotide changes during viral replication has led to the emergence of variant viruses and potentially impacts diagnostic test accuracy for detection of SARS-Cov-2 infection. This highlights the importance of monitoring performance of already released and under-development assays, as well as the need for continued genomic surveillance aimed at detection of variants and their impact on diagnostic target regions. Additionally, the wide circulation of virus variants and concerns regarding the ability of current molecular assays to reliably identify future SARS-CoV-2 emerging variants emphasizes the pressing need for increased and timely whole genome sequencing and surveillance.In one year, we have learnt a great deal about SARS-CoV-2, a novel coronavirus. As the pandemic continues, the state of knowledge will continue to evolve. This review provides an overview to assist providers in better understanding the testing options for detection of SARS-CoV-2 infections and to assist in the management of patients with COVID-19.


Analyzing host cells' transcriptional response to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection will help delineate biological processes underlying viral pathogenesis. First, analysis of expression profiles of lung cell lines A549 and Calu3 revealed upregulation of antiviral interferon signaling genes in response to all three SARS-CoV-2, MERS-CoV, or influenza A virus (IAV) infections. However, perturbations in expression of genes involved in inflammatory, mitochondrial, and autophagy processes were specifically observed in SARS-CoV-2-infected cells. Next, a validation study in infected human nasopharyngeal samples also revealed perturbations in autophagy and mitochondrial processes. Specifically, mTOR expression, mitochondrial ribosomal, mitochondrial complex I, lysosome acidification, and mitochondrial fission promoting genes were concurrently downregulated in both infected cell lines and human samples. SARS-CoV-2 infection impeded autophagic flux either by upregulating GSK3B in lung cell lines or by downregulating autophagy genes, SNAP29, and lysosome acidification genes in human samples, contributing to increased viral replication. Therefore, drugs targeting lysosome acidification or autophagic flux could be tested as intervention strategies. Finally, age-stratified SARS-CoV-2-positive human data revealed impaired upregulation of chemokines, interferon-stimulated genes, and tripartite motif genes that are critical for antiviral signaling. Together, this analysis has revealed specific aspects of autophagic and mitochondrial function that are uniquely perturbed in SARS-CoV-2-infected host cells. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a beta-coronavirus and the cause of the Coronavirus Disease 2019 (COVID-19) pandemic. Lack of effective treatment strategy and vaccine makes SARS-CoV-2 infection a big threat to human health and well-being. Understanding the cellular processes impacted in the host cells responding to a virus infection will be necessary to understand the virus pathogenesis and to develop drug intervention strategies.0) between 3 and 4 , which include four globally endemic hCoVs that cause a substantial portion of upper respiratory infections , as well as two other highly pathogenic strains that have also caused recent pandemics [SARS-CoV and MERS-CoV  specifically impacted by SARS-CoV-2 infection, we have utilized gene expression information from several datasets from cell lines  [see Methods  and Calu3 lung cell lines. How close these cell lines are to lung cells was assessed by evaluating the correlation of the gene expression profiles of cell lines with lung cells using the scRNA-seq information from lung. First, using the scRNA-seq data, cell-type expression profile was computed as the mean expression across cells within each cell type. The top 1,000 genes with the highest variance among the 57 cell-type expression profiles were selected as highly variable genes, which were presumably informative for differentiating the 57 cell types. Next, the expression profiles of lung cell lines were compared with the expression profile of (hACE2-transduced) A549 and Calu3 cell lines. Correlation between the highly variable genes from lung scRNA-seq data and either A549 or Calu3 cells was calculated and plotted . This anThe correlation analysis (presented above) suggests that the BPs impacted in SARS-CoV-2-infected A549 cells is likely impacted in the SARS-CoV-2-infected lung epithelial cells too. However, given the limitations of analyzing lung cell line data, gene expression analysis of lung samples from patients with severe or mild COVID-19 will help test if these processes are differently impacted depending on the severity of the disease. Together, these results support that SARS-CoV-2 infection impacts the expression of genes involved in the cytokine signaling, autophagy, and mitochondria/respiration.R = 0.68, p < 2.2e−16) between gene expression of SARS-CoV-2-infected A549 and Calu3 cells  as the receptor that interacts with the SARS-CoV-2 spike protein to mediate viral entry   young or old samples helped identify DE genes that significantly annotated to autophagy, neutrophils, and mitochondrial processes . HoweverThere were several age- and viral load-dependent gene expression changes observed in the human nasopharyngeal samples, which are described below. Several interferon pathway genes were upregulated in high viral infected young and old samples. However, the upregulation of these genes in high viral load positive old samples was muted compared to the corresponding young samples . The difThe gene expression analysis of the SAR-CoV-2-infected A549 and Calu3 cell lines revealed upregulation of the cytokine/inflammatory processes. However, this observation was inconsistent with the human nasopharyngeal expression profile where inflammatory process genes were downregulated. This difference could arise due to disparate cell type being compared, or that severe inflammatory symptoms may arise in severe case of COVID-19. Since the human nasopharyngeal data did not include clinical symptoms indicating the severity of COVID-19 in the samples whose sequence were analyzed, we could not stratify the samples based on disease severity. However, to test if the cytokine/inflammatory processes were also impacted in COVID-19 lungs, RNA-seq data from the healthy and COVID-19 lung biopsy were analyzed. It should be noted that COVID-19 lung biopsies were technical replicates and therefore statistical significance of this analysis is limiting. Future studies involving bigger sample size will be required to confirm these observations. Nevertheless, the gene expression profile of a SARS-CoV-2-infected lung was distinct from healthy lungs with up- and downregulated genes highlighted in the volcano plot . FurtherHighly pathogenic hCoVs are known to infect the lower respiratory airways and cause severe acute respiratory syndrome (SARS)  were specifically upregulated in high viral titer SARS-CoV-2-infected cell lines. Consistently, the C1q/TNF-related protein 6, a glycoprotein that regulates complement activation, was downregulated in both SARS-CoV-2-infected cells and human samples. This gene is implicated in arthritis, and intra-articular injection of the recombinant C1qTNF6 protein was shown as an effective strategy in improving arthritis and inflammation in C1qtnf6–/– mice , and reactive oxygen species (ROS) processes; and downregulated genes in the mitochondrial and electron transport chain processes. Consistently, analysis of DE genes in one of the correlated clusters from WGCNA showed significant enrichment in the interferon signaling processes. Additionally, GeneMANIA analysis of the correlated DE genes in two modules revealed PPI subnetworks of genes involved in ISGs and NFkB, which were both mostly upregulated in the infected cells. In addition to the ISGs, the JAK-STAT signal transduction genes, which play critical role in type I cytokine (such as IL6) signaling and inflammation  and old (>60 years) nasopharyngeal samples also revealed some age-specific changes in the gene expression profile. Notably, the ISGs  were upregulated in both low and high viral load SARS-CoV-2-positive young samples. Upregulation of these genes in high viral load infected old age samples were, however, less robust. Furthermore, in the low viral load positive old samples, most of the interferon genes (except IFIT3) were downregulated. In addition to the interferon genes, ADAP2, which is an ISG  expression was also significantly decreased in all SARS-CoV-2-infected samples. mTOR inhibits autophagy  samples. This analysis also revealed several BPs that were concordantly impacted in both cell line and human datasets, with few differences. Specifically, genes encoding mTOR were downregulated in infected cells, which likely caused downregulation of mitochondrial ribosomal genes in both cell line and human datasets. Additionally, genes encoding mitochondrial complex I and lysosome acidification were also concurrently downregulated in infected cells from both datasets. Several inflammation process genes and autophagy genes were discordantly regulated in both datasets. It is likely that the autophagic flux is impeded in infected cells lines and human samples due to increased expression of GSK3B gene or downregulation of p62 and SNAP29, respectively, which may further promote viral propagation. These data suggest that drugs that enhance autophagic flux or increase lysosome acidification could be tested as intervention strategies. Increased expression of inflammation process genes in A549 cells is likely due to these cells representing a severe COVID-19 infection state. Consistently, we found upregulation of inflammatory process genes in expression profiles of the COVID-19 lung biopsy sample. These data support a central role for cytokine/inflammation processes in COVID-19 pathogenesis. Finally, using the age-stratified expression profiles of infected human nasopharyngeal samples, we identified muted or downregulation of several chemokines, ISGs, and tripartite motif genes that are critical for innate immunity and antiviral signaling. It is likely that defective antiviral response in old age patients in combination with perturbations in autophagy and mitochondrial processes could result in severe COVID-19 disease state often seen in older population. In summary, using gene expression data of SARS-CoV-2-infected cells, we show that viral infection of host cells results in perturbations in specific aspects of autophagy and mitochondrial processes. Future studies focusing on how these perturbations either contribute to viral propagation or impede an effective immune response will be required to gain more understanding of the viral pathogenesis.GSE147507) , and infection with SARS-CoV-2 at 2  and 0.2  multiplicity of infection (MOI), after transduction with a vector expressing human ACE2 (hACE2) (N = 3 per group). The adenovirus Ad-GFP-h-ACE2 from Vector Biolabs was used for transduction of A549 cells at 500 MOI  were also analyzed. Since the A549 cells infected with SARS-CoV-2 at high and low MOI were used in the network analysis, and DE genes from A549 and Calu3 comparisons were used, a boxplot of the normalized counts showed that all samples were comparable with no outlier (data not shown). Additionally, gene expression data in FPKM were downloaded from GEO (accession number GSE139516) . Differential expression analysis was performed on mock- and MERS-CoV-infected cells for 24 h. Human lung single-cell RNA-seq (scRNA-seq) data with 57 annotated cell types were downloaded from Synapse (accession syn21041850)   < 0.05 were considered significant  was used for data visualization. The datasets supporting the results of this article are also available from Figshare (https://doi.org/10.6084/m9.figshare.12272351.v8)  Mehdi, .SCTransform implemented in Seurat. DE genes were computed for 57 cell types using FindAllMarkers implemented in Seurat with default parameters. The UMAP plot was plotted using the top 50 principal components computed from the expression of highly variable genes selected by SCTransform.Analysis of human lung single-cell RNA-seq (scRNA-seq) data with 57 annotated cell types was performed in R (v3.6) using Seurat (v3.1.1)  and the RNA of HCT-8 cells (VR-1558D) infected with OC43, a beta-coronavirus 1 strain, were purchased from ATCC. The control HCT-8 RNA was isolated after culturing the cells in RPMI medium supplemented with 10% fetal bovine serum (Gibco). The total RNA was isolated using the miRNeasy isolation Kit (Qiagen). The cDNA was synthesized using SuperScriptIII (Invitrogen). The transcripts were measured using FastStart Essential DNA Green Master (Roche). The 18s transcript measurements were used as control. All the primers were ordered from Qiagen QuantiTect assay. Four technical replicates are reported. The original contributions presented in the study are included in the article/KS and MP conceived the project. KS, YC, and MP designed the workflow and performed the analyses. KS, FS, and MP collected the data. KS, SH, KH, and MNS validated the results. KS and JJ drafted the manuscript. All authors contributed to the analysis and evaluation of the results. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


A 73-year-old male rural worker from the Brazilian Amazon region presented with a 4-year left facial ulceration, which became painful as it increased in size. Physical examination revealed a deep 8-cm ulcer in the left malar and periorbital regions, associated with necrosis and purulent exudation . Skull cLeishmania viannia. Immunohistochemical analysis of the samples revealed P-63-positivity, whereas the epithelial membrane was antigen-negative, confirming the diagnosis of basosquamous carcinoma (BSC).Histopathological examination of the lesion revealed atypical basaloid and squamous cell proliferation, with ovoid microstructures within the histiocyte cytoplasm, suggestive of leishmaniasis . PolymerTreatment with meglumine antimoniate for tegumentary leishmaniasis (TL) produced a satisfactory clinical response. The patient underwent radiotherapy and enucleation and was scheduled for reconstruction.To our knowledge, this is the first case describing the association between BSC and TL. TL may impair the immune system, thereby reducing clonal cell susceptibility to destruction


Human T-cell lymphotropic virus type 1 (HTLV-1) infection affects millions of individuals worldwide and can lead to severe leukemia, myelopathy/tropical spastic paraparesis, and numerous other disorders. Pursuing a safe and effective immunotherapeutic approach, we compared the viral polyprotein and the human proteome with a sliding window approach in order to identify oligopeptide sequences unique to the virus. The immunological relevance of the viral unique oligopeptides was assessed by searching them in the immune epitope database (IEDB). We found that HTLV-1 has 15 peptide stretches each consisting of uniquely viral non-human pentapeptides which are ideal candidate for a safe and effective anti-HTLV-1 vaccine. Indeed, experimentally validated HTLV-1 epitopes, as retrieved from the IEDB, contain peptide sequences also present in a vast number of human proteins, thus potentially instituting the basis for cross-reactions. We found a potential for cross-reactivity between the virus and the human proteome and described an epitope platform to be used in order to avoid it, thus obtaining effective, specific, and safe immunization. Potential advantages for mRNA and peptide-based vaccine formulations are discussed. Human T-cell leukemia virus-1 (HTLV-1) infection is associated with a broad spectrum of clinical manifestations such as bronchiectasis, bronchitis and bronchiolitis, dermatophytosis, community acquired pneumonia, strongyloides hyperinfection syndrome, liver, lymphoma and cervical cancer and several autoimmune/inflammatory disorders such as Sjögren’s Syndrome (SS), arthropathies, and uveitis . HAM/TSPWhile in certain endemic regions the prevalence and incidence of clinical symptoms among persons infected with HTLV-1 is significantly elevated, HTLV-1 infection leads to changes in the systemic immune response even in asymptomatic patients . The HTLTo evoke proper immune responses against HTLV-1, especially cellular immunity without undesired side effects, development of an effective and safe vaccine is essential. Synthetic peptide-based vaccines have been developed to evoke immune responses with various advantages in comparison to conventional vaccine formulations. Peptide vaccines are intended to induce cellular and humoral immunity and are chemically stable without oncogenic potential .Several peptide vaccines against HTLV-1 have been proposed  and seemWith the aim of investigating possible immunotherapeutic approaches against HTLV-1, we analyzed the HTLV-1 proteome in an attempt to extract peptide sequences belonging uniquely to the virus and absent in the human proteome. The research rationale was that immunotherapeutic approaches based on peptide sequences unique to the virus might be highly immunogenic by being unknown to the immune system, thus representing the “non-self” . In addihttps://www.uniprot.org/proteomes/?query=11926&sort=score, accessed on 1 September 2020 [https://research.bioinformatics.udel.edu/peptidematch/, accessed on 1 September 2020) [http://www.iedb.org/, accessed on 1 September 2020) was searched for peptide sequences unique to the virus in order to assess their immunological relevance [The analyzed HTLV-1 polyprotein sequence (accession NCBITaxId11926) is described at er 2020) . The Immelevance .As a second step in our investigation, we searched among pentapeptides absent in the human sequences and eventually selected unique consecutive viral pentapeptides overlapping each other by four residues. The results are reported in Finally, the peptides described in Data from B cell and T cell assays as retrieved from the IEDB are reported in The data reported above not only open new scenarios for effective and specific anti-HTLV-1 vaccine formulations, but can also provide a potential mechanistic link between HTLV-1 infection and related disorders including lymphomas and leukemias, respiratory disorders, fibromyalgia, rheumatoid arthritis, arthritis, tuberculosis, kidney and bladder infections, dermatophytosis, community acquired pneumonia, strongyloides hyperinfection syndrome, liver cancer, lymphoma, cervical cancer, and neurological disorders .Indeed, analyses of the experimentally validated epitopes described in Generation of autoantibodies following peptide sharing-induced cross-reaction would also explain the multitude of disorders that, to a greater or lesser extent, characterize HTLV-1 infection. Indeed, analyses of the peptide overlap between the viral epitopes and the human proteome show that, on the whole, 64 epitope-derived hexapeptides repeatedly occur among 143 human proteins , thus prA-kinase anchor protein 1, mitochondrial precursor (PSLALP) has a pivotal role in mitochondrial physiology, and its degradation leads to an increase in reactive oxygen species production, mitochondrial dysfunction, and ultimately cell death .A-kinase anchor protein 7 isoform gamma (HLTLPF) modulates L-type Ca2+ channels . AlteratAtaxin-2-like protein (QAIVSS) is involved in spinocerebellar ataxia type 2 , cutaneoB-cell CLL/lymphoma 6 member B protein and B-cell CLL/lymphoma 9-like protein, both of which share the peptide PPTAPP with HTLV-1. When altered, these two proteins relate to tumorigenesis .Cadherin-2 (APQVLP) may be associated with reduction in bone mineral density or vertebral fracture prevalence in survivors of childhood acute lymphoblastic leukemia .Constitutive coactivator of PPAR-gamma-like protein 2 (QLPPTA) deletion is associated with autism .Dedicator of cytokinesis protein 9  contributes to both risk and increased illness severity in bipolar disorder .DNA methyltransferase 1-associated protein 1 (APPLLP) is an essential regulator of activity and function of Ataxia Telangiectasia Mutated (ATM) kinase . AlteratDNA polymerase nu (PPPGPC) plays a role in translesion DNA synthesis during interstrand cross-link repair in human cells .E3 ubiquitin-protein ligase HECTD1 (APGYDP) is an important factor in promoting base excision repair (BER), which is the major cellular DNA repair pathway that recognizes and excises damaged DNA bases to help maintain genome stability .Fertilization-influencing membrane protein (PSQLPP) plays a role in sperm–oocyte fusion during fertilization .FLYWCH-type zinc finger-containing protein 1 (PSLALP) has a possible tumor suppressive role in preventing colorectal cancer metastasis .Heterogeneous nuclear ribonucleoprotein C-like 1 , alterations of which are found in sporadic and suspected Lynch syndrome endometrial cancer .Histone acetyltransferases KAT2A and KAT2B (DGRVIG), when altered, are associated with cardiovascular pathology .Islet cell autoantigen 1 (MKDLQA) Islet autoantibodies are typically associated with type 1 diabetes, but have been found in patients diagnosed with type 2 diabetes in whom they are associated with lower adiposity .La-related protein 1B (AIKQEV) is dysregulated in hepatocellular carcinoma .Mitochondrial dynamics protein MID49 (QPRPPP) is related to myopathies .Mucin-5AC precursor  is a major macromolecular component that determines the rheological properties of mucus; otherwise abnormal not-flowing mucus results in defective lung protection and leads to infection and inflammation .Neurofascin precursor (TGAVSS), which is a cell adhesion, ankyrin-binding protein, may be involved in neurite extension, axonal guidance, synaptogenesis, myelination, and neuron–glial cell interactions. Anti-neurofascin antibodies relate to optic, trigeminal, and facial neuropathy .Palmitoyltransferase ZDHHC1 (LALPAP) is involved in innate viral immune response .Protein piccolo (PPNHRP) is required for the development and function of neuronal networks formed between the brainstem and cerebellum. Alterations of protein piccolo may result in impaired motor coordination, cerebellar network dysfunction and pontocerebellar hypoplasia .Serine/threonine-protein kinase WNK1 (APQVLP) can cause hereditary sensory and autonomic neuropathy .Suppressor of tumorigenicity 7 protein (SLILPP) deficiency promotes laryngeal squamous cell carcinoma .Finally, to conclude this survey of pathologies that may be associated with HTLV-1 infection following cross-reactivity and autoantibody generation, we highlight the HTLV-1 epitope-derived VNFTQE peptide that is present in seventeen zinc finger proteins (ZFP)  and the related pathologies that could arise in case of cross-reactivity. Examples among the many are:Vaccines are a crucial tool for fighting viral infections and their profile of efficacy and safety is of paramount importance. Minimizing the risk of collateral autoimmune cross-reactivity might be advantageous for further optimizing the efficacy–safety tradeoff, as recently shown by the SARS-CoV-2 global vaccination campaign ,51.Homo sapiens proteome. These sequences show an immunological potential by being embedded in epitopes that were experimentally validated in the human host, as shown in Hence, in order to design a safe and effective HTLV-1 vaccine, we applied the scientific rationale according to which vaccines based on peptides unique to the infectious pathogens and absent in the human host might avoid cross-reactivity phenomena and offer high potential for immunogenicity and self-adjuvanticity ,53. We fMessenger ribonucleic acid (mRNA) vaccines are the results of decades of studies on different mRNA intracellular delivery technologies and have come under the spotlight as one of the main tools of the global vaccination campaign against the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) . DeliverThe epitope platform presented above can also be adopted in non-genetic peptide-based vaccine formulations, where the peptides are directly administered, possibly conjugated to a carrier . Such foWe presented here an epitope platform for effective HTLV-1 vaccination that minimizes the risks intrinsic to whole viral antigens, thus potentially reducing post-vaccination adverse events, cross-reactivity with human antigens and possible autoimmune pathologies .The short epitopes we identified are optimally suited for mRNA and nanoparticle vaccine technology, offering remarkable advantage in terms of production quality and stability of the final products, thus easing the currently challenging logistic aspects of storage and transportation. Moreover, the same epitope platform is a flexible resource that can also be used in peptide-based vaccines at lower cost, facilitating production and diffusion, for instance in developing countries.In sum, we presented an epitope set that offers remarkable real-world logistic advantages for a large-scale safe and effective prophylactic vaccination campaign against HTLV-1 that might be of cogent importance considering that no specific therapy exists.


The efficacy of the TRT was encouraging in shrinking tumor mass with remarkable SUVmax reduction (approximately 42%) on FDG PET-Scan despite relatively low-dose DCs were available. The low-dose intratumoral immunotherapy induced mild cutaneous side effects as expected. The transcriptomes were compared between pre-TRT and post-TRT biopsies to analyze underlying mechanical pathways of the TRT protocol. Over 10 highly significantly enriched T-cell-related pathways (P <0.0001) were identified in post-TRT biopsies. In addition, the activation of both innate and adaptive immunity was significantly enriched in post-TRT peripheral blood samples. We develop the easily accessible TRT which produces both local anti-tumor T-cell responses and systemic antitumor immunity for treating cSCC patients, especially for those with autoimmune disease.The combination of radiotherapy and immunotherapy improves the survival rate of patients with malignancies developed through escape from T-cell-mediated immune surveillance. Immune checkpoint inhibitors, such as anti-programmed cell death protein-ligand 1 (anti-PD-L1) antibody, are used to rescue exhausted T cells. Simultaneously, dendritic cells (DCs) which are antigen-presenting cells that can initiate T-cell activation, are used to induce a tumor-specific immune response. However, the synergistic antitumor efficacy of the aforementioned combinational immunotherapy with intratumoral injection of low-dose DCs has not been reported, and the underlying therapeutic mechanism requires further investigation. Herein, we present the special case of a psoriatic patient with cutaneous squamous cell carcinoma (cSCC) in the right inguinal region, these two diseases characterized by opposing contradiction, further complicating treatments and side-effect management efforts. To treat the intractable SCC without exaggerating psoriasis, we developed the triple-regimen therapy (TRT) with the intratumoral injection of low-dose autologous DCs and anti-PD-L1 combined with radiotherapy. The injected DCs were obtained simply through leukapheresis without prior G-CSF administration for mobilization nor tumor-antigen loading for expansion. The patient received three radiation doses  combined with three intratumoral injections of anti-PD-L1 antibody  plus autologous DCs (80% of the DC subpopulation being CD16 T-cell exhaustion and then restimulating T cells (+ myeloid DCs (mDCs) from the peripheral blood (PB) of a patient with PV who developed advanced cSCC. This treatment was implemented through a convenient process and exhibited efficacy for latent-stage cancer, when DC-enriched blood cells were combined with anti-PD-L1 immunotherapy plus radiotherapy.Cutaneous squamous cell carcinoma (cSCC), which accounts for 20% of cases of non-melanoma skin cancer, has a strong metastatic capability and thus a high mortality rate . Surgica T cells . Anti-PD T cells  as an al T cells . HoweverThis is a 63-year-old man with a history of hepatitis B virus (HBV)-related cirrhosis with liver function impairment and also psoriasis vulgaris (PV) for more than 25 years. Notably, there was an unusual feature presented with a palpable mass in the right inguinal region that had reportedly existed for 3 months. Local excision of the subcutaneous mass was performed with poor wound healing during regular follow-up. The patient subsequently developed regional progression, with magnetic resonance imaging revealing a cystic lesion measuring 5.6 cm × 4.2 cm in the axial dimension and 9 cm in craniocaudal distance from the tumor encasement of the right superficial femoral artery. Repeated percutaneous transluminal angioplasty with excision biopsy of the tumor was conducted because of several episodes of massive bleeding, which was possibly caused by pseudoaneurysm rupture. Pathological findings revealed moderately differentiated SCC of soft tissue with 65% expression of PD-L1. Positron emission tomography (PET) was further arranged, which revealed an irregularly shaped fluorodeoxyglucose (FDG)-avid lesion in the right inguinal region (>10 cm) with clinical staging T2N0M0 according to the eighth edition of the American Joint Committee on Cancer Staging Manual.For this case, complete surgical excision was not possible because the tumor had caused vascular encasement; moreover, systemic chemotherapy is not recommended for the prevention of HBV reactivation . After ain vivo and further expansion in vitro, which were later enriched through leukapheresis with PB stem cells (PBSC) collection in the COBE Spectra Apheresis System  instead of plasmacytoid DCs   from other granulocytes and lymphocytes by elutriation. However, only 60–70 ml of concentrated PBMCs was obtained in the collection bag through the leukapheresis. We also remove the excess plasma by centrifuge. We can maximize the volume of recirculating whole blood to produce maximal PBMCs in collection bag but the amount of existing DCs in PB is limited as well as the injectable volume of DCs into tumor mass. These findings demonstrate the potential for CD16+ mDCs to be enriched through a specific leukapheresis procedure on PBMCs collected from patients with PV who have developed advanced cSCC.The DC subsets in the purified PB samples were characterized through leukapheresis. The blood DC compartment was identified as Linresponse , 10. The+ DC-enriched PB plus anti-PD-L1 antibody—and radiotherapy is effective for treating locally advanced cSCCs with surgical contraindications.To determine the efficacy of the aforementioned immunotherapy plus radiotherapy on our cSCC patient, we first assessed the wound condition using pelvis computed tomography and found that the wound healing process improved gradually with the course of ongoing TRT (P <0.00001) identified in postintervention biopsies. These pathways included the following: leukocyte chemotaxis, positive regulation of T-cell proliferation, T-cell-mediated immunity, alpha-beta T-cell activation, interferon-gamma production, lymphocyte chemotaxis, alpha-beta T-cell differentiation, regulation of T-cell–mediated immunity, T-cell differentiation involved in immune response, and T-helper cell differentiation. These data indicated that T-cell-mediated immunity was locally induced after intratumoral injection with CD16+ mDC-enriched cells and anti-PD-L1 therapy  for PB with TRT versus no treatment).To identify the mechanisms underlying this TRT protocol and the potential of DC-mediated immunity, we compared the transcriptomes between pre-TRT and post-TRT biopsies using Metascape  to analy+ mDC-enriched cells plus anti-PD-L1 antibody could be effective for treating advanced cSCC through the upregulation of local T-cell-mediated immune responses and then systemic antitumor immunity that can reduce the tumor size when combined with radiotherapy.These findings suggest that immunotherapy using CD16We present a case in which combined radiotherapy and immunotherapy was applied for treating a psoriatic patient with cSCC and contraindications to surgery and chemotherapy, including vascular encasement by the tumor and risk of HBV reactivation.de novo autoimmune skin disease, or reactivation of previous autoimmune skin diseases, such as psoriasis   . Second,soriasis –15. Althin situ vaccination by low-dose DCs and anti-PD-L1 with potentiation by local RT, the combinational strategy obviated the need for high dose boosting of immunotherapy and remitted the dose dependent adverse effects. We therefore checked specific expression levels of PD-L1 expressed in tumor specimen before versus after TRT in our transcriptomic array, and surprisingly found that the expression level of PD-L1 in tumor specimen after TRT was 16.72-fold higher than that before therapy, suggesting that combination of radiotherapy improved the therapeutic efficacy of anti-PD-L1 and DC-based immunotherapy in the cSCC patient. The synergistic effects of combining different immunotherapies, or immunotherapies and RT have been discussed, and showed promise  and TNF-α and iNOS-producing DCs (Tip-DCs) can secrete IL-23 for enhanced development and expansion of Th17 cells in response to these damage derivatives, while cDC1 can produce IL-2 for Th1 differentiation which may enhance the inflammatory damage. Moreover, IL-1β is produced from damaged keratinocytes to activate LC for IL-23 release and also facilitate Th17 differentiation. The population of slan-DCs have been demonstrated to express CD16 which is considered as an inflammatory DC subset in various types of autoimmune diseases. All of these DC subpopulations then contribute to strong inflammatory T-cell responses and drive psoriasis , conventional DCs (cDCs), inflammatory DCs, and Langerhans cells (LCs). With external stimuli to cause keratinocyte damage, pDCs are activated soriasis , 9.+ myeloid DCs, which are considered as a critical inflammatory DC subset to secrete cytokines for T-cell activation in autoimmune diseases, are specifically enriched in the cSCC patients who were previously diagnosed with psoriasis. We therefore chose the activated DC subset as the target of immunotherapy to potently improve the T cell immunity against cSCC. Although the role of CD16+ myeloid DCs in cSCC pathogenesis is poorly understood, one in vitro study demonstrated SCC cell lines can significantly upregulate CD16 expression on DCs with an immature phenotype , Teh-Tzer Study Group for Human Medical Research Foundation of Taiwan (B1081050).The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Adverse drug reactions (ADRs) remain associated with significant mortality. Delayed hypersensitivity reactions (DHRs) that occur greater than 6 h following drug administration are T-cell mediated with many severe DHRs now associated with human leukocyte antigen (HLA) risk alleles, opening pathways for clinical prediction and prevention. However, incomplete negative predictive value (NPV), low positive predictive value (PPV), and a large number needed to test (NNT) to prevent one case have practically prevented large-scale and cost-effective screening implementation. Additional factors outside of HLA contributing to risk of severe T-cell-mediated DHRs include variation in drug metabolism, T-cell receptor (TCR) specificity, and, most recently, HLA-presented immunopeptidome-processing efficiencies via endoplasmic reticulum aminopeptidase (ERAP). Active research continues toward identification of other highly polymorphic factors likely to impose risk. These include those previously associated with T-cell-mediated HLA-associated infectious or auto-immune disease such as Killer cell immunoglobulin-like receptors (KIR), epistatically linked with HLA class I to regulate NK- and T-cell-mediated cytotoxic degranulation, and co-inhibitory signaling pathways for which therapeutic blockade in cancer immunotherapy is now associated with an increased incidence of DHRs. As such, the field now recognizes that susceptibility is not simply a static product of genetics but that individuals may experience dynamic risk, skewed toward immune activation through therapeutic interventions and epigenetic modifications driven by ecological exposures. This review provides an updated overview of current and proposed genetic factors thought to predispose risk for severe T-cell-mediated DHRs. Adverse drug reactions (ADRs) are estimated as the fourth to sixth leading cause of death . While tHLA.alleles.org). In 2002, Mallal demonstrated carriage of HLA-B∗57:01 among 78% of HIV patients with abacavir hypersensitivity, which is a well-characterized systemic syndrome, opposed to just 2% of tolerant patients  of 100% and a positive predictive value (PPV) of 55%  of 55% , demonst∗15:02 and carbamazepine (CBZ)-induced SJS/TEN in Taiwan was reported, which followed the translational roadmap provided by abacavir such that 0/4120 Taiwanese HLA-B∗15:02-negative patients developed SJS/TEN after CBZ exposure   to trigger T-cell activation . Each inunogenic . Polyclo(SMX-NO) . Here th(SMX-NO) . In 2019 blister . The dom blister . Furthernol-SCAR . While f+ T-cell response . Indeed, CF patients are far more likely to develop an allergy to beta-lactams than patients without ; thus, iabacavir . Such reabacavir .It is now well established that epigenetic modifications to open or close the transcriptional template of genes impacts immunological processes . EpigeneImmune checkpoints regulate T-cell activation to prevent uncontrolled activation. This complex process is the summation of varied co-stimulatory and opposingly co-inhibitory pathways . IntriguGiven a lack of a single HLA allele to provide complete PPV, other risk factors must further restrict response and recent advances have detailed (i) application of single-cell sequencing to define the HLA-restricted dominant TCR driving early response in tissue and (ii) the impact of ERAP variants to skew immunodominant peptide presentation. Intriguingly, other proposed risk factors such as checkpoint receptors span genetic and epigenetic risk, with expression subject to environmental or therapeutic pressures, implicating highly dynamic risk. Strategies are now needed to identify risk alleles in minority populations where large clinical cohorts are impossible to obtain. The availability of multi-omic approaches offers opportunity to merge high-resolution genotyping with single-cell phenotyping to tease out more complex risk signatures that may also enable cost-effective patient screening.YL, PD, RH, and AP contributed writing toward individual sections of the manuscript, led and majority authored by YL. AG and EP provided expert review, direction, and guidance. All authors contributed to the article and approved the submitted version.The reviewer AC declared a past co-authorship with the authors AG and EP to the handling editor. EP was Drug Allergy Section Editor and receives royalties from Uptodate and consulting fees from Biocryst, Janssen and Vertex. She is co-director of IIID Pty Ltd that holds a patent for HLA-B*57:01 testing for abacavir hypersensitivity, and she holds a patent for Detection of Human Leukocyte Antigen-A*32:01 in connection with Diagnosing Drug Reaction with Eosinophilia and Systemic Symptoms without any financial remuneration and not directly related to the submitted work. Funders played no role in any aspect of this Review. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


To report a patient with nonarteritic anterior ischemic optic neuropathy (NA-AION) occurring soon after the COVID-19 vaccination. A 55-year-old woman presented with a 4-day history of inferior visual field disturbance in the right eye 7 days after receiving the first dose of Pfizer-BioNTech COVID-19 vaccine. Examination revealed a best-corrected visual acuity of 20/20 in both eyes. A relative afferent pupillary defect was observed in the right eye. Fundoscopy revealed diffuse optic disc swelling in the right eye, which was prominent above the optic disc. Goldmann visual field testing identified an inferior altitudinal visual field defect with I/2 isopter in the right eye. Although typical complete inferior visual field defect was not detected, a diagnosis of NA-AION was made. The patient was followed without any treatment. During the 2-month follow-up period, the optic disc swelling was gradually improved, and visual acuity was maintained 20/20; however, the optic disc looked diffusely pale in the right eye. Although it is uncertain whether the development of NA-AION after COVID-19 vaccination was consequential or coincidental, we speculate that the close temporal relationship with COVID-19 vaccination suggests the possibility of vasculopathy on the microvascular network of optic nerve head as background of inflammatory or immune-mediated element to the timing of the onset of NA-AION. The aim of this case report is to present this biological plausibility and to elucidate potential ophthalmological complications. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and the resulting coronavirus disease 2019 (COVID-19) pandemic hit the world by storm, and Japan was no exception. Currently, there has been a tremendous increase in reports of ophthalmic manifestations related with COVID-19 and its vaccination .Nonarteritic anterior ischemic optic neuropathy (NA-AION) is an important cause of acute visual loss in middle-aged and elderly populations . TypicalHere, we report a case of NA-AION occurring soon after the COVID-19 vaccination.A 55-year-old woman presented with a 4-day history of inferior visual field disturbance in the right eye 7 days after receiving the first dose of Pfizer-BioNTech COVID-19 vaccine (BNT162b2 mRNA COVID-19 vaccine). Her personal and family histories as well as physical examination results were unremarkable. She had no other health complaints. Examination revealed a best-corrected visual acuity of 20/20 in both eyes. A relative afferent pupillary defect was observed in the right eye. There was no abnormal ocular motility in either eye. Fundoscopy revealed diffuse optic disc swelling in the right eye, which was prominent above the optic disc . In contAlthough typical complete inferior visual field defect was not detected nor above-mentioned examinations were not conducted, based on patient's history and the aforementioned examinations, a diagnosis of NA-AION was made. The patient was followed without any treatment. During the 2-month follow-up period, the optic disc swelling was gradually improved, and visual acuity was maintained 20/20; however, the optic disc looked diffusely pale in the right eye .NA-AION is thought to develop due to circulatory insufficiency of the posterior ciliary arteries supplying the optic nerve. Having small, crowded optic disc or other vasculopathies are risk factors for developing NA-AION. Although in the present case, the relatively young patient did not have any vasculopathic risk factors, she developed NA-AION following COVID-19 vaccination.The occurrence and significance of autoimmune manifestations after the administration of viral vaccines remain controversial. Only two previous cases of NA-AION following influenza vaccination have been reported in the literature , 6. ThesPrevious cases of NA-AION in the setting of COVID-19 infection were reported in the literature –9. SARS-In contrast, various adverse effects have been reported with COVID-19 vaccine , 3, but COVID-19 vaccines result in producing high levels of neutralizing antibodies after injection. These neutralizing antibodies recognize and target the spike proteins in the virus, killing it before the virus is disseminated and cause illness . NeutralFinally, the aim of this case report is to present this biological plausibility and to elucidate potential ophthalmological complications.


Severe methemoglobinemia (Met-Hb) is rare. The delayed diagnosis and treatment often cause further damage. The management of cellular hypoxemia is challenging and the use of extra-corporeal membrane oxygenation (ECMO) has never been reported.The young patient, healthy with unremarkable past medical history, was sent to emergency room with out-of-hospital circulatory arrest (OHCA) and severe generalized cyanosis. His family reported he ingested sodium nitrite accidentally.After successful resuscitation and return of spontaneous circulation (ROSC), the paradoxically normal arterial blood gas (ABG) with the unusual brownish blood led to the suspicion of Met-Hb. The lab test confirmed it and showed a very high level of 80%.Because of recovered and normal cardiac function, we placed veno-venous extracorporeal membrane oxygenation (VV-ECMO) for tissue hypoxemia in addition to exchange transfusion, vitamin C, and methylene blue.Met-Hb blood level dropped rapidly. After vigorous rehabilitation for weeks, the patient was able to be discharged home without major neurological sequela.VV-ECMO can hyper-oxygenate the hypoxemic tissue regardless the etiology and minimize hypoxemia-reperfusion injury while awaiting the definite diagnosis and therapy. Here we present a Met-Hb case treated with venous-venous extracorporeal membrane oxygenation (VV-ECMO) as rescue while awaiting antidote infusion and successfully survived without neurological deficits.Methemoglobinemia (Met-Hb) can be congenital or acquired. Most cases of Met-Hb are acquired, resulting from increased methemoglobin formation induced by various exogenous substances.22 levels by the arterial blood gas (ABG), Met-Hb was highly suspected and then confirmed by laboratory data (Met-Hb = 80%). For the status of OHCA with unusual presentation of blood gas physiology, cardiovascular surgeons were consulted for the opinions of ECMO. With stable hemodynamics without the need of strong inotropes and pressors, indicating recovered and normal cardiac function, we decided to implant VV-ECMO via both femoral veins at the bedside, while awaiting the dispensing of methylene blue from the pharmacy.This 23-year-old man ingested sodium nitrite accidentally at home. He was sent to emergency department presenting as out-of-hospital cardiac arrest (OHCA) and generalized cyanosis. Cardiopulmonary resuscitation (CPR) was initiated by the emergency technical technicians (EMT) on the ambulance. Return of spontaneous circulation (ROSC) was achieved 10 minutes after arriving the emergency room with the efforts of physicians and team members. Because of the brownish-colored blood with the paradoxically normal PaO2 100%, sweep 2 L/min titratable with PaCO2 from patient's ABG, pump flow 4 L/min, with heparin infusion that kept activated clotting time (ACT) from 180 to 200 seconds. The ventilator setting was adjusted from maximum to FiO2 60% and positive end expiratory pressure (PEEP) of 10 cm H2O. The subsequent ABG showed PaO2 of 550 mm Hg, although the blood color still remained chocolate-brownish  score of 1, showing no major neurological sequelae. At the outpatient clinic, the patient has signed the informed consent for publication of this case report.3This unusual case of Met-Hb demonstrated the usual role of ECMO: bridging to decision, therapy, or recovery. When an unknown scenario occurs, the ECMO support stops the crisis escalation and the next step can have time to be optimized, just as some examples from the cardiac surgery. and the severity may be shown as a spectrum from red to brown , is the only source available for tissue and cells. Thus, the hyper-oxygenation provided by the VV-ECMO becomes a key factor to the timely and successful management of this case.Even a timely diagnosis is made, the management of acquired severe Met-Hb is still challenging, regardless methylene blue is available or not.This is the first case report for the application of VV-ECMO on salvaging severe acquired Met-Hb. Acquired Met-Hb is uncommon in Taiwan and adjacent countries. It must be diagnosed timely from its unusual presentation and should be treated properly with antidotes and hyper-oxygenation support. If hemodynamics is stable, VV-ECMO should be placed to provide hyper-oxygenation that counter-acts the detrimental effect of Met-Hb.The authors thank all the staff members that involved in our ECMO program including (not limited to) the Emergency Medical Technicians, Emergency Department, Toxicity Laboratory, and Intensive Care Unit. Antidote was supported by Taichung Veterans General Hospital and they appreciated their help with their most sincere gratitude.Conceptualization: Yu-Hsuan Lien, Robert Jeenchen Chen.Funding acquisition: You-Cian Lin.Supervision: You-Cian Lin, Robert Jeenchen Chen.Writing – original draft: Yu-Hsuan Lien.Writing – review & editing: Robert Jeenchen Chen.