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    Figure 1.

    Viral load and antibody kinetics in COVID-19 patients during the course of disease. The kinetics of viral load of the upper respiratory tract from symptom onset (A) and the viral load at the first day of hospitalization (B). The kinetics of plasma IgG (C) and IgM (D) titer against SARS-CoV-2 S1 protein. If OD450 of 1/100 or 1/1,000 diluted sample exceeds 2.5, the endpoint titer (OD450 ratio) of IgG and IgM was determined by multiplication of dilution factor and OD450. Black significance bars compare two groups; asymptomatic and mild vs moderate, asymptomatic and mild vs severe and critical, or moderate vs severe and critical. Red bars indicate statistical differences among three groups. Blue dot = moderate; green dot = asymptomatic and mild; red dot = severe and critical. *P < 0.05, **P < 0.01, ***P < 0.001.

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    Figure 2.

    Plasma cytokines and chemokine concentrations in COVID-19 patients during the course of disease, according to the severity of illness. Black significance bars compare two groups; asymptomatic and mild vs. moderate, asymptomatic and mild vs. severe and critical, or moderate vs. severe and critical. Red bars indicate statistical differences among three groups. Blue dot = moderate; green dot = asymptomatic and mild; red dot = severe and critical. *P < 0.05, **P < 0.01, ***P < 0.001, ****P < 0.0001. IFN = interferon; IL = interleukin; IP = IFN-γ-induced; MCP = monocyte chemoattractant protein; MIG = monokine induced by IFN-γ; VEGF = vascular endothelial growth factor.

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Factors of Severity in Patients with COVID-19: Cytokine/Chemokine Concentrations, Viral Load, and Antibody Responses

Ji-Soo KwonGraduate School of Medical Science and Engineering, Korea Advanced Institute of Science and Technology, Daejeon, Republic of Korea;

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Ji Yeun KimDepartment of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea;

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Min-Chul KimDivision of Infectious Diseases, Department of Internal Medicine, Chung-Ang University Hospital, Chung-Ang University College of Medicine, Seoul, Republic of Korea;

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Se Yoon ParkDivision of Infectious Diseases, Department of Internal Medicine, Chung-Ang University Hospital, Chung-Ang University College of Medicine, Seoul, Republic of Korea;

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Baek-Nam KimDepartment of Infectious Diseases, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, Seoul, Republic of Korea;

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Seongman BaeDepartment of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea;

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Hye Hee ChaDepartment of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea;

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Jiwon JungDepartment of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea;

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Min-Jae KimDepartment of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea;

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Myung Jin LeeDepartment of Infectious Diseases, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, Seoul, Republic of Korea;

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Seong-Ho ChoiDivision of Infectious Diseases, Department of Internal Medicine, Chung-Ang University Hospital, Chung-Ang University College of Medicine, Seoul, Republic of Korea;

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Jin-Won ChungDivision of Infectious Diseases, Department of Internal Medicine, Chung-Ang University Hospital, Chung-Ang University College of Medicine, Seoul, Republic of Korea;

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Eui-Cheol ShinGraduate School of Medical Science and Engineering, Korea Advanced Institute of Science and Technology, Daejeon, Republic of Korea;

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Sung-Han KimDepartment of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea;

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ABSTRACT

The severity of COVID-19 ranges from mild to critical diseases. However, limited data have been published on the detailed kinetics of viral load and host immune response throughout the disease course depending on disease severity. In this study, we comprehensively analyzed viral load, antibody responses to SARS-CoV-2, and cytokines/chemokines during the disease course, and identified the factors related to severity. Nasopharyngeal (NP) and plasma specimens were obtained from 31 patients with COVID-19 during hospitalization. Viral RNA in NP specimens was quantified by reverse transcription–PCR. Anti–SARS-CoV-2 antibodies and cytokines/chemokines in plasma specimens were analyzed by ELISA and cytometric bead array. The viral load in patients with COVID-19 peaked at the early stage of the disease and continuously decreased. Severe and critical cases showed higher viral load and prolonged viral shedding than asymptomatic and mild cases. Whereas plasma IgG was gradually increased and maintained during hospitalization, plasma IgM peaked at 3 weeks after symptom onset and dissipated. The antibody response in severe and critical cases was slightly delayed but stronger than those in others. High levels of interferon (IFN)-α, IFN-γ–induced protein-10, monokine induced by IFN-γ, and interleukin-6 at 5–10 days from symptom onset were associated with the severity of COVID-19. Our data indicate that high viral load in the respiratory tract and excessive production of cytokines and chemokines between 1 and 2 weeks from the symptom onset were significantly associated with the severity of COVID-19.

INTRODUCTION

In December 2019, cases of pneumonia with unknown etiology were reported in Wuhan, China. In January 2020, a novel coronavirus was identified as the cause of the pneumonia, and its genome sequence had 79% identity to SARS-CoV; as such, the virus was designated as SARS-CoV-2 and the disease it causes as COVID-19.1,2 The WHO declared the outbreak of COVID-19 as a worldwide pandemic in March 2020.

Previous studies on the epidemiology and clinical features of COVID-19 have shown that SARS-CoV-2 infection usually results in mild disease, although some patients occasionally develop severe or critical illness.3 Poor clinical outcomes of COVID-19 has been associated with older age, male gender, and the presence of underlying conditions such as hypertension, obesity, and type 2 diabetes mellitus.46 However, the pathophysiologic mechanisms by which SARS-CoV-2 causes severe illness are largely unknown. Our previous single-cell RNA sequencing study revealed that monocytes from patients with severe COVID-19 exhibit increased type I interferon (IFN) response in addition to tumor necrosis factor (TNF)/interleukin (IL)-1β–driven inflammation7; by contrast, others reported that severe COVID-19 was associated with impaired type I IFN response with an excessive release of TNF-α and IL-6.8

However, previous studies do not reflect the cytokine responses during the various courses of the disease. In this study, we comprehensively analyzed the viral load, antibody responses to SARS-CoV-2, and cytokine/chemokine profiles during the disease course and identified the factors related to the severity of COVID-19.

MATERIALS AND METHODS

Patients and clinical samples.

We prospectively enrolled 31 confirmed cases of COVID-19 admitted to four university-affiliated hospitals in the Republic of Korea—Asan Medical Center, Chung-Ang University Hospital, Soonchunhyang University Seoul Hospital, and Inje University Sanggye Paik Hospital—from February 2020 to April 2020. COVID-19 was confirmed by real-time reverse transcription–PCR (RT-PCR) analysis for the RdRp gene of SARS-CoV-2. The severity of COVID-19 was categorized into mild, moderate, severe, and critical according to the WHO guidance.9 Peripheral blood was collected at admission and every 2–3 days thereafter until discharge. Plasma samples were immediately separated by centrifugation and stored at −70°C until further analysis; for cytokine and antibody analysis, approximately 1 mL of plasma was irradiated with up to 6 million rad from a60Co gamma source according to the method used in our previous study.10 The study was approved by the respective institutional review boards of each participating hospital.

SARS-CoV-2 RT-PCR.

Viral RNA was extracted from the upper respiratory tract swab samples using the MagNA Pure 96 system (Roche Diagnostics, Mannheim, Germany) according to the manufacturer’s instructions. RNA was analyzed with the PowerChek 2019-nCoV Real-Time PCR Kit (KogeneBiotech, Seoul, Republic of Korea) that targets the RdRp gene of SARS-CoV-2 and the E gene of beta-coronavirus, and the Allplex 2019-nCoV assay (Seegene) that targets the RdRp gene and N gene of SARS-CoV-2 and the E gene of beta-coronavirus. Ct values < 40 for RdRp gene were considered as positive results.

SARS-CoV-2 serology.

We measured the levels of human anti–SARS-CoV-2 IgG and IgM by using laboratory-developed ELISA. SARS-CoV-2 S1-His protein (Sino Biological, Beijing, China) was coated onto 96-well plates (MaxiSorp, Thermo Fisher Scientific, Waltham, MA) at a concentration of 2 μg/mL in PBS. Plasma samples were used at dilutions of 1:100, 1:1,000, and 1:10,000. horseradish peroxidase-conjugated antihuman IgG (Jackson Immunoresearch, West Grove, PA) and IgM (MilliporeSigma, Burlington, MA) were used as secondary antibodies. The optical density (OD) value of 450 nm (OD450) was measured. If OD450 of 1/100 or 1/1,000 diluted sample exceeds 2.5, the OD450 of next diluted sample was multiplied by dilution factor (OD450 ratio) and determined as the endpoint titer. The OD450 of plasma specimens that were not previously exposed to SARS-CoV-2 were used to determine the cutoff value (i.e., OD450 = 0.4) for both IgG and IgM.

Cytokine analysis.

Collected plasma samples were stored at −70°C until analysis and analyzed at once, on the same day. We simultaneously measured plasma concentrations of granulocyte colony-stimulating factor, granulocyte-macrophage colony-stimulating factor, IFN-α, IFN-γ, TNF-α, IL-1β, IL-2, IL-6, IL-7, IL-8, IL-10, IL-12p70, IL-13, IL-17A, monocyte chemotactic protein (MCP)-1, macrophage inflammatory protein (MIP)-1α, MIP-1β, regulated on activation and normally T-cell expressed and secreted, monokine induced by IFN-γ (MIG), IFN-γ–induced protein (IP)-10, and vascular endothelial growth factor (VEGF) using a cytometric bead array based on microspheres for detecting cytokine/chemokine according to the manufacturer’s instruction (BD Bioscience, San Jose, CA). Data were acquired using the FACS CANTO II flow cytometer, FACSDiva software (BD Bioscience), and FlowJo software (FlowJo LLC, Ashland, OR), as described in our previous study.10,11

Statistical analyses.

Categorical variables were compared using the Fisher’s exact test or the χ2 test, and continuous variables were compared with the Kruskal–Wallis test, Mann–Whitney U test, or unpaired Student’s t-test. All tests of significance were two-tailed and P-values less than 0.05 were considered statistically significant. Statistical analyses were performed using GraphPad Prism 8.4.3 (GraphPad Software, Inc., LA Jolla, CA).

RESULTS

Clinical characteristics and outcomes.

A total of 31 patients with COVID-19 confirmed by SARS-CoV-2–specific RT-PCR of Nasopharyngeal (NP) swab specimen were enrolled in this study. The patients were classified according to disease severity: five (16%) mild, 17 (55%) moderate, six (19%) severe, and two (7%) critical patients; one (3%) patient did not have any signs or symptoms and was therefore classified as an asymptomatic case (Table 1); for analysis, the patients were categorized into three groups: asymptomatic and mild (19%), moderate (55%), and severe and critical (26%). Of the 31 patients, 18 (58%) were female, and the mean age (±SD) was 50.0 (±3.3) years. The median time interquartile range (IQR) from symptom onset to admission was 6 days (3–8). The median time (IQR) from admission to discharge was 24 (18–33) days. Old age, initial low WBC count, low platelet count, high CRP level, and fever were identified as factors associated with severity. Detailed baseline characteristics, laboratory tests, and outcomes are shown in Tables 1 and 2.

Table 1

Baseline characteristics and outcomes in 31 patients with COVID-19

VariableTotal (n = 31), %Asymptomatic and mild (n = 6)Moderate (n = 17), %Severe and critical (n = 8)P-value (asymptomatic and mild vs. moderate)P-value (asymptomatic and mild vs severe and critical)P-value (moderate vs. severe and critical)
Age, mean (±SD) (years)50.0 (±3.3)32.8 (±9.5)45.8 (±17.0)71.9 (±12.9)0.105< 0.001< 0.001
Female gender18/31 (58)3/611/17 (65)4/80.5210.2360.665
Underlying condition or illness
 Diabetes mellitus4/31 (13)0/61/17 (6)3/81.0000.5420.081
 Hypertension9/31 (29)1/62/17 (12)6/81.0000.1030.004
 Chronic lung disease2/31 (6)0/60/172/81.0000.4730.093
 Chronic liver disease1/31 (3)0/61/17 (6)0/81.0001.0001.000
 Obesity (body mass index > 25)1/31 (3)0/60/171/81.0001.0000.320
 Smoking2/31 (6)2/60/170/80.0590.1651.000
Symptoms and signs at admission
 Fever17/31 (55)0/69/17 (53)8/80.048< 0.0010.026
 Chill2/19 (11)0/3*2/13 (15)0/31.0001.0001.000
 Cough20/31 (65)2/610/17 (59)8/80.3710.0070.057
 Sputum11/31 (35)1/65/17 (29)5/81.0000.1381.000
 Sore throat7/31 (23)0/64/17 (24)3/80.5390.2090.194
 Dyspnea2/31 (6)0/60/172/81.0000.4730.093
 Rhinorrhea2/31 (6)1/61/17 (6)0/80.4630.4291.000
 Chest pain2/31 (6)2/60/170/80.0590.1651.000
 Headache5/31 (16)0/63/17 (18)2/80.5390.4731.000
 Myalgia7/31 (23)0/63/17 (18)4/80.5390.8490.156
 Nasal congestion2/31 (6)1/61/17 (6)0/80.4630.4291.000
 Hyposmia6/31 (19)1/65/17 (29)0/81.0000.4290.140
 Hypogeusia5/31 (16)1/64/17 (24)0/81.0000.4290.239
 Pneumonia23/31 (74)0/615/17 (88)8/8< 0.001< 0.0011.000
 Time from symptom onset to admission6 (3–8)2 (0–4)6 (3–8)8 (8–9)0.005< 0.0010.024
 Hospital stay (interquartile range) (days)24 (18–33)19 (10–28)27 (21–33)24 (19–29)0.1820.3610.739
Treatment
 Lopinavir/ritonavir15/31 (48)0/68/17 (47)7/80.0580.0050.088
 Hydroxychloroquine14/31 (45)4/65/17 (29)5/80.1621.0000.194
 Steroid1/31 (3)0/60/171/81.0001.0000.320
 Antibiotics6/31 (19)0/60/176/81.0000.001< 0.001
 Plasmapheresis1/31 (3)0/60/171/81.0001.0000.320
 Pneumonia during hospitalization25/31 (81)0/617/17 (100)8/8< 0.001< 0.0011.000
 O2 supply8/31 (26)0/60/178/81.000< 0.001< 0.001
 Respiratory failure2/31 (6)0/60/172/81.0000.4730.093
 Septic shock2/31 (6)0/60/172/81.0000.4730.093
 Multiple organ failure1/31 (3)0/60/171/81.0001.0000.320
 Intensive care unit care3/31 (10)0/60/173/81.0000.2090.024
 Mechanical ventilation2/31 (6)0/60/172/81.0000.4730.093
 Extracorporeal membrane oxygenation1/31 (3)0/60/171/81.0001.0000.320

Values in parentheses indicate percentage of patients positive for variables in each group.

Not checked in three asymptomatic and mild.

Not checked in four moderate.

Not checked in five severe and critical.

Table 2

Laboratory tests, cytokine/chemokine, viral load, antibody responses, and clinical outcomes in patients with COVID-19

VariableAsymptomatic and mild (n = 6)Moderate (n = 17)Severe and critical (n = 8)P-value (asymptomatic and mild vs. moderate)P-value (asymptomatic and mild vs. severe and critical)P-value (moderate vs. severe and critical)
Initial laboratory finding, median (IQR)
 White blood cell/μL6,390 (4,813–7,960)4,080 (3,250–5,025)3,800 (2,838–4,358)0.0060.0430.669
 Hemoglobin, g/dL14.8 (14.0–15.2)13.7 (12.8–14.9)13.2 (12.8–14.6)0.1300.1080.875
 Platelets, 103/μL251.0 (216.5–287.3)162.0 (150.5–247.5)151.0 (118.0–201.8)0.0870.0080.110
 Blood urea nitrogen, mg/dL12.0 (8.9–16.0)14.4 (9.7–17.0)13.5 (12.3–21.3)0.5270.3410.596
 Creatinine, mg/dL0.78 (0.71–0.88)0.69 (0.56–0.90)0.79 (0.76–0.88)0.3630.7300.281
 Aspartate aminotransferase, IU/L30.5 (20.0–36.3)26.0 (22.0–34.0)38.0 (29.5–77.8)0.6970.0750.011
 Alanine aminotransferase, IU/L19.0 (11.8–30.3)19.0 (11.0–31.0)23.5 (17.3–32.3)0.9600.3960.366
 C-reactive protein, mg/dL0.47 (0.13–1.23)0.30 (0.30–1.15)3.12 (1.25–6.63)0.6170.013< 0.001
During the course of diseases, median (IQR)
On 5–10 days from symptom onset (1 week)
 Ct value (RdRp)35.2 (25.1–40.0)27.9 (23.8–31.8)26.7 (22.0–31.3)0.0440.0340.588
 IgG, OD450 ratio0.41 (0.24–2.82)0.42 (0.25–1.70)0.30 (0.19–0.60)0.8610.1130.143
 IgM, OD450 ratio0.43 (0.23–0.69)0.41 (0.18–0.70)0.14 (0.01–0.21)0.7340.2190.254
 IFN-α, pg/mL0.0 (0.0–0.0)0.0 (0.0–0.0)4.1 (3.5–5.1)0.8220.001< 0.001
 IP-10, pg/mL349.0 (146.2–482.8)691.7 (333.7–1,162.0)4,089.0 (2,291.0–6,433.0)0.200< 0.001< 0.001
 MIG, pg/mL270.5 (122.7–361.5)382.2 (282.9–584.1)1,448.0 (663.3–2,172.0)0.6870.0250.038
 IL-6, pg/mL5.1 (2.7–10.1)11.6 (2.6–28.6)68.3 (39.1–414.7)0.7730.5540.064
 IL-8, pg/mL14.8 (8.3–20.7)20.0 (11.9–29.8)52.7 (32.2–292.3)0.8980.2590.808
 MCP-1, pg/mL39.7 (14.9–237.3)82.6 (48.6–173.7)268.5 (100.2–616.7)0.1560.1900.047
 IFN-γ, pg/mL4.2 (3.0–5.2)4.1 (0.7–6.8)7.2 (6.3–16.1)0.9870.0950.006
 VEGF, pg/mL5.3 (3.1–43.8)19.0 (7.6–28.0)46.2 (21.1–81.6)0.9420.3840.041
 IL-10, pg/mL3.6 (1.0–5.1)3.3 (1.0–7.6)10.0 (5.4–36.1)0.9150.1670.007
On 11–16 days from symptom onset (2 weeks)
 Ct value (RdRp)39.2 (31.2–40.0)33.9 (29.9–40.0)29.8 (27.2–32.8)0.1880.0090.090
 IgG, OD450 ratio3.12 (0.88–8.12)5.12 (1.02–9.58)1.92 (0.41–22.07)0.6120.8620.507
 IgM, OD450 ratio0.61 (0.53–1.10)0.84 (0.57–1.44)1.23 (0.43–2.02)0.3490.7700.943
 IFN-α, pg/mL0.0 (0.0–0.0)0.0 (0.0–0.0)0.0 (0.0–0.0)0.8220.8020.842
 IP-10, pg/mL223.0 (137.9–836.9)310.9 (176.2–545.4)2,165.0 (595.9–4,011.0)0.2080.296< 0.001
 MIG, pg/mL213.7 (177.9–382.8)382.2 (244.0–616.0)1,270.0 (369.7–3,496.0)0.6870.3870.017
 IL-6, pg/mL6.3 (1.1–24.4)7.5 (2.2–17.8)94.4 (31.9–565.6)0.9030.6800.045
 IL-8, pg/mL8.6 (11.6–32.9)18.8 (11.6–32.9)83.0 (27.8–135.0)0.4940.3300.005
 MCP-1, pg/mL39.1 (21.9–209.3)47.9 (31.9–117.8)61.8 (146.5–433.0)0.9100.6660.073
 IFN-γ, pg/mL0.9 (0.0–4.1)4.6 (2.2–8.3)5.9 (3.2–11.7)0.7180.2290.904
 VEGF, pg/mL5.3 (3.1–43.8)19.0 (7.6–28.0)46.2 (21.1–81.6)0.9420.3840.041
 IL-10, pg/mL3.6 (1.0–5.1)3.3 (1.0–7.6)10.0 (5.4–36.1)0.9150.1670.007
On 17–24 days from symptom onset (3 weeks)
 Ct value (RdRp)40.0 (39.8–40.0)38.0 (33.0–40.0)40.0 (32.5–40.0)0.0900.1511.000
 IgG, OD450 ratio10.02 (1.41–18.62)15.07 (7.87–63.46)48.27 (21.76–89.48)0.6670.1710.241
 IgM, OD450 ratio0.93 (0.54–1.31)1.40 (1.00–1.80)1.92 (1.01–2.21)0.3330.2290.588
 IFN-α, pg/mL0.0 (0.0–0.0)0.0 (0.0–0.0)0.0 (0.0–0.0)N/A0.8420.704
 IP-10, pg/mL148.8 (139.0–158.6)267.0 (164.8–375.5)1,104.0 (335.9–2,445.0)0.8240.3710.049
 MIG, pg/mL217.8 (78.3–357.3)534.8 (295.7–836.5)705.6 (380.2–1729.0)0.6870.4530.253
 IL-6, pg/mL4.7 (0.0–9.4)1.6 (0.0–78.3)40.8 (7.5–47.6)0.9030.6800.712
 IL-8, pg/mL40.9 (11.4–70.4)18.2 (7.5–57.9)43.3 (28.7–58.3)0.8980.7060.458
 MCP-1, pg/mL195.0 (18.7–371.2)34.2 (21.1–49.0)99.3 (41.9–142.4)0.2270.5580.047
 IFN-γ, pg/mL1.7 (0.0–3.5)1.6 (0.0–17.6)4.5 (1.6–9.6)0.9560.4070.904
 VEGF, pg/mL0.0 (0.0–0.0)19.7 (10.9–42.6)42.4 (16.9–136.3)0.3700.3840.169
 IL-10, pg/mL0.0 (0.0–0.0)1.5 (0.1–49.0)4.1 (1.8–7.4)0.9150.6200.380
After 25 days from symptom onset (4 weeks∼)
 Ct value (RdRp)40.0 (40.0–40.0)40.0 (40.0–40.0)40.0 (40.0–40.0)1.0001.0001.000
 IgG, OD450 ratio7.83 (0.37–15.18)11.28 (3.86–18.7)42.77 (32.82–110.80)0.6670.0220.022
 IgM, OD450 ratio0.32 (0.31–0.32)0.91 (0.85–0.97)1.79 (1.10–2.77)0.3330.0220.088
 IFN-α, pg/mL0.0 (0.0–0.0)0.0 (0.0–0.0)0.0 (0.0–0.0)N/A0.8420.842
 IP-10, pg/mL162.8 (131.1–194.4)224.3 (208.1–240.5)364.6 (188.7–718.9)0.5360.4760.517
 MIG, pg/mL109.6 (69.4–149.9)229.6 (204.4–394.8)1,211.0 (448.0–3,224.0)0.6870.4530.415
 IL-6, pg/mL1.2 (1.0–1.4)3.4 (0.0–6.7)10.4 (8.2–71.0)0.9030.6800.712
 IL-8, pg/mL15.3 (4.9–25.8)5.9 (4.1–7.7)44.4 (24.3–90.9)0.8980.4300.415
 MCP-1, pg/mL30.9 (21.8–39.9)51.4 (48.6–54.1)39.1 (28.6–108.5)0.4130.5580.648
 IFN-γ, pg/mL3.6 (0.0–7.2)1.9 (0.0–3.8)3.4 (0.0–6.4)0.9770.9710.904
 VEGF, pg/mL9.9 (9.5–10.3)2.2 (0.0–4.4)17.2 (34.5–54.4)0.3260.4780.355
 IL-10, pg/mL1.3 (0.8–1.7)1.9 (0.0–3.7)3.5 (1.2–6.0)0.9550.6200.570

Ct = threshold cycle; IL = interleukin; IFN = interferon; MCP = monocyte chemotactic protein; MIG = monokine induced by IFN-γ; N/A = not available; OD = optical density.

Viral load kinetics.

The detailed kinetics of viral loads in NP swab specimens are shown in Figure 1A. The viral load within 16 days from symptom onset was lowest in asymptomatic and mild group compared with those of moderate group and severe and critical group (Figure 1A and Table 2, P = 0.044 and 0.034, respectively). The viral load at 11–16 days from symptom onset was significantly lower in asymptomatic and mild group than that in severe and critical group (Figure 1A and Table 2, P = 0.009). The viral load gradually decreased over time in all patients.

Figure 1.
Figure 1.

Viral load and antibody kinetics in COVID-19 patients during the course of disease. The kinetics of viral load of the upper respiratory tract from symptom onset (A) and the viral load at the first day of hospitalization (B). The kinetics of plasma IgG (C) and IgM (D) titer against SARS-CoV-2 S1 protein. If OD450 of 1/100 or 1/1,000 diluted sample exceeds 2.5, the endpoint titer (OD450 ratio) of IgG and IgM was determined by multiplication of dilution factor and OD450. Black significance bars compare two groups; asymptomatic and mild vs moderate, asymptomatic and mild vs severe and critical, or moderate vs severe and critical. Red bars indicate statistical differences among three groups. Blue dot = moderate; green dot = asymptomatic and mild; red dot = severe and critical. *P < 0.05, **P < 0.01, ***P < 0.001.

Citation: The American Journal of Tropical Medicine and Hygiene 103, 6; 10.4269/ajtmh.20-1110

The viral load on the day of admission was measured in 26 (84%) patients, and there was no significant difference in the viral load according to disease severity (Figure 1B). The initial viral load was compared at 5–10 days from symptom onset because unlike the other groups, patients in the severe and critical group were hospitalized at approximately a week later from the day of symptom onset compared with other groups. The mean (±SD) initial viral load at 5–10 days from symptom onset in asymptomatic and mild group, moderate group, and severe and critical group was 32.65 (±7.62), 27.68 (±6.98), and 26.52 (±4.82) cycles, respectively (P for trend = 0.038). The median time (IQR) to negative conversion of the RT-PCR result for SARS-CoV-2 from the day of symptom onset was 18 (14–24) days. The duration of positive RT-PCR results was significantly shorter in the asymptomatic and mild group than in the other groups (P = 0.021; Supplemental Figure 1A).

Antibody analysis.

The plasma concentrations of SARS-CoV-2–specific IgG and IgM were measured, and the detailed kinetics of antibody titers are shown in Figure 1C and D. The median time (IQR) to seroconversion of IgG from symptom onset in the asymptomatic and mild group, moderate group, and the severe and critical group was 3 days (1.5–12.0), 11 days (7.0–13.0), and 14 days (10.0–15.8), respectively (P = 0.033, Supplemental Figure 1B). The plasma IgG was gradually increased and maintained during hospitalization in all groups. By contrast, the plasma IgM in the asymptomatic and mild group peaked at around 3 weeks after symptom onset, and then almost disappears and not in other groups (P = 0.004). Although the severe and critical group showed a relatively delayed response in terms of IgG and IgM, the response size after 25 days since symptom onset was significantly higher than those in other groups (P < 0.001 and P = 0.004, respectively).

Cytokine analysis.

A total of 131 plasma specimens were available for multiplex cytokine bead array analysis. Among the 21 cytokines/chemokines measured, the plasma concentrations of IFN-α, IP-10, MIG, IL-6, IL-8, MCP-1, IFN-γ, VEGF, and IL-10 were found to be significantly higher in the severe and critical group than those in other groups. The detailed kinetic profiles of cytokines/chemokines in response to COVID-19 during hospitalization are shown in Figure 2 and Supplemental Figure 2. In particular, the plasma concentrations of IFN-α, IFN-γ, IP-10, MIG, and IL-6 were elevated in the severe and critical group at 5–10 days from symptom onset. Although the plasma concentrations of VEGF and IP-10 gradually decreased with time, their levels were significantly higher in the severe and critical group throughout hospitalization (Figure 2). The concentrations of other cytokines/chemokines were not significantly different according to disease severity (Supplemental Figure 2). Among 21 cytokines/chemokines, only MCP-1 had correlation with viral load (P = 0.034, Supplemental Figure 3). In addition, IFN-α and IP-10 had a trend to correlate with viral load (P for trend = 078 and 0.061, respectively).

Figure 2.
Figure 2.

Plasma cytokines and chemokine concentrations in COVID-19 patients during the course of disease, according to the severity of illness. Black significance bars compare two groups; asymptomatic and mild vs. moderate, asymptomatic and mild vs. severe and critical, or moderate vs. severe and critical. Red bars indicate statistical differences among three groups. Blue dot = moderate; green dot = asymptomatic and mild; red dot = severe and critical. *P < 0.05, **P < 0.01, ***P < 0.001, ****P < 0.0001. IFN = interferon; IL = interleukin; IP = IFN-γ-induced; MCP = monocyte chemoattractant protein; MIG = monokine induced by IFN-γ; VEGF = vascular endothelial growth factor.

Citation: The American Journal of Tropical Medicine and Hygiene 103, 6; 10.4269/ajtmh.20-1110

DISCUSSION

In our present study, we explored the kinetics of cytokine/chemokine, viral load, and antibodies in COVID-19 patients according to the disease severity. We found that viral loads in the upper respiratory tract were significantly higher in patients with severe disease than in those with mild disease between 1 week and 2 weeks from symptom onset. Moreover, compared with patients with mild disease, those with severe or critical disease had higher plasma concentrations of IFN-α, IP-10, MIG, IL-6, IL-8, MCP-1, IFN-γ, VEGF, and IL-10 between 1 week and 2 weeks from the symptom onset followed by higher antibody response after 3 weeks from symptom onset.

The pattern of viral load kinetics in COVID-19 is different from that of SARS, despite the high degree of similarity between the two viruses.12 Whereas the peak viral load of SARS-CoV-2 appears before symptom onset or immediately after, the highest viral load of SARS-CoV is detected after 10 days from symptom onset.1316 In this study, we compared the kinetics of viral load from symptom onset according to disease severity, and found that the viral load was higher in those with more severe disease. This finding is consistent with a previous study in which respiratory viral loads were higher in patients with severe COVID-19 than those with mild COVID-19.14

In our study, humoral immune responses to SARS-CoV-2 developed in all patients within 2 and 3 weeks after symptom onset. The median time to seroconversion tended to be longer in the severe and critical group (approximately 2 weeks from symptom onset) than in those with milder disease. Also, the levels of IgG and IgM were significantly higher in severe COVID-19 patients, similar to the results of previous studies.17,18 Collectively, our results on viral load and antibody response show that the high amount of SARS-CoV-2 RNA in patients with severe disease may contribute to the induction of larger antibody response.

It is well known that excessive release of pro-inflammatory cytokines and chemokines contributes to clinical outcomes in various infections. Among the cytokine and chemokines tested in our study, the levels of IFN-α, IP-10, MIG, IL-6, IL-8, MCP-1, IFN-γ, VEGF, and IL-10 were notable in COVID-19 patients throughout the clinical course, which is consistent with the findings of previous studies.19,20 One study reported that the use of glucocorticoid after 7 days from symptom onset has beneficial effect on 1-month mortality, suggesting that immunopathological factors may dominate during the stage of the disease after the first week from symptom onset.21 Therefore, our findings that the plasma concentrations of IFN-α, IFN-γ, IP-10, MIG, and IL-6 were elevated in the severe and critical group at 5–10 days from symptom onset support that the higher plasma concentrations of pro-inflammatory cytokines after approximately 1 week from symptom onset may have a role in the enhancement of severity.

It is worthwhile to note that in our patients, the plasma concentration of IFN-α had increased around 1 week after symptom onset and then quickly dissipated. Reports on the vigor of type I IFN response in severe COVID-19 patients have shown conflicting results, with some showing impaired response8 and others robust response.7,22 However, previous studies from a limited number of COVID-19 patients could not fully reflect the cytokine responses during the varying clinical course of COVID-19. In this aspect, our current findings suggest that early increases in type I IFN response might be involved in the pathophysiology of severe COVID-19 by eliciting subsequent excessive responses of multiple cytokines and chemokines. Intriguingly, a recent longitudinal analysis showed that plasma IFN-α was sustained at high levels in patients with severe COVID-19, whereas IFN-α levels declined in those with moderate COVID-19 during their clinical course.23 Therefore, further studies are needed to understand the exact role of type I IFN in the pathogenesis of COVID-19.

There are several limitations to our current study. First, as a relatively small number of patients were enrolled, we could not properly investigate the factors associated with fatal outcome. Second, we did not examine SARS-CoV-2–specific T cells. It might be helpful to measure the T-cell response in COVID-19 to investigate the role of immunity in its pathogenesis and vaccine development. Third, because of mild symptoms, the date of SARS-CoV-2 infection and the date of symptom onset that patients recognized can be very different in the asymptomatic and mild group. The median time to seroconversion was too earlier in the asymptomatic and mild group; it is possible that the date of symptom onset in this group may be the middle or late stage of the disease course of COVID-19.

In conclusion, our data on viral load kinetics, antibody response, and cytokines showed that higher viral load, stronger antibody response, and excessive inflammation at 1–2 weeks from symptom onset are associated with the severity of COVID-19.

Supplemental figures

ACKNOWLEDGMENT

Publication charges for this article were waived due to the ongoing pandemic of COVID-19.

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Author Notes

Address correspondence to Jin-Won Chung, Division of Infectious Diseases, Department of Internal Medicine, Chung-Ang University Hospital, 102, Heuseok-ro, Donjak-gu, Seoul, 06973, Republic of Korea. E-mail: drjwchung@cau.ac.kr, Eui-Cheol Shin, Laboratory of Immunology and Infectious Diseases, Graduate School of Medical Science and Engineering, KAIST, 291, Daehak-ro, Yuseong-gu, Bldg E18-3, Daejeon, 34141, Republic of Korea. E-mail: ecshin@kaist.ac.kr, or Sung-Han Kim, Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea. E-mail: kimsunghanmd@hotmail.com.

Financial support: This study was supported by a grant from the Korea Health Technology R&D Project through the Korea Health Industry Development Institute (KHIDI), funded by the Ministry of Health and Welfare, Republic of Korea (Grant no. HW20C2062).

Authors’ addresses: Ji-Soo Kwon and Eui-Cheol Shin, Graduate School of Medical Science and Engineering, Korea Advanced Institute of Science and Technology, Daejeon, Republic of Korea, E-mails: kwonjs92@kaist.ac.kr and euicheols@kaist.ac.kr. Ji Yeun Kim, Seongman Bae, Hye Hee Cha, Jiwon Jung, Min-Jae Kim, and Sung-Han Kim, Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea, E-mails: aeki22@snu.ac.kr, songman.b@gmail.com, heyhe0102@naver.com, trueblue27@naver.com, nahani99@gmail.com, and kimsunghanmd@hotmail.com. Min-Chul Kim, Seong-Ho Choi, and Jin-Won Chung, Division of Infectious Diseases, Department of Internal Medicine, Chung-Ang University Hospital, Chung-Ang University College of Medicine, Seoul, Republic of Korea, E-mails: pour-soi@hanmail.net, tobeserve@gmail.com, and drjwchung@cau.ac.kr. Se Yoon Park, Department of Infectious Diseases, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, Seoul, Republic of Korea, E-mail: livinwill2@gmail.com. Baek-Nam Kim and Myung Jin Lee, Department of Infectious Diseases, Inje University Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Republic of Korea, E-mails: kimbn@paik.ac.kr and mjinnie@naver.com.

These authors contributed equally to this work.

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