Inflammatory response cells during Acute Respiratory Distres
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A previous report of lung biopsies from a patient with coronavirus disease 2019 (COVID-19) and acute respiratory distress syndrome (ARDS) identified mononuclear cell infiltration but not the type of mononuclear cells. The objective of this study was to describe the type of immune cells identified by imaging mass cytometry in lung tissue from 2 patients with COVID-19 and fatal ARDS.

The first patient was a 94-year-old woman who had close contact with a confirmed case of COVID-19 eleven days earlier. She presented with an 8-day history of lethargy and fever, and her history included 10 years of coronary heart disease. Physical examination found wheezing in both lungs and peripheral edema, and chest radiography identified right pulmonary infiltration and consolidation with right pleural effusion. She had a C-reactive protein level of 115.1 mg/L and leukocyte count of 10.2 × 109 cells/L with 9% lymphocytes. Tests confirmed that she had COVID-19. At the direction of her relatives, we provided noninvasive therapy that included supplemental oxygen and symptomatic treatment. She gradually developed dyspnea and hypoxemia and had a fatal cardiac arrest on day 10 of the illness.

The second patient was a 65-year-old man whose wife had COVID-19. He presented with a 4-day history of dry cough, anorexia, and fever. On admission, computed tomography of the chest showed bilateral pneumonia. He had a C-reactive protein level of 13.5 mg/L and a leukocyte count of 3.0 × 109 cells/L with 27.4% lymphocytes. Tests confirmed that he had COVID-19. We initiated supportive therapy and administered moxifloxacin to prevent secondary infection.

On day 15 of the illness, he required invasive ventilatory support. We changed his antibiotics to vancomycin and imipenem for suspected sepsis and administered intravenous methylprednisolone and immune globulin to attenuate systemic inflammation. On day 16, he had a C-reactive protein level of 244.4 mg/L, leukocyte count of 10.1 × 109 cells/L with 1.6% lymphocytes, and blood lactic acid level of 3.13 mmol/L. He developed septic shock and died on day 21 of the illness.

Two previous studies of lung tissue from patients with severe acute respiratory syndrome found mononuclear cell infiltration and hyaline membrane formation, whereas 1 previous study of a patient with COVID-19 and ARDS found interstitial infiltration by mononuclear cells. This study suggests that these infiltrated mononuclear cells are CD4 T cells, CD8 T cells, natural killer cells, and macrophages; that recruitment of aberrant CD45RA+ T cells is the immunologic feature of COVID-19; and that once bacterial pneumonia occurs, some phagocytes recruited by CD4 T cells begin to play a major role in lung injury. It can be concluded that additional studies are needed to understand the immune response in patients with COVID-19.

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