Notch4 regulatory T cells and SARS‐CoV‐2 viremia shape COVID19 survival outcome

BackgroundImmune dysregulation and SARS-CoV-2 plasma viremia have been implicated in fatal COVID-19 disease. However, how these two factors interact to shape disease outcomes is unclear.MethodsWe carried out viral and immunological phenotyping on a prospective cohort of 280 patients with COVID-19 presenting to acute care hospitals in Boston, Massachusetts and Genoa, Italy between June 1, 2020 and February 8, 2022. Disease severity, mortality, plasma viremia, and immune dysregulation were assessed. A mouse model of lethal H1N1 influenza infection was used to analyze the therapeutic potential of Notch4 and pyroptosis inhibition in disease outcome.ResultsStratifying patients based on %Notch4+ Treg cells and/or the presence of plasma viremia identified four subgroups with different clinical trajectories and immune phenotypes. Patients with both high %Notch4+ Treg cells and viremia suffered the most disease severity and 90-day mortality compared to the other groups even after adjusting for baseline comorbidities. Increased Notch4 and plasma viremia impacted different arms of the immune response in SARS-CoV-2 infection. Increased Notch4 was associated with decreased Treg cell amphiregulin expression and suppressive function whereas plasma viremia was associated with increased monocyte cell pyroptosis. Combinatorial therapies using Notch4 blockade and pyroptosis inhibition induced stepwise protection against mortality in a mouse model of lethal H1N1 influenza infection.ConclusionsThe clinical trajectory and survival outcome in hospitalized patients with COVID-19 is predicated on two cardinal factors in disease pathogenesis: viremia and Notch4+ Treg cells. Intervention strategies aimed at resetting the immune dysregulation in COVID-19 by antagonizing Notch4 and pyroptosis may be effective in severe cases of viral lung infection.Notch4 expression on Treg cells and SARS-CoV-2 plasma viremia are associated with increased COVID-19 severity and mortality both independently and especially in combination. Stratification based on %Notch4 Treg cell and viremia identified patient subgroups with distinct clinical and immunological attributes. In a proxy influenza virus infection model, combinatorial targeting of Treg cell Notch4 and viremia-induced monocytic cell pyroptosis protected mice against mortality.imageAbbreviations: COVID-19, coronavirus disease 2019; Foxp3, forkhead box protein 3; H1N1, Influenza A virus subtype; LDC7559, gasdermin D inhibitor; Notch4, neurogenic locus notch homolog 4; SARS-CoV-2; severe acute respiratory syndrome coronavirus 2; Treg, regulatory T cell.