Skip to main content

Main menu

  • Home
  • Current issue
  • ERJ Early View
  • Past issues
  • ERS Guidelines
  • Authors/reviewers
    • Instructions for authors
    • Submit a manuscript
    • Open access
    • Peer reviewer login
  • Alerts
  • Subscriptions
  • ERS Publications
    • European Respiratory Journal
    • ERJ Open Research
    • European Respiratory Review
    • Breathe
    • ERS Books
    • ERS publications home

User menu

  • Log in
  • Subscribe
  • Contact Us
  • My Cart

Search

  • Advanced search
  • ERS Publications
    • European Respiratory Journal
    • ERJ Open Research
    • European Respiratory Review
    • Breathe
    • ERS Books
    • ERS publications home

Login

European Respiratory Society

Advanced Search

  • Home
  • Current issue
  • ERJ Early View
  • Past issues
  • ERS Guidelines
  • Authors/reviewers
    • Instructions for authors
    • Submit a manuscript
    • Open access
    • Peer reviewer login
  • Alerts
  • Subscriptions

Autoimmunity to Annexin A2 predicts mortality among hospitalised COVID-19 patients

Marisol Zuniga, Claudia Gomes, Steven E. Carsons, Michael T. Bender, Paolo Cotzia, Qing Robert Miao, David C. Lee, Ana Rodriguez
European Respiratory Journal 2021; DOI: 10.1183/13993003.00918-2021
Marisol Zuniga
1Department of Microbiology, NYU Grossman School of Medicine, New York, USA
8Authors contributed equally to this work
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Claudia Gomes
1Department of Microbiology, NYU Grossman School of Medicine, New York, USA
8Authors contributed equally to this work
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Steven E. Carsons
2Division of Rheumatology, Department of Medicine, NYU Long Island School of Medicine, New York, USA
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Michael T. Bender
3Division of Pulmonology and Critical Care Medicine, Department of Medicine, NYU Long Island School of Medicine, New York, USA
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Paolo Cotzia
4Department of Pathology, NYU Grossman School of Medicine, New York, USA
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Qing Robert Miao
5Department of Foundations of Medicine, NYU Long Island School of Medicine, New York, USA
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
David C. Lee
6Department of Emergency Medicine, NYU Grossman School of Medicine, New York, USA
7Department of Population Health, NYU Grossman School of Medicine, New York, USA
9Authors contributed equally to this work
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Ana Rodriguez
1Department of Microbiology, NYU Grossman School of Medicine, New York, USA
9Authors contributed equally to this work
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • Article
  • Figures & Data
  • Info & Metrics
  • PDF
Loading

Abstract

Levels of anti-Annexin A2 antibodies at admission strongly predicted mortality among hospitalised COVID-19 patients. Given its critical protective function in the lung, Annexin A2 antagonism may play an important role in the pathophysiology of COVID-19.

The pathophysiology of severe COVID-19 has largely been attributed to a hyper-inflammatory response without a clear indication of the underlying mechanism [1]. There is a characteristic delay in the onset of respiratory distress, approximately 6 to 12 days after the start of symptoms, which is somewhat atypical for other severe viral respiratory infections [2]. Several theories have been proposed for this delay such as an indolent infection or viral persistence. However, data from viral cultures of SARS-CoV-2 (not PCR) demonstrates a lack of positive cultures beyond day 9 of illness [3].

The timing of respiratory distress due to COVID-19 notably coincides with the onset of the humoral immune response, and there is evidence of autoantibodies among hospitalised COVID-19 patients including anti-interferon and antiphospholipid antibodies [4, 5]. The pathogenicity of these autoantibodies is unclear. However, a pivotal study demonstrated high levels of extrafollicular B cell activation among severe cases of COVID-19 [6]. This type of immune response is characteristic of several autoimmune diseases, which raises the question whether severe COVID-19 is the result of a catastrophic autoimmune response that occurs among a subset of patients infected by the SARS-CoV-2 virus [7].

This study investigated the possibility that COVID-19 patients have autoimmune antibodies to Annexin A2, a protective protein expressed in the lung and other organs. Since this phospholipid-binding protein is critical for fibrinolysis, lung elasticity, cell membrane repair, and integrity of the pulmonary vasculature, antagonism of Annexin A2 may explain many of the hallmark clinical features of severe COVID-19 cases [8].

To evaluate this possibility, we analysed patient plasma on hospital day 0 or 1 among 86 patients at NYU Langone Health who were hospitalised for COVID-19 and confirmed to be positive by PCR. Anti-Annexin A2 IgG antibodies were measured by ELISA. For comparison, we also studied IgG antibodies directed against Annexin A5, which is another target of prothrombotic antiphospholipid antibodies, but is not known to have a direct role in maintaining the integrity of the pulmonary vasculature [9]. Antibody levels were calculated as relative units (RU) using a plasma sample previously identified as a high responder for IgG autoantibodies. Patients were categorised as 1) non-critical if hospitalised, but not intubated, 2) critically ill if hospitalised and intubated, or 3) died from COVID-19 during their hospitalisation.

After a descriptive analysis of study population, we analyzsd the anti-Annexin A2 and A5 antibodies levels as stratified by disease severity using ANOVA. To perform our primary analysis, we tested the association between antibody levels and death using multivariable logistic regression, adjusting for age, sex, race, and history of hypertension, diabetes, and obesity (BMI>30 kg·m−2). A p-value of 0.025 was used to account for multiple comparisons. We used a margins analysis to graphically display mortality risk at a range of antibody levels. An analysis of outliers was performed to ensure that there were not extreme values for antibody levels that had an undue influence on the results. In addition, the robustness of the association between antibody levels and death was assessed with a sensitivity analysis that included the maximum laboratory values over the course of the hospitalisation for these COVID-19 patients. These commonly performed tests included white blood cell count (WBC), aspartate aminotransferase (AST), alanine aminotransferase (ALT), creatine kinase (CK), lactate dehydrogenase (LDH), C-reactive protein (CRP), ferritin, and D-dimer.

All statistical analyses were performed in Stata 16.2. Patients consented to use of their biospecimens for COVID-19 research through a central biorepository and protocol approved by the NYU IRB. A more detailed description of the methods can be accessed in a preprint of this study [10].

Of the 86 patients in our study, 28 were non-critical, 36 were critically ill, and 22 died. Those who died had higher rates of hypertension (p=0.04) and obesity (p=0.05) when compared to patients who survived. In analysing the WBC, AST, ALT, CK, LDH, CRP, ferritin, and D-dimer values among these hospitalised COVID-19 patients, the maximum values increased as expected by disease severity (p<0.01). We found higher average levels of anti-Annexin A2 IgG antibodies among the hospitalised COVID-19 patients who died (1.16 RU, 95% confidence interval (CI): 0.95–1.37) when compared with the non-critical (0.80 RU 95% CI: 0.66–0.94) and critically ill hospitalised COVID-19 patients (0.89 RU, 95% CI: 0.77–1.01). In comparison, there was no statistically significant difference in the average levels of anti-Annexin A5 IgG antibodies when stratified by disease severity (p=0.32).

In our primary analysis of mortality among the 86 hospitalised COVID-19 patients, we found that anti-Annexin A2 antibody levels strongly predicted death after adjustment for age, sex, race, and comorbidities with an odds ratio of 9.3 per RU (CI: 1.9–44.6, p=0.005). In comparison, anti-Annexin A5 antibody levels were not associated with a higher mortality rate (CI: 0.5–15.2, p=0.22). Using a margins analysis, we graphically depicted predicted mortality rates across a range of levels for anti-Annexin A2 antibodies (figure 1). In our sensitivity analysis, we added adjustments for the maximum WBC, AST, ALT, CK, LDH, CRP, ferritin, and D-dimer levels. This multivariable regression demonstrated that anti-Annexin A2 antibody levels strongly predicted mortality with an odds ratio of 12.9 per RU (CI: 1.5–108.7, p=0.019) even after adjustment for the maximum laboratory abnormalities during the hospitalisation of these COVID-19 patients.

FIGURE 1
  • Download figure
  • Open in new tab
  • Download powerpoint
FIGURE 1

Prediction of mortality based on anti-annexin A2 antibody levels. Margins analysis based on logistic regression results depicts predicted mortality across a range of anti-Annexin A2 antibody levels in relative units (RU). Error bars depict 95% confidence intervals.

Our study finds evidence of higher levels of IgG antibodies directed against Annexin A2 among COVID-19 patients who died. More importantly, anti-Annexin A2 antibody levels strongly predicted mortality after controlling for patient risk factors and for the maximum levels of key laboratory markers associated with severe COVID-19.

Autopsy evidence demonstrates that severe cases of COVID-19 have extensive thrombotic disease, diffuse alveolar damage, and endothelial disruption that leads to pulmonary edema and fibrin deposition [11]. These findings correlate with the clinical manifestations of severe COVID-19, which include diffuse clotting, adult respiratory distress syndrome (ARDS), non-cardiogenic pulmonary edema, and fibrinous pulmonary exudates generally without bacterial superinfection [1]. Though our study does not present any direct evidence of the pathogenicity of these autoantibodies, antagonism of Annexin A2 would explain many of the clinical findings that are characteristic of patients with severe COVID-19.

Annexin A2 is critical for fibrinolysis in the lung by acting as a co-receptor that activates endogenous tissue plasminogen activator (t-PA) to lyse clots and promote fibrin clearance [8]. More recently, Annexin A2 was found to maintain the endothelial cell junctions in the lung microvasculature, preventing pulmonary edema especially in response to hypoxia [12]. Finally, Annexin A2 promotes lung elasticity and is also involved cell membrane stabilisation and repair of pulmonary epithelial cells, thereby preventing apoptosis [13]. Its inhibition might also explain the diffuse alveolar damage, ARDS, and pulmonary fibrosis seen in severe cases of COVID-19.

Notably, prior studies of SARS-CoV-1 identified autoantibodies that were cytotoxic to lung epithelial and endothelial cells and also specifically targeted Annexin A2 among hospitalised SARS patients [14]. Loss of immune tolerance and a catastrophic autoimmune insult among a subset of patients could explain why certain patients develop severe symptoms of COVID-19 [15]. Other patients without this autoimmune response may have less severe symptoms consistent with other coronavirus infections which only cause asymptomatic or mild disease.

While these autoantibodies could be non-specific markers of lung injury, it is critical to explore the pathogenicity of these anti-Annexin A2 antibodies, as they could explain the underlying pathophysiology of severe COVID-19. Additional studies should assess the specificity of these autoantibodies to COVID-19 by investigating whether they also occur in other respiratory diseases such as influenza or other types of ARDS. Furthermore, we believe that the persistence of these anti-Annexin A2 antibodies should be studied, especially among Long COVID patients with persistent respiratory symptoms.

Acknowledgments

This research was supported by an internal grant from the NYU Langone COVID-19 Special Fund. We want to specifically thank the Center for Biospecimen Research and Development at the NYU School of Medicine, Brian Fallon for bioinformatics support, and all of the volunteers that helped to obtain and process the samples used in this study and other research related to COVID-19.

Footnotes

  • Support statement: NYU Langone COVID-19 Special Fund.

  • Author Contributions: A.R. and D.C.L. designed the study. M.Z. and C.G. performed the experiments. A.R. and P.C. collected the data and identified patient samples at NYU Langone Health. D.C.L. drafted the manuscript and performed the statistical analyses. All authors interpreted the data and provided critical input to the manuscript. None of the authors have any conflicts of interest to disclose.

  • Conflict of interest: Ms. Zuniga has nothing to disclose.

  • Conflict of interest: Dr. Gomez has nothing to disclose.

  • Conflict of interest: Dr. Carsons has nothing to disclose.

  • Conflict of interest: Dr. Bender has nothing to disclose.

  • Conflict of interest: Dr. Cotiza has nothing to disclose.

  • Conflict of interest: Dr. Miao has nothing to disclose.

  • Conflict of interest: Dr. Lee has nothing to disclose.

  • Conflict of interest: Dr. Rodriguez has nothing to disclose.

  • Received January 15, 2021.
  • Accepted June 24, 2021.
  • Copyright ©The authors 2021.
http://creativecommons.org/licenses/by-nc/4.0/

This version is distributed under the terms of the Creative Commons Attribution Non-Commercial Licence 4.0. For commercial reproduction rights and permissions contact permissions{at}ersnet.org

References

  1. ↵
    1. Wiersinga WJ,
    2. Rhodes A,
    3. Cheng AC, et al.
    Pathophysiology, transmission, diagnosis, and treatment of coronavirus disease 2019 (COVID-19): a review. Jama 2020: 324: 782–793. doi:10.1001/jama.2020.12839
    OpenUrlCrossRefPubMed
  2. ↵
    1. Grant RA,
    2. Morales-Nebreda L,
    3. Markov NS, et al.
    Circuits between infected macrophages and T cells in SARS-CoV-2 pneumonia. Nature 2021: 590: 635–641. doi:10.1038/s41586-020-03148-w
    OpenUrl
  3. ↵
    1. Cevik M,
    2. Tate M,
    3. Lloyd O, et al.
    SARS-CoV-2, SARS-CoV, and MERS-CoV viral load dynamics, duration of viral shedding, and infectiousness: a systematic review and meta-analysis. Lancet Microbe 2021: 2: e13–e22. doi:10.1016/S2666-5247(20)30172-5
    OpenUrlPubMed
  4. ↵
    1. Zuo Y,
    2. Estes SK,
    3. Ali RA, et al.
    Prothrombotic autoantibodies in serum from patients hospitalized with COVID-19. Sci Transl Med 2020: 12.
  5. ↵
    1. Bastard P,
    2. Rosen LB,
    3. Zhang Q, et al.
    Autoantibodies against type I IFNs in patients with life-threatening COVID-19. Science 2020: 370: eabd4585. doi:10.1126/science.abd4585
    OpenUrlAbstract/FREE Full Text
  6. ↵
    1. Woodruff MC,
    2. Ramonell RP,
    3. Nguyen DC, et al.
    Extrafollicular B cell responses correlate with neutralizing antibodies and morbidity in COVID-19. Nat Immunol 2020: 21: 1506–1516. doi:10.1038/s41590-020-00814-z
    OpenUrlPubMed
  7. ↵
    1. Zamvil SS,
    2. Hauser SL
    . Antigen presentation by B cells in multiple sclerosis. N Engl J Med 2021: 384: 378–381. doi:10.1056/NEJMcibr2032177
    OpenUrl
  8. ↵
    1. Hajjar KA
    . The biology of Annexin A2: from vascular fibrinolysis to innate immunity. Trans Am Clin Climatol Assoc 2015: 126: 144–155.
    OpenUrlPubMed
  9. ↵
    1. Rand JH,
    2. Wu XX,
    3. Quinn AS, et al.
    The Annexin A5-mediated pathogenic mechanism in the antiphospholipid syndrome: role in pregnancy losses and thrombosis. Lupus 2010: 19: 460–469. doi:10.1177/0961203310361485
    OpenUrlCrossRefPubMedWeb of Science
  10. ↵
    1. Zuniga M,
    2. Gomes C,
    3. Carsons SE, et al.
    Autoimmunity to the lung protective phospholipid-binding protein Annexin a2 predicts mortality among hospitalized COVID-19 patients. medRxiv 2021: 2020.2012.2028.20248807.
  11. ↵
    1. Rapkiewicz AV,
    2. Mai X,
    3. Carsons SE, et al.
    Megakaryocytes and platelet-fibrin thrombi characterize multi-organ thrombosis at autopsy in COVID-19: a case series. EClinicalMedicine 2020: 24: 100434. doi:10.1016/j.eclinm.2020.100434
    OpenUrl
  12. ↵
    1. Luo M,
    2. Flood EC,
    3. Almeida D, et al.
    Annexin A2 supports pulmonary microvascular integrity by linking vascular endothelial cadherin and protein tyrosine phosphatases. J Exp Med 2017: 214: 2535–2545. doi:10.1084/jem.20160652
    OpenUrlAbstract/FREE Full Text
  13. ↵
    1. Dassah M,
    2. Almeida D,
    3. Hahn R, et al.
    Annexin A2 mediates secretion of collagen VI, pulmonary elasticity and apoptosis of bronchial epithelial cells. J Cell Sci 2014: 127(Pt828–844.
    OpenUrlAbstract/FREE Full Text
  14. ↵
    1. Fang YT,
    2. Lin CF,
    3. Liao PC, et al.
    Annexin A2 on lung epithelial cell surface is recognized by severe acute respiratory syndrome-associated coronavirus spike domain 2 antibodies. Mol Immunol 2010: 47: 1000–1009. doi:10.1016/j.molimm.2009.11.019
    OpenUrlCrossRefPubMed
  15. ↵
    1. Theofilopoulos AN,
    2. Kono DH,
    3. Baccala R
    . The multiple pathways to autoimmunity. Nat Immunol 2017: 18: 716–724. doi:10.1038/ni.3731
    OpenUrlCrossRefPubMed
PreviousNext
Back to top
View this article with LENS
Vol 62 Issue 3 Table of Contents
European Respiratory Journal: 62 (3)
  • Table of Contents
  • Index by author
Email

Thank you for your interest in spreading the word on European Respiratory Society .

NOTE: We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail. We do not capture any email address.

Enter multiple addresses on separate lines or separate them with commas.
Autoimmunity to Annexin A2 predicts mortality among hospitalised COVID-19 patients
(Your Name) has sent you a message from European Respiratory Society
(Your Name) thought you would like to see the European Respiratory Society web site.
CAPTCHA
This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
Print
Citation Tools
Autoimmunity to Annexin A2 predicts mortality among hospitalised COVID-19 patients
Marisol Zuniga, Claudia Gomes, Steven E. Carsons, Michael T. Bender, Paolo Cotzia, Qing Robert Miao, David C. Lee, Ana Rodriguez
European Respiratory Journal Jan 2021, 2100918; DOI: 10.1183/13993003.00918-2021

Citation Manager Formats

  • BibTeX
  • Bookends
  • EasyBib
  • EndNote (tagged)
  • EndNote 8 (xml)
  • Medlars
  • Mendeley
  • Papers
  • RefWorks Tagged
  • Ref Manager
  • RIS
  • Zotero

Share
Autoimmunity to Annexin A2 predicts mortality among hospitalised COVID-19 patients
Marisol Zuniga, Claudia Gomes, Steven E. Carsons, Michael T. Bender, Paolo Cotzia, Qing Robert Miao, David C. Lee, Ana Rodriguez
European Respiratory Journal Jan 2021, 2100918; DOI: 10.1183/13993003.00918-2021
del.icio.us logo Digg logo Reddit logo Technorati logo Twitter logo CiteULike logo Connotea logo Facebook logo Google logo Mendeley logo
Full Text (PDF)

Jump To

  • Article
    • Abstract
    • Acknowledgments
    • Footnotes
    • References
  • Figures & Data
  • Info & Metrics
  • PDF
  • Tweet Widget
  • Facebook Like
  • Google Plus One

More in this TOC Section

  • Regular, low-dose, sustained-release morphine for persisting breathlessness in interstitial lung disease - a randomised, double-blind, placebo-controlled, crossover trial
  • Real-world cohort evaluation of the impact of the antifibrotics in patients with idiopathic pulmonary fibrosis
  • The skeletal muscle metaboreflex: a novel driver of ventilation, dyspnoea and pulmonary haemodynamics during exercise in pulmonary arterial hypertension
Show more Research letter

Related Articles

Navigate

  • Home
  • Current issue
  • Archive

About the ERJ

  • Journal information
  • Editorial board
  • Press
  • Permissions and reprints
  • Advertising

The European Respiratory Society

  • Society home
  • myERS
  • Privacy policy
  • Accessibility

ERS publications

  • European Respiratory Journal
  • ERJ Open Research
  • European Respiratory Review
  • Breathe
  • ERS books online
  • ERS Bookshop

Help

  • Feedback

For authors

  • Instructions for authors
  • Publication ethics and malpractice
  • Submit a manuscript

For readers

  • Alerts
  • Subjects
  • Podcasts
  • RSS

Subscriptions

  • Accessing the ERS publications

Contact us

European Respiratory Society
442 Glossop Road
Sheffield S10 2PX
United Kingdom
Tel: +44 114 2672860
Email: journals@ersnet.org

ISSN

Print ISSN:  0903-1936
Online ISSN: 1399-3003

Copyright © 2023 by the European Respiratory Society