IgM anti-ACE2 autoantibodies in severe COVID-19 activate complement and perturb vascular endothelial function

Background Some clinical features of severe COVID-19 represent blood vessel damage induced by activation of host immune responses initiated by the coronavirus SARS-CoV-2. We hypothesized autoantibodies against angiotensin-converting enzyme 2 (ACE2), the SARS-CoV-2 receptor expressed on vascular endothelium, are generated during COVID-19 and are of mechanistic importance. Methods In an opportunity sample of 118 COVID-19 inpatients, autoantibodies recognizing ACE2 were detected by ELISA. Binding properties of anti-ACE2 IgM were analyzed via biolayer interferometry. Effects of anti-ACE2 IgM on complement activation and endothelial function were demonstrated in a tissue-engineered pulmonary microvessel model. Results Anti-ACE2 IgM (not IgG) autoantibodies were associated with severe COVID-19 and found in 18/66 (27.2%) patients with severe disease compared with 2/52 (3.8%) of patients with moderate disease (OR 9.38, 95% CI 2.38–42.0; P = 0.0009). Anti-ACE2 IgM autoantibodies were rare (2/50) in non-COVID-19 ventilated patients with acute respiratory distress syndrome. Unexpectedly, ACE2-reactive IgM autoantibodies in COVID-19 did not undergo class-switching to IgG and had apparent KD values of 5.6–21.7 nM, indicating they are T cell independent. Anti-ACE2 IgMs activated complement and initiated complement-binding and functional changes in endothelial cells in microvessels, suggesting they contribute to the angiocentric pathology of COVID-19. Conclusion We identify anti-ACE2 IgM as a mechanism-based biomarker strongly associated with severe clinical outcomes in SARS-CoV-2 infection, which has therapeutic implications. FUNDING Bill & Melinda Gates Foundation, Gates Philanthropy Partners, Donald B. and Dorothy L. Stabler Foundation, and Jerome L. Greene Foundation; NIH R01 AR073208, R01 AR069569, Institutional Research and Academic Career Development Award (5K12GM123914-03), National Heart, Lung, and Blood Institute R21HL145216, and Division of Intramural Research, National Institute of Allergy and Infectious Diseases; National Science Foundation Graduate Research Fellowship (DGE1746891)

[1]  C. Lin,et al.  Presence and Implications of Anti‐Angiotensin Converting Enzyme‐2 Immunoglobulin M Antibodies in Anti‐Melanoma‐Differentiation‐Associated 5 Dermatomyositis , 2022, ACR open rheumatology.

[2]  J. Forrest,et al.  Development of ACE2 autoantibodies after SARS-CoV-2 infection , 2021, PloS one.

[3]  A. Rodriguez-Perez,et al.  Autoantibodies against ACE2 and angiotensin type-1 receptors increase severity of COVID-19 , 2021, Journal of Autoimmunity.

[4]  V. Frémeaux-Bacchi,et al.  Thrombotic microangiopathy in aHUS and beyond: clinical clues from complement genetics , 2021, Nature Reviews Nephrology.

[5]  R. Sebra,et al.  Pathophysiology of SARS-CoV-2: the Mount Sinai COVID-19 autopsy experience , 2021, Modern Pathology.

[6]  Gregory M. Goldgof,et al.  Magnitude and Kinetics of Anti-Severe Acute Respiratory Syndrome Coronavirus 2 Antibody Responses and Their Relationship to Disease Severity. , 2021, Clinical infectious diseases : an official publication of the Infectious Diseases Society of America.

[7]  A. Sette,et al.  Adaptive immunity to SARS-CoV-2 and COVID-19 , 2021, Cell.

[8]  W. Lim,et al.  Dexamethasone in Hospitalized Patients with Covid-19 , 2021 .

[9]  Elizabeth B White,et al.  Diverse Functional Autoantibodies in Patients with COVID-19 , 2020, Nature.

[10]  T. A. Feeser,et al.  COVID Purpura (Toes) Case Series: A Chilblains-Like Vasculopathy. , 2020, The American Journal of dermatopathology.

[11]  J. Knight,et al.  Prothrombotic autoantibodies in serum from patients hospitalized with COVID-19 , 2020, Science Translational Medicine.

[12]  Steven M. Holland,et al.  Autoantibodies against type I IFNs in patients with life-threatening COVID-19 , 2020, Science.

[13]  S. Zeger,et al.  Patient Trajectories Among Persons Hospitalized for COVID-19 , 2020, Annals of Internal Medicine.

[14]  Karl Erik Müller,et al.  Systemic complement activation is associated with respiratory failure in COVID-19 hospitalized patients , 2020, Proceedings of the National Academy of Sciences.

[15]  Eric Song,et al.  Longitudinal analyses reveal immunological misfiring in severe COVID-19 , 2020, Nature.

[16]  Aaron M. Rosenfeld,et al.  Comprehensive mapping of immune perturbations associated with severe COVID-19 , 2020, Science Immunology.

[17]  M. Plana,et al.  Recommendations for the treatment of anti-melanoma differentiation-associated gene 5-positive dermatomyositis-associated rapidly progressive interstitial lung disease. , 2020, Seminars in arthritis and rheumatism.

[18]  Axel Haverich,et al.  Pulmonary Vascular Endothelialitis, Thrombosis, and Angiogenesis in Covid-19. , 2020, The New England journal of medicine.

[19]  Eun Ji Kim,et al.  Presenting Characteristics, Comorbidities, and Outcomes Among 5700 Patients Hospitalized With COVID-19 in the New York City Area. , 2020, JAMA.

[20]  David Berlin,et al.  Complement associated microvascular injury and thrombosis in the pathogenesis of severe COVID-19 infection: A report of five cases , 2020, Translational Research.

[21]  S. Berentsen.  New Insights in the Pathogenesis and Therapy of Cold Agglutinin-Mediated Autoimmune Hemolytic Anemia , 2020, Frontiers in Immunology.

[22]  Linqi Zhang,et al.  Structure of the SARS-CoV-2 spike receptor-binding domain bound to the ACE2 receptor , 2020, Nature.

[23]  K. Shi,et al.  Structural basis of receptor recognition by SARS-CoV-2 , 2020, Nature.

[24]  J. Pober,et al.  Complement membrane attack complex: new roles, mechanisms of action, and therapeutic targets. , 2020, The American journal of pathology.

[25]  Kai Zhao,et al.  A pneumonia outbreak associated with a new coronavirus of probable bat origin , 2020, Nature.

[26]  T. Hla,et al.  Sphingosine 1-phosphate: Lipid signaling in pathology and therapy , 2019, Science.

[27]  Max I Bogorad,et al.  Human iPSC-derived blood-brain barrier microvessels: validation of barrier function and endothelial cell behavior. , 2019, Biomaterials.

[28]  C. Oddis,et al.  Anti-MDA5 Antibody Spectrum in Western World , 2018, Current Rheumatology Reports.

[29]  R. Watanabe,et al.  Intravenous immunoglobulin contributes to the control of antimelanoma differentiation‐associated protein 5 antibody‐associated dermatomyositis with palmar violaceous macules/papules , 2017, The British journal of dermatology.

[30]  H. Eisen.  Affinity Enhancement of Antibodies: How Low-Affinity Antibodies Produced Early in Immune Responses Are Followed by High-Affinity Antibodies Later and in Memory B-Cell Responses , 2014, Cancer Immunology Research.

[31]  R. Stevens,et al.  Sphingosine-1-phosphate and its receptors: structure, signaling, and influence. , 2013, Annual review of biochemistry.

[32]  A. Orbai,et al.  A Novel Dermato-Pulmonary Syndrome Associated With MDA-5 Antibodies: Report of 2 Cases and Review of the Literature , 2012, Medicine.

[33]  L. Chung,et al.  The mucocutaneous and systemic phenotype of dermatomyositis patients with antibodies to MDA5 (CADM-140): a retrospective study. , 2011, Journal of the American Academy of Dermatology.

[34]  Y. Ishizaka,et al.  Autoantibodies to angiotensin-converting enzyme 2 in patients with connective tissue diseases , 2010, Arthritis research & therapy.

[35]  T. Fujita,et al.  RNA helicase encoded by melanoma differentiation-associated gene 5 is a major autoantigen in patients with clinically amyopathic dermatomyositis: Association with rapidly progressive interstitial lung disease. , 2009, Arthritis and rheumatism.

[36]  J. Ravetch,et al.  Anti-inflammatory actions of intravenous immunoglobulin. , 2008, Annual review of immunology.

[37]  S. Milstien,et al.  Sphingosine Kinase Type 2 Activation by ERK-mediated Phosphorylation* , 2007, Journal of Biological Chemistry.

[38]  Arthur S Slutsky,et al.  Angiotensin-converting enzyme 2 protects from severe acute lung failure , 2005, Nature.

[39]  G. Navis,et al.  Tissue distribution of ACE2 protein, the functional receptor for SARS coronavirus. A first step in understanding SARS pathogenesis , 2004, The Journal of pathology.

[40]  M. Walport,et al.  The classical pathway is the dominant complement pathway required for innate immunity to Streptococcus pneumoniae infection in mice , 2002, Proceedings of the National Academy of Sciences of the United States of America.

[41]  B. Everitt,et al.  Analysis of longitudinal data , 1998, British Journal of Psychiatry.

[42]  H. Rus,et al.  Activation of Ras and mitogen-activated protein kinase pathway by terminal complement complexes is G protein dependent. , 1997, Journal of immunology.

[43]  S. Kaveri,et al.  Mechanisms of action of intravenous immune globulin in immune‐mediated diseases , 1996, Clinical and experimental immunology.

[44]  M. Dalakas,et al.  High-dose intravenous immunoglobulin exerts its beneficial effect in patients with dermatomyositis by blocking endomysial deposition of activated complement fragments. , 1994, The Journal of clinical investigation.

[45]  V. Huxley,et al.  Quantitative fluorescence microscopy on single capillaries: alpha-lactalbumin transport. , 1987, The American journal of physiology.

[46]  R. Geha,et al.  Immunoglobulin M antibodies present in the acute phase of Kawasaki syndrome lyse cultured vascular endothelial cells stimulated by gamma interferon. , 1986, The Journal of clinical investigation.

[47]  J. Ware,et al.  Random-effects models for longitudinal data. , 1982, Biometrics.

[48]  G. Klaus,et al.  Effects of cyclosporin A on the immune system of the mouse. I. Evidence for a direct selective effect of cyclosporin A on B cells responding to anti‐immunoglobulin antibodies , 1982, European journal of immunology.