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Autoimmunity Reviews
journal homepage: www.elsevier.com/locate/autrev
Interleukin-17A (IL-17A), a key molecule of innate and adaptive immunity,
and its potential involvement in COVID-19-related thrombotic and vascular
mechanisms
Federica Rauccia,1, Adel Abo Mansourb,c,1, Gian Marco Casilloa, Anella Savianoa,
⁎
⁎
Francesco Casod, Raffaele Scarpad, Nicola Mascoloa, Asif Jilani Iqbalb,a, , Francesco Maionea,
a
ImmunoPharmaLab, Department of Pharmacy, School of Medicine and Surgery, University of Naples Federico II, Via Domenico Montesano 49, 80131 Naples, Italy
Institute of Cardiovascular Sciences (ICVS), College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TT, UK
Department of Clinical Laboratory Sciences, College of Applied Medical Sciences, King Khalid University, Guraiger, Abha 62529, Saudi Arabia
d
Rheumatology Research Unit, Department of Clinical Medicine and Surgery, University of Naples Federico II, via S. Pansini 5, 80131 Naples, Italy
b
c
A R T I C LE I N FO
Keywords:
COVID-19
IL-17A
Platelet
Thrombus
Vascular diseases
1. Introduction
Coronavirus disease 2019 (COVID-19) is an infectious disease
caused by severe acute respiratory syndrome (SARS) which first appeared in Wuhan, China, December 2019, and has since spread globally
[1]. To date, official figures released by World Health Organization
(WHO), indicate over 3 million cases worldwide with over 200,000
deaths. However, the number of newly diagnosed patients has started to
decline, suggesting that the rate of transmission is beginning to be
controlled by countries [2]. Although most patients have mild symptoms and good prognosis after infection, some develop severe symptoms and die due to multiple organ failure [3–5]. Based on the published literature and clinical observations, researchers and clinicians
around the world have postulated about the pathogenesis of this viral
infection in humans. We know that the virus has the capacity to cross
mucous membranes (especially nasal and larynx mucosa), and in severe
cases leads to multiple systemic manifestations and pneumonia requiring mechanical ventilation [6].
Interestingly, COVID-19 disease prognosis is strongly correlated to
clinical characteristics of patients, with high risk associated to those
with a concomitance of cardiovascular risk factors, primarily obesity,
hypertension, and diabetes mellitus [4,7]. In the context of COVID-19associated cardiovascular manifestations, more recent studies report
that the disease is commonly complicated with coagulopathy linked to
disseminated intravascular coagulation (DIC) and/or thrombotic and
thromboembolic disease [4,8,9]. For these reasons, many patients with
severe COVID-19 meet the Third International Consensus Definitions
for Sepsis (SEPSIS-3) [10].
Moreover, we must consider that the development of thrombotic
and thromboembolic disease could be a direct consequence of the systemic inflammatory process related to interleukin (IL)-6 and IL-17A upregulation [11–14]. This clinical scenario has prompted the use of intravenous immunoglobulin (IVIG) and low molecular weight heparin
(LMWH) anticoagulant therapy as early as possible, particularly when
circulating T and B cells numbers decrease, and inflammatory cytokines
and D-Dimer (a non-specific parameter of thrombi formation) increase
abnormally [15–17]. While IVIG has shown efficacy in the treatment of
patients with influenza and SARS, more clinical data is required, for
Abbreviations: COVID-19, Coronavirus disease 2019; DIC, disseminated intravascular coagulation; DVT, deep vein thrombosis; EC, endothelial cells; ERK-2, extracellular signal regulated kinase-2; HUVECs, human umbilical vein endothelial cells; IL-, interleukin-; IVIG, intravenous immunoglobulin; LMWH, low molecular
weight heparin; SARS, severe acute respiratory syndrome; SEPSIS-3, Third International Consensus Definitions for Sepsis; TF, tissue factor; Th-, T-helper; TNF-α,
tumor necrosis factor-α; WHO, World Health Organization.
⁎
Corresponding authors.
E-mail addresses: A.J.Iqbal@bham.ac.uk (A.J. Iqbal), francesco.maione@unina.it (F. Maione).
1
These authors share first co-authorship.
https://doi.org/10.1016/j.autrev.2020.102572
Received 23 April 2020; Accepted 25 April 2020
1568-9972/ © 2020 Elsevier B.V. All rights reserved.
Please cite this article as: Federica Raucci, et al., Autoimmunity Reviews, https://doi.org/10.1016/j.autrev.2020.102572
Autoimmunity Reviews xxx (xxxx) xxxx
F. Raucci, et al.
Fig. 1. Schematic representation of inflammatory pathways (left part) involved in the COVID-19-related respiratory syndrome. The inflammatory scenario induced
by COVID-19 has cardiovascular implications (right part, top panel) in terms of Th-1/Th-17/T-reg balance that favors the production of IL-17A. The overproduction
of this cytokine (right part, bottom panel) amplifies platelet hyper-reactivity and thrombus formation.
increase, in both mouse and human, platelet activation [32] and to
modulate, in vivo, arterial thrombus formation [33] through the extracellular signal-regulated kinase-2 (ERK-2) signaling pathway [34].
Moreover, a study from Ding et al., [35] investigated the role of IL-17A
in mouse and human deep vein thrombosis (DVT) formation, and found
that this cytokine promotes DVT pathogenesis by enhancing platelet
activation/aggregation, neutrophil infiltration, and endothelial cell
(EC) activation. Collectively, these data suggest that the use of an antiIL-17A neutralising monoclonal antibody may be useful for DVT-related
syndromes.
both IVIG and LMWH, to confirm significant efficacy in COVID-19 patients [18–20].
2. IL-17A and COVID-19-related thrombotic and vascular
mechanisms
Viral infection and subsequent systemic and/or local inflammation
is a common cause of DIC [21–23] due to increased synthesis of cytokines such as as tumor necrosis factor-α (TNF-α), IL-1β, IL-6, IL-17A
and IL-18 [24].
IL-17A (commonly known as IL-17) is the most studied member of
the IL-17 cytokine family. It is produced by T-helper (Th)-17 lymphocytes, and by innate cellular components [25,26]. This “unique” proinflammatory cytokine, highly produced and modulated in patients
with chronic inflammatory-based diseases, also plays a role in the
cardiovascular system, more specifically, it is involved in cardiovascular complications associated with autoimmune and inflammatorybased diseases [27].
Indeed, in the attempt to find a link between inflammatory markers
and endothelial dysfunction, Marder et al., [28] demonstrated that
elevated IL-17A levels strongly correlated with vascular dysfunction in
subjects affected by rheumatoid arthritis. Furthermore, it has been
shown that, human umbilical vein endothelial cells (HUVECs), treated
with IL-17A, synergistically with TNF-α, induces tissue factor (TF) expression and modulates thrombomodulin [29] and thrombosis formation [30,31].
In addition to IL-17A role on the vascular endothelium, data, from
our research group and others has also highlighted a role for this cytokine in platelet biology. We previously reported IL-17A ability to
3. Discussion
Taking all these various pieces of evidence (albeit minimal), we
would like to hypothesize that in COVID-19 patients, IL-17A could
potentially promote a pro-thrombotic state in the vascular system.
Indeed, the increased level of this cytokine in COVID-19 infection
would not be, per se, a stimulus for thrombogenesis but, most likely,
support platelet aggregate formation at sites of vascular injury (Fig. 1).
Based on these assumptions, it would be fascinating to characterize IL17 levels in bronchoalveolar lavage fluid (BALF) and plasma/serum
samples of mild- and severe-infected COVID-19 patients, and potentially go on to test the efficacy of antibodies targeting IL-17A (alone or
in a sequential therapy with anti-IL-6 agents) for the treatment of
thrombotic, as well respiratory and systemic manifestations of severe
COVID-19. These could be useful not only for new therapeutic strategies
but also for improving our understanding of the etiopathogenesis and
genetic susceptibility of COVID-19 infection.
2
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Author contributions
[14]
FR, AAM, GMC and AS drafted the manuscript. FC, RS, NM, AJI and
FM wrote and revised the manuscript. All Authors gave final approval
to the publication.
[15]
Declaration of Competing Interest
[16]
This article has been conducted and written in the absence of any
commercial or financial relationships that could be construed as a potential conflict of interest.
[17]
Acknowledgments
[18]
This work was in part supported by MIUR (PRIN 2017;
2017A95NCJ/2017A95NCJ_002, “Stolen molecules - Stealing natural
products from the depot and reselling them as new drug candidates”).
AJI is supported by Birmingham Fellowship and AAM by a Saudi
Government/KKU scholarship.
[19]
[20]
[21]
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