key: cord-295341-wkehj39d authors: Faqihi, Fahad; Alharthy, Abdulrahman; Memish, Ziad A; Karakitsos, Dimitrios title: Comment on Hu et al: The cytokine storm and COVID‐19 date: 2020-08-06 journal: J Med Virol DOI: 10.1002/jmv.26396 sha: doc_id: 295341 cord_uid: wkehj39d We read with interest the excellent review by Hu et al(1) published in the recent issue of the Journal of Medical Virology. The authors outlined the main pathophysiologic features of the cytokine storm, which was linked to fulminant SARS‐CoV‐2 disease (COVID‐19) and its putative therapies, in the absence of effective vaccines and antiviral treatment. This article is protected by copyright. All rights reserved. The exaggerated inflammatory immune response and microthrombosis in results in multi-system organ failure with fatal outcomes. [1] [2] [3] [4] [5] [6] [7] [8] [9] [10] [11] Unlike several immunomodulatory therapies, there is no immunosuppression associated with plasma exchange. In our study, the decrease in inflammatory markers was associated with a sustained increase of lymphocytes counts as others also observed. 11, 14 Whether the drop in pro-inflammatory cytokine levels following TPE might be caused by the increments in lymphocyte counts, and not due to the reduction of these cytokines per se remains to be elucidated in future studies. We did not measure any specific subtypes of lymphocytes as this was not one of the study end-points. However, we observed that after TPE the decrease in inflammatory biomarkers was associated with a concomitant amelioration of oxygenation and SOFA scores. 11 No side-effects of therapy such as allergies, infections, coagulopathy, and deterioration of renal or cardiac function were observed. Convalescent plasma transfusion (CPT) was previously described as a rescue therapy in severe COVID-19. 15 However, this therapy is more technically demanding, and time consuming compared to TPE. 16 Moreover, the overall benefit of CPT on survival in critically ill patients with COVID-19 remains debatable as a recent randomized control Accepted Article which showed a beneficial effect on survival in critically ill patients with COVID-19 due to the administration of low-dose dexamethasone. 25 The use of TPE, which is a relatively safe and accessible therapeutic modality, could enrich our therapeutic arsenal in the fight against life-threatening COVID-19. Surely, the availability of TPE equipment and trained staff varies worldwide; moreover, the application of TPE requires close monitoring, preferably in a high-dependency unit. TPE still carries the risk of exposure to a highly transmissible virus; hence, proper application of personal protective equipment by the staff, careful handling of the TPE devices, and utilization of the pertinent disposables as biohazardous materials is deemed to be necessary as should be the case for all extracorporeal blood purification therapies used in COVID-19 patients. Obviously, TPE is not superior to other immunomodulatory therapies that were previously used in COVID-19, instead it should be considered as an adjunctive safe therapeutic strategy in life-threatening disease. Larger prospective studies are necessary to investigate the role of potential immunomodulatory therapies against life-threatening COVID-19 with associated CRS. We acknowledge all front line health care workers in the fight against COVID-19 around the globe. The cytokine storm and COVID-19 Is a "Cytokine Storm" Relevant to COVID-19? 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