key: cord-0889043-q3urtl72
authors: Zarnowski, Julia; Kage, Paula; Simon, Jan-Christoph; Treudler, Regina
title: Atopic comorbidity has no impact on severity and course of COVID-19 disease in adult patients
date: 2021-10-28
journal: Ann Allergy Asthma Immunol
DOI: 10.1016/j.anai.2021.10.026
sha: e8485e5554d7f90823199da447c63b0af33df735
doc_id: 889043
cord_uid: q3urtl72

nan

This was based on previous investigations demonstrating that pollen exposure can decrease immune defense against respiratory viruses 3, 4 . Also, high airborne pollen concentrations were correlated with increased SARS-CoV-2 infection rates, while pollen or particulate matter were not shown to serve as transmitters for viral particles 4, 5 . Studies have demonstrated, that Th-2-dominated diseases are associated with lower viral defense mechanisms due to a reduced antiviral interferon response, altogether increasing the susceptibility for respiratory viral infections or even systemic infections in atopic patients 1, 3, 4 . Several international studies, however none from Germany, have investigated possible effects of atopic disorders on COVID-19 disease and recently, even a protective effective was supposed [6] [7] .

In a retrospective, questionnaire-base study we aimed at analyzing the impact of atopic diseases on the course and severity of COVID-19 disease in adult patients with confirmed SARS-CoV-2 infection in our region. Patients were recruited after identification by the local health authorities or when presenting at the department of allergology of our university hospital. All subjects suffered from SARS-CoV2 infection before the local rise of mutant B1.1.7.

107 patients were included of which 53 (49.5%; mean age 44.4 years) presented a history of symptomatic atopic diseases in the past 12 months whereas 54 subjects without atopic history served as controls (50.5%; mean age 44.5 years). Characteristics of 107 patients are given in Table 1 . Baseline data showed no significant differences between atopic (group 1) and non-atopic subjects (group 2) with regard to gender or age. In group 1, 8/53 patients (15.1%) reported to suffer from atopic dermatitis, 47/53 patients (88.7%) had allergic rhinoconjuncitivis and 14/53 (26.4%) reported on allergic asthma. All patients had a known sensitization to inhalative allergens. In regard to plant-derived allergens, grass (64.2%) and birch (50.9%) pollen were reported most frequently, sensitization to non-herbal allergens were most commonly to mites (34%), cat (30.2%) or dog (18.9%) allergens. In group 1, five patients (9.4%) received allergen-specific immunotherapy (AIT) when COVID-19 infection occurred. 9/53 patients (17%) were treated with local or systemic immunosuppressive medications (n=3 topical nasal steroids, n=4 steroids ointment, n=6 inhalative steroids, n=1 ciclosporine, n=1 methotrexate and etanercept). In group 2, only one patient had omalizumab due to chronic urticaria while no other immunoactive drugs were reported to be taken.

Statistical analysis did not reveal a significant difference in experienced symptoms, treatment regime or recovery time between both groups. Also, atopic patients receiving immunotherapy or immunosuppressive medication did not show any significant differences for any of the parameters investigated. Hospitalization rates were comparable in both groups with n=3, respectively (5.7% and 5.6%).

In conclusion, our data supports the evidence that atopic comorbidities have no unfavorable impact on severity and course of COVID-19. Several studies have analyzed the effect of atopic diseases on the expression of ACE2 or transmembrane protease 2 (TMPRSS2), which induces the receptor binding of SARS-CoV-2 [6] [7] . It was shown that IL-13, commonly overexpressed in the context of Th2-inflammation, can significantly downregulate ACE2 expression 2, 6, 7 . Respiratory allergies, elevated IgE levels, topical and inhalative corticosteroids were also associated with a decreased ACE2 expression 2, 6 . Altogether this implicates that a decreased ACE2-expression in atopic manifestations may potentially reduce viral entrance of SARS-CoV-2 and thus lowers susceptibility for COVID-19 infection or disease severity in individuals with atopic background 2, 6, 7 .

As severe COVID-19 cases have been associated with eosinopenia, previous studies have discussed a potential anti-viral role of eosinophils in the immune system 6, 8 . In terms of their function in innate immunity, eosinophils are capable of antigen-presentation and recognition of viral particles, release of pro-inflammatory mediators through degranulation and promotion of type-2 cytokines 8 . Atopic diseases are often associated with elevated eosinophil levels, which can be induced by the Th-2-derived cytokine interleukin 5. An increased antiviral immune response in SARS-CoV-2 infected atopic patients with eosinophilia may be speculated, but further analysis is needed. With regard to commonly prescribed medication, inhalative, intranasal or systemic corticosteroids as well as allergen-specific immunotherapy show beneficial effects for local viral defense 9 . Furthermore, large cohort analyses of severe asthmatic patients have shown that risk of infection, course of COVID-19-disease or mortality is not increased when patients require treatment with biologicals 10 . Clinicians should be aware that patients suffering from atopic diseases might stop taking their effective medication as they fear severe COVID-19 illness, but due to the potential benefit of these therapies, an unnecessary discontinuation should be avoided, requiring good clinical care and patient education 9 . 

Atopic endotypes as a modulating factor for SARS-CoV-2 infection: mechanisms and implications

Association of respiratory allergy, asthma, and expression of the SARS-CoV-2 receptor ACE2

Pollen exposure weakens innate defense against respiratory viruses

Higher airborne pollen concentrations correlated with increased SARS-CoV-2 infection rates, as evidenced from 31 countries across the globe

No SARS-CoV-2 detected in air samples (pollen and particulate matter) in Leipzig during the first spread

Type 2 inflammation modulates ACE2 and TMPRSS2 in airway epithelial cells

Type 2 and interferon inflammation regulate SARS-CoV-2 entry factor expression in the airway epithelium

Eosinophil response against classical and emerging respiratory viruses: COVID-19

Concerns related to the coronavirus disease 2019 pandemic in adult patients with atopic dermatitis and psoriasis treated with systemic immunomodulatory therapy: a Danish questionnaire survey

Clinical characteristics in 545 patients with severe asthma on biological treatment during the COVID-19 outbreak