Patients with COVID-19 are at high risk for thrombotic arterial and venous occlusions. Lung histopathology often reveals fibrin-based blockages in the small blood vessels of patients who succumb to the disease. Antiphospholipid syndrome is an acquired and potentially life-threatening thrombophilia in which patients develop pathogenic autoantibodies targeting phospholipids and phospholipid-binding proteins (aPL antibodies). Case series have recently detected aPL antibodies in patients with COVID-19. Here, we measured eight types of aPL antibodies in serum samples from 172 patients hospitalized with COVID-19. These aPL antibodies included anticardiolipin IgG, IgM, and IgA; anti–β2 glycoprotein I IgG, IgM, and IgA; and anti-phosphatidylserine/prothrombin (aPS/PT) IgG and IgM. We detected aPS/PT IgG in 24% of serum samples, anticardiolipin IgM in 23% of samples, and aPS/PT IgM in 18% of samples. Antiphospholipid autoantibodies were present in 52% of serum samples using the manufacturer’s threshold and in 30% using a more stringent cutoff (≥40 ELISA-specific units). Higher titers of aPL antibodies were associated with neutrophil hyperactivity, including the release of neutrophil extracellular traps (NETs), higher platelet counts, more severe respiratory disease, and lower clinical estimated glomerular filtration rate. Similar to IgG from patients with antiphospholipid syndrome, IgG fractions isolated from patients with COVID-19 promoted NET release from neutrophils isolated from healthy individuals. Furthermore, injection of IgG purified from COVID-19 patient serum into mice accelerated venous thrombosis in two mouse models. These findings suggest that half of patients hospitalized with COVID-19 become at least transiently positive for aPL antibodies and that these autoantibodies are potentially pathogenic.

Dysosteosclerosis (DSS) is the form of osteopetrosis distinguished by the presence of skin findings such as red-violet macular atrophy, platyspondyly and metaphyseal osteosclerosis with relative radiolucency of widened diaphyses. At the histopathological level, there is a paucity of osteoclasts when the disease presents. In two patients with DSS, we identified homozygous or compound heterozygous missense mutations in SLC29A3 by whole-exome sequencing. This gene encodes a nucleoside transporter, mutations in which cause histiocytosis-lymphadenopathy plus syndrome, a group of conditions with little or no skeletal involvement. This transporter is essential for lysosomal function in mice. We demonstrate the expression of Slc29a3 in mouse osteoclasts in vivo. In monocytes from patients with DSS, we observed reduced osteoclast differentiation and function (demineralization of calcium surface). Our report highlights the pleomorphic consequences of dysfunction of this nucleoside transporter, and importantly suggests a new mechanism for the control of osteoclast differentiation and function.

Patients with coronavirus disease 19 (COVID-19) are at high risk for thrombotic arterial and venous occlusions. At the same time, lung histopathology often reveals fibrin-based occlusion of small vessels in patients who succumb to the disease. Antiphospholipid syndrome (APS) is an acquired and potentially life-threatening thrombophilia in which patients develop pathogenic autoantibodies (aPL) targeting phospholipids and phospholipid-binding proteins. Small case series have recently detected aPL in patients with COVID-19. Here, we measured eight types of aPL (anticardiolipin IgG/IgM/IgA, anti-beta-2 glycoprotein I IgG/IgM/IgA, and anti- phosphatidylserine/prothrombin (PS/PT) IgG/IgM) in the sera of 172 patients hospitalized with COVID-19. We detected anticardiolipin IgM antibodies in 23%, anti-PS/PT IgG in 24%, and anti-PS/PT IgM in 18%. Any aPL was present in 52% of patients using the manufacturer's threshold and in 30% using a more stringent cutoff (>40 units). Higher levels of aPL were associated with neutrophil hyperactivity (including the release of neutrophil extracellular traps/NETs), higher platelet count, more severe respiratory disease, and lower glomerular filtration rates. Similar to patients with known and longstanding APS, IgG fractions isolated from patients with COVID-19 promoted NET release from control neutrophils. Furthermore, injection of these COVID-19 IgG fractions into mice accelerated venous thrombosis. Taken together, these studies suggest that a significant percentage of patients with COVID-19 become at least transiently positive for aPL and that these aPL are potentially pathogenic.

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Neutrophil extracellular traps (NETs) are chromatin-derived webs extruded from neutrophils in response to either infection or sterile stimulation with chemicals, cytokines, or microbial products. The vast majority of studies have characterized NET release (also called NETosis) in pure neutrophil cultures in vitro. The situation is surely more complex in vivo as neutrophils constantly sample not only pathogens and soluble mediators but also signals from cellular partners, including platelets and endothelial cells. This complexity is beginning to be explored by studies utilizing in vitro co-culture, as well as animal models of sepsis, infective endocarditis, lung injury, and thrombosis. Indeed, various selectins, integrins, and surface glycoproteins have been implicated in platelet–neutrophil interactions that promote NETosis, albeit with disparate results across studies. NETosis can also clearly be regulated by soluble mediators derived from platelets, such as eicosanoids, chemokines, and alarmins. Beyond platelets, the role of the endothelium in modulating NETosis is being increasingly revealed, with adhesive interactions likely priming neutrophils toward NETosis. The fact that the same selectins and surface glycoproteins may be expressed by both platelets and endothelial cells complicates the interpretation of in vivo data. In summary, we suggest in this review that the engagement of neutrophils with activated cellular partners provides an important in vivo signal or “hit” toward NETosis. Studies should, therefore, increasingly consider the triumvirate of neutrophils, platelets, and the endothelium when exploring NETosis, especially in disease states.

Patients with coronavirus disease 19 (COVID-19) are at high risk for fibrin-based occlusion of vascular beds of all sizes. Although endothelial cell activation has regularly been described as part of the COVID-19 thrombo-inflammatory storm, the upstream mediators of this activation have yet to be fully elucidated. Here, we began by pursuing the hypothesis that circulating factors such as neutrophil extracellular trap (NET) remnants, D-dimer, or C-reactive protein might predict the COVID-19 serum samples (n=118) that most robustly activated cultured endothelial cells. Indeed, we found modest correlations between serum NET remnants (cell-free DNA, myeloperoxidase-DNA complexes, citrullinated histone H3) and upregulation of surface E-selectin, VCAM-1, and ICAM-1 on endothelial cells. However, a more robust predictor of the ability of COVID-19 serum to activate endothelial cells was the presence of circulating antiphospholipid antibodies, specifically anticardiolipin IgG and IgM and anti-phosphatidlyserine/prothrombin (anti-PS/PT) IgG and IgM. Depletion of total IgG from anticardiolipin-high and anti-PS/PT-high samples markedly restrained upregulation of E-selectin, VCAM-1, and ICAM-1. At the same time, supplementation of control serum with patient IgG was sufficient to trigger endothelial cell activation. These data are the first to reveal that patient antibodies are a driver of endothelial cell activation and add important context regarding thrombo-inflammatory effects of COVID-19 autoantibodies in severe COVID-19.

Objective While endothelial dysfunction has been implicated in the widespread thrombo‐inflammatory complications of coronavirus disease‐19 ( COVID‐19 ), the upstream mediators of endotheliopathy remain for the most part cryptic. Our aim was to identify circulating factors contributing to endothelial cell activation and dysfunction in COVID‐19. Methods Human endothelial cells were cultured in the presence of serum or plasma from 244 patients hospitalized with COVID‐19 and plasma from 100 patients with non‐COVID sepsis. Cell adhesion molecules (E‐selectin, VCAM‐1, and ICAM‐1) were quantified by in‐cell ELISA. Results Serum and plasma from patients with COVID‐19 increased surface expression of cell adhesion molecules. Furthermore, levels of soluble ICAM‐1 and E‐selectin were elevated in patient serum and tracked with disease severity. The presence of circulating antiphospholipid antibodies was a strong marker of the ability of COVID‐19 serum to activate endothelium. Depletion of total IgG from antiphospholipid antibody‐positive serum markedly restrained upregulation of cell adhesion molecules. Conversely, supplementation of control serum with patient IgG was sufficient to trigger endothelial activation. Conclusion These data are the first to suggest that some patients with COVID‐19 have potentially diverse antibodies that drive endotheliopathy, adding important context regarding thrombo‐inflammatory effects of autoantibodies in severe COVID‐19.

Neutrophils amplify inflammation in lupus through release of neutrophil extracellular traps (NETs). The endoplasmic reticulum stress sensor inositol-requiring enzyme 1 alpha (IRE1α) has been implicated as a perpetuator of inflammation in various chronic diseases; however, IRE1α has been little studied in relation to neutrophil function or lupus pathogenesis. Here, we found that neutrophils activated by lupus-derived immune complexes demonstrate markedly increased IRE1α ribonuclease activity. Importantly, heightened IRE1α activity was also detected in neutrophils isolated from lupus patients, where it correlated with global disease activity. Immune complex-stimulated neutrophils produced both mitochondrial reactive oxygen species (mitoROS) and the activated form of caspase-2 in IRE1α-dependent fashion, while inhibition of IRE1α mitigated immune complex-mediated NETosis (both in human neutrophils and in a mouse model of lupus). Administration of an IRE1α inhibitor to lupus-prone MRL/lpr mice over eight weeks reduced mitochondrial ROS levels in peripheral blood neutrophils, while also restraining plasma-cell expansion and autoantibody formation. In summary, these data are the first to identify a role for IRE1α in the hyperactivity of lupus neutrophils, with this pathway apparently upstream of mitochondrial dysfunction, mitochondrial ROS formation, and NETosis. Inhibition of the IRE1α pathway appears to be a novel strategy for neutralizing NETosis in lupus, and potentially other inflammatory conditions. The endoplasmic reticulum (ER) is an endomembrane compartment highly sensitive to inflammatory and oxidative perturbation. Indeed, beyond the ER's responsibility for synthesis and processing of membrane and secreted proteins, it also regulates calcium ion flux, the formation of autophagocytic vesicles, and the relay of oxidative and inflammatory signals (20). Key sensors of ER stress include: (i) inositol-requiring enzyme 1 alpha (IRE1α), (ii) PKR-like endoplasmic reticulum kinase (PERK), and (iii) cyclic AMP-dependent transcription factor (ATF6) (21). IRE1α signaling is the most phylogenetically conserved branch of the ER stress response, and the best studied in terms of its intersection with inflammatory pathways. For example, IRE1α may be activated by TLR2 and TLR4 in macrophages, TLR7 in dendritic cells, and TLR9 in B cells (22-24). IRE1α oligomerizes upon activation, facilitating transautophosphorylation and unmasking a unique cytosolic endoribonuclease (RNase) activity. One