To the Editor — We report the kinetics of immune responses in relation to clinical
and virological features of a patient with mild-to-moderate coronavirus disease 2019
(COVID-19) that required hospitalization. Increased antibody-secreting cells (ASCs),
follicular helper T cells (TFH cells), activated CD4+ T cells and CD8+ T cells and
immunoglobulin M (IgM) and IgG antibodies that bound the COVID-19-causing coronavirus
SARS-CoV-2 were detected in blood before symptomatic recovery. These immunological
changes persisted for at least 7 d following full resolution of symptoms.
A 47-year-old woman from Wuhan, Hubei province, China, presented to an emergency department
in Melbourne, Australia. Her symptoms commenced 4 d earlier with lethargy, sore throat,
dry cough, pleuritic chest pain, mild dyspnea and subjective fevers (Fig. 1a). She
traveled from Wuhan to Australia 11 d before presentation. She had no contact with
the Huanan seafood market or with known COVID-19 cases. She was otherwise healthy
and was a non-smoker taking no medications. Clinical examination revealed a temperature
of 38.5 °C, a pulse rate of 120 beats per minute, a blood pressure of 140/80 mm Hg,
a respiratory rate of 22 breaths per minute, and oxygen saturation 98% while breathing
ambient air. Lung auscultation revealed bi-basal rhonchi. At presentation on day 4,
SARS-CoV-2 was detected in a nasopharyngeal swab specimen by real-time reverse-transcriptase
PCR. SARS-CoV-2 was again detected at days 5–6 in nasopharyngeal, sputum and fecal
samples, but was undetectable from day 7 (Fig. 1a). Blood C-reactive protein was elevated
at 83.2, with normal counts of lymphocytes (4.3 × 109 cells per liter (range, 4.0
× 109 to 12.0 × 109 cells per liter)) and neutrophils (6.3 × 109 cells per liter (range,
2.0 × 109 to 8.0 × 109 × 109 cells per liter)). No other respiratory pathogens were
detected. Her management was intravenous fluid rehydration without supplemental oxygenation.
No antibiotics, steroids or antiviral agents were administered. Chest radiography
demonstrated bi-basal infiltrates at day 5 that cleared on day 10 (Fig. 1b). She was
discharged to home isolation on day 11. Her symptoms resolved completely by day 13,
and she remained well at day 20, with progressive increases in plasma SARS-CoV-2-binding
IgM and IgG antibodies from day 7 until day 20 (Fig. 1c and Extended Data Fig. 1).
The patient was enrolled through the Sentinel Travelers Research Preparedness Platform
for Emerging Infectious Diseases novel coronavirus substudy (SETREP-ID-coV) and provided
written informed consent before the study. Patient care and research were conducted
in compliance with the Case Report guidelines and the Declaration of Helsinki. Experiments
were performed with ethics approvals HREC/17/MH/53, HREC/15/MonH/64/2016.196 and UoM#1442952.1/#1443389.4.
Fig. 1
Emergence of immune responses during non-severe symptomatic COVID-19.
a, Timeline of COVID-19, showing detection of SARS-CoV-2 in sputum, nasopharyngeal
aspirates and feces but not urine, rectal swab or whole blood. SARS-CoV-2 was quantified
by rRT-PCR; cycle threshold (Ct) is shown. A higher Ct value means lower viral load.
Dashed horizontal line indicates limit of detection (LOD) threshold (Ct = 45). Open
circles, undetectable SARS-CoV-2. b, Anteroposterior chest radiographs on days 5 and
10 following symptom onset, showing radiological improvement from hospital admission
to discharge. c, Immunofluorescence antibody staining, repeated twice in duplicate,
for detection of IgG and IgM bound to SARS-CoV-2-infected Vero cells, assessed with
plasma (diluted 1:20) obtained at days 7–9 and 20 following symptom onset. d–f, Frequency
(left set of plots) of CD27hiCD38hi ASCs (gated on CD3–CD19+ lymphocytes) and activated
ICOS+PD-1+ TFH cells (gated on CD4+CXCR5+ lymphocytes) (d), activated CD38+HLA-DR+
CD8+ or CD4+ T cells (e), and CD14+CD16+ monocytes and activated HLA-DR+ natural killer
(NK) cells (gated on CD3–CD14–CD56+ cells) (f), detected by flow cytometry of blood
collected at days 7–9 and 20 following symptom onset in the patient and in healthy
donors (n = 5; median with interquartile range); gating examples at right. Bottom
right histograms and line graphs, staining of granzyme A (GZMA (A)), granzyme B (GZMB
(B)), granzyme K (GZMK (K)), granzyme M (GZMM (M)) and perforin (Prf) in parent CD8+
and CD4+ T cells and activated CD38+HLA-DR+ CD8+ and CD4+ T cells. Gating and experimental
details are in Extended Data Fig. 3.
Source data
We analyzed the kinetics and breadth of immune responses associated with clinical
resolution of COVID-19. As ASCs are key for the rapid production of antibodies following
infection with Ebola virus
1,2
and infection with and vaccination against influenza virus
2,3
, and activated circulating TFH cells (cTFH cells) are concomitantly induced following
vaccination against influenza virus
3
, we defined the frequency of CD3–CD19+CD27hiCD38hi ASC and CD4+CXCR5+ICOS+PD-1+ cTFH
cell responses before symptomatic recovery. ASCs appeared in the blood at the time
of viral clearance (day 7; 1.48%) and peaked on day 8 (6.91%). The emergence of cTFH
cells occurred concurrently in blood at day 7 (1.98%), increasing on day 8 (3.25%)
and day 9 (4.46%) (Fig. 1d). The peak of both ASCs and cTFH cells was markedly higher
in the patient with COVID-19 than in healthy control participants (0.61% ± 0.40% and
1.83% ± 0.77%, respectively (average ± s.d.); n = 5). Both ASCs and cTFH cells were
prominently present during convalescence (day 20) (4.54% and 7.14%, respectively;
Fig. 1d). Thus, our study provides evidence on the recruitment of both ASCs and cTFH
cells in this patient’s blood while she was still unwell and 3 d before the resolution
of symptoms.
Since co-expression of CD38 and HLA-DR is the key phenotype of the activation of CD8+
T cells in response to viral infections, we analyzed co-expression of CD38 and HLA-DR.
As per reports for Ebola and influenza
1,4
, co-expression of CD38 and HLA-DR on CD8+ T cells (assessed as the frequency of CD38+HLA-DR+
CD8+ T cells) rapidly increased in this patient from day 7 (3.57%) to day 8 (5.32%)
and day 9 (11.8%), then decreased at day 20 (7.05%) (Fig. 1e). Furthermore, the frequency
of CD38+HLA-DR+ CD8+ T cells was much higher in this patient than in healthy individuals
(1.47% ± 0.50%; n = 5). CD38+HLA-DR+ T cells were also recently documented in a patient
with COVID-19 at one time point
5
. Similarly, co-expression of CD38 and HLA-DR on CD4+ T cells (assessed as the frequency
of CD38+HLA-DR+ CD4+ T cells) increased between day 7 (0.55%) and day 9 (3.33%) in
this patient, relative to that of healthy donors (0.63% ± 0.28%; n = 5), although
at lower levels than that of CD8+ T cells. CD38+HLA-DR+ T cells, especially CD8+ T
cells, produced larger amounts of granzymes A and B and perforin (~34–54% higher)
than did their parent cells (CD8+ or CD4+ populations; Fig. 1e). Thus, the emergence
and rapid increase in activated CD38+HLA-DR+ T cells, especially CD8+ T cells, at
days 7–9 preceded the resolution of symptoms. Details on data reproducibility are
in the Life Sciences Reporting Summary.
Analysis of CD16+CD14+ monocytes, which are related to immunopathology, showed lower
frequencies of CD16+CD14+ monocytes in the blood of this patient at days 7, 8 and
9 (1.29%, 0.43% and 1.47%, respectively) than in that of healthy control donors (9.03%
± 4.39%; n = 5) (Fig. 1f), possibly indicative of the efflux of CD16+CD14+ monocytes
from the blood to the site of infection. No differences in activated HLA-DR+CD3–CD56+
natural killer cells were found.
As pro-inflammatory cytokines and chemokines are predictive of severe clinical outcomes
for influenza
6
, we quantified 17 pro-inflammatory cytokines and chemokines in plasma. We found low
levels of the chemokine MCP-1 (CCL2) in the patient’s plasma (Extended Data Fig. 2a),
although this was comparable to results obtained for healthy donors (22.15 ± 13.81;
n = 5), patients infected with influenza A virus or influenza B, assessed at days
7–9 (33.85 ± 30.12; n = 5), and a patient infected with the human coronavirus HCoV-229e
(40.56). Thus, in contrast to severe avian H7N9 disease, which had elevated cytokines
IL-6, IL-8, IL-10, MIP-1β and IFN-γ
6
, minimal pro-inflammatory cytokines and chemokines were found in this patient with
COVID-19, even while she was symptomatic at days 7–9.
As the single-nucleotide polymorphism rs12252-C/C in the gene IFITM3 (which encodes
interferon-induced transmembrane protein 3) is linked to severe influenza
6,7
, we analyzed IFITM3-rs12252 in the patient with COVID-19 and found the ‘risk’ IFITM3-rs12252-C/C
variant (Extended Data Fig. 2b). As the prevalence of IFITM3-rs12252-C/C in the Chinese
population is 26.5% (the 1000 Genomes Project)
6
, further investigation of the IFITM3-rs12252-C/C allele in larger cohorts of people
with COVID-19 is worth pursuing.
Collectively, our study provides novel contributions to the understanding of the breadth
and kinetics of immune responses during a non-severe case of COVID-19. This patient
did not experience complications of respiratory failure or acute respiratory distress
syndrome, did not require supplemental oxygenation, and was discharged within a week
of hospitalization, consistent with non-severe but symptomatic disease. We have provided
evidence on the recruitment of immune cell populations (ASCs, TFH cells and activated
CD4+ and CD8+ T cells), together with IgM and IgG SARS-CoV-2-binding antibodies, in
the patient’s blood before the resolution of symptoms. We propose that these immune
parameters should be characterized in larger cohorts of people with COVID-19 with
different disease severities to determine whether they could be used to predict disease
outcome and evaluate new interventions that might minimize severity and/or to inform
protective vaccine candidates. Furthermore, our study indicates that robust multi-factorial
immune responses can be elicited to the newly emerged virus SARS-CoV-2 and, similar
to the avian H7N9 disease
8
, early adaptive immune responses might correlate with better clinical outcomes.
Reporting Summary
Further information on research design is available in the Nature Research Reporting
Summary linked to this article.
Online content
Any methods, additional references, Nature Research reporting summaries, source data,
extended data, supplementary information, acknowledgements, peer review information;
details of author contributions and competing interests; and statements of data and
code availability are available at 10.1038/s41591-020-0819-2.
Supplementary information
Reporting Summary