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Vaccination does not affect leukocyte morphologic abnormalities of severe COVID-19
American Journal of Hematology ( IF 12.8 ) Pub Date : 2022-05-23 , DOI: 10.1002/ajh.26616
Gina Zini 1, 2 , Paola Arcuri 3 , Rossella Ladiana 3 , Eloisa Sofia Tanzarella 4, 5 , Gennaro De Pascale 4, 5 , Giuseppe d'Onofrio 6
Affiliation  

In April 2020, we described the morphological abnormalities in circulating leukocytes of the first set of SARS-CoV-2 infected patients admitted to our institution at the outbreak of the pandemic.1 The most typical anomalies concerned neutrophil granulocyte nuclei, with hyposegmentation and dark chromatin, and cytoplasm, with increased or decreased granularity, and Döhle bodies. We also described the presence in peripheral blood (PB) of a neutrophil left shift, with immature granulocytes and apoptotic cells, as well as occasional decrease of neutrophil myeloperoxidase. Such changes disappeared during or after recovery, when reactive lymphocytes became predominant. The existence of unusual, dysplasia-like morphological features in neutrophil granulocytes in COVID-19 has been confirmed, integrated and corroborated by many studies, verting on morphology,2-5 electron microscopy,5 immunophenotype,6 and genomics-transcriptomics-genetic analysis.7

Two years after our report, with almost 14.6 millions of COVID-19 cases diagnosed in Italy and more than 150 000 deaths (https://www.epicentro.iss.it/en/coronavirus/sars-cov-2-dashboard accessed on April 3, 2022), we have retrospectively re-evaluated PB film leukocyte morphology in light of the massive vaccination campaign implemented in our country (89.85% of the Italian population above 12 years of age has completed the vaccination cycle, see https://www.governo.it/it/cscovid19/report-vaccini/ accessed on April 3, 2022). Two expert observers prospectively recorded the qualitative alterations found in leukocytes at the microscope examination of anonymized PB films of 77 consecutive hospitalized patients with severe COVID-19 and positive PCR test for SARS-CoV-2 from January 22 to February 15, 2022. Results of blood cell counts in K2-EDTA, analyzed with a Siemens ADVIA 2120 hematologic analyzer (Siemens Healthcare, Milan, Italy) within 6 h from blood collection were also recorded. We also investigated a possible relationship with the vaccine status of the patients. All clinical data were anonymized prior to analysis.

Study patients (49 males/28 females) had a mean age of 69.2 years (range 20–96); 37 (48%) of them were unvaccinated, while 40 (52%) had received anti-SARS-COv-2-189 vaccines (14 fully vaccinated with a booster dose, 24 with two doses, and 2 with one dose). Co-morbidities were present in most patients, while the absence of co-morbidities was observed in seven unvaccinated cases. The respiratory situation was similar in the two groups, except for tracheostomy (two patients in the unvaccinated group). There were 11 deaths in unvaccinated patients and seven deaths in the vaccinated group.

Hemoglobin concentration was similar among the unvaccinated and the vaccinated patents (mean HB 11.4 g/dL [range: 7.4–14.1] vs. 10.6 [range: 8.0–12.9]). Mean platelet count was slightly higher in the vaccinated group (270 × 109/L [range: 32–649] vs. 212 [range: 16–722]). Unvaccinated patients displayed slightly higher white blood cell count (WBC) (mean 11.4 × 109/L [range: 7.1–15.0] vs. 6.8 [range 1.7–21.9]) and similar lymphocyte counts (1.26 × 109/L [0.30–1.95]) in unvaccinated cases vs. 1.33 [0.15–12.0]). Such differences were not statistically significant, except for PLT (p < .05).** Student's t-test.
The mean peroxidase neutrophil index (MPXI, laboratory reference range −10 to +5) was −0.25 in the vaccinated group (range: −18.1 to +6.8) and −5.1 in the unvaccinated COVID-19 patients (range −31.9 to +17.3) (p > .1). Partial neutrophil myeloperoxidase deficiency (MPXI <−10) was observed in 15/77 COVID-19 patients (18.2%, almost equally divided between seven vaccinated and eight unvaccinated); the MPXI was >10% in two vaccinated COVID-19 patients (+17.3 and +17.2, respectively).

Examinations of the PB films confirmed the presence of neutrophil morphological atypia in about one-third of COVID-19 patients. Table 1 shows the frequency of the main anomalous findings. A hyposegmented, pseudo-Pelger-like neutrophil nucleus, with hypercondensed chromatin, was the most frequent anomaly (not to be confounded with band cell nucleus): it was observed in both vaccinated and unvaccinated patients with a similar frequency of about 18% of PB films. Next in frequency, increased, toxic-like cytoplasm hypergranularity was more common in vaccinated patients (20%), while pale-blue, Döhle-body-like cytoplasmic areas were more frequent in unvaccinated patients (21.6%). The presence in the PB films of pyknotic and smudged cells was relatively common and difficult to quantify due to the variability of film preparation and possible artifacts. Lymphopenia with activated lymphocytes was also occasionally seen in patients with different vaccination statuses.

TABLE 1. Neutrophil morphological and cytochemical abnormalities observed in hospitalized patients with COVID-19, considering the vaccination status
Total cases (n = 77) Vaccinated (n = 40) Unvaccinated (n = 37)
Hyposegmented neutrophils 14 (18.2%) 7 (17.5%) 7 (18.9%)
Hypersegmented neutrophils 4 (5.2%) 2 (5.0%) 2 (5.4%)
Hypogranular neutrophils 7 (9.1%) 2 (5.0%) 5 (13.5%)
Hypergranular neutrophils 10 (13.0%) 8 (20%) 2 (5.4%)
Pale-blue cytoplasmic areas 8 (10.4%) 3 (7.5%) 5 (13.5%)
Nucleated red blood cells (any) 9 (11.7%) 5 (12.5%) 4 (10.8%)
Immature granulocytes (>1%) 7 (9.1%) 2 (5.0%) 5 (13.5%)
Advia MPXI <10 14 (18.2%) 7 (17.5%) 8 (21.6%)

In conclusion, we have confirmed that neutrophil morphological abnormalities are observed in patients with severe SARS-CoV-2 infection who require hospital admission, independently of their vaccination status. Their frequency and severity appear to have decreased compared with our previous observation.1, 2 Nuclear hyperdense chromatin with decreased segmentation still is the most common morphological feature, together with increased density and number of cytoplasmic granules. In addition, using the ADVIA 2120 hematologic analyzer with automated cytochemistry, we have found an increased frequency of cases of partial neutrophil myeloperoxidase deficiency, confirming our preliminary observation.1 The morphological and the cytochemical abnormalities can be related to the general inflammatory state and cytokine storm that characterize the clinical evolution of severe COVID-19 cases7-10 and seem to be generally not affected by prior vaccination.



中文翻译:

接种疫苗不会影响严重 COVID-19 的白细胞形态异常

2020 年 4 月,我们描述了大流行爆发时我们机构收治的第一组 SARS-CoV-2 感染患者的循环白细胞形态异常。1最典型的异常涉及中性粒细胞核(具有分节不足和深色染色质)和细胞质(粒度增加或减少)和 Döhle 小体。我们还描述了中性粒细胞左移外周血 (PB) 中的存在,具有未成熟的粒细胞和凋亡细胞,以及中性粒细胞髓过氧化物酶的偶尔减少。当反应性淋巴细胞占主导地位时,这些变化在恢复期间或恢复后消失。COVID-19 中中性粒细胞中存在异常的、发育异常样的形态学特征已经被许多研究证实、整合和证实,包括形态学、2-5电子显微镜、5免疫表型、6和基因组学-转录组学-遗传分析。7

在我们的报告发布两年后,意大利诊断出近 1460 万例 COVID-19 病例,超过 15 万例死亡(https://www.epicentro.iss.it/en/coronavirus/sars-cov-2-dashboard 访问于2022 年 4 月 3 日),鉴于我国实施的大规模疫苗接种运动(89.85% 的意大利 12 岁以上人口已完成疫苗接种周期,见 https:// www.governo.it/it/cscovid19/report-vaccini/ 于 2022 年 4 月 3 日访问)。两位专家观察员前瞻性地记录了 2022 年 1 月 22 日至 2 月 15 日期间连续 77 名重症 COVID-19 住院患者和 SARS-CoV-2 PCR 检测呈阳性的匿名 PB 胶片显微镜检查中发现的白细胞质量变化。结果K2-EDTA 中的血细胞计数,还记录了在采血后 6 小时内用 Siemens ADVIA 2120 血液分析仪(Siemens Healthcare,Milan,Italy)分析的。我们还调查了与患者疫苗状况的可能关系。所有临床数据在分析前均已匿名化。

研究患者(49 名男性/28 名女性)的平均年龄为 69.2 岁(范围 20-96);其中 37 人(48%)未接种疫苗,40 人(52%)接种了抗 SARS-COv-2-189 疫苗(14 人完全接种加强剂,24 人接种两剂,2 人接种一剂)。大多数患者存在合并症,而在 7 名未接种疫苗的病例中未观察到合并症。两组的呼吸情况相似,除了气管切开术(未接种疫苗组的两名患者)。未接种疫苗的患者中有 11 人死亡,而接种疫苗的患者中有 7 人死亡。

未接种疫苗和已接种疫苗的患者的血红蛋白浓度相似(平均 HB 11.4 g/dL [范围:7.4-14.1] vs. 10.6 [范围:8.0-12.9])。接种组的平均血小板计数略高(270 × 10 9 /L [范围:32-649] vs. 212 [范围:16-722])。未接种疫苗的患者白细胞计数 (WBC) 略高(平均 11.4 × 10 9 /L [范围:7.1–15.0] vs. 6.8 [范围 1.7–21.9])和相似的淋巴细胞计数(1.26 × 10 9 /L [0.30] –1.95])在未接种疫苗的情况下与 1.33 [0.15–12.0])。除 PLT ( p < .05)外,此类差异无统计学意义 。**学生t检验。
接种组的平均过氧化物酶中性粒细胞指数(MPXI,实验室参考范围 -10 至 +5)为 -0.25(范围:-18.1 至 +6.8),未接种疫苗的 COVID-19 患者为 -5.1(范围 -31.9 至 +17.3) ) ( p  > .1)。在 15/77 名 COVID-19 患者中观察到部分中性粒细胞髓过氧化物酶缺乏症(MPXI <-10)(18.2%,几乎均分在 7 名接种疫苗和 8 名未接种疫苗的患者中);两名接种疫苗的 COVID-19 患者的 MPXI > 10%(分别为 +17.3 和 +17.2)。

对 PB 胶片的检查证实,约三分之一的 COVID-19 患者存在中性粒细胞形态异型性。表 1 显示了主要异常发现的频率。具有超浓缩染色质的低分段、假 Pelger 样中性粒细胞核是最常见的异常(不要与带状细胞核混淆):在接种疫苗和未接种疫苗的患者中均观察到,其发生率相似,约为 PB 的 18%电影。其次,在接种疫苗的患者中,增加的毒性样细胞质超颗粒更常见(20%),而在未接种疫苗的患者中,淡蓝色、Döhle 体样细胞质区域更常见(21.6%)。由于薄膜制备的可变性和可能的​​伪影,PB 薄膜中存在固缩和污迹细胞相对常见且难以量化。

表 1.考虑到疫苗接种状态,在 COVID-19 住院患者中观察到的中性粒细胞形态和细胞化学异常
病例总数(n  = 77) 接种疫苗 ( n  = 40) 未接种疫苗 ( n  = 37)
低分中性粒细胞 14 (18.2%) 7 (17.5%) 7 (18.9%)
中性粒细胞过度分割 4 (5.2%) 2 (5.0%) 2 (5.4%)
中性粒细胞不足 7 (9.1%) 2 (5.0%) 5 (13.5%)
中性粒细胞过多 10 (13.0%) 8 (20%) 2 (5.4%)
淡蓝色细胞质区 8 (10.4%) 3 (7.5%) 5 (13.5%)
有核红细胞(任何) 9 (11.7%) 5 (12.5%) 4 (10.8%)
未成熟粒细胞 (>1%) 7 (9.1%) 2 (5.0%) 5 (13.5%)
Advia MPXI <10 14 (18.2%) 7 (17.5%) 8 (21.6%)

总之,我们已经确认在需要住院的严重 SARS-CoV-2 感染患者中观察到中性粒细胞形态异常,与他们的疫苗接种状态无关。与我们之前的观察相比,它们的频率和严重程度似乎有所降低。1, 2核高密度染色质与减少的分割仍然是最常见的形态特征,同时细胞质颗粒的密度和数量增加。此外,使用带有自动细胞化学的 ADVIA 2120 血液分析仪,我们发现部分中性粒细胞髓过氧化物酶缺乏症的病例频率增加,证实了我们的初步观察。1形态学和细胞化学异常可能与一般炎症状态和细胞因子风暴有关,这是严重 COVID-19 病例7-10临床演变的特征,并且似乎通常不受先前疫苗接种的影响。

更新日期:2022-05-23
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