Education

Dr. Miswar Fattah, MSi 1997 : SMAK Depkes Makassar

Makassar, 6th June 1978 2002 : Chemistry - UNHAS
2006 : Master of Science in Clinical Chemistry,
Biomedicine- UNHAS
2012 : Doctor of Medicine - UNHAS

Current position

1. Specialty & Research Laboratory Manager, Prodia Clinical Laboratory 2018- Now
2. PATELKI : Vice President 2017-Now & Member of Collegium PATELKI 2015 - Now
3. IACC: Member scientific committe, Indonesian Association for Clinical Chemistry 2013- Now
4. President of ASEAN Association of Clinical Laboratory Scientist (AACLS) 2018-2020
5. Corresponding Member Scientific Committee Asia Pacific Federation for Clinical Chemistry (APFCB)
2010 – Now
LABORATORY TESTING RELATED
CYTOKINE STORM IN COVID-19

Webinar XIII DPP PATELKI,

Jakarta, 22 Agustus 2020

Dr. Miswar Fattah, MSi

Specialty & Research Laboratory
Prodia Clinical Laboratory
miswarfattah@gmail.com
CYTOKINE

Greek: cyto, from Greek "κύτος" kytos "cavity, cell" +

kines, from Greek "κίνησις" kinēsis "movement".
Cytokines are a large group of proteins, peptides or
glycoproteins that are secreted by specific cells of immune
system. Cytokines are a category of signaling molecules
that mediate and regulate immunity, inflammation and
hematopoiesis

Cytokines are regulatory proteins, produced and secreted

by various cells, which control immune response,
hematopoiesis, inflammation, wound repair and tissue
morphogesis.
Cytokines may be secreted or membrane bound.

Secreted cytokines may act locally as autocrine or paracrine

factors or over some distance as would a hormone
CYTOKINE STORM
characterized by systemic
symptoms and signs derived
from a massive and
uncontrolled inflammatory
response caused by pro- and
anti-inflammatory cytokine
dysregulation
MAIN STRUCTURE OF CORONAVIRUSES
NORMAL IMMUNE RESPONSE TO VIRAL INFECTION

• In a normal immune response, a number of different types of

immune cells (lymphocytes) and chemical messengers are
released in an intricate sequence, causing a mild localized
inflammatory state
• The first cytokines released are interleukin 1β (IL-1β) and tumor
necrosis factor-α (TNF-α),
• Attract a variety of circulating white blood cells (WBCs) to the
infection site, including neutrophils, monocytes, macrophages
(monocytes that have migrated into tissues), and natural killer
(NK) cells (a type of WBC that can kill infected or neoplastic cells)

COVID-19 and cytokine storm syndrome. 2020. Medical Laboratory Observer. www.mlo-online.com
NORMAL CYTOKINE
RESPONSE TO
VIRAL INFECTION

COVID-19 and cytokine storm syndrome. 2020.

Medical Laboratory Observer. www.mlo-
online.com
Cytokines broadcast messages which stimulate
an immune response
 Pro- • IL−1β,IL-2, and its soluble
receptor, IL-6, IL-8, IL-17, G-
inflammatory CSF, GM-CSF, TNF-α, MCP1
cytokines or CCL2 and MIP-1α or CCL3

anti- • IL-10

inflammatory
cytokine
NORMAL IMMUNE RESPONSE TO VIRAL INFECTION

• the antipathogenic chemicals released by these cells (i.e.,

complement), comprise the innate immune response.
• These cells directly attack the invading pathogen and also
release additional cytokines, chief among them interleukin-6
(IL-6).
• IL-6 is essential for invoking the adaptive immune response,
which calls T-cells, B-cells, and T helper (Th) cells to the
infection site.
• IL-6 also stimulates further recruitment, proliferation and
activation of macrophages

COVID-19 and cytokine storm syndrome. 2020. Medical Laboratory Observer. www.mlo-online.com
PROFESSIONAL APCS
CD4+ TH1-CELLS
PROFESSIONAL APC
CD4+ TH2-CELLS
NORMAL IMMUNE RESPONSE TO VIRAL INFECTION
T-cells destroy pathogen-infected cells but are much more specific for the infecting
pathogen.

B-cells produce antibodies that specifically target pathogenic antigens and mark
them for elimination.

Th cells also release IL-6 and other cytokines, which assist in the process of recruiting
and maintaining T- and B-cell activation and proliferation.

IL-6 and other cytokines directly cause endothelial cells lining the vasculature and organs to become
slightly permeable, which facilitates movement of immune cells and complement into infected tissues

COVID-19 and cytokine storm syndrome. 2020. Medical Laboratory Observer. www.mlo-online.com
ABNORMAL IMMUNOLOGIC RESPONSE TO INFECTION

• Overexuberant immunologic responses can lead to

irreversible tissue damage
• the deadliest manifestations of the abnormal
immunological response, the cytokine storm syndrome
(CSS). This response is also referred to by some as the
cytokine release syndrome (CRS)
DYSREGULATED
IMMUNE
RESPONSE
RESULTING IN
CYTOKINE STORM

COVID-19 and cytokine storm syndrome. 2020.

Medical Laboratory Observer. www.mlo-
online.com
MAJOR CYTOKINES INVOLVED IN CSS IN THE CONTEXT OF
DIFFERENT DISEASES

Gao Y ‐M., Xu G, Wang B, Liu B ‐C. 2020. J Intern Med

 SEVERE AND CRITICAL COVID-19 PATIENTS

• The low number of peripheral lymphocytes in

the blood despite a high volume of lymphocytes
in the lungs (which are the primary target organs)
• Reduced lymphocytes in the spleen, thymus and
other lymphoid organs, is indicative of immune
exhaustion
COVID-19 and cytokine storm syndrome. 2020. Medical Laboratory Observer. www.mlo-online.com
HOW SARS COV-2 INDUCE CYTOKINE STORM?
HIGHLIGHTS PATHOPHYSIOLOGICAL FEATURES OF CORONAVIRUS DISEASE
2019 (COVID-19) IN THE LUNG, INCLUDING LOSS OF VASCULAR INTEGRITY

Teuwen L-A, Geldhof V, Pasut A, Carmeliet P. 2020. Nature Reviews Immunology. 20(7):389–91
HIGHLIGHTS PATHOPHYSIOLOGICAL FEATURES OF CORONAVIRUS DISEASE
2019 (COVID-19) IN THE LUNG, INCLUDING LOSS OF VASCULAR INTEGRITY

Teuwen L-A, Geldhof V, Pasut A, Carmeliet P. 2020. Nature Reviews Immunology. 20(7):389–91
SARS-COV2 CAUSES ENDOTHELIAL DYSFUNCTION AND
PULMONARY VASCULAR CHANGES

Huertas A, Montani D, Savale L, Pichon J, Tu L, et al. 2020. European Respiratory Journal

CHRONOLOGY OF
EVENTS DURING SARS-
COV-2 INFECTION

Teuwen L-A, Geldhof V, Pasut A, Carmeliet P.

2020. Nature Reviews Immunology.
20(7):389–91
IMMUNE RESPONSE IN
LUNG TISSUES AFTER
CORONAVIRUS INFECTION

Liu Y, Qi G, Bellanti JA, Moser R, Ryffel B, Zheng SG.

MedComm. n/a(n/a):
REPRESENTATION OF
COVID-19
PATHOGENESIS AND
CYTOKINE STORM

Nile SH, Nile A, Qiu J, Li L, Jia X, Kai G. 2020.

Cytokine & Growth Factor Reviews. 53:66–70
Renu K, Prasanna PL, Valsala Gopalakrishnan A. 2020. Life Sciences. 255:117839
CORONAVIRUSES PATHOGENESIS, COMORBIDITIES AND MULTI-
ORGAN DAMAGE

Renu K, Prasanna PL, Valsala Gopalakrishnan A. 2020. Life Sciences. 255:117839

CHARACTERIZATION OF KEY EVENTS IN COVID-19 DISEASE
PATHOPHYSIOLOGICAL PROGRESSION

Bohn MK, Hall A, Sepiashvili L, Jung B, Steele S, Adeli K. 2020. Physiology. 35(5):288–301
THREE STAGES OF DISEASE COVID-19

Calabrese LH. 2020. CCJM. 87(7):389–93

COVID-19 PATHOGENIC PHASES AND POTENTIAL THERAPEUTIC TARGETS

•Nile SH, Nile A, Qiu J, Li L, Jia X, Kai G. 2020. Cytokine & Growth Factor Reviews. 53:66–70
 CRITERIA FOR
SEVERITY

Nascimento JHP, Gomes BF de O, Carmo Júnior PR do, Petriz JLF, Rizk SI, et al. 2020. Arquivos Brasileiros de Cardiologia. 114(5):829–33
CLINICAL FEATURES VERSUS PATHOGENIC INFLAMMATORY
CYTOKINE RESPONSE IN SARS-COV-2 INFECTIONS.

Sun X, Wang T, Cai D, Hu Z, Chen J, et al. 2020. Cytokine & Growth Factor Reviews. 53:38–42
CYTOKINE STROM & COAGULATION
PULMONARY INTRAVASCULAR COAGULOPATHY IN COVID-19 PNEUMONIA

McGonagle D, O’Donnell JS, Sharif K, Emery P, Bridgewood C. 2020. The Lancet Rheumatology. 2(7):e437–45
Bohn MK, Hall A, Sepiashvili L, Jung B, Steele S, Adeli K. 2020. Physiology. 35(5):288–301
Pathogenesis of
Cytokine Storm

Gao Y ‐M., Xu G, Wang B, Liu

B ‐C. 2020. J Intern Med
DIFFERENT TYPE OF ANALYTE LABORATORY TESTING RELATED COVID-19

RNA Host Respons

Antigen Antibody Potencial
CBC
ORFla/b Gene
N Protein IgM CRP
Succebility
N Gene
E Gene S Protein IgG D Dimer ACE2 Gene
S Gene IgA SGOT HLA Gene
Albumin
LDH, etc

rRTPCR, LAMP, ELISA, Immuno- ELISA, Immuno- Enzymatic, Genotyping

chromatography, colorimetry, microarray, RTPCR,
NGS chromatography flowcytometry,
Chemiluminoscence Sanger Seq, NGS
immnoassay impedance
KEY LABORATORY CHARACTERISTICS DURING SARS-COV-2 INFECTIONS

Skevaki C, Fragkou PC, Cheng C, Xie M, Renz H. 2020. J Infect. 81(2):205–12

Gao Y ‐M., Xu G, Wang B, Liu B ‐C. 2020. J Intern Med
LABORATORY PARAMETERS IN ADULT COVID-19 PATIENTS.

Skevaki C, Fragkou PC, Cheng C, Xie M, Renz H. 2020. J Infect. 81(2):205–12

LABORATORY PARAMETERS IN ADULT COVID-19 PATIENTS.

Skevaki C,
Fragkou PC,
Cheng C, Xie M,
Renz H. 2020. J
Infect.
81(2):205–12
LABORATORY PARAMETERS IN ADULT COVID-19 PATIENTS.

Skevaki C, Fragkou
PC, Cheng C, Xie M,
Renz H. 2020. J
Infect. 81(2):205–12
Bohn MK, Hall A, Sepiashvili L, Jung B, Steele S, Adeli K. 2020. Physiology. 35(5):288–301
 • High levels of alanine aminotransferase
(ALT)
• High Levels aspartate aminotransferase
(AST)
LABORATORY • High level Lactate dehydrogenase (LDH)
• High Level Ferritin
FINDINGS RELATED • High level CRP
CYTOKINE STORM • High Level D Dimer
suggestive of lymphocyte, phagocytic
monocyte and phagocytic macrocyte
activation

COVID-19 and cytokine storm syndrome. 2020. Medical Laboratory Observer. www.mlo-online.com
THE ROLE OF CYTOKINE PROFILE AND LYMPHOCYTE SUBSETS IN THE
SEVERITY OF CORONAVIRUS DISEASE 2019 (COVID-19)

Akbari H, Tabrizi R, Lankarani KB, Aria H, Vakili S, et al. 2020. Life Sci. 258:118167
IL-6 LEVELS DIFFERENTIATING SEVERE FROM MILD DISEASE

COVID-19 and cytokine storm syndrome. 2020. Medical Laboratory Observer. www.mlo-online.com
Siddiqi HK, et al. J Heart Lung Transplant. 2020. https://doi.org/10.1016/j.healun.2020.03.012, . Zhou Y, et al. National Science Review. 2020. DOI: 10.1093/nsr/nwaa041
3. Zhou F, et al. The Lancet 2020. https://doi.org/10.1016/S0140-6736(20)30566-3, Qin C, et al. 2020 Clin Infect Dis. https://academic.oup.com/cid/advance-article/doi/10.1093/cid/ciaa248/5803306, 5. Del Valle, Kim-Schulze, Huang, et al. https://doi.org/10.1101/2020.05.28.20115758, *Products are not FDA
SERUM, PLASMA OR WHOLE BLOOD?

Standard sampling procedures

should be implemented when
processing blood samples to provide
comparable and meaningful values

Serum and plasma are not equivalent

Serum preparation involves the removal of fibrinogen, platelets, and
other circulating proteins
SERUM SAMPLES MAY CONTAIN IL-1 BETA SECRETED FROM BLOOD LEUKOCYTES DURING
THE CLOTTING PROCESS AS COMPARED TO EDTA PLASMA

Peripheral blood collection in sterile EDTA (ethylenediamine tetraacetic acid)-treated

tubes has shown to produce the most consistent results for many cytokines

Lithium heparin and sodium citrate can decrease the measured levels of some cytokines
(IL-6 and TNF-α) as compared to serum or EDTA-plasma

lithium heparin in certain collection tubes containing endotoxin can induce cytokine
synthesis

The presence of EDTA can inhibit endotoxin-induced cytokine synthesis and TNF synthesis
in the tube . However, EDTA plasma is not recommended for bioassays, since EDTA is a
chelating agent. Instead, serum or low-level preservative-free heparin plasma is
recommended for bioassays
TERIMA KASIH