Reaction of Human Monoclonal Antibodies to SARS-CoV-2 Proteins With Tissue Antigens: Implications for Autoimmune Diseases

Introduction

Coronavirus disease (COVID-19) has become one of the greatest global public health concerns of our century. The COVID-19 pandemic has placed an immediate call to action for medical researchers to investigate how SARS-CoV-2 can impact the worldwide human population. While, naturally, the search for a successful vaccine and efficient treatment protocols are paramount, immunologists who focus on autoimmunity have been concerned whether the infection or even a newly developed vaccine itself can trigger autoimmunity via cross-reactivity. Cross-reactivity occurs when amino acid sequence homology exists between a pathogen and self-tissue proteins (1). In this mechanism, antibodies formed against SARS-CoV-2 would also bind to human tissue proteins leading to autoimmune reactivity. An insufficiently vetted vaccine might mean trading freedom from COVID-19 to an autoimmune assault in the future.

There are three important questions regarding the role of cross-reactivity with SARS-CoV-2. First, does cross-reactivity play a role in the multi-system disorders associated with SARS-CoV-2 infection? Second, how does cross-reactivity contribute to the pathophysiology of SARS-CoV-2–induced autoimmunity? Third, are there any concerns for autoimmune development with either infection or vaccination with SARS-CoV-2?

We will begin with the first question of whether cross-reactivity can be involved in the multi-system response of COVID-19 infection. We believe the answer is probable, since some of the systemic disease clinical manifestations of COVID-19 cannot be explained solely by the binding of SARS-CoV-2 spike proteins with cell membranes of tissues that exhibit angiotensin-converting enzyme 2 (ACE2). For example, a significant deadly expression of the infection is the development of disseminated intravascular coagulopathy. Coagulopathy has become a key indicator of mortality in infected subjects (2). In a recent correspondence in the New England Journal of Medicine, the serology of infected patients suffering from coagulopathy demonstrated significantly elevated levels of anti-cardiolipin and anti–β2-glycoprotein autoantibodies (3). These findings suggest the possibility of autoimmune reactivity that may be part of the SARS-CoV-2 pathophysiological sequela. It is possible that some of the clinical manifestations of central nervous system, skin, gastrointestinal, and organ diseases may also be associated with autoimmune reactions.

The second important question is whether SARS-CoV-2 infection can lead to cross-reactivity. The development of pathogen-induced cross-reactivity requires two key criteria. First, the viral pathogen must exhibit sequence homology with human tissue proteins, and second, there must be loss of immune tolerance (4). Lyons-Wieler recently mapped out the immunogenic epitopes of SARS-CoV-2 proteins and compared them to human proteins in search of patterns of significant homologous matching in order to establish the possibility of viral-induced autoimmunity. He identified substantial cross-reactive mapping with many SARS-CoV-2 spike and nuclear proteins to human tissue protein sequences (5). There have also been several findings of immune dysregulation associated with loss of immune tolerance with COVID-19 infection. Giamarellos-Bourboulis described complex immune dysregulation in COVID-19 patients with severe respiratory failure (6). The unique pattern of immune dysfunction included: immune dysregulation or major decrease in HLA-DR14 on monocytes; macrophage activation syndrome; and lower absolute count for CD3+/CD4+/CD45+ T-lymphocytes, CD3−/CD16+/CD56+/CD45+ NK cells, and CD19+/CD45+ B-lymphocytes among patients with COVID-19 when compared to healthy subjects. These immunological shifts in combination with SARS-CoV-2 amino acid sequence homology mapping with human tissue proteins orchestrate a combination of immune variables that suggest cross-reactivity can potentially occur with patients infected with SARS-CoV-2.

The third important question to consider is whether cross-reactivity between COVID-19 and human tissue can lead to autoimmune disease development either from the infection or directly from vaccination. Determining this can be an enormous task because the development of most autoimmune diseases may take 3 to 18 years (7). Segal and Shoenfeld have raised concerns for vaccine-induced autoimmunity by citing examples of how previous vaccinations have induced cross-reactive autoimmunity in susceptible subgroups. They cite specific examples of how vaccine-induced cross-reactivity has led to the onset of systemic lupus erythematous, demyelinating autoimmune diseases, narcolepsy, and postural orthostatic tachycardia syndrome (8). In a very interesting letter, Kanduc and Shoenfeld addressed the issue of peptide sharing between SARS-CoV-2 spike glycoprotein and lung-surfactant-related proteins (9). They suggested that because the SARS-CoV-2 and lung surfactant proteins shared 13 out of 24 pentapeptides, the immune response following infection with SARS-CoV-2 may lead to cross-reactions with pulmonary surfactant proteins, followed by SARS-CoV-2–associated lung disease (9). Furthermore, very recently they presented indisputable proof of molecular mimicry as a potential mechanism for contributing to SARS-CoV-2 associated diseases (10). Based on their findings, they warned against the use of the entire SARS-CoV-2 antigens in the vaccines and cautioned that perhaps the use of only unique peptides would be the most effective way to fight the SARS-CoV-2 infection. Due to the significant red flags for the potential cross-reactivity between SARS-CoV-2 and human tissue, we have undertaken to study the interaction of antibodies made against SARS-CoV-2 spike protein, nucleoprotein, envelope protein and membrane protein with various autoimmune target proteins associated with many serious diseases. This way, we can establish the potential risk for autoimmunity and multi-system disorders with COVID-19 that may come from cross-reactivity between our own human tissues and this dreaded virus, and thus ensure that the badly-needed vaccines and treatments being developed for it are truly safe to use against this pandemic.