COVID-19 and upper respiratory tract: Collecting swab specimens from patients inhaling corticosteroids
Authors: Eftychios Siniorakis, Spyridon Arvanitakis, Titika Sfakianaki, Antonios Katsianis, Athanasios Sinaniotis, Veneta Papagiannopoulou
Journal: Journal of Allergy and Clinical Immunology (2020)

Jian et al1Jian L. Yi W. Zhang N. Wen W. Krysko O. Song W.J. et al.Perspective: COVID-19, implications of nasal diseases and consequences for their management.J Allergy Clin Immunol. 2020; 146: 67-69Abstract Full Text Full Text PDF PubMed Scopus (25) Google Scholar in a recent article refer to the immune reaction of the upper respiratory tract (URT) in patients infected by severe acute respiratory syndrome coronavirus (SARS-CoV)-2 (coronavirus disease 2019 [COVID-19] pandemic). The authors wonder about the consequences of inhaled corticosteroids (ICSs) on immune reaction. We share the queries of Jian et al, from a practical point of view. Since late February 2020, when the COVID-19 outbreak exploded in Greece, emergency departments (EDs) of major hospitals were enrolled in triaging patients with suspicious clinical presentation. Medical staff was called to perform nasopharyngeal and oropharyngeal swabbing, irrespective of specialization, and forwarding the samples for a PCR. Training was offered through educational videos.2Marty F.M. Chen K. Verrill K. How to obtain a nasopharyngeal swab specimen.N Engl J Med. 2020; 382: e76Crossref PubMed Scopus (176) Google Scholar The authors of this letter are going to maintain such a triage during the summer months when a wave of tourists from countries with different prevalence of COVID-19 is going to visit Greece. Pitfalls in performing nasopharyngeal or oropharyngeal swabbing are not negligible. Learning from the experience of previous medical personnel engaged in ED, we focus on an intriguing problem we are going to cope with. Given the pneumonologic character of the hospital and the seasonal allergies, 15% to 25% of patients admitted to the ED are expected to suffer exacerbations of chronic obstructive pulmonary disease, asthma, rhinitis, and rhinosinusitis. Most of them are under chronic or seasonal therapies with ICSs, oral or intranasal. With the URT sprayed by ICSs, we are wondering about the diagnostic accuracy of specimens collected. Asking patients to blow their nose, or postponing the procedure is not feasible, as far as we ignore the washout period needed for an ICS, especially in chronic administration. ICSs are likely to modify the replication of commensal and pathogenic virome in the nasopharynx, oropharynx, and saliva.3Ramakrishnan V.F. Holt J. Nelson L.F. Ir D. Robertson C.E. Frank D.N. Determinants of the nasal microbiome: pilot study of effects of intranasal medication use.Allergy Rhinol. 2018; 9: 1-10Crossref Google Scholar Medical literature regarding the effects of ICSs on pathogenic virome of the URT is scarce. We try to extrapolate data from previous coronavirus epidemics, namely, SARS-CoV, Middle East respiratory syndrome (MERS), and HCoV-229E. ICSs are expected to enhance pathogenic viral replications in the URT, predisposing to subsequent bacterial infection.4Singanayagam A, Johnston SL. Long-term impact of inhaled corticosteroid use in asthma and chronic obstructive pulmonary disease (COPD): review of mechanisms that underlie risks [published online ahead of print 2020]. J Allergy Clin Immunol. https://doi.org/10.1016/j.jaci.2019.12.907.Google Scholar This is likely for inhaled cortisone, prednisolone, dexamethasone, and fluticasone. Contrarily, mometasone inhibits the replication of SARS-CoV and HCoV-229E.5Matsuyama S. Kawase M. Nao N. Shirato K. Ujike M. Kamitani W. et al.The inhaled corticosteroid ciclesonide blocks coronavirus RNA replication by targeting viral NSP15.bioRxiv. 2020; Google Scholar Similarly, budesonide degrades the virulence of HCoV-229E.6Yamaya M. Nishimura H. Deng X. Sugawara M. Watanabe O. Nomura K. et al.Inhibitory effects of glucopyrronium, formoterol, and budesonide in coronavirus HCoV-229E replication and cytokine production by primary cultures of human nasal and tracheal epithelial cells.Respir Investig. 2020; 58: 155-168Crossref PubMed Scopus (199) Google Scholar Recently, the ICS ciclesonide was found to suppress the replication of SARS-CoV-2, by directly attacking the NSP15 viral endoribonuclease, demonstrating an antiviral function.7Jean S, Ko M, Lee J, Choi I, Byun SY, Park S, et al. Identification of antiviral drug candidates against SARS-CoV-2 from FDA-approved drugs [published online ahead of print 2020]. Antimicrob Agents Chemother. https://doi.org/10.1128/AAC.00819-20.Google Scholar Therapies with ICSs modulate the innate defensive mechanisms of the URT, interfering with cytokines, while at the same time perturbate the abundance and replication of commensal and pathogenic viruses.3Ramakrishnan V.F. Holt J. Nelson L.F. Ir D. Robertson C.E. Frank D.N. Determinants of the nasal microbiome: pilot study of effects of intranasal medication use.Allergy Rhinol. 2018; 9: 1-10Crossref Google Scholar,7Jean S, Ko M, Lee J, Choi I, Byun SY, Park S, et al. Identification of antiviral drug candidates against SARS-CoV-2 from FDA-approved drugs [published online ahead of print 2020]. Antimicrob Agents Chemother. https://doi.org/10.1128/AAC.00819-20.Google Scholar Depending on the chemical composition of ICSs, the impact on the virome of the URT is unpredictable. With this in mind, swabbing the URT of coronavirus-infected patients under an ICS regimen renders the quality of the viral load collected questionable. Taking alternative specimens from pleural effusions, stools, or even blood is of dubious diagnostic value. With all this scepticism in our minds, we are preparing ourselves to cope with the intricacies of triaging in a COVID-19 era, performing with responsibility the swabbing techniques, ensuring specimens of high diagnostic accuracy. Perspective: COVID-19, implications of nasal diseases and consequences for their managementJournal of Allergy and Clinical ImmunologyVol. 146Issue 1PreviewThe severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) has caused a global health emergency. With increasing numbers of infected people and deaths worldwide reported daily since the beginning of the year, we have to urgently focus on a new pandemic caused by the SARS-CoV-2, a betacoronavirus related to SARS-CoV. We have to urgently learn more about this virus, its ways of transmission to spread infection so fast all over the world, the pathomechanisms involved in human infection and intracellular entry, the consecutive spreading within the body, and finally the factors that determine the difference between a mild or even asymptomatic infection in one and a deadly disease in another patient. Full-Text PDF