There can be significant interactions between intracellular pathogens infecting the
same cells [1]. One possibility is that a chronic and/or latent first pathogen infection
can cause conventional T-cell exhaustion for T-cells targeting itself, and also accelerate
T-cell exhaustion for T-cells targeting a second pathogen [1]. This could involve
creating a cytokine environment which facilitates T-cell exhaustion, inducing T-cell
expressions of inhibitory receptors, such as PD-1; and inducing infected host cell
expressions of inhibitory ligands, such as PD-L1, to bind to the T-cell inhibitory
receptors [1]. A second distinct pathogen infection, particularly a virulent pathogen
which creates high antigen titers, can benefit from the T-cell exhaustion facilitating cytokine
environment, and/or expression of inhibitory ligands by the same infected cells, and
accelerate a T-cell exhaustion for the second pathogen [1].
T-cell exhaustion has been repeatedly linked to COVID-19 cases having severe outcomes
and/or mortality [2]. T-cell exhaustion can degrade the functions of both CD8+ and
CD4+ T-cells. This also includes follicular helper CD4+ T-cells, located primarily
in lymph node and spleen germinal centers, where these CD4+ T-cells have critical
roles in enabling antibody affinity maturation, isotype switching, generation of memory
B-cells and in B-cell differentiation into immunoglobulin (antibody) secreting plasma
cells [3]. Accelerated T-cell exhaustion could have significant effects on first-time
infections by the second pathogen, if germinal center follicular helper CD4+ T-cell
functions are inhibited, and immunoglobulins (antibodies) from B-cells are numerically
decreased or qualitatively inadequate in affinity selection/maturation from somatic
hypermutation to suppress the second pathogen [1, 4].
Such inadequate B-cell populations have been documented in severe cases of COVID-19,
where patients have relatively higher population fractions of the less-developed membrane-bround
IgM immunoglobulins on B-cells, in contrast to relatively higher population fractions
of the more developed membrane-bound IgG immunoglobulins on B-cells observed in control
patients or patients with mild cases [5]. These observations of isotype differences
in the immunoglobulin expression by B-cells suggest follicular helper CD4+ T-cell
interactions with B-cells in germinal centers did not promote adequate somatic hypermutation
and isotype switching and affinity maturation of immunoglobulins targeting the SARS-CoV-2
virus, which can be a result of CD4+ T-cell exhaustion in these severe cases [4].
In summary, accelerated T-cell exhaustion by its inhibition of follicular helper CD4+ T-cells
critical for conventional B-cells, can cause impaired B-cells and their production
of abnormally high proportions of less-developed antibodies.
One observed result of accelerated T-cell exhaustion may be elevated mortality rates
for COVID-19 and other epidemics, in which the second pathogen infection quickly achieves
T-cell exhaustion, and fatally overwhelms an individual's adaptive immune system [1].
However, dysfunctionality can have various degrees of expression. There may also be
rarer instances of accelerated T-cell exhaustion which result in dyfunctional B-cells
which release numerous quasi-dysfunctional immunoglobulins/antibodies sufficiently
functional to avoid mortality and severe infections, but having alternative unfortunate consequences.
In numerously documented cases, small percentages of mild cases of COVID-19 have resulted
in extensive hyperinflammatory diseases, including multisystem inflammatory syndrome
(MIS) and autoantibodies [6]. Hyperinflammatory diseases (MIS or other diseases similar
to Kawasaki disease) could be consequences of abnormally high levels of antibodies
secreted by B-cells and high titers of antigen–antibody immune complexes which could
not be promptly phagocytized by a small percentage of individuals [6, 7].
Pathogenesis of hyperinflammatory diseases could be initiated by pathogens that evade/impair
T-cell control and thus require antigen neutralization by a very large number of antibodies,
creating very large numbers of antigen–antibody immune complexes which cannot be quickly
phagocytized by certain individuals having transiently or permanently immuno-deficient
immune systems [6]. The steps by which antigen–antibody immune complexes can initiate
hyperinflammatory diseases through a Type III hypersensitivity immune reaction in
immuno-deficient individuals having impaired phagocytosis have already been outlined
[6]. There is also documented support from a 2020 study of intensive care cases of
COVID-19, where it was observed that a TH1 (cell-mediated immunity) response evolved
into a TH2 humoral immunity (antibody) response that then escalated into a Type III
hypersensitivity immune reaction with deposition of antigen–antibody immune complexes
in the walls of blood vessels to generate a severely inflammatory systemic vasculitis
[8]. Additionally, ten puzzling aspects of hyperinflammatory diseases, including their
prevalence in younger patients and mild cases and the tendency of hyperinflammatory
diseases to occur only once, can be plausibly explained by the steps previously outlined
[6].
Furthermore, hyperinflammatory diseases including MIS typically occur two to four
weeks after a SARS-CoV-2 infection [9]. This delay time is shorter than the time needed
for conventional complete T-cell exhaustion [1], and this delay time is plausibly
more consistent with a multistep process of accelerated T-cell exhaustion, inducing
less-developed antibody production, resulting in extensive antigen–antibody immune
complex titers in a phagocytosis impaired host, causing a Type III hypersensitivity
immune reaction. This would then produce protease secretions and express or expose autoantigens
which can result in autoantibodies, and this could ultimately achieve pathogenesis
of a hyperinflammatory disease [1, 6–8].
The development of chronic autoimmune diseases is an alternative outcome from a high
titer of antigen–antibody immune complexes, which cannot be quickly phagocytized in
immuno-deficient individuals, which can cause a Type III hypersensitivity immune reaction
with protease secretions which can express or expose autoantigens [7, 8, 10]. Therefore,
it is plausible that accelerated T-cell exhaustion in immuno-deficient individuals
can be an important factor in the pathogenesis of transient hyperinflammatory diseases,
including MIS and the various types of Kawasaki diseases [6], and/or an important
factor in the pathogenesis of chronic autoimmune diseases, such as diabetes, lupus
or another autoimmune disease [7, 8, 10].
Figure 1 summarizes various outcomes possibly leading to transient hyperinflammatory
diseases (e.g., MIS or one of the Kawasaki diseases) or chronic autoimmune diseases
(e.g., diabetes, lupus, or another disease).
Fig. 1
summarizes accelerated T-cell exhaustion outcomes which can cause one of the transient
hyperinflammatory diseases or one of the chronic autoimmune diseases or possibly a
fatal outcome
In conclusion, interactions between two intracellular pathogens can have significant
consequences, including accelerated T-cell exhaustion for a second pathogen. An immunologically
novel second pathogen infection, especially a virulent pathogen that creates large
antigen titers, could evade/impair T-cell defenses if there was accelerated exhaustion
of T-cells targeting the second pathogen. Accelerated T-cell exhaustion can occur
when the second pathogen can reuse the already expressed inhibitory ligands of the
infected cells. It is logically plausible that accelerated T-cell exhaustion can be
an important factor in causing several hyperinflammatory diseases and/or autoimmune
diseases in phagocytosis impaired, immuno-deficient individuals, by inhibiting follicular
helper CD4+ T-cell assistance to germinal center B-cell somatic hypermutation, affinity
maturation and isotype switching of antibodies, eventually resulting in a Type III
hypersensitivity immune reaction that leads to pathogenesis of a transient hyperinflammatory
disease or a chronic autoimmune disease.