Autoimmune response to COVID-19 characterised by eosinophilia, NETosis and EETosis

A previously healthy man in his 50s was admitted with severe COVID-19 pneumonia requiring extracorporeal membrane oxygenation (ECMO) support. He was found to have persistent eosinophilia, with a peak level of 7.5×10⁹/L. He had received multiple courses of steroids, including dexamethasone and methylprednisolone, with no improvement. On day 47, hydrocortisone was initiated for the treatment of septic shock. This resulted in the normalisation of the eosinophil count, which correlated with radiographic and clinical improvement. The patient was transitioned off ECMO and eventually weaned off mechanical ventilation. Studies conducted using the patient's serum identified circulating autoantibodies, which induced neutrophil extracellular traps (NETosis) and eosinophil extracellular traps (EETosis). A varying response of the eosinophils to different corticosteroids was observed in vivo that corresponded with the ex vivo experiments. This case highlights an unrecognised phenomenon of differential response to corticosteroids in severe COVID-19. Furthermore, this is the first reported case of EETosis in COVID-19.