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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The graphic represents a pathogenic model of 2019-nCoV considering different virus-host cell interactions&#46; The virus entry&#44; replication&#44; assembly and shedding indicating infectivity are shown at the left&#44; while the right side displays the innate antiviral response characterized by an interferon signature&#46; The center of the figure represents intracellular events unchained by the presence of the virus&#44; driving cell and mitochondrial stress and eventually ending in hypoxic damage&#46; The sites of action of different immunomodulatory drugs are marked&#46; ACE2&#58; angiotensin converting enzyme 2&#44; ANT&#58; adenine nucleotide translocation&#44; CARD&#58; caspase activation and recruitment domains&#44; CQ&#58; chloroquine&#44; CyD&#58; cyclophilin D&#44; ER&#58; endoplasmic reticulum&#44; FK506&#58; tacrolimus&#44; HSR&#58; heat shock response &#40;also unfolded-protein response of the cytosol&#41;&#44; IFN&#58; interferon&#44; IRF&#58; interferon regulatory factor&#44; iJAK&#58; inhibitor of Janus kinases&#44; MAS&#58; macrophage activation syndrome&#44; MAVS&#58; mitochondrial antiviral proteins&#44; MDA5&#58; melanoma differentiation-activated protein 5&#44; mtUPR&#58; mitochondrial unfolded-protein response&#44; NF&#954;B&#58; transcriptional activator kappa B&#44; polyA&#58; polyadenylated&#44; PTM&#58; postranslational modifications&#44; RIG-1&#58; retinoic acid inducible gene 1&#44; RLR&#58; RIG-1-like receptors&#44; Th&#58; T helper lymphocytes&#44; TCZ&#58; tocilizumab&#44; vRNA&#58; viral RNA&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The use of immunosuppressive therapies in COVID-19 infection is a recently raised topic which comes to fill an unmet need in the management of the patients&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">1</span></a> Intriguingly&#44; not only COVID-19 but also SARS and MERS CoVs &#8211; all members of the Betacoronavirus genus &#8211; associate to an increased risk of respiratory distress syndrome&#46; Already in patients with SARS-CoV&#44; the development of respiratory failure was thought to be the consequence of a vigorous innate immune response&#44; while effectiveness of tocilizumab in COVID-19 infected patients also supports the participation of a cytokine storm in severe phenotypes&#46;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">1&#44;2</span></a> A factor underlying this explosive response could be the capacity of betacoronaviruses to invade immune-competent cells&#44; particularly macrophages&#44; thereby hijacking the major drivers of innate immune responses&#46; Nonetheless&#44; targeting pro-inflammatory cytokines is neither the sole nor the first-line immunomodulatory approach in combating the infection&#46; As represented in the figure&#44; complex virus-host cell interactions providing opportunities for therapeutics should be regarded &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0010" class="elsevierStylePara elsevierViewall">Betacoronaviruses replicate and carry out transcriptional activities at the cell cytosol&#44; where the viral genome is detected by RIG-1 like receptor &#40;RLR&#41; helicases&#46; Upon binding of vRNA&#44; RLR activate mitochondrial antiviral proteins &#40;MAVS&#41;&#46; These in turn trigger phosphorylation of transcription factors and gene expression of interferons and cytokines&#44; which are pivotal for an effective antiviral response&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">3</span></a> Mitochondrial function is thus essential for the antiviral defense&#44; while these organelles also need to provide for the increased energetic needs of infected cells&#46; This fact points to mitochondrial failure as the mechanism unchaining severe forms of COVID-19 infection&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">4</span></a> In brief&#44; infected cells are exposed to an overload of nascent polypeptides&#44; transcriptional machinery and by-products of helicases activation&#44; altogether jeopardizing maintenance of protein folding and triggering cell and mitochondrial stress&#46;<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">5&#44;6</span></a> In addition&#44; COVID-19 genome polyadelnylation at the cytosol could waste adenine deposits and challenge mitochondrial permeability transition pore &#40;MPTP&#41;&#46; Ultimately&#44; mitochondrial proteostasis collapse would drive caspases activation and irreversible cell damage&#46; According to available literature&#44; calcineurin inhibitors could confer protection from these pathogenic processes&#46; Briefly&#44; these compounds help restore the unfolded-protein response &#40;UPR&#41; at the cytosol&#44; and may in this way rescue cells from necrosis&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">7</span></a> In addition&#44; upon targeting cyclophilin D&#44; cyclosporin A inhibits MPTP opening&#44; activates mitochondrial UPR &#40;mtUPR&#41; and prevents mitochondrial failure&#46;<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">8&#44;9</span></a> Moreover&#44; through this mechanism&#44; cyclosporin A has shown cardioprotective effects in patients with myocardial infarction&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">10</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Of interest&#44; there is a subtype of clinically amyopathic dermatomyositis &#40;CADM&#41; identified by the presence of antibodies against melanoma differentiation activated protein 5 &#40;MDA5&#41;&#44; which is an RLR helicase and also the putative cytoplasmic receptor for COVID-19&#46; Patients with MDA5 syndrome are prone to the development of rapidly progressive interstitial pneumonia and refractory respiratory failure&#46; Even though MDA5 syndrome is a rare condition&#44; its resemblance with the clinical features of CoV infections cannot go unnoticed&#46; Notably&#44; critically ill MDA5&#43; CADM patients can be rescued when a calcineurin inhibitor is administered early in the course of respiratory failure&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">11</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Finally&#44; it should be emphasized that cyclosporin A has shown remarkable antiviral activities in a variety of RNA viruses&#44; including the family of betacoronavirus&#44; which employ cyclophilins as chaperones and nuclear factor of activated T cells &#40;NFAT&#41; as a major signaling pathway&#46;<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">12&#44;13</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">On the whole&#44; we suggest that COVID-19 deadly action on host cells including pneumocytes and T lymphocytes&#44; results from their failure to adapt to cell and mitochondrial stress&#44; while dysfunctional macrophages remain as virus reservoir at the target tissue&#46; According to this model&#44; cyclosporin A could confer protection upstream of the cytokine storm in COVID-19 infected patients&#44; a hypothesis which it is planned to be tested in a randomized clinical trial in the coming weeks&#46;</p></span>"
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Letter to the Editor
Why choose cyclosporin A as first-line therapy in COVID-19 pneumonia
¿Por qué elegir ciclosporina A como primera línea terapéutica para la neumonía causada por COVID-19?
Olga Sanchez-Pernautea,
Corresponding author
osanchez@fjd.es

Corresponding author.
, Fredeswinda I. Romero-Buenoa, Albert Selva-O’Callaghanb
a Rheumatology Division, Jiménez Díaz Foundation University Hospital and Health Research Institute, Universidad Autónoma de Madrid, Madrid, Spain
b Department of Internal Medicine, Hospital Universitari Val d’Hebron, Universitat Autonoma de Barcelona, Barcelona, Spain
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The graphic represents a pathogenic model of 2019-nCoV considering different virus-host cell interactions&#46; The virus entry&#44; replication&#44; assembly and shedding indicating infectivity are shown at the left&#44; while the right side displays the innate antiviral response characterized by an interferon signature&#46; The center of the figure represents intracellular events unchained by the presence of the virus&#44; driving cell and mitochondrial stress and eventually ending in hypoxic damage&#46; The sites of action of different immunomodulatory drugs are marked&#46; ACE2&#58; angiotensin converting enzyme 2&#44; ANT&#58; adenine nucleotide translocation&#44; CARD&#58; caspase activation and recruitment domains&#44; CQ&#58; chloroquine&#44; CyD&#58; cyclophilin D&#44; ER&#58; endoplasmic reticulum&#44; FK506&#58; tacrolimus&#44; HSR&#58; heat shock response &#40;also unfolded-protein response of the cytosol&#41;&#44; IFN&#58; interferon&#44; IRF&#58; interferon regulatory factor&#44; iJAK&#58; inhibitor of Janus kinases&#44; MAS&#58; macrophage activation syndrome&#44; MAVS&#58; mitochondrial antiviral proteins&#44; MDA5&#58; melanoma differentiation-activated protein 5&#44; mtUPR&#58; mitochondrial unfolded-protein response&#44; NF&#954;B&#58; transcriptional activator kappa B&#44; polyA&#58; polyadenylated&#44; PTM&#58; postranslational modifications&#44; RIG-1&#58; retinoic acid inducible gene 1&#44; RLR&#58; RIG-1-like receptors&#44; Th&#58; T helper lymphocytes&#44; TCZ&#58; tocilizumab&#44; vRNA&#58; viral RNA&#46;</p>"
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particularly macrophages&#44; thereby hijacking the major drivers of innate immune responses&#46; Nonetheless&#44; targeting pro-inflammatory cytokines is neither the sole nor the first-line immunomodulatory approach in combating the infection&#46; As represented in the figure&#44; complex virus-host cell interactions providing opportunities for therapeutics should be regarded &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0010" class="elsevierStylePara elsevierViewall">Betacoronaviruses replicate and carry out transcriptional activities at the cell cytosol&#44; where the viral genome is detected by RIG-1 like receptor &#40;RLR&#41; helicases&#46; Upon binding of vRNA&#44; RLR activate mitochondrial antiviral proteins &#40;MAVS&#41;&#46; These in turn trigger phosphorylation of transcription factors and gene expression of interferons and cytokines&#44; which are pivotal for an effective antiviral response&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">3</span></a> Mitochondrial function is thus essential for the antiviral defense&#44; while these organelles also need to provide for the increased energetic needs of infected cells&#46; This fact points to mitochondrial failure as the mechanism unchaining severe forms of COVID-19 infection&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">4</span></a> In brief&#44; infected cells are exposed to an overload of nascent polypeptides&#44; transcriptional machinery and by-products of helicases activation&#44; altogether jeopardizing maintenance of protein folding and triggering cell and mitochondrial stress&#46;<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">5&#44;6</span></a> In addition&#44; COVID-19 genome polyadelnylation at the cytosol could waste adenine deposits and challenge mitochondrial permeability transition pore &#40;MPTP&#41;&#46; Ultimately&#44; mitochondrial proteostasis collapse would drive caspases activation and irreversible cell damage&#46; According to available literature&#44; calcineurin inhibitors could confer protection from these pathogenic processes&#46; Briefly&#44; these compounds help restore the unfolded-protein response &#40;UPR&#41; at the cytosol&#44; and may in this way rescue cells from necrosis&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">7</span></a> In addition&#44; upon targeting cyclophilin D&#44; cyclosporin A inhibits MPTP opening&#44; activates mitochondrial UPR &#40;mtUPR&#41; and prevents mitochondrial failure&#46;<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">8&#44;9</span></a> Moreover&#44; through this mechanism&#44; cyclosporin A has shown cardioprotective effects in patients with myocardial infarction&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">10</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Of interest&#44; there is a subtype of clinically amyopathic dermatomyositis &#40;CADM&#41; identified by the presence of antibodies against melanoma differentiation activated protein 5 &#40;MDA5&#41;&#44; which is an RLR helicase and also the putative cytoplasmic receptor for COVID-19&#46; Patients with MDA5 syndrome are prone to the development of rapidly progressive interstitial pneumonia and refractory respiratory failure&#46; Even though MDA5 syndrome is a rare condition&#44; its resemblance with the clinical features of CoV infections cannot go unnoticed&#46; Notably&#44; critically ill MDA5&#43; CADM patients can be rescued when a calcineurin inhibitor is administered early in the course of respiratory failure&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">11</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Finally&#44; it should be emphasized that cyclosporin A has shown remarkable antiviral activities in a variety of RNA viruses&#44; including the family of betacoronavirus&#44; which employ cyclophilins as chaperones and nuclear factor of activated T cells &#40;NFAT&#41; as a major signaling pathway&#46;<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">12&#44;13</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">On the whole&#44; we suggest that COVID-19 deadly action on host cells including pneumocytes and T lymphocytes&#44; results from their failure to adapt to cell and mitochondrial stress&#44; while dysfunctional macrophages remain as virus reservoir at the target tissue&#46; According to this model&#44; cyclosporin A could confer protection upstream of the cytokine storm in COVID-19 infected patients&#44; a hypothesis which it is planned to be tested in a randomized clinical trial in the coming weeks&#46;</p></span>"
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