Impact of prophylactic hydroxychloroquine on ultrastructural impairment and cellular SARS-CoV-2 infection in different cells of bronchoalveolar lavage fluids of COVID-19 patients
Shikha Chaudhary, Arti Joshi, Kishore Sesham, Preeti Rai, Shailendra Kumar, Asit Ranjan Mridha, Upendra Baitha, Tapas Chandra Nag, Subhash Chandra Yadav
Scientific Reports, doi:10.1038/s41598-023-39941-6
Many drugs were recommended as antiviral agents for infection control and effective therapy to reduce the mortality rate for COVID-19 patients. Hydroxychloroquine (HCQ), an antimalarial drug, has been controversially recommended for prophylactic use in many countries, including India, to control SARS-CoV-2 infections. We have explored the effect of prophylactic HCQ from the cells of bronchoalveolar lavage fluids from COVID-19-induced acute respiratory distress syndrome patients to determine the level of infection and ultrastructural alterations in the ciliated epithelium, type II pneumocytes, alveolar macrophages, neutrophils, and enucleated granulocytes. Ultrastructural investigation of ciliated epithelium and type II pneumocytes showed lesser infections and cellular impairment in the prophylactic HCQ + group than HCQ -group. However, macrophages and neutrophils displayed similar infection and ultrastructural alterations in both patient groups. The enucleated fragments of granulocytes showed phagocytosis of the matured virus in HCQ + groups. The present report unveils the ultrastructural proof to complement the paradox regarding the role of prophylactic HCQ in COVID-19 patients. The COVID-19 outbreak caused by severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) has rapidly propagated with nearly half a billion infected human beings globally 1 . There were negligible reports on specific and effective treatments for this deadly infection. Due to sudden outbreaks and very high mortality (29%) 2 by delta variant, many random trials and repurposing of existing drugs were conducted to control and cure the COVID-19 disease 2,3 . Hydroxychloroquine (HCQ), an antimalarial drug, has gained significant attention in the initial phase of COVID-19 from May 2020 onwards 4,5 . This drug was earlier reported to be effective (in vitro) in reducing viral internalization (by blocking proteolytic activation of S-protein) and replication (increasing the acidic environment of the endosome to inhibit viral assembly), including the SARS-CoV-2 and MERS-CoV 6-8 . The anti-SARS-CoV-2 effect of HCQ (by inhibiting internalization and proliferation) was proposed due to its ability to increase endosomal acidification, reduction of cathepsin L activation, interference with ACE-2 terminal glycosylation, proteolytic self-activation of furin, and the blockage of clathrin-mediated endocytosis 4, [9] [10] [11] . The immunomodulatory effects, alkalinization of vacuolar pH, Zinc ionophores, and binding ability of HCQ to sialic acids were proposed to inhibit the COVID-19 infection in vitro non-specifically 9,12-14 . Many clinical trials were initiated in various countries to investigate the effect of HCQ in the control and cure of COVID-19 disease [15] [16] [17] . It was reported that HCQ was very effective in reducing the multiplication of the SARS-COV-2 virus under in vitro culture conditions using Vero E6 cells with 6.90 µM concentration (EC) 90 18 .
Author contributions S.C. performed the experiments for sample processing, PAP and IF imaging standardization, electron microscopy, interpretation of the data, management of clinical records, and generation of the microscopy figures. P.R. performed the immunofluorescence imaging, recorded the clinical data, and helped S.C. with electron microscopyrelated experiments. A.J. performed the PAP imaging. K.S. collected the sample from the ICU wards. S.K. was involved in designing the study and standardizing the sample collection strategies. A.R.M. and T.C.N. helped interpret the results and the images and correction of manuscripts. A.R.M. and U.B. also helped in the correction of the manuscript. S.C.Y. designed the study, performed, and supervised COVID-19 patient experiments, analyzed the data, generated the figures, wrote the manuscript, and directed the project. All authors read and approved the final draft of this manuscript.
Competing interests The authors declare no competing interests.
Additional information
Supplementary Information The online version contains supplementary material available at https:// doi. org/ 10. 1038/ s41598-023-39941-6. Correspondence and requests for materials should be addressed to S.C.Y. Reprints and permissions information is available at www.nature.com/reprints. Publisher's note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
References
Altulea, Maassen, Baranov, Van Den Bogaart, What makes (hydroxy)chloroquine ineffective against COVID-19: Insights from cell biology, J. Mol. Cell. Biol,
doi:10.1093/jmcb/mjab016Carcaterra, Caruso, Alveolar epithelial cell type II as main target of SARS-CoV-2 virus and COVID-19 development via NF-Kb pathway deregulation: A physio-pathological theory, Med. Hypotheses,
doi:10.1016/j.mehy.2020.110412Catteau, Low-dose hydroxychloroquine therapy and mortality in hospitalised patients with COVID-19: A nationwide observational study of 8075 participants, Int. J. Antimicrob. Agents,
doi:10.1016/j.ijantimicag.2020.106144Chaudhary, Ultracellular imaging of bronchoalveolar lavage from young age COVID-19 patients with comorbidities showed greater SARS-COV-2 infection but lesser ultrastructural damage than the old age patients, Microsc. Microanal,
doi:10.1017/S1431927622012430Cortegiani, Ingoglia, Ippolito, Giarratano, Einav, A systematic review on the efficacy and safety of chloroquine for the treatment of COVID-19, J. Crit. Care,
doi:10.1016/j.jcrc.2020.03.005Falcao, De Goes Cavalcanti, Filgueiras Filho, De Brito, Case report: Hepatotoxicity associated with the use of hydroxychloroquine in a patient with COVID-19, Am. J. Trop. Med. Hyg,
doi:10.4269/ajtmh.20-0276Ferreira, Oliveira, Bettencourt, Chronic treatment with hydroxychloroquine and SARS-CoV-2 infection, J. Med. Virol,
doi:10.1002/jmv.26286Gao, Hu, Update on use of chloroquine/hydroxychloroquine to treat coronavirus disease 2019 (COVID-19), Biosci. Trends,
doi:10.5582/bst.2020.03072Gao, Tian, Yang, Breakthrough: Chloroquine phosphate has shown apparent efficacy in treatment of COVID-19 associated pneumonia in clinical studies, Scientific Reports |,
doi:10.5582/bst.2020.01047Gautret, Hydroxychloroquine and azithromycin as a treatment of COVID-19: Results of an open-label non-randomized clinical trial, Int. J. Antimicrob. Agents,
doi:10.1016/j.ijantimicag.2020.105949Grau-Pujol, Pre-exposure prophylaxis with hydroxychloroquine for COVID-19: A double-blind, placebo-controlled randomized clinical trial, Trials,
doi:10.1186/s13063-021-05758-9Guastalegname, Vallone, Could chloroquine/hydroxychloroquine be harmful in coronavirus disease 2019 (COVID-19) treatment?, Clin. Infect. Dis,
doi:10.1093/cid/ciaa321Infante, Ricordi, Alejandro, Caprio, Fabbri, Hydroxychloroquine in the COVID-19 pandemic era: In pursuit of a rational use for prophylaxis of SARS-CoV-2 infection, Expert Rev. Anti Infect. Ther,
doi:10.1080/14787210.2020.1799785Keyaerts, Antiviral activity of chloroquine against human coronavirus OC43 infection in newborn mice, Antimicrob. Agents Chemother,
doi:10.1128/AAC.01509-08Keyaerts, Vijgen, Maes, Neyts, Van Ranst, In vitro inhibition of severe acute respiratory syndrome coronavirus by chloroquine, Biochem. Biophys. Res. Commun,
doi:10.1016/j.bbrc.2004.08.085Kim, A rush to judgment? Rapid reporting and dissemination of results and its consequences regarding the use of hydroxychloroquine for COVID-19, Ann. Intern. Med,
doi:10.7326/M20-1223Liu, Hydroxychloroquine, a less toxic derivative of chloroquine, is effective in inhibiting SARS-CoV-2 infection in vitro, Cell Discov,
doi:10.1038/s41421-020-0156-0Molina, No evidence of rapid antiviral clearance or clinical benefit with the combination of hydroxychloroquine and azithromycin in patients with severe COVID-19 infection, Med. Mal. Infect,
doi:10.1016/j.medmal.2020.03.006Savarino, Boelaert, Cassone, Majori, Cauda, Effects of chloroquine on viral infections: An old drug against today's diseases?, Lancet Infect. Dis,
doi:10.1016/s1473-3099(03)00806-5Schrezenmeier, Dorner, Mechanisms of action of hydroxychloroquine and chloroquine: Implications for rheumatology, Nat. Rev. Rheumatol,
doi:10.1038/s41584-020-0372-xTabatabai, An analysis of COVID-19 mortality during the dominancy of alpha, delta, and omicron in the USA, J. Prim. Care Community Health,
doi:10.1177/21501319231170164Tang, Hydroxychloroquine in patients with mainly mild to moderate coronavirus disease 2019: Open label, randomised controlled trial, BMJ,
doi:10.1136/bmj.m1849Verscheijden, Chloroquine dosing recommendations for pediatric COVID-19 supported by modeling and simulation, Clin. Pharmacol. Ther,
doi:10.1002/cpt.1864Wang, Remdesivir and chloroquine effectively inhibit the recently emerged novel coronavirus (2019-nCoV) in vitro, Cell. Res,
doi:10.1038/s41422-020-0282-0Yao, In vitro antiviral activity and projection of optimized dosing design of hydroxychloroquine for the treatment of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), Clin. Infect. Dis,
doi:10.1093/cid/ciaa237Yazdany, Kim, Use of hydroxychloroquine and chloroquine during the COVID-19 pandemic: What every clinician should know, Ann. Intern. Med,
doi:10.7326/M20-1334Zhao, Cell morphological analysis of SARS-CoV-2 infection by transmission electron microscopy, J. Thorac. Dis,
doi:10.21037/jtd-20-1368Zhou, Dai, Tong, COVID-19: A recommendation to examine the effect of hydroxychloroquine in preventing infection and progression, J. Antimicrob. Chemother,
doi:10.1093/jac/dkaa114{ 'indexed': {'date-parts': [[2023, 8, 6]], 'date-time': '2023-08-06T04:09:53Z', 'timestamp': 1691294993004},
'reference-count': 47,
'publisher': 'Springer Science and Business Media LLC',
'issue': '1',
'license': [ { 'start': { 'date-parts': [[2023, 8, 5]],
'date-time': '2023-08-05T00:00:00Z',
'timestamp': 1691193600000},
'content-version': 'tdm',
'delay-in-days': 0,
'URL': 'https://creativecommons.org/licenses/by/4.0'},
{ 'start': { 'date-parts': [[2023, 8, 5]],
'date-time': '2023-08-05T00:00:00Z',
'timestamp': 1691193600000},
'content-version': 'vor',
'delay-in-days': 0,
'URL': 'https://creativecommons.org/licenses/by/4.0'}],
'funder': [ { 'name': 'IUSSTF Indo-US Virtual Network for the COVID-19 program and DBT SAHAJ',
'award': ['IUSSTF/VN- COVID/007/2020', 'BT/INF/22/SP44285/2021']}],
'content-domain': {'domain': ['link.springer.com'], 'crossmark-restriction': False},
'abstract': '<jats:title>Abstract</jats:title><jats:p>Many drugs were recommended as antiviral agents for '
'infection control and effective therapy to reduce the mortality rate for COVID-19 patients. '
'Hydroxychloroquine (HCQ), an antimalarial drug, has been controversially recommended for '
'prophylactic use in many countries, including India, to control SARS-CoV-2 infections. We '
'have explored the effect of prophylactic HCQ from the cells of bronchoalveolar lavage fluids '
'from COVID-19-induced acute respiratory distress syndrome patients to determine the level of '
'infection and ultrastructural alterations in the ciliated epithelium, type II pneumocytes, '
'alveolar macrophages, neutrophils, and enucleated granulocytes. Ultrastructural investigation '
'of ciliated epithelium and type II pneumocytes showed lesser infections and cellular '
'impairment in the prophylactic HCQ<jats:sup>+</jats:sup> group than HCQ<jats:sup>−</jats:sup> '
'group. However, macrophages and neutrophils displayed similar infection and ultrastructural '
'alterations in both patient groups. The enucleated fragments of granulocytes showed '
'phagocytosis of the matured virus in HCQ<jats:sup>+</jats:sup> groups. The present report '
'unveils the ultrastructural proof to complement the paradox regarding the role of '
'prophylactic HCQ in COVID-19 patients.</jats:p>',
'DOI': '10.1038/s41598-023-39941-6',
'type': 'journal-article',
'created': {'date-parts': [[2023, 8, 5]], 'date-time': '2023-08-05T15:01:40Z', 'timestamp': 1691247700000},
'update-policy': 'http://dx.doi.org/10.1007/springer_crossmark_policy',
'source': 'Crossref',
'is-referenced-by-count': 0,
'title': 'Impact of prophylactic hydroxychloroquine on ultrastructural impairment and cellular SARS-CoV-2 '
'infection in different cells of bronchoalveolar lavage fluids of COVID-19 patients',
'prefix': '10.1038',
'volume': '13',
'author': [ {'given': 'Shikha', 'family': 'Chaudhary', 'sequence': 'first', 'affiliation': []},
{'given': 'Arti', 'family': 'Joshi', 'sequence': 'additional', 'affiliation': []},
{'given': 'Kishore', 'family': 'Sesham', 'sequence': 'additional', 'affiliation': []},
{'given': 'Preeti', 'family': 'Rai', 'sequence': 'additional', 'affiliation': []},
{'given': 'Shailendra', 'family': 'Kumar', 'sequence': 'additional', 'affiliation': []},
{'given': 'Asit Ranjan', 'family': 'Mridha', 'sequence': 'additional', 'affiliation': []},
{'given': 'Upendra', 'family': 'Baitha', 'sequence': 'additional', 'affiliation': []},
{'given': 'Tapas Chandra', 'family': 'Nag', 'sequence': 'additional', 'affiliation': []},
{'given': 'Subhash Chandra', 'family': 'Yadav', 'sequence': 'additional', 'affiliation': []}],
'member': '297',
'published-online': {'date-parts': [[2023, 8, 5]]},
'reference': [ { 'key': '39941_CR1',
'unstructured': 'WHO Coronavirus (COVID-19) Dashboard. https://covid19.who.int/.'},
{ 'key': '39941_CR2',
'doi-asserted-by': 'publisher',
'first-page': '667',
'DOI': '10.1126/science.abm5154',
'volume': '375',
'author': 'P Jha',
'year': '2022',
'unstructured': 'Jha, P. et al. COVID mortality in India: National survey data and health '
'facility deaths. Science 375, 667–671. '
'https://doi.org/10.1126/science.abm5154 (2022).',
'journal-title': 'Science'},
{ 'key': '39941_CR3',
'doi-asserted-by': 'publisher',
'first-page': '215013192311701',
'DOI': '10.1177/21501319231170164',
'volume': '14',
'author': 'M Tabatabai',
'year': '2023',
'unstructured': 'Tabatabai, M. et al. An analysis of COVID-19 mortality during the '
'dominancy of alpha, delta, and omicron in the USA. J. Prim. Care '
'Community Health 14, 21501319231170164. '
'https://doi.org/10.1177/21501319231170164 (2023).',
'journal-title': 'J. Prim. Care Community Health'},
{ 'key': '39941_CR4',
'doi-asserted-by': 'publisher',
'first-page': '16',
'DOI': '10.1038/s41421-020-0156-0',
'volume': '6',
'author': 'J Liu',
'year': '2020',
'unstructured': 'Liu, J. et al. Hydroxychloroquine, a less toxic derivative of '
'chloroquine, is effective in inhibiting SARS-CoV-2 infection in vitro. '
'Cell Discov. 6, 16. https://doi.org/10.1038/s41421-020-0156-0 (2020).',
'journal-title': 'Cell Discov.'},
{ 'key': '39941_CR5',
'doi-asserted-by': 'publisher',
'first-page': '732',
'DOI': '10.1093/cid/ciaa237',
'volume': '71',
'author': 'X Yao',
'year': '2020',
'unstructured': 'Yao, X. et al. In vitro antiviral activity and projection of optimized '
'dosing design of hydroxychloroquine for the treatment of severe acute '
'respiratory syndrome coronavirus 2 (SARS-CoV-2). Clin. Infect. Dis. 71, '
'732–739. https://doi.org/10.1093/cid/ciaa237 (2020).',
'journal-title': 'Clin. Infect. Dis.'},
{ 'key': '39941_CR6',
'doi-asserted-by': 'publisher',
'first-page': '105923',
'DOI': '10.1016/j.ijantimicag.2020.105923',
'volume': '55',
'author': 'P Colson',
'year': '2020',
'unstructured': 'Colson, P., Rolain, J. M. & Raoult, D. Chloroquine for the 2019 novel '
'coronavirus SARS-CoV-2. Int. J. Antimicrob. Agents 55, 105923. '
'https://doi.org/10.1016/j.ijantimicag.2020.105923 (2020).',
'journal-title': 'Int. J. Antimicrob. Agents'},
{ 'key': '39941_CR7',
'doi-asserted-by': 'publisher',
'first-page': '722',
'DOI': '10.1016/s1473-3099(03)00806-5',
'volume': '3',
'author': 'A Savarino',
'year': '2003',
'unstructured': 'Savarino, A., Boelaert, J. R., Cassone, A., Majori, G. & Cauda, R. '
'Effects of chloroquine on viral infections: An old drug against today’s '
'diseases?. Lancet Infect. Dis. 3, 722–727. '
'https://doi.org/10.1016/s1473-3099(03)00806-5 (2003).',
'journal-title': 'Lancet Infect. Dis.'},
{ 'key': '39941_CR8',
'doi-asserted-by': 'publisher',
'first-page': '1432',
'DOI': '10.1136/bmj.m1432',
'volume': '369',
'author': 'RE Ferner',
'year': '2020',
'unstructured': 'Ferner, R. E. & Aronson, J. K. Chloroquine and hydroxychloroquine in '
'covid-19. BMJ 369, 1432. https://doi.org/10.1136/bmj.m1432 (2020).',
'journal-title': 'BMJ'},
{ 'key': '39941_CR9',
'doi-asserted-by': 'publisher',
'first-page': '175',
'DOI': '10.1093/jmcb/mjab016',
'volume': '13',
'author': 'D Altulea',
'year': '2021',
'unstructured': 'Altulea, D., Maassen, S., Baranov, M. V. & van den Bogaart, G. What '
'makes (hydroxy)chloroquine ineffective against COVID-19: Insights from '
'cell biology. J. Mol. Cell. Biol. 13, 175–184. '
'https://doi.org/10.1093/jmcb/mjab016 (2021).',
'journal-title': 'J. Mol. Cell. Biol.'},
{ 'key': '39941_CR10',
'doi-asserted-by': 'publisher',
'first-page': '755',
'DOI': '10.1002/jmv.26286',
'volume': '93',
'author': 'A Ferreira',
'year': '2021',
'unstructured': 'Ferreira, A., Oliveira, E. S. A. & Bettencourt, P. Chronic treatment '
'with hydroxychloroquine and SARS-CoV-2 infection. J. Med. Virol. 93, '
'755–759. https://doi.org/10.1002/jmv.26286 (2021).',
'journal-title': 'J. Med. Virol.'},
{ 'key': '39941_CR11',
'doi-asserted-by': 'publisher',
'first-page': '584',
'DOI': '10.1038/s41586-020-2558-4',
'volume': '585',
'author': 'P Maisonnasse',
'year': '2020',
'unstructured': 'Maisonnasse, P. et al. Hydroxychloroquine use against SARS-CoV-2 '
'infection in non-human primates. Nature 585, 584–587. '
'https://doi.org/10.1038/s41586-020-2558-4 (2020).',
'journal-title': 'Nature'},
{ 'key': '39941_CR12',
'doi-asserted-by': 'publisher',
'first-page': '1435',
'DOI': '10.1080/15548627.2018.1474314',
'volume': '14',
'author': 'M Mauthe',
'year': '2018',
'unstructured': 'Mauthe, M. et al. Chloroquine inhibits autophagic flux by decreasing '
'autophagosome-lysosome fusion. Autophagy 14, 1435–1455. '
'https://doi.org/10.1080/15548627.2018.1474314 (2018).',
'journal-title': 'Autophagy'},
{ 'key': '39941_CR13',
'doi-asserted-by': 'publisher',
'first-page': '910',
'DOI': '10.1016/j.immuni.2020.05.002',
'volume': '52',
'author': 'N Vabret',
'year': '2020',
'unstructured': 'Vabret, N. et al. Immunology of COVID-19: Current state of the science. '
'Immunity 52, 910–941. https://doi.org/10.1016/j.immuni.2020.05.002 '
'(2020).',
'journal-title': 'Immunity'},
{ 'key': '39941_CR14',
'doi-asserted-by': 'publisher',
'first-page': '13738',
'DOI': '10.1038/s41598-017-14221-2',
'volume': '7',
'author': 'J Wolfram',
'year': '2017',
'unstructured': 'Wolfram, J. et al. A chloroquine-induced macrophage-preconditioning '
'strategy for improved nanodelivery. Sci. Rep. 7, 13738. '
'https://doi.org/10.1038/s41598-017-14221-2 (2017).',
'journal-title': 'Sci. Rep.'},
{ 'key': '39941_CR15',
'doi-asserted-by': 'publisher',
'first-page': '279',
'DOI': '10.1016/j.jcrc.2020.03.005',
'volume': '57',
'author': 'A Cortegiani',
'year': '2020',
'unstructured': 'Cortegiani, A., Ingoglia, G., Ippolito, M., Giarratano, A. & Einav, S. A '
'systematic review on the efficacy and safety of chloroquine for the '
'treatment of COVID-19. J. Crit. Care 57, 279–283. '
'https://doi.org/10.1016/j.jcrc.2020.03.005 (2020).',
'journal-title': 'J. Crit. Care'},
{ 'key': '39941_CR16',
'doi-asserted-by': 'publisher',
'first-page': '105949',
'DOI': '10.1016/j.ijantimicag.2020.105949',
'volume': '56',
'author': 'P Gautret',
'year': '2020',
'unstructured': 'Gautret, P. et al. Hydroxychloroquine and azithromycin as a treatment of '
'COVID-19: Results of an open-label non-randomized clinical trial. Int. '
'J. Antimicrob. Agents 56, 105949–105949. '
'https://doi.org/10.1016/j.ijantimicag.2020.105949 (2020).',
'journal-title': 'Int. J. Antimicrob. Agents'},
{ 'key': '39941_CR17',
'doi-asserted-by': 'publisher',
'first-page': '215',
'DOI': '10.3785/j.issn.1008-9292.2020.03.03',
'volume': '49',
'author': 'J Chen',
'year': '2020',
'unstructured': 'Chen, J. et al. A pilot study of hydroxychloroquine in treatment of '
'patients with moderate COVID-19. Zhejiang Da Xue Xue Bao Yi Xue Ban 49, '
'215–219. https://doi.org/10.3785/j.issn.1008-9292.2020.03.03 (2020).',
'journal-title': 'Zhejiang Da Xue Xue Bao Yi Xue Ban'},
{ 'key': '39941_CR18',
'doi-asserted-by': 'publisher',
'first-page': '269',
'DOI': '10.1038/s41422-020-0282-0',
'volume': '30',
'author': 'M Wang',
'year': '2020',
'unstructured': 'Wang, M. et al. Remdesivir and chloroquine effectively inhibit the '
'recently emerged novel coronavirus (2019-nCoV) in vitro. Cell. Res. 30, '
'269–271. https://doi.org/10.1038/s41422-020-0282-0 (2020).',
'journal-title': 'Cell. Res.'},
{ 'key': '39941_CR19',
'unstructured': 'National Task Force Against COVID-19. Advisory on the Use of '
'Hydroxy-Chloroquine as Prophylaxis for SARS-CoV-2 Infection. (2020).'},
{ 'key': '39941_CR20',
'doi-asserted-by': 'publisher',
'first-page': '1667',
'DOI': '10.1093/jac/dkaa114',
'volume': '75',
'author': 'D Zhou',
'year': '2020',
'unstructured': 'Zhou, D., Dai, S. M. & Tong, Q. COVID-19: A recommendation to examine '
'the effect of hydroxychloroquine in preventing infection and '
'progression. J. Antimicrob. Chemother. 75, 1667–1670. '
'https://doi.org/10.1093/jac/dkaa114 (2020).',
'journal-title': 'J. Antimicrob. Chemother.'},
{ 'key': '39941_CR21',
'doi-asserted-by': 'publisher',
'first-page': '155',
'DOI': '10.1038/s41584-020-0372-x',
'volume': '16',
'author': 'E Schrezenmeier',
'year': '2020',
'unstructured': 'Schrezenmeier, E. & Dorner, T. Mechanisms of action of '
'hydroxychloroquine and chloroquine: Implications for rheumatology. Nat. '
'Rev. Rheumatol. 16, 155–166. https://doi.org/10.1038/s41584-020-0372-x '
'(2020).',
'journal-title': 'Nat. Rev. Rheumatol.'},
{ 'key': '39941_CR22',
'doi-asserted-by': 'publisher',
'first-page': '5',
'DOI': '10.1080/14787210.2020.1799785',
'volume': '19',
'author': 'M Infante',
'year': '2021',
'unstructured': 'Infante, M., Ricordi, C., Alejandro, R., Caprio, M. & Fabbri, A. '
'Hydroxychloroquine in the COVID-19 pandemic era: In pursuit of a '
'rational use for prophylaxis of SARS-CoV-2 infection. Expert Rev. Anti '
'Infect. Ther. 19, 5–16. https://doi.org/10.1080/14787210.2020.1799785 '
'(2021).',
'journal-title': 'Expert Rev. Anti Infect. Ther.'},
{ 'key': '39941_CR23',
'doi-asserted-by': 'publisher',
'first-page': '67',
'DOI': '10.1016/S1473-3099(06)70361-9',
'volume': '6',
'author': 'A Savarino',
'year': '2006',
'unstructured': 'Savarino, A., Di Trani, L., Donatelli, I., Cauda, R. & Cassone, A. New '
'insights into the antiviral effects of chloroquine. Lancet Infect. Dis. '
'6, 67–69. https://doi.org/10.1016/S1473-3099(06)70361-9 (2006).',
'journal-title': 'Lancet Infect. Dis.'},
{ 'key': '39941_CR24',
'doi-asserted-by': 'publisher',
'first-page': '808',
'DOI': '10.1186/s13063-021-05758-9',
'volume': '22',
'author': 'B Grau-Pujol',
'year': '2021',
'unstructured': 'Grau-Pujol, B. et al. Pre-exposure prophylaxis with hydroxychloroquine '
'for COVID-19: A double-blind, placebo-controlled randomized clinical '
'trial. Trials 22, 808. https://doi.org/10.1186/s13063-021-05758-9 '
'(2021).',
'journal-title': 'Trials'},
{ 'key': '39941_CR25',
'doi-asserted-by': 'publisher',
'first-page': 'e0261980',
'DOI': '10.1371/journal.pone.0261980',
'volume': '17',
'author': 'J Rojas-Serrano',
'year': '2022',
'unstructured': 'Rojas-Serrano, J. et al. Hydroxychloroquine for prophylaxis of COVID-19 '
'in health workers: A randomized clinical trial. PLoS ONE 17, e0261980. '
'https://doi.org/10.1371/journal.pone.0261980 (2022).',
'journal-title': 'PLoS ONE'},
{ 'key': '39941_CR26',
'doi-asserted-by': 'publisher',
'first-page': '588',
'DOI': '10.1038/s41586-020-2575-3',
'volume': '585',
'author': 'M Hoffmann',
'year': '2020',
'unstructured': 'Hoffmann, M. et al. Chloroquine does not inhibit infection of human lung '
'cells with SARS-CoV-2. Nature 585, 588–590. '
'https://doi.org/10.1038/s41586-020-2575-3 (2020).',
'journal-title': 'Nature'},
{ 'key': '39941_CR27',
'doi-asserted-by': 'publisher',
'first-page': '1849',
'DOI': '10.1136/bmj.m1849',
'volume': '369',
'author': 'W Tang',
'year': '2020',
'unstructured': 'Tang, W. et al. Hydroxychloroquine in patients with mainly mild to '
'moderate coronavirus disease 2019: Open label, randomised controlled '
'trial. BMJ 369, 1849. https://doi.org/10.1136/bmj.m1849 (2020).',
'journal-title': 'BMJ'},
{ 'key': '39941_CR28',
'unstructured': 'World Health Organisation. Coronavirus Disease (COVID-19): Solidarity '
'Trial and Hydroxychloroquine. Accessed 19 Jun 2020.'},
{ 'key': '39941_CR29',
'doi-asserted-by': 'publisher',
'first-page': '106144',
'DOI': '10.1016/j.ijantimicag.2020.106144',
'volume': '56',
'author': 'L Catteau',
'year': '2020',
'unstructured': 'Catteau, L. et al. Low-dose hydroxychloroquine therapy and mortality in '
'hospitalised patients with COVID-19: A nationwide observational study of '
'8075 participants. Int. J. Antimicrob. Agents 56, 106144. '
'https://doi.org/10.1016/j.ijantimicag.2020.106144 (2020).',
'journal-title': 'Int. J. Antimicrob. Agents'},
{ 'key': '39941_CR30',
'doi-asserted-by': 'publisher',
'first-page': '301',
'DOI': '10.1186/s12890-020-01343-z',
'volume': '20',
'author': 'L Pandolfi',
'year': '2020',
'unstructured': 'Pandolfi, L. et al. Broncho-alveolar inflammation in COVID-19 patients: '
'A correlation with clinical outcome. BMC Pulm. Med. 20, 301. '
'https://doi.org/10.1186/s12890-020-01343-z (2020).',
'journal-title': 'BMC Pulm. Med.'},
{ 'key': '39941_CR31',
'doi-asserted-by': 'publisher',
'first-page': '156',
'DOI': '10.5582/bst.2020.03072',
'volume': '14',
'author': 'J Gao',
'year': '2020',
'unstructured': 'Gao, J. & Hu, S. Update on use of chloroquine/hydroxychloroquine to '
'treat coronavirus disease 2019 (COVID-19). Biosci. Trends 14, 156–158. '
'https://doi.org/10.5582/bst.2020.03072 (2020).',
'journal-title': 'Biosci. Trends'},
{ 'key': '39941_CR32',
'doi-asserted-by': 'publisher',
'first-page': '72',
'DOI': '10.5582/bst.2020.01047',
'volume': '14',
'author': 'J Gao',
'year': '2020',
'unstructured': 'Gao, J., Tian, Z. & Yang, X. Breakthrough: Chloroquine phosphate has '
'shown apparent efficacy in treatment of COVID-19 associated pneumonia in '
'clinical studies. Biosci. Trends 14, 72–73. '
'https://doi.org/10.5582/bst.2020.01047 (2020).',
'journal-title': 'Biosci. Trends'},
{ 'key': '39941_CR33',
'doi-asserted-by': 'publisher',
'first-page': '264',
'DOI': '10.1016/j.bbrc.2004.08.085',
'volume': '323',
'author': 'E Keyaerts',
'year': '2004',
'unstructured': 'Keyaerts, E., Vijgen, L., Maes, P., Neyts, J. & Van Ranst, M. In vitro '
'inhibition of severe acute respiratory syndrome coronavirus by '
'chloroquine. Biochem. Biophys. Res. Commun. 323, 264–268. '
'https://doi.org/10.1016/j.bbrc.2004.08.085 (2004).',
'journal-title': 'Biochem. Biophys. Res. Commun.'},
{ 'key': '39941_CR34',
'doi-asserted-by': 'publisher',
'first-page': '3416',
'DOI': '10.1128/AAC.01509-08',
'volume': '53',
'author': 'E Keyaerts',
'year': '2009',
'unstructured': 'Keyaerts, E. et al. Antiviral activity of chloroquine against human '
'coronavirus OC43 infection in newborn mice. Antimicrob. Agents '
'Chemother. 53, 3416–3421. https://doi.org/10.1128/AAC.01509-08 (2009).',
'journal-title': 'Antimicrob. Agents Chemother.'},
{ 'key': '39941_CR35',
'doi-asserted-by': 'publisher',
'first-page': '248',
'DOI': '10.1002/cpt.1864',
'volume': '108',
'author': 'LFM Verscheijden',
'year': '2020',
'unstructured': 'Verscheijden, L. F. M. et al. Chloroquine dosing recommendations for '
'pediatric COVID-19 supported by modeling and simulation. Clin. '
'Pharmacol. Ther. 108, 248–252. https://doi.org/10.1002/cpt.1864 (2020).',
'journal-title': 'Clin. Pharmacol. Ther.'},
{ 'key': '39941_CR36',
'doi-asserted-by': 'publisher',
'first-page': '69',
'DOI': '10.1186/1743-422X-2-69',
'volume': '2',
'author': 'MJ Vincent',
'year': '2005',
'unstructured': 'Vincent, M. J. et al. Chloroquine is a potent inhibitor of SARS '
'coronavirus infection and spread. Virol. J. 2, 69. '
'https://doi.org/10.1186/1743-422X-2-69 (2005).',
'journal-title': 'Virol. J.'},
{ 'key': '39941_CR37',
'doi-asserted-by': 'publisher',
'first-page': '106247',
'DOI': '10.1016/j.ijantimicag.2020.106247',
'volume': '57',
'author': 'S Ruiz',
'year': '2021',
'unstructured': 'Ruiz, S. et al. Hydroxychloroquine lung pharmacokinetics in critically '
'ill patients with COVID-19. Int. J. Antimicrob. Agents 57, 106247. '
'https://doi.org/10.1016/j.ijantimicag.2020.106247 (2021).',
'journal-title': 'Int. J. Antimicrob. Agents'},
{ 'key': '39941_CR38',
'doi-asserted-by': 'publisher',
'first-page': '754',
'DOI': '10.7326/M20-1334',
'volume': '172',
'author': 'J Yazdany',
'year': '2020',
'unstructured': 'Yazdany, J. & Kim, A. H. J. Use of hydroxychloroquine and chloroquine '
'during the COVID-19 pandemic: What every clinician should know. Ann. '
'Intern. Med. 172, 754–755. https://doi.org/10.7326/M20-1334 (2020).',
'journal-title': 'Ann. Intern. Med.'},
{ 'key': '39941_CR39',
'doi-asserted-by': 'publisher',
'first-page': '384',
'DOI': '10.1016/j.medmal.2020.03.006',
'volume': '50',
'author': 'JM Molina',
'year': '2020',
'unstructured': 'Molina, J. M. et al. No evidence of rapid antiviral clearance or '
'clinical benefit with the combination of hydroxychloroquine and '
'azithromycin in patients with severe COVID-19 infection. Med. Mal. '
'Infect. 50, 384. https://doi.org/10.1016/j.medmal.2020.03.006 (2020).',
'journal-title': 'Med. Mal. Infect.'},
{ 'key': '39941_CR40',
'doi-asserted-by': 'publisher',
'first-page': '888',
'DOI': '10.1093/cid/ciaa321',
'volume': '71',
'author': 'M Guastalegname',
'year': '2020',
'unstructured': 'Guastalegname, M. & Vallone, A. Could chloroquine/hydroxychloroquine be '
'harmful in coronavirus disease 2019 (COVID-19) treatment?. Clin. Infect. '
'Dis. 71, 888–889. https://doi.org/10.1093/cid/ciaa321 (2020).',
'journal-title': 'Clin. Infect. Dis.'},
{ 'key': '39941_CR41',
'doi-asserted-by': 'publisher',
'first-page': '1214',
'DOI': '10.4269/ajtmh.20-0276',
'volume': '102',
'author': 'MB Falcao',
'year': '2020',
'unstructured': 'Falcao, M. B., de Goes Cavalcanti, L. P., Filgueiras Filho, N. M. & de '
'Brito, C. A. A. Case report: Hepatotoxicity associated with the use of '
'hydroxychloroquine in a patient with COVID-19. Am. J. Trop. Med. Hyg. '
'102, 1214–1216. https://doi.org/10.4269/ajtmh.20-0276 (2020).',
'journal-title': 'Am. J. Trop. Med. Hyg.'},
{ 'key': '39941_CR42',
'doi-asserted-by': 'publisher',
'first-page': '819',
'DOI': '10.7326/M20-1223',
'volume': '172',
'author': 'AHJ Kim',
'year': '2020',
'unstructured': 'Kim, A. H. J. et al. A rush to judgment? Rapid reporting and '
'dissemination of results and its consequences regarding the use of '
'hydroxychloroquine for COVID-19. Ann. Intern. Med. 172, 819–821. '
'https://doi.org/10.7326/M20-1223 (2020).',
'journal-title': 'Ann. Intern. Med.'},
{ 'key': '39941_CR43',
'doi-asserted-by': 'publisher',
'first-page': '4368',
'DOI': '10.21037/jtd-20-1368',
'volume': '12',
'author': 'J Zhao',
'year': '2020',
'unstructured': 'Zhao, J. et al. Cell morphological analysis of SARS-CoV-2 infection by '
'transmission electron microscopy. J. Thorac. Dis. 12, 4368–4373. '
'https://doi.org/10.21037/jtd-20-1368 (2020).',
'journal-title': 'J. Thorac. Dis.'},
{ 'key': '39941_CR44',
'doi-asserted-by': 'publisher',
'first-page': '110412',
'DOI': '10.1016/j.mehy.2020.110412',
'volume': '146',
'author': 'M Carcaterra',
'year': '2021',
'unstructured': 'Carcaterra, M. & Caruso, C. Alveolar epithelial cell type II as main '
'target of SARS-CoV-2 virus and COVID-19 development via NF-Kb pathway '
'deregulation: A physio-pathological theory. Med. Hypotheses 146, 110412. '
'https://doi.org/10.1016/j.mehy.2020.110412 (2021).',
'journal-title': 'Med. Hypotheses'},
{ 'key': '39941_CR45',
'doi-asserted-by': 'publisher',
'first-page': '1036',
'DOI': '10.1016/j.cell.2020.04.026',
'volume': '181',
'author': 'D Blanco-Melo',
'year': '2020',
'unstructured': 'Blanco-Melo, D. et al. Imbalanced host response to SARS-CoV-2 drives '
'development of COVID-19. Cell 181, 1036–1045. '
'https://doi.org/10.1016/j.cell.2020.04.026 (2020).',
'journal-title': 'Cell'},
{ 'key': '39941_CR46',
'doi-asserted-by': 'publisher',
'first-page': '1033',
'DOI': '10.1016/S0140-6736(20)30628-0',
'volume': '395',
'author': 'P Mehta',
'year': '2020',
'unstructured': 'Mehta, P. et al. COVID-19: Consider cytokine storm syndromes and '
'immunosuppression. Lancet 395, 1033–1034. '
'https://doi.org/10.1016/S0140-6736(20)30628-0 (2020).',
'journal-title': 'Lancet'},
{ 'key': '39941_CR47',
'doi-asserted-by': 'publisher',
'first-page': '2105',
'DOI': '10.1017/S1431927622012430',
'volume': '28',
'author': 'S Chaudhary',
'year': '2022',
'unstructured': 'Chaudhary, S. et al. Ultracellular imaging of bronchoalveolar lavage '
'from young age COVID-19 patients with comorbidities showed greater '
'SARS-COV-2 infection but lesser ultrastructural damage than the old age '
'patients. Microsc. Microanal. 28, 2105–2129. '
'https://doi.org/10.1017/S1431927622012430 (2022).',
'journal-title': 'Microsc. Microanal.'}],
'container-title': 'Scientific Reports',
'original-title': [],
'language': 'en',
'link': [ { 'URL': 'https://www.nature.com/articles/s41598-023-39941-6.pdf',
'content-type': 'application/pdf',
'content-version': 'vor',
'intended-application': 'text-mining'},
{ 'URL': 'https://www.nature.com/articles/s41598-023-39941-6',
'content-type': 'text/html',
'content-version': 'vor',
'intended-application': 'text-mining'},
{ 'URL': 'https://www.nature.com/articles/s41598-023-39941-6.pdf',
'content-type': 'application/pdf',
'content-version': 'vor',
'intended-application': 'similarity-checking'}],
'deposited': { 'date-parts': [[2023, 8, 5]],
'date-time': '2023-08-05T15:09:37Z',
'timestamp': 1691248177000},
'score': 1,
'resource': {'primary': {'URL': 'https://www.nature.com/articles/s41598-023-39941-6'}},
'subtitle': [],
'short-title': [],
'issued': {'date-parts': [[2023, 8, 5]]},
'references-count': 47,
'journal-issue': {'issue': '1', 'published-online': {'date-parts': [[2023, 12]]}},
'alternative-id': ['39941'],
'URL': 'http://dx.doi.org/10.1038/s41598-023-39941-6',
'relation': {},
'ISSN': ['2045-2322'],
'subject': ['Multidisciplinary'],
'container-title-short': 'Sci Rep',
'published': {'date-parts': [[2023, 8, 5]]},
'assertion': [ { 'value': '18 November 2022',
'order': 1,
'name': 'received',
'label': 'Received',
'group': {'name': 'ArticleHistory', 'label': 'Article History'}},
{ 'value': '2 August 2023',
'order': 2,
'name': 'accepted',
'label': 'Accepted',
'group': {'name': 'ArticleHistory', 'label': 'Article History'}},
{ 'value': '5 August 2023',
'order': 3,
'name': 'first_online',
'label': 'First Online',
'group': {'name': 'ArticleHistory', 'label': 'Article History'}},
{ 'value': 'The authors declare no competing interests.',
'order': 1,
'name': 'Ethics',
'group': {'name': 'EthicsHeading', 'label': 'Competing interests'}}],
'article-number': '12733'}
