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case_images: Clinical improvements in a long COVID patient.. A. Schematics of the case. B. Erythrocyte sedimentation rate, CRP, D-dimer, ferritin levels were assayed before each TPE procedure and were initially elevated but normalized by the TPE. C. Chest radiographs show reduced lung opacity after TPE. D. Clouded plasma appearance was reduced by TPE.
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case_images: Sedimentation rate, CRP, D-dimer and ferritin were abnormal in clinical lab tests ( Figure 1B). At that time, chest radiographs and a chest CT scan revealed ground-glass appearance areas diffusely spread throughout his lungs ( Figure 1C). The removed plasma was very dark and opaque ( Figure 1D). Typical biomarkers of systemic inflammation all became quickly and robustly normalized including erythrocyte sedimentation rate, CRP, ferritin, and D-dimer    ( Figure 1B). The plasma from the second TPE was clear ( Figure 1D). A week later his chest radiographs showed considerable clearing of the opacities in the lungs ( Figure 1C). The peripheral blood mononuclear cells (PBMC) and blood serum of this patient were collected and analyzed before the first round of TPE (R0) and before each subsequent round (R1-R3) ( Figure 1A). In agreement with the diminished inflammation and enhanced adaptive immunity that were suggested by Figures 1 and 2, this longitudinal serum proteomics revealed significant attenuation of inflammatory factors, which was stable and lasted several months ( Figure 3E and F).
case_images: Effect of TPE on lymphoid and myeloid gene expression.. A. The expression of T cell, B-cell NK cell markers and IL2 receptor are significantly increased in R2 and R3 compared to R0. CD11b myeloid marker increased in R1 and then returned to R0 levels. CD68 - the marker of inflammatory myeloid cells, was significantly decreased by the third round of TPE. B. The ratios of lymphoid/CD11b, lymphoid/CD68, CD25/CD11b and CD25/CD68 markers clearly demonstrate the positive effects of TPE in promoting the adaptive rather than the inflammatory immune response. Note the break in Y-axis scale. *
  P < 0.05, **
  P < 0.01, ***
  P < 0.001.
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case_images: CD68+ inflammatory myeloid cells' marker, and relatively fewer lymphocyte markers, which is indicative of a lack of adaptive immunity ( Figure 2). TPE increased the markers of T-cells, B-cells, NK cells, and diminished the markers of inflammatory macrophages, suggesting enhanced adaptive immunity and attenuated inflammatory response ( Figure 2 ). CD3, CD4 and CD19 initially diminished at 5 days after the first TPE, R1, but then steadily increased during the longer intervals of R2 and R3; CD94 and CD8, the markers of cytotoxic immune cells that combat viral infections also gradually and steadily increased ( Figure 2). Five days after the first TPE and the initial increase of CD11b+, the levels of this marker stabilized, while the CD68 marker of inflammatory macrophages were never elevated by TPE and were diminished by R2 and R3 ( Figure 2). T-cell and B-cell markers to myeloid and inflammatory macrophage markers (CD11b and CD68) demonstrates a rapid and robust shift toward adaptive immunity through the rounds of TPE ( Figure 2 ). The effects of TPE are particularly striking when looking at the relative increase in the CD8+/CD68+, e.g., anti-viral cytotoxic T cells in an inflammation reduced environment ( Figure 2 ). In agreement with the diminished inflammation and enhanced adaptive immunity that were suggested by Figures 1 and 2, this longitudinal serum proteomics revealed significant attenuation of inflammatory factors, which was stable and lasted several months ( Figure 3E and F).
case_images: The longitudinal profiling of serum proteome after rounds of TPE.. A. Comparative heat mapping of 507 proteins between TPE rounds was done on RayBiotech Array. B. Venn diagram showing the overlap between the proteins, which were influenced by the TPE rounds. 36 shared proteins were diminished each TPE round (0.65> Fold change). C. The KEGG signaling pathway analysis. D. The top 20 list of biological processes. E. Heat mapping of the proteins that relate to Aging and Inflammaging and are decreased by TPE. F. Volcano plots of proteomics as per TPE rounds. More proteins are downregulated by the second round than by the first. The red dots represent differently expressed proteins (
  P < 0.05; |Log
  2FC|<1.5), while the grey dots represent proteins with
  P > 0.05.
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case_images: Blood serum from the patient was profiled through comparative proteomics using RayBiotech antibody arrays, as we have published.    Heatmapping clearly demonstrated the profound influence of TPE on the circulatory proteome ( Figure 3A); Venn diagrams, KEGG and biological process databases uncovered 36 proteins that were commonly downregulated between the rounds of TPE, ( Figure 3B-D). In agreement with the diminished inflammation and enhanced adaptive immunity that were suggested by Figures 1 and 2, this longitudinal serum proteomics revealed significant attenuation of inflammatory factors, which was stable and lasted several months ( Figure 3E and F). Regulators of several growth factor pathways that are known to promote tissue repair increased in the systemic milieu: IGF, EGF, TGF-beta ( Figure 3E and F).