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. 2025 Feb;80(2):557-569.
doi: 10.1111/all.16333. Epub 2024 Oct 3.

Notch4 regulatory T cells and SARS-CoV-2 viremia shape COVID19 survival outcome

Mehdi Benamar  1   2 , Peggy S Lai  3   4 , Ching-Ying Huang  3   4 , Qian Chen  1   2 , Fatma Betul Oktelik  1   2 , Paola Contini  5   6 , Muyun Wang  1   2 , Daniel Okin  3   4 , Elena Crestani  1   2 , Jason Fong  1   2 , Tsz Man Chan Fion  1   2 , Merve Nida Gokbak  1   2 , Hani Harb  1   2   7 , Wanda Phipatanakul  1   2 , Luca Marri  5   6 , Chiara Vassallo  6 , Andrea Guastalla  6 , Minsik Kim  3 , Hui-Yu Sui  3 , Lorenzo Berra  8 , Marcia B Goldberg  9   10 , Claudia Angelini  11 , Raffaele De Palma  5   12 , Talal A Chatila  1   2
Affiliations

Notch4 regulatory T cells and SARS-CoV-2 viremia shape COVID19 survival outcome

Mehdi Benamar et al. Allergy. 2025 Feb.

Abstract

Background: Immune dysregulation and SARS-CoV-2 plasma viremia have been implicated in fatal COVID-19 disease. However, how these two factors interact to shape disease outcomes is unclear.

Methods: We carried out viral and immunological phenotyping on a prospective cohort of 280 patients with COVID-19 presenting to acute care hospitals in Boston, Massachusetts and Genoa, Italy between June 1, 2020 and February 8, 2022. Disease severity, mortality, plasma viremia, and immune dysregulation were assessed. A mouse model of lethal H1N1 influenza infection was used to analyze the therapeutic potential of Notch4 and pyroptosis inhibition in disease outcome.

Results: Stratifying patients based on %Notch4+ Treg cells and/or the presence of plasma viremia identified four subgroups with different clinical trajectories and immune phenotypes. Patients with both high %Notch4+ Treg cells and viremia suffered the most disease severity and 90-day mortality compared to the other groups even after adjusting for baseline comorbidities. Increased Notch4 and plasma viremia impacted different arms of the immune response in SARS-CoV-2 infection. Increased Notch4 was associated with decreased Treg cell amphiregulin expression and suppressive function whereas plasma viremia was associated with increased monocyte cell pyroptosis. Combinatorial therapies using Notch4 blockade and pyroptosis inhibition induced stepwise protection against mortality in a mouse model of lethal H1N1 influenza infection.

Conclusions: The clinical trajectory and survival outcome in hospitalized patients with COVID-19 is predicated on two cardinal factors in disease pathogenesis: viremia and Notch4+ Treg cells. Intervention strategies aimed at resetting the immune dysregulation in COVID-19 by antagonizing Notch4 and pyroptosis may be effective in severe cases of viral lung infection.

Keywords: COVID19; Notch4; pyroptosis; regulatory T cells; survival; viremia.

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Conflict of interest statement

Conflict of Interest Statement: T.A.C., H.H. M.B., P.S.L., P.C. and R.D.P. are inventors on provisional patent application US 63/038,186 titled “Methods and Compositions for treating coronavirus infectious disease”. H.H. and T.A.C. are co-founders of and hold equity in Alcea Therapeutics.

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