Prediction of COVID-19 disease progression by multiparametric analysis of circulating extracellular vesicles with flow cytometry

Extracellular vesicles (EVs) are released from all cells of the body. They are considered to mirror the state of the cells from which they are released and circulate in the blood, suggesting a possible use of EV analysis for diagnostic purposes. Here, we report that the analysis of single EVs by flow cytometry can detect infection of cells with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) by identifying expression of the SARS-CoV-2 spike (S) protein on the surface of EVs and the cellular origin of EVs by detecting cell-type-specific markers such as troponin (cTNT1) for cardiomyocytes. In coronavirus-associated disease 19 (COVID-19) patients, we detected a direct correlation of the frequencies of circulating S-expressing EVs, but not of cTNT/S-co-expressing EVs, with the subsequent development of a severe disease course. Detection of circulating S-expressing EVs indicates widespread SARS-CoV-2 infection in the body, which may contribute to the immune pathogenesis that triggers tissue and organ damage in COVID-19. Our findings suggest that detecting circulating viral antigen-expressing EVs may provide crucial predictive information on infection-associated disease courses in situations of a future viral pandemic.IMPORTANCEThe ability to predict which patients infected with the SARS-CoV-2 virus will develop severe disease remains a significant clinical challenge. The present study demonstrates that EVs in the peripheral blood, carrying the SARS-CoV-2 spike protein, can be detected by flow cytometry and serve as early biomarkers of disease progression. In contradistinction to PCR or serology, this method provides insight into systemic viral spread and potential organ involvement. The early identification of spike-positive EVs at the time of hospital admission has the potential to facilitate the timely identification of high-risk patients, thereby enhancing the efficacy of triage and subsequent care. This approach may also be of value in terms of facilitating a more rapid and precise response to future virus pandemics.