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COVID-19 cytokine storm: The anger of inflammation
Open accessAbstract
Patients with COVID-19 who require ICU admission might have the cytokine storm. It is a state of out-of-control release of a variety of inflammatory cytokines. The molecular mechanism of the cytokine storm has not been explored extensively yet. The attachment of SARS-CoV-2 spike glycoprotein with angiotensin-converting enzyme 2 (ACE2), as its cellular receptor, triggers complex molecular events that leads to hyperinflammation. Four molecular axes that may be involved in SARS-CoV-2 driven inflammatory cytokine overproduction are addressed in this work. The virus-mediated down-regulation of ACE2 causes a burst of inflammatory cytokine release through dysregulation of the renin-angiotensin-aldosterone system (ACE/angiotensin II/AT1R axis), attenuation of Mas receptor (ACE2/MasR axis), increased activation of [des-Arg9]-bradykinin (ACE2/bradykinin B1R/DABK axis), and activation of the complement system including C5a and C5b-9 components. The molecular clarification of these axes will elucidate an array of therapeutic strategies to confront the cytokine storm in order to prevent and treat COVID-19 associated acute respiratory distress syndrome.
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“Among them, IL-6 is a major player in chronic inflammatory diseases, autoimmune diseases, cancer and cytokine storm (1, 3, 10–26).”
From IL-6 in inflammation, autoimmunity and cancer (2021) · cites this paper as [13]
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“Therefore, SARS-CoV-1 and SARS-CoV-2 infection activate both NF-κB and STAT3, key elements of the IL-6 Amp, to cause cytokine storm (12, 13, 15, 349, 350).”
From IL-6 in inflammation, autoimmunity and cancer (2021) · cites this paper as [13]
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“ARDS in COVID-19 is considered the result of cytokine storm (12–17), resembling the disease caused by SARS-CoV-1 and Middle East respiratory syndrome coronavirus (MERS-CoV) (335).”
From IL-6 in inflammation, autoimmunity and cancer (2021) · cites this paper as [13]
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“Consistent with the notion that severe COVID-19 is a cytokine storm syndrome (12–17, 336), the severity of COVID-19 is associated with an increased level of inflammatory cytokines, such as IL-6, granulocyte macrophage colony-stimulating factor (GM-CSF) and TNFα (333, 337).”
From IL-6 in inflammation, autoimmunity and cancer (2021) · cites this paper as [13]
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The COVID-19 pandemic, heart and cardiovascular diseases: What we have learned
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“Since the outbreak of coronavirus disease 2019 (COVID-19 ), more COVID-19 is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (3), an enveloped, single-stranded RNA virus belonging to the β -coronavirus genus of the Coronaviridae family.”
BackgroundReaktionsmuster der lokoregionären Lymphknoten im Abflussgebiet von COVID-19-Lungen
Haslbauer, J. D., Matter, M. S., Stalder, A. K., & Tzankov, A. (2021) · Der Pathologe · doi:10.1007/s00292-021-00914-z · Cited by 4
“Schließlich resultiert diese Dysregulation in eine hochpathogene inflammatorische Monozyten-Makrophagen-Antwort, die bei SARS-CoV-1 und MERS sehr gut dokumentiert ist [7, 8, 24], welche für einen Großteil der Organschädigung in COVID-19 verantwortlich zu sein scheint [25, 48].”
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“org 7 helpful therapeutical strategy when it is controlled and does not allow an overreacted stormy feedback (120, 121).”
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“As angiotensin (1-7) binds to the Mas receptor and decreases inflammatory response, its decreased levels can also be a contributing factor for the hyper-inflammatory state [9].”
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“The union of the virus with its ACE2 cellular receptor triggers internalization of the complex into the cell, leading to the down-regulation of the ACE2 15 and favoring the interruption of angiotensin II (AngII) metabolism; causing an increase in its plasma concentration.”
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Potential Mechanisms of the SARS-CoV-2-induced AKI Progression to CKD: A Forward-Looking Perspective
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BackgroundMeasurement of serum ACE status may potentially improve the diagnosis of SARS-CoV-2 infection
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COVID-19 biology: cytokine storms and their implications
Atçeken, N., & Kozalak, G. (2024) · Elsevier eBooks · doi:10.1016/b978-0-323-95545-4.00009-8 · Cited by 1
Macrophage Activation Syndrome in Coinciding Pandemics of Obesity and COVID-19: Worse than Bad
Engin, A. B., Engin, D., & Engin, A. (2024) · Advances in experimental medicine and biology · doi:10.1007/978-3-031-63657-8_31 · Cited by 1
Malchair, P., Giol, J., Jacob, J., Villoria, J., Carnaval, T., & Videla, S. (2025) · Pathogens · doi:10.3390/pathogens14060533 · Cited by 1
“On the RAS side, it is part of the Mas Receptor pathway counter-regulatory branch, as it cleaves Ang-II into Ang-(1–7) (Figure 1), thereby exerting anti-inflammatory, anti-fibrotic, and vasodilating effects [9,10].”
InfluentialZerouak, N., Hentabli, S., Zitouni, A., Lehassani, M., Hentabli, H., Haroun, M. A., Khames, M., Benachour, K., Amrani, Y., & Oumouna, M. (2026) · International Journal of Molecular Sciences · doi:10.3390/ijms27052208 · Cited by 1
“SARS-CoV-2 infection and vaccination are known to induce robust immune activation, which in some individuals may unmask or exacerbate autoimmune phenomena [10,11].”
Covid-19 ve Kanser Covid-19 and Cance
Karataş, M., & Tunçdemi̇r, M. (2018) · AYDIN TIP FAKÜLTESİ KLİNİKLERİ DERGİSİ · doi:10.17932/iau.tfk.2018.008/tfk_v04i1001 · Cited by 1
CORONAVIRUS PANDEMIC: EXPERIENCE OF THE FIRST WAVE IN THE NIZHNY NOVGOROD REGION
Дмитриевич, Ф. В., TULICHEV, A. A., FEDOTOVA, O. O., Сергеевна, Д. И., & SHAKUROVA, D. N. (2021) · The Bulletin of Contemporary Clinical Medicine · doi:10.20969/vskm.2021.14(2).39-45 · Cited by 1
Afzali, S., Nakhaei, M. A., Shiari, S., Shirkavand, A., & Farivar, S. (2021) · Archives of Pediatric Infectious Diseases · doi:10.5812/pedinfect.113298 · Cited by 1
“Thereupon, the AT1RAngII axis activates NF-κB via phosphorylation of its P65 subunit (35).”
BackgroundFlores, C. A. P. (2022) · El Palma de la Juventud · doi:10.31381/epdlj.v4i4.4893 · Cited by 1
Extrapulmonary Manifestations of SARS-CoV-2: A Report of 3 Cases and a Literature Review
Barbachowska, A., Gozdowska, J., Piotrowska‐Kownacka, D., Sawicka, M., Dęborska−Materkowska, D., Skolimowska, E., & Durlik, M. (2022) · Annals of Transplantation · doi:10.12659/aot.935874 · Cited by 1
“As a consequence, it leads to excessive, out-of-control release of a various of inflammatory cytokines (a cytokine storm) through dysregulation of the renin-angiotensin-aldosterone system (RAAS), attenuation of Mas receptor (ACE2/MasR axis), increase activation of [desArg9]-bradykinin, and activation of the complement…”
BackgroundCappellari, A. R., de Souza, J. B., Nogueira-Librelotto, D. R., de Lara, J. D., Couto, J. C. M., Simões, J. L. B., Bagatini, M. D., Mello, C. F., & Pillat, M. M. (2022) · Springer eBooks · doi:10.1007/978-3-031-08045-6_3 · Cited by 1
COVID-19 e suas implicações na fertilidade masculina e feminina: impactos futuros
Pires, J. A. N., Felix, E. M. D. S., & Magalhães-Padilha, D. M. (2022) · Research Society and Development · doi:10.33448/rsd-v11i16.38217 · Cited by 2
Blood brain barrier disruption following COVID-19 infection and neurological manifestations
Deshwal, S., Dhiman, N., & Sandhir, R. (2023) · Elsevier eBooks · doi:10.1016/b978-0-443-15256-6.00005-2 · Cited by 1
Ali, R., Elnour, S., Higazi, H., Osman, A. L., Ismail, M., Altoum, A. A., Alfeel, A. H., Kandakurti, P. K., Moamen, N. K. A., Hussein, S. E. O., et al. (2023) · International Journal of Biomedicine · doi:10.21103/article13(2)_oa7 · Cited by 1
Plant Immunoenhancers: Promising Ethnopharmacological Candidates for Anti-SARS-CoV-2 Activity
Ghoran, S. H., Taktaz, F., & Ayatollahi, S. A. (2023) · Springer eBooks · doi:10.1007/978-981-99-3664-9_3 · Cited by 1
Puodžiūnaitė, M., Sadeckaitė, R., & Čikotienė, A. (2023) · Neurologijos seminarai · doi:10.29014/ns.2022.26.12 · Cited by 1
The Impact of SARS-CoV-2 on Patients With Lower Urinary Tract Symptoms (LUTS)
Balacescu, M. S., Ene, C., GEORGESCU, D. E., Bulai, C. A., Militaru, A., Ene, C. D., Văcăroiu, I. A., Georgescu, D. A., GEAVLETE, B. F., & Geavlete, P. A. (2024) · Cureus · doi:10.7759/cureus.59148 · Cited by 1
“…renin-angiotensin system (RAS) dysregulation [17], the androgen-related theory postulating an exacerbation of BPH symptoms due to increased androgen receptor activity associated with elevated dydrogesterone [18], inflammation-related factors [19], and metabolic derangement associations [20].”
BackgroundAre COVID-19 Polymorphisms in ACE and ACE2 Prognosis Predictors?
Guarienti, F. A., Xavier, F., Ferraz, M. D., Wagner, F., Marinowic, D., da Costa, J. C., & Machado, D. C. (2024) · Current Issues in Molecular Biology · doi:10.3390/cimb46080480
“Polymorphisms in ACE may contribute to this reduction in the immune response, through a deregulation of ACE activity, which would cause a deregulation of angiotensin II and a decrease in the activity of angiotensin1-7 [19].”
BackgroundCOVID- 19 vaccination reduces new-onset fibromyalgia risk in survivors
Liu, A., Liao, P., Jiang, H., Huang, S., Li, S., Wei, J. C., & Ying, Z. (2025) · BMC Medicine · doi:10.1186/s12916-025-04069-z · Cited by 1
“COVID-19 can exacerbate immune and inflammatory responses [35] and significantly increase the incidence of FM [12, 36].”
A Bioelectromagnetic Proposal Approaching the Complex Challenges of COVID-19
Szász, A. (2020) · Open Journal of Biophysics · doi:10.4236/ojbiphy.2021.111001 · Cited by 1
Interleukin Deficiency Disorder Patient Responses to COVID-19 Infections
Gillis, B. S., Gavin, I. M., Barkhordar, F., Mohapatra, G., Jin, M. Y., & Behm, F. G. (2021) · Journal of Advances in Medicine and Medical Research · doi:10.9734/jammr/2021/v33i830884 · Cited by 1
Cardoso, E., Fine, N. A., Glogauer, M., Johnson, F., Goldberg, M. B., Golub, L. M., & Tenenbaum, H. C. (2021) · Frontiers in Dental Medicine · doi:10.3389/fdmed.2021.674056 · Cited by 1
Is the mechanism of COVID-19 coagulopathy still a rabbit’s hole?
Rajan, A., Thirunavukkarasu, G. K., Lockey, R. F., & Kolliputi, N. (2021) · Journal of Cell Communication and Signaling · doi:10.1007/s12079-021-00613-7 · Cited by 1
COVID-19 pandemic: disease impact on nervous system, cognitive functioning and mental health
Janeczek, P. (2022) · Journal of Education Health and Sport · doi:10.12775/jehs.2022.12.09.037 · Cited by 1
“[40] Mahmudpour M, Roozbeh J, Keshavarz M, Farrokhi S, Nabipour I.”
BackgroundEpigenetic miRNA Mediated Regulation of RAS in Cardiovascular Diseases
Caliskan, A., Crouch, S. A. W., & Dangwal, S. (2023) · Advances in biochemistry in health and disease · doi:10.1007/978-3-031-14952-8_5 · Cited by 1
DOENÇAS AUTOIMUNES RELACIONADOS A SÍNDROME DO PÓS-COVID-19: NOVOS DESDOBRAMENTOS DA PANDEMIA
de Assunção, L. A., de Souza, P. M., de Lima, M. S., Quemel, G. K. C., Parente, J. S., Barbosa, A. P. F., Farias, D. C. D. S., & de Vasconcelos, L. A. (2023) · Revista Contemporânea · doi:10.56083/rcv3n2-026 · Cited by 1
Trombosis pada Pasien COVID-19
Tan, C. (2021) · Cermin Dunia Kedokteran · doi:10.55175/cdk.v48i12.156 · Cited by 1
Biswas, R., Eaker, S. S., Soni, D. K., Kar, S., LoBato, D. N., & Culiat, C. T. (2021) · bioRxiv (Cold Spring Harbor Laboratory) · doi:10.1101/2021.02.08.430254 · Cited by 1
On noise and hearing loss Prevalence and reference data
Johansson, M. (2003) · DiVA (Linkoping University) · Cited by 1
Puerta-Guardo, H. N. (2022) · Frontiers in Cellular and Infection Microbiology · doi:10.3389/fcimb.2021.827151 · Cited by 1
“…during respiratory diseases leading to chronic obstructive pulmonary disease and long term inflammation after hMPV infection (Haas et al., 2013; Malmo et al., 2016). rBCG-P also stimulated B cells and plasma cells resulting in an early-robust IgA and constant IgG responses that promoted an…”
BackgroundLong COVID, POTS, CFS and MTHFR: Linked by Biochemistry and NutritionPreprint
Chambers, P. W. (2023) · Preprints.org · doi:10.20944/preprints202303.0418.v3
A predominately pulmonary activation of complement in a mouse model of severe COVID-19Preprint
Szachowicz, P. J., Wohlford-Lenane, C., Heinen, C. J., Ghimire, S., Xue, B., Boly, T. J., Verma, A., MašinoviĆ, L., Bermick, J., Perlman, S. M., et al. (2024) · bioRxiv (Cold Spring Harbor Laboratory) · doi:10.1101/2024.05.31.596892 · Cited by 1
“Reported pathophysiologic features of severe COVID-19 include prothrombotic complications (10-13), “cytokine storm” (14, 15), NETosis (16), and excessive cytotoxic T-cell responses (17), all which can be driven by complement activation.”
Bukva, M., Islamović, M., Jusufović, S., Enisa, N., Meseldžić, N., & Bego, T. (2021) · World Congress on Medical Physics and Biomedical Engineering, September 7 - 12, 2009, Munich, Germany · doi:10.1007/978-3-030-73909-6_95
Проценко, Е. С., Remnyova, N. A., & Panchenko, N. V. (2021) · Ukraïnsʹkij žurnal medicini bìologìï ta sportu · doi:10.26693/jmbs06.03.053
Cyprian, F. S., Suleman, M., Abdelhafez, I., Doudin, A., Danjuma, M. I.-M., Mir, F. A., Parray, A., Yousaf, Z., Siddiqui, M. Y. A., Eldin, A., et al. (2021) · Research Square · doi:10.21203/rs.3.rs-682190/v1
A comparative study on ivermectin- doxycycline and favipiravir therapy in COVID19 patients
Oza, D., Luhadia, S., Luhadia, A., Sharma, R., Chhabra, G., Sharma, S., Gupta, A. K., Shukla, D., ., D., Kankrecha, R., et al. (2021) · International Journal of Advanced Research in Medicine · doi:10.22271/27069567.2021.v3.i2a.207
Ad26.COV2.S Prevents SARS-CoV-2 Induced Pathways of Inflammation and Thrombosis in HamstersPreprint
Aid, M., Vidal, S., Piedra-Mora, C., Ducat, S., Chan, C. N., Bondoc, S., Colarusso, A., Starke, C., Nekorchuk, M., Busman-Sahay, K., et al. (2021) · bioRxiv (Cold Spring Harbor Laboratory) · doi:10.1101/2021.09.30.462514
“Pathways of type I and II interferon responses, and proinflammatory cytokines and chemokines were previously reported in blood and lung tissue of hamsters infected with SARS-CoV-2 and in COVID-19 patients (6, 13, 14) (S3A and S3B Fig).”
MethodInfluentialPharmacotherapy of Cytokine Release Syndrome in Severe COVID-19 Patients: A Systematic Review
Robinson, J., Banerjee, I., & Leclézio, A. (2021) · Global Journal of Medical Pharmaceutical and Biomedical Update · doi:10.25259/gjmpbu_9_2021
Diferentes aspectos da resposta imunológica na COVID-19
Santos, A. A. R., de Paula, K. K. O., Marasco, B. F. D., & Castilho, D. G. (2021) · Research Society and Development · doi:10.33448/rsd-v10i14.22531
Nanomedicine, Viral Infection and Cytokine Stor
Kumar, R., & Mohammadipanah, F. (2021) · International Journal of Clinical Case Reports and Reviews · doi:10.31579/2690-4861/156
Point-of-care fully automated flow cytometry
Spijkerman, R. (2022) · Utrecht University Repository (Utrecht University) · doi:10.33540/915
Metadata
- Authors
- Mahmudpour, M., Roozbeh, J., Keshavarz, M., Farrokhi, S., & Nabipour, I.
- Affiliations
- Bushehr University of Medical Sciences (IR)
- Shiraz University of Medical Sciences (IR)
- Iranian Academy of Medical Sciences (IR)
- Corresponding author
- Nabipour, Iraj
- Venue
- Cytokine
- Publisher
- Elsevier BV
- Published
- 2020-09
- Volume
- 133
- Pages
- 155151
- ISSN
- 1043-4666 (ISSN-L)
- PMC
- PMC7260598
- OpenAlex
- W3030136428
- Cited by
- 461
- References
- 140
- Citations by year
- 2026: 8 · 2025: 18 · 2024: 47 · 2023: 61 · 2022: 104 · 2021: 168 · 2020: 52
- FWCI
- 4.55
- Type
- journal article
- Language
- en
- Open access
- green
- www.ncbi.nlm.nih.gov
- Locations
- Cytokine (publishedVersion)
- PubMed Central (publishedVersion)
- PubMed (publishedVersion)
- Funders
- Bushehr University of Medical Sciences
- Topics
- Health Sciences › Medicine › Infectious Diseases › COVID-19 Clinical Research Studies
- Health Sciences › Medicine › Infectious Diseases › SARS-CoV-2 and COVID-19 Research
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Renin-Angiotensin System Studies
- Keywords
- COVID-19 pandemic, cytokine storm, SARS-CoV-2, hyperinflammation, ACE2, renin-angiotensin-aldosterone system, Mas receptor, bradykinin B1 receptor, complement system, C5a, membrane attack complex, acute respiratory distress syndrome, intensive care unit patients, treatment options
- MeSH terms
- Betacoronavirus, Angiotensin-Converting Enzyme 2, COVID-19, SARS-CoV-2, Proto-Oncogene Mas, Bradykinin, Humans, Inflammation, Peptidyl-Dipeptidase A, Models, Molecular, Pneumonia, Viral, Proto-Oncogene Proteins, Renin-Angiotensin System, Complement C5a, Cytokines, Coronavirus Infections, Receptors, G-Protein-Coupled, Complement C5b, Pandemics, Spike Glycoprotein, Coronavirus
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