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| LETTER TO EDITOR |
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| Year : 2022 | Volume
: 22
| Issue : 2 | Page : 87-88 |
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Post-COVID-19 death among athletes: Is interleukin-6 screening needed?
Amr Ahmed1, Neveen Refaey2, Aml M Brakat3
1 Department of Public Health, Tuberculosis Program, First Health Cluster, Ministry of Health, Riyadh, Saudi Arabia
2 Department of Physical Therapy for Women's Health, Faculty of Physical Therapy, Cairo University, Giza, Egypt
3 Department of General Medicine, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| Date of Submission | 07-May-2022 |
| Date of Decision | 30-May-2022 |
| Date of Acceptance | 03-Jun-2022 |
| Date of Web Publication | 30-Aug-2022 |
Correspondence Address:
Dr. Amr Ahmed
Department of Public Health, Tuberculosis Program, First Health Cluster, Ministry of Health, Riyadh
Saudi Arabia
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/sjsm.sjsm_10_22
How to cite this article:
Ahmed A, Refaey N, Brakat AM. Post-COVID-19 death among athletes: Is interleukin-6 screening needed?. Saudi J Sports Med 2022;22:87-8 |
How to cite this URL:
Ahmed A, Refaey N, Brakat AM. Post-COVID-19 death among athletes: Is interleukin-6 screening needed?. Saudi J Sports Med [serial online] 2022 [cited 2023 Sep 29];22:87-8. Available from: https://www.sjosm.org/text.asp?2022/22/2/87/355189 |
Dear Editor,
Since COVID-19 or coronavirus disease 2019 (SARS CoV-2) was declared a global pandemic, this pandemic has dramatically impacted the health systems, economy, and lifestyles all around the world. Furthermore, SARS-CoV-2–related illness has a clear impact on physical activity, sport, and athletes of all levels. SARS-CoV-2 can cause medical complications, both short term and long term. The residual effects can complicate medical protocols for returning to play.[1]
Myocarditis is one of the most common causes of sports-related sudden cardiac death in athletes under the age of 35.[2] A common cause of sudden cardiac death in athletes is myocarditis preceded by a viral infection. Concerns about SARS-CoV-2 cardiovascular sequelae in athletes have been accentuated by reports of presumptive myocarditis in several high-profile athletes.[3]
In a cohort study of 1597 university competitive athletes in the United States, 37 athletes (2.3%) developed clinical and subclinical myocarditis after being infected with COVID-19.[4] Furthermore, myocarditis prevalence on cardiovascular magnetic resonance imaging (MRI) in athletes following positive COVID-19 test results is 1%–3%.[5] More than a third of 54 previously healthy college athletes who tested positive for COVID-19 had pericardial inflammation on imaging. Severe cases of myocarditis and pericarditis, in particular, can lead to chronic heart failure or death, posing major public health concerns.[6],[7]
Coronaviruses have the potential to disrupt host immune responses. Several studies have found a “cytokine storm” involving the release of interleukin-1 (IL-1) and IL-6, as well as tumor necrosis factor α and other inflammatory mediators. Myocarditis, arrhythmias, ventricular dysfunction, and sudden death are caused by a “cytokine storm.”[8]
IL-6 is an inflammatory IL that is primarily produced by macrophages and T lymphocytes in response to pathogens. It is crucial to control several viral infections at homeostatic levels, but its increased production significantly contributes to cytokine storms. IL-6 has been considered a critical mediator and a positive predictor of disease severity, radiologic changes, risk for mechanical ventilation, and death.[9]
In a recent study, IL-6 has a direct electrophysiological role of IL-6 in arrhythmogenesis as IL-6 alone was found to be more effective than the combination of azithromycin and hydroxychloroquine in lowering heart rate, increasing PR interval, and increasing QTc. Furthermore, combinations of IL-6, azithromycin, and hydroxychloroquine in vivo or in vitro caused significant bradycardia, conduction problems, QTc prolongation, and asystole.[10]
Skeletal muscles express cytokines through direct autocrine and paracrine effects, so acute and prolonged strenuous exercise raises circulating levels of IL-6, while chronic exercise decreases markers of chronic inflammation.[11] Severe SARS-CoV-2 causes catabolic muscle wasting which raises IL-6 levels.
The resumption of training and competitions without health risks in athletes with cardiovascular complications related to SARS-CoV-2 includes abstinence from competitive sports or aerobic activity for 3–6 months until resolution of myocardial inflammation by cardiac MRI or troponin normalization and monitoring of circulating IL-6 as we consider IL-6 as a relevant tool for prognostic evaluation.[2],[12]
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | |  |
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| 2. | Maron BJ, Udelson JE, Bonow RO, Nishimura RA, Ackerman MJ, Estes NA 3 rd, et al. Eligibility and disqualification recommendations for competitive athletes with cardiovascular abnormalities: Task force 3: Hypertrophic cardiomyopathy, arrhythmogenic right ventricular cardiomyopathy and other cardiomyopathies, and myocarditis: A scientific statement from the American Heart Association and American College of Cardiology. Circulation 2015;132:e273-80. |
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| 6. | Brito D, Meester S, Yanamala N, Patel HB, Balcik BJ, Casaclang-Verzosa G, et al. High prevalence of pericardial involvement in college student athletes recovering from COVID-19. JACC Cardiovasc Imaging 2021;14:541-55. |
| 7. | Husby A, Hansen JV, Fosbøl E, Thiesson EM, Madsen M, Thomsen RW, et al. SARS-CoV-2 vaccination and myocarditis or myopericarditis: Population based cohort study. BMJ 2021;375:e068665. |
| 8. | Ye Q, Wang B, Mao J. The pathogenesis and treatment of the 'Cytokine Storm' in COVID-19. J Infect 2020;80:607-13. |
| 9. | Liu Z, Li J, Chen D, Gao R, Zeng W, Chen S, et al. Dynamic interleukin-6 level changes as a prognostic indicator in patients with COVID-19. Front Pharmacol 2020;11:1093. |
| 10. | Zhu X, Wang Y, Xiao Y, Gao Q, Gao L, Zhang W, et al. Arrhythmogenic mechanisms of interleukin-6 combination with hydroxychloroquine and azithromycin in inflammatory diseases. Sci Rep 2022;12:1075. |
| 11. | Lambert CP, Wright NR, Finck BN, Villareal DT. Exercise but not diet-induced weight loss decreases skeletal muscle inflammatory gene expression in frail obese elderly persons. J Appl Physiol (1985) 2008;105:473-8. |
| 12. | Hendren NS, Drazner MH, Bozkurt B, Cooper LT Jr. Description and proposed management of the acute COVID-19 cardiovascular syndrome. Circulation 2020;141:1903-14. |
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