The anti-inflammatory cytokine response characterized by elevated interleukin-10 is a stronger predictor of severe disease and poor outcomes than the pro-inflammatory cytokine response in coronavirus disease 2019 (COVID-19)

Clin Chem Lab Med. 2020 Nov 26;59(3):599-607. doi: 10.1515/cclm-2020-1284. Print 2021 Feb 23.


Objectives: Severe coronavirus disease 2019 (COVID-19) is associated with a dysregulated immune state. While research has focused on the hyperinflammation, little research has been performed on the compensatory anti-inflammatory response. The aim of this study was to evaluate the anti-inflammatory cytokine response to COVID-19, by assessing interleukin-10 (IL-10) and IL-10/lymphocyte count ratio and their association with outcomes.

Methods: Adult patients presenting to the emergency department (ED) with laboratory-confirmed COVID-19 were recruited. The primary endpoint was maximum COVID-19 severity within 30 days of index ED visit.

Results: A total of 52 COVID-19 patients were enrolled. IL-10 and IL-10/lymphocyte count were significantly higher in patients with severe disease (p<0.05), as well as in those who developed severe acute kidney injury (AKI) and new positive bacterial cultures (all p≤0.01). In multivariable analysis, a one-unit increase in IL-10 and IL-10/lymphocyte count were associated with 42% (p=0.031) and 32% (p=0.013) increased odds, respectively, of severe COVID-19. When standardized to a one-unit standard deviations scale, an increase in the IL-10 was a stronger predictor of maximum 30-day severity and severe AKI than increases in IL-6 or IL-8.

Conclusions: The hyperinflammatory response to COVID-19 is accompanied by a simultaneous anti-inflammatory response, which is associated with poor outcomes and may increase the risk of new positive bacterial cultures. IL-10 and IL-10/lymphocyte count at ED presentation were independent predictors of COVID-19 severity. Moreover, elevated IL-10 was more strongly associated with outcomes than pro-inflammatory IL-6 or IL-8. The anti-inflammatory response in COVID-19 requires further investigation to enable more precise immunomodulatory therapy against SARS-CoV-2.

Keywords: SARS-CoV-2; anti-inflammatory response; cytokines; immunoparalysis; outcomes.

MeSH terms

  • Acute Kidney Injury / blood
  • Acute Kidney Injury / complications
  • Acute Kidney Injury / diagnosis
  • Adult
  • Aged
  • Bacterial Infections / blood
  • Bacterial Infections / complications
  • Bacterial Infections / diagnosis
  • COVID-19 / blood
  • COVID-19 / complications
  • COVID-19 / diagnosis*
  • Cohort Studies
  • Emergency Service, Hospital
  • Female
  • Hospitalization
  • Humans
  • Interleukin-10 / blood
  • Interleukin-10 / metabolism*
  • Lymphocyte Count
  • Male
  • Middle Aged
  • Prognosis


  • IL10 protein, human
  • Interleukin-10