Plasmablasts in COVID-19: Dual Role as Immune Effectors or Amplifiers of Inflammation

COVID-19 induces profound B-cell dysregulation, notably a marked expansion of plasmablasts (PB), whose functional role remains unclear. This study aimed to characterize PB dynamics and functions in COVID-19 and their association with disease severity. We performed longitudinal immune profiling in a prospective cohort of 50 patients with COVID-19 (cohort 1), including flow cytometry-based B-cell immunophenotyping and multiplex cytokine analysis at days 1, 7, 14, and 30. A second retrospective cohort of 282 corticosteroid-naïve patients (cohort 2) was used to validate PB dynamics, model PB trajectories, and perform transcriptomic profiling of sorted PB. PB expansion occurred early in COVID-19 and was positively correlated with maximal disease severity (r=0.53, p<0.0001). Two distinct PB expansion trajectories were identified: one rapidly resolving, and one persistent and amplified, the latter being associated with higher severity scores and 30-day mortality (31% vs. 5%, p<0.001). In cohort 1, BAFF levels at day 7 correlated positively with both PB proportion (r=0.59, p=0.002) and maximal disease severity (r=0.74, p<0.001). Transcriptomic profiling of PB in cohort 2 revealed severity-specific signatures: in severe cases, early PB upregulated genes related to purine metabolism and CD39 expression, suggesting a pro-inflammatory role. In non-severe cases, PB expressed interferon-related and CIITA-mediated MHC-II programs, indicative of antiviral function. PB display dual functional profiles in COVID-19, acting either as regulators of antiviral immunity or as amplifiers of inflammation in severe disease. These findings support exploring therapeutic strategies targeting the BAFF-PB axis in severe COVID-19.