Is Serotonin the Missing Link between COVID-19 Course of Severity in Patients with Diabetes and Obesity?

COVID-19 is an intriguing infectious condition with multisystemic manifestations and variable outcomes that are influenced by the concomitant presence of non-communicable diseases, such as obesity, diabetes, and cardiovascular disease, which were previously well established epidemics and therefore are considered global syndemics. Although an enormous progress towards understanding mechanisms of SARS-CoV-2 infection leading to COVID-19 has been made, there are still many areas of uncertainty to clarify. Systemic diseases are characterized by common links that allow integrating apparently unrelated disease manifestations. The authors launch the provocative hypothesis that serotonin is the putative mediator linking the lung, gut, cardiac, neurological, and other systemic manifestations that characterize severe COVID-19 in individuals with diabetes and obesity. In support of a role for serotonin in the mechanisms leading to disease severity are the similarities between acute and post-acute COVID-19 manifestations and neuroendocrine tumors presenting with carcinoid syndrome. Scientific discussion is set by highlighting the available clues that support this working hypothesis to trigger future research aimed at unravelling the molecular pathways underlying SARS-CoV-2 infection that are still far from being fully disclosed.