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Camp JV, Jonsson CB. A Role for Neutrophils in Viral Respiratory Disease. Front Immunol 2017; 8:550. [PMID: 28553293 PMCID: PMC5427094 DOI: 10.3389/fimmu.2017.00550] [Citation(s) in RCA: 158] [Impact Index Per Article: 22.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2016] [Accepted: 04/24/2017] [Indexed: 12/23/2022] Open
Abstract
Neutrophils are immune cells that are well known to be present during many types of lung diseases associated with acute respiratory distress syndrome (ARDS) and may contribute to acute lung injury. Neutrophils are poorly studied with respect to viral infection, and specifically to respiratory viral disease. Influenza A virus (IAV) infection is the cause of a respiratory disease that poses a significant global public health concern. Influenza disease presents as a relatively mild and self-limiting although highly pathogenic forms exist. Neutrophils increase in the respiratory tract during infection with mild seasonal IAV, moderate and severe epidemic IAV infection, and emerging highly pathogenic avian influenza (HPAI). During severe influenza pneumonia and HPAI infection, the number of neutrophils in the lower respiratory tract is correlated with disease severity. Thus, comparative analyses of the relationship between IAV infection and neutrophils provide insights into the relative contribution of host and viral factors that contribute to disease severity. Herein, we review the contribution of neutrophils to IAV disease pathogenesis and to other respiratory virus infections.
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Affiliation(s)
- Jeremy V Camp
- Institute of Virology, University of Veterinary Medicine at Vienna, Vienna, Austria
| | - Colleen B Jonsson
- Department of Microbiology, University of Tennessee-Knoxville, Knoxville, TN, USA
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52
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Lin WHW, Nelson AN, Ryon JJ, Moss WJ, Griffin DE. Plasma Cytokines and Chemokines in Zambian Children With Measles: Innate Responses and Association With HIV-1 Coinfection and In-Hospital Mortality. J Infect Dis 2017; 215:830-839. [PMID: 28119485 PMCID: PMC5388292 DOI: 10.1093/infdis/jix012] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2016] [Accepted: 01/05/2017] [Indexed: 12/19/2022] Open
Abstract
To identify immune factors present during the acute rash phase of measles and associations with outcome and human immunodeficiency virus type 1 (HIV-1) coinfection, we measured the plasma levels of 22 cytokines and chemokines in Zambian children hospitalized with measles (n = 148) and control children (n = 44). Children with measles had higher levels of innate cytokines tumor necrosis factor (TNF) α, interleukin 1β (IL-1β), interleukin 18, and interleukin 6; chemokines CCL2, CCL4, CCL11, CCL22, CXCL8, and CXCL10; and T-cell cytokines interferon γ, and interleukin 2, 10, and 17. Children who died in the hospital had higher levels of TNF-α, IL-1β, interleukin 12p70; CCL2, CCL4, CCL13, CCL17, CXCL8, CXCL10; and interleukin 2 and interferon γ than children who survived, and lower levels of interleukin 4. Children coinfected with HIV-1 had higher levels of TNF-α and IL-1β than HIV-uninfected children with measles, and lower levels of interleukin 4 and 5. Therefore, acute measles was characterized by activation of macrophages and T cells producing type 1, but not type 2, cytokines, which was more pronounced in fatal disease.
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Affiliation(s)
- Wen-Hsuan W Lin
- W. Harry Feinstone Department of Molecular Microbiology and Immunology, Baltimore, Maryland, USA
| | - Ashley N Nelson
- W. Harry Feinstone Department of Molecular Microbiology and Immunology, Baltimore, Maryland, USA
| | - Judith J Ryon
- W. Harry Feinstone Department of Molecular Microbiology and Immunology, Baltimore, Maryland, USA
| | - William J Moss
- W. Harry Feinstone Department of Molecular Microbiology and Immunology, Baltimore, Maryland, USA.,Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Diane E Griffin
- W. Harry Feinstone Department of Molecular Microbiology and Immunology, Baltimore, Maryland, USA
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53
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Thomas M, Mani RS, Philip M, Adhikary R, Joshi S, Revadi SS, Buggi S, Desai A, Vasanthapuram R. Proinflammatory chemokines are major mediators of exuberant immune response associated with Influenza A (H1N1) pdm09 virus infection. J Med Virol 2017; 89:1373-1381. [DOI: 10.1002/jmv.24781] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2016] [Accepted: 01/14/2017] [Indexed: 01/06/2023]
Affiliation(s)
- Maria Thomas
- Department of Neurovirology; National Institute of Mental Health and Neurosciences; Bangalore India
| | - Reeta Subramaniam Mani
- Department of Neurovirology; National Institute of Mental Health and Neurosciences; Bangalore India
| | - Mariamma Philip
- Department of Biostatistics; National Institute of Mental Health and Neurosciences; Bangalore India
| | | | - Sangeeta Joshi
- Department of Microbiology; Manipal Hospital; Bangalore India
| | - Srigiri S. Revadi
- Influenza Division; Rajiv Gandhi Institute for Chest Diseases; Bangalore India
| | - Shashidhar Buggi
- Influenza Division; Rajiv Gandhi Institute for Chest Diseases; Bangalore India
| | - Anita Desai
- Department of Neurovirology; National Institute of Mental Health and Neurosciences; Bangalore India
| | - Ravi Vasanthapuram
- Department of Neurovirology; National Institute of Mental Health and Neurosciences; Bangalore India
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54
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Zheng J, Shi Y, Xiong L, Zhang W, Li Y, Gibson PG, Simpson JL, Zhang C, Lu J, Sai J, Wang G, Wang F. The Expression of IL-6, TNF- α, and MCP-1 in Respiratory Viral Infection in Acute Exacerbations of Chronic Obstructive Pulmonary Disease. J Immunol Res 2017; 2017:8539294. [PMID: 28352642 PMCID: PMC5352889 DOI: 10.1155/2017/8539294] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2016] [Revised: 01/04/2017] [Accepted: 02/09/2017] [Indexed: 11/24/2022] Open
Abstract
Viral infection is a common trigger for acute exacerbations of chronic obstructive pulmonary disease (AECOPD). The aim of this study is to investigate the expression of cytokines in AECOPD. Patients with AECOPD requiring hospitalization were recruited. Meanwhile healthy volunteers of similar age that accepted routine check-ups and showed no clinical symptoms of inflammatory diseases were also recruited. Induced sputum and serum were collected. Induced sputum of participants was processed and tested for thirteen viruses and bacteria. Forty cytokines were assayed in serum using the Quantibody Human Inflammation Array 3 (Ray Biotech, Inc.). The most common virus detected in virus positive AECOPD (VP) was influenza A (16%). No virus was found in controls. Circulating levels of IL-6, TNF-α, and MCP-1 were elevated in VP and coinfection subjects (p < 0.05), while the levels of 37 other cytokines showed no difference, compared with virus negative groups and controls (p > 0.05). Additionally, VP patients were less likely to have received influenza vaccination. VP patients had a systemic inflammation response involving IL-6, TNF-α, and MCP-1 which may be due to virus-induced activation of macrophages. There are important opportunities for further investigating AECOPD mechanisms and for the development of better strategies in the management and prevention of virus-related AECOPD.
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Affiliation(s)
- Jingtong Zheng
- Departments of Pathogenic Biology, College of Basic Medical Sciences, Jilin university, Changchun, China
| | - Yue Shi
- Departments of Pathogenic Biology, College of Basic Medical Sciences, Jilin university, Changchun, China
| | - Lingxin Xiong
- Departments of Pathogenic Biology, College of Basic Medical Sciences, Jilin university, Changchun, China
- School of Pharmaceutical Sciences, Jilin University, Jilin, China
| | - Weijie Zhang
- Department of Respiratory Disease, Jilin Provincial People's Hospital, Changchun, China
| | - Ying Li
- Department of Disease Control and Prevention, Beijing Shunyi District Center, Beijing, China
| | - Peter G. Gibson
- Department of Respiratory and Sleep Medicine, John Hunter Hospital, Newcastle, NSW, Australia
| | - Jodie L. Simpson
- Department of Respiratory and Sleep Medicine, University of Newcastle, New Lambton, NSW, Australia
| | - Chao Zhang
- Departments of Pathogenic Biology, College of Basic Medical Sciences, Jilin university, Changchun, China
| | - Junying Lu
- Departments of Pathogenic Biology, College of Basic Medical Sciences, Jilin university, Changchun, China
- Department of Intensive Care Unit, First Hospital of Jilin University, Changchun 130021, China
| | - Jingying Sai
- Departments of Pathogenic Biology, College of Basic Medical Sciences, Jilin university, Changchun, China
- Department of Clinical Laboratory, The Second Hospital of Jilin University, Changchun 130021, China
| | - Guoqiang Wang
- Departments of Pathogenic Biology, College of Basic Medical Sciences, Jilin university, Changchun, China
| | - Fang Wang
- Departments of Pathogenic Biology, College of Basic Medical Sciences, Jilin university, Changchun, China
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55
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Li Z, Li L, Zhou H, Zeng L, Chen T, Chen Q, Zhou B, Wang Y, Chen Q, Hu P, Yang Z. Radix isatidis Polysaccharides Inhibit Influenza a Virus and Influenza A Virus-Induced Inflammation via Suppression of Host TLR3 Signaling In Vitro. Molecules 2017; 22:molecules22010116. [PMID: 28085062 PMCID: PMC6155848 DOI: 10.3390/molecules22010116] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2016] [Revised: 01/08/2017] [Accepted: 01/09/2017] [Indexed: 11/16/2022] Open
Abstract
Influenza remains one of the major epidemic diseases worldwide, and rapid virus replication and collateral lung tissue damage caused by excessive pro-inflammatory host immune cell responses lead to high mortality rates. Thus, novel therapeutic agents that control influenza A virus (IAV) propagation and attenuate excessive pro-inflammatory responses are needed. Polysaccharide extract from Radix isatidis, a traditional Chinese herbal medicine, exerted potent anti-IAV activity against human seasonal influenza viruses (H1N1 and H3N2) and avian influenza viruses (H6N2 and H9N2) in vitro. The polysaccharides also significantly reduced the expression of pro-inflammatory cytokines (IL-6) and chemokines (IP-10, MIG, and CCL-5) stimulated by A/PR/8/34 (H1N1) at a range of doses (7.5 mg/mL, 15 mg/mL, and 30 mg/mL); however, they were only effective against progeny virus at a high dose. Similar activity was detected against inflammation induced by avian influenza virus H9N2. The polysaccharides strongly inhibited the protein expression of TLR-3 induced by PR8, suggesting that they impair the upregulation of pro-inflammatory factors induced by IAV by inhibiting activation of the TLR-3 signaling pathway. The polysaccharide extract from Radix isatidis root therefore has the potential to be used as an adjunct to antiviral therapy for the treatment of IAV infection.
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Affiliation(s)
- Zhengtu Li
- State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Disease, First Affiliated Hospital of Guangzhou Medical University, (Guangzhou Medical University), Guangzhou 510120, China.
| | - Li Li
- The First Hospital of Yulin, Yuxi Da Dao Road, Yulin 719000, China.
| | - Hongxia Zhou
- State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Disease, First Affiliated Hospital of Guangzhou Medical University, (Guangzhou Medical University), Guangzhou 510120, China.
| | - Lijuan Zeng
- State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Disease, First Affiliated Hospital of Guangzhou Medical University, (Guangzhou Medical University), Guangzhou 510120, China.
| | - Tingting Chen
- State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Disease, First Affiliated Hospital of Guangzhou Medical University, (Guangzhou Medical University), Guangzhou 510120, China.
| | - Qiaolian Chen
- State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Disease, First Affiliated Hospital of Guangzhou Medical University, (Guangzhou Medical University), Guangzhou 510120, China.
| | - Beixian Zhou
- State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Disease, First Affiliated Hospital of Guangzhou Medical University, (Guangzhou Medical University), Guangzhou 510120, China.
| | - Yutao Wang
- State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Disease, First Affiliated Hospital of Guangzhou Medical University, (Guangzhou Medical University), Guangzhou 510120, China.
| | - Qiaoyan Chen
- Guangdong Provincial Hospital of Traditional Chinese Medicine, Guangzhou University of Traditinal Chinese Medicine, Guangzhou 510180, China.
| | - Ping Hu
- Shanghai Key Laboratory of Functional Materials Chemistry, School of Chemistry and Molecular Engineering, East China University of Science and Technology, Shanghai 200237, China.
| | - Zifeng Yang
- State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Disease, First Affiliated Hospital of Guangzhou Medical University, (Guangzhou Medical University), Guangzhou 510120, China.
- Macau University of Science and Technology, AvenidaWai Long, Taipa, Macau 519020, China.
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56
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Vidaña B, Martínez J, Martorell J, Montoya M, Córdoba L, Pérez M, Majó N. Involvement of the different lung compartments in the pathogenesis of pH1N1 influenza virus infection in ferrets. Vet Res 2016; 47:113. [PMID: 27825367 PMCID: PMC5101722 DOI: 10.1186/s13567-016-0395-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Accepted: 10/10/2016] [Indexed: 12/29/2022] Open
Abstract
Severe cases after pH1N1 infection are consequence of interstitial pneumonia triggered by alveolar viral replication and an exacerbated host immune response, characterized by the up-regulation of pro-inflammatory cytokines and the influx of inflammatory leukocytes to the lungs. Different lung cell populations have been suggested as culprits in the unregulated innate immune responses observed in these cases. This study aims to clarify this question by studying the different induction of innate immune molecules by the distinct lung anatomic compartments (vascular, alveolar and bronchiolar) of ferrets intratracheally infected with a human pH1N1 viral isolate, by means of laser microdissection techniques. The obtained results were then analysed in relation to viral quantification in the different anatomic areas and the histopathological lesions observed. More severe lung lesions were observed at 24 h post infection (hpi) correlating with viral antigen detection in bronchiolar and alveolar epithelial cells. However, high levels of viral RNA were detected in all anatomic compartments throughout infection. Bronchiolar areas were the first source of IFN-α and most pro-inflammatory cytokines, through the activation of RIG-I. In contrast, vascular areas contributed with the highest induction of CCL2 and other pro-inflammatory cytokines, through the activation of TLR3.
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Affiliation(s)
- Beatriz Vidaña
- Departament de Sanitat i Anatomia Animals, Universitat Autònoma de Barcelona, Bellaterra, Barcelona, Spain.,IRTA, Centre de Recerca en Sanitat Animal (CReSA, IRTA-UAB), Campus de la Universitat Autònoma de Barcelona, Bellaterra, Barcelona, Spain
| | - Jorge Martínez
- Departament de Sanitat i Anatomia Animals, Universitat Autònoma de Barcelona, Bellaterra, Barcelona, Spain. .,UAB, Centre de Recerca en Sanitat Animal (CReSA, IRTA-UAB), Campus de la Universitat Autònoma de Barcelona, Bellaterra, Barcelona, Spain.
| | - Jaime Martorell
- Departament de Medicina i Cirurgia Animals, Universitat Autònoma de Barcelona, Bellaterra, Barcelona, Spain
| | - María Montoya
- IRTA, Centre de Recerca en Sanitat Animal (CReSA, IRTA-UAB), Campus de la Universitat Autònoma de Barcelona, Bellaterra, Barcelona, Spain
| | - Lorena Córdoba
- IRTA, Centre de Recerca en Sanitat Animal (CReSA, IRTA-UAB), Campus de la Universitat Autònoma de Barcelona, Bellaterra, Barcelona, Spain
| | - Mónica Pérez
- IRTA, Centre de Recerca en Sanitat Animal (CReSA, IRTA-UAB), Campus de la Universitat Autònoma de Barcelona, Bellaterra, Barcelona, Spain
| | - Natàlia Majó
- Departament de Sanitat i Anatomia Animals, Universitat Autònoma de Barcelona, Bellaterra, Barcelona, Spain.,UAB, Centre de Recerca en Sanitat Animal (CReSA, IRTA-UAB), Campus de la Universitat Autònoma de Barcelona, Bellaterra, Barcelona, Spain
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57
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Kim ES, Choe PG, Park WB, Oh HS, Kim EJ, Nam EY, Na SH, Kim M, Song KH, Bang JH, Park SW, Kim HB, Kim NJ, Oh MD. Clinical Progression and Cytokine Profiles of Middle East Respiratory Syndrome Coronavirus Infection. J Korean Med Sci 2016; 31:1717-1725. [PMID: 27709848 PMCID: PMC5056202 DOI: 10.3346/jkms.2016.31.11.1717] [Citation(s) in RCA: 144] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2016] [Accepted: 06/12/2016] [Indexed: 01/07/2023] Open
Abstract
Clinical progression over time and cytokine profiles have not been well defined in patients with Middle East respiratory syndrome coronavirus (MERS-CoV) infection. We included 17 patients with laboratory-confirmed MERS-CoV during the 2015 outbreak in Korea. Clinical and laboratory parameters were collected prospectively. Serum cytokine and chemokine levels in serial serum samples were measured using enzyme-linked immunosorbent assay. All patients presented with fever. The median time to defervescence was 18 days. Nine patients required oxygen supplementation and classified into severe group. In the severe group, chest infiltrates suddenly began to worsen around day 7 of illness, and dyspnea developed at the end of the first week and became apparent in the second week. Median time from symptom onset to oxygen supplementation was 8 days. The severe group had higher neutrophil counts during week 1 than the mild group (4,500 vs. 2,200/μL, P = 0.026). In the second week of illness, the severe group had higher serum levels of IL-6 (54 vs. 4 pg/mL, P = 0.006) and CXCL-10 (2,642 vs. 382 pg/mL, P < 0.001). IFN-α response was not observed in mild cases. Our data shows that clinical condition may suddenly deteriorate around 7 days of illness and the serum levels of IL-6 and CXCL-10 was significantly elevated in MERS-CoV patients who developed severe diseases.
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Affiliation(s)
- Eu Suk Kim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Pyoeng Gyun Choe
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Wan Beom Park
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Hong Sang Oh
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | | | - Eun Young Nam
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Sun Hee Na
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Moonsuk Kim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Kyoung Ho Song
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Ji Hwan Bang
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Sang Won Park
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Hong Bin Kim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Nam Joong Kim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Myoung Don Oh
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea.
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58
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Fedson DS. Treating the host response to emerging virus diseases: lessons learned from sepsis, pneumonia, influenza and Ebola. ANNALS OF TRANSLATIONAL MEDICINE 2016; 4:421. [PMID: 27942512 DOI: 10.21037/atm.2016.11.03] [Citation(s) in RCA: 92] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
There is an ongoing threat of epidemic or pandemic diseases that could be caused by influenza, Ebola or other emerging viruses. It will be difficult and costly to develop new drugs that target each of these viruses. Statins and angiotensin receptor blockers (ARBs) have been effective in treating patients with sepsis, pneumonia and influenza, and a statin/ARB combination appeared to dramatically reduce mortality during the recent Ebola outbreak. These drugs target (among other things) the endothelial dysfunction found in all of these diseases. Most scientists work on new drugs that target viruses, and few accept the idea of treating the host response with generic drugs. A great deal of research will be needed to show conclusively that these drugs work, and this will require the support of public agencies and foundations. Investigators in developing countries should take an active role in this research. If the next Public Health Emergency of International Concern is caused by an emerging virus, a "top down" approach to developing specific new drug treatments is unlikely to be effective. However, a "bottom up" approach to treatment that targets the host response to these viruses by using widely available and inexpensive generic drugs could reduce mortality in any country with a basic health care system. In doing so, it would make an immeasurable contribution to global equity and global security.
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Affiliation(s)
- David S Fedson
- Formerly, Department of Medicine, University of Virginia School of Medicine, Charlottesville, Virginia, USA
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59
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Tavares LP, Teixeira MM, Garcia CC. The inflammatory response triggered by Influenza virus: a two edged sword. Inflamm Res 2016; 66:283-302. [PMID: 27744631 DOI: 10.1007/s00011-016-0996-0] [Citation(s) in RCA: 84] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Revised: 10/03/2016] [Accepted: 10/06/2016] [Indexed: 02/06/2023] Open
Abstract
Influenza A virus (IAV) is a relevant respiratory tract pathogen leading to a great number of deaths and hospitalizations worldwide. Secondary bacterial infections are a very common cause of IAV associated morbidity and mortality. The robust inflammatory response that follows infection is important for the control of virus proliferation but is also associated with lung damage, morbidity and death. The role of the different components of immune response underlying protection or disease during IAV infection is not completely elucidated. Overall, in the context of IAV infection, inflammation is a 'double edge sword' necessary to control infection but causing disease. Therefore, a growing number of studies suggest that immunomodulatory strategies may improve disease outcome without affecting the ability of the host to deal with infection. This review summarizes recent aspects of the inflammatory responses triggered by IAV that are preferentially involved in causing severe pulmonary disease and the anti-inflammatory strategies that have been suggested to treat influenza induced immunopathology.
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Affiliation(s)
- Luciana P Tavares
- Laboratório de Imunofarmacologia, Departamento de Bioquímica e Imunologia, ICB Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Mauro M Teixeira
- Laboratório de Imunofarmacologia, Departamento de Bioquímica e Imunologia, ICB Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Cristiana C Garcia
- Laboratório de Imunofarmacologia, Departamento de Bioquímica e Imunologia, ICB Universidade Federal de Minas Gerais, Belo Horizonte, Brazil. .,Laboratório de Vírus Respiratórios e do Sarampo, Instituto Oswaldo Cruz, Fiocruz, Avenida Brasil, 4365, 21040360, Rio de Janeiro, Brazil.
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60
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Crum-Cianflone NF. Invasive Aspergillosis Associated With Severe Influenza Infections. Open Forum Infect Dis 2016; 3:ofw171. [PMID: 27704024 PMCID: PMC5047415 DOI: 10.1093/ofid/ofw171] [Citation(s) in RCA: 89] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Accepted: 08/05/2016] [Indexed: 11/21/2022] Open
Abstract
Background. Invasive aspergillosis may occur in the setting of severe influenza infections due to viral-induced respiratory epithelium disruption and impaired immune effects, but data are limited. Methods. A retrospective study was conducted among severe influenza cases requiring medical intensive care unit (ICU) admission at an academic center during the 2015–2016 season. Data collected included respiratory cultures, medical conditions and immunosuppressants, laboratory and radiographic data, and outcomes. A systematic literature review of published cases in the English language of aspergillosis complicating influenza was conducted. Results. Six (75%) of 8 ICU influenza cases had Aspergillus isolated; 5 were classified as invasive disease. No ICU patient testing negative for influenza infection developed aspergillosis during the study period. Among cases with invasive aspergillosis, influenza infection was type A (H1N1) (n = 2) and influenza B (n = 3). Published and current cases yielded n = 57 (European Organization for Research and Treatment of Cancer/Invasive Fungal Infections Cooperative Group and the National Institute of Allergy and Infectious Diseases Mycoses Study Group criteria: 37% proven, 25% probable, and 39% possible cases). An increasing number of cases were reported since 2010. Sixty-five percent of cases lacked classic underlying conditions at admission for aspergillosis, 86% had lymphopenia, and 46% died. Conclusions. Aspergillosis may occur in the setting of severe influenza infections even among immunocompetent hosts. Risks may include influenza A (H1N1) or B infections and viral-induced lymphopenia, although further studies are needed. Prompt diagnosis and antifungal therapy are recommended given high mortality rates.
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61
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Lui G, Wong CK, Ip M, Chu YJ, Yung IMH, Cheung CSK, Zheng L, Lam JSY, Wong KT, Sin WWY, Choi KW, Lee N. HMGB1/RAGE Signaling and Pro-Inflammatory Cytokine Responses in Non-HIV Adults with Active Pulmonary Tuberculosis. PLoS One 2016; 11:e0159132. [PMID: 27434276 PMCID: PMC4951129 DOI: 10.1371/journal.pone.0159132] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Accepted: 06/28/2016] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND We aimed to study the pathogenic roles of High-Mobility Group Box 1 (HMGB1) / Receptor-for-Advanced-Glycation-End-products (RAGE) signaling and pro-inflammatory cytokines in patients with active pulmonary tuberculosis (PTB). METHODS A prospective study was conducted among non-HIV adults newly-diagnosed with active PTB at two acute-care hospitals (n = 80); age-and-sex matched asymptomatic individuals (tested for latent TB) were used for comparison (n = 45). Plasma concentrations of 8 cytokines/chemokines, HMGB1, soluble-RAGE, and transmembrane-RAGE expressed on monocytes/dendritic cells, were measured. Gene expression (mRNA) of HMGB1, RAGE, and inflammasome-NALP3 was quantified. Patients' PBMCs were stimulated with recombinant-HMGB1 and MTB-antigen (lipoarabinomannan) for cytokine induction ex vivo. RESULTS In active PTB, plasma IL-8/CXCL8 [median(IQR), 6.0(3.6-15.1) vs 3.6(3.6-3.6) pg/ml, P<0.001] and IL-6 were elevated, which significantly correlated with mycobacterial load, extent of lung consolidation (rs +0.509, P<0.001), severity-score (rs +0.317, P = 0.004), and fever and hospitalization durations (rs +0.407, P<0.001). IL-18 and sTNFR1 also increased. Plasma IL-8/CXCL8 (adjusted OR 1.12, 95%CI 1.02-1.23 per unit increase, P = 0.021) and HMGB1 (adjusted OR 1.42 per unit increase, 95%CI 1.08-1.87, P = 0.012) concentrations were independent predictors for respiratory failure, as well as for ICU admission/death. Gene expression of HMGB1, RAGE, and inflammasome-NALP3 were upregulated (1.2-2.8 fold). Transmembrane-RAGE was increased, whereas the decoy soluble-RAGE was significantly depleted. RAGE and HMGB1 gene expressions positively correlated with cytokine levels (IL-8/CXCL8, IL-6, sTNFR1) and clinico-/radiographical severity (e.g. extent of consolidation rs +0.240, P = 0.034). Ex vivo, recombinant-HMGB1 potentiated cytokine release (e.g. TNF-α) when combined with lipoarabinomannan. CONCLUSION In patients with active PTB, HMGB1/RAGE signaling and pro-inflammatory cytokines may play important roles in pathogenesis and disease manifestations. Our clinico-immunological data can provide basis for the development of new strategies for disease monitoring, management and control.
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Affiliation(s)
- Grace Lui
- Department of Medicine and Therapeutics, Prince of Wales Hospital, Hong Kong SAR, China
| | - Chun Kwok Wong
- Department of Chemical Pathology, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Margaret Ip
- Department of Microbiology, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Yi Jun Chu
- Department of Chemical Pathology, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Irene M. H. Yung
- Department of Medicine and Therapeutics, Prince of Wales Hospital, Hong Kong SAR, China
| | | | - Lin Zheng
- Department of Microbiology, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Judy S. Y. Lam
- Department of Imaging and Interventional Radiology, Prince of Wales Hospital, Hong Kong SAR, China
| | - Ka Tak Wong
- Department of Imaging and Interventional Radiology, Prince of Wales Hospital, Hong Kong SAR, China
| | - Winnie W. Y. Sin
- Department of Medicine, Alice Ho Miu Ling Nethersole Hospital, Hong Kong SAR, China
| | - Kin Wing Choi
- Department of Medicine, Alice Ho Miu Ling Nethersole Hospital, Hong Kong SAR, China
| | - Nelson Lee
- Department of Medicine and Therapeutics, Prince of Wales Hospital, Hong Kong SAR, China
- Stanley Ho Center for Emerging Infectious Diseases, The Chinese University of Hong Kong, Hong Kong SAR, China
- * E-mail:
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Abstract
A debate about the market-leading influenza antiviral medication, oseltamivir, which initially focused on treatment for generally mild illness, has been expanded to question the wisdom of stockpiling for use in future influenza pandemics. Although randomized controlled trial evidence confirms that oseltamivir will reduce symptom duration by 17-25 hours among otherwise healthy adolescents and adults with community-managed disease, no randomized controlled trials have examined the effectiveness of oseltamivir against more serious outcomes. Observational studies, although criticized on methodologic grounds, suggest that oseltamivir given early can reduce the risk for death by half among persons hospitalized with confirmed infection caused by influenza A(H1N1)pdm09 and influenza A(H5N1) viruses. However, available randomized controlled trial data may not be able to capture the effect of oseltamivir use among hospitalized patients with severe disease. We assert that data on outpatients with relatively mild disease should not form the basis for policies on the management of more severe disease.
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63
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Basile K, Dwyer DE, Kok J. Fat and flu: fact or fiction? Future Virol 2016. [DOI: 10.2217/fvl-2016-0014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Novel risk factors for severe influenza infection were described during the early phases of the influenza pandemic of 2009. Worldwide, the rate of severe influenza in the obese and morbidly obese population was disproportionate to that of the general population. This risk factor has now been recognized presumably due to the increasing prevalence of obesity. The cause behind this trend may extend beyond the known deleterious effects of obesity on respiratory physiology, as emerging evidence in animal models demonstrate A(H1N1)pdm09 itself confers worse outcomes compared with seasonal influenza subtypes. Currently, uncertainty remains regarding the optimal antiviral regimen and vaccination strategies in obese individuals. Therefore, further studies on the effects of obesity on influenza infection need to be prioritized.
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Affiliation(s)
- Kerri Basile
- Centre for Infectious Diseases & Microbiology Laboratory Services, Institute of Clinical Pathology & Medical Research, Westmead Hospital, University of Sydney, Westmead, New South Wales, Australia
- Marie Bashir Institute for Infectious Diseases & Biosecurity, Westmead Hospital, University of Sydney, Westmead, New South Wales, Australia
- Centre for Research Excellence in Critical Infections, Westmead Hospital, University of Sydney, Westmead, New South Wales, Australia
| | - Dominic E Dwyer
- Centre for Infectious Diseases & Microbiology Laboratory Services, Institute of Clinical Pathology & Medical Research, Westmead Hospital, University of Sydney, Westmead, New South Wales, Australia
- Marie Bashir Institute for Infectious Diseases & Biosecurity, Westmead Hospital, University of Sydney, Westmead, New South Wales, Australia
- Centre for Research Excellence in Critical Infections, Westmead Hospital, University of Sydney, Westmead, New South Wales, Australia
| | - Jen Kok
- Centre for Infectious Diseases & Microbiology Laboratory Services, Institute of Clinical Pathology & Medical Research, Westmead Hospital, University of Sydney, Westmead, New South Wales, Australia
- Marie Bashir Institute for Infectious Diseases & Biosecurity, Westmead Hospital, University of Sydney, Westmead, New South Wales, Australia
- Centre for Research Excellence in Critical Infections, Westmead Hospital, University of Sydney, Westmead, New South Wales, Australia
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64
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González Álvarez DA, López Cortés LF, Cordero E. Impact of HIV on the severity of influenza. Expert Rev Respir Med 2016; 10:463-472. [PMID: 26918376 DOI: 10.1586/17476348.2016.1157474] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Despite current antiretroviral therapy, HIV/AIDS is one of the most prelevant problems in healthcare worldwide. Similarly, influenza viruses are causes of epidemics outbreaks. HIV-infected patients are considered a high risk group for severe influenza infection, although several recent observational studies suggest that not all HIV-infected patients are equally susceptible to complications and that these patients should be stratified by their immunodeficiency status and other factors (such as smoking or comorbidities). Here, we have compiled the most recent data on the impact that HIV has on influenza infection.
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Affiliation(s)
| | | | - Elisa Cordero
- a Infectious Diseases Unit , University Hospital Virgen del Rocío , Sevilla , Spain
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65
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The Effect of Oseltamivir on the Disease Progression of Lethal Influenza A Virus Infection: Plasma Cytokine and miRNA Responses in a Mouse Model. DISEASE MARKERS 2016; 2016:9296457. [PMID: 27110056 PMCID: PMC4824134 DOI: 10.1155/2016/9296457] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/22/2016] [Accepted: 02/11/2016] [Indexed: 12/25/2022]
Abstract
Lethal influenza A virus infection leads to acute lung injury and possibly lethal complications. There has been a continuous effort to identify the possible predictors of disease severity. Unlike earlier studies, where biomarkers were analyzed on certain time points or days after infection, in this study biomarkers were evaluated over the entire course of infection. Circulating proinflammatory cytokines and/or miRNAs that track with the onset and progression of lethal A/Puerto Rico/8/34 (PR8) influenza A virus infection and their response to oseltamivir treatment were investigated up to 10 days after infection. Changes in plasma cytokines (IL-1β, IL-10, IL-12p70, IL-6, KC, TNF-α, and IFN-γ) and several candidate miRNAs were profiled. Among the cytokines analyzed, IL-6 and KC/GRO cytokines appeared to correlate with peak viral titer. Over the selected 48 miRNAs profiled, certain miRNAs were up- or downregulated in a manner that was dependent on the oseltamivir treatment and disease severity. Our findings suggest that IL-6 and KC/GRO cytokines can be a potential disease severity biomarker and/or marker for the progression/remission of infection. Further studies to explore other cytokines, miRNAs, and lung injury proteins in serum with different subtypes of influenza A viruses with varying disease severity may provide new insight into other unique biomarkers.
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66
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Bornand D, Toovey S, Jick SS, Meier CR. The risk of new onset depression in association with influenza--A population-based observational study. Brain Behav Immun 2016; 53:131-137. [PMID: 26681501 DOI: 10.1016/j.bbi.2015.12.005] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2015] [Revised: 11/20/2015] [Accepted: 12/05/2015] [Indexed: 10/22/2022] Open
Abstract
IMPORTANCE Case-reports provided evidence that influenza infections, particularly severe episodes, may exert neuronal damage in the CNS and thereby increase the risk of depression. OBJECTIVE It was the aim of this study to analyse the association between influenza infections and the risk of developing incident depression. DESIGN We conducted a case-control analysis between 2000 and 2013 using the large UK-based primary care database Clinical Practice Research Datalink (CPRD). SETTING This database contains anonymous longitudinal data from primary care. At present, it contains over 100 million person-years of data from some 10 million active patients. PARTICIPANTS We encompassed 103307 patients below the age of 80 years with an incident major depression diagnosis between 2000 and 2013, and matched each case to one control patient on age, sex, general practice, number of medical encounters, and years of history in the CPRD prior to the index date. EXPOSURE Major depression diagnosis was identified by READ-codes based on ICD-10 codes (F32), with a minimum of three prescriptions for antidepressant drugs recorded after the diagnosis. MAIN OUTCOME We calculated relative risk estimates of developing depression in association with previous influenza infections, stratified by the number, timing and severity of such events, and we adjusted for a variety of comorbidities, smoking status, alcohol intake, body mass index, use of oral corticosteroids, and benzodiazepines. RESULTS Patients with a previous influenza infection had an increased risk of developing depression (OR 1.30, 95%CI 1.25-1.34) compared to patients with no history of influenza infections. A recent influenza infection recorded within 30-180 days prior to the index date yielded an adjusted 1.57 (95%CI 1.36-1.81), and an increasing number of previous influenza infections was associated with increasing odds ratios (⩾ 3 recorded influenza infections, adjusted OR 1.48, 95%CI 1.22-1.81). CONCLUSION This study suggests that influenza infections are associated with a moderately increased risk of developing depression.
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Affiliation(s)
- Delia Bornand
- Basel Pharmacoepidemiology Unit, Division of Clinical Pharmacy and Epidemiology, Department of Pharmaceutical Sciences, University of Basel, Switzerland; Hospital Pharmacy, University Hospital Basel, Switzerland
| | - Stephen Toovey
- Division of Infection and Immunity, Academic Centre for Travel Medicine, Royal Free and University College Medical School, London, United Kingdom
| | - Susan S Jick
- Boston Collaborative Drug Surveillance Program, Boston University School of Public Health, Lexington, MA, USA
| | - Christoph R Meier
- Basel Pharmacoepidemiology Unit, Division of Clinical Pharmacy and Epidemiology, Department of Pharmaceutical Sciences, University of Basel, Switzerland; Hospital Pharmacy, University Hospital Basel, Switzerland; Boston Collaborative Drug Surveillance Program, Boston University School of Public Health, Lexington, MA, USA.
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67
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Peng N, Liu S, Xia Z, Ren S, Feng J, Jing M, Gao X, Wiemer EAC, Zhu Y. Inducible Major Vault Protein Plays a Pivotal Role in Double-Stranded RNA- or Virus-Induced Proinflammatory Response. THE JOURNAL OF IMMUNOLOGY 2016; 196:2753-66. [PMID: 26843330 DOI: 10.4049/jimmunol.1501481] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Accepted: 01/04/2016] [Indexed: 02/07/2023]
Abstract
Pathogen invasion triggers robust antiviral cytokine production via different transcription factor signaling pathways. We have previously demonstrated that major vault protein (MVP) induces type I IFN production during viral infection; however, little is known about the role of MVP in proinflammatory responses. In this study, we found in vitro that expression of MVP, IL-6, and IL-8 was inducible upon dsRNA stimulation or viral infection. Moreover, MVP was essential for the induction of IL-6 and IL-8, as impaired expression of IL-6 and IL-8 in MVP-deficient human PBMCs, human lung epithelial cells (A549), and THP-1 monocytes, as well as in murine splenocytes, peritoneal macrophages, and PBMCs from MVP-knockout (MVP(-/-)) mice, was observed. Upon investigation of the underlying mechanisms, we demonstrated that MVP acted in synergy with AP-1 (c-Fos) and CCAAT/enhancer binding protein (C/EBP)β-liver-enriched transcriptional activating protein to activate the IL6 and IL8 promoters. Introduction of mutations into the AP-1 and C/EBPβ binding sites on the IL6 and IL8 promoters resulted in the loss of synergistic activation with MVP. Furthermore, we found that MVP interacted with both c-Fos and C/EBPβ. The interactions promoted nuclear translocation and recruitment of these transcription factors to IL6 and IL8 promoter regions. In the MVP(-/-) mouse model, significantly decreased expression of early antiviral cytokines resulted in higher viral titer in the lung, higher mortality, and heavier lung damage after infection with lethal influenza A virus. Taken together, our findings help to delineate a novel role of MVP in host proinflammatory response.
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Affiliation(s)
- Nanfang Peng
- State Key Laboratory of Virology, College of Life Sciences, Wuhan University, Wuhan, Hubei 430072, China; and
| | - Shi Liu
- State Key Laboratory of Virology, College of Life Sciences, Wuhan University, Wuhan, Hubei 430072, China; and
| | - Zhangchuan Xia
- State Key Laboratory of Virology, College of Life Sciences, Wuhan University, Wuhan, Hubei 430072, China; and
| | - Sheng Ren
- State Key Laboratory of Virology, College of Life Sciences, Wuhan University, Wuhan, Hubei 430072, China; and
| | - Jian Feng
- State Key Laboratory of Virology, College of Life Sciences, Wuhan University, Wuhan, Hubei 430072, China; and
| | - Mingzhen Jing
- State Key Laboratory of Virology, College of Life Sciences, Wuhan University, Wuhan, Hubei 430072, China; and
| | - Xin Gao
- State Key Laboratory of Virology, College of Life Sciences, Wuhan University, Wuhan, Hubei 430072, China; and
| | - Erik A C Wiemer
- Department of Medical Oncology, Erasmus University Medical Center Cancer Institute, Rotterdam 3000 CA, the Netherlands
| | - Ying Zhu
- State Key Laboratory of Virology, College of Life Sciences, Wuhan University, Wuhan, Hubei 430072, China; and
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68
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Yawata N, Selva KJ, Liu YC, Tan KP, Lee AWL, Siak J, Lan W, Vania M, Arundhati A, Tong L, Li J, Mehta JS, Yawata M. Dynamic change in natural killer cell type in the human ocular mucosa in situ as means of immune evasion by adenovirus infection. Mucosal Immunol 2016; 9:159-70. [PMID: 26080707 DOI: 10.1038/mi.2015.47] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2014] [Accepted: 05/12/2015] [Indexed: 02/04/2023]
Abstract
The most severe form of virus-induced inflammation at the ocular surface is epidemic keratoconjunctivitis (EKC), often caused by group D human adenoviruses (HAdVs). We investigated the dynamics and mechanisms of changes in natural killer (NK) cell types in the human ocular mucosal surface in situ over the course of infection. In the acute phase of infection, the mature CD56(dim)NK cells that comprise a major subpopulation in the normal human conjunctiva are replaced by CD56(bright)NK cells recruited to the ocular surface by chemokines produced by the infected epithelium, and NKG2A-expressing CD56(dim) and CD56(bright) NK cells become the major subpopulations in severe inflammation. These NK cells attracted to the mucosal surface are however incapable of mounting a strong antiviral response because of upregulation of the inhibitory ligand human leukocyte antigen-E (HLA-E) on infected epithelium. Furthermore, group D HAdVs downregulate ligands for activating NK cell receptors, thus rendering even the mature NKG2A(-)NK cells unresponsive, an immune-escape mechanism distinct from other adenoviruses. Our findings imply that the EKC-causing group D HAdVs utilize these multiple pathways to inhibit antiviral NK cell responses in the initial stages of the infection.
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Affiliation(s)
- N Yawata
- Singapore Eye Research Institute, Singapore, Singapore
- Duke-NUS Graduate Medical School, Clinical Sciences, Singapore, Singapore
- Singapore Institute for Clinical Sciences (SICS), Agency for Science, Technology and Research (A*STAR), Singapore, Singapore
| | - K J Selva
- Singapore Eye Research Institute, Singapore, Singapore
| | - Y-C Liu
- Singapore Eye Research Institute, Singapore, Singapore
- Singapore National Eye Centre, Singapore, Singapore
| | - K P Tan
- Singapore Institute for Clinical Sciences (SICS), Agency for Science, Technology and Research (A*STAR), Singapore, Singapore
| | - A W L Lee
- Singapore Institute for Clinical Sciences (SICS), Agency for Science, Technology and Research (A*STAR), Singapore, Singapore
| | - J Siak
- Singapore Eye Research Institute, Singapore, Singapore
- Singapore National Eye Centre, Singapore, Singapore
| | - W Lan
- Singapore Eye Research Institute, Singapore, Singapore
| | - M Vania
- Singapore Eye Research Institute, Singapore, Singapore
| | - A Arundhati
- Singapore National Eye Centre, Singapore, Singapore
| | - L Tong
- Singapore Eye Research Institute, Singapore, Singapore
- Duke-NUS Graduate Medical School, Clinical Sciences, Singapore, Singapore
- Singapore National Eye Centre, Singapore, Singapore
- Department of Ophthalmology, Yong Loon Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - J Li
- Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - J S Mehta
- Singapore Eye Research Institute, Singapore, Singapore
- Duke-NUS Graduate Medical School, Clinical Sciences, Singapore, Singapore
- Singapore National Eye Centre, Singapore, Singapore
- Department of Ophthalmology, Yong Loon Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - M Yawata
- Singapore Institute for Clinical Sciences (SICS), Agency for Science, Technology and Research (A*STAR), Singapore, Singapore
- Department of Pediatrics, Yong Loon Lin School of Medicine, National University of Singapore, Singapore, Singapore
- National University Health System, Singapore, Singapore
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69
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McClain MT, Henao R, Williams J, Nicholson B, Veldman T, Hudson L, Tsalik EL, Lambkin-Williams R, Gilbert A, Mann A, Ginsburg GS, Woods CW. Differential evolution of peripheral cytokine levels in symptomatic and asymptomatic responses to experimental influenza virus challenge. Clin Exp Immunol 2015; 183:441-51. [PMID: 26506932 DOI: 10.1111/cei.12736] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2015] [Revised: 10/04/2015] [Accepted: 10/13/2015] [Indexed: 02/02/2023] Open
Abstract
Exposure to influenza virus triggers a complex cascade of events in the human host. In order to understand more clearly the evolution of this intricate response over time, human volunteers were inoculated with influenza A/Wisconsin/67/2005 (H3N2), and then had serial peripheral blood samples drawn and tested for the presence of 25 major human cytokines. Nine of 17 (53%) inoculated subjects developed symptomatic influenza infection. Individuals who will go on to become symptomatic demonstrate increased circulating levels of interleukin (IL)-6, IL-8, IL-15, monocyte chemotactic protein (MCP)-1 and interferon (IFN) gamma-induced protein (IP)-10 as early as 12-29 h post-inoculation (during the presymptomatic phase), whereas challenged patients who remain asymptomatic do not. Overall, the immunological pathways of leucocyte recruitment, Toll-like receptor (TLR)-signalling, innate anti-viral immunity and fever production are all over-represented in symptomatic individuals very early in disease, but are also dynamic and evolve continuously over time. Comparison with simultaneous peripheral blood genomics demonstrates that some inflammatory mediators (MCP-1, IP-10, IL-15) are being expressed actively in circulating cells, while others (IL-6, IL-8, IFN-α and IFN-γ) are probable effectors produced locally at the site of infection. Interestingly, asymptomatic exposed subjects are not quiescent either immunologically or genomically, but instead exhibit early and persistent down-regulation of important inflammatory mediators in the periphery. The host inflammatory response to influenza infection is variable but robust, and evolves over time. These results offer critical insight into pathways driving influenza-related symptomatology and offer the potential to contribute to early detection and differentiation of infected hosts.
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Affiliation(s)
- M T McClain
- Center for Applied Genomics and Precision Medicine, Duke University, Durham, NC, USA.,Durham Veterans Affairs Medical Center, Durham, NC, USA.,Division of Infectious Diseases, Duke University Medical Center, Durham, NC, USA
| | - R Henao
- Center for Applied Genomics and Precision Medicine, Duke University, Durham, NC, USA.,Department of Electrical Engineering, Duke University, Durham, NC, USA
| | - J Williams
- Durham Veterans Affairs Medical Center, Durham, NC, USA
| | - B Nicholson
- Durham Veterans Affairs Medical Center, Durham, NC, USA
| | - T Veldman
- Center for Applied Genomics and Precision Medicine, Duke University, Durham, NC, USA
| | - L Hudson
- Center for Applied Genomics and Precision Medicine, Duke University, Durham, NC, USA
| | - E L Tsalik
- Center for Applied Genomics and Precision Medicine, Duke University, Durham, NC, USA.,Durham Veterans Affairs Medical Center, Durham, NC, USA.,Division of Infectious Diseases, Duke University Medical Center, Durham, NC, USA
| | | | | | | | - G S Ginsburg
- Center for Applied Genomics and Precision Medicine, Duke University, Durham, NC, USA
| | - C W Woods
- Center for Applied Genomics and Precision Medicine, Duke University, Durham, NC, USA.,Durham Veterans Affairs Medical Center, Durham, NC, USA.,Division of Infectious Diseases, Duke University Medical Center, Durham, NC, USA
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70
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Hui DS, Lee N, Chan PKS. Update in Viral Infections 2014. Am J Respir Crit Care Med 2015; 192:676-81. [PMID: 26371813 DOI: 10.1164/rccm.201503-0637up] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Affiliation(s)
- David S Hui
- 1 Department of Medicine and Therapeutics.,2 Stanley Ho Center for Emerging Infectious Diseases, and
| | - Nelson Lee
- 1 Department of Medicine and Therapeutics.,2 Stanley Ho Center for Emerging Infectious Diseases, and
| | - Paul K S Chan
- 2 Stanley Ho Center for Emerging Infectious Diseases, and.,3 Department of Microbiology, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, New Territories, Hong Kong
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71
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Arriaga-Pizano L, Ferat-Osorio E, Rodríguez-Abrego G, Mancilla-Herrera I, Domínguez-Cerezo E, Valero-Pacheco N, Pérez-Toledo M, Lozano-Patiño F, Laredo-Sánchez F, Malagón-Rangel J, Nellen-Hummel H, González-Bonilla C, Arteaga-Troncoso G, Cérbulo-Vázquez A, Pastelin-Palacios R, Klenerman P, Isibasi A, López-Macías C. Differential Immune Profiles in Two Pandemic Influenza A(H1N1)pdm09 Virus Waves at Pandemic Epicenter. Arch Med Res 2015; 46:651-8. [PMID: 26696552 PMCID: PMC4914610 DOI: 10.1016/j.arcmed.2015.12.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2015] [Accepted: 12/01/2015] [Indexed: 11/26/2022]
Abstract
Background and Aims Severe influenza A(H1N1)pdm2009 virus infection cases are characterized by sustained immune activation during influenza pandemics. Seasonal flu data suggest that immune mediators could be modified by wave-related changes. Our aim was to determine the behavior of soluble and cell-related mediators in two waves at the epicenter of the 2009 influenza pandemic. Methods Leukocyte surface activation markers were studied in serum from peripheral blood samples, collected from the 1st (April–May, 2009) and 2nd (October 2009–February 2010) pandemic waves. Patients with confirmed influenza A(H1N1)pdm2009 virus infection (H1N1), influenza-like illness (ILI) or healthy donors (H) were analyzed. Results Serum IL-6, IL-4 and IL-10 levels were elevated in H1N1 patients from the 2nd pandemic wave. Additionally, the frequency of helper and cytotoxic T cells was reduced during the 1st wave, whereas CD69 expression in helper T cells was increased in the 2nd wave for both H1N1 and ILI patients. In contrast, CD62L expression in granulocytes from the ILI group was increased in both waves but in monocytes only in the 2nd wave. Triggering Receptor Expressed on Myeloid cells (TREM)-1 expression was elevated only in H1N1 patients at the 1st wave. Conclusions Our results show that during the 2009 influenza pandemic a T cell activation phenotype is observed in a wave-dependent fashion, with an expanded activation in the 2nd wave, compared to the 1st wave. Conversely, granulocyte and monocyte activation is infection-dependent. This evidence collected at the pandemic epicenter in 2009 could help us understand the differences in the underlying cellular mechanisms that drive the wave-related immune profile behaviors that occur against influenza viruses during pandemics.
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Affiliation(s)
- Lourdes Arriaga-Pizano
- Medical Research Unit in Immunochemistry, Specialties Hospital, National Medical Center Siglo XXI, IMSS, Mexico City, Mexico
| | - Eduardo Ferat-Osorio
- Medical Research Unit in Immunochemistry, Specialties Hospital, National Medical Center Siglo XXI, IMSS, Mexico City, Mexico; Gastrointestinal Surgery Service, Specialties Hospital, National Medical Center Siglo XXI, IMSS, Mexico City, Mexico
| | | | - Ismael Mancilla-Herrera
- Infectology and Immunology department, National Institute of Perinatology, SSA, Mexico City, Mexico
| | - Esteban Domínguez-Cerezo
- Medical Research Unit in Immunochemistry, Specialties Hospital, National Medical Center Siglo XXI, IMSS, Mexico City, Mexico; Graduate Program on Immunology, ENCB-IPN, Mexico City, Mexico
| | - Nuriban Valero-Pacheco
- Medical Research Unit in Immunochemistry, Specialties Hospital, National Medical Center Siglo XXI, IMSS, Mexico City, Mexico; Graduate Program on Immunology, ENCB-IPN, Mexico City, Mexico
| | - Marisol Pérez-Toledo
- Medical Research Unit in Immunochemistry, Specialties Hospital, National Medical Center Siglo XXI, IMSS, Mexico City, Mexico; Graduate Program on Immunology, ENCB-IPN, Mexico City, Mexico
| | - Fernando Lozano-Patiño
- Internal Medicine Service, Specialties Hospital of the National Medical Center Siglo XXI, IMSS, Mexico City, Mexico
| | - Fernando Laredo-Sánchez
- Internal Medicine Service, Specialties Hospital of the National Medical Center Siglo XXI, IMSS, Mexico City, Mexico
| | - José Malagón-Rangel
- Internal Medicine Service, Specialties Hospital of the National Medical Center Siglo XXI, IMSS, Mexico City, Mexico
| | - Haiko Nellen-Hummel
- Internal Medicine Service, Specialties Hospital of the National Medical Center Siglo XXI, IMSS, Mexico City, Mexico
| | - César González-Bonilla
- Unit for Epidemiological Surveillance, National Medical Center La Raza, IMSS, Mexico City, Mexico
| | | | | | | | - Paul Klenerman
- Oxford Biomedical Research Centre and Oxford Martin School, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Armando Isibasi
- Medical Research Unit in Immunochemistry, Specialties Hospital, National Medical Center Siglo XXI, IMSS, Mexico City, Mexico
| | - Constantino López-Macías
- Medical Research Unit in Immunochemistry, Specialties Hospital, National Medical Center Siglo XXI, IMSS, Mexico City, Mexico; Visiting Professor of Immunology, Nuffield Department of Medicine, University of Oxford, Oxford, UK.
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72
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Human Dendritic Cell Response Signatures Distinguish 1918, Pandemic, and Seasonal H1N1 Influenza Viruses. J Virol 2015. [PMID: 26223639 DOI: 10.1128/jvi.01523-15] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
UNLABELLED Influenza viruses continue to present global threats to human health. Antigenic drift and shift, genetic reassortment, and cross-species transmission generate new strains with differences in epidemiology and clinical severity. We compared the temporal transcriptional responses of human dendritic cells (DC) to infection with two pandemic (A/Brevig Mission/1/1918, A/California/4/2009) and two seasonal (A/New Caledonia/20/1999, A/Texas/36/1991) H1N1 influenza viruses. Strain-specific response differences included stronger activation of NF-κB following infection with A/New Caledonia/20/1999 and a unique cluster of genes expressed following infection with A/Brevig Mission/1/1918. A common antiviral program showing strain-specific timing was identified in the early DC response and found to correspond with reported transcript changes in blood during symptomatic human influenza virus infection. Comparison of the global responses to the seasonal and pandemic strains showed that a dramatic divergence occurred after 4 h, with only the seasonal strains inducing widespread mRNA loss. IMPORTANCE Continuously evolving influenza viruses present a global threat to human health; however, these host responses display strain-dependent differences that are incompletely understood. Thus, we conducted a detailed comparative study assessing the immune responses of human DC to infection with two pandemic and two seasonal H1N1 influenza strains. We identified in the immune response to viral infection both common and strain-specific features. Among the stain-specific elements were a time shift of the interferon-stimulated gene response, selective induction of NF-κB signaling by one of the seasonal strains, and massive RNA degradation as early as 4 h postinfection by the seasonal, but not the pandemic, viruses. These findings illuminate new aspects of the distinct differences in the immune responses to pandemic and seasonal influenza viruses.
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73
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Lower Respiratory Tract Infection of the Ferret by 2009 H1N1 Pandemic Influenza A Virus Triggers Biphasic, Systemic, and Local Recruitment of Neutrophils. J Virol 2015; 89:8733-48. [PMID: 26063430 DOI: 10.1128/jvi.00817-15] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2015] [Accepted: 06/04/2015] [Indexed: 11/20/2022] Open
Abstract
UNLABELLED Infection of the lower respiratory tract by influenza A viruses results in increases in inflammation and immune cell infiltration in the lung. The dynamic relationships among the lung microenvironments, the lung, and systemic host responses during infection remain poorly understood. Here we used extensive systematic histological analysis coupled with live imaging to gain access to these relationships in ferrets infected with the 2009 H1N1 pandemic influenza A virus (H1N1pdm virus). Neutrophil levels rose in the lungs of H1N1pdm virus-infected ferrets 6 h postinfection and became concentrated at areas of the H1N1pdm virus-infected bronchiolar epithelium by 1 day postinfection (dpi). In addition, neutrophil levels were increased throughout the alveolar spaces during the first 3 dpi and returned to baseline by 6 dpi. Histochemical staining revealed that neutrophil infiltration in the lungs occurred in two waves, at 1 and 3 dpi, and gene expression within microenvironments suggested two types of neutrophils. Specifically, CCL3 levels, but not CXCL8/interleukin 8 (IL-8) levels, were higher within discrete lung microenvironments and coincided with increased infiltration of neutrophils into the lung. We used live imaging of ferrets to monitor host responses within the lung over time with [(18)F]fluorodeoxyglucose (FDG). Sites in the H1N1pdm virus-infected ferret lung with high FDG uptake had high levels of proliferative epithelium. In summary, neutrophils invaded the H1N1pdm virus-infected ferret lung globally and focally at sites of infection. Increased neutrophil levels in microenvironments did not correlate with increased FDG uptake; hence, FDG uptake may reflect prior infection and inflammation of lungs that have experienced damage, as evidenced by bronchial regeneration of tissues in the lungs at sites with high FDG levels. IMPORTANCE Severe influenza disease is characterized by an acute infection of the lower airways that may progress rapidly to organ failure and death. Well-developed animal models that mimic human disease are essential to understanding the complex relationships of the microenvironment, organ, and system in controlling virus replication, inflammation, and disease progression. Employing the ferret model of H1N1pdm virus infection, we used live imaging and comprehensive histological analyses to address specific hypotheses regarding spatial and temporal relationships that occur during the progression of infection and inflammation. We show the general invasion of neutrophils at the organ level (lung) but also a distinct pattern of localized accumulation within the microenvironment at the site of infection. Moreover, we show that these responses were biphasic within the lung. Finally, live imaging revealed an early and sustained host metabolic response at sites of infection that may reflect damage and repair of tissues in the lungs.
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The placental protein syncytin-1 impairs antiviral responses and exaggerates inflammatory responses to influenza. PLoS One 2015; 10:e0118629. [PMID: 25831059 PMCID: PMC4382184 DOI: 10.1371/journal.pone.0118629] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2014] [Accepted: 01/21/2015] [Indexed: 12/22/2022] Open
Abstract
Background Pregnancy increases susceptibility to influenza. The placenta releases an immunosuppressive endogenous retroviral protein syncytin-1. We hypothesised that exposure of peripheral monocytes (PBMCs) to syncytin-1 would impair responses to H1N1pdm09 influenza. Methods and Findings Recombinant syncytin-1 was produced. PBMCs from non-pregnant women (n=10) were exposed to H1N1pdm09 in the presence and absence of syncytin-1 and compared to responses of PBMCs from pregnant women (n=12). PBMCs were characterised using flow cytometry, release of interferon (IFN)-α, IFN-λ, IFN-γ, IL-10, IL-2, IL-6 and IL-1β were measured by cytometric bead array or ELISA. Exposure of PBMCs to H1N1pdm09 resulted in the release of IFN-α, (14,787 pg/mL, 95% CI 7311-22,264 pg/mL) IFN-λ (1486 pg/mL, 95% CI 756-2216 pg/mL) and IFN-γ (852 pg/mL, 95% CI 193-1511 pg/mL) after 48 hours. This was significantly impaired in pregnant women (IFN-α; p<0.0001 and IFN-λ; p<0.001). Furthermore, in the presence of syncytin-1, PBMCs demonstrated marked reductions in IFN-α and IFN-λ, while enhanced release of IL-10 as well as IL-6 and IL-1β. Conclusions Our data indicates that a placental derived protein, syncytin-1 may be responsible for the heightened vulnerability of pregnant women to influenza.
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Abstract
Influenza viruses pose a substantial threat to human and animal health worldwide. Recent studies in mouse models have revealed an indispensable role for the innate immune system in defense against influenza virus. Recognition of the virus by innate immune receptors in a multitude of cell types activates intricate signaling networks, functioning to restrict viral replication. Downstream effector mechanisms include activation of innate immune cells and, induction and regulation of adaptive immunity. However, uncontrolled innate responses are associated with exaggerated disease, especially in pandemic influenza virus infection. Despite advances in the understanding of innate response to influenza in the mouse model, there is a large knowledge gap in humans, particularly in immunocompromised groups such as infants and the elderly. We propose here, the need for further studies in humans to decipher the role of innate immunity to influenza virus, particularly at the site of infection. These studies will complement the existing work in mice and facilitate the quest to design improved vaccines and therapeutic strategies against influenza.
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Affiliation(s)
- Michael B. A. Oldstone
- Department of Immunology and Microbial Science, The Scripps Research Institute, La Jolla, California USA
| | - Richard W. Compans
- IDepartment of Microbiology and Immunology, Emory University, Atlanta, Georgia USA
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Serum surfactant protein D (SP-D) is a prognostic marker of poor outcome in patients with A/H1N1 virus infection. Lung 2014; 193:25-30. [PMID: 25537934 PMCID: PMC7102134 DOI: 10.1007/s00408-014-9669-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2014] [Accepted: 12/01/2014] [Indexed: 12/17/2022]
Abstract
Introduction Surfactant protein D (SP-D) plays an important role in the innate responses against pathogens and its production is altered in lung disorders. Methods We studied the circulating levels of SP-D in 37 patients with acute respiratory distress syndrome due to the A/H1N1 virus infection and in 40 healthy controls. Cox logistic regression models were constructed to explore the association of SP-D levels and risk of death. Results Mortality rate after a 28-day was 32.42 %. Significant higher levels of SP-D were detected in A/H1N1 patients with fatal outcome (p < 0.05). After adjusting for confounding variables, levels of SP-D ≥250 ng/mL were associated with increased the risk of death (HR = 8.27, 95 % CI 1.1–64.1, p = 0.043). Conclusions Our results revealed that higher circulating levels of SP-D are associated with higher mortality risk in critically ill A/H1N1 patients. SP-D might be a predictive factor of poor outcomes in viral pneumonia.
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Bian JR, Nie W, Zang YS, Fang Z, Xiu QY, Xu XX. Clinical aspects and cytokine response in adults with seasonal influenza infection. Int J Clin Exp Med 2014; 7:5593-5602. [PMID: 25664078 PMCID: PMC4307525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2014] [Accepted: 11/25/2014] [Indexed: 06/04/2023]
Abstract
Cytokine responses play an important role in the pathogenesis of influenza infection. Previous studies found that cytokine expressions in patients infected with the novel A (H1N1) influenza virus (nvA (H1N1)) could reflect the severity of the disease. But the patterns of cytokine response in patients infected with seasonal influenza virus and the correlations between cytokine responses and clinical data are still unknown. Seventy-two outpatients for laboratory-confirmed seasonal influenza infection were studied: twenty-four seasonal influenza A patients and forty-eight seasonal influenza B patients. Thirty healthy volunteers were enrolled as a control group. Serum samples from influenza patients obtained on the admission day and 6 days later were measured for eight cytokines using enzyme-linked immunosorbent assay (ELISA). The clinical variables were recorded prospectively. The levels of interleukin (IL)-6, IL-33 and tumor necrosis factor (TNF)-α were significantly higher in influenza A patients than those in the control group while IL-6, IL-17A, IL-29, interferon (IFN)-γ and interferon gamma-induced protein (IP)-10 were significantly higher in influenza B patients than those in the control group. Furthermore, IL-17A, IL-29 and IP-10 were increased in seasonal influenza B patients when comparing with those in the seasonal influenza A patients. A positive correlation of IL-29 levels with fever (Spearman's rho, P-values < 0.05) and a negative correlation of IFN-γ and IP-10 levels with lymphocyte count (Spearman's rho, P-values < 0.05) were found in seasonal influenza infection. While a hyperactivated proinflammatory cytokine responses were found in seasonal influenza infection, a higher elevation of cytokines (IL-17A, IL-29 and IP-10) were found in seasonal influenza B infection versus influenza A. IL-29, IFN-γ and IP-10 were important hallmarks in seasonal influenza infection, which can help clinicians make timely treatment decision for severe patients.
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Affiliation(s)
- Jia-Rong Bian
- Department of Respiratory Medicine, Subei People's Hospital of Jiangsu Province, Clinical Medical School of Yangzhou University Yangzhou 225001, China ; Department of Respiratory Medicine, Shanghai Changzheng Hospital, Second Military Medical University Shanghai 200003, China
| | - Wei Nie
- Department of Respiratory Medicine, Shanghai Changzheng Hospital, Second Military Medical University Shanghai 200003, China
| | - Yuan-Sheng Zang
- Department of Respiratory Medicine, Shanghai Changzheng Hospital, Second Military Medical University Shanghai 200003, China
| | - Zheng Fang
- Department of Respiratory Medicine, Shanghai Changzheng Hospital, Second Military Medical University Shanghai 200003, China
| | - Qing-Yu Xiu
- Department of Respiratory Medicine, Shanghai Changzheng Hospital, Second Military Medical University Shanghai 200003, China
| | - Xing-Xiang Xu
- Department of Respiratory Medicine, Subei People's Hospital of Jiangsu Province, Clinical Medical School of Yangzhou University Yangzhou 225001, China
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Obesity and pro-inflammatory mediators are associated with acute kidney injury in patients with A/H1N1 influenza and acute respiratory distress syndrome. Exp Mol Pathol 2014; 97:453-7. [PMID: 25305354 DOI: 10.1016/j.yexmp.2014.10.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2014] [Accepted: 10/07/2014] [Indexed: 02/06/2023]
Abstract
BACKGROUND The obesity has been shown to increase the severity of A/H1N1 infection and the development of acute respiratory distress syndrome (ARDS) and organ involvement. METHODS Circulating levels of C-peptide, insulin, glucagon, leptin, acute phase reactants (procalcitonin, C-reactive protein, tissue plasminogen activator, and serum amyloids A and P), were measured in samples from 32 critically ill patients with A/H1N1 virus infection, 17 of whom had ARDS complicated by acute kidney injury (AKI) and 15 of whom had ARDS but did not develop AKI. RESULTS Patients with ARDS and AKI (ARDS/AKI) had higher BMI and higher levels of C-peptide, insulin, leptin, procalcitonin and serum amyloid A compared to those ARDS patient who did not develop AKI. Adjusting for confounding variables using logistic regression analysis, higher levels of C-peptide (>0.75 ng/mL) (OR=64.8, 95% CI = 2.1-1980, p = 0.0006) and BMI>30 Kg/m(2) (OR = 42.0, 95% CI = 1.2-1478, p = 0.04) were significantly associated with the development of AKI in ARDS patients. CONCLUSION High levels of C-peptide and BMI>30 kg/m(2) were associated with the development of AKI in ARDS patients due to A/H1N1 infection. These metabolic/obesity indicators, together with the profiles of pro-inflammatory acute phase proteins, may be important links between obesity and poor outcomes in A/H1N1 09 infection.
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Vidaña B, Martínez J, Martínez-Orellana P, García Migura L, Montoya M, Martorell J, Majó N. Heterogeneous pathological outcomes after experimental pH1N1 influenza infection in ferrets correlate with viral replication and host immune responses in the lung. Vet Res 2014; 45:85. [PMID: 25163545 PMCID: PMC4161856 DOI: 10.1186/s13567-014-0085-8] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2014] [Accepted: 07/31/2014] [Indexed: 01/13/2023] Open
Abstract
The swine-origin pandemic (p) H1N1 influenza A virus causes mild upper-respiratory tract disease in most human patients. However, some patients developed severe lower-respiratory tract infections with fatal consequences, and the cause of these infections remain unknown. Recently, it has been suggested that different populations have different degrees of susceptibility to pH1N1 strains due to host genetic variations that are associated with inappropriate immune responses against viral genetic characteristics. Here, we tested whether the pathologic patterns of influenza strains that produce different disease outcomes in humans could be reproduced in a ferret model. Our results revealed that the severities of infection did not correspond to particular viral isolate and were not associated with the clinical phenotypes of the corresponding patients. Severe pathological outcomes were associated with higher viral replication, especially in alveolar areas, and with an exacerbated innate cellular immune response that was characterised by substantial phagocytic and cytotoxic cell migration into the lungs. Moreover, detrimental innate cellular responses were linked to the up-regulation of several proinflammatory cytokines and chemokines and the down-regulation of IFNα in the lungs. Additionally, severe lung lesions were associated with greater up-regulations of pro-apoptotic markers and higher levels of apoptotic neutrophils and macrophages. In conclusion, this study confirmed that the clinicopathological outcomes of pH1N1 infection in ferrets were not only due to viral replication abilities but also depended on the hosts’ capacities to mount efficient immune responses to control viral infection of the lung.
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Affiliation(s)
- Beatriz Vidaña
- Departament de Sanitat i Anatomia Animals, Universitat Autònoma de Barcelona, Cerdanyola del Vallés, 08193 Bellaterra Spain ; Centre de Recerca en Sanitat Animal (CReSA), UAB-IRTA, Campus de la Universitat Autònoma de Barcelona, Cerdanyola del Vallés, 08193 Bellaterra Spain
| | - Jorge Martínez
- Departament de Sanitat i Anatomia Animals, Universitat Autònoma de Barcelona, Cerdanyola del Vallés, 08193 Bellaterra Spain ; Centre de Recerca en Sanitat Animal (CReSA), UAB-IRTA, Campus de la Universitat Autònoma de Barcelona, Cerdanyola del Vallés, 08193 Bellaterra Spain
| | - Pamela Martínez-Orellana
- Centre de Recerca en Sanitat Animal (CReSA), UAB-IRTA, Campus de la Universitat Autònoma de Barcelona, Cerdanyola del Vallés, 08193 Bellaterra Spain
| | - Lourdes García Migura
- Centre de Recerca en Sanitat Animal (CReSA), UAB-IRTA, Campus de la Universitat Autònoma de Barcelona, Cerdanyola del Vallés, 08193 Bellaterra Spain
| | - María Montoya
- Centre de Recerca en Sanitat Animal (CReSA), UAB-IRTA, Campus de la Universitat Autònoma de Barcelona, Cerdanyola del Vallés, 08193 Bellaterra Spain ; Institut de Recerca i Tecnologia Agroalimentaria (IRTA), Barcelona, Spain
| | - Jaime Martorell
- Departament de Medicina i Cirurgia Animals, Universitat Autònoma de Barcelona, Cerdanyola del Vallés, 08193 Bellaterra Spain
| | - Natàlia Majó
- Departament de Sanitat i Anatomia Animals, Universitat Autònoma de Barcelona, Cerdanyola del Vallés, 08193 Bellaterra Spain ; Centre de Recerca en Sanitat Animal (CReSA), UAB-IRTA, Campus de la Universitat Autònoma de Barcelona, Cerdanyola del Vallés, 08193 Bellaterra Spain
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Linko R, Hedger MP, Pettilä V, Ruokonen E, Ala-Kokko T, Ludlow H, de Kretser DM. Serum activin A and B, and follistatin in critically ill patients with influenza A(H1N1) infection. BMC Infect Dis 2014; 14:253. [PMID: 24885241 PMCID: PMC4101860 DOI: 10.1186/1471-2334-14-253] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2013] [Accepted: 05/02/2014] [Indexed: 12/29/2022] Open
Abstract
Background Activin A and its binding protein follistatin (FS) are increased in inflammatory disorders and sepsis. Overexpression of activin A in the lung causes similar histopathological changes as acute respiratory distress syndrome (ARDS). ARDS and severe respiratory failure are complications of influenza A(H1N1) infection. Interleukin 6 (IL-6), which in experimental studies increases after activin A release, is known to be related to the severity of H1N1 infection. Our aim was to evaluate the levels of activin A, activin B, FS, IL-6 and IL-10 and their association with the severity of respiratory failure in critically ill H1N1 patients. Methods A substudy of a prospective, observational cohort of H1N1 patients in Finnish intensive care units (ICU). Clinical information was recorded during ICU treatment, and serum activin A, activin B, FS, IL-6 and IL-10 were measured at admission to ICU and on days 2 and 7. Results Blood samples from 29 patients were analysed. At the time of admission to intensive care unit, elevated serum levels above the normal range for respective age group and sex were observed in 44% for activin A, 57% for activin B, and 39% for FS. In 13 of the 29 patients, serial samples at all time points were available and in these the highest activin A, activin B and FS were above the normal range in 85%, 100% and 46% of the patients, respectively. No difference in baseline or highest activin A or activin B was found in patients with or without acute lung injury (ALI) or ARDS (P > 0.05 for all). Peak levels of IL-6 were significantly elevated in ALI/ARDS patients. Peak activin A and activin A/FS were associated with ventilatory support free-days, severity of acute illness and length of ICU stay (P < 0.05 for all). Conclusions Higher than normal values of these proteins were common in patients with H1N1 infection but we found no association with the severity of their respiratory failure.
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Affiliation(s)
| | | | | | | | | | | | - David M de Kretser
- Monash Institute of Medical Research, Monash University, Melbourne, Australia.
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Hurt AC, Ison MG, Hayden FG, Hay AJ. Second isirv antiviral group conference: overview. Influenza Other Respir Viruses 2014; 7 Suppl 3:1-7. [PMID: 24215376 PMCID: PMC6499332 DOI: 10.1111/irv.12207] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Affiliation(s)
- Aeron C Hurt
- WHO Collaborating Centre for Reference and Research on Influenza, Melbourne, Vic., Australia
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Chemical and genetic tools to explore S1P biology. Curr Top Microbiol Immunol 2014; 378:55-83. [PMID: 24728593 PMCID: PMC7120161 DOI: 10.1007/978-3-319-05879-5_3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
The zwitterionic lysophospholipid Sphingosine 1-Phosphate (S1P) is a pleiotropic mediator of physiology and pathology. The synthesis, transport, and degradation of S1P are tightly regulated to ensure that S1P is present in the proper concentrations in the proper location. The binding of S1P to five G protein-coupled S1P receptors regulates many physiological systems, particularly the immune and vascular systems. Our understanding of the functions of S1P has been aided by the tractability of the system to both chemical and genetic manipulation. Chemical modulators have been generated to affect most of the known components of S1P biology, including agonists of S1P receptors and inhibitors of enzymes regulating S1P production and degradation. Genetic knockouts and manipulations have been similarly engineered to disrupt the functions of individual S1P receptors or enzymes involved in S1P metabolism. This chapter will focus on the development and utilization of these chemical and genetic tools to explore the complex biology surrounding S1P and its receptors, with particular attention paid to the in vivo findings that these tools have allowed for.
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83
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Oshansky CM, Gartland AJ, Wong SS, Jeevan T, Wang D, Roddam PL, Caniza MA, Hertz T, Devincenzo JP, Webby RJ, Thomas PG. Mucosal immune responses predict clinical outcomes during influenza infection independently of age and viral load. Am J Respir Crit Care Med 2014; 189:449-62. [PMID: 24308446 DOI: 10.1164/rccm.201309-1616oc] [Citation(s) in RCA: 130] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
RATIONALE Children are an at-risk population for developing complications following influenza infection, but immunologic correlates of disease severity are not understood. We hypothesized that innate cellular immune responses at the site of infection would correlate with disease outcome. OBJECTIVES To test the immunologic basis of severe illness during natural influenza virus infection of children and adults at the site of infection. METHODS An observational cohort study with longitudinal sampling of peripheral and mucosal sites in 84 naturally influenza-infected individuals, including infants. Cellular responses, viral loads, and cytokines were quantified from nasal lavages and blood, and correlated to clinical severity. MEASUREMENTS AND MAIN RESULTS We show for the first time that although viral loads in children and adults were similar, innate responses in the airways were stronger in children and varied considerably between plasma and site of infection. Adjusting for age and viral load, an innate immune profile characterized by increased nasal lavage monocyte chemotactic protein-3, IFN-α2, and plasma IL-10 levels at enrollment predicted progression to severe disease. Increased plasma IL-10, monocyte chemotactic protein-3, and IL-6 levels predicted hospitalization. This inflammatory cytokine production correlated significantly with monocyte localization from the blood to the site of infection, with conventional monocytes positively correlating with inflammation. Increased frequencies of CD14(lo) monocytes were in the airways of participants with lower inflammatory cytokine levels. CONCLUSIONS An innate profile was identified that correlated with disease progression independent of viral dynamics and age. The airways and blood displayed dramatically different immune profiles emphasizing the importance of cellular migration and localized immune phenotypes.
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Pfister R, Kochanek M, Leygeber T, Brun-Buisson C, Cuquemelle E, Machado MB, Piacentini E, Hammond NE, Ingram PR, Michels G. Procalcitonin for diagnosis of bacterial pneumonia in critically ill patients during 2009 H1N1 influenza pandemic: a prospective cohort study, systematic review and individual patient data meta-analysis. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2014; 18:R44. [PMID: 24612487 PMCID: PMC4056761 DOI: 10.1186/cc13760] [Citation(s) in RCA: 74] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/19/2013] [Accepted: 03/06/2014] [Indexed: 12/23/2022]
Abstract
Introduction Procalcitonin (PCT) is helpful for diagnosing bacterial infections. The diagnostic utility of PCT has not been examined thoroughly in critically ill patients with suspected H1N1 influenza. Methods Clinical characteristics and PCT were prospectively assessed in 46 patients with pneumonia admitted to medical ICUs during the 2009 and 2010 influenza seasons. An individual patient data meta-analysis was performed by combining our data with data from five other studies on the diagnostic utility of PCT in ICU patients with suspected 2009 pandemic influenza A(H1N1) virus infection identified by performing a systematic literature search. Results PCT levels, measured within 24 hours of ICU admission, were significantly elevated in patients with bacterial pneumonia (isolated or coinfection with H1N1; n = 77) (median = 6.2 μg/L, interquartile range (IQR) = 0.9 to 20) than in patients with isolated H1N1 influenza pneumonia (n = 84; median = 0.56 μg/L, IQR = 0.18 to 3.33). The area under the curve of the receiver operating characteristic curve of PCT was 0.72 (95% confidence interval (CI) = 0.64 to 0.80; P < 0.0001) for diagnosis of bacterial pneumonia, but increased to 0.76 (95% CI = 0.68 to 0.85; P < 0.0001) when patients with hospital-acquired pneumonia and immune-compromising disorders were excluded. PCT at a cut-off of 0.5 μg/L had a sensitivity (95% CI) and a negative predictive value of 80.5% (69.9 to 88.7) and 73.2% (59.7 to 84.2) for diagnosis of bacterial pneumonia, respectively, which increased to 85.5% (73.3 to 93.5) and 82.2% (68.0 to 92.0) in patients without hospital acquired pneumonia or immune-compromising disorder. Conclusions In critically ill patients with pneumonia during the influenza season, PCT is a reasonably accurate marker for detection of bacterial pneumonia, particularly in patients with community-acquired disease and without immune-compromising disorders, but it might not be sufficient as a stand-alone marker for withholding antibiotic treatment.
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85
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Kumar Y, Liang C, Limmon GV, Liang L, Engelward BP, Ooi EE, Chen J, Tannenbaum SR. Molecular analysis of serum and bronchoalveolar lavage in a mouse model of influenza reveals markers of disease severity that can be clinically useful in humans. PLoS One 2014; 9:e86912. [PMID: 24505273 PMCID: PMC3914809 DOI: 10.1371/journal.pone.0086912] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2013] [Accepted: 12/06/2013] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Management of influenza, a major contributor to the worldwide disease burden, is complicated by lack of reliable methods for early identification of susceptible individuals. Identification of molecular markers that can augment existing diagnostic tools for prediction of severity can be expected to greatly improve disease management capabilities. METHODOLOGY/PRINCIPAL FINDINGS We have analyzed cytokines, proteome flux and protein adducts in bronchoalveolar lavage (BAL) and sera from mice infected with influenza A virus (PR8 strain) using a previously established non-lethal model of influenza infection. Through detailed cytokine and protein adduct measurements of murine BAL, we first established the temporal profile of innate and adaptive responses as well as macrophage and neutrophil activities in response to influenza infection. A similar analysis was also performed with sera from a longitudinal cohort of influenza patients. We then used an iTRAQ-based, comparative serum proteome analysis to catalog the proteome flux in the murine BAL during the stages correlating with "peak viremia," "inflammatory damage," as well as the "recovery phase." In addition to activation of acute phase responses, a distinct class of lung proteins including surfactant proteins was found to be depleted from the BAL coincident with their "appearance" in the serum, presumably due to leakage of the protein following loss of the integrity of the lung/epithelial barrier. Serum levels of at least two of these proteins were elevated in influenza patients during the febrile phase of infection compared to healthy controls or to the same patients at convalescence. CONCLUSIONS/SIGNIFICANCE The findings from this study provide a molecular description of disease progression in a mouse model of influenza and demonstrate its potential for translation into a novel class of markers for measurement of acute lung injury and improved case management.
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Affiliation(s)
- Yadunanda Kumar
- Interdisciplinary research group in Infectious disease, Singapore-MIT Alliance for research and technology (SMART), Singapore, Singapore
- Department of Biological Engineering, Massachusetts Institute of Technology, Cambridge, Massachusetts, United States of America
- * E-mail:
| | - Cui Liang
- Interdisciplinary research group in Infectious disease, Singapore-MIT Alliance for research and technology (SMART), Singapore, Singapore
| | - Gino V. Limmon
- Interdisciplinary research group in Infectious disease, Singapore-MIT Alliance for research and technology (SMART), Singapore, Singapore
| | - Li Liang
- Interdisciplinary research group in Infectious disease, Singapore-MIT Alliance for research and technology (SMART), Singapore, Singapore
| | - Bevin P. Engelward
- Interdisciplinary research group in Infectious disease, Singapore-MIT Alliance for research and technology (SMART), Singapore, Singapore
- Department of Biological Engineering, Massachusetts Institute of Technology, Cambridge, Massachusetts, United States of America
| | - Eng Eong Ooi
- Interdisciplinary research group in Infectious disease, Singapore-MIT Alliance for research and technology (SMART), Singapore, Singapore
- DUKE-NUS Graduate Medical School, Singapore, Singapore
| | - Jianzhu Chen
- Interdisciplinary research group in Infectious disease, Singapore-MIT Alliance for research and technology (SMART), Singapore, Singapore
- Koch Institute for Integrative Cancer Research and Department of Biology, Massachusetts Institute of Technology, Cambridge, Massachusetts, United States of America
| | - Steven R. Tannenbaum
- Interdisciplinary research group in Infectious disease, Singapore-MIT Alliance for research and technology (SMART), Singapore, Singapore
- Department of Biological Engineering, Massachusetts Institute of Technology, Cambridge, Massachusetts, United States of America
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Oldstone MBA, Rosen H. Cytokine storm plays a direct role in the morbidity and mortality from influenza virus infection and is chemically treatable with a single sphingosine-1-phosphate agonist molecule. Curr Top Microbiol Immunol 2014; 378:129-47. [PMID: 24728596 PMCID: PMC7121493 DOI: 10.1007/978-3-319-05879-5_6] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Cytokine storm defines a dysregulation of and an excessively exaggerated immune response most often accompanying selected viral infections and several autoimmune diseases. Newly emerging and re-emerging infections of the respiratory tract, especially influenza, SARS, and hantavirus post considerable medical problems. Their morbidities and mortalities are often a direct result of cytokine storm. This chapter visits primarily influenza virus infection and resultant cytokine storm. It provides the compelling evidence that illuminates cytokine storm in influenza pathogenesis and the clear findings that cytokine storm is chemically tractable by therapy directed toward sphingosine-1-phosphate receptor (S1PR) modulation, specifically S1P1R agonist therapy. The mechanism(s) of how S1P1R signaling works and the pathways involved are subjects of this review.
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Affiliation(s)
- Michael B. A. Oldstone
- Department of Immunology and Microbial Sciiences, The Scripps Research Institute, La Jolla, California USA
| | - Hugh Rosen
- Department of Chemical Physiology, The Scripps Research Institute, La Jolla, California USA
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87
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Abstract
Influenza virus infection induces a potent initial innate immune response, which serves to limit the extent of viral replication and virus spread. However, efficient (and eventual) viral clearance within the respiratory tract requires the subsequent activation, rapid proliferation, recruitment, and expression of effector activities by the adaptive immune system, consisting of antibody producing B cells and influenza-specific T lymphocytes with diverse functions. The ensuing effector activities of these T lymphocytes ultimately determine (along with antibodies) the capacity of the host to eliminate the viruses and the extent of tissue damage. In this review, we describe this effector T cell response to influenza virus infection. Based on information largely obtained in experimental settings (i.e., murine models), we will illustrate the factors regulating the induction of adaptive immune T cell responses to influenza, the effector activities displayed by these activated T cells, the mechanisms underlying the expression of these effector mechanisms, and the control of the activation/differentiation of these T cells, in situ, in the infected lungs.
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88
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Abstract
Severe sepsis is traditionally associated with bacterial diseases. While fungi and parasites can also cause sepsis, they are significantly less common than bacterial causes. However, viruses are becoming a growing cause of severe sepsis worldwide. Among these viruses, influenza is crossing all geographic boundaries and is causing larger epidemics and pandemics. As a consequence, more critically ill patients with severe sepsis caused directly by influenza viruses, or indirectly by influenza-induced secondary bacterial infections are being admitted to hospitals worldwide. This manuscript aims to provide a pathophysiological and clinical update on the link between influenza and severe sepsis.
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Affiliation(s)
- Diana F Florescu
- Infectious Diseases Division; Internal Medicine Department; University of Nebraska Medical Center; Omaha, NE USA
| | - Andre C Kalil
- Infectious Diseases Division; Internal Medicine Department; University of Nebraska Medical Center; Omaha, NE USA
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89
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Paquette SG, Banner D, Chi LTB, Leόn AJ, Xu L, Ran L, Huang SSH, Farooqui A, Kelvin DJ, Kelvin AA. Pandemic H1N1 influenza A directly induces a robust and acute inflammatory gene signature in primary human bronchial epithelial cells downstream of membrane fusion. Virology 2013; 448:91-103. [PMID: 24314640 DOI: 10.1016/j.virol.2013.09.022] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2013] [Revised: 09/22/2013] [Accepted: 09/23/2013] [Indexed: 12/13/2022]
Abstract
Pandemic H1N1 influenza A (H1N1pdm) elicits stronger pulmonary inflammation than previously circulating seasonal H1N1 influenza A (sH1N1), yet mechanisms of inflammatory activation in respiratory epithelial cells during H1N1pdm infection are unclear. We investigated host responses to H1N1pdm/sH1N1 infection and virus entry mechanisms in primary human bronchial epithelial cells in vitro. H1N1pdm infection rapidly initiated a robust inflammatory gene signature (3 h post-infection) not elicited by sH1N1 infection. Protein secretion inhibition had no effect on gene induction. Infection with membrane fusion deficient H1N1pdm failed to induce robust inflammatory gene expression which was rescued with restoration of fusion ability, suggesting H1N1pdm directly triggered the inflammatory signature downstream of membrane fusion. Investigation of intra-virion components revealed H1N1pdm viral RNA (vRNA) triggered a stronger inflammatory phenotype than sH1N1 vRNA. Thus, our study is first to report H1N1pdm induces greater inflammatory gene expression than sH1N1 in vitro due to direct virus-epithelial cell interaction.
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Affiliation(s)
- Stéphane G Paquette
- Division of Experimental Therapeutics, Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada; Institute of Medical Science, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
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90
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Treating influenza with statins and other immunomodulatory agents. Antiviral Res 2013; 99:417-35. [PMID: 23831494 DOI: 10.1016/j.antiviral.2013.06.018] [Citation(s) in RCA: 128] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2013] [Revised: 06/19/2013] [Accepted: 06/25/2013] [Indexed: 12/28/2022]
Abstract
Statins not only reduce levels of LDL-cholesterol, they counteract the inflammatory changes associated with acute coronary syndrome and improve survival. Similarly, in patients hospitalized with laboratory-confirmed seasonal influenza, statin treatment is associated with a 41% reduction in 30-day mortality. Most patients of any age who are at increased risk of influenza mortality have chronic low-grade inflammation characteristic of metabolic syndrome. Moreover, differences in the immune responses of children and adults seem responsible for the low mortality in children and high mortality in adults seen in the 1918 influenza pandemic and in other acute infectious and non-infectious conditions. These differences probably reflect human evolutionary development. Thus the host response to influenza seems to be the major determinant of outcome. Outpatient statins are associated with reductions in hospitalizations and deaths due to sepsis and pneumonia. Inpatient statins are also associated with reductions in short-term pneumonia mortality. Other immunomodulatory agents--ACE inhibitors (ACEIs), angiotensin receptor blockers (ARBs), PPARγ and PPARα agonists (glitazones and fibrates) and AMPK agonists (metformin)--also reduce mortality in patients with pneumonia (ACEIs, ARBs) or in mouse models of influenza (PPAR and AMPK agonists). In experimental studies, treatment has not increased virus replication. Thus effective management of influenza may not always require targeting the virus with vaccines or antiviral agents. Clinical investigators, not systems biologists, have been the first to suggest that immunomodulatory agents might be used to treat influenza patients, but randomized controlled trials will be needed to provide convincing evidence that they work. To guide the choice of which agent(s) to study, we need new types of laboratory research in animal models and clinical and epidemiological research in patients with critical illness. These studies will have crucial implications for global public health. During the 2009 H1N1 influenza pandemic, timely and affordable supplies of vaccines and antiviral agents were unavailable to more than 90% of the world's people. In contrast, statins and other immunomodulatory agents are currently produced as inexpensive generics, global supplies are huge, and they would be available to treat patients in any country with a basic health care system on the first pandemic day. Treatment with statins and other immunomodulatory agents represents a new approach to reducing mortality caused by seasonal and pandemic influenza.
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91
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Bradley-Stewart A, Jolly L, Adamson W, Gunson R, Frew-Gillespie C, Templeton K, Aitken C, Carman W, Cameron S, McSharry C. Cytokine responses in patients with mild or severe influenza A(H1N1)pdm09. J Clin Virol 2013; 58:100-7. [PMID: 23790455 DOI: 10.1016/j.jcv.2013.05.011] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2013] [Revised: 04/08/2013] [Accepted: 05/06/2013] [Indexed: 01/15/2023]
Abstract
BACKGROUND Influenza virus affects millions of people worldwide each year. More severe infection occurs in the elderly, very young and immunocompromised. In 2009, a new variant of swine origin (influenza A(H1N1)pdm09 virus) emerged that produced severe disease in young healthy adults. OBJECTIVES The aim of this study was to determine whether cytokine concentrations are associated with clinical outcome in patients infected influenza A(H1N1)pdm09 virus. STUDY DESIGN Plasma concentration of 32 cytokines and growth factors were measured using a multiplex bead immunoassay and conventional ELISA in four patient groups. Patients with severe and mild influenza A(H1N1)pdm09 virus infection, rhinovirus infection and healthy volunteers were investigated. In addition, serial samples of respiratory secretions from five patients with severe influenza A(H1N1)pdm09 virus infection were examined. RESULTS The majority of cytokines measured were elevated in patients with viral respiratory infections compared to the healthy controls. Concentrations of IL-6, IL-10, IL-15, IP-10, IL-2R, HGF, ST2 and MIG were significantly higher (p<0.05) and EGF significantly lower (p=0.0001) in patients with severe influenza A(H1N1)pdm09 virus infection compared to those with mild influenza A(H1N1)pdm09 virus and rhinovirus infection. CONCLUSIONS A number of cytokines were found to be substantially elevated in patients with severe influenza A(H1N1)pdm09 virus infection. This supports and extends other published work suggesting a role for proinflammatory cytokines in influenza-induced lung pathology. Interestingly, EGF was significantly lower in patients with severe infection suggesting it is actively suppressed. As EGF has a role in role in cell proliferation and tissue repair, it may protect the lung from host or virus mediated damage.
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Affiliation(s)
- A Bradley-Stewart
- West of Scotland Specialist Virology Centre, Gartnavel General Hospital, 1053 Great Western Road, Glasgow G12 0YN, United Kingdom.
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92
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Affiliation(s)
- Marion Koopmans
- Virology Division, Laboratory for Infectious Diseases Research, Diagnosis and Screening, Centre for Infectious Disease Control, National Institute for Public Health and the Environment, Bilthoven 3720BA, Netherlands.
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93
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Echenique IA, Chan PA, Chapin KC, Andrea SB, Fava JL, Mermel LA. Clinical characteristics and outcomes in hospitalized patients with respiratory viral co-infection during the 2009 H1N1 influenza pandemic. PLoS One 2013; 8:e60845. [PMID: 23585856 PMCID: PMC3622008 DOI: 10.1371/journal.pone.0060845] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2012] [Accepted: 03/05/2013] [Indexed: 12/16/2022] Open
Abstract
Background The clinical consequences of co-infection with two or more respiratory viruses are poorly understood. We sought to determine if co-infection with pandemic 2009–2010 influenza A H1N1 (pH1N1) and another respiratory virus was associated with worse clinical outcomes. Methods A retrospective cohort study was performed of all hospitalized patients with a positive respiratory viral panel (RVP) for two or more viruses within 72 hours of admission at our institution from October 2009 to December 2009. We compared patients infected with one respiratory virus to those with respiratory viral co-infection. Results We identified 617 inpatients with a positive RVP sample with a single virus and 49 inpatients with a positive RVP sample for two viruses (i.e. co-infection). Co-infected patients were significantly younger, more often had fever/chills, tachypnea, and they more often demonstrated interstitial opacities suggestive of viral pneumonia on the presenting chest radiograph (OR 7.5, 95% CI 3.4–16.5). The likelihood of death, length of stay, and requirement for intensive care unit level of care were similar in both groups, but patients with any respiratory virus co-infection were more likely to experience complications, particularly treatment for a secondary bacterial pneumonia (OR 6.8, 95% CI 3.3–14.2). Patients co-infected with pH1N1 and another respiratory virus were more likely to present with chest radiograph changes suggestive of a viral pneumonia, compared to mono-infection with pH1N1 (OR 16.9, 95% CI 4.5–62.7). By logistic regression using mono-infection with non-PH1N1 viruses as the reference group, co-infection with pH1N1 was the strongest independent predictor of treatment for a secondary bacterial pneumonia (OR 17.8, 95% CI 6.7–47.1). Conclusion Patients with viral co-infection, particularly with pH1N1, were more likely to have chest radiograph features compatible with a viral pneumonia and complications during their hospital course, particularly treatment for secondary bacterial pneumonia. Despite this, co-infection was not associated with ICU admission.
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MESH Headings
- Adolescent
- Adult
- Aged
- Aged, 80 and over
- Antiviral Agents/therapeutic use
- Child
- Child, Preschool
- Coinfection
- Female
- Hospitalization
- Humans
- Infant
- Influenza A Virus, H1N1 Subtype
- Influenza, Human/diagnostic imaging
- Influenza, Human/epidemiology
- Influenza, Human/pathology
- Influenza, Human/therapy
- Intensive Care Units
- Male
- Middle Aged
- Pandemics
- Picornaviridae Infections/diagnostic imaging
- Picornaviridae Infections/epidemiology
- Picornaviridae Infections/pathology
- Picornaviridae Infections/therapy
- Pneumonia, Bacterial/diagnostic imaging
- Pneumonia, Bacterial/epidemiology
- Pneumonia, Bacterial/pathology
- Pneumonia, Bacterial/therapy
- Radiography
- Retrospective Studies
- Rhode Island/epidemiology
- Treatment Outcome
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Affiliation(s)
- Ignacio A. Echenique
- Department of Medicine, Alpert Medical School of Brown University, Providence, Rhode Island, United States of America
| | - Philip A. Chan
- Department of Medicine, Alpert Medical School of Brown University, Providence, Rhode Island, United States of America
- Division of Infectious Diseases, Rhode Island Hospital, Providence, Rhode Island, United States of America
| | - Kimberle C. Chapin
- Department of Medicine, Alpert Medical School of Brown University, Providence, Rhode Island, United States of America
- Department of Pathology, Rhode Island Hospital, Providence, Rhode Island, United States of America
| | - Sarah B. Andrea
- Department of Pathology, Rhode Island Hospital, Providence, Rhode Island, United States of America
| | - Joseph L. Fava
- Centers for Behavioral and Preventive Medicine, The Miriam Hospital, Alpert Medical School of Brown University, Providence, Rhode Island, United States of America
| | - Leonard A. Mermel
- Department of Medicine, Alpert Medical School of Brown University, Providence, Rhode Island, United States of America
- Division of Infectious Diseases, Rhode Island Hospital, Providence, Rhode Island, United States of America
- * E-mail:
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94
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Lee N, Wong CK, Hui DSC, Lee SKW, Wong RYK, Ngai KLK, Chan MCW, Chu YJ, Ho AWY, Lui GCY, Wong BCK, Wong SH, Yip SP, Chan PKS. Role of human Toll-like receptors in naturally occurring influenza A infections. Influenza Other Respir Viruses 2013; 7:666-75. [PMID: 23552014 PMCID: PMC5781199 DOI: 10.1111/irv.12109] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/26/2013] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND We investigated the roles of Toll-like receptors (TLRs) in naturally occurring influenza. METHODS A prospective, case - control study was conducted. Adults hospitalized with virologically confirmed influenza A infections (onset <48 hours, before treatment) were compared with age-/gender-matched controls. TLRs (2, 3, 4, 7, 8, 9) expression in monocytes and dendritic cells (DCs - total, myeloid, plasmacytoid) was quantitated using flow cytometry. Gene expression of RLRs (RIG-1, MDA-5) was evaluated using real-time PCR. Concomitant signaling molecules expression, plasma cytokine/chemokine concentrations, and respiratory tract viral loads were measured. PBMCs were cultured and stimulated ex vivo with TLR-specific ligands for cytokine responses. RESULTS Forty two patients with influenza (24 A/H3N2, 18 A/H1N1pdm09) and 20 controls were studied. Patients' mean age was 68 ± 16 years; 81% had respiratory/cardiovascular complications. There were increased cellular expressions of TLR9, TLR8, TLR3, and TLR7 during influenza; TLR2 and TLR4 were suppressed. Results were similar for both virus strains. Higher TLR expression levels at presentation significantly correlated with lower viral loads (Spearman's rho: -0.46 to -0.69 for TLR9, TLR8, and TLR3; P-values <0.05). Multivariate regression models (adjusted for age, comorbidity, disease severity, time from onset) confirmed their independent associations. Increased signaling molecules (phospho-MAPKs, IκB) and inflammatory cytokines (IL-6, sTNFR-1, CCL2/MCP-1; CXCL10/IP-10, IFN-γ) correlated with increased TLR expression. RLRs were upregulated simultaneously. PBMCs of patients with influenza showed significant, dynamic changes in their cytokine responses upon TLR stimulation, compared with controls. CONCLUSIONS Our results suggest that TLRs play an important role in early, innate viral inhibition in naturally occurring influenza. Inflammatory cytokine responses are concomitantly induced. These findings support investigation of TLR targeting as a novel intervention approach for prophylaxis against influenza.
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Affiliation(s)
- Nelson Lee
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, China.
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95
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Bautista E, Arcos M, Jimenez-Alvarez L, García-Sancho MC, Vázquez ME, Peña E, Higuera A, Ramírez G, Fernández-Plata R, Cruz-Lagunas A, García-Moreno SA, Urrea F, Ramírez R, Correa-Rotter R, Pérez-Padilla JR, Zúñiga J. Angiogenic and inflammatory markers in acute respiratory distress syndrome and renal injury associated to A/H1N1 virus infection. Exp Mol Pathol 2013; 94:486-92. [PMID: 23542734 DOI: 10.1016/j.yexmp.2013.03.007] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2012] [Accepted: 03/20/2013] [Indexed: 12/11/2022]
Abstract
Acute kidney injury (AKI) is often associated to acute respiratory distress syndrome (ARDS) due to influenza A/H1N1 virus infection. The profile of angiogenic and inflammatory factors in ARDS patients may be relevant for AKI. We analyzed the serum levels of several angiogenic factors, cytokines, and chemokines in 32 patients with A/H1N1 virus infection (17 with ARDS/AKI and 15 ARDS patients who did not developed AKI) and in 18 healthy controls. Significantly higher levels of VEGF, MCP-1, IL-6, IL-8 and IP-10 in ARDS/AKI patients were detected. Adjusting by confusing variables, levels of MCP-1 ≥150 pg/mL (OR=12.0, p=0.04) and VEGF ≥225 pg/mL (OR=6.4, p=0.03) were associated with the development of AKI in ARDS patients. Higher levels of MCP-1 and IP-10 were significantly associated with a higher risk of death in patients with ARDS (hazard ratio (HR)=10.0, p=0.02; HR=25.5, p=0.03, respectively) even taking into account AKI. Patients with influenza A/H1N1 infection and ARDS/AKI have an over-production of MCP-1, VEGF and IP-10 possibly contributing to kidney injury and are associated to a higher risk of death.
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Affiliation(s)
- Edgar Bautista
- Instituto Nacional de Enfermedades Respiratorias Ismael Cosío Villegas, Tlalpan 4502, Tlalpan, 14080, Mexico City, Mexico.
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96
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Innate immune function and mortality in critically ill children with influenza: a multicenter study. Crit Care Med 2013; 41:224-36. [PMID: 23222256 DOI: 10.1097/ccm.0b013e318267633c] [Citation(s) in RCA: 128] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To prospectively evaluate relationships among serum cytokine levels, innate immune responsiveness, and mortality in a multicenter cohort of critically ill children with influenza infection. DESIGN Prospective, multicenter, observational study. SETTING Fifteen pediatric ICUs among members of the Pediatric Acute Lung Injury and Sepsis Investigators network. PATIENTS Patients ≤18 yrs old admitted to a PICU with community-acquired influenza infection. A control group of outpatient children was also evaluated. INTERVENTIONS ICU patients underwent sampling within 72 hrs of ICU admission for measurement of a panel of 31 serum cytokine levels and quantification of whole blood ex vivo lipopolysaccharide-stimulated tumor necrosis factor-α production capacity using a standardized stimulation protocol. Outpatient control subjects also underwent measurement of tumor necrosis factor-α production capacity. MEASUREMENTS AND MAIN RESULTS Fifty-two patients (44 survivors, eight deaths) were sampled. High levels of serum cytokines (granulocyte macrophage colony-stimulating factor, interleukin-6, interleukin-8, interferon-inducible protein-10, monocyte chemotactic protein-1, and macrophage inflammatory protein-1α) were associated with mortality (p < 0.0016 for each comparison) as was the presence of secondary infection with Staphylococcus aureus (p = 0.007), particularly methicillin-resistant S. aureus (p < 0.0001). Nonsurvivors were immunosuppressed with leukopenia and markedly reduced tumor necrosis factor-α production capacity compared with outpatient control subjects (n = 21, p < 0.0001) and to ICU survivors (p < 0.0001). This association remained after controlling for multiple covariables. A tumor necrosis factor-α response <250 pg/mL was highly predictive of death and longer duration of ICU stay (p < 0.0001). Patients with S. aureus coinfection demonstrated the greatest degree of immunosuppression (p < 0.0001). CONCLUSIONS High serum levels of cytokines can coexist with marked innate immune suppression in children with critical influenza. Severe, early innate immune suppression is highly associated with both S. aureus coinfection and mortality in this population. Multicenter innate immune function testing is feasible and can identify these high-risk children.
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97
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Davey RT, Lynfield R, Dwyer DE, Losso MH, Cozzi-Lepri A, Wentworth D, Lane HC, Dewar R, Rupert A, Metcalf JA, Pett SL, Uyeki TM, Bruguera JM, Angus B, Cummins N, Lundgren J, Neaton JD. The association between serum biomarkers and disease outcome in influenza A(H1N1)pdm09 virus infection: results of two international observational cohort studies. PLoS One 2013; 8:e57121. [PMID: 23468921 PMCID: PMC3584122 DOI: 10.1371/journal.pone.0057121] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2012] [Accepted: 01/15/2013] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Prospective studies establishing the temporal relationship between the degree of inflammation and human influenza disease progression are scarce. To assess predictors of disease progression among patients with influenza A(H1N1)pdm09 infection, 25 inflammatory biomarkers measured at enrollment were analyzed in two international observational cohort studies. METHODS Among patients with RT-PCR-confirmed influenza A(H1N1)pdm09 virus infection, odds ratios (ORs) estimated by logistic regression were used to summarize the associations of biomarkers measured at enrollment with worsened disease outcome or death after 14 days of follow-up for those seeking outpatient care (FLU 002) or after 60 days for those hospitalized with influenza complications (FLU 003). Biomarkers that were significantly associated with progression in both studies (p<0.05) or only in one (p<0.002 after Bonferroni correction) were identified. RESULTS In FLU 002 28/528 (5.3%) outpatients had influenza A(H1N1)pdm09 virus infection that progressed to a study endpoint of complications, hospitalization or death, whereas in FLU 003 28/170 (16.5%) inpatients enrolled from the general ward and 21/39 (53.8%) inpatients enrolled directly from the ICU experienced disease progression. Higher levels of 12 of the 25 markers were significantly associated with subsequent disease progression. Of these, 7 markers (IL-6, CD163, IL-10, LBP, IL-2, MCP-1, and IP-10), all with ORs for the 3(rd) versus 1(st) tertile of 2.5 or greater, were significant (p<0.05) in both outpatients and inpatients. In contrast, five markers (sICAM-1, IL-8, TNF-α, D-dimer, and sVCAM-1), all with ORs for the 3(rd) versus 1(st) tertile greater than 3.2, were significantly (p≤.002) associated with disease progression among hospitalized patients only. CONCLUSIONS In patients presenting with varying severities of influenza A(H1N1)pdm09 virus infection, a baseline elevation in several biomarkers associated with inflammation, coagulation, or immune function strongly predicted a higher risk of disease progression. It is conceivable that interventions designed to abrogate these baseline elevations might affect disease outcome.
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Affiliation(s)
- Richard T Davey
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA.
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98
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Viral pneumonitis is increased in obese patients during the first wave of pandemic A(H1N1) 2009 virus. PLoS One 2013; 8:e55631. [PMID: 23418448 PMCID: PMC3572103 DOI: 10.1371/journal.pone.0055631] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2012] [Accepted: 01/03/2013] [Indexed: 01/19/2023] Open
Abstract
Introduction There is conflicting data as to whether obesity is an independent risk factor for mortality in severe pandemic (H1N1) 2009 influenza (A(H1N1)pdm09). It is postulated that excess inflammation and cytokine production in obese patients following severe influenza infection leads to viral pneumonitis and/or acute respiratory distress syndrome. Methods Demographic, laboratory and clinical data prospectively collected from obese and non-obese patients admitted to nine adult Australian intensive care units (ICU) during the first A(H1N1)pdm09 wave, supplemented with retrospectively collected data, were compared. Results Of 173 patients, 100 (57.8%), 73 (42.2%) and 23 (13.3%) had body mass index (BMI) <30 kg/m2, ≥30 kg/m2 (obese) and ≥40 kg/m2 (morbidly obese) respectively. Compared to non-obese patients, obese patients were younger (mean age 43.4 vs. 48.4 years, p = 0.035) and more likely to develop pneumonitis (61% vs. 44%, p = 0.029). Extracorporeal membrane oxygenation use was greater in morbidly obese compared to non-obese patients (17.4% vs. 4.7%, p = 0.04). Higher mortality rates were observed in non-obese compared to obese patients, but not after adjusting for severity of disease. C-reactive protein (CRP) levels and hospital length of stay (LOS) were similar. Amongst ICU survivors, obese patients had longer ICU LOS (median 11.9 vs. 6.8 days, p = 0.017). Similar trends were observed when only patients infected with A(H1N1)pdm09 were examined. Conclusions Among patients admitted to ICU during the first wave of A(H1N1)pdm09, obese and morbidly obese patients with severe infection were more likely to develop pneumonitis compared to non-obese patients, but mortality rates were not increased. CRP is not an accurate marker of pneumonitis.
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99
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Skovgaard K, Cirera S, Vasby D, Podolska A, Breum SØ, Dürrwald R, Schlegel M, Heegaard PMH. Expression of innate immune genes, proteins and microRNAs in lung tissue of pigs infected experimentally with influenza virus (H1N2). Innate Immun 2013; 19:531-44. [PMID: 23405029 DOI: 10.1177/1753425912473668] [Citation(s) in RCA: 79] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
This study aimed at providing a better understanding of the involvement of innate immune factors, including miRNA, in the local host response to influenza virus infection. Twenty pigs were challenged by influenza A virus subtype H1N2. Expression of microRNA (miRNA), mRNA and proteins were quantified in lung tissue at different time points after challenge (24 h, 72 h and 14 d post-infection (p.i.). Several groups of genes were significantly regulated according to time point and infection status including pattern recognition receptors (TLR2, TLR3, TLR7, retinoic acid-inducible gene I, melanoma differentiation associated protein-5), IFN and IFN-induced genes (IFN-β, IFN-γ, IRF7, STAT1, ISG15 and OASL), cytokines (IL-1 β, IL-1RN, IL-6, IL-7, IL-10, IL-12A, TNF-α, CCL2, CCL3 and CXCL10) and several acute phase proteins. Likewise, the following miRNAs were differentially expressed in one or more time groups compared with the control pigs: miR-15a, miR-21, miR-146, miR-206, miR-223 and miR-451. At d 1 p.i. lung tissue protein levels of IL-6, IL-12 and IFN-α were significantly increased compared with the control group, and haptoglobin and C-reactive protein were significantly increased at d 3 p.i. Our results suggest that, in addition to a wide range of innate immune factors, miRNAs may also be involved in controlling acute influenza infection in pigs.
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Affiliation(s)
- Kerstin Skovgaard
- 1Innate Immunology Group, National Veterinary Institute, Technical University of Denmark, Copenhagen, Denmark
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100
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Fedson DS, Opal SM. The controversy over H5N1 transmissibility research: an opportunity to define a practical response to a global threat. Hum Vaccin Immunother 2013; 9:977-86. [PMID: 23391967 DOI: 10.4161/hv.23869] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Since December 2011, influenza virologists and biosecurity experts have been engaged in a controversial debate over research on the transmissibility of H5N1 influenza viruses. Influenza virologists disagreed with the NSABB's recommendation not to publish experimental details of their findings, whereas biosecurity experts wanted the details to be withheld and future research restricted. The virologists initially declared a voluntary moratorium on their work, but later the NSABB allowed their articles to be published, and soon transmissibility research will resume. Throughout the debate, both sides have had understandable views, but both have overlooked the more important question of whether anything could be done if one of these experimentally derived viruses or a naturally occurring and highly virulent influenza virus should emerge and cause a global pandemic. This is a crucial question, because during the 2009 H1N1 influenza pandemic, more than 90% of the world's people had no access to timely supplies of affordable vaccines and antiviral agents. Observational studies suggest that inpatient statin treatment reduces mortality in patients with laboratory-confirmed seasonal influenza. Other immunomodulatory agents (glitazones, fibrates and AMPK agonists) improve survival in mice infected with influenza viruses. These agents are produced as inexpensive generics in developing countries. If they were shown to be effective, they could be used immediately to treat patients in any country with a basic health care system. For this reason alone, influenza virologists and biosecurity experts need to join with public health officials to develop an agenda for laboratory and clinical research on these agents. This is the only approach that could yield practical measures for a global response to the next influenza pandemic.
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