1
|
Bearnot CJ, Mbong EN, Muhayangabo RF, Laghari R, Butler K, Gainey M, Perera SM, Michelow IC, Tang OY, Levine AC, Colubri A, Aluisio AR. Derivation and Internal Validation of a Mortality Prognostication Machine Learning Model in Ebola Virus Disease Based on Iterative Point-of-Care Biomarkers. Open Forum Infect Dis 2024; 11:ofad689. [PMID: 38379568 PMCID: PMC10878059 DOI: 10.1093/ofid/ofad689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 01/03/2024] [Indexed: 02/22/2024] Open
Abstract
Background Although multiple prognostic models exist for Ebola virus disease mortality, few incorporate biomarkers, and none has used longitudinal point-of-care serum testing throughout Ebola treatment center care. Methods This retrospective study evaluated adult patients with Ebola virus disease during the 10th outbreak in the Democratic Republic of Congo. Ebola virus cycle threshold (Ct; based on reverse transcriptase polymerase chain reaction) and point-of-care serum biomarker values were collected throughout Ebola treatment center care. Four iterative machine learning models were created for prognosis of mortality. The base model used age and admission Ct as predictors. Ct and biomarkers from treatment days 1 and 2, days 3 and 4, and days 5 and 6 associated with mortality were iteratively added to the model to yield mortality risk estimates. Receiver operating characteristic curves for each iteration provided period-specific areas under curve with 95% CIs. Results Of 310 cases positive for Ebola virus disease, mortality occurred in 46.5%. Biomarkers predictive of mortality were elevated creatinine kinase, aspartate aminotransferase, blood urea nitrogen (BUN), alanine aminotransferase, and potassium; low albumin during days 1 and 2; elevated C-reactive protein, BUN, and potassium during days 3 and 4; and elevated C-reactive protein and BUN during days 5 and 6. The area under curve substantially improved with each iteration: base model, 0.74 (95% CI, .69-.80); days 1 and 2, 0.84 (95% CI, .73-.94); days 3 and 4, 0.94 (95% CI, .88-1.0); and days 5 and 6, 0.96 (95% CI, .90-1.0). Conclusions This is the first study to utilize iterative point-of-care biomarkers to derive dynamic prognostic mortality models. This novel approach demonstrates that utilizing biomarkers drastically improved prognostication up to 6 days into patient care.
Collapse
Affiliation(s)
- Courtney J Bearnot
- Department of Emergency Medicine, Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Eta N Mbong
- International Medical Corps, Goma, Democratic Republic of Congo
| | | | - Razia Laghari
- International Medical Corps, Goma, Democratic Republic of Congo
| | - Kelsey Butler
- Program in Bioinformatics and Integrative Biology, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
| | | | | | - Ian C Michelow
- Division of Infectious Diseases and Immunology, Department of Pediatrics, School of Medicine, University of Connecticut, Farmington, Connecticut, USA
| | - Oliver Y Tang
- Department of Emergency Medicine, Alpert Medical School of Brown University, Providence, Rhode Island, USA
- Department of Neurosurgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Adam C Levine
- Department of Emergency Medicine, Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Andrés Colubri
- Program in Bioinformatics and Integrative Biology, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
| | - Adam R Aluisio
- Department of Emergency Medicine, Alpert Medical School of Brown University, Providence, Rhode Island, USA
| |
Collapse
|
2
|
Friedman SL, Sanyal AJ. The future of hepatology. Hepatology 2023; 78:637-648. [PMID: 37013924 DOI: 10.1097/hep.0000000000000389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 03/11/2023] [Indexed: 04/05/2023]
Abstract
The field of hepatology has made impressive progress over its ~75 years of existence. Advances in understanding liver function and its dysregulation in disease, genetic determinants of disease, antiviral therapy, and transplantation have transformed the lives of patients. However, there are still significant challenges that require ongoing creativity and discipline, particularly with the emergence of fatty liver diseases, as well as managing autoimmune disease, cancer, and liver disease in children. Diagnostic advances are urgently needed to accelerate risk stratification and efficient testing of new agents with greater precision in enriched populations. Integrated, holistic care models should be extended beyond liver cancer to diseases like NAFLD with systemic manifestations or extrahepatic comorbidities such as cardiovascular disease, diabetes, addiction, and depressive disorders. To meet the growing burden of asymptomatic liver disease, the workforce will need to be expanded by incorporating more advanced practice providers and educating other specialists. The training of future hepatologists will benefit from incorporating emerging skills in data management, artificial intelligence, and precision medicine. Continued investment in basic and translational science is crucial for further progress. The challenges ahead are significant, but with collective effort, the field of hepatology will continue to make progress and overcome obstacles.
Collapse
Affiliation(s)
- Scott L Friedman
- Division of Liver Diseases, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Arun J Sanyal
- Division of Gastroenterology, Hepatology and Nutrition, Department of Internal Medicine, Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA
| |
Collapse
|
3
|
Chavez S, Koyfman A, Gottlieb M, Brady WJ, Carius BM, Liang SY, Long B. Ebola virus disease: A review for the emergency medicine clinician. Am J Emerg Med 2023; 70:30-40. [PMID: 37196593 DOI: 10.1016/j.ajem.2023.04.037] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 04/07/2023] [Accepted: 04/24/2023] [Indexed: 05/19/2023] Open
Abstract
INTRODUCTION Ebolavirus, the causative agent of Ebola virus disease (EVD) has been responsible for sporadic outbreaks mainly in sub-Saharan Africa since 1976. EVD is associated with high risk of transmission, especially to healthcare workers during patient care. OBJECTIVE The purpose of this review is to provide a concise review of EVD presentation, diagnosis, and management for emergency clinicians. DISCUSSION EVD is spread through direct contact, including blood, bodily fluids or contact with a contaminated object. Patients may present with non-specific symptoms such as fevers, myalgias, vomiting, or diarrhea that overlap with other viral illnesses, but rash, bruising, and bleeding may also occur. Laboratory analysis may reveal transaminitis, coagulopathy, and disseminated intravascular coagulation. The average clinical course is approximately 8-10 days with an average case fatality rate of 50%. The mainstay of treatment is supportive care, with two U.S. Food and Drug Administration-approved monoclonal antibody treatments (Ebanga and Inmazeb). Survivors of the disease may have a complicated recovery, marked by long-term symptoms. CONCLUSION EVD is a potentially deadly condition that can present with a wide range of signs and symptoms. Emergency clinicians must be aware of the presentation, evaluation, and management to optimize the care of these patients.
Collapse
Affiliation(s)
- Summer Chavez
- Department of Health Systems and Population Health Sciences, Tilman J. Fertitta Family College of Medicine, United States of America.
| | - Alex Koyfman
- The University of Texas Southwestern Medical Center, Department of Emergency Medicine, 5323 Harry Hines Boulevard, Dallas 75390, TX, United States of America
| | - Michael Gottlieb
- Department of Emergency Medicine, Rush University Medical Center, Chicago, IL, United States of America
| | - William J Brady
- Department of Emergency Medicine, University of Virginia School of Medicine, Charlottesville, VA, United States of America.
| | | | - Stephen Y Liang
- Divisions of Emergency Medicine and Infectious Diseases, Washington University School of Medicine, 660 S. Euclid Ave, St. Louis 63110, MO, United States of America.
| | - Brit Long
- SAUSHEC, Emergency Medicine, Brooke Army Medical Center, United States of America
| |
Collapse
|
4
|
Spengler JR, Welch SR, Ritter JM, Harmon JR, Coleman-McCray JD, Genzer SC, Seixas JN, Scholte FEM, Davies KA, Bradfute SB, Montgomery JM, Spiropoulou CF. Mouse models of Ebola virus tolerance and lethality: characterization of CD-1 mice infected with wild-type, guinea pig-adapted, or mouse-adapted virus. Antiviral Res 2023; 210:105496. [PMID: 36567020 DOI: 10.1016/j.antiviral.2022.105496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 12/12/2022] [Accepted: 12/14/2022] [Indexed: 12/24/2022]
Abstract
Development of lethal models of Ebola virus disease has been achieved by the serial passage of virus isolates from human cases in mice and guinea pigs. Use of mice infected with non-adapted virus has been limited due to the absence of overt clinical disease. In recent years, newly recognized sequelae identified in human cases has highlighted the importance of continued investigations of non-lethal infection both in humans and animal models. Here, we revisit the use of rodent-adapted and non-adapted Ebola virus (EBOV) in mice to investigate infection tolerance and future utility of these models in pathogenesis and therapeutic intervention studies. We found that like non-adapted wild-type EBOV, guinea pig-adapted EBOV resulted in widespread tissue infection, variably associated with tissue pathology, and alterations in clinical and immunological analytes in the absence of overt disease. Notably, infection with either non-lethal variant did not greatly differ from lethal mouse-adapted EBOV until near the time end-point criteria are reached in these mice. These data support future investigations of pathogenesis, convalescence, and sequelae in mouse models of virus tolerance.
Collapse
Affiliation(s)
- Jessica R Spengler
- Viral Special Pathogens Branch, Division of High-Consequence Pathogens and Pathology, Centers for Disease Control and Prevention, Atlanta, GA, USA.
| | - Stephen R Welch
- Viral Special Pathogens Branch, Division of High-Consequence Pathogens and Pathology, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Jana M Ritter
- Infectious Disease Pathology Branch, Division of High Consequence Pathogens and Pathology, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Jessica R Harmon
- Viral Special Pathogens Branch, Division of High-Consequence Pathogens and Pathology, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - JoAnn D Coleman-McCray
- Viral Special Pathogens Branch, Division of High-Consequence Pathogens and Pathology, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Sarah C Genzer
- Viral Special Pathogens Branch, Division of High-Consequence Pathogens and Pathology, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Josilene N Seixas
- Infectious Disease Pathology Branch, Division of High Consequence Pathogens and Pathology, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Florine E M Scholte
- Viral Special Pathogens Branch, Division of High-Consequence Pathogens and Pathology, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Katherine A Davies
- Viral Special Pathogens Branch, Division of High-Consequence Pathogens and Pathology, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Steven B Bradfute
- Center for Global Health, Department of Internal Medicine, University of New Mexico Health Sciences Center, Albuquerque, NM, USA
| | - Joel M Montgomery
- Viral Special Pathogens Branch, Division of High-Consequence Pathogens and Pathology, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Christina F Spiropoulou
- Viral Special Pathogens Branch, Division of High-Consequence Pathogens and Pathology, Centers for Disease Control and Prevention, Atlanta, GA, USA
| |
Collapse
|
5
|
Bettini A, Lapa D, Garbuglia AR. Diagnostics of Ebola virus. Front Public Health 2023; 11:1123024. [PMID: 36908455 PMCID: PMC9995846 DOI: 10.3389/fpubh.2023.1123024] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 01/31/2023] [Indexed: 02/25/2023] Open
Abstract
Ebola is a highly pathogenic virus, which in humans reaches a mortality rate above 50%. Due to a lack of laboratories in territories where Ebola viruses are endemic and the limited number of surveillance programmes, tests for the confirmation of suspected cases of Ebola are often performed in Reference Laboratories. While this provides guarantees regarding the accuracy of results, the shipment of samples to a centralized facility where the diagnostic test can be performed and the time required to achieve the results takes several days, which increases costs and entails delays in the isolation of positive subjects and therapeutic intervention with negative consequences both for patients and the community. Molecular tests have been the most frequently used tool in Ebola diagnosis in recent outbreaks. One of the most commonly used molecular tests is the Real-Star Altona, which targets a conserved area of the L gene. This assay showed different sensitivities depending on the Ebola virus: 471 copies/mL (EBOV) and 2871 copies/ml (SUDAN virus). The Cepheid system also showed good sensitivity (232 copies/mL). The LAMP platform is very promising because, being an isothermal reaction, it does not require high-precision instrumentation and can be considered a Point of Care (PoC) tool. Its analytical sensitivity is 1 copy/reaction. However, since data from real life studies are not yet available, it is premature to give any indications on its feasibility. Moreover, in November 2014, the WHO recommended the development of rapid diagnostic tests (RDT) according to ASSURED criteria. Several RDT assays have since been produced, most of which are rapid tests based on the search for antibody anti-Ebola viral proteins with immunochromatographic methods. Several viral antigens are used for this purpose: VP40, NP and GP. These assays show different sensitivities according to the protein used: VP40 57.4-93.1%, GP 53-88.9% and 85% for NP compared to reference molecular assays. From these results, it can be deduced that no RDT reaches the 99% sensitivity recommended by the WHO and therefore any RDT negative results in suspected cases should be confirmed with a molecular test.
Collapse
Affiliation(s)
- Aurora Bettini
- Laboratory of Virology, National Institute for Infectious Diseases Lazzaro Spallanzani (IRCCS), Rome, Italy
| | - Daniele Lapa
- Laboratory of Virology, National Institute for Infectious Diseases Lazzaro Spallanzani (IRCCS), Rome, Italy
| | - Anna Rosa Garbuglia
- Laboratory of Virology, National Institute for Infectious Diseases Lazzaro Spallanzani (IRCCS), Rome, Italy
| |
Collapse
|
6
|
Kjaldgaard L, Claude KM, Mukadi-Bamuleka D, Kitenge-Omasumbu R, Dixit D, Edidi-Atani F, Kuamfumu MM, Bulabula-Penge J, Mambu-Mbika F, Tshiani-Mbaya O, Diaz J, Mulangu S, Legand A, Mbala-Kingebeni P, Formenty P, Ahuka-Mundeke S, Muyembe-Tamfum JJ, Hawkes MT. Virus kinetics and biochemical derangements among children with Ebolavirus disease. EClinicalMedicine 2022; 53:101638. [PMID: 36105872 PMCID: PMC9465268 DOI: 10.1016/j.eclinm.2022.101638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2022] [Revised: 08/02/2022] [Accepted: 08/11/2022] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND A paucity of data is available on virologic and biochemical characteristics of paediatric Ebolavirus disease (EVD), compared to adults. METHODS We conducted a retrospective chart review of children (<16 years old) and a comparator group of young adults (16-44 years) from two treatment centres during the 2018-2020 EVD epidemic in Eastern Democratic Republic of the Congo. Statistical methods included chi-squared and Fisher's exact tests (dichotomous and categorical variables), Mann-Whitney U-test (continuous variables), multivariable linear regression (for determinants of admission viral load), linear mixed-effects models (for analysis of longitudinal viral load), and Cox proportional hazard models (to examine risk factors for mortality). FINDINGS We included 73 children and 234 adults admitted from April to October 2019. Paediatric patients commonly had electrolytes imbalances: hypokalaemia in 26/73 (36%), hyperkalaemia in 38/73 (52%), and hyponatraemia in 54/73 (74%). Hypoglycaemia occurred in 20/73 (27%), acute kidney injury in 43/73 (59%), and rhabdomyolysis in 35/73 (48%). Biochemical abnormalities were detected in a similar proportion of children and adults. The viral load (VL, log10 copies/mL) at admission (7.2 versus 6.5, p=0.0001), the peak viral load (7.5 versus 6.7, p=<0.0001), and the time for viraemia clearance (16 days versus 12 days, p=<0.0001) were significantly different in children. The duration of hospital stay was prolonged in children (20 versus 16 days, p=<0.0001). Risk factors for mortality in children were: VL >7.6 log10copies/mL, alanine transaminase >525 U/L, C-reactive protein >100 mg/L, blood urea nitrogen >7.5 mmol/L, rhabdomyolysis, and.acute kidney injury. INTERPRETATION Paediatric EVD patients, like adults, experience multiorgan dysfunction with life-threatening electrolyte imbalances, hypoglycaemia, kidney injury, liver injury, and rhabdomyolysis. Paediatric patients have significantly higher VLs throughout the course of EVD than adults. FUNDING This study was not funded.
Collapse
Affiliation(s)
- Lindsey Kjaldgaard
- Department of Paediatrics, University of Alberta, Edmonton, AB, Canada
- Member, Women and Children's Research Institute, University of Alberta, Edmonton, AB, Canada
| | | | - Daniel Mukadi-Bamuleka
- Institut National de Recherche Biomédicale (INRB), Kinshasa, Democratic Republic of the Congo
| | - Richard Kitenge-Omasumbu
- Programme National d'Urgences et Actions Humanitaires (PNUAH), Ministry of Health of the Democratic Republic of the Congo (DRC), Democratic Republic of the Congo
| | - Devika Dixit
- Department of Medicine, Division of Infectious Diseases, University of Saskatchewan, Saskatoon, SK, Canada
| | - François Edidi-Atani
- Institut National de Recherche Biomédicale (INRB), Kinshasa, Democratic Republic of the Congo
| | - Meris Matondo Kuamfumu
- Institut National de Recherche Biomédicale (INRB), Kinshasa, Democratic Republic of the Congo
| | - Junior Bulabula-Penge
- Institut National de Recherche Biomédicale (INRB), Kinshasa, Democratic Republic of the Congo
| | - Fabrice Mambu-Mbika
- Institut National de Recherche Biomédicale (INRB), Kinshasa, Democratic Republic of the Congo
| | - Olivier Tshiani-Mbaya
- Institut National de Recherche Biomédicale (INRB), Kinshasa, Democratic Republic of the Congo
| | - Janet Diaz
- World Health Organization (WHO), Geneva, Switzerland
| | - Sabue Mulangu
- Institut National de Recherche Biomédicale (INRB), Kinshasa, Democratic Republic of the Congo
| | - Anais Legand
- World Health Organization (WHO), Geneva, Switzerland
| | - Placide Mbala-Kingebeni
- Institut National de Recherche Biomédicale (INRB), Kinshasa, Democratic Republic of the Congo
| | | | - Steve Ahuka-Mundeke
- Institut National de Recherche Biomédicale (INRB), Kinshasa, Democratic Republic of the Congo
| | | | - Michael T. Hawkes
- Member, Women and Children's Research Institute, University of Alberta, Edmonton, AB, Canada
- Department of Paediatrics, University of Alberta, Edmonton, AB, Canada
- Department of Medical Microbiology and Immunology, University of Alberta, Edmonton, AB, Canada
- School of Public Health, University of Alberta, Edmonton, AB, Canada
- Distinguished Researcher, Stollery Science Lab, University of Alberta, Edmonton, AB, Canada
- Corresponding author at: Department of Paediatrics, University of Alberta, 3-588D Edmonton Clinic Health Academy, 11405 87 Ave NW, Edmonton, AB T6G 1C9, Canada.
| |
Collapse
|
7
|
Exotic viral hepatitis: A review on epidemiology, pathogenesis, and treatment. J Hepatol 2022; 77:1431-1443. [PMID: 35817222 DOI: 10.1016/j.jhep.2022.06.031] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 06/14/2022] [Accepted: 06/19/2022] [Indexed: 12/04/2022]
Abstract
Certain "exotic" viruses are known to cause clinical diseases with potential liver involvement. These include viruses, beyond regular hepatotropic viruses (hepatitis A, -B(D), -C, -E, cytomegalovirus, Epstein-Barr virus), that can be found in (sub)tropical areas and can cause "exotic viral hepatitis". Transmission routes typically involve arthropods (Crimean Congo haemorrhagic fever, dengue, Rift Valley fever, yellow fever). However, some of these viruses are transmitted by the aerosolised excreta of rodents (Hantavirus, Lassa fever), or via direct contact or contact with bodily fluids (Ebola). Although some exotic viruses are associated with high fatality rates, such as Ebola for example, the clinical presentation of most exotic viruses can range from mild flu-like symptoms, in most cases, right through to being potentially fatal. A smaller percentage of people develop severe disease with haemorrhagic fever, possibly with (fulminant) hepatitis. Liver involvement is often caused by direct tropism for hepatocytes and Kupffer cells, resulting in virus-mediated and/or immune-mediated necrosis. In all exotic hepatitis viruses, PCR is the most sensitive diagnostic method. The determination of IgM/IgG antibodies is a reasonable alternative, but cross-reactivity can be a problem in the case of flaviviruses. Licenced vaccines are available for yellow fever and Ebola, and they are currently under development for dengue. Therapy for exotic viral hepatitis is predominantly supportive. To ensure that preventive measures can be introduced to control possible outbreaks, the timely detection of these viruses is very important.
Collapse
|
8
|
Toroghi MK, Al‐Huniti N, Davis JD, DiCioccio A, Rippley R, Baum A, Kyratsous CA, Sivapalasingam S, Kantrowitz J, Kamal MA. A drug-disease model for predicting survival in an Ebola outbreak. Clin Transl Sci 2022; 15:2538-2550. [PMID: 35895082 PMCID: PMC9579403 DOI: 10.1111/cts.13383] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Revised: 06/30/2022] [Accepted: 07/11/2022] [Indexed: 01/25/2023] Open
Abstract
REGN-EB3 (Inmazeb) is a cocktail of three human monoclonal antibodies approved for treatment of Ebola infection. This paper describes development of a mathematical model linking REGN-EB3's inhibition of Ebola virus to survival in a non-human primate (NHP) model, and translational scaling to predict survival in humans. Pharmacokinetic/pharmacodynamic data from single- and multiple-dose REGN-EB3 studies in infected rhesus macaques were incorporated. Using discrete indirect response models, the antiviral mechanism of action was used as a forcing function to drive the reversal of key Ebola disease hallmarks over time, for example, liver and kidney damage (elevated alanine [ALT] and aspartate aminotransferases [AST], blood urea nitrogen [BUN], and creatinine), and hemorrhage (decreased platelet count). A composite disease characteristic function was introduced to describe disease severity and integrated with the ordinary differential equations estimating the time course of clinical biomarkers. Model simulation results appropriately represented the concentration-dependence of the magnitude and time course of Ebola infection (viral and pathophysiological), including time course of viral load, ALT and AST elevations, platelet count, creatinine, and BUN. The model estimated the observed survival rate in rhesus macaques and the dose of REGN-EB3 required for saturation of the pharmacodynamic effects of viral inhibition, reversal of Ebola pathophysiology, and survival. The model also predicted survival in clinical trials with appropriate scaling to humans. This mathematical investigation demonstrates that drug-disease modeling can be an important translational tool to integrate preclinical data from an NHP model recapitulating disease progression to guide future translation of preclinical data to clinical study design.
Collapse
Affiliation(s)
| | | | | | | | - Ronda Rippley
- Formerly of Regeneron Pharmaceuticals, Inc.TarrytownNew YorkUSA
| | - Alina Baum
- Regeneron Pharmaceuticals, Inc.TarrytownNew YorkUSA
| | | | | | | | | |
Collapse
|
9
|
Jeremiah Matson M, Ricotta E, Feldmann F, Massaquoi M, Sprecher A, Giuliani R, Edwards JK, Rosenke K, de Wit E, Feldmann H, Chertow DS, Munster VJ. Evaluation of viral load in patients with Ebola virus disease in Liberia: a retrospective observational study. THE LANCET MICROBE 2022; 3:e533-e542. [PMID: 35617976 PMCID: PMC9254266 DOI: 10.1016/s2666-5247(22)00065-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Revised: 02/15/2022] [Accepted: 03/09/2022] [Indexed: 11/30/2022] Open
Abstract
Background Viral load in patients with Ebola virus disease affects case fatality rate and is an important parameter used for diagnostic cutoffs, stratification in randomised controlled trials, and epidemiological studies. However, viral load in Ebola virus disease is currently estimated using numerous different assays and protocols that were not developed or validated for this purpose. Here, our aim was to conduct a laboratory-based re-evaluation of the viral loads of a large cohort of Liberian patients with Ebola virus disease and analyse these data in the broader context of the west Africa epidemic. Methods In this retrospective observational study, whole blood samples from patients at the Eternal Love Winning Africa Ebola treatment unit (Monrovia, Liberia) were re-extracted with an optimised protocol and analysed by droplet digital PCR (ddPCR) using a novel semi-strand specific assay to measure viral load. To allow for more direct comparisons, the ddPCR viral loads were also back-calculated to cycle threshold (Ct) values. The new viral load data were then compared with the Ct values from the original diagnostic quantitative RT-PCR (qRT-PCR) testing to identify differing trends and discrepancies. Findings Between Aug 28 and Dec 18, 2014, 727 whole blood samples from 528 individuals were collected. 463 (64%) were first-draw samples and 409 (56%) were from patients positive for Ebola virus (EBOV), species Zaire ebolavirus. Of the 307 first-draw EBOV-positive samples, 127 (41%) were from survivors and 180 (59%) were from non-survivors; 155 (50%) were women, 145 (47%) were men, and seven (2%) were not recorded, and the mean age was 29·3 (SD 15·0) years for women and 31·8 (SD 14·8) years for men. Survivors had significantly lower mean viral loads at presentation than non-survivors in both the reanalysed dataset (5·61 [95% CI 5·34–5·87] vs 7·19 [6·99–7·38] log10 EBOV RNA copies per mL; p<0·0001) and diagnostic dataset (Ct value 28·72 [27·97–29·47] vs 26·26 [25·72–26·81]; p<0·0001). However, the prognostic capacity of viral load increased with the reanalysed dataset (odds ratio [OR] of death 8·06 [95% CI 4·81–13·53], p<0·0001 for viral loads above 6·71 log10 EBOV RNA copies per mL vs OR of death 2·02 [1·27–3·20], p=0·0028 for Ct values below 27·37). Diagnostic qRT-PCR significantly (p<0·0001) underestimated viral load in both survivors and non-survivors (difference in diagnostic Ct value minus laboratory Ct value of 1·79 [95% CI 1·16–2·43] for survivors and 5·15 [4·43–5·87] for non-survivors). Six samples that were reported negative by diagnostic testing were found to be positive upon reanalysis and had high viral loads. Interpretation Inaccurate viral load estimation from diagnostic Ct values is probably multifactorial; however, unaddressed PCR inhibition from tissue damage in patients with fulminant Ebola virus disease could largely account for the discrepancies observed in our study. Testing protocols for Ebola virus disease require further standardisation and validation to produce accurate viral load estimates, minimise false negatives, and allow for reliable epidemiological investigation.
Collapse
Affiliation(s)
- M Jeremiah Matson
- Laboratory of Virology, Rocky Mountain Laboratories, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Hamilton, MT, USA; Marshall University Joan C Edwards School of Medicine, Huntington, WV, USA
| | - Emily Ricotta
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Disease, National Institutes of Health, Bethesda, MD, USA
| | - Friederike Feldmann
- Rocky Mountain Veterinary Branch, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Hamilton, MT, USA
| | | | | | | | | | - Kyle Rosenke
- Laboratory of Virology, Rocky Mountain Laboratories, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Hamilton, MT, USA
| | - Emmie de Wit
- Laboratory of Virology, Rocky Mountain Laboratories, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Hamilton, MT, USA
| | - Heinz Feldmann
- Laboratory of Virology, Rocky Mountain Laboratories, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Hamilton, MT, USA
| | - Daniel S Chertow
- Critical Care Medicine Department, Clinical Center, National Institute of Allergy and Infectious Disease, National Institutes of Health, Bethesda, MD, USA; Laboratory of Immunoregulation, National Institute of Allergy and Infectious Disease, National Institutes of Health, Bethesda, MD, USA
| | - Vincent J Munster
- Laboratory of Virology, Rocky Mountain Laboratories, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Hamilton, MT, USA.
| |
Collapse
|
10
|
Koehler FC, Di Cristanziano V, Späth MR, Hoyer-Allo KJR, Wanken M, Müller RU, Burst V. OUP accepted manuscript. Clin Kidney J 2022; 15:1231-1252. [PMID: 35756741 PMCID: PMC9217627 DOI: 10.1093/ckj/sfac008] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Indexed: 01/18/2023] Open
Abstract
Hantavirus-induced diseases are emerging zoonoses with endemic appearances and frequent outbreaks in different parts of the world. In humans, hantaviral pathology is characterized by the disruption of the endothelial cell barrier followed by increased capillary permeability, thrombocytopenia due to platelet activation/depletion and an overactive immune response. Genetic vulnerability due to certain human leukocyte antigen haplotypes is associated with disease severity. Typically, two different hantavirus-caused clinical syndromes have been reported: hemorrhagic fever with renal syndrome (HFRS) and hantavirus cardiopulmonary syndrome (HCPS). The primarily affected vascular beds differ in these two entities: renal medullary capillaries in HFRS caused by Old World hantaviruses and pulmonary capillaries in HCPS caused by New World hantaviruses. Disease severity in HFRS ranges from mild, e.g. Puumala virus-associated nephropathia epidemica, to moderate, e.g. Hantaan or Dobrava virus infections. HCPS leads to a severe acute respiratory distress syndrome with high mortality rates. Due to novel insights into organ tropism, hantavirus-associated pathophysiology and overlapping clinical features, HFRS and HCPS are believed to be interconnected syndromes frequently involving the kidneys. As there are no specific antiviral treatments or vaccines approved in Europe or the USA, only preventive measures and public awareness may minimize the risk of hantavirus infection. Treatment remains primarily supportive and, depending on disease severity, more invasive measures (e.g., renal replacement therapy, mechanical ventilation and extracorporeal membrane oxygenation) are needed.
Collapse
Affiliation(s)
- Felix C Koehler
- Department II of Internal Medicine and Center for Molecular Medicine Cologne, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
- CECAD, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - Veronica Di Cristanziano
- Institute of Virology, University of Cologne, Faculty of Medicine and University Hospital of Cologne, Cologne, Germany
| | - Martin R Späth
- Department II of Internal Medicine and Center for Molecular Medicine Cologne, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
- CECAD, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - K Johanna R Hoyer-Allo
- Department II of Internal Medicine and Center for Molecular Medicine Cologne, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
- CECAD, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - Manuel Wanken
- Department II of Internal Medicine and Center for Molecular Medicine Cologne, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - Roman-Ulrich Müller
- Department II of Internal Medicine and Center for Molecular Medicine Cologne, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
- CECAD, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | | |
Collapse
|
11
|
White JM, Schiffer JT, Bender Ignacio RA, Xu S, Kainov D, Ianevski A, Aittokallio T, Frieman M, Olinger GG, Polyak SJ. Drug Combinations as a First Line of Defense against Coronaviruses and Other Emerging Viruses. mBio 2021; 12:e0334721. [PMID: 34933447 PMCID: PMC8689562 DOI: 10.1128/mbio.03347-21] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
The world was unprepared for coronavirus disease 2019 (COVID-19) and remains ill-equipped for future pandemics. While unprecedented strides have been made developing vaccines and treatments for COVID-19, there remains a need for highly effective and widely available regimens for ambulatory use for novel coronaviruses and other viral pathogens. We posit that a priority is to develop pan-family drug cocktails to enhance potency, limit toxicity, and avoid drug resistance. We urge cocktail development for all viruses with pandemic potential both in the short term (<1 to 2 years) and longer term with pairs of drugs in advanced clinical testing or repurposed agents approved for other indications. While significant efforts were launched against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), in vitro and in the clinic, many studies employed solo drugs and had disappointing results. Here, we review drug combination studies against SARS-CoV-2 and other viruses and introduce a model-driven approach to assess drug pairs with the highest likelihood of clinical efficacy. Where component agents lack sufficient potency, we advocate for synergistic combinations to achieve therapeutic levels. We also discuss issues that stymied therapeutic progress against COVID-19, including testing of agents with low likelihood of efficacy late in clinical disease and lack of focus on developing virologic surrogate endpoints. There is a need to expedite efficient clinical trials testing drug combinations that could be taken at home by recently infected individuals and exposed contacts as early as possible during the next pandemic, whether caused by a coronavirus or another viral pathogen. The approach herein represents a proactive plan for global viral pandemic preparedness.
Collapse
Affiliation(s)
- Judith M. White
- University of Virginia, Department of Cell Biology, Charlottesville, Virginia, USA
- University of Virginia, Department of Microbiology, Charlottesville, Virginia, USA
| | - Joshua T. Schiffer
- University of Washington, Division of Allergy and Infectious Diseases, Seattle, Washington, USA
- Fred Hutchinson Cancer Research Center, Vaccine and Infectious Diseases Division, Seattle, Washington, USA
| | - Rachel A. Bender Ignacio
- University of Washington, Division of Allergy and Infectious Diseases, Seattle, Washington, USA
- Fred Hutchinson Cancer Research Center, Vaccine and Infectious Diseases Division, Seattle, Washington, USA
| | - Shuang Xu
- Fred Hutchinson Cancer Research Center, Vaccine and Infectious Diseases Division, Seattle, Washington, USA
| | - Denis Kainov
- Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
- Institute of Technology, University of Tartu, Tartu, Estonia
- Institute for Molecular Medicine Finland, FIMM, University of Helsinki, Helsinki, Finland
| | - Aleksandr Ianevski
- Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
- Institute for Molecular Medicine Finland, FIMM, University of Helsinki, Helsinki, Finland
| | - Tero Aittokallio
- Institute for Molecular Medicine Finland, FIMM, University of Helsinki, Helsinki, Finland
- Oslo Centre for Biostatistics and Epidemiology (OCBE), University of Oslo, Oslo, Norway
- Institute for Cancer Research, Oslo University Hospital, Oslo, Norway
| | - Matthew Frieman
- Department of Microbiology and Immunology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | | | - Stephen J. Polyak
- Virology Division, Department of Laboratory Medicine and Pathology, University of Washington, Seattle, Washington, USA
- Department of Global Health, University of Washington, Seattle, Washington, USA
- Department of Microbiology, University of Washington, Seattle, Washington, USA
| |
Collapse
|
12
|
Yamaoka S, Ebihara H. Pathogenicity and Virulence of Ebolaviruses with Species- and Variant-specificity. Virulence 2021; 12:885-901. [PMID: 33734027 PMCID: PMC7993122 DOI: 10.1080/21505594.2021.1898169] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 02/10/2021] [Accepted: 02/19/2021] [Indexed: 01/05/2023] Open
Abstract
Ebola virus (EBOV), belonging to the species Zaire ebolavirus in the genus Ebolavirus, causes a severe febrile illness in humans with case fatality rates (CFRs) up to 90%. While there have been six virus species classified, which each have a single type virus in the genus Ebolavirus, CFRs of ebolavirus infections vary among viruses belonging to each distinct species. In this review, we aim to define the ebolavirus species-specific virulence on the basis of currently available laboratory and experimental findings. In addition, this review will also cover the variant-specific virulence of EBOV by referring to the unique biological and pathogenic characteristics of EBOV variant Makona, a new EBOV variant isolated from the 2013-2016 EBOV disease outbreak in West Africa. A better definition of species-specific and variant-specific virulence of ebolaviruses will facilitate our comprehensive knowledge on genus Ebolavirus biology, leading to the development of therapeutics against well-focused pathogenic mechanisms of each Ebola disease.
Collapse
Affiliation(s)
- Satoko Yamaoka
- Department of Molecular Medicine, Mayo Clinic, Rochester, USA
| | - Hideki Ebihara
- Department of Molecular Medicine, Mayo Clinic, Rochester, USA
| |
Collapse
|
13
|
Downs I, Johnson JC, Rossi F, Dyer D, Saunders DL, Twenhafel NA, Esham HL, Pratt WD, Trefry J, Zumbrun E, Facemire PR, Johnston SC, Tompkins EL, Jansen NK, Honko A, Cardile AP. Natural History of Aerosol-Induced Ebola Virus Disease in Rhesus Macaques. Viruses 2021; 13:v13112297. [PMID: 34835103 PMCID: PMC8619410 DOI: 10.3390/v13112297] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 11/03/2021] [Accepted: 11/12/2021] [Indexed: 02/06/2023] Open
Abstract
Ebola virus disease (EVD) is a serious global health concern because case fatality rates are approximately 50% due to recent widespread outbreaks in Africa. Well-defined nonhuman primate (NHP) models for different routes of Ebola virus exposure are needed to test the efficacy of candidate countermeasures. In this natural history study, four rhesus macaques were challenged via aerosol with a target titer of 1000 plaque-forming units per milliliter of Ebola virus. The course of disease was split into the following stages for descriptive purposes: subclinical, clinical, and decompensated. During the subclinical stage, high levels of venous partial pressure of carbon dioxide led to respiratory acidemia in three of four of the NHPs, and all developed lymphopenia. During the clinical stage, all animals had fever, viremia, and respiratory alkalosis. The decompensatory stage involved coagulopathy, cytokine storm, and liver and renal injury. These events were followed by hypotension, elevated lactate, metabolic acidemia, shock and mortality similar to historic intramuscular challenge studies. Viral loads in the lungs of aerosol-exposed animals were not distinctly different compared to previous intramuscularly challenged studies. Differences in the aerosol model, compared to intramuscular model, include an extended subclinical stage, shortened clinical stage, and general decompensated stage. Therefore, the shortened timeframe for clinical detection of the aerosol-induced disease can impair timely therapeutic administration. In summary, this nonhuman primate model of aerosol-induced EVD characterizes early disease markers and additional details to enable countermeasure development.
Collapse
Affiliation(s)
- Isaac Downs
- US Army Medical Research Institute of Infectious Diseases (USAMRIID), Fort Detrick, Frederick, MD 21702, USA; (J.C.J.); (F.R.); (D.D.); (D.L.S.); (N.A.T.); (H.L.E.); (W.D.P.); (J.T.); (E.Z.); (P.R.F.); (S.C.J.); (E.L.T.); (N.K.J.); (A.H.); (A.P.C.)
- Correspondence: ; Tel.: +1-301-619-0369
| | - Joshua C. Johnson
- US Army Medical Research Institute of Infectious Diseases (USAMRIID), Fort Detrick, Frederick, MD 21702, USA; (J.C.J.); (F.R.); (D.D.); (D.L.S.); (N.A.T.); (H.L.E.); (W.D.P.); (J.T.); (E.Z.); (P.R.F.); (S.C.J.); (E.L.T.); (N.K.J.); (A.H.); (A.P.C.)
- Moderna, Inc., Cambridge, MA 02139, USA
| | - Franco Rossi
- US Army Medical Research Institute of Infectious Diseases (USAMRIID), Fort Detrick, Frederick, MD 21702, USA; (J.C.J.); (F.R.); (D.D.); (D.L.S.); (N.A.T.); (H.L.E.); (W.D.P.); (J.T.); (E.Z.); (P.R.F.); (S.C.J.); (E.L.T.); (N.K.J.); (A.H.); (A.P.C.)
| | - David Dyer
- US Army Medical Research Institute of Infectious Diseases (USAMRIID), Fort Detrick, Frederick, MD 21702, USA; (J.C.J.); (F.R.); (D.D.); (D.L.S.); (N.A.T.); (H.L.E.); (W.D.P.); (J.T.); (E.Z.); (P.R.F.); (S.C.J.); (E.L.T.); (N.K.J.); (A.H.); (A.P.C.)
| | - David L. Saunders
- US Army Medical Research Institute of Infectious Diseases (USAMRIID), Fort Detrick, Frederick, MD 21702, USA; (J.C.J.); (F.R.); (D.D.); (D.L.S.); (N.A.T.); (H.L.E.); (W.D.P.); (J.T.); (E.Z.); (P.R.F.); (S.C.J.); (E.L.T.); (N.K.J.); (A.H.); (A.P.C.)
| | - Nancy A. Twenhafel
- US Army Medical Research Institute of Infectious Diseases (USAMRIID), Fort Detrick, Frederick, MD 21702, USA; (J.C.J.); (F.R.); (D.D.); (D.L.S.); (N.A.T.); (H.L.E.); (W.D.P.); (J.T.); (E.Z.); (P.R.F.); (S.C.J.); (E.L.T.); (N.K.J.); (A.H.); (A.P.C.)
| | - Heather L. Esham
- US Army Medical Research Institute of Infectious Diseases (USAMRIID), Fort Detrick, Frederick, MD 21702, USA; (J.C.J.); (F.R.); (D.D.); (D.L.S.); (N.A.T.); (H.L.E.); (W.D.P.); (J.T.); (E.Z.); (P.R.F.); (S.C.J.); (E.L.T.); (N.K.J.); (A.H.); (A.P.C.)
| | - William D. Pratt
- US Army Medical Research Institute of Infectious Diseases (USAMRIID), Fort Detrick, Frederick, MD 21702, USA; (J.C.J.); (F.R.); (D.D.); (D.L.S.); (N.A.T.); (H.L.E.); (W.D.P.); (J.T.); (E.Z.); (P.R.F.); (S.C.J.); (E.L.T.); (N.K.J.); (A.H.); (A.P.C.)
| | - John Trefry
- US Army Medical Research Institute of Infectious Diseases (USAMRIID), Fort Detrick, Frederick, MD 21702, USA; (J.C.J.); (F.R.); (D.D.); (D.L.S.); (N.A.T.); (H.L.E.); (W.D.P.); (J.T.); (E.Z.); (P.R.F.); (S.C.J.); (E.L.T.); (N.K.J.); (A.H.); (A.P.C.)
- Defense Threat Reduction Agency, Fort Belvoir, VA 22060, USA
| | - Elizabeth Zumbrun
- US Army Medical Research Institute of Infectious Diseases (USAMRIID), Fort Detrick, Frederick, MD 21702, USA; (J.C.J.); (F.R.); (D.D.); (D.L.S.); (N.A.T.); (H.L.E.); (W.D.P.); (J.T.); (E.Z.); (P.R.F.); (S.C.J.); (E.L.T.); (N.K.J.); (A.H.); (A.P.C.)
| | - Paul R. Facemire
- US Army Medical Research Institute of Infectious Diseases (USAMRIID), Fort Detrick, Frederick, MD 21702, USA; (J.C.J.); (F.R.); (D.D.); (D.L.S.); (N.A.T.); (H.L.E.); (W.D.P.); (J.T.); (E.Z.); (P.R.F.); (S.C.J.); (E.L.T.); (N.K.J.); (A.H.); (A.P.C.)
| | - Sara C. Johnston
- US Army Medical Research Institute of Infectious Diseases (USAMRIID), Fort Detrick, Frederick, MD 21702, USA; (J.C.J.); (F.R.); (D.D.); (D.L.S.); (N.A.T.); (H.L.E.); (W.D.P.); (J.T.); (E.Z.); (P.R.F.); (S.C.J.); (E.L.T.); (N.K.J.); (A.H.); (A.P.C.)
| | - Erin L. Tompkins
- US Army Medical Research Institute of Infectious Diseases (USAMRIID), Fort Detrick, Frederick, MD 21702, USA; (J.C.J.); (F.R.); (D.D.); (D.L.S.); (N.A.T.); (H.L.E.); (W.D.P.); (J.T.); (E.Z.); (P.R.F.); (S.C.J.); (E.L.T.); (N.K.J.); (A.H.); (A.P.C.)
| | - Nathan K. Jansen
- US Army Medical Research Institute of Infectious Diseases (USAMRIID), Fort Detrick, Frederick, MD 21702, USA; (J.C.J.); (F.R.); (D.D.); (D.L.S.); (N.A.T.); (H.L.E.); (W.D.P.); (J.T.); (E.Z.); (P.R.F.); (S.C.J.); (E.L.T.); (N.K.J.); (A.H.); (A.P.C.)
| | - Anna Honko
- US Army Medical Research Institute of Infectious Diseases (USAMRIID), Fort Detrick, Frederick, MD 21702, USA; (J.C.J.); (F.R.); (D.D.); (D.L.S.); (N.A.T.); (H.L.E.); (W.D.P.); (J.T.); (E.Z.); (P.R.F.); (S.C.J.); (E.L.T.); (N.K.J.); (A.H.); (A.P.C.)
- Investigator at National Emerging Infectious Diseases Laboratories, Boston University School of Medicine, Boston, MA 02118, USA
| | - Anthony P. Cardile
- US Army Medical Research Institute of Infectious Diseases (USAMRIID), Fort Detrick, Frederick, MD 21702, USA; (J.C.J.); (F.R.); (D.D.); (D.L.S.); (N.A.T.); (H.L.E.); (W.D.P.); (J.T.); (E.Z.); (P.R.F.); (S.C.J.); (E.L.T.); (N.K.J.); (A.H.); (A.P.C.)
| |
Collapse
|
14
|
Mt10-CVB3 Vaccine Virus Protects against CVB4 Infection by Inducing Cross-Reactive, Antigen-Specific Immune Responses. Microorganisms 2021; 9:microorganisms9112323. [PMID: 34835449 PMCID: PMC8622534 DOI: 10.3390/microorganisms9112323] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Revised: 11/05/2021] [Accepted: 11/06/2021] [Indexed: 12/29/2022] Open
Abstract
Group B coxsackieviruses (CVB) containing six serotypes, B1–B6, affect various organs, and multiple serotypes can induce similar diseases such as myocarditis and pancreatitis. Yet, no vaccines are currently available to prevent these infections. Translationally, the derivation of vaccines that offer protection against multiple serotypes is highly desired. In that direction, we recently reported the generation of an attenuated strain of CVB3, termed Mt10, which completely protects against both myocarditis and pancreatitis induced by the homologous wild-type CVB3 strain. Here, we report that the Mt10 vaccine can induce cross-protection against multiple CVB serotypes as demonstrated with CVB4. We note that the Mt10 vaccine could induce cross-reactive neutralizing antibodies (nABs) against both CVB1 and CVB4. In challenge studies with CVB4, the efficacy of the Mt10 vaccine was found to be 92%, as determined by histological evaluation of the heart and pancreas. Antibody responses induced in Mt10/CVB4 challenged animals indicated the persistence of cross-reactive nABs against CVB1, CVB3, and CVB4. Evaluation of antigen-specific immune responses revealed viral protein 1 (VP1)-reactive antibodies, predominantly IgG2a, IgG2b, IgG3, and IgG1. Similarly, by using major histocompatibility complex class II tetramers, we noted induction of VP1-specific CD4 T cells capable of producing multiple T cell cytokines, with interferon-γ being predominant. Finally, none of the vaccine recipients challenged with CVB4 revealed the presence of viral nucleic acid in the heart or pancreas. Taken together, our data suggest that the Mt10 vaccine can prevent infections caused by multiple CVB serotypes, paving the way for the development of monovalent CVB vaccines to prevent heart and pancreatic diseases of enteroviral origin.
Collapse
|
15
|
Luan YY, Yin CH, Yao YM. Update Advances on C-Reactive Protein in COVID-19 and Other Viral Infections. Front Immunol 2021; 12:720363. [PMID: 34447386 PMCID: PMC8382792 DOI: 10.3389/fimmu.2021.720363] [Citation(s) in RCA: 59] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Accepted: 07/21/2021] [Indexed: 01/08/2023] Open
Abstract
Severe coronavirus disease 2019 (COVID-19) can manifest as a viral-induced hyperinflammation with multiorgan dysfunction. It has been documented that severe COVID-19 is associated with higher levels of inflammatory mediators than a mild disease, and tracking these markers may allow early identification or even prediction of disease progression. It is well known that C-reactive protein (CRP) is the acute-phase protein and the active regulator of host innate immunity, which is highly predictive of the need for mechanical ventilation and may guide escalation of treatment of COVID-19-related uncontrolled inflammation. There are numerous causes of an elevated CRP, including acute and chronic responses, and these can be infectious or non-infectious in etiology. CRP are normally lacking in viral infections, while adaptive immunity appears to be essential for COVID-19 virus clearance, and the macrophage activation syndrome may explain the high serum CRP contents and contribute to the disease progression. Nevertheless, for the assessment of host inflammatory status and identification of viral infection in other pathologies, such as bacterial sepsis, the acute-phase proteins, including CRP and procalcitonin, can provide more important information for guiding clinical diagnosis and antibiotic therapy. This review is aimed to highlight the current and most recent studies with regard to the clinical significance of CRP in severe COVID-19 and other viral associated illnesses, including update advances on the implication of CRP and its form specifically on the pathogenesis of these diseases. The progressive understanding in these areas may be translated into promising measures to prevent severe outcomes and mitigate appropriate treatment modalities in critical COVID-19 and other viral infections.
Collapse
Affiliation(s)
- Ying-Yi Luan
- Translational Medicine Research Center, Medical Innovation Research Division and the Fourth Medical Center of PLA General Hospital, Beijing, China.,Department of Central Laboratory, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing, China
| | - Cheng-Hong Yin
- Department of Central Laboratory, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing, China
| | - Yong-Ming Yao
- Translational Medicine Research Center, Medical Innovation Research Division and the Fourth Medical Center of PLA General Hospital, Beijing, China
| |
Collapse
|
16
|
Antibody responses to filovirus infections in humans: protective or not? THE LANCET. INFECTIOUS DISEASES 2021; 21:e348-e355. [PMID: 34175003 DOI: 10.1016/s1473-3099(21)00006-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 12/17/2020] [Accepted: 01/04/2021] [Indexed: 12/16/2022]
Abstract
Disease outbreaks caused by Ebola virus and other filoviruses highlight the urgent need for an in-depth understanding of the role of antibody responses in recovery. In this Personal View we aim to discuss the controversial biological role of antibodies during natural filovirus infections in humans. Survival during natural human filovirus infections correlates with the magnitude of the process of antibodies binding to the filovirus glycoprotein and neutralising the virus. Despite the severity of the disease, highly potent monoclonal antibodies have been isolated from survivors of natural filovirus infections, suggesting that the magnitude of the antibody response is insufficient for prevention of severe disease. Unlike natural infections, filovirus vaccines, which express the viral glycoprotein, do induce protective concentrations of antibodies, albeit only when administered at very high doses. Multiple mechanisms by which filoviruses can delay and reduce the antibody response have been identified in the past decade. Furthermore, subneutralising antibody concentrations have been shown to enhance filovirus infections of immune cells bearing Fc receptors. Understanding the role of antibody responses during natural filovirus infections is important for the development of safe and potent vaccines and antibody-based treatments.
Collapse
|
17
|
The impact of malaria coinfection on Ebola virus disease outcomes: A systematic review and meta-analysis. PLoS One 2021; 16:e0251101. [PMID: 34029352 PMCID: PMC8143409 DOI: 10.1371/journal.pone.0251101] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Accepted: 04/13/2021] [Indexed: 11/19/2022] Open
Abstract
Introduction Viral outbreaks present a particular challenge in countries in Africa where there is already a high incidence of other infectious diseases, including malaria which can alter immune responses to secondary infection. Ebola virus disease (EVD) is one such problem; understanding how Plasmodium spp. and Ebolavirus (EBOV) interact is important for future outbreaks. Methods We conducted a systematic review in PubMed and Web of Science to find peer-reviewed papers with primary data literature to determine 1) prevalence of EBOV/Plasmodium spp. coinfection, 2) effect of EBOV/Plasmodium spp. coinfection on EVD pathology and the immune response, 3) impact of EBOV/Plasmodium spp. coinfection on the outcome of EVD-related mortality. Random effects meta-analyses were conducted with the R package meta to produce overall proportion and effect estimates as well as measure between-study heterogeneity. Results From 322 peer-reviewed papers, 17 were included in the qualitative review and nine were included in a meta-analysis. Prevalence of coinfection was between 19% and 72%. One study reported significantly lower coagulatory response biomarkers in coinfected cases but no difference in inflammatory markers. Case fatality rates were similar between EBOV(+)/Pl(+) and EBOV(+)/Pl(-) cases (62.8%, 95% CI 49.3–74.6 and 56.7%, 95% CI 53.2–60.1, respectively), and there was no significant difference in risk of mortality (RR 1.09, 95% CI 0.90–1.31) although heterogeneity between studies was high. One in vivo mouse model laboratory study found no difference in mortality by infection status, but another found prior acute Plasmodium yoeli infection was protective against morbidity and mortality via the IFN-γ signalling pathway. Conclusion The literature was inconclusive; studies varied widely and there was little attempt to adjust for confounding variables. Laboratory studies may present the best option to answer how pathogens interact within the body but improvement in data collection and analysis and in diagnostic methods would aid patient studies in the future.
Collapse
|
18
|
Reynard S, Gloaguen E, Baillet N, Madelain V, Guedj J, Raoul H, de Lamballerie X, Mullaert J, Baize S. Early control of viral load by favipiravir promotes survival to Ebola virus challenge and prevents cytokine storm in non-human primates. PLoS Negl Trop Dis 2021; 15:e0009300. [PMID: 33780452 PMCID: PMC8031739 DOI: 10.1371/journal.pntd.0009300] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 04/08/2021] [Accepted: 03/09/2021] [Indexed: 12/02/2022] Open
Abstract
Ebola virus has been responsible for two major epidemics over the last several years and there has been a strong effort to find potential treatments that can improve the disease outcome. Antiviral favipiravir was thus tested on non-human primates infected with Ebola virus. Half of the treated animals survived the Ebola virus challenge, whereas the infection was fully lethal for the untreated ones. Moreover, the treated animals that did not survive died later than the controls. We evaluated the hematological, virological, biochemical, and immunological parameters of the animals and performed proteomic analysis at various timepoints of the disease. The viral load strongly correlated with dysregulation of the biological functions involved in pathogenesis, notably the inflammatory response, hemostatic functions, and response to stress. Thus, the management of viral replication in Ebola virus disease is of crucial importance in preventing the immunopathogenic disorders and septic-like shock syndrome generally observed in Ebola virus-infected patients. Ebola virus was responsible for several epidemics in the recent years and is now considered as a major public health concern in Central and West African countries. We and others demonstrated that pathogenic events observed during Ebola virus disease are linked to a deleterious immune response. However, the mechanisms implicated are not fully understood. Here, we studied immune responses depending on the viral loads observed in infected cynomolgus monkeys. An antiviral treatment allowed the reduction of viral load in some animals and we observed that these animals did not experience deleterious immune response and the loss of hemostasis. The release of pathogen-associated molecular patterns may thus be limited by the inhibition of viral replication, avoiding the overstimulation of the immune system and consequently the pathogenic events observed in Ebola virus disease.
Collapse
Affiliation(s)
- Stéphanie Reynard
- Unité de Biologie des Infections Virales Emergentes, Institut Pasteur, Lyon, France
- CIRI, Centre International de Recherche en Infectiologie, Univ Lyon, Inserm, U1111, Université Claude Bernard Lyon 1, CNRS, UMR5308, ENS de Lyon, Lyon, France
| | | | - Nicolas Baillet
- Unité de Biologie des Infections Virales Emergentes, Institut Pasteur, Lyon, France
- CIRI, Centre International de Recherche en Infectiologie, Univ Lyon, Inserm, U1111, Université Claude Bernard Lyon 1, CNRS, UMR5308, ENS de Lyon, Lyon, France
| | | | | | - Hervé Raoul
- Laboratoire P4 Jean Mérieux–INSERM, INSERM US003, Lyon, France
| | - Xavier de Lamballerie
- Unité des Virus Émergents (UVE Aix-Marseille Université-IRD 190-Inserm 1207-IHU Méditerranée Infection), Marseille, France
| | | | - Sylvain Baize
- Unité de Biologie des Infections Virales Emergentes, Institut Pasteur, Lyon, France
- CIRI, Centre International de Recherche en Infectiologie, Univ Lyon, Inserm, U1111, Université Claude Bernard Lyon 1, CNRS, UMR5308, ENS de Lyon, Lyon, France
- * E-mail:
| |
Collapse
|
19
|
Formulation, Stability, Pharmacokinetic, and Modeling Studies for Tests of Synergistic Combinations of Orally Available Approved Drugs against Ebola Virus In Vivo. Microorganisms 2021; 9:microorganisms9030566. [PMID: 33801811 PMCID: PMC7998926 DOI: 10.3390/microorganisms9030566] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 03/01/2021] [Accepted: 03/05/2021] [Indexed: 12/28/2022] Open
Abstract
Outbreaks of Ebola ebolavirus (EBOV) have been associated with high morbidity and mortality. Milestones have been reached recently in the management of EBOV disease (EVD) with licensure of an EBOV vaccine and two monoclonal antibody therapies. However, neither vaccines nor therapies are available for other disease-causing filoviruses. In preparation for such outbreaks, and for more facile and cost-effective management of EVD, we seek a cocktail containing orally available and room temperature stable drugs with strong activity against multiple filoviruses. We previously showed that (bepridil + sertraline) and (sertraline + toremifene) synergistically suppress EBOV in cell cultures. Here, we describe steps towards testing these combinations in a mouse model of EVD. We identified a vehicle suitable for oral delivery of the component drugs and determined that, thus formulated the drugs are equally active against EBOV as preparations in DMSO, and they maintain activity upon storage in solution for up to seven days. Pharmacokinetic (PK) studies indicated that the drugs in the oral delivery vehicle are well tolerated in mice at the highest doses tested. Collectively the data support advancement of these combinations to tests for synergy in a mouse model of EVD. Moreover, mathematical modeling based on human oral PK projects that the combinations would be more active in humans than their component single drugs.
Collapse
|
20
|
Development of a Well-Characterized Rhesus Macaque Model of Ebola Virus Disease for Support of Product Development. Microorganisms 2021; 9:microorganisms9030489. [PMID: 33652589 PMCID: PMC7996724 DOI: 10.3390/microorganisms9030489] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 02/23/2021] [Accepted: 02/23/2021] [Indexed: 11/17/2022] Open
Abstract
Ebola virus (EBOV) is a negative-sense RNA virus that can infect humans and nonhuman primates with severe health consequences. Development of countermeasures requires a thorough understanding of the interaction between host and pathogen, and the course of disease. The goal of this study was to further characterize EBOV disease in a uniformly lethal rhesus macaque model, in order to support development of a well-characterized model following rigorous quality standards. Rhesus macaques were intramuscularly exposed to EBOV and one group was euthanized at predetermined time points to characterize progression of disease. A second group was not scheduled for euthanasia in order to analyze survival, changes in physiology, clinical pathology, terminal pathology, and telemetry kinetics. On day 3, sporadic viremia was observed and pathological evidence was noted in lymph nodes. By day 5, viremia was detected in all EBOV exposed animals and pathological evidence was noted in the liver, spleen, and gastrointestinal tissues. These data support the notion that EBOV infection in rhesus macaques is a rapid systemic disease similar to infection in humans, under a compressed time scale. Biomarkers that correlated with disease progression at the earliest stages of infection were observed thereby identifying potential "trigger-to-treat" for use in therapeutic studies.
Collapse
|
21
|
A Surrogate Animal Model for Screening of Ebola and Marburg Glycoprotein-Targeting Drugs Using Pseudotyped Vesicular Stomatitis Viruses. Viruses 2020; 12:v12090923. [PMID: 32842671 PMCID: PMC7552044 DOI: 10.3390/v12090923] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 08/20/2020] [Accepted: 08/20/2020] [Indexed: 12/25/2022] Open
Abstract
Filoviruses, including Ebola virus (EBOV) and Marburg virus (MARV), cause severe hemorrhagic fever in humans and nonhuman primates with high mortality rates. There is no approved therapy against these deadly viruses. Antiviral drug development has been hampered by the requirement of a biosafety level (BSL)-4 facility to handle infectious EBOV and MARV because of their high pathogenicity to humans. In this study, we aimed to establish a surrogate animal model that can be used for anti-EBOV and -MARV drug screening under BSL-2 conditions by focusing on the replication-competent recombinant vesicular stomatitis virus (rVSV) pseudotyped with the envelope glycoprotein (GP) of EBOV (rVSV/EBOV) and MARV (rVSV/MARV), which has been investigated as vaccine candidates and thus widely used in BSL-2 laboratories. We first inoculated mice, rats, and hamsters intraperitoneally with rVSV/EBOV and found that only hamsters showed disease signs and succumbed within 4 days post-infection. Infection with rVSV/MARV also caused lethal infection in hamsters. Both rVSV/EBOV and rVSV/MARV were detected at high titers in multiple organs including the liver, spleen, kidney, and lungs of infected hamsters, indicating acute and systemic infection resulting in fatal outcomes. Therapeutic effects of passive immunization with an anti-EBOV neutralizing antibody were specifically observed in rVSV/EBOV-infected hamsters. Thus, this animal model is expected to be a useful tool to facilitate in vivo screening of anti-filovirus drugs targeting the GP molecule.
Collapse
|
22
|
Madelain V, Mentré F, Baize S, Anglaret X, Laouénan C, Oestereich L, Nguyen THT, Malvy D, Piorkowski G, Graw F, Günther S, Raoul H, de Lamballerie X, Guedj J. Modeling Favipiravir Antiviral Efficacy Against Emerging Viruses: From Animal Studies to Clinical Trials. CPT-PHARMACOMETRICS & SYSTEMS PHARMACOLOGY 2020; 9:258-271. [PMID: 32198838 PMCID: PMC7239338 DOI: 10.1002/psp4.12510] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Accepted: 12/30/2019] [Indexed: 12/14/2022]
Abstract
In 2014, our research network was involved in the evaluation of favipiravir, an anti-influenza polymerase inhibitor, against Ebola virus. In this review, we discuss how mathematical modeling was used, first to propose a relevant dosing regimen in humans, and then to optimize its antiviral efficacy in a nonhuman primate (NHP) model. The data collected in NHPs were finally used to develop a model of Ebola pathogenesis integrating the interactions among the virus, the innate and adaptive immune response, and the action of favipiravir. We conclude the review of this work by discussing how these results are of relevance for future human studies in the context of Ebola virus, but also for other emerging viral diseases for which no therapeutics are available.
Collapse
Affiliation(s)
| | | | - Sylvain Baize
- UBIVE, Institut Pasteur, Centre International de Recherche en Infectiologie, Lyon, France
| | - Xavier Anglaret
- INSERM, UMR 1219, Université de Bordeaux, Bordeaux, France.,Programme PACCI/site ANRS de Côte d'Ivoire, Abidjan, Côte d'Ivoire
| | | | - Lisa Oestereich
- Bernhard-Nocht-Institute for Tropical Medicine, Hamburg, Germany.,German Center for Infection Research (DZIF), Partner Site Hamburg, Germany
| | | | - Denis Malvy
- INSERM, UMR 1219, Université de Bordeaux, Bordeaux, France.,Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
| | - Géraldine Piorkowski
- UMR "Emergence des Pathologies Virales" (EPV: Aix-Marseille University - IRD 190 - Inserm 1207 - EHESP) - Institut Hospitalo-Universitaire Méditerranée Infection, Marseille, France
| | - Frederik Graw
- Center for Modeling and Simulation in the Biosciences (BIOMS), BioQuant-Center, Heidelberg University, Heidelberg, Germany
| | - Stephan Günther
- Bernhard-Nocht-Institute for Tropical Medicine, Hamburg, Germany.,German Center for Infection Research (DZIF), Partner Site Hamburg, Germany
| | - Hervé Raoul
- Laboratoire P4 Inserm-Jean Mérieux, US003 Inserm, Lyon, France
| | - Xavier de Lamballerie
- UMR "Emergence des Pathologies Virales" (EPV: Aix-Marseille University - IRD 190 - Inserm 1207 - EHESP) - Institut Hospitalo-Universitaire Méditerranée Infection, Marseille, France
| | | |
Collapse
|
23
|
Kangbai JB, Heumann C, Hoelscher M, Sahr F, Froeschl G. Sociodemographic and clinical determinants of in-facility case fatality rate for 938 adult Ebola patients treated at Sierra Leone Ebola treatment center. BMC Infect Dis 2020; 20:293. [PMID: 32316923 PMCID: PMC7171792 DOI: 10.1186/s12879-020-04994-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Accepted: 03/27/2020] [Indexed: 11/30/2022] Open
Abstract
Background The 2013–2016 West Africa Ebola Virus Disease (EVD) outbreak recorded the highest incidence and mortality since the discovery of the virus in Zaire in 1976; with more than 28,000 probable and confirmed EVD cases and 11,000 deaths. Studies relating to previous outbreaks usually involved small sample sizes. In this study we are set to identify those sociodemographic and clinical features that predict in-facility mortality among EVD patients using a large sample size. Methods We analysed the anonymized medical records of 938 laboratory-confirmed EVD patients 15 years old and above who received treatment at The 34 Military Hospital and The Police Training School EVD Treatment Centers in Sierra Leone in the period June 2014 to April 2015. We used both univariable and multivariable logistic regression to determine the predictors for in-facility mortality of these patients based on their sociodemographic and clinical characteristics. Results The median age of the EVD cases was 33 years (interquartile range = 25 to 40 years). The majority of the EVD cases were male (59.0%) and had secondary level education (79.3%). We reported a low overall in-facility case fatality rate of 26.4%. The associations between case fatality rates and EVD patients who reported fever, abdominal pain, cough, diarrhoea, vomiting, fatigue, haemorrhage, dysphagia, conjunctival injection, dyspnea, and skin rash at the time of admission were all statistically significant (p < 0.05). Our preferred model with the age group 65 years and above alongside the following clinical symptoms; diarrhoea, vomiting, fatigue, dysphagia, conjunctival injection, dyspnea and cough produced a receiver operating characteristic (ROC) curve with an AUC (area under the curve) value of 0.93. Conclusions We constructed a simple model that can be optimally used alongside other rapid EVD diagnostic tools to identify EVD in-facility treatment mortality predictors based on the sociodemographic characteristics and clinical symptoms of adult EVD patients. We also reported low EVD cases among patients with secondary and tertiary education. These subpopulations of our patients who are generally informed about the signs and symptoms of EVD, alongside our treatment regimen may have been responsible for our comparatively lower case fatality rate.
Collapse
Affiliation(s)
- Jia Bainga Kangbai
- Center for International Health, University of Munich (LMU), Munich, Germany. .,Department of Environmental Health Sciences, School of Community Health Sciences, Njala University, Bo, Sierra Leone.
| | - Christian Heumann
- Department of Statistics, University of Munich (LMU), Munich, Germany
| | - Michael Hoelscher
- Center for International Health, University of Munich (LMU), Munich, Germany.,Division of Infectious Diseases and Tropical Medicine, University Hospital, LMU, Munich, Germany
| | - Foday Sahr
- Department of Microbiology, College of Medicine and Allied Health Sciences, University of Sierra Leone, Freetown, Sierra Leone.,34 Military Hospital, Wilberforce, Sierra Leone
| | - Guenter Froeschl
- Center for International Health, University of Munich (LMU), Munich, Germany.,Division of Infectious Diseases and Tropical Medicine, University Hospital, LMU, Munich, Germany
| |
Collapse
|
24
|
Rogers KJ, Shtanko O, Vijay R, Mallinger LN, Joyner CJ, Galinski MR, Butler NS, Maury W. Acute Plasmodium Infection Promotes Interferon-Gamma-Dependent Resistance to Ebola Virus Infection. Cell Rep 2020; 30:4041-4051.e4. [PMID: 32209467 PMCID: PMC7172281 DOI: 10.1016/j.celrep.2020.02.104] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Revised: 01/06/2020] [Accepted: 02/27/2020] [Indexed: 10/24/2022] Open
Abstract
During the 2013-2016 Ebola virus (EBOV) epidemic, a significant number of patients admitted to Ebola treatment units were co-infected with Plasmodium falciparum, a predominant agent of malaria. However, there is no consensus on how malaria impacts EBOV infection. The effect of acute Plasmodium infection on EBOV challenge was investigated using mouse-adapted EBOV and a biosafety level 2 (BSL-2) model virus. We demonstrate that acute Plasmodium infection protects from lethal viral challenge, dependent upon interferon gamma (IFN-γ) elicited as a result of parasite infection. Plasmodium-infected mice lacking the IFN-γ receptor are not protected. Ex vivo incubation of naive human or mouse macrophages with sera from acutely parasitemic rodents or macaques programs a proinflammatory phenotype dependent on IFN-γ and renders cells resistant to EBOV infection. We conclude that acute Plasmodium infection can safeguard against EBOV by the production of protective IFN-γ. These findings have implications for anti-malaria therapies administered during episodic EBOV outbreaks in Africa.
Collapse
Affiliation(s)
- Kai J Rogers
- Department of Microbiology and Immunology, University of Iowa, Iowa City, IA 52242, USA
| | - Olena Shtanko
- Host-Pathogen Interactions, Texas Biomedical Research Institute, San Antonio, TX 78227, USA
| | - Rahul Vijay
- Department of Microbiology and Immunology, University of Iowa, Iowa City, IA 52242, USA
| | - Laura N Mallinger
- Department of Microbiology and Immunology, University of Iowa, Iowa City, IA 52242, USA
| | - Chester J Joyner
- Division of Pulmonary, Allergy, Critical Care & Sleep Medicine, Department of Medicine, Emory University, Atlanta, GA 30322, USA; Malaria Host-Pathogen Interaction Center, Emory Vaccine Center, Yerkes National Primate Center, Emory University, Atlanta, GA 30322, USA
| | - Mary R Galinski
- Malaria Host-Pathogen Interaction Center, Emory Vaccine Center, Yerkes National Primate Center, Emory University, Atlanta, GA 30322, USA; Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Noah S Butler
- Department of Microbiology and Immunology, University of Iowa, Iowa City, IA 52242, USA; Interdisciplinary Graduate Program in Immunology, University of Iowa, Iowa City, IA 52242, USA
| | - Wendy Maury
- Department of Microbiology and Immunology, University of Iowa, Iowa City, IA 52242, USA; Interdisciplinary Graduate Program in Immunology, University of Iowa, Iowa City, IA 52242, USA.
| |
Collapse
|
25
|
Maleki KT, García M, Iglesias A, Alonso D, Ciancaglini M, Hammar U, Ljunggren HG, Schierloh P, Martínez VP, Klingström J. Serum Markers Associated with Severity and Outcome of Hantavirus Pulmonary Syndrome. J Infect Dis 2020; 219:1832-1840. [PMID: 30698699 PMCID: PMC6500549 DOI: 10.1093/infdis/jiz005] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Accepted: 12/11/2018] [Indexed: 12/11/2022] Open
Abstract
Background Hantavirus pulmonary syndrome (HPS) is caused by Andes virus (ANDV) and related hantaviruses in the Americas. Despite a fatality rate of 40%, the pathogenesis of HPS is poorly understood and factors associated with severity, fatality, and survival remain elusive. Methods Ninety-three ANDV-infected HPS patients, of whom 34 had a fatal outcome, were retrospectively studied. Serum levels of cytokines and other inflammation-associated markers were analyzed using multiplex immunoassay and enzyme-linked immunosorbent assay. Associations with disease severity, fatal outcome, and survival were identified using logistic regression. Results HPS patients exhibited increased serum levels of markers associated with inflammation, intestinal damage, and microbial translocation compared to controls. Patients with fatal outcome displayed higher levels of interleukin (IL) 6, IL-10, interferon-γ, soluble tumor necrosis factor-related apoptosis-inducing ligand, and intestinal fatty acid–binding protein (I-FABP) than survivors. Levels of complement factor 5/5a were higher in survivors compared with fatal cases. IL-6 and I-FABP, the latter a marker for intestinal damage, were by multivariate analyses identified as independent markers associated with disease severity (odds ratio [OR], 2.25; 95% confidence interval [CI], 1.01–5.01) and fatal outcome (OR, 1.64; 95% CI, 1.01–2.64), respectively. Conclusions HPS patients displayed a multifaceted, systemic inflammatory response, with IL-6 and I-FABP as independent markers of disease severity and fatality, respectively.
Collapse
Affiliation(s)
- Kimia T Maleki
- Center for Infectious Medicine, Department of Medicine Huddinge, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Marina García
- Laboratorio de Inmunología de Enfermedades Respiratorias, Instituto de Medicina Experimental, Consejo Nacional de Investigaciones Científicas y Técnicas (CONICET), Academia Nacional de Medicina
| | - Ayelén Iglesias
- Laboratorio Nacional de Referencia para Hantavirus, Servicio de Biología Molecular, Instituto Nacional de Enfermedades Infecciosas, Administración Nacional de Laboratorios e Institutos de Salud, "Dr Carlos G. Malbrán," Buenos Aires, Argentina
| | - Daniel Alonso
- Laboratorio Nacional de Referencia para Hantavirus, Servicio de Biología Molecular, Instituto Nacional de Enfermedades Infecciosas, Administración Nacional de Laboratorios e Institutos de Salud, "Dr Carlos G. Malbrán," Buenos Aires, Argentina
| | - Matías Ciancaglini
- Laboratorio Nacional de Referencia para Hantavirus, Servicio de Biología Molecular, Instituto Nacional de Enfermedades Infecciosas, Administración Nacional de Laboratorios e Institutos de Salud, "Dr Carlos G. Malbrán," Buenos Aires, Argentina
| | - Ulf Hammar
- Unit of Biostatistics, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Hans-Gustaf Ljunggren
- Center for Infectious Medicine, Department of Medicine Huddinge, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Pablo Schierloh
- Laboratorio de Microscopía Aplicada a Estudios Moleculares y Celulares, Instituto de Investigación y Desarrollo en Bioingeniería y Bioinformática, CONICET, Facultad de Ingeniería, Universidad Nacional de Entre Ríos, Argentina
| | - Valeria P Martínez
- Laboratorio Nacional de Referencia para Hantavirus, Servicio de Biología Molecular, Instituto Nacional de Enfermedades Infecciosas, Administración Nacional de Laboratorios e Institutos de Salud, "Dr Carlos G. Malbrán," Buenos Aires, Argentina
| | - Jonas Klingström
- Center for Infectious Medicine, Department of Medicine Huddinge, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| |
Collapse
|
26
|
Jacob ST, Crozier I, Fischer WA, Hewlett A, Kraft CS, Vega MADL, Soka MJ, Wahl V, Griffiths A, Bollinger L, Kuhn JH. Ebola virus disease. Nat Rev Dis Primers 2020; 6:13. [PMID: 32080199 PMCID: PMC7223853 DOI: 10.1038/s41572-020-0147-3] [Citation(s) in RCA: 272] [Impact Index Per Article: 68.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/10/2020] [Indexed: 12/16/2022]
Abstract
Ebola virus disease (EVD) is a severe and frequently lethal disease caused by Ebola virus (EBOV). EVD outbreaks typically start from a single case of probable zoonotic transmission, followed by human-to-human transmission via direct contact or contact with infected bodily fluids or contaminated fomites. EVD has a high case-fatality rate; it is characterized by fever, gastrointestinal signs and multiple organ dysfunction syndrome. Diagnosis requires a combination of case definition and laboratory tests, typically real-time reverse transcription PCR to detect viral RNA or rapid diagnostic tests based on immunoassays to detect EBOV antigens. Recent advances in medical countermeasure research resulted in the recent approval of an EBOV-targeted vaccine by European and US regulatory agencies. The results of a randomized clinical trial of investigational therapeutics for EVD demonstrated survival benefits from two monoclonal antibody products targeting the EBOV membrane glycoprotein. New observations emerging from the unprecedented 2013-2016 Western African EVD outbreak (the largest in history) and the ongoing EVD outbreak in the Democratic Republic of the Congo have substantially improved the understanding of EVD and viral persistence in survivors of EVD, resulting in new strategies toward prevention of infection and optimization of clinical management, acute illness outcomes and attendance to the clinical care needs of patients.
Collapse
Affiliation(s)
- Shevin T Jacob
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
- Global Health Security Department, Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Ian Crozier
- Integrated Research Facility at Fort Detrick, Clinical Monitoring Research Program Directorate, Frederick National Laboratory for Cancer Research supported by the National Cancer Institute, Frederick, MD, USA
| | - William A Fischer
- Department of Medicine, Division of Pulmonary Disease and Critical Care Medicine, Chapel Hill, NC, USA
| | - Angela Hewlett
- Nebraska Biocontainment Unit, Division of Infectious Diseases, University of Nebraska Medical Center, Omaha, NE, USA
| | - Colleen S Kraft
- Microbiology Section, Emory Medical Laboratory, Emory University School of Medicine, Atlanta, GA, USA
| | - Marc-Antoine de La Vega
- Department of Microbiology, Immunology & Infectious Diseases, Université Laval, Quebec City, QC, Canada
| | - Moses J Soka
- Partnership for Ebola Virus Disease Research in Liberia, Monrovia Medical Units ELWA-2 Hospital, Monrovia, Liberia
| | - Victoria Wahl
- National Biodefense Analysis and Countermeasures Center, Fort Detrick, Frederick, MD, USA
| | - Anthony Griffiths
- Department of Microbiology and National Emerging Infectious Diseases Laboratories, Boston University School of Medicine, Boston, MA, USA
| | - Laura Bollinger
- Integrated Research Facility at Fort Detrick, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Fort Detrick, Frederick, MD, USA
| | - Jens H Kuhn
- Integrated Research Facility at Fort Detrick, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Fort Detrick, Frederick, MD, USA.
| |
Collapse
|
27
|
Hendricks K, Parrado MG, Bradley J. Opinion: An Existing Drug to Assess In Vivo for Potential Adjunctive Therapy of Ebola Virus Disease and Post-Ebola Syndrome. Front Pharmacol 2020; 10:1691. [PMID: 32082173 PMCID: PMC7002323 DOI: 10.3389/fphar.2019.01691] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Accepted: 12/24/2019] [Indexed: 01/02/2023] Open
Affiliation(s)
| | | | - John Bradley
- Division of Infectious Diseases, Department of Pediatrics, UCSD School of Medicine, San Diego, CA, United States
| |
Collapse
|
28
|
Couturier C, Wada A, Louis K, Mistretta M, Beitz B, Povogui M, Ripaux M, Mignon C, Werle B, Lugari A, Pannetier D, Godard S, Bocquin A, Mely S, Béavogui I, Hébélamou J, Leuenberger D, Leissner P, Yamamoto T, Lécine P, Védrine C, Chaix J. Characterization and analytical validation of a new antigenic rapid diagnostic test for Ebola virus disease detection. PLoS Negl Trop Dis 2020; 14:e0007965. [PMID: 31951615 PMCID: PMC6992227 DOI: 10.1371/journal.pntd.0007965] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Revised: 01/30/2020] [Accepted: 11/27/2019] [Indexed: 01/16/2023] Open
Abstract
Hemorrhagic fever outbreaks are difficult to diagnose and control in part because of a lack of low-cost and easily accessible diagnostic structures in countries where etiologic agents are present. Furthermore, initial clinical symptoms are common and shared with other endemic diseases such as malaria or typhoid fever. Current molecular diagnostic methods such as polymerase chain reaction require trained personnel and laboratory infrastructure, hindering diagnostics at the point of need, particularly in outbreak settings. Therefore, rapid diagnostic tests such as lateral flow can be broadly deployed and are typically well-suited to rapidly diagnose hemorrhagic fever viruses, such as Ebola virus. Early detection and control of Ebola outbreaks require simple, easy-to-use assays that can detect very low amount of virus in blood. Here, we developed and characterized an immunoassay test based on immunochromatography coupled to silver amplification technology to detect the secreted glycoprotein of EBOV. The glycoprotein is among the first viral proteins to be detected in blood. This strategy aims at identifying infected patients early following onset of symptoms by detecting low amount of sGP protein in blood samples. The limit of detection achieved by this sGP-targeted kit is 2.2 x 104 genome copies/ml in plasma as assayed in a monkey analytical cohort. Clinical performance evaluation showed a specificity of 100% and a sensitivity of 85.7% when evaluated with plasma samples from healthy controls and patients infected with Zaire Ebola virus from Macenta, Guinea. This rapid and accurate diagnostic test could therefore be used in endemic countries for early detection of infected individuals in point of care settings. Moreover, it could also support efficient clinical triage in hospitals or clinical centers and thus reducing transmission rates to prevent and better manage future severe outbreaks. Ebola virus disease is a severe disease caused by Ebola virus, a member of the filovirus family, which occurs in humans and other primates. Ebola is believed to be zoonotic, however the natural reservoir is unknown. Overlapping symptoms with other endemic diseases, such as malaria and cholera, make accurate diagnostic challenging. Outbreaks of Ebola have been widespread as the consequence of the absence of available rapid, sensitive, specific, robust, and affordable licensed diagnostic test in remote areas, where outbreaks usually start. Here we have established and validated a rapid diagnostic test, which is fast, sensitive, specific, efficient, affordable, and user-friendly. Its analytical characteristics make it suitable for clinical management during Ebola virus outbreaks in remote areas. Of interest, this rapid diagnostic test detects the presence of an early viral antigen, the secreted glycoprotein, found in blood of patients shortly after infection, suggesting that it could be used to identify infected patients shortly after onset of symptoms.
Collapse
Affiliation(s)
| | - Atsuhiko Wada
- FUJIFILM, Ushijima, Kaisei-machi, Ashigarakami-gun Kanagawa, Japan
| | | | | | | | - Moriba Povogui
- Centre de Recherche Et de Formation en Infectiologie de Guinée (CERFIG), République de Guinée
| | | | | | | | | | | | | | - Anne Bocquin
- INSERM Jean Mérieux BSL4 Laboratory, LYON, France
| | | | - Ismaël Béavogui
- CHRS Macenta, c/o Mission Philafricaine, Conakry, République de Guinée
| | - Jean Hébélamou
- CHRS Macenta, c/o Mission Philafricaine, Conakry, République de Guinée
| | - David Leuenberger
- CHRS Macenta, c/o Mission Philafricaine, Conakry, République de Guinée
| | | | - Takeshi Yamamoto
- FUJIFILM, Ushijima, Kaisei-machi, Ashigarakami-gun Kanagawa, Japan
| | | | | | | |
Collapse
|
29
|
Characterization of Ebola Virus Disease (EVD) in Rhesus Monkeys for Development of EVD Therapeutics. Viruses 2020; 12:v12010092. [PMID: 31941095 PMCID: PMC7019527 DOI: 10.3390/v12010092] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Revised: 01/06/2020] [Accepted: 01/08/2020] [Indexed: 01/02/2023] Open
Abstract
Recent Ebola virus (EBOV) outbreaks in West Africa and the Democratic Republic of the Congo have highlighted the urgent need for approval of medical countermeasures for treatment and prevention of EBOV disease (EVD). Until recently, when successes were achieved in characterizing the efficacy of multiple experimental EVD therapeutics in humans, the only feasible way to obtain data regarding potential clinical benefits of candidate therapeutics was by conducting well-controlled animal studies. Nonclinical studies are likely to continue to be important tools for screening and development of new candidates with improved pharmacological properties. Here, we describe a natural history study to characterize the time course and order of progression of the disease manifestations of EVD in rhesus monkeys. In 12 rhesus monkeys exposed by the intramuscular route to 1000 plaque-forming units of EBOV, multiple endpoints were monitored for 28 days following exposure. The disease progressed rapidly with mortality events occurring 7–10 days after exposure. Key disease manifestations observed consistently across the infected animals included, but were not limited to, viremia, fever, systemic inflammation, coagulopathy, lymphocytolysis, renal tubular necrosis with mineralization, and hepatocellular degeneration and necrosis.
Collapse
|
30
|
Clément C, Adhikari NKJ, Lamontagne F. Evidence-Based Clinical Management of Ebola Virus Disease and Epidemic Viral Hemorrhagic Fevers. Infect Dis Clin North Am 2019; 33:247-264. [PMID: 30712765 DOI: 10.1016/j.idc.2018.10.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
The 2014 to 2016 Ebola virus disease outbreak underscored the threat posed by hemorrhagic fevers. Filoviral outbreaks have been identified since 1967, but data collection has remained sparse, limiting current knowledge of these illnesses. Documentation of objective physical signs and laboratory parameters and appropriate clinical management are connected and interdependent. Implementing both is necessary to improve outcomes. Clinical features include severe volume depletion due to diarrhea and vomiting, shock, rhabdomyolysis, and metabolic disturbances. Overt hemorrhage is uncommon. Point-of-care devices and inexpensive electronic equipment enable better monitoring and record keeping in resource-limited settings.
Collapse
Affiliation(s)
- Christophe Clément
- Intensive Care Unit, Polyclinique Bordeaux Nord Aquitaine, 15 rue Claude Boucher, Bordeaux 33000, France; Intensive Care Unit, Mamoudzou Hospital, rue de l'Hôpital, Mayotte 97600, France
| | - Neill K J Adhikari
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, Ontario M4N 3M5, Canada; Interdepartmental Division of Critical Care, University of Toronto, 209 Victoria Street, 4th Floor, Room 411, Toronto, Ontario M5B 1T8, Canada
| | - François Lamontagne
- Interdepartmental Division of Critical Care, University of Toronto, 209 Victoria Street, 4th Floor, Room 411, Toronto, Ontario M5B 1T8, Canada; Department of Medicine, Université de Sherbrooke, 300112e Avenue Nord, Sherbrooke, Québec J1H 5N4, Canada.
| |
Collapse
|
31
|
Litwinowicz K, Choroszy M, Waszczuk E. Changes in the composition of the human intestinal microbiome in alcohol use disorder: a systematic review. THE AMERICAN JOURNAL OF DRUG AND ALCOHOL ABUSE 2019; 46:4-12. [DOI: 10.1080/00952990.2019.1669629] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Kamil Litwinowicz
- Department of Medical Biochemistry, Wroclaw Medical University, Wroclaw, Poland
| | - Marcin Choroszy
- Department of Microbiology, Wroclaw Medical University, Wroclaw, Poland
| | - Ewa Waszczuk
- Department of Gastroenterology and Hepatology, Wroclaw Medical University, Wroclaw, Poland
| |
Collapse
|
32
|
Rojek AM, Salam A, Ragotte RJ, Liddiard E, Elhussain A, Carlqvist A, Butler M, Kayem N, Castle L, Odondi L', Stepniewska K, Horby PW. A systematic review and meta-analysis of patient data from the West Africa (2013-16) Ebola virus disease epidemic. Clin Microbiol Infect 2019; 25:1307-1314. [PMID: 31284032 PMCID: PMC7116468 DOI: 10.1016/j.cmi.2019.06.032] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Revised: 06/25/2019] [Accepted: 06/28/2019] [Indexed: 01/08/2023]
Abstract
BACKGROUND Over 28 000 individuals were infected with Ebola virus during the West Africa (2013-2016) epidemic, yet there has been criticism of the lack of robust clinical descriptions of Ebola virus disease (EVD) illness from that outbreak. OBJECTIVES To perform a meta-analysis of published data from the epidemic to describe the clinical presentation, evolution of disease, and predictors of mortality in individuals with EVD. To assess the quality and utility of published data for clinical and public health decision-making. DATA SOURCES Primary articles available in PubMed and published between January 2014 and May 2017. ELIGIBILITY Studies that sequentially enrolled individuals hospitalized for EVD and that reported acute clinical outcomes. METHODS We performed meta-analyses using random-effect models and assessed heterogeneity using the I2 method. We assessed data representativeness by comparing meta-analysis estimates with WHO aggregate data. We examined data utility by examining the availability and compatibility of data sets. RESULTS In all, 3653 articles were screened and 34 articles were included, representing 16 independent cohorts of patients (18 overlapping cohorts) and at least 6168 individuals. The pooled estimate for case fatality rate was 51% (95% CI 46%-56%). However, pooling of estimates for clinical presentation, progression, and predictors of mortality in individuals with EVD were hampered by significant heterogeneity, and inadequate data on clinical progression. Our assessment of data quality found that heterogeneity was largely unexplained, and data availability and compatibility were poor. CONCLUSIONS We have quantified a missed opportunity to generate reliable estimates of the clinical manifestations of EVD during the West Africa epidemic. Clinical data standards and data capture platforms are urgently needed.
Collapse
Affiliation(s)
- A M Rojek
- Epidemic Diseases Research Group, University of Oxford, Oxford, UK.
| | - A Salam
- Epidemic Diseases Research Group, University of Oxford, Oxford, UK; United Kingdom Public Health Rapid Support Team, London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - R J Ragotte
- Epidemic Diseases Research Group, University of Oxford, Oxford, UK
| | - E Liddiard
- Epidemic Diseases Research Group, University of Oxford, Oxford, UK
| | - A Elhussain
- Epidemic Diseases Research Group, University of Oxford, Oxford, UK
| | - A Carlqvist
- Epidemic Diseases Research Group, University of Oxford, Oxford, UK
| | - M Butler
- Epidemic Diseases Research Group, University of Oxford, Oxford, UK
| | - N Kayem
- Epidemic Diseases Research Group, University of Oxford, Oxford, UK
| | - L Castle
- Epidemic Diseases Research Group, University of Oxford, Oxford, UK
| | - L 'o Odondi
- Epidemic Diseases Research Group, University of Oxford, Oxford, UK
| | - K Stepniewska
- Epidemic Diseases Research Group, University of Oxford, Oxford, UK; WorldWide Antimalarial Resistance Network, Oxford, UK
| | - P W Horby
- Epidemic Diseases Research Group, University of Oxford, Oxford, UK
| |
Collapse
|
33
|
Rosenke K, Mercado-Hernandez R, Cronin J, Conteh S, Duffy P, Feldmann H, de Wit E. The Effect of Plasmodium on the Outcome of Ebola Virus Infection in a Mouse Model. J Infect Dis 2019; 218:S434-S437. [PMID: 29878224 DOI: 10.1093/infdis/jiy236] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Following the Ebola virus epidemic in West Africa, several studies investigated whether there was an effect of Plasmodium coinfection on survival in Ebola virus (EBOV) disease patients. Different effects of coinfection were found in different patient cohorts. To determine whether an effect of Plasmodium coinfection on EBOV survival may exist, we modeled coinfection of Plasmodium yoelii and mouse-adapted EBOV (MA-EBOV) in CD1 mice. Subsequent infection with MA-EBOV at different time points after P. yoelii infection did not have any significant effect on survival.
Collapse
Affiliation(s)
- Kyle Rosenke
- Laboratory of Virology, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Hamilton, Montana
| | - Reinaldo Mercado-Hernandez
- Laboratory of Virology, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Hamilton, Montana
| | - Jacqueline Cronin
- Laboratory of Virology, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Hamilton, Montana
| | - Solomon Conteh
- Laboratory of Malaria Immunology and Vaccinology, NIAID, NIH Bethesda, Maryland
| | - Patrick Duffy
- Laboratory of Malaria Immunology and Vaccinology, NIAID, NIH Bethesda, Maryland
| | - Heinz Feldmann
- Laboratory of Virology, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Hamilton, Montana
| | - Emmie de Wit
- Laboratory of Virology, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Hamilton, Montana
| |
Collapse
|
34
|
Speranza E, Ruibal P, Port JR, Feng F, Burkhardt L, Grundhoff A, Günther S, Oestereich L, Hiscox JA, Connor JH, Muñoz-Fontela C. T-Cell Receptor Diversity and the Control of T-Cell Homeostasis Mark Ebola Virus Disease Survival in Humans. J Infect Dis 2019; 218:S508-S518. [PMID: 29986035 DOI: 10.1093/infdis/jiy352] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Differences in T-cell phenotype, particularly the expression of markers of T-cell homeostasis, have been observed in fatal and nonfatal Ebola virus disease (EVD). However, the relationship between these markers with T-cell function and virus clearance during EVD is poorly understood. To gain biological insight into the role of T cells during EVD, combined transcriptomics and T-cell receptor sequencing was used to profile blood samples from fatal and nonfatal EVD patients from the recent West African EVD epidemic. Fatal EVD was characterized by strong T-cell activation and increased abundance of T-cell inhibitory molecules. However, the early T-cell response was oligoclonal and did not result in viral clearance. In contrast, survivors mounted highly diverse T-cell responses, maintained low levels of T-cell inhibitors, and cleared Ebola virus. Our findings highlight the importance of T-cell immunity in surviving EVD and strengthen the foundation for further research on targeting of the dendritic cell-T cell interface for postexposure immunotherapy.
Collapse
Affiliation(s)
- Emily Speranza
- Department of Microbiology, Boston University School of Medicine, Boston MA.,Department of Bioinformatics Program, Boston University, Boston MA.,Department of National Emerging Infectious Diseases Laboratories, Boston University, Boston MA.,Department of Mathematics and Statistics, Boston University, Boston MA
| | - Paula Ruibal
- Bernhard Nocht Institute for Tropical Medicine, Hamburg, Germany
| | - Julia R Port
- Bernhard Nocht Institute for Tropical Medicine, Hamburg, Germany.,German Center for Infection Research (DZIF), Partner SiteHamburg, Germany
| | - Feng Feng
- Department of Microbiology, Boston University School of Medicine, Boston MA.,Department of Mathematics and Statistics, Boston University, Boston MA
| | - Lia Burkhardt
- Heinrich Pette Institute, Leibniz Institute for Experimental Virology, Hamburg, Germany
| | - Adam Grundhoff
- Heinrich Pette Institute, Leibniz Institute for Experimental Virology, Hamburg, Germany
| | - Stephan Günther
- Bernhard Nocht Institute for Tropical Medicine, Hamburg, Germany.,German Center for Infection Research (DZIF), Partner SiteHamburg, Germany
| | - Lisa Oestereich
- Bernhard Nocht Institute for Tropical Medicine, Hamburg, Germany.,German Center for Infection Research (DZIF), Partner SiteHamburg, Germany
| | - Julian A Hiscox
- Institute for Infection and Global Health, University of Liverpool, United Kingdom.,Singapore Immunology Network, A*STAR, Singapore
| | - John H Connor
- Department of Microbiology, Boston University School of Medicine, Boston MA.,Department of Bioinformatics Program, Boston University, Boston MA.,Department of National Emerging Infectious Diseases Laboratories, Boston University, Boston MA.,Department of Mathematics and Statistics, Boston University, Boston MA
| | - César Muñoz-Fontela
- Bernhard Nocht Institute for Tropical Medicine, Hamburg, Germany.,German Center for Infection Research (DZIF), Partner SiteHamburg, Germany
| |
Collapse
|
35
|
Cytokine Effects on the Entry of Filovirus Envelope Pseudotyped Virus-Like Particles into Primary Human Macrophages. Viruses 2019; 11:v11100889. [PMID: 31547585 PMCID: PMC6832363 DOI: 10.3390/v11100889] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Revised: 09/09/2019] [Accepted: 09/18/2019] [Indexed: 12/25/2022] Open
Abstract
Macrophages are one of the first and also a major site of filovirus replication and, in addition, are a source of multiple cytokines, presumed to play a critical role in the pathogenesis of the viral infection. Some of these cytokines are known to induce macrophage phenotypic changes in vitro, but how macrophage polarization may affect the cell susceptibility to filovirus entry remains largely unstudied. We generated different macrophage subsets using cytokine pre-treatment and subsequently tested their ability to fuse with beta-lactamase containing virus-like particles (VLP), pseudotyped with the surface glycoprotein of Ebola virus (EBOV) or the glycoproteins of other clinically relevant filovirus species. We found that pre-incubation of primary human monocyte-derived macrophages (MDM) with interleukin-10 (IL-10) significantly enhanced filovirus entry into cells obtained from multiple healthy donors, and the IL-10 effect was preserved in the presence of pro-inflammatory cytokines found to be elevated during EBOV disease. In contrast, fusion of IL-10-treated macrophages with influenza hemagglutinin/neuraminidase pseudotyped VLPs was unchanged or slightly reduced. Importantly, our in vitro data showing enhanced virus entry are consistent with the correlation established between elevated serum IL-10 and increased mortality in filovirus infected patients and also reveal a novel mechanism that may account for the IL-10-mediated increase in filovirus pathogenicity.
Collapse
|
36
|
Younan P, Iampietro M, Santos RI, Ramanathan P, Popov VL, Bukreyev A. Role of Transmembrane Protein 16F in the Incorporation of Phosphatidylserine Into Budding Ebola Virus Virions. J Infect Dis 2019; 218:S335-S345. [PMID: 30289531 DOI: 10.1093/infdis/jiy485] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Viral apoptotic mimicry, which is defined by exposure of phosphatidylserine (PtdSer) into the outer leaflet of budding enveloped viruses, increases viral tropism, infectivity and promotes immune evasion. Here, we report that the calcium (Ca2+)-dependent scramblase, transmembrane protein 16F (TMEM16F), is responsible for the incorporation of PtdSer into virion membranes during Ebola virus infection. Infection of Huh7 cells with Ebola virus resulted in a pronounced increase in plasma membrane-associated PtdSer, which was demonstrated to be dependent on TMEM16F function. Analysis of virions using imaging flow cytometry revealed that short hairpin RNA-mediated down-regulation of TMEM16F function directly reduced virion-associated PtdSer. Taken together, these studies demonstrate that TMEM16F is a central cellular factor in the exposure of PtdSer in the outer leaflet of viral membranes.
Collapse
Affiliation(s)
- Patrick Younan
- Departments of Pathology, University of Texas Medical Branch, Galveston.,Departments of Galveston National Laboratory, University of Texas Medical Branch, Galveston.,Departments of University of Texas Medical Branch, Galveston
| | - Mathieu Iampietro
- Departments of Pathology, University of Texas Medical Branch, Galveston.,Departments of Galveston National Laboratory, University of Texas Medical Branch, Galveston.,Departments of University of Texas Medical Branch, Galveston
| | - Rodrigo I Santos
- Departments of Pathology, University of Texas Medical Branch, Galveston.,Departments of Galveston National Laboratory, University of Texas Medical Branch, Galveston.,Departments of University of Texas Medical Branch, Galveston
| | - Palaniappan Ramanathan
- Departments of Pathology, University of Texas Medical Branch, Galveston.,Departments of Galveston National Laboratory, University of Texas Medical Branch, Galveston.,Departments of University of Texas Medical Branch, Galveston
| | - Vsevolod L Popov
- Departments of Pathology, University of Texas Medical Branch, Galveston.,Departments of University of Texas Medical Branch, Galveston
| | - Alexander Bukreyev
- Departments of Pathology, University of Texas Medical Branch, Galveston.,Departments of Microbiology and Immunology, University of Texas Medical Branch, Galveston.,Departments of Galveston National Laboratory, University of Texas Medical Branch, Galveston.,Departments of University of Texas Medical Branch, Galveston
| |
Collapse
|
37
|
TSLP Exacerbates Septic Inflammation via Murine Double Minute 2 (MDM2) Signaling Pathway. J Clin Med 2019; 8:jcm8091350. [PMID: 31480519 PMCID: PMC6780965 DOI: 10.3390/jcm8091350] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Revised: 08/12/2019] [Accepted: 08/26/2019] [Indexed: 02/07/2023] Open
Abstract
Thymic stromal lymphopoietin (TSLP) is crucial for Th2-mediated inflammation. Sepsis is a serious systemic inflammatory reaction with organ dysfunction by infection. However, the function of TSLP during sepsis is poorly understood. Thus, we investigated a role and regulatory mechanism of TSLP during sepsis. Sepsis was induced by lipopolysaccharides (LPS) or Escherichia coli DH5α injection in mice. TSLP levels were measured in human subjects, mice, and macrophages. TSLP deficiency or murine double minute 2 (MDM2) deficiency was induced using siRNA or an MDM2 inhibitor, nutlin-3a. We found that TSLP levels were elevated in serum of patients and mice with sepsis. TSLP deficiency lowered liver damage and inflammatory cytokine levels in mice with sepsis. TSLP was produced by the MDM2/NF-κB signaling pathway in LPS-stimulated macrophages. TSLP downregulation by an MDM2 inhibitor, nutlin-3a, alleviated clinical symptoms and septic inflammatory responses. Pharmacological inhibition of TSLP level by cisplatin reduced the septic inflammatory responses. Altogether, the present results show that TSLP exacerbates septic inflammation via the MDM2 signaling pathway, suggesting that TSLP may be a potential target for the treatment of sepsis.
Collapse
|
38
|
Wu CQ, Lin QR, Ying SJ, Luo JK, Hong WJ, Lin ZJ, Jiang Y. Association of Crohn's Disease with Aryl Hydrocarbon Receptor Gene Polymorphisms in Patients from Southeast China. Immunol Invest 2019; 48:809-821. [PMID: 31405308 DOI: 10.1080/08820139.2019.1569677] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Aims The aryl hydrocarbon receptor (AhR) plays a pivotal role in regulating the innate and the acquired immune systems. The present study aimed to investigate the association of Crohn's disease (CD) with AhR polymorphisms in a cohort of patients from Southeast China. Methods An improved multiple ligase detection reaction technique was applied to examine the polymorphisms of rs2158041, rs2066853, and rs10249788 in 310 patients with CD and 573 controls. Results Compared to the controls, the variant allele (T) and genotype (CT+TT) of rs2158041 were less frequent in patients with CD (both p < 0.05). Similar conclusions were drawn from patients with ileal CD and with stricture CD as compared to the controls (all p < 0.0083). However, no significant differences were observed in allele and genotype frequencies of rs2066853 and rs10249788 between patients with CD and the controls (all p > 0.05). Although rs2158041 and rs10249788 were in complete linkage disequilibrium with rs2066853, respectively, only the frequency of haplotype (TG) formed by rs2158041 and rs2066853 was significantly lower in patients with CD than that in the controls (p < 0.05). Conclusions AhR (rs2158041) might be a susceptible locus for CD, especially for the two subtypes: ileal CD and stricture CD.
Collapse
Affiliation(s)
- Chao-Qun Wu
- Department of Gastroenterology, The Second Affiliated Hospital of Wenzhou Medical University , Wenzhou , Zhejiang Province , China
| | - Qian-Ru Lin
- Department of Gastroenterology, The Second Affiliated Hospital of Wenzhou Medical University , Wenzhou , Zhejiang Province , China
| | - Shi-Jie Ying
- Department of Gastroenterology, The Second Affiliated Hospital of Wenzhou Medical University , Wenzhou , Zhejiang Province , China
| | - Jia-Kai Luo
- Department of Gastroenterology, The Second Affiliated Hospital of Wenzhou Medical University , Wenzhou , Zhejiang Province , China
| | - Wei-Jun Hong
- Department of Gastroenterology, The Second Affiliated Hospital of Wenzhou Medical University , Wenzhou , Zhejiang Province , China
| | - Zi-Jian Lin
- Department of Gastroenterology, The Second Affiliated Hospital of Wenzhou Medical University , Wenzhou , Zhejiang Province , China
| | - Yi Jiang
- Department of Gastroenterology, The Second Affiliated Hospital of Wenzhou Medical University , Wenzhou , Zhejiang Province , China
| |
Collapse
|
39
|
Characterization of Biomarker Levels in Crimean-Congo Hemorrhagic Fever and Hantavirus Fever with Renal Syndrome. Viruses 2019; 11:v11080686. [PMID: 31357521 PMCID: PMC6722556 DOI: 10.3390/v11080686] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Revised: 07/20/2019] [Accepted: 07/25/2019] [Indexed: 01/02/2023] Open
Abstract
Hemorrhagic fever with renal syndrome (HFRS) and Crimean-Congo hemorrhagic fever (CCHF) are important viral hemorrhagic fevers (VHF), especially in the Balkan region. Infections with Dobrava or Puumala orthohantavirus and Crimean-Congo hemorrhagic fever orthonairovirus can vary from a mild, nonspecific febrile illness, to a severe disease with a fatal outcome. The pathogenesis of both diseases is poorly understood, but it has been suggested that a host’s immune mechanism might influence the pathogenesis of the diseases and survival. The aim of our study is to characterize cytokine response in patients with VHF in association with the disease progression and viral load. Forty soluble mediators of the immune response, coagulation, and endothelial dysfunction were measured in acute serum samples in 100 HFRS patients and 70 CCHF patients. HFRS and CCHF patients had significantly increased levels of IL-6, IL-12p70, IP-10, INF-γ, TNF-α, GM-CSF, MCP-3, and MIP-1b in comparison to the control group. Interestingly, HFRS patients had higher concentrations of serum MIP-1α, MIP-1β, which promote activation of macrophages and NK cells. HFRS patients had increased concentrations of IFN-γ and TNF-α, while CCHF patients had significantly higher concentrations of IFN-α and IL-8. In both, CCHF and HFRS patients’ viral load significantly correlated with IP-10. Patients with fatal outcome had significantly elevated concentrations of IL-6, IFN-α2 and MIP-1α, while GRO-α, chemokine related to activation of neutrophils and basophils, was downregulated. Our study provided a comprehensive characterization of biomarkers released in the acute stages of CCHF and HFRS.
Collapse
|
40
|
Nakano A, Mori A, Arima S, Asano D, Morita A, Sakamoto K, Nagamitsu T, Nakahara T. Attenuation of Retinal Endothelial Vasodilator Function in a Rat Model of Retinopathy of Prematurity. Curr Eye Res 2019; 44:1360-1368. [DOI: 10.1080/02713683.2019.1641825] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- Ayuki Nakano
- Department of Molecular Pharmacology, Kitasato University School of Pharmaceutical Sciences, Tokyo, Japan
| | - Asami Mori
- Department of Molecular Pharmacology, Kitasato University School of Pharmaceutical Sciences, Tokyo, Japan
| | - Shiho Arima
- Department of Organic Synthesis, Kitasato University School of Pharmaceutical Sciences, Tokyo, Japan
| | - Daiki Asano
- Department of Molecular Pharmacology, Kitasato University School of Pharmaceutical Sciences, Tokyo, Japan
| | - Akane Morita
- Department of Molecular Pharmacology, Kitasato University School of Pharmaceutical Sciences, Tokyo, Japan
| | - Kenji Sakamoto
- Department of Molecular Pharmacology, Kitasato University School of Pharmaceutical Sciences, Tokyo, Japan
| | - Tohru Nagamitsu
- Department of Organic Synthesis, Kitasato University School of Pharmaceutical Sciences, Tokyo, Japan
| | - Tsutomu Nakahara
- Department of Molecular Pharmacology, Kitasato University School of Pharmaceutical Sciences, Tokyo, Japan
| |
Collapse
|
41
|
Sim J, Sockolosky JT, Sangalang E, Izquierdo S, Pedersen D, Harriman W, Wibowo AS, Carter J, Madan A, Doyle L, Harrabi O, Kauder SE, Chen A, Kuo TC, Wan H, Pons J. Discovery of high affinity, pan-allelic, and pan-mammalian reactive antibodies against the myeloid checkpoint receptor SIRPα. MAbs 2019; 11:1036-1052. [PMID: 31257988 PMCID: PMC6748616 DOI: 10.1080/19420862.2019.1624123] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Targeting the CD47-signal-regulatory protein α (SIRPα) pathway represents a novel therapeutic approach to enhance anti-cancer immunity by promoting both innate and adaptive immune responses. Unlike CD47, which is expressed ubiquitously, SIRPα expression is mainly restricted to myeloid cells and neurons. Therefore, compared to CD47-targeted therapies, targeting SIRPα may result in differential safety and efficacy profiles, potentially enabling lower effective doses and improved pharmacokinetics and pharmacodynamics. The development of effective SIRPα antagonists is restricted by polymorphisms within the CD47-binding domain of SIRPα, necessitating pan-allele reactive anti-SIRPα antibodies for therapeutic intervention in diverse patient populations. We immunized wild-type and human antibody transgenic chickens with a multi-allele and multi-species SIRPα regimen in order to discover pan-allelic and pan-mammalian reactive anti-SIRPα antibodies suitable for clinical translation. A total of 200 antibodies were isolated and screened for SIRPα reactivity from which approximately 70 antibodies with diverse SIRPα binding profiles, sequence families, and epitopes were selected for further characterization. A subset of anti-SIRPα antibodies bound to both human SIRPα v1 and v2 alleles with high affinity ranging from low nanomolar to picomolar, potently antagonized the CD47/SIRPα interaction, and potentiated macrophage-mediated antibody-dependent cellular phagocytosis in vitro. X-ray crystal structures of five anti-SIRPα antigen-binding fragments, each with unique epitopes, in complex with SIRPα (PDB codes 6NMV, 6NMU, 6NMT, 6NMS, and 6NMR) are reported. Furthermore, some of the anti-SIRPα antibodies cross-react with cynomolgus SIRPα and various mouse SIRPα alleles (BALB/c, NOD, BL/6), which can facilitate preclinical to clinical development. These properties provide an attractive rationale to advance the development of these anti-SIRPα antibodies as a novel therapy for advanced malignancies. Abbreviations: ADCC: antibody-dependent cellular cytotoxicity; ADCP: antibody-dependent cellular phagocytosis; CFSE: carboxyfluorescein succinimidyl ester; Fab: fragment antigen binding; Fc: fragment crystallizable; FcγR: Fcγ receptor; Ig: immunoglobulin; IND: investigational new drug; MDM⊘: monocyte-derived macrophage; NOD: non-obese diabetic; scFv: single chain fragment variable; SCID: severe combined immunodeficiency; SIRP: signal-regulatory protein.
Collapse
Affiliation(s)
- Janet Sim
- a ALX Oncology, Departments of Protein Sciences and Translational Biology , Burlingame , CA , USA
| | - Jonathan T Sockolosky
- a ALX Oncology, Departments of Protein Sciences and Translational Biology , Burlingame , CA , USA
| | - Emma Sangalang
- a ALX Oncology, Departments of Protein Sciences and Translational Biology , Burlingame , CA , USA
| | | | | | | | | | | | - Anup Madan
- d Covance Genomics Laboratory , Redmond , WA , USA
| | - Laura Doyle
- a ALX Oncology, Departments of Protein Sciences and Translational Biology , Burlingame , CA , USA
| | - Ons Harrabi
- a ALX Oncology, Departments of Protein Sciences and Translational Biology , Burlingame , CA , USA
| | - Steven E Kauder
- a ALX Oncology, Departments of Protein Sciences and Translational Biology , Burlingame , CA , USA
| | - Amy Chen
- a ALX Oncology, Departments of Protein Sciences and Translational Biology , Burlingame , CA , USA
| | - Tracy C Kuo
- a ALX Oncology, Departments of Protein Sciences and Translational Biology , Burlingame , CA , USA
| | - Hong Wan
- a ALX Oncology, Departments of Protein Sciences and Translational Biology , Burlingame , CA , USA
| | - Jaume Pons
- a ALX Oncology, Departments of Protein Sciences and Translational Biology , Burlingame , CA , USA
| |
Collapse
|
42
|
AbdelAl O, Ashraf M, Sampani K, Sun JK. "For Mass Eye and Ear Special Issue" Adaptive Optics in the Evaluation of Diabetic Retinopathy. Semin Ophthalmol 2019; 34:189-197. [PMID: 31188056 DOI: 10.1080/08820538.2019.1620794] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Retinal imaging is a fundamental tool for clinical and research efforts in the evaluation and management of diabetic retinopathy. Adaptive optics (AO) is an imaging technique that enables correction of over 90% of the optical aberrations of an individual eye induced primarily by the tear film, cornea and lens. The two major tasks of any AO system are to measure the optical imperfections of the eye and to then compensate for these aberrations to generate a corrected wavefront of reflected light from the eye. AO scanning laser ophthalmoscopy (AOSLO) provides a theoretical lateral resolution limit of 1.4 μm, allowing the study of microscopic features of the retinal vascular and neural tissue. AOSLO studies have revealed irregularities of the photoreceptor mosaic, vascular loss, and details of vascular lesions in diabetic eyes that may provide new insight into development, regression, and response to therapy of diabetic eye disease.
Collapse
Affiliation(s)
- Omar AbdelAl
- a Beetham Eye Institute , Joslin Diabetes Center , Boston , MA , USA.,b Department of Ophthalmology , Harvard Medical School , Boston , MA , USA
| | - Mohammed Ashraf
- a Beetham Eye Institute , Joslin Diabetes Center , Boston , MA , USA.,b Department of Ophthalmology , Harvard Medical School , Boston , MA , USA
| | - Konstantina Sampani
- a Beetham Eye Institute , Joslin Diabetes Center , Boston , MA , USA.,c Department of Medicine , Harvard Medical School , Boston , MA , USA
| | - Jennifer K Sun
- a Beetham Eye Institute , Joslin Diabetes Center , Boston , MA , USA.,b Department of Ophthalmology , Harvard Medical School , Boston , MA , USA
| |
Collapse
|
43
|
Yeh PT, Wang LC, Chang SW, Yang WS, Yang CM, Yang CH. Effect of Fenofibrate on the Expression of Inflammatory Mediators in a Diabetic Rat Model. Curr Eye Res 2019; 44:1121-1132. [PMID: 31109206 DOI: 10.1080/02713683.2019.1622020] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Purpose: To investigate the mechanisms of anti-inflammatory and anti-oxidative effects of fenofibrate, a peroxisome proliferator-activated receptors-α agonist, in preventing diabetic retinopathy (DR) progression via a diabetic rat model. Methods: Diabetes was induced by intraperitoneal injection of streptozotocin in 6-week-old female Wistar rats. Diabetic rats were divided into diabetes without treatment (n = 10), diabetes treated with low dose fenofibrate (30 mg/kg/day) (n = 10) and high dose fenofibrate (100 mg/kg/day) (n = 10). Serum aqueous humor (AqH) and ocular tissues were gathered after 3-month treatment. Expressions of NF-κB and inflammatory chemokines (monocyte chemoattractant protein-1, fractalkine, and intercellular adhesion molecule-1) were detected by reverse transcription-polymerase chain reaction, Western blot, enzyme-linked immunosorbent assay (ELISA), immunohistochemistry (IHC), and electrophoretic mobility shift assay. The levels of oxidative biomarkers, including acrolein, nitrotyrosine, and 8-hydroxy-2'-deoxyguanosin (8-OHdG), were determined by IHC and ELISA. The reactive oxygen species (ROS) levels in serum and AqH were measured by chemiluminescence methods. Results: After 3 months of treatment, the expressions of mRNA and protein of monocyte chemoattractant protein-1, fractalkine, and intercellular adhesion molecule-1 in the retina of diabetic rats were significantly inhibited by fenofibrate in a dose-dependent manner. These effects were mediated by inhibition of NF-κB by fenofibrate. The levels of oxidative markers, including acrolein, nitrotyrosine, and 8-OHdG, decreased in the retina of diabetic rats after fenofibrate treatment. The ROS levels in the AqH of diabetic rats also suppressed by fenofibrate. Conclusions: Fenofibrate significantly inhibited the expressions of NF-κB and inflammatory chemokines and reduced oxidative products within diabetic retina. Treatment of fenofibrate might be beneficial to preventing DR progression.
Collapse
Affiliation(s)
- Po-Ting Yeh
- Department of Ophthalmology, National Taiwan University Hospital , Taipei , Taiwan
| | - Lu-Chun Wang
- Department of Ophthalmology, National Taiwan University Hospital, Yun-Lin Branch , Douliou City, Yunlin County , Taiwan
| | - Shu-Wen Chang
- Department of Ophthalmology, Far Eastern Memorial Hospital , NewTaipei City , Taiwan
| | - Wei-Shiung Yang
- Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University , Taipei , Taiwan.,Department of Internal Medicine, National Taiwan University Hospital , Taipei , Taiwan
| | - Chung-May Yang
- Department of Ophthalmology, National Taiwan University Hospital , Taipei , Taiwan.,Department of Ophthalmology, College of Medicine, National Taiwan University , Taipei , Taiwan
| | - Chang-Hao Yang
- Department of Ophthalmology, National Taiwan University Hospital , Taipei , Taiwan.,Department of Ophthalmology, College of Medicine, National Taiwan University , Taipei , Taiwan
| |
Collapse
|
44
|
Kouchaki E, Nikoueinejad H, Akbari H, Azimi S, Behnam M. The investigation of relevancy between PIAS1 and PIAS2 gene expression and disease severity of multiple sclerosis. J Immunoassay Immunochem 2019; 40:396-406. [PMID: 31084243 DOI: 10.1080/15321819.2019.1613244] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Introduction: PIAS1 and PIAS2 (protein inhibitor of activated STAT 1,2) play key roles in the pathogenesis of autoimmune and inflammatory diseases. This study aims to evaluate the gene expression of these factors in multiple sclerosis (MS) patients compared to healthy individuals and correlate them with the severity of MS. Materials and methods: Sixty participants, including 30 patients with MS and 30 healthy controls were studied. The expression of PIAS1 and PIAS2 genes in peripheral blood samples of all participants was measured by real-time PCR. The severity of MS was evaluated using the Expanded Disability Status Scale (EDSS). Finally, we evaluated the correlation between the expression of PIAS1 and PIAS2 genes with disease severity. Results: The expression of PIAS1 gene was increased in patients with MS compared to healthy subjects (P value<.001). Also, there was a significant correlation between the expression of PIAS1 and PIAS2 genes with disease severity according to EDSS. Conclusion: Our study suggests the expression of PIAS1 and PIAS2 genes as a prognostic and diagnostic marker in MS disease.
Collapse
Affiliation(s)
- Ebrahim Kouchaki
- a Physiology Research Center , Kashan University of Medical Sciences , Kashan , Iran.,b Department of Neurology , Kashan University of Medical Sciences , Kashan , Iran
| | - Hassan Nikoueinejad
- c Nephrology and Urology Research Center , Baqiyatallah University of Medical Sciences , Tehran , Iran
| | - Hossein Akbari
- d Trauma Research Center , Kashan University of Medical Sciences , Kashan , Iran
| | - Shirin Azimi
- e Student Research Committee , Kashan University of Medical Sciences , Kashan , Iran
| | - Mohammad Behnam
- f Research Center for Biochemistry and Nutrition in Metabolic Diseases , Kashan University of Medical Sciences , Kashan , Iran
| |
Collapse
|
45
|
Inflammatory and Humoral Immune Response during Ebola Virus Infection in Survivor and Fatal Cases Occurred in Sierra Leone during the 2014⁻2016 Outbreak in West Africa. Viruses 2019; 11:v11040373. [PMID: 31018522 PMCID: PMC6520887 DOI: 10.3390/v11040373] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Revised: 04/19/2019] [Accepted: 04/21/2019] [Indexed: 02/04/2023] Open
Abstract
Ebola virus (EBOV) infection is characterized by an excessive inflammatory response, a loss of lymphocytes and a general paralysis of the immune system, however pathophysiological mechanisms are not fully understood. In a cohort of 23 fatal and 21 survivors of ebola virus disease (EVD) cases admitted to the Emergency Ebola-Treatment-Center in Goderich (Freetown, Sierra Leone) during the 2014 to 2016 EBOV epidemic in Western Africa, we analyzed the pathway-focused gene expression profile of secreted proteins involved in the immune response and the levels of specific anti-EBOV IgM and IgG from the time of admission till discharge or death. We observed a dysregulated inflammatory response in fatal patients as compared to survivors, mainly consisting of the upregulation of inflammatory mediators, whose extent directly correlated with viremia levels. The upregulation persisted and intensified during the late phase of infection. Relevant differences were also found in humoral immunity, as an earlier and more robust EBOV antibody response was observed in survivor patients.
Collapse
|
46
|
Reyes-Sandoval A. 51 years in of Chikungunya clinical vaccine development: A historical perspective. Hum Vaccin Immunother 2019; 15:2351-2358. [PMID: 30735447 DOI: 10.1080/21645515.2019.1574149] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Abstract
Chikungunya fever (CHIKF) is a mosquito-borne disease caused by Chikungunya virus (CHIKV). This virus is considered a priority pathogen to the UK government, the US National Institute of Allergy and Infectious Diseases (NIAID) and the US military personnel, due to the potential of CHIKV to cause major outbreaks. Nearly all CHIKV infections are symptomatic, often incapacitating and patients experience severe joint pain and inflammation that can last for more than one year with 0.4-0.5% fatality rates. Mother-to-child transmission has also been described. Despite this re-emerging disease has been documented in more than 100 countries in Europe, Oceania, Africa, Asia, the Caribbean, South and North America, no licensed vaccine is yet available to prevent CHIKF. Nevertheless, various developments have entered phase I and II trials and are now viable options to fight this incapacitating disease. This review focuses on the development of CHIKV vaccines that have reached the stage of clinical trials since the late 1960s up until 2018.
Collapse
Affiliation(s)
- Arturo Reyes-Sandoval
- The Jenner Institute, Nuffield Department of Medicine, University of Oxford. The Henry Wellcome Building for Molecular Physiology , Oxford , UK
| |
Collapse
|
47
|
Schaeffer J, Reynard S, Carnec X, Pietrosemoli N, Dillies MA, Baize S. Non-Pathogenic Mopeia Virus Induces More Robust Activation of Plasmacytoid Dendritic Cells than Lassa Virus. Viruses 2019; 11:v11030287. [PMID: 30901952 PMCID: PMC6466290 DOI: 10.3390/v11030287] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Revised: 03/04/2019] [Accepted: 03/18/2019] [Indexed: 12/28/2022] Open
Abstract
Lassa virus (LASV) causes a viral haemorrhagic fever in humans and is a major public health concern in West Africa. An efficient immune response to LASV appears to rely on type I interferon (IFN-I) production and T-cell activation. We evaluated the response of plasmacytoid dendritic cells (pDC) to LASV, as they are an important and early source of IFN-I. We compared the response of primary human pDCs to LASV and Mopeia virus (MOPV), which is very closely related to LASV, but non-pathogenic. We showed that pDCs are not productively infected by either MOPV or LASV, but produce IFN-I. However, the activation of pDCs was more robust in response to MOPV than LASV. In vivo, pDC activation may support the control of viral replication through IFN-I production, but also improve the induction of a global immune response. Therefore, pDC activation could play a role in the control of LASV infection.
Collapse
Affiliation(s)
- Justine Schaeffer
- Unité de Biologie des Infections Virales Emergentes, Institut Pasteur, 69007 Lyon, France.
- Centre International de Recherche en Infectiologie (INSERM, CNRS, ENS Lyon, Université Lyon I), 69007 Lyon, France.
| | - Stéphanie Reynard
- Unité de Biologie des Infections Virales Emergentes, Institut Pasteur, 69007 Lyon, France.
- Centre International de Recherche en Infectiologie (INSERM, CNRS, ENS Lyon, Université Lyon I), 69007 Lyon, France.
| | - Xavier Carnec
- Unité de Biologie des Infections Virales Emergentes, Institut Pasteur, 69007 Lyon, France.
- Centre International de Recherche en Infectiologie (INSERM, CNRS, ENS Lyon, Université Lyon I), 69007 Lyon, France.
| | - Natalia Pietrosemoli
- Hub de Bioinformatique et Biostatistique⁻C3BI, Institut Pasteur, USR 3756 CNRS, 75015 Paris, France.
| | - Marie-Agnès Dillies
- Hub de Bioinformatique et Biostatistique⁻C3BI, Institut Pasteur, USR 3756 CNRS, 75015 Paris, France.
| | - Sylvain Baize
- Unité de Biologie des Infections Virales Emergentes, Institut Pasteur, 69007 Lyon, France.
- Centre International de Recherche en Infectiologie (INSERM, CNRS, ENS Lyon, Université Lyon I), 69007 Lyon, France.
| |
Collapse
|
48
|
Kakooza-Mwesige A, Tshala-Katumbay D, Juliano SL. Viral infections of the central nervous system in Africa. Brain Res Bull 2019; 145:2-17. [PMID: 30658129 DOI: 10.1016/j.brainresbull.2018.12.019] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Revised: 12/17/2018] [Accepted: 12/19/2018] [Indexed: 12/26/2022]
Abstract
Viral infections are a major cause of human central nervous system infection, and may be associated with significant mortality, and long-term sequelae. In Africa, the lack of effective therapies, limited diagnostic and human resource facilities are especially in dire need. Most viruses that affect the central nervous system are opportunistic or accidental pathogens. Some of these viruses were initially considered harmless, however they have now evolved to penetrate the nervous system efficiently and exploit neuronal cell biology thus resulting in severe illness. A number of potentially lethal neurotropic viruses have been discovered in Africa and over the course of time shown their ability to spread wider afield involving other continents leaving a devastating impact in their trail. In this review we discuss key viruses involved in central nervous system disease and of major public health concern with respect to Africa. These arise from the families of Flaviviridae, Filoviridae, Retroviridae, Bunyaviridae, Rhabdoviridae and Herpesviridae. In terms of the number of cases affected by these viruses, HIV (Retroviridae) tops the list for morbidity, mortality and long term disability, while the Rift Valley Fever virus (Bunyaviridae) is at the bottom of the list. The most deadly are the Ebola and Marburg viruses (Filoviridae). This review describes their epidemiology and key neurological manifestations as regards the central nervous system such as meningoencephalitis and Guillain-Barré syndrome. The potential pathogenic mechanisms adopted by these viruses are debated and research perspectives suggested.
Collapse
Affiliation(s)
- Angelina Kakooza-Mwesige
- Department of Paediatrics & Child Health, Makerere University College of Health Sciences and Mulago Hospital, Kampala, Uganda; Astrid Lindgren Children's Hospital, Neuropediatric Research Unit, Karolinska Institutet, Sweden.
| | - Desire Tshala-Katumbay
- Department of Neurology and School of Public Health, Oregon Health & Science University, Portland, OR, USA; Department of Neurology, University of Kinshasa, and Institut National de Recherches Biomedicales, University of Kinshasa, Democratic Republic of the Congo.
| | | |
Collapse
|
49
|
Reynard S, Journeaux A, Gloaguen E, Schaeffer J, Varet H, Pietrosemoli N, Mateo M, Baillet N, Laouenan C, Raoul H, Mullaert J, Baize S. Immune parameters and outcomes during Ebola virus disease. JCI Insight 2019; 4:125106. [PMID: 30626757 DOI: 10.1172/jci.insight.125106] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Accepted: 11/29/2018] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND The West African Ebola virus epidemic from 2014-2016 highlighted the lack of knowledge about the pathogenicity of the virus and the factors responsible for outcome. A performant and rapid diagnosis is of crucial importance, as is overcoming the difficulty of providing high-quality patient management during such an extensive outbreak. Here, we propose to study the role of the immune mediators during Ebola virus disease and to define some molecules of importance in the outcome. METHODS Plasma from Guinean patients sampled during the outbreak were analyzed using RT-qPCR, magnetic bead assay, ELISA, and high-quality statistical analyses. We also performed a transcriptomic analysis in leukocytes samples. Therefore, we deeply characterized the immune responses involved in Ebola virus disease. RESULTS We evaluated the immune patterns depending on the outcome of the disease. Survivors presented an efficient and well-balanced immune response, whereas fatalities were characterized by an intense inflammatory response, overexpression of multiple cytokines, and a "chemokine storm." The plasma concentration of most of the parameters tested increased until death. Statistical analyses also allowed us to define a panel of markers highly predictive of outcome. CONCLUSION The immune response observed in fatalities was highly similar to that characterizing septic shock syndrome. Our results suggest that immune responses can play a major pathogenic role during severe Ebola virus infection and argue in favor of therapeutic approaches that act on both viral replication and the induction of shock syndrome. FUNDING French Ministry of Foreign Affairs, the Agence Française de Développement, and the Institut Pasteur.
Collapse
Affiliation(s)
- Stéphanie Reynard
- Unité de Biologie des Infections Virales Emergentes, Institut Pasteur, Centre International de Recherche en Infectiologie, Université Lyon I, INSERM, CNRS, ENS Lyon, Lyon, France
| | - Alexandra Journeaux
- Unité de Biologie des Infections Virales Emergentes, Institut Pasteur, Centre International de Recherche en Infectiologie, Université Lyon I, INSERM, CNRS, ENS Lyon, Lyon, France
| | - Emilie Gloaguen
- Infection Antimicrobials Modelling Evolution, UMR 1137, INSERM, Université Paris Diderot, Sorbonne Paris Cité, Paris, France
| | - Justine Schaeffer
- Unité de Biologie des Infections Virales Emergentes, Institut Pasteur, Centre International de Recherche en Infectiologie, Université Lyon I, INSERM, CNRS, ENS Lyon, Lyon, France
| | - Hugo Varet
- Institut Pasteur, Hub Bioinformatique et Biostatistique, Centre de Bioinformatique, Biostatistique et Biologie Intégrative, C3BI, USR 3756 IP CNRS, Paris, France
| | - Natalia Pietrosemoli
- Institut Pasteur, Hub Bioinformatique et Biostatistique, Centre de Bioinformatique, Biostatistique et Biologie Intégrative, C3BI, USR 3756 IP CNRS, Paris, France
| | - Mathieu Mateo
- Unité de Biologie des Infections Virales Emergentes, Institut Pasteur, Centre International de Recherche en Infectiologie, Université Lyon I, INSERM, CNRS, ENS Lyon, Lyon, France
| | - Nicolas Baillet
- Unité de Biologie des Infections Virales Emergentes, Institut Pasteur, Centre International de Recherche en Infectiologie, Université Lyon I, INSERM, CNRS, ENS Lyon, Lyon, France
| | - Cédric Laouenan
- Infection Antimicrobials Modelling Evolution, UMR 1137, INSERM, Université Paris Diderot, Sorbonne Paris Cité, Paris, France.,Assistance Publique - Hôpitaux de Paris, Hôpital Bichat Claude Bernard, Paris, France
| | - Hervé Raoul
- Laboratoire P4 Jean Mérieux-INSERM, INSERM, Lyon, France
| | - Jimmy Mullaert
- Infection Antimicrobials Modelling Evolution, UMR 1137, INSERM, Université Paris Diderot, Sorbonne Paris Cité, Paris, France
| | - Sylvain Baize
- Unité de Biologie des Infections Virales Emergentes, Institut Pasteur, Centre International de Recherche en Infectiologie, Université Lyon I, INSERM, CNRS, ENS Lyon, Lyon, France
| |
Collapse
|
50
|
Hoeres T, Holzmann E, Smetak M, Birkmann J, Wilhelm M. PD-1 signaling modulates interferon-γ production by Gamma Delta (γδ) T-Cells in response to leukemia. Oncoimmunology 2018; 8:1550618. [PMID: 30723581 DOI: 10.1080/2162402x.2018.1550618] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Revised: 11/06/2018] [Accepted: 11/14/2018] [Indexed: 12/30/2022] Open
Abstract
Gamma delta (γδ) T-cell based immunotherapy is a promising concept for the treatment of hematologic malignancies. Not only in vitro but also in early phase clinical trials, zoledronic acid (Zol) and interleukin-2 (IL-2) have been successfully used to activate human γδ T-cells and to induce clinical anti-tumor effects. Aiming to improve the effectiveness of future γδ T-cell based immunotherapies against leukemia, we analyzed the impact of programmed cell death protein 1 (PD-1) signaling, on the different phases of γδ T-cell activation, of proliferation, production of anti-tumor cytokines and cytotoxic function in vitro. PD-1 expression was found significantly upregulated between day 2 and day 4 following stimulation with Zol and IL-2. However, proliferation or expression of activation markers of γδ, αβ and NK-cells are not altered by additional PD-1 blockade. Pembrolizumab increases interferon-γ (IFN-γ) production in γδ T-cells upon direct stimulation with Zol and in response to Zol treated primary acute myeloid leukemia (AML) cells by approximately 57% and 30%, respectively. Zol sensitized primary AML cells also induce PD-1 expression in co-cultured γδ T-cells and such PD-1(+) cells contain more IFN-γ. In contrast, PD-1 blockade does not have a significant effect on direct cell dependent lysis of leukemia cells by γδ T-cells. This study demonstrates that PD-1 blockade impacts cell dependent cytotoxicity and cytokine production in response to leukemia cells differently. While Pembrolizumab did not increase cell lysis of stimulated and expanded γδ T-cells, it induces significant upregulation of the potent pro-inflammatory and anti-tumor cytokine IFN-γ, which might facilitate anti-leukemia effects.
Collapse
Affiliation(s)
- Timm Hoeres
- Department of Hematology and Medical Oncology, Paracelsus Medical University, Nuremberg, Germany
| | - Elisabeth Holzmann
- Department of Hematology and Medical Oncology, Paracelsus Medical University, Nuremberg, Germany
| | - Manfred Smetak
- Department of Hematology and Medical Oncology, Paracelsus Medical University, Nuremberg, Germany
| | - Josef Birkmann
- Department of Hematology and Medical Oncology, Paracelsus Medical University, Nuremberg, Germany
| | - Martin Wilhelm
- Department of Hematology and Medical Oncology, Paracelsus Medical University, Nuremberg, Germany
| |
Collapse
|