The online version of this article (doi:10.1186/cc9259) contains supplementary material, which is available to authorized users.
The authors declare that they have no competing interests.
JFBM, IML, JR, ROL assisted in the design of the study, coordinated patient recruitment, analyzed and interpreted the data, and assisted in writing the paper. DK assisted in the design of the study, analyzed and interpreted the data, and assisted in writing the paper. AA, TP, MAM, MCG, VF, DV, BN, Sro, CC performed the virology works, RA, GLC, FMS and LR were in charge of the bioinformatic analysis. PR, LS, AL, DA, EM, MJGS, MG, SA, CL, PM, JB, FG, FB supervised clinical aspects, participated in patient recruitment and assisted in the analysis, interpretation of data, and writing the report. DB and DCN developed HAI assays and assisted in the analysis of data. LR, LX, and VI carried out microarray data, cytokine profiling and sample processing. SRE assisted in the statistical analysis.
Pandemic A/H1N1/2009 influenza causes severe lower respiratory complications in rare cases. The association between host immune responses and clinical outcome in severe cases is unknown.
We utilized gene expression, cytokine profiles and generation of antibody responses following hospitalization in 19 critically ill patients with primary pandemic A/H1N1/2009 influenza pneumonia for identifying host immune responses associated with clinical outcome. Ingenuity pathway analysis 8.5 (IPA) (Ingenuity Systems, Redwood City, CA) was used to select, annotate and visualize genes by function and pathway (gene ontology). IPA analysis identified those canonical pathways differentially expressed (P < 0.05) between comparison groups. Hierarchical clustering of those genes differentially expressed between groups by IPA analysis was performed using BRB-Array Tools v.3.8.1.
The majority of patients were characterized by the presence of comorbidities and the absence of immunosuppressive conditions. pH1N1 specific antibody production was observed around day 9 from disease onset and defined an early period of innate immune response and a late period of adaptive immune response to the virus. The most severe patients (n = 12) showed persistence of viral secretion. Seven of the most severe patients died. During the late phase, the most severe patient group had impaired expression of a number of genes participating in adaptive immune responses when compared to less severe patients. These genes were involved in antigen presentation, B-cell development, T-helper cell differentiation, CD28, granzyme B signaling, apoptosis and protein ubiquitination. Patients with the poorest outcomes were characterized by proinflammatory hypercytokinemia, along with elevated levels of immunosuppressory cytokines (interleukin (IL)-10 and IL-1ra) in serum.
Our findings suggest an impaired development of adaptive immunity in the most severe cases of pandemic influenza, leading to an unremitting cycle of viral replication and innate cytokine-chemokine release. Interruption of this deleterious cycle may improve disease outcome.
Additional file 1: Methods additional material. Additional information on viral load quantification, microarrays and number of samples analyzed is provided here. (DOC 26 KB)
Additional file 2: Figure S1: qPCR validation of microarray results. A significant positive correlation was observed between the levels of expression obtained by qPCR and microarray analysis. Results are shown as adimensional units. (PDF 33 KB)
Additional file 4: Figure S2: IPA modeling of the B cell development signaling pathway. Expression in MV < NMV, represented in green. (PDF 97 KB)
Additional file 5: Figure S3: IPA modeling of the CD28 signaling pathway in T helper cells. Expression in MV < NMV, represented in green. (PDF 107 KB)
Additional file 6: Figure S4: IPA modeling of the Granzyme B signaling pathway. Expression in MV < NMV, represented in green. (PDF 82 KB)
Additional file 7: Figure S5: IPA modeling of the IL-6 signaling pathway. Expression in MV > NMV, represented in red. (PDF 107 KB)
Additional file 8: Figure S6: IPA modeling of the IL-10 signaling pathway. Expression in MV > NMV, represented in red. (PDF 96 KB)
Additional file 9: Table S2: Gene expression levels by intracellular signaling pathway (antigen presentation pathway, B cell development, granzyme B signaling). Difference between MV-NMV gene expression means is shown for each gene in the late period (from day 9 in the course of the disease). (DOC 62 KB)
Additional file 10: Table S3: Gene expression levels by intracellular signaling pathway (CD28 signaling in T helper cells). Difference between MV-NMV gene expression means is shown for each gene in the late period (from day 9 in the course of the disease). (DOC 62 KB)
Additional file 11: Table S4: Gene expression levels by intracellular signaling pathway (dendritic cell maturation). Difference between MV-NMV gene expression means is shown for each gene in the late period (from day 9 in the course of the disease). (DOC 72 KB)
Additional file 12: Table S5: Gene expression levels by intracellular signaling pathway (T helper cell differentiation). Difference between MV-NMV gene expression means is shown for each gene in the late period (from day 9 in the course of the disease). (DOC 73 KB)
Additional file 13: Table S6: Gene expression levels by intracellular signaling pathway (protein ubiquitination pathway). Difference between MV-NMV gene expression means is shown for each gene in the late period (from day 9 in the course of the disease). (DOC 92 KB)
Additional file 14: Table S7: Gene expression levels by intracellular signaling pathway (apoptosis signaling). Difference between MV-NMV gene expression means is shown for each gene in the late period (from day 9 in the course of the disease). (DOC 56 KB)
Additional file 15: Table S8: Gene expression levels by intracellular signaling pathway (B cell receptor signaling). Difference between MV-NMV gene expression means is shown for each gene in the late period (from day 9 in the course of the disease). (DOC 66 KB)
Additional file 16: Table S9: Gene expression levels by intracellular signaling pathway (IL-6, IL-10 signaling). Difference between MV-NMV gene expression means is shown for each gene in the late period (from day 9 in the course of the disease). (DOC 67 KB)
Additional file 17: Table S10: Comparison of immune mediator levels, early period (before day 9 in the course of the disease). Data are represented as median (interquartile range) of the ratios MV/(control median) and NMV/(control median). *Significant differences at the level P < 0.05. (n.s.), nonsignificant differences. IFN-α, IFN-λ (IL-28) and IL-23 were undetectable in the vast majority of the patients in both groups along the course of the disease. (DOC 54 KB)
Additional file 18: Table S11: Comparison of immune mediator levels, late period (from day 9 in the course of the disease). Data are represented as median (interquartile range) of the ratios MV/(control median) and NMV/(control median). *P < 0.05. n.s., nonsignificant differences. IFN-α, IFN-λ(IL-28) and IL-23 were undetectable in the vast majority of the patients in both groups along the course of the disease. (DOC 54 KB)
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- Host adaptive immunity deficiency in severe pandemic influenza
Jesus F Bermejo-Martin
Derek Cheuk Ng
Maria J Gómez-Sánchez
Maria C Gallegos
Maria Ángeles Marcos
Raul Ortiz de Lejarazu
- BioMed Central
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