Host adaptive immunity deficiency in severe pandemic influenza

Abstract

Introduction: 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.

Methods: 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.

Results: 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.

Conclusions: 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.

Figure 1

Viral load in MV and NMV patients in pharynx. (a) Early phase (before day 9 in the course of the disease). (b) Late phase (from day 9 in the course of the disease).

Figure 2

Histogram depicting the mean and median of the differences in gene expression levels between MV-NMV by intracellular signaling pathways. (< 0) means that expression in MV < expression in NMV; (> 0) means that expression in MV > expression in NMV).

Figure 3

Antigen presentation gene expression analysis. (a) IPA canonical pathway modeling of the antigen presentation pathway in the late period (from day 9 in the course of the disease) using the microarray analysis of gene expression data from the peripheral blood mononuclear cells of the patients (red, upregulated; green, downregulated). (b and c) One-way hierarchical clustering of those genes selected by IPA (red, upregulated; blue, downregulated) in the early and late phases of the disease.

Figure 4

Immune mediator levels in the late phase (from day 9 in the course of the disease). Boxplots show the ratios MV/[control median] and NMV/[control median]. All the comparisons showed significant differences at the level P < 0.05.

Figure 5

Host adaptive immunity deficiency (HAID) model in severe pandemic influenza. The picture shows the unvirtuous circle of the response to the virus.