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Three fatal cases of pandemic 2009 influenza A virus infection in Shenzhen are associated with cytokine storm
Respiratory Physiology & Neurobiology 175 (2011) 185–187
Contents lists available at ScienceDirect
Respiratory Physiology & Neurobiology journal homepage: www.elsevier.com/locate/resphysiol
Short communication
Three fatal cases of pandemic 2009 influenza A virus infection in Shenzhen are associated with cytokine storm Xiao-Wen Cheng a,1 , Juan Lu b,c,1 , Chun-Li Wu a , Li-Na Yi c,d , Xu Xie a , Xiang-Dong Shi d , Shi-Song Fang a , Hong Zan f , Hsiang-fu Kung c,e , Ming-Liang He c,e,∗ a
The Shenzhen Center for Disease Control and Prevention, Shenzhen, China Department of Otolaryngology-Head and Neck Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, China Stanley Ho Center for Emerging Infectious Diseases, School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong, China d The Futian Center for Disease Control and Prevention, Shenzhen, China e Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong, China f Institute for Immunology, University of California at Irvine, CA, USA b c
a r t i c l e
i n f o
Article history: Accepted 4 November 2010 Keywords: Influenza A H1N1 Cytokine storm
a b s t r a c t China had taken strict measures for pandemic 2009 H1N1 infection with enhanced surveillance and hospital isolation since April 2009. In Shenzhen, over 1200 confirmed cases of H1N1 infection were identified. Three young patients died of severe pneumonia. Among them, two boys developed neurological complications. Cytokine storm seemed an important cause. © 2010 Elsevier B.V. All rights reserved.
1. Introduction In April 2009, a novel swine originated influenza virus (S-OIV) caused lots of illness and death in Mexico and rapidly spread worldwide (Chowell et al., 2009; Perez-Padilla et al., 2009). WHO declared a global pandemic of this novel influenza A (H1N1) in June 2009, and adults and children with underlying chronic disease were at high risk of developing severe or complicated disease from H1N1 (Jain and Goldman, 2009). Although most cases were mild with complete and uneventful recovery, pulmonary complications including bronchitis and pneumonia, neurological complications including encephalitis and encephalopathy, and multiorgan failure had also been reported even in previously healthy adolescents (Centers for Disease Control and Prevention, 2009; Lyon et al., 2010). China had taken very strict containment measures to control the virus spread since April 2009. As the first Economic Special Zone, Shenzhen was located in Southern China bordering HongKong, and over 200,000 passengers passed the Shenzhen-HongKong ports every day. The global travel could easily bring H1N1 to Shenzhen and spread the virus to other areas of China. Therefore, we had
paid attention to the passengers and local people who had even mild fever (>37.2 ◦ C) and other symptoms of influenza-like illness. Till December 2009, more than 1200 individuals had been tested positive for the novel H1N1 in Shenzhen, and three fatal cases had been documented. Here we reviewed the unique clinical features of all three fatal cases. Their immune responses were studied and compared with mild, uncomplicated H1N1 infections and healthy controls. 2. Patients and methods 2.1. Patients Three fatal cases and 10 mild cases with 2009 pandemic H1N1 infection were included in this study. Twenty healthy controls were recruited from volunteers in Luohu Hospital. Blood samples were collected to test inflammatory cytokines and chemokines. Moreover, nasopharyngeal specimens were collected to test for H1N1 viral RNA. Informed consent was obtained from all subjects, and the research protocols were approved by the Ethics Committee of Shenzhen Center for Disease Control and Prevention. 2.2. Measurement of plasma cytokines and chemokines
∗ Corresponding author at: Li ka Shing Medical Science Building, Rm708, Prince of Wales Hospital, Stanley Ho Center for Emerging Infectious Diseases, The Chinese University of Hong Kong, Hong Kong, China. Tel.: +852 37636096; fax: +852 21458013. E-mail address: [email protected] (M.-L. He). 1 Authors contributed equally to this work. 1569-9048/$ – see front matter © 2010 Elsevier B.V. All rights reserved. doi:10.1016/j.resp.2010.11.004
Blood samples were collected. Plasma was separated by centrifugation. Inflammatory cytokines IL-1, IL-6, IL-10, IL-12, IFN␥ and TNF␣ and chemokine IL-8, MCP-1, IP-10 and RANTES were measured by ELISA.
186
X.-W. Cheng et al. / Respiratory Physiology & Neurobiology 175 (2011) 185–187
Table 1 Clinical features of three fatal cases of pandemic H1N1 infection in Shenzhen. Patient
Sex
Age (years)
1 2 3
M M F
9 11 20
Hospital days
12 20 2
Clinical features Fever
Cough
Sore throat
Fatigue
Chest pain
Vomiting
Convulsion
Y Y Y
N N Y
Y Y Y
N N Y
N N Y
Y Y N
Y Y N
3. Results
pneumonia, multiorgan failure and diffuse intravascular coagulation (DIC). Patient 2. A 11-year-old boy was presented to the hospital with a 3-day history of fever, cough and vomiting. Three days before admission, he had a fever of 39.5 ◦ C, cough, headache, abdominal pain, and vomiting. Neurologic examination revealed ataxia. Soon after admission, the patient had a seizure consisting of episodic eye rolling and tongue thrusting. During hospitalization, the patient had visual hallucinations, had difficulty responding to questions and following commands, and required supplemental oxygen via facemask for mild hypoxia and hypopnea attributed to encephalopathy. The results of an electroencephalogram (EEG) were consistent with encephalopathy. The patient’s mental status became worse after 2 days admission to hospital, and then presented to PICU. Then the patient died of ARDS and neurological complications. Autopsy findings of histopathological examination confirmed the existence of encephalopathy and H1N1 antigen in brain. Patient 3. A 20-year-old girl was presented to the emergency department with 2-day history of fever, cough, rhinorrhea and dyspnea. During hospitalization, she was treated with antiviral and antimicrobial drugs. Then she developed secondary bacterial pneumonia with severe staphylococcal aureus infection, and was admitted to ICU. Mechanical ventilation could not improve the respiratory dysfunction, and she died of ARDS and refractory hypoxia by rapid clinical course.
3.1. Clinical features of three fatal cases with 2009 pandemic H1N1 infection Three patients were previously healthy before symptom onset. High risk factors, such as pregnant, an extreme of age, or underlying chronic disease, that would cause severe illness in H1N1 infected individuals, were not found for all of them. Their clinical features were carefully recorded when they were administrated to the hospital (Table 1). Common symptoms for novel H1N1, such as fever and sore throat were presented for all of the three patients, other symptoms including fatigue and chest pain were observed in the young girl. Two boys were admitted with signs of influenza-like illness and seizures or other altered mental status. A complete neurological examination was difficult to perform because of their poor cooperation. Computed-tomography (CT) of the head and contrast-enhanced magnetic resonance imaging (MRI) of the brain had normal findings. An analysis of cerebrospinal fluid (CSF) specimens showed that CSF total protein levels raised to over 4000 mg/L. Another girl was admitted with fever and influenza-like illness. Then she was admitted to intensive care unit (ICU) with severe staphylococcal pneumonia and acute respiratory distress syndrome (ARDS). Chest radiograph showed infiltrates. In all three patients, H1N1 viral RNA was confirmed positive in nasopharyngeal specimens, but tests performed on two CSF specimens had negative results. The blood samples were collected upon hospitalization and 10 different cytokines and chemokines in the plasma were evaluated. Patient 1. A 9-year-old boy was presented to the emergency department because of persistent high fever, increased weakness, profuse vomiting and diarrhea, and deteriorative mental status. Two days before admission, he developed a febrile illness with fever reaching 38.5 ◦ C, cough, headache, dizziness and abdominal complaints. On physical examination, the patient was noted to be confused and unable to provide history of his own illness. He received antiviral treatment during hospitalization, but his mental status rapidly deteriorated. Then he was admitted to pediatric ICU (PICU) and received mechanical ventilation. Lastly he died of severe
3.2. Plasma cytokine and chemokine concentrations As cytokine dysregulation (cytokine storm) was related to the syndrome of acute respiratory distress, multiple-organ dysfunction, lymphopenia, and hemophagocytosis (Beigel et al., 2005), we measured the levels of 10 cytokines and chemokines as described by Lee et al. (2007). Compared with reference levels of patients with mild H1N1 infection and healthy controls, the level of IL-6 increased at least 2.7- to 12.9-fold and 6.5- to 31-fold in all three patients respectively (Table 2). The levels of TNF␣, IL-8 and MCP-1 significantly increased in two younger boys but not in the older girl. On the contrary, IP-10, IL-12 and RANTES significantly decreased.
Table 2 Plasma concentrations of 10 cytokines and chemokines in three fatal cases of Shenzhen. Cytokine or chemokine
IFN␥ IL-1 IL-6 IL-8 IL-10 IL-12 IP-10 TNF␣ MCP-1 RANTES
Concentration (pg/mL, IQR) Patient 1
Patient 2
Patient 3
Mild H1N1 infection
Healthy control
ND ND 509.7 934.2 11.1 ND ND 43.8 91.8 ND
ND ND 452.9 109.6 ND ND 12.8 82.3 177.1 ND
ND ND 107.1 33.0 ND 1.6 4.2 0.8 10.3 58.0
ND ND <16.40 <32.965 ND <0.22 <28.23 <15.9 <23.36 251.49 (197.91–305.07)
ND ND 39.54 (21.09–57.04) 35.04 (4.82–69.66) ND 14.1 (0.91–35.14) 104.8 (50.35–170.62) 27 (5.06–74.83) 20.15 (5.62–54.37) 750.04 (386.78–1010.77)
IQR, interquartile range; IP-10, IFN-induced protein 10; MCP-1, monocyte chemoattractant protein 1; RATES, regulated upon activation, normal T cell-expressed and secreted; ND, not detectable.
X.-W. Cheng et al. / Respiratory Physiology & Neurobiology 175 (2011) 185–187
187
Other cytokines and chemokines (IL-1, IFN␥, and IL-10) appeared to be at very low levels, similar to the reference.
posed to be a low-risk group for the novel H1N1 infection. However, studies on larger sample size are needed.
4. Discussion
Acknowledgements
In Shenzhen, H1N1 infection caused three deaths with notable unique clinical features. Since the breakout in April 2009, the clinical presentations of H1N1 infection had been extensively studied and compared among patient groups worldwide. The infants (0–4 year of age) and adults (25–64 years of age) were reported to be at increased risk (Echevarría-Zuno et al., 2009; Presanis et al., 2009). For individuals, underlying conditions such as pregnant, with a BMI greater than 35 or having chronic disease, H1N1 infection seemed to be more easily to develop life-threatening illness. The clinical features of all three deaths in Shenzhen (China) were similar to those fatal cases in other parts of the world, such as fever, cough, and sore throat. Vomiting, another clinical presentation especially prevalent among pediatric age group, was also shown in both of the two little boys. A unique characteristic of these three deaths was that, despite their common clinical features, none of them is among a high-risk group for H1N1 infection. All of them were previously healthy before the onset of H1N1 infection, and no one was at extremes of age, or with underlying chronic disease. Cytokine storm seemed to be the main cause of death. The pathogenesis of H1N1 infection remained unclear, however, it had been shown that the dysregulation of cytokines and chemokines was associated with the severity of influenza A virus infection. Studies of influenza A virus subtype H5N1 disease also suggested that cytokine dysregulation might play an important role in these deadly infections (Beigel et al., 2005; Lee et al., 2007). In our study, the levels of IL-6 increased in the plasma of all three patients while increased TNF␣, IL-8 and MCP-1 levels were observed in the plasma of two boys. IP-10, IL-12 and RANTES significantly reduced to a very low or undetectable level. Our findings were consistent with those of earlier studies of human influenza, which showed that local and systemic cytokine responses, such as elevated serum concentrations of IL-6 and IL-8 in patients infected with the H5N1 strain (de Jong et al., 2006; Peiris et al., 2004; To et al., 2001). Notably, a large decrease in the level of RANTES was observed in all these three patients. Early reports demonstrated that influenza A virusinfected monocytes or macrophages could secrete RANTES, which preferentially favored the recruitment of blood mononuclear cell population to the site of the infection (Julkunen et al., 2001). In addition to its chemotactic activity, it was also involved in direct antiviral activity by inducing NO in macrophages (Villalta et al., 1998). We suggest that the decreased level of RANTES might play a critical role in the pathogenesis of these three patients with severe H1N1 infection.
We thank the Shenzhen Center for Disease Control and Prevention for providing technical support. This study is partly supported by the Research Fund for Control of Infectious Diseases (CU-09-0101), Food and Health Bureau, the Government of Hong Kong Special Administration Region (HKSAR); Research Grant Council (RGC) of Hong Kong Government (CUHK4428/06M, to M.L.H.).
5. Conclusions Our findings highlight the importance of cytokine storm in novel influenza associated death among young individuals, who are sup-
References Beigel, J.H., Farrar, J., Han, A.M., Hayden, F.G., Hyer, R., de Jong, M.D., Lochindarat, S., Nguyen, T.K., Nguyen, T.H., Tran, T.H., Nicoll, A., Touch, S., Yuen, K.Y., Writing Committee of the World Health Organization (WHO) Consultation on Human Influenza A/H5, 2005. Avian influenza A (H5N1) infection in humans. N. Engl. J. Med. 353, 1374–1385. Centers for Disease Control and Prevention (CDC), 2009. Neurologic complications associated with novel influenza A (H1N1) virus infection in children—Dallas, Texas, May 2009. MMWR Morb. Mortal. Wkly. Rep. 58, 773–778. Chowell, G., Bertozzi, S.M., Colchero, M.A., Lopez-Gatell, H., Alpuche-Aranda, C., Hernandez, M., Miller, M.A., 2009. Severe respiratory disease concurrent with the circulation of H1N1 influenza. N. Engl. J. Med. 361, 674–679. de Jong, M.D., Simmons, C.P., Thanh, T.T., Hien, V.M., Smith, G.J., Chau, T.N., Hoang, D.M., Chau, N.V., Khanh, T.H., Dong, V.C., Qui, P.T., Cam, B.V., Ha do, Q., Guan, Y., Peiris, J.S., Chinh, N.T., Hien, T.T., Farrar, J., 2006. Fatal outcome of human influenza A (H5N1) is associated with high viral load and hypercytokinemia. Nat. Med. 12, 1203–1207. ˜ Echevarría-Zuno, S., Mejía-Aranguré, J.M., Mar-Obeso, A.J., Grajales-Muniz, C., Robles-Pérez, E., González-León, M., Ortega-Alvarez, M.C., Gonzalez-Bonilla, C., Rascón-Pacheco, R.A., Borja-Aburto, V.H., 2009. Infection and death from influenza A H1N1 virus in Mexico: a retrospective analysis. Lancet 374, 2072–2079. Jain, R., Goldman, R.D., 2009. Novel influenza A (H1N1): clinical presentation, diagnosis, and management. Pediatr. Emerg. Care 25, 791–796. Julkunen, I., Sareneva, T., Pirhonen, J., Ronni, T., Melén, K., Matikainen, S., 2001. Molecular pathogenesis of influenza A virus infection and virus-induced regulation of cytokine gene expression. Cytokine Growth Factor Rev. 12, 171– 180. Lee, N., Wong, C.K., Chan, P.K., Lun, S.W., Lui, G., Wong, B., Hui, D.S., Lam, C.W., Cockram, C.S., Choi, K.W., Yeung, A.C., Tang, J.W., Sung, J.J., 2007. Hypercytokinemia and hyperactivation of phospho-p38 mitogen-activated protein kinase in severe human influenza A virus infection. Clin. Infect. Dis. 45, 723–731. Lyon, J.B., Remigio, C., Milligan, T., Deline, C., 2010. Acute necrotizing encephalopathy in a child with H1N1 influenza infection. Pediatr. Radiol. 40, 200–205. Peiris, J.S., Yu, W.C., Leung, C.W., Cheung, C.Y., Ng, W.F., Nicholls, J.M., Ng, T.K., Chan, K.H., Lai, S.T., Lim, W.L., Yuen, K.Y., Guan, Y., 2004. Re-emergence of fatal human influenza A subtype H5N1 disease. Lancet 363, 617–619. Perez-Padilla, R., de la Rosa-Zamboni, D., Ponce de Leon, S., Hernandez, M., INER Working Group on Influenza, 2009. Pneumonia and respiratory failure from swine-origin influenza A (H1N1) in Mexico. N. Engl. J. Med. 361, 680–689. Presanis, A.M., De Angelis, D., New York City Swine Flu Investigation Team, Hagy, A., Reed, C., Riley, S., Cooper, B.S., Finelli, L., Biedrzycki, P., Lipsitch, M., 2009. The severity of pandemic H1N1 influenza in the United States, from April to July 2009: a Bayesian analysis. PLoS Med. 6, e1000207. To, K.F., Chan, P.K., Chan, K.F., Lee, W.K., Lam, W.Y., Wong, K.F., Tang, N.L., Tsang, D.N., Sung, R.Y., Buckley, T.A., Tam, J.S., Cheng, A.F., 2001. Pathology of fatal human infection associated with avian influenza A H5N1 virus. J. Med. Virol. 63, 242–246. Villalta, F., Zhang, Y., Bibb, K.E., Kappes, J.C., Lima, M.F., 1998. The cysteine–cysteine family of chemokines RANTES. MIP-1alpha, and MIP-1beta induce trypanocidal activity in human macrophages via nitric oxide. Infect. Immun. 66, 4690– 4695.
Contents lists available at ScienceDirect
Respiratory Physiology & Neurobiology journal homepage: www.elsevier.com/locate/resphysiol
Short communication
Three fatal cases of pandemic 2009 influenza A virus infection in Shenzhen are associated with cytokine storm Xiao-Wen Cheng a,1 , Juan Lu b,c,1 , Chun-Li Wu a , Li-Na Yi c,d , Xu Xie a , Xiang-Dong Shi d , Shi-Song Fang a , Hong Zan f , Hsiang-fu Kung c,e , Ming-Liang He c,e,∗ a
The Shenzhen Center for Disease Control and Prevention, Shenzhen, China Department of Otolaryngology-Head and Neck Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, China Stanley Ho Center for Emerging Infectious Diseases, School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong, China d The Futian Center for Disease Control and Prevention, Shenzhen, China e Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong, China f Institute for Immunology, University of California at Irvine, CA, USA b c
a r t i c l e
i n f o
Article history: Accepted 4 November 2010 Keywords: Influenza A H1N1 Cytokine storm
a b s t r a c t China had taken strict measures for pandemic 2009 H1N1 infection with enhanced surveillance and hospital isolation since April 2009. In Shenzhen, over 1200 confirmed cases of H1N1 infection were identified. Three young patients died of severe pneumonia. Among them, two boys developed neurological complications. Cytokine storm seemed an important cause. © 2010 Elsevier B.V. All rights reserved.
1. Introduction In April 2009, a novel swine originated influenza virus (S-OIV) caused lots of illness and death in Mexico and rapidly spread worldwide (Chowell et al., 2009; Perez-Padilla et al., 2009). WHO declared a global pandemic of this novel influenza A (H1N1) in June 2009, and adults and children with underlying chronic disease were at high risk of developing severe or complicated disease from H1N1 (Jain and Goldman, 2009). Although most cases were mild with complete and uneventful recovery, pulmonary complications including bronchitis and pneumonia, neurological complications including encephalitis and encephalopathy, and multiorgan failure had also been reported even in previously healthy adolescents (Centers for Disease Control and Prevention, 2009; Lyon et al., 2010). China had taken very strict containment measures to control the virus spread since April 2009. As the first Economic Special Zone, Shenzhen was located in Southern China bordering HongKong, and over 200,000 passengers passed the Shenzhen-HongKong ports every day. The global travel could easily bring H1N1 to Shenzhen and spread the virus to other areas of China. Therefore, we had
paid attention to the passengers and local people who had even mild fever (>37.2 ◦ C) and other symptoms of influenza-like illness. Till December 2009, more than 1200 individuals had been tested positive for the novel H1N1 in Shenzhen, and three fatal cases had been documented. Here we reviewed the unique clinical features of all three fatal cases. Their immune responses were studied and compared with mild, uncomplicated H1N1 infections and healthy controls. 2. Patients and methods 2.1. Patients Three fatal cases and 10 mild cases with 2009 pandemic H1N1 infection were included in this study. Twenty healthy controls were recruited from volunteers in Luohu Hospital. Blood samples were collected to test inflammatory cytokines and chemokines. Moreover, nasopharyngeal specimens were collected to test for H1N1 viral RNA. Informed consent was obtained from all subjects, and the research protocols were approved by the Ethics Committee of Shenzhen Center for Disease Control and Prevention. 2.2. Measurement of plasma cytokines and chemokines
∗ Corresponding author at: Li ka Shing Medical Science Building, Rm708, Prince of Wales Hospital, Stanley Ho Center for Emerging Infectious Diseases, The Chinese University of Hong Kong, Hong Kong, China. Tel.: +852 37636096; fax: +852 21458013. E-mail address: [email protected] (M.-L. He). 1 Authors contributed equally to this work. 1569-9048/$ – see front matter © 2010 Elsevier B.V. All rights reserved. doi:10.1016/j.resp.2010.11.004
Blood samples were collected. Plasma was separated by centrifugation. Inflammatory cytokines IL-1, IL-6, IL-10, IL-12, IFN␥ and TNF␣ and chemokine IL-8, MCP-1, IP-10 and RANTES were measured by ELISA.
186
X.-W. Cheng et al. / Respiratory Physiology & Neurobiology 175 (2011) 185–187
Table 1 Clinical features of three fatal cases of pandemic H1N1 infection in Shenzhen. Patient
Sex
Age (years)
1 2 3
M M F
9 11 20
Hospital days
12 20 2
Clinical features Fever
Cough
Sore throat
Fatigue
Chest pain
Vomiting
Convulsion
Y Y Y
N N Y
Y Y Y
N N Y
N N Y
Y Y N
Y Y N
3. Results
pneumonia, multiorgan failure and diffuse intravascular coagulation (DIC). Patient 2. A 11-year-old boy was presented to the hospital with a 3-day history of fever, cough and vomiting. Three days before admission, he had a fever of 39.5 ◦ C, cough, headache, abdominal pain, and vomiting. Neurologic examination revealed ataxia. Soon after admission, the patient had a seizure consisting of episodic eye rolling and tongue thrusting. During hospitalization, the patient had visual hallucinations, had difficulty responding to questions and following commands, and required supplemental oxygen via facemask for mild hypoxia and hypopnea attributed to encephalopathy. The results of an electroencephalogram (EEG) were consistent with encephalopathy. The patient’s mental status became worse after 2 days admission to hospital, and then presented to PICU. Then the patient died of ARDS and neurological complications. Autopsy findings of histopathological examination confirmed the existence of encephalopathy and H1N1 antigen in brain. Patient 3. A 20-year-old girl was presented to the emergency department with 2-day history of fever, cough, rhinorrhea and dyspnea. During hospitalization, she was treated with antiviral and antimicrobial drugs. Then she developed secondary bacterial pneumonia with severe staphylococcal aureus infection, and was admitted to ICU. Mechanical ventilation could not improve the respiratory dysfunction, and she died of ARDS and refractory hypoxia by rapid clinical course.
3.1. Clinical features of three fatal cases with 2009 pandemic H1N1 infection Three patients were previously healthy before symptom onset. High risk factors, such as pregnant, an extreme of age, or underlying chronic disease, that would cause severe illness in H1N1 infected individuals, were not found for all of them. Their clinical features were carefully recorded when they were administrated to the hospital (Table 1). Common symptoms for novel H1N1, such as fever and sore throat were presented for all of the three patients, other symptoms including fatigue and chest pain were observed in the young girl. Two boys were admitted with signs of influenza-like illness and seizures or other altered mental status. A complete neurological examination was difficult to perform because of their poor cooperation. Computed-tomography (CT) of the head and contrast-enhanced magnetic resonance imaging (MRI) of the brain had normal findings. An analysis of cerebrospinal fluid (CSF) specimens showed that CSF total protein levels raised to over 4000 mg/L. Another girl was admitted with fever and influenza-like illness. Then she was admitted to intensive care unit (ICU) with severe staphylococcal pneumonia and acute respiratory distress syndrome (ARDS). Chest radiograph showed infiltrates. In all three patients, H1N1 viral RNA was confirmed positive in nasopharyngeal specimens, but tests performed on two CSF specimens had negative results. The blood samples were collected upon hospitalization and 10 different cytokines and chemokines in the plasma were evaluated. Patient 1. A 9-year-old boy was presented to the emergency department because of persistent high fever, increased weakness, profuse vomiting and diarrhea, and deteriorative mental status. Two days before admission, he developed a febrile illness with fever reaching 38.5 ◦ C, cough, headache, dizziness and abdominal complaints. On physical examination, the patient was noted to be confused and unable to provide history of his own illness. He received antiviral treatment during hospitalization, but his mental status rapidly deteriorated. Then he was admitted to pediatric ICU (PICU) and received mechanical ventilation. Lastly he died of severe
3.2. Plasma cytokine and chemokine concentrations As cytokine dysregulation (cytokine storm) was related to the syndrome of acute respiratory distress, multiple-organ dysfunction, lymphopenia, and hemophagocytosis (Beigel et al., 2005), we measured the levels of 10 cytokines and chemokines as described by Lee et al. (2007). Compared with reference levels of patients with mild H1N1 infection and healthy controls, the level of IL-6 increased at least 2.7- to 12.9-fold and 6.5- to 31-fold in all three patients respectively (Table 2). The levels of TNF␣, IL-8 and MCP-1 significantly increased in two younger boys but not in the older girl. On the contrary, IP-10, IL-12 and RANTES significantly decreased.
Table 2 Plasma concentrations of 10 cytokines and chemokines in three fatal cases of Shenzhen. Cytokine or chemokine
IFN␥ IL-1 IL-6 IL-8 IL-10 IL-12 IP-10 TNF␣ MCP-1 RANTES
Concentration (pg/mL, IQR) Patient 1
Patient 2
Patient 3
Mild H1N1 infection
Healthy control
ND ND 509.7 934.2 11.1 ND ND 43.8 91.8 ND
ND ND 452.9 109.6 ND ND 12.8 82.3 177.1 ND
ND ND 107.1 33.0 ND 1.6 4.2 0.8 10.3 58.0
ND ND <16.40 <32.965 ND <0.22 <28.23 <15.9 <23.36 251.49 (197.91–305.07)
ND ND 39.54 (21.09–57.04) 35.04 (4.82–69.66) ND 14.1 (0.91–35.14) 104.8 (50.35–170.62) 27 (5.06–74.83) 20.15 (5.62–54.37) 750.04 (386.78–1010.77)
IQR, interquartile range; IP-10, IFN-induced protein 10; MCP-1, monocyte chemoattractant protein 1; RATES, regulated upon activation, normal T cell-expressed and secreted; ND, not detectable.
X.-W. Cheng et al. / Respiratory Physiology & Neurobiology 175 (2011) 185–187
187
Other cytokines and chemokines (IL-1, IFN␥, and IL-10) appeared to be at very low levels, similar to the reference.
posed to be a low-risk group for the novel H1N1 infection. However, studies on larger sample size are needed.
4. Discussion
Acknowledgements
In Shenzhen, H1N1 infection caused three deaths with notable unique clinical features. Since the breakout in April 2009, the clinical presentations of H1N1 infection had been extensively studied and compared among patient groups worldwide. The infants (0–4 year of age) and adults (25–64 years of age) were reported to be at increased risk (Echevarría-Zuno et al., 2009; Presanis et al., 2009). For individuals, underlying conditions such as pregnant, with a BMI greater than 35 or having chronic disease, H1N1 infection seemed to be more easily to develop life-threatening illness. The clinical features of all three deaths in Shenzhen (China) were similar to those fatal cases in other parts of the world, such as fever, cough, and sore throat. Vomiting, another clinical presentation especially prevalent among pediatric age group, was also shown in both of the two little boys. A unique characteristic of these three deaths was that, despite their common clinical features, none of them is among a high-risk group for H1N1 infection. All of them were previously healthy before the onset of H1N1 infection, and no one was at extremes of age, or with underlying chronic disease. Cytokine storm seemed to be the main cause of death. The pathogenesis of H1N1 infection remained unclear, however, it had been shown that the dysregulation of cytokines and chemokines was associated with the severity of influenza A virus infection. Studies of influenza A virus subtype H5N1 disease also suggested that cytokine dysregulation might play an important role in these deadly infections (Beigel et al., 2005; Lee et al., 2007). In our study, the levels of IL-6 increased in the plasma of all three patients while increased TNF␣, IL-8 and MCP-1 levels were observed in the plasma of two boys. IP-10, IL-12 and RANTES significantly reduced to a very low or undetectable level. Our findings were consistent with those of earlier studies of human influenza, which showed that local and systemic cytokine responses, such as elevated serum concentrations of IL-6 and IL-8 in patients infected with the H5N1 strain (de Jong et al., 2006; Peiris et al., 2004; To et al., 2001). Notably, a large decrease in the level of RANTES was observed in all these three patients. Early reports demonstrated that influenza A virusinfected monocytes or macrophages could secrete RANTES, which preferentially favored the recruitment of blood mononuclear cell population to the site of the infection (Julkunen et al., 2001). In addition to its chemotactic activity, it was also involved in direct antiviral activity by inducing NO in macrophages (Villalta et al., 1998). We suggest that the decreased level of RANTES might play a critical role in the pathogenesis of these three patients with severe H1N1 infection.
We thank the Shenzhen Center for Disease Control and Prevention for providing technical support. This study is partly supported by the Research Fund for Control of Infectious Diseases (CU-09-0101), Food and Health Bureau, the Government of Hong Kong Special Administration Region (HKSAR); Research Grant Council (RGC) of Hong Kong Government (CUHK4428/06M, to M.L.H.).
5. Conclusions Our findings highlight the importance of cytokine storm in novel influenza associated death among young individuals, who are sup-
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