Anuradha S. Tripathy

Systemic involvements and fatalities during Chikungunya epidemic in India, 2006.

BACKGROUND In addition to classical manifestations of Chikungunya infection, severe infections requiring hospitalization were reported during outbreaks in India in 2006. OBJECTIVES To describe the systemic syndromes and risk groups of severe Chikungunya infections. STUDY DESIGN We prospectively investigated suspected Chikungunya cases hospitalized in Ahmedabad, Gujarat during September-October 2006, and retrospectively investigated laboratory-confirmed Chikungunya cases hospitalized with neurologic syndromes in Pune, Maharashtra. Hospital records were reviewed for demographic, comorbidity, clinical and laboratory information. Sera and/or cerebrospinal fluid were screened by one or more methods, including virus-specific IgM antibodies, viral RNA and virus isolation. RESULTS Among 90 laboratory-confirmed Chikungunya cases hospitalized in Ahmedabad, classical Chikungunya was noted in 25 cases and severe Chikungunya was noted in 65 cases, including non-neurologic (25) and neurologic (40) manifestations. Non-neurologic systemic syndromes in the 65 severe Chikungunya cases included renal (45), hepatic (23), respiratory (21), cardiac (10), and hematologic manifestations (8). Males (50) and those aged >or=60 years (50) were commonly affected with severe Chikungunya, and age >or=60 years represented a significant risk. Comorbidities were seen in 21 cases with multiple comorbidities in 7 cases. Among 18 deaths, 14 were males, 15 were aged >or=60 years and 5 had comorbidities. In Pune, 59 laboratory-confirmed Chikungunya cases with neurologic syndromes were investigated. Neurologic syndromes in 99 cases from Ahmedabad and Pune included encephalitis (57), encephalopathy (42), and myelopathy (14) or myeloneuropathy (12). CONCLUSIONS Chikungunya infection can cause systemic complications and probably deaths, especially in elderly adults.

Clinical findings and pro-inflammatory cytokines in dengue patients in Western India: a facility-based study.

Background Descriptions of dengue immunopathogenesis have largely relied on data from South-east Asia and America, while India is poorly represented. This study characterizes dengue cases from Pune, Western India, with respect to clinical profile and pro-inflammatory cytokines. Methodology/Principal Findings In 2005, 372 clinically suspected dengue cases were tested by MAC-ELISA and RT-PCR for dengue virus (DENV) aetiology. The clinical profile was recorded at the hospital. Circulating levels of IFN-γ, TNF-α, IL-6, and IL-8 were assessed by ELISA and secondary infections were defined by IgM to IgG ratio. Statistical analysis was carried out using the SPSS 11.0 version. Of the 372 individuals, 221 were confirmed to be dengue cases. Three serotypes, DENV-1, 2 and 3 were co-circulating and one case of dual infection was identified. Of 221 cases, 159 presented with Dengue fever (DF) and 62 with Dengue hemorrhagic fever (DHF) of which six had severe DHF and one died of shock. There was a strong association of rash, abdominal pain and conjunctival congestion with DHF. Levels of IFN-γ were higher in DF whereas IL-6 and IL-8 were higher in DHF cases (p<0.05). The mean levels of the three cytokines were higher in secondary compared to primary infections. Levels of IFN-γ and IL-8 were higher in early samples collected 2–5 days after onset than late samples collected 6–15 days after onset. IFN-γ showed significant decreasing time trend (p = 0.005) and IL-8 levels showed increasing trend towards significance in DHF cases (interaction p = 0.059). There was a significant association of IL-8 levels with thrombocytopenia and both IFN-γ and IL-8 were positively associated with alanine transaminase levels. Conclusions/Significance Rash, abdominal pain and conjunctival congestion could be prognostic symptoms for DHF. High levels of IL-6 and IL-8 were shown to associate with DHF. The time trend of IFN-γ and IL-8 levels had greater significance than absolute values in DHF pathogenesis.

Role of host immune response and viral load in the differential outcome of pandemic H1N1 (2009) influenza virus infection in Indian patients.

Background An unusually high number of severe pneumonia cases with considerable mortality is being observed with the pandemic H1N1 2009 virus infections globally. In India, all mild as well as critically ill cases were admitted and treated in the government hospitals during the initial phase of the pandemic. The present study was undertaken during this early phase of the pandemic. Methodology The role of viral load and host factors in the pathogenesis were assessed by examining 26 mild (MP), 15 critically ill patients (CIP) and 20 healthy controls from Pune, India. Sequential blood and lung aspirate samples were collected from CIP. Viral load and cytokines/chemokine levels were determined from the plasma and lung aspirates of the patients. TLR levels were determined by staining and FACS analysis. Gene profiling was done for both cells in the lung aspirates and PBMCs using TaqMan Low Density arrays. Antibody titres and isotyping was done using HA protein based ELISAs. Principal Findings 13/15 critically ill patients expired. All plasma samples were negative for the virus irrespective of the patients category. Sequential lung samples from CIP showed lower viral loads questioning association of viral replication with the severity. Anti-rpH1N1-09-HA-IgG titres were significantly higher in critically ill patients and both categories circulated exclusively IgG1 isotype. Critically ill patients exhibited increase in TLR-3, 4, 7 and decrease in TLR-2 expressions. The disease severity correlated with increased plasma levels of IL1RA, IL2, IL6, CCL3, CCL4 and IL10. Majority of the immune-function genes were down-regulated in the PBMCs and up-regulated in the cells from lung aspirates of critically ill patients. No distinct pattern differentiating fatal and surviving patients was observed when sequential samples were examined for various parameters. Conclusions Disease severity was associated with pronounced impairment of host immune response.

Development of candidate combination vaccine for hepatitis E and hepatitis B: A liposome encapsulation approach

To reduce extra injections, cost and ensure better coverage, use of combination vaccines is preferable. An attempt was made to evaluate the encapsulation of hepatitis E virus neutralizing epitope (NE) region and hepatitis B virus surface antigen (HBsAg) in liposomes as DNAs, proteins and DNA+protein. Mice groups were immunized with different liposome-encapsulated formulations and monitored for anti-HEV and anti-HBs titres, IgG subtypes, antigen-specific lymphocyte proliferation and cytokine levels. The protective levels of anti-HBs and in vitro virus-binding capacity of anti-HEV antibodies were assessed. Liposome-encapsulated DNA either singly or in combination did not elicit antibody response. Anti-HEV and anti-HBs IgG titres of individual component of protein alone (Lipo-E-P/Lipo-B-P) or DNA+protein formulations (Lipo-E-DP/Lipo-B-DP) were comparable to respective titres in combination vaccine of protein (Lipo-BE-P) and DNA+protein formulations (Lipo-BE-DP). IgG1 levels were significantly higher in Lipo-BE-P group whereas, equivalent levels of IgG1 and IgG2a were observed in Lipo-BE-DP group against both components of the vaccine. Combination vaccine group showed mixed Th1/Th2 cytokine profile. Liposome entrapped NE and HBsAg in protein and DNA+protein formats induce excellent immune response to both the components and need to be evaluated in higher animals.

Cytokine Profiles, CTL Response and T Cell Frequencies in the Peripheral Blood of Acute Patients and Individuals Recovered from Hepatitis E Infection

Background Hepatitis E is a major public health problem in the developing countries. Pathogenesis of hepatitis E virus (HEV) infection is poorly understood. Methods This case-control study included 124 Hepatitis E patients (46 acute and 78 recovered), 9 with prior exposure to HEV and 71 anti-HEV negative healthy controls. HEV induced CTL response by Elispot, cytokines/chemokines quantitation by Milliplex assay and peripheral CD4+ & CD8+ T cell frequencies by flow cytometry were assessed. Results Among the patient categories, HEV specific IFN-γ responses as recorded by Elispot were comparable. Comparisons of cytokines/chemokines revealed significantly high levels of IL-1α and sIL-2Rα during acute phase. Circulating peripheral CD4/CD8+ T-cell subsets in acute and recovered individuals were comparable compared to controls, while among patient categories CD8+T cell subset was significantly higher in recovered individuals. Conclusions Our findings suggest that IL-1α and sIL-2Rα play a role in the pathogenesis of acute Hepatitis E infection. Lack of robust HEV ORF2-specific CTL response in the peripheral blood of HEV infected patients during the acute and recovered phases of the disease may be associated with involvement of innate immune cells/localization of the immune events at the site of infection.

Peripheral T regulatory cells and cytokines in hepatitis E infection

This study addresses the involvement of regulatory T cells in hepatitis E (HE) infection. The study population comprised 77 acute viral HE patients, 52 recovered individuals (overall, 129 individuals with HE) and 53 healthy controls. Peripheral CD4+CD25+Foxp3+ and CD4+CD25−Foxp3+ frequencies by flow cytometry and HE-specific cytokines/chemokines quantitation were carried out. The median percentage of CD4+CD25+Foxp3+ and CD4+CD25−Foxp3+ T cells in acute patients were significantly higher compared to controls and recovered individuals. Both of the T regulatory (Treg) subset populations in overall HE were significantly elevated compared to controls. Comparisons of cytokines/chemokines revealed that the levels of IL-10 were elevated in: (a) acute viral hepatitis E (AVH-E) versus recovered individuals and controls, and (b) HE versus controls. Overall, the elevation of CD4+CD25+Foxp3+ and CD4+CD25−Foxp3+ frequencies and the rise in IL-10 suggest that Treg cells might be playing a pivotal role in hepatitis E virus (HEV) infection.

Epidemic of Hepatitis B with high mortality in India: association of fulminant disease with lack of CCL4 and natural killer T cells

Summary.  An explosive outbreak of Hepatitis B with high mortality was reported in 2009, in Modasa, Gujarat, India. Mortality was associated with basal core promoter and precore mutant hepatitis B virus (HBV). The current study addresses the role of immunological parameters in the progression to fulminant hepatitis. The study population comprised of 22 acute HBV patients, 13 fulminant HBV liver failure patients and 54 healthy controls. Hepatitis B surface antigen‐induced CTL responses by enzyme‐linked immunosorbent spot (ELISPOT), cytokine and chemokine quantitation by Bioplex assay, peripheral NK, natural killer T (NKT), CD4 and CD8 T‐cell frequencies by flow cytometry were carried out. The median percentage of NK cells in the lymphocytes of the acute and fulminant liver failure patients were significantly lower compared to controls. Acute and fulminant liver failure patients had significantly high and comparable NKT cells compared to controls, respectively. Importantly, NKT cells were significantly lower in fulminant HBV liver failure than acute HBV patients. Circulating peripheral CD4/CD8 T‐cell subsets among the patient categories and controls were comparable. In acute HBV patients, a significant increase in IFN‐γ release was recorded (ELISPOT) by the unstimulated, antigen‐stimulated and mitogen‐stimulated cells when compared to controls. Comparisons of cytokines and chemokines among the disease categories revealed significantly lower levels of CCL4 in fulminant liver failure patients. NKT cells and CCL4 might be playing a pivotal role in limiting HBV infection among the patients investigated.

Increased expressions of NKp44, NKp46 on NK/NKT-like cells are associated with impaired cytolytic function in self-limiting hepatitis E infection

Abstract We have characterized the NK/NKT-like cells in patients with self-limiting hepatitis E infection. The distribution of peripheral NK/NKT-like cells, expressions of activation receptors, cytotoxic potential and effector function of NK/NKT-like cells from fresh peripheral blood mononuclear cells of 86 acute patients, 101 recovered and 54 control individuals were assessed. Activated NKT-like (CD16+ CD56+ CD3+) cells were high in the patient groups. On CD56+ CD3− cells, NKp44 and NKp46 expressions were high in the acute patients, whereas NKp30, NKp44, NKp46 and NKG2D were high in the recovered individuals. On CD56+ CD3+ cells, NKp44, NKp46 and NKG2D expressions were high in the recovered but NKp30 was low in both the patient groups. Collectively, the current study elucidates the role of NK/NKT-like cells demonstrating phenotypic alterations of activated NKT-like cells and activation receptors, lack of CD107a expression and functional impairment of peripheral NK/NKT-like cells in self-limiting hepatitis E infection.

Phenotypic and functional analyses of NK and NKT-like populations during the early stages of chikungunya infection

The aim of this study was to characterize NK (CD56+CD3−) and NKT-like cell (CD56+CD3+) responses early after chikungunya infection. Expression profiling and functional analysis of T/NK/NKT-like cells were performed on samples from 56 acute and 31 convalescent chikungunya patients and 56 control individuals. The percentages of NK cells were high in both patient groups, whereas NKT-like cell percentages were high only in the convalescent group. The percentages of NKp30+CD3−CD56+, NKp30+CD3+CD56+, CD244+CD3−CD56+, and CD244+CD3+CD56+cells were high, whereas the percentages of NKG2D+CD3−CD56+ and NKG2D+CD3+CD56+cells were low in both patient groups. The percentages of NKp44+CD3−CD56+ cells were high in both patient groups, whereas the percentages of NKp44+CD3+CD56+ cells were higher in the acute group than in convalescent and control groups. The percentages of NKp46+CD3−CD56+ cells were high in both patient groups. Higher percentages of perforin+CD3−CD56+ and perforin+CD3+CD56+ cells were observed in acute and convalescent patients, respectively. Higher cytotoxic activity was observed in acute patients than in controls. IFN-γ expression on NK cells of convalescent patients and on NKT-like cells of both patient groups was indicative of the regulatory role of NK and NKT-like cells. Collectively, these data showed that higher expression of activating receptors on NK/NKT-like cells and perforin+ NK cells in acute patients could be responsible for increased cytotoxicity. The observed expression of perforin+ NK cells in the acute phase and IFN-γ+ NKT-like cells in the subsequent convalescent stage showed that NK/NKT-like cells mount an early and efficient response to chikungunya virus. Further study of the molecular mechanisms that limit viral dissemination/establishment of chronic disease will aid in understanding how NK/NKT-like cells control chikungunya infection.

Suppressive activity and altered conventional phenotype markers/mediators of regulatory T cells in patients with self-limiting hepatitis E

Hepatitis E virus (HEV) is a major cause of self‐limiting acute viral hepatitis in several developing countries. Elevated levels of peripheral CD4+CD25+Foxp3+, CD4+CD25−Foxp3+ and rise in IL‐10 in hepatitis E have been associated with the involvement of regulatory T cells (Treg). The functional role of the same is yet elusive. In the current study, we have assessed (i) Foxp3 expression by real‐time PCR and by flow cytometry, (ii) the levels of antigen‐specific IL‐10 and TGF‐β by ELISA, (iii) functional analysis of Treg cells and (iv) expression of Treg‐associated conventional phenotypes by flow cytometry in 54 acute patients, 44 recovered individuals from hepatitis E and in 33 healthy controls. Foxp3 mRNA elevation in the acute compared with recovered group and elevation in Foxp3+ cells in both patient groups were significantly elevated. The levels of IL‐10 and TGF‐β in the acute patients and TGF‐β in the recovered individuals were elevated. Significantly higher expression of CTLA‐4, PD1, GITR, CD95, CD103 and CD73 on Treg and T effector (Teff) cells was detected in the patient groups. Treg cells of acute patients and recovered individuals exhibited suppressive activity indicating that the Treg cells of hepatitis E patients are functional. The suppressive capacity of Treg cells in acute hepatitis E patients was significantly higher compared with the recovered individuals. Based on our findings, the suppressive functionality of these key markers associated with hepatitis E Treg function need further exploration to get a better understanding of the mechanisms of Treg‐mediated suppression.