title: Association between severe pandemic 2009 influenza A (H1N1) virus infection and immunoglobulin G(2) subclass deficiency.
abstract: BACKGROUND
  . Severe pandemic 2009 influenza A virus (H1N1) infection is associated with risk factors that include pregnancy, obesity, and immunosuppression. After identification of immunoglobulin G(2) (IgG(2)) deficiency in 1 severe case, we assessed IgG subclass levels in a cohort of patients with H1N1 infection.
  
  
  METHODS
  Patient features, including levels of serum IgG and IgG subclasses, were assessed in patients with acute severe H1N1 infection (defined as infection requiring respiratory support in an intensive care unit), patients with moderate H1N1 infection (defined as inpatients not hospitalized in an intensive care unit), and a random sample of healthy pregnant women.
  
  
  RESULTS
  Among the 39 patients with H1N1 infection (19 with severe infection, 7 of whom were pregnant; 20 with moderate infection, 2 of whom were pregnant), hypoabuminemia (P < .001), anemia (P < .001), and low levels of total IgG (P= .01), IgG(1) (P= .022), and IgG(2) (15 of 19 vs 5 of 20; P= .001; mean value +/- standard deviation [SD], 1.8 +/- 1.7 g/L vs 3.4 +/- 1.4 g/L; P= .003) were all statistically significantly associated with severe H1N1 infection, but only hypoalbuminemia (P= .02) and low mean IgG(2) levels (P= .043) remained significant after multivariate analysis. Follow-up of 15 (79%) surviving IgG(2)-deficient patients at a mean (+/- SD) of 90 +/- 23 days (R, 38-126) after the initial acute specimen was obtained found that hypoalbuminemia had resolved in most cases, but 11 (73%) of 15 patients remained IgG(2) deficient. Among 17 healthy pregnant control subjects, mildly low IgG(1) and/or IgG(2) levels were noted in 10, but pregnant patients with H1N1 infection had significantly lower levels of IgG(2) (P= .001).
  
  
  CONCLUSIONS
  Severe H1N1 infection is associated with IgG(2) deficiency, which appears to persist in a majority of patients. Pregnancy-related reductions in IgG(2) level may explain the increased severity of H1N1 infection in some but not all pregnant patients. The role of IgG(2) deficiency in the pathogenesis of H1N1 infection requires further investigation, because it may have therapeutic implications.
authors.affiliation: Infectious Diseases Department, Austin Health, University of Melbourne, Australia.
authors.forename: C L
authors.initials: CL
authors.lastname: Gordon
authors.forename: P D R
authors.initials: PD
authors.lastname: Johnson
authors.forename: M
authors.initials: M
authors.lastname: Permezel
authors.forename: N E
authors.initials: NE
authors.lastname: Holmes
authors.forename: G
authors.initials: G
authors.lastname: Gutteridge
authors.forename: C F
authors.initials: CF
authors.lastname: McDonald
authors.forename: D P
authors.initials: DP
authors.lastname: Eisen
authors.forename: A J
authors.initials: AJ
authors.lastname: Stewardson
authors.forename: J
authors.initials: J
authors.lastname: Edington
authors.forename: P G P
authors.initials: PG
authors.lastname: Charles
authors.forename: N
authors.initials: N
authors.lastname: Crinis
authors.forename: M J
authors.initials: MJ
authors.lastname: Black
authors.forename: J
authors.initials: J
authors.lastname: Torresi
authors.forename: M L
authors.initials: ML
authors.lastname: Grayson
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D005260:Female; D006801:Humans; D017099:IgG Deficiency / Q000453:epidemiology*; D053118:Influenza A Virus, H1N1 Subtype / Q000302:isolation & purification*; D007251:Influenza, Human / Q000453:epidemiology* / Q000473:pathology / Q000821:virology*; D008297:Male; D008875:Middle Aged; D011247:Pregnancy; D055815:Young Adult