title: Human infections with the emerging avian influenza A H7N9 virus from wet market poultry: clinical analysis and characterisation of viral genome.
abstract: BACKGROUND
  Human infection with avian influenza A H7N9 virus emerged in eastern China in February, 2013, and has been associated with exposure to poultry. We report the clinical and microbiological features of patients infected with influenza A H7N9 virus and compare genomic features of the human virus with those of the virus in market poultry in Zhejiang, China.
  
  
  METHODS
  Between March 7 and April 8, 2013, we included hospital inpatients if they had new-onset respiratory symptoms, unexplained radiographic infiltrate, and laboratory-confirmed H7N9 virus infection. We recorded histories and results of haematological, biochemical, radiological, and microbiological investigations. We took throat and sputum samples, used RT-PCR to detect M, H7, and N9 genes, and cultured samples in Madin-Darby canine kidney cells. We tested for co-infections and monitored serum concentrations of six cytokines and chemokines. We collected cloacal swabs from 86 birds from epidemiologically linked wet markets and inoculated embryonated chicken eggs with the samples. We identified and subtyped isolates by RT-PCR sequencing. RNA extraction, complementary DNA synthesis, and PCR sequencing were done for one human and one chicken isolate. We characterised and phylogenetically analysed the eight gene segments of the viruses in the patient's and the chicken's isolates, and constructed phylogenetic trees of H, N, PB2, and NS genes.
  
  
  RESULTS
  We identified four patients (mean age 56 years), all of whom had contact with poultry 3-8 days before disease onset. They presented with fever and rapidly progressive pneumonia that did not respond to antibiotics. Patients were leucopenic and lymphopenic, and had impaired liver or renal function, substantially increased serum cytokine or chemokine concentrations, and disseminated intravascular coagulation with disease progression. Two patients died. Sputum specimens were more likely to test positive for the H7N9 virus than were samples from throat swabs. The viral isolate from the patient was closely similar to that from an epidemiologically linked market chicken. All viral gene segments were of avian origin. The H7 of the isolated viruses was closest to that of the H7N3 virus from domestic ducks in Zhejiang, whereas the N9 was closest to that of the wild bird H7N9 virus in South Korea. We noted Gln226Leu and Gly186Val substitutions in human virus H7 (associated with increased affinity for α-2,6-linked sialic acid receptors) and the PB2 Asp701Asn mutation (associated with mammalian adaptation). Ser31Asn mutation, which is associated with adamantane resistance, was noted in viral M2.
  
  
  CONCLUSIONS
  Cross species poultry-to-person transmission of this new reassortant H7N9 virus is associated with severe pneumonia and multiorgan dysfunction in human beings. Monitoring of the viral evolution and further study of disease pathogenesis will improve disease management, epidemic control, and pandemic preparedness.
  
  
  BACKGROUND
  Larry Chi-Kin Yung, National Key Program for Infectious Diseases of China.
authors.affiliation: State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China.
authors.forename: Yu
authors.initials: Y
authors.lastname: Chen
authors.forename: Weifeng
authors.initials: W
authors.lastname: Liang
authors.forename: Shigui
authors.initials: S
authors.lastname: Yang
authors.forename: Nanping
authors.initials: N
authors.lastname: Wu
authors.forename: Hainv
authors.initials: H
authors.lastname: Gao
authors.forename: Jifang
authors.initials: J
authors.lastname: Sheng
authors.forename: Hangping
authors.initials: H
authors.lastname: Yao
authors.forename: Jianer
authors.initials: J
authors.lastname: Wo
authors.forename: Qiang
authors.initials: Q
authors.lastname: Fang
authors.forename: Dawei
authors.initials: D
authors.lastname: Cui
authors.forename: Yongcheng
authors.initials: Y
authors.lastname: Li
authors.forename: Xing
authors.initials: X
authors.lastname: Yao
authors.forename: Yuntao
authors.initials: Y
authors.lastname: Zhang
authors.forename: Haibo
authors.initials: H
authors.lastname: Wu
authors.forename: Shufa
authors.initials: S
authors.lastname: Zheng
authors.forename: Hongyan
authors.initials: H
authors.lastname: Diao
authors.forename: Shichang
authors.initials: S
authors.lastname: Xia
authors.forename: Yanjun
authors.initials: Y
authors.lastname: Zhang
authors.forename: Kwok-Hung
authors.initials: KH
authors.lastname: Chan
authors.forename: Hoi-Wah
authors.initials: HW
authors.lastname: Tsoi
authors.forename: Jade Lee-Lee
authors.initials: JL
authors.lastname: Teng
authors.forename: Wenjun
authors.initials: W
authors.lastname: Song
authors.forename: Pui
authors.initials: P
authors.lastname: Wang
authors.forename: Siu-Ying
authors.initials: SY
authors.lastname: Lau
authors.forename: Min
authors.initials: M
authors.lastname: Zheng
authors.forename: Jasper Fuk-Woo
authors.initials: JF
authors.lastname: Chan
authors.forename: Kelvin Kai-Wang
authors.initials: KK
authors.lastname: To
authors.forename: Honglin
authors.initials: H
authors.lastname: Chen
authors.forename: Lanjuan
authors.initials: L
authors.lastname: Li
authors.forename: Kwok-Yung
authors.initials: KY
authors.lastname: Yuen
mesh_terms: D000818:Animals; D002681:China; D021821:Communicable Diseases, Emerging / Q000188:drug therapy / Q000635:transmission / Q000821:virology*; D005260:Female; D016679:Genome, Viral / Q000235:genetics*; D006801:Humans; D009980:Influenza A virus / Q000145:classification / Q000235:genetics*; D005585:Influenza in Birds / Q000235:genetics* / Q000635:transmission; D007251:Influenza, Human / Q000188:drug therapy / Q000635:transmission / Q000821:virology*; D008297:Male; D008875:Middle Aged; D011200:Poultry; D014057:Tomography, X-Ray Computed; D015047:Zoonoses / Q000635:transmission* / Q000821:virology