title: Widespread Virus Replication in Alveoli Drives Acute Respiratory Distress Syndrome in Aerosolized H5N1 Influenza Infection of Macaques.
abstract: Human infections with highly pathogenic avian influenza A (H5N1) virus are frequently fatal but the mechanisms of disease remain ill-defined. H5N1 infection is associated with intense production of proinflammatory cytokines, but whether this cytokine storm is the main cause of fatality or is a consequence of extensive virus replication that itself drives disease remains controversial. Conventional intratracheal inoculation of a liquid suspension of H5N1 influenza virus in nonhuman primates likely results in efficient clearance of virus within the upper respiratory tract and rarely produces severe disease. We reasoned that small particle aerosols of virus would penetrate the lower respiratory tract and blanket alveoli where target cells reside. We show that inhalation of aerosolized H5N1 influenza virus in cynomolgus macaques results in fulminant pneumonia that rapidly progresses to acute respiratory distress syndrome with a fatal outcome reminiscent of human disease. Molecular imaging revealed intense lung inflammation coincident with massive increases in proinflammatory proteins and IFN-α in distal airways. Aerosolized H5N1 exposure decimated alveolar macrophages, which were widely infected and caused marked influx of interstitial macrophages and neutrophils. Extensive infection of alveolar epithelial cells caused apoptosis and leakage of albumin into airways, reflecting loss of epithelial barrier function. These data establish inhalation of aerosolized virus as a critical source of exposure for fatal human infection and reveal that direct viral effects in alveoli mediate H5N1 disease. This new nonhuman primate model will advance vaccine and therapeutic approaches to prevent and treat human disease caused by highly pathogenic avian influenza viruses.
authors.affiliation: Center for Vaccine Research, University of Pittsburgh, Pittsburgh, PA 15261.|Department of Infectious Diseases and Microbiology, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA 15261.
authors.forename: Elizabeth R
authors.identifier: 0000-0002-0773-6569
authors.initials: ER
authors.lastname: Wonderlich
authors.affiliation: Center for Vaccine Research, University of Pittsburgh, Pittsburgh, PA 15261.|Department of Infectious Diseases and Microbiology, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA 15261.
authors.forename: Zachary D
authors.initials: ZD
authors.lastname: Swan
authors.affiliation: Division of Neuropathology, Department of Pathology, University of Pittsburgh School of Medicine, Pittsburgh, PA 15261.
authors.forename: Stephanie J
authors.initials: SJ
authors.lastname: Bissel
authors.affiliation: Center for Vaccine Research, University of Pittsburgh, Pittsburgh, PA 15261.|Department of Infectious Diseases and Microbiology, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA 15261.
authors.forename: Amy L
authors.initials: AL
authors.lastname: Hartman
authors.affiliation: Department of Radiology, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213.
authors.forename: Jonathan P
authors.initials: JP
authors.lastname: Carney
authors.affiliation: Center for Vaccine Research, University of Pittsburgh, Pittsburgh, PA 15261.|Department of Immunology, University of Pittsburgh School of Medicine, Pittsburgh, PA 15261.
authors.forename: Katherine J
authors.initials: KJ
authors.lastname: O'Malley
authors.affiliation: Department of Population Health, University of Georgia, Athens, GA 30602.
authors.forename: Adebimpe O
authors.initials: AO
authors.lastname: Obadan
authors.affiliation: Department of Population Health, University of Georgia, Athens, GA 30602.
authors.forename: Jefferson
authors.identifier: 0000-0001-5895-4163
authors.initials: J
authors.lastname: Santos
authors.affiliation: Division of Laboratory Animal Resources, University of Pittsburgh, Pittsburgh, PA 15260.
authors.forename: Reagan
authors.initials: R
authors.lastname: Walker
authors.affiliation: Center for Vaccine Research, University of Pittsburgh, Pittsburgh, PA 15261.
authors.forename: Timothy J
authors.initials: TJ
authors.lastname: Sturgeon
authors.affiliation: Department of Microbiology and Molecular Genetics, University of Pittsburgh School of Medicine, Pittsburgh, PA 15219; and.
authors.forename: Lonnie J
authors.identifier: 0000-0002-3694-3866
authors.initials: LJ
authors.lastname: Frye
authors.affiliation: Department of Microbiology and Molecular Genetics, University of Pittsburgh School of Medicine, Pittsburgh, PA 15219; and.
authors.forename: Pauline
authors.initials: P
authors.lastname: Maiello
authors.affiliation: Department of Microbiology and Molecular Genetics, University of Pittsburgh School of Medicine, Pittsburgh, PA 15219; and.
authors.forename: Charles A
authors.identifier: 0000-0003-3654-5603
authors.initials: CA
authors.lastname: Scanga
authors.affiliation: Center for Vaccine Research, University of Pittsburgh, Pittsburgh, PA 15261.|Department of Infectious Diseases and Microbiology, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA 15261.
authors.forename: Jennifer D
authors.identifier: 0000-0002-1432-0211
authors.initials: JD
authors.lastname: Bowling
authors.affiliation: Center for Vaccine Research, University of Pittsburgh, Pittsburgh, PA 15261.|Department of Infectious Diseases and Microbiology, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA 15261.
authors.forename: Anthea L
authors.initials: AL
authors.lastname: Bouwer
authors.affiliation: Center for Vaccine Research, University of Pittsburgh, Pittsburgh, PA 15261.|Department of Infectious Diseases and Microbiology, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA 15261.
authors.forename: Parichat A
authors.identifier: 0000-0001-6931-417X
authors.initials: PA
authors.lastname: Duangkhae
authors.affiliation: Division of Neuropathology, Department of Pathology, University of Pittsburgh School of Medicine, Pittsburgh, PA 15261.
authors.forename: Clayton A
authors.identifier: 0000-0002-2697-7691
authors.initials: CA
authors.lastname: Wiley
authors.affiliation: Department of Microbiology and Molecular Genetics, University of Pittsburgh School of Medicine, Pittsburgh, PA 15219; and.
authors.forename: JoAnne L
authors.identifier: 0000-0001-7874-8981
authors.initials: JL
authors.lastname: Flynn
authors.affiliation: Division of Pulmonary Medicine, Allergy, and Immunology, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213.
authors.forename: Jieru
authors.initials: J
authors.lastname: Wang
authors.affiliation: Center for Vaccine Research, University of Pittsburgh, Pittsburgh, PA 15261.|Department of Immunology, University of Pittsburgh School of Medicine, Pittsburgh, PA 15261.
authors.forename: Kelly S
authors.identifier: 0000-0002-2254-1217
authors.initials: KS
authors.lastname: Cole
authors.affiliation: Department of Population Health, University of Georgia, Athens, GA 30602.
authors.forename: Daniel R
authors.initials: DR
authors.lastname: Perez
authors.affiliation: Center for Vaccine Research, University of Pittsburgh, Pittsburgh, PA 15261.|Department of Immunology, University of Pittsburgh School of Medicine, Pittsburgh, PA 15261.
authors.forename: Douglas S
authors.initials: DS
authors.lastname: Reed
authors.affiliation: Center for Vaccine Research, University of Pittsburgh, Pittsburgh, PA 15261; smbb@pitt.edu.|Department of Infectious Diseases and Microbiology, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA 15261.|Department of Immunology, University of Pittsburgh School of Medicine, Pittsburgh, PA 15261.
authors.forename: Simon M
authors.initials: SM
authors.lastname: Barratt-Boyes
mesh_terms: D000336:Aerosols; D056809:Alveolar Epithelial Cells / Q000276:immunology / Q000473:pathology / Q000821:virology; D000818:Animals; D002478:Cells, Cultured; D016207:Cytokines / Q000096:biosynthesis / Q000276:immunology; D004195:Disease Models, Animal; D007113:Immunity, Innate / Q000276:immunology; D053124:Influenza A Virus, H5N1 Subtype / Q000276:immunology / Q000472:pathogenicity / Q000502:physiology*; D008168:Lung / Q000276:immunology / Q000821:virology; D008252:Macaca fascicularis; D016676:Macrophages, Alveolar / Q000276:immunology / Q000473:pathology / Q000821:virology; D009976:Orthomyxoviridae Infections / Q000276:immunology / Q000503:physiopathology / Q000821:virology*; D011024:Pneumonia, Viral / Q000276:immunology / Q000821:virology*; D011650:Pulmonary Alveoli / Q000821:virology*; D012128:Respiratory Distress Syndrome / Q000276:immunology / Q000503:physiopathology / Q000821:virology*; D014779:Virus Replication
chemical_list: D000336:Aerosols; D016207:Cytokines