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Article Ebola Hf

Article Ebola Hf

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Published by: David Brayan Reyna Gomez on May 09, 2011
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Pathogenesis of Ebola Hemorrhagic Fever inCynomolgus Macaques
Evidence that Dendritic Cells Are Early and Sustained Targetsof Infection
Thomas W. Geisbert,* Lisa E. Hensley,*Tom Larsen,* Howard A. Young,
Douglas S. Reed,* Joan B. Geisbert,*Dana P. Scott,* Elliott Kagan,
Peter B. Jahrling,*and Kelly J. Davis*
From the United States Army Medical Institute of Infectious Diseases,
Fort Detrick; the Laboratory of Experimental Immunology,
Center for Cancer Research, NCI-Frederick,Frederick; and the Uniformed Services University of the Health Sciences,
Bethesda, Maryland 
Ebola virus (EBOV) infection causes a severe and fatal hemorrhagic disease that in many ways appears to besimilar in humans and nonhuman primates; how-ever, little is known about the development of EBOV hemorrhagic fever. In the present study, 21 cynomol-gus monkeys were experimentally infected witEBOV and examined sequentially over a 6-day period to investigate the pathological events of EBOV infec-tion that lead to death. Importantly, dendritic cells in lymphoid tissues were identified as early and sus-tained targets of EBOV, implicating their important role in the immunosuppression characteristic of EBOV infections. Bystander lymphocyte apoptosis,previously described in end-stage tissues, occurred early in the disease-course in intravascular and ex-travascular locations. Of note, apoptosis and loss of NK cells was a prominent finding, suggesting the im-portance of innate immunity in determining the fateof the host. Analysis of peripheral blood mononu-clear cell gene expression showed temporal increasesin tumor necrosis factor-related apoptosis-inducing ligand and Fas transcripts, revealing a possible mech-anism for the observed bystander apoptosis, while up-regulation of NAIP and cIAP2 mRNA suggest that EBOV has evolved additional mechanisms to resist host defenses by inducing protective transcripts in cells that it infects. The sequence of pathogeneticevents identified in this study should provide new targets for rational prophylactic and chemotherapeu-ticinterventions.
Among viruses causing hemorrhagic fever (HF), andamong emerging infectious diseases with global impactin general, Ebola virus (EBOV) stands out for its impres-sive lethality. Along with Marburg virus (MBGV), the fourspecies of EBOV (Zaire, Sudan, Reston, Ivory Coast)make up the negative-stranded, enveloped RNA virusfamily
. Acute mortality caused by the Zairespecies of EBOV is approximately 80% in human out-breaks
and greater than 90% in monkey models of thegenus
There is currently no vaccine or ther-apy for EBOV or MBGV hemorrhagic fever approved forhuman use. Progress in understanding the origins of thepathophysiologic changes that make EBOV infections ofhumanssodevastatinghavebeenslow;aprimaryreasonis the status of filoviruses as biosafety level 4 pathogensnecessitating study in high-containment settings.Animal models that adequately reproduce humanEBOV HF are clearly needed to gain further insight intothe pathogenesis of this disease. Previous vaccine anddrug intervention strategies in rodents, with few excep-tions, have failed to predict protection of nonhuman pri-mates against infection with Ebola virus (EBOV). We re-cently showed that two rodent models of EBOV infectionare not ideal for studying human EBOV HF; neither micenor guinea pigs exhibit the hemorrhagic manifestationsthat characterize human EBOV infections.
Others havealso noted differences in coagulopathy between the non-human primate and rodent models.
Furthermore, lym-phocyte apoptosis, which is associated with humanEBOV HF, was not a prominent feature of EBOV infectionin mice or guinea pigs.
Clinical disease and relatedpathology in nonhuman primates infected with EBOV ap-pear to more closely resemble features described inhuman EBOV hemorrhagic fever.
However, with fewexceptions, previous investigations examined naturallyinfected monkeys or animals killed when moribund, and
Supported by the Medical Chemical/Biological Defense Research Pro-gram, U.S. Army Medical Research and Material Command (project num-ber 02–4-4J-081).Accepted for publication August 26, 2003.Address reprint requests to Thomas W. Geisbert, USAMRIID, Attn:MCMR-UIV, 1425 Porter Street, Fort Detrick, MD 21702-5011. E-mail:tom.geisbert@amedd.army.mil.
American Journal of Pathology, Vol. 163, No. 6, December 2003 Copyright © American Society for Investigative Pathology 
shed little light on the pathogenesis of EBOV infectionduring times before death. The requirements to demon-strate efficacy of vaccines and/or various chemothera-peutic regimens intended for use in humans demand thatthe pathogenesis of the disease and correlates of immu-nity be understood in nonhuman primates.Several nonhuman primate species have been usedto model EBOV (Zaire) HF including African green mon-keys (
Chlorocebus aethiops
, formerly
Cercopithecus ae-thiops
cynomolgus macaques (
Macaca fascicu- laris
rhesus macaques (
Macaca mulatta
and hamadryad baboons (
Papio hamadryas
Similarpathological features of EBOV infection have been docu-mented among these species; however, African greenmonkeys do not present with a macular cutaneous rash,which is a characteristic feature of disease in macaquesand baboons.
Importantly, this rash is also aprominent feature of human disease.
We focusedmuch of our recent work on cynomolgus macaques, thespecies most frequently used for filoviral vaccine stud-ies.
Our cynomolgus monkey model uses a challengedose and route that reflects a likely laboratory exposureand has been uniformly lethal with animals dying 6 to 7days after exposure.
Modern virological methods have made it possible toinvestigate the genetic basis of virulence and to identifythe genes and their expression products affecting theseverity of the course of disease. While various clinicalpathology parameters have provided valuable informa-tion regarding filoviral disease, paradigms concerningthe intricate pathogenetic mechanisms of EBOV HF re-quire a more thorough understanding of the cells thatmaintain viral replication and functional changes in in-fected cells. The aim of this study was to characterize theearly stages of EBOV HF in a relevant nonhuman primatemodel of human disease. Understanding the kinetics ofhost-pathogen relationships and identification of criticalpathogenetic processes are important for the rationaldevelopment of vaccines and antiviral therapeutics. Inthe study described here, cynomolgus monkeys wereexperimentally inoculated with EBOV, and virological andhostparametersofinfectionwerelongitudinallyanalyzed.
Materials and Methods 
 Animals and Inoculations
Healthy, filovirus-seronegative, adult male cynomolgus(
Macaca fascicularis
) macaques (
21, 4 to 6.5 kg) wereused for these studies. Animals were inoculated in the leftor right caudal thigh with 1 ml of virus stock that con-tained 1000 plaque-forming units (PFU) of EBOV (Zairespecies). The EBOV used in this study was originallyobtained from a fatally infected human from the formerZaire in 1995.
Inoculated animals were monitored twiceeach day for signs of illness. Scheduled necropsies wereperformed at 1 (
3), 2 (
3), 3 (
4), 4 (
4), 5(
4), and 6 (
3) days postinfection. Longitudinalblood samples were analyzed by complete blood counts,clinical chemistry, and fluorescence-activated cell sorteranalysis of various cell populations (described below). Inaddition to animals euthanized and exsanguinated fornecropsy each day, blood was also collected from 9 ofthe monkeys at day 1, 12 at day 2, 6 at day 3, and 3 atday 4 postinfection.
Clinical Evaluation
Monkeys were observed twice daily for clinical signs ofillness, and signs were recorded on an individual clinicaldata record maintained for each animal. Each monkey wasspecifically evaluated for anorexia, diarrhea, nasal exu-dates, vomiting, conjunctivitis, cutaneous rash, dehydra-tion,centralnervoussystemdisturbances,reducedactivity,and hemorrhage, using a subjective scoring system.
Total white blood cell counts, white blood cell differen-tials, red blood cell counts, platelet counts, hematocritvalues, total hemoglobin, mean cell volume, mean cor-puscular volume, and mean corpuscular hemoglobinconcentration were determined from blood samples col-lected in tubes containing ethylene diaminetetraaceticacid (EDTA), using a laser-based hematological Analyzer(Coulter Electronics, Hialeah, FL). The white blood celldifferentials were performed manually on Wright-stainedblood smears.
Coagulation Tests and Serum Biochemistry 
Plasma levels of fibrin degradation products (D-dimers)were quantitated by an enzyme-linked immunosorbentassay (ELISA) according to manufacturer
s directions(Asserachrom D-Di; Diagnostica Stago, Inc., Parsippany,NJ). Serum samples were tested for sodium, potassium,chloride, calcium, phosphorus, partial pressure of oxy-gen (PO
), partial pressure of carbon dioxide (PCO
),bicarbonate as total CO
content (TCO
), and pH usingan i-STAT Portable Clinical Analyzer (i-STAT Corporation,Princeton, NJ). Concentrations of albumin (ALB), amylase(AMY), alanine aminotransferase (ALT), aspartate amino-transferase (AST), alkaline phosphatase (ALP),
-glutamyl-transferase (GGT), glucose (GLU), cholesterol (CHOL), to-tal protein (TP), total bilirubin (TBIL), urea nitrogen (BUN),and creatinine (Cr) were measured using a Piccolo Point-Of-Care Blood Analyzer (Abaxis, Sunnyvale, CA).
Detection of Endotoxin
Levels of gram-negative bacterial endotoxin in frozenplasma samples were measured with a commerciallyavailable chromogenic limulus amebocyte assay (Bio-Whittaker, Walkersville, MD). The absorbance of eachmicroplate well was read at 405 to 410 nm, and endotoxinconcentrations were calculated by linear regression. Tocontrol for nonspecific background, baseline absor-bance levels were collected immediately after addition ofchromagen (before development) and subtracted from
2348 Geisbert et al
AJP December 2003, Vol. 163, No. 6 
the absorbance measured after development. This cor-rected value was then used for the calculation of endo-toxin concentration. The virus inoculum used in this studywas assayed and shown to be free of endotoxin (
Cytokine/Chemokine and Nitrate Production
Cytokine/chemokine levels in monkey sera/plasma wereassayed using commercially available ELISA kits accord-ing to manufacturer
s directions. Cytokines/chemokinesassayed included monkey interleukin (IL)-2, IL-4, IL-10,IL-12, interferon (IFN)-
, and tumor necrosis factor(TNF)-
(BioSource International, Inc., Camarillo, CA).ELISAs for human proteins known to be compatible withcynomolgus macaques included IL-6, IFN-
, IFN-
, MIP-1
, and MIP-1
(BioSource); and human IL-1
, IL-8, IL-18, and MCP-1 (R&D Systems, Minneapolis, MN). Nitratelevels were determined using a colorimetric assay ac-cording to manufacturer
s directions (R&D Systems).
A complete necropsy was performed on all animals. Tis-sue samplesofall majororganswere collectedfromeachmonkey for histopathological, immunohistochemical, and
 in situ
hybridization examination andwereimmersion-fixedin 10% neutral-buffered formalin. Select tissues for ultra-structural examination were immersion-fixed in 4% formal-dehyde plus 1% glutaraldehyde in 0.1 mol/L Millonig
sphosphate buffer for transmission electron microscopy(TEM) or 2% formaldehyde plus 0.1% glutaraldehyde in theMillonig
s buffer for immunoelectron microscopy.
Formalin-fixed tissues for histology, immunohistochemis-try, and
in situ
hybridization were processed and embed-ded in paraffin according to conventional methods.
Histology sections were cut at 5 to 6
m on a rotarymicrotome, mounted on glass slides, and stained withhemotoxylin and eosin. Replicate sections of all tissueswere mounted on positively charged glass slides (Super-frost Plus; Fisher Scientific, Pittsburgh, PA) and immuno-histochemically stained for detection of viral antigen byan immunoperoxidase method according to kit proce-dures (Envision System; DAKO Corporation, Carpinteria,CA), or by a fluorescence-based method.
Immunoenzymatic Methodology 
Sections were deparaffinized and rehydrated througha series of graded ethanols, pretreated with ready-to-useProteinase K (DAKO) for 6 minutes at room temperature,and blocked with Protein Block Serum-Free (DAKO) for20 minutes before exposure to antibody. Tissue sectionswere incubated with primary antibody overnight a 4
Cusing an anti-EBOV rabbit polyclonal (kindly provided byCindy Rossi) (1:500) or an equal mixture of mouse mono-clonal antibodies to EBOV GP and VP40 (1:5000).
Analkaline phosphatase-labeled polymer (DAKO EnvisionSystem, alkaline phosphatase) was added for 30 minutesand color development was achieved by exposing tissueto the substrate 6-bromo-2-hydroxyl-3-naphtholic acid(Histomark Red; Kirkegaard and Perry, Gaithersburg, MD)for 50 minutes in the dark. Sections were counterstainedwith hematoxylin. Negative controls included replicate sec-tions exposed to anti-Marburg virus antibodies and unex-posedcynomolgusmonkeytissue;archivedEBOV-infectedcynomolgus tissue served as positive controls.
Immunofluorescence Methodology 
Tissue sections were deparaffinized, rehydrated, andincubated in 20
g/ml of proteinase K for 30 minutes atroom temperature. Sections were subsequently rinsed,placedinnormalgoatserumfor20minutesandtransferredto a mixture of the anti-EBOV monoclonal antibodies asdescribed above for 30 minutes at room temperature. Afterincubation, sections were rinsed and stained with goat anti-mouse Alexa 594 (Molecular Probes, Eugene, OR), incu-bated with a pan T-cell marker, CD3 (DAKO) for 30 minutesat room temperature, rinsed, and incubated in goat anti-mouse Alexa 488 (Molecular Probes).For co-localization of macrophage and/or dendritic cellmarkers and EBOV antigens, two different techniqueswere performed. Briefly, deparaffinized tissue sectionswere pretreated with proteinase K (20
g/ml) for 30 min-utes at room temperature and incubated in normal goatserum for 20 minutes. Sections were then incubated ineither a macrophage marker (Ab-1, Oncogene ResearchProducts, San Diego, CA), or a marker for dendritic cells(DC-SIGN, kindly provided by Dr. Vineet KewalRamani,NCI-Frederick), for 30 minutes at room temperature. Afterincubation, sections were placed in goat anti-mouse Al-exa 594 (Molecular Probes) for 30 minutes at room tem-perature and rinsed. Sections were transferred to ablocking solution consisting of a cocktail of mouse IgGsand irrelevant mouse anti-Marburg virus antibodies, andincubated for 20 minutes at room temperature. The ex-cess blocking cocktail was removed and sections wereincubated in a fluorescein isothiocyanate (FITC)-conju-gated EBOV for 30 minutes at room temperature. TheFITC-conjugated anti-EBOV pool was produced by dilut-ing the purified, concentrated anti-EBOV murine mono-clonal antibodies (described above) to 1 mg/ml and dia-lyzing overnight at 4
C in 0.1 mol/L sodium bicarbonatebuffer (pH 8.5). The antibodies were recovered andmixed with FITC on celite (
-Aldrich, St. Louis, MO) andincubated, rotating, for 2 hours at room temperature.FITC-conjugated antibodies were then separated fromunbound FITC by passage over a Sephadex G-25 (Am-ersham Biosciences, Piscataway, NJ) column. To in-crease the sensitivity of the staining, sections were incu-bated in an anti-FITC Alexa 488 (Molecular Probes) for 30minutes at room temperature. After rinsing in PBS, sec-tions were mounted in an aqueous mounting mediumcontaining 4
-diamidino-2-phenylindole (DAPI) (Vector
Ebola Pathogenesis in Cynomolgus Monkeys 2349
AJP December 2003, Vol. 163, No. 6 

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