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Mashkoor Y, Nadeem A, Fatima T, Aamir M, Vohra LI, Habib A, Khan A, Raufi N, Habte A. Neurological complications of influenza vaccination: navigating the spectrum with a focus on acute disseminated encephalomyelitis (ADEM). Ann Med Surg (Lond) 2024; 86:1029-1041. [PMID: 38333316 PMCID: PMC10849354 DOI: 10.1097/ms9.0000000000001656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Accepted: 12/13/2023] [Indexed: 02/10/2024] Open
Abstract
Introduction Acute disseminated encephalomyelitis (ADEM) is a rare neurological disorder characterized by inflammation in the brain and spinal cord. This systematic review aims to investigate the potential association between ADEM and influenza vaccination by analyzing relevant case reports. ADEM is traditionally thought to be a monophasic condition, predominantly affecting children, often following viral illnesses or immunizations. Recent attention has focused on a possible link between ADEM and influenza vaccination, prompting the need for a thorough investigation. Methods The systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and the AMSTAR2 (A MeaSurement Tool to Assess systematic Reviews 2) guidelines. Electronic searches were conducted on PubMed, Cochrane Library, and clinicaltrials.gov databases, spanning up to August 2023. Inclusion criteria encompassed full-text articles in English, observational studies, case reports, and case series providing comprehensive details for confirming clinical diagnoses of ADEM following influenza vaccination. Data were extracted, including demographic information, vaccination details, clinical symptoms, diagnostic evaluations, treatment modalities, and outcomes. Quality assessment was performed using the Joanna Briggs Institute (JBI) Critical Appraisal tool. Results A total of 23 cases of ADEM following influenza vaccination were identified from 19 included articles. The mean age of affected individuals was 40.2 years (±25.7) with 60.8% being male. Common presenting symptoms included muscle weakness (52.1%), urinary abnormalities (30.4%), altered consciousness (26%), and sensory disturbances (26%). Neurological examination revealed findings such as extensor plantar reflex (positive Babinski sign) in 26%, hyperreflexia in 30.4%, and generalized hyporeflexia in 13% of the cases. Diagnostic evaluations involved MRI, showing multiple hyperintense lesions in cerebral hemispheres (43.4%), subcortex (60.8%), and spinal cord (39.1%). Cerebrospinal fluid analysis indicated elevated white blood cell count in 69.5% of cases, with lymphocytic pleocytosis in 52.1%. Oligoclonal bands were reported positively in 8.6% of cases. Treatment approaches varied, with intravenous methylprednisolone being the most common (39.1%). Out of the 23 cases, two (8.6%) patients had a fatal outcome, while the rest showed clinical improvement with complete or partial resolution of symptoms. Persisting symptoms included numbness in the lower extremities (8.6%) and impaired ability to walk after 10 months (4.3%). Conclusion While the association between ADEM and influenza vaccination is rare, healthcare professionals should remain vigilant and consider patients' vaccination history, particularly following an influenza immunization. This systematic review highlights the clinical manifestations, diagnostic tools, treatment approaches, and outcomes of ADEM cases post-influenza vaccination. Further research is essential to understand this association and improve clinical decision-making, ensuring the safety and efficacy of immunization programs.
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Affiliation(s)
| | | | - Tehreem Fatima
- Department of Medicine, Dow University of Health Sciences
| | - Minahil Aamir
- Department of Medicine, Dow University of Health Sciences
| | - Laiba I. Vohra
- Department of Medicine, Ziauddin University, Karachi, Sindh, Pakistan
| | | | - Afsheen Khan
- Department of Medicine, Dow University of Health Sciences
| | - Nahid Raufi
- Department of Medicine, Kabul Medical University, Kabul, Afghanistan
| | - Alexander Habte
- Department of Surgery, Assab Military Hospital, Assab, Eritrea
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Chen WT, Huang YC, Peng MC, Wang MC, Lin KP. Acute Disseminated Encephalomyelitis After Influenza Vaccination: A Case Report. Crit Care Nurse 2018; 36:e1-6. [PMID: 27252106 DOI: 10.4037/ccn2016808] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Acute disseminated encephalomyelitis is an inflammatory demyelinating disease of the central nervous system that has been associated with influenza immunization, but only a few cases related to vaccination for influenza have been reported. Acute disseminated encephalomyelitis developed in a 42-year-old woman within 3 weeks of receiving the seasonal influenza vaccine. She had 80% recovery after 3 months of treatment with methylprednisolone. Although cases of acute disseminated encephalomyelitis after vaccination for influenza are rare, enough of them have occurred that critical care nurses should be aware of the possibility. Early treatment can prevent serious residual signs and symptoms; therefore, correct and quick diagnosis is important. Medical history obtained from patients with central nervous system problems should include history of recent vaccinations.
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Affiliation(s)
- Wei-Ti Chen
- Wei-Ti Chen is an assistant professor, Yale University, School of Nursing, West Haven, Connecticut.Yi-Chen Huang and Meng-Chin Peng are assistant head nurses, and Ming-Chu Wang is a staff nurse at Veterans General Hospital, Taipei, Taiwan.Kon-Ping Lin is an attending physician, Department of Neurology, Veterans General Hospital, Taipei, Taiwan
| | - Yi-Chen Huang
- Wei-Ti Chen is an assistant professor, Yale University, School of Nursing, West Haven, Connecticut.Yi-Chen Huang and Meng-Chin Peng are assistant head nurses, and Ming-Chu Wang is a staff nurse at Veterans General Hospital, Taipei, Taiwan.Kon-Ping Lin is an attending physician, Department of Neurology, Veterans General Hospital, Taipei, Taiwan
| | - Meng-Chin Peng
- Wei-Ti Chen is an assistant professor, Yale University, School of Nursing, West Haven, Connecticut.Yi-Chen Huang and Meng-Chin Peng are assistant head nurses, and Ming-Chu Wang is a staff nurse at Veterans General Hospital, Taipei, Taiwan.Kon-Ping Lin is an attending physician, Department of Neurology, Veterans General Hospital, Taipei, Taiwan
| | - Ming-Chu Wang
- Wei-Ti Chen is an assistant professor, Yale University, School of Nursing, West Haven, Connecticut.Yi-Chen Huang and Meng-Chin Peng are assistant head nurses, and Ming-Chu Wang is a staff nurse at Veterans General Hospital, Taipei, Taiwan.Kon-Ping Lin is an attending physician, Department of Neurology, Veterans General Hospital, Taipei, Taiwan
| | - Kon-Ping Lin
- Wei-Ti Chen is an assistant professor, Yale University, School of Nursing, West Haven, Connecticut.Yi-Chen Huang and Meng-Chin Peng are assistant head nurses, and Ming-Chu Wang is a staff nurse at Veterans General Hospital, Taipei, Taiwan.Kon-Ping Lin is an attending physician, Department of Neurology, Veterans General Hospital, Taipei, Taiwan.
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Vaccine-associated inflammatory diseases of the central nervous system: from signals to causation. Curr Opin Neurol 2018; 29:362-71. [PMID: 27023738 DOI: 10.1097/wco.0000000000000318] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
PURPOSE OF REVIEW As the most cost-effective intervention in preventive medicine and as a crucial element of any public health program, vaccination is used extensively with over 90% coverage in many countries. As approximately 5-8% of the population in developed countries suffer from an autoimmune disorder, people with an autoimmune disease are most likely to be exposed to some vaccines before or after the disease onset. In fact, a number of inflammatory disorders of the central nervous system have been associated with the administration of various vaccines. These adverse events, be they spurious associations or genuine reactions to the vaccine, may lead to difficulties in obtaining public trust in mass vaccination programs. There is, thus, an urgent need to understand whether vaccination triggers or enhances autoimmune responses. RECENT FINDINGS By reviewing vaccine-associated inflammatory diseases of the central nervous system, this study describes the current knowledge on whether the safety signal was coincidental, as in the case of multiple sclerosis with several vaccines, or truly reflected a causal link, as in narcolepsy with cataplexy following pandemic H1N1 influenza virus vaccination. SUMMARY The lessons learnt emphasize a central role of thorough, ideally prospective, epidemiological studies followed, if the signal is deemed plausible or real, by immunological investigations.
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Sadasivan S, Zanin M, O’Brien K, Schultz-Cherry S, Smeyne RJ. Induction of microglia activation after infection with the non-neurotropic A/CA/04/2009 H1N1 influenza virus. PLoS One 2015; 10:e0124047. [PMID: 25861024 PMCID: PMC4393251 DOI: 10.1371/journal.pone.0124047] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2014] [Accepted: 02/26/2015] [Indexed: 12/29/2022] Open
Abstract
Although influenza is primarily a respiratory disease, it has been shown, in some cases, to induce encephalitis, including people acutely infected with the pandemic A/California/04/2009 (CA/09) H1N1 virus. Based on previous studies showing that the highly pathogenic avian influenza (HPAI) A/Vietnam/1203/2004 H5N1 virus was neurotropic, induced CNS inflammation and a transient parkinsonism, we examined the neurotropic and inflammatory potential of the CA/09 H1N1 virus in mice. Following intranasal inoculation, we found no evidence for CA/09 H1N1 virus neurotropism in the enteric, peripheral or central nervous systems. We did, however, observe a robust increase in microglial activity in the brain characterized by an increase in the number of activated Iba-1-positive microglia in the substantia nigra (SN) and the hippocampus, despite the absence of virus in the brain. qPCR analysis in SN tissue showed that the induction of microgliosis was preceded by reduced gene expression of the neurotrophic factors bdnf, and gdnf and increases in the immune modulatory chemokine chemokine (C-C motif) ligand 4 (ccl4). We also noted changes in the expression of transforming growth factor-1 (tgfβ1) in the SN starting at 7 days post-infection (dpi) that was sustained through 21 dpi, coupled with increases in arginase-1 (arg1) and csf1, M2 markers for microglia. Given that neuroinflammation contributes to generation and progression of a number of neurodegenerative disorders, these findings have significant implications as they highlight the possibility that influenza and perhaps other non-neurotropic viruses can initiate inflammatory signals via microglia activation in the brain and contribute to, but not necessarily be the primary cause of, neurodegenerative disorders.
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Affiliation(s)
- Shankar Sadasivan
- Department of Developmental Neurobiology, Saint Jude Children’s Research Hospital, Memphis, Tennessee, 38105, United States of America
| | - Mark Zanin
- Department of Infectious Diseases, Saint Jude Children’s Research Hospital, Memphis, Tennessee, 38105, United States of America
| | - Kevin O’Brien
- Department of Infectious Diseases, Saint Jude Children’s Research Hospital, Memphis, Tennessee, 38105, United States of America
| | - Stacey Schultz-Cherry
- Department of Infectious Diseases, Saint Jude Children’s Research Hospital, Memphis, Tennessee, 38105, United States of America
| | - Richard J. Smeyne
- Department of Developmental Neurobiology, Saint Jude Children’s Research Hospital, Memphis, Tennessee, 38105, United States of America
- * E-mail:
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Lateef TM, Johann-Liang R, Kaulas H, Hasan R, Williams K, Caserta V, Nelson KB. Seizures, encephalopathy, and vaccines: experience in the National Vaccine Injury Compensation Program. J Pediatr 2015; 166:576-81. [PMID: 25477158 DOI: 10.1016/j.jpeds.2014.10.054] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2014] [Revised: 09/12/2014] [Accepted: 10/22/2014] [Indexed: 10/24/2022]
Abstract
OBJECTIVES To describe the demographic and clinical characteristics of children for whom claims were filed with the National Vaccine Injury Compensation Program (VICP) alleging seizure disorder and/or encephalopathy as a vaccine injury. STUDY DESIGN The National VICP within the Department of Health and Human Services compensates individuals who develop medical problems associated with a covered immunization. We retrospectively reviewed medical records of children younger than 2 years of age with seizures and/or encephalopathy allegedly caused by an immunization, where a claim was filed in the VICP between 1995 through 2005. RESULTS The VICP retrieved 165 claims that had sufficient clinical information for review. Approximately 80% of these alleged an injury associated with whole-cell diphtheria, pertussis (whooping cough), and tetanus or tetanus, diphtheria toxoids, and acellular pertussis vaccine. Pre-existing seizures were found in 13% and abnormal findings on a neurologic examination before the alleged vaccine injury in 10%. A final diagnostic impression of seizure disorder was established in 69%, of whom 17% (28 patients) had myoclonic epilepsy, including possible severe myoclonic epilepsy of infancy. Specific conditions not caused by immunization, such as tuberous sclerosis and cerebral dysgenesis, were identified in 16% of subjects. CONCLUSION A significant number of children with alleged vaccine injury had pre-existing neurologic or neurodevelopmental abnormalities. Among those developing chronic epilepsy, many had clinical features suggesting genetically determined epilepsy. Future studies that include genotyping may allow more specific therapy and prognostication, and enhance public confidence in vaccination.
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Affiliation(s)
- Tarannum M Lateef
- Department of Neurology, Children's National Medical Center and George Washington University School of Medicine, Washington, DC.
| | - Rosemary Johann-Liang
- Division of Vaccine Injury Compensation, Department of Health and Human Services, Rockville, MD
| | - Himanshu Kaulas
- Department of Neurology, Children's National Medical Center and George Washington University School of Medicine, Washington, DC
| | - Rakibul Hasan
- Department of Neurology, Children's National Medical Center and George Washington University School of Medicine, Washington, DC
| | - Karen Williams
- Division of Vaccine Injury Compensation, Department of Health and Human Services, Rockville, MD
| | - Vito Caserta
- Division of Vaccine Injury Compensation, Department of Health and Human Services, Rockville, MD
| | - Karin B Nelson
- Department of Neurology, Children's National Medical Center and George Washington University School of Medicine, Washington, DC; National Institute of Neurologic Disorders and Stroke, National Institutes of Health, Bethesda, MD
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Maeda K. [Acute disseminated encephalomyelitis following influenza vaccination]. Rinsho Shinkeigaku 2015; 55:269. [PMID: 25904259 DOI: 10.5692/clinicalneurol.55.269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Affiliation(s)
- Kengo Maeda
- Department of Neurology, National Hospital Organization Higashi-ohmi General Medical Center
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Urayoshi S, Matsumoto S, Miyatani H, Yoshida Y. A case of myositis of the deltoid muscle of the upper arm developing 1 week after influenza vaccination: case report. Clin Case Rep 2014; 3:135-8. [PMID: 25838900 PMCID: PMC4377242 DOI: 10.1002/ccr3.177] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2014] [Revised: 10/15/2014] [Accepted: 10/25/2014] [Indexed: 11/30/2022] Open
Abstract
We report a case of an elderly man who developed myositis of the deltoid muscle 8 days after influenza vaccination. Adverse reactions to influenza vaccine are generally immediate reactions. However, delayed-type hypersensitivity reactions, although rare, can occur after routine influenza vaccination.
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Affiliation(s)
| | - Satohiro Matsumoto
- Department of Gastroenterology, Saitama Medical Center, Jichi Medical University Saitama, Japan
| | - Hiroyuki Miyatani
- Department of Gastroenterology, Saitama Medical Center, Jichi Medical University Saitama, Japan
| | - Yukio Yoshida
- Department of Gastroenterology, Saitama Medical Center, Jichi Medical University Saitama, Japan
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Lessa R, Castillo M, Azevedo R, Azevedo F, Azevedo H. Neurological complications after H1N1 influenza vaccination: magnetic resonance imaging findings. ARQUIVOS DE NEURO-PSIQUIATRIA 2014; 72:496-9. [DOI: 10.1590/0004-282x20140064] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/24/2013] [Accepted: 04/22/2014] [Indexed: 11/21/2022]
Abstract
Objective: To report 4 different neurological complications of H1N1 virus vaccination. Method: Four patients (9, 16, 37 and 69 years of age) had neurological symptoms (intracranial hypertension, ataxia, left peripheral facial palsy of abrupt onset, altered mental status, myelitis) starting 4-15 days after H1N1 vaccination. MRI was obtained during the acute period. Results: One patient with high T2 signal in the cerebellum interpreted as acute cerebellitis; another, with left facial palsy, showed contrast enhancement within both internal auditory canals was present, however it was more important in the right side; one patient showed gyriform hyperintensities on FLAIR with sulcal effacement in the right fronto-parietal region; and the last one showed findings compatible with thoracic myelitis. Conclusion: H1N1 vaccination can result in important neurological complications probably secondary to post-vaccination inflammation. MRI detected abnormalities in all patients.
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Ussel IV, Boer W, Parizel P, Cras P, Jorens PG. Encephalitis related to a H1N1 vaccination: case report and review of the literature. Clin Neurol Neurosurg 2014; 124:8-15. [PMID: 24996055 DOI: 10.1016/j.clineuro.2014.06.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2013] [Revised: 05/24/2014] [Accepted: 06/02/2014] [Indexed: 10/25/2022]
Abstract
OBJECTIVES To illustrate that acute, even dramatic, demyelination of the central nervous system and encephalitis can occur after viral, i.e., influenza A/H1N1 vaccination or infection. PATIENTS AND METHODS We describe a case of encephalitis/acute disseminated encephalomyelitis associated with vaccination against influenza A/H1N1 and review the available literature. RESULTS We report a case of a 26-year-old female who developed symptoms of acute encephalitis 5 days after vaccination against the pandemic 2009 A/H1N1 influenza. MRI of the brain showed confluent T2-hyperintense signal intensity changes in the deep white matter which further confirmed the diagnosis of encephalitis/acute disseminated encephalomyelitis. Despite therapy with immunoglobulins and corticosteroids, her persistent vegetative state continued. In light of the dramatic cause of this case, we reviewed all 21 other previously reported cases of central nervous system demyelination related to H1N1 vaccination and/or infection. CONCLUSIONS The available data suggest that even severe central nervous system demyelination i.e. acute encephalitis/disseminated encephalomyelitis and transverse myelitis may very rarely be associated with vaccination against novel influenza A/H1N1 or with A/H1N1 infection itself.
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Affiliation(s)
- Isabelle Van Ussel
- Department of Critical Care Medicine, Antwerp University Hospital, University of Antwerp, Edegem, Belgium
| | - Willem Boer
- Department of Critical Care Medicine, Heerlen, The Netherlands
| | - Paul Parizel
- Department of Radiology, Antwerp University Hospital, University of Antwerp, Edegem, Belgium
| | - Patrick Cras
- Department of Neurology, Antwerp University Hospital, University of Antwerp, Edegem, Belgium; Born Bunge Institute, Wilrijk, Belgium
| | - Philippe G Jorens
- Department of Critical Care Medicine, Antwerp University Hospital, University of Antwerp, Edegem, Belgium.
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Karussis D, Petrou P. The spectrum of post-vaccination inflammatory CNS demyelinating syndromes. Autoimmun Rev 2014; 13:215-24. [DOI: 10.1016/j.autrev.2013.10.003] [Citation(s) in RCA: 125] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2013] [Accepted: 10/10/2013] [Indexed: 01/04/2023]
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Perricone C, Colafrancesco S, Mazor RD, Soriano A, Agmon-Levin N, Shoenfeld Y. Autoimmune/inflammatory syndrome induced by adjuvants (ASIA) 2013: Unveiling the pathogenic, clinical and diagnostic aspects. J Autoimmun 2013; 47:1-16. [PMID: 24238833 DOI: 10.1016/j.jaut.2013.10.004] [Citation(s) in RCA: 161] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2013] [Accepted: 10/21/2013] [Indexed: 12/23/2022]
Abstract
In 2011 a new syndrome termed 'ASIA Autoimmune/Inflammatory Syndrome Induced by Adjuvants' was defined pointing to summarize for the first time the spectrum of immune-mediated diseases triggered by an adjuvant stimulus such as chronic exposure to silicone, tetramethylpentadecane, pristane, aluminum and other adjuvants, as well as infectious components, that also may have an adjuvant effect. All these environmental factors have been found to induce autoimmunity by themselves both in animal models and in humans: for instance, silicone was associated with siliconosis, aluminum hydroxide with post-vaccination phenomena and macrophagic myofasciitis syndrome. Several mechanisms have been hypothesized to be involved in the onset of adjuvant-induced autoimmunity; a genetic favorable background plays a key role in the appearance on such vaccine-related diseases and also justifies the rarity of these phenomena. This paper will focus on protean facets which are part of ASIA, focusing on the roles and mechanisms of action of different adjuvants which lead to the autoimmune/inflammatory response. The data herein illustrate the critical role of environmental factors in the induction of autoimmunity. Indeed, it is the interplay of genetic susceptibility and environment that is the major player for the initiation of breach of tolerance.
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Affiliation(s)
- Carlo Perricone
- The Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel-Hashomer, Israel; Reumatologia, Dipartimento di Medicina Interna e Specialità Mediche, Sapienza Università di Roma, Rome, Italy
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microRNAs in circulation are altered in response to influenza A virus infection in humans. PLoS One 2013; 8:e76811. [PMID: 24116168 PMCID: PMC3792094 DOI: 10.1371/journal.pone.0076811] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2013] [Accepted: 08/28/2013] [Indexed: 12/24/2022] Open
Abstract
Changes in microRNA expression have been detected in vitro in influenza infected cells, yet little is known about them in patients. microRNA profiling was performed on whole blood of H1N1 patients to identify signature microRNAs to better understand the gene regulation involved and possibly improve diagnosis. Total RNA extracted from blood samples of influenza infected patients and healthy controls were subjected to microRNA microarray. Expression profiles of circulating microRNAs were altered and distinctly different in influenza patients. Expression of highly dysregulated microRNAs were validated using quantitative PCR. Fourteen highly dysregulated miRNAs, identified from the blood of influenza infected patients, provided a clear distinction between infected and healthy individuals. Of these, expression of miR-1260, -26a, -335*, -576-3p, -628-3p and -664 were consistently dysregulated in both whole blood and H1N1 infected cells. Potential host and viral gene targets were identified and the impact of microRNA dysregulation on the host proteome was studied. Consequences of their altered expression were extrapolated to changes in the host proteome expression. These highly dysregulated microRNAs may have crucial roles in influenza pathogenesis and are potential biomarkers of influenza.
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