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Elevated VEGF Levels in Pulmonary Edema Fluid and PBMCs from Patients with Acute Hantavirus Pulmonary Syndrome

DOI: 10.1155/2012/674360

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Hantavirus pulmonary syndrome is characterized by vascular permeability, hypoxia, and acute pulmonary edema. Vascular endothelial growth factor (VEGF) is induced by hypoxia, potently induces vascular permeability, and is associated with high-altitude-induced pulmonary edema. Hantaviruses alter the normal regulation of β3 integrins that restrict VEGF-directed permeability and hantavirus infected endothelial cells are hyperresponsive to the permeabilizing effects of VEGF. However, the role of VEGF in acute pulmonary edema observed in HPS patients remains unclear. Here we retrospectively evaluate VEGF levels in pulmonary edema fluid (PEF), plasma, sera, and PBMCs from 31 HPS patients. VEGF was elevated in HPS patients PEF compared to controls with the highest levels observed in PEF samples from a fatal HPS case. VEGF levels were highest in PBMC samples during the first five days of hospitalization and diminished during recovery. Significantly increased PEF and PBMC VEGF levels are consistent with acute pulmonary edema observed in HPS patients and HPS disease severity. We observed substantially lower VEGF levels in a severe HPS disease survivor after extracorporeal membrane oxygenation. These findings suggest the importance of patients’ VEGF levels during HPS, support the involvement of VEGF responses in HPS pathogenesis, and suggest targeting VEGF responses as a potential therapeutic approach. 1. Introduction Hantavirus Pulmonary Syndrome (HPS) is a hallmark capillary leak syndrome with a ~40% mortality rate, and Sin Nombre (SNV) is a prototypical HPS causing hantavirus associated with outbreaks of HPS disease in the Southwestern United States [1–5]. HPS is characterized by an acute febrile prodrome with thrombocytopenia rapidly progressing to acute pulmonary edema, hypoxia respiratory insufficiency, hypotension, and cardiogenic shock [1, 2, 5–7]. Hantaviruses predominantly infect the endothelial cell lining of vessels that form the primary fluid barrier of the vasculature. The pathogenesis of HPS is likely to result from the direct infection of pulmonary endothelial cells as well as hantavirus-induced responses of endothelial and immune cells. Immune cells are hypothesized to contribute to hantavirus disease through elevated levels of CD8+ T cells and cytokines such as TNF, yet the vascular endothelium is not disrupted in patients [5, 8–15]. In vitro SNV-infected endothelial cells are not permeabilized by infection alone or following the addition of TNF [14, 16], however pathogenic hantaviruses bind and inactivate β3 integrins which normally restrict


[1]  F. Koster, K. Foucar, B. Hjelle et al., “Rapid presumptive diagnosis of hantavirus cardiopulmonary syndrome by peripheral blood smear review,” American Journal of Clinical Pathology, vol. 116, no. 5, pp. 665–672, 2001.
[2]  F. Koster and E. R. Mackow, “Pathogenesis of the hantavirus pulmonary syndrome,” Future Virology, vol. 7, no. 1, pp. 41–51, 2012.
[3]  S. T. Nichol, C. F. Spiropoulou, S. Morzunov et al., “Genetic identification of a hantavirus associated with an outbreak of acute respiratory illness,” Science, vol. 262, no. 5135, pp. 914–917, 1993.
[4]  C. Schmaljohn and B. Hjelle, “Hantaviruses: a global disease problem,” Emerging Infectious Diseases, vol. 3, no. 2, pp. 95–104, 1997.
[5]  S. R. Zaki, P. W. Greer, L. M. Coffield et al., “Hantavirus pulmonary syndrome: pathogenesis of an emerging infectious disease,” American Journal of Pathology, vol. 146, no. 3, pp. 552–579, 1995.
[6]  J. S. Duchin, F. T. Koster, C. J. Peters et al., “Hantavirus pulmonary syndrome: a clinical description of 17 patients with a newly recognized disease,” New England Journal of Medicine, vol. 330, no. 14, pp. 949–955, 1994.
[7]  K. B. Nolte, R. M. Feddersen, K. Foucar et al., “Hantavirus pulmonary syndrome in the United States: a pathological description of a disease caused by a new agent,” Human Pathology, vol. 26, no. 1, pp. 110–120, 1995.
[8]  M. Kanerva, J. Mustonen, and A. Vaheri, “Pathogenesis of puumala and other hantavirus infections,” Reviews in Medical Virology, vol. 8, no. 2, pp. 67–86, 1998.
[9]  E. D. Kilpatrick, M. Terajima, F. T. Koster, M. D. Catalina, J. Cruz, and F. A. Ennis, “Role of specific CD8+ T cells in the severity of a fulminant zoonotic viral hemorrhagic fever, hantavirus pulmonary syndrome,” Journal of Immunology, vol. 172, no. 5, pp. 3297–3304, 2004.
[10]  T. Krakauer, J. W. Leduc, and H. Krakauer, “Serum levels of tumor necrosis factor-α, interleukin-1, and interleukin-6 in hemorrhagic fever with renal syndrome,” Viral Immunology, vol. 8, no. 2, pp. 75–79, 1995.
[11]  E. R. Mackow and I. N. Gavrilovskaya, “Hantavirus regulation of endothelial cell functions,” Thrombosis and Haemostasis, vol. 102, no. 6, pp. 1030–1041, 2009.
[12]  P. Maes, J. Clement, P. H. P. Groeneveld, P. Colson, T. W. J. Huizinga, and M. Van Ranst, “Tumor necrosis factor-α genetic predisposing factors can influence clinical severity in nephropathia epidemica,” Viral Immunology, vol. 19, no. 3, pp. 558–564, 2006.
[13]  M. Mori, A. L. Rothman, I. Kurane et al., “High levels of cytokine-producing cells in the lung tissues of patients with fatal hantavirus pulmonary syndrome,” Journal of Infectious Diseases, vol. 179, no. 2, pp. 295–302, 1999.
[14]  J. B. Sundstrom, L. K. McMullan, C. F. Spiropoulou et al., “Hantavirus infection induces the expression of RANTES and IP-10 without causing increased permeability in human lung microvascular endothelial cells,” Journal of Virology, vol. 75, no. 13, pp. 6070–6085, 2001.
[15]  M. Temonen, J. Mustonen, H. Helin, A. Pasternack, A. Vaheri, and H. Holth?fer, “Cytokines, adhesion molecules, and cellular infiltration in nephropathia epidemica kidneys: an immunohistochemical study,” Clinical Immunology and Immunopathology, vol. 78, no. 1, pp. 47–55, 1996.
[16]  S. F. Khaiboullina, D. M. Netski, P. Krumpe, and S. C. S. Jeor, “Effects of tumor necrosis factor alpha on Sin Nombre virus infection in vitro,” Journal of Virology, vol. 74, no. 24, pp. 11966–11971, 2000.
[17]  I. N. Gavrilovskaya, E. E. Gorbunova, and E. R. Mackow, “Pathogenic hantaviruses direct the adherence of quiescent platelets to infected endothelial cells,” Journal of Virology, vol. 84, no. 9, pp. 4832–4839, 2010.
[18]  I. N. Gavrilovskaya, E. E. Gorbunova, N. A. Mackow, and E. R. Mackow, “Hantaviruses direct endothelial cell permeability by sensitizing cells to the vascular permeability factor VEGF, while angiopoietin 1 and sphingosine 1-phosphate inhibit hantavirus-directed permeability,” Journal of Virology, vol. 82, no. 12, pp. 5797–5806, 2008.
[19]  I. N. Gavrilovskaya, T. Peresleni, E. Geimonen, and E. R. Mackow, “Pathogenic hantaviruses selectively inhibit β3 integrin directed endothelial cell migration,” Archives of Virology, vol. 147, no. 10, pp. 1913–1931, 2002.
[20]  T. Raymond, E. Gorbunova, I. N. Gavrilovskaya, and E. R. Mackow, “Pathogenic hantaviruses bind plexin-semaphorin-integrin domains present at the apex of inactive, bent αvβ3 integrin conformers,” Proceedings of the National Academy of Sciences of the United States of America, vol. 102, no. 4, pp. 1163–1168, 2005.
[21]  S. D. Robinson, L. E. Reynolds, L. Wyder, D. J. Hicklin, and K. M. Hodivala-Dilke, “β3-integrin regulates vascular endothelial growth factor-A-dependent permeability,” Arteriosclerosis, Thrombosis, and Vascular Biology, vol. 24, no. 11, pp. 2108–2114, 2004.
[22]  B. Chang, M. Crowley, M. Campen, and F. Koster, “Hantavirus cardiopulmonary syndrome,” Seminars in Respiratory and Critical Care Medicine, vol. 28, no. 2, pp. 193–200, 2007.
[23]  E. Geimonen, S. Neff, T. Raymond, S. S. Kocer, I. N. Gavrilovskaya, and E. R. Mackow, “Pathogenic and nonpathogenic hantaviruses differentially regulate endothelial cell responses,” Proceedings of the National Academy of Sciences of the United States of America, vol. 99, no. 21, pp. 13837–13842, 2002.
[24]  E. Gorbunova, I. N. Gavrilovskaya, and E. R. Mackow, “Pathogenic hantaviruses Andes virus and Hantaan virus induce adherens junction disassembly by directing vascular endothelial cadherin internalization in human endothelial cell,” Journal of Virology, vol. 84, no. 14, pp. 7405–7411, 2010.
[25]  S. F. Khaiboullina, A. A. Rizvanov, E. Otteson, A. Miyazato, J. Maciejewski, and S. S. Jeor, “Regulation of cellular gene expression in endothelial cells by Sin Nombre and Prospect Hill viruses,” Viral Immunology, vol. 17, no. 2, pp. 234–251, 2004.
[26]  R. Yanagihara and D. J. Silverman, “Experimental infection of human vascular endothelial cells by pathogenic and nonpathogenic hantaviruses,” Archives of Virology, vol. 111, no. 3-4, pp. 281–286, 1990.
[27]  K. M. Hodivala-Dilke, K. P. McHugh, D. A. Tsakiris et al., “β3-integrin-deficient mice are a model for Glanzmann thrombasthenia showing placental defects and reduced survival,” Journal of Clinical Investigation, vol. 103, no. 2, pp. 229–238, 1999.
[28]  A. R. Reynolds, L. E. Reynolds, T. E. Nagel et al., “Elevated Flk1 (vascular endothelial growth factor receptor 2) signaling mediates enhanced angiogenesis in β3-integrin-deficient mice,” Cancer Research, vol. 64, no. 23, pp. 8643–8650, 2004.
[29]  I. N. Gavrilovskaya, M. Shepley, R. Shaw, M. H. Ginsberg, and E. R. Mackow, “β3 integrins mediate the cellular entry of hantaviruses that cause respiratory failure,” Proceedings of the National Academy of Sciences of the United States of America, vol. 95, no. 12, pp. 7074–7079, 1998.
[30]  E. E. Gorbunova, I. N. Gavrilovskaya, T. Pepini, and E. R. Mackow, “VEGFR2 and Src kinase inhibitors suppress Andes virus-induced endothelial cell permeability,” Journal of Virology, vol. 85, no. 5, pp. 2296–2303, 2011.
[31]  T. Pepini, E. E. Gorbunova, I. N. Gavrilovskaya, J. E. Mackow, and E. R. Mackow, “Andes virus regulation of cellular microRNAs contributes to hantavirus-induced endothelial cell permeability,” Journal of Virology, vol. 84, no. 22, pp. 11929–11936, 2010.
[32]  H. F. Dvorak, L. F. Brown, M. Detmar, and A. M. Dvorak, “Vascular permeability factor/vascular endothelial growth factor, microvascular hyperpermeability, and angiogenesis,” American Journal of Pathology, vol. 146, no. 5, pp. 1029–1039, 1995.
[33]  M. Hanaoka, Y. Droma, A. Naramoto, T. Honda, T. Kobayashi, and K. Kubo, “Vascular endothelial growth factor in patients with high-altitude pulmonary edema,” Journal of Applied Physiology, vol. 94, no. 5, pp. 1836–1840, 2003.
[34]  M. M. Berger, C. Hesse, C. Dehnert et al., “Hypoxia impairs systemic endothelial function in individuals prone to high-altitude pulmonary edema,” American Journal of Respiratory and Critical Care Medicine, vol. 172, no. 6, pp. 763–767, 2005.
[35]  M. Dehler, E. Zessin, P. B?rtsch, and H. Mairb?url, “Hypoxia causes permeability oedema in the constant-pressure perfused rat lung,” European Respiratory Journal, vol. 27, no. 3, pp. 600–606, 2006.
[36]  H. F. Dvorak, “Vascular permeability to plasma, plasma proteins, and cells: an update,” Current Opinion in Hematology, vol. 17, no. 3, pp. 225–229, 2010.
[37]  K. R. Stenmark, K. A. Fagan, and M. G. Frid, “Hypoxia-induced pulmonary vascular remodeling: cellular and molecular mechanisms,” Circulation Research, vol. 99, no. 7, pp. 675–691, 2006.
[38]  N. Tang, L. Wang, J. Esko et al., “Loss of HIF-1α in endothelial cells disrupts a hypoxia-driven VEGF autocrine loop necessary for tumorigenesis,” Cancer Cell, vol. 6, no. 5, pp. 485–495, 2004.
[39]  R. J. Kaner and R. G. Crystal, “Pathogenesis of high altitude pulmonary edema: does alveolar epithelial lining fluid vascular endothelial growth factor exacerbate capillary leak?” High Altitude Medicine and Biology, vol. 5, no. 4, pp. 399–409, 2004.
[40]  R. J. Kaner, J. V. Ladetto, R. Singh, N. Fukuda, M. A. Matthay, and R. G. Crystal, “Lung overexpression of the vascular endothelial growth factor gene induces pulmonary edema,” American Journal of Respiratory Cell and Molecular Biology, vol. 22, no. 6, pp. 657–664, 2000.
[41]  B. Hjelle, S. Jenison, N. Torrez-Martinez et al., “Rapid and specific detection of Sin Nombre virus antibodies in patients with hantavirus pulmonary syndrome by a strip immunoblot assay suitable for field diagnosis,” Journal of Clinical Microbiology, vol. 35, no. 3, pp. 600–608, 1997.
[42]  G. W. Hallin, S. Q. Simpson, R. E. Crowell et al., “Cardiopulmonary manifestations of hantavirus pulmonary syndrome,” Critical Care Medicine, vol. 24, no. 2, pp. 252–258, 1996.
[43]  M. R. Crowley, R. W. Katz, R. Kessler et al., “Successful treatment of adults with severe Hantavirus pulmonary syndrome with extracorporeal membrane oxygenation,” Critical Care Medicine, vol. 26, no. 2, pp. 409–414, 1998.
[44]  H. F. Dvorak, T. M. Sioussat, L. F. Brown et al., “Distribution of vascular permeability factor (vascular endothelial growth factor) in tumors: concentration in tumor blood vessels,” Journal of Experimental Medicine, vol. 174, no. 5, pp. 1275–1278, 1991.
[45]  E. A. Bustamante, H. Levy, and S. Q. Simpson, “Pleural fluid characteristics in hantavirus pulmonary syndrome,” Chest, vol. 112, no. 4, pp. 1133–1136, 1997.
[46]  H. F. Dvorak, “Discovery of vascular permeability factor (VPF),” Experimental Cell Research, vol. 312, no. 5, pp. 522–526, 2006.
[47]  I. Pham, T. Uchida, C. Planes et al., “Hypoxia upregulates VEGF expression in alveolar epithelial cells in vitro and in vivo,” American Journal of Physiology-Lung Cellular and Molecular Physiology, vol. 283, no. 5, pp. L1133–L1142, 2002.
[48]  E. Dejana, F. Orsenigo, and M. G. Lampugnani, “The role of adherens junctions and VE-cadherin in the control of vascular permeability,” Journal of Cell Science, vol. 121, no. 13, pp. 2115–2122, 2008.
[49]  J. Gavard and J. S. Gutkind, “VEGF Controls endothelial-cell permeability promoting β-arrestin-dependent Endocytosis VE-cadherin,” Nature Cell Biology, vol. 8, no. 11, pp. 1223–1234, 2006.
[50]  M. G. Lampugnani and E. Dejana, “The control of endothelial cell functions by adherens junctions,” Novartis Foundation Symposium, vol. 283, pp. 4–13, 2007.
[51]  M. G. Lampugnani and E. Dejana, “Adherens junctions in endothelial cells regulate vessel maintenance and angiogenesis,” Thrombosis Research, vol. 120, supplement 2, pp. S1–S6, 2007.
[52]  R. J. Kaner and R. G. Crystal, “Compartmentalization of vascular endothelial growth factor to the epithelial surface of the human lung,” Molecular Medicine, vol. 7, no. 4, pp. 240–246, 2001.
[53]  S. R. Hopkins, J. Garg, D. S. Bolar, J. Balouch, and D. L. Levin, “Pulmonary blood flow heterogeneity during hypoxia and high-altitude pulmonary edema,” American Journal of Respiratory and Critical Care Medicine, vol. 171, no. 1, pp. 83–87, 2005.
[54]  G. Thurston, J. S. Rudge, E. Ioffe et al., “Angiopoietin-1 protects the adult vasculature against plasma leakage,” Nature Medicine, vol. 6, no. 4, pp. 460–463, 2000.
[55]  G. Thurston, C. Suri, K. Smith et al., “Leakage-resistant blood vessels in mice transgenically overexpressing angiopoietin-1,” Science, vol. 286, no. 5449, pp. 2511–2514, 1999.
[56]  Y. Wang, S. Pampou, K. Fujikawa, and L. Varticovski, “Opposing effect of angiopoietin-1 on VEGF-mediated disruption of endothelial cell-cell interactions requires activation of PKCβ,” Journal of Cellular Physiology, vol. 198, no. 1, pp. 53–61, 2004.
[57]  M. Watanabe, J. L. Boyer, and R. G. Crystal, “Genetic delivery of bevacizumab to suppress vascular endothelial growth factor-induced high-permeability pulmonary edema,” Human Gene Therapy, vol. 20, no. 6, pp. 598–610, 2009.
[58]  C. A. Dietl, J. A. Wernly, S. B. Pett et al., “Extracorporeal membrane oxygenation support improves survival of patients with severe Hantavirus cardiopulmonary syndrome,” Journal of Thoracic and Cardiovascular Surgery, vol. 135, no. 3, pp. 579–584, 2008.
[59]  D. Mukhopadhyay, L. Tsiokas, X. M. Zhou, D. Foster, J. S. Brugge, and V. P. Sukhatme, “Hypoxic induction of human vascular endothelial growth factor expression through c-Src activation,” Nature, vol. 375, no. 6532, pp. 577–581, 1995.
[60]  P. Salven, A. Orpana, and H. Joensuu, “Leukocytes and platelets of patients with cancer contain high levels of vascular endothelial growth factor,” Clinical Cancer Research, vol. 5, no. 3, pp. 487–491, 1999.
[61]  J. Zhang, T. Silva, T. Yarovinsky et al., “VEGF blockade inhibits lymphocyte recruitment and ameliorates immune-mediated vascular remodeling,” Circulation Research, vol. 107, no. 3, pp. 408–417, 2010.
[62]  L. B. Ware, R. J. Kaner, R. G. Crystal et al., “VEGF levels in the alveolar compartment do not distinguish between ARDS and hydrostatic pulmonary oedama,” European Respiratory Journal, vol. 26, no. 1, pp. 101–105, 2005.
[63]  R. Xiao, S. Yang, F. Koster, C. Ye, C. Stidley, and B. Hjelle, “Sin Nombre viral RNA load in patients with hantavirus cardiopulmonary syndrome,” Journal of Infectious Diseases, vol. 194, no. 10, pp. 1403–1409, 2006.
[64]  F. Gracia, B. Armien, S. Q. Simpson et al., “Convalescent pulmonary dysfunction following hantavirus pulmonary syndrome in panama and the United States,” Lung, vol. 188, no. 5, pp. 387–391, 2010.


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