








key: cord-102458-7sssm3zk
authors: Milanez-Almeida, Pedro; Martins, Andrew J.; Torabi-Parizi, Parizad; Franco, Luis M.; Tsang, John S.; Germain, Ronald N.
title: Blood gene expression-based prediction of lethality after respiratory infection by influenza A virus in mice
date: 2020-10-27
journal: bioRxiv
DOI: 10.1101/2020.10.27.357053
sha: 
doc_id: 102458
cord_uid: 7sssm3zk

Lethality after respiratory infection with influenza A virus (IAV) is associated with potent immune activation and lung tissue damage. In a well-controlled animal model of infection, we sought to determine if one could predict lethality using transcriptional information obtained from whole blood early after influenza virus exposure. We started with publicly available transcriptomic data from the lung, which is the primary site of the infection and pathology, to derive a multigene transcriptional signature of death reflective of innate inflammation associated with tissue damage. We refined this affected tissue signature with data from infected mouse and human blood to develop and validate a machine learning model that can robustly predict survival in mice after IAV challenge using data obtained from as little as 10 μl of blood from early time points post infection. Furthermore, in genetically identical, cohoused mice infected with the same viral bolus, the same model can predict the lethality of individual animals but, intriguingly, only within a specific time window that overlapped with the early effector phase of adaptive immunity. These findings raise the possibility of predicting disease outcome in respiratory virus infections with blood transcriptional data and pave the way for translating such approaches to humans.

Influenza A virus (IAV) infection of the respiratory tract can lead to severe immune activation and lung tissue damage in mice, ferrets, macaques and humans (1-6). Intrinsic virulence, replication capacity and initial infectious dose, together with the host's genetic background, immune status and overall health, determine the extent to which host immunity is triggered (7, 8) . Substantial evidence indicates that lethality is associated with an excessive innate immune response, with lung dysfunction arising from epithelial and endothelial damage induced by infiltrating leukocytes, in particular monocytes and neutrophils (9) (10) (11) (12) (13) .

Our previous work in a murine model of infection with IAV uncovered clusters of co-regulated genes in the lung associated with lethal influenza infection; one of those lethal clusters was highly associated with an overwhelming neutrophil response and, consistently, early post-infection partial neutrophil depletion rescued animals from lethality, establishing a direct link between the innate response in the tissue and death (13) . While that earlier work focused on gene expression signatures in the infected pulmonary tissue, here we sought to identify a blood-based signature for prediction of lethality.

Previous attempts to develop gene expression signatures in blood in the context of IAV-induced illness focused mostly on distinguishing IAV from non-IAV infections, symptomatic from asymptomatic IAV carriers, or low from high influenza vaccine responders (14) (15) (16) (17) (18) (19) (20) . A notable exception was the recent description of blood transcriptomics data from a large cohort of subjects enrolled in the Mechanisms of Severe Acute Influenza Consortium (MOSAIC) study (21) . In that report, severity of infectionmeasured in terms of need for mechanical ventilation -was associated with a weak transcriptional "viral response" signal and a strong transcriptional "bacterial response" (and activated-neutrophil) signal in blood in comparison with non-severe cases. However, these transcription patterns were also strongly associated with duration of illness and the authors emphasized the importance of timing in the interpretation of immune activity to IAV infection (21), which, for obvious reasons, can be hard to control for in natural human infection studies.

We aimed to develop a blood biomarker for early identification of individuals at risk of adverse disease outcome after influenza infection in a well-controlled mouse model of IAV infection, where a precise delineation of the evolution of the response associated with severity could be achieved. We utilized transcriptomic data from the lungs, the focal point of infection, and also data from blood post infection, to derive a transcriptional signature of lethality across various IAV and mouse strains. This early-response signature could distinguish mice at high risk of death with different influenza A virus strains. These results provide an impetus for seeking to translate this approach to human respiratory virus infection characterized by damaging inflammatory responses.

The first question was how to select a panel of candidate genes whose expression in blood could be used to predict lethality after IAV exposure. We focused on genes whose expression early after infection was associated with eventual lethal outcome, rather than with infection (14, 16) . We reasoned that the focal point of infection, the lungs, where lethal processes unfold, would contain the relevant biological signal.

Several whole-genome transcriptomics datasets from mouse lung tissues after infection with IAV are publicly available, including from our own previous work (13, 22, 23) . We utilized these resources (i.e., transcriptomic data from the mouse lungs at several time points after infection) to derive a gene signature of lethality from the lung across several IAV and mouse strains, followed by integration with blood data from influenza-infected mice and humans.

Briefly, to be considered for inclusion in the signature of lethality, on days 1 to 3 after infection genes had to be differentially expressed (DE) , in comparison to PBS-treated animals, in the lungs of lethally infected mice but not DE in the lungs of non-lethally infected animals (see Fig. 1 and Methods for more details) (13, 22, 23) . Furthermore, genes were included in the signature only if they were in at least one of the gene clusters associated with lethal, but not with non-lethal, IAV infections that we uncovered previously in the lungs (13).

The above procedure (the lung signature of lethal influenza infection) yielded 1,069 genes, which were enriched for several biological processes, including regulation of epithelial cell proliferation, cell adhesion, morphogenesis of an epithelium, regulation of vasculature development and regulation of To refine this lung lethality signature with blood data, we only retained genes that were DE in the blood of mice two days after infection with a lethal dose of the highly pathogenic H1N1/PR8 IAV strain (Fig. S1) , and excluded genes that were DE in the blood of humans upon low pathogenicity infection (24). 81 genes passed these pre-selection filters. As a positive control for detection of IAV infection itself, independent of lethal outcome, 10 genes previously used as classifiers of respiratory virus infection in blood were selected (14, 16) as well as 5 reference "housekeeping" genes for normalization (25). Primers against 96 genes were designed for high throughput RT-qPCR (Table S1 ).

Since (a) our past work used non-lethal infection data to develop the specific set of lethalityassociated gene clusters, (b) we excluded genes using human low pathogenicity data, and (c) we excluded genes DE in the lungs of non-lethally infected mice, the hope was that the candidate genes selected into the integrated tissue and blood signature would have better specificity for association with lethality.

To determine whether the expression of these candidate genes in blood could be used as a starting point to train a machine learning model of lethality in mice after challenge with IAV, gene expression data were collected from RNA isolated from 50 µl of blood drawn from 34 animals four days after treatment with PBS or a range of lethal and sublethal influenza strain A/Puerto Rico/8/1934 H1N1 (PR8) doses ( Fig. 2a-b) . We used a statistical learning method known as elastic net and leave-one-out cross validation to assess whether predictive models could be built from our data (26-28).

Briefly, survival (Fig. 2b ) and gene expression data (Fig. S2) were fitted via elastic netregularized multinomial logistic regression to generate a model to classify mice into three categories: 1) not infected, 2) surviving upon infection, or 3) dying upon infection. During training (i.e., model selection via cross-validation), the algorithm learned that 23 genes had expression values in blood that could be linearly combined to determine the probability of an individual animal being in one of the training categories ( Fig. 2c and Fig. S3a ). Some of the positive control genes were selected by the algorithm to help differentiate between infected and non-infected animals, and fewer to separate infected survivors from non-survivors (Fig. S3a) , suggesting that the death-associated candidate genes were indeed enriched for detecting signals of lethality in blood.

In the approach described above using logistic regression, the algorithm attempts to learn how the expression of each gene can be combined to discriminate mice in one category from another. In a hypothetical scenario of resource prioritization, however, one might also be interested in estimating the time to a relevant clinical event -death, in this case. This can be achieved with Cox proportional hazards regression, where time to event is taken into consideration and the relative risk of death for each subject can be derived.

Hence, to examine whether the expression of lethal candidate genes in blood would distinguish mice at high risk of early death after challenge, we combined survival and gene expression data from the 81 lethal candidate genes in Cox regression regularized via the elastic net. During training (i.e., model selection via cross-validation), the algorithm learned that 11 genes had expression values in blood that could be linearly combined to generate a scoring system of infected animals as a function of the day of death ( In both the multinomial and the lethal Cox models, high levels of expression of genes associated with monocytes and neutrophils, together with low levels of transcripts associated with lymphocytes, indicated high risk of death (Fig. S3 ), consistent with previously described analyses of the immune response to IAV infection (10, 12, 13) and also recent data from COVID-19 patients (29). Art4, the gene most positively associated with lethality in both models, is highly expressed in hematopoietic stem cells and immature lymphocytes according to the Immgen database (30), indicating a potential association of lethality with dysregulated hematopoiesis and release of immature cells into circulation.

An important aspect of machine learning-derived models is whether their performance is generalizable, which means whether they perform well on unseen test data that has not been used in training. Here, the models were tested for their ability to predict lethality based on gene expression data from independent cohorts of mice that were not available for training. Performance was tested in three different ways: 1) on mice infected with high doses of either a low or a high pathogenicity influenza strain (i.e., non-lethal high dose strain A/Texas/36/91 H1N1 (Tx91) vs. lethal high dose PR8); 2) by training our models on this second dataset (low vs. high pathogenicity data) while testing on our first dataset described above from infection with different doses of PR8; and 3) by testing on the scenario of infection at one lethal dose 50 (LD50), where mice are challenged with virtually the same viral dose but only half of them survives the infection.

In the first round of validation, an independent cohort of 14 mice bled on day two after treatment with PBS or with a high dose of either Tx91 or PR8 provided the data ( Fig. 3a-b) . Although the test set was from an earlier time point of infection and included one virus strain and one dose not used in training, both the multinomial and the lethal Cox models showed good predictive accuracy ( Fig. 3c-d) .

In the second round of validation, after reversing the roles of each dataset (i.e., training on the set with two different IAV strains on day two of infection and testing on the set with five different doses of PR8 on day four of infection), the multinomial model did not perform as well as the lethal Cox model, which showed good accuracy for predicting outcome ( Fig. S4a-b) .

Considering only the lethal Cox model, for our third round of validation we turned our attention to the challenging scenario of predicting lethality among genetically identical, sex and age matched, cohoused mice given the same infectious bolus at an LD50 of PR8 (N = 24 mice). In this setting, typically about half of the mice succumb while the other half survives viral exposure. Importantly, it is not known mechanistically what drives this outcome dichotomy, since measuring putative candidate factors such as lung viral titer and immune infiltration requires sacrificing the mice and, thus, precludes assessment of the actual outcome of disease. To us, the most obvious candidate mechanism was that differences in initial infectious bolus effectively received by each animal during the infection procedure would determine the dichotomy. In that case, our lethal model should be able to predict the outcome of infection very early on, and thus help shed light on the biological mechanisms of life or death under these particular conditions.

Incubation period is the time that transpires from the moment of exposure to a pathogenic agent to when the host starts showing signs of infection. During this period, a virus needs to arrive at accessible tissues and bind to receptors to enter and replicate in susceptible cells. From infected cells, new infectious viral particles are released, and the cycle starts again, with viral titers temporarily following an exponential growth curve at least while virus replication is unperturbed by the host immune system. Naturally, the time to trigger effective host immunity is influenced by viral virulence, replication capacity and initial infectious dose. S5c) . Considering that only a very small number of PR8 virions is required to induce pathogenic lung disease, these results indicate that on day two of 1 LD50 PR8 infection the virus had not yet reached high enough levels in the respiratory tree for the early anti-viral response to become detectable in blood, and, thus, our model was not able to detect any signs of lethality in the blood of mice on day two post 1 LD50 PR8 infection.

By day four, however, DE of all 9 positive control of infection genes could be detected in the blood of animals infected with 1 LD50 PR8 (Fig. S5c) , likely reflecting the spread of PR8 in the lungs and evolving host immunity. In addition, on day four, our lethal model correctly placed the animals at an intermediate level of risk of death -higher than mice infected with low pathogenicity Tx91, where no mice were at any risk of death, and lower than high dose lethal PR8, where every animal would eventually succumb (Fig. S5d) . However, on day four, our model was unable to predict accurately which of the individual mice within the 1 LD50 group would survive and which would die (Fig. S5e ).

Retraining our model on 1 LD50 blood gene expression data also failed, as did predictions based on loss of body weight up to day four, suggesting that the fate of these mice might be indistinguishable at this early point after infection.

In an attempt to further characterize the infection dynamics, we devised a longitudinal experiment in which ethically small samples of blood (~10 µl) were taken daily from the same animals in a different cohort of 16 mice during days four to eight of infection with 1 LD50 PR8 (Fig. 4a) , followed by RNA isolation, high-throughput RT-qPCR, and testing based on the existing lethality model (i.e., without retraining). The model had statistically significant power to distinguish within group, interindividual differences in relative risk of death after 1 LD50 challenge on days five and six, but not on days four, seven or eight (Fig. 4b) . These results suggest a specific time window within which processes associated with LD50 lethality is reflected by our signature in blood. While the lack of accuracy later in the course of infection (i.e., days seven and eight) was likely due to the fact that the model was trained for early detection of lethality, before adaptive immune cells fully developed and reached the circulation, these data suggest that PAMPs and DAMPs eventually reach different levels in the lungs of different mice, impacting their blood cell composition and lethal score, which can be used for prediction of lethality of individual animals even in the challenging scenario of experimental infection with an 1 LD50 IAV dose.

Prediction tools for infectious disease outcomes would enable evidence-based treatment decisions and resource allocation, in particular during pandemics. We show that a transcriptional signature predictive of lethality can be developed via machine learning in a mouse model of influenza infection early after exposure, from as little as 10 µl of blood. This was achieved by integrating tissue and blood signatures of lethal influenza infection. The model also revealed a specific time window for prediction of lethality in the challenging scenario of 1 LD50 PR8 infection.

Earlier in the course of infection, our model tended to place mice infected with 1 LD50 PR8 at an intermediate risk level in comparison to mice infected with high dose PR8 or Tx91, suggesting that our model can delineate effects associated with infection severity. In the scenario of LD50 PR8 infection of inbred and cohoused littermates with virtually the same infectious bolus, our model revealed a later split (~days 5 and 6) between animals who would eventually die or survive.

These intriguing results raise the possibility that differences in initial infectious bolus were not the primary determinants of life or death of mice infected with 1 LD50. Rather, these mice seem to behave like one group undergoing similar responses until they reach the boundaries of a tipping point, with survival or death being the result of biological variation around that tipping point (schematic model in Fig. S5f) . The time when these differences were observed (i.e., days 5 and 6) overlaps with the early effector phase of adaptive immunity.

Since adaptive immunity, in particular cytotoxic T cells, plays an important role in reducing viral load and, hence, in stopping the feedforward stimulation of the damaging innate response (13, (31) (32) (33) (34) (35) (36) (37) (38) (39) (40) (41) (42) (43) , the timing when predictions can be made suggests that early inter-individual differences in the adaptive response may make a critical contribution to differences in the outcome of disease. Although the average T cell response to infection is remarkably efficient and constant (44-48), formation of the naïve repertoire of antigen-specific T cells is a semi-stochastic process that varies in each host, resulting in a range of precursor frequencies (49-51) and, presumably, leading to a spread among the mice in the kinetics of reaching an adequate effector T cell number for effective viral clearance.

Therefore, the timing of the split between survivors and non-survivors in the 1 LD50 scenario potentially reflects differential interference with virus production during the early phase of the effector T cell response, which may be the determinant of life or death at the tipping point of infection. However, a cause/effect relationship is difficult to test directly due to the lack of tools to accurately examine, for example, virus titer, lung infiltration by antigen-specific cells, or the size of their precursor population in live mice, because these would require terminal experiments that would preclude determination of which animals would eventually die several days later due to the actual infection. Nonetheless, preliminary experiments adding gene probes to our panel that report activated CD8+ T cell abundance in the blood samples suggest that there is a relationship between the strength of these lymphocyterelated signals in day 5 or 6 samples and survival after infection. Further tests along these lines are planned to refine the signature and relate these blood findings in a large cohort of infected animals to effector function and viral abundance in the lungs as directly assessed by multiplex tissue imaging.

Our experiments have several limitations, such as the lack of validation of the models on human IAV infection data. Unfortunately, to our knowledge the only report to contain both whole blood wholegenome transcriptomics and disease severity data that includes severe human IAV infection, contained data from only three severe cases beginning five days after onset of symptoms or earlier (21). Beside the fact that such low number of early cases preclude attempts to validate our models, one also needs to take into consideration the incubation time -the time from exposure until development of symptoms -when considering the temporal evolution of infection.

The models presented here were developed for prediction very early after exposure, and, while animal models of infection can be used to clearly delineate the evolution of the immune response along its temporal component, it remains to be determined which time window post exposure in mice most closely translates to time after onset of symptoms in human infection. Experimental IAV challenge in humans with relatively mild strains indicates a peak of symptoms (mostly runny nose and sore throat but no need for mechanical ventilation) around day 3-4 after exposure (52), but it is not clear how long it takes, on average, for a symptomatic carrier to seek medical treatment, in particular in case of severe disease with highly virulent and/or highly pathogenic strains. Such questions would need to be addressed to enhance preparedness for the next pandemic and before predictive models developed in animal experiments could be realistically deployed to human populations, including with respect to the ongoing SARS-CoV2 pandemic.

Although mice and humans have substantial differences, including different distributions of influenza viral receptors in the respiratory tree, which is crucial to create an inter-species barrier for transmission, the immunobiology of highly pathogenic influenza infection, once transmission has been established, is quite similar across the several species that have been studied with regard to strong innate immune activation (7, 53, 54) . genes that are part of the lethal Cox model are highlighted (Fig. S3b) . 

Data visualization and analysis was performed in R 4.0.2 and RStudio (60), using packages downloaded from CRAN and Bioconductor 3.11 (61) . Data were handled, plotted and visualized with the foreach (62), dplyr (63) , ggfortify (64), ggplot2 (65) and gridExtra (66) packages. 

For RNA-seq, blood was collected postmortem via heart puncture on day two after infection (n = 3 mice/treatment) and kept at -20 °C in RNAlater (Thermo Fisher Scientific 

A list of candidate genes for the affected lung tissue signature of lethal influenza infection, as well as respiratory virus infection positive controls and reference genes was created by checking for overlap between the gene lists that were either downloaded from the original publications or created using the GEO data with the GEO2R tool (BH-FDR = 0.1; see text and Fig. 1 for details) (13, (22) (23) (24) . When Entrez gene IDs were not available, the Mouse Genome Informatics database (Jackson) was used to find current and old gene symbols as well as synonyms. A final list with selected genes and primers is shown in Table S1 . Bioanalyzer. Only samples with RIN score above 7 were further analyzed. Primer design and gene expression analysis were performed with the 96.96 IFC using Delta Gene Assays software (D3 Assay Design) and protocols for pre-amplified samples for use with Biomark HD, following the manufacturer's instructions (Fluidigm) as described previously (71) . To generate a standard curve for assessment of primer performance, samples from infected and non-infected animals were pooled and applied in a standard curve in duplicates (two no-sample controls were also included). Initial quality control was performed on the Biomark HD using Real-Time PCR Analysis v4.1.3 (Fluidigm), with automatic threshold generation. Genes with primers unable to generate high quality results across the range of dilutions of the standard curve (R 2 > 0.85 in Ct value vs. dilution plots) or generating more than one peak in the melting curve were excluded from further analysis.

Data was imported to R and normalized with HTqPCR (72) . Normalization was based on the standard delta Ct method (subtraction of the mean of the reference "housekeeping" genes from all other values).

In the machine learning algorithm, training was performed with glmnet (26-28) using leave-one-out cross-validation to tune the regularization parameter lambda (alpha = 0.5, family = "multinomial" for 

The test error of the scoring model was estimated both using leave-one-out cross-validation within the training cohort (also known as nested cross-validation, in which the leave-one-out procedure is used (a) in a sub-cohort of the training samples to tune the hyperparameter lambda, followed by predicting on the one sample not included in that sub-cohort, and (b) repeated for every sample in the training cohort) and on an independent cohort of mice. A Cox proportional hazards regression model was fitted to the predicted score (i.e., the relative risk derived using the predict function of the glmnet package [type = response]) of each mouse using the survival package and checked that they did not violate the proportional hazards assumption at alpha = 0.05 using the cox.zph function also in the survival package (74). Importantly, the low number of mice per category precluded the use of cross-validation to estimate the test error of the classification model, which was done only using the independent cohort of mice.

Fatal outcome of human influenza A (H5N1) is associated with high viral load and hypercytokinemia

Genomic analysis of increased host immune and cell death responses induced by 1918 influenza virus

Avian influenza virus (H5N1): a threat to human health

Aberrant innate immune response in lethal infection of macaques with the 1918 influenza virus

Severe seasonal influenza in ferrets correlates with reduced interferon and increased IL-6 induction

In vitro and in vivo characterization of new swine-origin H1N1 influenza viruses

Into the eye of the cytokine storm

Innate immunity to influenza virus infection

CCR2+ monocyte-derived dendritic cells and exudate macrophages produce influenza-induced pulmonary immune pathology and mortality

Lung epithelial apoptosis in influenza virus pneumonia: the role of macrophageexpressed TNF-related apoptosis-inducing ligand

Innate immune responses to influenza A H5N1: friend or foe?

TNF/iNOS-producing dendritic cells are the necessary evil of lethal influenza virus infection

A systems analysis identifies a feedforward inflammatory circuit leading to lethal influenza infection

Gene expression signatures diagnose influenza and other symptomatic respiratory viral infections in humans

Pathological findings of COVID-19 associated with acute respiratory distress syndrome

Suppressive myeloid cells are a hallmark of severe COVID-19

Disease severity-specific neutrophil signatures in blood transcriptomes stratify COVID-19 patients

Orchestrating high-throughput genomic analysis with Bioconductor

ggfortify: Unified Interface to Visualize Statistical Results of

Ggplot2: Elegant Graphics For Data Analysis

Pathogen-related differences in the abundance of presented antigen are reflected in CD4+ T cell dynamic behavior and effector function in the lung

Fast gapped-read alignment with Bowtie 2

Moderated estimation of fold change and dispersion for RNAseq data with DESeq2

PANTHER in 2013: modeling the evolution of gene function, and other gene attributes, in the context of phylogenetic trees

Distinct NF-κB and MAPK Activation Thresholds Uncouple Steady-State Microbe Sensing from Anti-pathogen Inflammatory Responses

HTqPCR: high-throughput analysis and visualization of quantitative realtime PCR data in R

Predicted relative risk (log) for each mouse is shown for comparison, with the red dot and red line representing mean and standard deviation in each group. (f) Schematic model of risk of lethal inflammation rising with time early after infection with different doses of and strains IAV. N = 31 in a/b (all infected mice

New expression profiling by high throughput sequencing data reported here are available on GEO with accession number GSE124404. We would like to thank Emily Condiff, Dr. Antonio P. 

 Table   Table S1 : Selected genes whose expression was measured in the blood of mice upon treatment for training and testing model. Class defines whether a gene is part of the lethal affected tissue signature (lethal), positive controls of infection (infection) or reference "housekeeping" genes (reference); FP: forward primer; RP: reverse primer.

