The Toxoplasma MAG1 peptides induce sex-based humoral immune response in mice and distinguish active from chronic human infection

To distinguish active from inactive/chronic infection in Toxoplasma gondii-seropositive individuals, we have developed an enzyme-linked immunosorbent assay (ELISA) using specific peptides derived from Toxoplasma matrix antigen MAG1. We used this assay to measure matrix specific antibodies and pilot studies with infected mice established the validity of two peptides. The immune response against MAG1 occurs in about 12 days postinfection and displays a sex difference later on in mouse model, with males producing higher antibody titers than females. Serum samples from 22 patients with clinical toxoplasmosis and from 26 patients with serological evidence of past exposure to Toxoplasma (more than one year infection history) were analyzed. Both MAG1 peptides detected antibodies significant frequently and robustly from active stage than from the chronic stage of toxoplasmosis. The results indicate that both MAG1 peptides may be used as a tool to differentiate active from inactive infection. It also may be considered in the design of potential vaccines in humans.     

In vivo and in vitro effects of monoclonal antibody to Ly antigens on immunity to infection

Injection of CBA mice with Brucella abortus strain 19 leads to chronic infection during which both cell-mediated immunity (delayed hypersensitivity and macrophage activation) and antibody production occur. Protection was efficiently transferred to naive mice using spleen cells from mice infected 5 or 12 weeks earlier. Selective lysis in vitro of these cells by antibody to cell surface antigens showed that Thy-1⁺ Ly-1⁺2⁺ T lymphocytes were required for transfer. Treatment with anti-Ia serum neither suppressed nor enhanced adoptive transfer. Thus Ia⁺ B lymphocytes were not required, and Ia⁺ suppressor T cells were not active in the response. Three injections per week of anti-Ly-1 monoclonal antibody beginning 5 days before infection led to a 10-fold increase in bacterial numbers 25 days after infection when acquired immunity was well established in untreated mice. The delayed hypersensitivity response was unaffected. In addition cells from these in vivo treated mice were unable to transfer resistance. Beginning the treatment on the day of infection abolished the IgG antibody response without affecting bacterial numbers. The studies emphasize the unique role of Ly-1⁺2⁺ T cells in immunity to Brucella and indicate the usefulness of these techniques in dissecting out those components of the immune response which contribute to recovery from infection.     

Effect of Campylobacter-Specific Maternal Antibodies on Campylobacter jejuni Colonization in Young Chickens

Using laboratory challenge experiments, we examined whether Campylobacter-specific maternal antibody (MAB) plays a protective role in young chickens, which are usually free of Campylobacter under natural production conditions. Kinetics of C. jejuni colonization were compared by infecting 3-day-old broiler chicks, which were naturally positive for Campylobacter-specific MAB, and 21-day-old broilers, which were negative for Campylobacter-specific MAB. The onset of colonization occurred much sooner in birds challenged at the age of 21 days than it did in the birds inoculated at 3 days of age, which suggested a possible involvement of specific MAB in the delay of colonization. To further examine this possibility, specific-pathogen-free layer chickens were raised under laboratory conditions with or without Campylobacter infection, and their 3-day-old progenies with (MAB⁺) or without (MAB⁻) Campylobacter-specific MAB were orally challenged with C. jejuni. Significant decreases in the percentage of colonized chickens were observed in the MAB⁺ group during the first week compared with the MAB⁻ group. These results indicate that Campylobacter-specific MAB plays a partial role in protecting young chickens against colonization by C. jejuni. Presence of MAB in young chickens did not seem to affect the development of systemic immune response following infection with C. jejuni. However, active immune responses to Campylobacter occurred earlier and more strongly in birds infected at 21 days of age than those infected at 3 days of age. Clearance of Campylobacter infection was also observed in chickens infected at 21 days of age. Taken together, these findings (i) indicate that anti-Campylobacter MAB contributes to the lack of Campylobacter infection in young broiler chickens in natural environments and (ii) provide further evidence supporting the feasibility of development of immunization-based approaches for control of Campylobacter infection in poultry.     

Intestinal absorption of hexoses in rats infected with Nippostrongylus brasiliensis

The net absorption and accumulation of d-galactose and d-glucose by the small intestine of rats infected with N. brasiliensis were studied in vivo and in vitro. There was no change from control levels in the rate of galactose transfer in vivo by the entire intestine 10 days after infection but fluid transfer was significantly lower at this time. Mucosal galactose transfer in vitro by the entire intestine or by each one-third of the intestine did not change significantly during infection but 10 days after infection mucosal glucose transfer was significantly lower in the infected proximal one-third of the intestine and significantly greater in the distal one-third than in the comparable segments in controls; mucosal glucose transfer by the entire intestine was not affected by infection. Serosal transfer of both hexoses by the proximal two-thirds of the intestine and by the entire intestine was significantly reduced 10 days after infection. Between 10 and 18 days after infection the rate of serosal galactose transfer in vitro was significantly lower than control levels. The difference in response of mucosal and serosal hexose transfer rates to infection appears to be due, in part, to an increase in intestinal glucose metabolism or increased tissue retention of galactose during infection. Mucosal fluid transfer in vitro by the entire intestine was not significantly different from control levels at 10 days of infection when either hexose was used, although there was a significant reduction in the jejunal segment when glucose was used. Mucosal fluid transfer by the entire intestine in the presence of galactose was significantly greater during the rejection phase of the parasite population than in controls.     

Trypanosoma congolense: Natural and acquired resistance in the bovine

A total of 42 animals of various ages were infected with Trypanosoma congolense to investigate age resistance. Ten of eleven animals between 4 months and 1 year of age survived the infection without treatment. Two of eleven animals in the age range of 1 to 2 years also survived the infection whereas all 20 animals between 2 and 5 years of age died or needed treatment to survive. Young animals which needed no treatment to survive were refractive to challenge for at least 1 year after their last patent parasitemia. Older animals which required treatment to survive were also challenged at intervals after therapy. Three animals infected for 49 to 75 days before treatment were rechallenged 198 to 296 days later. Extensions in prepatent periods ranged from 5 to 13 days when compared to controls and the resulting infections were of a relapsing nature followed by self-cure. Effects of this disease on clinical parameters of previously infected animals were minimal. One animal infected for 196 days and rechallenged 501 days later had a prepatent period of 14 days as compared to 5 days for controls. This animal developed a brief relapsing infection followed by self-cure. Animals which were infected for periods of 41 to 77 days, received treatment, and were then rechallenged from 600 to 900 days later, showed some resistance to infection. Prepatent periods were extended from 1 to 3 days over those of control animals and although the resulting disease was severe, one of four animals self-cured without treatment. When animals which had self-cured primary challenges were rechallenged at periods up to 2 years later, they were completely refractory. When 12 animals which were presumed to be immune to syringe-passaged T. congolense were challenged by tsetse fly bite with the same strain of trypanosome, an appreciable immunity was evident. Five of twelve immune animals did not become patent while the other seven developed mild infections without severe clinical signs. All nine controls developed severe infections with eight requiring treatment to survive. When animals immune to the Trans-Mara I strain of T. congolense were challenged either by syringe or tsetse fly bite with a heterologous strain of T. congolense obtained from a different geographical area, no evidence of immunity was detected.     

Identification of One Novel Candidate Probiotic Lactobacillus plantarum Strain Active against Influenza Virus Infection in Mice by a Large-Scale Screening

In this study, we developed a large-scale screening of bacterial strains in order to identify novel candidate probiotics with immunomodulatory properties. For this, 158 strains, including a majority of lactic acid bacteria (LAB), were screened by two different cellular models: tumor necrosis factor alpha (TNF-α)-activated HT-29 cells and peripheral blood mononuclear cells (PBMCs). Different strains responsive to both models (pro- and anti-inflammatory strains) were selected, and their protective effects were tested in vivo in a murine model of influenza virus infection. Daily intragastric administrations during 10 days before and 10 days after viral challenge (100 PFU of influenza virus H1N1 strain A Puerto Rico/8/1934 [A/PR8/34]/mouse) of Lactobacillus plantarum CNRZ1997, one potentially proinflammatory probiotic strain, led to a significant improvement in mouse health by reducing weight loss, alleviating clinical symptoms, and inhibiting significantly virus proliferation in lungs. In conclusion, in this study, we have combined two cellular models to allow the screening of a large number of LAB for their immunomodulatory properties. Moreover, we identified a novel candidate probiotic strain, L. plantarum CNRZ1997, active against influenza virus infection in mice.     

Enhanced resistance to infection with Haemonchus contortus in sheep treated with a corticosteroid

Adams D. B. and Davies H. I. 1982. Enhanced resistance to infection with Haemonchus contortus in sheep treated with a corticosteroid. International Journal for Parasitology12: 523–529. Fewer worms established from experimental infections with Haemonchus contortus in either immune or naive sheep or in sheep of undefined immune status given the corticosteroid, dexamethasone, around the time of challenge. In four experiments, the number of adult worms present in sheep treated with dexamethasone ranged from 32 to 36% of that in untreated animals. That the phenomenon did not stem from direct action of dexamethasone on the worms themselves was demonstrated by comparing continuous treatment with the drug from infection until patency with treatment given at infection and four days later. Sheep continuously treated with dexamethasone harboured similar numbers of worms as the infection controls whereas fewer parasites were found in sheep given dexamethasone around the time of infection. The results imply that active regulation of immunological unresponsiveness operates in sheep during infection with H. contortus and that disruption of immunoregulation by dexamethasone released protective responses thereby decreasing worm burdens. Because suppressor lymphocytes are implicated, cellular perturbations following treatment with dexamethasone were investigated. Dexamethasone did not cause marked lymphopenia. It, however, reduced blastogenic responses by lymphocytes to con A but not PHA. Comparison of responses to these mitogens in cells from blood and lymph demonstrates that con A and PHA-reactivity resides in identifiably different cell populations in sheep.     

Active Immunization with an Octa-Valent Staphylococcus aureus Antigen Mixture in Models of S. aureus Bacteremia and Skin Infection in Mice

Proteomic studies with different Staphylococcus aureus isolates have shown that the cell surface-exposed and secreted proteins IsaA, LytM, Nuc, the propeptide of Atl (pro-Atl) and four phenol-soluble modulins α (PSMα) are invariantly produced by this pathogen. Therefore the present study was aimed at investigating whether these proteins can be used for active immunization against S. aureus infection in mouse models of bacteremia and skin infection. To this end, recombinant His-tagged fusions of IsaA, LytM, Nuc and pro-Atl were isolated from Lactococcus lactis or Escherichia coli, while the PSMα1-4 peptides were chemically synthesized. Importantly, patients colonized by S. aureus showed significant immunoglobulin G (IgG) responses against all eight antigens. BALB/cBYJ mice were immunized subcutaneously with a mixture of the antigens at day one (5 μg each), and boosted twice (25 μg of each antigen) with 28 days interval. This resulted in high IgG responses against all antigens although the response against pro-Atl was around one log lower compared to the other antigens. Compared to placebo-immunized mice, immunization with the octa-valent antigen mixture did not reduce the S. aureus isolate P load in blood, lungs, spleen, liver, and kidneys in a bacteremia model in which the animals were challenged for 14 days with a primary load of 3 × 10⁵ CFU. Discomfort scores and animal survival rates over 14 days did not differ between immunized mice and placebo-immunized mice upon bacteremia with S. aureus USA300 (6 × 10⁵ CFU). In addition, this immunization did not reduce the S. aureus isolate P load in mice with skin infection. These results show that the target antigens are immunogenic in both humans and mice, but in the used animal models do not result in protection against S. aureus infection.     

Lupus-Prone Mice Fail to Raise Antigen-Specific T Cell Responses to Intracellular Infection

Systemic lupus erythematosus (SLE) is characterized by multiple cellular abnormalities culminating in the production of autoantibodies and immune complexes, resulting in tissue inflammation and organ damage. Besides active disease, the main cause of morbidity and mortality in SLE patients is infections, including those from opportunistic pathogens. To understand the failure of the immune system to fend off infections in systemic autoimmunity, we infected the lupus-prone murine strains B6.lpr and BXSB with the intracellular parasite Toxoplasma gondii and survival was monitored. Furthermore, mice were sacrificed days post infection and parasite burden and cellular immune responses such as cytokine production and cell activation were assessed. Mice from both strains succumbed to infection acutely and we observed greater susceptibility to infection in older mice. Increased parasite burden and a defective antigen-specific IFN-gamma response were observed in the lupus-prone mice. Furthermore, T cell:dendritic cell co-cultures established the presence of an intrinsic T cell defect responsible for the decreased antigen-specific response. An antigen-specific defect in IFN- gamma production prevents lupus-prone mice from clearing infection effectively. This study reveals the first cellular insight into the origin of increased susceptibility to infections in SLE disease and may guide therapeutic approaches.     

Mycobacterium Tuberculosis-Specific TNF-α Is a Potential Biomarker for the Rapid Diagnosis of Active Tuberculosis Disease in Chinese Population

Interferon-gamma release assays (IGRAs) have proven to be useful to accurately detect Mycobacterium tuberculosis (Mtb) infection, but they cannot reliably discriminate between active tuberculosis (TB) and latent tuberculosis infection (LTBI). This study aims to test whether Mtb-specific tumor necrosis factor-alpha (TNF-α) could be used as a new tool for the rapid diagnosis of active TB disease. The secretion of TNF-α by Mtb-specific antigen-stimulated peripheral blood mononuclear cells (PBMCs) of sixty seven participants was investigated in the study. Our results showed that the total measurement of TNF-α secretion by Mtb-specific antigen-stimulated PBMCs is not a good biomarker for active TB diagnosis. However, we found that calculation of Mtb-specific TNF-α not only distinguish between active and latent TB infection, but also can differentiate active TB from non-TB patients. Using the cutoff value of 136.9 pg/ml for Mtb-specific TNF-α, we were able to differentiate active TB from LTBI. Sensitivity and specificity were 72% and 90.91%. These data suggest that Mtb-specific TNF-α could be a potential biomarker for the diagnosis of active TB disease.     

Nucleotide-binding oligomerization domain-2 (NOD2) regulates type-1 cytokine responses to Mycobacterium avium but is not required for host control of infection

Nucleotide-binding oligomerization domain-2 (NOD2) is an innate immune receptor that recognizes peptidoglycan-derived muramyl dipeptide from intracellular bacteria and triggers proinflammatory signals. In this study, we sought to evaluate the role played by this receptor during early and late stages of infection with Mycobacterium avium in mice. We demonstrated that NOD2 knockout (KO) animals were able to control M. avium infection similarly to wild-type mice at all time points studied, even though IL-12 and TNF-α production was impaired in NOD2-deficient macrophages. At 100 days following infection with this bacterium, but not at 30 days post-infection, NOD2-deficient mice showed significantly diminished production of IFN-γ, as confirmed by reduced accumulation of IFN-γ and IL-12 mRNA in the spleens of KO mice. Additionally, a reduction in the size and in the number of lymphocytes/granulocytes of hepatic granulomas from NOD2 KO animals was observed only during late time points of M. avium infection. Taken together, these data demonstrate that NOD2 regulates type-1 cytokine responses to M. avium but is not required for the control of infection with this bacterium in vivo.     

Detailed Analysis of Sequence Changes Occurring during vlsE Antigenic Variation in the Mouse Model of Borrelia burgdorferi Infection

Lyme disease Borrelia can infect humans and animals for months to years, despite the presence of an active host immune response. The vls antigenic variation system, which expresses the surface-exposed lipoprotein VlsE, plays a major role in B. burgdorferi immune evasion. Gene conversion between vls silent cassettes and the vlsE expression site occurs at high frequency during mammalian infection, resulting in sequence variation in the VlsE product. In this study, we examined vlsE sequence variation in B. burgdorferi B31 during mouse infection by analyzing 1,399 clones isolated from bladder, heart, joint, ear, and skin tissues of mice infected for 4 to 365 days. The median number of codon changes increased progressively in C3H/HeN mice from 4 to 28 days post infection, and no clones retained the parental vlsE sequence at 28 days. In contrast, the decrease in the number of clones with the parental vlsE sequence and the increase in the number of sequence changes occurred more gradually in severe combined immunodeficiency (SCID) mice. Clones containing a stop codon were isolated, indicating that continuous expression of full-length VlsE is not required for survival in vivo; also, these clones continued to undergo vlsE recombination. Analysis of clones with apparent single recombination events indicated that recombinations into vlsE are nonselective with regard to the silent cassette utilized, as well as the length and location of the recombination event. Sequence changes as small as one base pair were common. Fifteen percent of recovered vlsE variants contained “template-independent” sequence changes, which clustered in the variable regions of vlsE. We hypothesize that the increased frequency and complexity of vlsE sequence changes observed in clones recovered from immunocompetent mice (as compared with SCID mice) is due to rapid clearance of relatively invariant clones by variable region-specific anti-VlsE antibody responses.     

Recovery of the ciliate Paramecium multimicronucleatum following bacterial infection with Holospora obtusa

The macronucleus (Ma) of Paramecium multimicronucleatum can be experimentally infected with bacteria of the species Holospora obtusa, a macronuclear-specific parasite of P. caudatum. However, usually all bacteria disappear from the nucleus within 1–2 days after infection. The results of infecting several different stocks of P. multimicronucleatum with several different isolates of H. obtusa from P. caudatum were studied during some days after infection to investigate this disappearance. Using light, fluorescence and electron microscopy at different stages of bacterial disappearance, it was shown that what we call “cleaning” of the nucleus is a fast and active process. P. multimicronucleatum can be infected with the infectious forms of H. obtusa within 2 h, but the majority of the bacteria were lost from the Ma by 10–19 h. They were released from the host nucleus into the cytoplasm and then to the surrounding medium. At first, the infected Ma shortened and became almost rounded. Before leaving the Ma, the majority of the bacteria somehow assembled into groups and these aggregates, coated with material that appears to be nuclear chromatin, protruded into the cytoplasm and were finally separated from the Ma. Sometimes single bacteria were extruded in the same manner. Bacterial release from infected Ma can be stopped by low temperature and is delayed and reduced by nocodazole treatment suggesting that intra-macronuclear microtubules may be involved.     

The Effects of Continuous In Vivo Administration of Nisin on Staphylococcus aureus Infection and Immune Response in Mice

Mice were intraperitoneally infected with 2 × 10⁸ cfu Staphylococcus aureus Xen 36 and treated with 2,130 AU (arbitrary units) nisin (equivalent to 27.7 μg pure nisin), a class Ia lantibiotic, over 7 days. The metabolic activity of S. aureus Xen 36, concluded from changes in cell bioluminescence, declined for the first 3.5 h, but increased over the next 24 h and remained at this level for the remainder of the 7-day trial. Similar results were obtained with heat-inactivated (25 min at 121 °C) nisin, suggesting that the decline in metabolic activity of S. aureus Xen 36 cannot be attributed to the bacteriostatic activity of nisin. The decline in lymphocyte numbers in infected mice was of smaller magnitude after treatment with active nisin compared to inactive nisin, suggesting that active nisin limited the apoptosis of lymphocytes. The drastic increase in neutrophil versus lymphocyte (N:L) ratio observed in the presence of active nisin suggested that the decline in metabolic activity of S. aureus Xen 36 was due to an immune response triggered by the infection. Nisin, active or inactive, stimulated the activity of cytokines interleukin-6, interleukin-10 and tumour necrosis factor. However, the overall immune response triggered by both forms of nisin was too minute to trigger an abnormally high antigenic immune reaction.     

Interferon-Gamma Release Assay: An Effective Tool to Detect Early Toxoplasma gondii Infection in Mice

Early diagnosis of Toxoplasma gondii infection before the formation of tissue cysts is vital for treatment, as drugs available for toxoplasmosis cannot kill bradyzoites contained in the cysts. However, current methods, such as antibody-based ELISA, are ineffective for detection of early infection. Here, we developed an interferon-gamma release assay (IGRA), measuring the IFN-γ released by T lymphocytes stimulated by Toxoplasma antigen peptides in vitro, for the detection of T. gondii infection in mice. Splenocytes isolated from infected mice were stimulated by peptides derived from dense granule proteins GRA4 and GRA6 and rhoptry protein ROP7, and released IFN-γ was measured by ELISA. Results showed that both acute and chronic infection could be detected by IGRA. More importantly, IGRA detected infection as early as the third day post infection; while serum IgM and IgG were detected 9 days and 13 days post infection, respectively. Our findings demonstrated that an IGRA-positive and ELISA-negative sample revealed an early infection, indicating the combination of IGRA and ELISA can be employed for the early diagnosis of T. gondii infection in human beings, cats and livestock.     

The migration and development of Parascaris equorum in the horse.

Eight worm-free pony foals, aged 2–4 weeks received a single infection of 8000 Parascaris equorum eggs. The foals were killed at intervals to investigate the migration and subsequent development of P. equorum. Signs of larval invasion were found in the liver within 48 h after infection. Larvae migrated from the liver to the lungs from 7 to 14 days after infection and the majority had returned to the small intestine via the tracheooesophageal route by day 23.After completion of their tissue migration, the parasites grew rapidly in size in the lumen of the small intestine, but after day 37 the total number of worms present in this site decreased. Patent infections developed on days 101–104.     

Toxoplasma gondii: P30 peptides recognition pattern in human toxoplasmosis

In this study, human sera reactivity against nine peptides derived from the Toxoplasma gondii P30 protein was assessed by ELISA in patients with different clinical forms of toxoplasmosis. Same as has been reported in mice, sera from congenital, ocular and chronic asymptomatic toxoplasmosis patients recognized more strongly peptides from the protein’s carboxy-terminus, being peptide 2017 (amino acids 301-320) the one most strongly recognized by sera from patients with ocular toxoplasmosis. Serum samples collected from 13 patients without ocular infection, 13 with inactive chorioretinal scars, 6 with active ocular infection and 10 seronegative individuals were then screened for anti-2017 IgG. Peptide 2017 was recognized by all patients’ samples but not by sera from T. gondii-seronegative individuals. No statistically significant differences were found between the absorbance levels of groups with and without lesions or with active or inactive ocular lesions, as determined by ANOVA.     

Postoperative Staphylococcus aureus Infections in Medicare Beneficiaries

Staphylococcus aureus (S. aureus) infections are important because of their increasing frequency, resistance to antibiotics, and high associated rates of disabilities and deaths. We examined the incidence and correlates of S. aureus infections following 219,958 major surgical procedures in a 5% random sample of fee-for-service Medicare beneficiaries from 2004–2007. Of these surgical patients, 0.3% had S. aureus infections during the hospitalizations when index surgical procedures were performed; and 1.7% and 2.3%, respectively, were hospitalized with infections within 60 days or 180 days following admissions for index surgeries. S. aureus infections occurred within 180 days in 1.9% of patients following coronary artery bypass graft surgery, 2.3% following hip surgery, and 5.9% following gastric or esophageal surgery. Of patients first hospitalized with any major infection reported during the first 180 days after index surgery, 15% of infections were due to S. aureus, 18% to other documented organisms, and no specific organism was reported on claim forms in 67%. Patient-level predictors of S. aureus infections included transfer from skilled nursing facilities or chronic hospitals and comorbid conditions (e.g., diabetes, congestive heart failure, chronic obstructive pulmonary disease, and chronic renal disease). In a logarithmic regression, elective index admissions with S. aureus infection stayed 130% longer than comparable patients without that infection. Within 180 days of the index surgery, 23.9% of patients with S. aureus infection and 10.6% of patients without this infection had died. In a multivariate logistic regression of death within 180 days of admission for the index surgery with adjustment for demographics, co-morbidities, and other risks, S. aureus was associated with a 42% excess risk of death. Due to incomplete documentation of organisms in Medicare claims, these statistics may underestimate the magnitude of S. aureus infection. Nevertheless, this study generated a higher rate of S. aureus infections than previous studies.     

Oral administration of a Spirulina extract enriched for Braun-type lipoproteins protects mice against influenza A (H1N1) virus infection

A growing body of research indicates that oral administration of bacteria (such as probiotics) can exhibit a protective effect against influenza A (H1N1) viral infection in mice. In the present study, we used a mouse model to examine whether oral administration of Immulina^®, a commercial extract from the cyanobacteria Arthrospira (Spirulina) platensis, can reduce the severity of illness resulting from influenza A (H1N1) viral infection. The main active compounds within Immulina^® are bacterial Braun-type lipoproteins that activate innate immune cells through a toll-like receptor (TLR) 2-dependent pathway. Mice that were fed Immulina^® for 30 days before and 21 days after infection with influenza A (H1N1) virus exhibited a statistically significant reduction in the severity of infection. Compared to the control group, Immulina^®-fed mice exhibited less weight loss, increased appetite, decreased clinical signs of disease, and lower lung histopathology scores. The results from the present study adds to the increasing evidence that oral administration of bacterial components that activate innate immune cells, whether derived from a bacterial preparation (probiotics or cyanobacteria) or from plant material containing endophytic bacteria, can exhibit a protective effect against influenza A (H1N1) viral infection.