Longitudinal characterization of dysfunctional T cell-activation during human acute Ebola infection

Data on immune responses during human Ebola virus disease (EVD) are scanty, due to limitations imposed by biosafety requirements and logistics. A sustained activation of T-cells was recently described but functional studies during the acute phase of human EVD are still missing. Aim of this work was to evaluate the kinetics and functionality of T-cell subsets, as well as the expression of activation, autophagy, apoptosis and exhaustion markers during the acute phase of EVD until recovery. Two EVD patients admitted to the Italian National Institute for Infectious Diseases, Lazzaro Spallanzani, were sampled sequentially from soon after symptom onset until recovery and analyzed by flow cytometry and ELISpot assay. An early and sustained decrease of CD4 T-cells was seen in both patients, with an inversion of the CD4/CD8 ratio that was reverted during the recovery period. In parallel with the CD4 T-cell depletion, a massive T-cell activation occurred and was associated with autophagic/apoptotic phenotype, enhanced expression of the exhaustion marker PD-1 and impaired IFN-gamma production. The immunological impairment was accompanied by EBV reactivation. The association of an early and sustained dysfunctional T-cell activation in parallel to an overall CD4 T-cell decline may represent a previously unknown critical point of Ebola virus (EBOV)-induced immune subversion. The recent observation of late occurrence of EBOV-associated neurological disease highlights the importance to monitor the immuno-competence recovery at discharge as a tool to evaluate the risk of late sequelae associated with resumption of EBOV replication. Further studies are required to define the molecular mechanisms of EVD-driven activation/exhaustion and depletion of T-cells.Ebola virus (EBOV) is one of the most deadly human pathogens, causing a severe hemorrhagic fever syndrome in both humans and non-human primates with fatality rates ranging from 50 to 70%.¹ The recent outbreak of Ebola Virus Diseases (EVD) in West Africa highlights the pathogenic nature of this virus, the high mortality rates and pandemic potential. To date, there have been over 27 700 cases and >11 280 deaths.^{1, 2} Although EVD is usually an acute illness, increasing evidences exist of persistent infections and post infection syndromes,^{3, 4, 5, 6} highlighting the need to identify immune correlates of a protective immune response.Defining human immune responses to EBOV infection, pathogenesis and correlates of protection are important for designing effective therapeutic and vaccination interventions. A decrease in lymphocytes has been observed in studies in mice,⁷ non-human primates⁸ and humans,⁹ and is attributed to apoptotic mechanisms.^{7, 10} Persistent B and T-cell activation has been described in four survivors as long as one month after discharge from the hospital, suggesting recurrent antigenic stimulation.¹¹ While aberrant immune responses have been described after EBOV infection (reviewed in^{12, 13}), and different patterns of inflammatory mediators have been associated with different clinical outcomes,^{9, 10, 11, 14, 15, 16, 17} data on human immune responses to Ebola virus remain scanty, due to difficulties in obtaining sequential samples through the course of illness and to limitations imposed by biosafety requirements for laboratory analyses.We conducted a longitudinal study aimed to characterize the kinetics of T-cell phenotypes, activation/differentiation profile, autophagic/apoptotic markers and functionality in two EVD patients from soon after symptom onset through their hospitalization until recovery.