FEMS Pathogens and Disease, 73, 2015, ftv074

doi: 10.1093/femspd/ftv074
Advance Access Publication Date: 22 September 2015
Minireview

MINIREVIEW

Downloaded from https://academic.oup.com/femspd/article-abstract/73/8/ftv074/2467709 by guest on 13 December 2018

Novel therapies for the treatment of pertussis disease
Karen M. Scanlon† , Ciaran Skerry† and Nicholas. H. Carbonetti∗
Department of Microbiology and Immunology, University of Maryland Medical School, Baltimore, MD 21201,
USA
∗ Corresponding author: Department of Microbiology and Immunology, University of Maryland Medical School, Baltimore, MD 21201, USA.
Tel: +410-706-7677; Fax: +410-706-2129; E-mail: [email protected]
†
Authors contributed equally.
One sentence summary: This review covers existing and potentially new treatments for the resurgent disease pertussis.
Editor: David Rasko

ABSTRACT
Whooping cough, or pertussis, incidence has reached levels not seen since the 1950s. Previous studies have shown that
antibiotics fail to improve the course of disease unless diagnosed early. Early diagnosis is complicated by the non-diagnostic
presentation of disease early in infection. This review focuses on previous attempts at developing novel host-directed
therapies for the treatment of pertussis. In addition, two novel approaches from our group are discussed. Manipulation of
the signaling pathway of sphingosine-1-phosphate, a lipid involved in many immune processes, has shown great promise,
but is in its infancy. Pendrin, a host epithelial anion exchanger upregulated in the airways with B. pertussis infection,
appears to drive mucus production and dysregulation of airway surface liquid pH and salinity. In addition to detailing these
potential new therapeutic targets, the need for greater focus on the neonatal model of disease is highlighted.

Keywords: respiratory disease; sphingosine-1-phosphate; pendrin; acetazolamide; leucocytosis; ECMO

INTRODUCTION strategies have apparently selected for the emergence of strains

lacking pertactin, a common component of DTaP (Barkoff et al.
Whooping cough, or pertussis, is a vaccine preventable, acute
2012; Lam et al. 2014; Pawloski et al. 2014; Zeddeman et al. 2014).
respiratory disease caused by infection with Bordetella pertussis
The reemergence of pertussis, the presence of ‘vaccine escape
or B. parapertussis. The majority of whooping cough research to
strains’ and recent reports highlighting the appearance of an-
date has focused on the optimization and development of safe,
tibiotic resistant B. pertussis necessitates a change in how we
effective vaccines. In the USA, a sharp decline in incidence and
treat this disease (Guillot et al. 2012). In the absence of an im-
mortality of disease was observed following the introduction of
mediate change in vaccine formulation or administration policy,
the whole cell vaccine, DTP, in the 1940s, with historically low
we believe that it is of great importance to place new focus on
incidence reported in the 1970s (CDC 2013). However, safety con-
therapeutics for the treatment of those who have contracted the
cerns over reactogenicity led to the development and use of the
disease. This is also necessary as those individuals most suscep-
acellular vaccine, DTaP. Unfortunately, the acellular vaccine has
tible to severe disease are typically at pre-vaccine age.
reduced efficacy in terms of both duration of protection and in-
In unvaccinated children, the duration and severity of dis-
duction of an appropriate immune memory for bacterial clear-
ease is typically lesser for those patients infected with B. paraper-
ance (Rowe et al. 2000, 2005; Klein et al. 2012). The rapidly waning
tussis than B. pertussis infection (Heininger et al. 1994; Liese et al.
immunity provided by DTaP has been associated with a resur-
2003). Coinfection with B. pertussis and B. parapertussis has been
gence of whooping cough incidence in recent years and the pro-
documented (Mertsola 1985; Iwata et al. 1991), and it has been
posal of new vaccine strategies involving multiple booster ad-
postulated that, under these conditions, pertussis toxin (PT) pro-
ministrations. In addition to reduced efficacy, current vaccine
duced by B. pertussis enhanced the ability of B. parapertussis to

Received: 9 July 2015; Accepted: 16 September 2015


C FEMS 2015. All rights reserved. For permissions, please e-mail: [email protected]

1
 2 FEMS Pathogens and Disease, 2015, Vol. 73, No. 8

Downloaded from https://academic.oup.com/femspd/article-abstract/73/8/ftv074/2467709 by guest on 13 December 2018

Figure 1. Schematic of pertussis classical and severe disease and points of therapeutic intervention. Classical pertussis (A) is readily broken into three stages, each
with specific clinical manifestations. Severe disease (B), most commonly observed in unvaccinated infants, presents with multiple complications. S1P, sphingosine-1-
phosphate; ACTZ, acetazolamide; ECMO, extracorporeal membrane oxygenation.

colonize the host, thereby providing a competitive advantage to paroxysmal cough with vigorous inspiratory effort resulting in
the bacterium (Worthington, Van Rooijen and Carbonetti 2011). the characteristic whooping sound associated with the disease.
This review will focus on the more significant disease caused by However, disease symptoms are quite heterogeneous, ranging
B. pertussis and assess current treatment options as well as dis- from a mild manifestation indistinguishable from viral respi-
cussing emerging novel therapeutics. ratory infection to severe disease with paroxysmal cough. This
heterogeneity is associated with stage of disease, degree of im-
CLINICAL MANIFESTATIONS OF WHOOPING munity and patient age. The classic course of B. pertussis infec-
tion is broken into three stages: catarrhal, paroxysmal and con-
COUGH DISEASE
valescent (illustrated in Fig. 1).
In order to assess the therapeutic benefits of proposed treat- The first phase of disease, the catarrhal stage, is a critical
ments, it is first important to understand the disease itself. point for intervention. However, pertussis is often under diag-
The classical manifestation of pertussis disease is its distinct nosed at this period due to the presence of mild, non-specific
 Scanlon et al. 3

symptoms such as rhinorrhea and progressive cough. Consid- The classical convalescent stage is characterized by a gradual
erable efforts have been made to address disease at increas- (1–3 weeks), continuous decline in cough and return to normal.
ingly early stages. These efforts include the screening of house- Therefore, it is of little benefit to intervene with therapeutics at
hold contacts and PCR-based diagnostics (Lind-Brandberg et al. this phase of disease.
1998; Raymond et al. 2007). In patients identified early as hav- As mentioned above, there is a wide spectrum of clinical
ing pertussis, the use of macrolide antibiotics has been associ- manifestations associated with whooping cough disease: while
ated with improved survival rates in infants (<3 months) (Winter most individuals will experience symptoms similar to or milder
et al. 2015). However, for other individuals, despite increasing the than the classical characteristics, a small percentage of infected
speed at which patients become culture negative, antibiotics do persons, mostly unvaccinated infants, develop a severe exac-
not change the clinical course of disease (Altunaiji et al. 2007). erbated disease which can lead to hospitalization and death.
While untreated patients remain contagious into the paroxys- Between 1997 and 2000 in the United States, there were 7203
mal stage, the catarrhal stage is considered the most contagious cases of reported pertussis disease in infants <6 months of age,

Downloaded from https://academic.oup.com/femspd/article-abstract/73/8/ftv074/2467709 by guest on 13 December 2018

(CDC 2015a). Hence, antibiotic intervention at this initial phase with 63.1% of those requiring hospitalization (Mattoo and Cherry
of infection, and the resulting nasopharyngeal sterilization, has 2005). In 2008, 195 000 childhood deaths were attributed to per-
the potential to greatly reduce transmission rates, thereby ben- tussis worldwide (WHO 2011), while in the USA there were 76
efiting the herd even in the absence of improving patients’ 916 cases of whooping cough reported in 2012/2013, of which 33
symptoms. resulted in death. The majority of deaths in the USA are among
The catarrhal stage lasts 1–2 weeks and is followed by more infants <3 months old (27 of 33 deaths) (CDC 2015b). These in-
severe symptoms characterizing the paroxysmal phase of dis- fants are typically unvaccinated, as the vaccination schedule in
ease. During the classical paroxysmal stage, the preceding mild the USA starts at 2 months of age, and is not complete until 6
cough develops into a full paroxysmal cough, with fits of 5–10 or months of age. This leaves infants less capable of bacterial clear-
more forceful coughs in a single expiration. Coughing episodes ance by the adaptive immune system. In addition to reduced
average 15 attacks per 24 h but can increase to 30 or more in ability to control the infection, an immature immune system
severe cases and may persist for up to 10 weeks. This paroxys- and/or general differences in physiology may contribute to the
mal cough is exacerbated by the presence of thick, non-purulent disease severity, as immunocompromised adults rarely report
mucus that is difficult to clear and hence drives more force- severe pertussis disease, and birth weight and gestational age
ful expirations (Olson 1975; Soane et al. 2000). Samples obtained were recently identified predictors of death (Winter et al. 2015).
postmortem from infected infants have highlighted the impact There are a number of clinical features associated with se-
of this mucus—one investigation described widespread mucus vere disease (Fig. 1), though not all are concomitant with in-
plugging of the airways (Smith and Vyas 2000), while another creased likelihood of death. Cough-associated apnea persists in
detailed the partial occlusion of small bronchioles with a mix all age groups, though severity is reduced with increasing pa-
of mucus, bacteria, necrotic debris and inflammatory cells (Pad- tient age. Infected infants may be too weak to whoop or their
dock et al. 2008), though it should be noted that these are ex- cough so faint that it goes unrecognized; however, apnea still
amples of extreme cases where B. pertussis infection resulted in presents as a common disease manifestation in this age group
death. Among infants and younger children, the intensity of B. (Christie and Baltimore 1989). In this population, it is common,
pertussis-induced cough brings with it other complications; pa- with severe disease, for hypoxia as a result of apnea to cause
tients will also present with posttussive vomiting. In addition seizures (Mattoo and Cherry 2005); however, apnea itself does
to the cough-related effects, apnea and cyanosis may also be not appear to correlate with death. Conversely, the seizures
present at this stage. Classical symptoms are reduced in their themselves are strong predictors of mortality (Winter et al. 2015).
severity but not duration amongst B. pertussis infected, other- While an increase in circulating immune cells is typical of B.
wise healthy, adolescents and adults. One study described the pertussis infection, among infants, disease severity correlates di-
mean duration of cough as 10 weeks for adolescents (12–17 rectly with white blood cell (WBC) count and lymphocytosis (Mc-
years old) and 12 weeks for adults (≥18 years old), with inspira- Gregor, Ogle and Curry-Kane 1986; Christie and Baltimore 1989).
tory whoop observed in 24% and 74% respectively and posttus- Young infants will present with WBC counts of >30 000 cells/ml
sive vomiting present in 25% of adolescents and 64% of adults and may reach up to 100 000 cells/ml (Mattoo and Cherry 2005),
(De Serres et al. 2000). A study by Strebel et al. (2001) described with 60–80% lymphocytes. Fatal cases are linked to higher peak
a paroxysmal cough in adults that lasted a median of 6 weeks, WBC and lymphocyte counts and a more rapid onset (Winter
with 26% of subjects presenting with a whoop, 56% with post- et al. 2015). This clinical manifestation is driven by a virulence
tussive vomiting and 100% with posttussive gagging. Hence, al- factor secreted by B. pertussis, PT, and is hypothesized to be the
though pertussis can be considered at its most severe as a pedi- cause of the occlusion of pulmonary arterioles, venules and lym-
atric infection, the disease still has a significant impact on the phatics observed postmortem in lung tissue samples from lethal
lives of adolescents and adults. Studies on the economic burden pertussis cases (Paddock et al. 2008). These small vessel leuko-
of this pathogen indicated that individual adults incurred indi- cytic aggregates are considered one of the factors contributing
rect, nonmedical costs of approximately US $450 and missed a to the irreversible pulmonary hypertension, which is associated
mean of 9.8 days from work, while adolescents typically missed with the largest increase in risk of death. Other factors thought
5.5 days of school and, as expected, experienced lower indi- to contribute to pulmonary hypertension include acute respi-
rect costs (Caro et al. 2005). However, those studies were based ratory distress syndrome and pulmonary vasoconstriction as a
on costs prior to 2003 and have likely increased with inflation. result of hypoxia (Paddock et al. 2008). Hence, in cases of se-
Hence, targeting cough for therapeutic intervention during both vere disease, therapeutic interventions targeting cough, apnea,
the catarrhal and paroxysmal phases of disease has the poten- leukocytosis or pulmonary hypertension represent great can-
tial to (i) reduce transmission (as the pathogen is spread via didates to reduce B. pertussis-linked morbidity and mortality
aerosolized droplets Warfel et al. 2012; predominantly during the (Fig. 1). Currently, no reproducibly effective therapy exists for the
catarrhal stage), (ii) reduce the paroxysm-associated physiolog- treatment of severe pertussis. Here, we aim to evaluate previous
ical complications and (iii) reduce overall socioeconomic costs. attempts at treating pertussis using host-directed approaches.
 4 FEMS Pathogens and Disease, 2015, Vol. 73, No. 8

ADJUNCT PERTUSSIS TREATMENTS 1981). The effect of PT on histamine sensitivity, combined with
the knowledge that histamine can induce cough, led to the hy-
Anti-PT immunoglobulin
pothesis that treatment of infected patients with antihistamines
Compelling evidence exists suggesting that anti-PT antibodies may reduce pertussis cough.
are sufficient to confer protection against the severest manifes- The only clinical trial on the impact of antihistamines on
tations of pertussis. Single component acellular pertussis vac- pertussis disease, using the antihistamine diphenhydramine,
cines demonstrate that these antibodies can protect against dis- showed no significant ability to reduce cough paroxysms (Dan-
ease (Ad Hoc Group for the Study of Pertussis Vaccines 1988; Olin, zon et al. 1988). However, in a 1951 letter to the British Medical
Storsaeter and Romanus. 1989). In addition, during the conva- Journal, Clifton J. Strauss detailed his experience using the anti-
lescent stage of disease, patients develop strong antibody re- histamine pyribenzamine in treating pertussis patients (Strauss
sponses to PT. Since 1935, attempts have been made to utilize 1951). Strauss claimed to see a reduction in both the number and
immune sera in the treatment of pertussis (Bradford 1935). Early severity of paroxysms in over 65% of patients. As a consequence

Downloaded from https://academic.oup.com/femspd/article-abstract/73/8/ftv074/2467709 by guest on 13 December 2018

trials using sera from convalescent patients produced inconclu- of this reduction in cough, Strauss noted decreases in vomiting
sive results. Murine studies, using pooled plasma from donors and dehydration, common complications of pertussis disease. It
immunized with inactivated PT demonstrated normalization of is also noted that removal of treatment resulted in the return of
leukocyte counts, improved weight gain, and significantly im- cough, demonstrating that the drug failed to alter the course of
proved survival following administration of sera (Bruss and Siber disease, but was effective in managing disease symptoms. One
1999). Bruss et al. (1999) went on to perform human trials using reason for the difference in results noted between these studies
multiple doses of intravenous antipertussis immunoglobulin (P- could be the potential antispasmodic activity of pyribenzamine
IGIV) in 26 pertussis-infected infants. Administration of P-IGIV compared to diphenhydramine. While this is not clear, it may
resulted in boosts of serum anti-PT antibody titers, decline in warrant a reinvestigation of adjunct therapy with dedicated an-
lymphocytosis and reduced paroxysmal coughing. These data, tispasmodic drugs.
and the data of others (Adler and Morse 1973), confirm that
PT-directed therapies are a viable approach in the treatment of
Steroids and corticosteroids
pertussis, despite the long-lived nature of PT-mediated G pro-
tein modifications. Unfortunately, however, the most recent at- Citing links to a possible ‘allergic effect of B. pertussis on the
tempts at examining the use of P-IGIV were not as successful. coughing centre’ (Frobisher 1965), Zoumboulakis et al. (1973)
A 2007 multicenter trial detailing 25 patients undergoing daily investigated the use of the steroid hydrocortisone for 7 days
P-IGIV infusions found no benefit in terms of number of parox- on pertussis-related cough. The authors noted a reduction in
ysmal coughs per hour (Halperin et al. 2007). One possible ex- ‘cough, whoop and vomiting’ after 3 days of treatment, with pa-
planation for the differences noted in these studies is the age of tients <9 months of age experiencing the greatest benefit. De-
patients receiving P-IGIV. In the successful study of Bruss et al. spite this relative success, the authors caution that steroid treat-
(1999), inclusion was limited to infants less than 2 years old, ment should only be considered in the most severe cases. An
compared to the cut-off of 5 years in the later study (Halperin increase in pulmonary inflammatory infiltrate was also noted
et al. 2007), even though both patient sets had similar mean in those receiving hydrocortisone compared to control (15% vs
ages (9.7 weeks vs 2.3 months). It should also be noted that the 10%), further highlighting the need for caution with such an ap-
Halperin et al. study was concluded prematurely due to the ex- proach.
piration of P-IGIV preparations, achieving only 15% of their in- One study with the corticosteroid dexamethasone measured
tended study size. the impact of administration on hospital stay (Roberts, Gavin
and Lennon 1992). Roberts et al. found that patients receiving
dexamethasone did not spend significantly less time in hospital
Bronchodilators
than their placebo controls.
The paroxysmal cough associated with pertussis may contribute
to many of the complications associated with severe pertus-
Extracorporeal membrane oxygenation
sis. In an effort to reduce complications associated with this
cough, multiple efforts have focused on the potential impact A common complication associated with severe pertussis is re-
of bronchodilators. In a case report focusing on the treatment duced gaseous exchange owing to obstruction of the alveolar
of two infant patients, the use of the bronchodilator salbuta- spaces with infiltrating immune cells (Paddock et al. 2008). To
mol was shown to reduce both the number of paroxysms and treat patients with breathing difficulties, mechanical ventila-
their duration, within 24 hours of treatment (Tam and Yeung tion or extracorporeal membrane oxygenation therapy (ECMO)
1986). However, larger clinical trials on the impact of salbu- can be used. ECMO involves removing the carbon dioxide from
tamol have been less encouraging. One double-blind, placebo- a patient’s blood while oxygenating their red blood cells. ECMO
controlled crossover study in nine hospitalized children aged be- is used in intensive care medicine when a patient’s heart and
tween 1.5 and 27 months demonstrated no significant effects on lungs are unable to provide sufficient gaseous exchange to sup-
the course or severity of disease (Krantz, Norrby and Trollfors port life. ECMO is recommended for treatment of hypoxemic res-
1985). A similar study performed one year later reached sim- piratory failure, hypercapnic respiratory failure, refractory car-
ilar conclusions while measuring impact on cough paroxysms diogenic shock and cardiac arrest among other maladies (ELSO
(Mertsola, Viljanen and Ruuskanen 1986). 2013) and has been used in the treatment of recalcitrant pertus-
sis when respiration is sufficiently impacted.
In one study of 800 children undergoing ECMO, 12 were be-
Antihistamines
ing treated for severe, life-threatening pertussis (Pooboni et al.
Active PT causes a robust histamine sensitization, which, in an- 2003). All children were less than 3 months of age and had yet
imal models where histamine is administered post-PT inocu- to receive a pertussis vaccination. Despite ECMO treatment, 7 of
lation, can lead to anaphylactic shock and death (Munoz et al. the 12 patients succumbed to infection. Mortality was associated
 Scanlon et al. 5

with elevated neutrophil counts and pulmonary hypertension at evaluating the role of pendrin during infection. Preliminary work
presentation. The authors of this meta-analysis suggested that from Adams et al. (2012) suggests that pendrin is also upregu-
ECMO should be offered to children with severe pertussis and lated in the airways of Staphylococcus aureus-infected mice, while
respiratory failure refractory to mechanical ventilation. slc26a4 gene levels also appear to correlate with common cold
severity among human subjects (Nakagami et al. 2008). In our
B. pertussis infection model, and perhaps in response to other
Leukodepletion
respiratory pathogens, we hypothesize that upregulation of
Elevated WBCs are associated with severe pertussis and among pendrin serves as an antimicrobial response by the host, via ef-
the best predictors of fatal infection (Mikelova et al. 2003). Row- flux of thiocyanate. In the airways, thiocyanate (SCN− ) is ox-
lands et al. (2010) described the treatment of 19 patients over idized by H2 O2 , in a reaction catalyzed by lactoperoxidase, to
an 8-year span receiving leukodepletion therapy. To deplete produce hypothiocyanate (OSCN− ). This molecule is bacterici-
leukocytes, ECMO was performed with a leukocyte filter, thereby dal and bacteriostatic, functioning by inhibiting bacterial respi-

Downloaded from https://academic.oup.com/femspd/article-abstract/73/8/ftv074/2467709 by guest on 13 December 2018

removing cells before reinfusion of oxygenated blood. ECMO ration (Thomas and Aune 1978). In support of this theory, we
therapy, used exclusively in intensive care situations, has been found that B. pertussis-infected pendrin knockout mice had ele-
associated with a 70% fatality rate, due to its use being restricted vated bacterial loads throughout the course of infection (Scan-
to intensive care situations. Patients undergoing leukodeple- lon et al. 2014). However, further investigation is necessary to
tion in this study had mortality rates of 45% between 2001 and directly attribute this increased colonization to a reduction in
2004, and 10% from 2005 to 2009 (Rowlands et al. 2010). The im- OSCN− levels.
provement in survival rates following additive leukocyte deple- A role for pendrin in the induction of airway inflamma-
tion, in conjunction with the potential benefit associated with tion and pathology has already been established for diseases
earlier administration of ECMO therapy, highlights the as-yet- of the airways unrelated to infection. One study by Yick et al.
unrealized potential of this therapy. Recent case reports have (2013) described pendrin as the most highly upregulated gene in
also shown success in treating severe pertussis with combined bronchial biopsies from asthmatics versus controls, and in ad-
ECMO and leukodepletion (Assy et al. 2015). Techniques such as dition, functional mutations of pendrin, that result in enhanced
ECMO, leukodepletion and exchange blood transfusion (not dis- activity, have been proposed to play a role in the pathogene-
cussed here) are currently limited by the last resort nature of sis of hypertension and/or asthma and COPD (Dossena et al.
their use. Studies examining the use of these interventions ear- 2011). In mouse models, overexpression of pendrin in the air-
lier in disease may produce superior outcomes. ways drives enhanced mucus production and neutrophil infil-
tration, along with increased chemokine production and airway
hyperreactivity (Nakao et al. 2008). In an ovalbumin challenge
NOVEL POTENTIAL THERAPEUTIC TARGETS model of airway hyperresponsiveness, pendrin-deficient mice
FOR PERTUSSIS displayed reduced pulmonary pathology, airway hyperreactivity
and inflammatory cell influx. Tracheal epithelial cells from these
Manipulation of airway anion channels
mice also exhibited increased ASL thickness in response to IL-
The role of anion exchangers is well established in cystic fibrosis, 13 stimulation compared with IL-13-stimulated control pendrin-
a disease also associated with a persistent cough. Cystic fibro- expressing cells, suggesting that reductions in airway pathology
sis is initiated by chromosomal mutations in the CF transmem- in pendrin-deficient mice result from improved ASL hydration
brane conductance regulator (CFTR). In the airways, this anion (Nakagami et al. 2008). Work from our group has demonstrated
channel mediates the export of Cl− and thiocyanate ions from a similar role for pendrin in infection-induced airway inflam-
epithelial cells. When mutations occur in CFTR, the Cl− airway mation. Pendrin-deficient mice infected with B. pertussis pre-
surface liquid (ASL) levels are reduced, leading to dehydration of sented with a significant reduction in lung inflammatory pathol-
the ASL and hyperconcentrated mucus. These conditions then ogy, compared with infected pendrin-expressing mice. In our
drive a reduction in periciliary liquid depth, which inhibits cilia model, however, we were surprised to observe higher levels of
beating, thereby reducing mucociliary clearance of pathogens inflammatory cytokines and chemokines in infected pendrin-
and making the airways vulnerable to infection and inflamma- deficient mice compared with infected pendrin-expressing mice
tion. Hence, pharmacological strategies are now aimed at im- (Scanlon et al. 2014). As pendrin exports HCO3 − and imports Cl− ,
proving CFTR function with corrector–potentiator combination we hypothesize that in the absence of pendrin the ASL would
therapies (in cases where CFTR is present on the epithelial sur- have an increased acidity and salinity. Such conditions would
face but specific mutations have led to reduced functionality) or be suboptimal for the activity of both antimicrobial factors and
targeting other ion channels in an effort to restore ASL home- chemokines (Pezzulo et al. 2012). Dairaghi et al. (1997) found that
ostasis using specific activators and blockers (Mall and Galietta the activity of the chemokine receptor CCR3 in its interaction
2015). with CCL11 was greatly decreased by a modest decrease in pH
In a microarray analysis of murine pulmonary genes reg- and increase in salinity. Hence, while in the absence of pendrin,
ulated by B. pertussis infection in the absence or presence cytokine and chemokine levels are high despite low infection-
of PT, our group identified an anion exchanger, slc26a4, as induced airway pathology, we propose that the activity of those
one of the most highly induced PT-associated genes (Connelly, proteins is reduced due to the ASL environment.
Sun and Carbonetti 2012). Tissue samples from B. pertussis- In an attempt to modulate pendrin function in a murine
infected baboons also display upregulation of this gene com- model of B. pertussis infection, we treated mice daily with the car-
pared with mock-infected animals (Scanlon et al. unpublished bonic anhydrase inhibitor, acetazolamide (ACTZ). By inhibiting
data). SLC26A4, or pendrin, is an anion exchanger found at the production of HCO3 − , we hoped to recreate the ASL pheno-
multiple sites throughout the body, including the lungs. In type observed in pendrin-deficient mice. We found that indeed
the airways, pendrin mediates the export of HCO3 − and thio- when infected mice received this daily treatment a significant
cyanate from the cytoplasm and imports Cl− (Pedemonte et al. reduction in airway pathology was observed, despite unchanged
2007; Garnett et al. 2011). To date, there have been few studies pendrin levels (Scanlon et al. 2014). But how would ACTZ
 6 FEMS Pathogens and Disease, 2015, Vol. 73, No. 8

treatment in mice compare with its effect on humans with associated with research and development while expediting the
pertussis disease? This question is difficult to answer as there time to market (Skerry et al. 2012, 2014). The S1P receptor ago-
is no research directly linking B. pertussis-induced inflamma- nist Fingolimod received FDA approval in 2010 for the treatment
tory pathology in the mouse with the human disease. However, of multiple sclerosis. Fingolimod is a S1P receptor modulator,
examination of how inhaled ACTZ has been used previously whose function in MS is most likely tied to its ability to sequester
to treat other exacerbated airway conditions may allow us to lymphocytes within lymph nodes, preventing the amplification
hypothesize on how this drug may benefit pertussis patients. of the autoimmune response. Other S1P receptor agonist drugs
Cough induced by low-chloride-ion solutions in healthy indi- are in clinical trials for treatment of a number of inflammation-
viduals was significantly attenuated when inhaled ACTZ was associated pathologies (Gonzalez-Cabrera et al. 2014).
administered prior to challenge (Foresi et al. 1996). Asthmatic S1P signaling occurs via five high-affinity G protein-coupled
hyperresponsiveness induced by hyperventilation of cold, dry receptors, S1P1-5. As S1P signaling occurs via PT-sensitive Gi/o-
air was also diminished with ACTZ inhalation (O’Donnell et al. coupled receptors, it has been hypothesized that the action of

Downloaded from https://academic.oup.com/femspd/article-abstract/73/8/ftv074/2467709 by guest on 13 December 2018

1992), while metabisulfite- or deep inspiration-induced bron- PT on these Gi/o proteins may prolong inflammation in whoop-
choconstriction among asthmatics was also lessened with treat- ing cough. The potential for S1P pathway manipulation in per-
ment (O’Connor et al. 1994; Spicuzza et al. 2003). Hence, it is pos- tussis was highlighted by our work using the S1P receptor ago-
sible that reduced pathology in our murine model may translate nist AAL-R. A single dose of AAL-R, shortly after infection, was
to a reduction in cough among pertussis patients with classi- shown to dramatically reduce pertussis-mediated inflammatory
cal disease. In addition, ACTZ has been shown to be efficacious cytokine expression and lung pathology (Skerry et al. 2015). Fur-
and safe for treatment of high-altitude pulmonary hypertension ther work by us demonstrated that treatment can be delayed and
(Richalet et al. 2008), so perhaps a role for ACTZ in pertussis- still have a significant impact on pathology, indicating potential
induced infant hypertension is also yet to be discovered. therapeutic use of this approach (Skerry et al. unpublished data).
Given that CFTR functions to export Cl− and pendrin func- Many questions remain to be addressed before S1P agonism can
tions to import Cl− , it is possible that overexpression of pen- be thought of as a valid treatment in pertussis. One issue with
drin, as observed with B. pertussis infection (Connelly, Sun and targeting the S1P pathway is the potential for PT, produced by
Carbonetti 2012; Scanlon et al. 2014), yields a similar phenotype the bacterium post-inoculation but before treatment is admin-
to mutation of CFTR in the lungs. The excess Cl− reabsorption istered, to inactivate the Gi/o proteins coupled to the S1P recep-
would correlate with increased water uptake by the cells and tors, potentially disabling the treatment target. For this reason,
hence a dehydration of the ASL. Furthermore, the observations studies addressing treatment at time points more closely related
of enhanced mucus production with elevated pendrin expres- to clinical presentation are needed.
sion and increased ASL thickness in the absence of pendrin, all A common issue with murine pertussis studies is the fo-
point towards pendrin as a major regulator of ASL hydration and cus on the adult mouse model. Adult mice, like humans, will
mucus density. Therefore, we hypothesize that pertussis disease clear B. pertussis infection, with inflammation and infection re-
drives pendrin overexpression leading to reduced ASL depth and solving without intervention. However, infant mice and humans
increased mucus thickness and, through this pathway, poten- are much more susceptible to fatal infection than their adult
tially facilitates the production of the non-purulent, thick, dif- counterparts. For this reason, increased focus on neonatal mod-
ficult to clear mucus observed during the catarrhal stage of the els of pertussis infection will be helpful. Neonatal mouse mod-
disease. This suggests that modulation of Cl− import by pendrin els have been used in the pertussis field, but efforts have fo-
during B. pertussis infection or stimulation of enhanced Cl− se- cused mostly on their utility in vaccine studies (Nascimento et al.
cretion by other anion channels could also serve to attenuate the 2009; Skerry et al. 2009; Gracia et al. 2011; Polewicz et al. 2011;
mucus-induced pathology. Feunou et al. 2014). Despite widespread efforts to find adjunct
treatments, little effort has focused on potential interventional
treatments of neonatal disease. Our preliminary work (Skerry et
Manipulation of the sphingosine-1-phosphate pathway
al. unpublished work) with this model suggests that S1P receptor
Sphingosine-1-phosphate (S1P) is a signaling lysophospholipid, agonist treatment may be highly beneficial in reducing neona-
involved in multiple biological processes. Importantly, its regu- tal death associated with pertussis infection, and that, as in hu-
lation is linked to the control of inflammation (Rivera, Proia and man disease, PT-dependent increases in leukocytosis may be a
Olivera 2008; Spiegel and Milstien 2011). Sphingosine is phos- key contributor to neonatal death. It is conceivable, based on the
phorylated by sphingosine kinase 1 and 2, following its produc- sequestering of lymphocytes by Fingolimod in MS, that similar
tion via the N-deacylation of ceramide. S1P levels are tightly treatments in pertussis may impact leukocytosis. Indeed, early
controlled, with S1P lyases and phosphatases responsible for its studies with murine analogs of Fingolimod suggest an ability to
degradation and dephosphorylation. improve neonatal disease in both lethal and sublethal models
Limited work has been done determining the potential im- (Skerry et al. unpublished work).
pact of exogenous S1P receptor agonism in an infectious dis-
ease setting. Early work in this field demonstrated increased in-
tracellular killing of Mycobacterium tuberculosis by macrophages,
CONCLUSION/OUTLOOK
grown in media containing S1P. Additionally, Garg et al. (2004)
noted a 47% decrease in mycobacterial growth in mice receiv- This minireview provides an overview of B. pertussis pathogen-
ing 20 nanomoles of S1P via i.v injection. However, no work of esis along with current and potential host-directed therapies.
clinical significance followed. Work by the Rosen group demon- Pertussis incidence in the USA is at a level not seen since the
strated that S1P receptor agonism during influenza virus infec- 1950s. Pediatric populations, too young to be protected by vac-
tion resulted in quelling of the cytokine storm and rescued mice cination, experience much more severe disease than that ob-
from lethal infections (Teijaro et al. 2011; Walsh et al. 2011a, b). served in adults. Current state of care represents limited ad-
The repurposing of FDA-approved drugs for treating in- vances over the use of antibiotics, an intervention that fails to
fectious diseases is becoming a popular way to defer costs improve the course of disease in the absence of early detection.
 Scanlon et al. 7

The re-emergence of pertussis as a public health concern, a gen- responsibility of the authors and does not necessarily represent
eral increase in parents forgoing vaccination for their children the official views of the National Institutes of Health.
and the lack of effective therapeutics all highlight the urgent
Conflict of interest. None declared.
need for novel approaches to treating this potentially deadly
childhood disease.
Several attempts at developing a novel pertussis treatment
REFERENCES
are detailed in the literature (reviewed above). However, at this
time, no treatment has shown reproducible success in the clinic. Adams KM, Abraham V, Spielman D, et al. Pendrin expres-
The most promising approaches, ECMO and leukodepletion, sion in Staphylococcus aureus pneumonia. Am J Resp Crit Care
have been reserved for intensive care situations. Recent reports 2012;185:A3532.
further highlight the potential of this combination approach in Ad Hoc Group for the Study of Pertussis Vaccines. Placebo-
treating severe pertussis, but mortality rates are still unaccept- controlled trial of two acellular pertussis vaccines in

Downloaded from https://academic.oup.com/femspd/article-abstract/73/8/ftv074/2467709 by guest on 13 December 2018

ably high (Assy et al. 2015). Earlier use of these interventions may Sweden–protective efficacy and adverse events. Lancet
allow for improved success and save many lives that would have 1988;1:955–60.
been lost with traditional therapeutics. Adler A, Morse SI. Interaction of lymphoid and nonlymphoid
Few groups are currently investigating novel potential ther- cells with the lymphocytosis-promoting factor of Bordetella
apeutics for pertussis. Our group is investigating the role of PT pertussis. Infect Immun 1973;7:461–7.
in B. pertussis infection and pertussis disease pathogenesis, pri- Altunaiji S, Kukuruzovic R, Curtis N, et al. Antibiotics for whoop-
marily in animal models. Since PT catalyzes a long-lived modi- ing cough (pertussis). Cochrane Db Syst Rev 2007;3:CD004404.
fication of Gi proteins in target host cells (Carbonetti et al. 2007), Assy J, Seguela PE, Guillet E, et al. Severe neonatal pertussis
a potential therapy would be to reverse this modification, per- treated by leukodepletion and early extra corporeal mem-
haps by increasing G protein turnover in affected cells. Unfortu- brane oxygenation. Pediatr Infect Dis J 2015;34:1029–30.
nately, no mechanisms to achieve this have been identified, and Barkoff AM, Mertsola J, Guillot S, et al. Appearance of Bordetella
a more realistic approach is to intervene at host targets down- pertussis strains not expressing the vaccine antigen pertactin
stream from PT effects. We are currently investigating two such in Finland. Clin Vaccine Immunol 2012;19:1703–4.
novel targets for host-directed pertussis treatment, S1P recep- Bradford W. Use of convalescent blood in whooping cough, with
tor agonism and inhibition of pendrin activity. Both approaches a review of the literature. Am J Dis Child 1935;50:918–23.
potentially take advantage of drugs that are currently FDA ap- Bruss JB, Malley R, Halperin S, et al. Treatment of severe per-
proved, reducing the cost and time required to introduce these tussis: a study of the safety and pharmacology of intra-
compounds to the clinic. Targeting ASL HCO3 − levels or pendrin venous pertussis immunoglobulin. Pediatr Infect Dis J 1999;18:
activity via inhaled ACTZ or anion channel activators/inhibitors 505–11.
may reduce airway inflammatory cell influx, in addition to po- Bruss JB, Siber GR. Protective effects of pertussis immunoglob-
tentially attenuating mucus production and cough. S1P receptor ulin (P-IGIV) in the aerosol challenge model. Clin Diagn Lab
agonism dramatically reduces pulmonary inflammation with- Immun 1999;6:464–70.
out increasing bacterial burden in adult mice (Skerry et al. 2015). Carbonetti NH, Artamonova GV, Van Rooijen N, et al. Pertus-
However, as infants are the most seriously impacted population, sis toxin targets airway macrophages to promote Borde-
studies using neonatal mouse models are also justified. Unlike tella pertussis infection of the respiratory tract. Infect Immun
adult mice, neonatal mice often succumb to pertussis infection, 2007;75:1713–20.
an effect strongly linked to PT-mediated leukocytosis and pos- Caro JJ, Getsios D, El-Hadi W, et al. Pertussis immunization of
sibly pulmonary hypertension (our unpublished work). These adolescents in the United States: an economic evaluation.
results are consistent with the observed impact of combined Pediatr Infect Dis J 2005;24:S75–82.
ECMO and leukodepletion in treatment of severe pertussis in hu- Centers for Disease Control and Prevention (CDC). Pertus-
man infants. If either of these novel approaches proves success- sis (Whooping Cough): Outbreaks, 2013. http://www.cdc.gov/
ful at improving survival or reducing lymphocytosis in neonatal pertussis/outbreaks/index.html (27 September 2015, date
mice, a next logical step would be to test their effectiveness in last accessed).
the baboon model of pertussis disease. Positive results in this Centers for Disease Control and Prevention (CDC). Epidemiology
model would indicate that these novel therapies represent the and Prevention of Vaccine Preventable Diseases, 2015a. http://
most promising attempt at treating severe infant pertussis avail- www.cdc.gov/vaccines/pubs/pinkbook/downloads/pert.pdf
able to date. (27 September 2015, date last accessed).
Future studies might focus on the improvement of ECMO, ex- Centers for Disease Control and Prevention (CDC). Pertus-
change blood transfusion and leukodepletion to impact leuko- sis (Whooping Cough) - Surveillance and Reporting, 2015b.
cytosis and survival in the infant. In addition, our group aims http://www.cdc.gov/pertussis/surv-reporting.html (27 Sept
to continue efforts to identify and characterize novel targets for ember 2015, date last accessed).
host-directed therapeutics, with a deliberate focus on the repur- Christie CD, Baltimore RS. Pertussis in neonates. Am J Dis Child
posing of current FDA approved drugs in order to quicken time 1989;143:1199–202.
to market. Connelly CE, Sun Y, Carbonetti NH. Pertussis toxin exacerbates
and prolongs airway inflammatory responses during Borde-
tella pertussis infection. Infect Immun 2012;80:4317–32.
Dairaghi DJ, Oldham ER, Bacon KB, et al. Chemokine receptor
CCR3 function is highly dependent on local pH and ionic
FUNDING
strength. J Biol Chem 1997;272:28206–9.
This work was supported by the National Institute of Allergy Danzon A, Lacroix J, Infante-Rivard C et al. A double-blind clini-
and Infectious Diseases of the National Institutes of Health cal trial on diphenhydramine in pertussis. Acta Paediatr Scand
[R01AI101055 and R21AI119566 to NHC]. The content is solely the 1988;77:614–5.
 8 FEMS Pathogens and Disease, 2015, Vol. 73, No. 8

De Serres G, Shadmani R, Duval B, et al. Morbidity of pertussis in Mall MA, Galietta LJ. Targeting ion channels in cystic fibrosis.
adolescents and adults. J Infect Dis 2000;182:174–9. J Cyst Fibros 2015;14:561–70.
Dossena S, Bizhanova A, Nofziger C, et al. Identification of allelic Mattoo S, Cherry JD. Molecular pathogenesis, epidemiology, and
variants of pendrin (SLC26A4) with loss and gain of function. clinical manifestations of respiratory infections due to Borde-
Cell Physiol Biochem 2011;28:467–76. tella pertussis and other Bordetella subspecies. Clin Microbiol Rev
Extracorporeal Life Support Organization (ELSO). ELSO Guide- 2005;18:326–82.
lines for Cardiopulmonary Extracorporeal Life Support, Ann Arbor: Mertsola J. Mixed outbreak of Bordetella pertussis and Borde-
ELSO, 2013. tella parapertussis infection in Finland. Eur J Clin Microbiol
Feunou PF, Kammoun H, Debrie AS et al. Heterologous prime- 1985;4:123–8.
boost immunization with live attenuated B. pertussis BPZE1 Mertsola J, Viljanen MK, Ruuskanen O. Salbutamol in the
followed by acellular pertussis vaccine in mice. Vaccine treatment of whooping cough. Scand J Infect Dis 1986;18:
2014;32:4281–8. 593–4.

Downloaded from https://academic.oup.com/femspd/article-abstract/73/8/ftv074/2467709 by guest on 13 December 2018

Foresi A, Cavigioli G, Pelucchi A, et al. Effect of acetazolamide Mikelova LK, Halperin SA, Scheifele D, et al. Predictors of
on cough induced by low-chloride-ion solutions in normal death in infants hospitalized with pertussis: a case-control
subjects: comparison with furosemide. J Allergy Clin Immunol study of 16 pertussis deaths in Canada. J Pediatr 2003;143:
1996;97:1093–9. 576–81.
Frobisher M. General microbiology. In: Wright AW (ed.). Rypins’ Munoz JJ, Arai H, Bergman RK, et al. Biological activities of
Medical Licensure Examinations 10th edn. Philadelphia: Lip- crystalline pertussigen from Bordetella pertussis. Infect Immun
pincott, 1965, 313. 1981;33:820–6.
Garg SK, Volpe E, Palmieri G, et al. Sphingosine 1-phosphate in- Nakagami Y, Favoreto S, Jr, Zhen G, et al. The epithelial anion
duces antimicrobial activity both in vitro and in vivo. J Infect transporter pendrin is induced by allergy and rhinovirus in-
Dis 2004;189:2129–38. fection, regulates airway surface liquid, and increases airway
Garnett JP, Hickman E, Burrows R, et al. Novel role for pendrin in reactivity and inflammation in an asthma model. J Immunol
orchestrating bicarbonate secretion in cystic fibrosis trans- 2008;181:2203–10.
membrane conductance regulator (CFTR)-expressing airway Nakao I, Kanaji S, Ohta S, et al. Identification of pendrin as
serous cells. J Biol Chem 2011;286:41069–82. a common mediator for mucus production in bronchial
Gonzalez-Cabrera PJ, Brown S, Studer SM, et al. S1P signal- asthma and chronic obstructive pulmonary disease. J Im-
ing: new therapies and opportunities. F1000Prime Rep 2014; munol 2008;180:6262–9.
6:109. Nascimento IP, Dias WO, Quintilio W, et al. Construction of an
Gracia A, Polewicz M, Halperin SA, et al. Antibody responses unmarked recombinant BCG expressing a pertussis antigen
in adult and neonatal BALB/c mice to immunization by auxotrophic complementation: protection against Borde-
with novel Bordetella pertussis vaccine formulations. Vaccine tella pertussis challenge in neonates. Vaccine 2009;27:7346–51.
2011;29:1595–604. O’Connor BJ, Yeo CT, Chen-Worsdell YM, et al. Effect of acetazo-
Guillot S, Descours G, Gillet Y, et al. Macrolide-resistant Borde- lamide and amiloride against sodium metabisulphite-
tella pertussis infection in newborn girl, France. Emerg Infect induced bronchoconstriction in mild asthma. Thorax
Dis 2012;18:966–8. 1994;49:1096–8.
Halperin SA, Vaudry W, Boucher FD, et al. Is pertussis immune O’Donnell WJ, Rosenberg M, Niven RW, et al. Acetazolamide and
globulin efficacious for the treatment of hospitalized infants furosemide attenuate asthma induced by hyperventilation
with pertussis? No answer yet. Pediatr Infect Dis J 2007;26: of cold, dry air. Am Rev Respir Dis 1992;146:1518–23.
79–81. Olin P, Storsaeter J, Romanus V. The efficacy of acellular pertus-
Heininger U, Stehr K, Schmitt-Grohe S, et al. Clinical character- sis vaccine. JAMA 1989;261:560.
istics of illness caused by Bordetella parapertussis compared Olson LC. Pertussis. Medicine 1975;54:427–69.
with illness caused by Bordetella pertussis. Pediatr Infect Dis J Paddock CD, Sanden GN, Cherry JD, et al. Pathology and patho-
1994;13:306–9. genesis of fatal Bordetella pertussis infection in infants. Clin
Iwata S, Aoyama T, Goto A, et al. Mixed outbreak of Bordetella Infect Dis 2008;47:328–38.
pertussis and Bordetella parapertussis in an apartment house. Pawloski LC, Queenan AM, Cassiday PK, et al. Prevalence
Dev Biol Stand 1991;73:333–41. and molecular characterization of pertactin-deficient Bor-
Klein NP, Bartlett J, Rowhani-Rahbar A, et al. Waning protection detella pertussis in the United States. Clin Vaccine Immunol
after fifth dose of acellular pertussis vaccine in children. N 2014;21:119–25.
Engl J Med 2012;367:1012–9. Pedemonte N, Caci E, Sondo E, et al. Thiocyanate transport in
Krantz I, Norrby SR, Trollfors B. Salbutamol vs. placebo for treat- resting and IL-4-stimulated human bronchial epithelial cells:
ment of pertussis. Pediatr Infect Dis 1985;4:638–40. role of pendrin and anion channels. J Immunol 2007;178:
Lam C, Octavia S, Ricafort L, et al. Rapid increase in pertactin- 5144–53.
deficient Bordetella pertussis isolates, Australia. Emerg Infect Pezzulo AA, Tang XX, Hoegger MJ, et al. Reduced airway surface
Dis 2014;20:626–33. pH impairs bacterial killing in the porcine cystic fibrosis lung.
Liese JG, Renner C, Stojanov S, et al. Clinical and epidemiolog- Nature 2012;487:109–13.
ical picture of B. pertussis and B. parapertussis infections af- Polewicz M, Gracia A, Buchanan R, et al. Influence of maternal an-
ter introduction of acellular pertussis vaccines. Arch Dis Child tibodies on active pertussis toxoid immunization of neonatal
2003;88:684–7. mice and piglets. Vaccine 2011;29:7718–26.
Lind-Brandberg L, Welinder-Olsson C, Lagergard T, et al. Evalua- Pooboni S, Roberts N, Westrope C, et al. Extracorporeal life sup-
tion of PCR for diagnosis of Bordetella pertussis and Bordetella port in pertussis. Pediatr Pulmonol 2003;36:310–5.
parapertussis infections. J Clin Microbiol 1998;36:679–83. Raymond J, Armengaud JB, Cosnes-Lambe C, et al. Pertussis in
McGregor J, Ogle JW, Curry-Kane G. Perinatal pertussis. Obstet young infants: apnoea and intra-familial infection. Clin Mi-
Gynecol 1986;68:582–6. crobiol Infect 2007;13:172–5.
 Scanlon et al. 9

Richalet JP, Rivera-Ch M, Maignan M, et al. Acetazolamide for Spiegel S, Milstien S. The outs and the ins of sphingosine-1-
Monge’s disease: efficiency and tolerance of 6-month treat- phosphate in immunity. Nat Rev Immunol 2011;11:403–15.
ment. Am J Resp Crit Care 2008;177:1370–6. Strauss CJ. Correspondence. Brit Med J 1951;2:970.
Rivera J, Proia RL, Olivera A. The alliance of sphingosine-1- Strebel P, Nordin J, Edwards K, et al. Population-based incidence
phosphate and its receptors in immunity. Nat Rev Immunol of pertussis among adolescents and adults, Minnesota, 1995–
2008;8:753–63. 1996. J Infect Dis 2001;183:1353–9.
Roberts I, Gavin R, Lennon D. Randomized controlled trial of Tam AY, Yeung CY. Severe neonatal pertussis treated by salbu-
steroids in pertussis. Pediatr Infect Dis J 1992;11:982–3. tamol. Arch Dis Child 1986;61:600–2.
Rowe J, Macaubas C, Monger TM, et al. Antigen-specific re- Teijaro JR, Walsh KB, Cahalan S, et al. Endothelial cells are cen-
sponses to diphtheria-tetanus-acellular pertussis vaccine tral orchestrators of cytokine amplification during influenza
in human infants are initially Th2 polarized. Infect Immun virus infection. Cell 2011;146:980–91.
2000;68:3873–7. Thomas EL, Aune TM. Lactoperoxidase, peroxide, thiocyanate

Downloaded from https://academic.oup.com/femspd/article-abstract/73/8/ftv074/2467709 by guest on 13 December 2018

Rowe J, Yerkovich ST, Richmond P, et al. Th2-associated local re- antimicrobial system: correlation of sulfhydryl oxidation
actions to the acellular diphtheria-tetanus-pertussis vaccine with antimicrobial action. Infect Immun 1978;20:456–63.
in 4- to 6-year-old children. Infect Immun 2005;73:8130–5. Walsh KB, Teijaro JR, Rosen H, et al. Quelling the storm: utiliza-
Rowlands HE, Goldman AP, Harrington K, et al. Impact of rapid tion of sphingosine-1-phosphate receptor signaling to ame-
leukodepletion on the outcome of severe clinical pertussis in liorate influenza virus-induced cytokine storm. Immunol Res
young infants. Pediatrics 2010;126:e816–27. 2011a;51:15–25.
Scanlon KM, Gau Y, Zhu J, et al. Epithelial anion transporter Walsh KB, Teijaro JR, Wilker PR, et al. Suppression of cy-
pendrin contributes to inflammatory lung pathology in tokine storm with a sphingosine analog provides protec-
mouse models of Bordetella pertussis infection. Infect Immun tion against pathogenic influenza virus. P Natl Acad Sci USA
2014;82:4212–21. 2011b;108:12018–23.
Skerry C, Harper J, Klunk M, et al. Adjunctive TNF inhibi- Warfel JM, Beren J, Merkel TJ. Airborne transmission of Bordetella
tion with standard treatment enhances bacterial clearance pertussis. J Infect Dis 2012;206:902–6.
in a murine model of necrotic TB granulomas. PLoS One Winter K, Zipprich J, Harriman K, et al. Risk factors associated
2012;7:e39680. with infant deaths from pertussis: a case-control study. Clin
Skerry C, Pinn ML, Bruiners N, et al. Simvastatin increases the in Infect Dis 2015;61:1099–106.
vivo activity of the first-line tuberculosis regimen. J Antimi- World Health Organization (WHO). Immunization, Vaccines
crob Chemother 2014;69:2453–7. and Biologicals – Pertussis, 2011. http://www.who.int/
Skerry C, Scanlon K, Rosen H, et al. Sphingosine-1-phosphate immunization monitoring/diseases/pertussis/en/index.html
receptor agonism reduces Bordetella pertussis-mediated lung (27 September 2015, date last accessed).
pathology. J Infect Dis 2015;211:1883–6. Worthington ZE, Van Rooijen N, Carbonetti NH. Enhancement
Skerry CM, Cassidy JP, English K, et al. A live attenuated Borde- of Bordetella parapertussis infection by Bordetella pertussis in
tella pertussis candidate vaccine does not cause disseminat- mixed infection of the respiratory tract. FEMS Immunol Med
ing infection in gamma interferon receptor knockout mice. Mic 2011;63:119–28.
Clin Vaccine Immunol 2009;16:1344–51. Yick CY, Zwinderman AH, Kunst PW, et al. Transcriptome
Smith C, Vyas H. Early infantile pertussis; increasingly prevalent sequencing (RNA-Seq) of human endobronchial biopsies:
and potentially fatal. Eur J Pediatr 2000;159:898–900. asthma versus controls. Eur Respir J 2013;42:662–70.
Soane MC, Jackson A, Maskell D, et al. Interaction of Bordetella Zeddeman A, van Gent M, Heuvelman CJ, et al. Investigations
pertussis with human respiratory mucosa in vitro. Respir Med into the emergence of pertactin-deficient Bordetella pertussis
2000;94:791–9. isolates in six European countries, 1996 to 2012. Euro Surveill
Spicuzza L, Ciancio N, Pellegrino R, et al. The effect of inhaled 2014;19:pii=20881.
furosemide and acetazolamide on bronchoconstriction in- Zoumboulakis D, Anagnostakis D, Albanis V, et al. Steroids in
duced by deep inspiration in asthma. Monaldi Arch Chest Dis treatment of pertussis. A controlled clinical trial. Arch Dis
2003;59:150–4. Child 1973;48:51–4.