Thrombotic thrombocytopenic purpura (TTP) is clinically characterized by the occurrence of thrombocytopenia and microangiopathic hemolytic anemia [1, 2, 3]. TTP was first described as a pathological entity in 1924 by Moschcowitz  and was clearly identified as an autoimmune disorder by Harrington et al. in 1951 . Currently, after 70 years, we know that the majority of TTP patients suffer from acquired TTP caused by the presence of autoantibodies (AAbs) against ADAMTS13 [5, 6, 7], a protease that cleaves the von Willebrand factor (vWF) multimers into smaller forms thereby controlling vWF-mediated platelet thrombus formation . However, the molecular basis and the mechanism(s) that lead to the loss of immunotolerance toward ADAMTS13 and permit the production of anti-ADAMTS13 AAbs are still unknown .
Therefore, it assumes a scientific relevance the clinical observation by Kosugi et al. , that influenza infection triggers TTP by producing anti-ADAMTS13 IgGs. The observation is crucial in light of the fact that the association between influenza infection and TTP is clinically well known [11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29], so making feasible the hypothesis that the anti-influenza immune responses that follow influenza infection may cross-react with ADAMTS13 protein thus generating anti-ADAMTS13 AAbs. To prove or disprove the cross-reactivity hypothesis, the present study analyzed the peptide commonality between influenza virus and ADAMTS13 proteins since, actually, peptide sharing can lead to autoimmunity through cross-reactivity phenomena following pathogen infection. It was found a wide influenza virus vs ADAMTS13 peptide overlap that can represent a cross-reactive molecular platform underlying anti-ADAMTS13 AAb production.
Sequence analyses were conducted on ADAMTS13 (or A disintegrin and metalloproteinase with thrombospondin motifs 13 or vWF-cleaving protease) and cytoplasmic and perinuclear autoantigens of antineutrophil cytoplasmic antibodies, ie, c-ANCA myeloblastin and p-ANCA myeloperoxidase. The three human proteins are described in detail in the Uniprot database at https://www.uniprot.org [30, 31]. Protein primary sequences were decomposed into overlapping pentapeptides offset by one residue, ie, MGVPF, GVPFF, and VPFFS. Next, each pentapeptide was analyzed for occurrences in viral proteomes using Peptide Match program (https://research.bioinformatics.udel.edu/peptidematch) .
Proteomes from nine viruses were analyzed: influenza A virus, H1N1 (NCBI:txid211044), influenza A virus, H3N2 (NCBI:txid385580), influenza A virus, H5N1 (NCBI:txid93838), influenza A virus, H10N7 (NCBI:txid382838), influenza B virus (NCBI:txid518987), and influenza C virus (NCBI:txid11553). Tobacco mosaic virus (NCBI:txid12243), human parvovirus B19 (NCBI:txid648237), and dengue virus (NCBI:txid11059) were used as controls.
ADAMTS13 protein sequence was analyzed for peptide sharing with influenza virus proteomes. In addition, c-ANCA myeloblastin and p-ANCA myeloperoxidase, two autoantigens that characterize a group of small vessel vasculitis [34, 35], were analyzed for comparison.
Analyses were extended to human parvovirus B19 because B19 infection, although predominantly affects erythrocytes, shows clinically nonsignificant lymphopenia, neutropenia, and thrombocytopenia  and to dengue virus because thrombocytopenia and clotting abnormalities are at the heart of dengue pathology . Tobacco mosaic virus was utilized as a negative TTP-unrelated viral control.
Operationally, the pentapeptide was used as a probe in sequence analyses since, in immunobiology, a functional/structural unit is generally represented by five amino acid (aa) residues . In fact, biological interactions can be described by peptide–protein interactions involving a pentapeptide [39, 40, 41, and pertinent references therein]. Alike, the capability of generating immune responses (immunogenicity) as well as the immune recognition process (antigenicity) appears to be circumscribed to the space of five residues [42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52].
4 Peptide sharing between influenza viruses and ADAMTS13
The pentapeptide sharing between the viral proteomes and c-ANCA myeloblastin, p-ANCA myeloperoxidase, and ADAMTS13 is described in Table 1. Main points are as follows:
Description of the pentapeptide sharing between B19, dengue, and influenza proteomes and the ANCA and ADAMTS13 autoantigens
|Virus||c-ANCA myeloblastin||p-ANCA myeloperoxidase||ADAMTS13|
|Tobacco mosaic virus||–||–||–|
|Human parvovirus B19||–||FEQVM||ALVRP|
|Dengue virus 1||–||ARASF, SGSAS||AGEKA, TLRVL AGILA, GAGLA, GANAS, SLRTT,|
|Influenza A virus, H1N1||–||–||GDMLL, GHADL, GILHL, LESSL, PGHAD|
|Influenza A virus, H5N1||–||–||ALTED, GDMLL, GHADL GILHL, PGHAD|
|Influenza A virus, H3N8||–||–||ALTED, PGHAD, ELLVA, QGSLL GDMLL, GHADL, GILHL,|
|Influenza A virus, H10N7||–||–||ALTED, PGHAD ELLVA, GDMLL, GHADL, GILHL,|
|Influenza B virus||VTVVT, TVVTF||LERKL, RLATE||GGVLL, RQRQR, TGTID|
|Influenza C virus||–||–||–|
- –•On the whole, the viral vs human peptide overlap consists of 24 pentapeptide matches, 17 of which occur in ADAMTS13 and mainly involve influenza A and dengue viruses.
- –•The viral peptide sharing with the two ANCA autoantigens amounts to seven pentamers and is restricted to influenza B, B19, and dengue viruses.
- –•Influenza C virus and the negative control tobacco mosaic virus have no pentapeptide sequences in common with any of the three analyzed human proteins.
In commenting data from Table 1, two further observations merit notice. First, the extent of the viral vs human peptide overlap is mathematically unexpected since the probability that two proteins may share a pentapeptide is equal to 20˗5 (ie, probability 1 out of 3,200,000 or 0.0000003125). Second, the present study examines only reference influenza proteomes, ie, selected proteomes that cover well-studied model organisms [30, 31], and neglects the hundreds of existing influenza subtypes and variants. That is to say that the cross-reactivity scenario between influenza infection and ADAMTS13 might be more intense and varied than that summarized in Table 1. As an example, the influenza A virus, H5N1 (NCBI:txid176674) shares the additional pentapeptide SLEPC with ADAMTS13 when compared to the, here, analyzed influenza A virus, H5N1 (NCBI:txid93838).
5 Immunologic potential of the peptide sharing between influenza viruses and ADAMTS13
The peptide sharing as summarized in Table 1 has a high immunologic potential. In fact, using IEDB , a catalog of experimentally validated epitopes, and searching within IEDB epitopes, it was found that almost all of the shared pentapeptides described in Table 1 repeatedly occur in immunoreactive epitopic sequences. Table 2 lists the immunopositive epitopes containing sequences shared between B19, dengue, and influenza proteomes and the ANCA and ADAMTS13 autoantigens and highlights the disproportionately high number of epitopes containing ADAMTS13 pentapeptides.
Epitopes containing peptides shared between B19, dengue, and influenza proteomes and ANCA and ADAMTS13 autoantigens
|c-ANCA myeloblastin||p-ANCA myeloperoxidase||ADAMTS13|
|IEDB ID1||Epitope sequence2,3||IEDB ID1||Epitope sequence2,3||IEDB ID1||Epitope sequence2,3|
Numerous pentapeptides are shared between influenza A and B viruses and ADAMTS13, the autoantigen of TTP (Table 1). The peptide sharing is higher than expected by being very low the chance for two proteins to share a pentapeptide. Moreover, the peptide sharing is immunologically significant by being most of the shared peptides also part of experimentally validated epitopes (Table 2). Hence, the present study substantiates the hypothesis of cross-reactivity involvement in the generation of anti-ADAMTS13 AAbs following influenza infection, in this way flanking previous findings [53, 54, 55, 56, 57] that indicate autoimmune cross-reactions as a basic mechanism in the generation of autoimmune diseases following infections.
The data warrant further collaborative research efforts, especially in light of the fact that low levels of ADAMTS13 protease are a risk factor for the development of myocardial infarction [58,59], stroke [59, 60, 61], preeclampsia , disseminated intravascular coagulation , cerebrovascular disease , etc.
This research received no specific grants from any funding agency in public, commercial, or not-for-profit sectors.
Moschcowitz E. An acute febrile pleiochromic anemia with hyaline thrombosis of the terminal arterioles and capillaries an undescribed disease Am. J. Med. 1952 13 56-569.
Stanley M. Michalski J.M. Thrombotic thrombocytopenic purpura (TTP). StatPearls [Internet]. StatPearls Publishing Treasure Island FL 2018. Available from http://www.ncbi.nlm.nih.gov/books/NBK430721/
Harrington W.J. Minnich V. Hollingsworth J.W. Moore C.V. Demonstration of a thrombocytopenic factor in the blood of patients with thrombocytopenic purpura J. Lab. Clin. Med. 1951 38 1-10.
Scully M. Yarranton H. Liesner R. Cavenagh J. Hunt B. Benjamin S. et al. Regional UK TTP registry: correlation with laboratory ADAMTS 13 analysis and clinical features Br. J. Haematol. 2008 142 819-826.
Joly B.S Coppo P. Veyradier A. Thrombotic thrombocytopenic purpura Blood 2017 129 2836-2846.
Deforche L. Tersteeg C. Roose E. Vandenbulcke A. Vandeputte N. Pareyn I. et al. Generation of anti-murine ADAMTS-13 antibodies and their application in a mouse model for acquired thrombotic thrombocytopenic purpura PLoS One 2016 11 e0160388.
- Export Citation
Deforche, L., Tersteeg, C., Roose, E., Vandenbulcke, A., Vandeputte, N., Pareyn, I., et al. Generation of anti-murine ADAMTS-13 antibodies and their application in a mouse model for acquired thrombotic thrombocytopenic purpura, PLoS One, 2016, 11, e0160388.)| false 10.1371/journal.pone.0160388
Fujikawa K. Suzuki H. McMullen B. Chung D. Purification of human von Willebrand factor-cleaving protease and identification as a new member of the metalloproteinase family Blood 2001 98 1662-1666.
Hrdinová J. D‘Angelo S. Graça N.A.G. Ercig B. Vanhoorelbeke K. Veyradier A. et al. Dissecting the pathophysiology of immune thrombotic thrombocytopenic purpura: interplay between genes and environmental triggers Haematologica 2018 103 1099-1109.
- Export Citation
Hrdinová, J., D‘Angelo, S., Graça, N.A.G., Ercig, B., Vanhoorelbeke, K., Veyradier, A., et al. Dissecting the pathophysiology of immune thrombotic thrombocytopenic purpura: interplay between genes and environmental triggers, Haematologica, 2018, 103, 1099-1109.)| false 10.3324/haematol.2016.151407 29674502
Kosugi N. Tsurutani Y. Isonishi A. Hori Y. Matsumoto M. Fujimura Y. Influenza A infection triggers thrombotic thrombocytopenic purpura by producing the anti-ADAMTS13 IgG inhibitor Intern. Med. 2010 49 689-693.
- Export Citation
Kosugi, N., Tsurutani, Y., Isonishi, A., Hori, Y., Matsumoto, M., Fujimura, Y., Influenza A infection triggers thrombotic thrombocytopenic purpura by producing the anti-ADAMTS13 IgG inhibitor, Intern. Med., 2010, 49, 689-693.)| false 20371960 10.2169/internalmedicine.49.2957
Kaneko H. Ohkawara Y. Nomura K. Horiike S. Taniwaki M. Relapse of idiopathic thrombocytopenic purpura caused by influenza A virus infection: a case report J. Infect. Chemother. 2004 10 364-366.
Mamori S. Amano K. Kijima H. Takagi I. Tajiri H. Thrombocytopenic purpura after the administration of an influenza vaccine in a patient with autoimmune liver disease Digestion 2008 77 159-160.
Dias P.J. Gopal S. Refractory thrombotic thrombocytopenic purpura following influenza vaccination Anaesthesia 2009 64 444-446.
Mantadakis E. Farmaki E. Thomaidis S. Tsalkidis A. Chatzimichael A. A case of immune thrombocytopenic purpura after influenza vaccination: consequence or coincidence? J Pediatr Hematol Oncol. 2010 32 e227-9.
Hermann R. Pfeil A. Busch M. Kettner C. Kretzschmar D. Hansch A. et al. Very severe thrombotic thrombocytopenic purpura (TTP) after H1N1 vaccination Med. Klin. (Munich). 2010 105 663-668.
Hage J.E. Petelin A. Cunha B.A. Before influenza tests results are available can droplet precautions be instituted if influenza is suggested by leukopenia relative lymphopenia or thrombocytopenia? Am. J. Infect. Control 2011 39 619-621.
Mammas I.N. Koutsaftiki C. Papantzimas K. Symeonoglou Z. Koussouri M. Theodoridou M. et al. Thrombocytic thrombocytopenic purpura in a child with A/H1N1 influenza infection J. Clin. Virol. 2011 51 146-147.
Lee C.Y. Wu M.C. Chen P.Y. Chou T.Y. Chan Y.J. Acute immune thrombocytopenic purpura in an adolescent with 2009 novel H1N1 influenza A virus infection J. Chin. Med. Assoc. 2011 74 425-427.
Akiyama R. Komori I. Hiramoto R. Isonishi A. Matsumoto M. Fujimura Y. H1N1 influenza (swine flu)-associated thrombotic microangiopathy with a markedly high plasma ratio of von Willebrand factor to ADAMTS13 Intern. Med. 2011 50 643-647.
- Export Citation
Akiyama, R., Komori, I., Hiramoto, R., Isonishi, A., Matsumoto, M., Fujimura, Y., H1N1 influenza (swine flu)-associated thrombotic microangiopathy with a markedly high plasma ratio of von Willebrand factor to ADAMTS13, Intern. Med., 2011, 50, 643-647.)| false 21422695 10.2169/internalmedicine.50.4620
Allen U. Licht C. Pandemic H1N1 influenza A infection and (atypical) HUS – more than just another trigger? Pediatr. Nephrol. 2011 26 3-5.
Koh Y.R. Hwang S.H. Chang C.L. Lee E.Y. Son H.C. Kim H.H. Thrombotic thrombocytopenic purpura triggered by influenza A virus subtype H1N1 infection Transfus. Apher Sci. 2012 46 25-28.
Gurjar M. Kothari N. Baronia A.K. Pandemic H1N1 influenza with atypical presentation: Encephalopathy and severe thrombocytopenia Indian J. Crit. Care Med. 2012 16 60-61.
Yasuda H. Nagata M. Moriyama H. Kobayashi H. Akisaki T. Ueda H. et al. Development of fulminant Type 1 diabetes with thrombocytopenia after influenza vaccination: a case report Diabet. Med. 2012 29 88-89.
Lopez-Delgado J.C. Rovira A. Esteve F. Rico N. Mañez Mendiluce R. Ballús Noguera J. et al. Thrombocytopenia as a mortality risk factor in acute respiratory failure in H1N1 influenza. Swiss Med. Wkly. 2013 143 w13788.
Jonsson M.K. Hammenfors D. Oppegaard O. Bruserud Ø. Kittang A.O. A 35-year-old woman with influenza A-associated thrombotic thrombocytopenic purpura. Blood Coagul Fibrinolysis 2015 26 469-472.
Nagasaki J Manabe M Ido K Ichihara H Aoyama Y Ohta T et al. Postinfluenza vaccination idiopathic thrombocytopenic purpura in three elderly patients Case Rep. Hematol. 2016 2016 7913092.
Sellers S.A. Hagan R.S. Hayden F.G. Fischer W.A. 2nd. The hidden burden of influenza: A review of the extrapulmonary complications of influenza infection Influenza Other Respir. Viruses 2017 11 372-393.
Hamiel U. Kventsel I. Youngster I. Recurrent immune thrombocytopenia after influenza vaccination: a case report Pediatrics 2016 138 pii: e20160124.
Bitzan M. Zieg J. Influenza-associated thrombotic microangiopathies Pediatr. Nephrol. 2018 33 2009-2025.
Breuza L. Poux S. Estreicher A. Famiglietti M.L. Magrane M. Tognolli M. et al. The UniProtKB guide to the human proteome. Database (Oxford) 2016 2016. pii: bav120.
UniProt Consortium. UniProt: a worldwide hub of protein knowledge Nucleic Acids Res. 2019 47 D506-515.
Chen C. Li Z. Huang H. Suzek B.E. Wu C.H. UniProt Consortium. A fast Peptide Match service for UniProt knowledgebase Bioinformatics 2013 29 2808-2809.
Vita R. Overton J.A. Greenbaum J.A. Ponomarenko J. Clark J.D. Cantrell J.R. et al. The immune epitope database (IEDB) 3.0 Nucleic Acids Res. 2015 43 D405-412.
Lamprecht P. Kerstein A. Klapa S. Schinke S. Karsten C.M. Yu X. et al. Pathogenetic and clinical aspects of anti-neutrophil cytoplasmic autoantibody-associated vasculitides Front. Immunol. 2018 9 680.
Gapud E.J. Seo P. Antiochos B. ANCA-associated vasculitis pathogenesis: a commentary Curr. Rheumatol. Rep. 2017 19 15.
Goldthorpe S.C. Conway M.J. New insight on Dengue virus-induced thrombocytopenia Virulence 2017 8 1492-1493.
Lucchese G. Stufano A. Trost B. Kusalik A. Kanduc D. Peptidology: short amino acid modules in cell biology and immunology Amino Acids 2007 33 703-737.
Kanduc D. 2010. Protein information content resides in rare peptide segments Peptides 31 983-988.
Kanduc D. Pentapeptides as minimal functional units in cell biology and immunology Curr. Protein Pept. Sci. 2013 14 111-120.
Dummer R. Mittelman A. Fanizzi F.P. Lucchese G. Willers J. Kanduc D. Non-self-discrimination as a driving concept in the identification of an immunodominant HMW-MAA epitopic peptide sequence by autoantibodies from melanoma cancer patients Int. J. Cancer 2004 111 720-726.
- Export Citation
Dummer, R., Mittelman, A., Fanizzi, F.P., Lucchese, G., Willers, J., Kanduc, D., Non-self-discrimination as a driving concept in the identification of an immunodominant HMW-MAA epitopic peptide sequence by autoantibodies from melanoma cancer patients, Int. J. Cancer, 2004, 111, 720-726.)| false 15252841 10.1002/ijc.20310
Kanduc D. Peptimmunology: immunogenic peptides and sequence redundancy Curr. Drug. Discov. Technol. 2005 2 239-244.
Kanduc D. Correlating low-similarity peptide sequences and allergenic epitopes. Curr. Pharm. Des. 2008 14 289-295.
Kanduc D. Immunogenicity in peptide-immunotherapy: from self/nonself to similar/dissimilar sequences Adv. Exp. Med. Biol. 2008 640 198-207.
Kanduc D. Tessitore L. Lucchese G. Kusalik A. Farber E. Marincola F.M.. Sequence uniqueness and sequence variability as modulating factors of human anti-HCV humoral immune response Cancer Immunol. Immunother. 2008 57 1215-1223.
- Export Citation
Kanduc, D., Tessitore, L., Lucchese, G., Kusalik, A., Farber, E., Marincola, F.M.., Sequence uniqueness and sequence variability as modulating factors of human anti-HCV humoral immune response, Cancer Immunol. Immunother., 2008, 57, 1215-1223.)| false 10.1007/s00262-008-0456-y 18256830
Polimeno L. Mittelman A. Gennero L. Ponzetto A. Lucchese G. Stufano A. et al. Sub-epitopic dissection of HCV E1315-328HRMAWDMMMNWSPT sequence by similarity analysis Amino Acids 2008 34 479-484.
Lucchese G. Calabro’ M. Kanduc D. Circumscribing the conformational peptide epitope landscape Curr. Pharm. Des. 2012 18 832-839.
Lucchese G. Sinha A.A. Kanduc D. How a single amino acid change may alter the immunological information of a peptide Front. Biosci. 2012 4 1843-1852.
Lucchese A. Serpico R. Crincoli V. Shoenfeld Y. Kanduc D. Sequence uniqueness as a molecular signature of HIV-1-derived B-cell epitopes Int. J. Immunopathol. Pharmacol. 2009 22 639-646.
Kanduc D. Serpico R. Lucchese A. Shoenfeld Y. Correlating low-similarity peptide sequences and HIV B-cell epitopes. Autoimmun. Rev. 2008 7 291-296.
Polito A. Polimeno R. Kanduc D. Peptide sharing between Parvovirus B19 and DNA methylating/histone modifying enzymes: a potential link to childhood acute lymphoblastic leukemia Int. J. Pediatr. Child Health 2017 5 29-39.
Kanduc D. Epstein-Barr virus immunodeficiency and cancer: a potential crossreactivity connection. Intern. Med. Rev. 2018 4 1–17.
Kanduc D. Shoenfeld Y. Inter-pathogen peptide sharing and the original antigenic sin: Solving a paradox Open Immunol. J. 2018 8 11–27.
Kanduc D. Polito A. From viral infections to autistic neurodevelopmental disorders via cross-reactivity. J. Psychiatry Brain Sci. 2018 3 14.
Kanduc D. Influenza and sudden unexpected death: the possible role of peptide cross-reactivity Infect. Int. 2018 7.
Chion C.K. Doggen C.J. Crawley J.T. Lane D.A. Rosendaal F.R. ADAMTS13 and von Willebrand factor and the risk of myocardial infarction in men Blood 2007 109 1998-2000.
Andersson H.M. Siegerink B. Luken B.M. Crawley J.T. Algra A. Lane D.A. High VWF low ADAMTS13 and oral contraceptives increase the risk of ischemic stroke and myocardial infarction in young women Blood 2012 119 1555–1560.
Allie S. Stanley A. Bryer A. Meiring M. Combrinck M.I. High levels of von Willebrand factor and low levels of its cleaving protease ADAMTS13 are associated with stroke in young HIV-infected patients Int. J. Stroke 2015 10 1294-1296.
Zheng X.L. ADAMTS13 and von Willebrand factor in thrombotic thrombocytopenic purpura Annu. Rev. Med. 2015 66 211-225.
Iba T. Ito. T Maruyama I. Jilma B. Brenner T. Müller M.C. et al. Potential diagnostic markers for disseminated intravascular coagulation of sepsis Blood Rev. 2016 30 149-155.
Denorme F. Kraft P. Pareyn I. Drechsler C. Deckmyn H. Vanhoorelbeke K. et al. Reduced ADAMTS13 levels in patients with acute and chronic cerebrovascular disease PLoS One 2017 12 e0179258.