The genus
Coronavirus (family
Coronaviridae, order
Nidovirales) comprises a group of enveloped positive-strand RNA viruses of mammals and birds. With a genome of 27 to 31 kb, encoding an ∼750-kDa pp1ab replicase polyprotein, four structural proteins (S, M, N, and E) and up to five accessory nonstructural proteins, coronaviruses (CoVs) are the largest RNA viruses known to date (
5,
11). In humans, they are mostly associated with mild enteric or respiratory infections, such as the common cold, and hence were long considered of modest clinical importance. However, the sudden emergence of severe acute respiratory syndrome (SARS) has sparked wide interest in CoV biology and pathogenesis (
12,
22,
23,
34,
36). The more recent discovery of yet another human CoV, HCoV-NL63 (
14,
45), also implicated in severe respiratory disease, further emphasizes the pathogenic potential of CoVs and stresses the need for the development of new prophylactic and therapeutic strategies.
Among the most conspicuous clinicopathological findings reported for SARS are the protracted multiphasic course of the infection with recurrence of fever and disease after initial apparent improvement and a consistent CD4
+ and CD8
+ T-cell lymphopenia (
4,
8,
23,
36,
44,
56). In this respect, there are striking similarities with a lethal CoV infection occurring in cats. Feline infectious peritonitis (FIP) is a progressive debilitating condition caused by FIP viruses (FIPVs) (for a review, see reference
9), pathogenic virulence mutants spontaneously arising from apathogenic feline enteric CoV field strains (
18,
35,
49). Typical for the disease are the widespread pyogranulomatous lesions, which occur in various tissues and organs, including lung, liver, spleen, omentum, and brain (
32,
50,
54). The infection of macrophages and monocytes is thought to be key to the pathogenic mechanism (
40,
52). There is ample evidence for a crucial involvement of the immune system. A profound T-cell depletion from the periphery and the lymphatic tissues, observed in cats with end-stage FIP (
16,
21), and the common occurrence of hypergammaglobulinemia (
29,
50) are indicative of a severe virus-induced immune dysregulation (
20). The humoral response against FIPV does not seem to be protective and can in fact lead to “early death syndrome,” a more fulminating and drastically shortened course of the disease (
31,
52). Antibodies directed against the spike protein S, when present at subneutralizing titers, apparently opsonize the virus and enhance the infection of target cells via Fc receptor-mediated attachment (
7,
19,
47). It is commonly believed that the control of infection and FIPV clearance are primarily achieved through cell-mediated immunity (CMI) (
17,
35,
51).
Here, we present a comprehensive study of the natural history and immunobiology of FIP, based upon longitudinal infection experiments performed with the highly virulent FIPV strain 79-1146. We show that FIPV causes a multiphasic recurrent infection with waves of enhanced FIPV replication coinciding with fever, weight loss, and a dramatic decline in peripheral CD4+ and CD8+ T-cell counts. Consistent with the notion that CMI is protective, we detected FIPV-specific Th1 T-cell responses in surviving animals with the spike protein S as the main CD8+ T-cell antigen. A model is discussed in which cellular immunity is counteracted by virus-induced T-cell depletion and in which the efficacy of the initial T-cell responses critically determines disease progression and the ultimate outcome of the infection.
DISCUSSION
FIP, a paradigm of CoV-mediated chronic disease, was already recognized in earlier studies as a complex multiphasic condition with recurrent (biphasic) fever as one of its most distinctive traits (
41,
47,
50,
53). The pathogenic mechanisms, however, remain poorly understood. Here, we extend previous findings (
16,
32,
50,
53) and present a comprehensive study of the natural history, viral dynamics, and immunobiology of FIP. In a longitudinal experiment, we followed disease progression in a large cohort of cats after oronasal infection with the highly virulent FIPV strain 79-1146. We found that the very early stages of experimentally induced FIP were virtually identical among the different animals, irrespective of the final outcome, i.e., death or recovery. All cats presented characteristic signs of acute infection with fever, weight loss, acute lymphopenia, and the presence of viral RNA in blood cells and plasma. Then, by day 7 to 8 p.i., disease seemingly resolved and the animals improved: fever subsided, body weight stabilized or increased, and the amounts of viral RNA in the blood decreased below detection levels. However, all cats but one suffered a major relapse, and most of them inexorably progressed to lethal disease within 16 to 54 days. We distinguished five groups on the basis of survival time, which were operationlly designated as rapid, intermediate, or delayed progressors and prolonged or long-term survivors. Animals in the latter two groups succeeded in countering the second wave of disease either to succumb to a subsequent, final relapse or to gain apparent control of the infection, respectively. It is unknown whether long-term survivors really achieved complete viral clearance or remained persistently infected at a low level. In similar cases, FIP could be induced even up to 1 year after initial FIPV inoculation by performing a superinfection with the immunosuppressive feline leukemia virus (
33).
Perhaps the most intriguing aspect of FIPV infection is its effect on the CD4
+ and CD8
+ T-cell levels. FIPV-induced T-cell depletion has been documented before (
16,
21), but we are first to show that this phenomenon already occurs very early in infection and correlates with (enhanced) viral replication. After the initial general lymphopenia, total lymphocyte numbers rose again and remained at levels equal to or exceeding those at day 0. In contrast, CD4
+ and CD8
+ T-cell counts remained consistently low. During the periods of apparent convalescence, T-cell counts increased modestly only to fall again with the renewed onset of overt disease. In agreement with earlier reports (
16,
21), T cells were virtually depleted from lymphatic tissue and from peripheral tissue in the animals with end-stage FIP. How FIPV causes T-cell lymphopenia is not clear. As there are no indications that T cells are susceptible to infection, their depletion most likely occurs through indirect effects (
16). In other examples of virus-induced T-cell depletion, e.g., measles, the infection of antigen-presenting cells, and of dendritic cells (DCs) in particular, is thought to cause T-cell apoptosis (
28,
30,
38,
39). Likewise, FIPV reportedly targets antigen-presenting cells, such as macrophages and monocytes (
16,
29,
40,
52), the serotype II strains via the dedicated cell receptor CD13 (
43). Given the fact that human immature myeloid DCs express CD13 (
42), it is likely that certain DC subsets of the cat do so as well and hence are susceptible to FIPV.
We propose that the virus-driven T-cell depletion results in an acute immunodeficiency and that in the early stages of infection the immune system is already facing an uphill struggle. Still, all animals were able to at least temporarily contain the first wave of disease. In agreement with the general view that humoral immunity is not protective, virus-neutralizing antibodies appeared and rose with identical kinetics and to similar titers in survivors and nonsurvivors (Fig.
2). Moreover, antibodies seem to be generated too late during the course of acute FIPV infection to contribute to host defenses. We therefore assume that the partial control of viral replication, which occurs during the early days after infection, is primarily T-cell mediated. Indeed, the onset of apparent convalescence around day 7 p.i. would correlate temporally with the expected peak of the early virus-specific effector CD8
+ T-cell response, as described with other systems (
1,
26).
Our combined observations are therefore consistent with a model for FIP pathogenesis in which virus-induced T-cell depletion and the antiviral T-cell responses are opposing forces. The net result is an intermittent infection, with episodes of disease driven by enhanced viral replication punctuated by short periods of apparent convalescence. The efficacy of the primary T-cell responses most likely determines to what extent the initial wave of infection can be contained and hence would be the decisive factor in disease progression. If the first response is too weak, a second wave of increased virus replication will further reduce T-cell numbers and swiftly overwhelm the immune system (rapid progressors; type A) (Fig.
3). If, however, the initial T-cell responses succeed in largely containing viral replication, the animal may develop a more protracted course of the disease (delayed progressors; type C) (Fig.
3) or even get a second chance (prolonged and long-term survivors; types D and E) (Fig.
3). The rising amounts of viral RNA in the blood, consistently seen in animals with end-stage FIP, indicate that progression to fatal disease is the direct consequence of a loss of immune control, ultimately resulting in unchecked viral replication. Whether or not an animal is able to mount a protective immune response may be determined at least in part by its haplotype. Indeed, cheetahs (
Acinonyx jubatus) are extremely sensitive to FIP, a peculiarity which has been ascribed to their genetic uniformity and their lack of major histocompatibility complex class I polymorphism (
27).
If CMI does confer protection, the question arises as to which viral antigens are involved. Our analysis of the specificity of splenic (memory) T-cell pools in three long-term survivors and in two persistently infected, partially protected animals identified the spike protein as the dominant target for CD8
+ T cells. The immunodominance of epitopes from a viral envelope glycoprotein after chronic infection is reminiscent of the situation in inbred mice chronically infected with the mouse hepatitis CoV (MHV) or with the lymphocytic choriomeningitis arenavirus (LCMV). In both cases, immunodominance shifted during the course of persistent infection from epitopes on the highly expressed cytoplasmic nucleocapsid proteins (N for MHV and NP for LCMV) towards those from the envelope glycoproteins (S for MHV and GP for LCMV) (
3,
46,
55). In LCMV-infected animals, the NP-specific CD8
+ T cells undergo rapid inactivation (exhaustion) or even deletion as a result of antigenic overstimulation (
55). A similar mechanism has been postulated to explain the inversion of immunodominance during chronic MHV infection (
3). It is therefore tempting to speculate that the immunodominance of S-derived CD8
+ T-cell epitopes after chronic FIPV infection reflects the selective survival of S-specific CD8
+ T cells at the expense of T cells recognizing epitopes of other viral proteins, in particular of N (
46). The apparent dominance of S-derived epitopes becomes even more remarkable if one takes into account that cats are outbred. Indeed, the anti-S responses measured in individual cats were directed against different epitopes, implying that the immunodominance of S did not merely reflect the chance dominance of a single epitope-major histocompatibility complex class I combination.
The pathogenic phenomena described here may not be limited to FIP but likely bear relevance to the immunobiology and pathogenesis of other chronic CoV infections, in particular of SARS, for which acute T-cell lymphopenia, multiphasic disease, and viral persistence have been previously reported (
2,
4,
8,
12,
24,
36,
44,
56). FIP presents a relevant, safe, and well-defined model to study CoV-mediated immunosuppression. Moreover, as disease progression is highly reproducible and primarily driven by viral replication, it should provide an attractive and convenient model system for in vivo testing of anti-CoV drugs.