Collin Sanderson

Middle East Respiratory Syndrome

Overview
Middle East Respiratory Syndrome (MERS) is a recently discovered virus from the
Betacoronaviral genus. It is an enveloped virus with a nucelocapsid-encased genome of singlestranded, positive RNA. The non-segmented genome is slightly above the average size of a viral
genome, with 32,000 base pairs. The virus was first discovered in connection with the
phylogenetically similar virus Severe Acute Respiratory Syndrome (SARS), and the first cases
emerged in 2012 in Saudi Arabia (Chan, Lau and Woo). It is believed that MERS originated
from bat populations, where it developed in coordination with bat evolution. MERS makes use
of the DPP4 (also known as CD-26) protein as a cell-entry receptor. The DPP4 gene evolutionary
footprint shows that the gene evolved as a result of natural selection in favor of bats that were
less susceptible to MERS. However, the receptor-binding domain of the MERS virus evolved in
harmony with bat DPP4, permitting continued infection among the bat populations (Cui, Eden
and Holmes). Thus, when the MERS virus came into contact with human individuals, it was
already highly developed for mammalian DPP4.
The connection between MERS and bats is clear, but the reservoir more closely
associated with human infection is camels. Contact with camels in the Middle East is frequent,
and camels milk and meat are lightly consumed as well. A recent study shows that a coronavirus
isolated from dromedary camels is 99.9% genomically identical to human MERS, significantly
more similar than to the MERS strain found in bats (Raj, Farag and Reusken). Evidently, MERS

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continued to evolve beyond its infection of bats and happened to grow an affinity for humans. Its
strong human affinity contributes to its great ability to establish an infection in a host patient.
MERS is an extremely deadly disease, and has been shown to be somewhat transmissible
between humans. As of June 2015, 483 deaths have occurred out of 1180 confirmed cases of
MERS (40% mortality) (Zumla, Hui and Perlman).
Pathogenesis/Disease Mechanism
The clinical signs of MERS infection include acute severe community-acquired
pneumonia in almost all cases, acute renal failure, cough, difficulty breathing, and gastrointestinal symptoms, including diarrhea. Complete respiratory failure also occurred in a majority
of cases, requiring ventilator support (Chan, Lau and Woo). Tropism of MERS is linked to
several cell-surface proteins, including previously mentioned DPP4 (CD-26). Many of these
proteins are common to respiratory epithelia as well as renal and enteric epithelial cells.
Additionally, DPP4 is involved in the regulation of several key cellular and systemic processes,
namely chemokine regulation, T-cell activation, and apoptosis (Matteucci and Giampietro).
More about DPP4 is discussed later on.
Many of the common symptoms of MERS can be traced to the cellular effect of infection.
More about the cytopathology of MERS is discussed later, but the most notable effect is that cell
detachment from the tissue eventually occurs. Detachment causes damage, or more specifically,
thinning of infected tissues (van den Brand, Smits and Haagmans). No literature directly
addresses the mechanisms whereby MERS causes its disease, so I will present inferences based
on the research observations of the cellular effect of MERS infection and the related
pathophysiology.

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The majority of the cells in MERS cellular tropism spectrum are epithelial cells. The
several respiratory symptoms (pneumonia, cough, difficulty breathing, and complete respiratory
failure) are all results of thinning of bronchial and alveolar epithelia. Alveolar epithelia are
responsible for respiratory gas exchange, as well as the production of pulmonary surfactants that
keep alveoli from collapsing during expiration (Ward and Nicholas). Bronchial epithelia have
cilia that move mucus, fluids, and foreign particles up the bronchi and out of the lungs (Jacquot,
Spilmont and de Bentzmann). Damage to these two tissues leads to fluid and particulate matter in
the lungs (pneumonia), poor pulmonary gas exchange, mucosal build-up which can cause
blockage of bronchi leading to coughing and difficulty breathing, and collapse of alveoli all
resulting in complete respiratory failure (Ketai and Godwin).
Renal epithelia are involved in the transport of blood filtrates into and out of the nephron
tubules for concentrating urine. Damage to this tissue can lead to decreased production of urine,
also known as kidney failure (Clark, Kirby and Baker). Enteric epithelia make up intestinal villi,
which are responsible for fluid and nutrient absorption. Damage to this tissue interferes with the
absorption of water, leading to diarrhea (Berkes, Viswanatha and Savkovic).
Avoiding the Immune System & Hypothesis
A goal of current research is to explain the mechanisms that MERS uses to avoid the
immune system. MERS has been found to inhibit antigen-presentation in infected cells, inhibit
cell death, and cause cells to eventually detach from tissue. I also present the hypothesis that
MERS inhibits/avoids an interferon response, and that this is key to the propagation of the
infection. I will provide evidences of my hypothesis, some of which are highly connected to
other immune avoidance mechanisms.

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Many viruses cause death of the cells they infect. Macrophages clean up dead cell
remains, and release inflammatory cytokines to bring additional blood flow to the area,
catalyzing an immune system response. Macrophages also release interferon during cleanup.
However, MERS causes cell detachment from tissues instead of cell death, preventing
macrophage involvement. In one article, the research team involved studied the effects of MERS
infection on cells over time. They infected an immortalized Vero cell line derived from kidney
epithelial cells (expressing the necessary DPP4 protein) with MERS and found that they
displayed only mild cytopathic effects up to six days after infection. Thereafter the infected cells
began to detach from the culture container surface, without cell death occurring. This matches
the common MERS incubation period of 5-7 days. This observation contrasted with the infection
progression of various non-MERS coronaviruses, all of which induced severe cytopathic effects
quickly after infection and observable cell death (de Wilde, Raj and Oudshoorn). Detachment of
cells instead of cell death agrees with the recorded observation that inflammation is very limited
in MERS infection (Lau, Lau and Chan). This illustrates the MERS infection strategy to avoid
an interferon and inflammatory response to cell death, supporting my hypothesis.
A few possible explanations of MERS inhibition of cell death exist. One explanation is in
its replication mechanism. The nucleocapsid-encased genome acquires its envelope by budding
from the organelle-membranes surrounding the cellular endoplasmic reticulum and Golgi
apparatus as an intracellular vesicle. The virions then exocytose from the cell, leaving the
cellular membrane intact (Stadler, Masignani and Eickmann). This mechanism prevents cell
death early in the infection process, preventing an immediate interferon response until the
infection is more pervasive. Additionally, the DPP4 gene is linked with regulation of apoptosis
in the cells where it is expressed, as mentioned previously. MERS strong connection to DPP4

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may give MERS some control over other ways that infected cells can induce apoptosis in
response to the virus, but this has not been researched thus far.
In a previously discussed article, the team studied the effects of interferon induction on
MERS infection, and compared it to the phylogenetically similar SARS virus. The data recorded
shows that SARS virus was unaffected by interferon until higher concentrations were present.
MERS, however, showed dramatic decrease in its cytopathic effects by even the smallest
concentrations of interferon that were tested (data below). This data provides evidence to my
hypothesis that inhibition of interferon is key to MERS infection progression (de Wilde, Raj and
Oudshoorn).

One of the strongest triggers of an interferon response is double-stranded RNA.

According to a recent review of MERS research, the positive sense MERS genome is replicated
in its full length into a negative sense copy (J. F. Chan, S. K. Lau and K. K. To). The coexistence of positive and negative sense RNA causes a strong presence of dsRNA in the infected
cell, which would be guaranteed to trigger interferon production. Therefore, MERS must have

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some interferon-inhibition mechanism to compensate for the volume of dsRNA it creates. A

recently discovered protein in the MERS transcriptome displays this ability. In the study, MERS
protein 4a bound to dsRNA created during viral replication (Siu, Yeung and Kok). We can then
infer that protein 4a would compete with PACT for binding in an infected cell. PACT is a
cellular protein that stimulates interferon production when bound to dsRNA (Patel and Sen).
This discovery hints at a highly specialized mechanism whereby MERS avoids an interferon
response. I believe that these several evidences provide strong support for my hypothesis that
MERS avoids and inhibits interferon in order to successfully propagate.
As a final immune-avoidance method, MERS substantially down-regulates the expression
of nine genes that are vital to the cells antigen-presentation---the means of activating the
adaptive immune system in response to an infection. Among these are genes from the
proteasome (PSMB8/9) and peptide-loading complex (PDIA3 and TAPBP), which are necessary
for the MHC class I pathway, and CD74 in the MHC class II pathway (data below) (Josset,
Menachery and Gralinski). The exact method whereby MERS causes this down-regulation is
unknown, but it is likely through proteins in MERS transcriptome, or a side effect of viral
replication.

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All of these mechanisms contribute to the high mortality of Middle East Respiratory
Syndrome. As such a newly emerging disease, there are no specialized medical treatments or
vaccines against it. Research is limited but ongoing in the search for a counterattack to this
deadly virus.

Scholarly Sources
Berkes, J., et al. "Intestinal epithelial responses to enteric pathogens: effects on the tights junction barrier, ion
transport, and inflammation." Gut 52.3 (2003): 439-451.
Chan, Jasper F.W., et al. "Middle East Respiratory Syndrome Coronavirus: Another Zoonotic Betacoronavirus
Causing SARS-Like Disease." Clinical Microbiology Reviews 28.2 (2015): 465-522.
Chan, Jasper Fuk-Woo, Susanna Kar-Pui Lau and Patrick Chiu-Yat Woo. "The emerging novel Middle East
respiratory syndrome coronavirus: The "knowns" and "unknowns"." Journal of the Formosan Medical
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Clark, K.R., et al. "Renal epithelium: reversal of cytotoxic damage by addition of anti-ththymocyte globulin."
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Cui, Jie, et al. "Adaptive evolution of bat dipeptidyl peptidase 4 (dpp4): implications for the origin and emergence
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de Wilde, Adriaan H., et al. "MERS-coronavirus replication induces severe in vitro cytopathology and is strongly
inhibited by cyclosporin A or interferon-alpha treatment." Journal of General Virology 94 (2013): 17491760.
Jacquot, J., et al. "Structure and secretory functions of the respiratory epithelium." Archives internationales de
physiologie, de biochimie et de biophysique 100.4 (1992): A41-46.
Josset, Laurence, et al. "Cell Host Response to Infection with Novel Human Coronavirus EMC Predicts Potential
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Matteucci, E. and O. Giampietro. "Dipeptidyl Peptidase-4 (CD26): Knowing the Function before Inhibiting the
Enzyme." Current Medicinal Chemistry 16.23 (2009): 2943-2951.
Patel, Rekha C. and Ganes C. Sen. "PACT, a protein activator of the interferon-induced protein kinase, PKR." The
EMBO Journal 17 (1998): 4379-4390.
Raj, VS, EABA Farag and CBEM Reusken. "Isolation of MERS Coronavirus from a Dromedary Camel." Emerging
Infectious Diseases (2014): 1339-1342.

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Siu, Kam-Leung, et al. "Middle East Respiratory Syndrome Coronavirus 4a Protein Is a Double-Stranded DNABinding Protein That Suppresses PACT-Induced Activation of RIG-I and MDA5 in the Innate Antiviral
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Ward, HE and TE Nicholas. "Alveolar type I and type II cells." Australian & New Zealand Journal of Medicine 5.3
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