The LCMV-infected monkey model for Lassa fever was investigated with the goal of finding transcriptome changes that could eventually be used as prognostic biomarkers to discriminate virulent and mild infections. Transcriptome analysis of rhesus macaque liver showed that both mild and virulent LCMV infections had tremendous effects on glucose, amino acid and fatty acid metabolism, and on the complement and coagulation cascades. As with our previous transcriptome analysis using blood , prominent expression of inflammatory-response genes was also seen in liver.
A transcriptome study using the HuH-7 liver cell line  showed that Lassa infection up-regulated only laminin-a and ribosomal protein L28 with respect to gene expression in uninfected cells. It is frequently observed that studies of single cell types will show few differences in comparison to studies of complex tissues. Although our study did not see changes in expression of the laminin-a gene, several ribosomal protein genes were up-regulated in LCMV-infected liver: approximately 30 were moderately up-regulated, and 20 were highly up-regulated, with L28 being the most up-regulated of all (Additional File 8). None of the ribosomal gene expression changes observed in LCMV-infected liver differed significantly when comparing the virulent and mild infections. It is possible that L28 is a co-factor of arenavirus replication, since replicating LCMV is associated with ribosomal protein complexes [42–44].
Other liver transcriptome studies have identified major molecular events associated with viral infection, with higher levels of interferon-responsive genes being a common theme. We observed significant up-regulation of ISG15, IFIT1, and STAT1 in LCMV-WE-infected (diseased) monkey liver with respect to non-diseased liver, and similar increased expression was seen in human liver infected with hepatitis C virus . As noted in a recent paper on the Ebola virus transcriptome , the majority of cells profiled are uninfected bystanders and are responding to plasma interferon despite the interferon-antagonistic activity of viral genes within infected cells . In two liver transcriptome studies of human beings infected with hepatitis C virus, MHC class I and II genes were up-regulated in infected versus uninfected liver [45, 48]; in our studies, several MHC genes are up-regulated in liver, with concomitant down-regulation in PBMC , possibly due to migration of activated monocytes from the circulation to infected sites. A noteable difference between the hepatitis C liver transcriptome and the LCMV-liver transcriptome is that Serpin D1 and C genes are down-regulated by hepatitis C, whereas Serpin C is 30-fold up-regulated in the LCMV liver (Figure 2) and would be expected to inhibit the intrinsic coagulation pathway.
Two crucial liver functions are glycogen breakdown and gluconeogenesis from non-sugars like fatty acids, pyruvate, lactate, and amino acids, with both functions beginning a few hours after the onset of fasting. Elevated rates of fat breakdown (lipolysis) increase the release of free fatty acids that simultaneously stimulate gluconeogenesis and inhibit glycogenolysis [49, 50]. The oxidation of fatty acids by liver mitochondria leads to the generation of ketone bodies, which appear in the blood in inverse proportion to glucose and provide an important alternative fuel source [51, 52]. In LCMV-infected monkey liver there was a significant increase in transcripts promoting gluconeogenesis in both stages of infection and a decrease in transcripts promoting glycogenolysis (e. g. G6PC and FBP1) in the early stage of infection. It is likely that gluconeogenesis was driven by hydrolysis of triglycerides since transcripts for β-oxidation enzymes and lipases were up-regulated in LCMV-infected livers (Table 6). Glycolysis and gluconeogenesis constituted a "futile cycle" that would be predicted to waste energy during LCMV infection (Table 2). During the early stage of infection the macaque liver increased the usage of fatty acids and ketone bodies, and later in the infection, the liver functioned in a glucose-producing role, using amino acids and fatty acids as an energy source.
Other viral infections are also inter-twined with glucose, amino acid and fatty-acid metabolism. The transcription of hepatitis B virus, a DNA virus, requires a key regulatory enzyme of gluconeogenesis, peroxisome proliferator-activated receptor γ C1 (PPARGC1. This enzyme acts through nuclear receptors (the glucocorticoid receptor, the forkhead transcription factor, and the nuclear receptor 4a) to stimulate transcription of hepatitis B. PPARGC1 is known to be up-regulated by fasting, cold temperature or stress , and, remarkably, it is significantly up-regulated in the mild LCMV infection but not in the virulent infection; this has been validated by quantitative PCR (Table 2). Another glycolytic enzyme, phosphoglycerate kinase (PGK), stimulates Sendai virus transcription through its interaction with tubulin in the initiation complex . Vero cells infected with the alphavirus, Mayaro, have altered glucose metabolism and increased glucose consumption , but it is unclear whether this is directly related to virus replication. The key glycolytic enzyme, glyceraldeyde 3-phosphate dehydrognase (GAPDH) is involved in the life cycle of parainfluenza virus type 3 (HPIV3) . Interestingly, the genes for both PGK and GAPDH were strongly up-regulated in both mild and virulent LCMV infections. Hepatitis C virus (HCV) infection also affects hepatic glucose metabolism. HCV down-regulates insulin-receptor substrate genes (IRS1 and IRS2) through up-regulation of suppressor of cytokine signaling (SOCS) . Similarly in the LCMV-infected primate, IRS1 expression is decreased and expression of IRS2 is moderate, but SOCS2 is up-regulated (7.2-fold) at the pre-viremic stage of infection (Additional File 8).
The acute LCMV disease has characteristics of starvation that resemble both cachexia (TNF-α or IL-6-mediated wasting) and anorexia (appetite loss). High levels of IL-6 were detected in LCMV-WE-infected liver . IL-6 is known to stimulate protein catabolism in order to maintain glucose levels via gluconeogenesis , whereas anorexia, is largely driven by IL-1β  and is known to mobilize fat stores in lieu of protein stores . Here, though we failed to detect increases in IL-1β, we observed increased expression of both lipid-oxidation and protein catabolism genes. We also observed an early decrease in blood triglycerides (Table 1) that corroborates our transcriptome result of suppressed ACACB. The low triglycerides we observe also contrast with the profile of bacterial sepsis in which high liver IL-6 coincides with high triglycerides . Although high IL-6 is detected by day 7  high circulating triglycerides are not seen until day 11 or 12 in the LCMV-WE-infected macaques (Table 1).
It is difficult to relate changes in intermediary metabolism of LCMV-infected liver to a lethal disease that resembles Lassa fever. Although the liver transcriptome may resemble that of a starving organism, and such a profile is supported by the dehydration and appetite-loss observed in diseased monkeys, it is known that primates can survive weeks of starvation ; so it is unlikely that starvation alone explains such a rapid disease. Since most of the transcriptome changes that affected intermediary metabolism were seen in both the diseased and non-diseased animals it is unlikely that those changes were the primary cause of disease. Importantly, several genes involved in intermediary metabolism (ARG2, GOT1, G6PC, IRS2, LIPG, PCK1, SDS, PPARGC1) were considerably more up-regulated in the mild than in the fatal infections (Figure 4) leading to the possibility that the altered energy metabolism is primarily a self-preserving rather than a pathogenic activity.
Some of the differences between virulently – and mildly-infected liver could be ascribed to the over-expression of interferon-response genes (e.g. IFI44, Figure 4). A large drop in hemoglobin gene expression in virulent infections was likely due to interferon inhibition of erythropoiesis . Paradoxically, circulating levels of red blood cells and hemoglobin were unaffected by LCMV-WE infection (Table 1), but events in the liver may precede what is detectable in the circulation. A recent paper describes lethal hemorrhagic anemia in LCMV-infected mice that did not occur in IFN-α/β knockout mice . In the murine model, both LCMV-WE and LCMV-ARM caused platelet dysfunction and life-threatening anemia. The murine studies used much higher doses of virus than we used for our primate pathogenesis studies, i. e. mice were given 106 pfu virus, whereas the monkeys were given 103 pfu. Also, the disease in mice is generally considered immunopathological, i.e. alleviated by immunosuppression, unlike the disease in guinea pigs and primates . In the monkey model, only LCMV-WE replicates well in monkey liver whereas LCMV-ARM replicates poorly , and only LCMV-WE elicits detectable levels of interferon in plasma . Nevertheless, it is quite reasonable that in the primate, IFN-α/β initiates platelet dysfunction, and it might be reasonable to treat the primate disease with platelet transfusions, as was done in the murine model.