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The lung tissues of 37 of these cases were positive for influenza viral antigens or viral RNA, including four from the prepandemic period (May\u2013August). The prepandemic and pandemic peak cases were indistinguishable clinically and pathologically. All 68 cases had histological evidence of bacterial pneumonia, and 94% showed abundant bacteria on Gram stain. Sequence analysis of the viral hemagglutinin receptor-binding domain performed on RNA from 13 cases suggested a trend from a more \u201cavian-like\u201d viral receptor specificity with G222 in prepandemic cases to a more \u201chuman-like\u201d specificity associated with D222 in pandemic peak cases. Viral antigen distribution in the respiratory tree, however, was not apparently different between prepandemic and pandemic peak cases, or between infections with viruses bearing different receptor-binding polymorphisms. The 1918 pandemic virus was circulating for at least 4 mo in the United States before it was recognized epidemiologically in September 1918. The causes of the unusually high mortality in the 1918 pandemic were not explained by the pathological and virological parameters examined. These findings have important implications for understanding the origins and evolution of pandemic influenza viruses.<\/jats:p>","DOI":"10.1073\/pnas.1111179108","type":"journal-article","created":{"date-parts":[[2011,9,20]],"date-time":"2011-09-20T04:23:28Z","timestamp":1316492608000},"page":"16416-16421","update-policy":"https:\/\/doi.org\/10.1073\/pnas.cm10313","source":"Crossref","is-referenced-by-count":141,"title":["Autopsy series of 68 cases dying before and during the 1918 influenza pandemic peak"],"prefix":"10.1073","volume":"108","author":[{"given":"Zong-Mei","family":"Sheng","sequence":"first","affiliation":[{"name":"Viral Pathogenesis and Evolution Section, Laboratory of Infectious Diseases,"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Daniel S.","family":"Chertow","sequence":"additional","affiliation":[{"name":"Viral Pathogenesis and Evolution Section, Laboratory of Infectious Diseases,"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Xavier","family":"Ambroggio","sequence":"additional","affiliation":[{"name":"Bioinformatics and Computational Biosciences Branch,"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sherman","family":"McCall","sequence":"additional","affiliation":[{"name":"Clinical Pathology Laboratory, US Army Medical Research Institute of Infectious Diseases, Fort Detrick, MD 21702;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ronald M.","family":"Przygodzki","sequence":"additional","affiliation":[{"name":"Department of Veterans Affairs, Washington, DC 20420; and"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Robert E.","family":"Cunningham","sequence":"additional","affiliation":[{"name":"Department of Biophysics, Armed Forces Institute of Pathology, Rockville, MD 20850"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Olga A.","family":"Maximova","sequence":"additional","affiliation":[{"name":"Office of the Chief, Laboratory of Infectious Diseases, and"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"John C.","family":"Kash","sequence":"additional","affiliation":[{"name":"Viral Pathogenesis and Evolution Section, Laboratory of Infectious Diseases,"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"David M.","family":"Morens","sequence":"additional","affiliation":[{"name":"Office of the Director, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD 20892;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jeffery K.","family":"Taubenberger","sequence":"additional","affiliation":[{"name":"Viral Pathogenesis and Evolution Section, Laboratory of Infectious Diseases,"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"341","published-online":{"date-parts":[[2011,9,19]]},"reference":[{"key":"e_1_3_4_1_2","doi-asserted-by":"crossref","first-page":"105","DOI":"10.1353\/bhm.2002.0022","article-title":"Updating the accounts: Global mortality of the 1918\u20131920 \u201cSpanish\u201d influenza pandemic","volume":"76","author":"Johnson NP","year":"2002","unstructured":"NP Johnson, J Mueller, Updating the accounts: Global mortality of the 1918\u20131920 \u201cSpanish\u201d influenza pandemic. 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