Patent Publication Number: US-2006003352-A1

Title: Mass tag PCR for mutliplex diagnostics

Description:
This application claims benefit of U.S. Provisional Application No. 60/566,967, filed Apr. 29, 2004, the contents of which are hereby incorporated by reference. 
    
    
      The invention disclosed herein was made with Government support under grant no. AI51292 from the National Institutes of Health. Accordingly, the U.S. Government has certain rights in this invention. 
    
    
      Throughout this application, various publications are referenced. Full citations for these references may be found at the end of the specification immediately preceding the claims. The disclosures of these publications in their entireties are hereby incorporated by reference into this application to more fully describe the state of the art to which this invention pertains.  
     BACKGROUND OF THE INVENTION  
      Establishing a causal relationship between infection with a virus and a specific disease may be complex. In most acute viral diseases, the responsible agent is readily implicated because it replicates at high levels in the affected tissue at the time the disease is manifest, morphological changes consistent with infection are evident, and the agent is readily cultured with standard microbiological techniques. In contrast, implication of viruses in chronic diseases may be confounded because persistence requires restricted gene expression, classical hallmarks of infection are absent, and/or Methods for cloning nucleic acids of microbial pathogens directly from clinical specimens offer new opportunities to investigate microbial associations in chronic diseases. The power of these methods is that they can succeed where methods for pathogen identification through serology or cultivation may fail due to absence of specific reagents or fastidious requirements for agent replication. Over the past decade, the application of molecular pathogen discovery methods resulted in identification of novel agents associated with both acute and chronic diseases, including Borna disease virus, Hepatitis C virus, Sin Nombre virus, HHV-6, HHV-8,  Bartonella henselae , and  Tropherema whippeli.    
      Various methods are employed or proposed for cultivation-independent characterization of infectious agents. These can be broadly segregated into methods based on direct analysis of microbial nucleic acid sequences. (e.g., cDNA microarrays, consensus PCR, representational difference analysis, differential display), direct analysis of microbial protein sequences (e.g., mass spectrometry), immunological systems for microbe detection (e.g., expression libraries, phage display) and host response profiling. A comprehensive program in pathogen discovery would need to exploit most, if not all, of these technologies.  
      The decision to employ a specific method is guided by the clinical features, epidemiology, and spectrum of potential pathogens to be implicated. Expression libraries, comprised of cDNAs or synthetic peptides, may be useful tools in the event that large quantities of acute and convalescent sera or cerebrospinal fluid are available for screening purposes; however, the approach is cumbersome, labor-intensive, and success is dependent on the presence of a specific, high affinity humoral immune response. The utility of host response mRNA profile analysis has been demonstrated in several in vitro paradigms and some inbred animal models; nonetheless, it is important to formally consider the possibility that a variety of organisms may activate similar cascades of chemokines, cytokines, and other soluble factors that influence host gene expression to produce what are likely to be convergent gene expression profiles. Thus, at least in virology, it is prudent to explore complementary methods for pathogen identification based on agent-encoded nucleic acid motifs. Given the potential for high density printing of microarrays, it is feasible to design slides or chips decorated with both host and pathogen targets. This would provide an unprecedented opportunity to simultaneously survey host response mRNA profiles and viral flora, providing insights into microbial pathogenesis not apparent with either method of analysis alone.  
      Representational difference analysis (RDA) is an important tool for pathogen identification and discovery. However, RDA is a subtractive cloning method for binary comparisons of nucleic acid populations. Thus, although ideal for analysis of cloned cells or tissue samples that differ only in a single variable of interest, RDA is less well suited to investigation of syndromes wherein infection with any of several different pathogens results in similar clinical manifestations, or infection is not invariably associated with disease. An additional caveat is that because the method is dependent upon the presence of a limited number of restriction sites, RDA is most likely to succeed for agents with large genomes. Indeed, in this context, it is noteworthy that the two viruses detected by RDA in the listing above were herpesviruses.  
      Consensus PCR (cPCR) has been a remarkably productive tool for biology. In addition to identifying pathogens, particularly genomes of prokaryotic pathogens, this method has facilitated identification of a wide variety of host molecules, including cytokines, ion channels, and receptors. Nonetheless, until recently, a difficulty in applying cPCR to pathogen discovery in virology has been that it is difficult to identify conserved viral sequences of sufficient length to allow cross-hybridization, amplification, and discrimination using traditional cPCR format. While this may not be problematic when one is targeting only a single virus family, the number of assays required becomes infeasible when preliminary data are insufficient to allow a directed, limited analysis.  
      Real-time PCR methods have significantly changed diagnostic molecular microbiology by providing rapid, sensitive, specific tools for detecting and quantitating genetic targets. Because closed systems are employed, real-time PCR is less likely than nested PCR to be confounded by assay contamination due to inadvertent aerosol introduction of amplicon/positive control/cDNA templates that can accumulate in diagnostic laboratories. The specificity of real time PCR is both a strength and a limitation. Although the potential for false positive signal is low so is the utility of the method for screening to detect related but not identical genetic targets. Specificity in real-time PCR is provided by two primers (each approximately 20 matching nucleotides (nt) in length) combined with a specific reporter probe of about 27 nt. The constraints of achieving hybridization at all three sites may confound detection of diverse, rapidly evolving microbial genomes such as those of single-stranded RNA viruses. These constraints can be compensated in part by increasing numbers of primer sets accommodating various templates. However, because real-time PCR relies on fluorescent reporter dyes, the capacity for multiplexing is limited to the number of emission peaks that can be unequivocally separated. At present up to four dyes can be identified simultaneously. Although the repertoire may increase, it will not likely change dramatically.  
     SUMMARY OF THE INVENTION  
      This invention provides a method for simultaneously detecting in a sample the presence of one or more of a plurality of different target nucleic acids comprising the steps of: 
          (a) contacting the sample with a plurality of nucleic acid primers simultaneously and under conditions permitting, and for a time sufficient for, primer extension to occur, wherein (i) for each target nucleic acid at least one predetermined primer is used which is specific for that target nucleic acid, (ii) each primer has a mass tag of predetermined size bound thereto via a labile bond, and (iii) the mass tag bound to any primer specific for one target-nucleic acid has a different mass than the mass tag bound to any primer specific for any other target nucleic acid;     (b) separating any unextended primers from any extended primers;     (c) simultaneously cleaving the mass tags from any extended primers; and     (d) simultaneously determining the presence and sizes of any mass tags so cleaved, 
 
 wherein the presence of a cleaved mass tag having the same size as a mass tag of predetermined size previously bound to a predetermined primer indicates the presence in the sample of the target nucleic acid specifically recognized by that predetermined primer. 
       

      This invention further provides the instant method, wherein the method detects the presence in the sample of 10 or more, 50 or more, 100 or more, or 200 or more different target nucleic acids. This invention further provides the instant method, wherein the sample is contacted with 4 or more, or 10 or more, or 50 or more, or 100 or more, or 200 or more different primers.  
      This invention further provides the instant method, wherein one or more primers comprises the sequence set forth in one of SEQ ID NOs:1-96, and 98-101. This invention further provides the instant method, wherein at least two different primers are specific for the same target nucleic acid. This invention further provides the instant method, wherein a first primer is a forward primer for the target nucleic acid and a second primer is a reverse primer for the same target nucleic acid.  
      This invention further provides the instant method, wherein the mass tags bound to the first and second primers are of the same size. This invention further provides the instant method, wherein the mass tags bound to the first and second primers are of a different size.  
      This invention further provides the instant method, wherein at least one target nucleic acid is from a pathogen.  
      This invention further provides the instant method, wherein the presence and size of any cleaved mass tag is determined by mass spectrometry. This invention further provides the instant method, wherein the mass spectrometry is selected from the group consisting of atmospheric pressure chemical ionization mass spectrometry, electrospray ionization mass spectrometry, and matrix assisted laser desorption ionization mass spectrometry.  
    
    
     BRIEF DESCRIPTION OF THE FIGURES  
       FIG. 1 : This figure shows the structure of mass tag precursors and four photoactive mass tags.  
       FIG. 2 : This figure shows an ACPI mass spectrum of mass tag precursors for digital virus detection.  
       FIG. 3 : This figure shows DNA sequencing sample preparation for MS analysis using biotinylated dideoxynucleotides and a streptavidin coated solid phase.  
       FIG. 4 : This figure shows a mass spectrum from Sanger sequencing reactions using dd(A, G, C)TP-11-biotin and ddTTP-16-biotin.  
       FIG. 5 : This figure shows synthesis of NHS ester of one mass tag for tagging amino-primer (SEQ ID NO:97).  
       FIG. 6 : This figure shows the general structure of mass tags and photocleavage mechanism to release the mass tags from DNA for MS detection.  
       FIG. 7 : This figure shows four mass tagged biotinylated ddNTPs.  
       FIG. 8 : This figure shows the structure of four mass tag precursors and the four photoactive mass tags.  
       FIG. 9 : This figure shows APCI mass spectra for four mass tags after cleavage from primers. 2-nitrosacetophenone, m/Z 150; 4 fluoro-2-nitrosacetophenone, m/z 168; 5-methoxy-2-nitrosacetophenone, m/z 180; and 4,5-dimethoxy-2-nitrosacetophenone.  
       FIG. 10 : This figure shows four mass tag-labeled DNA molecules.  
       FIG. 11 : This figure shows differential real-time PCR for HCoV SARS, OC43, and 229E.  
       FIG. 12 : This figure shows 58 tags cleaved from oligonucleotides and detected using ACPI-MS. Each peak represents a different tag structure as a unique signature of the oligonucleotide it was originally attached to.  
       FIG. 13 : This figure shows singleplex mass tag PCR for (1) influenza A virus matrix protein, (2) human coronavirus SARS, (3) 229E, (4) OC43, and (5) the bacterial agent  M. pneumoniae . (6) shows a 100 bp ladder.  
       FIG. 14 : This figure shows mass spectrum representative of data collected using a miniaturized cylindrical ion trap mass analyzer coupled with a corona discharge ionization source.  
       FIG. 15 : This figure shows mass spectrum of perfluoro-dimethylcyclohexane collected on a prototype atmospheric sampling glow discharge ionization source.  
       FIG. 16 : This figure shows the sensitivity of a 21-plex mass tag PCR. Dilutions of cloned gene target standards (10 000, 1 000, 500, 100 molecules/assay) diluted in human placenta DNA were analyzed by mass tag PCR. Each reaction mix contained 2× Multiplex PCR Master Mix (Qiagen), the indicated standard and 42 primers at 1×nM concentration labeled with different mass tags. Background in reactions without standard (no template control, 12.5 ng human DNA) was subtracted and the sum of Integrated Ion Current for both tags was plotted.  
       FIG. 17 : This figure shows analysis of clinical specimens; respiratory infection. RNA from clinical specimens was extracted by standard procedures and reverse transcribed into cDNA (Superscript RT system, Invitrogen, Carlsbad, Calif.; 20 ul volume). Five microliter of reaction was then subjected to mass tag PCR.  
       FIG. 18 : This figure shows multiplex mass tag PCR analysis of six human respiratory specimens. Mass tag primer sets employed in a single tube assay are indicated at the bottom of the figure.  
       FIG. 19 : This figure shows structures of MASSCODE tags.  
       FIG. 20 : This figure shows differential real-time PCR for West Nile virus and St. Louis encephalitis virus.  
      FIGS.  21 A- 21 B: (A) This figure shows serial dilutions of plasmid standards (5×10 5 , 5×10 4 , 5×10 3 , 5×10 2 , 5×10 1 , and 5×10 0 ) for RSV group A, RSV group B, Influenza A, HCoV-SARS, HCoV-229E, HCoV-OC43, and  M. pneumoniae  were each analyzed by mass tag PCR in a multiplex format. (B) This figure shows simultaneous detection of multiple targets in multiplex format using mixtures of two templates per assay (5×10 4  copies each): HCoV-SARS and  M. pneumoniae , HCoV-229E and  M. pneumoniae , HCoV-OC43 and  M. pneumoniae , and HCoV-229E and HCoV-OC43.  
       FIG. 22 : This figure shows a schematic of the mass tag PCR procedure.  
       FIG. 23 : Thus figure shows identification of various infections using masscode tags.  
    
    
     DETAILED DESCRIPTION OF THE INVENTION  
      Terms  
      As used herein, and unless stated otherwise, each of the following terms shall have the definition set forth below.  
      “Mass tag” shall mean any chemical moiety (i) having a fixed mass, (ii) affixable to a nucleic acid, and (iii) whose mass is determinable using mass spectrometry. Mass tags include, for example, chemical moieties such as small organic molecules, and have masses which range, for example, from 100 Da to 2500 Da.  
      “Nucleic acid” shall mean any nucleic acid molecule, including, without limitation, DNA, RNA and hybrids thereof. The nucleic acid bases that form nucleic acid molecules can be the bases A, C, G, T and U, as well as derivatives thereof. Derivatives of these bases are well known in the art, and are exemplified in PCR Systems, Reagents and Consumables (Perkin Elmer Catalogue 1996-1997, Roche Molecular Systems, Inc., Branchburg, N.J., USA).  
      “Pathogen” shall mean an organic entity including, without limitation, viruses and bacteria, known or suspected to be involved in the pathogenesis of a disease state in an organism such as an animal or human.  
      “Sample” shall include, without limitation, a biological sample derived from an animal or a human, such as cerebro-spinal fluid, lymph, blood, blood derivatives (e.g. sera), liquidized tissue, urine and fecal material.  
      “Simultaneously detecting”, with respect to the presence of target nucleic acids in a sample, means determining, in the same reaction vessels(s), whether none, some or all target nucleic acids are present in the sample. For example, in the instant method of simultaneously detecting in a sample the presence of one or more of 50 target nucleic acids, the presence of each of the 50 target nucleic acids will be determined simultaneously, so that results of such detection could be, for example, (i) none of the target nucleic acids are present, (ii) five of the target nucleic acids are present, or (iii) all 50 of the target nucleic acids are present.  
      “Specific”, when used to describe a primer in relation to a target nucleic acid, shall mean that, under primer extension-permitting conditions, the primer specifically binds to a portion of the target nucleic acid and is extended.  
      “Target nucleic acid” shall mean a nucleic acid whose presence in a sample is to be detected by any of the instant methods.  
      “5-UTR” shall mean the 5′-end untranslated region of a nucleic that encodes a protein.  
      The following abbreviations shall have the meanings set forth below: “A” shall mean Adenine; “bp” shall mean base pairs; “C” shall mean Cytosine; “DNA” shall mean deoxyribonucleic acid; “G” shall mean Guanine; “mRNA” shall mean messenger ribonucleic acid; “RNA” shall mean ribonucleic acid; “PCR” shall mean polymerase chain reaction; “T” shall mean Thymine; “U” shall mean Uracil; “Da” shall mean dalton.  
      Finally, with regard to the embodiments of this invention, where a numerical range is stated, the range is understood to encompass the embodiments of each and every integer between the lower and upper numerical limits. For example, the numerical range from 1 to 5 is understood to include 1, 2, 3, 4, and 5.  
     EMBODIMENTS OF THE INVENTION  
      To address the need for enhanced multiplex capacity in diagnostic molecular microbiology we have established a PCR platform based on mass tag reporters that are easily distinguished in Mass Spectrometry (MS) as discrete signal peaks. Major advantages of the PCR/MS system include: (1) hybridization to only two sites is required (forward and reverse primer binding sites) vs real time PCR where an intermediate third oligonucleotide is used (probe binding site); this enhances flexibility in primer design; (2) tried and proven consensus PCR primers can be adapted to PCR/MS; this reduces the time and resources that must be invested to create new reagents and assay controls; (3) the large repertoire of tags allows highly multiplexed assays; additional tags can be easily synthesized to allow further complexity; and (4) sensitivity of real time PCR is maintained. We view PCR/MS as a tool with which to rapidly screen clinical materials for the presence of candidate pathogens. Thereafter, targeted secondary tests, including real time PCR, can be used to quantitate microbe burden and pursue epidemiologic studies.  
      Specifically, this invention provides a method for simultaneously detecting in a sample the presence of one or more of a plurality of different target nucleic acids comprising the steps of: 
      (a) contacting the sample with a plurality of nucleic acid primers simultaneously and under conditions permitting, and for a time sufficient for, primer extension to occur, wherein (i) for each target nucleic acid at least one predetermined primer is used which is specific for that target nucleic acid, (ii) each primer has a mass tag of predetermined size bound thereto via a labile bond, and (iii) the mass tag bound to any primer specific for one target nucleic acid has a different mass than the mass tag bound to any primer specific for any other target nucleic acid;     (b) separating any unextended primers from any extended primers;     (c) simultaneously cleaving the mass tags from any extended primers; and     (d) simultaneously determining the presence and sizes of any mass tags so cleaved, 
 
 wherein the presence of a cleaved mass tag having the same size as a mass tag of predetermined size previously bound to a predetermined primer indicates the presence in the sample of the target nucleic acid specifically recognized by that predetermined primer. 
   

      In one embodiment of the instant method, the method detects the presence in the sample of 10 or more different target nucleic acids. In another embodiment, the method detects the presence in the sample of 50 or more different target nucleic acids. In a further embodiment, the method detects the presence in the sample of 100 or more different target nucleic acids. In a further embodiment, the method detects the presence in the sample of 200 or more different target nucleic acids.  
      In one embodiment of the instant method, the sample is contacted with 4 or more different primers. In another embodiment, the sample is contacted with 10 or more different primers. In a further embodiment, the sample is contacted with 50 or more different primers. In a further embodiment, the sample is contacted with 100 or more different primers. In yet a further embodiment, the sample is contacted with 200 or more different primers.  
      In one embodiment of the instant method, one or more primers comprises the sequence set forth in one of SEQ ID NOs:1-96, and 98-101.  
      In another embodiment of the instant method, at least two different primers are specific for the same target nucleic acid. For example, in one embodiment a first primer is a forward primer for the target nucleic acid and a second primer is a reverse primer for the same target nucleic acid. In this example, the mass tags bound to the first and second primers can be of the same size or of different sizes. In another embodiment, a first primer is directed to a 5′-UTR of the target nucleic acid and a second primer is directed to a 3D polymerase region of the target nucleic acid.  
      In one embodiment of the instant method, wherein each primer is from 15 to 30 nucleotides in length. In another embodiment, each mass tag has a molecular weight of from 100 Da to 2,500 Da. In a further embodiment, the labile bond is a photolabile bond, such as a photolabile bond cleavable by ultraviolet light.  
      In another embodiment of the instant method, at least one target nucleic acid is from a pathogen. Pathogens include, without limitation,  B. anthracis , a Dengue virus, a West Nile virus, Japanese encephalitis virus, St. Louis encephalitis virus, Yellow Fever virus, La Crosse virus, California encephalitis virus, Rift Valley Fever virus, CCHF virus, VEE virus, EEE virus, WEE virus, Ebola virus, Marburg virus, LCMV, Junin virus, Machupo virus, Variola virus, SARS corona virus, an enterovirus, an influenza virus, a parainfluenza virus, a respiratory syncytial virus, a bunyavirus, a flavivirus, and an alphavirus.  
      In another embodiment, the pathogen is a respiratory pathogen. Respiratory pathogens include, for example, respiratory syncytial virus A, respiratory syncytial virus B, Influenza A (N1), Influenza A (N2), Influenza A (M), Influenza A (H1), Influenza A (H2), Influenza A (H3), Influenza A (H5), Influenza B, SARS coronavirus, 229E coronavirus, OC43 coronavirus, Metapneumovirus European, Metapneumovirus Canadian, Parainfluenza 1, Parainfluenza 2, Parainfluenza 3, Parainfluenza 4A, Parainfluenza 4B, Cytomegalovirus, Measles virus, Adenovirus, Enterovirus,  M. pneumoniae, L. pneumophilae , and  C. pneumoniae.    
      In a further embodiment, the pathogen is an encephalitis-inducing pathogen. Encephalitis-inducing pathogens include, for example, West Nile virus, St. Louis encephalitis virus, Herpes Simplex virus, HIV 1, HIV 2,  N. meningitides, S. pneumoniae, H. influenzae , Influenza B, SARS coronavirus, 229E-CoV, OC43-CoV, Cytomegalovirus, and a Varicella Zoster virus. In a further embodiment, the pathogen is a hemorrhagic fever-inducing pathogen. In a further embodiment, the sample is a forensic sample, a food sample, blood, or a derivative of blood, a biological warfare agent or a suspected biological warfare agent.  
      In one embodiment of the instant method, the mass tag is selected from the group consisting of structures V1 to V4 of  FIG. 1  or  FIG. 8 .  
      In another embodiment of the instant method, the presence and size of any cleaved mass tag is determined by mass spectrometry. Mass spectrometry includes, for example, atmospheric pressure chemical ionization mass spectrometry, electrospray ionization mass spectrometry, and matrix assisted laser desorption ionization mass spectrometry.  
      In one embodiment of the instant method, the target nucleic acid is a ribonucleic acid. In another embodiment, the target nucleic acid is a deoxyribonucleic acid. In a further embodiment, the target nucleic acid is from a viral source.  
      This invention provides a kit for simultaneously detecting in a sample the presence of one or more of a plurality of different target nucleic acids comprising a plurality of nucleic acid primers wherein (i) for each target nucleic acid at least one predetermined primer is used which is specific for that target nucleic acid, (ii) each primer has a mass tag of predetermined size bound thereto via a labile bond, and (iii) the mass tag bound to any primer specific for one target nucleic acid has a different mass than the mass tag bound to any primer specific for any other target nucleic acid.  
      This invention also provides a kit for simultaneously detecting in a sample the presence of one or more of a plurality of different target nucleic acids comprising (a) a plurality of nucleic acid primers wherein (i) for each target nucleic acid at least one predetermined primer is used which is specific for that target nucleic acid, (ii) each primer has a mass tag of predetermined size bound thereto via a labile bond, and (iii) the mass tag bound to any primer specific for one target nucleic acid has a different mass than the mass tag bound to any primer specific for any other target nucleic acid; and (b) a mass spectrometer.  
      This invention further provides a kit for simultaneously detecting in a sample the presence of one or more of a plurality of different target nucleic acids comprising (a) a plurality of nucleic acid primers wherein (i) for each target nucleic acid at least one predetermined primer is used which is specific for that target nucleic acid, (ii) each primer has a mass tag of predetermined size bound thereto via a labile bond, and (iii) the mass tag bound to any primer specific for one target nucleic acid has a different mass than the mass tag bound to any primer specific for any other target nucleic acid, and (b) instructions for use.  
      Finally, this invention provides a kit for simultaneously detecting in a sample the presence of one or more of a plurality of different target nucleic acids comprising (a) a plurality of nucleic acid primers wherein (i) for each target nucleic acid at least one predetermined primer is used which is specific for that target nucleic acid, (ii) each primer has a mass tag of predetermined size bound thereto via a labile bond, and (iii) the mass tag bound to any primer specific for one target nucleic acid has a different mass than the mass tag bound to any primer specific for any other target nucleic acid; (b) a mass spectrometer; and (c) instructions for simultaneously detecting in a sample the presence of one or more of a plurality of different target nucleic acids using the primers and the mass spectrometer.  
      This invention will be better understood by reference to the Experimental Details which follow, but those skilled in the art will readily appreciate that the specific experiments detailed are only illustrative of the invention as described more fully in the claims which follow thereafter.  
     EXPERIMENTAL DETAILS  
     Example 1  
      Abbreviations: 5′-UTR, 5′-untranslated region; ALS, Amyotrophic Lateral Sclerosis; APCI, atmospheric pressure chemical ionization; ESI, electrospray ionization; PCR, polymerase chain reaction; MALDI-TOF, matrix assisted laser desorption ionization time of flight; MS, mass spectrometry  
      Background  
      Establishing a causal relationship between infection with a virus and a specific disease may be complex. In most acute viral diseases, the responsible agent is readily implicated because it replicates at high levels in the affected tissue at the time the disease is manifest, morphological changes consistent with infection are evident, and the agent is readily cultured with standard microbiological techniques. In contrast, implication of viruses in chronic diseases may be confounded because persistence requires restricted gene expression, classical hallmarks of infection are absent, and/or mechanisms of pathogenesis are indirect or subtle. Methods for cloning nucleic acids of microbial pathogens directly from clinical specimens offer new opportunities to investigate microbial associations in chronic diseases (21). The power of these methods is that they can succeed where methods for pathogen identification through serology or cultivation may fail due to absence of specific reagents or fastidious requirements for agent replication. Over the past decade, the application of molecular pathogen discovery methods resulted in identification of novel agents associated with both acute and chronic diseases, including Borna disease virus, Hepatitis C virus, Sin Nombre virus, HHV-6, HHV-8,  Bartonella henselae , and  Tropherema whippeli  (5-7, 17, 19, 22, 23, 27).  
      Various methods are employed or proposed for cultivation-independent characterization of infectious agents. These can be broadly segregated into methods based on direct analysis of microbial nucleic acid sequences (e.g., cDNA microarrays, consensus PCR, representational difference analysis, differential display), direct analysis of microbial protein sequences (e.g., mass spectrometry), immunological systems for microbe detection (e.g., expression libraries, phage display) and host response profiling. A comprehensive program in pathogen discovery will need to exploit most, if not all, of these technologies.  
      The decision to employ a specific method is guided by the clinical features, epidemiology, and spectrum of potential pathogens to be implicated. Expression libraries, comprised of cDNAs or synthetic peptides, may be useful tools in the event that large quantities of acute and convalescent sera or cerebrospinal fluid are available for screening purposes; however, the approach is cumbersome, labor-intensive, and success is dependent on the presence of a specific, high affinity humoral immune response. The utility of host response mRNA profile analysis has been demonstrated in several in vitro paradigms and some inbred animal models (8, 26, 30); nonetheless, it is important to formally consider the possibility that a variety of organisms may activate similar cascades of chemokines, cytokines, and other soluble factors that influence host gene expression to produce what are likely to be convergent gene expression profiles. Thus, at least in virology, it is prudent to explore complementary methods for pathogen identification based on agent-encoded nucleic acid motifs. Given the potential for high density printing of microarrays, it is feasible to design slides or chips decorated with both host and pathogen targets. This would provide an unprecedented opportunity to simultaneously survey host response mRNA profiles and viral flora, providing insights into microbial pathogenesis not apparent with either method of analysis alone. Representational difference analysis (RDA) is an important tool for pathogen identification and discovery. However, RDA is a subtractive cloning method for binary comparisons of nucleic acid populations (12, 18). Thus, although ideal for analysis of cloned cells or tissue samples that differ only in a single variable of interest, RDA is less well suited to investigation of syndromes wherein infection with any of several different pathogens results in similar clinical manifestations, or infection is not invariably associated with disease. An additional caveat is that because the method is dependent upon the presence of a limited number of restriction sites, RDA is most likely to succeed for agents with large genomes. Indeed, in this context, it is noteworthy that the two viruses detected by RDA in the listing above (see first paragraph) were herpesviruses (5, 6). Consensus PCR (cPCR) has been a remarkably productive tool for biology. In addition to identifying pathogens, particularly genomes of prokaryotic pathogens, this method has facilitated identification of a wide variety of host molecules, including cytokines, ion channels, and receptors. Nonetheless, until recently, a difficulty in applying cPCR to pathogen discovery in virology has been that it is difficult to identify conserved viral sequences of sufficient length to allow cross-hybridization, amplification, and discrimination using traditional cPCR format. While this may not be problematic when one is targeting only a single virus family, the number of assays required becomes infeasible when preliminary data are insufficient to allow a directed, limited analysis. To address this issue, we adapted cPCR to Differential Display, a PCR-based method for simultaneously displaying the genetic composition of multiple sample populations in an acrylamide gel format (16). This hybrid method, domain-specific differential display (DSDD), employs short, degenerate primer sets designed to hybridize to viral genes representing larger taxonomic categories than can be resolved in cPCR. The major advantages to this approach are: (i) reduction in numbers of reactions required to identify genomes of known viruses, and (ii) potential to detect viruses less closely related to known viruses than those found through cPCR. The differential display format also permits identification of syndrome-specific patterns of gene expression (host and pathogen) that need not be present in all clinical samples. Additionally, because multiple samples can be analyzed in side-by-side comparisons, DSDD allows examination of the timecourse of gene expression patterns. Lastly, recent experience with isolation of the West Nile virus responsible for the outbreak of encephalitis in New York in the summer of 1999 indicates that DSDD may be advantageous in instances where template is suboptimal due to degradation (e.g., postmortem field specimens).  
      The development and application of sensitive high throughput methods for detecting a wide range of viruses is anticipated to provide new insights into the pathogenesis of chronic diseases. We are funded through AI51292 to support these objectives by establishing DNA microarray, multiplexed bead-based flow cytometric (MB-BFC) and domain specific differential display (DSDD) assay platforms for viral surveillance and discovery in chronic diseases. Each of these methods has its strengths; however, none is ideal. Microarrays provide a platform wherein one can simultaneously query thousands of microbial and host gene targets but lack sensitivity and are difficult to modify as new targets are identified. Bead-based arrays are flexible but similar in sensitivity to microarrays.  
      Domain specific differential display is sensitive and flexible but labor intensive. Real time PCR (not a component of our original application but useful to note for purposes of method comparisons), is rapid and sensitive, but cannot be used for broad range detection of viral sequences, because of stringent sequence constraints for the three oligonucleotides comprising the system (two primers, one probe).  
      Mass-Tag PCR would integrate PCR and mass spectrometry (MS) into a stable and sensitive digital assay platform. It is similar in sensitivity and efficiency to real time PCR but provides the advantages of simultaneous detection and discrimination of multiple targets, due to less stringent constraints on primer selection. Additionally, whereas multiplexing is limited in real time PCR by overlapping fluorescence emission spectra, Mass-Tag PCR allows discrimination of a large repertoire of mass tags with molecular weights between 150 and 2500 daltons.  
      In Mass-Tag PCR, virus identity is be defined by the presence of label of a specific molecular weight associated with an amplification product. Primers are be designed such that the tag can be cleaved by irradiation with UV light. Following PCR, the amplification product can be immobilized on a solid support and excess soluble primer removed. After cleavage by UV irradiation (˜350 nm), the released tag will be analyzed by mass spectrometry. Detection is sensitive, fast, independent of DNA fragment length, and ideally suited to the multiplex format required to survey clinical materials for infection with a wide range of infectious agents.  
      Results  
      Mass spectrometry (MS) is a rapid, sensitive method for detection of small molecules. With the development of new ionization techniques such as matrix assisted laser desorption ionization (MALDI) and electrospray ionization (ESI), mass spectrometry has become an indispensable tool in many areas of biomedical research. Although these ionization methods are suitable for the analysis of bioorganic molecules, such as peptides and proteins, improvements in both detection and sample preparation will be required before mass spectrometry can be used to directly detect long DNA fragments. A major confound in exploiting MS for genetic investigation has been that long DNA molecules are fragmented during the analytic process. The mass tag approach overcomes this limitation by detecting small stable mass tags that serve as signatures for specific DNA sequences rather than the DNA sequences themselves.  
      Atmospheric pressure chemical ionization (APCI) has advantages over ESI and MALDI for some applications. Because buffer and inorganic salts impact ionization efficiency, performance in ESI is critically dependent upon sample preparation conditions. In MALDI, matrix must be added prior to sample introduction into the mass spectrometer; speed is often limited by the need to search for an ideal irradiation spot to obtain interpretable mass spectra. APCI requires neither desalting nor mixing with matrix to prepare crystals on a target plate. Therefore in APCI, mass tag solutions can be injected directly. Because mass tags are volatile and have small mass values, they are easily detected by APCI ionization with high sensitivity. The APCI mass tag system is easily scaled up for high throughput operation.  
      We have established methods for synthesis and APCI analysis of mass tags coupled to DNA fragments. Precursors of four mass tags [(a) acetophenone; (b) 3-fluoroacetophenone; (c) 3,4-difluoroacetophenone; and (d) 3,4-dimethoxyacetophenone] are shown in  FIG. 1 . Upon nitration and reduction, the photoactive tags are produced and used to code for the identity of up to four different primer pairs (or target sequences). In a simulation experiment, we have obtained clean APCI mass spectra for the 4 mass tag precursors (a, b, c, d) as shown in  FIG. 2 . The peak with m/z of 121 is a, 139 is b, 157 is c and 181 is d. This result indicates that the 4 compounds we designed as mass tags are stable and produce discrete high resolution digital data in an APCI mass spectrometer. In the research described below, each of the unique m/z from each mass tag translates to the identity of a viral sequence (V) [Tag-1 (m/z, 150)=V-1; Tag-2 (m/z, 168)=V-2; Tag-3 (m/z, 186)=V-3; Tag-4 (m/z, 210)=V-4]. A variety of functional groups can be introduced to the mass tag parent structure for generating a large number of mass tags with different molecular weights. Thus, a library of primers labeled with mass tags that can discriminate between hundreds of viral sequence targets.  
      DNA Sequencing with Biotinylated Dideoxynucleotides on a Mass Spectrometer  
      PCR amplification can be nonspecific; thus, products are commonly sequenced to verify their identity as bona fide targets. Here we apply the rapidity and sensitivity of mass tag analyses to direct MS-sequencing of PCR amplified transcripts.  
      MALDI-TOF MS has recently been explored widely for DNA sequencing. The Sanger dideoxy procedure (25) is used to generate the DNA sequencing fragments. The mass resolution in theory can be as good as one dalton; however, in order to obtain accurate measurement of the mass of the sequencing DNA fragments, the samples must be free from alkaline and alkaline earth salts and falsely stopped DNA fragments (fragments terminated at dNTPs instead of ddNTPs). Our method for preparing DNA sequencing fragments using biotinylated dideoxynucleotides and a streptavidin-coated solid phase is shown in  FIG. 3 . DNA template, dNTPs (A, C, G, T) and ddNTP-biotin (A-b, C-b, G-b, T-b), primer and DNA polymerase are combined in one tube. After polymerase extension and termination reactions, a series of DNA fragments with different lengths are generated. The sequencing reaction mixture is then incubated for a few minutes with a streptavidin-coated solid phase. Only the DNA sequencing fragments that are terminated with biotinylated dideoxynucleotides at the 3′ end are captured on the solid phase. Excess primers, falsely terminated DNA fragments, enzymes and all other components from the sequencing reaction are washed away. The biotinylated DNA sequencing fragments are then cleaved off the solid phase by disrupting the interaction between biotin and streptavidin using ammonium hydroxide or formamide to obtain a pure set of DNA sequencing fragments. These fragments are then mixed with matrix (3-hydroxypicolinic acid) and loaded onto a mass spectrometer to produce accurate mass spectra of the DNA sequencing fragments. Since each type of nucleotide has a unique molecular mass, the mass difference between adjacent peaks of the mass spectra gives the sequence identity of the nucleotides. In DNA sequencing with mass spectrometry, the purity of the samples directly affects the quality of the obtained spectra. Excess primers, salts, and fragments that are prematurely terminated in the sequencing reactions (false stops) will create extra noise and extraneous peaks (11). Excess primers can also dimerize to form high molecular weight species that give a false signal in mass spectrometry (29). False stops occur in DNA sequencing reaction when a deoxynucleotide rather than a dideoxynucleotide terminates a sequencing fragment. A deoxynucleotide terminated false stop has a mass difference of 16 daltons compared with its dideoxy counterpart. This mass difference is identical to the difference between adenine and guanine. Thus, false stops can be misinterpreted or interfere with existing peaks in the mass spectra. Our method is designed to eliminate these confounds. We previously established a procedure for accurately sequencing DNA using fluorescent dye-labeled primers and biotinylated dideoxynucleotides. In this procedure, accurate and clean DNA sequencing data were obtained by removing falsely stopped fragments prior to analysis through use of an intermediate purification step on streptavidin-coated magnetic beads (13, 14).  
      Sequencing experiments for a 55 bp synthetic template using MALDI-TOF mass spectrometry were recently performed (9). Four commercially available biotinylated dideoxynucleotides ddATP-11-biotin, ddGTP-11-biotin, ddCTP-11-biotin and ddTTP-11-biotin (NEN, Boston) were used to produce the sequencing ladder in a single tube by cycle sequencing. Clean sequence peaks were obtained on the mass spectra, with the first peak being primer extended by one biotinylated dideoxynucleotide. Although the identity of A and G residues were determined unambiguously, C and T could not be differentiated because the one dalton mass difference between the ddCTP-11-biotin and ddTTP-11-biotin cannot be consistently resolved by using the current mass detector for DNA fragments. Nonetheless, these results confirmed that clean sequencing ladders can be obtained by capture/release of DNA sequencing fragments with biotin located on the 3′ dideoxy terminators. The procedure has been improved by using biotinylated ddTTPs that have large mass differences in comparison to ddCTP-11-biotin. Pairing ddTTP-16-biotin (Enzo, Boston), which has a large mass difference in comparison to ddCTP-11-biotin, with ddATP-11-biotin, ddCTP-11-biotin, and ddGTP-11-biotin, allowed unambiguous sequence determination in the mass spectra ( FIG. 4 ). Mass spectrum from Sanger sequencing reactions using dd(A,G,C)TP-11-biotin and ddTTP-16-biotin. All four bases are unambiguously identified in the spectrum. Data presented here were generated using a synthetic template mimicking a portion of the HIV type 1 protease gene. DNA sequencing was performed in one tube by combining the biotinylated ddNTPs, regular dNTPs, DNA polymerase, and reaction buffer (9).  
               TABLE 1                          Cloned enterovirus targets                                 Virus   5′ UTR   pol                       Echovirus 3   +   +           Echovirus 6   +   +           Echovirus 9   +   +           Echovirus 16   +   +           Echovirus 17   +   +           Echovirus 25   +   +           Echovirus 30   +   +           Poliovirus 1   +   +           Poliovirus 2   +   +           Poliovirus 3   +   +           Coxsackie A9   +   +           Coxsackie B2   +   +                             In Propagation                                 Coxsackie (A9), Coxsackie A16, Coxsackie B1, Coxsackie B3,           Coxsackie B4, Coxsackie B5, Coxsackie B6, Echovirus 7,           Echovirus 13, Echovirus 18                      
 
 Cloning Viral Targets as Controls for Mass-Tag PCR 
 
      Multiple sequence alignment algorithms have been used by our bioinformatics core to extract the most conserved genomic regions amongst the GenBank published enteroviral sequences. Regions wherein sequence conservation meets or exceeds 80% for an enteroviral serogroup or genetically related subgroup have been identified in the 5′-untranslated region (UTR) and the polymerase gene (3D) of the enterovirus genus. A representative collection of virus isolates has been obtained to generate calibrated standards for Mass-Tag PCR (Table 1). The current panel includes 22 isolates representing all characterized serogroups of pathogenic relevance (A, B, C, and D; covering about 90% of all US enterovirus isolates in the past 10 years; the remaining 10% include non-typed isolates). Twelve isolates have been grown and the relevant regions cloned for spotting onto DNA microarrays and use as transcript controls for DSDD, multiplex bead based, and real time PCR assays. Viruses can be propagated in the appropriate cell lines to generate working and library stocks (Rd, Vero, HeLa, Fibroblast, or WI-38 cells). Library stocks can be frozen and maintained in curated collections at −70° C. Viral RNA can be extracted from working stocks using Tri-Reagent (Molecular Research Center, Inc.). Purified RNA can be reverse transcribed into cDNA using random hexamer priming [to avoid 3′ bias] (Superscript II, Invitrogen/Life Technologies).  
      Target regions of 100-200 bp representing the identified core sequences will be amplified by PCR from cDNA template using virus-specific primers. Products are cloned (via a single deoxyadenosine residue added in template-independent fashion by common Taq-polymerases to 3′-ends of amplification products) into the transcription vector pGEM T-Easy (Promega Corp.). After transformation and amplification in  Escherichia coli , plasmids are analyzed by restriction mapping and automated dideoxy sequencing (Columbia Genome Center) to determine insert orientation and fidelity of PCR. Plasmid libraries will be maintained as both cDNAs and glycerol stocks.  
      Multiple sequence alignment algorithms can be used to identify highly conserved (&gt;95%) sequence stretches of 20-30 bp length within the identified core sequences to serve as targets for primer design.  
      Synthesis of Primers for Use in Mass-Tag PCR  
      Highly conserved target regions within the core sequences suitable for primer design are identified by using multiple sequence alignment algorithms adjusted for the appropriate window size (20-30 bp) and conservation threshold (&gt;95%). Final alignments are color-coded to facilitate manual inspection. Parameters implicated in primer performance including melting temperature, 3′-terminal stability, internal stability, and propensity of potential primers to form stem loops or primer-dimers can be assessed using standard primer selection software programs OLIGO (Molecular Biology Insights), Primer Express (PE Applied Biosystems), and Primer Premiere (Premiere Biosoft International). Primers can be synthesized with a primary amine-group at the 5′-end for subsequent coupling to NHS esters of the mass tags ( FIG. 5 ). Mass tags with molecular weights between 150 and 2500 daltons can be generated by introducing various functional groups [Rn] in the mass tag parent structure to code for individual primers and thus for the targeted viral sequence (see  FIG. 6 ; also showing the photocleavage reaction). MS is capable of detecting small stable molecules with high sensitivity, a mass resolution greater than one dalton, and the detection requires only microseconds. The mass tagging approach has been successfully used to detect multiplex single nucleotide polymorphisms (15).  
      Sensitivity and Specificity of Mass-Tag PCR for Detection of Enteroviral Transcripts  
      Although the method disclosed here is useful for detecting viral RNA, plasmid DNA is an inexpensive, easily quantitated sequence target; thus, primer sets can be initially validated by using dilutions of linearized plasmid DNA. Plasmids are selected to carry the viral insert in mRNA sense orientation with respect to the T7 promoter sequence. Plasmids will be linearized by restriction digestion using an appropriate enzyme that cleaves in the polylinker region downstream of the insert. Where the cloned target sequence is predicted to contain the available restriction sites, a suitable unique restriction site is introduced via the PCR primer used during cloning of the respective target. Purified linearized plasmid DNA is serially diluted in background DNA (human placenta DNA, Sigma) to result in 5×10 5 , 5×10 4 , 5×10 3 , 5×10 2 , 5×10 1 , and 5×10 0  copies per assay.  
      Once optimal primer sets for detection of all relevant enteroviruses are identified, the sensitivity of the entire procedure including RNA extraction and reverse transcription is assessed. Synthetic RNA transcripts of each target sequence are generated from the linearized plasmid DNA using T7 RNA polymerase. Transcripts are serially diluted in background RNA relevant to the primary hypothesis (e.g., ALS, normal spinal cord RNA). Individual dilutions representing 5×10 5 , 5×10 4 , 5×10 3 , 5×10 2 , 5×10 1 , and 5×10 0  copies per assay in a background of 25 ng/ul total RNA are extracted with Tri-Reagent, reverse transcribed, and then subjected to Mass-Tag PCR.  
      Specificity of the identified primer sets relevant to multiplexing can be assessed by using one desired primer set in conjunction with its respective target sequence at 5 times threshold concentration in the presence of all other, potentially cross-reacting, target sequences at a  10   2 -, 10 4 - and 10 6 -fold excess.  
      PCR amplification is performed using photocleavable mass tagged primers in the presence of a biotinylated nucleotide (e.g. Biotin-16-dUTP, Roche) to allow removal of excess primer after PCR. Amplification products will be purified from excess primer by binding to a streptavidin-coated solid phase such as streptavidin-Sepharose (Pharmacia) or streptavidin coated magnetic beads (Dynal) via biotin-streptavidin interaction.  
      Molecular mass tags can be made cleavable by irradiation with near UV light (˜350 nm), and the released tags introduced by either chromatography or flow injection into a pneumatic nebulizer for detection in an atmospheric pressure chemical ionization mass spectrometer. Alternatively, to increase the specificity of detection by analyzing only PCR products of the expected size range, the mass tagged amplicons, can be size-selected (without the requirement for biotinylated nucleotides) using HPLC.  
      Multiplex Detection and Identification of Enteroviral Transcripts  
      A method that allows simultaneous detection of a broad range of enteroviruses with similar sensitivity was developed. A series of 4 primer sets were identified in the 5′-UTR predicted to detect all enteroviruses. These can be combined into two or perhaps even one mixed set for multiplex PCR. Two different genomic regions, 5′-UTR and polymerase, are targeted with independent primer panels, in order to confirm presence of enterovirus infection.  
      Once the presence of enteroviral sequences are confirmed using broad range primer sets, a different primer set is used to discriminate amongst the various enteroviral species. Whereas broad range primers are be selected from the highly conserved 5′-UTR and polymerase 3D gene regions, the primer sets used to identify the enterovirus species target the most divergent genomic regions in VP3 and VP1.  
      Limitations must be considered in that although cerebral spinal fluid is unlikely to contain more than a single enterovirus (the virus responsible for clinical disease in an individual patient), individual stool samples may contain several enteroviruses. It is important, therefore, that assays not favor amplification or detection of one viral species over another. Second, multiplexing can result in loss of sensitivity. Thus, panels should be assessed for sensitivity (and specificity) with addition of new primer sets.  
      Direct MS-Sequencing of PCR Amplified Enteroviral Transcripts for Virus Species Identification  
      MALDI MS has been explored widely for DNA sequencing; however, this approach requires that the DNA sequencing fragments be free from alkaline and alkaline earth salts, as well as other contaminants, to ensure accurate measurements of the masses of the DNA fragments. We explored a novel MS DNA sequencing method that generates Sanger-sequencing fragments using biotinylated dideoxynucleotides labeled with mass tags.  
      The ability to distinguish various nucleotide bases in DNA using mass spectrometry is dependent on the mass differences of the DNA ladders in the mass spectra. Smith et al. have shown that using dye labeled ddNTP paired with a regular dNTP to space out the mass difference can increase the detection resolution in a single nucleotide extension assay (10). Preliminary studies using biotin-11-dd(A, C, G)TPs and biotin-16-ddTTP, indicated that the smallest mass difference between any two nucleotides is 16 daltons. To enhance the ability to distinguish peaks in the sequencing spectra, the mass separation of the individual ddNTPs can be increased by systematically modifying the biotinylated dideoxynucleotides by incorporating mass linkers assembled using 4-aminomethyl benzoic acid derivatives. The mass linkers can be modified by incorporating one or two fluorine atoms to further space out the mass differences between the nucleotides. The structures of the newly designed biotinylated ddNTPs are shown in  FIG. 7 . Linkers are attached to the 5 position on the pyrimidine bases (C and T), and to the 7 position on the purines (A and G) to facilitate conjugation with biotin. It has been established that modification of these positions on the bases in the nucleotides, even with bulky energy transfer (ET) fluorescent dyes, still allows efficient incorporation of the modified nucleotides into the DNA strand by DNA polymerase (24, 31). Biotin and the mass linkers are considerably smaller than the ET dyes, ameliorating difficulties in incorporation of ddNTP-linker-biotin molecules into DNA strands in sequencing reactions.  
      The DNA sequencing fragments that carry a biotin at the 3′-end are made free from salts and other components in the sequencing reaction by capture with streptavidin-coated magnetic beads. Thereafter, the correctly terminated biotinylated DNA fragments are released and loaded onto the mass spectrometer. Results indicate that MS can produce high resolution of DNA-sequencing fragments, fast separation on microsecond time scales, and eliminate the compressions associated with gel electrophoresis.  
      Amplification products obtained by PCR with broad range 5′-UTR or polymerase 3D primer sets can be used as template. Sequencing permits discrimination between bona fide enteroviral amplification products and artifacts. Where analysis of the semi-divergent sequence region located toward the 3′-end of the 5′-UTR region is inadequate for speciation, targeting the more divergent VP3 and/or VP1 regions is preferred.  
     REFERENCES FOR EXAMPLE 1  
     
         
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     Example 2  
     Multiplex Mass Tag PCR Detection of Respiratory Pathogens  
      Background and Significance  
      The advent of SARS in 2003 poignantly demonstrated the urgency of establishing rapid, sensitive, specific, inexpensive tools for differential laboratory diagnosis of infectious diseases. Through unprecedented global collaborative efforts, the causative agent was rapidly implicated and characterized, facilitating development of serologic and molecular assays for infection, and containment of the outbreak. Nonetheless, as the northern hemisphere entered the winter season of 2004, the diagnosis of SARS still rested on clinical and epidemiological as well as laboratory criteria.  
      Methods for cloning nucleic acids of microbial pathogens directly from clinical specimens offer new opportunities to investigate microbial associations in diseases. The power of these methods is not only sensitivity and speed but also the potential to succeed where methods for pathogen identification through serology or cultivation may fail due to absence of specific reagents or fastidious requirements for agent replication.  
      Various methods are employed or proposed for cultivation-independent characterization of infectious agents. These can be broadly segregated into methods based on direct analysis of microbial nucleic acid sequences, direct analysis of microbial protein sequences, immunological systems for microbe detection, and host response profiling. Any comprehensive armamentarium should include most, if not all, of these tools. Nonetheless, classical methods for microbiology remain important. Indeed, the critical breakthrough during the SARS outbreak was the cultivation of the agent in tissue culture.  
      Real-time PCR methods have significantly changed diagnostic molecular microbiology by providing rapid, sensitive, specific tools for detecting and quantitating genetic targets. Because closed systems are employed, real-time PCR is less likely than nested PCR to be confounded by assay contamination due to inadvertent aerosol introduction of amplicon/positive control/cDNA templates that can accumulate in diagnostic laboratories. The specificity of real time PCR is both a strength and a limitation. Although the potential for false positive signal is low so is the utility of the method for screening to detect related but not identical genetic targets. Specificity in real-time PCR is provided by two primers (each approximately 20 matching nucleotides (nt) in length) combined with a specific reporter probe of about 27 nt. The constraints of achieving hybridization at all three sites may confound detection of diverse, rapidly evolving microbial genomes such as those of single-stranded RNA viruses. These constraints can be compensated in part by increasing numbers of primer sets accommodating various templates. However, because real-time PCR relies on fluorescent reporter dyes, the capacity for multiplexing is limited to the number of emission peaks that can be unequivocally separated. At present up to four dyes can be identified simultaneously. Although the repertoire may increase, it will unlikely to change dramatically.  
      To address the need for enhanced multiplex capacity in diagnostic molecular microbiology we have established a PCR platform based on mass tag reporters that are easily distinguished in MS as discrete signal peaks. Major advantages of the PCR/MS system include: (1) hybridization to only two sites is required (forward and reverse primer binding sites) vs real time PCR where an intermediate third oligonucleotide is used (probe binding site); this enhances flexibility in primer design; (2) tried and proven consensus PCR primers can be adapted to PCR/MS; this reduces the time and resources that must be invested to create new reagents and assay controls; (3) the large repertoire of tags allows highly multiplexed assays; additional tags can be easily synthesized to allow further complexity; and (4) sensitivity of real time PCR is maintained. We view PCR/MS as a tool with which to rapidly screen clinical materials for the presence of candidate pathogens. Thereafter, targeted secondary tests, including real time PCR, can be used to quantitate microbe burden and pursue epidemiologic studies.  
      Preliminary Data  
      We have developed bioinformatic tools to facilitate sequence alignments, motif identification, and primer design; established banks of viral strains, cDNA templates, and primers; and built relationships with collaborators in national and global public health laboratory networks that provide access to data, organisms, sera, and cDNAs that facilitate assay development and validation. Over the past two years we have integrated PCR and MS into a stable and sensitive digital assay platform similar in sensitivity and efficiency to real time PCR but with the advantages of simultaneous detection and discrimination of multiple targets. Using the 4 tags created for DNA sequencing we initially tested the method with flavivirus and bunyavirus targets as a proof of principle for an encephalitis project. The collaboration was later expanded to include two industrial partners: QIAGEN GmbH, a partner with a large validated library of proprietary photocleavable mass tags (Masscode™) and expertise in manufacture and commercial distribution, and Griffin Analytical Technologies, a partner actively engaged in design and fabrication of low cost portable MS instruments for field applications.  
      Selection of APCI LCMS Platform  
      Mass spectrometry is a rapid, sensitive method for detection of small molecules. With the development of Ionization techniques such as matrix assisted laser desorption ionization (MALDI) and electrospray ionization (ESI), MS has become a indispensable tool in many areas of biomedical research. Although these ionization methods are suitable for the analysis of bioorganic molecules, such as peptides and proteins, improvements in both detection and sample preparation will be required before mass spectrometry can be used to directly detect long DNA fragments. A major confound in exploiting MS for genetic investigation has been that long DNA molecules are fragmented during the analytic process. The mass tag approach we have developed overcomes this limitation by detecting small stable mass tags that serve as signatures for specific DNA sequences rather than the DNA sequences themselves.  
      We have explored the kinetics of photocleavable primer conjugation. Ionization and detection of the photocleaved mass tags have been extensively characterized using atmospheric pressure chemical ionization (APCI) as the ionization source while using a single quadrupole mass spectrometer as the detector (Jingyue et al., Kim et al. 2003; Kokoris et al. 2000). Because buffer and inorganic salts impact ionization efficiency, performance in ESI was determined to be critically dependent upon sample preparation conditions. In MALDI, matrix must be added prior to sample introduction into the mass spectrometer, which is a time consuming step that requires costly sample spotting instrumentation. Similary, speed is often limited by the need to search for an ideal irradiation spot to obtain interpretable mass spectra.  
      In contrast, APCI is much more tolerant of residual inorganic salts (than ESI) and does not require mixing with matrix to prepare crystals on a target plate. Thus, mass tag solutions can be injected directly into the MS via a Liquid Chromatography (LC) delivery system. Since mass tags ionize well under APCI conditions and have small mass values (less that 800 amu), they are detected with high sensitivity (&lt;5 femtomolar limit of detection) with the APCI-Quadrupole LCMS platform.  
      Methods for synthesis and APCI-MS analysis of mass tags coupled to DNA fragments are illustrated in  FIG. 8  where precursors are (a) acetophenone; (b) 4-fluoroacetophenone; (c) 3-methoxyacetophenone; and (d) 3,4-dimethoxyacetophenone.  
      Upon nitration and reduction, the photoactive tags are produced and used to code for the identity of different primer pairs. An example for photocleavage and detection of four tags is shown in  FIG. 9  which shows APCI mass spectra for four mass tags after from the corresponding primers (mass tag # 1,2-nitrosoacetophenone, m/z 150; mass tag # 2,4-fluoro-2-nitrosoacetophenone, m/z 168; mass tag # 3,5-methoxy-2-nitrosoacetophenone, m/z 180; mass tag # 4,4,5-dimethoxy-2-nitrosoacetopheone, m/z 210). The four mass tag-labeled primers were mixed together and the mixture was irradiated under UV light (λ˜340 nm) for 5 seconds, introduced into an APCI mass spectrometer and analyzed for the four masses to produce the above spectrum. The peak with m/z of 150 is mass-tag 1, 168 is mass-tag 2, 180 is mass-tag 3 and 210 is mass-tag 4. The mechanism for release of these tags from DNA is shown in  FIG. 10 —Four mass tag-labeled DNA molecules (Bottom) Chemical structures of the corresponding photocleaved mass tags (2-nitrosoacetophenone, 4-fluoro-2-nitrosoacetophenone, 5-methoxy-2-nitrosoacetophenone and 4,5-dimethoxy-2-nitrosoacetophenone) after UV irradiation at 340 nm. This result indicates that the 4 compounds designed as mass tags are stable and produce discrete high-resolution digital data in an APCI mass spectrometer. The unique m/z from each mass tag translates to the identity of a viral sequence. In a recent collaboration with Qiagen, which has used a library of mass tags to discriminate up to 25 SNPs (Kokoris et al. 2000), we have significantly expanded the number of the mass tags.  
      Establishment of a PCR/MS Assay for Respiratory Pathogens  
      During the SARS 2003 Beijing outbreak we established a specific and sensitive real time PCR assay for SARS-CoV (Zhai et al, 2004). The assay was extended to allow simultaneous detection of SARS-CoV as well as human coronaviruses OC43 and 229E in light of recent data from China suggesting the potential for coinfection and increased morbidity ( FIG. 11 ). This human coronavirus assay (3 viral genes and 1 housekeeping gene) exhausted the repertoire of fluorescent tags with which to pursue multiplex real time PCR analysis of clinical materials. The importance of extending rapid molecular assays to include other respiratory pathogens is reinforced by the reappearance of SARS in China and reports of a new highly virulent influenza virus strain in Vietnam.  
      To build a more comprehensive respiratory pathogen surveillance assay we adapted the human coronavirus primers to the PCR/MS platform, and added reagents required to detect other relevant microbes. Influenza A virus was included through a set of established primer sequences obtained through Georg Pauli (Robert Koch Institute, Germany; Schwaiger et al 2000). For the bacterial pathogen  M. pneumoniae  we also used unmodified primer sequences published for real time PCR (Welti et al 2003) to evaluate their use on the PCR/MS platform. Using a panel of mass tags developed by QIAGEN, experiments were performed demonstrating the feasibility of detecting several respiratory pathogens in a single multiplexed assay on the PCR/MS platform.  
      The current Masscode™ photocleavable mass tag repertoire comprises over 80 tags.  FIG. 12  demonstrates the specificity of the mass tag detection approach in an example where 58 different mass tags conjugated to oligonucleotides via a photocleavable linkage were identified after UV cleavage and MS. Each of the 10 primers for the 5-plex assay (SARS-CoV, CoV-229E, CoV-OC43, Influenza A virus, and  M. pneumoniae ) was conjugated to a different mass tag such that the identity of a given pathogen was encoded by a specific binary signal (e.g. SARS-CoV, forward primer, 527 amu; reverse primer 666 amu; see  FIG. 13B ).  
      The presence of mass tags did not impair performance of primers in PCR and yielded clear signals for all 5 agents ( FIG. 13A ,  13 B—Singleplex mass tag PCR for (1) Influenza A virus matrix protein (618 amu fwd-primer, 690 amu rev-primer), human coronaviruses (2) SARS (527/666), (3) 229E (670/558), (4) OC43 (686/548), and the bacterial agent (5)  M. pneumoniae  (602/614). (6) 100 bp ladder). No noise was observed using unmodified or mass tag-modified primer sets in a background of 125 ng of normal total human DNA per assay ( FIG. 13C ). In subsequent experiments we extended the respiratory pathogen panel to include respiratory syncytial virus groups A and B. Non-optimized pilot studies in this 7-plex system indicated a detection threshold of &lt;500 molecules. As a test of feasibility for PCR/MS detection of coinfection, mixtures of DNA templates representing two different pathogens were analyzed successful detection of two targets confirmed the suitability of this technology for clinical applications where coinfection may be critical to pathogenesis and epidemiology.  
      Establishment of a Platform for Portable MS  
      Griffin has developed a portable mass spectrometer that is roughly the size of a tower computer (including vacuum system), weighs less than 50 lbs, and consumes ˜150 W depending on operating conditions. This system has a mass range of 400 Da with unit mass resolution. It has been used to detect part-per-trillion level atmospheric constituents.  FIG. 14  shows a representative spectrum of methyl salicylate collected on a miniature cylindrical ion trap mass analyzer coupled to a corona discharge ionization source (data collected in Prof. R. G. Cooks research laboratory at Purdue University). This data demonstrates the feasibility of using this type of instrumentation to detect the mass tags of interest as well as the specificity of the ionization source.  FIG. 14  shows mass spectrum representative of data collected using a miniature cylindrical ion trap mass analyzer coupled with a corona discharge ionization source.  
       FIG. 15  shows a mass spectrum of perflouro-dimethclcyclohexane collected on a prototype atmospheric sampling glow discharge ionization (ASGDI) source. ASGDI is an external ionization source related to the APCI source discussed here.  
      Experimental Design  
      Labeled amplification products are generated during PCR amplification with mass tagged primers. After isolation from non-incorporated primers by binding to silica in Qiagen 96-well or 384-well PCR purification modules, products are eluted into the injection module of the mass-spectrometer. The products traverse the path of a UV light source prior to entering the nebulizer, releasing photocleavable tags. (one each from the forward and reverse primer). Mass tags are then ionized. Analysis of the mass code spectrum defines the pathogen composition of the specimen.  
      A non-comprehensive list of target pathogens is listed in Tables 2 and 3. Forward and reverse primer pairs for pathogens listed in Table 2 are (reading from top to bottom starting with RSV-A and ending with  M. Pneumoniae ), SEQ ID NOS:1 and 2, 3 and 4, 9 and 10, 21 and 22, 23 and 24, 26 and 27, and 49 and 50.  
                   TABLE 2                          Respiratory Panel Mass-Tag Primers                                             Forward       Reverse               Pathogen   primer   Sequence   primer   Sequence               RSV A   RSA-   AgATCAACTTCTgTC   RSV-   gCACATCATAATTAggAg               U1137   ATCCAgCAA   L1192   TATCAAT               RSV B   RSB-   AAgATgCAAATCAT   RSV-1318   TgATATCCAgCATCTTTA           U1248   AAATTCACAggA       AgTATCTTTATAgTg               Influenza A       (N1)               Influenza A       (N2)               Influenza A   AM-U151   CATggAATggCTAAA   AM-L397   AAgTgCACCAgCAgAATA       (M)       gACAAgACC       ACTgAg               Influenza B       SARS-CoV   CIID-   AAg CCT CgC CAA   CIID-   AAg TCA gCC ATg TTC           28891F   AAA CgT AC   29100R   CCg AA               229E-CoV   Taq-Co22-   ggC gCA AgA ATT   Taq-Co22-   TAA gAg CCg CAg CAA           418F   CAg AAC CA   636R   CTg C               OC43-CoV   Taq-Co43-   TgT gCC TAT TgC   Taq-Co43-   CCC gAT CgA CAA TgT           270F   ACC Agg AgT   508R   CAg C               Metapneumo-       virus               Parainfluenza       1               Parainfluenza       2               Parainfluenza       3               Parainfluenza       4               M   MTPM1   CCAACCAAACAACA   MTPM2   ACCTTgACTggAggCCgTT       pneumoniae       ACgTTCA       A               L.       pneumophilae               C.       pneumoniae                  
 
 Design and Synthesis of Primers 
 
      Primers are designed using the same approach as employed for the 7-plex assay. Available sequences are be extracted from GenBank. Conserved regions suitable for primer design are identified using standard software programs as well as custom software (patent application XYZ). Primer properties can be assessed by commercial primer selection software including OLIGO (Molecular Biology Insights), Primer Express (PE Applied Biosystems), and Primer Premiere (Premiere Biosoft International). Primers are evaluated for signal strength and specificity against a background of total human DNA.  
      Isolation and Cloning of Template Standards  
      Targeted genes can be cloned into the transcription vector pGEM-Teasy (Invitrogen) by conventional RT-PCR cloning methods. Quantitated plasmid standards are used in initial assay establishment. Thereafter, RNA transcripts generated by in vitro transcription, quantitated and diluted in a background of random human RNA (representing brain, liver, spleen, lung and placenta in equal proportions) are employed to establish sensitivity and specificity parameters of RT-PCR/MS assays. One representative isolate for each targeted pathogen/gene is used during initial establishment of the assay.  
      Inherent in the exquisite sensitivity of PCR is the risk of false positive results due to inadvertent introduction of synthetic templates such as those comprising positive control and calibration reagents, and so calibration reagents are preferred components of kits. Thus, to allow recognition of control vs authentic, natural amplification products, calibration reagents are modified by introducing a restriction enzyme cleavage site in between the primer binding sites through site directed mutagenesis. This approach has been employed in projects concerned with epidemiology of viral infection in various chronic diseases including Bornaviruses in neuropsychiatric disease (NIH/MH57467), measles virus in autism (CDC/American Academy of Pediatrics), and enteroviruses in type I diabetes mellitus (NIH/AI55466).  
      Multiplex Assay Using Cloned Template Standards  
      Initially, the performancance of individual primer sets with unmodified primers is tested. Amplification products in these single assays can be detected by gel electrophoresis. This strategy will not serve for multiplex assays because products of individual primer sets will be similar in size i.e. &lt;300 bp. Thus, after confirmation of performance in single assays, mass tagged primers are generated for multiplex analyses. All assays are first optimized for PCR using serial dilutions of plasmid DNA, and then for RT-PCR using serial dilutions of synthetic transcripts. A multiplex assay is considered successful if it detects all target sequences at a sensitivity of 50 copies plasmid DNA per assay and 100 copies RNA per assay. Successful multiplex assay performance includes detection of all permutative combinations of two agents to ensure the feasibility of diagnosing simultaneous infection.  
      Optimizing Multiplex Assay Using Cell Culture Extracts  
      After establishing performance parameters with calibrated synthetic reagents, cell culture extracts of authentic pathogens are used. Performance of assays with RNA extracted using readily available commercial systems that do or do not include organic solvents (e.g, Tri-Reagent vs RNeasy) is assessed. A protocol disclosed here employs Tri-Reagent. Similarly, although Superscript reverse transcriptase (Invitrogen) and HotStart polymerase (QIAGEN) can be used, performance of ThermoScript RT (Invitrogen) at elevated temperature can be assessed, as are single-step RT-PCR systems like the Access Kit (Promega). To optimize efficiency where clinical material mass is limited and to reduce the complexity of sample preparation, both viral and bacterial agents can be identified using RT-PCR. Where an agent is characterized by substantive phylogenetic diversity, cell culture systems should include at least three divergent isolates of each pathogen  
      Sample Processing  
      Samples may be obtained by nasal swabs, sputum and lavage specimens will be spiked with culture material to optimize recovery methods for viral as well as bacterial agents.  
      Portable APCI MS Instruments to Support Multiplex PCR/MS Platform  
      The multiplex mass tag approach is well-suited to implementation on a miniaturized MS system, as the photocleavable mass tags are all relatively low in molecular weight (&lt;500 Da.), and hence the constraints on the mass spectrometer in terms of mass range and mass resolution are not high. The technical challenge associated with this approach is the development of an atmospheric-pressure chemical ionization (APCI) source for use on a miniaturized MS to generate the mass tag ions. Such a source has been coupled with a miniaturized MS in an academic setting.  
      Detection of NIAD Category A, B, and C Priority Agents  
      Using the same approach as outlined for respiratory pathogen detection, a multiplex assay for detection of selected NIAD Category A, B, and C priority agents can be created (Table 3). Primers and PCR conditions for several agents are already established and can be adapted to the PCR/MS platform.  
               TABLE 3                       NIAD Priority Agents                                              B. anthracis             Dengue viruses           West Nile virus           Japanese encephalitis virus           St. Louis encephalitis virus           Yellow Fever virus           La Crosse virus           California encephalitis virus           Rift Valley Fever virus           CCHF virus           VEE virus           EEE virus           WEE virus           Ebola virus           Marburg virus           LCMV           Junin virus           Machupo virus           Variola virus                      
 
     Example 3  
      Background  
      Efficient laboratory diagnosis of infectious diseases is increasingly important to clinical management and public health. Methods for direct detection of nucleic acids of microbial pathogens in clinical specimens are rapid, sensitive and may succeed where fastidious requirements for agent replication confound cultivation. Nucleic acid amplification systems are indispensable tools in HIV and HCV diagnosis, and are increasingly applied to pathogen typing, surveillance, and diagnosis of acute infectious disease. Clinical syndromes are only infrequently specific for single pathogens; thus, assays for simultaneous consideration of multiple agents are needed. Current multiplex assays employ gel-based formats where products are distinguished by size, fluorescent reporter dyes that vary in color, or secondary enzyme hybridization assays. Gel-based assays are reported that detect 2-8 different targets with sensitivities of 2-100 pfu or &lt;1-5 pfu, depending on whether amplification is carried out in a single or nested format, respectively (Ellis and Zambon 2002, Coiras et all. 2004). Fluorescence reporter systems achieve quantitative detection with sensitivity similar to nested amplification; however, their capacity to simultaneously query multiple targets is limited to the number of fluorescent emission peaks that can be unequivocally separated. At present up to four fluorescent reporter dyes are detected simultaneously (Vet et al. 1999, Verweij et al. 2004). Multiplex detection of up to 9 pathogens was achieved in hybridization enzyme systems; however, the method requires cumbersome post-amplification processing (Gröndahl et al. 1999).  
      To address the need for sensitive multiplex assays in diagnostic molecular microbiology we created a polymerase chain reaction (PCR) platform wherein microbial gene targets are coded by 64 distinct mass tags. Here we describe this system, mass tag PCR, and demonstrate its utility in differential diagnosis of respiratory tract infections.  
      Oligonucleotide primers for mass tag PCR were designed to detect the broadest number of members for a given pathogen species through efficient amplification of a 50-300 basepair product. In some instances we selected established primer sets; in others we employed a software program designed to cull sequence information from GenBank, perform multiple alignments, and maximize multiplex performance by selecting primers with uniform melting temperatures and minimal cross-hybridization potential. Primers, synthesized with a 5′ C6-spacer and aminohexyl modification, were covalently conjugated via a photocleavable linkage to small molecular weight tags (Kokoris et al. 2000) to encode their respective microbial gene targets. Forward and reverse primers were labeled with differently sized tags to produce a dual code for each target that facilitates assessment of signal specificity.  
      Microbial gene target standards for sensitivity and specificity assessment were cloned by PCR using cDNA template obtained by reverse transcription of extracts from infected cultured cells or by assembly of overlapping synthetic polynucleotides. Cloned standards representing genetic sequence of the targeted microbial pathogens were diluted in 12.5 ug/ml human placenta DNA (Sigma, St. Louis, Mo., USA) and subjected to multiplex PCR amplification using the following cycling protocol: 9×C for X sec., 55 C for X sec., 72 C for X sec.; 50 cycles, MJ PTC200 (MJ Research, Waltham, Mass., USA). Amplification products were purified using QIAquick 96 PCR purification cartridges (Qiagen, Hilden, Germany) with modified binding and wash buffers (RECIPES). Mass tags of the amplified products were analyzed after ultraviolet photolysis and positive-mode atmospheric pressure chemical ionization (APCI) by single quadrapole mass spectrometry.  FIG. 1  indicates discrimination of individual microbial targets in a 21-plex assay comprising sequences of 16 human pathogens. The threshold of detection met or exceeded 500 molecules corresponding in sensitivity to less than 0.1 TCID 50 /ml (0.001 TCID 50 /assay), in titered cell culture virus of coronaviruses as well as parainfluenza viruses (data not shown). For 19 of 21 microbial targets the detection threshold was less than 100 molecules (Table 4).  
      We next analyzed samples from individuals with respiratory infection using a larger panel comprising 30 gene targets (26 pathogens). Mass Tag PCR correctly identified infection with respiratory syncitial, human parainfluenza, SARS corona, adeno, entero, metapneumo and influenza viruses (Table 4 and  FIG. 16 ). A smaller panel comprising 18 gene targets (18 central nervous system pathogens) was used to analyze cerebrospinal fluid from individuals with meningitis or encephalitis. Two of, four cases of West Nile virus encephalitis were identified. Fifteen of seventeen cases of enteroviral meningitis were detected representing serotypes CV-B2, CV-B3, CV-B5, E-6, E-11, E-13, E-18, and E-30.  
      Our results indicate that mass tag PCR is a useful method for molecular characterization of microflora. Sensitivity is similar to real time PCR assays but with the advantage of allowing simultaneous screening for several candidate pathogens. Potential applications include differential diagnosis of infectious diseases, blood product surveillance, forensic microbiology, and biodefense.  
       FIG. 16  shows the sensitivity of 21-plex mass tag PCR. Dilutions of cloned gene target standards (10 000, 1 000, 500, 100 molecules/assay) diluted in human placenta DNA were analyzed by mass tag PCR. Each reaction mix contained 2× Multiplex PCR Master Mix (Qiagen), the indicated standard and 42 primers at 1×nM concentration labeled with different mass tags. Background in reactions without standard (no template control, 12.5 ng human DNA) was subtracted and the sum of Integrated Ion Current for both tags was plotted.  
       FIG. 17  shows analysis of clinical specimens. (A) Respiratory infection; (B) Encephalitis. RNA from clinical specimens was extracted by standard procedures and reverse transcribed into cDNA (Superscript RT system, Invitrogen, Carlsbad, Calif.; 20 ul volume). Five microliter of reaction was then subjected to mass tag PCR. (A) Detection of Influenza A (H1N1), RSV-B, SARS-CoV, HPIV-3, HPIV-4, and ENTERO using a 31-plex assay including 64 primers targeting Influenza A virus (FLUAV) matrix gene, and for typing H1, H2, H3, H5, N1, and N2 sequence, as well as influenza B virus (FLUBV), respiratory syncytial virus (RSV) groups A and B, human coronaviruses 229E, OC43, and SARS(HCoV-229E, -OC43, and -SARS), human parainfluenza virus (HPIV) types 1, 2, 3, and 4 (groups A and B combined), metapneumovirus, enteroviruses (EV, targeting all serogroups), adenoviruses (HAdV, targeting all serogroups),  Mycoplasma pneumoniae, Chlamydia pneumoniae, Legionalla pneumophila, Streptococcus pneumoniae, Haemophilus influenzae , Human herpesvirus 1 (HHV-1, Herpes simplex virus), Human herpesvirus 3 (HHV-3; Varicella-zoster virus), Human herpesvirus 5 (HHV-5, Human cytomegalovirus), Human immunodeficiency virus 1 (HIV-1) and Human immunodeficiency virus 1HIV-2. (B) Detection of ENTERO XX, YY, and ZZ using an 18-plex assay including 36 primers targeting FLUAV matrix gene, H1, H2, H3, H5, N1, and N2 sequence, FLUBV, HCoV 229E, OC43, and SARS, EV, HAdV, HHV-1, -3, and -5, HIV-1, and -2, measles virus (MEV), West Nile virus (WNV), St. Louis virus (SLEV),  S. pneumoniae, H. influenzae , and  Neisseria meningitides .  
               TABLE 4                       Sensitivity of 22-plex mass tag PCR. Numbers in cells indicate target copy threshold.                                                                            Influenza   Influenza   Influenza   Influenza   Influenza   Influenza   Influenza   Influenza                   A   A   A   A   A   A   A   B   RSV   RSV   Metapneumo       Matrix   N1   N2   HA1   HA2   HA3   HA5   HA   Group A   group B   virus               100   100   100   100   100   100   100   500   100     100     100               CoV-   CoV-   CoV-                           Enterovirus   Adenovirus       SARS   OC43   229E   HPIV-1   HPIV-2   HPIV-3     C. pneumoniae       M. pneumoniae       L. pneumophila     (genus)   (genus)               100   100   100   100   100   100   100   100   100   5 000   5 000                    
     Example 4  
      Multiplex PCR  
      Conventional multiplex PCR assays are established, however, none allow sensitive detection of more than 10 genetic targets. The most sensitive of these assays, real time PCR, is limited to four fluorescent reporter dyes. Gel based systems are cumbersome and limited to visual distinction of products that differ by 20 bp; multiplexing is restricted to the number of products that can be distinguished at 20 bp intervals within the range of 100 to 250 bp (amplification efficiency decreases with larger products); nesting or Southern hybridization is required for high sensitivity. A 9-plex assay has been achieved using hybridization capture enzyme assay.  
      Disclosed here are panels of nucleic acid sequences to be used in assays for the detection of infectious agents. The sequences include primers for polymerase chain reaction, enzyme sites for initiating isothermal amplification, hybridization selection of nucleic acid targets, as well as templates to serve as controls for validation of these assays. This example focuses on the use of these panels for multiplex mass tag PCR applications. Nucleic acid databases were queried to identify regions of sequence conservation within viral and bacterial taxa wherein primers could be designed that met the following critera: (i) the presence of motifs required to create specific or low degeneracy PCR primers that targeted all members of a microbial group (or subgroup); (ii) Tm of 59-61 C; (iii) GC content of 48-60%; (iv) length of 18-24 bp; (v) no more than three consecutive identical bases; (vi) 3 or more G and/or C residues in the 5′-hexamer; (vii) less than 3 G and/or C residues in the 3′-pentamer; (vii) no propensity for secondary structure (stem-loop) formation; (viii) no inter-primer complementarity that could predispose to primer-dimer formation; (ix) amplification of an 80-250 bp region with no or little secondary structure at 59-61 C. Primers meeting these criteria were then evaluated empirically for equal performance in context of the respective multiplex panel. In the event that no ideal primer candidates could be identified, primers that did not meet one or more of these criteria were synthesized and evaluated for appropriate performance. Those that yielded 80-250 bp amplification products, had Tm of 59-61 C, and showed no primer-dimer artifacts were selected for inclusion into panels.  
      As a proof-of-principle we designed a panel of primers for detection of 31 target sequences of respiratory pathogens (25-plex respiratory panel) and demonstrated successful detection of all potential targets in a 25-plex PCR reaction. Detection of amplification products was achieved through use of the MASSCODE® technology. Individual primers were conjugated with a unique masscode tag through a photocleavable linkage. Photocleavage of the masscode tag from the purified PCR product and mass spectrometric analysis identifies the amplified target through the two molecular weights assigned to the forward and reverse primer. Primer panels focus on groups of infectious pathogens that are related to differential diagnosis of respiratory disease, encephalitis, or hemorrhagic fevers; screening of blood products; biodefense; food safety; environmental contamination; or forensics.  
     Example 5  
      Background and Significance  
      The advent of SARS in 2003 poignantly demonstrated the urgency of establishing rapid, sensitive, specific, inexpensive tools for differential laboratory diagnosis of infectious diseases. Through unprecedented global collaborative efforts, the causative agent was rapidly implicated and characterized, facilitating development of serologic and molecular assays for infection, and containment of the outbreak. Nonetheless, as the northern hemisphere entered the winter season of 2004, the diagnosis of SARS still rests on clinical and epidemiological as well as laboratory criteria. The WHO SARS International Reference and Verification Laboratory Network met on Oct. 22, 2003 to review the status of laboratory diagnostics in acute severe pulmonary disease. Quality assurance testing indicated that false positive SARS CoV PCR results were infrequent in network labs. However, participants registered concern that current assays did not allow simultaneous detection of a wide range of pathogens that could aggravate disease or themselves result in clinical presentations similar to SARS.  
      Methods for cloning nucleic acids of microbial pathogens directly from clinical specimens offer new opportunities to investigate microbial associations in diseases. The power of these methods is not only sensitivity and speed but also the potential to succeed where methods for pathogen identification through serology or cultivation may fail due to absence of specific reagents or fastidious requirements for agent replication.  
      Various methods are employed or proposed for cultivation-independent characterization of infectious agents. These can be broadly segregated into methods based on direct analysis of microbial nucleic acid sequences, direct analysis of microbial protein sequences, immunological systems for microbe detection, and host response profiling. Any comprehensive armamentarium should include most, if not all, of these tools. Nonetheless, classical methods for microbiology remain important. Indeed, the critical breakthrough during the SARS outbreak was the cultivation of the agent in tissue culture.  
      Real-time PCR methods have significantly changed diagnostic molecular microbiology by providing rapid, sensitive, specific tools for detecting and quantitating genetic targets. Because closed systems are employed, real-time PCR is less likely than nested PCR to be confounded by assay contamination due to inadvertent aerosol introduction of amplicon/positive control/cDNA templates that can accumulate in diagnostic laboratories. The specificity of real time PCR is both, a strength and a limitation. Although the potential for false positive signal is low so is the utility of the method for screening to detect related but not identical genetic targets. Specificity in real-time PCR is provided by two primers (each approximately 20 matching nucleotides (nt) in length) combined with a specific reporter probe of about 27 nt. The constraints of achieving hybridization at all three sites may confound detection of diverse, rapidly evolving microbial genomes such as those of single-stranded RNA viruses. These constraints can be compensated in part by increasing numbers of primer sets accommodating various templates. However, because real-time PCR relies on fluorescent reporter dyes, the capacity for multiplexing is limited to the number of emission peaks that can be unequivocally separated. At present up to four dyes can be identified simultaneously. Although the repertoire may increase, it will unlikely to change dramatically.  
      To address the need for enhanced multiplex capacity in diagnostic molecular microbiology we have established a PCR platform based on mass tag reporters that are easily distinguished in MS as discrete signal peaks. Major advantages of the PCR/MS system include: (1) hybridization to only two sites is required (forward and reverse primer binding sites) vs real time PCR where an intermediate third oligonucleotide is used (probe binding site); this enhances flexibility in primer design; (2) tried and proven consensus PCR primers can be adapted to PCR/MS; this reduces the time and resources that must be invested to create new reagents and assay controls; (3) the current repertoire of 60 tags allows highly multiplexed assays; additional tags can be easily synthesized to allow further complexity; and (4) sensitivity of real time PCR is maintained. A limitation of PCR/MS is that it is unlikely to provide more than a semi-quantitative index of microbe burden. Thus, we view PCR/MS as a tool with which to rapidly screen clinical materials for the presence of candidate pathogens. Thereafter, targeted secondary tests, including real time PCR, should be used (to quantitate microbe burden and pursue epidemiologic studies.  
      Selection of APCI LCMS Platform  
      Mass spectrometry is a rapid, sensitive method for detection of small molecules. With the development of Ionization techniques such as matrix assisted laser desorption ionization (MALDI) and electrospray ionization (ESI), MS has become a indispensable tool in many areas of biomedical research. Although these ionization methods are suitable for the analysis of bioorganic molecules, such as peptides and proteins, improvements in both detection and sample preparation will be required before mass spectrometry can be used to directly detect long DNA fragments. A major confound in exploiting MS for genetic investigation has been that long DNA molecules are fragmented during the analytic process. The mass tag approach we have developed overcomes this limitation by detecting small stable mass tags that serve as signatures for specific DNA sequences rather than the DNA sequences themselves.  
      Ionization and detection of the photocleaved mass tags have been extensively characterized using atmospheric pressure chemical ionization (APCI) as the ionization source while using a single quadrupole mass spectrometer as the detector (Jingyue et al., Kim et al. 2003; Kokoris et al. 2000). Because buffer and inorganic salts impact ionization efficiency, performance in ESI was determined to be critically dependent upon sample preparation conditions. In MALDI, matrix must be added prior to sample introduction into the mass spectrometer, which is a time consuming step that requires costly sample spotting instrumentation. Similarly, speed is often limited by the need to search for an ideal irradiation spot to obtain interpretable mass spectra. In contrast, APCI is much more tolerant of residual inorganic salts (than ESI) and does not require mixing with matrix to prepare crystals on a target plate. Thus, mass tag solutions can be injected directly into the MS via a Liquid Chromatography (LC) delivery system. Since mass tags ionize well under APCI conditions and have small mass values (less that 800 amu), they are detected with high sensitivity (&lt;5 femtomolar limit of detection) with the APCI-Quadrupole LCMS platform.  
      Methods for synthesis and APCI-MS analysis of mass tags coupled to DNA fragments are illustrated in  FIG. 1  where precursors are (a) acetophenone; (b) 4-fluoroacetophenone; (c) 3-methoxyacetophenone; and (d) 3,4-dimethoxyacetophenone.  
      Upon nitration and reduction, the photoactive tags are produced and used to code for the identity of different primer pairs. An example for photocleavage and detection of four tags is shown in  FIG. 9 . APCI mass spectra for four mass tags after from the corresponding primers (mass tag # 1,2-nitrosoacetophenone, m/z 150; mass tag # 2, 4-fluoro-2-nitrosoacetophenone, m/z 168; mass tag # 3, 5-methoxy-2-nitrosoacetophenone, m/z 180; mass tag # 4, 4,5-dimethoxy-2-nitrosoacetopheone, m/z 210). The four mass tag-labeled primers were mixed together and the mixture was irradiated under UV light (λ˜340 nm) for 5 seconds, introduced into an APCI mass spectrometer and analyzed for the four masses to produce the spectrum. The peak with m/z of 150 is mass-tag 1, 168 is mass-tag 2, 180 is mass-tag 3 and 210 is mass-tag 4.  
      The mechanism for release of these tags from DNA is shown in  FIG. 10 . Four mass tag-labeled DNA molecules (Bottom) Chemical structures of the corresponding photocleaved mass tags (2-nitrosoacetophenone, 4-fluoro-2-nitrosoacetophenone, 5-methoxy-2-nitrosoacetophenone and 4,5-dimethoxy-2-nitrosoacetophenone) after UV irradiation at 340 nm.  
      This result indicates that the 4 compounds designed as mass tags are stable and produce discrete high-resolution digital data in an APCI mass spectrometer. In the research plan described below, the unique m/z from each mass tag will translate to the identity of a viral sequence. Qiagen has developed a large library of more than 80 proprietary masscode tags (Kokoris et al. 2000). Examples are shown in  FIG. 19 .  
      Establishment of a PCR/MS Assay for Respiratory Pathogens  
      During the SARS 2003 Beijing outbreak we established a specific and sensitive real time PCR assay for SARS-CoV (Zhai et al, 2004). The assay was extended to allow simultaneous detection of SARS-CoV as well as human coronaviruses OC43 and 229E in light of recent data from China suggesting the potential for coinfection and increased morbidity ( FIG. 11 ). This human coronavirus assay (3 viral genes and 1 housekeeping gene) exhausted the repertoire of fluorescent tags with which to pursue multiplex real time PCR analysis of clinical materials. The importance of extending rapid molecular assays to include other respiratory pathogens is reinforced by the reappearance of SARS in China and reports of a new highly virulent influenza virus strain in Vietnam.  
      To build a more comprehensive respiratory pathogen surveillance assay we adapted the human coronavirus primers to the PCR/MS platform, and added reagents required to detect other relevant microbes. Influenza A virus was included through a set of established primer sequences obtained through Georg Pauli (Robert Koch Institute, Germany; Schwaiger et al 2000). For the bacterial pathogen  M. pneumoniae  we also used unmodified primer sequences published for real time PCR (Welti et al 2003) to evaluate their use on the PCR/MS platform. Using a panel of mass tags developed by QIAGEN, pilot experiments were performed, demonstrating the feasibility of detecting several respiratory pathogens in a single multiplexed assay on the PCR/MS platform.  
      Subsequent to the 1999 West Nile Virus (WNV) outbreak in the U.S. we also built a real time PCR assay for differential diagnosis of flaviviruses WNV and St. Louis encephalitis virus—see  FIG. 20 . Other validated tools for broad range detection of NIAID priority agents include universal primer stes for detection of Dengue type 1, 2, 3, and 4; various primer sets detecting all members of the bunyamwera and  California encephalitis  serogroups of the bunyaviruses, see table 13, and not yet validated primer sets for detection of all six Venezuelan equine encephailitis virus serotypoes developed for Molecular Epidemiology, AFEIRA/SDE. Brooks, Tex.  
      The current Masscode photocleavable mass tag repertoire comprises over 80 tags.  FIG. 12  demonstrates the specificity of the mass tag detection approach in an example where 58 different mass tags conjugated to oligonucleotides via a photocleavable linkage were identified after UV cleavage and MS. Each of the 10 primers for the 5-plex assay (SARS-CoV, CoV-229E, CoV-OC43, Influenza A virus, and  M. pneumoniae ) was conjugated to a different mass tag such that the identity of a given pathogen was encoded by a specific binary signal (e.g. SARS-CoV, forward primer, 527 amu; reverse primer 666 amu; see  FIG. 13B ). The presence of mass tags did not impair performance of primers in PCR and yielded clear signals for all 5 agents ( FIGS. 13A, 13B ). No noise was observed using unmodified or mass tag-modified primer sets in a background of 125 ng of normal total human DNA per assay ( FIG. 13C ). In general,  FIG. 13  shows singleplex mass tag PCR for (1) Influenza A virus matrix protein (618 amu fwd-primer, 690 amu rev-primer), human coronaviruses (2) SARS (527/666), (3) 229E (670/558), (4) OC43 (686/548), and the bacterial agent (5)  M. pneumoniae  (602/614). (6) 100 bp ladder. In subsequent experiments we extended the respiratory pathogen panel to include respiratory syncytial virus groups A and B. Non-optimized pilot studies in this 7-plex system indicated a detection threshold of &lt;500 molecules ( FIG. 21 ). As a test of feasibility for PCR/MS detection of coinfection, mixtures of DNA templates representing two different pathogens were analyzed successful detection of two targets ( FIG. 21 ) confirmed the suitability of this technology for clinical applications where coinfection may be critical to pathogenesis and epidemiology.  
      Establishment of a Platform for Portable MS  
      Griffin has developed a portable mass spectrometer that is roughly the size of a tower computer (including vacuum system), weighs less than 50 lbs, and consumes ˜150 W depending on operating conditions. This system has a mass range of 400 Da with unit mass resolution. It has been used to detect part-per-trillion level atmospheric constituents. Included below is a representative spectrum of methyl salicylate collected on a miniature cylindrical ion trap mass analyzer coupled to a corona discharge ionization source (data collected in Prof. R. G. Cooks research laboratory at Purdue University). This data demonstrates the feasibility of using this type of instrumentation to detect the mass tags of interest as well as the specificity of the ionization source.  FIG. 14  shows mass spectrum data representative of data collected using a miniature cylindrical ion trap mass analyzer coupled with a corona discharge ionization source.  FIG. 15  shows a mass spectrum of perflouro-dimethclcyclohexane collected on a prototype atmospheric sampling glow discharge ionization (ASGDI) source. ASGDI is an external ionization source related to the APCI source proposed here.  
      Griffin has developed a mass spectrometer for field transportable use. Power consumption, weight, size, and ease of use have been focus design points in the development of this instrument. It has not been designed specifically for interface to an atmospheric pressure ionization (API) source like the one proposed here for pathogen surveillance and discovery. Thus, our focus in this proposal is directed toward the integration of an atmospheric pressure chemical ionization (APCI) source and the required vacuum, engineering, and software considerations associated with this integration.  
      Experimental Design  
      A cartoon of the assay procedure is shown in  FIG. 22 . Labeled amplification products will be generated during PCR amplification with mass tagged primers. After isolation from non-incorporated primers by binding to silica in Qiagen 96-well or 384-well PCR purification modules, products will be eluted into the injection module of the mass-spectrometer. The products traverse the path of a UV light source prior to entering the nebulizer, releasing photocleavable tags (one each from the forward and reverse primer). Mass tags are then ionized. Analysis of the mass code spectrum defines the pathogen composition of the specimen.  
      The repertoire of potential pathogens to be targeted during this project is listed in Table 13. Forward and reverse primer pairs for pathogens listed in Table 13 are (reading from top to bottom starting with RSV-A and ending with  M. Pneumoniae ), SEQ ID NOS:1 and 2, 3 and 4, 9 and 10, 21 and 22, 23 and 24, 26 and 27, and 49 and 50.  
                   TABLE 13                          Respiratory Panel Mass-Tag Primers                                             Forward       Reverse               Pathogen   primer   Sequence   primer   Sequence               RSV A   RSA-U1137   AgATCAACTTCTgTCATCCA   RSV-L1192   gCACATCATAATTAggAgTATCAAT                   gCAA               RSV B   RSB-U1248   AAgATgCAAATCATAAATTC   RSV-1318   TgATATCCAgCATCTTTAAgTATCT               ACAggA       TTATAgTg               Influenza A       (N1)               Influenza A       (N2)               Influenza A   AM-U151   CATggAATggCTAAAgACAAg   AM-L397   AAgTgCACCAgCAgAATAACTgAg       (M)       ACC               Influenza B       SARS-CoV   CIID-28891F   AAg CCT CgC CAA AAA CgT   CIID-29100R   AAg TCA gCC ATg TTC CCg AA               AC               229E-CoV   Taq-Co22-   ggC gCA AgA ATT CAg AAC   Taq-Co22-   TAA gAg CCg CAg CAA CTg C           418F   CA   636R               OC43-CoV   Taq-Co43-   TgT gCC TAT TgC ACC Agg   Taq-Co43-   CCC gAT CgA CAA TgT CAg C           270F   AgT   508R               Metapneumovirus               Parainfluenza       1               Parainfluenza       2               Parainfluenza       3               Parainfluenza       4               M.   MTPM1   CCAACCAAACAACAACgTTC   MTPM2   ACCTTgACTggAggCCgTTA       pneumoniae       A               L.       pneumophilae               C.       pneumoniae                  
 
 Design and Synthesize Primers 
 
      Missing primers will be designed using the same approach as employed for the 7-plex assay. Available sequences will be extracted from GenBank. Conserved regions suitable for primer design will be identified using standard software programs as well as custom software (patent application XYZ). Primer properties will be assessed by commercial primer selection software including OLIGO (Molecular Biology Insights), Primer Express (PE Applied Biosystems), and Primer Premiere (Premiere Biosoft International). Non-tagged primers will be synthesized, and performance assessed using cloned target sequences as described in preliminary data. Primers will be evaluated for signal strength and specificity against a background of total human DNA. Currently, 80% of primers perform as predicted by our algorithms. Thus, to minimize delay we typically synthesize multiple primer sets for similar genetic targets and evaluate their performance in parallel.  
      Inherent in the exquisite sensitivity of PCR is the risk of false positive results due to inadvertent introduction of synthetic templates such as those comprising positive control and calibration reagents. Calibration reagents will be components of kits distributed to network laboratories and customers. Thus, to allow recognition of control vs authentic, natural amplification products, we will modify calibration reagents by introducing a restriction enzyme cleavage site in between the primer binding sites through site directed mutagenesis. We have used this approach in projects concerned with epidemiology of viral infection in various chronic diseases including Bornaviruses in neuropsychiatric disease (NIH/MH57467), measles virus in autism (CDC/American Academy of Pediatrics), and enteroviruses in type I diabetes mellitus (NIH/AI55466).  
      Establish Multiplex Assay Using Cloned Template Standards  
      Before committing resources to generating mass tagged primers we will test the performance of individual primer sets with unmodified primers. Amplification products in these single assays will be detected by gel electrophoresis. This strategy will not serve for multiplex assays because products of individual primer sets will be similar in size i.e., all will be &lt;300 bp. Although individual products in multiplex assays could be resolved by sequence analysis our experience suggests it will be more cost effective to proceed directly to PCR/MS analysis. Thus, after-performance is confirmed in single assays we will generate mass tagged primers for multiplex analyses. All assays will be optimized first for PCR using serial dilutions of plasmid DNA, and then for RT-PCR using serial dilutions of synthetic transcripts. A multiplex assay will be considered successful if it detects all target sequences at a sensitivity of 50 copies plasmid DNA per assay and 100 copies RNA per assay. Successful multiplex assay performance will also include detection of all permutative combinations of two agents to ensure the feasibility of diagnosing simultaneous infection.  
      Optimize Multiplex Assay Using Cell Culture Extracts  
      After establishing performance parameters with calibrated synthetic reagents, cell culture extracts of authentic pathogens will be used. We will recommend specific kits for nucleic acid extraction and RT-PCR. Nonetheless, we recognize that some investigators may choose to use other reagents. Thus, we will assess performance of assays with RNA extracted using readily available commercial systems that do or do not include organic solvents (e.g, Tri-Reagent vs RNeasy). Our current protocol employs Tri-Reagent. Similarly, although we use Superscript reverse transcriptase (Invitrogen) and HotStart polymerase (QIAGEN), we will also assess the performance of ThermoScript RT (Invitrogen) at elevated temperature, and of single-step RT-PCR systems like the Access Kit (Promega). To optimize efficiency where clinical material mass is limited and to reduce the complexity of sample preparation, both viral and bacterial agents will be identified using RT-PCR. In the event network collaborators agree an agent is characterized by substantive phylogenetic diversity, cell culture systems will include at least three divergent isolates of each pathogen. Nasal swabs, sputum and lavage specimens will be spiked with culture material to optimize recovery methods for viral as well as bacterial agents. Assays are validated using banked specimens from naturally infected humans, and naturally infected animals.  
     REFERENCES FOR EXAMPLE 5  
     
         
          Briese, T., Jia, X. Y., Huang, C., Grady, L. J., and Lipkin, W. I. (1999). Identification of a Kunjin/West Nile-like flavivirus in brains of patients with New York encephalitis. Lancet 354, 1261-1262.  
          Briese, T., Rambaut, A., Pathmajeyan, M., Bishara, J., Weinberger, M., Pitlik, S., and Lipkin, W. I. (2002). Phylogenetic analysis of a human isolate from the 2000 Israel West Nile virus epidemic. Emerg Infect Dis 8(5), 528-31.  
          Briese, T., Schneemann, A., Lewis, A. J., Park, Y. S., Kim, S., Ludwig, H., and Lipkin, W. I. (1994). Genomic organization of Borna disease virus. Proc Natl Acad Sci USA 91(10), 4362-6.  
          Ju, J., Li, Z., and Itagaki, Y. (2003). Massive parallel method for decoding DNA and RNA. U.S. Pat. No. 6,664,079.  
          Kim, S., Edwards, J. R., Deng, L., Chung, W., and Ju, J. (2002). Solid phase capturable dideoxynucleotides for multiplex genotyping using mass spectrometry. Nucleic Acids Res 30(16), e85.  
          Kim, S., Ruparel, H. T., Gilliam, T. C., and Ju, J. (2003). Digital genotyping using molecular affinity and mass spectrometry. Nat Rev Genet 4, 1001-1008.  
          Kokoris, M., Dix, K., Moynihan, K., Mathis, J., Erwin, B., Grass, P., Hines, B., and Duesterhoeft, A. (2000). High-throughput SNP genotyping with the Masscode system. Mol. Diagn. 5, 329-340.  
          Li, Z., Bai, X., Ruparel, H., Kim, S., Turro, N. J., and Ju, J. (2003). A photocleavable fluorescent nucleotide for DNA sequencing and analysis. Proc Natl Acad Sci USA 100(2), 414-9.  
          Lipkin, W. I., Travis, G. H., Carbone, K. M., and Wilson, M. C. (1990). Isolation and characterization of Borna disease agent cDNA clones. Proc Natl Acad Sci USA 87(11), 4184-8.  
          Schweiger, B., Zadow, I., Heckler, R., Timm, H., and Pauli, G. (2000). Application of a fluorogenic PCR assay for typing and subtyping of influenza viruses in respiratory samples. J Clin Microbiol 38(4), 1552-8.  
          Walker, M. P., Schlaberg, R., Hays, A. P., Bowser, R., and Lipkin, W. I. (2001). Absence of echovirus sequences in brain and spinal cord of amyotrophic lateral sclerosis patients. Ann Neurol 49(2), 249-53.  
          Welti, M., Jaton, K., Altwegg, M., Sahli, R., Wenger, A., and Bille, J. (2003). Development of a multiplex real-time quantitative PCR assay to detect  Chlamydia pneumoniae, Legionella pneumophila  and  Mycoplasma pneumoniae  in respiratory tract secretions. Diagn Microbiol Infect Dis 45(2), 85-95.  
          Zhai, J., Briese, T., Dai, E., Wang, X., Pang, X., Du, Z., Liu, H., Wang, J., Wang, H., Guo, Z., Chen, Z., Jiang, L., Zhou, D., Han, Y., Jabado, O., Palacios, G., Lipkin, W. I., and Yang, R. (2004). Real-time polymerase chain reaction for detecting SARS coronavirus, Beijing 2003. Emerg Infect Dis 10, 300-303.  
       
    
     Example 6  
      Primer Design and Synthesis, Template Design and Synthesis  
      Respiratory Panel includes 27 gene targets with validated primer sets as shown below in Table 5. Forward and reverse primer pairs (SEQ ID NOs:1-54) are given for each pathogen (reading from top to bottom starting with RSV-A and ending with  C. Pneumoniae ). For example, forward primer for RSV-A is SEQ ID NO:1, reverse primer for RSV-A is SEQ ID NO:2. Forward primer for RSV-B is SEQ ID NO:3, reverse primer for RSV-B is SEQ ID NO:4, etcetera.  
                   TABLE 5                          Respiratory Panel Mass-Tag Primers                                             Forward       Reverse               Pathogen   primer   Sequence   primer   Sequence               RSV A   RSA-U1137   AgATCAACTTCTgTCATCCAgC   RSV-L1192   gCACATCATAATTAggAgTATCAAT                   AA               RSV B   RSB-U1248   AAgATgCAAATCATAAATTCAC   RSV-1318   TgATATCCAgCATCTTTAAgTATCT               AggA       TTATAgTg               Influenza A   NA1-U1078   ATggTAATggTgTTTggATAggA   NA1-L1352   AATgCTgCTCCCACTAgTCCAg       (N1)       Ag               Influenza A   NA2-U560   AAgCATggCTgCATgTTTgTg   NA2-L858   ACCAggATATCgAggATAACAggA       (N2)               Influenza A   AM-U151   CATggAATggCTAAAgACAAgA   AM-L397   AAgTgCACCAgCAgAATAACTgAg       (M)       CC               Influenza A   HA1-U583   ggTgTTCATCACCCgTCTAACA   HA1-L895   gTgTTTgACACTTCgCgTCACAT       (H1)       T               Influenza A   H2A208U27   gCTATgCAAACTAAACggAATY   H2A559L26   TATTgTTgTACgATCCTTTggCAAC       (H2)       CCTCC       C               Influenza A   HA3-U115   gCTACTgAgCTggTTCAgAgTT   HA3-L375   gAAgTCTTCATTgATAAACTCCAg       (H3)       C               Influenza A   HA5human-   TTACTgTTACACATgCCCAAgA   HA5human-   AggYTTCACTCCATTTAgATCgCA       (H5)   u71   CA   L147               Influenza B   BHA-U188   AgACCAgAgggAAACTATgCCC   BHA-L347   CTgTCgTgCATTATAggAAAgCAC               SARS-CoV   CIID-28891F   AAgCCTCgCCAAAAACgTAC   CIID-   AAgTCAgCCATgTTCCCgAA                   29100R               229E-CoV   Taq-Co22-   ggCgCAAgAATTCAgAACCA   Taq-Co22-   TAAgAgCCgCAgCAACTgC           418F       636R               OC43-CoV   Taq-Co43-   TgTgCCTATTgCACCAggAgT   Taq-Co43-   CCCgATCgACAATgTCAgC           270F       508R               Metapneumovirus   MPV01.2   AACCgTgTACTAAgTgATgCAC   MPV02.2   CATTgTTTgACCggCCCCATAA       European       TC               Metapneumovirus   MV-Can-U918   AAgTCCAAAggCAggRCTgTTA   MV-Can-   CCTgAAgCATTRCCAAgAACAACA       Canadian       TC   L992   C               Parainfluenza   HPIV1-U82   TACTTTTgACACATTTAgTTCC   HPIV1-L167   CggTACTTCTTTgACCAggTATAAT       1       AggAg       Tg               Parainfluenza   HPIV2-U908   ggACTTggAACAAgATggCCT   HPIV2-L984   AgCATgAgAgCYTTTAATTTCTggA       2               Parainfluenza   HPIV3-U590   gCTTTCAgACAAgATggAACAg   HPIV3-L668   gCATKATTgACCCAATCTgATCC       3       Tg               Parainfluenza   HPIV4A-U191   AACAgAAggAAATgATggTggAA   HPIV4A-   TgCTgTggATgTATgggCAg       4A       C   L269               Parainfluenza   HPIV4B-U194   AgAAgAAAACAACgATgAgACA   HPIV4B-   gTTTCCCTggTTCACTCTCTTCA       4B       Agg   L306               Cytomegalovirus   CMV-U421   TACAgCACgCTCAACACCAAC   CMV-L501   CCCggCCTTCACCACCAACCgAAA               gCCT       A               Measles virus   MEA-U1103   CAAgCATCATgATYgCCATTC   MEA-L1183   CCTgAATCYCTgCCTATgATgggTT               CTgg       T               Adenovirus   ADV2F-A   CCCMTTYAACCACCACCg   ADV1R-A   ACATCCTTBCKgAAgTTCCA               Enterovirus   5UTR-U447   TCCTCCggCCCCTgAATgCggC   5UTR-L541   gAAACACggWCACCCAAAgTASTC               TAATCC       g               M.   MTPM1   CCAACCAAACAACAACgTTCA   MTPM2   ACCTTgACTggAggCCgTTA       pneumoniae               L.   Legpneu-   gCATWgATgTTARTCCggAAgC   LegPneu-   CggTTAAAgCCAATTgAgCg       pneumophilae   U149   A   L223               C.   CLPM1   CATggTgTCATTCgCCAAgT   CLPM2   CgTgTCgTCCAgCCATTTTA       pneumoniae                  
 
 Table 6, NIAID Priority Agent Panel. 
 
      Assays have been designed using 4 primer sets and their cognate synthetic Rift Valley Fever, Crimean Congo Hemorrhagic Fever, Ebola Zaire and Marburg virus templates created via PCR using overlapping polynucleotides, as shown in Table 6. Forward and reverse primer pairs (SEQ ID NOs:55-62) are given for four of the listed pathogens (reading from top to bottom starting with Rift Valley Fever virus and ending with Marburg virus). For example, forward primer for Rift Valley Fever virus is SEQ ID NO:55, reverse primer for Rift Valley Fever virus is SEQ ID NO:56. Forward primer for CCHF virus is SEQ ID NO:57, reverse primer for CCHF virus is SEQ ID NO:58, etcetera.  
                   TABLE 6                          NIAID Priority Agents Panel Mass-Tag Primers                                             Forward       Reverse               Pathogen   primer   Sequence   primer   Sequence               B. anthracis                                   Dengue viruses               West Nile virus               Japanese enc.       virus               St. Louis enc.       virus               Yellow Fever       virus               La Crosse virus               California enc.       virus               Rift Valley   RVF-L660   ggATTgACCTgTgCCTgTTg   RVF-L660   gCATTAgAAATgTCCTCTTT       Fever virus       C       TgCTgC               CCHF virus   CCHV-   AgAACACgTgCCgCTTACg   CCHV-   CCATTCYTTYTTRAACTCYT           L120   CCCA   L120   CAAACCA               VEE virus               EEE virus               WEE virus               Ebola virus   EboZA-   AACACCgggTCTTAATTCT   EboZA-   ggTggTAAAATTCCCATAgT           L319   TATATCAA   L319   AgTTCTTT               Marburg virus   Mar-L372   TTCCgTCACAAgCCgAAAT   Mar-L372   TTATTTTAgTTgAgAAAAgAg               T       gTTCATgC               LCMV               Junin virus               Machupo virus               Variola virus                  
 
 Encephalitis Agent Panel 
 
      Table 7 shows primer sets for encephalitis-inducing agents. Forward and reverse primer pairs (SEQ ID NOs:63-96) are given for each pathogen (reading from top to bottom starting with West Nile virus and ending with Enterovirus). For example, forward primer for West Nile virus is SEQ ID NO:63, reverse primer for West Nile virus is SEQ ID NO:64. Forward primer for St. Louis Encephalitis virus is SEQ ID NO:65, reverse primer for St. Louis Encephalitis virus is SEQ ID NO:66, etcetera.  
                   TABLE 7                          Encephalitis Agent Panel Mass-Tag Primers                                             Forward       Reverse               Pathogen   primer   Sequence   primer   Sequence               West Nile   DF3-87F   gCTCCgCTgTCCCTgTgA   DF3-156R   CACTCTCCTCCTgCATggATg           virus               St. Louis   SLE-D-   CATTTgTTCAgCTgTCCCAgTC   SLE-D-   CTCACCCTTCCCATgAATTg       enc. virus   73F       145R   AC               Herpes   HSV-U27   CCCggATgCggTCCAgACgATT   HSV-L121   CCCgCggAggTTgTACAAAAAA       Simplex       AT       gCT       virus               HIV 1   SK68i   TTCTTIggAgCAgCIggAAgCACI   SK69i   TTMATgCCCCAgACIgTIAgTT               ATgg       ICAACA               HIV 2   HIV2TMF   ggCTgCACgCCCTATgATA   HIV2TMR   TCTgCATggCTgCTTgATg           PR2       PR2               N.   Nmen-   TCTgAAgCCATTggCCgT   Nmen-   CCAAACACACCACgCgCAT       meningitidis   U829       L892               S.   SPPLY-   AgCgATAgCTTTCTCCAAgTgg   SPPLY-   CTTAgCCAACAAATCgTTTA       pneumoniae   U532       L606   CCg               H. influenzae   HINF-U82   AAgCTCCTTgMATTTTTTgTAT   Hinf-L158   gCTgAATTggCTTRgATACCg               TAgAA       Ag               Influenza B   BHA-U188   AgACCAgAgggAAACTATgCCC   BHA-L347   CTgTCgTgCATTATAggAAAg                       CAC               SARS-CoV   CIID-   AAgCCTCgCCAAAAACgTAC   CIID-   AAgTCAgCCATgTTCCCgAA           28891F       29100R               229E-CoV   Taq-Co22-   ggCgCAAgAATTCAgAACCA   Taq-Co22-   TAAgAgCCgCAgCAACTgC           418F       636R               OC43-CoV   Taq-Co43-   TgTgCCTATTgCACCAggAgT   Taq-Co43-   CCCgATCgACAATgTCAgC           270F       508R               Cytomegalovirus   CMV-   TACAgCACgCTCAACACCAAC   CMV-L501   CCCggCCTTCACCACCAACC           U421   gCCT       gAAAA               Varicella   VZV-U138   ACgTggATCgTCggATCAgTTgT   VZV-L196   TCgCTATgTgCTAAAACACgC       Zoster virus               gg               Measles   MEA-   CAAgCATCATgATYgCCATTCC   MEA-   CCTgAATCYCTgCCTATgATg       virus   U1103   Tgg   L1183   ggTTT               Adenovirus   ADV2F-A   CCCMTTYAACCACCACCg   ADV1R-A   ACATCCTTBCKgAAgTTCCA               Enterovirus   5UTR-   TCCTCCggCCCCTgAATgCggC   5UTR-   gAAACACggWCACCCAAAgT           U447   TAATCC   L541   ASTCg                  
 
 Improvements in Multiplexing 
 
      Initially, multiplex detection of 7 respiratory pathogen targets at 500 copy sensitivity: RSV group A, RSV group B, Influenza A, HCoV-SARS, HCoV-229E, HCoV-OC43, and  M. pneumoniae  was determined. Subsequently, sensitivity was improved. Detection at 100 copy sensitivity has been confirmed for 18 respiratory pathogen targets in a 20-plex assay (Table 8). Two of 20 targets, the influenza A M gene and influenza H1 gene, were detected at 500 copies. This typically corresponds in our laboratory to &lt;0.001 TCID 50  per assay, a threshold comparable to many useful microbiological assays.  
               TABLE 8                       Sensitivity of respiratory panel                                                                                        Influenza   Influenza A   Influenza A   Influenza   Influenza   Influenza A   Influenza A   Influenza           RSV A   RSV B   A (N1)   (N2)   (matrix)   A (H1)   A (H2)   (H3)   (H5)   B               500   +   +   +   +   +   +   +   +   +   +       copies       100   +   +   +   +   −   −   +   +   +   +       copies                   HCoV-   HCoV-   HCoV-   Metapneumo-           SARS   229E   OC43   virus (Eur.)   HPIV-1   HPIV-2   HPIV-3     M. pneumoniae       C. pneumoniae       L. pneumophilae                 500   +   +   +   +   +   +   +   +   +   +       copies       100   +   +   +   +   +   +   +   +   +   +       copies                  
 
 Clinical Samples 
 
      Although assays of synthetic targets were optimized in a complex background of normal tissue nucleic acids, analysis of clinical materials was performed. Banked clinical respiratory specimens were obtained from Cinnia Huang of the Wadsworth Laboratory of the New York State Department of Health and Pilar Perez-Brena of the National Center for Microbiology of Spain. Organisms included: metapneumovirus (n=3), RSV-B (n=3), RSV-A (n=2), adenovirus (n=2), HPIV-1 (n=1), HPIV-3 (n=2), HPIV-4 (n=2), enterovirus (n=2), SARS-CoV (n=4), influenza A (n=2). Six representative results are shown in  FIG. 18 ; Multiplex Mass Tag PCR analysis of six human respiratory specimens. Signal to noise ratio is on the ordinate and primer sets are listed on the abscissa. Mass Tag primer sets employed in a single tube assay are indicated at the bottom of the figure.  FIG. 18A —Influenza A (N1, M, H1) H1); 18B—Human Parainfluenza Type 1; 18C—Respiratory Syncytial Group B; 18D—Enterovirus; 18E—SARS CoV; and 18F—Human Parainfluenza Type 3.  
      Pathogens  
      Tables 9-12 show a non-comprehenisve list of various target pathogens and corresponding primer sequences. In Table 10, the forward and reverse primer pairs for Cytomegalovirus, SEQ ID NOS: 87 and 88; for HPIV-4A, SEQ ID NOS: 37 and 38; for HPIV-4B, SEQ ID NOS: 39 and 40; for Measles, SEQ ID NOS: 91 and 92; for Varicella Zoster virus, SEQ ID NOS: 89 and 90; for HIV-1, SEQ ID NOS: 69 and 70; for HIV-2, SEQ ID NOS: 71 and 72; for  S. Pneumoniae , SEQ ID NOS: 100 and 101; for  Haemophilus  Influenzae, SEQ ID NOS: 77 and 78; for Herpes Simplex, SEQ ID NOS: 67 and 68; for MV Canadian isolates, SEQ ID NOS: 29 and 30; for Adenovirus 2 A/B 505/630, SEQ ID NOS: 93 and 94; for Enterovirus A/B 702/495, SEQ ID NOS: 95 and 96; and forward primers for Enterovirus A/B 702/495, SEQ ID NOS: 98 and 99.  
                               TABLE 9                       Primer sequence   Name   Target   Previous Masscode   Panel                                                        HIV2   HIV2TMFPR2       586   Respiratory/Enc   30       HIV2   HIV2TMRPR2       570   Respiratory/Enc         Streptococcus pneumoniae     SPPLY-U532   Forward A   714   Respiratory/Enc   31         Streptococcus pneumoniae     SPPLY-L606   Reverse B   694   Respiratory/Enc         Haemophilus influenza     HINF-U82   Forward A   734   Respiratory/Enc   32         Haemophilus influenza     Hinf-L158   Reverse B   726   Respiratory/Enc         Herpes Simplex     HSV-U27   Forward A   722   Respiratory/Enc   33         Herpes Simplex     HSV-L121   Reverse B   706   Respiratory/Enc       Metaneumovirus Canadian   MV-Can-U918   Forward A   718   Respiratory   34       Metaneumovirus Canadian   MV-Can-L992   Reverse B   654   Respiratory       Adenovirus   ADV2F-A   Forward A   503   Respiratory/Enc   12       Adenovirus   ADV1R-A   Reverse B   630   Respiratory/Enc       Enterovirus   5UTR-U447   Forward A   702   Respiratory/Enc   14       Enterovirus   5UTR-U450   Forward A   702   Respiratory/Enc       Enterovirus   5UTR-u457   Forward A   702   Respiratory/Enc   14       Enterovirus   5UTR-L541   Reverse B   495   Respiratory/Enc         Neisseria meningitidis     Nmen-U829   Forward A   730   Encephalitis/Resp         Neisseria meningitidis     Nmen-L892   Reverse B   439   Encephalitis/Resp       WNV1   DF3-87F   Forward A   539   Encephalitis       WNV1   DF3-156R   Reverse B   499   Encephalitis       WNV2   WN-Ax-FWD   Forward A   539   Encephalitis       WNV2   WN-Ax-REV   Reverse B   499   Encephalitis       SLE   SLE-D-73F   Forward A   658   Encephalitis       SLE   SLE-D-145R   Reverse B   642   Encephalitis       Cytomegalovirus   CMV-U421   Forward A   626   Respiratory/Enc   24       Cytomegalovirus   CMV-L501   Reverse B   610   Respiratory/Enc       HPIV4A   HPIV4A-U191   Forward A   622   Respiratory   25       HPIV4a   HPIV4A-L269   Reverse B   606   Respiratory       HPIV4B   HPIV4B-U194   Forward A   622   Respiratory   26       HPIV4b   HPIV4B-L306   Reverse B   606   Respiratory       Measles   MEA-U1103   Forward A   578   Respiratory/Enc   27       Measles   MEA-L1183   Reverse B   562   Respiratory/Enc       VZV   VZV-U138   Forward A   515   Respiratory/Enc   28       VZV   VZV-L196   Reverse B   471   Respiratory/Enc       HIV1   SK68i       574   Respiratory/Enc   29       HIV1   SK69i       383   Respiratory/Enc       RSV A gen N   RSA-U1137   Forward A   467   Respiratory   1       RSV A gen N   RSV-L1192   Reverse B   455   Respiratory       RSV B gen N   RSB-U1248   Forward A   483   Respiratory   2       RSV B gen N   RSV-1318   Reverse B   479   Respiratory       Flu A - N1   NA1-U1078   Forward A   499   Respiratory   3       Flu A - N1   NA1-L1352   Reverse B   439   Respiratory       Flu A - N2   NA2-U560   Forward A   658   Respiratory   4       Flu A - N2   NA2-L858   Reverse B   730   Respiratory       Flu A (MATRIX)   AM-U151   Forward A   618   Respiratory/Enc   5       Flu A (MATRIX)   AM-L397   Reverse B   690   Respiratory/Enc       Flu B   BHA-U188   Forward A   698   Respiratory/Enc   6       Flu B   BHA-L347   Reverse B   598   Respiratory/Enc       SARS-Coronavirus   CIID-28891F   Forward A   527   Respiratory/Enc   7       SARS-Coronavirus   CIID-29100R   Reverse B   666   Respiratory/Enc       229E-Coronavirus   Taq-Co22-418F   ForwardA   670   Respiratory/Enc   8       229E-Coronavirus   Taq-Co22-636R   Reverse B   558   Respiratory/Enc       OC43-Coronavirus   Taq-Co43-270F   ForwardA   686   Respiratory/Enc   9       OC43-Coronavirus   Taq-Co43-508R   Reverse B   548   Respiratory/Enc       Metapneumovirus   MPV01.2   ForwardA   718   Respiratory   10       Metapneumovirus   MPV02.2   Reverse B   654   Respiratory         Mycoplasma pneumoniae     MTPM1   Forward A   602   Respiratory   11         Mycoplasma pneumoniae     MTPM2   Reverse B   614   Respiratory       adenovirus   ADV1F-A   Forward A   503   Respiratory/Enc   12       adenovirus   ADV2R-A   Reverse B   630   Respiratory/Enc         Chlamydia     CLPM1   Forward A   519   Respiratory   13         Chlamydia     CLPM2   Reverse B   371   Respiratory       enterovirus   EV1f   Forward A   702   Respiratory/Enc   14       enterovirus   EV1r   Reverse B   495   Respiratory/Enc       flavivirus1   Fla-U9093   Forward A   710   Encephalitis   15       flavivirus1   Fla-L9279   Reverse B   594   Encephalitis       flavivirus2   Fla-U9954   Forward A   710   Encephalitis   15       flavivirus2   Fla-L10098   Reverse B   594   Encephalitis       fluHA1   HA1-U583   Forward A   650   Respiratory   16       fluHA1   HA1-L895   Reverse B   634   Respiratory       fluHA2   H2A208U27   Forward A   662   Respiratory   17       fluHA2   H2A559L26   Reverse B   638   Respiratory       fluHA3   HA3-U115   Forward A   375   Respiratory   18       fluHA3   HA3-L380   Reverse B   475   Respiratory       fluHA5   HA5-u71   Forward A   646   Respiratory   19       fluHA5   HA5-L147   Reverse B   395   Respiratory       HPIV1   HPIV1-U82   Forward A   566   Respiratory   20       HPIV1   HPIV1-L167   Reverse B   357   Respiratory       HPIV2   HPIV2-U908   Forward A   483   Respiratory   21       HPIV2   HPIV2-L984   Reverse B   590   Respiratory       HPIV3   HPIV3-U590   Forward A   642   Respiratory   22       HPIV3   HPIV3-L668   Reverse B   539   Respiratory       Legionella1   Legpneu-U149   Forward A   678   Respiratory   23       Legionella1   LegPneu-L223   Reverse B   582   Respiratory                  
 
     
       
         
           
               
               
               
             
               
                 TABLE 10 
               
               
                   
               
               
                   
               
             
            
               
                 Respiratory Panel 
                   
                   
               
               
                 Mass-Tag Primers 
               
            
           
           
               
               
               
               
               
               
               
               
               
               
               
            
               
                 Tagged 
                   
                 Stand- 
                 Primer 
                   
                   
                   
                   
                   
                   
                   
               
               
                 Pairs 
                 Tier 
                 ards 
                 Name 
                 Start 
                 Length 
                 Tm 
                 Primer forward 
               
               
                   
               
            
           
           
               
               
               
               
               
               
               
               
               
            
               
                 CYTO- 
                 1 
                 YES 
                 CMV-U421 
                 421 
                 25 
                 64.51 
                 TACAGCACGCTCAACACCAACGCCT 
                   
               
               
                 MEGALO- 
               
               
                 VIRUS 
               
               
                   
               
               
                 HPIV-4A 
                 1 
                 clon- 
                 HPIV4A-U191 
                 191 
                 24 
                 59 
                 AACAGAAGGAAATGATGGTGGAAC 
               
               
                   
                   
                 ing 
               
               
                   
               
               
                 HPIV-4B 
                 1 
                 clon- 
                 HPIV4B-U194 
                 194 
                 25 
                 59 
                 AGAAGAAAACAACGATGAGACAAGG 
               
               
                   
                   
                 ing 
               
               
                   
               
               
                 MEASLES 
                 1 
                 syn- 
                 MEA-U1103 
                 1103 
                 25 
                 59.33 
                 CAAGCATCATGATYGCCATTCCTGG 
               
               
                   
                   
                 thetic 
               
               
                   
               
               
                 VARI- 
                 1 
                 YES 
                 VZV-U138 
                 138 
                 23 
                 59.84 
                 ACGTGGATCGTCGGATCAGTTGT 
               
               
                 CELLA 
               
               
                 ZOSTER 
               
               
                 VIRUS 
               
               
                   
               
               
                 HIV1 
                 1 
                 Thomas 
                 SK68i 
                 SK68i 
                 28 
                 70 to 75 
                 TTC TTI GGA GCA GCI GGA AGC 
               
               
                   
                   
                   
                   
                   
                   
                   
                 ACI ATG G 
               
               
                   
               
               
                 HIV2 
                 1 
                 syn- 
                 HIV2TMFPR2 
                 hiv2tmfpr2 
                 18 
                   
                 GGCTGCACGCCCTATGATA 
               
               
                   
                   
                 thetic 
               
               
                   
               
               
                 STREPTO- 
                 1 
                 syn- 
                 SPPLY-U532 
                 532 
                 22 
                 59 
                 AGCGATAGCTTTCTCCAAGTGG 
               
               
                 COCCUS 
                   
                 thetic 
               
               
                 PNEUMON- 
               
               
                 IAE 
               
               
                   
               
               
                 HAEMO- 
                 1 
                 syn- 
                 HINF-U82 
                 82 
                 27 
                 59 
                 AAGCTCCTTGMATTTTTTGTATTAGAA 
               
               
                 PHILUS 
                   
                 thetic 
               
               
                 INFLUEN- 
               
               
                 ZAE 
               
               
                   
               
               
                 HERPES 
                 1 
                 YES 
                 HSV-U27 
                 27 
                 24 
                 62.09 
                 CCCGGATGCGGTCCAGACGATTAT 
               
               
                 SIMPLEX 
               
               
                   
               
               
                 MV-Cana- 
                 1 
                 syn- 
                 MV-Can-U918 
                 918 
                 24 
                 59 
                 AAGTCCAAAGGCAGGRCTGTTATC 
               
               
                 dian 
                   
                 thetic 
               
               
                 isolates 
               
               
                   
               
               
                 Adeno- 
                 1 
                 YES 
                 ADV2F-A 
                 ADV2F-A 
                   
                 58 TO 81 
                 CCCMTTYAACCACCACCG 
               
               
                 virus2 
               
               
                 A/B 503/ 
               
               
                 630 
               
               
                   
               
               
                 Entero- 
                 1 
                 YES 
                 5UTR-U447 
                 447 
                   
                 76 
                 TCCTCCGGCCCCTGAATGCGGCTAATCC 
               
               
                 virus 
               
               
                 A/B 702/ 
               
               
                 495 
               
               
                   
               
               
                 Entero- 
                 1 
                 YES 
                 5UTR-U450 
                 450 
                   
                 72 
                 TCCGGCCCCTGAATGCGGCTAATCC 
               
               
                 virus 
               
               
                 A/B 702/ 
               
               
                 495 
               
               
                   
               
               
                 Entero- 
                 1 
                 YES 
                 5UTR-457 
                 457 
                   
                 83 
                 CCCCTGAATGCGGCTAATCC 
               
               
                 virus 
               
               
                 A/B 702/ 
               
               
                 495 
               
               
                   
               
            
           
           
               
               
               
               
               
               
               
               
               
               
               
            
               
                 Tagged 
                   
                   
                   
                   
                   
                   
                   
                   
                   
                   
               
               
                 Pairs 
                   
                   
                   
                 Start 
                 Length 
                 Tm 
                 Primer reverse 
               
               
                   
               
            
           
           
               
               
               
               
               
               
               
               
               
               
               
               
            
               
                 CYTO- 
                   
                   
                 CMV-L501 
                 501 
                 25 
                 65.08 
                 CCC GGC CTT CAC CAC CAA CCG 
                   
                 GIDL 
                   
                   
               
               
                 MEGALO- 
                   
                   
                   
                   
                   
                   
                 AAA A 
               
               
                 VIRUS 
               
               
                   
               
               
                 HPIV-4A 
                   
                   
                 HPIV4A-L269 
                 269 
                 20 
                 59 
                 TGCTGTGGATGTATGGGCAG 
                 GIDL 
               
               
                   
               
               
                 HPIV-4B 
                   
                   
                 HPIV4B-L306 
                 306 
                 23 
                 58 
                 GTTTCCCTGGTTCACTCTCTTCA 
                 GIDL 
               
               
                   
               
               
                 MEASLES 
                   
                   
                 MEA-L1183 
                 1183 
                 28 
                 58.98 
                 CCT GAA TCY CTG CCT ATG ATG 
                 GIDL 
               
               
                   
                   
                   
                   
                   
                   
                   
                 GGT TT 
               
               
                   
               
               
                 VARI- 
                   
                   
                 VZV-L196 
                 196 
                 23 
                 59.97 
                 TCG CTA TGT GCT AAA ACA CGC 
                 GIDL 
               
               
                 CELLA 
                   
                   
                   
                   
                   
                   
                 GG 
               
               
                 ZOSTER 
               
               
                 VIRUS 
               
               
                   
               
               
                 HIV1 
                   
                   
                 SK69i 
                 SK69i 
                 26 
                   
                 TTMATGCCCCAGACIGTIAGTTICAACA 
                 H 
                 Robert Koch 
               
               
                   
                   
                   
                   
                   
                   
                   
                   
                 Etterbrok 
                 Institute 
               
               
                   
               
               
                 HIV2 
                   
                   
                 HIV2TMRPR2 
                   
                   
                   
                 TCTGCATGGCTGCTTGATG 
                 Schulten, 
                 JVM 88 
               
               
                   
                   
                   
                   
                   
                   
                   
                   
                 M 
                 (2000) 
               
               
                   
                   
                   
                   
                   
                   
                   
                   
                   
                 81-87 
               
               
                   
               
               
                 STREPTO- 
                   
                   
                 SPPLY-L606 
                 606 
                 23 
                 59 
                 CTTAGCCAACAAATCGTTTACCG 
                 GIDL 
               
               
                 CCUS 
               
               
                 PHEUMON- 
               
               
                 IAE 
               
               
                   
               
               
                 HAEMO- 
                   
                   
                 Hin1-L158 
                 158 
                 23 
                 58 
                 GCTGAATTGGCTTRGATACCGAG 
                 GIDL 
               
               
                 PHILUS 
               
               
                 INFLUEN- 
               
               
                 ZAE 
               
               
                   
               
               
                 HERPES 
                   
                   
                 HSV-L121 
                 121 
                 24 
                 61.55 
                 CCC GCG GAG GTT GTA CAA AAA 
                 GIDL 
               
               
                 SIMPLEX 
                   
                   
                   
                   
                   
                   
                 GCT 
               
               
                   
               
               
                 MV- 
                   
                   
                 MV-Can-L992 
                 992 
                 25 
                 60 
                 CCTGAAGCATTRCCAAGAACAACAC 
                 GIDL 
               
               
                 Canadian 
               
               
                 isolates 
               
               
                   
               
               
                 Adeno- 
                   
                   
                 ADV1R-A 
                 ADV1R-A 
                   
                 54 TO 58 
                 ACATCCTTBCKGAAGTTCCA 
                 Ana 
                 VM 92 
               
               
                 virus2 
                   
                   
                   
                   
                   
                   
                   
                 Avetton 
                 (2001) 113- 
               
               
                 A/B 503/ 
                   
                   
                   
                   
                   
                   
                   
                   
                 120 
               
               
                 630 
               
               
                   
               
               
                 Entero- 
                   
                   
                 5UTR-L541 
                 5UTR-L541 
                   
                 67 T0 87 
                 GAAACACGGWCACCCAAAGTASTCG 
               
               
                 Virus 
               
               
                 A/B 702/ 
               
               
                 495 
               
               
                   
               
               
                 Entero- 
               
               
                 Virus 
               
               
                 A/B 702/ 
               
               
                 495 
               
               
                   
               
               
                 Entero- 
               
               
                 Virus 
               
               
                 A/B 702/ 
               
               
                 495 
               
               
                   
               
            
           
         
       
     
     
       
         
           
               
               
               
               
               
             
               
                 TABLE 11 
               
               
                   
               
               
                   
               
             
            
               
                 Tagged Pairs 
                 Standards 
                 LIST OF PRIMERS 
                 Name FWD 
                 Forward-A 
               
               
                   
               
            
           
           
               
               
               
               
               
               
            
               
                 RSVA-1A/B 467/455 
                 YES 
                 RSV A gen N 
                 RSA-U1137 
                 AGATAACTTCTGTCATCCAGCAA 
                   
               
               
                   
               
               
                   
                   
                 RSV A gen N 
                 rsh1ce.fa-777F 
                 GGTGCAGGGCAAGTGATGTTA 
               
               
                   
               
               
                   
                   
                 RSV A gen P 
                 RSHP1.fa-235F 
                 CAGGGAACAAGCCCAATTATCA 
               
               
                   
               
               
                 RSVB-1A/B 483/479 
                 YES 
                 RSV B gen N 
                 RSB-U1248 
                 AAGATGCAAATCATAAATTCACAGGA 
               
               
                   
               
               
                   
                 YES 
                 RSV B gen N 
                 rshbcnp.fa-775F 
                 ATGGTTCAGGGCAAGTAATGCT 
               
               
                   
               
               
                   
                 YES 
                 RSV B gen P 
                 RSHPQ.fa-189F 
                 TCTGGCACCAACATCATCAATC 
               
               
                   
               
               
                 FluA-N1 A/B 499/439 
                 YES 
                 N1 
                 NA1-U1078 
                 ATGGTAATGGTGTTTGGATAGGAAG 
               
               
                   
               
               
                 FluA-N2 A/B 658/730 
                 YES 
                 N2 
                 NA2-U560 
                 AAGCATGGCTGCATGTTTGTG 
               
               
                   
               
               
                 FLuA-M A/B 618/690 
                 YES 
                 A (MATRIX) 
                 AM-U151 
                 CATGGAATGGCTAAAGACAAGACC 
               
               
                   
               
               
                 FluB A/B 698/598 
                 YES 
                 B 
                 BHA-U188 
                 AGACCAGAGGGAAACTATGCCC 
               
               
                   
               
               
                   
                 YES 
                 B 
               
               
                   
               
               
                 SARS A/B 527/666 
                 YES 
                 SARS-Coronavirus 
                 CIID-28891F 
                 AAg CCT CgC CAA AAA CgT AC 
               
               
                   
               
               
                 229E A/B 670/558 
                 YES 
                 229E-Coronavirus 
                 Taq-Co22-418F 
                 ggC gCA AgA ATT CAg AAC CA 
               
               
                   
               
               
                 OC43 A/B 686/548 
                 YES 
                 OC43-Coronavirus 
                 Taq-Co43-270F 
                 TgT gCC TAT TgC ACC Agg AgT 
               
               
                   
               
               
                 Melapnuemo A/B 718/654 
                 YES 
                 Melapneumovirus 
                 MPV01.2 
                 AACCGTGTACTAAGTGATGCACTC 
               
               
                   
               
               
                 Mycoplasma - 1 A/B 602/614 
                 YES 
                 Mycoplasma1 
                 MTPM1 
                 CCAACCAAACAACAACGTTCA 
               
               
                   
               
               
                   
                   
                 Mycoplasma2 
                 MpnA 
                 CCGCGAAGAGCAATGAAAAACTCC 
               
               
                   
               
               
                 HPIV1 A/B 566/357 
                 YES 
                 Parainfluenza 1 
                 HPIV1-U82 
                 TACTTTTGACACATTTAGTTCCAGGAG 
               
               
                   
               
               
                 HPIV2 A/B 566/357 
                 YES 
                 Parainfluenza 2 
                 HPIV2-U908 
                 GGACTTGGAACAAGATGGCCT 
               
               
                   
               
               
                 HPIV3 A/B 566/357 
                 YES 
                 Parainfluenza 3 
                 HPIV3-U590 
                 GCTTTCAGACAAGATGGAACAGTG 
               
               
                   
               
               
                 Legionella 1 A/B 678/582 
                 YES 
                 Legionella1 
                 Legpneu-U149 
                 GCATWGATGTTARTCCGGAAGCA 
               
               
                   
               
               
                   
                 YES 
                 Legionella2 
                 LGPM1 
                 AAA GGC ATG CAA GAC GCT ATG 
               
               
                   
               
               
                   
                   
                 Legionella3 
                 LgnA 
                 GGCGACTATAGCGATTTGGAA 
               
               
                   
               
               
                 Chlamydia A/B 519/383 
                 YES 
                 Chlamydia pneumoniae 
                 CLPM1 
                 CAT GGT GTC ATT CGC CAA GT 
               
               
                   
               
               
                 FluHA1 A/B 650/590 
                 YES 
                 HA1 
                 HA1-U583 
                 GGTGTTCATCACCCGTCTAACAT 
               
               
                   
               
               
                 FluHA2 A/B 662/539 
                 YES 
                 HA2 
                 H2A208U27 
                 GCTATGCAAACTAAACGGAATYCCTCC 
               
               
                   
               
               
                 FluHA3-1 A/B 586/475 
                 YES 
                 HA3 
                 HA3-U115 
                 GCTACTGAGCTGGTTCAGAGTTC 
               
               
                   
               
               
                 FluHA3-2 A/B 586/475 
                 YES 
                 HA3 
                 HA3-U115 
                 GCTACTGAGCTGGTTCAGAGTTC 
               
               
                   
               
               
                 FluHA5 A/B 646/395 
                 YES 
                 HA5-human 
                 HA5human-u71 
                 TTACTGTTACACATGCCCAAGACA 
               
               
                   
               
               
                   
               
            
           
           
               
               
               
               
               
               
               
            
               
                   
                   
                   
                   
                 Tm 
                 Product 
                   
               
               
                 Tagged Pairs 
                 Tm primer 
                 Name REV 
                 Reverse-B 
                 primer 
                 Size 
               
               
                   
               
            
           
           
               
               
               
               
               
               
               
            
               
                 RSVA-1A/B 467/455 
                 62 
                 RSV-L1192 
                 GCACATCATAATTAGGAGTATCAAT 
                 56 
                 80 
                   
               
               
                   
               
               
                   
                 63 
                 rsh1ce.la-1013R 
                 GCCAGCAGCATTGCCTAATAC 
                 62 
                 240 
               
               
                   
               
               
                   
                 63 
                 RSHP1.la-540R 
                 CTCTTAAACCAACCATGGCATCTC 
                 63 
                 320 
               
               
                   
               
               
                 RSVB-1A/B 483/479 
                 62 
                 RSV-1318 
                 TGATATCCAGCATCTTTAAGTATCTTTATAGTG 
                 62 
                 105 
               
               
                   
               
               
                   
                 62 
                 rshbcnp.fa-913R 
                 TCTCCTCCCAACTTCTGTGCA 
                 63 
                 180 
               
               
                   
               
               
                   
                 63 
                 RSHPQ.fa-295R 
                 GGGGTGAGATCTTCTTTGAAGCT 
                 62 
                 120 
               
               
                   
               
               
                 FluA-N1 A/B 499/439 
                 61 
                 NA1-L1352 
                 AATGCTGCTCCCACTAGTCCAG 
                 63 
                 274 
               
               
                   
               
               
                 FluA-N2 A/B 658/730 
                 64 
                 NA2-L858 
                 ACCAGGATATCGAGGATAACAGGA 
                 62 
                 298 
               
               
                   
               
               
                 FLuA-M A/B 618/690 
                 63 
                 AM-L397 
                 AAGTGCACCAGCAGAATAACTCAG 
                 62 
                 246 
               
               
                   
               
               
                 FluB A/B 698/598 
                 63 
                 BHA-L347 
                 CTGTCGTGCATTATAGGAAAGCAC 
                 62 
                 159 
               
               
                   
               
               
                 SARS A/B 527/666 
                 62 
                 CIID-2910R 
                 AAg TCA gCC ATg TTC CCg AA 
                 63 
                 130 
               
               
                   
               
               
                 229E A/B 670/558 
                 64 
                 Taq-Co22.636R 
                 TAA gAg CCg CAg CAA CTg C 
                 63 
                 240 
               
               
                   
               
               
                 OC43 A/B 686/548 
                 63 
                 Taq-Co43-508R 
                 CCC gAT CgA CAA TgY CAg C 
                 63 
                 260 
               
               
                   
               
               
                 Melapnuemo A/B 718/654 
                 60 
                 MPV02.2 
                 CATTGTTTGACCGGCCCCCATAA 
                 68 
                 205 
               
               
                   
               
               
                 Mycoplasma - 1 A/B 602/614 
                 62 
                 MTPM2 
                 ACCTTGACTGGAGGCCGTTA 
                 62 
                 76 
               
               
                   
               
               
                   
                 60 
                 MpnB 
                 TCGAGGCGGATCATTTGGGGAGGT 
                 63 
                 380 
               
               
                   
               
               
                 HPIV1 A/B 566/357 
                 61 
                 HPIV1-L167 
                 CGGTACTTCTTTGACCAGGTATAATTG 
                 62 
                 110 
               
               
                   
               
               
                 HPIV2 A/B 566/357 
                 63 
                 HPIV2-L964 
                 AGCATGAGAGCYTTTAATTTCTGGA 
                 63 
                 102 
               
               
                   
               
               
                 HPIV3 A/B 566/357 
                 62 
                 HPIV3-L668 
                 GCATKATTGACCCAATCTGATCC 
                 63 
                 103 
               
               
                   
               
               
                 Legionella 1 A/B 678/582 
                 66 
                 LegPneu-L223 
                 CGGTTAAAGCCAATTGAGCG 
                 63 
                 79 
               
               
                   
               
               
                   
                 63 
                 LGPM2 
                 TGT TAA GAA CGT CTT TCA TTT GCT G 
                 62 
                 75 
               
               
                   
               
               
                   
                 56 
                 LgnB 
                 GCGATGACCTACTTTCGCATGA 
                 56 
                 100 
               
               
                   
               
               
                 Chlamydia A/B 519/383 
                 62 
                 CLPM2 
                 CGT GTC GTC CAG CCA TTT TA 
                 62 
                 85 
               
               
                   
               
               
                 FluHA1 A/B 650/590 
                 62 
                 HA1-L895 
                 GTGTTGACACTTCGCGTCACAT 
                 65 
                 312 
               
               
                   
               
               
                 FluHA2 A/B 662/539 
                 67 
                 H2A559L26 
                 TATTGTTGTACGATCCTTTGGCAACC 
                 66 
                 377 
               
               
                   
               
               
                 FluHA3-1 A/B 586/475 
                 60 
                 HA3-L375 
                 GAAGTCTTCATTGATAAACTCCAG 
                 56 
                 260 
               
               
                   
               
               
                 FluHA3-2 A/B 586/475 
                 60 
                 HA3-L380 
                 ATGCTGAGCCGACTCCAGTCC 
                 60 
                 265 
               
               
                   
               
               
                 FluHA5 A/B 646/395 
                 62 
                 HA5human-L147 
                 AGGyTTCACTCCATTTAGATCGCA 
                 64 
                 105 
               
               
                   
               
            
           
         
       
     
     
       
         
           
               
               
               
               
               
               
               
             
               
                 TABLE 12 
               
               
                   
               
               
                   
               
               
                   
                   
                   
                   
                 Previous 
                   
                   
               
               
                 Primer sequence 
                   
                 Name 
                 Target 
                 Masscode 
                 Panel 
               
               
                   
               
             
            
               
                   
               
            
           
           
               
               
               
               
               
               
               
            
               
                 TACAGCACGCTCAACACCAACGCCT 
                 25 
                 CMV-U421 
                 Citomegalovirus 
                   
                 Respiratory 
                   
               
               
                   
               
               
                 AACAGAAGGAAATGATGGTGGAAC 
                 24 
                 HPIV4A-U191 
                 HPIV4A 
                   
                 Respiratory 
               
               
                   
               
               
                 AGAAGAAAACAACGATGAGACAAGG 
                 25 
                 HPIV4B-U194 
                 HPIV4B 
                   
                 Respiratory 
               
               
                   
               
               
                 CAAGCATCATGATYGCCATTCCTGG 
                 25 
                 MEA-U1103 
                 Measles 
                   
                 Respiratory 
               
               
                   
               
               
                 ACGTGGATCGTCGGATCAGTTGT 
                 23 
                 VZV-U138 
                 VZV 
                   
                 Respiratory 
               
               
                   
               
               
                 TTCTTIGGAGCAGCIGGAAGCACIATGG 
                 28 
                 SK68i 
                 HIV1 
                   
                 Respiratory 
               
               
                   
               
               
                 GGCTGCACGCCCTATGATA 
                 18 
                 HIV2TMFPR2 
                 HIV2 
                   
                 Respiratory 
               
               
                   
               
               
                 AGCGATAGCTTTCTCCAAGTGG 
                 22 
                 SPPLY-U532 
                 Streptococcus pneumonie 
                   
                 Respiratory 
               
               
                   
               
               
                 AAGCTCCTTGMATTTTTTGTATTAGAA 
                 27 
                 HINF-U82 
                 Haemophilus influenza 
                   
                 Respiratory 
               
               
                   
               
               
                 CCCGGATGCGGTCCAGACGATTAT 
                 24 
                 HSV-U27 
                 Herpes Simplex 
                   
                 Respiratory 
               
               
                   
               
               
                 AAGTCCAAAGGCAGGRCTGTTATC 
                 24 
                 Mv-Can-U918 
                 Metaneumovirus Canadian 
                   
                 Respiratory 
               
               
                   
               
               
                 CCCMTTYAACCACCACCG 
                 18 
                 ADV2F-A 
                 Adenovirus 
                 Adenovirus2 
                 Respiratory 
               
               
                   
                   
                   
                   
                 503 
               
               
                   
               
               
                 TCCTCCGGCCCCTGAATGCGGCTAATCC 
                 28 
                 5UTR-U447 
                 Enterovirus 
                 EnteroVirus 
                 Respiratory 
               
               
                   
                   
                   
                   
                 702 
               
               
                   
               
               
                 TCCGGCCCCTGAATGCGGCTAATCC 
                 25 
                 5UTR-U450 
                 Enterovirus 
                 EnteroVirus 
                 Respiratory 
               
               
                   
                   
                   
                   
                 702 
               
               
                   
               
               
                 CCCCTGAATGCGGCTAATCC 
                 20 
                 5UTR-u457 
                 Enterovirus 
                 EnteroVirus 
                 Respiratory 
               
               
                   
                   
                   
                   
                 702 
               
               
                   
               
               
                 CCCGGCCTTCACCACCAACCGAAAA 
                 25 
                 CMV-L501 
                 Citomegalovirus 
                   
                 Respiratory 
               
               
                   
               
               
                 TGCTGTGGATGTATGGGCAG 
                 20 
                 HPIV4A-L269 
                 HPIV4a 
                   
                 Respiratory 
               
               
                   
               
               
                 GTTTCCCTGGTTCACTCTCTTCA 
                 23 
                 HPIV4B-L306 
                 HPIV4b 
                   
                 Respiratory 
               
               
                   
               
               
                 CCTGAATCYCTGCCTATGATGGGTTT 
                 26 
                 MEA-L1183 
                 Measles 
                   
                 Respiratory 
               
               
                   
               
               
                 TCGCTATGTGCTAAAACACGCGG 
                 23 
                 VZV-L196 
                 VZV 
                   
                 Respiratory 
               
               
                   
               
               
                 TTMATGCCCCAGACIGTIAGTTICAACA 
                 28 
                 SK69i 
                 HIV1 
                   
                 Respiratory 
               
               
                   
               
               
                 TCTGCATGGCTGCTTGATG 
                 18 
                 HIV2TMRPR2 
                 HIV2 
                   
                 Respiratory 
               
               
                   
               
               
                 CTTAGCCAACAAATCGTTTACCG 
                 23 
                 SPPLY-L606 
                 Streptococcus pneumonie 
                   
                 Respiratory 
               
               
                   
               
               
                 GCTGAATTGGCTTRGATACCGAG 
                 23 
                 Hinf-L158 
                 Haemophilus influenza 
                   
                 Respiratory 
               
               
                   
               
               
                 CCCGCGGAGGTTGTACAAAAAGCT 
                 24 
                 HSV-L121 
                 Herpes Simplex 
                   
                 Respiratory 
               
               
                   
               
               
                 CCTGAAGCATTRCCAAGAACAACAC 
                 25 
                 MV-Can-L992 
                 Metaneumovirus Canadian 
                   
                 Respiratory 
               
               
                   
               
               
                 ACATCCTTBCKGAAGTTCCA 
                 20 
                 ADV1R-A 
                 Adenovirus 
                 Adenovirus2 
                 Respiratory 
               
               
                   
                   
                   
                   
                 630 
               
               
                   
               
               
                 GAAACACGGWCACCCAAAGTASTCG 
                 25 
                 5UTR-L541 
                 Enterovirus 
                 EnteroVirus 
                 Respiratory 
               
               
                   
                   
                   
                   
                 495 
               
               
                   
               
               
                 AACACCGGGTCTTAATTCTTATATCAA 
                 27 
                 EboZa-U234 
                 Ebola Zaire 
                   
                 Hemorrhagic Fevers 
               
               
                   
               
               
                 TTCCGTCACAAGCCGAAATT 
                 20 
                 Mar-U292 
                 Marburg 
                   
                 Hemorrhagic Fevers 
               
               
                   
               
               
                 AGAACACGTGCCGCTTACGCCCA 
                 23 
                 CCHV-U4 
                 CCHV 
                   
                 Hemorrhagic Fevers 
               
               
                   
               
               
                 TCCCAAAGATGTTAGTGCCTGA 
                 22 
                 Sabia-U344 
                 Sabia 
                   
                 Hemorrhagic Fevers 
               
               
                   
               
               
                 CCACCCGTCACCTGAGAGACACAATT 
                 28 
                 Machupo-U212 
                 Machupo 
                   
                 Hemorrhagic Fevers 
               
               
                   
               
               
                 GCTGGGAGCGCGGTATC 
                 17 
                 YF-U186 
                 Yellow Fever 
                   
                 Hemorrhagic Fevers 
               
               
                   
               
               
                 GGATTGACCTGTGCCTGTTGC 
                 21 
                 RVF-U578 
                 Rift Valley fever 
                   
                 Hemorrhagic Fevers 
               
               
                   
               
               
                 TCTGAAGCCATTGGCCGT 
                 18 
                 Nmen-U829 
                 Neisseria meningitidis 
                   
                 Hemorrhagic Fevers 
               
               
                   
               
               
                 CRTATTATTAMTGGCTATAAATGTTGC 
                 27 
                 RSF-U255 
                 Rickettsia Spotted fever 
                   
                 Hemorrhagic Fevers 
               
               
                   
               
               
                 YACAATGACMGATGAGGTTGTRGC 
                 24 
                 Bburg-U896 
                 Borrelia burgdorferi 
                   
                 Hemorrhagic Fevers 
               
               
                   
               
               
                 GATGGAGGRTGCATCATGG 
                 18 
                 OMSK-U171 
                 OMSK 
                   
                 Hemorrhagic Fevers 
               
               
                   
               
               
                 AACTTAGGAGCTACCCAAAACAGC 
                 24 
                 CHKP-U68 
                 Chikungunya POL 
                   
                 Hemorrhagic Fevers 
               
               
                   
               
               
                 CAATGTCYTMGCCTGGACACCT 
                 23 
                 CHKE-U223 
                 Chikungunya ENV 
                   
                 Hemorrhagic Fevers 
               
               
                   
               
               
                 AYACAGCAGCAGTTAGCCTCCT 
                 22 
                 HAN-U179 
                 Hantaan 
                   
                 Hemorrhagic Fevers 
               
               
                   
               
               
                 ATGAARGCAGATGARATYACACC 
                 23 
                 DOB-U222 
                 Dobrava 
                   
                 Hemorrhagic Fevers 
               
               
                   
               
               
                 AAGGTGTTTTTGATCAGGCTAGAGA 
                 25 
                 TAC-U114 
                 Tacaribe 
                   
                 Hemorrhagic Fevers 
               
               
                   
               
               
                 GCCRTGTGARTGCCTRCTTCCATT 
                 24 
                 GUAV-U321 
                 Guanarito 
                   
                 Hemorrhagic Fevers 
               
               
                   
               
               
                 CAGGATTGCAGCAGGGAAGA 
                 20 
                 SEO-U243 
                 Seoul 
                   
                 Hemorrhagic Fevers 
               
               
                   
               
               
                 TGGAAGCCTGGCTGAAAGAG 
                 20 
                 KYF-U170 
                 Kyasanur forest 
                   
                 Hemorrhagic Fevers 
               
               
                   
               
               
                 TGACCTTYACMAATGAYTCCAT 
                 22 
                 LCMV-U47b 
                 LCMV 
                   
                 Hemorrhagic Fevers 
               
               
                   
               
               
                 GGTGGTAAAATTCCCATAGTAGTTCTTT 
                 28 
                 EboZA-L319 
                 Ebola Zaire 
                   
                 Hemorrhagic Fevers 
               
               
                   
               
               
                 TTATTTTAGTTGAGAAAAGAGGTTCATGC 
                 29 
                 Mar-L372 
                 Marburg 
                   
                 Hemorrhagic Fevers 
               
               
                   
               
               
                 CCATTCYTTYTTRAACTCYTCAAACCA 
                 27 
                 CCHV-L120 
                 CCHV 
                   
                 Hemorrhagic Fevers 
               
               
                   
               
               
                 CCTGCACTGACAATCGCTTG 
                 20 
                 SABIA-L424 
                 Sabia 
                   
                 Hemorrhagic Fevers 
               
               
                   
               
               
                 TGCAAGTCAAGCGAAAAGAGGGGATG 
                 26 
                 Machupo-L290 
                 Machupo 
                   
                 Hemorrhagic Fevers 
               
               
                   
               
               
                 GGAAGCCCAATGGTCCTCAT 
                 20 
                 YF-L249 
                 Yellow Fever 
                   
                 Hemorrhagic Fevers 
               
               
                   
               
               
                 GCATTAGAAATGTCCTCTTTTGCTGC 
                 26 
                 RVF-L660 
                 Rift Valley fever 
                   
                 Hemorrhagic Fevers 
               
               
                   
               
               
                 CAAACACACCACGCGCAT 
                 18 
                 Nmen-L892 
                 Neisseria meningitidis 
                   
                 Hemorrhagic Fevers 
               
               
                   
               
               
                 ACKRTTTAAAGTTAARCTTTTGCC 
                 24 
                 RSF-L394 
                 Rickettsia Spotted fever 
                   
                 Hemorrhagic Fevers 
               
               
                   
               
               
                 GCAATGACAAAACATATTGRGGAASTTGA 
                 29 
                 Bburg-L977 
                 Borrelia burgdorferi 
                   
                 Hemorrhagic Fevers 
               
               
                   
               
               
                 TGACCACTTGGCCTGATCC 
                 19 
                 OMSK-L234 
                 OMSK 
                   
                 Hemorrhagic Fevers 
               
               
                   
               
               
                 GGACGGTACAGGCGCTTCTG 
                 19 
                 CHKP-L132 
                 Chikungunya POL 
                   
                 Hemorrhagic Fevers 
               
               
                   
               
               
                 TCRCCAAATTGTCCTGGTCTTCCTG 
                 25 
                 CHKE-L310 
                 Chikungunya ENV 
                   
                 Hemorrhagic Fevers 
               
               
                   
               
               
                 GCTGCCGTARGTAGTCCCTGTT 
                 22 
                 HAN-L245 
                 Hantaan 
                   
                 Hemorrhagic Fevers 
               
               
                   
               
               
                 CCTGRGCTGGRTATARTCCACA 
                 22 
                 DOB-L289 
                 Dobrava 
                   
                 Hemorrhagic Fevers 
               
               
                   
               
               
                 CCATCCTTGATGGTGGTAACATG 
                 23 
                 TAC-L192 
                 Tacaribe 
                   
                 Hemorrhagic Fevers 
               
               
                   
               
               
                 TATGTRCACTGYTTCAGAAAACCTCA 
                 26 
                 GUA-L265 
                 Guanarito 
                   
                 Hemorrhagic Fevers 
               
               
                   
               
               
                 ATGATCACCAGGYTCTACCCC 
                 21 
                 SEOUL-L309 
                 Seoul 
                   
                 Hemorrhagic Fevers 
               
               
                   
               
               
                 TCATCCCCACTGACCAGCAT 
                 20 
                 KYF-L233 
                 Kyassanur forest 
                   
                 Hemorrhagic Fevers 
               
               
                   
               
               
                 TATRCTCATGAGTGTGTGGTCAA 
                 23 
                 LCMV-L142a 
                 LCMV 
                 Same than 
                 Hemorrhagic Fevers 
               
               
                   
                   
                   
                   
                 below 
               
               
                   
               
               
                 TATRCTCATAAGTGTGTGATCAA 
                 23 
                 LCMV-L142b 
                 LCMV 
                 Same than 
                 Hemorrhagic Fevers 
               
               
                   
                 1598 
                   
                   
                 above 
               
               
                   
               
            
           
         
       
     
     Example 7  
      Efficient laboratory diagnosis of infectious diseases is increasingly important to clinical management and public health. Methods to directly detect nucleic acids of microbial pathogens in clinical specimens are rapid, sensitive, and may succeed when culturing the organism fails. Clinical syndromes are infrequently specific for single pathogens; thus, assays are needed that allow multiple agents to be simultaneously considered. Current multiplex assays employ gel-based formats in which products are distinguished by size, fluorescent reporter dyes that vary in color, or secondary enzyme hybridization assays. Gel-based assays are reported that detect 2-8 different targets with sensitivities of 2-100 PFU or less than 1-5 PFU, depending on whether amplification is carried out in a single or nested format, respectively (1-4). Fluorescence reporter systems achieve quantitative detection with sensitivity similar to that of nested amplification; however, their capacity to simultaneously query multiple targets is limited to the number of fluorescent emission peaks that can be unequivocally resolved. At present, up to 4 fluorescent reporter dyes can be detected simultaneously (5,6). Multiplex detection of up to 9 pathogens has been achieved in hybridization enzyme systems; however, the method requires cumbersome postamplification processing (7).  
      Experimental Results  
      To address the need for sensitive multiplex assays in diagnostic molecular microbiology, we created a polymerase chain reaction (PCR) platform in which microbial gene targets are coded by a library of 64 distinct Masscode tags (Qiagen Masscode technology, Qiagen, Hilden, Germany). A schematic representation of this approach is shown in  FIG. 22 . Microbial nucleic acids (RNA, DNA, or both) are amplified by multiplex reverse transcription (RT)-PCR using primers labeled by a photocleavable link to molecular tags of different molecular weight. After removing unincorporated primers, tags are released by UV irradiation and analyzed by mass spectrometry. The identity of the microbe in the clinical sample is determined by its cognate tags. As a first test of this technology, we focused on respiratory disease because differential diagnosis is a common clinical challenge, with implications for outbreak control and individual case management. Multiplex primer sets were designed to identify up to 22 respiratory pathogens in a single Mass Tag PCR reaction; sensitivity was established by using synthetic DNA and RNA standards as well as titered viral stocks; the utility of Mass Tag PCR was determined in blinded analysis of previously diagnosed clinical specimens. Oligonucleotide primers were designed in conserved genomic regions to detect the broadest number of members for a given pathogen species by efficiently amplifying a 50- to 300-bp product. In some instances, we selected established primer sets; in others, we used a software program designed to cull sequence information from GenBank, perform multiple alignments, and maximize multiplex performance by selecting primers with uniform melting temperatures and minimal cross-hybridization potential (Appendix Table, available at http://www.cdc. gov/ncidod/eid/vol11no02/04-0492_app.htm). Primers, synthesized with a 5′C6 spacer and aminohexyl modification, were covalently conjugated by a photocleavable link to Masscode tags (Qiagen Masscode technology) (8,9). Masscode tags have a modular structure, including a tetrafluorophenyl ester for tag conjugation to primary amines; an o-nitrobenzyl photolabile linker for photoredox cleavage of the tag from the analyte; a mass spectrometry sensitivity enhancer, which improves the efficiency of atmospheric pressure chemical ionization of the cleaved tag; and a variable mass unit for variation of the cleaved tag mass (8,10-12). A library of 64 different tags has been established. Forward and reverse primers in individual primer sets are labeled with distinct molecular weight tags. Thus, amplification of a microbial gene target produces a dual signal that allows assessment of specificity. Gene target standards were cloned by PCR into pCR2.1-TOPO (Invitrogen, Carlsbad, Calif., USA) by using DNA template (bacterial and DNA viral targets) or cDNA template (RNA viral targets) obtained by reverse transcription of extracts from infected cultured cells or by assembly of overlapping synthetic polynucleotides. Assays were initially established by using plasmid standards diluted in 2.5-μg/mL human placenta DNA (Sigma, St. Louis, Mo., USA) and subjected to PCR amplification with a multiplex PCR kit (Qiagen), primers at 0.5 μmol/L each, and the following cycling protocol: an annealing step with a temperature reduction in 1° C. increments from 65° C. to 51° C. during the first 15 cycles and then continuing with a cycling profile of 94° C. for 20 s, 50° C. for 20 s, and 72° C. for 30 s in an MJ PTC200 thermal cycler (MJ Research, Waltham, Mass., USA). Amplification products were separated from unused primers by using QIAquick 96 PCR purification cartridges (Qiagen, with modified binding and wash buffers). Masscode tags were decoupled from amplified products through UV light-induced photolysis in a flow cell and analyzed in a single quadrapole mass spectrometer using positive-mode atmospheric pressure chemical ionization (Agilent Technologies, Palo Alto, Calif., USA). A detection threshold of 100 DNA copies was determined for 19 of 22 cloned targets by using a 22-plex assay (Table 1). Many respiratory pathogens have RNA genomes; thus, where indicated, assay sensitivity was determined by using synthetic RNA standards or RNA extracts of viral stocks. Synthetic RNA standards were generated by using T7 polymerase and linearized plasmid DNA. After quantitation by UV spectrometry, RNA was serially diluted in 2.5-μg/mL yeast tRNA (Sigma), reverse transcribed with random hexamers by using Superscript II (Invitrogen, Carlsbad, Calif., USA), and used as template for Mass Tag PCR. As anticipated, sensitivity was reduced by the use of RNA instead of DNA templates (Table 15).  
                           TABLE 15                                       Detection threshold           Pathogen or protein   (DNA copies/RNA copies)                          Influenza A matrix     100/1,000           Influenza A N1     100/NA           Influenza A N2     100/NA           Influenza A H1     100/NA           Influenza A H2     100/NA           Influenza A H3     100/NA           Influenza A H5     100/NA           Influenza B H     500/1,000           RSV group A     100/1,000           RSV group B     100/500           Metapneumovirus     100/1,000           CoV-SARS     100/500           CoV-OC43     100/500           CoV-229E     100/500           HPIV-1     100/1,000           HPIV-2     100/1,000           HPIV-3     100/500             Chlamydia pneumoniae       100/NA             Mycoplasma pneumoniae       100/NA             Legionella pneumophila       100/NA           Enterovirus (genus)     500/1,000           Adenovirus (genus)   5,000/NA                         *NA, not assessed;                RSV, respiratory syncytial virus;                CoV, coronavirus;                SARS, severe acute respiratory syndrome;                HPIV, human parainfluenza virus.             
 
      The sensitivity of Mass Tag PCR to detect live virus was tested by using RNA extracted from serial dilutions of titered stocks of coronaviruses (severe acute respiratory syndrome [SARS] and OC43) and parainfluenzaviruses (HPIV 2 and 3). A 100-μL volume of each dilution was analyzed. RNA extracted from a 1-TCID50/mL dilution, representing 0.025 TCID50 per PCR reaction, was consistently positive in Mass Tag PCR. RNA extracted from banked sputum, nasal swabs, and pulmonary washes of persons with respiratory infection was tested by using an assay panel comprising 30 gene targets that represented 22 respiratory pathogens. Infection in each of these persons had been previously diagnosed through virus isolation, conventional nested RT-PCR, or both. Reverse transcription was performed using random hexamers, and Mass Tag PCR results were consistent in all cases with the established diagnosis. Infections with respiratory syncytial virus, human parainfluenza virus, SARS coronavirus, adenovirus, enterovirus, metapneumovirus, and influenza virus were correctly identified (Table 16 and  FIG. 23 ).  
                           TABLE 16                                   Pathogen   No. positive/no. tested†                          RSV A   2/2           RSV B   3/3           HPIV-1   1/1           HPIV-3   2/2           HPIV-4   2/2           CoV-SARS   4/4           Metapneumovirus   2/3           Influenza B   1/3           Influenza A   2/6           Adenovirus   2/2           Enterovirus   2/2                         *RSV, respiratory syncytial virus;                HPIV, human parainfluenza virus;                CoV, coronavirus;                SARS, severe acute respiratory syndrome.                †No. positive and consistent with previous diagnosis/number tested (with respective previous diagnosis).             
 
      A panel comprising gene targets representing 17 pathogens related to central nervous system infectious disease (influenza A virus matrix gene; influenza B virus; human coronaviruses 229E, OC43, and SARS; enterovirus; adenovirus; human herpesvirus-1 and -3; West Nile virus; St. Louis encephalitis virus; measles virus; HIV-1 and -2; and  Streptococcus pneumoniae, Haemophilus influenzae , and  Nesseria meningitidis ) was applied to RNA obtained from banked samples of cerebrospinal fluid and brain tissue that had been previously characterized by conventional diagnostic RT-PCR. Two of 3 cases of West Nile virus encephalitis were correctly identified. Eleven of 12 cases of enteroviral meningitis were detected representing serotypes CV-B2, CV-B3, CV-B5, E-6, E-11, E-13, E-18, and E-30 (data not shown).  
     CONCLUSIONS  
      Our results indicate that Mass Tag PCR is a sensitive and specific tool for molecular characterization of microflora. The advantage of Mass Tag PCR is its capacity for multiplex analysis. Although the use of degenerate primers (e.g., enteroviruses and adenoviruses, and Table 16) may reduce sensitivity, the limit of multiplexing to detect specific targets will likely be defined by the maximal primer concentration that can be accommodated in a PCR mix. Analysis requires the purification of product from unincorporated primers and mass spectroscopy. Although these steps are now performed manually, and mass spectrometers are not yet widely distributed in clinical laboratories, the increasing popularity of mass spectrometry in biomedical sciences and the advent of smaller, lower-cost instruments could facilitate wider use additional pathogen panels, our continuing work is focused on optimizing multiplexing, sensitivity, and throughput. Potential applications include differential diagnosis of infectious diseases, blood product surveillance, forensic microbiology, and biodefense.