Herpesvirus, Poxvirus, Rhabdovirus, Arenavirus DANILO D. DEVEZA JR., M.D.

1. HERPES SIMPLEX VIRUS (HSV)

Mode of transmission HSV 1: saliva HSV 2: sexually/ maternal genital infections Growth cycle: 8 6 hours Viral glycoproteins gD: most potent inducer of neutralizing antibodies gC: complement (C3b)-binding protein gE: Fc receptor, binding Fc portion of IgG gG: type-specific, allows antigenic discrimination between HSV-1 (gG-1), HSV-2 (gG-2)

1.Herpes Simplex Virus 2.Varicella Zoster Virus 3.Cytomegalovirus 4.Epstein Barr Virus 5.Human Herpes Virus 6, 7 & 8 HEPESVIRUSES Double stranded DNA virus Establish latent infections Persist indefinitely in infected hosts Reactivated in immunosuppressed hosts Some cause cancer

LATENT INFECTION Virus resides in ganglia in a nonreplicating state Last for the lifetime of the host Provocative stimuli can reactivate infection Most are asymptomatic (viral shedding) Symptomatic episodes (HSV 1): cold sores 80% harbor HSV 1 in latent form CLINICAL FINDINGS 1. Oropharyngeal Diseases (Primary Infection) Involves children (1-5 yrs old) Incubation : 2-12 days Clinical Illness: 2-3 weeks Vesicular & ulcerative lesions in buccal & gingival mucosa Gingivitis: most striking lesion Adults: pharyngitis & tonsillitis 2. Oropharyngeal Disease (Recurrent Disease) Clusters of vesicles at border of lip Intense pain Lesions progress to pustular & crusting stages Healing w/o scarring in 8-10 days Lesions may recur, repeatedly in the same location Keratoconjunctivitis HSV 1 Recurrent lesions: dendritic keratitis, corneal ulcers, vesicles in eyelids May have permanent blindness Genital Herpes (Primary Infection) HSV 2, HSV 1 occasional Can be severe lasting for 3 weeks Vesiculoulcerative lesions in penis, cervix, vulva, vagina & perineum Viral excretion for 3 weeks

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Antigenic cross reactivity between HSV 1 & 2

Genital Herpes ( Recurrent Illness) Common but mild Limited lesion, heal in 10 days Some are asymptomatic Person shedding virus can transmit virus sexually Skin Infections Intact skin is resistant Traumatic herpes: infected thru broken skin Herpetic whitlow: lesions on fingers of hospital personnel Herpetic gladiatorium/ mat herpes: body of wrestlers Eczema Herpeticum: with eczema or burns, extensive local viral replication Encephalitis HSV 1: most common cause of sporadic & fatal encephalitis in US High mortality rate Can be caused by primary and recurrent infection Neonatal Herpes Acquired in utero, during birth process, during neonatal period( 75% transmitted thru contact in infected birth canal) Almost always SYMPTOMATIC Lesions localized to eyes, mouth, skin Encephalitis with or without skin involvement Disseminated disease involving multiple organs, including CNS Survivors left with permanent neurologic impairment

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PATHOLOGY Necrosis of infected cells with inflammation Same lesions: HSV 1 & HSV 2 HISTOPATHOLOGIC CHANGES Ballooning of infected cells Production of Cowdry type A intranuclear inclusion bodies Margination of chromatin Formation of multinucleated giant cells PRIMARY INFECTION Mucosa or broken skin HSV 1: limited to oropharynx Replicates first at site of infection Invades local nerve endings Transported by retrograde axonal flow Latency is established Mild, usually asymptomatic Viremia more common in primary HSV 2 HSV 1: latent infections in trigeminal nerve HSV 2: latent infections in sacral ganglia

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LABORATORY DIAGNOSIS Isolation in cell culture Multinucleated giant cells Monoclonal antibody or restriction endonuclease (for epidemiologic studies) Immunological and molecular tests PCR

Zoster (Recurrent Infection) Skin lesions same as varicella Acute inflammation of sensory nerves Only a single ganglion is involved Virus travels to nerves to the skin Latent infection trigger: unclear Cell mediated immunity: most important host defence

DIAGNOSIS Tzanck smear Multinucleated giant cells Immunofluorescence Intracellular viral antigen Viral culture Cultures of human cells from vesicle fluid FAT, latex agglutination, TREATMENT Oral acyclovir Not recommended in healthy children Decrease in symptoms if given within 24h May be considered in people at increased risk of moderate to severe varicella < 12 years of age Chronic cutaneous or pulmonary disorders Long-term salicylate therapy Short courses of corticosteroids IV acyclovir Immunocompromised patients Patients treated with chronic corticosteroids Famciclovir, Valacyclovir

3. CYTOMEGALOVIRUS
Largest genetic content of the HHV Species-specific and cell-type specific Replicates in vitro only in human fibroblast Produces a characteristic cytopathic effect

2. VARICELLA ZOSTER VIRUS

Morphologically identical to HSV No animal reservoir Virus propagates in human embryonic tissue & produces typical intranuclear inclusion bodies

CLINICAL FINDINGS Varicella Incubation period: 10 - 21 days Malaise & fever first symptoms Rash: first on trunks, face, limbs, mouth Vesicles, macules and papules at one time Rash last for 5 days Complications: Bacterial superinfection, pneumonia, encephalitis, congenital varicella Zoster Occurs in immunocompromised persons Starts with severe pain in skin/ mucosa supplied by 1 or more groups of sensory ganglia A few days: vesicle appear over the skin Trunk, head & neck: most commonly affected Most common complication in elderly: post herpetic neuralgia

PATHOGENESIS Person-to-person Incubation period: 4 - 8 weeks Systemic infection Immunosuppresed Host Greater risks: organ transplant, with malignant tumors receiving chemotherapy, AIDS patients Congenital and Perinatal Developmental defects and mental retardation Transmitted in utero, during delivery, and from maternal breast milk 1/3 of pregnant women with primary infection transmits the virus

PATHOGENESIS & PATHOLOGY Varicella (Primary Infection) Route: upper respiratory tract & conjunctiva Replication in lymph nodes Primary viremia spreads virus Replication in liver & spleen Secondary viremia transports virus to skin Vesicles: swelling of epithelial cells, ballooning degeneration, & accumulation of tissue fluids

IMMUNITY Previous infection believed to concur lifelong immunity to varicella Varicella vaccine: antibodies for 20 years

PREVENTION Varicella vaccine 12months - 12 years : 1 dose > 13 years: 2 doses at least 4 weeks apart 95% effective in preventing severe disease Median of fewer than 50 vesicles Lower rate of fever Faster recovery Post-exposure prophylaxis Vaccine should be given within 72h up to 120h (3 5 days)

CLINICAL FINDINGS In a normal host May be asymptomatic Occasionally infectiousmononucleosis syndrome Hepatosplenomegaly : <7 years old Restenosis Lymphocytosis Immunocompromised hosts Pnuemonia Virus-associated leukopenia Obliterative bronchiolitis Graft atherosclerosis Renal allograft rejection Gastroenteritis Chorioretinitis (often leading to blindness)

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CLINICAL FINDINGS Congenital and Perinatal infection Fetal death, IUGR, jaundice, hepatosplenomegaly, thrombocytopenia, microcephaly, retinitis, isolated pneumonia Mortality rate: 30% Survivors CNS defects severe hearing loss (10%) ocular abnormalities mental retardation LABORATORY DIAGNOSIS PCR and Antigen Detection assay Isolation of Virus Serology TREATMENT & PREVENTION Ganciclovir, Foscarnet, Acyclovir, Valacyclovir Isolation of newborns Screening of transplant donors

Cross-linking cell surface immunoglobulin

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Low-grade fever and malaise may persist for weeks to months TUMORS Burkitts lymphoma, nasopharyngeal CA, Hodgkins dse Complication for immunodeficient patients

VIRAL ANTIGENS Latent phase antigens EBNAs and LMPs Early antigens Non-structural proteins not dependent on viral DNA replication Indicates the onset of productive viral replication Late antigens Structural components of viral capsid (viral capsid Ag) and viral envelope (glycoproteins) Produced abundantly in cells undergoing productive viral replication EPIDEMIOLOGY EBV persists in the population through sporadic shedding via the oropharynx into saliva (Kissings disease) Infections occur early in life, >90% of children are infected by age 6 During adolescence usually results in infectious mononucleosis 90 % of adults have antibodies to EBV PATHOGENESIS & PATHOLOGY 1. PRIMARY INFECTION Usually subclinical Acute infectious mononucleosis Latently infected lymphocytes may persist REACTIVATION Immunosuppresion Usually clinically silent CLINICAL FINDINGS Infectious mononucleosis Incubation period: 30-50 days Self-limiting lasts 2-4 weeks Enlarged lymph nodes and spleen are characteristics Increased WBC count predominantly lymphocytes

EPIDEMIOLOGY Ubiquitous in the human population, 90-100% of healthy adults have IgG antibodies Children are primarily infected between 6 months and 2 years of age Adults rarely present with primary infection PRIMARY INFECTION Causes Sixth Disease or Exanthem Subitum (Roseola) in children Benign disease Fever, rash Complications include febrile convulsions 60-70% of infections are unapparent Serious complications of primary infections Hepatitis, fatal fulminant hepatitis Meningitis and encephalitis Infectious mononucleosis-like syndrome has been reported in adults and children

CLINICAL FINDINGS Oral hairy leukoplakia o Epithelial focus of EBV replication Nasopharyngeal carcinoma o Common in males of Chinese origin Burkitts lymphoma o contains EBV DNA and express EBNA 1 antigen Lymphoproliferative diseases o Polyclonal/monoclonal B cell proliferation LABORATORY DIAGNOSIS Isolation and identification of virus Nucleic acid hybridization Serology ELISA test, immunoblot assays, indirect IF Heterophil agglutination test PREVENTION No EBV vaccine available TREATMENT Acyclovir

4. EPSTEIN-BARR VIRUS
2 types : EBV 1 , EBV 2 Based on latency nuclear antigen genes EBNAs, EBERs B lymphocyte : major target cell Initiates infection of B cells by binding to viral receptors (CR2 or CD21) Enters latent state without undergoing complete viral replication Hallmarks of latency Viral persistence Restricted virus expression Potential for reactivation and lytic replication Replicates thru a variety of stimuli Chemical inducing agents

RECURRENT INFECTION Reactivation has been demonstrated in renal, liver and bone marrow transplant recipients Role in post-transplantation disease has not been well defined Serious disease reported in BMT recipients, with interstitial pneumonia, fatal encephalitis and marrow suppression CHRONIC DISEASE May cause various collagen vascular diseases Role in chronic fatigue syndrome Possible cause of serious CNS disease such as multiple sclerosis

5. HUMAN HERPESVIRUS 6
Grows predominantly in activated lymphocytes Genetic similarity and growth cycle to CMV led to classification as a betaherpesvirus Two variants of HHV-6 have been identified on basis of genetic and biological properties (variants A and B)

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DIAGNOSIS of HPV6 Clinically confused with other febrile syndromes involving rash (measles, rubella, parvovirus, echovirus) Children: most effective diagnosis Isolation of HHV-6 from PBMC during the symptomatic phase Together with seroconversion For reactivated infections in immunocompromised adults May be isolated from PBMC and detected in serum by PCR CNS disease may be diagnosed by the detection of HHV-6 DNA in the CSF

Closely associated with KS, but now shown to be more widespread Found in biopsies of body cavity lymphomas (Castlemans Disease) Castlemans disease is a rare B cell lympho-proliferative disorder related to excess IL-6 activity Diagnosis by PCR using specific primers

1. Orthomyxovirus
1.1. VACCINA & VARIOLA
CONTROL & ERADICATION OF SMALLPOX First viral disease eradicated (1980) Success due to Vaccine was easily prepared, stable & safe Could be given by any personnel Mass vaccination was not necessary VACCINA
Broad host range Used for smallpox vaccine Localized lesions Some stains can cause severe disease Variola: progression from day 1 - 7

1. Orthomyxovirus Variola, Vaccina Monkeypox Cowpox 2. Parapoxvirus Orf, Bovine papular stomatitis 3. Mulluscipoxvirus Molluscum contagiosum 4. Yatapoxvirus Tanapox, Yabapox Virion: oval or brick shape, external surface has ridges; contains core & lateral bodies Genome: Double Stranded DNA Replication: Cytoplasmic factories Characteristics: o Largest & most complex virus o Very resistant to inactivation

VARIOLA
Narrow host range (humans & monkeys) Systemic infection Vaccina: localized lesion

LABORATORY DIAGNOSIS 1. Histopathology Skin: proliferation of prickle cell layer Cytoplasmic inclusions Infiltration with mononuclear cells Ballooning degeneration of cytoplasm All layers are involved 2. PCR related methods for DNA identification, (e.g., real-time PCR) 3. Electron microscopy 4. Culture 5. Serology Antigen detection (IFA, EIA ag capture) IgM capture Neutralization antibodies IgG ELISA TREATMENT Vaccinia immune globulin recommended treatment for all complications except postvaccinial encephalitis Methisazone effective as prophylaxis but is not useful as treatment Cidofovir shows activity against poxvirus in vitro

HUMAN HERPESVIRUS 7
First isolated from a healthy adult in 1992 Frequently isolated from the saliva of most healthy adults Shown to be distinct from other herpesviruses including HHV-6 Act as a helper virus for HHV-6 reactivation in vitro. 80-85% of healthy adults have antibodies to HHV-7 There is no clear evidence for the involvement in human disease Isolated from a patient with Roseola

HUMAN HERPESVIRUS 8
First detected in 1995 in Kaposi sarcoma biopsies from AIDS patients DNA sequences detected by differential PCR Virus was not isolated or visualized Genome sequence analysis identified a new herpesvirus classified as a gammaherpesvirus Contains a pirated oncogenic clusterof cellular genes

PATHOGENESIS & PATHOLOGY OF SMALLPOX Entry of variola: upper respiratory tract Primary multiplication in lymphoid tissue Transient viremia & infection of reticuloendothelial cells Secondary phase of multiplication in those cells Secondary, more intense viremia Clinical disease CLINICAL FINDINGS (VARIOLA SMALLPOX) Incubation period: 10 14 days 1 5 days of fever & malaise Macules papules vesicles pustules Form crust that fell after 2 weeks pink scars Lesions at the same stage in a time Lesions most abundant in the face Fatality rate: 5 40%

1.2. MONKEYPOX INFECTION

Species of Orthopoxvirus First recognized in monkeys Rare zoonosis Acquired by direct contact with infected animals Not easily transmitted from person to person

CLASSIFICATION Two subfamilies Infect vertebrate Insect host Cause human diseases Orthomyxovirus (Variola, Vaccina, Monkeypox, Cowpox) Parapoxvirus (Orf, Bovine papular stomatitis) Mulluscipoxvirus (Molluscum contagiosum) Yatapoxvirus (Tanapox, Yabapox)

CLINICAL FINDINGS Similar to smallpox Cropping of rash occur in some patient: diagnostic problem with chickenpox Pronounced lymphadenopathy: not seen in smallpox & chickenpox Complications are common & serious

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Pulmonary distress & 2o bacterial infections Vaccination with vaccina Protect against monkeypox or lessen the severity

3. Mulluscipoxvirus
MOLLUSCUM CONTAGIOSUM
Molluscipoxvirus Benign epidermal tumor, occurs only in humans Not transmitted to animals Typically affects children, but can be transmitted sexually in adults Antibodies does not cross-react with ant poxvirus Not been grown in tissue culture

1.3. COWPOX INFECTION

Orthopoxvirus Occurs by direct contact Reservoir: Rodents Human & cattle: accidental hosts

EPIDEMIOLOGY (Rabies) Most important viral zoonosis 50,000 cases each year 10th among the major killer diseases All deaths in developing countries 90% in Asia Children 5 15 years are at particular risk All warm blooded animals can be infected Susceptibility varies Very high: foxes, wolves Moderate: dogs Antigenic Property Single serotype Strain differences (epitopes in neucloprotein & glycoprotein) G glycoprotein: major factor in neuroivasiveness & pathogenicity

CLINICAL FINDINGS Hemorrhagic skin lesions, fever, malaise Similar to smallpox immunologically No treatment

2. Parapoxvirus
BUFFALOPOX & ORF VIRUS

Buffalopox

Derivative of vaccina Indistinguishable from cowpox Can be transmitted from human to human Localized pox lesions

Orf Virus
Parapoxvirus Disease in sheep & goats Contagious pustular dermatitis or sore mouth Transmitted by direct contact: skin trauma Single lesion on finger, hand or forearm, sometime in face or neck Lesions: large painful, nodule

CLINICAL FINDINGS Lesions begin as small papules, smooth, flesh-colored domes with a central dimple. Inside the papule is a white, curdlike core that can be easily expressed Occur anywhere on the skin and mucous membranes, Genitalia being the predominant site in adults Lesions are characteristically asymptomatic Incubation period: up to 6 months Lesions may itch, leading to autoinculation Lesions may persist up to 2 years Will regress spontaneously Poor immunogen: seccond attacks are common

PATHOGENICITY & PATHOLOGY (Rabies Infection) Rabies virus multiplies in muscles/ connective tissues at site of inoculation Enters peripheral nerves at NMJ and spreads to CNS Multiplies in CNS (encephalities) Virus spreads to tissues Highest titer in submaxillary salivary glands Not isolated from blood Susceptibility & incubation period Hosts age & immune status Viral strain Amount of inoculum &severity of laceration Distance the virus travel from point of entry to CNS Shorter incubation period in face or head Longer in the legs

CLINICAL FINDINGS (Rabies Infection) Incubation period: 1 - 2 months As short as 1 week As long as up to 19 years Three Phases Short prodromal phase Acute neurologic phase Coma

Single stranded RNA virus Rod or bullet shaped Wide array of viruses with broad host range Group includes rabies virus Family Rhabdoviridae Genus Lyssavirus Rabies virus Genus Vesiculovirus Stomatitis-like viruses Rabies only medically important Rhabdovirus

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CLINICAL FORMS (Rabies Infection) Encephalitic or Furious type Nonspecific symptoms Paresthesias at or near the site of bite Encephalitis, hydrophobia and aerophobia Death in 2-3 weeks after onset Paralytic or Dumb type Ascending motor weakness affecting both limbs and cranial nerves Some element of encephalopathy LABORATORY DIAGNOSIS Enlargement of a Negri body in Sellers stained brain tissue. Note the basophilic (dark blue granules in the inclusion). TREATMENT No successful treatment for clinical rabies Symptomatic treatment may prolong life, but outcome is always fatal PREVENTION & CONTROL Animal rabies control is the cornerstone of any rabies control program Dog vaccination Decrease incidence of dog rabies Decrease incidence of human rabies Decrease incidence of bites Anti-Rabies Act of 2007 Republic Act No. 9482 Provides free routine immunization of pre-exposure prophylaxis of school children aged 5 - 14 PREVENTION & CONTROL Pre-exposure prophylaxis benefits Need for passive immunization product (RIG) is eliminated PEP vacine regimen is reduced from 5 to 2 doses

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OLD WORLD VIRUSES Lassa virus Lymphocytic choriomeningitis virus NEW WORLD VIRUSES Junin virus: Argentine HF Machupo virus: Bolivian HF Guanarito virus: Venezuelan HF Sabia virus: Brazilian HF ARENAVIRUS Single-stranded RNA viruses Cause chronic infections in rodents Zoonotically acquired disease in humans through rodent excreta LASSA FEVER Endemic to West Africa Host: Mastomys natalensis Ability to spread from person to person Incubation period: 1 3 weeks Clinical Findings Very high fever, mouth ulcers, skin rashes w/ hemorrhages, pneumonia, heart & kidney damage & deafness Drug of choice: ribavarin

SOUTH AMERICAN HEMMORHAGIC FEVERS Members of Tacaribe complex Junin Machupo Guanarito Sabia JUNIN/ ARGENTINE HEMMORHAGIC FEVER Rodent reservoir: Calomys musculinus Produces both humoral & cell mediated immunodepression Death due to inability to initiate cell mediated immune response Self-limited neurologic symptoms Treatment & Prevention Convalescent human plasma Live attenuated vaccine MACHUPO/ BOLIVIAN HEMMORHAGIC FEVER Rodent reservoir: Calomys callosus Clinical Findings Bleeding Skin rash, petechiae Proteinuria Acute tubular necrosis in half of patients GUANARITO/ VENEZUELAN HEMMORHAGIC FEVER and SABIA/ BRAZILIAN HEMMORHAGIC FEVER Clinical disease same as Argentine HF

LYMPHOCYTIC CHORIOMENINGITIS Rodent reservoir: Mus Musculus No person to person spread Can be transmitted during pregnancy Lead to serious defects in fetus Clinical Findings Aseptic meningitis Mild systemic influenzalike illness

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