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Introduction to Virology.......................................................................................................................................................... 2
(+) RNA Viruses ....................................................................................................................................................................... 5
HIV (and retroviruses) ............................................................................................................................................................. 8
Small DNA Viruses: Parvoviruses & Papillomaviruses .......................................................................................................... 12
Influenza: Epidemics, Pandemics, and Prevention Strategies .............................................................................................. 15
Viral gastroenteritis............................................................................................................................................................... 18
Gammaherpesviruses: EBV / KSHV ....................................................................................................................................... 20
Viral Hepatitis........................................................................................................................................................................ 23
1
Introduction to Virology
History: “filterable agent” (not like bacteria); nucleic acid infectious, no binary 3 basic types of virus
fission, requires host, first described in 19th century (agriculture (TMV) 1. Bacteriophage
animals (foot/mouth) humans (yellow fever) 2. Animal/plant (DNA or RNA)
3. Retrovirius (RNADNARNA)
Virion: virus particle (viral nucleic acid + structural proteins)
Structural proteins = payload vehicle to deliver nucleic acids Properties of viruses
Example: alphavirus is enveloped, icosahedral
Small, infectious, obligate
Structural proteins: encoded by viral genome; packaged into virion (protective intracellular parasite
coat for nucleic acid) Genome: DNA or RNA
Protein capsid ± lipoprotein envelope (cell membrane of host cell) In host cell: genome
replicated, synthesis of other
Nonstructural proteins: encoded by viral genome, not packaged into virion virion components via host
Enzymes (polymerases, helicases, etc) or transcription factors systems, progeny assembled
Needed for viral replication in cell
Usually nonstructural proteins encoded 1st on genome (5’ end) because they’re needed for translation/transcription
Linear
Double stranded
Circular
Viruses evolve rapidly; produce large #s progeny; RNApol has no proofreading function (population = “quasispecies”)
Mutation
Recombination (two viruses in same cell, recombine)
Reassortment (2 viruses with segmented genomes in same cell, e.g. flu)
One step growth curves: takes a day or two, then kicks into gear. Many fold higher # organisms than bacteria
Viral replication cycle: attachment, penetration, uncoating, transcription of early mRNA/translation early proteins,
replication of viral DNA, transcription of late mRNA, translation of late proteins, assembly, release.
Receptor binding sites: can be depressions (picornavirus “canyons”) or projections (rotavirus “fibers”)
2
Neutralizing antibodies can bind to these receptor sites; block ability to interact with receptor (e.g. bind to
rhinovirus canyon)
Disease : can be at site of entry (e.g. HSV) or at distant target organs(Coxsackie virus, enters via GI tract myocarditis)
Time course of symptoms: due to local & systemic infection
Local: earlier onset of Sx, due to infection of body surface (e.g. cold)
Systemic: later onset of Sx, from immune response (e.g. measles)
Rabies, hepatitis can be weeks, others are pretty short
Immune response
Interferon:
1. dsRNA intermediate presence triggers Mϕ to synthesize & release IFN
2. IFN signals other cells via JAK-STAT pathway to induce antiviral protein genes (inhibit viral release /
products; ↑ MHC CLASS I EXPRESSION
3. Actually appears to control spread of virus before acquired immune response (acquired mops up,
allows for long-lasting immunity)
Antiviral Antibodies:
3
1. Serological tests: Dx (ELISA, radioimmunoassay, Westerns)
2. Biological activity: function of Ab?
Neutralizing (can’t cause productive infection). Effective immune response
1. Eliminate virus from blood/other
Can block attachment, endocytosis, uncoating.
C’ fixation (causes cell death) fluids (prevent further spread)
Hemagglutination inhibition (binds viruses 2. Eliminate virus-infected cells
together; can’t productively infect) from tissues (“cure infection”)
3. Roles of antibodies: protect against reinfection, clear 3. Immunity to re-infection
virus from fluids, downregulate intracellular virus replication (not completely understood)
MHC Class I:
1. Mouse experiment: cytotoxic t-cells only kill MHC-I matched virus-infected target cells
Cell-mediated immunity: focus immune response (target), clear infected cells, recruit other effector cells,
activate Mϕ , provide help for production of Ab by B cells
4
(+) RNA Viruses
Picornaviruses
Picornaviruses: Pico (small) RNA Viruses
Icosahedral Human picornaviruses
Receptor binds into canyon; neutralizing antibodies bind canyon too Rhinoviruses
Entry: endocytosis uncoating conformational change in acidified “Enteroviruses”
endosome extrusion of RNA into cytoplasm (injected) o Polioviruses
Plus-strand viruses: produce (-) strand intermediate in cytoplasm of cell o ECHO viruses
Replication: (+) RNA translated as single polyprotein; viral proteases o Enteroviruses 68-71
cleave into individual proteins o Coxsackie viruses A&B
Translation: have internal ribosomal entry site (IRES) in 5’UTR of RNA Hepatitis A virus
o IRES: RNA can bind directly to ribosome w/o 5’ 7-methyl cap or
cap-binding protein
Clinical presentation
Rhinoviruses: cause local upper respiratory disease (stay in resp. tract)
o Generally pediatric problem and nuisance
o Exception: asthma patients
Enteroviruses: systemic infection
o Fecal-oral transmission GI tract viremia (in blood)
o Can go to
o Skin (hand-foot-mouth disease): Rash: pustules on skin
o Muscle (echovirus, coxsackie A/B): myocarditis, pericarditis
o CNS: Brain (polio, coxsackie A&B), meninges (echo, polio, coxsackie)
Example: paralytic sequelae of poliovirus: limb atrophy
Poliovirus
Transmission: fecal-oral (land runoff, sewage, solid waste landfills)
5
Vaccines:
Sabin’s live virus vaccine helped reduce polio SALK VACCINE SABIN VACCINE
incidence big-time; wild polio eradicated (inactivated) (live virus)
o Advantages: spread immunity via shedding, Use Currently in US Not used in US
mucosal immunity, etc. Revertants to wt? No Yes (rare)
Problem: tendency to revert to virulence (rapid Administration Injected Sugar cube
emergence of mutations) Mucosal immunity? No Yes
o Vaccine-associated paralytic polio: couldn’t completely get rid of polio as a disease with Sabin’s vaccine
(all new polio cases due to live virus vaccine)
Switched to Salk’s inactivated virus vaccine (no more revertants)
Current problems:
1. importation of polio from endemic to polio-free areas
2. circulation of virulent vaccine-derived/recombinant viruses
3. prolonged excretion of vaccine viruses by immunodeficient individuals (e.g. AIDS pts)
Rubella
Respiratory transmission, worldwide distribution
Clinical presentation:
Children / adults: mild maculopapular rash
Congenital rubella syndrome (CRS):
o requires: maternal exposure, maternal blood invasion, placental Features of CRS:
infection, entry to baby’s blood, fetal infection 1. mental retardation
lack of any of these means the baby will be healthy. 2. heart defects
o Don’t see CRS if mom gets rubella after 17-18 wks gestation 3. cataracts
Flaviviruses
Mosquito-borne viruses (yellow fever, dengue, Japanese encephalitis, West Nile)
Tick-borne viruses
Hepatitis C too!
Transmission: birds are animal reservoir; humans infected incidentally via mosquito
West nile virus: spread really fast
appeared in 1999, across USA over 5 years, caused lots of human disease
now seems like more American birds have acquired immunity, human cases more sporadic
6
Coronaviruses
(+)-strand RNA virus, transcribed and then translated
o Uses subgenomic RNA (along with genomic RNA) as mRNA, like togaviruses
Morphology: looks like a crown
Cause common cold and severe acute respiratory syndrome (SARS), which has pretty much disappeared
Transmission Presentation
Picornaviruses Human (resp, fecal/oral) Variety: colds, polio, rashes
Togaviruses Human (resp) for rubella Rash, CRS
Mosquitos for alphaviruses encephalitis
Flaviviruses Mosquitos/ticks Fever, encephalitis
Coronaviruses Humans, ?animal for SARS Colds, SARS
7
HIV (and retroviruses)
History
AIDS: originally described as opportunistic infections in young adults: PCP pneumonia / oral candidiasis (1981)
Thought to be transmissible (epidemiology, hemophiliacs, epidemic in NYC & SF); HIV-1 discovered in 1983
HIV-1: 3 groups, from SIV (simian), cross-species transmission responsible (SIV doesn’t often cause disease in
natural hosts but does in humans animal model, use Asian macaques, which aren’t usual host causes dz)
o M group causing AIDS epidemic currently
o (33M+ living with AIDS, 2.7M new each year, 2.0M deaths each year)
HIV-2: SIV from West Africa, more slowly progressive, not as widespread as HIV-1
Retroviruses
Enveloped, small genome (10kb), (+) ssRNA
ssRNA capped, polyadenylated like host mRNA Retrovirus genes:
Has reverse transcriptase & can integrate into host cell genome gag: structural proteins
RNA virus benefit: high mutation rate; DNA virus benefit: latent form in pol: enzymes (protease,
host genome RT, integrase)
env: coat protein
Complex viruses (also have accessory genes – regulatory gene expression)
HIV Structure
gp120: surface glycoprotein, trimers, mediates interaction between virus & cell receptor
o Target of neutralizing & cytotoxic AB
gp41: transmembrane glycoprotein: causes fusion of cell membrane, anchors gp120
Core:
o 2 copies of viral RNA (needed for the RT step
o Protease, integrase, reverse transcriptase already packaged inside
Cell targets of HIV
CD4+ lymphocytes are targeted and killed by HIV
Lose CD4+ lymphocytes in: peripheral blood, lymphoid/gut-associated lymphoid tissues
o (normal: 46%, decreased to 3%, etc). CD8 stays the same, so CD8/CD4 ratio increases
CD4 < 200 is AIDS-defining (normal > 1000); blood level gives good indication of whole compartment
o Onset of opportunistic infections
Normal jobs: Central in immune response (all arms)
o Mature in thymus into blood
o Recognize antigenic peptides (MHC class II), activate Mϕ, activate B-cells to produce antibodies
Natural History
Initial viremia (virus up, CD4 down)
8
Innate, adaptive immune can control at first, CD4 rebounds but not to normal
Virus keeps replicating (lymphoid tissues, dumped into blood), goes to set point (for longer period of time)
o The lower the set point, the better the prognosis
(immune system doing better)
o Therapy: keep viral load low
6. Maturation
a. Protease gets bundled along; cleaves itself out of Gag-pol precursor protein
b. After budding: cleaves gag & gag-pol to form mature virion (infectious)
c. Maturation is essential to be infectious PROTEASE INHIBITOR TARGET
Pathogenesis
Not that virus itself kills all CD4 cells: 2 accepted theories
Immune activation: so much activation of immune system exhausted (high level of activation)
Bystander killing: activated T-cells more prone to apoptosis (more dying)
Transmission
Not a tough virus: fragile (not on surfaces, aerosol, etc)
Sexual transmission (incl oral)
Contaminated needles (IV drug use mainly; P=0.3% for needle stick, use antiretroviral PEP, call 5-STIX)
Mother-child (in utero, at delivery, breastfeeding: all preventable with antiretroviral Rx)
Probability of transmission depends on viral load (highest in acute infection & during AIDS)
Spread:
1. Transmission dendritic cells / infected Mϕ
2. local LN CD4 lymphocytes, Mϕ viremia in blood
3. spread to tissues viremia in CSF (brain infected)
4. Long-lived reservoirs: resting lymphocytes (blood, tissues), Mϕ (tissues)
Stages of infection
1. Primary (acute) HIV infection: rapid replication (first few weeks),
a. Ab tests initially negative, viral load varies (104-106/mL), CD4 depletion (esp. GALT).
b. Acute retroviral syndrome: fever, lymphadenopathy, pharyngitis, rash
c. Viremia falls: innate, adaptive (CTL) immune response develops
d. Levels off to set point (different in different pts; prognostic)
e. LN full of virus; dendritic cells trapping virus inside LN, adaptive immune response clears
f. Viral load lowers, CD4 counts rebound
Treatment
Multiple drugs: mutation rate high (1 error/genome per 3 replication cycles)
No editing function (single strand)
“every base pair mutates every day”
Partial suppression: rapid production of mutant viruses
“Do it right or don’t do it” sequential monotherapy = develop resistance to all!
o Never treat with one drug
o Never add 1 drug to a failing regimen
3 drugs: likelihood of getting resistance to 3 drugs on same viral genome is low!
Vaccine?
6 yr trial in Thailand: guarded possibility of vaccine? 30% reduction in those who receive vaccine; no reduction in
HIV load in vaccinees with HIV (?)
Why so hard? All current viral vaccines prevent development of disease, don’t stop infection; HIV vaccine would
need to induce “sterilizing immunity” to prevent infection/latency; HIV infection doesn’t induce natural
immune response to prevent progression; would need vaccine against many variable clades of HIV-1/2, diverse
antigenicity among HIV in population
Serology: remember: HIV antibodies take 2-4wks to develop (can’t use right away!)
1. ELISA used as first test
ELISA + WESTERN PCR
o Pt. serum + HIV proteins in well; look for binding of
Inexpensive Expensive
pt. antibodies
Rapid Requires sample prep
o False-positive: 0.4%
2. Western Blot: Blood test (1985) Requires Ab against Detect early infection
o Used after ELISA to confirm (combined false- virus (2-4wks post- (3d post infection)
positive 0.005%) infection) Can quantify viral load
o Purified virions lysed, run on SDS-PAGE Almost no difference in sensitivity
o Western-blot with patient sera to look for anti-HIV ab
RT-PCR
Amplify RNA in virus (detects infection earlier: 1st week!)
Gives you viral load: how much virus do you actually have in blood?
CD4 and viral levels are most important clinical measures
Viral load, CD4 count (via flow cytometry) are the two best prognostic indicators
11
Small DNA Viruses: Parvoviruses & Papillomaviruses
DNA viruses: unlike RNA viruses, can use host cell nuclear enzymes to transcribe DNARNA & replicate DNADNA
Must either:
1. infect a dividing cell (parvoviruses)
2. induce host cell DNA synthesis (papillomaviruses, polyomaviruses, adenoviruses)
Parvoviruses
Among smallest of DNA viruses; icosahedral virion (3 proteins + linear ssDNA, ~5000nt)
Replicate in host cell nucleus
Don’t have enough room to code for DNA synthesis enzymes: can only replicate in:
1. dividing cells that have necessary DNA synthesis enzymes
autonomous parvoviruses can replicate alone
2. cells co-infected with a “helper” virus (that provides the enzymes)
dependoviruses need a helper virus like adeno/herpes
Virions: non-enveloped, icosahedral, linear + or – sense ssDNA, no enzymes, very resistant to inactivation
Parvovirus B19
Pathogenesis:
B19 cellular receptor = globoside (P antigen), found
primarily on erythroid cells
Virus replicates primarily in erythroid precursor cells
Cytopathic effect: giant pronormoblasts with nuclear
inclusions, cytoplasmic vacuolization in bone marrow
Toxicity: express B19 nonstructural protein (NSP)
apoptosis induction
o Megakaryocytes: nonproductively infected
(no transcription of mRNA for structural
proteins) but NSP compromises & kills
Normal child/adult
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0. 5-6d incubation
1. Viremic phase (108-1014/mL): fever, malaise, myalgias
2. “slapped face” rash (erythematous, strikingly flushed) afterwards ( immune response )
a. extends to extremities (lacy, evanescent, maculopapular)
b. Adults: develop arthritis during immune response
Destruction of erythroid precursors during acute phase absence of reticulocytes in blood (transient mild anemia)
Not clinically important usually, unless:
1. If patient has chronic hemolytic anemia (sickle cell, thalassemia, hereditary spherocytosis)
More virus made & released (more bone marrow cells being produced & turned over more quickly)
Already have shortened life for circulating erythrocytes, add on more anemia
Result: APLASTIC CRISIS (“Transient Aplastic Crisis = TAC”, life threatening!)
2. If patient is immunodeficient:
Can’t clear virus chronic anemia (“pure red cell aplasia”)
3. If fetus
Can cause severe anemia hydrops fetalis (abnormal fluid in at least 2 compartments), infant death
Greatest risk: first 2 trimesters,
Treat: transfuse in utero, but baby might become tolerant to virus & have persistent infection / red cell aplasia
Epidemiology:
Humans only (esp. school age kids & parents), respiratory transmission (also possible by transfusion)
Dx: serology later, PCR during acute phase
If immunocompetent: clear w/o tx, immunity is life-long
Tx for immunocompromised: immune globulins; no vaccine
Papillomaviruses
HPVs: human papillomaviruses
Icosahedral, covalently closed supercoiled circular dsDNA molecule, 8kb with histones (“minichromosome”)
Cause warts & squamous carcinomas (e.g. cervical carcinoma)
Culture: difficulty; typed via PCR usually
Epidemiology:
Common worldwide in men & women; also linked to penile squamous carcinoma, some head/neck tumors
Most infected women are asymptomatic, clear infection, and do NOT develop malignant disease
If developing disease
o Histopathologic progression: cervical intraepithelial neoplasia (CIN) invasive disease
o Papanicolau smear: screening device; detects cellular changes
o PCR can be used to detect type
o Tx: removal of involved tissue
Immunization:
Virus-like particles (VLPs) from L1 capsid protein (antigenically different between strains)
o Immunogenic: assemble into empty aggregate
VLPs for HPVs 16, 18 (high-risk) & 6 ,8 (low risk, cause condyloma, prevent warts = good for marketing) in
current vaccine: prevents against both cancer & genital warts
Possible therapeutic vaccine: E6/E7; for HPV-induced tumors
14
Influenza: Epidemics, Pandemics, and Prevention Strategies
Influenza quick review:
wild waterfowl = natural reservoir; many strains circulate in birds
influenza A & B = major cause of human disease (A is vast majority)
Subtypes: classified by Hemagglutinin (H x 16), Neuraminidiase (N x 9)
o H1N1, H1N2, H3N2, novel (Swine) H1N1 circulating recently
Mutations: antigenic drift (variations within same H&N classes) vs antigenic shift (complete H/N change)
o Shift: H, N, or both H & N: e.g. bird strain & human strain re-assort
pigs are good facilitators (resp epithelium have both human-like & bird-like receptors)
high association of shift with pandemics
Pandemics of 20th c: 1918-19 (Spanish, H1N1, 20M dead Steps to cause an epidemic
worldwide), 1957-8 (asian, H2N2), 1968-9 (“hong kong”) 1. Susceptible population
2. Animalhuman transmission
Novel H1N1 3. Human human transmission
Very rapid progression, in viral spread & response (says good 4. Sustained humanhuman
things about current collaborative epidemiological efforts)
Several steps removed phylogenetically from seasonal flu
Now counting deaths instead of cases, expect combinations of infections with seasonal flu in winter
Unusual features:
o Summer outbreak (seasonal=winter)
o High mortality in young adults without comorbidities (seasonal = elderly, infants, comorbidities)
Symptoms = usually the same, just in young, healthy people too! 5-24yo unusually affected
Asthma, COPD, CVD, diabetes, immunosuppresed seem to be important comorbidities
Seasonal influenza
Annual epidemic spread like clockwork: late fall, winter, early spring (peak = Jan, Feb).
All ages affected, highest rates among children, most serious in >65 and <2 years old + high risk conditions
Annually 36k deaths, 226k hospitalizations in US; most deaths in >65yo
50% peds deaths: no underlying high risk condition (secondary bacterial pneumonia is #1 cause)
Signs/symptoms: malaise, myalgias, headache, fever, non-productive cough, rhinitis, sore throat, otitis (peds)
Normally a non-specific viral constellation; together = influenza-like illness (ILI)
Uncomplicated: resolves in 3-7d with cough/malaise up to 2 wks (self-limited)
Complications
Primary viral pneumonia
Can exacerbate underlying medical diseases
Secondary bacterial pneumonia / sinusitis / otitis
Co-infection with viral/bacterial pathogens
Uncommon: encephalopathy, transverse myelitis, myocarditis, pericarditis, Reye’s syndrome
Dx: difficult clinically to distinguish from other resp viruses; absence of ILI Sx doesn’t rule out flu
Need lab Dx + high level of suspicion
Lab dx:
o Nasopharyngeal aspirate: suction catheter, mucous trap, aspirate from posterior nasopharynx, add to
transport media, process < 1 hr
o Nasopharyngeal swab: have to get back to NP, better because won’t aerosolize (esp H1N1)
o After you get the sample: viral culture, immunofluorescente DFA antibody, RT-PCR, Serology
15
Transmission of influenza
Person-Person via large particle respiratory droplets, coughs/sneezes, 3 foot radius – can use surgical mask
Close contact, contaminated surfaces
Some evidence of airborne spread (small particle residue evaporated/suspended like TB – would indicate more
than just a surgical mask!)
Observational studies in healthcare settings: contact/droplet are primary means; anecdotal airborne spread
Incubation: 1-4d
o Adults: infectious from 1d prior to Sx through 5d post sx
o Children: infectious from several days prior to 10+d post sx
o Immunocompromised: can shed virus for months
o Shedding prior to Sx: more transmission (less precautions taken)
Vaccines
Most effective way to prevent infection/complications
Annually (antigenic drift)
Two types
o Trivalent inactivate vaccine (TIV)
Injected, grown in eggs, 3 strains (A/H3N2, A/H1N1, B)
Inactivated/killed; subunit/subvirion/purified surface protein
Cannot cause influenza (killed!) ACIP Recommendations
o Live, attenuated influenza vaccine (LAIV) for seasonal flu vaccine
Intra—nasal administration; grown in eggs, 3 strains
Children (6mo-19yr)
(A/H3N2, A/H1N1, B)
Pregnant women
Live attenuated virus; can cause mild signs / sx of
>50yo
attenuated influenza
Chronic med conditions
o Cold-adapted, LAIV (FluMist)
2-50yo (FDA) and also 50-64; efficacy comparable to Nursing homes / long-term
injected (85% healthy adults) care
Well tolerated (rhinorrhea, nasal congestion) Live with / care for high risk
Don’t give to pregnant/immunosuppressed for complications
Safe in healthcare setting (shedding short duration, Healthcare personnel
less than dose to vaccinate, doesn’t replicate well at Household contacts of
37F, genotypically stable, etc.) persons of high risk for
Efficacy: prevention of illness among vaccinated subjects in complications; out of home
controlled trials caregivers of children < 6mo
Effectiveness: prevelance of illness among vaccinated populations
o Depends on age, immunocompetence, match between ACIP Recommendations
vaccine/strains, outcome measured (death, hosp., etc) for H1N1 flu vaccine
o Good (80-87% kids, 77-90% working adults, less in elderly in Pregnant women
community / long-term-care) Household contacts of
persons of high risk for
Medical conditions with ↑ risk of complications complications; out of home
COPD + asthma caregivers of children < 6mo
CVD (not HTN) Healthcare / EMS
Renal, hepatic, hematological, metabolic disorders (incl. DM) 6mo – 24yo (ALL)
Immunosuppresion (meds/disease like HIV) 25-64 with higher risk
Cognitive/neuro dysfunction that compromises resp function or conditions
increases risk of aspiration
*note: no prioritization of
elderly!
Hard to make vaccine: WHO decides in feb which strains to include; 6-8 mo
16
of production, 10s of millions of hand-picked 11-day-old chicken eggs to inject with strain, incubate for several days,
extract/purify egg white: LABORIOUS
Vaccination “season”: people stop getting vaccinated after Thanksgiving although most influenza is in Jan/Feb
Need to keep up vaccination efforts!
Influenza in health care workers: common (23%, most can’t remember flu or resp symptoms)
Vaccinate: ↓ patient mortality, ↓ lost hours, ↑ normal function of institution in flu season
Doesn’t make you sick (large double-blind placebo study)
Other prevention
Hand-washing, respiratory etiquette, community mitigation (close schools, avoid mass gatherings wear masks)
Respiratory etiquette:
o Cover nose/mouth, use tissues, use hand-hygiene after resp secretions / contaminated objects,
healthcare facilities need to make tissues / hand sanitizer available in waiting rooms!
o Provide no-touch receptacles, tissues; dispensers of alcohol, use masking/separation if resp. symptoms
o Droplet precautions: use mask if sx of resp infection, esp in setting of fever
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Viral gastroenteritis
Some viruses replicate in GI tract but don’t cause GI disease: (Enteroviruses: polio, coxsackie, echo, HAV, reoviruses, adenoviruses)
To infect GI tract: need resistance to low pH, detergents (bile), proteases (small intestine)
Some viruses even co-opt these features as part of life cycle!
Review: anatomy of small intestine
Some viruses replicate in GI tract and cause gastroenteritis Crypt cells (dividing, secretory)
Norovirus: (+) RNA no envelope Villus cells (tip = mature, non-dividing, absorptive)
Rotavirus: segmented dsRNA no envelope M-cells (Peyer’s patches, like LNs)
Pathogenesis of viral gastroenteritis: Different viruses infect different sites in small intestine
ingestion mucosal infection diarrhea more transmission
Rotavirus
Rotavirus diarrhea: most common cause of severe dehydrating diarrhea in young children
Steps in infection:
1. Ingest virion to small intestine trypsin cleaves VP4 entry mediated
2. Intermediate sub-viral particle formed (ISVP) enters lysosome, cytoplasm, etc.
STAYS as ISVP (intact) – doesn’t fully uncoat like other viruses to show genome
3. ISVP has its own VIRAL RNApol – makes (+)-strand RNA & extrudes into cell
4. New RNA can be used as mRNA to make proteins, assemble virus, etc.
Cypopathic effects:
see blunted, vacuolated villi
MATURE enterocytes infected, not dividing cells at base of crypts
o In one week: everything restored (more being made at base, infected cells turned over)
Pathogenesis:
If you have neutralizing antibodies (anti-VP4/7), halts infection (VACCINE target)
Rotavirus infects mature absorptive enterocytes in small intestine; produce & release NSP4
o Cellular disruption leads to ↑Ca+2 malabsorption & osmotic diarrhea
Productive infection production of NSP4: viral enterotoxin
NSP4:
1. Stimulates Cl- secretion from crypt cells (causes osmotic diarrhea)
18
2. May also stimulate enteric nervous system (more diarrhea)
Diarrhea: good for virus: more transmission Rotavirus Dx
Often hard to
Clinical features: (vs other virus causes): high prevalence of vomiting & dehydration culture viruses
Esp. important in infants – can’t tolerate huge volume depletion Use antigen-
specific enzyme
Epidemiology: immunoassay
younger kids (6mo-1yr) get more rotavirus gastroenteritis, diarrhea (stool specimen)
Biggest single cause of infant diarrhea in both developing & developed countries
o (US: million cases/yr, 150 deaths, $350M in costs; developing countries: 150M cases, 900K deaths/yr)
Seasonality: more in winter (opposite of enteroviruses)
Vaccine: made by reassortants (rhesus monkey/bovine + human – less virulent but still antigenic)
One was pulled (linked to intussusception – one part of bowel slides into another like telescope – in infants) in
1999 (rare cases)
Two live, oral, attenuated vaccines are FDA approved now (bovine reassortment, no intussusception risk)
o Now routine in US
Norovirus
Outbreak of gastroenteritis (1972, Norwalk, OH) – “winter vomiting disease” but no true seasonality
Found viral source: related to small rounded structure viruses; all termed Calciviruses
Norovirus:
(+) ssRNA, no envelope
Cup-shaped indentations on surface (β-parallel sheets)
Only infects some people: depends on receptor status in host & blood type
o FUT2 encodes a carbohydrate that’s part of receptor
o If receptor present: “secretor” (secretor ≫ non-secretor for susceptibility)
o O > A/B for susceptibility (blood types)
Clinical features: high level of variability (some vomit w/o diarrhea, others vice-versa, some both)
Delayed gastric emptying might be involved (asx infected = no delay)
Epidemiology:
Everybody, everywhere (>95% adults worldwide)
Primary infection: transmitted in saliva
o Asymptomatic if infected as a kid (most exposed in early childhood)
o Infectious mononucleosis if infected later in life (25-70% of adults infected develop Sx)
Most important diseases are associated with latency (tumors) – very uncommon
Virology:
Has a lytic and a latent phase of infection (Burkitt’s cells are slightly different because they have less protein
expression and are therefore less immunogenic)
o Lytic phase: spread via infectious virions like normal virus
o Latent phase: hangs out in epitopes
Lytic infection of B-cells Latent infection of B-cells Burkitt’s B-cells
(“immortalized”)
Genome Linear Circular epitopes
Viral (acyclovir susceptible), Host (not acyclovir susceptible)
DNApol used
Viral enzymes expressed Viral enzymes not expressed
Lots of proteins expressed Lots (antigenic) Only one (invisible to CD8+
Gene expression T-cells because of lack of
MHC-1 presentation)
Immune response Big response Big T-cell response No T-cell response
Infectious virions Host cellular proliferation; no virions made
Spread
(epitopes partitioneddaughter cells when replicating)
Infectious Mononucleosis
Especially prevalent if primary EBV infection occurs as adult
Pathogenesis
1. Transmission: Saliva (“kissing disease”)
2. Immortalization of lymphocytes in vivo
3. T cell response, most immortalized B-cells are killed
4. A small number of EBV-infected resting B-cells have minimal antigen expression (like Burkitt’s cells) escape
5. Reactivation of these infected, resting B-cells occurs sporadically (unknown why)
6. Intermittent in everyone (reactivation): Production of virus, shedding in saliva, infectivity
Clinical features
Sore throat, fever, generalized lymphadenopathy (esp. cervical)
Atypical lymphocytosis (activated T & NK cells): “ mononucleosis” is really a lymphocytosis
Diagnosis
(+) heterophilic monophile test
20
o Turns out that Abs generated during infectious mononucleosis will agglutinate horse RBCs (weird &
accidental cross-rxn)
o “ Monospot” test used currently based on this
o Disappears with resolution of acute illness
Serology: IgM to viral capsid antigen (VCA) for current infection; IgG for post-infection
Burkitt’s Lymphoma
Young males, maxillary / periorbital tumor
EBV Tumor associations
Equitorial Africa only (malarial distribution): not high
Lymphomas Other
altitudes or deserts
Endemic Burkitt’s Nasopharyngeal carcinoma
Escape immune detection (makes few viral proteins) B-cell in immunodeficient Gastric carcinoma
Exact EBV – BL relationship unknown Hodgkin’s disease
Patients:
Transplant patients on cyclosporine, etc – if stop suppression, tumor regresses
Severe combined immunodeficiency (SCID), X-linked immunodeficiency: often die of EBV B-cell lymphoma
AIDS lymphoma: 50% increased risk
(X-linked agammaglobulinemia, XLA): no risk (no B-cells = no EBV, no B-cell lymphoma)
Hodgkin’s lymphoma
EBV in tumor cells in 30% of cases (associated)
o Find EBV DNA/RNA/Ag at each tumor site, during presentation & during relapse
Nasopharyngeal carcinoma
Especially prevalent in Southern China (genetic & environmental)
Virtually ALWAYS EBV-associated (not well understood)
Kaposi’s sarcoma
KHSV infection is required
Geographic: Children in Africa (hands/legs); old men in Mediterranean (Italy, Greece, etc.),
Immunosuppresion:
o Organ transplant recipients (regress with withdrawal of immunosuppresion
o AIDS patients: especially MSM in North America & Western Europe
Presentation: tumor, most commonly on skin, may also be GI/lungs
o Neovascular proliferation purplish color
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Primary Effusion Lymphoma
In AIDS patients, B-cells float in pleural/peritoneal fluid (no solid component)
Exceedingly rare
Pts DUALLY INFECTED (EBV+KSHV)
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Viral Hepatitis
Hepatitis = inflammation in the liver
Nonspecific: alcohol use, acetaminophen, etc. can cause too
Infectious causes: nonviral (syphilis, TB, histo, etc.) and viral (CMV, EBV, HIV, H[A-C]V, etc.)
Clinical course of Hepatitis: exposure incubation (3-4wks) symptoms (jaundice) recovery or persistence
Acute viral hepatitis (USA): A>B>C for frequency
Chronic viral hepatitis: B & C (A can’t cause chronic hepatitis)
Transmission:
A (& E) is nonenveloped, not killed by bile, so can be Exposure HAV & HEV HBV & HDV HCV
transmitted fecal-oral (acute) Fecal-oral +4 0 0
Note that the chronic ones can be transmitted via blood Sexual +1 +4 +1
(makes sense) Blood +1 +4 +4
Sexual: oral or vaginal Perinatal +1 +4 +2
Consequences:
Liver: largest organ in body, stores vitamins A, B12, D, E, K; metabolizes lipids, makes cholesterol, stores
glycogen
Fibrosis: scarring (overgrowth of connective tissue), restricts function bridging (bands of fibrosis)
o Cirrhosis: widespread fibrosis with nodule formation macronodular cirrhosis
Hepatocellular carcinoma (primary cancer of the liver; one of most common in world, cirrhosis is risk)
Lab Dx:
Elevated transaminases (ALT, AST > 10x normal): liver-specific enzymes, spilled out in ongoing damage
Antibodies
o IgM antibodies: markers of recent infection (6 mo)
o IgG: markers of any past infection
o Neutralizing Ab: recovery process under way
Viral particles(protein/nucleic acid, “antigen”): ongoing infection and infectivity
Hepatitis A virus
Picornavirus, RNA virus
NO ENVELOPE bile stable (can be transmitted fecal-oral)
Capsid proteins elicit a universal neutralizing antibody (one serotype vaccine possible)
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Hepatitis B virus
S-gene: surface antigen, makes surface antigen in outer envelope;
o first recombinant vaccine (yeast) produced against it (1st anti-cancer vaccine)
Genome: tiny (3200nt), uses overlapping reading frames
Replication: entry uncoating genome incompletely closed (opened from circle) to be imported to nucleus
o Completly Closed Circular DNA (cccDNA): genome closed & repaired inside nucleus
Makes a bunch of transcript for viral replication
Can be INTEGRATED into host genome (stable, reservoir) – hard to eliminate
Transmission: makes TONS of virus and extra surface antigens (serum packed); environmentally stable (can
hang out on tables, equipment, etc). Very transmissible
Hepatitis D virus
Has Dependency issues: needs Hepatitis B (either via co-infection or prior chronic infection)
o Uses HBV to put on its capsule (has HbsAg) but has its own RNA
Hepatitis C virus
Tons of genomic diversity
o Error rate: 1x10-4; turnover is really high (1010-12 per day)
o Mutations: every base, every day, every person (like HIV)
Forms quasispecies
Even more genetic diversity than HIV
o Explains failure of vaccine & immune response to clear (some variants can evade & persist)
Abs don’t neutralize (too much diversity)
Steady progression of chronic disease, often cirrhosis end-stage liver disease (ESLD)
ALT at constant elevated rate; RNA present the whole time
Clinical correlations of genetic diversity
o 80% persistence, resistance to treatment
o HCV is hard vaccine target, hard target for antiviral drugs
o Reservoir: infections last for decades
Hepatitis E
40d average incubation; 1-3% CFR
Pregnancy: often fulminant (15-25% CFR!)
Higher severity with age; no chronic sequelae
Summary/Review
5 hepatotropic viruses
TRANSMISSION COURSE KEY FEATURE
HAV Fecal/oral Self-limited No envelope = bile stability
HBV Surface antigen in vaccine
HCV Blood/sex/etc Chronic Viral diversity
HDV Needs HBV
HEV Fecal/oral Self-limited Fatal in pregnant women
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