Myco Virology

MLS 3A MODULE 1: ❏ The term ‘virus’ derives from the Latin for slimy liquid or
BASIC CONCEPTS IN VIROLOGY poison and was gradually introduced during this period to
INTRODUCTION replace the term ‘filterable agents’.
❏ Until the latter half of the nineteenth century, it was believed
that certain submicroscopic infectious agents of mammalian TOBACCO MOSAIC VIRUS (TMV)
hosts were merely small forms or bacteria. Scientists in ❏ The first virus to be visualized by x-ray crystallography and
these earlier times rationalized that their inability to cultivate electron microscopy which was reported in 1939 and 1941,
these small bacteria only implied they were fastidious in their respectively. These advances introduced the notion that
nutritional requirements. After the turn of the century, viruses were structurally composed of repeating subunits
scientists proposed that these submicroscopic forms of life
be called viruses. In 1915, even bacteria were discovered to
be capable of being infected by viruses. The bacterial
invaders were called bacteriophages or phages.
❏ Not until the discovery of the electron microscope and other
technological advances were scientists able to discard fact
from fiction regarding viruses.
❏ A virus is now defined as a subcellular agent consisting of a
core of nucleic acid surrounded by a protein coat that must
use the metabolic machinery of a living host to replicate and
produce more viral particles.
BACKGROUND AND DISCOVERY

❏ The concept behind modern virology can be traced back to
Adolf Mayer, Dimitri Ivanofsky, and Martinus Beijerinck
who, independently in the late 1880’s, discovered what was
.
later to be called tobacco mosaic virus (TMV), first virus
❏ Frederick Twort and Felix d’Herelle, working
discovered.
independently, are credited with the discovery of viruses
❏ Their discoveries led to the descriptions of filterable agents,
which could infect and lyse bacteria in 1915. They called this
too small to be seen with the light microscope, that could be
“bacteriophage”, a virus that infects bacteria. This discovery
grown in living cells and cause disease. They called this
of this agent gave birth to Modern Virology.
agent “filterable virus”.
❏ D’Herelle introduced the term ‘bacteriophages’ for these
❏ Foot and Mouth Disease Virus
agents and also described the concepts of virus adsorption
➔ the first filterable agent from animals
to its target, cell lysis and release of infectious particles.
➔ was described by Loeffler and Frosch in 1898
Over the next 35-40 years, work with phages led to
❏ Yellow Fever Virus
numerous discoveries including how the introduction of DNA
➔ the first human filterable agent discovered was
into a target cell could reproduce itself and the regulation of
➔ discovered by Walter Reed in 1901
cellular macromolecular synthesis directed by viruses. In
MLS 13A: MYCOLOGY & VIROLOGY | RMT 2022 | Page 1

essence, the field of molecular biology was opened up ➔ Non-enveloped viruses or naked viruses are
during this period. those that have capsid but do not have
❏ Advances in animal virology were noted throughout the 20th envelopes.
century but the major breakthrough came through the 2. Nucleocapsid.
development of tissue culture systems that led, for example, ➔ The complete protein-nucleic acid complex.
to the isolation of poliovirus by Enders et al. in 1949. This ➔ Composed of nucleic acid core and capsid.
markedly facilitated detailed study of this agent and, most
importantly, the development of poliovirus vaccines. The B. SATELLITE OR DEFECTIVE VIRUSES
ensuing 60 years have seen diagnostic virology mature as a ❏ Viruses which require a second virus (helper virus) for
field with the discovery of new agents and diseases and the replication.
parallel determination of the importance of viruses in our ❏ Hepatitis Delta Virus is the major human pathogen
understanding of molecular biology and cancer. example. It requires the presence of hepatitis B virus to
complete its replication cycle.
DEFINITIONS
VIRUS C. VIROIDS
❏ The smallest replication intracellular microorganism that ❏ Viroids are the smallest known autonomously replicating
comprises sets of genes either DNA (DNA viruses) or RNA molecules.
(RNA viruses). ❏ They consist of single-stranded, circular RNA molecules that
❏ viruses are parasites at the genetic level, replicating only in lack protein shells, 240-375 residues in length and are plant
living cells and are inert in the extracellular environment. pathogens.
❏ A single virus is called a Virus particle or virion
D. PRIONS
A. VIRUS PARTICLE / VIRION ❏ These are not viruses but are often discussed within this
❏ An infectious agent composed of nucleic acid (RNA or DNA), microbiologic category. They are not genetic materials
a protein shell (capsid) and, in some cases, a lipid envelope. (neither RNA or DNA).
❏ Virions have full capacity for replication when a susceptible ❏ Misfolded or defective proteins that cause normal proteins in
target cell is encountered. the brain to misfold because they have the ability to transmit
❏ The virion is the entire infectious unit of the virus. Its basic their misfolded shape onto normal variants of the same
unit is the nucleic acid (RNA OR DNA) encased in capsid protein.
with or without envelope. ❏ The pathogenic prion protein, PrPSc, is formed from a
1. Capsid and capsomeres normal human protein, PrPC, through post-translational
➔ The protein coat that surrounds the viral processing.
nucleic acid. This is composed of repeating ❏ Infectious protein molecules that contain no definable nucleic
protein MID 29 subunits called capsomeres. acid and are responsible for the transmissible and familial
Generally, capsids have either helical or spongiform encephalopathies:
icosahedral symmetry. ➔ Kuru
➔ Capsid protects the nucleic acid, the capsid ➔ Creutzfeldt Jakob disease
may also be surrounded by a lipid-containing ➔ Gerstmann-Straussler- Sheinker syndrome
membrane (envelope). ➔ Fatal Familial Insomnia

➔ Scrapie in sheep
➔ Bovine Spongiform Encephalopathy (BSE) in cattle
(“mad cow disease”)
CLASSIFICATION
❏ Viral classification has been confusing and oft-changing over
the years.
❏ In the past, viruses were often classified by host, target
organ or vector and these are still used vernacularly (e.g.,
the hepatitis viruses and arboviruses). Modern
classification is based on the following four characteristics:
1. Type of viral nucleic acid (RNA or DNA,
single-stranded or double-stranded) and its
replication strategy.
2. Capsid symmetry (icosahedral or helical).
3. Presence or absence of lipid envelope. Figure 1.2: Viral Capsid Shape
4. Structure
Figure 1.1: Structure of Virions

ADDITIONAL NOTE: (Sir Robert)
Basis of classification of viruses:
1. Morphology of the Virion
2. Genome properties of the virus
3. Physicochemical properties of the virion
4. Virus protection properties
5. Genome organization and replication
6. Antigenic properties
7. Biologic properties
A. GENOME STRUCTURE
❏ The genome of the viruses can either be RNA or DNA, but
not both.
❏ DNA or RNA genomes may be single or double stranded
❏ May be linear or circular
❏ Some genomes are segmented, every segment can encode
a protein
❏ RNA genomes could be:
➔ Positive (+) sense - can be translated directly into a
viral protein, also called “Translated ready genome”.
These are infectious genetic material.
➔ Negative (-) sense - can’t be translated directly to
viral protein, it needs to be transformed to +ssRNA
by RNA dependent RNA polymerase (RdRP). These
are non-infectious genetic material.
➔ Ambisense (+/-) sense
DAVID BALTIMORE - classified viruses using their nucleic acid

bases

B. CAPSID STRUCTURE 3. COMPLEX SYMMETRY
❏ Made up of capsomeres (virus-encoded specific proteins) ❏ Some virus particles do not exhibit simple cubic or
that protect the genome and confer shapes to viruses. helical symmetry but are more complicated in
❏ Present in all viruses and very specific for each type structure
❏ Functions: ➔ Ex. Pox Virus and Bacteriophage
➔ It protects the nucleic acid core from the external NOTE: All DNA viruses (except poxviruses) and most of the RNA
environment viruses have icosahedral symmetry
➔ In non-enveloped viruses, it initiates the first step of
viral replication by attaching to specific receptors on
the host cells thus facilitating the entry of the virus
➔ It is antigenic and specific from each virus
NOTE: Purpose of capsid is to bind to specific receptors that would
initiate replication.
TYPE OF SYMMETRY
1. HELICAL SYMMETRY
❏ Simplest structure for capsid
❏ Protein subunits are bound in a periodic way to the
viral nucleic acid, winding it into a helix
❏ The filamentous viral nucleic acid-protein complex C. ENVELOPE STRUCTURE
(nucleocapsid) is then coiled inside a lipid containing ❏ Many human viruses have an outer lipid bilayer membrane
envelope. that is derived from cellular membranes, mainly the plasma
❏ It is not possible for “empty” helical particles to form membrane, but also, in some cases, cytoplasmic or nuclear
because it needs genetic material to form a membranes
nucleocapsid. Most common example: Tobacco ❏ The viral envelope lipid layer membrane contains
mosaic virus (TMV) virus-encoded glycoproteins called “spikes” or “peplomers”
or “viral envelope proteins”
2. CUBIC SYMMETRY ❏ The envelope spikes bind to the receptor on the host cells,
❏ Aka spherical or icosahedral symmetry help the virus envelope membrane fuse with the cellular
❏ Composed of a number of repeated protein subunits membrane of the host cells and act as principal antigens
(polypeptides) called capsomeres against which the host mounts immune response for the
❏ All cubic symmetry observed with animal viruses is of recognition of the virus
the icosahedral pattern, the most efficient ❏ Envelope virus are only infectious if they acquire envelop
arrangement for subunits in a closed shell. ➔ Example: SARS-CoV 2
❏ Most viruses that have icosahedral symmetry do not
have an icosahedral shape-rather, the physical NOTE:
appearance of the particle is spherical ❏ Enveloped viruses are more sensitive to detergents,
solvents, ethanol, ether, and heat compared with non

enveloped (naked capsid) viruses whose outer coat is capsid RNA VIRUSES
protein
❏ Main purpose of spikes is to initiate replication or attach to
receptor present in human cells. Spikes can be found on
envelopes if viruses have envelopes. Viruses with no
evelope, it can be found on capsid.
VIRUSES AND THEIR STRUCTURE

DNA VIRUSES

3. TRANSMISSION FROM ANIMAL TO ANIMAL, WITH
HUMANS AS AN ACCIDENTAL HOST
Spread may be:
➔ By bite - (e.g. rabies)
➔ By droplets or aerosol infection from
rodent-contaminated quarters (e.g. hantaviruses,
arenaviruses)
4. TRANSMISSION BY MEANS OF ARTHROPOD VECTOR

➔ (E.g. dengue virus)
NOTE:
❏ All Icosahedral RNA viruses are naked except
Togaviridae
❏ All Helical and Complex RNA viruses are enveloped
MODE OF TRANSMISSION
Viruses may be transmitted in the following ways:
1. DIRECT TRANSMISSION FROM PERSON TO PERSON
BY CONTACT VIRAL PHYSIOLOGY
The major means of transmission include: VIRAL REPLICATION
➔ Droplet or aerosol (Influenza, Rhinovirus, Measles ❏ Viruses can only multiply inside living cells and require a
and Smallpox) host cell to survive. The host cell must contain the required
➔ By sexual contact (Papilloma virus, Hepatitis B, machinery to synthesize the viral proteins and nucleic acids.
HSV 2 and HIV)
➔ Hand-mouth, hand-eye, or mouth-mouth contact Viral replication occurs in several stages, namely;
(HSV1-found in mouth and HSV2- found in genitals)
➔ By exchange of contaminated blood (Hepatitis B, 1. ATTACHMENT – The virus becomes attached to the cell by
Hepatitis C and HIV) specific cellular receptors which can be glycoproteins,
phospholipids or glycolipids.
2. INDIRECT TRANSMISSION 2. ENTRY– Following attachment, the virus can enter the cell,
➔ By the fecal-oral route - improper sanitation (e.g most commonly via receptor mediated endocytosis
Rotavirus, enteroviruses, Hepa A virus) (sometimes through fission of envelope). This is the same
➔ By fomites - non-living things that may harbor
process by which many hormones enter the cell.
pathogens (e.g. Norwalk virus, Rhinovirus)

3. UNCOATING– Once inside the host cell, the viral capsid
must be uncoated to release the viral nucleic acid. Uncoating
may be achieved by host or viral enzymes that will degrade
the capsid.
4. REPLICATION– Once uncoated, viruses (DNA or RNA)
replicate by switching the host machinery from cellular
protein synthesis to viral synthesis and viral proteins are
produced.
5. ASSEMBLY– Newly synthesised viral proteins are
post-transcriptionally modified and packaged into virions that
can be released from the infected host cell to infect other
cells.
6. RELEASE – Virions are released from the cell either by lysis
or budding. In lysis, the infected cell dies and the virions are
released. In budding, the virion takes some of the host cell’s
membrane with it as it leaves – this normally does not kill
the infected cell.
SPECIMEN COLLECTION, PROCESSING & HANDLING
❏ Laboratory diagnosis of viral infections requires an
understanding of the pathogenesis of the suspected agent,
stage of infection, as well as age and immunocompetence of
the infected individual.
❏ It is important to select the appropriate specimens, collect
the specimen carefully to optimize recovery of the infectious
agent, and transport the specimens as directed so as to
maintain viability and minimize overgrowth with
contaminating organisms.
SELECTION OF SPECIMENS
❏ The specimen should be collected from the target organ
most closely associated with clinical symptoms to identify
etiologic agents responsible for the patient's disease.

NOTE: animal or arthropod contacts or bites, recent travel to areas
❏ Selection of the appropriate type of specimen is one of the of endemic infections, and recent vaccines.
keys to a correct test result
❏ Specimen for the detection of virus should be collected as GUIDELINES FOR THE CHOICE AND HANDLING OF
early as possible after the onset of symptomatic disease SPECIMENS
- Virus may no longer be present as early as 2 days Table 1.1 Specimen for viral isolation and their preparation
after the appearance of symptoms (since the virus
Specimen Preparation
does not stay at the site of infection after 2 days)
❏ Calcium Alginate Swabs interfere with PCR, the recovery
The patient gargles with 10 mL of sterile
of some enveloped viruses and fluorescent-antibody tests balanced salt solution (Hank's or Earle's
and therefore should not be used. Throat wash
BSS) or trypticase soy broth (TSB);
expelled into a sterile container.
SPECIMEN COLLECTION GUIDELINES
❏ Collect specimens as soon as possible after the onset of Random clean-catch sample collected in a
Urine
symptoms. The chance of virus recovery is best during the sterile container
first 3 days after onset and is greatly reduced beyond 5
days with many viruses. Autopsy samples need to be Collect 7-10 mL of blood in a Yellow ACD
collected as soon as possible after death before tissues start tube (Solution A or B). Blood more than 72
Blood
hrs old from time of collection to the time of
decomposing.
processing will be rejected.
❏ Refer to the specimen collection guide table for viral culture.
In general, place swabs into a tube containing a small Insert a flexible fine-shafted swab through
volume of VTM, and scrapings and small pieces of tissue Naso-Pharyngeal the nostril into the nasopharynx and rotate
into a tube containing a small volume of VTM or saline. Swab the swab gently a few times. Place into M4
Place fluid and bulk specimens (e.g., tissue) into a sterile viral transport media.
leak proof container; add a volume of VTM sufficient to
Withdraw vesicle fluid using a tuberculin
prevent drying of tissue.
syringe or swab the vesicle and place it in
❏ Collect specimens as aseptically as possible to avoid an M4 Culture Transport Tube or 1 ml of
introduction of contaminating organisms that can take over Vesicle fluids
BSS or TSB; crusted, dry lesions are not
the culture later and make accurate diagnosis difficult. vesicles and are not appropriate for virus
❏ Place each specimen into a separate container labeled with isolation.
the patient's name and identification number, the collection
site, the date of collection, and the time of the collection.
❏ Obtain a complete patient history, including the date of
onset of symptoms, clinical findings, recent exposure history,

➔ It should also not be allowed to stay at higher
Collect aseptically and keep moist by temperatures, since enveloped viruses are sensitive
placing in a sterile container with 2 mL of
Tissue to heat, alcohol, ether and detergents.
BSS (Hanks Phosphate Buffered Saline),
TSB, saline or viral transport media M4. ❏ Specimen should be kept cool (4OC) and immediately
transported to the laboratory
Stool Approximately 5 gm of stool placed in a ➔ For storage up to 5 days: 4OC
tightly-capped sterile container without ➔ Storage for 6 days or longer: -20OC or preferable
preservatives. A swab covered with stool is -70OC
acceptable for culture but not preferred.
Swabs are UNACCEPTABLE for
MATERIALS
Clostridium difficile toxin.
A. REAGENTS
VIRAL TRANSPORT MEDIUM (VTM)
NOTE: ❏ prevents specimen drying
❏ All specimens except blood should be tightly sealed, kept ❏ maintains viral viability
cold, and sent on wet ice or a "cool pack" (not frozen) to the ❏ retards the growth of microbial contaminants (All
laboratory as soon as possible, preferably on the day of contaminants are fast growers and may deplete the nutrients
collection. present in the medium needed by the desired pathogens to
❏ Specimens for cytomegalovirus (CMV) isolation should be grow)
sent as soon as possible to our laboratory since this virus is ❏ VTM contains gelatin and antimicrobial agents in a buffered
very heat labile and the probability of isolating it decreases salt solution.
rapidly with time. ❏ Some specimes for virus culture are collected in tube with
❏ If absolutely necessary, all specimens except blood and VTM
those for CMV, RSV and VZ can be frozen at -50°C or ❏ Laboratories have different guidelines in different specimen
below (do not use -20°C) and sent to the laboratory on dry for viral culture
ice.
B. SUPPLIES
SPECIMEN TRANSPORT AND STORAGE ❏ Sterile, leakproof, screw-cap containers including urine cups,
❏ Ideally all specimens collected for detection of virus should disposable centrifuge tubes (15 and 50 mL), and smaller
be processed immediately tubes (e.g., 4-mL Nunc vials, 13x100 tubes), suitable for
❏ Specimen for viral isolation should not be allowed to sit at holding 1-2 mL of VTM.
room or higher temperature ❏ Sterile cotton-, Dacron-, or rayon-tipped swabs with plastic or
➔ If viruses stay at RT, it loses its structure and aluminum shafts small-tip flexible (fine- shafted aluminum)
infectivity and must be preserved through swabs are used for certain samples such as urethral swabs.
refrigeration.

Do not use calcium alginate swabs or wooden-shafted ❏ A serological diagnosis can be made by the detection of
swabs. rising titers of antibody between acute and convalescent
❏ Tuberculin syringe with 26- or 27-gauge needle for aspirating stages of infection, or the detection of IgM.
vesicular fluid ❏ In general, the majority of common viral infections can be
❏ Blood collection tubes containing anticoagulant (ACD-yellow diagnosed by serology. The specimen used for direction
top). For serologic testing, use a red-topped tube. detection and virus isolation is very important. A positive
result from the site of disease would be of much greater
C. EQUIPMENT diagnostic significance than those from other sites. For
❏ Refrigerator (2-8OC) example, in the case of herpes simplex encephalitis, a
positive result from the CSF or the brain would be much
LABORATORY TESTS FOR IDENTIFICATION OF VIRUSES greater significance than a positive result from an oral ulcer,
OVERVIEW OF DIAGNOSTIC METHODS since reactivation of oral herpes is common during times of
❏ In general, diagnostic tests can be grouped into 3 categories: stress.
A. DIRECT DETECTION / EXAMINATION DIAGNOSTIC METHODS:

❏ In direct examination, the clinical specimen is examined A. DIRECT EXAMINATION OF SPECIMEN
directly for the presence of virus particles, virus antigen or ❏ Electron Microscopy morphology / immune electron
viral nucleic acids. microscopy
❏ Cytological and Histological Appearance through Light ❏ Light microscopy histological appearance - e.g. inclusion
microscope bodies
❏ Electron Microscope ❏ Antigen detection immunofluorescence, ELISA etc.
❏ Immunodiagnosis (Antigen Detection) ❏ Molecular techniques for the direct detection of viral
❏ PCR genomes
B. INDIRECT EXAMINATION (VIRUS ISOLATION) NOTES FROM SIR ROBERT

❏ In indirect examination, the specimen into cell culture, eggs UNDER DIRECT EXAMINATION:
or animals in an attempt to grow the virus: this is called CYTOLOGICAL AND HISTOLOGICAL APPEARANCE
virus isolation. ❏ Uses light microscope
❏ Usually performed for the detection of viral inclusions
C. SEROLOGY / SEROLOGIC EXAMINATION ❏ Viral inclusions are intracellular structures formed by
❏ Serology actually constitutes by far the bulk of the work of aggregates of virus or viral components in an infected cell of
any virology laboratory. abnormal accumulations of cellular materials resulting from
virus-induced metabolic disruption.
❏ Inclusions occur in single or syncytial cells

❏ Syncytial cells are aggregates of cells fused to form one
large cell with multiple nuclei allowing it to be visible under
the light microscope
Adenovirus - naked and may not be destroyed using alcohol

NOTE: Familiarize the Inclusion bodies
2. IMMUNODIAGNOSIS
❏ Direct and Indirect Immunofluorescent method
➔ Both usually use FITC (Fluorescein Isothiocyanate)
as the labelled antibody
➔ Direct Method: best suited in dealing with high
concentration of viruses
E.g. Intracytoplasmic Virus ➔ Indirect Method: suitable for low concentration of
viruses
1. ELECTRON MICROSCOPY ❏ Enzyme Immunoassay
❏ Most helpful for detecting viruses that do not grow readily in - E.g ELISA
cell culture ❏ Latex Agglutination
➔ But labor intensive and relative insensitive - Easy method but lacks sensitivity
❏ Works best if the titer of the virus is at least 10^6 to 10^7 ❏ Immunoperoxidase Test
particles per mL - Stains histologic section
❏ Immune Electron Microscopy (IEM) allows visualization of
virus particles present in numbers too small for easy direct 3. POLYMERASE CHAIN REACTION
detection (Modified electron microscopy) ❏ Target amplification
➔ The addition of specific antiserum to the ❏ Divided into three: denaturation, annealing, and synthesizing
suspension causes the virus particles to form ❏ Purpose: to increase the target and to visualize the genetic
antibody-bound aggregates which are more easily material of viruses through amplification or increasing the
detected than are single virus particles concentration.
➔ Antiserum contains antibodies that will bind with the
virus to form aggregates.

❏ Replication is performed to increase the concentration of
viruses.
❏ Denaturation @ 95OC: Parent DNA is separated into two
strands
❏ Annealing @ 55OC: Addition of DNA Primer to the template
strand or the INitial replication.
❏ Synthesizing @ 72OC
B. INDIRECT EXAMINATION
❏ Cell Culture - cytopathic effect, haemadsorption,
confirmation by neutralization, interference,
immunofluorescence etc.
➔ Viruses are strict intracellular parasites,
requiring a living cell for multiplication and
reproduction
➔ There are three basic types of conventional
cell culture: Primary, Secondary, and Tertiary
❏ Eggs pocks on CAM - haemagglutination, inclusion
bodies
❏ Animals disease or death confirmation by
neutralization

NOTE: DIRECT EXAMINATION
PRIMARY CELL CULTURE ❏ Direct examination methods are often also called rapid
❏ widely acknowledged as the best cell culture systems diagnostic methods because they can usually give a result
available since they support the widest range of viruses. either within the same or the next day.
❏ However, they are very expensive and it is often difficult to ❏ This is extremely useful in cases when the clinical
obtain a reliable supply. Continuous cells are the easiest to management of the patient depends greatly on the rapid
handle but the range of viruses supported is often limited. availability of laboratory results e.g. diagnosis of RSV
TERTIARY CELL CULTURE infection in neonates, or severe CMV infections in
❏ For Tertiary Culture, it cannot be used for vaccine immunocompromised patients. However, it is important to
production since it is derived from cancer cells and may realize that not all direct examination methods are rapid, and
replicate indefinitely conversely, virus isolation and serological methods may
❏ Supply is unlimited coming from cancer cells sometimes give a rapid result. With the advent of effective
antiviral chemotherapy, rapid diagnostic methods are
C. SEROLOGY / SEROLOGIC EXAMINATION expected to play an increasingly important role in the
➔ Detection of rising titers of antibody between acute and diagnosis of viral infections.
convalescent stages of infection, or the detection of IgM in
primary infection. The serological methods involved in the A. ANTIGEN DETECTION
identification are listed in Table 1.2. ❏ Examples of antigen detection include:
➔ Usually, a method is used to detect antibody concentration in ➔ Immunofluorescence testing of nasopharyngeal
the plasma or serum of a patient. aspirates for respiratory viruses e.g.. RSV, flu A, flu
B, and adenoviruses
Table 1.2 Serologic methods in the identification of viral antibodies ➔ Detection of rotavirus antigen in faeces
Classical Techniques Newer Techniques
➔ pp65 CMV antigenemia test
➔ Detection of HSV and VZV in skin scrapings, and
❏ Complement fixation tests ❏ Radioimmunoassay (RIA) ➔ Detection of HBsAg in serum.
(CFT) ❏ Enzyme linked ❏ (However, the latter is usually considered as a serological
❏ Hemagglutination immunosorbent assay
inhibition tests (EIA) test). The main advantage of these assays is that they are
❏ Immunofluorescence ❏ Particle agglutination rapid to perform with the result being available within a few
techniques (IF) ❏ Western Blot (WB) hours. However, the technique is often tedious and time
❏ Neutralization tests ❏ Recombinant immunoblot
consuming, the result difficult to read and interpret, and the
❏ Single Radial Hemolysis assay (RIBA)
❏ Line Immunoassay sensitivity and specificity poor.
❏ The quality of the specimen obtained is of utmost importance
in order for the test to work properly.

Figure 1.6 Electron micrographs of viruses commonly found in stool
specimens from patients suffering from gastroenteritis. From left to
right: rotavirus, adenovirus, astroviruses, Norwalk-like viruses.
B. ELECTRON MICROSCOPY (EM)
C. LIGHT MICROSCOPY
❏ Virus particles are detected and identified on the basis of
❏ Replicating viruses often produce histological changes in
morphology. A magnification of around 50,000 is normally
infected cells. These changes may be characteristic or
used. EM is now mainly used for the diagnosis of viral
non-specific. Viral inclusion bodies are basically collections
gastroenteritis by detecting viruses in feces e.g. rotavirus,
of replicating virus particles either in the nucleus or
adenovirus, astrovirus, calicivirus and Norwalk-like
cytoplasm.
viruses. Occasionally it may be used for the detection of
❏ Examples of inclusion bodies include the negri bodies and
viruses in vesicles and other skin lesions, such as
cytomegalic inclusion bodies found in rabies and CMV
herpesviruses and papillomaviruses.
infections, respectively. Although not sensitive or specific,
❏ The sensitivity and specificity of EM may be enhanced by
histology nevertheless serves as a useful adjunct in the
immune electron microscopy, whereby virus specific
diagnosis of certain viral infections.
antibody is used to agglutinate virus particles together and
thus making them easier to recognize, or to capture virus
particles onto the EM grid. The main problem with EM is the
expense involved in purchasing and maintaining the facility.
In addition, the sensitivity of EM is often poor, with at least
10^5 to 10^6 virus particles per ml in the sample required for
visualization. Therefore, the observer must be highly skilled.
❏ With the availability of reliable antigen detection and
Figure 1.7 Inclusion bodies. Left: Negri bodies pointed by the arrow;
molecular methods for the detection of viruses associated
Right CMV inclusion body pointed by the arrow.
with viral gastroenteritis, EM is becoming less and less
widely used.

D. VIRAL GENOME DETECTION to interpret as it does not necessarily indicate the presence
❏ Methods based on the detection of viral genome are also of disease.
commonly known as molecular methods. It is often said that ❏ This problem is particularly great in the case of latent viruses
molecular methods are the future direction of viral diagnosis. such as CMV, since latent CMV genomes may be amplified
However, in practice, although the use of these methods is from the blood of healthy individuals. Despite all this, PCR is
indeed increasing, the role played by molecular methods in a being increasingly used for the rapid diagnosis of rapid. This
routine diagnostic virus laboratory is still small compared to is especially as the cost of the assay comes down and the
conventional methods. availability of closed automated systems that could also
❏ It is certain though that the role of molecular methods will perform quantification (Quantitative PCR) e.g. real-time PCR
increase rapidly in the near future. Classical molecular and Cobas Amplicor.systems. Other amplification techniques
techniques such as dot-blot and Southern- blot depend on such as LCR and NASBA are just as susceptible to
the use of specific DNA/RNA probes for hybridization. contamination as PCR but that is ameliorated to a great
❏ The specificity of the reaction depends on the conditions extent by the use of proprietary closed systems.
used for hybridization. These techniques may allow for the ❏ It is unlikely though that other amplification techniques will
quantification of DNA/RNA present in the specimen. challenge the dominance of PCR since it is much easier to
However, it is often found that the sensitivity of these set up a house PCR assay than other assays. One
techniques is not better than conventional viral diagnostic advantage of PCR assays is that the PCR product can be
methods. sequenced and thus used for epidemiological investigation
❏ Newer molecular techniques such as the polymerase chain and drug susceptibility testing.
reaction (PCR), ligase chain reaction (LCR), nucleic
acid-based amplification (NASBA), and branched DNA VIRUS ISOLATION
(bDNA) depend on some form of amplification, either the ❏ Cell cultures, eggs, and animals may be used for isolation.
target nucleic acid, or the signal itself. However, eggs and animals are difficult to handle and most
❏ bDNA is essentially a conventional hybridization technique viral diagnostic laboratories depend on cell culture only.
with increased sensitivity. However, it is not as sensitive as ❏ There are 3 types of cell cultures:
PCR and other amplification techniques.
❏ PCR is the only amplification technique which is in common TYPES OF CELL CULTURES
use. PCR is an extremely sensitive technique: it is possible A. Primary cells - e.g. Monkey Kidney. These are essentially
to achieve a sensitivity of down to 1 DNA molecule in a normal cells obtained from freshly killed adult animals. These
clinical specimen. However, PCR has many problems, the cells can only be passaged once or twice.
chief among which is contamination, since only a minute
amount of contamination is needed to give a false positive B. Semi-continuous cells - e.g. Human embryonic kidney and
result. In addition, because PCR is so sensitive compared to skin fibroblasts. These are cells taken from embryonic tissue,
other techniques, a positive PCR result is often very difficult and may be passaged up to 50 times.

C. Continuous cells - e.g. HeLa, Vero, Hep2, LLC-MK2, BGM.
These are immortalized cells i.e. tumour cell lines and may
be passaged indefinitely.
➔ Primary cell culture is widely acknowledged as the
best cell culture systems available since they support
the widest range of viruses. However, they are very
expensive and it is often difficult to obtain a reliable
supply. Continuous cells are the easiest to handle but Figure 1.8 Left to Right: Cytopathic effect of HSV, enterovirus 71,
the range of viruses supported is often limited. and RSV in cell culture. Note the ballooning of cells in the cases of
HSV and enterovirus 71. Note syncytia formation in the case of
NOTE: Passage - number of times you allowed a culture to be RSV.
multiplied.
PROBLEMS WITH CELL CULTURE
IDENTIFICATION OF GROWING VIRUS ❏ The main problem with cell culture is the long period (up to 4
❏ The presence of growing virus is usually detected by: weeks) required for a result to be available. Also, the
➔ Cytopathic Effect (CPE) - may be specific or sensitivity is often poor and depends on many factors, such
non-specific e.g. HSV and CMV produce a specific as the condition of the specimen, and the condition of the
CPE, whereas enteroviruses do not. cell sheet. Cell cultures are also very susceptible to bacterial
➔ Haemadsorption - cells acquire the ability to stick to contamination and toxic substances in the specimen. Lastly,
mammalian red blood cells. Hemadsorption is mainly many viruses will not grow in cell culture at all e.g. Hepatitis
used for the detection of influenza and parainfluenza B and C, Diarrheal viruses, parvovirus etc.
viruses.
❏ Confirmation of the identity of the virus may be carried out RAPID CULTURE TECHNIQUES
using neutralization, hemadsorption-inhibition, ❏ Rapid culture techniques are available whereby viral
immunofluorescence, or molecular tests. antigens are detected 2 to 4 days after inoculation.
Examples of rapid culture techniques include shell vial
cultures and the CMV DEAFF test. In the CMV DEAFF test,
the cell sheet is grown on individual cover slips in a plastic
bottle. After inoculation, the bottle is then spun at a low
speed for one hour (to speed up the adsorption of the virus)
and then incubated for 2 to 4 days. The cover slip is then
taken out and examined for the presence of CMV early
antigens by immunofluorescence.

➔ Take note of the suffix:
- Subgenus & Genus: Virus
- Subfamily: Virinae
- Family: Viridae
PREVENTION AND CONTROL

PREVENTION AND THERAPY
Figure 1.9 Left: Haemadsorption of red blood cells onto the surface ❏ Immunizations are available for some viruses capable of
of a cell sheet infected by mumps virus. Also note the presence of causing human disease.
syncytia which is indistinguishable from that of RSV. ❏ For viruses for which there are no available vaccines, the
most effective means of preventing viral infection involves:
❏ The role of cell culture (both conventional and rapid ➔ Regular, thorough handwashing (easiest way to
techniques) in the diagnosis of viral infections is being break chain of infection)
increasingly challenged by rapid diagnostic methods i.e. ➔ Avoiding contact with others during episodes of
antigen detection and molecular methods. Therefore, the evident signs and symptoms
role of cell culture is expected to decline in future and is ● Fever
likely to be restricted to large central laboratories. ● Cough
● Diarrhea
ADDITIONAL NOTE: NOMENCLATURE ● Respiratory Infections

MODULE 2: PATHOGENESIS OF VIRAL DISEASE CHAIN OF INFECTION
OUTLINE OF THE LESSON
I. INTRODUCTION
A. Chain of infection
II. VIRAL PATHOGENESIS
A. Specific steps involved in viral pathogenesis
III. PATHOGENESIS OF VIRAL DISEASE
A. Key elements of the virus-host interaction
IV. PATHOGENIC STEPS IN HUMAN INFECTION
A. Viruses and their specific receptor
VIRAL PATHOGENESIS
V. VIRAL REPLICATION PROCESS
VI. VIRAL INTERACTION ❏ process by which viruses cause disease in the host
A. Ways of viral interaction ➔ From the entry to the excretion of the virus from the
VII. TERMINOLOGIES host
A. Terms describing infections of an organism ➔ Viruses cause disease when they breach the host’s
primary physical and natural protective barriers;
B. Terms describing virus transmission
VIII. IMMUNE RESPONSE TO VIRAL INFECTIONS evade local, and immune defenses; spread in the
A. Non-specific / innate immunity body; and destroy cells either directly or via
B. Specific immunity / adaptive bystander immune and inflammatory responses.
C. Intense immunologic reaction ➔ Signs and symptoms of a disease usually appear
once the host’s cells are destroyed and the virus has
undergone replication.
INTRODUCTION
❏ Once the virus is introduced into a host, the virus infects SPECIFIC STEPS INVOLVED IN VIRAL PATHOGENESIS:
susceptible cells, frequently in the upper respiratory tract. 1. Viral entry into the host and primary viral replication (viral
❏ Viral infections may produce one of three characteristic replication can occur in in the nucleus or the cytoplasm)
clinical presentation: 2. Viral spread and tropism
➔ Acute viral infection 3. Cell injury and clinical illness
➔ Latent infection 4. Recovery from infection
➔ Chronic infection 5. Virus shedding
❏ In this module, we will discuss the mechanism of viral
disease and know the sequence of events involved in viral
replication.

PATHOGENESIS OF VIRAL DISEASE THE NET RESULT OF THIS INTERACTION MAY BE:
❏ As with other infectious agents which cause human disease, 1. No infection
the outcome of the interaction of a particular virus with the 2. Abortive infection with limited viral replication
human host is dependent on both pathogen and host ➔ Cells that have been infected with a virus but did not
factors. produce any progeny virus, infection was stopped.
❏ Viral strains within a genus may have differential cell 3. Asymptomatic infection
tropisms, replication capacities, and cytopathogenic effects. 4. Symptomatic infection
❏ Example: Strains of HIV may preferentially: 5. Depending upon the agent and the immune status of the
➔ target monocyte/macrophages or T-lymphocytes, host,
may use 5 different coreceptors (e.g., the ➔ Persistent/latent or
chemokine receptors, CCR5 or CXCR4) on the cell ➔ Self limited infection
surface
➔ may replicate to different levels and may induce PATHOGENETIC STEPS IN HUMAN INFECTION
different degrees of cell killing. ❏ A generalized schema of viral infection leading to disease in
These traits have direct clinical correlates for HIV the human host is as follows:
infected persons with respect to the rates of CD4 cell (SIR ROBERT)
decline and progression to clinical AIDS. 1. VIRAL ENTRY AND R EPLICATION
❏ On the host side, the nature of the exposure and the host ❏ Most viral infections are initiated when viruses attach
immune status are probably the two most important and enter cells of one of the body surfaces
determinants of outcome. ➔ skin, respiratory tract, gastrointestinal tract,
urogenital tract, or the conjunctiva.
KEY ELEMENTS OF THE VIRUS-HOST INTERACTION ❏ The majority of viruses enter their hosts through the
1. Viral Strain mucosa of the respiratory or gastrointestinal tract
➔ i.e New strains are usually more virulent/ pathogenic (these surfaces have a direct contact with the outside
than older strains. environment
2. Inoculum Size ❏ Depending upon the agent, the virus enters through:
➔ i.e ID50 and LD50 ➔ Skin,
3. Route of exposure ➔ Mucous membranes,
4. Susceptibility of host ➔ Respiratory tract,
➔ i.e Is there pre-existent from past exposure or ➔ Gastrointestinal tract,
vaccination?) ➔ Conjunctiva
5. Immune Status and Age of Host ➔ Urogenital tract
➔ i.e babies and pregnant women ➔ via a transfusion or transplanted organ
➔ via maternal-fetal transmission.

❏ After entry, the viral nucleic acid and ➔ Peripheral nerve routes to the central
virion-associated proteins interact with cellular nervous system ( e.g., rabies virus).
macromolecules to ultimately produce new virions ➔ For other neurotrophic agents, the central
that are released from the host cells by shedding or nervous system is seeded following viremia.
cell lysis. ❏ For many agents, there is replication in regional
❏ There is local replication at the site of the lymph nodes with subsequent viremia and spread to
inoculation. Certain agents exhibit pathology at the target organs. Some viruses travel:
skin or mucous membrane surface ➔ Bloodstream free in plasma (e.g.,
➔ e.g., herpes simplex virus, human picornaviruses)
papillomavirus. ➔ Cell associated (e.g., cytomegalovirus).
NOTE: the first step in viral pathogenesis is the viral entry and ➔ Replication in target organs may lead to
replication inside the host cell local damage and further rounds of viremia.
2. VIRAL SPREAD AND CELL TROPISM VIRUSES AND THEIR SPECIFIC RECEPTOR
❏ Mechanisms of viral spread vary, but the most
VIRUS RECEPTOR
common route is via the bloodstream or lymphatics.
❏ The presence of virus in the blood is called viremia Adenovirus Integrins
❏ Virus tend to exhibit organ and cell-type specificities,
or Viral tropism Arenavirus a-dystroglycan
❏ Tropism is the capacity of viruses to infect a specific Cytomegalovirus Heparan sulfate
cell type within a tissue or organ
❏ Tropism is determined by the specific interactions Coronavirus Aminopeptidase N
between the viral surface proteins and cellular
receptors. Sulfated glycosaminoglycans
➔ Example: HIV contains glycoproteins that Lectin
allows specific binding to the CD4+ cell
receptor. Once the virus binds to the receptor, Epstein barr virus CR2 (CD21)
it then replicates itself and spreads to other
Filovirus(ebola and marburg) TIM-1
CD4+ cells.
❏ For some neurotropic viruses there may be spread Hantavirus Integrins
along:
➔ Peripheral nerve routes to ganglia Hepatitis A virus HAVCR1/TIM1
(e.g., herpes simplex virus)
Herpes simplex Heparan sulfate

➔ Clinical illness from viral infections is the
Human herpes 7 CD4
result of complex serie of events
HIV CD4, CXCR4, CCRS ● The destruction of cells and the
reaction of our immune system
Influenza A Sialic acid ➔ Many of the factors that determine the degree
Measles CD46 of illness are still unknown
➔ Non-specific and specific host immune
Papillomavirus Alpha-6-beta-4 integrin responses come into play to try to control
and downregulate the viral replicative
Rabies Acetylcholine receptor process.
Reovirus Sialic acid
EGF receptor 4. VIRAL SHEDDING
❏ The last stage in viral pathogenesis
Rhinoviruses ICAM-1 NOTE: It is important for a virus to shed in order to maintain its
pathogenicity
Alpha1-beta1 and alpha2-
beta2 Integrins ❏ This is a necessary step to maintain a viral infection
in populations of hosts
vaccinia EGF receptor ❏ Shedding usually occurs from the body surfaces
involved in viral entry
NOTE: ❏ Shedding occurs at different stages of disease
❏ People that do not have the coreceptors CXCR4 and CCRS depending on the particular virus involved
receptor are resistant to HIV. ❏ Shedding represents the time at which an infected
individual is infectious. In some viral infections, such
3. CELL INJURY AND CLINICAL ILLNESS as rabies, human represent dead-end infections, and
❏ Destruction of virus infected cells in the target tissue shedding does not occur
➔ Presence of virus does not necessarily cause
illness but the destruction
➔ Physiologic alterations produced in the host
by tissue injury responsible for the
development of the disease
➔ Some physiologic effects may result from
nonlethal impairment of specialized function
of cells

EXAMPLE:
STAGES OF POLIOVIRUS PATHOGENESIS
STEP 1 ➔ Poliovirus is ingested

➔ The virus will enter the oropharynx
STEP 2 ➔ After ingestion the virus will migrate to the gut

associated lymphoid tissue
➔ Tonsils, peyer’s patches
STEP 3 ➔ Will then spread via the lymphatic vessels

➔ Regional lymph nodes
➔ Virus replicates
STEP 4 ➔ Distributed via the bloodstream
STEP 5 ➔ Crosses the blood-brain barrier

● Virus crossed the endothelium
➔ Spinal cord
● Virus replicates in anterior horn cells
● Affects motor functions
● Results in destruction of spinal cord Figure 2.1 Schematic representation of viral infection from entry to
● Paralysis the signs of the disease
STEP 6 ➔ Sheds through the gut VIRAL REPLICATION PROCESS

➔ Excreted in the feces GENERAL STEPS
❏ Viruses do not undergo binary fission unlike bacteria, but
undergo a complex way of replication
❏ Replication of viruses through six sequential steps
1. ATTACHMENT
❏ The attachment is the first step in viral infection, interaction
of virion with a specific receptor on the host cell

❏ Receptor molecules are generally glycoproteins
❏ Each susceptible cell may contain upto 100,000 receptors for
a given virus,
2.PENETRATION / ENTRY
❏ Also known as engulfment
❏ Virus particle is taken up inside the cell
❏ Sometimes accomplished through receptor-mediated
endocytosis with uptake of the ingested virus particles
within an endosome
➔ Virus that exhibit cell tropism
❏ Sometimes accompanied through direct penetration of
virus particles across the plasma membrane
❏ Sometimes accomplished by fusion of the virion envelope 4. EXPRESSION OF VIRAL GENOME
with the plasma membrane cell ❏ Occurs after uncoating of the viral genome
➔ Fusion is possible because the virion envelope is ❏ Various classes of viruses use different pathways to
also from the host cell synthesize mRNAs depending on the structure of the viral
nucleic acid
3. U NCOATING ➔ Specific mRNA are transcribed from the viral nucleic
❏ Occurs with penetration or shortly after penetration acid for successful expression and duplication of viral
❏ Physical separation of viral nucleic acid from the outer genome
structural components of the virion TERMS:
❏ Release of genetic material from a nucleocapsid. Genome VIRAL REPLICATION
may be released as a free nucleic acid or as nucleocapsid ❏ duplicates the genetic material of the virus
❏ Nucleocapsid usually contains polymerase VIRAL TRANSLATION
➔ Polymerase is responsible for replication inside the ❏ produces a capsomere that will form a capsid that will house
nucleocapsid the replicated genome
NOTE: Once nucleic acid is released into the cell, the virus CAPSID
opportunistically replicates using the host’s organelles ❏ is the protein shell of a virus, enclosing its genetic material.
❏ It may require an acidic pH in an endosome. The infectivity CAPSOMERE
of the parental virus is lost at the uncoating stage ❏ is a subunit of the capsid, an outer covering of protein that
protects the genetic material of a virus. Capsomeres
self-assemble to form the capsid

NOTE:
5. SYNTHESIS OF VIRAL COMPONENTS ❏ Budding enables viruses to exit the host cell and is mostly
used by enveloped viruses which must acquire a
host-derived membrane enriched in viral proteins to form
their external envelope.
❏ Enveloped virus are not infectious unless the acquire their
envelopes
Enveloped virus (Budding)
6. MORPHOGENESIS
❏ Newly synthesized viral genomes and polypeptides
assemble together to from progeny viruses
❏ Capsids of icosahedral viruses can condense in the
absence of nucleic acid
❏ Capsids of helical viruses cannot form without RN
7. RELEASE
❏ Naked viruses accumulate in infected cells and the cells
eventually lyse and release the virus
❏ Enveloped viruses are released through budding
Naked virus

VIRAL INTERACTION NOTE:
❏ When two or more viruses infect the same host cell, they ❏ In complementation the normal cell will provide the defective
may interact in a number of ways: cell with the necessary structure in order to produce a
➔ Recombination functioning virus
➔ Complementation
➔ Phenotypic mixing 3. PHENOTYPIC MIXING
➔ Interferences ❏ A special case of complementation
❏ This occurs when the genome of one virus becomes
WAYS OF VIRAL INTERACTION: randomly incorporated within capsid proteins specified by a
1. RECOMBINATION different virus or a capsid consisting of components of both
❏ Results in the formation of progeny virus (recombinant) that viruses
carries traits not found in either parent ❏ It usually occurs between different members o the same
➔ The resulting progeny virus is different from the virus family;the intermixed capsid proteins must be able to
parent virus interact correctly to form a structurally intact capsid
❏ The classic mechanism is that the nucleic acid strands ❏ There is no genetic change only the phenotype
break, and a part of the genome of one parent is joined to ❏ Mixing of the capsid proteins
part of the genome of the second parent ❏ Can result to resistance to antibody neutralization
❏ The recombinant virus is genetically stable, yielding progeny
similar to itself upon replication 4. INTERFERENCES
NOTE: ❏ Infection with 2 viruses often leads to an inhibition of
❏ Recombination hinders vaccine studies due to the constant multiplication of one of the viruses
production of new strains that are different from their parent ❏ Several mechanisms have been elucidated as cause of
viirus interference:
1. One virus may inhibit the ability of the second to
2. COMPLEMENTATION adsorb to the cell, either by blocking its
❏ This refers to the interaction of viral gene products in cells receptors(retroviruses, enteroviruses) or by
infected with two viruses, one or both of which may be destroying its receptors (orthomyxovirus)
defective 2. One virus may compete with the second for
❏ It results in the replication of one or both under conditions in components of the replication apparatus(polymerase,
which replication would not ordinarily occur translation initiation factor).
❏ The basis for complementation is that one virus provides a NOTE:
gene product in which the second is defective, allowing the ❏ The first virus may cause the infected cell to produce an
second virus to grow. The genotype of the two viruses inhibitor that prevent replication of the second virus
remain unchanged

TERMINOLOGIES ACUTE INFECTION
❏ It is a rapid onset of disease symptoms resulting in severe
TERMS DESCRIBING INFECTIONS OF AN ORGANISM illness or death of the infected animal (influenza, viral
hemorrhagic fever).
CHRONIC INFECTION
❏ It is a prolonged infection in which the organism is not
immediately killed and may carry the virus for long periods of
time (hepatitis, HIV).
TERMS DESCRIBING VIRUS TRANSMISSION

HORIZONTAL TRANSMISSION
❏ is defined as the transmission of virus or other pathogen to
host at any age after birth.
VERTICAL TRANSMISSION
❏ is the passage of a virus from mother to the new born child.
ZOONOSIS
LYTIC INFECTION
❏ is defined as the disease which is naturally transmitted
❏ When a virus enters the cell and hijacks its cellular
between animals and man (Rabies, H1N1 influenza virus,
machinery to rapidly multiply and in the process kills the cell
Rift valley fever virus).
is termed as lytic infection (many influenza viruses).
❏ Sometimes, the virus can be transmitted through an insect
vector (arboviruses). Viruses present in the saliva of the
LYSOGENIC INFECTION
infected insect are transmitted during feeding of blood meal
❏ It is the process characterized by the incorporation of viral
to the susceptible host.
DNA to the cellular DNA. Once incorporated, the viral DNA
replicates along with the host DNA. The incorporated viral
PERSISTENT INFECTION
DNA permits the host cell to undergo normal cell cycle.
❏ is a condition where the virus remains associated with the
(Does not cause damage to cell & transforms the cell into
cell without actively multiplying or killing it. This often occurs
oncogenic cell)
when the viral genome gets integrated into the host genome
(retroviruses) and sometimes without integration
(Herpesvirus).

❏ CATEGORIES:
1. Virus genome persists within the cell without actual
release of the virus, eg. Some retroviruses.
2. Virus released sporadically but remains in a state of
"latent" for most of the time (herpes simplex).
3. Virus released continuously without lysis of the host
cell, eg. hepatitis B virus. (lysogenic cycle, budding)
MULTIPLICITY OF INFECTION (M.O.I.)

Figure 2.2 Schematic diagrams showing the patterns of viral
❏ This is the ratio of total virus infected to the number of target
infections
cells in an infection condition. This is usually used to
describe the infection of a cell type grown invitro in a culture
IMMUNE RESPONSE TO VIRAL INFECTIONS
system.(ex. 5:10, 5 virus and 10 target cells) A. NON-SPECIFIC / INNATE IMMUNITY
❏ refers to those elements of the immune system that
“INFECTIOUS DOSE 50” (ID50) can clear virus or virus infected cells immediately
❏ Median Infectious Dose upon or shortly after viral exposure and which are not
❏ The dose required to infect 50% of the inoculated animals. dependent upon immunologic memory. Non-specific
immunity may include:
“LETHAL DOSE 50” (LD50) ➔ Phagocytic cells (neutrophils and monocytes
❏ The dose required to kill 50% of the inoculated animals. / macrophages).
➔ Cytokines (e.g., interferons) and
INCUBATION PERIOD chemokines.
❏ The time between the initial infection to the actual onset of ➔ Natural killer cells - kills infected cells
disease symptoms. This period can range from a few days ➔ Poorly defined antiviral factors that may
(cold viruses) to years (HIV). exist in blood or body fluids.
B. SPECIFIC IMMUNITY / ADAPTIVE

❏ refers to antigen specific B and T cell responses that
lead to the development of antibodies, cytotoxic T
cells and antibody dependent cellular cytotoxicity.

C. INTENSE IMMUNOLOGIC REACTION
❏ In some instances, an intense immunologic
reaction to a viral agent can result in
immunopathology and a serious clinical syndrome. A
prime example is dengue hemorrhagic fever which
is likely due to antibody dependent enhancement and
T cell activation on re-exposure to dengue virus.

MODULE 3: CHARACTERISTICS, LABORATORY TEST, EPIDEMIOLOGY, Although the incidence varies inversely with age (ie, greater
PREVENTION AND CONTROL OF RESPIRATORY AND among younger children than healthy young adults), the
CHILDHOOD FEVER VIRUS morbidity is significantly higher in elderly population.
Seasonality is also a feature; incidence is lowest in the
OUTLINE OF THE LESSON summer months and highest in the winter.
❏ In addition to the ability to cause a variety of Acute
I. INTRODUCTION Respiratory Disease syndromes, this group of viruses
II. RESPIRATORY AND CHILDHOOD FEVER VIRUSES
discussed in this module shares a relatively short incubation
A. Parvoviridae
B. Adenoviridae period (1-4 days) and a person-to-person mode of spread.
C. Poxviridae Transmission is direct, by infectious droplet nuclei, or
D. Orthomyxoviridae indirect, by hand transfer of contaminated secretions to nasal
➔ Influenza A Virus or conjunctival epithelium. These respiratory viral agents are
E. Paramyxoviridae associated with an increased risk of bacterial superinfection
➔ Parainfluenza of the damaged tissue of the respiratory tract, and all have a
➔ Respiratory Syncytial Virus (RSV)
worldwide distribution.
➔ Mumps (Rubula) Virus
➔ Measles (Rubeola) Virus
➔ German Measles (Rubella) Virus (SIR ROBERT)
F. Coronaviridae ❏ Viral infections account for most of acute morbidity
➔ SARS-CoV associated with respiratory diseases
➔ SARS-CoV 2 ❏ Respiratory viruses are represented from different virus
➔ MERS-CoV families:
HIGHLIGHTING OF TOPICS BULLET PLACEMENT ➔ Parvoviridae
➔ Adenoviridae
AAAAAA - Family of virus ❏ (Main definition) ➔ Poxviridae
AAAAAA - Main topic ➔ (Sub-definition/Enumerate) ➔ Orthomyxoviridae
AAAAAA - Subtopics ● (Super Sub-detail) ➔ Paramyxoviridae and Rubella
➔ Coronaviridae
INTRODUCTION ❏ Transmission of respiratory viruses by droplet, nuclei, or
❏ Respiratory disease accounts for an estimated 75% to 80% hand transfer of contaminated secretions
of all acute morbidity and most of these illnesses
(approximately 80%) are viral infections. Although a majority
of the episodes may not require medical attention, the overall
average is three to four illnesses per year per person.

RESPIRATORY AND CHILDHOOD FEVER VIRUSES
❏ Biopsy
PARVOVIRIDAE Portal of Entry Pharynx of the respiratory route
Mode of ❏ Droplets
GENERAL CHARACTERISTICS OF PARVOVIRIDAE
Transmission ❏ Blood
Family Parvoviridae ❏ Transplacental
Common Name Parvovirus Diseases ❏ Erythema infectiosum (fifth disease)

❏ Aplastic crisis in patients with chronic
Virus Parvovirus B-19 hemolytic anemia
❏ Fetal infection and stillbirth
Characteristics ❏ Single-stranded DNA virus
❏ Icosahedral capsid, no envelope Treatment Supportive
❏ Parvovirus B-19 is the only known human
pathogen Prevention Avoid contact
❏ Icosahedral
❏ 18-26 nm in diameter GENERAL CHARACTERISTICS
❏ 32 capsomeres (made up of proteins: ❏ Parvovirus came from a Latin word “parvus”, meaning
VP1 and VP2)
small. Parvoviruses are the smallest DNA animal viruses.
Genome ❏ Single-stranded DNA It is widely distributed among warm blooded animals.
❏ Linear ❏ Parvovirus B19 represents the one human pathogen in the
family. Its replication in human cells is restricted to erythroid
Proteins ❏ VP1 (minor protein) progenitor cells, making adult bone marrow and fetal
❏ VP 2 (major protein)
liver, the site of erythropoiesis during fetal development, the
Envelope None major sites of viral replication.
❏ Parvovirus B19 is pathogenic for humans and has tropism
Replication Nucleus for erythroid progenitor cells
➔ Globoside or Blood Group P Antigen (antigen on
Outstanding ❏ Environmentally stable
erythroid progenitor cells in which the Parvovirus B19
Characteristics ❏ Parvovirus has tropism for RBC
progenitor binds to)
Detection ❏ Serology/Antigen Detection

❏ PCR

STRUCTURE OF PARVOVIRUSES PARVOVIRUSES REPLICATION
- Parvovirus B19 encodes two capsid proteins (VP1 and VP2) ❏ Parvovirus B19 has a tropism for cells with group P antigen
that encapsulate a single stranded DNA molecule into (Globoside) receptors
icosahedral symmetry. ❏ Globoside is expressed on
- VP2 is the major capsid protein that comprises almost 90% ➔ Mature erythrocyte
of the virion capsid. ➔ Erythroid progenitors
➔ Megakaryocytes
➔ Endothelial cells
➔ Placenta
➔ Fetal liver
➔ Heart
❏ Replication occurs in the nucleus (because the RNA
polymerase of the host cell is in the nucleus so in order to
replicate the virus must be inside the nucleus)
❏ All DNA viruses replicate in the nucleus (except
poxviruses) because they need to be converted into mRNA
Figure 3.1 Structure of Parvovirus (left) and Slapped Cheek Rash first.
caused by Parvovirus B19 ❏ All RNA viruses replicate in the cytoplasm (except
orthomyxoviruses & retroviruses) because it is where
ribosomes are found. The ribosomes are the ones
responsible for the translation of RNA into viral proteins.
PATHOGENESIS
GENERAL PATHOGENESIS:
❏ The virus is spread through the respiratory route. Pharynx
is the site of viral shedding for parvovirus B19 .
❏ The virus can be transmitted parenterally by blood
transfusions or by infected blood products (coagulation
PARVOVIRUSES CLASSIFICATION factors and immunoglobulin concentrates) and vertically from
There are two subfamilies of Parvoviridae: mother to fetus.
A. Parvovirinae - infect vertebrates; Human parvovirus B19 is ❏ Parvovirus B19 can survive in the coagulation factors and
the most common member of this subfamily immunoglobulin concentrates because it is naked, which
B. Densovirinae - infect insects makes it resistant to harsh environments.

❏ Occur throughout the year in all age groups and many B. ARTHRALGIA-ARTHRITIS
infections are subclinical. ❏ Joint involvement is prominent in adult cases. There
❏ Parvovirus causes a biphasic illness in humans. will be formation of antigen-antibody complexes.
a. FIRST PHASE - comprises fever, malaise, myalgia, These complexes will be deposited in the joints
and chills, which corresponds to peak levels of virus causing inflammation and pain. Joint symptoms
destruction or erythroblasts. This phase when mild, mimic rheumatoid arthritis.
may be overlooked or considered nonspecific viral
disease. C. TRANSIENT APLASTIC CRISIS
b. SECOND PHASE - includes rash and arthralgia ❏ There will be transient aplastic crisis in patients with
occurring after the virus has disappeared but at a Hemolytic disorders which might lead to severe acute
time when parvovirus- specific antibody can be anemia. Remember that the receptor for parvovirus
detected, consistent with the conclusion that the rash B19 is present on the surface of RBCs.
is caused by immune complexes in the capillaries of
the skin. D. PURE RED CELL APLASIA
❏ Manifests in immunodeficient hosts which will lead to
DISEASES CAUSED: chronic anemia.
A. ERYTHEMA INFECTIOSUM (FIFTH DISEASE)
❏ Most common manifestation of human parvovirus E. HYDROPS FETALIS
B19 infection ❏ Happens when a pregnant woman is infected with
❏ Fifth disease because there are six other diseases parvovirus B19. The virus will cross the placenta and
that cause exanthems and Erythema infectiosum is the baby will develop fetal anemia.
the fifth.
❏ Most common manifestation of human parvovirus LABORATORY DIAGNOSIS
B19 infection. It is a characteristic cutaneous rash. ❏ Laboratory diagnosis is accomplished by using
❏ Most common in children of early school age and parvovirus-specific IgM or virus-specific IgG antibody
occasionally affects adults. Fever and mild rash testing with acute and convalescent sera. Parvovirus
“slapped-cheek” appearance manifest in children. cannot be cultivated in usual cells available in clinical
❏ The appearance of erythematous facial rash and virology laboratories. PCR, serologic assays, and
lacelike rash on the limbs and trunks will appear 2 immunohistochemistry can be used.
weeks after the start of incubation. ➔ PCR is the most sensitive among the three.
➔ IgM or cold antibody is seen in recent/acute
infection. It is the first antibody produced during
infection.

➔ IgG or warm antibody indicates past infection and
❏ Fiber projects from each vertex
immunity.
➔ Immunohistochemistry can also be used to detect Composition 13% - DNA
parvovirus B19 antigens in fetal tissues and bone 87% - Protein
marrow.
Genome ❏ Double-stranded DNA
❏ Linear
TREATMENT, PREVENTION, AND CONTROL ❏ Protein bound to terminal portion
❏ Erythema Infectiosum (Fifth disease) and transient aplastic
crisis are treated symptomatically. There is no antiviral drug Proteins Important antigens (240 hexon, 12 penton
therapy parvovirus B19. base, fibers) are associated with the major
❏ Commercial immunoglobulin preparations contain outer capsid proteins
neutralizing antibodies to human parvovirus used for Envelope None
treatment and prevention of B19 infection.
❏ There is no vaccine against human parvovirus but there are Replication Nucleus
effective vaccines for use in cats, dogs and pigs.
❏ Good hygienic practices for prevention Outstanding Excellent models for molecular studies of
Characteristics eukaryotic cell processes
ADENOVIRIDAE Site of Latency Replication in oropharynx
Disease ❏ Pharyngitis
GENERAL CHARACTERISTICS OF ADENOVIRIDAE ❏ Pharyngoconjunctival fever
❏ Keratoconjunctivitis (pink eye)
Family Adenoviridae
❏ Pneumonia
Common Adenovirus ❏ Hemorrhagic cystitis
Name ❏ Disseminated disease
❏ Gastroenteritis in children
Virus Adenovirus
Diagnosis ❏ Cell culture (Hep-2 and other continuous
Characteristics ❏ Double-stranded DNA genome human epithelial lines)
❏ Icosahedral capsid ❏ EIA for gastroenteritis serotypes 40-41
❏ No envelope
❏ Approximately 50 human serotypes Treatment Supportive
❏ 70-90 nm in diameter
Prevention Vaccine (adenovirus serotypes 4 and 7)
❏ 252 capsomeres

KNOB DOMAIN
❏ Found at the end of a fiber
❏ detects the receptor of the adenovirus (integrins) and
bind to the host cell or the surface of epithelial cells
COXSACKIE-ADENOVIRUS RECEPTOR (CAR)

❏ Integrin - receptor where adenovirus binds
❏ found in epithelial cells
❏ provides and maintain tight junction integrity in epithelial
cells
Figure 3.2 Virion structure of Adenovirus
GENERAL CHARACTERISTICS
❏ Adenovirus is a member of family Adenoviridae and the
genus Mastadenovirus. The virus has a linear
double-stranded DNA, icosahedral symmetry, and a size of
70-90 nm.
❏ Adenoviruses were first isolated from human adenoid
tissues. At present, approximately 50 serotypes of human
adenoviruses have been described; however, most disease
is associated with only one third of these types.
Adenoviruses cause less than 5% of all acute respiratory ADENOVIRIDAE CLASSIFICATION
disease in the general population. In addition, adenovirus ❏ Adenoviruses have been recovered from a wide variety of
serotypes 40 and 41 cause gastroenteritis in infants and species and grouped into five genera.
young children. Other diseases occur but are less common. ❏ All of the human adenoviruses are classified in the
Mastadenovirus genus.
PROPERTIES OF ADENOVIRIDAE ❏ Human adenoviruses are divided into seven groups (A-G)
❏ Adenovirus is a non-enveloped virus on the basis of their genetic, physical, chemical, and biologic
❏ 252 capsomeres = 240 hexon and 12 penton base properties.
➔ Each penton base has a projected fiber
➔ The importance of the fiber is for the attachment of
the virus

ADENOVIRIDAE REPLICATION ❏ The name “adenovirus” reflects the recovery of the initial
❏ Adenoviruses can replicate and produce disease in the isolate from explanations of human adenoids.
respiratory, gastrointestinal, and urinary tracts and in the ❏ Adenoviruses are responsible for about 5% of acute
eye. respiratory disease in young children, but they account for
❏ Adenovirus only replicates well in cells of epithelial origin and much less in adults.
inside the nucleus.
❏ Adenoviruses infect and replicate in epithelial cells of the
respiratory tract, eye, gastrointestinal tract, and urinary tract.
❏ They usually do not spread beyond the regional lymph
nodes.
PATHOGENESIS
❏ Adenoviruses are spread by:
➔ Direct Contact
➔ Fecal-oral route
➔ Respiratory droplets (replicates in the epithelial cells) NOTE:
➔ Contaminated fomites ❏ Bold numbers - serotypes that causes outbreak in the
❏ About one-third of the known human serotypes are specific syndromes
commonly associated with human illness. ➔ Childhood febrile illness - 3, 7a
❏ It should be noted that a single serotype may cause different ➔ Pneumonia - 3, 5, 7a, 7b, 14a
clinical diseases and, conversely, that more than one type ➔ Pertussis-like - 3, 19
may cause the same clinical illness. ➔ Keratoconjunctivitis - 3, 19
❏ Most infections are mild and self-limited. ❏ Pharyngoconjunctival fever - swimming pool conjunctivitis
❏ The viruses occasionally cause disease in other organs, ❏ Conjunctivitis/ Keratoconjunctivitis - looks like sore eyes;
particularly the eye and the gastrointestinal tract. highly contagious
❏ Many adenovirus infections are subclinical, and viruses may
LABORATORY DIAGNOSIS
persist in the host for months.
❏ Specimens to be collected include throat swabs, nasal
❏ Group C viruses persist as latent infections for years in
washings, conjunctival swabs or scrapings, or feces.
adenoids and tonsils and are shed in the feces for many
Laboratory diagnosis is accomplished by conventional cell
months after the initial infection.
culture using HEp-2 cells and serologic methods.
(Adenoids - secondary lymphoid organs present behind
nasal cavity)

A. DETECTION, ISOLATION, AND IDENTIFICATION OF ❏ Adenovirus (naked capsid) is relatively resistant to
VIRUS disinfectants and more stable than other enveloped
❏ Adenovirus may be recovered from stool, urine, respiratory viruses
throat, conjunctiva or rectum:
➔ Virus isolation in cell cultures TREATMENT, PREVENTION AND CONTROL
➔ Immunofluorescence ❏ There is no specific treatment for adenoviruses infection
➔ Hemagglutination-inhibition and Neutralization ➔ Adenovirus is self-limiting therefore the immune
tests system of an immunocompetent individual can
➔ Cell staining handle the infection)
➔ PCR (most sensitive) - for DNA virus ❏ Ways to prevent Adenovirus infections:
➔ RT-PCR - for mRNA virus ➔ Careful handwashing
➔ Electron microscopy ➔ DIsinfection of environmental surfaces
➔ ELISA ➔ Chlorination of swimming pools
➔ Latex-Agglutination Test ➔ Adequate sterilization of ophthalmic equipment
(adenoviruses can infect the eyes)
B. SEROLOGICAL TESTS ❏ Attempts to control adenovirus infections in the military have
❏ Complement fixing antibodies (least specific, least focused on vaccines.
sensitive) ➔ Live adenovirus vaccine containing types 4 and 7,
❏ Hemagglutination-inhibition tests (more specific, encased in gelatin-coated capsules and given orally,
more sensitive) was introduced in 1971.
❏ Neutralization Tests (most specific, most sensitivity) ➔ Virus first replicates in the respiratory tract. The
vaccine is given orally to bypass the replication of
EPIDEMIOLOGY virus and for it to be killed immediately by the
❏ Adenoviruses exist in all parts of the world immune system)
❏ They are present year-round and usually do not cause ❏ The vaccine proved highly effective but was discontinued in
community outbreaks of disease 1999, and was reapproved in 2011 for US military personnel
❏ Infections with Types 1,2,5 and 6 occur chiefly during the only.
first years of life
❏ Infections with Types 3 and 7 are contracted during school
years (take note of this)
❏ Infections with types 4, 8, and 19 are encountered during
adulthood

POXVIRIDAE
❏ Virus encoded proteins to help evade host's
immune defense system
GENERAL CHARACTERISTICS OF POXVIRUSES ❏ Smallpox was the first viral disease in the
world
Family Poxviridae
Transmission Respiratory droplets (smallpox); direct contact
Common Name Poxvirus (molluscum and orf)
Virus ❏ Small, molluscum contagiosum, and orf Disease All disease of the skin; smallpox is a
virus generalized infection with pustular rash
❏ Complex structure (10-25% fatal); molluscum manifests as benign
❏ Oval or brick shaped nodules of skin; orf manifests as localized
❏ 300-400 nm in length papules/vesicles of the skin
❏ 230 nm in diameter
Detection Electron Microscopy - skin lesion material
Characteristics ❏ Largest and most complex of all viruses
❏ Brick-shaped virion with nonconforming Epidemiology: Smallpox eradicated from world in 1977;
symmetry reffered to as complex smallpox and molluscum and limited to
❏ Double-stranded DNA genome humans; orf is zoonotic
Composition 3% - DNA Treatment: Supportive

90% - Proteins
5% - Lipids Prevention: Vaccine for smallpox.
Avoid contact for others.
Genome ❏ Double-stranded DNA
❏ Linear
Proteins ❏ Contains >100 polypeptides

❏ Many enzymes are present in core,
including transcriptional system
Envelope Formation of multiple membranes
Replication Cytoplasmic factories
Outstanding ❏ Large and complex viruses

characteristics ❏ Very resistant to inactivation

GENERAL CHARACTERISTICS ❏ Pox virus replicates in the cytoplasm because it can make its
❏ The Poxviruses are the largest and most complex of all the own DNA and RNA polymerase. DNA viruses only enter the
viruses, with a size of 225 x 300 nm. These are nucleus because RNA polymerase is only present in the
DNA-containing viruses that are enveloped with complex nucleus of the host’s cell.
coats with brick shape and complex morphology.
❏ The Family includes variola, the smallpox virus, and STRUCTURE OF THE POXVIRUSES
vaccinia virus, as well as the agents of cowpox,
monkeypox and canarypox.
POXVIRUS REPLICATION
NOTE:
❏ Poxviridae that infects vertebrates are classified into 8
genera
❏ Among these 8 genus, only 4 genus can cause diseases to
humans.
PROPERTIES OF POXVIRUSES
❏ All DNA viruses replicate in the nucleus except for Pox
viruses
❏ It is unique since it contains an enzyme in its core which can
produce its own RNA

PATHOGENESIS ❏ The virus spreads through the capillaries to the skin followed
❏ Diseases caused by poxviruses include smallpox, ; again by a viral replication and evolution of rash
molluscum contagiosum,; and orf, . ❏ By the virus further spread cell-to-cell or through the mid and
A. VARIOLA VIRUS (SMALLPOX) basal layers of the skin causing necrosis and pustules
❏ a devastating and frequently fatal disease of (pantal of lesions)
historical importance (eliminated from the world in ❏ Later, pustules breakdown and will form crusts and
1980) discharge the virus into the environment of the smallpox
❏ Deadly; Highly contagious and can survive well in the patient
extracellular environment.
❏ In 1067 the WHO) launched an ambitious program to
eradicate smallpox because of two main reasons:
➔ Humans are the only reservoir of smallpox.
➔ Asymptomatic carriage apparently did not
occur
❏ Global eradication of Smallpox was confirmed in
1979 and accepted by WHO in May 1980. Since
then, the virus has been solely secured in two
WHO-restricted laboratories: USA and Russia
❏ 1st virus to be eradicated
MECHANISM OF VARIOLA VIRUS

❏ Infections with most pox viruses are characterized by a rash,
although lesions induced by some members of the family are
markedly proliferative.
❏ The virus enters the mucous membranes of the upper
respiratory tract through inhalation followed by viral
replication at the site of entry and infection of mononuclear
phagocytic cells in regional lymph nodes.
❏ Viremia allows the virus be transported to the liver, spleen
and other tissues
❏ At the end of the incubation period (10 to 14 days)
inflammatory mediators are released causing fever and other
symptoms.

B. MOLLUSCUM CONTAGIOSUM ❏ Antigenic cross - reactivity was so much that Variola was
❏ an exclusively human disease of the skin that is able to eradicate variola globally
self-limited but may recur during periods of severe ❏ Vaccinia virus
immunosuppression ❏ Pathogenic to animals
❏ Non-pathogenic to humans
C. ORF ❏ Used for smallpox vaccine
❏ a localized infection of the skin caused by viruses
responsible for dermatitis in sheep, goats, and B. COWPOX VACCINE
related animals (zoonotic) ❏ Discovered by Edward Jener (the father of
Vaccination) was in use before vaccinia was
LABORATORY DIAGNOSIS OF VARIOLA VIRUS available
❏ Direct examination of material from skin lesions NOTE:
❏ Cell culture can be used for virus isolation ❏ Cowpox vaccine was replaced with live vaccinia vaccine
❏ Viral DNA detection via PCR because the vaccinia vaccine had less severe effects and
❏ Identification of antigen from lesions was more effective.
❏ Demonstration of antibodies in the blood
C. VARIOLATION
VACCINATION ❏ Was the first attempt of providing artificial immunity
A. LIVE VACCINIA VACCINE against Smallpox it was in use even before the
❏ Was highly effective cowpox vaccine was available
❏ Used live Vaccinia Virus
❏ it was given as single dose between one and two ADDITIONAL INFO:
years of age ❏ Since the Variola virus (pox viruses) is stable in the outside
❏ as an un-attenuated live virus was used adverse environment, they have high potential for bioterrorism
reactions were common; such as mild vaccinia
induced rashes
❏ Eradicated smallpox
NOTE:
❏ The mechanism behind the vaccine was Cross-immunity
because Vaccinia virus is serologically related to smallpox,
although its exact origin is unknown
❏ Vaccinia cross-reacts with variola and the antibodies
produced against vaccinia are protective against variola.

ORTHOMYXOVIRIDAE
❏ Influenza causes worldwide epidemics
GENERAL CHARACTERISTICS OF ORTHOMYXOVIRIDAE INFLUENZA A INFLUENZA B
Family Orthomyxoviridae
Transmission Contact with respiratory secretions
Common Name Orthomyxovirus
Disease ❏ Influenza (malaise, Similar to mild
Characteristics ❏ Segmented (eight separate molecules) headache, myalgia, influenza
❏ Single-stranded RNA genome cough)
❏ Spherical (Because of the presence of the ❏ primary Influenza
envelope) pneumonia
❏ Helical nucleocapsid, 9nm ❏ in children, croup,
❏ Three major antigenic types: Influenza A, B, bronchiolitis, and
and C. otitis media
➔ Type A and B cause nearly all human
disease. Detection Cell culture (PMK), EIA, FA stain
Composition ❏ RNA (1%) Epidemiology Viral subtypes based Antigenic drift only,
❏ Protein (73%) on hemagglutinin and resulting in local
❏ Lipid (20%) neuraminidase outbreaks every 1-3
❏ Carbohydrate(6%) glycoproteins years
abbreviated “H” and
Genome ❏ Single stranded RNA “N”, respectively (e.g.,
❏ Segmented (eight molecules) H1N1 or H3N2); infects
❏ Negative-sense humans and other
animals;
Proteins ❏ Nine structural proteins, ❏ Antigenic drift,
❏ One non-structural
resulting in minor
Envelope Contains viral hemagglutinin and antigenic change,
neuraminidase proteins causes local
outbreaks of
Replication Nuclear transcription influenza every 1-3
years;
Outstanding ❏ Genetic reassortment common among ❏ Antigenic shift,
Characteristics members of the same genus resulting in major
antigenic change,

causes periodic
worldwide ❏ Causative agents of Flu (trangkaso)
outbreaks ❏ Influenza viruses (A, B, and C)
❏ The orthomyxoviridae (influenza viruses) are a major
Treatment ❏ Supportive ❏ Supportive determinant of morbidity and mortality caused by respiratory
❏ Antivirals ❏ Zanamivir and disease and outbreaks of infection sometimes occur in
❏ Amantadine and Oseltamivir
worldwide epidemics
rimantadine
(Influenza A only) ❏ The viruses contain positive sense, single-stranded RNA and
❏ Zanamivir and helical symmetry and are enveloped. Influenza viruses range
Oseltamivir for in size from: 80-120 nm.
influenza A and B ❏ Their structures transform that is why yearly you can be
infected with the flu
❏ Influenza has been responsible for millions of deaths
Prevention Influenza vaccine or antiviral prophylaxis
worldwide
NOTE:
“H or HA” = Hemagglutinin STRUCTURE OF THE ORTHOMYXOVIRIDAE
“N” = Neuraminidase ❏ Because of the segmented nature of the viral genome (eight
segments), when a cell is co-infected of two strains of
Orthomyxoviruses, there is a possibility of recombination
❏ Influenza viruses are divided into three types: A, B, C based
on antigenic differences in their ribonucleoprotein (NP) and
matrix (M) protein antigens
❏ Influenza A virus has the greatest virulence and
predominance in epidemic spreads, because of their ability
to undergo genetic changes and existence in several species
Table 3.4 Virion Structure of Orthomyxoviruses

FEATURE INFLUENZA A INFLUENZA B INFLUENZA C RNA
Gene 8 8 7 6 NA - Neuraminidase Virus release from

segments infected cells
Unique M2 NB HEF 7 M1,M2 - matrix proteins Matrix, ion channel

proteins
8 NS1,NS2 Nonstructural NS1 in interferon
Host range Humans,swine, Humans, seals Humans, swine proteins antagonist
avians,
equines,marine
mammals, bats NOTE:
❏ Segment 6 of RNA is not present in INFLUENZA B
Disease Often severe Occasionally Usually mild ❏ RNA 1,2,3 produces RNA Polymerase
severity severe
IMPORTANCE OF HEMAGGLUTININ (HA)
Epidemic Extensive, Outbreaks, Limited
potential epidemics and occasionally outbreaks ❏ Hemagglutinin attach to N-Acetylneuraminic (sialic acid)
pandemics epidemics (antigenic drift acid-only containing glycoprotein or glycolipid receptor
(antigenic drifts (antigenic drift only) sites on human respiratory cell surfaces, which is critical first
and shifts) only) step in initiating infection of the cell
❏ HA also promotes the fusion of the viral envelope to the host
cell membrane and can hemagglutinate human, chicken, and
RNA PROTEINS FUNCTION guinea pig red blood cells. HA also elicits the neutralizing
SEGMENT
antibody response.
1 PB2 - Polymerase RNA synthesis, virulence ❏ Influenza viruses display cell tropism towards respiratory
component cells, because respiratory cells contain sialic acid
(N-Acetylneuraminic acid)
2 PB1- polymerase RNA synthesis
component
IMPORTANCE OF NEURAMINIDASE
3 PA - Polymerase RNA synthesis ❏ Neuraminidase promotes a smooth passage for the virus in
component respiratory tract by inactivating mucoprotein receptors in
respiratory secretions
4 HA - Hemagglutinin Viral attachment ❏ Neuraminidase destroys viral receptors, thus preventing
5 NP - Nucleocapsid RNA synthesis, binds to aggregation and superinfection in infected cells

❏ NA permits the virus entry into the host cell and also cleaves Example : A/Goose/Guangdong/1/1997 (H5N1)
the sialic acid on the viral particle (uncoating), which helps to ❏ If the infected is human, no need to put the description of the
release the virus from the host cells. infected animal.
NOTE: ❏ H5N1- Bird Flu
❏ Neuraminidase will destroy the sialic acid to allow the
release of the influenza virus outside the host cell. PROPERTIES OF ORTHOMYXOVIRIDAE
❏ The Orthomyxoviridae family includes the influenza (A, B
ORTHOMYXOVIRUS REPLICATION and C) viruses. Important characteristics of the family
❏ Orthomyxoviridae are RNA viruses, but they replicate inside includes the presence of hemagglutinin antigen (HA) and
the nucleus because they first need to steal the Cap neuraminidase antigen (NA).
sequences of the host’s mRNA and transfer it to their own ❏ Mutability and high frequency of genetic reassortment and
mRNA for replication of viral mRNA. resultant antigenic changes in the viral surface glycoproteins
❏ Once the virus obtains the cap sequence, it then goes to the make influenza viruses from edible challenges for control
cytoplasm to replicate. efforts
ORTHOMYXOVIRIDAE NOMENCLATURE ANTIGENIC DRIFT

IN ORDER: ❏ Caused by mutation during genome replication, results in
1. Antigenic type minor antigenic change and relatively mild influenza
2. Infected animal outbreaks every 1-3 years.
3. Geographic site of isolation ❏ Gene recombination occurs when influenza viruses
4. strain # re-assort, accumulation of a series of minor genetic
5. Year of isolation mutations, HA antigen changes change.
6. (Antigenic description H-Hemagglutinin and
N-Neuraminidase)

ANTIGENIC SHIFT
❏ caused by reassortment or mixing of the segmented viral
genome during co-infection in nonhuman animals, results in
major antigenic change and periodic worldwide outbreaks
(pandemics). Co-infection occurs when a human virus infects
a cell at the same time as an animal influenza virus.
❏ Genetic change that enables a flu strain to jump from one
animal virus to another which allows gene recombination
making a new strain (yearly) .
INFLUENZA A VIRUS
INFLUENZA A VIRUS
❏ Influenza A virus genome has eight negative sense RNA
segments each encoding at least one protein
❏ A unique aspect of this virus is their ability to develop a wide
variety of subtypes through the process of mutation and
Whole-gene swapping between strains called reassortment
❏ Mutation (antigenic drift) and reassortment (antigenic
shift) which produces antigenic changes in the virus
➔ That is why yearly, you can be infected by influenza
virus. Because no two viruses are the same
❏ 18 recognized subtypes of Hemagglutinin (HA) and 11
Neuraminidase (N) subtypes are known to exist among
influenza A viruses
❏ Three subtypes of H (H1,H2, and H3) and two subtypes of
N(N1 and N2) exist in humans
➔ This is why we are not infected by other influenza
❏ These subtypes are designated according to the H and N
antigens on their surface (eg, H1N1 , H3N2)

❏ Subtle changes known as Antigenic drift (mutation) occurs in LABORATORY DIAGNOSIS OF INFLUENZA A VIRUS
all strains, whereas drastic changes as antigenic shift ❏ Specimens collected for identification of influenza virus
(reassortment) occurs when two closely related strains of include throat swabs and nasal aspirates or nasopharyngeal
influenza A infect the same cell swabs. Influenza virus disease is detected in the laboratory
❏ Antigenic drift occurs every year to few years with influenza by cell culture, fluorescent antibody (FA) staining or
A viruses, whereas antigenic shift occurs abruptly and other antigen detection methods, serologic testing and
unpredictably PCR.
❏ Nasopharyngeal swabs and nasal aspirate or lavage fluid
PANDEMICS CAUSED BY INFLUENZA A are the best specimens for diagnostic testing and should be
A. SWINE INFLUENZA obtained within 3 days after the onset of symptoms.
❏ An infectious viral disease of the swine ➔ RT-PCR
❏ Swine viruses such as A(H1N1) and A(H3N2) have ➔ Isolation and Identification of Influenza virus using
caused serious infections in humans cell cultures and inoculation in embryonated egg
➔ Serological method for detection of influenza virus
B. AVIAN INFLUENZA protein antibodies
❏ Commonly called “Bird Flu”
❏ An infectious viral disease of birds EPIDEMIOLOGY OF INFLUENZA A VIRUS
❏ Most avian influenza viruses do not infect humans ❏ Humans are the major hosts of the influenza viruss, and
❏ A(H5N1) is a highly pathogenic avian influenza A severe respiratory disease is the primary manifestation of
virus infection.
❏ Influenza occur worldwide and cause annual outbreaks
INFLUENZA A TARGETS especially during cold months
❏ H1N1 (human) and H5N1 (avian) target different regions of ❏ Every 10-40 years, a new subtype of influenza A appears to
the respiratory tract cause pandemics.
❏ Receptors for H1N1 (human) are dominant in the upper part
of the respiratory tract
ortion of the
❏ H5N1 (avian) receptors are found in the lower p
lung in humans
❏ H1N1 (swine) interacts with both receptors in the upper and
lower respiratory tract
NOTE: H5N1 (avian) is rare due to the position of receptors (lower

portion of the lungs)

❏ Lipid (20%)
TREATMENT ❏ Carbohydrates (6%)
Proteins 6-8 structural proteins
Envelope ❏ Contains viral glycoprotein G (RSV),

❏ H (measles) or HN (paramyxovirus & mumps)
➔ for viral attachment which sometimes carries
hemagglutinin or neuraminidase activity)
NOTE: Amantadine and Rimantadine are not currently ❏ Fusion (f) glycoproteins
recommended for use due to resistance ➔ causes syncytia / multinucleated cell
➔ very fragile
PREVENTION AND CONTROL Replication Cytoplasm; particles bud from plasma membrane
❏ The best available control method of controlling influenza NOTE: All RNA viruses replicates in the cytoplasm
infections is to annually vaccinate all people aged 6 months except Orthomyxoviridae and Reoviridae
and older. Outstanding ❏ Antigenically stable (not capable of antigenic shift &
❏ Studies shown that handwashing with soap and water of the Characteristics drift)
use of alcohol-based hand rubs is highly effective at ❏ Particles are labile yet highly infectious
reducing the amount of virus in hands
Respiratory
Measles Virus Mumps Parainfluenza Syncytial
PARAMYXOVIRIDAE Virus
Transmission
GENERAL CHARACTERISTICS OF PARAMYXOVIRIDAE
Contact with Person-to-person Contact with Person-to-pers
Family Paramyxoviridae respiratory contact, respiratory on by hand and
secretions; presumably secretions respiratory
Common Name Paramyxovirus extremely respiratory contact
contagious droplets
Characteristics ❏ Single stranded
❏ RNA genome Disease
❏ Linear
❏ Helical capsid with envelope Measles, atypical Mumps Adults: upper Primarily in
❏ No segmented genomes like orthomyxoviruses measles (occurs respiratory, infants and
❏ Negative sense in those with rarely children.
waning pneumonia Infants:
Composition ❏ RNA (1%) “vaccine”, Children: bronchiolitis,
❏ Protein (73%) respiratory pneumonia and

and subacute including croup, croup. transmission
sclerosing bronchiolitis, Children: upper with isolation
panencephalitis and pneumonia respiratory and cohorting.
Detection
Cell culture Cell Culture Cell culture Cell culture ❏ The Paramyxoviruses include the genera Paramyxovirus,
(PMK) and (PMK) and (PMK), shell (Hep-2 cells),
Morbillivirus, and Pneumovirus. The family possesses
serology serology viral culture, EIA, and FA
and FA stain stain negative sense, single stranded RNA, helical symmetry, an
Four serotypes, envelope, and an average size of 150 – 300 nm.
disease occurs Disease occurs ❏ Paramyxoviruses do not have segmented genomes, and
year-round annually late
therefore do not undergo antigenic shift like the
fall through
early spring; orthomyxoviruses. The Morbillivirus includes rubeola which
nosocomial causes measles. The Genus Pneumovirus includes the
transmission respiratory syncytial virus (RSV).
can occur
readily
❏ The paramyxoviruses include the most important agents of
respiratory infections of infants and young children (RSV &
Treatment Parainfluenza Virus) as well as the causative agents of two
of the most common contagious diseases of childhood
Supportive; Supportive Supportive Supportive;
immunocompromi treat severe (Mumps & Measles).
sed patients can disease in ❏ All members of the Paramyxoviridae family initiate infection
be treated with compromised via the respiratory tract. Whereas replication of the
immune serum infants with
respiratory pathogen is limited to the respiratory epithelia,
globulin ribavirin
measles and mumps become disseminated throughout the
Prevention body and produce generalized disease.
❏ Laboratory detection is performed using cell culture with
Prevention: Mumps Vaccine Avoid contact Avoid contact
Measles vaccine with virus with viruses.
hemadsorption, FA staining, or enzyme immunoassay.
Immune
globulin for PARAMYXOVIRIDAE CLASSIFICATION
infants with ❏ The Paramyxoviridae family is divided into two subfamilies
underlying lung
disease; and seven genera, six of which contain human pathogens
prevent ❏ Most of the members are monotypic
nosocomial

CLASSIFICATION: PARAINFLUENZA
❏ Parainfluenza viruses are ubiquitous and cause common
PARAMYXOVIRINAE
respiratory illness in persons of all ages.
Respirovirus Rubulavirus Morbillivirus Henipavirus ❏ They are major pathogens of severe respiratory tract disease
in infants and young children (parainfluenza 1 & 3)
Parainfluenza Mumps Measles Hendra ❏ Reinfections with parainfluenza viruses are common (due to
1 and 3
many serotype)
Parainfluenza Nipah
2, 4a,and 4b
PATHOGENESIS
❏ Parainfluenza virus replication in the immunocompetent host
PNUEMOVIRINAE appears to be limited to respiratory epithelia
❏ The infection may involve only the nose and throat, resulting
Pneumovirus Metapneumovirus in a “common cold” syndrome
Respiratory Syncytial Human Metapneumovirus ❏ The production of virus-specific IgE antibodies during
Virus (RSV) primary infections has been associated with disease
severity
❏ The mechanism may involve release of mediators of
REPLICATION OF PARAMYXOVIRIDAE
inflammation that alter airway function
TYPES OF PARAINFLUENZA
A. Type 1 & 2
❏ May involve the larynx and the upper trachea,
resulting in croup (laryngotracheobronchitis)
❏ Croup is characterized by respiratory obstruction
caused by swelling of the larynx and related
structures
❏ Croup is more likely to occur in older children
between 6-18 months of age

EPIDEMIOLOGY
❏ Parainfluenza viruses are widely distributed geographically
❏ Parainfluenza viruses are a major cause of lower respiratory
tract disease in young children
❏ Parainfluenza viruses are spread by:
➔ Direct person to person contact
➔ Large droplet aerosols
TREATMENT , PREVENTION, AND CONTROL

❏ Contact isolation precaution
❏ Proper hand hygiene
B. Type 3 ❏ Ribavirin has been used with some benefit in treatment of
❏ May spread deeper to the lower trachea and the immunocompromised patients with lower respiratory tract
ronchi to become pneumonia or bronchiolitis disease
❏ No vaccine available
C. Type 4
❏ Does not cause serious disease even on the first RESPIRATORY SYNCYTIAL VIRUS (PNEUMOVIRUS)
infection ❏ RSV is the single most important agent of bronchiolitis and
pneumonia in infants younger than 1 year of age
LABORATORY DIAGNOSIS ❏ RSV replication occurs initially in epithelial cell of the
❏ Nucleic acid amplification tests RT-PCR are the preferred nasopharynx
diagnostic methods because of their sensitivity and ❏ Virus may spread into lower respiratory tract and cause
specificity, their ability to detect a broad range of viruses, bronchiolitis and pneumonia
and the rapidity of results. ❏ Viral antigen can be detected in the upper respiratory tract
❏ Antigen detection methods are also useful for rapid and in shed epithelial cells
diagnosis.
❏ A continuous monkey kidney cell line, LLC-MK2, is NOTE:
suitable for isolation of parainfluenza viruses (multinucleated ❏ Respiratory syncytial virus (RSV) contains a surface
giant cell appearance in cultured cells). protein called F (fusion) protein.
❏ Antibody responses can be measured using neutralization, ❏ F PROTEIN
hemagglutination-inhibition (HI), or enzyme-linked ➔ mediates host cell fusion into syncytial cells, which
immunosorbent assay (ELISA) tests. are the hallmark of RSV infections. RSV disease in

newborns with underlying medical conditions, TREATMENT, PREVENTION, AND CONTROL
especially premature children with developing lung ❏ The antiviral drug ribavirin is approved for treatment of
functions, can be prophylaxed with RSV immune lower respiratory tract disease caused by RSV
serum that prevents severe RSV bronchiolitis during ❏ No vaccine available
susceptible early months of life. Except for RSV, the ❏ Contact isolation precaution
paramyxoviruses hemasorb guinea pig red blood ❏ Proper hand hygiene
cells. ❏ Supportive care
LABORATORY DIAGNOSIS MUMPS (RUBULA) VIRUS

❏ RSV differs from other Paramyxoviruses as RSC does not ❏ An acute contagious disease characterized by
have hemagglutinin nonsuppurative enlargement of one or both salivary glands
➔ Diagnostic methods for RSV infections cannot use ❏ Mostly causes a mild childhood disease, but in adults
hemagglutinin or hemadsorption complications incuding erningit6ius andf orchtitis are fairly
➔ Antigen detection common
➔ Isolation and identification of RSV from nasal ❏ Causes parotitis, a painful infection of the parotid glands
secretions on human HeLa and Hep-2 cell lines characterized by swelling behind the ears and difficulty of
➔ Detection of viral RNA using RT-PCR swallowing. Mumps virus possesses both HA and NA
antigens and a hemolysin Secondary target is gonads but it
EPIDEMIOLOGY can cause sterility.
❏ Distributed worldwide and is recognized as the major ❏ Humans are the only natural hosts for mumps virus. Primary
pediatric respiratory tract pathogen replication occurs in nasal or upper respiratory tract epithelial
❏ About 70% infants are infected by age 1 and almost all by cells
AGE 2 years ❏ Viremia then disseminates the virus to the salivary glands
❏ The virus can be isolated from most infants younger than and other major organ systems
age 6 months with bronchiolitis, but it is almost never
isolated from healthy infants
❏ Subgroup A infections appear to cause more severe illness
than subgroup B infections
❏ Most common cause of viral pneumonia in children younger
that age 5 years but may also cause pneumonia in elderly
adults or in immunocompromised persons

IMMUNITY
❏ Immunity is permanent after single infection
❏ There is only one antigenic type of mumps virus and it does
not exhibit significant antigens variation
❏ Antibodies to the HN glycoprotein, the F glycoprotein, and
the nucleocapsid protein (NP) develop in serum after natural
infection
❏ Antibodies to the NP proteins appear earliest (3-7 days after
the onset of clinical symptoms) but are transient and are
usually gone within 6 months
❏ Antibodies to HN antigen develop more slowly (~4 weeks
after onset) but persist for years
MUMPS VIRUS COMPLICATION WITHOUT PAROTITIS LABORATORY DIAGNOSIS

❏ The diagnosis of typical cases usually can be made on the
Meningitis Approximately 10% of all infected patients basis of clinical findings
developed meningitis. It is usually mild, but ➔ RT-PCR is a very sensitive method that can detect
can be confused with bacterial meningitis mumps genome sequence in clinical samples
Encephalitis Encephalitis is occasionally severe ➔ Isolation and identification of Mumps virus from
saliva, CSF, and urine using monkey kidney cell
Pancreatitis Suggested by upper abdominal pain, nausea cultures
and vomiting ➔ Serology
Orchitis Orchitis (inflammation of the testes) is

estimated to occur in 10% to 20 % of infected EPIDEMIOLOGY
men, which could be unilateral or bilateral in ❏ High frequency of mumps in 5 to 15 years age group
post-pubertal men. Although subsequent ❏ Person-to-person transmission via respiratory route
sterility is a concern,it appears that this ❏ High infectivity is resent 7 days before and 9 days after onset
outcome is rare. of illness
❏ Replicate in the upper respiratory tract epithelium and local
Oophoritis Oophoritis (inflammation of ovaries) is an
lymph nodes
unusual, usually benign, inflammation of the
ovarian glands

MEASLES (RUBEOLA) VIRUS ❏ Isolation and identification of Measles virus from
❏ An acute, highly infectious disease characterized by fever nasopharyngeal and conjunctiva swabs, bloods, respiratory
respiratory symptoms and a maculopapular rash secretions,and urine collected during febrile phase on
❏ possesses hemagglutinin antigen (HA) and a hemolysin but monkey , human, or B95
does not possess neuraminidase antigen.
❏ Humans are the only natural hosts for measles virus, IMMUNITY
although numerous other species, including monkeys, dogs ❏ Only one antigenic type of measles virus
and mice can be experimentally infected. ❏ Infection confers lifelong immunity
❏ Causative agent of first disease
EPIDEMIOLOGY
PATHOGENESIS ❏ The key epidemiologic features of measle are as follow:
❏ The virus gains access to the human body via the respiratory ➔ The virus is highly contagious
tract, where it multiplies locally; the infection then spread to ➔ There is a single serotype
the regional lymphoid tissue, where further multiplication ➔ There is no animal reservoir
occurs ➔ Inapparent infections are rare
❏ Primary viremia disseminates the virus, which then replicates ➔ Infection confers lifelong immunity
in the reticuloendothelial system ❏ Transmission occurs predominantly via the respiratory route
❏ Finally, a secondary viremia seeds the epithelial surface of (by inhalation of large droplets of infected secretions)
the body, including the skin respiratory tract , and the
conjunctiva , where focal replication occurs. TREATMENT, PREVENTION, AND CONTROL
❏ Live attenuated rubella vaccine (MR)
❏ Live attenuated rubella and mumps vaccines (MMR)
❏ Live attenuated varicella vaccine (MMRV)
GERMAN MEASLES (RUBELLA) VIRUS

❏ Rubella (German measles; 3-day measles) is an acute
febrile illness characterized by a rash and lymphadenopathy
that affects children and young adults
LABORATORY DIAGNOSIS ❏ It is the mildest of common viral exanthems
❏ Detection of Measle antigen in epithelial cells from ❏ However infection during early pregnancy may result in
respiratory secretions, the nasopharynx , conjunctiva , and serious abnormalities of the fetus, including congenital
urine in Serology malformations and mental retardation
❏ Detection of antibodies to Measles nucleoproteins ❏ Causative agent for third disease

NOTE:
VIRAL EXANTHEMS
➔ 1st disease : Measles
➔ 2nd disease: Scarlet Fever (Streptococcus pyogenes)
➔ 3rd disease: German measles (Rubella)
➔ 4th disease: Staphylococcus aureus
➔ 5th disease: Parvovirus B-19
➔ 6th disease : Herpes NOTE: E1 - initiation of replication
CLASSIFICATION OF RUBELLA VIRUS RUBELLA VIRUS REPLICATION

❏ A member of the Togaviridae family, is the sole member of
the genus Rubivirus
❏ It is simple, icosahedral, enveloped virus, and contains a
single-stranded , positive-sense RNA genome
❏ Although its morphologic features and physicochemical
properties place it in the togavirus group, rubella is not
transmitted by arthropods.
STRUCTURE OF RUBELLA VIRUS

❏ There is a single species of capsid protein, and the lipid
bilayer envelope contains two glycoproteins -- E1 and E2 NOTE:
❏ E1 interacts with the receptor on the host cell and comprises ➔ Replicates in cytoplasms
the principal antigenic determinants or epitopes involved in ➔ Envelope of RNA virus is from plasma membrane
virus neutralization and hemagglutination.
❏ E2 interacts with capsid and E1 to reach the Golgi apparatus CLINICAL INFECTION
for viral assembly. ❏ German measles infection are classified as either:
1. Postnatal Rubella
2. Congenital Rubella Syndrome (CRS)
3. Progressive Rubella Panencephalitis (20 yrs old
above)

PATHOGENESIS LABORATORY DIAGNOSIS:
A. Postnatal Rubella ➔ RT-PCR
❏ The virus enters the host through the upper ➔ ELISA
respiratory tract, replicartes, and then spreads by the
bloodstream to distant sites, including lymphoid EPIDEMIOLOGY
tissue , skin, and organs ❏ Rubella Virus has high infectivity but low virulence
❏ A major focus of concern is susceptible women of
childbearing age, who carry a risk of exposure during
pregnancy and transmitting the virus to their babies
(congenital infection )
❏ Congenital Rubella Syndrome ( CRS) is the highest in
Africa and Southeast Asia where the vaccination is the
lowest. The disease is preventable by vaccination.
IMMUNITY
❏ Natural infection al;so results in the procuring of specific
secretory IgA antibodies in the respiratory tractImmunity to
disease is nearly always lifelong; however m, re-exposure
B. CRS can lead to transient respiratory tract infection, with an
❏ Congenital infection occurs as a result of maternal anamnestic rise in IgG and secretory IgA antibodies, but
viremia that leads to placental infection and then without resultant viremia or illness.
transplacental spread to the fetus
❏ CRS Classic Triad TREATMENT, PREVENTION, AND CONTROL
❏ Rubella is mild, self-limiting which requires no treatment
❏ Attenuated live Rubella vaccines may be monovalent ot
given in combination with Measles and Mumps
❏ Primary purpose of your Rubella vaccination is to prevent
congenital rubella infections

Characteristics ❏ Single-stranded
❏ RNA genome
❏ Helical capsid with envelope
❏ Spherical, 120-160 nm in diameter
Genome ❏ Single-stranded RNA

❏ Linear
❏ Non-segmented
❏ Positive sense
Proteins ❏ Two glycoproteins and one

phosphoprotein
❏ Some viruses contain a third
glycoprotein (hemagglutinin esterase)
Envelope Contain large, widely spaced,

club-or-petal-shaped spikes
Replication Cytoplasm; particles mature by budding

into endoplasmic reticulum and Golgi.
Outstanding ❏ Cause colds, SARS, and MERS

Characteristics ❏ Display high frequency of recombination
❏ Difficult to grow in a cell culture
Figure 3.5 Virion structure of Paramyxoviruses Transmission Unknown, probably direct contact or
aerosol
CORONAVIRIDAE
Disease Common cold; possibly gastroenteritis,
especially in children
GENERAL CHARACTERISTICS OF CORONAVIRIDAE
Detection Electron Microscopic
Family Coronaviridae
Treatment Supportive
Common Name Coronaviruses
Prevention Avoid contact with virus
Virus Coronavirus

GENERAL CHARACTERISTICS ❏ Mechanism of replication is in the cytoplasm
❏ Coronaviruses are large, enveloped RNA viruses ❏ Its envelope i s formed from the endoplasmic reticulum
❏ The human coronaviruses cause common colds, may cause
lower respiratory tract infections, and have been implicated
in gastroenteritis in infants.
❏ Novel coronaviruses have been identified as the cause of
severe acute respiratory syndrome (SARS) and Middle East
respiratory syndrome (MERS). Many coronaviruses of
humans and other animals exist.
❏ The prefix corona- is used because of the crown- like surface
projections that are seen when the virus is examined by Figure 3.6 Virion Structure of Coronaviruses
electron microscopy. Human respiratory coronaviruses
cause colds, and occasionally, pneumonia in adults. PATHOGENESIS
❏ Coronaviruses are thought to cause diarrhea in infants ❏ Coronavirus infections in humans usually, but not always,
based on the presence (using electron microscopy) of remain limited to the respiratory tract.
coronavirus-like particles in stool of symptomatic patients.
SEVERE ACUTE RESPIRATORY SYNDROME - CORONAVIRUS
❏ Characterized by serious respiratory illness, including
pneumonia and progressive respiratory failure.
❏ The SARS virus probably originated in a nonhuman host,
most likely bats.
❏ ACE 2- receptor of SARS-CoV
SEVERE ACUTE RESPIRATORY SYNDROME - CORONAVIRUS 2

❏ Just like SARS-CoV and MERS-CoV, SARS-CoV 2
originates from bats.
❏ SARS-CoV 2 uses the angiotensin-converting enzyme 2
(ACE 2) receptor to facilitate viral entry into the target cells.
NOTE: CORONAVIRUS DISEASE (COVID-19) / (SARS-Cov-2)
❏ Peplomers - appearance is like “crown of thorns” or ❏ is an infectious disease caused by a newly discovered
“solar corona; spike glycoproteins of the virus that will coronavirus. Most people infected with the COVID-19 virus
detect the receptors will experience mild to moderate respiratory illness and
❏ Coronavirus is an RNA virus recover without requiring special treatment.

❏ Older people, and those with underlying medical problems been reported. Some laboratory-confirmed cases of
like cardiovascular disease, diabetes, chronic respiratory MERS-CoV infection are reported as asymptomatic,
disease, and cancer are more likely to develop serious meaning that they do not have any clinical symptoms, yet
illness. they are positive for MERS-CoV infection following a
❏ The COVID-19 virus spreads primarily through droplets of laboratory test.
saliva or discharge from the nose when an infected person ❏ Most of these asymptomatic cases have been detected
coughs or sneezes, so it’s important that you also practice following aggressive contact tracing of a
respiratory etiquette (for example, by coughing into a flexed laboratory-confirmed case. Approximately 35% of reported
elbow). patients with MERS-CoV infection have died.
❏ The new strain lineage B.1.1.7 is characterized by 17 ❏ Middle East respiratory syndrome (MERS), although most
mutations that cause amino acid changes, 8 of which occur human cases of MERS-CoV infections have been attributed
in the gene for the spike (S) protein. There are mutations in to human-to-human infections in health care settings, in
other regions of the SARS-CoV-2 genome that provide a current scientific evidence suggests that dromedary
genomic signature for this lineage. camels are a major reservoir host for MERS-CoV and an
❏ Another highly transmissible strain lineage, designated as animal source of MERS infection in humans. However, the
B.1.351 (also known as variant 501Y.V2), was recently exact role of dromedaries in transmission of the virus and the
identified and found to have multiple mutations in the S exact route(s) of transmission are unknown.
gene.
MIDDLE EAST RESPIRATORY SYNDROME - CORONAVIRUS ❏ Coronavirus antigens in cells in respiratory secretions may
❏ characterized by pneumonia and respiratory failure, though be detected using the ELISA test if a high-quality antiserum
most patients who died had medical comorbidities. is available.
❏ MERSCoV likely originated in bats and became widespread ❏ Polymerase chain reaction (PCR) assays are the preferred
in camels. methods to detect coronavirus nucleic acid in respiratory
❏ A viral respiratory disease caused by a novel coronavirus secretions and stools.
(Middle East respiratory syndrome coronavirus, or ❏ Isolation of viruses using Vero monkey kidney cells
MERS-CoV) that was first identified in Saudi Arabia in 2012. ❏ ELISA, indirect immunofluorescent antibody assays, and
Typical MERS symptoms include fever, cough and shortness hemagglutination tests may be used.
of breath.
❏ CD26 / Dipeptidyl Peptidase-4 (DPP4) - receptor of MERS- EPIDEMIOLOGY
CoV ❏ Coronaviruses are distributed worldwide and are a major
❏ Pneumonia is common, but not always present. cause of respiratory illness in adults.
Gastrointestinal symptoms, including diarrhea, have also

❏ Coronaviruses are transmitted by contact with respiratory
droplets, contaminated surfaces and fomites (contaminated
inanimate objects).
TREATMENT, CONTROL, AND PREVENTION

❏ There is no proven treatment for coronavirus infections and
no vaccine.
❏ SARS and MERS vaccines are under development
❏ Control measures that were effective in stopping the spread
of SARS included isolation of patients, quarantine of those
who had been exposed, and travel restrictions, as well as the
“Di ka nag-iisa sa laban na to.”
use of gloves, gowns, goggles and respirators by health care
workers.
Figure 3.7 SARS-CoV-2 Origin and Transmission
ADDITIONAL NOTE:
❏ Alpha & Beta strain - zoonotic infection, more virulent
❏ Delta & Gamma strain - not common
❏ Spike protein mutations may be due to post translational
factors
❏ RNA viruses are faster to mutate than DNA viruses.

MODULE 4: HERPESVIRUSES ➔ Cytomegalovirus (CMV) can also cause mononucleosis
symptoms in adults, and is a leading cause of congenital
OUTLINE OF THE LESSON blindness;
➔ HHV types 6 and 7 (HHV-6 and HHV-7), which cause
I. INTRODUCTION roseola in infants; and
II. PROPERTIES OF HERPES VIRUSES ➔ Kaposi Sarcoma (KS)-associated herpesvirus (KSHV),
III. CLASSIFICATION OF HERPES VIRUSES also known as HHV-8.
IV. HERPES VIRUS REPLICATION
V. CYTOPATHIC EFFECT OF HERPES VIRUSES REPLICATION NOTE: They can all undergo latency. Once you get infected by herpes, you
VI. HERPES INFECTION IN HUMANS will forever have herpes. They can reactivate if the immune system is
A. HSV 1&2 weakened and can cause infection.
B. Varicella-Zoster Virus (HHV3)
C. Epstein-Barr Virus (HHV4) ❏ In addition, the simian herpesvirus, herpes B virus, has
D. Cytomegalovirus (HHV5) occasionally caused lethal human disease in primate center
E. Human Herpesvirus 6 workers.
F. Human Herpesvirus 7 ❏ All herpesviruses establish lifelong latent infections in their hosts
G. Human Herpesvirus 8 with periodic reactivation events.
❏ Herpes viruses are widely disseminated among animal species.
HIGHLIGHTING OF TOPICS BULLET PLACEMENT However, the zoonotic forms of herpes do not infect humans,
except for herpes B virus from non-human primates but is not
AAAAAA - Family of virus ❏ (Main definition) counted among the eight human herpes viruses.
AAAAAA - Main topic ➔ (Sub-definition/Enumerate)
AAAAAA - Subtopics ● (Super Sub-detail) PROPERTIES OF HERPES VIRUSES
INTRODUCTION PROPERTY DESCRIPTION

❏ The Herpesviridae is composed of large, enveloped,
double-stranded DNA viruses. There are eight known human Virion ❏ Spherical
herpesviruses (HHVs) and a very large number of animal ❏ 150–200 nm in diameter
herpesviruses. ❏ Icosahedral symmetry
❏ The word “herpes” is derived from the Greek word meaning “to
creep” (hide from the immune cells) and was historically used to Genome ❏ Double-stranded DNA
describe the spreading, ulcerative skin lesions typically seen in ❏ Linear reiterated (or repeated) genes
HSV (Herpes simplex virus) infection.
❏ Eight human herpes group viruses have been described: Proteins More than 35 proteins in virion
➔ Herpes simplex virus-1 (HSV-1) and HSV-2, which
cause facial and genital lesions; Envelope ❏ Contains viral glycoproteins
➔ Varicella-zoster virus (VZV), which causes chickenpox ❏ Fc receptors
and later in life can reactivate to cause shingles;
➔ Epstein-Barr virus (EBV), an infectious cause of Replication ❏ Nucleus
mononucleosis as well as Burkitt lymphoma (BL) among ❏ Bud from nuclear membrane
other B-cell lymphomas;
Outstanding ❏ Encode many enzymes

CLASSIFICATION OF HERPES VIRUSES
❏ Establish latent infections
❏ Persist indefinitely in infected hosts
❏ Frequently reactivated in immunosuppressed hosts
❏ Some cause cancer
Table 4.1 Properties of Herpes Virus
❏ The capsid is surrounded by the tegument, a relatively amorphous

protein-filled region unique to herpesviruses. The tegument
contains viral proteins and enzymes that play a structural role and
many are required immediately for viral replication upon initial
infection.
❏ Surrounding the tegument is a lipoprotein envelope originally
derived from the nuclear membrane of the infected host cell. The
envelope contains multiple viral glycoproteins that act as viral
binding, fusion, and entry proteins.
Table 4.2 Classification of Human Herpesviruses
1. Alphaherpesviruses are fast-growing, cytolytic (lyse cells causing

lesions) viruses that tend to establish latent infections in neurons;
➔ HSV 1 and 2 (genus Simplex Virus)
➔ VZVs (genus Varicellovirus) are members.
2. Betaherpesviruses are slow growing and may be cytomegalic
(massive enlargements of infected cells) and become latent in
secretory glands and kidneys;
➔ CMV is classified in the Cytomegalovirus genus. They are
latent in glands and in kidneys.
➔ HHV-6 and HHV-7, classified under the genus
Roseolovirus. They are latent in lymphoid tissue. By
Figure 4.1 Diagram of Herpes complex virus particle structure biologic criteria, they are similar to gammaherpesviruses
because they infect lymphocytes (T lymphotropic), but
molecular analyses of their genomes reveal that they are
NOTE:
What should you remember about Herpes structure? more closely related to the betaherpesviruses.
3. Gammaherpesviruses, exemplified by
❏ Double-stranded DNA
➔ EBV (genus Lymphocryptovirus), infect and become latent
❏ Presence of envelope
❏ Icosahedral in lymphoid cells
➔ HHV-8/KSHV is classified in the Rhadinovirus genus.
❏ Presence of tegument

HERPES VIRUSES REPLICATION 2. Viral nucleocapsid is transported to the nuclear pore
❏ Replication of herpesviruses takes place in the host cell nucleus, 3. Uncoating releases linear DNA into the nucleus
and is similar to replication of any other dsDNA virus. The only 4. Linear DNA become circular DNA
difference is that the linear dsDNA of herpesviruses becomes 5. Circular DNA is transcribed to form immediate-early mRNA
circular inside the host cell and then replicates by rolling circle 6. Immediate-early mRNA is transported to cytoplasm
mechanism. 7. Immediate-early mRNA in the cytoplasm is translated to α-proteins
EARLY PHASE
1. α-proteins are transported back to the nucleus and is the start of
the early phase
2. α-proteins transcribe circular DNA in nucleus to form Early mRNA
3. Early mRNA is transported to cytoplasm
4. Early mRNA in the cytoplasm is translated to β-proteins
LATE PHASE
1. β-proteins are transported back to the nucleus
2. β-proteins transform circular DNA in nucleus to concatemeric DNA
➔ Repeated sequences of nucleotides
3. Concatemeric DNA is replicated and transcribed to form late
mRNA
4. Late mRNA is transported to the cytoplasm
5. Replicated concatemeric DNA is cleaved to form viral DNA
6. Some late mRNAs in the cytoplasm are translated to structural
У-proteins
7. Structural У-proteins are transported to the nucleus
8. Some late mRNAs in the cytoplasm are translated to viral
glycoproteins
9. Viral glycoproteins will attach to the nuclear membrane
10. Viral nucleocapsids bud off from nuclear membrane with viral
glycoprotein to form enveloped progeny viruses
Figure 4.2 Replication cycle of herpes simplex virus 11. Enveloped progeny viruses pass through ER and Golgi apparatus
12. Enveloped progeny viruses are released from Golgi apparatus to
❏ The replication of the herpesviruses is divided into: outside the cell by exocytosis.
A. Immediate-early phase
B. Early phase CYTOPATHIC EFFECTS OF HERPESVIRUSES REPLICATION
C. Late phase ❏ HSV in Hep-2 cells cause swollen, rounded cells
❏ VZV in human kidney cells cause multinucleated giant cells with
IMMEDIATE-EARLY PHASE acidophilic intranuclear inclusion
1. Viral envelope glycoproteins fuse with the cell surface ❏ CMV shows multinucleated giant cells with acidophilic intranuclear
glycosaminoglycans (GAGs) especially Heparan Sulfate and cytoplasmic inclusions
➔ Cellular receptor of herpesviruses ➔ Different from adenovirus because CMV has 2 nuclei
➔ Has a similar structure with heparin which is a natural
anticoagulant but the heparin is more sulfated

Figure 4.3 Multinucleated giant cells (Owl’s eye inclusion)
HERPES INFECTION IN HUMANS

1. Herpes Simplex Virus 1
2. Herpes Simplex Virus 2
3. Varicella-Zoster Virus
4. Epstein-Barr Virus
5. Cytomegalovirus
6. Human Herpesvirus 6
HERPES SIMPLEX VIRUSES (HSV)

INTRODUCTION
❏ Herpes simplex viruses belong to the α-subfamily of Herpesviridae.
They are extremely widespread and exhibit a broad host range;
can infect many types of cells and different animals.
❏ However, the human herpesviruses infect exclusively men. They
replicate fast (8 - 16 hours cycle), spread fast and are cytolytic.
❏ They can cause a spectrum of diseases, involving skin, mucosa
and various organs.
❏ They undergo latency in nerve cells; reactivate later causing
recurrent lesions. Herpes simplex viruses (HSV) are of two distinct
types: HSV-1 and HSV-2. They differ from each other in many
aspects

HSV ACID FAST STAIN
❏ Multinucleated giant cells and intranuclear inclusion bodies. The
pink areas within the epithelial cell nuclei are intranuclear inclusion
bodies.
A. PRIMARY / ACUTE INFECTION

❏ Both HSV-1 and HSV-2 initially infect and replicate in the
muco-epithelial cells and initiate lytic or productive
infection at the site of contact (lesions are produced).
❏ Transmission occurs through abraded skin or mucosa from
any site, but more commonly by: HSV-1: Oropharyngeal
contact with infected saliva or direct skin contact for
HSV-1, and Sexual contact or rarely vertical mode (from
PATHOGENESIS AND PATHOLOGY mother 10 fetus) for HSV-2. HSV-1 is more often
❏ Characteristic histopathologic changes include ballooning of associated with disease “above the waist” or facial herpes,
infected cells, production of Cowdry type A intranuclear whereas HSV-2 is most often associated with genital
inclusion bodies, margination of chromatin, and formation of infections or “below the waist” infections.
multinucleated giant cells. ❏ Virus then invades the local nerve ending and is
transported by retrograde axonal flow to the dorsal root
ganglia, where it replicates further, and then undergoes
latency.
❏ Primary HSV infections are usually mild; in fact, most are
asymptomatic. However, in immunocompromised hosts,
viremia occurs that leads to widespread organ involvement
and systemic manifestations.
B. LATENT INFECTION
❏ In humans, latent infection by
➔ HSV-1 has been demonstrated in trigeminal,
superior cervical, and vagal nerve ganglia, and
Figure 4.4 Multinucleated and Balloon cells occasionally in the S2-S3 dorsal sensory nerve
root ganglia.
➔ HSV-2 infection has been demonstrated in the
sacral (S2-S3) region.

NOTE: Herpes virus hides in these regions, since these regions are
nearest to the site of entry.
❏ HSV does not replicate in latent stage except for a small RNA,
called micro-RNA (encoded by a latency- associated viral gene) CLINICAL FINDINGS
which maintains the latent infection and prevents cell death. ❏ Infection with herpes simplex virus may take several clinical forms.
The infection is most often not apparent. The usual clinical
C. RECURRENT INFECTION (REACTIVATION) manifestation is a vesicular eruption of the skin or mucous
❏ Reactivation of the latent virus can occur following various membranes. Infection is sometimes seen as severe keratitis,
provocative stimuli, such as fever, axonal injury (release of meningoencephalitis and a disseminated illness of the newborn.
virus), physical or emotional stress, and exposure to
ultraviolet light.
❏ Via the axonal spread, the virus goes back to the
peripheral site and further replicates in skin or mucosa
producing secondary lesions. Recurrent infections are less
extensive and less severe because of the presence of
pre-existing host immunity that limits the local viral
replication.
❏ The mechanisms by which latent infection is reactivated
are unknown.
Table 4.4 HSV-1 and HSV-2 Clinical Association

NOTE: How to prevent neonatal herpes?
❏ Perform cesarean section since there will be no exposure to
genitals of mother
DISEASES CAUSED BY HSV 1 & HSV 2

A. HERPES LABIALIS
❏ Caused by HSV 1
❏ Also known as cold sores or herpes febrilis
❏ The most common recurrent disease produced by type 1.
❏ Clusters of localized vesicles occur, usually at the
mucocutaneous junction of the lips.
❏ The vesicle ruptures, leaving a painful ulcer that heals
without scarring. C. GENITAL HERPES
❏ The lesions may recur, repeatedly and at various intervals ❏ Cause by HSV 2
of time, in the same location. ❏ Characterized by vesiculoulcerative lesions of the penis of
❏ The permanent site of latent herpes simplex virus is the male or the cervix, vulva, vagina and perineum of the
trigeminal-ganglion. female.
❏ The lesions are more severe during primary infection and
may be associated with fever, malaise, and inguinal
lymphadenopathy.
❏ Remains latent in lumbar and sacral ganglia
HSV 1 lesions outside the mouth

Herpes labialis or cold sores
B. KERATOCONJUNCTIVITIS HSV 2 lesions in the genitals

❏ Cause by HSV 1 Herpes progenitalis or genital herpes
❏ Initial infection may be in the eye, producing severe
keratoconjunctivitis. D. NEONATAL HERPES
❏ Recurrent infection of the eye appears as dendritic keratitis ❏ Caused by HSV 2
or corneal ulcers or as vesicles on the eyelids. ❏ transmitted to the newborn during birth by contact with
❏ With recurrent keratitis, there may be progressive herpetic lesions in the birth canal.
involvement of the corneal stroma, with permanent ❏ Spectrum of illness may vary from subclinical of local to
opacification and blindness. severe generalized disease with a fatal outcome.
❏ Severely affected infants who survive may have
permanent brain damage.

POLYMERASE CHAIN REACTION (PCR) ASSAYS
❏ can be used to detect viruses in vesicle swabs, blood, CSF, and
tissue and are sensitive and specific. PCR amplification of viral
DNA from cerebrospinal fluid is the most sensitive means of
detection and is recommended for diagnosis of herpes
meningitis/encephalitis.
VIRUS CULTURE
❏ is commonly used, particularly for diagnosis of mucocutaneous
disease. Inoculation of tissue cultures is used for viral isolation.
HSV is relatively easy to cultivate, with cytopathic effects typically
occurring in 2–3 days (18-36 hours). The agent is then identified
by neutralization test or immunofluorescence staining with specific
antiserum. HV, Immunofluorescence test
NOTE: Cytopathic effect - infected cells develop intranuclear acidophilic
inclusion and then undergo necrosis EPIDEMIOLOGY
❏ HSV are worldwide in distribution. No animal reservoirs or vectors
are involved with the human viruses.
➔ Humans are only reservoirs
❏ Transmission is by contact with infected secretions. The
epidemiology of HSV-1 and HSV-2 differs.
➔ HSV-1 is more constantly present in humans than any
other virus.
➔ HSV-2 is usually acquired as a STD.
TREATMENT, PREVENTION, CONTROL

❏ Several antiviral drugs have proved effective against HSV
RAPID CYTOLOGIC METHOD infections, including acyclovir, valacyclovir, and vidarabine.
❏ is to stain scrapings obtained from the base of a vesicle (eg, with Newborns and persons with eczema should be protected from
Giemsa’s stain); the presence of multinucleated giant cells exposure to persons with active herpetic lesions. Patients with
indicates that herpesvirus (HSV-1, HSV-2, or varicella-zoster) is genital herpes should be counseled that asymptomatic shedding is
present. frequent and that the risk of transmission can be reduced by
antiviral therapy and condom usage. Experimental vaccines of
SEROLOGY various types are being developed.
❏ Antibodies appear in 4–7 days after infection and reach a peak in
2–4 weeks. They persist with minor fluctuations for the life of the ACTION OF ANTIVIRAL DRUGS
host. Detection methods available include neutralization, ➔ Suppress clinical manifestation
immunofluorescence, and enzyme-linked immunosorbent assay. ➔ Shorten time of acute infection
➔ Speed up healing but can’t remove virus in neurons

VARICELLA- ZOSTER VIRUS ➔ lesions are only located where the varicella-zoster virus
was latent
Other name: HUMAN HERPES VIRUS 3 / HHV-3 ❏ Both diseases are caused by the same virus. Whereas varicella is
the acute disease that follows primary contact with the virus, zoster
INTRODUCTION is the response of the partially immune host to reactivation of
❏ Varicella (chickenpox) is a mild, highly contagious disease, chiefly varicella virus present in latent form in neurons in sensory ganglia.
of children, characterized clinically by a generalized vesicular ➔ reactivated form of chickenpox after undergoing latency
eruption of the skin and mucous membranes. The disease may be ❏ Varicella-zoster virus is morphologically identical to HSV. It has no
severe in adults and in immunocompromised individuals. animal reservoir. The virus propagates in cultures of human
embryonic tissue and produces typical intranuclear inclusion
Reasons why it is called chickenpox: bodies
1. The lesions looked liked chicken peas
2. The rash that is produced looked like peck marks of chicken PATHOGENESIS AND PATHOLOGY
VARICELLA:
❏ Route of infection is probably the mucosa of the upper respiratory
CHICKENPOX SMALLPOX
tract.
❏ Virus then circulates in the blood and localizes in the skin where
Causative agent Varicella-zoster virus Variola virus
there will be swelling of the epithelial cells, ballooning,
degeneration, and the accumulation of tissue fluids result in vesicle
Lesions Vary in appearance undergo stages of
formation.
and stages. development and are
❏ In nuclei of infected cells, particularly in early stages, eosinophilic
overall the same
inclusion bodies are found.
ZOSTER:
❏ In addition to the skin lesions, histopathologically identical with
those of varicella, there is an inflammatory reaction of the dorsal
nerve roots and sensory ganglia.
❏ Often only a single ganglion may be involved. As a rule, the
distribution of the lesions in the skin corresponds closely to the
areas of innervation from an individual dorsal root ganglia.
❏ There is cellular infiltration, necrosis of nerve cells, and
inflammation of the ganglion sheath.
❏ Herpes zoster (shingles) is a sporadic, incapacitating disease of

elderly or immunocompromised individuals that is characterized by
pain and vesicular rash limited in distribution to the skin innervated
by a single sensory ganglion. The lesions are similar to those of
varicella/chickenpox.

NOTE:
➔ #5 from figure 4.5: Once infected by the varicella zoster virus it
will undergo latency in the nerve cells. The immune system would
only destroy those viruses that do not undergo latency.
NOTE: If a person is exposed to someone who has shingles, you will still
get chickenpox because shingles can only be acquired after chickenpox.
CLINICAL FINDINGS
VARICELLA (ACUTE INFECTION)
❏ Also known as chickenpox
❏ Mild, highly infectious disease, mainly by children, characterized by
vesicular eruption of the skin and mucous membranes.
❏ Subclinical varicella is unusual. The incubation period of typical
disease is 10–21 days.
❏ Malaise and fever are the earliest symptoms, soon followed by the
rash, first on the trunk and then on the face, the limbs, and the
buccal and pharyngeal mucosa in the mouth.
❏ Successive fresh vesicles appear in crops, so that all stages of
macules, papules, vesicles, and crusts may be seen at one time.
❏ The rash lasts about 5 days, and most children develop several
hundred skin lesions.
Figure 4.5 The pathogenesis of primary infection with varicella-zoster virus ❏ Immunocompromised patients are at increased risk of
complications of varicella, including those with malignancies, organ
transplants, or HIV infection and those receiving high doses of
corticosteroids. Disseminated intravascular coagulation may occur

that is rapidly fatal. Children with leukemia are especially prone to
developing severe, disseminated VZV disease.
Figure 4.6 Multiple stages or “crops” of varicella skin lesions
HERPES ZOSTER
❏ Also known as Shingles or Zona (REACTIVATION) Figure 4.7 Shingles
❏ Usually occurs in persons immunocompromised as a result of
disease, therapy, or aging, but it occasionally develops in healthy LABORATORY DIAGNOSIS
young adults. CYTOPATHOLOGY
➔ It is a reactivation of varicella virus present in the sensory ❏ Giemsa staining of the scrapings from the ulcer base (Tzanck
ganglia. smear) reveals cytopathological changes similar to that of HSV
❏ It usually starts with severe pain in the area of skin or mucosa infection, such as formation of multinucleated giant cells.
supplied by one or more groups of sensory nerves and ganglia and ➔ Its cell culture and cytopathic effects are the same
is often unilateral. with HSV-1 and HSV-2.
❏ Within a few days after onset, a crop of vesicles appears over the VIRUS ISOLATION
skin supplied by the affected nerves. ❏ Virus isolation in various cell lines can also produce HSV-like
❏ The trunk, head, and neck are most commonly affected. cytopathic effects such as diffuse rounding and ballooning of
❏ The most common complication of zoster in elderly adults is infected cells.
postherpetic neuralgia—protracted pain that may continue for
months. VZV-SPECIFIC METHODS
❏ Sporadic, incapacitating disease of adults (rare in children) that is ❏ Specific antigen detection by direct immunofluorescence staining
characterized by an inflammatory reaction of the posterior nerve and PCR detecting VZV-specific genes.
roots and ganglia, accompanied by crops of vesicles (like those of ➔ Direct Immunofluorescence: detect antigens
varicella) over the skin supplied by the affected sensory nerve. produced
➔ PCR: detect varicella zoster genome
EPIDEMIOLOGY
❏ Varicella and herpes zoster occur worldwide. Varicella
(chickenpox) is highly communicable and is a common epidemic
disease of childhood (most cases occur in children < 10 years of
age). Adult cases do occur. It is much more common in winter and

spring than in summer in temperate climates. Herpes zoster occurs
sporadically, chiefly in adults and without seasonal prevalence.
❏ Contact infection is less common in zoster
TREATMENT, PREVENTION, CONTROL

❏ Varicella in normal children is a mild disease and requires no
treatment.
➔ Self-limiting
❏ Neonates and immunocompromised patients with severe infections
should be treated.
➔ Since their system can’t produce antibody themselves
❏ High risk patients exposed to Varicella can be protected by
immunoglobulin before onset of varicella. Several antiviral
compounds provide effective therapy for varicella, including Figure 4.8 Attachment of EBV to B cells
acyclovir, valacyclovir, famciclovir, and foscarnet.
❏ Use of live attenuated Varicella vaccine to prevent chickenpox in PATHOGENESIS
children and the use of a more potent vaccine to prevent shingles A. PRIMARY INFECTION
in adults are also widely used to prevent acquiring the disease. ❏ EBV is transmitted by oropharyngeal contact through
➔ Chickenpox can still be developed even after vaccination infected salivary secretions.
but milder ❏ EBV binds to specific receptors present on B cells (CD21
or CR2) which are also receptors for the C3b component of
EPSTEIN-BARR VIRUS complement.
❏ Such receptors are also present on pharyngeal epithelial
Other name: HUMAN HERPESVIRUS 4 / HHV-4 cells.
➔ Primary infection occurs in the oropharynx.
INTRODUCTION ❏ EBV replicates in epithelial cells or surface B lymphocytes
❏ EBV is a ubiquitous herpesvirus that is the causative agent of of the pharynx and salivary glands.
acute infectious mononucleosis and is associated with ❏ Following entry into the B cells, EBV directly enters into
nasopharyngeal carcinoma, Burkitt lymphoma, Hodgkin and latent phase without completing the viral replication.
non-Hodgkin lymphomas, other lymphoproliferative disorders in ❏ Though the majority of the infected cells are eliminated, a
immunodeficient individuals, and gastric carcinoma. small number of infected cells may persist for lifetime.
❏ The major target cell for EBV is the B lymphocyte. ❏ Virus spreads from the oropharynx to other sites of the
➔ receptor of virus is located in B lymphocytes (CR2/ CD21) body and is capable of undergoing reactivation later. Viral
❏ When human B lymphocytes are infected with EBV, continuous shedding continues in oropharyngeal secretions at low
cell lines can be established, indicating that cells have been levels for weeks to months and serves as a source of
immortalized by the virus. infection.
➔ EBV is a herpes virus and needs to undergo latency in the ❏ In children, most primary infections are subclinical, but
B lymphocytes young adults often develop a condition called acute
➔ Very few of the immortalized cells produce infectious infectious mononucleosis.
viruses. EBV initiates infection of B cells by binding to the NOTE: Mononucleosis is a polyclonal stimulation of lymphocytes.
viral receptor, which is the receptor for the C3d component EBV-infected B cells synthesize immunoglobulin. Autoantibodies are
of complement (CR2 or CD21).

typical of the disease, with heterophile antibodies that react with antigens
on sheep erythrocytes detectable in acute cases.
REMEMBER:
❏ In Children – Subclinical
❏ In Adults – Infectious Mononucleosis
B. REACTIVATION FROM LATENCY

❏ Reactivation is due to immunosuppression
❏ Reactivation of EBV latent infections can occur or be
observed when there is:
➔ Increased levels of virus in saliva
➔ Increased levels of DNA in blood cells
CLINICAL FINDINGS
A. INFECTIOUS MONONUCLEOSIS
❏ Primary Infection of Epstein-Barr Virus
❏ Aka Kissing Disease
➔ Disease can be get through kissing because of
increased levels of virus in saliva
➔ Virus can be isolated in the saliva of an infected
person B. CANCERS ASSOCIATED WITH EBV
❏ After an incubation period of 30–50 days, symptoms of ❏ Nasopharyngeal carcinoma
headache, fever, malaise, fatigue, and sore throat occur. ❏ Burkitt Lymphoma (Cancer of the B lymphocyte)
Enlarged lymph nodes and spleen are characteristic. ➔ Respond to chemotherapy (few weeks/ month)
Some patients develop signs of hepatitis. ❏ Hodgkin Lymphoma
❏ The typical illness is self-limited and lasts for 2–4 weeks. ❏ Non-hodgkin lymphoma
➔ Disease is self-limiting as long as your immune ❏ Gastric Carcinoma
system is competent ❏ Oral Hairy Leukoplakia
❏ During the disease, there is an increase in the number of
circulating white blood cells, with a predominance of ONCOGENIC PROPERTIES
lymphocytes. ❏ Herpesviruses have been linked with malignant disease in
❏ Rely on serologic test for diagnosis humans:
❏ Many of these are large, atypical T lymphocytes. ➔ Herpes simplex virus type 2 and vulvar carcinoma
➔ Larger with more cytoplasm than the nucleus and ➔ EB virus with Burkilt’s lymphoma of African children and
have nucleoli with nasopharyngeal carcinoma.
➔ “Dutch skirt" appearance because of RBC that
sticks in the cytoplasm and forms indentions
❏ Low-grade fever and malaise may persist for weeks to
months after acute illness.

LABORATORY DIAGNOSIS CYTOMEGALOVIRUS
MOLECULAR TEST
❏ detection of the genome of the virus Other name: HUMAN HERPESVIRUS 5
❏ Nucleic acid hybridization is the most sensitive means of detecting
EBV in patient materials. It can be isolated from saliva, peripheral INTRODUCTION
blood or lymphoid tissue
❏ PCR ❏ CMV is a ubiquitous herpesvirus that is a common cause of human
disease. CMV is the most common cause of congenital infection,
SEROLOGIC TEST which can lead to severe abnormalities. Inapparent infection is
❏ detection of the antigen and antibody common during childhood and adolescence. Severe CMV
❏ Common serological procedures for detecting EBV antibodies infections are frequently found in adults who are
include: immunosuppressed.
➔ ELISA ➔ It can be found in the cervix of up to 10% of healthy
➔ Immunoblot assays women.
➔ Indirect immunofluorescence ➔ It affects pregnant women at an increased severity since it
can affect the fetus.
EPIDEMIOLOGY ❏ CMV is named for the cytopathic effect it produces in cell culture.
❏ EBV is common in all parts of the world, with more than 90% of In addition to nuclear inclusions (“owl’s eye cells” or “owl’s eye
adults being seropositive. It is transmitted primarily by contact with inclusion”, CMV produces perinuclear cytoplasmic inclusions and
oropharyngeal secretions. enlargement of the cell (cytomegaly). CMV possesses the largest
❏ In developing areas, infections occur early in life; more than 90% genome of the HHVs.
of children are infected by age 6 years. ❏ Inapparent infection is common during childhood and adolescence.
❏ In almost half of cases, the infection is manifested by infectious Severe CMV infections are frequently found in adults receiving
mononucleosis. immunosuppressive therapy.
❏ Note: Infectious Mononucleosis - Acute infection of epstein-barr ❏ It affects the vascular endothelial cells and wbcs
virus and characteristic is the presence of atypical lymphocytes.
❏ Transmitted by intimate contact
TREATMENT, PREVENTION AND CONTROL

❏ There is no EBV vaccine available.
❏ Acyclovir reduces EBV shedding from the oropharynx during the
period of drug administration, but it does not affect the number of
EBV-immortalized B cells.
➔ This is used to minimize the transmission of the virus to
others. Since it is a herpesvirus, there is latency infection
occurring inside the monocyte. However, it does not
remove this infection. Also, this is a self-limiting virus in 1-2
months.

PATHOGENESIS B. CMV INFECTION IN IMMUNOCOMPROMISED HOSTS
❏ Cytomegalovirus can cause persistent infection in various tissues, ❏ CMV may involve the lungs, GIT, liver retina
including those of the salivary glands, breasts, kidneys, ❏ CMV produces markedly severe infection in
endocervix, seminal vesicles and peripheral leukocytes. immunosuppressed individuals; most of which are due to
❏ This persistent infection leads to chronic viral excretion by the reactivation of their own latent viruses.
involved organ. ❏ ln AIDS patients with CD4 T cell count <50/uL, CMV may
❏ Transmission of virus through contact with infected secretions cause chorioretinitis, gastroenteritis, dementia and other
❏ Kidneys of organ donors can be a source of CMV for the recipient disseminated CMV infection.
and that peripheral blood leukocytes. ❏ CMV is probably the most common viral infection that
❏ The average incubation period is 4-6 weeks. occurs usually between 1- and 4-months following
transplantation and presents in various forms such as:
A. CMV INFECTION IN NORMAL HOSTS ➔ Bilateral interstitial pneumonia is the most
❏ In healthy adults, CMV produces an infection following common form, seen in 15-20% of bone marrow
blood transfusion called mononucleosis-like syndrome. transplant recipients.
This condition is similar to infectious mononucleosis ➔ Febrile leukopenia is seen among solid organ
caused by EBV transplant recipients
❏ Mononucleosis syndrome (fever, malaise, atypical ➔ Obliterative bronchiolitis in lung transplants.
lymphocytosis, pharyngitis and rarely, cervical adenopathy ➔ Graft atherosclerosis in heart transplants
or hepatitis. ➔ Rejection of renal allografts
❏ The third clinical entity is cytomegalovirus infection in
severely immunocompromised patients C. CONGENITAL CMV INFECTION
❏ CMV is probably the most common intrauterine infection
associated with congenital defects. About 1 % of infants
born are infected with CMV. Cytomegalic inclusion disease
develops in about 5% of the infected fetus, the remaining
are although asymptomatic at birth, 5-25% of them may
develop significant psychomotor, hearing, ocular, or dental
defects within 2 years. Mortality rate is very high (20%).
❏ Hepatosplenomegaly, retinitis, petechial/purpuric skin rash,
and involvement of the CNS.
D. PERINATAL CMV INFECTION

❏ Transmission to the newborn occurs either during:
➔ Delivery - through infected birth canal or
➔ Postnatal - through infected breast milk /
Table 4.5 Comparison of infectious and mononucleosis-like syndrome secretions from mother.
❏ Most of the infected infants remain asymptomatic, but
NOTE: shed virus in urine from 8- 12 weeks of age, up to several
➔ Both EBV and CMS contain atypical lymphocytes. years. Few infants, especially premature babies develop
➔ They have specific antibodies (CMV and EBV) interstitial pneumonitis.
➔ Heterophile antibodies is elevated in EBV

presence of CMV infection, but does not provide
❏ POLYMERASE CHAIN REACTION
proof that CMV is the cause of disease unless
❏ SEROLOGIC TESTS
other pathogens are excluded. Seroconversion is
➔ CMV IgG Antibodies: Indicative of Past Infection
diagnostic but rarely occurs, especially in patients
● IgG is only produced after an infection that’s why it
with AIDS, because more than 95% of these
indicates a past infection
patients are seropositive for CMV before infection
➔ CMV IgM Antibodies: Indicative of Current Infection
with human immunodeficiency virus (HIV).
● IgM is first produced by the body that’s why it
indicates a current infection
CMV Infection in Seroconversion and presence of IgM antibody
❏ Humans are the only known host for CMV
Normal Hosts specific for CMV are best indicators of primary
❏ Transmission requires close person-to-person contact
infection. Urine culture positivity supports the
❏ Virus may be shed in urine, saliva, semen, breast milk, and
diagnosis of CMV infection, but may reflect remote
cervical secretions and is carried in circulating white blood cells.
infection because positivity may continue for
➔ CMV is carried by WBCs
months to years. A positive blood assay for CMV
➔ CMV is a sexually-transmitted virus
antigen or DNA, however, is diagnostic in this
❏ Oral and respiratory spread are probably the dominant routes of
patient population.
CMV transmission
➔ Most common MOT Table 4.6 Recommended procedure to facilitate the diagnosis of CMV
❏ CMV can be transmitted by blood transfusion, though the risk is infection
low with leuko-reduced blood products
➔ Since CMV is carried by wbcs, blood products must be EPIDEMIOLOGY
converted into leuko-reduced products to reduce the risk. ❏ CMV is endemic in all parts of the world; epidemics are unknown.
WBC concentration must be reduced in the blood. It is present throughout the year, with no seasonal variation seen in
infection rates.
❏ Humans are the only known host for CMV. Transmission requires
Clinical Laboratory Diagnosis
close person-to-person contact. Virus may be shed in urine, saliva,
Condition
semen, breast milk, and cervical secretions and is carried in
circulating white blood cells. Oral and respiratory spread are
Congenital CMV Virus culture or viral DNA assay positive at birth or
probably the dominant routes of CMV transmission. CMV can be
Infection within 1 to 2 weeks (to distinguish from natally or
transmitted by blood transfusion, though the risk is low with
perinatally infected infants, who will not begin to
leuko-reduced blood products.
excrete virus until 3-4 weeks after delivery)
Perinatal CMV Culture-negative specimens at birth but positive
❏ Drug treatments of CMV infections have shown some encouraging
Infection specimens at 4 weeks or more after birth suggest
results. Ganciclovir has been shown to be successful in treating
natal or early postnatal acquisition. Seronegative
serious life-threatening CMV infections.
infants may acquire CMV from exogenous
➔ Other drugs used to treat CMV infections are Foscarnet,
sources, such as from blood transfusion.
Acyclovir and Valacycovir
❏ These drugs are used for immunocompromised individuals since
CMV Infection in Demonstration of virus by viral antigen or DNA in
CMV is also a self-limiting virus.
Immunocompro blood documents viremia. Demonstration of
mised hosts inclusions or viral antigen in diseased tissue (e.g, ❏ Vaccine is under development.
lung, esophagus, or colon) establishes the

HUMAN HERPES VIRUS 6 susceptible to acyclovir, because the virus has no thymidine
INTRODUCTION kinase.
❏ In 1986, a herpesvirus, now called human herpesvirus type 6 ❏ No specific treatment and it is self-limiting.
(HHV-6), was identified in cultures of peripheral blood lymphocytes
from patients with lymphoproliferative diseases. HHV-6 is a
β-herpesvirus subfamily. The virus morphologically similar to other HUMAN HERPES VIRUS 7
herpesviruses with similar replication patterns of other ❏ Isolation of human herpesvirus 7 (HHV-7) was first reported in
herpesviruses. HHV-6 replicates in lymphoid tissue, especially 1990. The virus was isolated from activated CD4+ T lymphocytes
CD4+ T lymphocytes, and has two distinct variants, A and B, that of a healthy individual.
are genetically disparate enough that some consider them different ❏ The CD4 molecule appears to be a receptor for virus attachment.
species. ❏ HHV-7 is closely related to HHV-6 and is in the β-herpesvirus
genus.
CLINICAL FINDINGS ❏ Seroepidemiologic studies indicate that this virus usually does not
❏ HHV-6 type B is the main etiologic agent of exanthem subitum infect children until after infancy, but that nearly 90% of children
(roseola) or 6th disease, and both types A and B can cause are antibody positive by 3 years of age.
acute febrile illnesses with or without seizures or rashes. ❏ As with HHV-6, this virus is frequently isolated from saliva, and
Exanthem subitum generally occurs in infants aged 6 months to 1 close personal contact is the probable means of transmission.
year. In the first 6 months, infants are generally protected by the ❏ There is little disease associated with HHV-7, however, it may also
mother’s IgG. Exanthem subitum is characterized by fever (usually be a cause of exanthem subitum, but the association has only
about 39°C) for 3 days, followed by a faint maculopapular rash been found in rare cases.
spreading from the trunk to the extremities, which begins during ❏ The diagnosis of acute infection can be made by the
defervescence. Exanthem subitum is one of the six classic demonstration of seroconversion. No treatment has been
childhood exanthems. identified.
NOTE: HHV-6 and HHV-7 are the etiologic agents of exanthem subitum. NOTE: No specific treatment
EPIDEMIOLOGY (SIR TUBOLA)

❏ Of the herpesviruses, HHV-6 is the most rapidly spread and is Both HHV-6 & HHV-7
shed in the throats of 10% of babies by age 5 months, 70% by 12 A. PROPERTIES OF HHV-6 AND 7
months, and 30% of adults. Greater than 90% of the population ❏ Belong to the betaherpesvirus subfamily of herpesvirus
has antibodies to this virus by the age of 5 years. ❏ HHV-6 and HHV-7 share limited nucleotide homology and
antigenic cross-reactivity.
❏ Primary virus infection can be documented by seroconversion. B. EPIDEMIOLOGY AND PATHOGENESIS
Active virus infection can be documented by culture, antigenemia, ❏ HHV-6 and 7 are ubiquitous and are found worldwide
or DNA detection in the blood (by PCR). Because asymptomatic ❏ They are transmitted mainly through contact with saliva
viremic reactivation is common, it is very difficult to use these tools and through breast feeding
to identify HHV-6 as the cause of febrile or other miscellaneous ❏ HHV-6 and HHV-7 infection are acquired rapidly after the
syndromes. age of 4 months when the effect of maternal antibody
wears off
TREATMENT, PREVENTION AND CONTROL ❏ By the time of adulthood 90-99 % of the population had
❏ Definitive therapy has not been established, but like the better been infected by both viruses.
characterized β-herpesvirus, CMV, HHV- 6 appears to be
susceptible in vitro to ganciclovir and foscarnet. It is less

❏ Like other herpesviruses, HHV-6 and HHV-7 remains ❏ Therefore very few virology laboratories offer a diagnostic
latent in the body after primary infection and reactivation service for HHV-6 or HHv-7 infection.
from time to time. ❏ The technique for virus isolation is complicated and thus
not practicable as a routine diagnostic procedure
C. CLINICAL MANIFESTATIONS ❏ Therefore serology is the mainstay diagnosis where
❏ Primary HHV-6 infection is associated with Roseola specific IgG and IgM are detected
Infantum, which is a classical disease of childhood ❏ There is no specific antiviral treatment for HHV-6 infection
❏ Most cases occur in infants between the ages of 4 months
and two years HUMAN HERPES VIRUS 8
❏ A spiking fever develops over a period of 2 days followed INTRODUCTION
by a mild rash. The fever is high enough to cause febrile ❏ During the AIDS epidemic in the 1980, in the United States,
convulsions. Kaposi Sarcoma (KS) occurred in 20% to 30% of gay or bisexual
❏ There are reports that the disease may be complicated bt males with AIDS but in only around 1% of hemophiliacs with AIDS.
encephalitis This led to the proposal that there was another infectious agent
❏ If primary infection is delayed until adulthood, there is a associated with KS.
small chance that an infectious mononucleosis-like ❏ In 1994, unique viral DNA sequences were identified in KS tumors
disease may develop in a similar manner to EBV and CMV using subtractive hybridization analysis. The sequences bore
❏ There is no firm evidence linking HHV-6 to lymphomas or homology to γ-herpesviruses and were used to clone the entire
lymphoproliferative diseases. 165 kbp genome of the eighth HHV, commonly known as
❏ There is no firm disease associations with HHV-7 at KS-associated herpesvirus (KSHV) or HHV-8. KSHV is found in
present 100% of KS tumors.
❏ Although both viruses may be reactivated in ❏ KSHV is cancer associated in the mouth
immunocompromised patients, it is yet uncertain whether ❏ Belong to gammaherpesviruses subfamily of herpesviruses
they cause significant disease since CMV is almost ❏ Originally isolated from cells of Kaposi’s sarcoma (KS)
invariably present. ❏ Now appears to be firmly associated with Kaposi’s sarcoma as well
as lesser known malignancies such as Castleman’s disease and
primary effusion lymphomas
❏ HHV-8 DNA is found in almost 100% of cases of Kaposi’s sarcoma
❏ Most patients with KS have antibodies against HHV-8
❏ The seroprevalence of HHV-8 is low among the general population
but is high in groups of individuals susceptible to KS, such as
homosexuals
❏ Unlike other herpes viruses, HHV-8 does not have a ubiquitous
distribution
Roseola Infantum
D. DIAGNOSIS AND MANAGEMENT

❏ Roseola Infantum has a very characteristic presentation
and a diagnosis can usually be made on clinical grounds
alone.

PATHOGENESIS
❏ KSHV infects the oral epithelium and can be shed into saliva for
Note: HIV must be treated first for Epidemic Kaposi
transmission. In B cells, KSHV is predominantly in the latent state
sarcoma to be treated.
although lytic antigens can be found in a low percentage of the
cells. In KS tumors, KSHV is found in the main tumor cell, the Table 4.7 The four main forms of Kaposi Sarcoma
spindle cell, a cell of endothelial origin. KSHV is found in all spindle
cells in later stage tumors. Again, the virus is found predominantly
in the latent state, though 1% to 5% of the spindle cells support
lytic antigens and likely replication and virus production. In culture,
KSHV can infect many cell types where it establishes latency in
most of the cells. Similar to the KS tumor, a low percentage of
endothelial cells infected in culture also express lytic antigens.
CLINICAL FINDINGS
Kaposi
Sarcoma Description
KAPOSI’S SARCOMA
Forms ❏ Human herpes virus 8 or Kaposi sarcoma associated herpes virus
(KSHV) is also associated with:
Classic Originally described in the 1800s by Moriz Kaposi, it is
➔ Primary Effusion Lymphoma (PEL))
Kaposi a rare, fairly indolent tumor mainly found on the lower
➔ Multicentric Castleman disease (MCD)
Sarcoma extremities. It is mostly seen in elderly men of
Mediterranean origin and was also described in
EPIDEMIOLOGY
Ashkenazi jews.
❏ KSHV is the least widespread HHV. As noted earlier, KS was
common in the gay and bisexual AIDS community where the
Endemic In the middle of the 20th century, KS became common
seroprevalence rates perfectly match the KS rates at around 25%,
Kaposi in central Africa, where in countries like Uganda it is the
whereas in hemophiliacs with AIDS the seroprevalence rates were
Sarcoma most common tumor reported in hospitals. It is more
similar to healthy blood donors.
aggressive than classic KS and tumors can be seen
❏ The virus is not found in sexual secretions but is shed in saliva.
higher on the extremities and in the oral cavity and the
Because the virus is not ubiquitous like the other saliva-transmitted
torso.
herpesvirus, it is not likely to be easily transmitted by kissing and
may require more prolonged intimate contact.
Iatrogenic KS also arises in posttransplant patients, but generally
NOTE:
Kaposi regresses upon the removal of immunosuppression.
❏ Immunocompromised individuals are only infected
Sarcoma
❏ HSV8 is spread through sexual intercourse, blood transfusion, or
Note: Immune system must be weakened to protect the
vertical transmission or from mother to fetus.
transplanted organs.
Epidemic or This is the most aggressive form of KS, with the tumors
❏ Diagnosis for KSHV infection is currently imperfect.
AIDS-associ often appearing first in the mouth, on the torso, and
Immunofluorescence with sera from infected patients is a standard
ated Kaposi face, and can also be found on internal organs. Without
technique but has a sensitivity of only 70% to 90%.
Sarcoma treatment for HIV, it can lead to death.
❏ PCR

❏ SEROLOGIC TESTS: to detect antigen produced by HHV-8
➔ Indirect Immunofluorescence
➔ Western blot
➔ ELISA

❏ A number of anti herpesvirus drugs inhibit lytic replication of KSHV
with foscarnet being the most active followed by ganciclovir. There
is evidence that treatment with ganciclovir is positively indicated for
MCD because it is a more lytic disease.
❏ No treatment for latently infected cells or vaccines is available.
❏ Antiviral drugs:
➔ Foscarnet
➔ Ganciclovir
➔ Cidofovir
TAKEAWAY NOTES:
❏ HHSV undergoes latency and there is a possibility of reactivation.
It is only reactivated once the immune system is severely
compromised or due to old age resulting in a weakened immune
system. Once infected, it will stay in the host’s body forever.
Figure 4.11 Kaposi Sarcoma of the Oral Cavity

MODULE 5: HEPATITIS VIRUSES possible. The severity and course of the disease depend on the
particular virus and the state of the host.
OUTLINE OF THE LESSON ❏ Hepatitis is diagnosed serologically through the identification of
specific antigens or antibodies. Also, liver enzymes, including
I. INTRODUCTION Alanine Aminotransferase (ALT), Aspartate Aminotransferase
II. PROPERTIES OF HEPATITIS VIRUS (AST), Lactate dehydrogenase (LD), and Alkaline Phosphatase
III. HEPATITIS VIRUSES (ALP) may be increased up to 10 times the normal value in
A. Hepatitis A Virus (HAV) hepatitis. The serum bilirubin level also is increased in
B. Hepatitis B Virus (HBV) symptomatic patients.
C. Hepatitis C Virus (HCV)
D. Hepatitis D Virus (HDV) PROPERTIES OF HEPATITIS VIRUS
E. Hepatitis E Virus (HEV)
HIGHLIGHTING OF TOPICS BULLET PLACEMENT
AAAAAA - Family of virus ❏ (Main definition)

AAAAAA - Subtopics ● (Super Sub-detail)
INTRODUCTION
❏ Viral hepatitis is a systemic disease primarily involving the liver.
Most cases of acute viral hepatitis in children and adults are
caused by one of the following five agents: hepatitis A virus
(HAV), hepatitis B virus (HBV), hepatitis C virus (HCV),
hepatitis D (HDV), or hepatitis E virus (HEV).
❏ Hepatitis viruses produce acute inflammation of the liver,
resulting in a clinical illness characterized by fever, gastrointestinal
symptoms such as nausea and vomiting, and jaundice. Hepatitis
viruses cause similar appearing histopathologic lesions in the liver
during acute disease.
Currently, there are five recognized hepatitis viruses:

1. Hepatitis A Virus (HAV)
2. Hepatitis B Virus (HBV)
3. Hepatitis C Virus (HCV) – previously known as non-A, non-B
(NANB)
4. Hepatitis D Virus (HDV)
5. Hepatitis E Virus (HEV)
❏ Viral hepatitis, or infectious disease from hepatitis viruses, may

range from mild and self-limiting disease to acute fulminating
cirrhosis; chronic disease and asymptomatic carriage also are
Table 5.1 Characteristics of Hepatitis Virus

NOTE: Take note of the family, genus, envelope, genome, and NOTE: Take note of the definitions in the table.
transmission. ➔ Core antigen is found in the nucleocapsid.
❏ All of them have vaccines except Hepatitis C ➔ In HBV, HBsAg, HBeAg, HBcAg are the antigens being detected
❏ Most common in the world: Hepatitis A and B in the laboratory.
❏ Classified according to host cell and diseases caused, but they are ➔ Immune globulins (IG) or IGIV (Intravenous) is a type of passive
not genetically related. immunity made for immunocompromised persons. Antibodies are
❏ Parenteral: other routes aside from the enteral or GIT route. directly injected into the body.
❏ Fulminant disease: end-stage disease, frequent in Hepatitis D
infection IMPORTANT INFO:
❏ Oncogenic disease: can cause cancer Hepatitis viruses do not cause cross-reactivity since they don’t have similar
antigenic properties. They are just named because they affect the liver and
the letters signify the sequence of discovery.
HEPATITIS A VIRUS (HAV)

INTRODUCTION
❏ HAV is a distinct member of the picornavirus family. HAV is a
spherical particle with cubic symmetry containing a linear
single-stranded RNA genome. It is assigned to the picornavirus
genus, Hepatovirus. There is no antigenic cross-reactivity with the
other hepatitis viruses. It is also known as “Infectious Hepatitis
Virus”.
❏ Alpha2-macroglobulin in the hepatocytes is the receptor of
Hepatitis A.
❏ It has only one serotype or monotypic, once you get infected and
recovered, you will acquire life-long immunity.
❏ There is no antigenic cross-reactivity with the other hepatitis virus
since they are from different families.
❏ HAV is stable (because it is naked) to treatment with 20% ether,
acid (pH 1.0 for 2 hours), and heat (60°C for 1 hour), and its
infectivity can be preserved for at least 1 month after being dried
and stored at 25°C (air conditioned room) or for years at −20°C
(freezer).
❏ The virus is destroyed by:
➔ Autoclaving (121°C for 20 minutes)
➔ Boiling in water for 5 minutes
➔ Dry heat (oven) (180°C for 1 hour)
➔ Ultraviolet irradiation (1 minute at 1.1 watts
➔ Treatment with formalin (1:4000 for 3 days at 37°C)
➔ Treatment with chlorine (10–15 ppm for 30 minutes).
❏ Heating food to above 85°C (185°F) for 1 minute and disinfecting
surfaces with sodium hypochlorite (1:100 dilution of chlorine
Table 5.2 Nomenclature and Definitions of Hepatitis Viruses, Antigens and bleach) are necessary to inactivate HAV. The relative resistance of
Antibodies

HAV to disinfection procedures emphasizes the need for extra
Assay Result Interpretation
precautions in dealing with hepatitis patients and their products.
❏ HAV initially was identified in stool and liver preparations by using
Anti- HAV IgM Positive Acute Infection with HAV
immune electron microscopy. Sensitive serologic assays and
polymerase chain reaction (PCR) methods have made it possible
Anti-HAV IgG Positive Past Infection with HAV
to detect HAV in stools and other samples and to measure specific
antibodies in serum. Various primate cell lines will support growth Table 5.3 Interpretation of HAV Serologic MArkers in Patients with
of HAV, although fresh isolates of virus are difficult to adapt and Hepatitis
grow. Usually, no cytopathic effects are apparent. Mutations in the
viral genome are selected during adaptation to tissue culture.
LABORATORY TESTS
❏ Virus appears early in the disease and disappears within 2 weeks
following the onset of jaundice. HAV can be detected in the liver,
stool, bile, and blood of naturally infected humans and
experimentally infected non-human primates by immunoassays,
nucleic acid hybridization assays, or PCR. HAV is detected in the
stool from about 2 weeks prior to the onset of jaundice up to 2
weeks after.
❏ RT-PCR is the method of choice for mRNA viruses.
❏ The Anti-HAV is an antibody usually used to detect the infection
caused by the Hepatitis A Virus. Anti- HAV appears in the IgM
fraction during the acute phase, peaking about 2 weeks after
elevation of liver enzymes. Anti-HAV IgM appears soon after the
onset of disease and persists for decades. Thus, detection of
IgM-specific anti-HAV in the blood of an acutely infected patient
confirms the diagnosis of hepatitis
❏ ELISA is the method of choice for measuring HAV antibodies.
Figure 5-2. Immunologic and biologic events associated with human

infection with hepatitis A virus. IgG, immunoglobulin G; IgM,
immunoglobulin M.
❏ Virus in the blood (viremia) appears 2 weeks after exposure. By

the time signs & symptoms appear, the virus in the blood is already
undetectable. This is the reason why blood could not be used as a
diagnostic specimen for HAV. During the appearance of signs &
symptoms, HAV RNA appears in the feces (virus shedding
occurs).

❏ Jaundice / symptoms appear 4 weeks after exposure. Liver ➔ Persons with clotting factor disorders
enzymes will also start to be elevated. ➔ Persons working with non-human primates.
❏ HAV undergoes replication inside the hepatocytes and they will be
released through lysis. Aminotransferases elevate before the ❏ Individuals with chronic liver disease are at increased risk for
appearance of jaundice, this means that there is inflammation in fulminant hepatitis if a hepatitis A infection occurs. These groups
the liver (hepatitis). should be vaccinated.
❏ Since there is inflammation in the liver, bilirubin could not be
converted into a soluble substance for excretion, there will be TREATMENT
excess bilirubin resulting in jaundice. ❏ Treatment of patients with hepatitis A is supportive and directed at
❏ IgM appears approximately 4 weeks after exposure, during the allowing hepatocellular damage to resolve and repair itself.
acute infection. ❏ Food supplements and vitamins like Liver Aid
❏ IgG will gradually rise and will confer life-long immunity against
HAV. PREVENTION AND CONTROL
❏ FORMALIN-INACTIVATED HAV VACCINES
EPIDEMIOLOGY ➔ made from cell culture adapted virus are safe, effective,
❏ HAV is widespread throughout the world. Outbreaks of type A and recommended for use in persons more than 1 year of
hepatitis are common in families and institutions, summer camps, age. Routine vaccination of all children is now
day care centers, neonatal intensive care units, and among military recommended, as is vaccination of persons at increased
troops. risk, including international travelers, men who have sex
❏ The most likely mode of transmission under these conditions is by with men, and drug users.
the fecal–oral route through close personal contact. Stool
specimens may be infectious for up to 2 weeks before to 2 weeks ❏ Until all susceptible at-risk groups are immunized, prevention and
after onset of jaundice. Under crowded conditions and poor control of hepatitis A still must emphasize interrupting the chain of
sanitation, HAV infections occur at an early age; most children in transmission and using passive immunization. The appearance of
such circumstances become immune by age 10 years. hepatitis in camps or institutions is often an indication of poor
❏ Clinical illness is uncommon in infants and children; disease is sanitation and poor personal hygiene.
most often manifest in children and adolescents, with the highest ❏ Control measures are directed toward the prevention of fecal
rates in those between 5 and 14 years of age. contamination of food, water, or other sources by the individual.
❏ HAV is seldom transmitted by the use of contaminated needles ➔ Reasonable hygiene—such as handwashing,
and syringes or through the administration of blood. ➔ The use of disposable plates and eating utensils, and
➔ the use of 0.5% sodium hypochlorite (eg, 1:10 dilution of
Transfusion-associated hepatitis A is rare because: chlorine bleach) as a disinfectant—is essential in
➔ The viremic stage of infection occurs during the preventing the spread of HAV during the acute phase of
prodromal phase and is of short duration, the illness.
➔ The titer of virus in the blood is low,
➔ And there is no carrier state. There is little evidence for ❏ IMMUNE (γ) GLOBULIN (Ig)
HAV transmission by exposure to urine or nasopharyngeal ➔ passive immunity
secretions of infected patients. ➔ is prepared from large pools of normal adult plasma and
confers passive protection in about 90% of those
Groups that are at increased risk of acquiring hepatitis A are: exposed when given within 1–2 weeks after exposure to
➔ Travelers to developing countries from developed countries hepatitis A.
➔ Men who have sex with men, users of injection and non-injection ➔ Its prophylactic value decreases with time, and its
drugs administration more than 2 weeks after exposure or after

onset of clinical symptoms is not indicated. In the doses
generally prescribed, IG does not prevent infection but
rather makes the infection mild or subclinical and permits
active immunity to develop. HAV vaccine produces a more
enduring immunity and should replace the use of IG.
NOTE:
❏ The purpose of the Immune (y) globulin (IG) is for prophylaxis, it
gives the body (active immunity) enough time to produce
antibodies against the virus.
HEPATITIS B VIRUS
INTRODUCTION
❏ HBV is classified as a Hepadnavirus. HBV establishes chronic
infections, especially in those infected as infants; it is a major
factor in the eventual development of liver disease and
hepatocellular carcinoma in those individuals.
❏ The Hepa B virus targets the liver because the receptor of the
Hepatitis B virus are the NTCP (Sodium taurocholate
Co-transporting polypeptides) which is found on the hepatocytes
❏ Electron microscopy of hepatitis B surface antigen (HBsAg)- FORMS DESCRIPTION
positive serum reveals three morphologic forms.
Pleomorphic / ● Most numerous form and contain only HBsAg
THREE MORPHOLOGICAL FORMS OF HEPATITIS B VIRUS: Spherical ● Not a complete virion
1. SPHERICAL / PLEOMORPHIC Particles ● Non-infectious
➔ Most numerous; these small particles are made up
exclusively of HBsAg—as are tubular or filamentous Filamentous / ● Contains only HBsAg but are longer
forms—and result from overproduction of HBsAg. Elongated ● Not a complete virion
2. ELONGATED / FILAMENTOUS particles which have the same Form ● Non-infectious
components as the spherical ones.
3. SPHERICAL VIRIONS Spherical ● The complete virion
➔ Larger than the two Virion (Dane ● Infectious
➔ originally referred to as Dane particles Particle)
➔ are less frequently observed. The outer surface, or Table 5.4 Morphologic Features of HBV
envelope, contains HBsAg and surrounds an inner
nucleocapsid core that contains hepatitis B core antigen NOTE: Increased surface antigen production, little capsid and genome
(HBcAg). The viral genome (Figure 5-3A) consists of production.
partially double-stranded circular DNA.
❏ The virus is stable at 37°C for 60 minutes and remains viable after
being dried and stored at 25°C for at least 1 week.
❏ HBV (but not HBsAg) is sensitive to higher temperatures (100°C
for 1 minute) or to longer incubation periods (60°C for 10 hours).

HBsAg is stable at a pH of 2.4 for up to 6 hours, but HBV 3. HBeAg
infectivity is lost. ❏ Hepatitis B e antigen
➔ Sodium hypochlorite, 0.5% (eg, 1:10 chlorine bleach), ❏ Secreted from nucleocapsid core of unknown function
destroys antigenicity within 3 minutes at low protein ❏ Used as an indication of active HBV replication
concentrations, but undiluted serum specimens require ❏ Marker of potential infectivity
higher concentrations (5%). ❏ If a test is (+) for HBeAg this indicates active Hepatitis B
❏ HBsAg is not destroyed by ultraviolet irradiation of plasma or other infection
blood products, and viral infectivity may also resist such treatment.
HBV REPLICATION
❏ Replication occurs in the nucleus of hepatocytes
Figure 5.4 The complete HBV Virion

Figure 5-5. HBV Replication Cycle
THE COMPLETE HBV VIRION
1. HBsAg ❏ The infectious virion attaches to cells and becomes uncoated. In
❏ Hepatitis B surface antigen the nucleus, the partially double-stranded viral genome is
❏ Found on the HBV envelope converted to covalently closed circular double-stranded DNA
❏ Always in excess (cccDNA).
❏ If (+) in a test, it Indicates acute infection of Hepatitis B ➔ The cccDNA serves as a template for all viral transcripts,
including a 3.5-kb pre-genome RNA.
2. HBcAg ❏ The pre-genome RNA becomes encapsulated with newly
❏ Hepatitis B core antigen synthesized HBcAg.
❏ Found on the HBV nucleocapsid core\ ❏ Within the cores, the viral polymerase synthesizes by reverse
❏ Cannot be found in serum transcription a negative-strand DNA copy. The polymerase starts
❏ Can be found in the nucleus of the hepatocytes where the to synthesize the positive DNA strand, but the process is not
replication of the virus occurs completed.

❏ Cores bud from the pre-Golgi membranes, acquiring HBsAg ❏ Recovery from the hepatitis B virus, the HbsAg and HbeAg will
containing envelopes, and may exit the cell. Alternatively, cores decrease because the antibodies will increase
may be reimported into the nucleus and initiate another round of ❏ Window period or equivalence zone - small period characterized
replication in the same cell. by the disappearance of HBsAg and before the appearance of
Anti-HBsAg
LABORATORY TESTS ➔ Might give false negative results if samples are collected
❏ PCR - method of choice for detection of viral DNA during this period.
❏ ELISA - method of choice for detecting viral antigen and antibody ➔ Anti-HBc is detected in this period
❏ Once Anti HBsAg develops, it indicates immunity against Hepatitis
B virus
RISE OF SEROLOGIC MARKERS (during Hepatitis B Virus infection):

1. HBsAG - first to increase
2. HBSeAG - after 1-2 months
3. HBcAG - more or less 2 months
4. Anti HBcAG
5. Anti HBeAg
6. Anti HBsAg- Indicates immunity against Hepatitis B
NOTE: During vaccination, HBsAg is given.

❏ HBcAG is only present during Hepatitis B virus infection that is why
during vaccination there is no HBcAg and Anti HBcAg detected,
only Anti HBsAG
❏ Common on screening tests are HBsAg and Anti HBs, but if there
is an issue Anti HBc is used.
❏ Level of detection - Minimum level of detection of antigen
❏ (+/-) - would mean it's either above or below the line (refer to the
table)
Figure 5-6. Clinical and serologic events occurring in a patient with acute
hepatitis B virus infection.
NOTE: (SIR ROBERT)
❏ During the acute episode of the disease, if there is active
replication, there will be large amounts of HBSAg and HBeAG in
the serum.
➔ The increase in HBSAg indicates an ongoing
infection(replication)of Hepatitis B virus
➔ There is no detection of HBcAG in the serum because it is
only found in hepatocytes
➔ During the start of an acute infection the antibody against
HBcAg will quickly rise resulting in the removal of the
antigen in the serum

EPIDEMIOLOGY TREATMENT
❏ HBV is worldwide in distribution. Most individuals infected as ❏ Treatment of HBV infection is recommended for patients with
infants develop chronic infections. As adults, they are subject to chronic active hepatitis to prevent progression of liver fibrosis and
liver disease and are at high risk of developing hepatocellular development of hepatocellular carcinoma.
carcinoma. The major modes of HBV transmission during infancy
are from an infected mother to her newborn during delivery and THERAPIES FOR HEPATITIS B
from an infected household contact to an infant. 1. First-line therapies for Hepatitis B
❏ There is no seasonal trend for HBV infection and no high ➔ Pegylated interferon alfa-2a
predilection for any age group, although there are definite high-risk ➔ Entecavir
groups, such as: ➔ Tenofovir
➔ parenteral drug abusers, NOTE: Medication is given as Peglylated interferon alfa-2a with either
➔ institutionalized persons, Entecavir or Tenofovir
➔ health care personnel, 2. Second-line therapy for Hepatitis B
➔ multiple transfused patients, ➔ Telbivudine
➔ organ transplant patients, 3. Third-line therapy for Hepatitis B
➔ hemodialysis patients and staff, ➔ Lamivudine, also known as 3TC
➔ highly promiscuous persons, ➔ Adefovir
➔ newborn infants born to mothers with hepatitis B.
❏ Mandatory screening of blood donors for markers of HBV infection PREVENTION AND CONTROL
(HBsAg, HBc Ab, and HBV DNA) has substantially reduced the ❏ Hepatitis B Virus infection can be prevented by currently available
number of cases of transfusion-associated hepatitis. People have vaccine
been infected by improperly sterilized syringes, needles, or
scalpels and even by tattooing or ear piercing. HEPATITIS C VIRUS (HCV)
❏ HBsAg can be detected in: INTRODUCTION
➔ Saliva ❏ Clinical and epidemiologic studies and cross- challenge
➔ Nasopharyngeal washings experiments in chimpanzees in the past had suggested that there
➔ Semen were several non-A, non-B (NANB) hepatitis agents that, based
➔ Menstrual fluid on serologic tests, were not related to HAV or HBV. The major
➔ Vaginal secretions agent was identified as HCV.
➔ Blood ❏ Most cases of post-transfusion NANB hepatitis were caused by
❏ Transmision from carriers to close contacts by the oral route or by HCV. Heparan sulfate proteoglycans are the receptors for
sexual or other intimate exposure occurs. Hepatitis C which is found in the hepatocytes
❏ There is strong evidence of transmission from persons with
subclinical cases and carriers of HBsAg to homosexual and
heterosexual long-term partners. Transmission by the fecal–oral
route has not been documented.
❏ Recalling that there may be more than 1 billion virions/mL of blood
from an HBeAg positive carrier and that the virus is resistant to
drying, it should be assumed that all bodily fluids from
HBV-infected patients may be infectious. Subclinical infections are
common, and these unrecognized infections represent the
principal hazard to hospital personnel.
Figure 5.7 HCV Structure

❏ Anti-HCV antibodies can be detected in 50–70% of patients at the
❏ HCV is a positive-stranded RNA virus, classified as family onset of symptoms, but in others, antibody appearance is delayed
Flaviviridae, genus Hepacivirus. Most cases of post-transfusion 3–6 weeks.
NANB hepatitis were caused by HCV. Most new infections with ❏ Antibodies are directed against core, envelope, and NS3 and NS4
HCV are subclinical. proteins and tend to be relatively low in titer. Nucleic acid-based
❏ The majority (70–90%) of HCV patients develop chronic hepatitis, assays (eg, reverse transcription PCR) detect the presence of
and many are at risk of progressing to chronic active hepatitis and circulating HCV RNA and are useful for diagnosis of acute infection
cirrhosis (10–20%). In 1–5% of infected individuals, HCV leads to soon after exposure and for monitoring patients on antiviral
hepatocellular carcinoma, which is the fifth most common cause therapy.
of cancer worldwide.
ASSAY RESULT INTERPRETATION
LABORATORY TESTS
Anti-HCV Positive Current or Past infection with HCV
EPIDEMIOLOGY
❏ Infections by HCV are extensive throughout the world. The World
Health Organization estimates that about 1% of the world
population has been infected, with population subgroups in Africa
having prevalence rates as high as 10%. Other high-prevalence
areas are found in South America and Asia.
❏ HCV is transmitted primarily through direct percutaneous
exposures to blood, although in 10–50% of cases, the source of
HCV cannot be identified. In roughly decreasing order of
prevalence of infection are:
➔ Injecting drug users (∼80%)
➔ Individuals with hemophilia treated with clotting factor
products before 1987
➔ Recipients of transfusions from HCV-positive donors,
chronic hemodialysis patients (10%)
➔ Persons who engage in high-risk sexual practices
➔ Health care workers (1%)
Figure 5.8 Clinical and serologic events associated with hepatitis C virus ❏ The virus can be transmitted from mother to infant, although not as
(HCV) frequently as for HBV. Estimates of mother-to-child vertical
INFECTION: transmission vary from 3% to 10%. Mothers with higher HCV viral
❏ RT PCR - confirmation of ELISA loads or coinfection with HIV more frequently transmit HCV. No risk
❏ ELISA of transmission has been associated with breastfeeding. HCV was
NOTE: ALT increases since HCV affects the liver. found in saliva from more than one-third of patients with HCV and
HIV co infections.
❏ Serologic assays are available for diagnosis of HCV infection. ❏ HCV infection has been associated with tattooing and, in some
Enzyme immunoassays detect antibodies to HCV but do not countries, with folk medicine practices.
distinguish among acute, chronic, or resolved infection ❏ HCV can be transmitted to an organ transplant recipient from an
because anti-HCV antigens persist for life HCV-positive donor.

❏ The average incubation period for HCV is 6–7 weeks. The
average time from exposure to seroconversion is 8–9 weeks,
and about 90% of patients are anti-HCV positive within 5 months.
TREATMENT
❏ Orthotopic liver transplantation is a treatment for chronic
hepatitis B and C end-stage liver damage.
❏ Pegylated interferon combined with ribavirin has been the
standard treatment for chronic hepatitis C.
❏ First-generation protease inhibitor drugs
➔ Telaprevir
➔ Boceprevir
● They are given in combination with interferon and
ribavirin.
❏ Second-generation protease inhibitor drugs
➔ Sofosbuvir Figure 5.9 Structural representation of hepatitis B and delta viruses.
● These drugs have less toxicity than
first-generation antivirals, and greater efficacy. LABORATORY TESTS
❏ RT-PCR
PREVENTION AND CONTROL ❏ ELISA
❏ There is currently no vaccine for Hepatitis C
HEPATITIS D VIRUS (HDV)

INTRODUCTION
❏ An antigen–antibody system termed the delta antigen (deltaAg)
and antibody (anti-delta) is detected in some HBV infections. The
antigen is found within certain HBsAg particles. In blood, HDV
(delta agent) contains delta-Ag (HDAg) surrounded by an HBsAg
envelope.
❏ HDV is a defective virus that requires the HBsAg coat for
transmission that is why they are only found in individuals with
acute or chronic Hepatitis B infection. No Hep B, no Hep D
❏ The genome of HDV consists of single-stranded, circular,
negative-sense RNA.
❏ It is the smallest of known human pathogens and resembles
subviral plant pathogens (ie, viroids. HDAg is the only protein
coded for by HDV RNA and is distinct from the antigenic
determinants of HBV. HDV is a defective virus that requires the Figure 5.10
HBsAg coat for transmission.
❏ It is often associated with the most severe forms of hepatitis in ❏ Because HDV depends on a coexistent HBV infection, acute type
HBsAg-positive patients. It is classified in the Deltavirus genus, D infection occurs either as a simultaneous infection (coinfection)
which is not assigned to any virus family. with HBV or as a superinfection of a person chronically infected
with HBV.

❏ In the coinfection pattern, antibody to HDAg develops late in the transfusions, intravenous drug abusers, and their close contacts
acute phase of infection and may be of low titer. Assays for HDAg are at high risk.
or HDV RNA in the serum or for IgM-specific anti-HDV are ❏ The primary routes of transmission are believed to be similar to
preferable. All markers of HDV replication disappear during those of HBV, although HDV does not appear to be a sexually
convalescence; even the HDV antibodies may disappear within transmitted disease.
months to years. ❏ Infection depends on HBV replication because HBV provides
❏ Superinfection by HDV usually results in persistent HDV infection an HBsAg envelope for HDV. The incubation period varies from 2
(>70% of cases). High levels of both IgM and IgG anti-HD persist, to 12 weeks, being shorter in HBV carriers who are superinfected
as do levels of HDV RNA and HDAg. HDV superinfections may be with the agent than in susceptible persons who are simultaneously
associated with fulminant hepatitis. infected with both HBV and HDV. HDV has been transmitted
perinatally, but fortunately, it is not prevalent in regions of the world
(e.g, Asia) where perinatal transmission of HBV occurs frequently.
ASSAY RESULT INTERPRETATION
TREATMENT
Anti-HDV (+), HBsAg(+) Infection with HDV
❏ Treatment of patients with hepatitis D is supportive (treatment of
symptoms only) and directed at allowing hepatocellular damage
Anti-HDV (+), Anti-HBc IgM (+) Coinfection with HDV and HBV
to resolve and repair itself.
❏ Vaccination for Hepatitis B can prevent Hepatitis D since HBV is
Anti-HDV (+), Anti-HBc IgM (-) Superinfection of Chronic HBV
needed by HDV.
infection with HDV
SIR ROBERT ❏ Delta hepatitis can be prevented by vaccinating HBV susceptible
persons with hepatitis B vaccine.
Anti HDV Anti HBc IgM Total Anti HBc
❏ However, vaccination does not protect hepatitis B carriers from
superinfection by HDV.
+ + + coinfection
HEPATITIS E VIRUS (HEV)
+ - + superinfection
INTRODUCTION
❏ HEV is transmitted enterically and occurs in epidemic form in
NOTE: developing countries, where water or food supplies are sometimes
❏ IgG cannot be detected on its own, that is why we test for the total fecally contaminated. (can cause epidemic)
Anti HBc. ❏ The viral genome has been cloned and is a positive-sense,
❏ If Anti HBc IgM is negative but positive for total HBc this means single-stranded RNA. The virus is classified in the virus family,
that the one responsible for making the total anti HBc positive was Hepeviridae, in the genus Hepevirus. HEV resembles, but is
anti HBc IgG. IgG is present in chronic Hepatitis B distinct from, caliciviruses.
❏ Animal strains of HEV are common throughout the world. There is
EPIDEMIOLOGY evidence of HEV or HEV-like infections in rodents, pigs, sheep,
❏ HDV is found throughout the world but with a nonuniform and cattle in the United States, with occasional transmission to
distribution. Its highest prevalence has been reported in Italy, the humans. (zoonotic disease)
Middle East, central Asia, West Africa, and South America. HDV
infects all age groups. Persons who have received multiple EPIDEMIOLOGY
❏ Hepatitis E is found worldwide, but the prevalence is highest in
East and South Asia

TREATMENT
❏ Treatment of patients with hepatitis E is supportive and directed at
allowing hepatocellular damage to resolve and repair itself.
❏ Self limiting
❏ A vaccine to prevent hepatitis E virus infection has been developed
and is licensed in China, but is not yet available elsewhere.
❏ Immunization only provides short-term protection and
there is no specific therapy available

❏ A vaccine to prevent hepatitis E virus infection has been developed
and is licensed in China, but is not yet available elsewhere.
Immunization only provides short-term protection and there is no
specific therapy available
NOTE: Hepatitis transmission:
❏ Fecal oral : A and E
❏ Parenteral: B,C,D
NEVER SHALL WE FAIL!

#GetThatRMTBro!

MODULE 6: PICORNAVIRUSES ❏ They include two major groups of human pathogens:
OUTLINE OF THE LESSON enteroviruses and rhinoviruses.
A. ENTEROVIRUSES
I. INTRODUCTION ❏ are transient inhabitants of the human alimentary tract and
II. PROPERTIES OF PICORNAVIRUSES may be isolated from the throat or lower intestine.
III. PICORNAVIRUSES) B. RHINOVIRUSES
A. Enteroviruses ❏ are associated with the respiratory tract and isolated
B. Polio Viruses
chiefly from the nose and throat.
C. Coxsackie Viruses
D. Echo Virus and Other Enteroviruses
E. Parechoviruses ❏ Less common picornaviruses associated with human illness
F. Rhinoviruses include hepatitis A virus, parechovirus, cardiovirus, and Aichi virus.
G. Aphthovirus Several genera of picornaviruses are also associated with animal,
plant, and insect disease.
HIGHLIGHTING OF TOPICS BULLET PLACEMENT ❏ Many picornaviruses cause diseases in humans ranging from
AAAAAA - Family of virus ❏ (Main definition) severe paralysis to aseptic meningitis, pleurodynia, myocarditis,
AAAAAA - Main topic ➔ (Sub-definition/Enumerate) vesicular and exanthematous skin lesions, mucocutaneous
AAAAAA - Subtopics ● (Super Sub-detail) lesions, respiratory illnesses, undifferentiated febrile illness,
conjunctivitis, and severe generalized disease of infants.
INTRODUCTION ❏ The most serious disease caused by any enterovirus is
❏ The Picornaviridae are a large, diverse viral family, which poliomyelitis. A worldwide effort is making progress toward the
includes the enterovirus and rhinoviruses. It comprises a large goal of total eradication of poliomyelitis.
number of very small RNA (pico, meaning small, RNA:rna)
❏ They are non-enveloped viruses, resistant to ether and other lipid NOTE:
solvents ❏ All are respiratory viruses:
❏ The viruses have a very small size of 20nm to 30nm, which is ➔ Largest Virus: Poxviridae
described by the prefix “pico” in their names. ➔ Smallest DNA Virus: Parvoviridae
❏ The Picornaviridae cause a variety of infections, which include ➔ Smallest RNA Virus: Picornaviridae
central nervous system disorders, such as: ❏ The Picornaviridae family has more than 230 members that are
➔ Aseptic meningitis divided into six genera:
➔ Polio ➔ Enterovirus
➔ Myocarditis ➔ Rhinovirus
➔ Mild or asymptomatic respiratory disease ➔ Cardiovirus
❏ Often, poor personal hygiene, overcrowding, or substandard ➔ Aphthovirus
sanitation are factors in the acquisition of these infections. ➔ Hepatovirus
❏ Picornaviruses represent a very large virus family with respect to ➔ Parechovirus
the number of members but one of the smallest in terms of virion
size and genetic complexity.

PROPERTIES OF PICORNAVIRUSES
Culture ➔ Many enterovirus (poliovirus, echovirus,
come coxsackieviruses) can be grown
PROPERTY DESCRIPTION at 37°C in humans and monkey cells
➔ Most rhinovirus strains can be
Virion ➔ Icosahedral recovered only in human cells at 33°C
➔ 28–30 nm in diameter ➔ Coxsackieviruses are pathogenic for
➔ Contains 60 subunits newborn mice
Table 6.1 Important properties of picornaviruses
Composition ➔ RNA (30%)
➔ Protein (70%)
Genome ➔ Single-stranded RNA

➔ Linear
➔ Positive sense
➔ 7.2–8.4 kb in size
➔ Molecular weight 2.5 million
➔ Infectious
➔ Contains genome-linked protein (VPg)
Proteins ➔ Four major polypeptides cleaved from a

large precursor polyprotein.
➔ Surface capsid proteins VP1 and VP3
are major antibody-binding sites.
➔ VP4 is an internal protein.
Envelope None NOTE: P ICO RNA

P- Positive sense; Ico - Icosahedral; RNA - RNA virus
Replication Cytoplasm
Outstanding ➔ Family is made up of many enterovirus

Characteristics and rhinovirus types that infect humans
and lower animals, causing various
illnesses ranging from poliomyelitis to
aseptic meningitis to the common
cold.
➔ Poliomyelitis and Aseptic Meningitis
(non-bacterial meningitis) - caused by
enteroviruses
➔ Common cold - caused by rhinoviruses

The Picornaviridae family contains 12 genera:
Figure 6.1 Structure of a typical picornavirus. A. GENUS ENTEROVIRUS
❏ Exploded diagram showing internal location of the RNA genome ❏ Enteroviruses
surrounded by capsid composed of monomers of proteins VP1, ➔ Poliovirus types 1, 2 and 3
VP2, VP3, and VP4. ➔ Coxsackie A virus types 1-22 and 24
❏ There is a prominent cleft or canyon around each pentameric ➔ Coxsackie B virus types 1-6
vertex on the surface of the virus particle. ➔ Echovirus (ECHO virus) types 1-9, 11-27 and
❏ The receptor-binding site used to attach the virion to a host cell is 29-34
thought to be located near the floor of the canyon. ➔ Enterovirus 68-72
❏ This location would presumably protect the crucial cell attachment ❏ Rhinoviruses type 1 - 100+ most important cause of the
site from structural variation influenced by antibody selection in common cold
hosts because the canyon is too narrow to permit deep penetration B. GENUS HEPATOVIRUS
of antibody molecules. ❏ Hepatitis A virus
NOTE: C. GENUS KOBUVIRUS
VP4 - present in the interior of the capsid ❏ Aichi virus
VP1, VP2, and VP3 - present in the exterior of the capsid D. GENUS PARECHOVIRUS
VP1, 2, 3, and 4 will combine to form a PROTOMER, a protomer will bind ❏ Parechoviruses
with other protomers to form a PENTAMER which will complex with other ➔ Echovirus 22 and 23
pentamers to form a CAPSID. E. GENUS CARDIOVIRUS
❏ Cardiovirus of mice, including the encephalomyocarditis
CLASSIFICATION OF PICORNAVIRIDAE virus
F. GENUS APHTHOVIRUS
❏ Foot-and-mouth disease of cattle
❏ Rhinoviruses historically were placed in a separate genus but are

now considered to be members of the Enterovirus genus.

REPLICATION OF PICORNAVIRUS GENUS ENTEROVIRUS
INTRODUCTION
❏ Enterovirus of medical importance include:
➔ Polioviruses
➔ Coxsackieviruses
➔ echoviruses
❏ They are all found in the intestines and are excreted in the feces.
❏ At least 72 serotypes of human enteroviruses exist, including the:
➔ Poliovirus types 1- 3
➔ Coxsackie A virus types 1- 24
➔ Coxsackie B virus types 1-6
➔ Echovirus (ECHO virus) types 1-34
➔ Enterovirus 68-72
❏ Enterovirus 72 is the virus causing infections hepatitis ( Hepatitis
type A) , which has been reclassified as a separate genus
Figure 6.2 Overview of the picornavirus replication cycle Hepatovirus
PICORNAVIRUS REPLICATION CYCLE IMMUNE RESPONSE

1. Virion attaches to a specific receptor in the plasma membrane ➔ Complement fixing and neutralizing antibodies
2. Release of viral linear (+)ssRNA into the cytosol ➔ Early specific IgM response followed by a much longer-lasting
3. (+)ssRNA is translated to viral proteins production of IgG
4. (+)ssRNA is transcribed to (-)ssRNA ➔ IgA at mucosal surfaces
5. (-)ssRNA is used as template to form many (+)ssRNA ➔ Newly born babies are protected by maternal antibodies (for 6
6. Viral proteins form protomers months)
7. Protomers become pentamers
8. Pentamers are packaged with (+)ssRNA EPIDEMIOLOGY
9. Provirions are activated to become infectious virion ❏ Transmission
10. Virions are released when cell lyses ➔ Fecal- oral
❏ At risk or risk factors
NOTE: The Picornavirus replication occurs in the cytoplasm of the host ➔ Poor sanitation
cells and are released through cell lysis or apoptosis ❏ Distribution
➔ Worldwide
➔ Disease most common in summer
❏ Vaccines or antiviral drugs
➔ No vaccines
➔ No licensed antiviral drugs

PATHOGENESIS
❏ The virus is transmitted by the fecal-oral route through ingestion
❏ Virus is ingested and multiplies initially in the lymphoid tissue of the
tonsil or Peyer’s patches in the small intestine
❏ It then spreads to the regional lymph nodes and enters the
bloodstream (minor or primary viremia)
❏ Primary viremia spreads the virus to receptor-bearing target
tissues, where a second phase of viral replication may occur,
resulting in symptoms and a secondary viremia
NOTE:
❏ ALL are ENTEROVIRUSES which are divided into 2 groups:
➔ Poliovirus -
➔ Non-polioviruses - coxsackievirus, Echovirus, Enterovirus,
Parechovirus POLIO VIRUSES
INTRODUCTION
❏ They replicate in the GI tract.
❏ Poliomyelitis is an acute infectious disease that in its serious form
❏ It can survive stomach’s acidity because it is a naked virus. Not all
affects the central nervous system (CNS).
can cause nausea, vomiting, diarrhea and other symptoms of
➔ The destruction of motor neurons in the spinal cord results
enteric infection because some travels in the circulation and cause
in flaccid paralysis.
signs and symptoms to other organ
➔ Most poliovirus infections are subclinical.
❏ MOT: Fecal-oral route
➔ Poliovirus has served as a model enterovirus in many
laboratory studies of the molecular biology of picornavirus
SPECIES AND SUBTYPES TO BE CONSIDERED:
replication.
➔ Poliovirus
➔ Some parts of the body undergo paralysis and are
➔ Coxsackievirus
immobile because of motor neuron dysfunction resulting in
➔ ECHO Viruses and other Enterovirus
atrophy.
➔ Enterovirus in the Environment
➔ Only 1% of infected individuals exhibit signs and
➔ Rhinovirus
symptoms such as atrophy
NOTE:
❏ In order to develop immunity against poliovirus, one must be
PATHOGENESIS AND PATHOLOGY
vaccinated three times and must develop immunity against its
❏ The mouth is the portal of entry of the virus, and primary
three serotypes
multiplication takes place in the oropharynx or intestine.
❏ Vaccine is only available for polioviruses
❏ The virus is regularly present in the throat and in the stools before
the onset of illness. One week after infection, there is little virus
in the throat, but the virus continues to be excreted in the stools for
several weeks even though high antibody levels are present in the
blood.

❏ The CNS may then be invaded by way of the circulating blood. POLIOMYELITIS: CLINICAL MANIFESTATIONS
Poliovirus can spread along axons of peripheral nerves to the ❏ Three types of paralytic polio are described:
CNS, where it continues to progress along the fibers of the lower a. Spinal polio (79%) - asymmetric paralysis usually
motor neurons to increasingly involve the spinal cord or the brain. involving the legs
Poliovirus invades certain types of nerve cells, and in the process b. Bulbar polio (2%) - weakness of the muscles innervated
of its intracellular multiplication, it may damage or completely by cranial nerves
destroy these cells. c. Bulbospinal polio (19%) - combination
❏ Poliovirus does not multiply in muscle in vivo. The changes that
occur in peripheral nerves and voluntary muscles are secondary to
DISEASE DESCRIPTION
the destruction of nerve cells.
❏ Poliomyelitis in 90% of individuals infected are subclinical and Mild Disease ➔ Most common form of poliovirus infection
manifests as a localized infection in the gastrointestinal tract. In 8% 90% ➔ Symptoms: Fever, Malaise, Drowsiness,
of the infected individuals, the virus could be found in the Headache, Nausea,
circulation. 1% of the infected population may develop ➔ Vomiting, Constipation and Sore Throat
non-paralytic meningitis. <1% may develop paralytic poliomyelitis. ➔ Complete recovery occurs in few days
Non-Paralytic ➔ Same symptoms with Mild Disease with

CLINICAL FINDINGS Poliomyelitis added features of stiffness and pain in back
❏ Most infections are subclinical; only about 1% of infections result in (Aseptic Meningitis) and neck
clinical illness. The incubation period is usually 7–14 days, but it 1% ➔ Disease lasts for 2-10 days with rapid and
may range from 3 to 35 days. complete recovery
❏ Following exposure to poliovirus , 90-95% of susceptible ➔ Non-bacterial meningitis
individuals develop only inapparent infection, which causes
Paralytic ➔ The destruction of lower motor neurons in
seroconversion alone. Poliomyelitis the spinal cord results in flaccid paralysis
❏ It is only in 5-10% that any sort of clinical illness results <1% which further leads to atrophy of the affected
part.
PARALYTIC POLIOMYELITIS ➔ Invasion of Poliovirus in the brainstem may
❏ the major illness; occurs in 0.1 - 2% of persons with poliovirus lead to
infections. ➔ incoordination and painful muscle spasms
➔ Maximal recovery in six months
❏ The predominating complaint is flaccid paralysis resulting from Progressive Post ➔ Infected individuals may develop paralysis
lower motor neuron damage. Poliomyelitis and muscle wasting
❏ Depending on the distribution of paralysis, cases are classified as Muscle Atrophy ➔ Years after poliovirus infection
spinal, bulbar or bulbospinal ➔ Muscle wasting due to progression of
❏ Mortality ranges from 5-10% and is mainly due to respiratory paralytic poliomyelitis
failure Table 6.3 Clinical Findings of Poliovirus Infections
❏ Even children who seem to fully recover can develop new muscle
pain, weakness, or paralysis as adults, 15 to 40 years later

LABORATORY DIAGNOSIS than adults because of the acquired immunity of the adult
❏ The virus may be recovered from throat swabs taken soon after population.
onset of illness and from rectal swabs or stool samples collected ❏ Humans are the only known reservoir of infection.
over long periods. ❏ There are three wild types of poliovirus (WPV). Type 2 and 3 are
➔ The mere isolation of poliovirus from feces does not eradicated, while type 1 is still prevalent.
constitute a diagnosis of poliomyelitis
❏ Poliovirus is uncommonly recovered from the cerebrospinal fluid, PREVENTION AND CONTROL
unlike some coxsackieviruses and echoviruses. ❏ There are no antiviral drugs for treatment of Poliovirus infection.
❏ Cultures of human or monkey cells are inoculated, incubated, The WHO launched a campaign for global eradication of Poliovirus
and observed. Cytopathogenic effects appear in 3–6 days. An in 1988 through Vaccination:
isolated virus is identified and typed by neutralization with specific a. FORMALIN INACTIVATED POLIOVIRUS VACCINE
antiserum. (SALK - IPV) – Injection
➔ Primary monkey kidney cells are usually employed ➔ Poliovirus suspension from the supernatant fluid of
❏ Virus can also be identified more rapidly by polymerase chain infected monkey kidney cell culture, formalin
reaction (PCR) assays. RT-PCR may be used for virus treated
identification from throat swabs, rectal swabs, and stool samples. ➔ IPV contains 3 serotypes , given as 2 injections at
RT-PCR is used since it is an RNA virus. monthly intervals
➔ Virus isolation must be interpreted along with clinical and ➔ Inactivated vaccine was developed by Salk
serological evidence ➔ It is given intramuscularly
❏ Demonstration of antibody titer b. LIVE ATTENUATED POLIO VACCINE (SABIN- OPV) –
Oral Administration
NEUTRALIZATION TECHNIQUE ➔ Prepared by repeated subculturing of poliovirus to
❏ In this procedure, patient serum is mixed with a suspension of reduce infectivity
infectious virus particles of the same type as those suspected of ➔ Sabin vaccine is given orally in four doses ate
causing disease in the patient monthly intervals
❏ A control suspension of virus is mixed with normal serum and is (SIR ROBERT)
the inoculated into an appropriate cell culture ❏ OPV is recommended over IPV.
❏ If the patent serum contains antibody tp the virus, the antibody will ➔ In OPV, both IgG and IgA will develop. IgA will develop in
bind to the virus particles and prevent them from invading the cells the secretory glands of GIT, thus preventing the replication
in culture thereby neutralizing the infectivity of the virus of poliovirus. There is circulation and secretory immunity
against poliovirus.
EPIDEMIOLOGY ❏ In IPV, only IgG will develop. it can only protect you from the virus
❏ Before global eradication efforts began, poliomyelitis occurred once the virus is in the circulation and it does not prevent the
worldwide—year-round in the tropics and during summer and fall in replication of poliovirus in the GIT since no IgA is produced
the temperate zones. Winter outbreaks were rare. The disease through IPV.
occurs in all age groups, but children are usually more susceptible

kidney
2. Effect in Generalized myositis Patchy focal myositis

suckling mice Flaccid paralysis Spastic paralysis
Death within a week Necrosis of the brown fat
and often pancreatitis,
hepatitis, myocarditis and
encephalitis
3. Types 23 (1-24*) 6 (1-6)
PATHOGENESIS AND PATHOLOGY

❏ Virus has been recovered from the blood in the early stages of
natural infection in humans. Virus is also found in the throat for a
few days early in the infection and in the stools for up to 5–6
weeks. Virus distribution is similar to that of the other
enteroviruses.
❏ Herpangina is only caused by Coxsackievirus A.
❏ Pleurodynia, Myocarditis, and Pericarditis is caused by
Coxsackievirus B.
COXSACKIE VIRUSES ➔ Coxsackievirus B is associated with cardiac and muscular
INTRODUCTION syndromes.
❏ The virus was isolated by Dalldorf and Sickles (1948) from the ❏ Both Coxsackievirus A & B can cause aseptic meningitis and
village of Coxsackie in New York Hand-foot-and-mouth disease.
❏ Coxsackieviruses, a large subgroup of the enteroviruses, were ❏ The most common cause of aseptic meningitis are enteroviruses.
divided into two groups: (based on the pathological changes
produced) CLINICAL FINDINGS
➔ Coxsackievirus A - 24 types ❏ Like other enteroviruses, coxsackie viruses inhabit the alimentary
➔ Coxsackievirus B - 6 types most commonly identified canal primarily, and are spread by the fecal-oral route
causative agents of viral heart disease in humans ❏ Young infants are commonly affected
❏ They are now classified into HEV groups A, B, and C. ❏ The incubation period of coxsackievirus infection ranges from 2
❏ It is a non-poliovirus. to 9 days.
❏ The clinical manifestations of infection with various
coxsackieviruses are diverse and may present as distinct disease
FEATURES COXSACKIEVIRUS A COXSACKIEVIRUS B
entities. They range from mild febrile illness to CNS, skin, cardiac,
1. Growth in and respiratory diseases.
+ +
monkey ❏ Enteroviruses are associated with aseptic meningitis

NOTE: Take note of the syndromes associated with coxsackievirus
B. HAND-FOOT AND MOUTH DISEASE

➔ Can be caused by both type A and B, but mainly type A
➔ Characterized by oral vesicles and lesions that are found
on the hands and foot
NOTE: Hand-foot and mouth disease(coxsackievirus) is not to be
confused with foot-and-mouth(aphthovirus) disease of cattle, which is
caused by an unrelated picornavirus that does not normally infect humans.
Table 6.4 Coxsackievirus and their commonly associated clinical

syndromes
NOTE: Hand-foot-and-Mouth disease is not to be confused with

foot-and-mouth disease of cattle, which is caused by an unrelated
picornavirus that does not normally infect humans.
A. HERPANGINA ❏ Virus can be isolated from throat washings during the first few days
❏ Self limiting disease of illness and from stools during the first few weeks.
❏ Caused by type a ❏ Sample of Choice:
❏ Characterized by fever, sore throat and small red vesicles ➔ Throat swab and washings
on the back of the throat ➔ Nasal Secretions

➔ CSF ❏ Echoviruses (enteric cytopathogenic human orphan viruses),
➔ Stool based on historical terminology, were grouped together because
❏ MOLECULAR DIAGNOSTIC TEST they infect the human enteric tract and because they can be
➔ RT-PCR recovered from humans only by inoculation of certain tissue
❏ SEROLOGIC TEST cultures.
➔ Immunofluorescence ❏ Was termed orphan because it was thought to be unrelated to
❏ Strains have been recovered from the CSF in aseptic meningitis. specific illnesses
Largest amount of Coxsackievirus A21 is found in nasal ❏ They were called orphans as they could not be associated with any
secretions. In hemorrhagic conjunctivitis, Coxsackievirus A24 can particular clinical disease then
be isolated from conjunctival swabs, throat swabs, and feces. ❏ There is still no clear association of some types with specific
disease
EPIDEMIOLOGY ❏ More than 30 serotypes are known but not all have been
❏ Viruses of the coxsackie group have been encountered around the associated with human illness.
globe. Isolations have been made mainly from human feces, ❏ Many echoviruses have been associated with aseptic meningitis.
pharyngeal swabbings, and sewage. Rashes are most common in young children. Infantile diarrhea may
❏ The most frequent types of coxsackieviruses recovered worldwide be associated with some types, but causality has not been
over an 8-year period (1967–1974) were types A9 and B2–B5. established.
❏ Familial exposure is important in the acquisition of infections with
coxsackieviruses. After the virus is introduced into a household, all ENTEROVIRUS 68
susceptible persons usually become infected, although all do not ❏ Shares several characteristics with rhinoviruses, including acid
develop clinically apparent disease. lability and lower optimum growth temperature, and had been
❏ The coxsackieviruses share many properties with other previously classified as rhinovirus 87.
enteroviruses. Because of their epidemiologic similarities, various
enteroviruses may occur together in nature even in the same ENTEROVIRUS 70
human host or the same specimens of sewage. ❏ The chief cause of acute hemorrhagic conjunctivitis. It was isolated
❏ from the conjunctiva of patients with this striking eye disease,
PREVENTION AND CONTROL which occurred in pandemic form from 1969 to 1971 in Africa and
❏ There are no vaccines or antiviral drugs currently available for Southeast Asia. The virus is highly communicable and spreads
prevention or treatment of diseases caused by coxsackieviruses; rapidly under crowded or unhygienic conditions.
symptomatic/supportive treatment is given.
❏ Vaccination is not practicable as there are several serotypes and ENTEROVIRUS 71
immunity is type-specific ❏ Has been isolated from patients with meningitis, encephalitis, and
paralysis resembling poliomyelitis. It is one of the main causes of
ECHO VIRUSES AND OTHER ENTEROVIRUS CNS disease, sometimes fatal, around the world. An outbreak of
INTRODUCTION hand-foot-and- mouth disease caused by enterovirus 71 occurred
ECHO Virus (Enteric Cytopathogenic Human Orphan Viruses) in China in 2008 and involved about 4500 cases and 22 deaths in
infants and young children.

❏ It is the most common Enterovirus recovered from fecal samples of
patients with acute flaccid paralysis in Australia between 1996 and ENTEROVIRUS IN THE ENVIRONMENT
2004
ECHO VIRUS AND OTHER ENTEROVIRUS
❏ It is impossible to diagnose ECHO virus infection on clinical
grounds. ECHO viruses are considered in the following epidemic
situations:
➔ Summer outbreaks of aseptic meningitis
➔ Summer epidemics, especially in young children, of a
febrile illness with rash
❏ The diagnosis depends on laboratory tests:
➔ RT-PCR
➔ Virus isolation from throat swabs, stool, rectal swabs, CSF
➔ Neutralizing and hemagglutination-inhibiting antibodies
➔ *Serologic tests are impractical because of the many
different viral types
❏ Specimen of choice: ❏ Humans are the only known reservoir for members of the human
➔ Throat swabs enterovirus group. These viruses are generally shed for longer
➔ Stool periods of time in stools than in secretions from the upper
➔ Rectal swabs alimentary tract. Thus, fecal contamination (hands, utensils, food,
➔ CSF water) is the usual avenue of virus spread.
❏ Enteroviruses are present in variable amounts in sewage. This
EPIDEMIOLOGY may serve as a source of contamination of water supplies used for
❏ ECHO Virus and other Enteroviruses occur in all parts of the globe drinking, bathing, irrigation, or recreation.
and are usually found in younger individuals. In the temperate ❏ Enteroviruses survive exposure to the sewage treatments and
zone, infections occur chiefly in the summer and autumn and are chlorination in common practice, and human wastes in much of the
about five times more prevalent in children of lower income world are discharged into natural waters with little or no treatment.
families ➔ Waterborne outbreaks caused by enteroviruses are difficult
to recognize, and it has been shown that the viruses can
PREVENTION AND CONTROL travel long distances from the source of contamination and
❏ Avoidance of contact with patients exhibiting acute febrile illness is remain infectious.
advisable for very young children. There are no antivirals or ➔ Adsorption to organics and sediment material protects
vaccines (other than polio vaccines) available for the treatment or viruses from inactivation and helps in transport.
prevention of any enterovirus diseases. ❏ Filter-feeding shellfish (oysters, clams, mussels) have been
found to concentrate viruses from water and, if inadequately

cooked, may transmit disease. Bacteriologic standards using fecal ❏ Human rhinoviruses can be divided into major and minor receptor
coliform indices as a monitor of water quality probably are not an groups.
adequate reflection of a potential for transmission of viral disease. ➔ Major group of Rhinovirus - use intercellular adhesion
molecule-1 (ICAM-1) as receptor
GENUS PARECHOVIRUS ➔ Minor group of Rhinovirus - bind members of the
INTRODUCTION low-density lipoprotein receptor (LDLR) family.
❏ This genus was defined in the 1990s and contains 19 types, of ❏ Rhinoviruses are more thermostable than other enteroviruses and
which types 1 and 2 were originally classified as echoviruses 22 may survive for hours on environmental surfaces.
and 23. ❏ More than 100 serotypes exist - low optimum temperature of
❏ Parechoviruses are highly different from enteroviruses in terms of growth (33 degrees Celsius)
protein characteristics. Parechovirus infections are often acquired ❏ Infection is spread by aerosol and by hand contact
in early childhood. ❏ Incubation period: 2-3 days
❏ The viruses replicate in the respiratory and gastrointestinal ❏ Virus is inactivated at pH 3 at 37 degrees Celsius for 1 hour, while
tracts. They have been reported to cause diseases similar to other enteroviruses are stable
enteroviruses, such as mild gastrointestinal and respiratory illness, ❏ They differ from enterovirus in being more acid labile, but more
meningitis, and neonatal sepsis. heat stable
❏ Human parechovirus 1 was one of the 15 most common
enterovirus detections from 2006 to 2008. PATHOGENESIS AND PATHOLOGY
❏ However, human parechovirus cannot be detected by ❏ The virus enters via the upper respiratory tract. High titers of virus
enterovirus-specific nucleic acid typing assays commonly used, so in nasal secretions—which can be found as early as 2–4 days after
it may be underreported. Specific PCR methods are available to exposure—are associated with maximal illness. Thereafter, viral
detect parechovirus in patient samples. titers fall, although illness persists. In some instances, viruses may
remain detectable for 3 weeks. There is a direct correlation
RHINOVIRUS between the amount of virus in secretions and the severity of
INTRODUCTION illness. Replication is limited to the surface epithelium of the nasal
❏ Rhinoviruses are the common cold viruses. They are the most mucosa.
commonly recovered agents from people with mild upper ❏ Local inflammation and cytokines may be responsible for the
respiratory illnesses. symptoms of common cold
❏ They are usually isolated from nasopharyngeal secretions but
may also be found in throat and oral secretions.
❏ Common cold can be caused by coronavirus or rhinovirus, but
among the two, rhinovirus causes common colds more frequently.
❏ These viruses—as well as coronaviruses, adenoviruses,
enteroviruses, parainfluenza viruses, and influenza viruses—cause
upper respiratory tract infections, including the common cold
syndrome. Rhinoviruses are also responsible for about half of
→
asthma exacerbations.

CLINICAL FINDINGS hand-to-eye, or hand-to-object-to-hand (e.g. doorknob)
❏ The incubation period is brief—from 2 to 4 days (2 -3 days, sir contamination.
Tubola ppt)—and the acute illness usually lasts for 7 days, ➔ Aerosols
➔ although a nonproductive cough (does not produce ➔ Contact with contaminated hands
mucus/phlegm) may persist for 2–3 weeks. The average ❏ Rhinoviruses can survive for hours on contaminated environmental
adult has one or two attacks each year. surfaces. Self-inoculation after hand contamination may be a more
❏ Usual symptoms in adults include: important mode of spread than that by airborne particles.
➔ Sneezing ❏ Infection rates are highest among infants and children and
➔ Nasal obstruction decrease with increasing age. The family unit is a major site of
➔ Nasal discharge spread of rhinoviruses.
➔ Sore throat ❏ At risk or risk factors: Pre-Existing respiratory condition
➔ Other symptoms: ❏ Distribution
● Headache ➔ Worldwide
● mild cough ➔ Disease most common in early autumn, late spring
● Malaise ❏ Vaccines or antiviral drugs
● chilly sensation. ➔ No vaccines
● there is little or no fever ➔ No licensed antiviral drugs
❏ Secondary bacterial infection may produce:
➔ Acute otitis media PREVENTION AND CONTROL
➔ Sinusitis ❏ No specific prevention method or treatment is available. Because it
➔ Bronchitis and Pneumonitis is self limiting
❏ The development of a potent rhinovirus vaccine is unlikely because
LABORATORY DIAGNOSIS of the difficulty in growing rhinoviruses to high titer in culture, the
❏ Antibody develops 7–21 days after infection; the time of fleeting immunity, and the multiplicity of serotypes causing colds.
appearance of neutralizing antibody in nasal secretions parallels ❏ Antiviral drugs are thought to be a more likely control measure for
that of serum antibodies. rhinoviruses because of the problems with vaccine development.
❏ Because recovery from illness usually precedes the appearance of Many compounds effective in vitro have failed to be effective
antibodies, it seems that recovery is not dependent on antibodies. clinically
❏ However, antibodies may accomplish final clearance of infection.
Serum antibody persists for years but decreases in titer. TREATMENT AND PROPHYLAXIS
❏ Antiviral drugs are thought to be more likely control measure for
EPIDEMIOLOGY rhinoviruses
❏ The disease occurs throughout the world. The virus is believed ❏ Pleconaril is one such drug showing activity against rhinoviruses
to be transmitted through close contact by means of and enteroviruses.
virus-contaminated respiratory secretions. ➔ The drug inhibits the penetration of picornavirus into the
❏ The fingers of a person with a cold are usually contaminated, and cell. It must administered early in the course of infection
transmission to susceptible persons then occurs by hand-to-hand,

❏ Hand washing and the disinfection of contaminated objects are the Never Shall We Fail
best means of preventing the spread of the virus
#RMT2022Manifesting
GENUS APHTHOVIRUS
❏ Causes Foot-and-Mouth disease.
❏ This highly infectious disease of cloven-hoofed animals such as
cattle, sheep, pigs, and goats. It may be transmitted to humans by
contact or ingestion.
❏ In humans, the Foot-and-Mouth disease is characterized by:
➔ Fever
➔ Salivation
➔ Vesiculation of the mucous membranes of the oropharynx
and of the skin of the feet
❏ The disease in animals is highly contagious in the early stages of
infection when viremia is present and when vesicles in the mouth
and on the feet rupture and liberate large amounts of virus.
❏ Excreted material remains infectious for long periods. The mortality
rate in animals is usually low but may reach 70%. Infected animals
become poor producers of milk and meat.
➔ Many cattle serve as a foci of infection for up to 8 months.
❏ Immunity after infection is of short duration.
❏ Formalin-treated vaccines have been prepared from viruses
grown in tissue cultures, but such vaccines do not produce
long-lasting immunity. New vaccines are being developed based
on recombinant DNA techniques.

❏ Slaughtering all exposed animals and destroying their carcasses.
Vaccines could be given to animals.
❏ Strict quarantine can also help control the spread of virus:
➔ Area is not presumed to be safe until susceptible animals
fail to develop symptoms within 30 days
➔ Quarantine the herd and vaccinate all unaffected animals
➔ Forbid the importation of potentially infectious materials
such as meat.

MODULE 7: GASTROINTESTINAL VIRUSES countries. In the developed world, viruses are already the most
Characteristics, Laboratory Tests, Epidemiology, Prevention, and Control of common pathogens causing diarrhea.
Gastrointestinal Viruses ❏ Viral gastroenteritis is caused by rotaviruses, caliciviruses,
astroviruses, and some serotypes of adenoviruses, which results in
vomiting and/ or diarrhea.
OUTLINE OF THE LESSON ❏ Replication happens in the gastrointestinal tract.
I. INTRODUCTION
VIRUSES TO CONSIDER IN THIS MODULE
II. LIST OF VIRUSES
1. Family Reoviridae
III. ETIOLOGIC AGENTS OF GASTROENTERITIS
IV. GASTROINTESTINAL VIRUSES ➔ Genus Orthoreovirus
A. Family Reoviridae ➔ Genus Coltivirus
➔ Genus Rotavirus ➔ Genus Rotavirus (most important cause of gastroenteritis)
➔ Genus Reovirus ➔ Genus Orbivirus
➔ Genus Orbivirus ➔ Genus Reovirus
➔ Genus Coltivirus
B. Family Caliciviridae
➔ Genus Norovirus 2. Family Caliciviridae
C. Family Astroviridae ➔ Genus Norovirus (Norwalk viruses)
D. Enteric Adenoviruses ➔ Genus Sapovirus
E. Candidate Viruses ● Sapporo-like viruses
➔ Genus Nebovirus
HIGHLIGHTING OF TOPICS BULLET PLACEMENT ● Bovine enteric viruses;
➔ Genus Lagovirus
AAAAAA - Main topic ➔ (Sub-definition/Enumerate) ● Rabbit hemorrhagic disease virus
AAAAAA - Subtopics ● (Super Sub-detail) ➔ Genus Vesivirus
● Vesicular exanthem virus of swine, feline calicivirus
● Marine viruses found in pinnipeds, whales, and fish
INTRODUCTION
❏ The Gastrointestinal tract is a vulnerable organ for infections as
3. Family Astroviridae
there is constant contact with the outside, mainly via the oral route.
➔ Genus Mamastrovirus
Inflammation of the stomach and the intestines (Gastroenteritis)
can cause nausea, vomiting and diarrhea.
❏ Gastroenteritis is responsible for 2-3 million deaths each year,
making it one of the most common causes of mortality. Mainly
children in developing countries, but also immunocompromised
individuals in developed countries, suffer from diarrhea.
❏ While bacterial and parasitic gastrointestinal infections are
declining as a result of proper disposal of sewage and safe
drinking water, viral gastroenteritis is not declining in developing

ETIOLOGIC AGENTS OF GASTROENTERITIS FAMILY REOVIRIDAE
❏ Of all the 5 Genus listed under the family reoviridae, only 4 are
able to infect humans: Orthoreovirus, Rotavirus, Coltivirus, and
Orbivirus.
The genera are divided into two subfamilies.

1. SUBFAMILY SPINAREOVIRINAE
❏ Contains viruses with large spikers at the 12 vertices on
the particle
➔ Genus Orthoreovirus
2. SUBFAMILY SEDOREOVIRINAE
❏ Appears more smooth, lacking the large surface
projections
● Genus Rotavirus - Has 8 Species (A-H); Only A,
B and C can infect Humans
● Genus Orbivirus
NOTE:
❏ Arbovirus - arthropod-borne viruses. Genus included are:
a. Genus Coltivirus
b. Genus Orbivirus
❏ All RNA viruses have linear genome except BAD (since they are
circular)
❏ Remember BAD Circle
➔ Bunyaviridae
➔ Arenaviridae
➔ Delta virus (Hepatitis D)
❏ Rotavirus is important because it is the major cause of infantile
diarrhea.
NOTE:
- All are RNA viruses except Adenovirus
- All RNA viruses are single-stranded except Reoviridae
(specifically Rotavirus)
- All are naked viruses, meaning they are resistant to acidity of
gastrointestinal tract

GENERAL PROPERTIES AND CHARACTERISTICS OF REOVIRIDAE ❏ Following partial uncoating, viral RNA-dependent RNA
polymerase directs the transcription of viral mRNAs followed by
synthesis of viral proteins, by genome replication by using the
PROPERTY DESCRIPTION
negative-strand RNA of the double-stranded RNA genome.
Virion ● Icosahedral ❏ Rotavirus assembles by associating its core with a nonstructural
● 60–80 nm in diameter protein (NSP4) and acquiring VP7 and a membrane budding from
● Double capsid shell (inner and outer) the ER. The virus eventually loses the membrane in the ER and is
released upon cell lysis.
Composition ● RNA (15%) ❏ Some virions are packaged by the endoplasmic reticulum to be
● Protein (85%)
transported out of the cell through vesicular transport.
Genome ● Double-stranded RNA
● Linear
● Segmented (10–12 segments)
● Total genome size 16–27 kbp
Proteins ● Nine structural proteins

● Core contains several enzymes
Envelope None (transient pseudoenvelope is present during

rotavirus particle morphogenesis)
Replication ● Cytoplasm; virions not completely uncoated (only

outer coat is destroyed)
Outstanding ● Genetic reassortment occurs readily

Characteristics ● Rotaviruses are the major cause of infantile
diarrhea
● Reoviruses are good models for molecular
studies of viral pathogenesis
Table 7.1 Properties of Reoviridae
NOTE: Reoviridae is the only Double-stranded RNA virus
Figure 7.1 Overview of the rotavirus replication cycle. ER,
REPLICATION OF ROTAVIRUS endoplasmic reticulum.
❏ Rotavirus outer capsid spike (VP4) binds to the receptor (sialic
acid-containing glycoprotein) followed by a:
➔ Conformational change
➔ Removal of outer layer
➔ Penetration of the virus in the target cells.

GENUS ROTAVIRUS Important information:
INTRODUCTION ❏ Rotaviruses are classified into seven groups, A to G, based on the
❏ The rotaviruses belong to the family Reoviridae. The genome of internal capsid protein, VP6. Human infections are predominantly
rotaviruses is unique in the sense that they have 11 segments of caused by group A and less commonly by group B or C.
double-stranded RNA. The 11 segments of the genome encode six ❏ Wheel-shaped virus - The complete particle of rotavirus
structural (VP1–VP4 and VP6–VP7) and six nonstructural ❏ The name Rotavirus comes from “rota” which means wheel. It
(NSP1–NSP6) proteins. looks like a wheel under the microscope with the inner capsid and
outer capsid connected by spikes which are projected in this virus.
❏ Major outer capsid proteins:
➔ VP4 and VP7 are responsible for attachment to cells.
➔ VP7 is viral protein for viral entry
❏ Major inner capsid protein:
➔ VP6 classifies the Rotavirus into eight classes (A-H). A, B,
and C can cause disease.
➔ Rotavirus A is the predominant cause of gastroenteritis
PATHOGENESIS
❏ Rotaviruses infect cells in the villi of the small intestine (gastric and
colonic mucosa are spared). They multiply in the cytoplasm of
Figure 7.2 Structure of Rotavirus enterocytes and damage their transport mechanisms. Damaged
cells may slough into the lumen of the intestine and release large
Based on the diagram quantities of virus, which appear in the stool (up to 10-12
A. Eleven segments of rotavirus are shown on a gel, each segment particles per gram of feces).
encoding ❏ Viral excretion usually lasts from 2 to 12 days in otherwise healthy
➔ corresponding structural (VP1–VP7), which are patients but maybe prolonged in those with poor nutrition and
important for capsid formation immunocompromised patients.
➔ nonstructural (NSP1–NSP6) proteins are shown. ❏ Diarrhea caused by rotaviruses may also be due to impaired
B. Structure of rotavirus showing outer layer capsid proteins, sodium and glucose absorption as damaged cells on villi are
including VP4 (spikes) and VP7 (outer capsid layer). replaced by non-absorbing immature crypt cells. It may take from 3
C. A cutaway view of rotavirus showing the inner VP6 (blue) and VP2 to 8 weeks for normal function to be restored.
(green layers).
D. Rotavirus dsRNA genome segments represented as inverted
conical spirals.

Direct examination of the specimen by electron microscopy can
also be done primarily in research settings.
EPIDEMIOLOGY
❏ Rotaviruses are the single most important worldwide cause of
gastroenteritis in young children. Estimates range from 3 to 5
billion for annual diarrheal episodes in children younger than 5
years of age in Africa, Asia, and Latin America, resulting in as
many as 1 million deaths. Developed countries have a high
morbidity rate but a low mortality rate.
❏ Typically, up to 50% of cases of acute gastroenteritis of
hospitalized children throughout the world are caused by
rotaviruses.
NOTE: Rotavirus is the major cause of infantile diarrhea or the
gastroenteritis in infants or children
❏ Rotavirus is transmitted by fecal–oral route, and the virus particle
Based on the picture is partially digested in the gastrointestinal tract
❏ Rotavirus will attach to the receptor on the enterocytes. It will enter
the enterocytes to undergo replication. After replication, it will lyse TREATMENT
the enterocytes to be released. ❏ Treatment of gastroenteritis is supportive to correct the loss of
❏ Epithelial cells die, fluid will exit the body and cause diarrhea as water and electrolytes that may lead to dehydration, acidosis,
well as dehydration. shock, and death.
➔ Supportive = no specific treatment
CLINICAL FINDINGS ➔ Only signs and symptoms are what is treated
❏ Rotaviruses cause the major portion of diarrheal illness in infants ➔ Gastroenteritis is self-limiting as long as immune system is
and children worldwide but not in adults. Typical symptoms include competent enough
watery diarrhea, fever, abdominal pain, and vomiting, leading to ❏ Management consists of replacement of fluids and restoration of
dehydration. In infants and children, severe loss of electrolytes and electrolyte balance either intravenously or orally as feasible.
fluids may be fatal unless treated.
❏ Signs and symptoms is mainly due to dehydration caused by the ROTAVIRUS VACCINE
pathogenesis ❏ Live oral rotavirus vaccine
❏ Provide immunity in the mucosal surfaces
LABORATORY DIAGNOSIS ❏ Increases IgA content which is a secretory immunoglobulin and
❏ Diagnosis of acute rotavirus infection is usually by detection of will travel to the mucosal surface.
virus particles, antigen or virion RNA in the stools during the acute ❏ Should not be given to infants aged 15 months and above due to
phase of illness. This can be accomplished by immunologic lack of availability of safety data.
detection of antigen with EIA methods or virion RNA by RT-PCR.

❏ While the vaccine is safe, mild problems such as temporary ➔ Transmitted by tick
diarrhea or vomiting may occur. In addition, 1 in 20 000 to 1 in 100 ➔ Able to infect humans
000 infants may have intussusception (a bowel blockage) with ➔ Found in the southwestern United States and can cause:
rotavirus vaccination. ● Fever, chills, headache, photophobia
● Myalgia, arthralgia, lethargy
GENUS REOVIRUS ● Rash
❏ The viruses of this genus, which have been studied most ● systemic symptoms in infected patients
thoroughly by molecular biologists, are not known to cause human ➔ Colorado Tick Fever Virus infection can lead to
disease. encephalitis or meningitis
❏ Reoviruses contain a hemagglutinin for human group O or bovine
erythrocytes. FAMILY CALICIVIRIDAE
❏ Reoviruses cause many inappropriate infections because most ❏ Although the caliciviruses were the first to be clearly associated
people have serum antibodies by early adulthood. Human with outbreaks of gastroenteritis, considerably less is known about
volunteer studies have failed to demonstrate a clear their biology than about that of the rotaviruses. Caliciviruses are
cause-and-effect relationship of reoviruses to human illness. In similar to picornaviruses but are slightly larger.
inoculated volunteers, reovirus is recovered far more readily from
feces than from the nose or throat. GENERAL PROPERTIES AND CHARACTERISTICS OF CALICIVIRIDAE
GENUS ORBIVIRUS
❏ They commonly infect insects, and many are transmitted by
insects to vertebrates. Virion ● Icosahedral
➔ arbovirus - arthropod-borne virus ● 27–40 nm in diameter
❏ About 100 serotypes are known. ● Cup-like depressions on capsid surface
❏ None of these viruses cause serious clinical disease in humans,
but they may cause mild fevers. Genome ● Single-stranded RNA
❏ Serious animal pathogens include: ● Linear
● Positive-sense
➔ Bluetongue virus of sheep ● Non-segmented
➔ African horse sickness virus ● 7.4–8.3 kb in size
● These are responsible for veterinary diseases ● Contains genome-linked protein (VPg)
❏ Antibodies to orbiviruses are found in many vertebrates, including
humans. The replicative cycle is similar to that of reoviruses. Proteins ● Polypeptides cleaved from a precursor polyprotein
Orbiviruses are sensitive to low pH, in contrast with the general ● Capsid is composed of a single protein
stability of other reoviruses.
Envelope None ( Naked )
GENUS COLTIVIRUS Replication Cytoplasm

❏ Coltiviruses include Colorado tick fever virus
❏ An arbovirus - arthropod-borne virus

illness can be incapacitating during the symptomatic phase, but
Outstanding ● Noroviruses are major cause of nonbacterial
Characteristics epidemic gastroenteritis hospitalization is rarely required.
● Human viruses are non cultivable ➔ Most common signs and symptoms is abdominal pain,
nausea, vomiting and watery diarrhea
Table 7.2 Properties of Caliciviridae
➔ Nausea and vomiting occurs more often than diarrhea
❏ Norovirus infections are more likely to induce vomiting than
GENUS NOROVIRUS
those with Sapporo-like viruses.
❏ Most important genus in Family Caliciviridae
❏ Dehydration is the most common complication in young and
❏ Noroviruses or Norwalk viruses are the most important cause of
elderly individuals.
epidemic viral gastroenteritis in adults.
NOTE:
❏ Gastroenteritis in adults : Noroviruses
❏ Specimens/Samples:
❏ Gastroenteritis in infants: Rotavirus
➔ Feces
❏ Why is it called Norwalk?
➔ Vomitus (used because nausea and vomiting occurs more
➔ The name of the virus is derived from the place of its first
often than diarrhea)
outbreak which is in Norwalk, Ohio.
➔ Food
➔ Water
❏ Epidemic non-bacterial gastroenteritis is characterized by:
❏ RT-PCR is the most widely used technique for detecting
1. Absence of bacterial pathogens
Caliciviruses in clinical specimens like feces and vomitus and in
2. Gastroenteritis with rapid onset and recovery and relatively
environmental samples like food and water.
mild systemic signs
❏ Electron microscopy can also detect Caliciviruses in stool.
3. An epidemiologic pattern of a highly communicable
Norovirus are identified by Immune Electron Microscopy.
disease that spreads rapidly with no particular predilection
❏ ELISA immunoassays based on recombinant virus-like particles
in terms of age or geography.
can detect antibody responses
❏ Various descriptive terms have been used in reports of different
outbreaks (eg, epidemic viral gastroenteritis, viral diarrhea, and
EPIDEMIOLOGY
winter vomiting disease) depending on the predominant clinical
❏ Human caliciviruses have worldwide distribution.
feature.
❏ The viruses are most often associated with epidemic outbreaks of
➔ Gastroenteritis caused by Norovirus usually occurs in the
waterborne, foodborne, and shellfish-associated gastroenteritis.
winter months that is why it is also called Winter Vomiting
❏ All age groups can be affected. Outbreaks occur throughout the
Disease
year, with a seasonal peak during cooler months.
❏ Fecal–oral spread is the primary means of transmission.
CLINICAL FINDINGS
❏ Most outbreaks involve foodborne or person-to-person
❏ Norwalk viral gastroenteritis has an incubation period of 24–48
transmission via fomites or aerosolization of contaminated body
hours. The onset is rapid, and the clinical course is brief, lasting
fluids (vomitus, fecal material).
12–60 hours; symptoms include diarrhea, nausea, vomiting,
low-grade fever, abdominal cramps, headache, and malaise. The

❏ Characteristics of norovirus include a low infectious dose (as few ❏ They contain single-stranded, positive-sense RNA, 6.4–7.4 kb in
as 10 virus particles), relative stability in the environment, and size.
multiple modes of transmission. ❏ The family Astroviridae contains two genera; all human viruses are
➔ Easy to be acquired especially when eating shellfish classified in the Mamastrovirus genus.
TREATMENT AND CONTROL EPIDEMIOLOGY

❏ Treatment is symptomatic. ❏ Astroviruses cause diarrheal illness and may be shed in
➔ No specific treatment. Only signs and symptoms are extraordinarily large quantities in feces.
treated. ❏ The viruses are transmitted by the fecal–oral route through
➔ Self-limiting as long as immune system is competent contaminated food or water, person-to-person contact, or
enough contaminated surfaces.
❏ The low infectious dose permits efficient transmission of the virus. ❏ They are recognized as pathogens for infants and children, elderly
❏ Effective handwashing is probably the most important method to institutionalized patients, and immunocompromised persons.
prevent norovirus infection and transmission. Because of the
infectious nature of the stools, care should be taken in their LABORATORY DIAGNOSIS
disposal. ❏ Clinical testing for astroviruses is not commonly performed, but
❏ There is currently no vaccine available detection can be achieved with electron microscopy, antigen, or
RT-PCR methods.
NOTE:
❏ Electron microscopy - star-like appearance
❏ RT-PCR - because it is an RNA virus
FAMILY ASTROVIRUSES
❏ Astroviruses are about 28–30 nm in diameter and exhibit a
distinctive starlike morphology in the electron microscope.
➢ Name is derived from its star-like appearance

ENTERIC ADENOVIRUS
❏ Some adenoviruses serotypes (double-stranded DNA, naked
capsid virus) are now recognized as significant intestinal
pathogens. These adenovirus serotypes may account for an
estimated 5% to 15% of all viral gastroenteritis in young children.
❏ Adenoviruses that can cause gastroenteritis:
➔ Adenovirus serotype 38
❏ These adenoviruses mainly infect infants aged around less than 2
years.
❏ They are transmitted by fecal–oral route and the incubation period
is 8 to 10 days and the symptoms of gastroenteritis last for 5 to 12
days.
❏ The diagnosis can be done by antigen detection, PCR, virus
isolation, and serology. Treatment and prevention strategies are
similar to those of other diarrheal viruses.
CANDIDATE VIRUSES
❏ Other agents that have been associated with gastrointestinal
diseases include coronavirus- like agents, toroviruses NEVER SHALL WE FAIL!
(coronavirus) which may cause diarrhea,
❏ Some group A coxsackieviruses (the latter primarily cause
gastrointestinal symptoms in severely immunocompromised
patients).
❏ This list may grow in the future; however, until more is learned
about their biology, epidemiologic behavior, and impact on human
health, they remain “candidate” viruses for now.
➔ Candidate because their biology and effect on human
health is still not fully understood

MODULE 8: ZOONOTIC VIRUS HIGHLIGHTING OF TOPICS BULLET PLACEMENT
I. INTRODUCTION AAAAAA - Main topic ➔ (Sub-definition/Enumerate)
II. CLASSIFICATION OF ARBOVIRUSES AAAAAA - Subtopics ● (Super Sub-detail)
III. ARBOVIRUSES INFECTION IN HUMAN
1. Family Bunyaviridae INTRODUCTION
➔ La Crosse Virus ❏ The zoonotic viruses discussed here are divided into two groups:
➔ Sandy Fever Virus
➔ Rift Valley Fever Virus Arthropod-borne (arboviruses) and non- arthropod-borne
➔ Heartland Fever Virus zoonotic viruses.
2. Family Flaviviridae
➔ Japanese B Encephalitis Virus
Arthropod-borne Viruses Non-Arthropod-borne Viruses
➔ West Nile Fever Virus
(Arbovirus)
➔ Zika Virus
➔ Yellow Fever Virus
Transmitted to humans by Transmitted by inhalation of
➔ Dengue ever Virus
infected blood- sucking insects, infected animal excretions, by
3. Family Reoviridae
such as mosquitoes, ticks, and the conjunctival route, or
➔ Genus Orbivirus
Phlebotomus flies (sandflies). occasionally by direct contact
with infected animal (e.g., animal
4. Family Togaviridae
bite)
➔ Genus Alphavirus
● Western Equine Encephalitis
● Eastern Equine Encephalitis
● Chikungunya Virus ❏ In most cases, the zoonotic viruses were first named after the
IV. NON-ARBOVIRUSES INFECTION IN HUMAN place or region of initial isolation or reported infection (e.g., St.
1. Family Arenaviridae
Louis encephalitis virus, West Nile virus, Zika virus) or after the
➔ Lassa Virus
➔ Lujo Virus disease produced (e.g., yellow fever).
➔ Junin Virus ❏ More recent studies have assigned the majority to families and
➔ Machupo Virus genera on the basis of properties including morphologic and
➔ Guanarito Virus genetic features, geographic distribution, and disease spectrum.
➔ Sabia Virus
➔ Chapare Virus
➔ Lymphocytic Choriomeningitis Virus
2. Family Bunyaviridae
➔ Hantaviruses
3. Family Filovirdae
➔ Marburg Virus
➔ Ebola Virus
4. Family Rhabdovirdae

CLASSIFICATION OF ARBOVIRUSES
NOTE:
❏ Epidemic cycle: Human to peridomestic vectors
❏ Sylvatic/Enzootic cycle: Vertebrate hosts to insect vectors (occurs
in the wild). Humans can be accidentally infected and they are
called dead-end host because they can’t transfer the virus to
other humans
❏ Rural epizootic cycle: Domestic animals to insect vectors.
Humans can be accidentally infected and they are called
dead-end hosts because they can’t transfer the virus to other
humans.
ARBOVIRUS INFECTION IN HUMANS

Table 8.1 Arboviruses of Major Importance to Humans BUNYAVIRIDAE
NOTE: Yellow fever virus - jaundice, increase in hemolysis, yellowish
sclera of the eye Virion ➔ Spherical
➔ 80 - 120 nm
Genome ➔ Single-stranded RNA

➔ Negative sense or ambisense RNA
➔ Triple segmented (3 RNA genomes)

Envelope ➔ Present with 2 glycoproteins (G1 & G2)
Replication Cytoplasm ❏ There are four genera of Bunyaviridae family:

(3 arboviruses, 1 non-arthropod zoonotic virus)
Table 8.3 Properties of Bunyaviruses
1. Bunyavirus – Negative sense RNA
2. Phlebovirus – Negative sense RNA
3. Nairovirus - Ambisense RNA
4. Hantavirus – Negative sense RNA (non-arthropod virus)
❏ All bunyaviruses are arboviruses, except Hantavirus, which is a
non-arthropod zoonotic virus and discussed later.
La Crosse Virus
❏ Under the genus Bunyavirus
❏ La Crosse virus is a significant virus under the California
encephalitis virus complex, and is a major cause of encephalitis
and aseptic meningitis in children in the upper Midwest part of the
world.
❏ Transmitted by various woodland mosquitoes, primarily Aedes
Figure 8.1 Virion structure of Bunyaviruses.
triseriatus
❏ The virions of bunyaviruses contain single-stranded, negative
❏ The onset of California encephalitis viral infection is abrupt,
sense RNA viruses that are spherical and enveloped with an
typically with severe headache, fever, and in some cases vomiting
external diameter of 80 to 120 nm.
and convulsions. About half of patients develop seizures, and the
❏ The envelope contains two glycoproteins, G1 and G2, and
case-fatality rate is about 1%. Less frequently, patients have only
encloses three helical nucleocapsids containing RNA, namely,
aseptic meningitis. The illness lasts from 10 to 14 days, although
large (L), medium (M), and small (S), associated with an
convalescence may be prolonged. Neurologic sequelae are rare.
RNA-dependent RNA polymerase (L) and nonstructural
There are many infections for every case of encephalitis. Serologic
proteins (N).
confirmation by Hemagglutination Inhibition, ELISA, or
neutralization tests is done on acute and convalescent specimens
NOTE:
❏ S-nucleocapsid- codes for nucleocapsid
Sandy Fever Virus
❏ M-nucleocapsid - codes for G1 and G2 proteins, which is
❏ Under the genus Phlebovirus
essential for attachment to host cell for viral replication
❏ Sandfly fever is a mild, insect-borne disease. Sandfly fever (also
➔ G1 protein - responsible for attachment to receptor of host
called Phlebotomus fever) is caused by a bunyavirus in the
cells
Phlebovirus genus. The disease is transmitted by the female
❏ L-nucleocapsid- codes for L-protein
sandfly, Phlebotomus papatasi.
➔ L-protein - name of the RNA-dependent RNA polymerase
of Bunyaviruses which is used to convert negative-sense
RNA to positive-sense RNA for it to be translated.

❏ The disease begins abruptly after an incubation period of 3–6 FLAVIVIRIDAE
days. The virus is found in the blood briefly near the time of onset PROPERTY DESCRIPTION
of symptoms.
❏ Clinical features consist of headache, malaise, nausea, fever, Virion ➔ Icosahedral capsid
photophobia, stiffness of the neck and back, abdominal pain, and ➔ 40 - 60 nm
leukopenia. All patients recover and there is no specific treatment.
❏ Prevention of disease in endemic areas relies on use of insect Genome ➔ Single-stranded RNA
➔ Positive sense
repellents during the night and residual insecticides around living
quarters. Envelope ➔ Present with 2 glycoproteins
● M protein
Rift Valley Fever Virus ● E protein
❏ Under the genus Phlebovirus
❏ A mosquito-borne zoonotic virus pathogenic primarily for domestic Replication Cytoplasm
livestock.
Outstanding ➔ All flaviviruses are antigenically related
❏ Humans are secondarily infected during the course of epizootics in Characteristics ➔ Hepatitis C virus, classified in a separate genus
domesticated animals. in the Flaviviridae family, has no arthropod vector
❏ Epizootics occur periodically after heavy rains that allow hatches and is not an arbovirus
of the primary vector and reservoir (Aedes and Culex species Table 8.4 Properties of Flaviviridae
mosquitoes). Viremia in animals leads to infection of other vectors NOTE:
with collateral transmission to humans. Transmission to humans is ❏ Flavivirus are similar to togavirus in several aspects such that they
primarily by contact with infected animal blood and body fluids and are positive sense, single-stranded RNA, icosahedral capsid,
mosquito bites. enveloped virus. However, the virions of flavivirus are smaller than
❏ Disease in humans is usually a mild febrile illness that is short those of togaviruses.
lived, and recovery almost always is complete. ❏ Other genus of Flaviviridae is Hepacivirus (hepatitis C virus) that is
❏ Complications include retinitis, encephalitis, and hemorrhagic a blood-borne virus and causes hepatitis C.
fever. Permanent loss of vision may occur (1–10% of cases with ❏ All flaviviruses are antigenically related. Since they have the same
retinitis). About 1% of infected patients die. antigen present in their envelope, there is a possibility of
cross-reaction. Antibodies against other genus can cross-react
Heartland Fever Virus against other viruses under the same family.
❏ Under the genus Phlebovirus ❏ The coating of this antibody will enhance the replication process of
❏ Patients infected with this virus presented fever, fatigue, anorexia, the flaviviridae since genus under flaviviridae can bind on the Fc
nausea, or diarrhea and had leukopenia, thrombocytopenia, and receptor present on the macrophages and monocytes which will
elevated liver enzymes. It is thought that Lone Star ticks transmit enhance the entry or penetration of the virus.
the virus. ❏ Zika virus babies are protected against dengue virus because
❏ Another related Phlebovirus, Lone Star virus, has been recovered there is a possibility of cross reaction. Zika virus babies that have
from Lone Star ticks and can infect human cell lines, but no human been infected with dengue present a severe form of dengue
cases have been reported. infection.

❏ In the vast majority of infections, the virus is controlled before
neuro-invasion occurs. Invasion depends on many factors,
including the level of viremia, the genetic background of the host,
the host's innate and adaptive immune responses, and the
virulence of the virus strain. Humans show an age-dependent
susceptibility to central nervous system infections, with infants and
elderly adults being most susceptible
LABORATORY DIAGNOSIS FOR MOST ARBOVIRUSES
Samples Direct Detection Serology

Figure 8.2 Virion Structure of Flaviviridae
Two types of virions, intracellular and extracellular virions, are shown. ➔ Blood ➔ Common Cell lines ➔ Hemagglutination
❏ Intracellular virion = precursor to M protein / prM, E monomer ➔ CSF ➔ Mosquito Cell lines Inhibition Test
➔ Intracerebral ➔ ELISA
❏ Extracellular virion = precursor to M protein / prM, M protein, E
inoculation of
dimer suckling mice or
➔ E protein = essential for viral attachment hamsters
NOTE: ➔ RT-PCR
❏ The positive-sense, single stranded RNA genome is packaged into
an icosahedral capsid wrapped into a lipid bilayer envelope
St. Louis Encephalitis Virus
containing membrane (M) protein and spike glycoprotein (E).
❏ St. Louis encephalitis virus is the most important cause of
❏ The prM is the precursor to M protein. The size of flavivirus virion
epidemic encephalitis in humans in North America. Highest
ranges from 40 to 60 nm in diameter.
infection rate occurs among adults who are >40 years old.
❏ There are two major differences between intracellular and
❏ Vector: Culex tarsalis
extracellular virions:
❏ The presence of infected mosquitoes is required before human
➔ Intracellular virions have only prM and E as monomers
infections can occur, although socioeconomic and cultural factors
➔ Extracellular virions have prM and M and E as dimer.
(air conditioning, screens, mosquito control) affect the degree of
exposure of the population to these virus-carrying vectors.
PATHOGENESIS OF FLAVIVIRUSES
❏ In susceptible vertebrate hosts, primary viral multiplication occurs
Japanese B Encephalitis Virus
either in myeloid and lymphoid cells or in vascular endothelium.
❏ Japanese B encephalitis is the leading cause of viral encephalitis
Multiplication in the central nervous system depends on the ability
in Asia. The mortality rate can exceed 30%. A high percentage of
of the virus to pass the blood– brain barrier and to infect nerve
survivors (up to 50%) are left with neurologic and psychiatric
cells. In natural infection of birds and mammals, an inappropriate
sequelae. Infections during the first and second trimesters of
infection is usual. For several days there is viremia, and arthropod
pregnancy have reportedly led to fetal death.
vectors acquire the virus by sucking blood during this period—the
❏ Vector: Culex tritaeniorhynchus
first step in its dissemination to other hosts.

❏ .There is no treatment. Several effective Japanese encephalitis ❏ Prevention of mosquito exposure in endemic regions is important
vaccines are available in Asia. An inactivated Vero cell to reduce infection rates.
culture-derived vaccine was licensed in the United States in 2009.
West Nile Fever Virus

❏ It is now the leading cause of arboviral encephalitis in the United
States.
❏ Vector: Culex genus mosquitoes
❏ It is estimated that about 80% of West Nile infections are
asymptomatic, with about 20% causing West Nile fever and less
than 1% causing neuro-invasive disease (meningitis, encephalitis,
or acute flaccid paralysis).
❏ West Nile virus produces viremia and an acute, mild febrile
disease with lymphadenopathy and rash. Transitory meningeal Zika Babies in Brazil
involvement may occur during the acute stage. Only one antigenic
type of virus exists, and immunity is presumably permanent. Yellow Fever Virus
❏ A West Nile vaccine for horses became available in 2003. There is A. INTRODUCTION
no human vaccine. Prevention of West Nile virus disease ❏ Yellow fever virus is the prototype member of the
depends on mosquito control and protection against mosquito Flaviviridae family. It causes yellow fever, an acute, febrile,
bites. mosquito-borne illness that occurs in the tropics and
subtropics of Africa and South America. Severe cases are
Zika Virus characterized by liver and renal dysfunction and
❏ Zika virus can be found in blood, urine, and other body fluids hemorrhage, with a high mortality rate. There is a single
including semen, leading to potential sexual transmission. serotype (monotypic). It is the first virus to be studied
❏ Vector: Aedes aegypti under Flaviviridae.
❏ Most infected individuals are asymptomatic, others can develop ❏ Vector: Aedes spp. or Haemagogus spp.
rash, arthralgia, conjunctivitis, and fever.
❏ Severe cases are rare; however, the virus can pass through the B. PATHOGENESIS
placenta during pregnancy and infect fetal neuronal tissue, leading ❏ The virus is introduced by a mosquito through the skin,
to microcephaly and neurologic abnormalities. where it multiplies. It spreads to the local lymph nodes,
❏ Zika virus infection in adults can lead to Guillain-Barre liver (major target organ), spleen, kidney, bone marrow,
Syndrome (GBS). and myocardium, where it may persist for days. It is
❏ MOT: Mosquito bite, vertical transmission, sexual, blood present in the blood early during infection.
transfusion ❏ The lesions of yellow fever are caused by the localization
❏ Treatment is generally supportive, and screening is available for and propagation of the virus in a particular organ.
pregnant women potentially exposed to infection. Infections may result in necrotic lesions in the liver and
kidney. Degenerative changes also occur in the spleen,

lymph nodes, and heart. Serious disease is characterized NOTE: No hepatitis but jaundice is evident
by hemorrhage and circulatory collapse. Virus injury to the C. LABORATORY DIAGNOSIS
myocardium may contribute to shock.
PATHOGENESIS (SIR TUBOLA) ➔ Blood ➔ RT-PCR ➔ Hemagglutination

1. Mosquito bites leads to the inoculation of the virus in the host. ➔ Postmortem Inhibition Test
2. Virus will move to the lymph nodes and disseminate towards the tissue ➔ ELISA - detection of
target organ. IgM
3. Hepatocytes are infected 24 hours after inoculation and undergo
apoptosis leading to death without inflammation.
➔ Jaundice due to destruction of hepatocytes. During liver D. EPIDEMIOLOGY
damage, bilirubin can’t be conjugated for excretion leading ❏ There are two major epidemiologic cycles of transmission
to deposition of bilirubin and jaundice (thus, the name of yellow fever
“yellow” fever).
Urban Yellow Fever Sylvatic or Jungle Yellow Fever
4. Kidney cells undergo tissue changes that will eventually lead to
disruption of the Bowman’s capsule. ➔ Involves person-to-person ➔ Primarily a disease of
5. The presence of virus in the system allows the lymphocytes (T transmission by domestic monkeys. Transmitted from
helper) to release cytokines that will cause hypertension and Aedes mosquitoes. monkey to monkey by arboreal
shock. ➔ Occurs in highly populated mosquitoes.
6. Hypotension will lead to further kidney damage due to a decreased areas. ➔ Humans serve as tangential
host or dead-end host.
perfusion of the renal tubules and this will lead to renal failure with ➔ Persons involved in
associated decreased urine output. forest-clearing activities come
in contact with these
mosquitoes in the forest and
become infected.
E. TREATMENT, PREVENTION, AND CONTROL

❏ There is no antiviral drug therapy. The 17D strain of yellow
fever virus is an excellent attenuated live-virus vaccine.
❏ Vaccination is the most effective preventive measure
against yellow fever , a potentially severe infection with a
high death rate for which there is no specific treatment.
NOTE: If not vaccinated avoid areas with abundant mosquitos.

Dengue Fever Virus ❏ The reason why secondary dengue infection is more
A. INTRODUCTION severe is because of the Antibody Dependent
❏ Dengue Fever virus has four serotypes (DEN-1 to DEN-4). Enhancement (ADE).
Recently, the fifth serotype (DEN-5) was discovered in
2013 from Bangkok. ANTIBODY DEPENDENT ENHANCEMENT (ADE)
❏ Aedes aegypti is the principal vector followed by Aedes ❏ Infection with dengue virus induces the production of both
albopictus. neutralizing and non-neutralizing antibodies
➔ They bite during the daytime (early morning,
dawn).
Neutralizing antibodies Non-neutralizing antibodies
❏ It causes breakbone fever that is characterized by fever,
severe headache, muscle and joint pain, nausea and ➔ Protective in nature ➔ Last lifelong and they are
vomiting, eye pain, and rash. ➔ Such antibodies are produced heterotypic in nature
❏ Severe forms of the disease, dengue hemorrhagic fever against the infective serotype ➔ Such antibodies produced
and dengue shock syndrome (DSS) , principally affect (which last lifelong) as well as following:
children. against other serotypes (which ● the first serotype infection,
last for some time) can bind to a second
➔ Hence, protection to infective serotype; but instead of
VECTORS OF DENGUE FEVER VIRUS serotypes stays lifelong but neutralizing the second
cross protection to other serotype, it protects it from
Aedes aegypti Aedes albopictus serotypes diminishes over a the host immune system
few months. by inhibiting bystander B
➔ A nervous feeder (so, it bites ➔ Found in peripheral urban cell activation against the
repeatedly to more than one areas NOTE: Temporary protection if second serotype
person to complete a blood ➔ It is an aggressive and secondary infection occurs. NOTE:
meal) concordant feeder (can ❏ Cover the antigen so there will
➔ Resides in domestic places, complete blood meal in one be no antigen detected by the
hence it is the most efficient go; hence is less efficient in adaptive immunity. As a result,
vector. transmission) the virus will not be eliminated
in the circulation.
- Aedes becomes infective only when it feeds on viremic patients. ❏ Called Antibody-Dependent
Enhancement because the
B. PATHOGENESIS replication of the virus in the
❏ Primary dengue infection occurs when a person is circulation is enhanced by the
binding of the non-neutralizing
infected with dengue virus for the first time with any one
antibody on the antigen present
serotype. in the surface of the second
❏ Months to years later, a more severe form of dengue infection.
illness may appear (called secondary dengue infection)
NOTE: Secondary infection is more dangerous compared to primary
due to infection with another second serotype which is
infection because of the Antibody-Dependent Enhancement.
different from the first serotype causing primary infection.

C. CLINICAL CLASSIFICATION
There are two classifications of Dengue infection
1. The traditional (1997) WHO Classifications
2. 2009 WHO Classifications
NOTE: Figure 8.3 2009 WHO Classification of Dengue Infection

❏ DHF and DSS if platelets are degraded. NOTE: Familiarize the criteria under dengue infection.
❏ DF if platelets are not degraded.
D. LABORATORY DIAGNOSIS
TOURNIQUET TEST Direct Detection Serology
❏ Tourniquet is placed on arm and after two minutes, check for and
count petechiae spots ➔ RT-PCR ➔ Hemagglutination Inhibition
➔ If more than 20 spots, positive test Test
➔ ELISA - detection of IgM and
➔ If less than 20 spots, negative test
IgG
E. EPIDEMIOLOGY
❏ There are more than 100 countries where dengue has
become endemic. These viral agents are widespread
throughout the world, particularly Africa, the Americas, the
Eastern Mediterranean, South Asia, South-east Asia and
the Western Pacific, the Middle East, Africa, the Far East,
and the Caribbean Islands.
❏ Globally, it is estimated that about 100 million people are
infected by dengue virus, 500 000 dengue hemorrhagic

fever cases, and 22 000 deaths mostly in children every GENUS COLTIVIRUS
year. ❏ Colorado Tick Fever Virus
➔ Transmitted by ticks
F. TREATMENT, PREVENTION, AND CONTROL ➔ Able to infect humans
❏ There is no antiviral drug therapy. Dengue hemorrhagic ➔ Clinical Findings:
fever can be treated by fluid replacement therapy. There is ● Fever, chills, headache, photophobia
no vaccine, but candidate vaccines are under ● Myalgia, arthralgia, lethargy
development. Vaccine development is difficult because a ● Rach
vaccine must provide protection against all four serotypes ● Systemic symptoms in infected patients
of virus. Therapeutic antibodies able to neutralize multiple ➔ Colorado Tick Fever Virus infection can lead to
genotypes of dengue are also under development. encephalitis or meningitis
❏ Control depends on anti-mosquito measures, including
elimination of breeding places and the use of insecticides. TOGAVIRIDAE
Screened windows and doors can reduce exposure to the PROPERTY DESCRIPTION
vectors.
Virion ➔ Icosahedral capsid
REOVIRIDAE ➔ Approximately 70 nm
❏ Reoviruses are spherical, naked capsid icosahedral,
double-stranded segmented RNA viruses. The reoviruses Genome ➔ Single-stranded RNA
described here are arboviruses that are transmitted through insect ➔ Linear
➔ Positive sense
(tick) bites.
❏ The most important North American arbovirus of this family, which Envelope ➔ Present with 2 glycoproteins
is a member of the genus Coltivirus, causes Colorado tick fever in ◆ E1 and E2
humans. The other arboviruses from the Reoviridae family are
Orbivirus which includes African horse sickness and bluetongue Replication Cytoplasm
viruses, mainly causing disease in animals.
Outstanding ➔ Alphaviruses have the ability to hemagglutinate
Characteristics via fusion of E1 glycoprotein to lipids in
GENUS ORBIVIRUS erythrocyte membrane and E2 also participates in
❏ They commonly infect insects, and many are transmitted by this process.
insects to vertebrates. NOTE: Most efficient in attachment is E1 but both
❏ None of these viruses cause serious clinical disease in humans, proteins participate in attachment.
but they may cause mild fevers.
❏ Serious animal pathogens include:
➔ Bluetongue virus of sheep
➔ African horse sickness virus

ALPHAVIRUSES
❏ Alphavirus genus includes most arboviruses within this family
that infect humans.
❏ Usually causes persistent infection in arthropods but acute
infection in humans.
❏ All alphaviruses are antigenically related. Cross reactivity occurs
❏ The viruses are inactivated by acidic pH, heat, lipid solvents,
detergents, bleach, phenol, 70% alcohol, and formaldehyde due to
the presence of envelope.
Western Equine Encephalitis

❏ Western equine encephalitis virus (Alphavirus/Togavirus)
causes western equine encephalitis
❏ The virus is transmitted through mosquito (Culex tarsalis) bites.
Horses and humans represent blind-end hosts; both are
susceptible to infection and illness, commonly manifested as
encephalitis.
❏ Although human infection in endemic areas is commonplace,
Figure 8.3 Virion structure of alphavirus. overall, only 1 of 1000 infections causes clinical symptoms.
❏ The single-stranded, positive-sense RNA genome is encapsidated However, in young infants, 1 of every 25 infections may produce
into an icosahedral capsid (C protein) wrapped by a lipid bilayer severe illness. The attack rates are therefore far higher in young
envelope (viral membrane) containing viral-encoded glycoproteins infants than in other groups.
(spikes), E1 and E2 with an external diameter of 70 nm. ❏ The disease spectrum may range from mild, nonspecific
➔ E1 has the ability to hemagglutinate via fusion to lipids on febrile illness to aseptic meningitis or severe, overwhelming
erythrocyte membrane and E2 also participates in this encephalitis.
process. ❏ Mortality rate is estimated at 5% for cases of encephalitis. It is a
➔ E1 is most efficient in attachment among the 2 very serious disease in infants less than 1 year of age; as many
glycoproteins as 60% of survivors have permanent neurologic impairment.
➔ Viral membrane - ouses the spike proteins
Eastern Equine Encephalitis
A. PATHOGENESIS ❏ The mosquito vector (principally Culiseta melanura) generally
❏ Same as Flaviviruses restricts its feeding to horses and birds, although occasional
B. LABORATORY DIAGNOSIS outbreaks among humans have occurred. Increasing numbers of
❏ Same as Flaviviruses human infections have been observed in 2005 and 2012, which is
a cause of concern.

❏ The virus can cause severe encephalitis in horses and also in wild PATHOGENESIS
birds.
❏ The mortality rate for eastern equine encephalitis among humans
is estimated at 33% for individuals of all ages, and the incidence
of severe sequelae among survivors is high.
Chikungunya Virus
❏ Chikungunya (a native term for “that which bends up”) is an
Alphavirus (Togaviruses) transmitted by mosquitoes (Aaegypti
and some other species), particularly in urban areas of Asia,
Africa, and most recently in limited areas of Southern Europe and
the Caribbean.
❏ The incubation period is between 2 and 12 (average 3-7) days
and a majority of infected people develop some symptoms. Illness
is characterized by an abrupt onset of fever, accompanied by
excruciating myalgia and polyarthritis.
❏ Infected people may experience additional symptoms such as:
➔ Headache
➔ Myalgia
➔ Arthritis CHIKUNGUNYA VIRUS INFECTION
➔ Conjunctivitis 1. Chikungunya virus infection begins when an infected mosquito
➔ Nausea bites a human and the virus is introduced into the skin and
➔ Vomiting bloodstream.
➔ Maculopapular rash. 2. The virus replicates in the fibroblasts of the dermis and
❏ Symptoms usually last 1 week, but the musculoskeletal complaints disseminate through the bloodstream to severe tissues.
can sometimes persist for weeks to months. The disease is usually 3. Viral replication occurs in target tissues mainly muscles, joints,
not fatal. and skin, as well as the liver , spleen, and meninges in neonates
❏ Diagnosis is done by detecting IgM by ELISA or RNA by RT-PCR. and patients with underlying conditions.
There is no specific treatment or vaccine. 4. Inflammatory cells are recruited to infected tissues.
5. Joints (including in the fingers, wrists, elbows, knees, ankles and
toes) become inflamed in response to viral replication and
inflammatory infiltrates.
6. That is why Chikungunya infection presents with both myalgia and
polyarthritis

NON-ARBOVIRUS INFECTION IN HUMANS ARENAVIRIDAE
❏ The non-arthropod-borne zoonotic viruses are those that are not
transmitted through arthropod vectors but transmitted through
small mammals and rodents. Virion ➔ Pleomorphic
❏ These viruses include arenaviruses, hantaviruses (bunyavirus), ➔ 50-300 nm
and filoviruses.
Genome ➔ Bisegmented
➔ One large negative sense RNA
➔ One small ambisense RNA
Envelope ➔ Present with large, club-shaped peplomers

● Peplomers: G1 and G2
Outstanding ➔ The virion contains host cell ribosomes in their

Characteristics interior.
● These ribosomes confer a granular
appearance to the viruses; hence their
name (from the Latin arenosus for “sandy”).
Table 8.6 Properties of Arenaviridae
❏ Arenavirus causes persistent infection in rodents and are also

transmitted to humans from the excreta of infected rodents.
❏ The most significant arenavirus infections in humans are the
hemorrhagic fevers caused by Lassa virus in West Africa.
➔ In addition, the South American hemorrhagic fevers are
caused by arenaviruses, including Junin virus, Machupo
virus, Guanarito virus, and Sabia virus. LCMV is
occasionally transmitted to humans from infected mice and
other rodents, and associated with CNS infection that may
NOTE: persist for several months.
❏ Hantavirus is the non-arbovirus among the 4 genus of
bunyaviridae
❏ Filoviridae - includes dangerous viruses that can cause the most
fatal hemorrhagic fever (Marburg and Ebola).

Lassa Virus
❏ Causative agent of Lassa fever
❏ The disease is characterized by very high fever, mouth ulcers,
severe muscle aches, skin rash with hemorrhages, pneumonia,
Figure 8.4 Virion Structure of Arenaviridae. and heart and kidney damage.
❏ Arenaviruses are enveloped containing two surface glycoproteins: ❏ Deafness is a common complication, affecting about 25% of
➔ G1 and G2 patients during recovery; hearing loss is often permanent
❏ RNA genome comprises large (L) single-stranded, ❏ Lassa virus is highly virulent—the mortality rate is about 15% for
negative-sense (–) and a small (S) ambisense (–/+) RNA that patients hospitalized with Lassa fever. Overall, about 1% of Lassa
form L and S nucleocapsids. virus infections are fatal.
❏ The size of virions ranges from 50 to 300 nm in diameter. ❏ The incubation period for Lassa fever is 1–3 weeks from time of
❏ The virion contains host cell ribosomes inside the virus particle. exposure. The disease can involve many organ systems, although
➔ These ribosomes confer a granular or sandy appearance symptoms may vary in the individual patient. Onset is gradual, with
to the virions; hence their name (from the Latin arenosus fever, vomiting, and back and chest pain.
for “sandy”). ❏ Lassa virus infections cause fetal death in more than 75% of
NOTE: pregnant women. During the third trimester, maternal mortality is
❏ L nucleocapsid codes for L protein or RNA polymerase. increased (30%), and fetal mortality is very high (>90%)
❏ S nucleocapsid codes for N protein, G1 and G2 glycoproteins.
❏ Presence of host ribosomes provides the granular appearance. A. LABORATORY DIAGNOSIS
❏ G1 is the glycoprotein that acts with a cell-surface receptor to
Direct Detection Serology
facilitate the entry of viruses in the target cell.
➔ RT-PCR ➔ Immunohistochemistry - to
detect viral antigen in tissue
specimen
➔ ELISA - detection of IgG and
IgM

B. EPIDEMIOLOGY ❏ Junin virus produces both humoral and cell-mediated
❏ A house rat (Mastomys natalensis) is the principal rodent immunodepression; deaths caused by Junin hemorrhagic fever
reservoir of Lassa virus. may be related to an inability to initiate a cell-mediated immune
❏ The virus can be transmitted by human-to-human contact. response.
When the virus spreads within a hospital, human contact is ❏ An effective live attenuated Junin virus vaccine is used to
the mode of transmission. vaccinate high-risk individuals in South America.
❏ Meticulous barrier nursing procedures and standard
precautions to avoid contact with virus-contaminated blood Machupo Virus
and body fluids can prevent transmission to hospital ❏ Agent of Machupo hemorrhagic fever (Bolivian hemorrhagic
personnel. fever) that was identified in Bolivia in 1962. An effective rodent
control program directed against infected Calomys callosus, the
C. TREATMENT, PREVENTION, AND CONTROL host of Machupo virus, was undertaken in Bolivia and has greatly
❏ Rodent control measures are one way to minimize virus reduced the number of cases of Machupo hemorrhagic fever.
spread but are often impractical in endemic areas.
❏ The antiviral drug ribavirin is the drug of choice for Lassa Guanarito Virus
fever and is most effective if given early in the disease ❏ The agent of Venezuelan hemorrhagic fever, and was identified
process. in 1990; it has a mortality rate of about 33%. Its emergence was
❏ No vaccine exists, although a vaccinia virus recombinant tied to clearance of forest land for small farm use.
that expresses the glycoprotein gene of Lassa virus is able
to induce protective immunity both in guinea pigs and in Sabia Virus
monkeys. ❏ Was isolated in 1990 from a fatal case of hemorrhagic fever in
NOTE: Lassa virus causes the most significant hemorrhagic fever/infection Brazil. Brazil hemorrhagic fever
in humans.
Chapare Virus
Lujo Virus ❏ Was isolated in Bolivia and is the causative agent of Chapare
❏ Lujo virus was identified in 2008 as a cause of hemorrhagic fever (Bolivia) hemorrhagic fever
in South Africa. The source of infection is unknown. Rodents are
thought to be the primary host, similar to other arenaviruses. Lymphocytic Choriomeningitis Virus
Lymphocytic choriomeningitis (LCM) virus was discovered in 1933 and
Junin Virus is widespread in Europe and in the United States. Its natural vector is the
❏ Agent of Junin hemorrhagic fever (Argentine hemorrhagic wild house mouse, Mus musculus.
fever), a major public health problem in certain agricultural areas The illness usually consists of fever, headache, and myalgia, although
of Argentina. meningitis or meningoencephalitis also occurs occasionally.
❏ The infection occurs almost exclusively among workers in maize Such CNS infections may persist as long as 3 months. There is also
and wheat fields who are exposed to the reservoir rodent, Calomys evidence that transplacental infection can occur in humans, resulting in
musculinus. fetal death, hydrocephalus, or chorioretinitis. No person-to-person
transmission of infection has been documented.

The diagnosis of lymphocytic choriomeningitis is suggested by a history of
➔ Helical Capsid
rodent contact. The virus may be isolated in the early stages of disease
by cell culture or intracerebral inoculation of blood or CSF into weanling Genome ➔ Single-stranded
mice or young guinea pigs. Serologic testing of acute and convalescent ➔ Negative sense RNA
sera is usually performed by indirect immunofluorescence. RT-PCR to
detect viral RNA is also available. Envelope ➔ Present with 10 nm peplomers or spike
BUNYAVIRIDAE
Hantaviruses Outstanding ➔ Two members of filoviruses: Marburg (0
❏ A negative-sense RNA, enveloped virus, is the only Bunyavirus Characteristics subtypes) and Ebola (4 subtypes) viruses that
that is a non-arthropod transmitted zoonotic virus cause hemorrhagic fevers
❏ Hantaviruses are classified in the Hantavirus genus of the
Table 8.7 Properties of Filoviridae
Bunyaviridae family. The viruses are found worldwide and cause
two serious and often fatal human diseases:
Figure 8.5 Virion Structure of Filoviruses.
1. Hemorrhagic fever with renal syndrome (HFRS)
❏ Filoviruses are enveloped,
2. Hantavirus Pulmonary Syndrome (HPS)
single-stranded, negative- sense RNA viruses
with filamentous and highly pleomorphic
virions, averaging 80 nm in diameter and 300
to 14 000 nm in length.
❏ The nucleocapsid (Np) has a helical
symmetry
❏ The envelope is derived from plasma
membrane containing 10 nm peplomers or
spikes, the (GP) glycoprotein, which
mediate virus entry into susceptible cells.
NOTE:
❏ Filoviruses are highly virulent and
require maximum containment facilities
(Biosafety Level 4) for laboratory work.
Filovirus infectivity is destroyed by heating for
FILOVIRIDAE 30 minutes at 60°C, by ultraviolet and
γ-irradiation, by lipid solvents, and by bleach
PROPERTY DESCRIPTION and phenolic disinfectants. The natural hosts
and vectors are suspected to be African fruit
Virion ➔ Filamentous and highly pleomorphic bats.

❏ Filoviruses have a tropism for cells of the macrophage system, organized. The use of isolation facilities in hospital settings
dendritic cells, interstitial fibroblasts, and endothelial cells. Very remains the most effective means of controlling Ebola
high titers of virus are present in many tissues, including the liver, disease outbreaks
spleen, lungs, and kidneys, and in blood and other fluids. These
viruses have the highest mortality rates (25–90%) of all the viral Marburg Virus
hemorrhagic fevers. ❏ Marburg virus disease was recognized in 1967 among laboratory
workers exposed to tissues of African green monkeys
A. EPIDEMIOLOGY (Cercopithecus aethiops) imported into Germany and Yugoslavia.
❏ It is probable that Marburg and Ebola viruses have a ❏ Causes acute diseases characterized by
reservoir host, most likely the fruit bat, and become ➔ Fever
transmitted to humans only accidentally. ➔ Headache
❏ Monkeys are not considered to be reservoir hosts because ➔ sore throat
most infected animals die too rapidly to sustain virus ➔ muscle pain (myalgia)
survival. Once monkeys are infected, they die and cannot ➔ followed by abdominal pain, vomiting, diarrhea, and rash,
sustain the replication of the virus with both internal and external bleeding, often leading to
❏ Human infections are highly communicable and fatal to shock and death.
human contacts, generally by direct contact with blood, ❏ The most recent outbreak was in Angola (2005), affecting 252
body fluids, or recently deceased victims. people with 272 deaths (mortality rate (90%)
❏ Transmission from patients to medical personnel occurred, with
B. LABORATORY DIAGNOSIS high mortality rates. Antibody surveys have indicated that the virus
is present in East Africa and causes infection in monkeys and
Direct Detection Serology
humans.
➔ RT-PCR ❏ Recorded cases of the disease are rare, but outbreaks have been
➔ Fresh virus isolates can be ➔ ELISA - detection of viral documented in Kenya, South Africa, Democratic Republic of the
cultured in cell lines such antibodies and antigen Congo, and Angola. Marburg virus can infect guinea pigs, mice,
as Vero and MA-104 hamsters, monkeys, and various cell culture systems.
monkey cell lines
Ebola Virus
C. TREATMENT, PREVENTION AND CONTROL ❏ In 1976, severe outbreaks of hemorrhagic fever occurred in
❏ There are no specific antiviral therapies available. northern Zaire and southern Sudan, with case fatality rates of 90%
Treatment is directed at maintaining renal function and and 50%, respectively. The illnesses were similar to those
electrolyte balance and combating hemorrhage and shock. described for Marburg virus, but were later shown to be caused by
An experimental vaccine is now available and is being an antigenically different agent known as Ebola virus. Ebola virus
tested for effectiveness as a targeted outbreak control has four subtypes (Zaire, Sudan, Reston, Ivory Coast).
measure (Supportive treatment) NOTE:
❏ Because the natural reservoirs of Marburg and Ebola ❏ Zaire - Northern Sudan
viruses are still unknown, no control activities can be ❏ Sudan - South Sudan

❏ Reston- No recorded cases
❏ Ivory Coast (New name is Tai Forest) NOTE:
❏ Causes acute diseases characterized by symptoms similar to ❏ G-glycoproteins - important for the attachment of this virus to the
Marburg virus. receptors (Acetylcholine and NCAM or Neural Cell Adhesion
❏ The largest known Ebola outbreak occurred in Western Africa in Molecule)
2014–2016, with over 28,000 cases and 11,000 deaths in Guinea, (a) Electron micrograph of bullet-shaped particle typical of the
Liberia, and Sierra Leone was caused by the Zaire subtype. rhabdovirus family
Intense international emergency response and quarantine (b) Schematic model of rabies virus showing the surface glycoprotein
measures followed, eventually containing the outbreak in June spikes extending from the lipid envelope that surrounds the internal
2016. nucleocapsid and the matrix protein lining the envelope
RHABDOVIRIDAE CLASSIFICATION
PROPERTY DESCRIPTION ❏ Rabies viruses belong to the Lyssavirus, which is a genus under
the family Rhabdoviridae. The rhabdoviruses are very widely
Virion ➔ Bullet-shaped distributed in nature, infecting vertebrates, invertebrates, and
➔ Helical Nucleocapsid plants. Rabies is the major medically important rhabdovirus. Many
➔ 75 nm in diameter x 180 nm in length of the animal rhabdoviruses infect insects, but rabies virus does
not.
Genome ➔ Single-stranded, Linear
➔ Negative sense RNA
ANTIGENIC PROPERTIES
Envelope ➔ Present with knob-like glycoproteins ❏ There is a single serotype of rabies virus. However, there are
strain differences among viruses isolated from different species
Replication Cytoplasm (raccoons, foxes, skunks, canines, bats) in different geographic
Table 8.8 Properties of Rhabdoviruses areas.
PATHOGENESIS
❏ Rabies virus multiplies in muscle or connective tissue at the site of
inoculation and then enters peripheral nerves at neuromuscular
junctions and spreads up the nerves to the central nervous system.
❏ However, it is also possible for rabies virus to enter the nervous
system directly without local replication.
❏ It multiplies in the central nervous system and progressive
encephalitis develops. The virus then spreads through peripheral
nerves to the salivary glands and other tissues.
❏ The organ with the highest titers of virus is the submaxillary
salivary gland.
Figure 8.6 Virion structure of Rhabdoviruses.

➔ Other organs where rabies virus has been found include ➔ Incubation Period (replication): 10 days-1 year
pancreas, kidney, heart, retina, and cornea. Rabies virus ➔ Average: 20-90 days
has not been isolated from the blood of infected persons. ➔ During this period of time (10 days), vaccination
NOTE: is needed to prevent the migration of the virus to
❏ Nervous system is affected by rabies so dogs can’t swallow water the neural tissue after the incubation period. If not
well so they avoid water. vaccinated, the virus will enter the PNS and travel
to the CNS wherein it will replicate exclusively in
the gray matter.
3. It will migrate to other tissues such as:
➔ Salivary glands: (in animals) enhances
transmission
➔ Eye
➔ Skin
➔ Medulla
➔ Kidneys
➔ lungs
PATHOLOGY
❏ Rabies virus produces a specific eosinophilic cytoplasmic
inclusion, the Negri body, in infected nerve cells. Negri bodies are
filled with viral nucleocapsids. The presence of such inclusions is
pathognomonic of rabies but is not observed in at least 20% of
cases. Therefore, the absence of Negri bodies does not rule out
rabies as a diagnosis.
RABIES
❏ An acute fatal illness of the CNS which can result in Viral
Encephalitis.
❏ Has cell tropism to neural tissue because its receptors are
Acetylcholine and NCAM
❏ It is deadly since it affects neurons and neurons are not
regenerated
1. Virus is inoculated to the epidermis Figure 8.6 Negri bodies.
2. Viral replication in the striated muscle at the site of bite Pathognomic inclusion of Rabies virus: Negri bodies

❏ Acute Neurologic Stage: Hyperactive; foaming of mouth because
CLINICAL FINDINGS of excessive production of saliva
❏ Rabies is primarily a disease of lower animals and is spread to ❏ Coma: low chance of survival and once the patient has not
humans by bites of rabid animals or by contact with saliva from recovered in this stage, it can lead to death.
rabid animals. It presents as an acute, fulminant, fatal encephalitis;
human survivors have been reported only occasionally. The clinical EPIDEMIOLOGY
stages of rabies infection are summarized in Table 8.9 below. ❏ Rabies is enzootic in both wild and domestic animals. Domestic
animal bites are very important sources of rabies in developing
countries because of lack of enforcement of animal immunization.
Infection in domestic animals usually represents a spillover from
infection in wildlife reservoirs. Human infection tends to occur
where animal rabies is common and where there is a large
population of unimmunized domestic animals.
❏ Human-to-human rabies infection is very rare.
❏ The only documented cases involve rabies transmitted by corneal
and organ transplants.
➔ Saliva ➔ RT-PCR ➔ Immunofluorescen

➔ Neck biopsy ➔ Negri bodies in ce tests
➔ Serum the brain or the
➔ CSF in human ante spinal cord
mortem (light microscope)
NOTE:
❏ Furious: Hyperactivity, excitement, disorientation, hallucination,
bizarre behavior, hydrophobia, convulsions, aggressive TREATMENT, PREVENTION AND CONTROL
❏ Dumb (paralytic phase): lethargy, paralysis, (respiratory) ❏ There is no specific treatment available, thus Prevention is the
❏ Rabies should be considered in any cause encephalitis or myelitis mainstay of controlling rabies in humans immediately after
of unknown cause even in the absence of an exposure exposure by starting the rabies vaccination process. The
❏ Incubation period: No signs and symptoms prevention of rabies is divided into preexposure prophylaxis
❏ Prodromal Stage: Appearance of signs and symptoms (refer to (PreEP) and postexposure prophylaxis (PEP).
table 8.9) ❏ All vaccines for human use contain only inactivated rabies virus.
➔ Sensory neurons are affected that's why there is a tingling, (Named based on where it is cultured)
itching sensation at the site of bite 1. Human diploid cell vaccine (HDCV)
2. Purified chick embryo cell vaccine (PCEC)

PRE-exposure Prophylaxis POST-exposure Prophylaxis
(PreEP) (PEP)
Recommended for individuals with The decision to administer rabies

high risk of contact with rabies antibody or rabies vaccine—or
virus, such as veterinarians, both—depends on several factors:
spelunkers, laboratory workers,
and animal handlers. 1. The nature of the biting
animal (species, state of
health, domestic, or wild) and
its vaccination status
2. The availability of the animal

for laboratory examination (all
bites by wild animals and bats
require rabies immune
globulin and vaccine)
3. The existence of rabies in the

area
4. The manner of attack

(provoked or unprovoked)
5. The severity of the bite and

contamination by saliva of the
animal
6. Advice from local public

health officials
Never Shall We Fail

#RMT2022Manifesting

MODULE 9: SEXUALLY-TRANSMITTED VIRUS There are 8 pathogens that are linked to the greatest incidence of STDs.
4 Curable 4 Incurable
1. Syphilis (bacteria) 1. Hepatitis B
I. INTRODUCTION 2. Gonorrhoea (bacteria) 2. Herpes Simplex virus infection
II. VIRUSES TO CONSIDER IN THE MODULE 3. Chlamydia (bacteria) 3. HIV infection
A. Human Immunodeficiency Virus (HIV) 4. Trichomoniasis (parasite) 4. Human Papillomavirus Infection
1. Introduction
2. Structural Proteins NOTE: Caused by BACTERIA or NOTE: Caused by VIRUSES
3. Non-structural Proteins and Enzymes PARASITES
4. Replication Cycle of HIV
5. Clinical Manifestation
VIRUSES TO CONSIDER IN THIS MODULE:
6. Epidemiology
1. FAMILY RETROVIRIDAE
7. Transmission of HIV
❏ Genus Lentivirus
8. Laboratory Diagnosis
➔ Human Immunodeficiency Virus 1 and 2 (HIV 1and
9. Treatment
2)
B. Human Papillomavirus (HPV)
2. FAMILY PAPOVAVIRIDAE
1. Introduction
❏ Papilloma viruses
2. Pathogenesis
3. Clinical Features
HUMAN IMMUNODEFICIENCY VIRUS (HIV)
4. Laboratory Diagnosis
INTRODUCTION
5. Epidemiology
6. Prevention, Treatment, and Control
Virion ● Spherical
AAAAAA - Family of virus ❏ (Main definition) ● 80–100 nm in diameter
AAAAAA - Main topic ➔ (Sub-definition/Enumerate) ● Cylindrical core
Genome ● 2 Single-stranded RNA
INTRODUCTION ● Linear
❏ Sexually transmitted diseases (STDs) — or sexually ● Positive-sense
transmitted infections (STIs) — are generally acquired by sexual ● Diploid
● Contains up to six additional replication genes
contact. The organisms (bacteria, viruses or parasites) that cause
sexually transmitted diseases may pass from person to person in Proteins ● Envelope glycoprotein undergoes antigenic
blood, semen, or vaginal and other bodily fluids. Sometimes these variation
infections can be transmitted non-sexually, such as from mother to ● Reverse transcriptase enzyme contained inside
infant during pregnancy or childbirth, or through blood transfusions virions
or shared needles. ● Protease required for production of infectious
virus

❏ The development of highly active antiretroviral therapy
Envelope Present with 2 glycoprotein spikes (Gp120, Gp41)
(HAART) for chronic suppression of HIV replication and prevention
Replication ● Nucleus of AIDS has been a major achievement in HIV medicine.
Outstanding ● Members are non-oncogenic and may be FORMER NAMES OF HIV:

Characteristics cytocidal ❏ Lymphadenopathy-associated virus (LAV)
● Infect cells of the immune system (CD4+ cells) ❏ Human T Lymphocyte Virus 3 (HTLV-3)
NOTE:
❏ The reverse transcriptase enzyme is essential for conversion of
RNA to DNA to be integrated/combined by the integrase to the
human DNA. The HIV DNA will then replicate with the human
DNA.
❏ Human immunodeficiency virus (HIV) types, derived from

primate lentiviruses, are the etiologic agents of Acquired Immune
Deficiency Syndrome (AIDS). The illness was first described in
1981, and HIV-1 was isolated by the end of 1983.
➔ Initial reports were based on an unusual increase in the
incidence of Kaposi sarcoma (KS) and Pneumocystis
pneumonia (PCP), diseases that were considered at that
Based on the picture:
time to occur rarely.
ANTIGENS
❏ There are two types: HIV-1 and HIV-2, which cause AIDS. AIDS is
❏ Gp120 (Surface glycoprotein) is essential for viral attachment to
a devastating disease worldwide, for which there is no permanent
host cells. Circle on the stalk of the antigen.
cure or preventive vaccine for protection, AIDS has spurred
❏ Gp41 (Transmembrane protein) is essential to fuse the viral
unprecedented research efforts to determine the nature and
membrane and the cell membrane of the target cell. The stalk of
immunopathogenic mechanisms of the virus in the hope of finding
the antigen.
more and new effective drugs and a preventive AIDS vaccine.
❏ RECEPTORS OF HIV: (essential for attachment)
Most of our present knowledge of HIV is derived from studies on
❏ CD4+ is the main receptor (yellow)
HIV-1, which is the major cause of AIDS worldwide.
❏ CCR5 or CXCR4 is the cofactor (purple)
Important Information:
STRUCTURAL PROTEINS
❏ HIV-1 and HIV-2 are under the Genus Lentiviruses of the Family
❏ The HIV Matrix Proteins - Consisting of the p17 protein, lie
Retroviridae.
between the envelope and core.
➔ HIV-1 is the major cause of AIDS worldwide.
❏ Gag Proteins - The gag gene gives rise to the 55 kilodalton Gag
➔ HIV-2 is common in Africa.
precursor protein, also called p55, which is expressed from the
unspliced viral mRNA.

❏ Envelope Proteins - Env exists as a multimer, most likely a trimer,
on the surface of the cell of the virion. Interactions between HIV
and the virion receptor, CD4, are mediated through specific
domains of gp120.
NOTE: (Structural proteins in virion of HIV)

❏ p7 or Nucleocapsid protein
❏ p24 or Capsid protein
❏ P17 or Membrane associated matrix protein
Table 9.2 Major Retroviral Genes and Proteins
NON-STRUCTURAL PROTEINS & ENZYMES
❏ HIV-1 protease - The HIV-1 protease is an aspartyl protease that NOTE:
acts as a dimer. Protease activity is required precursors during ❏ gag = codes for structural proteins and enzyme protease
virion maturation. ➔ p17 = membrane-associated matrix protein
➔ It processes the polyprotein (non-functional proteins) ➔ p24 = capsid protein
produced by the HIV RNA for it to become functional ➔ p7 = nucleocapsid protein
protein. ❏ pol = codes the 3 enzymes for viral survival/replication
❏ Reverse transcriptase - During the process of reverse ❏ env = codes for envelope glycoproteins
transcription, the polymerase makes a double stranded DNA copy ➔ gp120 = surface glycoprotein (for adsorption)
of the dimer of single stranded genomic RNA present in the virion. ➔ gp41 = for fusion of the envelope of HIV virion with the
❏ Integrase - The integrase protein mediates the insertion of the HIV plasma membrane of the target cell
proviral DNA into the genomic DNA of an infected cell.
REPLICATION CYCLE OF HIV
REGULATOR PROTEINS 1. HIV ENTRY
❏ Tat - Tat is a transcriptional transactivator that is essential for HIV-1 ❏ CD4 as a primary receptor for HIV embedded in the outer
replication. membrane of the HIV virion bind to receptors on the surface of
❏ Rev - Rev is a 13-kD sequence-specific RNA binding protein. Rev target cells. T-cells (white blood cells) have CD4 and CCR5
acts to induce the transition from the early to the late phase of HIV receptors to which HIV can bind.
gene expression. ❏ Binding of the HIV envelope protein to CD4 and CCR5 allows the
HIV-1 outer membrane to fuse with the cell’s outer membrane and
ACCESSORY PROTEINS: the contents of the virus particle to enter the cell.
❏ Vpr - Vpr can block cell division. ➔ CD4 = present in T-helper cells which releases cytokines
❏ Vpu - Vpu also increases the release of HIV from the surface of an that are essential for regulation of immune cell response
infected cell. ➔ CCR5 and CXCR4 = also essential receptors for the
attachment of HIV virus
➔ gp120 = mediates entry or attachment of HIV virus

2. FUSION AND RELEASE 6. ASSEMBLY
❏ The HIV envelope and the CD4 cell membrane fuse (join together), ❏ Components that are required to build new virus particles, namely
which allows HIV to enter the cell. viral proteins, enzymes and genetic material (viral RNA) move
➔ gp41 = mediates the fusion and release to the cell’s outer membrane where they accumulate and assemble
in the form of a bud.
3. REVERSE TRANSCRIPTION
➔ The genetic material of the virus is in the form of RNA, or 7. RELEASE AND MATURATION
ribonucleic acid. There are two strands of RNA (diploid) in each ❏ Host-cell proteins cut the virus bud from the cell’s outer membrane,
HIV-1 virus particle. An enzyme known as reverse transcriptase thereby releasing a new virus particle. During and after assembly
initiates the formation of one double stranded molecule of viral and release, a viral enzyme called protease cuts the HIV
DNA (deoxyribonucleic acid) by copying the sequence of the RNA polypeptide chains at several positions, in a process called
strands contained in the virus particle. maturation, to make the finished components of the new,
➔ Why need to convert? The double stranded viral DNA is essential infectious, virus particle.
for the integration process. ❏ A single infected cell can release many new HIV particles which
move on to infect other cells in various parts of the body, where the
4. INTEGRATION OF THE VIRAL DNA INTO CELLULAR GENOMIC viral life cycle is repeated.
DNA ❏ The infected cells are eventually destroyed.
❏ The viral DNA enters the nucleus of the host and becomes
integrated into the host’s DNA. An enzyme called integrase is key
in this process. Once the viral DNA has integrated into the cell’s
DNA, the cell is infected for the remainder of its life. The integrated
viral DNA is now referred to as a provirus.
➔ Provirus = viral DNA integrated in the host DNA
5. REPLICATION IN THE NUCLEUS

❏ Transcription - The provirus DNA serves as a template for the
creation of new viral RNA via a process known as transcription.
The host cell’s own machinery that is normally used for the
transcription of human genes is used by the virus to create new
viral RNA molecules. The newly formed viral RNA moves out of the
infected cell’s nucleus going to the cytoplasm.
❏ Translation - The viral RNA carries code for the synthesis of viral
proteins and enzymes. The code is translated into long chains of
amino-acids, known as polypeptide chains, which fold to form
the protein and enzyme components of new virus particles.

A. Viral entry and post entry (reverse transcription, DNA synthesis,
(mildly symptomatic stage) are unexplained weight loss of less
and integration) events; than 10 percent of total body weight and recurrent respiratory
B. Viral gene expression (transcription and protein synthesis); infections (such as sinusitis, bronchitis, otitis media, and
C. Virus assembly and release. pharyngitis)
❏ Also, a range of dermatological conditions including herpes
CLINICAL MANIFESTATION zoster flares, angular cheilitis, recurrent oral ulcerations, papular
❏ In 1993, the CDC definition of AIDS stated that all patients who are pruritic eruptions, seborrhoeic dermatitis, and fungal nail
infections
HIV antibody positive and have CD4+ T Lymphocyte counts lower
than 200/mm3 or less than 14% of total T-lymphocytes have the
disease. HIV-1 infection is characterized as a four-stage process. STAGE 3
➔ HIV-1 infection is characterized as a four-stage process
● Stage 4: AIDS ❏ As disease progresses, additional clinical manifestations may
● CD4+ count: lower than 200/mm3 appear. Those encompassed by the WHO clinical stage 3 (the
moderately symptomatic stage) category are weight loss of
greater than 10 percent of total body weight, prolonged (more
STAGE 1 than 1 month) unexplained diarrhea, pulmonary
tuberculosis, and severe systemic bacterial infections
❏ Patients who are asymptomatic or have persistent including pneumonia, pyelonephritis, empyema, pyomyositis,
generalized lymphadenopathy (lymphadenopathy of at least meningitis, bone and joint infections, and bacteremia.
two sites [not including inguinal] for longer than 6 months are ❏ Mucocutaneous conditions, including recurrent oral
categorized as being in stage 1, where they may remain for candidiasis, oral hairy leukoplakia, and acute necrotizing
several years. ulcerative stomatitis, gingivitis, or periodontitis, may also occur
at this stage.
STAGE 4
❏ The WHO clinical stage 4 (the severely symptomatic stage)

designation includes all of the AIDS-defining illnesses. Clinical
manifestations for stage 4 disease that allow presumptive
diagnosis of AIDS to be made based on clinical findings alone
are HIV wasting syndrome, Pneumocystis pneumonia (PCP),
recurrent severe or radiological bacterial pneumonia,
Figure 9.3 Generalized Lymphadenopathy extrapulmonary tuberculosis, HIV encephalopathy, CNS
toxoplasmosis, chronic (more than 1 month) or orolabial herpes
simplex infection, esophageal candidiasis, and Kaposi’s
STAGE 2 sarcoma.
❏ Other conditions that should arouse suspicion that a patient is in
❏ Even in early HIV infection, patients may demonstrate several clinical stage include cytomegaloviral (CMV) infections (CMV
clinical manifestations. Clinical findings included in stage 2 retinitis or infection of organs other than the liver, spleen or

EPIDEMIOLOGY OF HIV
lymph nodes), extrapulmonary cryptococcosis, disseminated
endemic mycoses (e.g., coccidiomycosis, penicilliosis, ❏ First recognized in male homosexuals, hemophiliacs, and drug
histoplasmosis), cryptosporidiosis, isosporiasis, disseminated abusers
non-tuberculous mycobacteria infection, tracheal, bronchial or ❏ HIV-1 major cause of AIDS worldwide
pulmonary candida infection, visceral ❏ HIV-2 is endemic in West Africa
NOTE: ❏ AIDS was first recognized in the United States in 1981, when it
❏ Stage 1: Enlargement of lymph nodes is an indication that the became apparent that an unusual number of rare skin cancers
immune system is trying to fight the virus (Kaposi sarcoma) and opportunistic infections were occurring
❏ Stage 2: 2 common manifestations: among male homosexuals. These patients were found to have a
➔ unexplained weight loss of less than 10% of marked reduction in CD4+ T-lymphocytes and were subject to a
total body weight wide range of opportunistic infections normally controlled by an
➔ Recurrent respiratory infection intact immune system. The disease was found to progress
❏ Stage 3: Complications are present such as severe systemic relentlessly to a fatal outcome and was first identified in male
bacterial infections homosexuals, hemophiliacs, who were receiving blood-derived
❏ Stage 4: AIDS or Acquired Immunodeficiency Syndrome coagulation factors, and injection drug users.
➔ Fungi are considered to be normal flora of the
body however when the host in
immunocompromised, it can be an opportunistic
pathogen such as Candida albicans
Figure 9.3 Adults and children estimated to be living with HIV/AIDS, by

continent or region, as of December 2009, totaling 33.3 million. It is
estimated that about 1.8 million people worldwide died of HIV/AIDS in
2009. (Data from the Joint United Nations Program on HIV/AIDS.)
Figure 9.4 HIV/AIDS Disease Progression

NOTE:
➔ Screening tests: Simple/rapid test and ELISA
➔ Confirmatory Test: Western blot test
DISADVANTAGE:
Figure 9.4 HIV data and statistics ❏ Testing a patient during a window period may cause false negative
result (serologic test is for the detection of antibodies)
❏ Window period is the phase when you have been infected with
NOTE: HIV, but antibody levels are not detectable
❏ Antiretroviral drugs ❏ What occurs during the window period is called
➔ very helpful in inhibiting the replication process or stop SEROCONVERSION:
severe damage that HIV may cause in our immune system ➔ It is a term used to describe the change from undetectable
➔ it does not kill the virus but only slows down the replication to detectable antibody levels. Specimens may test initially
process non-reactive, but change to testing reactive after a certain
time period.
TRANSMISSION OF HIV ➔ Occurs generally 3-8 weeks after the initial infection
❏ HIV is transmitted through:
➔ Unprotected sexual contact with an infected partner
➔ Exposure of broken skin or wound to infected blood or
body fluids.
➔ Transfusion with HIV-infected blood • Injection with
contaminated objects
➔ Mother to child during pregnancy, birth, or breastfeeding
❏ Proper preventive measures such as avoiding sexual contact to
those infected with HIV as well as frequent exposure to blood
infected with HIV must be observed.
Figure 9.5 Serologic Profile of HIV-1 Infection
❏ SEROLOGIC METHOD
➔ Antibodies to HIV can be measured by a variety of
Based on the Figure 9.5 :
techniques. None of these detect HIV itself, but rather
Order of appearance:
detect an immune response to the virus, and therefore
1. HIV Ag
take some time to develop and become reactive (or
2. Anti-HIV IgM
positive) after HIV infection has been acquired.
3. Anti-HIV Env
➔ Antibodies to HIV-1 and HIV-2 are detected by EIA, also
4. Anti-HIV Core
known as enzyme-linked immunosorbent assay (ELISA),
5. HIV Ag (recurrence)
simple/rapid test devices, and western blot (WB) tests.

❏ NUCLEIC ACID DETECTION TREATMENT
A) REVERSE TRANSCRIPTASE - POLYMERASE CHAIN ❏ A growing number of antiviral drugs are approved for treatment of
REACTION (RT-PCR) HIV infections.
❏ it exponentially amplifies the DNA target by many ❏ Therapy with combinations of antiretroviral drugs, referred to as
orders of magnitude by cycling the temperature of HAART (Highly active antiretroviral therapy), became available
the reaction several times. in 1996. It often can suppress viral replication to below limits of
❏ DNA primers define the region of the target detection in plasma, decrease viral loads in lymphoid tissues, allow
sequence to be amplified by a DNA polymerase the recovery of immune responses to opportunistic pathogens, and
that duplicates the number of sequences in each prolong patient survival.
cycle of the reaction. ❏ There is currently no cure for HIV, but the availability of HAART
❏ In the case of RNA specimens such as HIV, the means that HIV is manageable through lifelong treatment. When
RNA must be converted to DNA by a reverse HAART is discontinued or there is treatment failure, virus
transcriptase enzyme in an isothermal reaction production rebounds.
before initiating the PCR. This reaction is referred
to as RT-PCR. Table 9.3 Antiretroviral Drugs
B) NUCLEIC ACID SEQUENCE-BASED AMPLIFICATION

(NASBA)
❏ it selectively amplifies the target RNA through
isothermal production of an intermediate DNA by a
reverse transcriptase.
❏ This DNA serves as a template for the cyclical
amplification of RNA using an RNA polymerase.
❏ Fluorescent-labelled probes hybridize to newly
synthesized RNA and quantification is determined
by comparing the fluorescence of the target with
internal standards.
C) BRANCHED-CHAIN DNA (B-DNA) NOTE:

❏ It is based on amplifying the signal rather than the ❏ Fixed combination:
target RNA. ➔ A combination of other drugs with different mechanisms
and targets to enhance the action of a certain
D) TRANSCRIPTION-MEDIATED AMPLIFICATION (TMA) anti-retroviral drug. It prevents the proliferation of virus not
❏ This is a qualitative method that can detect either cure.
RNA or DNA. It uses the same principle as the ❏ CCR5 Antagonist drugs- to prevent binding of HIV to receptor
NASBA methodology. ❏ Gp41 Fusion inhibitor - to prevent fusion of HIV to host cell

NOTE:
HUMAN PAPILLOMA VIRUS ➔ This is considered to be an Oncogenic Virus. If left untreated or
INTRODUCTION persistent infection occurs, there is a higher risk or a greater
chance of developing a cancer-associated HPV infection.
Virion ● Icosahedral
● 55 nm in diameter
Genome ● Double-stranded DNA

● Circular
Proteins ● Two structural proteins

● Cellular histones condense DNA in virion
● Note: DNA is complexed with histones
Envelope None
Replication Nucleus Figure 9.6 Structure of Papillomavirus
Outstanding ● Stimulate cell DNA synthesis

Characteristics ➔ Targets the stratified squamous epithelium NOTE:
(specifically the basal cell) because it ➔ Capsid protein L1- capsid protein
rapidly replicates. ➔ The genomic DNA of the virus is wrapped around a histone in
● Restricted host range and tissue tropism
order to condense itself and decrease the length of the circular
● Significant cause of human cancer, especially
cervical cancer DNA
● Viral oncoproteins interact with cellular tumor
suppressor proteins PATHOGENESIS
❏ HPV targets stratified squamous epithelium through the
❏ HPV is a very common virus that can be spread from one person damaged area of the epithelium and infects the basal cells.
to another person through anal, vaginal, or oral sex, or through NOTE:
other close skin-to-skin touching during sexual activity. ➔ Basal cells are highly replicative this is why HPV also replicates
❏ There were about 43 million HPV infections in 2018, many among rapidly
people in their late teens and early 20s.
❏ Nearly all sexually active people who do not get the HPV vaccine ❏ Infections of HPV are commonly called Warts/kalunggo. This is
get infected with HPV at some point in their lives why warts are embossed/damol/taas/gabukol which is due to the
accumulation of keratin caused by the repeated division of basal
cells invaded by HPV

❏ Although the incidence of infection is high, most infections resolve including cervical, anal, vaginal, vulvar, penile, and some head and
spontaneously. neck cancer.
❏ A small proportion of infected persons become persistently
infected; persistent infection is the most important risk factor for Table 9.5 Examples of Association of Human Papillomaviruses with
the development of cervical cancer precursor lesions. Clinical Lesions
❏ The most common clinically significant manifestation of persistent
genital HPV infection is cervical intraepithelial neoplasia, or CIN.
Within a few years of infection, low-grade CIN—called CIN 1—may
develop, which may spontaneously resolve and the infection clear.
❏ Persistent HPV infection, however, may progress directly to
high-grade CIN, called CIN2 or CIN3. High-grade abnormalities are
at risk of progression to cancer and so are considered cancer
precursors. A small proportion of high grade abnormalities
spontaneously regress.
❏ If left undetected and untreated, years or decades later CIN2 or 3
can progress to cervical cancer. Infection with one type of HPV
does not prevent infection with another type. Of persons infected
with mucosal HPV, 5% to 30% are infected with multiple types of
the virus.
Cervical Intraepithelial Neoplasia Genital Warts

NOTE:
CLINICAL FEATURES ➔ Familiarize the HPV types and their clinical lesions
❏ Most HPV infections are asymptomatic and result in no clinical
disease. Clinical manifestations of HPV infection include
anogenital warts, recurrent respiratory papillomatosis, cervical
cancer precursors (cervical intraepithelial neoplasia), and cancers,

LABORATORY DIAGNOSIS issue recommendations for cervical cancer screening, but
❏ HPV has not been isolated in culture. Infection is identified by various professional groups have published
detection of HPV DNA from clinical samples. recommendations.
❏ The American College of Obstetricians and Gynecologists
1. NUCLEIC ACID DETECTION (ACOG), the American Cancer Society (ACS), and the
❏ Epidemiologic and basic research studies of HPV U.S. Preventive Services Task Force (USPSTF) guidelines
generally use nucleic acid amplification methods that recommend that all women should have a Pap test for
generate type specific results. The PCR assays used cervical cancer screening within 3 years of beginning
most commonly in epidemiologic studies target genetically sexual activity or by age 21, whichever occurs first. While
conserved regions in the L1 gene. the USPSTF recommends a conventional Pap test at least
❏ Currently, only the Digene Hybrid Capture 2 ® (hc2) High every 3 years regardless of age, ACS and ACOG
Risk HPV DNA Test is approved by the Food and Drug recommend annual or biennial screening of women
Administration for clinical use. younger than age 30, depending on use of conventional or
❏ The hc2 uses liquid nucleic acid hybridization and detects liquid–based cytology.
13 high-risk types (HPV 16, 18, 31, 33, 35, 39, 45, 51, ❏ According to these organizations, women over age 30 with
52, 56, 58, 59, 68). three normal consecutive Pap tests should be screened
❏ Results are reported as positive or negative and are not every 2 to 3 years. The use of HPV vaccine does not
type-specific. The hc2 test is approved for triage of women eliminate the need for continued Pap test screening, since
with equivocal Papanicolaou (Pap) test results (ASC-US, 30% of cervical cancers are caused by HPV types not
atypical cells of undetermined significance) and in included in the vaccine.
combination with the Pap test for cervical cancer screening
in women 30 years of age and older. The test is not
clinically indicated nor approved for use in men.
Nucleic Acid Serologic Test Cytology
Detection
2. SEROLOGIC METHOD
❏ The most frequently used HPV serologic assays are ● PCR ➔ VLP-based ➔ Pap Test screening
VLP-based enzyme immunoassays. However, laboratory ● Brand of the enzyme
reagents used for these assays are not standardized and Machine: Digene immunoassays
there are no standards for setting a threshold for a positive hybrid Capture 2*
(hc2) High risk
result.
HPV DNA Test
3. CYTOLOGIC METHOD NOTE:

❏ Most cases and deaths from cervical cancer can be ➔ Women should have a Pap Test for cervical cancer screening
prevented through detection of precancerous changes within 3 years of beginning sexual activity or by age 21, whichever
within the cervix by cervical cytology using the Pap test. occurs first.
Currently available Pap test screening can be done by a
conventional Pap or a liquid-based cytology. CDC does not

➔ Digene hybrid capture 2- method to detect the 13 high risk types of TREATMENT, PREVENTION AND CONTROL
HPV. but it does not detect the specific subtype only the presence ❏ There is no specific treatment for HPV infection(supportive
(Positive or Negative) treatment only). Medical management depends on treatment of the
➔ 13 High risk subtypes of HPV specific clinical manifestation of the infection (such as genital warts
● 16, 18 or abnormal cervical cell cytology).
● 31, 33, 35, 39 ❏ HPV transmission can be reduced but not eliminated with the use
● 45 of physical barriers such as condoms. Recent studies
● 51, 52. 56, 58, 59 demonstrated a significant reduction in HPV infection among
● 68 young women after initiation of sexual activity when their partners
➔ Women should undergo pap smear test for cervical cancer used condoms consistently and correctly.
screening within 3 years beginning sexual activity or by the age of ❏ Abstaining from sexual activity (i.e., refraining from any genital
21, whichever occurs first contact with another individual) is the surest way to prevent genital
HPV infection.
EPIDEMIOLOGY ❏ For those who choose to be sexually active, a monogamous
❏ HPV infection occurs throughout the world. relationship with an uninfected partner is the strategy most likely to
❏ Humans are the only natural reservoir of HPV. prevent future genital HPV infections.
❏ It is transmitted by direct contact, usually sexual, with an infected ❏ There is a vaccine for Human Papilloma Virus (HPV) though not
person. sure if it covers all the serotypes mentioned.
❏ Transmission occurs most frequently with sexual intercourse but
can occur following non penetrative sexual activity. Studies of
newly acquired HPV infection demonstrate that infection occurs Never Shall We Fail
soon after onset of sexual activity. Genital HPV infection also may
be transmitted by nonsexual routes, but this appears to be #RMT2022Manifesting
uncommon.
❏ Non-sexual routes of genital HPV transmission include
transmission from a woman to a newborn infant at the time of
birth(vertical transmission).
❏ HPV is presumably communicable during the acute infection and
during persistent infection. This issue is difficult to study because
of the inability to culture the virus. Communicability can be
presumed to be high because of the large number of new
infections estimated to occur each year.

MODULE 10: BOVINE SPONGIFORM ENCEPHALOPATHY NOTE:
AGENTS AND OTHER PRIONS ➔ Prion proteins are normal but sometimes they misfold and are
called “Prions”
➔ The misfolded prion proteins are the causative agent of
I. PRIONS transmissible spongiform encephalopathies (TSEs)
A. Prion Proteins
B. Prion Diseases
1. Classic Creutzfeldt-jakob Disease (CJD)
2. Variant Creutzfeldt-jakob Disease (vCJD)
3. Kuru
4. Scrapie
5. Bovine Spongiform Encephalopathy

PRION PROTEINS
PRIONS ❏ Prion protein (PrP) appears to be the major, and possibly
❏ Prion diseases or transmissible spongiform encephalopathies exclusive component of prions. PrPc (cellular) is the protein
(TSEs) are a family of rare progressive neurodegenerative product that is thought to be the target for prion disease.
disorders that affect both humans and animals. They are ❏ In the wild type, it is a normal host glycoprotein encoded by a
distinguished by long incubation periods, characteristic spongiform single exon of a single copy gene (PRNP on chromosome 20). It
changes associated with neuronal loss, and a failure to induce assumes an alpha helical structure and is located on the cell
inflammatory response. surface with a glycoinositol phospholipid anchor.
❏ The causative agents of TSEs are believed to be prions. The term ❏ Treatment with proteases results in complete digestion.
“prions” refers to abnormal, pathogenic agents that are ❏ In infected individuals, the PrPc protein is deranged to become
transmissible and can induce abnormal folding of specific normal the PrPsc (scrapie) protein. This glycoprotein assembles into
cellular proteins called prion proteins that are found most beta-sheets and is located in cytoplasmic vesicles.
abundantly in the brain. ❏ The insoluble PrPsc accumulates inside cells instead of being
❏ The functions of these normal prion proteins are still not completely located on the cell surface. It is only incompletely digested by
understood. The abnormal folding of the prion proteins leads to proteases and this insolubility is thought to contribute to storage
brain damage and the characteristic signs and symptoms of the problems and aggregation.
disease. Prion diseases are usually rapidly progressive and always
fatal.

PRION DISEASES
PNS:
❏ There are several distinguishing hallmarks of these prion diseases. ● Parkinson’s disease
Although the etiologic agent may be recoverable from other ● Alzheimer’s Disease
organs, the diseases are confined to the nervous system. The ● Huntington’s Disease
highest concentration of prion proteins are found in the nervous ● Lou Gehrig's disease
system
❏ The basic features are neurodegeneration and spongiform NOTE:
changes. Amyloid plaques may be present. Long incubation ➔ A newly discovered prion disease attacks the PNS rather than the
periods (months to decades) precede the onset of clinical illness brain causing chronic diarrhea. Some evidence prions may be
and are followed by chronic progressive disease (weeks to years). involved in:
❏ The diseases are always fatal, with no known cases of ● Parkinson’s Disease
remission or recovery. ● Alzheimer’s Disease
❏ The host shows no inflammatory response and no immune
response (the agents do not appear to be antigenic); no 1. CLASSIC CREUTZFELDT-JAKOB DISEASE (CJD)
production of interferon is elicited; and there is no effect on ➔ Creutzfeldt-Jakob disease (CJD) is a rapidly progressive,
host B-cell or T-cell function. invariably fatal neurodegenerative disorder believed to be caused
❏ Immunosuppression of the host has no effect on pathogenesis; by an abnormal isoform of a cellular glycoprotein known as the
however, chronic inflammation induced by other factors (viruses, prion protein. CJD occurs worldwide and the estimated annual
bacteria, autoimmunity) may affect prion pathogenesis. incidence in many countries has been reported to be about one
❏ It has been observed that prions accumulate in organs with chronic case per million population.
lymphocytic inflammation. When coincident with nephritis, prions ➔ The vast majority of CJD usually die within 1 year of illness onset.
are excreted in urine. ➔ Confirmatory diagnosis of CJD requires neuropathologic and/or
immunodiagnostic testing of brain tissue obtained either at biopsy
HUMAN PRION DISEASES ANIMAL PRION DISEASES or autopsy.
➔ Treatment of prion diseases remains supportive; no specific
Prion diseases of the: ● Bovine Spongiform therapy has been shown to stop the progression of these diseases.
CNS: Encephalopathy (BSE)
● Creutzfeldt-Jakob Disease ● Chronic Wasting Disease
(CJD), Classic (CWD)(deer)
● Variant Creutzfeldt-Jakob ● Scrapie(sheep)
Disease (vCJD) ● Transmissible mink
● Gerstmann-Straussler-Sch encephalopathy
einker Syndrome ● Feline spongiform
● Fatal Familial Insomnia encephalopathy
● Kuru ● Ungulate spongiform
encephalopathy

Figure 10.1 Pathology of Normal brain (left) and pathology of the
brain of a patient with CJD (right). Note the spongiform pathology
of the left picture
NOTE:
➔ Vacuolation - white spaces, sign of damage in the brain,
spongiform appearance of the brain
2. VARIANT CREUTZFELDT-JAKOB DISEASE (VCJD)

➔ Variant Creutzfeldt-Jakob disease (vCJD) is a prion disease that Table 10.1 Comparison of Classic CJD and Variant CJD
was first described in 1996 in the United Kingdom.
➔ There is now strong scientific evidence that the agent responsible 3. KURU
for the outbreak of prion disease in cows, bovine spongiform ➔ First prion disease discovered in humans
encephalopathy (BSE or ‘mad cow’ disease), is the same agent ➔ Kuru is an incurable, degenerative, neurologic disorder endemic to
responsible for the outbreak of vCJD in humans. the Fore population of Papua New Guinea.
NOTE: ➔ Note: due to cannibalism, kuru is widespread in papua new guinea.
➔ Even though vCJD and BSE share the same agent, vCJD ➔ A dead infected individual’s meat will also contain prions. Ingestion
is not a mad cow disease of infected meat will cause misfolding of prion proteins.
➔ Kuru occurred only in the eastern highlands of New Guinea and
➔ Variant CJD (vCJD) is not the same disease as classic CJD (often ➔ was spread by customs surrounding the ritual of dead relatives.
simply called CJD). It has different clinical and pathologic Since the practice has ceased, the disease has disappeared.
characteristics from classic CJD. Each disease also has a ➔ In the Fore language (spoken in Papua New Guinea), the term
particular genetic profile of the prion protein gene. “kuru” refers to body tremors, which are a characteristic feature of
➔ Both disorders are invariably fatal brain diseases with unusually the disease.
long incubation periods measured in years, and are caused by an ➔ Symptoms progress from unsteady gait and tremors, to loss of
unconventional transmissible agent called a prion. muscle coordination, severe ataxia, and death, over the course of
➔ Treatment of prion diseases remains supportive; no specific 3 months to 2 years.
therapy has been shown to stop the progression of these
diseases.

4. SCRAPIE
➔ Scrapie, also called rida or tremblante du mouton, is a fatal
neurodegenerative disease of sheep and goats. Scrapie has a long
incubation time, typically between about 18 months and five years
following transmission.
➔ The first signs to arise are usually behavioral changes such as
general apprehensiveness and nervousness.
➔ As the disease progresses, the animal loses weight and weakens,
develops head and neck tremors, loses muscular coordination, and
begins to rub or scrape its body against objects, wearing away its
fleece or hair—hence the name “scrapie”.
➔ The disease inevitably causes death within one to six months. 6. CHRONIC WASTING DISEASE
➔ No treatment or palliative measures are known. ➔ A scrapie-like disease, designated chronic wasting disease, is
➔ Sheep should not be fed food that contains prions. found in mule deer and elk in the United States and Canada. It is
laterally transmitted with high efficiency, but there is no evidence
that it has been transmitted to humans.
➔ Infectivity has been detected in feces of deer before they become
ill; the agent is retained in the soil, where it can then be ingested
by other deer and elk.
➔ CWD is Scrapie of the mule deer and elk
5. BOVINE SPONGIFORM ENCEPHALOPATHY

➔ BSE (bovine spongiform encephalopathy) is a progressive
neurological disorder of cattle that results from infection by an
unusual transmissible agent called a prion. BSE possibly
originated as a result of feeding cattle meat-and-bone meals that
contained BSE-infected products from a spontaneously occurring
case of BSE or scrapie-infected sheep products.
➔ If a cow is infected, it has trouble walking and getting up. It may
also act very nervous or violent, which is why BSE is often called Never Shall We Fail
“mad cow disease.” #RMT2022Manifesting

MODULE 11: BASIC CONCEPTS OF MYCOLOGY considered clinical rarities, human fungal infections are becoming
OUTLINE OF THE LESSON increasingly common, especially among immunocompromised
patients. Therefore, it is important to understand the unique clinical
I. INTRODUCTION and microbiological features of these diseases.
A. Cellular Structure ❏ Mycology is the study of fungi, which are eukaryotic organisms
II. GENERAL FEATURES AND CHARACTERISTICS that evolved in tandem with the animal kingdom.
A. Hyphae vs Mycelium ➔ Unlike animals, most fungi are nonmotile and possess a
B. Structure of Hyphae
rigid cell wall.
C. Type of Hyphae
D. Plasticity of Fungi ➔ Unlike plants, fungi are non photosynthetic.
E. Methods of Reproduction ❏ Like all eukaryotes, each fungal cell has at least one nucleus with
F. Reproduction of Molds a nuclear membrane, endoplasmic reticulum, mitochondria, and
➔ Asexual Reproduction secretory apparatus.
➔ Sexual Reproduction ❏ Most fungi are obligate or facultative aerobes. They are
G. Spores of Sexual Reproduction chemotrophic, secreting enzymes that degrade a wide variety of
H. Spores of Asexual Reproduction
organic substrates into soluble nutrients that are then passively
III. MODE OF TRANSMISSION
IV. SPECIMEN COLLECTION absorbed or taken into the cell by active transport.
V. SPECIMEN TRANSPORT AND HANDLING
VI. SPECIMEN PROCESSING CELLULAR STRUCTURE
VII. LABORATORY DIAGNOSIS
A. Direct Examination Of Specimens
➔ Wet mount Preparation
➔ 10% KOH Mount
➔ Fungal Stains
B. Fungal Culture
C. Miscellaneous Tests

INTRODUCTION
❏ The fungal kingdom encompasses a diverse and rich group of Figure 11.1 A yeast cell showing the cell wall and internal structures of the
organisms ranging from microscopic yeasts to mushrooms. Most fungal eukaryotic cell plan.
fungi are free-living in nature where they function as
decomposers in the energy cycle. ➔ Fungal cells have a rigid cell wall external to the cytoplasmic
❏ Of the more than 90 000 known fungal species, fewer than 200 membrane, which differs in its chemical composition from the cell
have been reported to produce disease in humans. Once walls of bacteria and plants. In addition to the cell wall, another

important difference from mammalian cells is the sterol makeup of Table 11.1 Yeast vs. Molds
the cytoplasmic membrane.
Point of Yeast Molds
➔ In mammalian cells, the dominant membrane sterol is cholesterol; Distinction
in fungi, it is ergosterol.
➔ Fungi are usually haploid in their DNA content, although diploid Structure Mostly unicellular and Multicellular with tubular,
nuclei are formed through nuclear fusion in the process of sexual existing individually or filamentous hyphae
reproduction. with buds growing on (branches)
➔ The chemical structure of the cell wall in fungi is markedly different them
from that of bacterial cells in that it does not contain Appearance Round or oval-shaped Threadlike
peptidoglycan, glycerol, teichoic acids, or lipopolysaccharide.
➔ In their place are complex polysaccharides such as mannans, Methods of Budding or binary Production of sexual or
glucans, and chitins in close association with each other and with Reproduction fission asexual spores
structural proteins.
Figure 11.2 Yeast (left) and mold (right) forms of fungal growth
NOTE:
Based on the figure 11.2:
➔ Hyphae of molds - filamentous or threadlike structures, not the
spores
➔ Budding - asexual reproduction
GENERAL FEATURES AND CHARACTERISTICS
❏ Fungi that cause human infections can be broadly divided based HYPHAE VS MYCELIUM
on their morphological forms.
1. Yeast - single cells, usually spherical to ellipsoid in shape and
varying in diameter from 3 to 15 µm.
2. Molds - fungi that primarily grow as filamentous, tube-like
structures called hyphae that vary in diameter from 2 to 10 µm.

➔ Hypha- basic/ building block of mold ➔ Although it is useful to consider this basic distinction based on cell
➔ Mycelium- collection of hyphal elements shape, it is important to remember that some fungi can transition
between yeast-like and hyphal morphologies. Often, this plasticity
STRUCTURE OF HYPHAE of shape is directly related to pathogenesis since different forms
may be better suited for different microenvironments.
PLASTICITY OF FUNGI
❏ Some fungi can transition between yeast-like and hyphal
morphologies
Table 11.2 Plasticity of Shape of Fungi

Fungal Forms Growth Phase
NOTE: Based on appearance under the microscope
➔ SEPTATE HYPHAE - presence of demarcation in between cells Monomorphic ● Has only one growth phase (Yeast or Mold)
➔ COENOCYTIC (NONSEPTATE) HYPHAE - no demarcation Fungi throughout its life
between cells
➔ PSEUDOHYPHAE - structure of yeast cells that divide by binary Dimorphic ● Mold at Room Temperature
fission but it did not separate into cells yet; incomplete budding of Fungi ● Yeast at 37°C and in tissues
yeast cells; not a true hyphae
Diphasic Fungi ● Mold at Room temperature and at 37°C
● Yeast in tissues
TYPES OF HYPHAE
NOTE: Based on appearance on culture media
➔ VEGETATIVE HYPHAE – penetrate the media and absorb food METHODS OF REPRODUCTION
from agar (towards under the agar not above) ❏ Fungi may reproduce by either asexual or sexual process.
➔ AERIAL HYPHAE – directed above the surface of the media ❏ The asexual form is called the anamorph, and its reproductive
➔ REPRODUCTIVE HYPHAE – aerial hyphae that carry elements are termed conidia. Asexual reproduction involves
reproductive spores. mitotic division of the haploid nucleus and is associated with
production by budding, spore-like conidia or, alternatively by the
separation of hyphal elements.
❏ The sexual form is called the teleomorph, and its reproductive
structures are called spores (eg, ascospores, zygospores,
basidiospores). In sexual reproduction, the haploid nuclei of donor
and recipient cells fuse to form a diploid nucleus/zygote, which
then divides by classic meiosis to produce haploid cells.
Figure 11.3 Types of Hyphal Growth

ASEXUAL REPRODUCTION
YEAST MOLDS
❏ Mycelium will undergo mitosis, producing spores, spores will
ASEXUAL ASEXUAL germinate to form hyphal cells, which will accumulate to form
mycelium
Budding forming a blastoconidia Produces a spore-like conidia ❏ Budding forming a blastoconidia
❏ Blastoconidia will detach from mother cell to form new yeast cell
SEXUAL SEXUAL
Possible but asexual process is Formation of spores

the most comon reporductiove for
yeast
NOTE:
➔ Fungi that exhibit a sexual stage are known as the perfect fungi
REPRODUCTION OF MOLDS
SEXUAL REPRODUCTION
❏ Hyphal cells of different mycelium will fuse forming heterokaryotic
cell (diploid; 2n), it will undergo meiosis producing spores (haploid;
1n), spores will germinate to become hyphal cell, hyphal cells will
accumulate to form mycelium
SPORES OF SEXUAL REPRODUCTION

❏ Sexual reproduction happens in 3 phases:
➔ Fusion of cells (fusion of haploid cells to produce a zygote)
➔ Meiosis (meiosis of zygote to produce a haploid spore)
➔ Mitosis (germination of spores to become a fungal cell)
➔ Molds exhibit both sexual & asexual reproduction

Table 11.3 Spores Involved in Sexual Reproduction
SPORES DESCRIPTION
1. Ascospores ➔ Spores are contained in a saclike ascus.
NOTE:
➔ Aka Homosexual Reproduction.
➔ It will mature into a zygospore.
3. Oospores ➔ Involve the fusion of cells from two

separate, nonidentical hyphae.
Note: 2 Hyphal cells undergo nuclear fusion. It will

form a zygote (diploid 2N). It will then undergo
meiosis to become a haploid cell. And lastly, it will
undergo mitosis to form spores inside an ascus.
2. Zygospores ➔ Involve the fusion of two identical cells

arising from the same hyphae.
NOTE:
➔ Heterosexual Reproduction.
➔ There is an involvement of male gamete
(Antheridium) and female gamete

SPORES OF ASEXUAL REPRODUCTION
(Oogonium)
➔ Antegonium fuses with Oogonium to form Characteristics of Asexual Production
a spore 1. Fission of nucleus
2. Budding
4. Basidiospores Spores are contained in a club-shaped basidium. 3. Conidia
Table 11.4 Spores Involved in Asexual Reproduction

SPORES DESCRIPTION
1. Conidia ➔ Spores produced singly or multiply in

long chains or clusters by specialized
vegetative hyphae known as
conidiophores.
➔ Conidia - spores of conidiophores
NOTE: (in order)

1. Nuclear fusion of two molds forming a
zygote
2. Meiosis to form haploid cell
3. Sterigmata
4. Basidiospores production
➔ oval structures that bud from
Sterigmata
Macroconidia – large, multicellular
NOTE:
➔ The structure of fungi is very important since this is what we see
under the microscope in order to identify them.

4. Arthroconidia ➔ Involve the simple fragmentation of the
mycelium.
➔ It appears “jointed”
rectangular/barrel-shaped spores
Microconidia – small, unicellular
2. Blastoconidia ➔ Develops as daughter cell buds off the

(Blastospores) ➔ mother cell and is pinched off
➔ Produced when yeast cell undergo
binary fission
NOTE:
➔ The single bud once separated from
the fungi will form a new fungi.
5. Sporangiospores ➔ Spores contained in a sporangia or

sacs that are produced terminally on
sporangiophore or aseptate hyphae
3. Chlamydoconidia ➔ Thick walled, resistant, resting spores

(Chlamydospores) produced by rounding up and
enlargement of the hyphal part.
Classification based on Spore formation:

1. Terminal – end of hypha
2. Intercalary – within hypha NOTE:
3. Sessile – side of hypha ➔ Spores are those transparent circles
near the hyphae and it comes from the
sporangia.
➔ Sporangia is a common contaminant
in the laboratory that is why the bacte
lab is separated from the myco lab.
➔ Can only be seen on the tip of
aseptate hyphae

MODE OF TRANSMISSION
Usually clipped, need to be finely minced before
❏ Fungal infections are most often acquired from the external
inoculating to media
environment.
❏ Fungi are ubiquitous. Hair Obtained from the edge of the infected area of the scalp.
❏ One common mechanism of infection is by the inhalation of Use a wood’s lamp (fluorescence) to help locate infected
infectious conidia generated from environmental molds. Some of hair.
these molds are ubiquitous, whereas others are restricted to Hair can be obtained by plucking, brushing, oor sticky
specific endemic areas and geographic regions whose climate tape.
favors their growth. Body Fluids Normal sterile collection procedures
❏ Inhalation of spores leads to infection
❏ Many fungi produce disease only after they are accidentally NOTE:
injected past the skin/mucosal barrier, especially in ➔ Spatula or blunt part of feather lancet - is usually used for
immunocompromised patients. Other pathogenic fungi have more scraping the skin.
sophisticated means of tissue penetration and invasion.
SPECIMEN TRANSPORT AND HANDLING
❏ Hair & nails sent in a dry envelope, inside a proper container.
❏ Most fungi are opportunists, causing serious disease only in
Other specimens are usually sent frozen or on dry ice. Specimens
individuals with impaired host defense systems.
must be inside a packaging with biohazard regulations.
❏ Ex. Candida albicans - a normal flora however it can only
❏ Any growing cultures must be on tube media, not in plates. Similar
infect humans when the host is severely
to slant used in bacterial culture.
immunocompromised
❏ Aluminum screw-capped inner with outer cardboard mailing
❏ Only a few fungi are able to cause diseases in previously healthy
tube is usually the container of fungal specimens.
persons
LABELLING
SPECIMEN COLLECTION
❏ Skin specimens should be cleaned with 70% alcohol to remove ❏ Inside labeling information must contain Patient ID, specimen
dirt, oil and surface saprophytes. Same procedure must be done if source, suspected organism.
the specimen is a nail, but it should be clipped and needs to be ❏ Outside labeling information must state,
finely minced before inoculating to the media. Hair can be obtained WARNING: POTENTIAL PATHOGEN.
by plucking, brushing, or with sticky tape. Normal sterile procedure NOTE:
must be done if the specimen is a body fluid. ➔ This labeling format still depends on the protocol of every
laboratory.
Specimen Collection
Skin Cleaned with 70% alcohol to remove dirt, oil, and

surface saprophytes
Nails Cleaned same as for skin

SPECIMEN PROCESSING LABORATORY DIAGNOSIS
DIRECT EXAMINATION OF SPECIMENS
Table 11.5 Specimen Processing to Recover Fungi ❏ Fungi can often be identified by directly observing their distinctive
morphologic features on direct microscopic examination of infected
Specimen Processing
pus, fluids, or tissues.
Skin, nails & hair Direct exam following KOH preparation ❏ Direct microscopic exam is required on any material sent to the lab
(specimen is submerged in KOH for a while for fungus culture.
before it is processed since its hard) ❏ Medical technologists usually look for spores, hyphae, mycelial
elements, budding yeast, mycotic granules.
CSF Centrifuged; examine sediment
microscopically, inoculate media
1. WET MOUNT PREPARATION
Pleural fluid, sputum, Specimens must be fresh as saprophytes ❏ Good for yeast because examination is done in a natural
and bronchial would overgrow pathogens such as H. environment, so loss of fragile structure is minimized.
aspiration capsulatum (causative agent of endemic ❏ For wet samples
mycoses)
Specimens may be refrigerated up to 2 hours
Gastric washings Same as for pleural fluids
Genito-urinary First morning specimen preferred

specimens
Blood/bone marrow Generally inoculated directly to BHI broth and

BHI slant
BHI = Brain Heart Infusion
Wound abscess or Should be cultured anaerobically, especially

drainage if actinomycosis is suspected (only anaerobic
culture)
● Actinomycosis = causative agent is the
bacteria, Actinomycetes which are
anaerobic
● Mycosis, Eumycosis, Madura foot = 2. 10% KOH MOUNT
causative agent is fungi ❏ Done on skin scrapings, hair, nails, sputum, vaginal
specimens, etc.
Tissue specimens Examine for pus, caseous material or
granules; mince aseptically, can use small ❏ The KOH clears the specimen’s tissue cells, mucous, etc.,
amount of sterile saline and the supernatant without destroying the cell wall so fungal elements can be
inoculated seen.

purplish-red with blue nuclei
Gomori Outlines fungi in black due to the silver

Methenamine precipitating on the fungi cell wall. Internal
Silver Stain structures are deep rose (red) to black;
background is light green
Based on the photo, the appearance of the hyphae of the molds are
septated.
3. FUNGAL STAINS
❏ Direct examinations can be aided by the use of fungal
stain that can enhance the visualization of fungal
structures under the microscope.
Gridley Stain Hyphae and yeast stain dark blue or rose.
Table 11.6 Selected Fungal Stains Tissues stain deep blue and background is
Stains Use yellow
Lactophenol Very popular for quick evaluation of fungal

Cotton Blue (LPCB) structures; will stain the chitin in cell walls of
fungi
● Appearance would be color blue
Mayer Mucicarmine Will stain capsules of Cryptococcus neoformans

Stain deep rose
Periodic Acid - Stains certain polysaccharide (ex: glucans,

Schiff Stain (PAS) mannans) in the cell walls of fungi. Fungi stain

➔ 30OC for Molds
Table 11.7 Selected Fungal Culture Media

Stains Use
Birdseed Agar Isolation and preliminary identification of C.

neoformans (Cryptococcus neoformans).
Appear as black colonies
Fluorescent Simple, sensitive, and specific. Applications for Cornmeal Agar ● Cultivation of chlamydospore-bearing C.
Antibody Stain many different fungal organisms albicans (Candida albicans
● Used for the enhancement or detection of
Papanicolaou Stain Good for initial differentiation of dimorphic fungi. the chlamydospores
Works well on sputum smears ● Enhances the sporulation of Candida
albicans
Gram Stain Most fungi are gram-positive (purple)
Cornmeal Agar with ● Improves the pigment production to
Giemsa Stain Used on blood and bone marrow specimens. 1% Dextrose differentiate T. rubrum and T.
● To preserve structure mentagrophytes.
● T. rubrum – produces red pigment
India Ink / Nigrosin Demonstrates the capsule of Cryptococcus ● T. mentagrophytes – does not produce red
neoformans in CSF specimens pigment
● It is important to differentiate T.rubrum and T.
mentagrophytes since both are causative
agents of cutaneous mycoses
Czapek’s agar Used to isolate Aspergillus spp.(an opportunistic

fungi)
Dermatophytes Test Used to isolate dermatophytes from cutaneous

medium specimens (skin, scalp, nails, hair, etc.)
FUNGAL CULTURE Mycosel/Mycobiotic Selective media used to isolate pathogenic
❏ In most cases, the culture is more sensitive than the direct Agar fungi, dermatophytes, and systemic fungi.
examination, and a portion of the material collected for microscopy Contains cycloheximide, which suppresses the
should be cultured. growth of saprophytic fungi (which can outgrow
❏ Culture must be held for 21 days at room temperature, 25-30°C. the desired fungi), and chloramphenicol, which
➔ Culture is done to increase the sensitivity of testing inhibits bacterial contaminants
❏ Yeasts grow better at 37°C and molds at 30°C. Sabouraud dextrose Contains glucose and modified peptone (pH
❏ Two cultures are made: agar (SDA) 7.0), supports the growth of fungi, and restricts
➔ 37OC for Yeast (incubator)

the growth of bacteria.
Note: Commonly used in laboratory for isolation
MISCELLANEOUS TESTS
A. GERM TUBE
❏ Yeasts are incubated with sterile serum at 37°C for up to 3
hours. C. UREASE TEST (+) CONTROL
❏ Tests for the presence of the true hyphae of the fungi ❏ C. neoformans is positive for this test
which is candida albicans
❏ Test for C. albicans D. HAIR BAITING TEST
❏ Germ tube refers to the hyphae of the candida ❏ V-shaped penetration of hair shaft - positive result
albicans ❏ Differentiates:
NOTE: even though Candida albicans is a yeast it is capable of producing ❏ T. mentagrophytes – positive
hyphae (only produced by molds) ❏ T. rubrum – negative
NOTE: differentiated since both are causative agents of cutaneous
mycoses
NOTE:
❏ How to perform: Place a few drops of urine in a test tube and add
sterile serum. Incubate at 37 degrees for 3 hours. If Candida
albicans is present, there is tube-like budding.
NOTE:
B. L-DOPA FERRIC CITRATE TEST ❏ How to perform: Sterile soil is collected and hair is placed on top
❏ For phenol oxidase of C. neoformans of it. If there is fungi present, it would spread to other hair.
❏ Positive color is BLACK
NOTE: Phenol oxidase is produced by the C.neoformans which oxidizes
L-DOPA FERRIC CITRATE
Never Shall We Fail
#RMT2022Manifesting

MODULE 12: MORPHOLOGY, IDENTIFICATION TECHNIQUES, ❏ The manifestations vary depending on the site of infection and
PATHOLOGY, PREVENTION, AND CONTROL OF vigor of the host response, but they often involve erythema,
SUPERFICIAL AND CUTANEOUS DERMATOPHYTES induration, itching, and scaling.
❏ The most familiar name is “ringworm” ,describing the annular
shape of the advancing edge of this cutaneous infection.
I. INTRODUCTION
II. SUPERFICIAL MYCOSES
Superficial Mycoses Agents Cutaneous Mycoses Agents
A. Malassezia spp.
B. Hortea werneckii
➔ Malassezia spp. ➔ Microsporum species
C. Piedraia hortea
➔ Hortaea werneckii ➔ Trichophyton species
D. Trichosporon cutaneum
➔ Trichosporon spp. ➔ Epidermophyton
III. CUTANEOUS MYCOSES
➔ Piedraia hortae floccosum
A. Pathogenesis
B. Clinical Manifestation
● Tinea pedis SUPERFICIAL MYCOSES
● Tinea unguium MALASSEZIA SPP.
● Tinea corporis ❏ Pityriasis versicolor / Tinea versicolor is a very common
● Tinea cruris superficial fungal infection of the skin.
● Tinea manuum ➔ It is characterized by discrete patches of either
● Tinea capitis
● Tinea barbae hypopigmentation or hyperpigmentation, especially on
C. Laboratory Diagnostic the skin of the torso and upper arms.
D. Treatment ❏ There are 14 currently recognized species of Malassezia, but the
vast majority of cases of pityriasis versicolor are caused by:
HIGHLIGHTING OF TOPICS BULLET PLACEMENT ➔ Malassezia globosa
➔ Malassezia furfur
➔ Malassezia sympodialis.
AAAAAA - Subtopics ● (Super Sub-detail) ❏ Layman's term: alap-ap
INTRODUCTION
❏ Mycoses - disease caused by a pathogenic fungi
❏ The least invasive of the pathogenic fungi are the
dermatophytes and other superficial fungi that are adapted to
the keratinized outer layers of the skin.
➔ Dermatophytes - causative agent of cutaneous
Figure 12.1 Pityriasis (tinea) versicolor
mycoses
❏ Dermatophytosis are slowly progressive eruptions of the skin and
its appendages. Although often unsightly, they are not typically
painful or life-threatening.

MORPHOLOGICAL DESCRIPTION MORPHOLOGIC DESCRIPTION
❏ On media like modified Dixon’s agar, colonies are: ❏ The colonies of Hortaea werneckii grow slowly and mature within
➔ cream to yellowish 21 days. From the front, they are initially pale in color, moist,
➔ smooth or slightly wrinkled shiny, and yeast-like
➔ glistening or dull ❏ In time, these colonies become velvety (cotton-like), olive black
➔ and with the margin being either entire or lobulate. and are covered with a thin layer of mycelium
❏ Malassezia is characterized by globose, oblong-ellipsoidal to ❏ From the reverse, the color is black
cylindrical yeast cells. Reproduction is by budding on a broad base ❏ Hortaea werneckii is halophilic.
and form the same site at one pole (unipolar) ➔ It can tolerate and grow in existence of 10% NaCL
❏ Significantly, it does not grow at 37 degrees Celsius
NOTE: Top view and Bottom side of the petri dish is observed under the
microscope.
HORTAEA WERNECKII
❏ Tinea nigra or (tinea nigra palmaris) is a superficial chronic and
asymptomatic infection of the stratum corneum caused by the
dematiaceous fungus Hortaea (Exophiala) werneckii.
❏ The lesions appear as a dark (brown to black) discoloration,
often on the palm. PIEDRAIA HORTAE
❏ Causative agent of Black piedra which is a nodular infection of the
hair shaft.
NOTE: Fungal growth is inside the shaft
Figure 12.2 Tinea nigra
Figure 12.3 Piedra is an infection of the hair characterized by black.

MORPHOLOGICAL DESCRIPTION MORPHOLOGICAL DESCRIPTION
❏ Colonies of Piedraia hortae are slow growing, small, folded, ❏ Trichosporon colonies are yeast-like, rapid growing, smooth,
velvety and dark brown to black in color wrinkled, raised, folded, glabrous to velvety, dull brittle, waxy, white
❏ They may remain glabrous or covered with short aerial hyphae or yellowish white to cream colored.
❏ Piedraia hortae may produce a reddish brown diffusible pigment. ❏ The wrinkled appearance becomes more prominent in time.
From the reverse, the colony is dark brown color ❏ Heaping at the center of the colony is typical.
❏ Urease enzyme production is a significant feature of this genus.
TRICHOSPORON CUTANEUM CUTANEOUS MYCOSES

❏ Causative agent of White Piedra. ❏ Cutaneous mycoses are caused by fungi that infect only the
❏ This superficial mycosis presents as larger, softer, yellowish keratinized tissue (skin, hair, and nails).
nodules on the hairs ➔ Caused by dermatophytes
➔ Other name - ringworm / dermatophytoses
❏ The most important of these are the dermatophytes, a group of
about 40 related fungi that belong to three genera:
➔ Microsporum
➔ Trichophyton
➔ Epidermophyton.
PATHOGENESIS
❏ Dermatophytoses begin when the infecting fungus comes in
contact with skin, especially if there are minor breaks in the skin
integrity.
❏ Detached hair and skin scales containing dermatophytes can
Figure 12.3 White nodules attached to the hair shaft. remain infectious for months in the environment.
➔ extremely stable in environment
❏ Once the stratum corneum is penetrated, the organism can
proliferate in the keratinized layers of the skin, with a variety of
proteinases helping to establish infection.

❏ Most dermatophyte infections are self-limited, spontaneously TINEA PEDIS (ATHLETE’S FOOT)
resolving with time. ❏ Ringworm of the foot
➔ It can be treated with antifungal creams or other ❏ Causative agent: T. rubrum, T. mentagrophytes, E. floccosum
treatments for fast healing ❏ Tinea pedis is the most prevalent of all dermatophytoses. It
usually occurs as a chronic infection of the toe webs.
CLINICAL MANIFESTATIONS ❏ Initially, there is itching between the toes and the development of
❏ Dermatophyte infections range from inapparent colonization to small vesicles that rupture and discharge a thin fluid. The skin of
chronic progressive eruptions that last months or years, causing the toe webs becomes macerated and peels, whereupon cracks
considerable discomfort and disfiguration. appear that are prone to develop secondary bacterial infection.
❏ Dermatologists often give each infection its own “disease” name ❏ When the fungal infection becomes chronic, peeling and cracking
based on the Latin name for the anatomic site at which the of the skin are the principal manifestations, accompanied by pain
infection is found. and pruritus.
❏ For example, these names include:
➔ tinea capitis (scalp)
➔ tinea pedis (feet, athlete’s foot)
➔ tinea manuum (hands)
➔ tinea cruris (groin) Figure 12.4 Tinea Pedis
➔ tinea barbae (beard, hair)
➔ tinea unguium (nail beds) TINEA UNGUIUM (ONYCHOMYCOSIS)
❏ Skin infections otherwise not included in this anatomic list are ❏ Ringworm of the nails
called tinea corporis (body). There are certain clinical, etiologic, ❏ Causative agent: T. rubrum, T. mentagrophytes, E. floccosum
and epidemiologic differences among these syndromes, but they ❏ Nail infection may follow prolonged tinea pedis.
are basically the same disease in different locations. ❏ With hyphal invasion, the nails become yellow, brittle, thickened,
and crumbly. One or more nails of the feet or hands may be
involved.
Figure 12.5 Tinea unguium
TINEA CORPORIS
❏ Ringworm of the body
❏ Causative agent:T. rubrum, E. floccosum
❏ Most usually seen ringworm

❏ Superficial fungal infection of the skin that can affect any part of TINEA CAPITIS
the body, excluding the hands and feet, scalp, face and beard, ❏ Ringworm of the scalp
groin, and nails. It is commonly called 'ringworm' as it presents ❏ Causative agent: T. mentagrophytes, M. canis, T. tonsurans
with characteristic ring-shaped lesions. ❏ Infection of hair and scalp begins with an erythematous papule
around the hair shaft, which progresses to scaling of the scalp, and
discoloration/fracture of the shaft.
❏ Spread to adjacent hair follicles progresses in a ring-like fashion,
leaving behind broken, discolored hairs, and sometimes black dots
where the hair is absent but the infection has invaded the follicle.
Figure 12.6 Tinea Corporis (Ringworm of the Body)
TINEA CRURIS
❏ Ringworm of the groin
❏ aka “Jock itch”
❏ Causative agent: T. rubrum, T. mentagrophytes, E. floccosum Figure 12.9 Tinea capitis
TINEA BARBAE
❏ Ringworm of the beard and mustache
❏ Causative agent: T. mentagrophytes, T. rubrum, T. verrucosum
Figure 12.7 Tinea Cruris
TINEA MANUUM
❏ Ringworm of hands (palms, and between fingers)
❏ Causative agent:T. rubrum
Figure 12.10 Tinea barbae
Figure 12.8 Tinea manuum

1. LACTOPHENOL COTTON BLUE
Left = T. rubrum Right = T. mentagrophytes

Figure12.11 Microscopic appearance of Microsporum (left),
Trichophyton (Middle) and Epidermophyton (right)
3. WOOD’S LAMP TEST
❏ Some species of dermatophyte fluoresce when exposed to
Based on the pic:
ultraviolet light
The conidia that can be seen are:
❏ Used to locate presence of fungi
❏ Microsporum = spindle-shaped macroconidia
❏ Trichophyton = microconidia, blunt and non-septate
❏ Epidermophyton = club-shaped macroconidia, elongated, blunt
and septated
NOTE: Heading of this slide is KOH or calcofluor white preparation if

based on Sir Tubola’s ppt but we clarified it with Sir Robert and confirmed
that it is indeed Lactophenol Cotton Blue
Figure 12.13 Wood’s lamp test of the scalp
2. HAIR BAITING TEST / TECHNIQUE
❏ Used to differentiate T. mentagrophytes from T. rubrum
❏ V-shaped penetration of hair shaft if positive Disease Fluorescent organism Fluorescent
➔ T. mentagrophytes – positive; wedge-shaped or site color
perforations
Tinea Capitis Microsporum Brilliant green
➔ T. rubrum – negative (red) audouinii/canii
Favus Trichophyton schoenleinii Pale green
Pityriasis versicolor Malassezia furfur Pale yellow to

white
Erythrasma Corynebacterium Brilliant color

minutissimum red

❏ Nail infections are especially difficult to cure, likely due to the
Tuberous sclerosis Hypopigmented skin Pale white
slow turnover of the infected nail and poor penetration of antifungal
Vitiligo Depigmented skin Bright whhite agents. Therapy for nail infections must be continued over weeks
to months, and relapses may occur.
Incontinentia pigmenti Atrophic streaks on skin Pale white ❏ Keratolytic agents (Whitfield’s ointment) may be useful for
reducing the size of hyperkeratotic lesions.
Congenital Teeth / Urine Red-Orange
❏ Dermatophyte infections can usually be prevented simply by
erythropoietic porphyria
observing general hygiene measures.
Erythropoietic Erythrocytes Red ❏ No specific preventive measures such as vaccines exist.
protoporphyria
Porphyria cuntenaue Urine Red

Never Shall We Fail
tarda
#RMT2022Manifesting
NOTE: (Sir Tubola) “focus on the first three only”
TREATMENT
❏ Remember, cutaneous mycoses and superficial mycoses are
self-limited, spontaneously resolving with time but can also be
treated.
❏ Therapy consists of thorough removal of infected and dead
epithelial structures and application of a topical antifungal drug.
❏ Many local skin infections resolve spontaneously without
therapy.
❏ Those that do not resolve may be treated with topical terbinafine
or azoles (miconazole, ketoconazole) are usually sufficient
❏ More extensive skin infections, especially those involving the

scalp, often require systemic therapy with griseofulvin,
itraconazole, or oral terbinafine, often combined with topical
therapy.

MODULE 13: MORPHOLOGY, IDENTIFICATION TECHNIQUES, cut or abrasion may introduce an environmental mold with the
PATHOLOGY, PREVENTION, AND CONTROL OF ability to infect the exposed dermis.
SUBCUTANEOUS MYCOSIS ❏ In general, the lesions become granulomatous and expand slowly
from the area of implantation. Extension via the lymphatics
draining the lesion is slow except in sporotrichosis.
I. INTRODUCTION ❏ These mycoses are usually confined to the subcutaneous tissues,
II. SPOROTRICHOSIS but in rare cases they become systemic and produce
A. Morphology of Sporothrix schenckii life-threatening disease.
B. Diagnostic Laboratory Test
C. Treatment, Prevention and Control Subcutaneous mycoses to consider:
III. CHROMOBLASTOMYCOSIS
1. Sporotrichosis - S. schenckii
A. Morphology of Dematiaceous Fungi
B. Diagnostic Laboratory Test 2. Chromoblastomycosis - dematiaceous fungi
C. Treatment, Prevention, and Control 3. Phaeohyphomycosis - dematiaceous fungi
IV. PHAEOHYPHOMYCOSIS 4. Mycetoma - saprophytic fungi & actinomycete
A. Treatment
V. MYCETOMA SPOROTRICHOSIS
A. Diagnostic Laboratory Test ❏ Rose gardener’s disease
B. Treatment, Prevention, and Control
❏ Sporothrix schenckii is a thermally dimorphic fungus that lives on
HIGHLIGHTING OF TOPICS BULLET PLACEMENT vegetation. It is associated with a variety of plants—grasses, trees,
sphagnum moss, rose bushes, and other horticultural plants.
AAAAAA - Family of virus ❏ (Main definition) ❏ At ambient temperatures, it grows as a mold, producing branching,
AAAAAA - Main topic ➔ (Sub-definition/Enumerate) septate hyphae and conidia, and in tissue or in vitro at 35–37°C as
AAAAAA - Subtopics ● (Super Sub-detail) a small budding yeast.
❏ Following a traumatic introduction into the skin, S. schenckii
INTRODUCTION causes sporotrichosis, a chronic granulomatous infection.
❏ Many fungal pathogens can produce subcutaneous lesions as part ➔ The initial episode is typically followed by secondary
of their disease spectrum. spread with involvement of the draining lymphatics and
❏ The fungi that cause subcutaneous mycoses normally reside in soil lymph nodes.
or on vegetation. ❏ Infection is acquired by traumatic inoculation of the fungus
❏ Those considered here are introduced traumatically through the through the skin.
skin, with infection typically limited to subcutaneous tissues, ❏ The skin of gardeners, farmers, and rural laborers is frequently
lymphatic vessels, and contiguous tissues. traumatized by thorns or other material that may be contaminated
❏ These fungi rarely spread to distant organs and are usually with conidia of S. schenckii which can be found in hay, soil,
localized. decaying vegetables & surface of plants.
❏ They enter the skin or subcutaneous tissue by traumatic
inoculation with contaminated material. For example, a superficial

A. MICROSCOPIC
❏ Direct microscopic examination for S. schenckii is usually
unrewarding because there are too few organisms to
detect readily with KOH and Calcofluor white preparations.
❏ Fungal cell wall stains that can enhance the sensitivity of
microscopic test:
1. Gomori methenamine silver (stains the cell walls
black),
2. Periodic Acid-Schiff stain (imparts a red color to
Sporotrichosis the cell walls)
3. Fluorescent antibody stain (depends on the
MORPHOLOGY OF Sporothrix schenckii dye used)
❏ Sporothrix schenckii is a dimorphic fungus that grows as a ❏ Another structure termed an asteroid body (suggestive of
cigar-shaped, 3- to 5-mm yeast in tissues and in culture at 37°C. Sporotrichosis) is often seen in tissues of individuals
❏ The mold, which grows in cultures incubated at 25°C, is infected with S. schenckii.
presumably the infectious form in nature. ❏ In hematoxylin and eosin-stained tissue, the asteroid body
❏ Mold conidiophores convert to cigar-shaped yeast during infection. consists of a central basophilic yeast cell surrounded by
radiating extensions of eosinophilic material, which are
NOTE: depositions of antigen–antibody complexes and
❏ Cigar shaped - yeast form complement.
❏ Grape-like appearance of conidiophores in molds
Figure 13.2 Asteroid Body

Figure 13.1 Yeast (left) and Mold (Right) form of S. schenckii Yeast cell surrounded by amorphous eosinophilic rays(hyphae)
DIAGNOSTIC LABORATORY TEST B. CULTURE

❏ Specimens, like biopsy material or exudate from granulomatous or ❏ The most reliable method of diagnosis is culture.
ulcerative lesions, are examined directly with KOH or calcofluor ❏ Commonly used Culture Media:
white stain, the yeasts are rarely found. 1. Inhibitory Mold Agar
2. Sabouraud Dextrose Agar
➔ Both contain antibacterial antibiotics and
incubate at 25–30°C.

❏ Definitive diagnosis depends on the culture of infected ❏ All are dematiaceous fungi, having melanized cell walls. These
pus or tissue. fungi produce dark pigments.
❏ The identification is confirmed by growth at 35°C and 1. Phialophora verrucosa
conversion to the yeast form. 2. Fonsecaea pedrosoi
3. Fonsecaea compacta
4. Rhinocladiella aquaspersa
5. Cladophialophora carrionii
❏ The infection is chronic and characterized by the slow
development of progressive granulomatous lesions that in time
induce hyperplasia of the epidermal tissue.
TREATMENT, PREVENTION, AND CONTROL

❏ Saturated solution of potassium iodide (SSKI) – administered
orally.
❏ Although the oral administration of saturated solution of potassium
iodide in milk is quite effective, it is difficult for many patients to
tolerate. NOTE:
❏ In some cases, the infection is self-limited. ❏ Common in barefooted persons
❏ The treatment of choice is oral itraconazole (recommended) or ❏ Primary lesions appear as papules that develop into scaly,
another azole. wart-like structures, usually under the feet
❏ For systemic disease, amphotericin B is given. ❏ Fully developed lesions have been likened to the tips of a
❏ Prevention includes measures to minimize accidental inoculation cauliflower
and the use of fungicides, where appropriate, to treat wood.
MORPHOLOGY OF DEMATIACEOUS FUNGI
CHROMOBLASTOMYCOSIS (CHROMOMYCOSIS) ❏ The dematiaceous fungi are similar in their pigmentation, antigenic
❏ Chromoblastomycosis (chromomycosis) is a subcutaneous structure, morphology, and physiologic properties. The colonies
mycotic infection that is usually caused by traumatic inoculation of are compact, deep brown to black, and develop a velvety, often
any of the recognized fungal agents, which reside in soil and wrinkled surface. Fully developed lesions look like tips of
vegetation. cauliflower. The agents of chromoblastomycosis are identified by
➔ Occurs chiefly on legs or lower extremities of agrarian their modes of conidiation.
workers.

❏ In tissue they appear the same, producing spherical brown cells (in TREATMENT , PREVENTION AND CONTROL
10% KOH) termed Muriform cells or Medlar or Copper penny or ❏ Flucytosine or itraconazole are the systemic antifungal agents
Sclerotic bodies that divide by transverse septation. most frequently used for this infection.
❏ Septation in different planes with delayed separation may give rise ❏ Surgical excision with wide margins is the therapy of choice for
to a cluster of four to eight cells. small lesions.
❏ Chemotherapy with flucytosine or itraconazole may be efficacious
for larger lesions.
❏ The application of local heat is also beneficial. Relapse is common.
❏ The disease occurs chiefly on the legs of barefoot agrarian
workers following the traumatic introduction of the fungus.
❏ Chromoblastomycosis is not communicable.
❏ Wearing shoes and protecting the legs probably would prevent
infection.
Figure 13. 3 Sclerotic bodies

PHAEOHYPHOMYCOSIS
NOTE: ❏ Fungal infections characterized by the presence of darkly
❏ Detection of sclerotic bodies is diagnostic of chromoblastomycosis pigmented septate hyphae in tissue. Both cutaneous and
regardless of the etiologic agent systemic infections have been described.
❏ Over 100 species of dematiaceous molds have been associated
DIAGNOSTIC LABORATORY TEST with various types of phaeohyphomycotic infections.
❏ Specimens of scrapings or biopsies from lesions are examined
microscopically in KOH for dark, spherical cells. Table 13.1 Causative agents of Phaeohyphomycosis
❏ Specimens should be cultured on IMA or SDA with antibiotics.
❏ The dematiaceous species is identified by its characteristic conidial Subcutaneous Systemic
Phaeohyphomycosis Phaeohyphomycosis
structures. There are many similar saprophytic dematiaceous
molds, but they differ from the pathogenic species in being unable ● Exophiala jeanselmei ● Exophiala jeanselmei
to grow at 37°C and being able to digest gelatin. Incubate at RT ● Phialophora richardsiae ● Phialophora richardsiae
● Bipolaris spicifera ● Bipolaris spicifera
● Wangiella dermatitidis ● Wangiella dermatitidis
● Exserohilum rostratum
● Alternaria species
● Curvularia species
❏ In tissue, the hyphae are large (5–10 µm in diameter), often

distorted and may be accompanied by yeast cells, but these
structures can be differentiated from other fungi by the melanin in
their cell walls. Specimens are cultured on routine fungal media to
identify the etiologic agent.

TREATMENT
❏ In general, itraconazole or flucytosine is the drug of choice for ❏ The infection is characterized by local swelling of the infected
subcutaneous phaeohyphomycosis. tissue and interconnecting, often draining, sinuses or fistulae that
❏ Brain abscesses or systemic are usually fatal, but when contain granules, which are microcolonies of the agent embedded
recognized, they are managed with amphotericin B and surgery. in tissue material.
❏ The leading cause of cerebral phaeohyphomycosis is C. bantiana. ❏ An actinomycetoma is a mycetoma caused by an actinomycete; a
eumycetoma (maduromycosis, Madura foot) is a mycetoma
caused by a fungus. The fungal agents of mycetoma include,
among others, Pseudallescheria boydii, Madurella mycetomatis,
Madurella grisea, Exophiala jeanselmei.
❏ E. jeanselmei and the Madurella species are dematiaceous molds.
These molds are identified primarily by their mode of conidiation.
❏ In tissue, the mycetoma granules may range up to 2 mm in size.

The color of the granule may provide information about the agent.
❏ For example, the granules of mycetoma caused by:
➔ P. boydii and A. falciforme are white
➔ M. grisea and E. jeanselmei are black
➔ M. mycetomatis produces a dark red to black granule.
MYCETOMA ❏ These granules are hard and contain intertwined, septate hyphae
❏ Mycetoma is a chronic subcutaneous infection induced by
(3–5 µm in width). The hyphae are typically distorted and enlarged
traumatic inoculation with any of several saprophytic species of
at the periphery of the granule.
fungi or actinomycetous bacteria that are normally found in soil.
Eumycetoma
(Maduromycosis, Madura foot) Actinomycetoma
● Caused by fungi ● Caused by bacteria

● Mycetoma caused by ● Mycetoma caused by
saprophytic fungi actinomycetes
Figure 13.4 Madura Foot

DIAGNOSTIC LABORATORY TEST
❏ Granules can be dissected out from the pus or biopsy material
for examination and culture on appropriate media.
❏ The granule color, texture, and size and the presence of hyaline or
pigmented hyphae (or bacteria) are helpful in determining the
causative agent.
White Granules Black Granules Dark Red to Black
P. Boydii M. grisea M. mycetomatis

A. falciforme E. jeanselmei
TREATMENT , PREVENTION AND CONTROL

❏ The management of eumycetoma is difficult, involving surgical
debridement or excision and chemotherapy. P. boydii is treated
with topical nystatin or miconazole. Itraconazole, ketoconazole,
and even amphotericin B can be recommended for Madurella
infections and flucytosine for E. jeanselmei. Chemotherapeutic
agents must be given for long periods to adequately penetrate
these lesions.
❏ The organisms producing mycetoma occur in soil and on
vegetation. Barefoot farm laborers are therefore commonly
exposed.
❏ Properly cleaning wounds and wearing shoes are reasonable
control measures.
P. boydii Madurella infections E. jeanselmei
Topical Nystatin Itraconazole Flucytosine

Topical Miconazole Ketoconazole
Amphotericin B
Never Shall We Fail

#RMT2022Manifesting

MODULE 14: MORPHOLOGY, IDENTIFICATION TECHNIQUES, ❏ Each of these fungi is restricted to geographic niches
PATHOLOGY, PREVENTION, AND CONTROL OF corresponding to the environmental habitats of the mold form of
ENDEMIC MYCOSES the species (Endemic). None of these infections is transmitted from
OUTLINE OF THE LESSON human to human.
❏ Coccidioidomycosis, Histoplasmosis, Blastomycosis, and
I. INTRODUCTION Paracoccidioidomycosis are systemic mycoses that are
II. HISTOPLASMOSIS
geographically restricted to specific areas of endemicity.
A. Morphology of H. capsulatum
B. Laboratory Diagnosis
C. Treatment, Prevention, and Control Table 14.1 Summary of Endemic Mycoses
III. COCCIDIOIDOMYCOSIS
A. Morphology of C. posadasii and C. immitis
C. Treatment, Prevention, and Control
IV. BLASTOMYCOSIS
A. Morphology of B. dermatitidis
V. PARACOCCIDIOIDOMYCOSIS
A. Morphology of P. brasiliensis NOTE:
B. Laboratory Diagnosis ❏ The habitat of Blastomycosis is unknown but outbreaks have been
linked with riverbanks. Paracoccidioidomycosis habitat is also
HIGHLIGHTING OF TOPICS BULLET PLACEMENT unknown but is linked with soil
❏ All four endemic mycoses are caused by dimorphic fungi
AAAAAA - Family of virus ❏ (Main definition) ❏ Dimorphic fungi: are considered molds in the environment and
AAAAAA - Main topic ➔ (Sub-definition/Enumerate) become yeasts inside the body.
HISTOPLASMOSIS
INTRODUCTION ❏ H. capsulatum is a dimorphic soil saprophyte that causes
❏ The fungi discussed in this module cause a variety of infections, histoplasmosis, the most prevalent pulmonary fungal infection
each ranging in severity from subclinical to progressive, debilitating in humans and animals.
disease ❏ In nature, H. capsulatum grows as a mold in association with soil
❏ Some of these species are dimorphic, growing in the infectious and avian habitats, being enriched by alkaline nitrogenous
mold form in the environment but switching to a round, yeast-like substrates in guano.
form in infected tissues. They differ from the opportunistic fungi in ❏ Once the conidia(spore) of H.capsulatum is inhaled, the conidia
their ability to cause disease in previously healthy persons. will develop into a yeast form and is ingested by the alveolar
However, the most serious infections still occur in patients with macrophages (Kupffer cells), The fungi then replicates inside the
compromised immune systems. macrophages

❏ Systemic infection occurs due to the circulation of the
macrophages infected by H.capsulatum
NOTE: Chickens are not infected but their feces provide nutrients to the
soil for the growth of H.capsulatum
SPECIMENS MICROSCOPIC CULTURE
➔ Sputum (most ➔ Use of fungal wall ➔ Glucose-cysteine-

common) stains to visualize blood agar at
➔ Urine the small ovoid 37°C
➔ Scrapings from cells. ● to facilitate the
superficial conversion of
MORPHOLOGY OF H. capsulatum ➔ lesions 1. GMS(Gomori the mold into
❏ At temperatures below 37°C, primary isolates of H. capsulatum ➔ Bone marrow Methenamine Silver a yeast form
often develop brown mold colonies, but the appearance varies. aspirates stain)
❏ In tissue or in vitro on a rich medium at 37°C, the hyphae and ➔ Buffy coat blood 2. PAS(periodic acid ➔ SDA(Sabouraud
conidia convert to small, oval yeast cells (2 × 4 µm). cells. schiff) dextrose agar) or
❏ Dimorphic NOTE: Sputum is 3. Giemsa- used for IMA(Inhibitory
most common since bone marrow Mold Agar) at
❏ Received its name from the appearance of the yeast cells in
the initial site of aspirates and Buffy 25–30°C.-
histopathologic sections; however, it is neither a protozoan nor infection is the lungs coat blood cells ● visualizes the
does it have a capsule. mold form
NOTE:
❏ Appearance is rays of the sun
❏ In the tissues, look for macrophage with yeast form that buds

Note:
❏ Blue color on top view
❏ Reddish brown on bottom view

❏ Primary infections and localized lung lesions usually resolve
without treatment
❏ Acute pulmonary histoplasmosis is managed with supportive
therapy and rest. Figure 14.1 Erythema multiforme due to coccidioidomycosis.
❏ Itraconazole is the treatment for mild to moderate infection .
❏ In disseminated disease, systemic treatment with amphotericin B MORPHOLOGY OF C. posadasii and C. immitis
is often curative, though patients may need prolonged treatment ❏ These agents produce a white to tan cottony colony.
and monitoring for relapses. ❏ The hyphae form chains of arthroconidia (arthrospores),which
❏ Patients with AIDS typically relapse despite therapy that would be often develop in alternate cells of a hypha. These chains fragment
curative in other patients. Therefore, AIDS patients require into individual arthroconidia, which are readily airborne and highly
maintenance therapy with itraconazole. resistant to adverse environmental conditions.
❏ Histoplasmosis is not communicable from person to person. ❏ These small arthroconidia (3 × 5 µm) remain viable for years and
❏ Spraying formaldehyde on infected soil may destroy H. are highly infectious. Following their inhalation, the arthroconidia
capsulatum. become spherical and enlarge, forming spherules that contain
endospores
COCCIDIOIDOMYCOSIS
❏ Coccidioidomycosis is caused by C. posadasii or C. immitis.
They are phenotypically indistinguishable, cause similar clinical
manifestations, and are not differentiated in the clinical laboratory.
NOTE: Most Coccidioidomycosis infections are caused by C.posadasii, but
according to sir fundal, since C.immitis is easier to pronounce it is the one
most commonly used by textbooks.
❏ Acute primary infection with C. immitis is most often asymptomatic,
but it can manifest as a complex of symptoms called “Valley
Fever” by residents of the endemic areas
NOTE: It was termed “Valley fever” since it was first observed in the San
Joaquin Valley in California that is why it is also known as San Joaquin
Valley fever
❏ Valley Fever includes fever, malaise, dry cough, joint pains, and
sometimes a rash. Due to the joint pains associated with the
disease it is also called “Desert Rheumatism”

Figure 14.2 The saprobic cycle is found in the environment and produces NOTE:
infectious arthroconidia. They may become airborne and be inhaled by the ❏ “Why are there a lot of specimens?”
host or may return to the environment to continue the saprobic life cycle. ➔ Remember that endemic mycoses are systemic mycosis
meaning they are able to disseminate in the different parts
NOTE: of the body.
❏ Mycelia-the basic structure of molds, the hyphal elements. ❏ Histologic stains - enhance the structure of fungal cell wall
❏ Mycelium- the collection of hyphal elements ➔ Hematoxylin and Eosin (H&E)
➔ Gomori Methenamine Silver (GMS)
Based on the picture above: ➔ Periodic Acid Schiff (PAS)
❏ The mycelia would reproduce asexually, forming Arthroconidia that ➔ The direct detection of spheroles in the clinical sample can
would be distributed in the soil. When not inhaled by humans, they be diagnostics for Coccidiomycosis
will germinate and form more mycelia, repeating the cycle. ❏ Culture:
❏ But when the soil is disturbed and the arthroconidia are inhaled, ➔ Inhibitory Mold Agar (IMA)
they increase in size inside the lungs and develop into Spherules ➔ Should be incubated at RT or 37 degrees Celsius to
which contain endospores. determine the mold and yeast form of this fungal
❏ These spherules can rupture and release the endospores into the
environment, these endospores will develop into tubular
structures and eventually Mycelia.
❏ But if the endospores are not released into the environment they
can develop into more spherules.
SPECIMENS MICROSCOPIC CULTURE Based on the picture above: (left)

❏ Spherules contain many endospores inside the structure. There is
➔ Sputum ➔ 10 % KOH ➔ IMA also a ruptured spherole which will release the endospores
➔ Exudate from ➔ Calcofluor white ➔ Brain–heart
causing formation of another spherule and the cycle continues.
cutaneous lesions stain infusion blood agar
➔ Spinal fluid ➔ slant Based on the picture above: (right)
➔ Blood Histologic Stains ❏ These are the mold forms of Coccidioides species. The
➔ Urine ➔ H&E NOTE: Incubate at individual cells/circles are the arthroconidia, the asexual spores.
➔ Tissue biopsies ➔ GMS room temperature The arthroconidia, once inhaled, will become spherules with
➔ PAS or at 37°C endospores.

❏ In most persons, symptomatic primary infection is self-limited and
requires only supportive treatment, although itraconazole may

reduce the symptoms. However, patients who have severe disease
require treatment with amphotericin B, which is administered
intravenously.
❏ Primary coccidioidomycosis is self-limited and no antifungal
therapy is indicated
❏ Itraconazole is preferred for acute or progressive pulmonary
disease
❏ Disseminated, extrapulmonary infection may require
Figure 14.2 Extraplumonary Blastomycosis
amphotericin B
❏ Cases of coccidioidal meningitis have been treated with oral
MORPHOLOGY OF B. dermatitidis
fluconazole, which has good penetration of the central nervous
❏ When B. dermatitidis is grown on SDA at room temperature, a
system (enhanced CSF penetration); however, long-term therapy
white or brownish colony develops, with branching hyphae bearing
is required, and relapses have occurred.
spherical, ovoid, or piriform conidia (3–5 µm in diameter) on
❏ The disease is not communicable from person to person, and there
slender terminal or lateral conidiophores. In tissue or culture at
is no evidence that infected rodents contribute to its spread.
37°C, B. dermatitidis grows as a thick-walled, multinucleated,
❏ Some measure of control can be achieved by reducing dust,
spherical yeast (8–15 µm) that usually produces single buds.
paving roads and airfields, planting grass or crops, and using oil
NOTE:
sprays.
➔ Molds at RT
➔ Yeast at 37°C and in tissue
BLASTOMYCOSIS
❏ Blastomyces dermatitidis causes blastomycosis, a chronic
infection with granulomatous and suppurative lesions that is
initiated in the lungs, whence dissemination may occur to any
organ but preferentially to the skin and bones. The disease has
been called North American blastomycosis because it is endemic,
and most cases occur in the United States and in Canada.
❏ B. dermatitidis is a thermally dimorphic fungus that grows as a
mold in culture, producing hyaline, and branching septate hyphae
and conidia. At 37°C or in the host, it converts to a large, singly Figure 14.3 Mold form (L) and Yeast form (R) of B. dermatitidis
budding yeast cell.
Based on the picture above: (left)
❏ Also causes systemic infection
❏ The blue circles are the microconidia
❏ Blastomycosis will occur if microconidia is inhaled.
❏ Septate hyphae
Based on the picture above: (right)

❏ Once the microconidia is inhaled, there is formation of yeast in the
lungs. Once yeast would bud, it would form a blastoconidia.

LABORATORY DIAGNOSIS PARACOCCIDIOIDOMYCOSIS
❏ Paracoccidioidomycosis is progressive mycosis of the lungs, skin,
mucous membranes, lymph nodes, and internal organs caused by
Paracoccidioides brasiliensis.
➔ Sputum Wet mounts of Colonies usually ❏ P. brasiliensis is the thermally dimorphic fungal agent of
➔ Pus specimens may show develop within 2 paracoccidioidomycosis (South American blastomycosis), which is
➔ Exudates broadly attached weeks on confined to endemic regions of Central and South America.
➔ Urine buds on thick-walled Sabouraud’s or ❏ P. brasiliensis is inhaled, and initial lesions occur in the lung. After
➔ Biopsies from yeast cells. These enriched blood agar at a period of dormancy that may last for decades, the pulmonary
lesions may also be apparent 30°C
granulomas may become active, leading to chronic, progressive
in histologic section
pulmonary disease or dissemination.
❏ Also systemic mycosis
NOTE:
❏ Sputum is used as a specimen for this infection since it affects the
respiratory system.
❏ In microscopic examination, what you will see would be the yeast
cells since the spores had already entered the tissue. Since this
species is a dimorphic fungus, we cannot see molds.

❏ Severe cases (more serious or disseminated infections) of
blastomycosis are treated with amphotericin B. Figure 14.4 Paracoccidioidomycosis lesion
❏ In patients with confined lesions (mild to moderate disease), a
6-month course of itraconazole is very effective. MORPHOLOGY OF P. brasiliensis
❏ Blastomycosis is a relatively common infection of dogs (and rarely ❏ Cultures of the mold form of P. brasiliensis grow very slowly and
other animals) in endemic areas. produce chlamydospores and conidia. The features are distinctive.
❏ Blastomycosis cannot be transmitted by animals or humans. At 36°C, on a rich medium, it forms large, multiply budding yeast
❏ Unlike C. immitis and H. capsulatum, B. dermatitidis has only cells (up to 30 µm). The yeasts are larger and have thinner walls
rarely (and not reproducibly) been isolated from the environment, than those of B. dermatitidis. The buds are attached by a narrow
so its natural habitat is unknown. However, the occurrence of connection
several small outbreaks has linked B. dermatitidis to rural river
banks.
❏ Spores are infectious units of fungi. You can be infected if you
disturb the soil where fungi lives.
Figure 14.5 Mold (left) and Yeast (right) form of P. brasiliensis

NOTE: ➔ All endemic mycosis is caused by a dimorphic fungi and they are
➔ Paracoccidioides brasiliensis is a dimorphic fungi. Meaning at not communicable.
RT, it appears as mold but if it will invade the tissue at 37 degrees ➔ They are present in the environment and if our immune system is
Celsius, it would transform into a yeast. severely compromised, these opportunistic fungi can take the
➔ Based on the picture on the left, these are the mold forms and it opportunity to invade the body.
will have the conidia of the P. brasiliensis.
➔ Based on the picture on the right, these are the yeast forms and
they resemble a ship’s steering wheel. This is why the yeast of P.
brasiliensis is called the Captain’s Wheel.This appearance is due Never Shall We Fail
to the budding of the yeast cell to form a blastoconidia. #RMT2022Manifesting
MICROSCOPIC CULTURE
Yeasts are often apparent on direct Cultures on Sabouraud’s or yeast

microscopic examination with KOH extract agar are incubated at
or calcofluor white room temperature and confirmed
(Captain’s Wheel appearance or by conversion to the yeast form by
Ship’s Wheel appearance) in vitro growth at 36°C.
TREATMENT, PREVENTION, AND CONTROL

❏ Itraconazole appears to be most effective against
paracoccidioidomycosis, but ketoconazole and trimethoprim–
sulfamethoxazole are also efficacious.
❏ Severe disease can be treated with amphotericin B.
❏ Since P. brasiliensis has only rarely been isolated from nature, its
natural habitat has not been definitively determined.
❏ As with the other endemic mycoses, paracoccidioidomycosis is not
communicable.
NOTE: Remember, we have four endemic mycoses:

➔ Histoplasmosis
➔ Coccidioidomycosis
➔ Blastomycosis
➔ Paracoccidioiodomycosis

MODULE 15: MORPHOLOGY, IDENTIFICATION TECHNIQUES, ❏ Can't normally produce a disease in a healthy individual and can
PATHOLOGY, PREVENTION, AND CONTROL OF only produce a disease on immunocompromised individuals.
OPPORTUNISTIC MYCOSES ❏ Candida albicans is present endogenously or inside the body
CANDIDIASIS
I. INTRODUCTION ❏ Candidiasis is the most prevalent systemic mycosis, and the most
II. CANDIDIASIS common agents are:
A. Morphology ➔ C. albicans
B. Laboratory Diagnosis ➔ Candida parapsilosis
C. Treatment, Prevention, and Control ➔ Candida glabrata
III. ASPERGILLOSIS ➔ Candida tropicalis
A. Morphology
➔ Candida guilliermondii
C. Treatment, Prevention, and Control ➔ Candida dubliniensis
IV. ZYGOMYCOSIS
A. Morphology ❏ Candidiasis occurs in localized and disseminated forms. Localized
B. Laboratory Diagnosis disease is seen as erythema and white plaques in moist skinfolds
C. Treatment, Prevention, and Control (diaper rash) or on mucosal surfaces (oral thrush). It may also
cause the itching and thick white discharge of vulvovaginitis. Deep
tissue and disseminated infections are limited almost exclusively to
AAAAAA - Family of virus ❏ (Main definition) the immunocompromised.
INTRODUCTION
❏ The “opportunistic fungi” are usually found as members of the
resident human microbiota or as saprophytes in the environment.
❏ With the breakdown of host defenses, they can cause infections
ranging from skin/mucous membrane involvement to
life-threatening, systemic disease.
❏ Candida and related yeasts are endogenous opportunists.
❏ Other opportunistic mycoses are caused by exogenous fungi that NOTE:
are globally present in soil, water, and air. ❏ Fibronectin present on the surface of the epithelial cell, is the
❏ The coverage here will focus on the more common pathogens and covering essential for the attachment on the cell wall of candida
the diseases they cause—candidiasis, aspergillosis and species.
mucormycosis. ❏ Surface Mannan receptors are present in the cell wall of the
candida that can attach the candida cell to fibronectin. It is

considered as a normal flora because they can normally reside on MORPHOLOGY
the surface of the skin. ❏ Candida albicans, the most common cause of human invasive
➔ If there is a breakage in the skin, it becomes an fungal infections, is also able to form hyphae triggered by changes
opportunity for the candida to enter the host cell by forming in conditions such as temperature, pH, and available nutrients.
as a hyphae as it penetrates the host cell and causes ❏ When observed in their initial stages of germination from the yeast
candidiasis. cell, these nascent hyphae resemble sprouts and are called “germ
tubes”. Other elongated forms with restrictions at regular intervals
are called pseudohyphae because they lack the parallel walls and
Cutaneous candidiasis Systemic candidiasis
septation of true hyphae.
● It is established by an increase ● Occurs when Candida enters NOTE: C. albicans grows with varied morphologies: yeast, hyphae
in the local census of Candida the bloodstream and the (Germ tube), and pseudohyphae
and damage to the skin or innate phagocytic host ❏ What makes it unique is that even though it is a yeats, it can form a
epithelium that permits local defenses are inadequate to hyphae
invasion by the yeasts and contain the growth and
pseudohyphae. dissemination of the yeasts.
● The yeasts can enter the
Examples: circulation by crossing the
● Thrush - present in the mouth intestinal mucosa.
● Many nosocomial cases are
caused by contamination of
Indwelling intravenous
catheters with Candida.
● Once in the circulation,
Candida can infect the
kidneys, attach to prosthetic
● Vaginal candidiasis (thrush-like) heart valves, or produce
candidal infections almost
anywhere (eg, arthritis, Figure 15.1 Three forms of Candida albicans
meningitis, and
endophthalmitis). LABORATORY DIAGNOSIS

● Some diaper rash
● Swabs and Tissue biopsies, All specimens are
scrapings from centrifuged spinal cultured on fungal or
superficial lesions fluid, and other bacteriologic media at
● Blood specimens may be room temperature or
● Spinal fluid examined in at 37°C. (germ tube is
● Tissue biopsies Gram-stained smears formed at this tempt)
● Urine or histopathological

● Exudates slides for Yeast colonies are
● Material from pseudohyphae and examined for the
removed budding cells presence of
intravenous pseudohyphae.
catheters. For dermatophytosis,
skin or nail C. albicansis
scrapings are first identified by the
placed in a drop of production of germ
10% KOH and tubes or by
calcofluor white chlamydospores.
➔ To enhance the
formation
chlamydospores,
culture it in a
cornmeal agar TREATMENT, PREVENTION AND CONTROL
❏ Thrush and other mucocutaneous forms of candidiasis are
Under culture: usually treated with topical nystatin or oral ketoconazole or
CHROMagar® is a useful commercial medium for the rapid identification fluconazole.
of several Candida species based on fungal enzymatic action on ❏ Systemic candidiasis is treated with amphotericin B, sometimes
chromogenic substrates in the medium.
in conjunction with oral flucytosine, fluconazole, or caspofungin.
➔ Each candida specie colony has a specific color
❏ The most important preventive measure is to avoid disturbing the
normal balance of microbiota and intact host defenses.
CHROMagar ❏ Candidiasis is not communicable, since virtually all persons
normally harbor the organism.
Species Colors
ASPERGILLOSIS
C. albicans Green ❏ Aspergillosis is a spectrum of diseases that may be caused by a
number of Aspergillus species, a common mold (a type of
C. tropicalis Blue
fungus) that lives indoors and outdoors.
C. glabrata White or dark purple ❏ Aspergillus species are ubiquitous saprobes in nature, and
aspergillosis occurs worldwide.
C. parapsilosis Pinkish hue ❏ A. fumigatus is the most common human pathogen, but many
C. lusitaniae others, including:
C. guilliermondii ➔ Aspergillus flavus
C. krusei
➔ Aspergillus niger
➔ Aspergillus terreus
➔ Aspergillus lentulus, may cause disease.
❏ This mold produces abundant small conidia that are easily
aerosolized.

❏ Following inhalation of these conidia, atopic individuals often terminal vesicles on which phialides produce basipetal chains
develop severe allergic reactions to the conidial antigens. In of conidia (see figure 15.2).
immunocompromised patients— especially those with leukemia, ❏ The species are identified according to morphologic differences in
stem cell transplant patients, and individuals taking these structures, including the size, shape, texture, and color of the
corticosteroids—the conidia may germinate to produce hyphae that conidia.
invade the lungs and other tissues.
❏ Aspergillus infections typically present in one of four major ways,
with the clinical findings completely dependent on the immune
status of the host. These clinical presentations include:
1. Aspergillus pneumonia
2. Disseminated aspergillosis
3. Allergic respiratory disease
4. Aspergilloma (fungus ball)
Figure 15.2 Aspergillus
NOTE:
❏ Invades the lungs, irritate the airway and produce excessive
amount of mucus LABORATORY DIAGNOSIS
❏ Most people breathe in Aspergillus spores every day without
getting sick. SPECIMENS MICROSCOPIC CULTURE
❏ However, people with weakened immune systems or lung
diseases are at a higher risk of developing health problems due to ● Sputum ➔ KOH Aspergillus species
Aspergillus. ● Other respiratory ➔ Calcofluor grow within a few
tract specimens white days on most media
● Lung biopsy tissue ➔ Histologic at room temperature
MORPHOLOGY
stains
❏ Aspergillus species grow rapidly, producing aerial hyphae that bear
characteristic conidial structures: long conidiophores with

➔ The rhinocerebral form produces a dramatic clinical
syndrome in which agents of zygomycosis show striking
invasive capacity. They penetrate the mucosa of the nose,
paranasal sinuses, or palate, often resulting in ulcerative
lesions. Once beyond the mucosa, they progress through
tissue, nerves, blood vessels, fascial

❏ Voriconazole, are the preferred treatments for invasive
aspergillosis.
❏ Caspofungin and amphotericin B are alternatives. Figure 15.3 Rhinocerebral disease
❏ No regimen is considered highly effective because the mortality
rate of invasive disease is high. LABORATORY DIAGNOSIS
❏ Surgical removal of localized lesions is sometimes helpful, even in ❏ Direct examination or culture of nasal discharge, tissue, or sputum
the brain. will reveal broad, ribbon-like hyphae (10–15 µm) with uneven
❏ Construction of rooms with filtered air has been effective in thickness, irregular branching, and sparse septations.
reducing exposure to environmental conditions. ❏ These fungi grow rapidly on laboratory media, producing abundant
cottony colonies. Identification is based on the sporangial
ZYGOMYCOSIS (MUCORMYCOSIS) structures.
❏ Zygomycosis (mucormycosis) is the term applied to infection
with any of a group of zygomycetes, the most common of which
are Absidia, Rhizopus, and Mucor (bread mold).
❏ These fungi are ubiquitous soil saprophytes and are commonly
found on bread and many other food-stuffs.
❏ They occasionally cause disease in persons with diabetes mellitus
and in immunosuppressed patients receiving corticosteroid
therapy. Diabetic ketoacidosis has a particularly strong association
with zygomycosis.
❏ Pulmonary or rhinocerebral disease is acquired by inhalation of
Figure 15.3 Broad, ribbon-like, non-septate
conidia.
(aseptate) hyphae in tissue sample
➔ The pulmonary form has clinical findings similar to those
of other fungal pneumonias.

❏ Treatment consists of aggressive surgical debridement, rapid
administration of amphotericin B, and control of the underlying
disease (supportive treatment)
❏ Many patients survive, but there may be residual effects such as
partial facial paralysis or loss of an eye.
❏ Therapy involves control of underlying disease (eg, recovery from
neutropenia, treatment of hyperglycemia) and high-dose
antifungal therapy (lipid-associated amphotericin B, selected
azoles).
❏ Surgical debridement is the most important intervention favoring
survival and cure of infection.
➔ Removal of the necrotic tissue of the skin
Never Shall We Fail

#RMT2022Manifesting

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MLS 3A MODULE 1: ❏ The term ‘virus’ derives from the Latin for slimy liquid or

BACKGROUND AND DISCOVERY

MLS 13A: MYCOLOGY & VIROLOGY | RMT 2022 | Page 1

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Figure 1.1: Structure of Virions

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DAVID BALTIMORE - classified viruses using their nucleic acid

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VIRUSES AND THEIR STRUCTURE

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4. TRANSMISSION BY MEANS OF ARTHROPOD VECTOR

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A. DIRECT DETECTION / EXAMINATION DIAGNOSTIC METHODS:

B. INDIRECT EXAMINATION (VIRUS ISOLATION) NOTES FROM SIR ROBERT

MLS 13A: MYCOLOGY & VIROLOGY | RMT 2022 | Page 11

Adenovirus - naked and may not be destroyed using alcohol

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PREVENTION AND CONTROL

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OUTLINE OF THE LESSON

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STEP 1 ➔ Poliovirus is ingested

STEP 2 ➔ After ingestion the virus will migrate to the gut

STEP 3 ➔ Will then spread via the lymphatic vessels

STEP 4 ➔ Distributed via the bloodstream

STEP 5 ➔ Crosses the blood-brain barrier

STEP 6 ➔ Sheds through the gut VIRAL REPLICATION PROCESS

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Enveloped virus (Budding)

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TERMS DESCRIBING ​VIRUS TRANSMISSION

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MULTIPLICITY OF INFECTION (M.O.I.)

B. SPECIFIC IMMUNITY / ADAPTIVE

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Common Name Parvovirus Diseases ❏ Erythema infectiosum (fifth disease)

Detection ❏ Serology/Antigen Detection

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ADENOVIRIDAE Site of Latency Replication in oropharynx

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COXSACKIE-ADENOVIRUS RECEPTOR (CAR)

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Composition 3%​ - DNA Treatment: Supportive

TERMS DESCRIBING VIRUS TRANSMISSION

Composition 3% - DNA Treatment: Supportive

GENERAL CHARACTERISTICS OF ORTHOMYXOVIRIDAE INFLUENZA A INFLUENZA B

Table 3.4 Virion Structure of Orthomyxoviruses

Gene 8 8 7 6 NA - Neuraminidase Virus release from

Unique M2 NB HEF 7 M1,M2 - matrix proteins Matrix, ion channel

NOTE: H5N1 (avian) is rare due to the position of receptors (lower

Envelope ❏ Contains viral glycoprotein G (RSV),

Figure 3.7 SARS-CoV-2 Origin and Transmission

❏ The capsid is surrounded by the tegument, a relatively amorphous

Table 4.2 Classification of Human Herpesviruses

1. Alphaherpesviruses are fast-growing, cytolytic (lyse cells causing

Table 4.4 HSV-1 and HSV-2 Clinical Association