Viru OGENESIS OF VIRAL INFECTION i Routes of entry ‘Spread of virus inthe body Significance ofthe incubation period OST RESPONSE TO VIRUS INFECTIONS Immunological response 'Norsimmunalogical responses {RY DIAGNOSIS OF VIRAL DISEASES -ROPHYLAXIS OF VIRAL DISEASES INTRODUCTION Virus-host interactions may be considered at different levels: the cel, the individual and the community. At the cellular level, viral infection may cause a broad spectrum of effects, ranging from no apparent cellular damage to rapid cell destruction. Some vi ruses, like the poliovirus, cause cell death (cytocidal effect) or even lysis (cytolysis). Others may cause cellular proliferation (as molluscum contagiosum) or ‘malignant transformation (as oncogenic viruses). In some instances, the virus and host cells enter into peaceful co-existence, both replicating independently without any cellular injury, a condition known as steady state infection. In tissue culture, viral infection may Jead to readily observable cellular changes (eytopathic effects). These may not parallel the changes produced in the infected animal, asin the latter situation, infection is influenced by the various defence mechanisms of the body. Causes of cellular injury: © Early or non-structural viral proteins often cause shutdown of host protein and DNA synthesis. ® Large amounts of viral macromolecules that accumulate in the infected cell may distort the cellular architecture and exert a toxic effect, s-Host Interactions: Viral Infections ‘The permeability of plasma membrane, aie releasing lysosomal enzymes an ia ui is. / fernaes produce alterations in the membrane of infected cells. Some (such as the respiratory syneyay cause fusion of adjacent cell membranes, lean polykaryooytosis or syncytium formation, "8 Virus-coded antigens may appear on the sy, of infected cells. These antigens. may new properties on the cell. For exami hhemagglutininappearson hesutfaceofceiny withthe influenza virus and causes adsorp enters 10 the cel sure themasoge Virus-coded antigens aso appear onthe surge calls transformed by oncogenic viruses, Certain viruses such a8 measles, ugg, adenoviruses, cytomegalovirus and varicella vrs ca damage to the chromosomes of host cels. Chroma gaps and breaks in chromosome 17 occur frequent cultured cels infected with adenovirus types 12 and, Inclusion bodies: The most characteristic histology feature in virus infected cells is the appearance ¢ inclusion bodies. Inclusion bodies are structures yi distinct size, shape, location and staining propetss that can be demonstrated in virus infected cells under the light microscope. They may be situated in the cytoplasm (as wih poxviruses), nucleus (herpesviruses) or both (measks virus). They are generally acidophilic and can be seenes pink structures when stained by the Giemsa method cr with eosin methylene blue. Some viruses (for exam, adenovirus) form basophilic inclusions. Demonstration of inclusion bodies helps in the diagnosis of some viral infections. The presence of intracytoplasmic eosinophilic inclusions (Negri bods) in the brain cells of animals justifies the presumptive diagnosis of rabies, Vaccinia infected cells show ratet smaller multiple inclusions known as Guarniti bodies. Large inclusions (Bollinger bodies) are seat fowlpox. Inclusion bodies in molluscum contagiosi oH 7 © scanned with OKEN Scanner(qnolluscum bodies) are very large (20-30 um) and can be readily seen under the low power microscope. Intranuclear inclusion bodies were classified into two types by Cowdry (1954): Cowdry type A inclusions i) are of variable size and have a granular appearance Sag with herpesvirus, yellow fever virus), while type B ly. jaotusions are more circumscribed and often multiple alt (aswith adenovirus, poliovirus). Si) “Inclusion bodies may be crystalline aggregates of "iy. virions or made up of virus antigens present at the site of ta. Gras synthesis. Some inclusions represent degenerative SX Ghanges produced by viral infection which confer ig. altered staining properties on the cell Fig. 48.1). ig, PATHOGENESIS OF VIRAL INFECTION Depending on the clinical outcome, viral infections can be classified as follows: Inapparent (subelinical) infections Apparent (clinical or overt) infections which may be acute, subacute or chronic © Latent infections: & — Recurrent herpes simplex and herpes zoster are & examples of latent infections in which clinical t manifestations appear after prolonged periods of quiescence during which the viruses remain hidden in the nerve root ganglia Persistent tolerant infection occurs when the virus is readily demonstrable in the tissues of the host but neither disease nor immune response develops. The host is immunologically tolerant to the virus as a result of congenital or neonatal infection. Disease sets in when the tolerance is interrupted. The classical example of persistent tolerant infection is lymphocytic choriomeningitis | of mice, ~ Slowly progressive or slow infect period is unusually long) is seen in neurolog! diseases such as scrapie in sheep and kurt in fhuman beings. — Infection by oncogenic viruses ~ The HIV virus leads to a special type of latency, with an initial asymptomatic period followed by progressive immune damage causing secondary diseases, ending fatally after many years. ion (incubation ical Routes of entry Viruses enter the body through the respiratory and alimentary tracts, skin, conjunctiva and the genital tract, Many viruses are transmitted vertically from mother to child. ‘The respiratory tract offers the most important portal of entry for viruses. A large number of viruses can infect the ceils of this tract. Some of them multiply locally to initiate a silent local infection which is followed by lymphatic or hematogenous transport to other situations ‘where more extensive multiplication takes place before systemic illness is manifested. Smallpox and chickenpox are examples of such systemic diseases in which the portal of entry is the respiratory tract, Other viruses such as influenza and rhinoviruses are restricted to the respiratory tract, where they multiply and produce local disease, These are known as respiratory viruses. The alimentary tract is the next most important route of entry for viruses. However, only some viruses can establish infection in the intestines. All enveloped viruses are destroyed by bile. Rhinoviruses are inactivated by gastric acidity. Only enteroviruses, adenoviruses, reoviruses, hepatitis viruses and the viruses causing gastroenteritis can set up intestinal infection. Some of these such as rotavirus remain confined to the gut, causing local disease, Others such as poliovirus, after initial multiplication locally, are transported to other sites for further multiplication and subsequent spread to the target organs. Of the viruses that enter through the skin, only a few produce local lesions. Papilloma, vaccinia, cowpox, molluscum contagiosum and orf are viruses that produce dermal lesions at the site of entry. Skin lesions of exanthematous viral diseases are secondary to systemic infection, Viruses enter the skin through abrasions (papillomavirus), insect bites (arboviruses), animal bites (rabies) or injections (type B hepatitis). © scanned with OKEN Scannerrn Systemic spread ovcts through lymphatics or blood. The yates Virus Qavels along the nerves to the spinal wont or brain, The con) entry for viruses: etiva also may act as a portal of This may lead to local disease irus) of £9 systemic spread (measles). Some eves may enter through the genital tract oF other jes of sexual contact (HIV), Congenital infeetion may oecur at any stage, from © development of the ovum up to birth, tn acute systemic infections, congenital infection usually leads to ‘otal death and abortion, Rubella and eytomegalovir produce maldevelopment or severe neonatal disease, Vertical transmission is the natural mode of spread ‘of many tumout viruses, The avian leukosis virus is ‘ransmitted in ovo and murine mammary tumour virus through breast milk. Spread of virus in the body he manner in whieh the infecting vius spre fy the point of entry, tultiplcs in sites of election causes lesions in target tissues. was First studied Fenner (1948) using mousepox as the experin model (Fig. 48.2), The skin, where fae ental nOUSEPOX viFUS enters yp e multiplies initially and proceeds alo esto the local nodes. Aer multipicig® in the Iyph nodes, the virus enters the bloodsa ary viremia) and is transported tothe spleen any which act as the ‘central foc” for viral malig cation. Alter extensive multiplication in the cent foci, there occurs a massive spillover ofthe virus in the bloodstream (secondary viremia). This heal the onset of clinical symptoms (the prodromal phase in eruptive fevers). The virus reaches the target orgen ‘Small intestine: mutipliction ‘Mesenteric lymph node: ‘mutiplicaion Bloodstream: ‘primary viremia Central focus of multiplication Initial antibody ‘appearance | one: rutipteaton ‘anal spread 1 High eve of antbody in serum 11 Paraiysis othe Day invasion ‘ ‘mutipicaton Regional mph nade: 1 rutipication Bloodstream . rimay viremia Spleen and ver: ‘multiplication 3 4 Bloodstream: . secondary viremia 6 ‘Sir: ‘focal mutipication S Antibody inserum 8 Z 8 Early rash 10. Contamination of environment ‘severe rash, 1 eration Mousepox Excretion in feces Human poliomyelitis Fig 48.2 Schematic illustrations of the pathogenesis of mousepox and poliomyelitis al © scanned with OKEN Scanneree ——— ine fv018) through the « io Moodstrea, vee tg ies IMOUWES the dsting et thainor MOsCatIONS, his Model hohe eave viru diseases, The reasons fy po cot Syste " <0 a he ost of utiphcaion an tage Syme aco ferent vases ate obscure ace a of the incubation period 3 peviod represents the time taken for from the site of entry tothe organs jon and thence to the target orgs “sto ps pv s of entry, ion, Where the site of entry sion are the same, the incubation period wt pe co ree days, a8 in respiratory viral spin gastroenteritis. In systemic diseases sso Mut enters through the respiratory op sss Pc and produces lesions in remote target ni ebation period is Tonger—10-20 days, = apo or poliomyelitis. Thee ae, however, 2 t iis rule. In arbovirus diseases, as in yelloy carne the incubation period may be shorter i Fe) probably because the virus is introduced othe loodstream bythe insect vectors, The an eid in tye Bhepaitis may be 2-6 months Sado irl infetions, many years, Paplomas and = eum cotagjosum Have long incubation periods, pecs the viruses multiply slowly. HOST RESPONSE TO VIRUS INFECTIONS ‘re oucome of a virus infection is influenced by the lence of the infecting strain and the resistance cffeed by the host. Mechanisms of host resistance ‘uy be immunological or non-specific. The latter includes various genetic and physiological factors such ssinerferon production, body temperature, nutrition and hormones. Immunological response Virions in general are good antigens and induce tath humoral and cellular immune response, ‘The nukipcation of a virus in the body during infection | induces not only a quantitatively greater immune | reponse but also liberates and makes available to the inmune system the whole range of virus antigens, ‘cluding surface and internal antigens as well as non- ‘nstural antigens such as early proteins. — eo Mos Interactions: Vial infections vi (mor UW me He important ef dla UA. 18 an ty tissue space surface ‘Vating.hurnoral anivieal immunity, Sses of antibodies are IgG, IgM and wi ney 4 major role in blood and Ant wis ‘more important on mucosal mechanisne c ect virus neutralisation several 10 cll may prevent adsorption of the virus ‘cause enhanced virus degradation or ise of the Progeny virus from infected ni Sur tin conjunction with antibodies Surface damage to enveloped virions and in They n eplor Prevent the rele cells. Complem in cau oe NE voi of view infected cel, Antibodig bodies can neutralise vial infectivity es to internal antigens are non-neutralising. sores rae ‘antigens vary in their neutralising appear foloc tne 18° types of surface antibodies and ani inven infection: antihemageluinin infty rise. The former can neutrals antibody ca ete ant. Te antneuraminidase Vitions fat Rowe inhibit the release of progenl m infected cells. Some antibodies can Paradoxically enhance viral. infectivity. Humoral antibodies may sometimes actually contribute to pathogenesis. Antibodies may cause complement dependent injury to cells or induce an immune complex ‘ypeoftissue injury. Theenhanced severity ofrespiratory Syncytial viral infection in early infancy is believed to be due to the presence of passively acquited maternal antibodies. In older children who have no antibody, the Virus causes a milder disease, The pathogenesis of some Viral hemorrhagic fevers is immune thrombocytopenia. Most extrahepatic lesions in type B hepatitis are due to damage caused by immune complexes. Cell mediated: Cell-mediated immunity is of critical importance in viral infections. The earliest indication of cell-mediated immunity in viral infections was the demonstration of delayed hypersensitivity following vaccination in immune individuals, Similar skin reactivity is also seen in mumps. The normal resistance to virus infections shown by agammaglobulinemics is ascribed to their cell-mediated immunity, though it may also be due to interferon or other non-immune mechanisms, Individuals with deficient cellular immunity show heightened susceptibility to infection by the herpes, pox and measles viruses. The administration cof antlymphooyte serum induces fatal infection in mice injected with a sublethal dose of the ectromelia virus. Cell-mediated immunity is considered to play a major role in recovery from viral infections in which viremia is not important and in which infected cells have © scanned with OKEN ScannerVaROLOGY foo their surface, Hy some Vttts NON nat imvavunity may contribute x. a6 0 fumyphaxntie chortomeningitis Seppression, Some viral infections cause suppression Jos infection induces a spnee, Mo itis or Towkemia vitw antibody N ens, HIV strikes at the centre 1 by infecting the CD4+ helper sstions are followed by solid fection, which may offen be rarent cwseptions like the common cold aviuenza are net due to lack of immunity but t0 ng caused by antigenically different Sruses. Live virus vaccines also induce more durable than bacterial vaccines. Non-immunological responses Phagocytosis: | Polymorphonuclear leucocytes do not significant role in the defence against viral ns. In fact, more viral diseases are characterised vmorphonvclear leucopenia. On the other hand, ages phagocytose viruses and are important in Body temperature: Fever mayact asanatural defence mechanism against viral infections as most viruses are inhibited by temperatures above 39°C. An exception is herpes simplex which is usually reactivated by fever to produce ‘fever blisters’. Herpes febrils is a frequent accompaniment of fevers caused by pneumococci, streptococci, influenza virus and malaria parasites, but for some unknown reason, is very rare in other fevers (typhoid, tuberculosis). Hormones: Corticosteroid administration enhances most viral infections. Coxsackie virus B1 does not normally cause disease in adult mice but will induce a fatal fection in mice treated with cortisone. Normally infections such as varicella and vaccinia may be lethal in patients on cortisone. Injudicious use of steroids in the treatment of herpetic keratoconjunctivitis may cause blindness. The particularly severe course of ‘many viral infections in pregnancy may be related to the associated hormonal changes. The deleterious effect of cortisone may be due to its depression of the immune response and inhibition of interferon synthesis. nt Malnuteition: Some vital info ke proce a tc higher incidene of compen My A higher ease fatality rate it malnourghg 8a tha in vel fe patients hig Ages Most ira infections are commoner gq dangerous at the $0 extremes Of age, 4 exception was the influenza pandemic of ite h caused the highest fatality in young a wh ; ts, 19 twterferon:Isaaes and Lindenmann (1957 9 that chick chotioallantoe membrane Fragmang ed th live oF inactivated influenza virus peg Md diffusible antiviral substance which renderaget cals resistant to viral infection, They gave t interferonto thisantiviral substance, Itwas upg, found that interferon production is «at th tnechanism possessed by vertebrate cel, agai infection. * ia Interferons are a family of host-coded py produced by cells on induction by vir Os viral inducers. Interferon by itself has. np. ge action on viruses but acts on other cels of thy spevis, rendering them refractory to vial infess On exposure to interferon, cll produce a pr (rasan inhibiting protein, TIP) which se inhibits translation of viral mRNA, without a cellular mRNA. What has been called TIP is seq amintue of at least three different enaymes (a pre kinase, an oligonultide synthetase and an RNAse which together block translation of viral mRNA ing viral proteins, Ithas aso been suggested thatinhibiss of viral transcription may also be responsible forgo antiviral activity of interferon Interferons are species specifi, in that the interferon produced by one species can protect only cel of te same or related species against viral infections but nop cells of unrelated species. Thus, the antiviral efx fon human cells is shown by human interferon, and to some extent by monkey interferon but not by chick or mouse interferon. The activity is not vtus specif, ‘The interferon induced by one virus (or even by non viral inducers) can confer protection agains infection by the same or unrelated viruses. However, viruses vary in their susceptit ferferon. Viruses ako vary in their capacity 10 induce interferon, cyto and virulent viruses being poor inducers and avirulent viruses being good inducers, RNA viruses are better inducers than DNA viruses, Examples of potetinduces are togaviruses, vesicular stomatitis virus, Sendai vins ecting © scanned with OKEN ScannerVirus-Host interactions: Viral Infections DV. Nucleic acids (for example, double-stranded and f Ran some ste pelymers (for example, Poly Fare tly feet ind Tayerferon production is increased by increasing ape eoporate (0 about 40°C and is inhibited by AN Fas andHnereased Oxygen tension, Interferon sete begits Within about at hour of induction and saps high eels in 6-12 hours, The prompiness of ‘fen induetion—much quicker than the antibody i prse—suggests that interferons may playa primary bin host defence against viral infections. Celular Treripton and protein synthesis are necessary for jnterferon production. sypes: Based on antigen character, cell of origin and caher properties, interferons have been classified into three types: alpha, beta and gamma. The abbrevia tion IFN designates interferon and species of origin is indicated asa prefix—for example, human interferon alpais usually abbreviated as HulFN-c. ‘Alpha interferon (IEN-o), formerly known as leucocyte interferon, is produced by leucocytes following induction by suitable viruses. Itis a non- slycosylated protein. At least 16 antigenic subtypes have been identified. «Beta interferon (IFN-6), formerly known as ‘fibroblast interferon, is produced by fibroblasts and cpthelal cells following stimulation by viruses or polynucleotides. Its a glycoprotein, ¢ Gamma interferon (IFN), formerly known as immune interferon, is produced by T lymphocytes on stimulation by antigens or mitogens. It is a glycoprotein, It is more concerned with immunomodulatory and anti-proliferative functions than with antiviral defence. It also differs from alpha and beta interferons in having a separate cell receptor. Interferons are inactivated by proteolytic enzymes but not by nucleases or lipases. They resist heating at 56-60°C for 30-60 minutes and are stable over a wide range of pH (2-10), except gamma IFN, which is labile at pH 2. They have a molecular weight of about 17,000, are non-dialysable and non-sedimentable (100,000 g). They are poorly antigenic, so no routi serological tests are available for their detection and ‘timation, Interferon assay is based on its biological activity, such as the ability to inhibit plaque formation bya sensitive virus. The potency of IFN is expressed as International Units (IU) per ml Clinical uses: Many properties of interferon make it an ‘deal candidate for use in the prophylaxis and treatment of viral infeetionsitisnon-toxic, non-antigenic, diffuses freely in the body and has a wide spectrum of antiviral The major drawback initially was its species specificty—interferon produced by non-human cells ‘was not clinically useful. This was overcome to some extent by producing interferon from buffy coat leuco- cytes from blood banks, with NDV or the Sendai virus as the inducer. Now, human interferon is available in unlimited quantities following its commercial produc- tion by cloning in bacteria and yeast. Even so, its initial promise as an antiviral agent has not been ful- filled. Local application of high doses has shown some benefit against upper respiratory infections, herpetic keratitis and genital warts. Limited success has also been reported against generalised herpes infection in immunocompromised hosts, and against hepatitis B and C infections. Some encouraging results have been reported in the use of interferon as an anticancer agent, particularly in lymphomas but there have been reports of toxic effects in cancer patients given high doses of interferon. Although interferon was first recognised as an antiviral agent; itis now known to be a more general regulatory peptide belonging to the class of eytokines. “The main biological effects of interferons are as follows: © Antiviral effects: Induction of resistance to infection © Antimicrobial effects: Resistance to intracellular infections, for example toxoplasma, chlamydia, malaria © Cellular effects: Inhibition of cell growth and proliferation; and of DNA and protein synthesis; increased expression of MHC antigens on cell sur- faces © Immunoregulatory effects: Enhanced cytotoxic activity of NK, K and T cells; activation of macrophage cytocidal activity; modulation of antibody formation; activation of suppressor T cells; suppression of DTH LABORATORY DIAGNOSIS OF VIRAL DISEASES Technical difficulties in virusisolationandidentitication, the length of time required for these procedures and the lack of specific therapy for viral infections have contributed to the sparse use of diagnostic virology © scanned with OKEN Scanner