VIRAL INFECTIONS OF THE CENTRAL NERVOUS SYSTEM(POLIO, RABIES)

Ochung Muge
Odhiambo Samwel
Faith Mwende
 Viral infections of the CNS

 No normal flora in CNS and PNS

 Nervous system disease
Meningitis:
inflammation of the meninges =
membranes surrounding the brain & SC
Encephalitis: inflammation of the brain .
 INTRODUCTION

1. Blood-borne invasion takes place across

 BBB – encephalitis
 Blood-CSF barrier – meningitis
 Microbes can traverse these barriers by infecting the
cells that comprise the barrier.
 CNS infection are usually
 Blood-borne invasion most common e.g. poliovirus or
Neisseria meningitides
 Invasion via peripheral nerves; less common e.g. herpes
simplex, varicella zoster virus (chickenpox),
2. Invasion via peripheral nerves
 HSV and varicella-zoster virus present in skin or
mucosal lesions travel up axons to reach the
dorsal root ganglia
 Rabies V, introduced into muscle tissue by bite
of a rabid animal. It enters peripheral nerves &
travel to CNS to reach the neurons
 Common characteristics of CNS Viral infections

 Clinical presentation
 Typically acute onset
 Healthy hosts are often afflicted
 Frequency occurs as meningoencephalitis
Meningitis – fever, headache, stiff neck
Encephalitis – meningitis with mental status changes (seizures,
decreased consciousness, confusion)
Most CNS infections – meningoencephalitis
Pure encephalitis – rabies Virus
Pure meningitis – Coxsackie Virus
 CNS virus pathogenesis

 Exposure (epithelial layer disruption. Local replication) 

dissemination (viremia, secondary amplification)  CNS
entry (BBB disruption, axonal transport)  inflammation
(direct & indirect cell damage target cells- neurons, glial
cells, endothelial cells)  clinical disease
 Causes of Viral encephalitis

 Herpes V: HSV1 & 2, VZV, CMV, EBV, HHV-6

 Adenovirus
 Enteroviruses, poliovirus
 Measles, mumps, & rubella Virus
 Rabies virus
 Arboviruses: Japanese encephalitis, St. Louis encephalitis V;
West Nile encephalitis Virus
 Reoviruses: Colorado tick fever Virus
 Arenaviruses: lymphocytic choriomeningitis virus
Poliovirus

 +ssRNA
 Picornaviridae family
 Enterovirus genus
 Poliovirus spp.
 It’s an enterovirus (RNA)
 Has 3 serotypes (1,2,3)
 Minimal heterotypic immunity btn serotypes
 Rapidly inactivated by heat, formaldehyde, chlorine, UV light -
enveloped
Poliovirus
 Poliovirus epidemiology

 PVs are distributed globally. B4 the availability of immunization, almost 100% of

the population in developing countries b4 the age 5 were susceptible to PV
infections
 The availability of immunization and the PV eradication campaign has eradicated
PV in most endemic regions except in India Subcontinent & Africa.
 As of 2013, polio remains endemic in only 3 countries: Nigeria, Pakistan &
Afghanistan – PV vaccine thought to be a bioweapon in some Arab countries
 Poliomyelitis in Kenya

 The 1st recorded poliomyelitis epidemic in Kenya occurred in 1921-1922

 The last case of confirmed poliomyelitis in Kenya was in 1984 and was isolated
on stool culture to have been due to PV2
 Kenya confirmed a case of circulating vaccine derived polio Virus in Dadaab
refugee camps.
 Modes of transmission

 Source of infection: Apparent and subclinical patients

 Oral-oral infections: direct droplet infections
 Faeco-oral infections
 Food-borne (ingestion) infections through the ingestion of
contaminated foods. Vehicles include milk, water
 Hand to mouth infections.
 Poliomyelitis

 Polio = gray matter

 Myelitis = inflammation of SC
 The most commonly associated with paralysis
 Polio Virus infects and causes disease in humans alone!
 Individual exposed to Polio virus (infections or vaccination) develop immunity to
Polio virus
 3 serotypes of Polio virus have been identified – PV type1, PV2, PV3 – each with a
slightly different capsid protein
 All 3 are extremely virulent and produce the same disease symptoms
 PV1 is the most commonly encountered form, and the one most closely associated
with paralysis.
 Pathogenesis of polio virus

• PV enters the host via ingestion-oral

• Hpvr/CD155 is the main receptor for polio virus(marker for Dentritic and
macrophages)
• The virus multiplies in the alimentary mucosa, and possibly in the tonsils and Peyer’s
patches
• The virus then moves to blood stream through the putative barrier(virulent poliovirus
strains cross more efficiently than attenuated strains)
• Virus invades the CNS and replicates in neurons particularly motor neurons
• 2 ways in which the virus enters the CNS-
Permeation through the blood-brain barrier (BBB)
Virus transmission via peripheral nerves
• Paralytic poliomyelitis occurs as a result of neuronal destruction by lytic replication of
the poliovirus
 Replication of the Polio virus

• Binding/ attachment -to CD155/PVR

• Entry/penetration -the poliovirus capsid dissociates, releasing the RNA genome into the
cytoplasm
• Translation- the viral RNA is translated to provide viral proteins needed for genome
replication and the production of new viral particles.
• RNA synthesis- it is done by virus-encoded RNA-dependent RNA polymerase
• Newly synthesized +-strand RNA can enter the RNA synthesis cycle, or it can become
mRNA (whereupon its 5′ terminal VPg is cleaved off), or it can be encapsulated once
enough capsid proteins have been synthesized.
The replication cycle of poliovirus is located in the cytoplasm of the host cell. The major
steps are (1) virus binding to the receptor and uncoating, (2) translation, (3) processing of
the polyprotein into functional proteins, (4) RNA replication, (5) encapsidation and virus
morphogenesis. Newly synthesized plus-stranded RNA molecules may have three
destinies: translation, template for RNA transcription, or encapsulation.
 Clinical Syndromes

 Incubation: 7-14 days

 Asymptomatic illness: 90%
 Abortive poliomyelitis, the minor illness: 5% infected people
 Non-paralytic poliomyelitis or aseptic meningitis: 1%-2% of patients with poliovirus
infections.
 Paralytic polio, the major illness: 0.1% to 2%of persons with poliovirus
POLIOMYELITIS – SEQUENCE OF EVENTS
Time Event
(days)
0 Small intestine: 1o infect,
replication
1 Mesenteric lymph nodes –
replication
2 Blood stream – 1o viremia

5 Initial appearance of antibodies

6-7 CNS– infect, replic, intraneural

spread
10 High level of antibody in serum

11 Paralysis

12 Excretion of virus in faeces

 Immune response to polio virus

Innate response
•Including macrophages, neutrophils, natural killer (NK) cells, dendritic cells (DCs), and
innate lymphoid cells (ILCs)
•Neutrophils- kills infected cells via oxygen dependent and oxygen independent pathways
•N.K cells have ability to detect low expression of MHC molecules hence attack the
infected cells(FAS/FASL)
•Interferons- they have antiviral effect

Adaptive immunity
•Humoral response-neutralizing antibodies IgM will be produced at initial stages of
infection can be detected in serum 3 days after infection
•secretory IgA will prevent the virus from establishment
•IgG peaks after 3-4 weeks and plays a key role in viral elimination and to encounter 2 nd
infection
•T-cells CD8 cells will eliminated the viral infected cells
•CD4 plays a role in elimination of the virus
 Polio virus immune eversion

•To evade immune monitoring by pattern recognition receptor pathways, polio virus
encode a small protein, Vpg, that binds to the 5’ end of its RNA genome and allows the
RNA to escape molecular recognition

•Reduce expression of MHC-1

 Lab Diagnosis

 Definitive diagnosis is made by isolation of the virus from stool, CFS, oropharyngeal
secretions
 Cell culture involves fibroblastic MRC-5 cells
 CPE is usually evident within 36 hours
 Serotyping is based on neutralization of CPE by standardized antisera using intersecting
pool followed by specific sera.
 ELISA
 IFA
 neutralizing Test
 Compliment fixation test
 Virus isolation

 Polio virus can be readily isolated from throat swabs, feces, & rectal swabs
 Requires molecular techniques to differentiate between the wild type & the vaccine
type.
Serological testing
 A 4-fold titer rise between the acute & convalescent specimens suggestive of Polio
virus infections
CSF analysis
 The CSF contains an increased number of leukocytes – from 10-200 cells/mm 3
(primary lymphocytes) and a mildly elevated protein, from 40-50 mg/100 ml.
 Prevention

 General prevention
 Health promotion through environmental sanitation
 Health education (modes of spread, protective value of vaccination)
 Vaccines
 1st vaccine was made in Canada by Connaugt
 Immunity
 Secretory IgA and neutralizing antibody (IgG, IgA, IgM) persist for life span
 Prevention – vaccination

 Active immunization
 Sabine vaccine-1957
 Oral Polio Trivalent live attenuated vaccine
 Contains 3 serotypes of vaccine V
 Grown on monkey kidney (vero) cells
 Shed in stool for up to 6 weeks following vaccination
 Salk vaccine – 1954
 Intramuscular Polio Trivalent killed/ inactivated vaccine
 IPV is used for adult immunization and Immunocompromised patients
 Sabin vaccine - Oral Polio Vaccine

Advantages
 Highly effective in producing immunity to PV
 50% immune after 1 dose
 > 95% immune after 3 doses
 Lifelong immunity- – no polio booster necessary.
 Local immunity-Induction of secretory antibody response similar to that of natural
infection
 Possibility of attenuated virus circulating in community by spread to contacts (indirect
immunization)(herd immunity)
 Ease of administration
 Lack of need for repeated boosters
 Stops viral replication in G.I.T. Dead Salk vaccine virus has no effect on gut replication
 No problem with selective inactivation
 Greater cross reaction as vaccine virus also has antigenic drift

Disadvantages
 Risk of vaccine-associated poliomyelitis in vaccine recipients or contacts
 Spread of vaccine to contacts without their consent
 Unsafe administration for immunocompromised patients
 Salk vaccine – Intramuscular Polio
Vaccine

Advantages
 Effectiveness
 Good stability during transport and in storage
 Safe administration in immunocompromised patients
 No risk of vaccine-related disease
Disadvantages
 Lack of induction of local (gut) immunity
 Need for booster vaccine for lifelong immunity
 Fact that injection is more painful than oral administration
 Fact that higher community immunization levels are needed than with live vaccine
 RABIES

 Definition: is an acute progressive encephalomyelitis

 Another CNS virus
 It is a preventable viral dx of mammals most often transmitted through the bite of
a rabid animal
 The dog and bats are the main a reservoir of rabies
 Rabies is primarily a dx of terrestrial and airborne mammals
 The leading viral zoonosis as regards global public health significance. The case to
fatality rate is the highest of any infectious disease
 Rabies Virus

 It’s a member of the genus Lyssavirus of the family Rhabdoviridae.

 SS (single-stranded) RNA enveloped Virus, characteristic bullet-shaped
appearance with 6-7 nm spike projections
 Virion 130-240 nm * 80 nm
 Exceedingly wide range of hosts i.e. cats, dogs, bats, racoons
 There are 5 other members of Lyssavirus that cause rabies: Mokola, lagosbat,
Duvenhage, EBL-1 &2(European Bat lyssavirus 1&2)
 Duvenhage and EBL2 have been associated with human rabies.
 Viral structure

 The virus genome encodes five proteins associated with either the ribonucleoprotein
(RNP) complex or the viral envelope.
 The L (transcriptase),
 N (nucleoprotein), and NS (transcriptase-associated) proteins comprise the RNP
complex, together with the viral RNA.
 These aggregate in the cytoplasm of virus-infected neurons and compose Negri
bodies, the characteristic histopathologic finding of rabies virus infection.
 The M (matrix) and G (glycoprotein) proteins are associated with the lipid
envelope. The G protein forms the protrusions that cover the outer surface of the
virion envelope and is the only rabies virus protein known to induce virus-
neutralizing antibody
 Rabies hosts

 All warm-blooded vertebrates are susceptible to

experimental infections
 Mammals are the natural hosts of rabies
 Reservoirs consist of the Carnivora (canids,
skunks, racoons, mongoose, etc.) and Chiroptera
(bats)
 Epidemiology of Rabies

 Rabies is distributed on all continents ( with the exception of Antarctica)

 Several areas are considered ‘free’ of the dx, including many islands in Pacific
Oceania
 Globalization may threaten the dx-free status of many localities, due to the
introduction of rabid animals.
 More than ~55,000 human rabies deaths per year
 Most occur in developing countries
 Millions of human exposure per year
 The domestic dog is the single most important animal reservoir
 Wildlife important, especially in developed countries
 RABIES PATHOGENESIS

 Virus is transmitted via bite

 Multiplies in the Salivary glands
 Enter peripheral nerves
 Travel by retrograde axon flow in axoplasm of nerves to
CNS
 Once it reaches this stage, immunization not effective
 Replicate in brain
 Centrifugal flow to innervated organs, including the
portal of exit, the salivary glands
 Viral excretion in saliva
 Intervention has to be very fast before it disseminates!
 Replication of rabies virus

 The replication of rabies virus is believed to be similar to that of other negative-

stranded RNA viruses.
 The virus attaches to the host cell membranes via the G protein, penetrates the
cytoplasm by fusion or pinocytosis, and is uncoated to RNP. The core initiates
primary transcription of the five complementary messenger RNAs by using the
virion-associated RNA-dependent RNA polymerase.
 Each RNA is then translated into an individual viral protein. After viral proteins have
been synthesized, replication of the genomic RNA continues with the synthesis of
full length, positive-stranded RNA, which acts as a template for the production of
progeny negative-stranded RNA
 Host defense

 Host defense to rabies virus depends on-The host animal species, viral variant, inoculum
concentration, body location and severity of exposure, and host immune status.
 The association of virus-neutralizing antibody, principally IgG, and protective immunity
is well known.
 Production of cytokine, such as interferon, induced during rabies virus infection or
vaccination, has been reported to abort the disease if it occurs shortly after viral
infection. In one clinical trial, however, all subjects died despite experimental treatment
with high doses of alpha interferon.
 Recently it has been demonstrated that animals immunized with purified RNP
complexes or recombinant nucleoprotein vaccines resisted lethal challenge with rabies
virus, although the role of N protein in protection, illness, or recovery is unclear
 Clinical stages

 Incubation period (range = ~<7 days to >6 year: average is ~4-6 weeks)
 Prodromal phase (non-specific signs)
 Acute neurological phase
 Coma
 Death
 Rabies Diagnosis

 Based upon history of animal exposure & typical neurological clinical signs
 Post-mortem demo of viral antigen in CNS is gold standard
 In humans, ante mortem detection of viral amplicons, antibodies, or antigens (e.g.
sera, CSF, saliva, nuchal biopsy
 Control and Prevention

 Animal rabies is prevented by vaccinating susceptible species, particularly dogs

and cats.
 Human rabies control and preventions involves;
1.Pre-exposure vaccination
 Provided to subjects at risk b4 occupational or vocational exposure to rabies
 Subjects include diagnosticians, lab & vaccine workers, vets, cavers, etc.
 Simplifies Post exposure management
2. Post exposure prophylaxis (PEP)
 Provided to subjects after rabies exposure
 Consists of wound care, rabies immunoglobulin, and vaccine
 If PEP is prompt and proper, survival virtually is assured.
 Rabies Vaccines (for pre- & PEP)
 Rabies immunoglobulin (only in PEP)
 2 human rabies vaccines in USA: Human Diploid Cell Vaccine Imovax (HDCV)
Purified Chick Embryo Cell Rabavert (PCEC)
 Rabies Immunoglobulin

 2 human Rabies immune globulins

 hyperRab TM S/D
 imogam Rabies-HT
 Both supplied in vials at ~ 150 IU/ml
 Human rabies immune globulin (HRIG) is administered only once, at the
beginning of anti-rabies prophylaxis, to previously unvaccinated persons
 This will provide immediate antibodies until the body can respond to the vaccine
by actively producing antibodies of its own.
Pre-exposure Vaccination
 Vaccine given on days 0, 7, and 21 or 28
 Serology occurs every 6 months to 2 year (if remaining at risk)
 If antibody titer not adequate, administer a single booster dose
 If ever exposed, give a vaccine dose on days 0 and 3, regardless of titer.
Post-exposure Prophylaxis
 Wash lesions well with soap and water (tetanus booster ad hoc)
 Infiltrate rabies immune globulin (20 IU/kg) into and around the margin of the bites
 Administer vaccine on days 0,3,7,14 & 28.
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