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Pathology of Viral Infection
Pathogenesis: how viruses cause disease in the host VIRAL STRATEGIES HOST DEFENSES
Viruses: too small to examine with a light microscope like Rapid replication Barriers to viral entry
bacteria. Have to look for patterns in path. Mutation Innate immunity
Virulence genes Adaptive immunity
Viruses are obligate intracellular parasites
Genome: RNA or DNA
Must enter intact host cell; use host to synthesize components
Progeny virus = virions are assembled in cell, can spread to another cell
Each class of virus has specific host cells (species and often tissue specific)
Many similarities in viruses that have similar classification; similar symptoms Taxonomy:
even across species (good for animal models) 1. nucleic acid (DNA/RNA; +/-, ds/ss)
2. capsid (symmetry of protein shell:
Typical life cycle: entrygenome exposure genome replicationmRNA icosahedral/helical)
synthesis protein synthesis assembly (viral proteins/virions) release 3. envelope (lipid membrane,
infection of new cell naked/enveloped)
4. dimensions of virion / capsid
Budding: enveloped viruses take part of the host cell membrane with ‘em.
Patterns of disease: vast majority of infections are subclinical. See chart (dark sections = viremia; can detect in blood )
Acute (rhino, rota, influenza)
Persistent (lymphocytic choriomeningitis v.)
Latent/reactivating (herpes)
Slow (HIV, measles)
Types of viral virulence genes: studied with tissue culture & animal models + mutations
1. Viral replication: herpesviruses’ DNApol brain only; poliovirus 5’ NCR mutated so not in brain
2. Defeat host defense:
o virokines (viral equivalent of chemokines, subvert immune response),
o viroceptors (tie up host chemo/cytokines)
o not required for growth in vitro but help out in vivo
3. Promote virus spread within/among hosts: gD protein in HSV1 recognizes cell receptors; pt mutation blocks CNS spread
4. Toxic gene products: cause cell injury directly (virotoxins), cause Cl secretion (osmotic diarrhea), etc.
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Tropism: virus has to enter the cell (susceptibility) and then replicate inside it (permissivity)
Neurotropism, Pneumotropism, Enterotropism: or all (pantropism)
Viral receptors: required for viral entry; determines tropism (host & tissue), some also need co-receptor, active process
E.g. HIV-1: two tropic strains depending on co-receptors
o T-cell-line-tropic strain (CD4 + CXCr4 co-receptor)
o Macrophage tropic strain (CD4 + CCr5 co-receptor)
Receptors can be integrins, Ig-like molecules, GAGs, CHOs
target for treatment & protection (e.g. CCR5 antagonists in HIV Rx)
Cytopathic effects (cyto=cell, pathic = abnormal): can be in vivo or in vitro; NOTE: not all viruses produce CPE
1. Cell swelling: bloating of cells
2. Necrosis:
a. ballooning degeneration from membrane injury Cytopathic effects
b. host protein/nucleic acid synthesis shuts down 1. Cell swelling
c. Cell death (pyknosis, hypereosinophilia) 2. Necrosis
i. Single cell necrosis 3. Apoptosis
ii. more widespread (depending on virulence of pathogen) 4. Inclusion bodies
d. Lysis / detachment allows virion release 5. Syncitia/multinucleated
e. Tissue architecture disrupted (caseous or coagulation) giant cells
f. Vesicles can form (necrotic cells, fluid-filled space under epithelium) 6. Cellular hyperplasia /
proliferation 3
g. Can cause malformations during fetal development
3. Apoptosis:
a. Some viral genes promote apoptosis (aid in virus dissemination)
b. Some inhibit apoptosis (longer replication, establish latency)
c. Some do both (HIV’s “Tat”) depending on context.
4. Inclusion bodies: arrays/aggregates of viral/cellular products
a. Often present only very early in infection
b. Intranuclear and/or intracytoplasmic
c. Can be eosinophilic, basophilic, or amphophilic
d. Usually > ½ diameter of cell
e. Can see peripheralization of chromatin in big inclusions; some look like owl’s eyes
f. Not pathognomonic but a signature microscopic finding, good for aiding in Dx
i. Not all viral: e.g. bismuth inclusions in liver
5. Syncitia/multinucleated giant cells
a. Viral fusion proteins expressed on cell surface cells fuse together (in vivo/vitro)
b. Allows virus transmission without exposure to host defenses
c. Differentiate from: foreign body giant cells, osteoclasts, megakaryocytes
6. Cellular hyperplasia/proliferation
a. Self-limited & transient usually but may be PRE-NEOPLASTIC
b. May be due to atypical differentiation or accumulation of viral products
c. E.g. molluscum contagiosum, pox virus, EBV burkitt’s lymphoma, HPV cervical carcinoma
Alteration of host cell functions leads to the visible cytopathic effects – can also alter other functions (cytoskeletal
depolymerization, for instance)
Host Responses
Virus-induced immunopathology: can be CD8 or CD4 (Th1 or TH2) T-cell mediated, antibody mediated, etc.
Can result in immune deposits in glomeruli & cause pathology there
Why study this stuff? Viruses are constantly emerging and re-emerging; classes tend to cause similar diseases, so if we
study something we’ve seen before, we might be better prepared when something new emerges.
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Negative Strand Viruses
Positive vs Negative strand viruses
Negative strand: antisense genome, polymerase included with Key features of Negative Strand Viruses
incoming virion; first step is to make a + strand (full length RNA is not infectious
antigenome)
Virion contains RNA-dep-RNApol
Postive strand: sense genome, no polymerase included with
Encapsidation: Genomic RNA
incoming virion; polymerase synthesized as first step via packaged in protein (“nucleocapsid”)
genomic RNA translation
Nucleocapsids have helical structure
Enveloped virions
Influenza Viruses Entry: virion fusion or cell-cell fusion
3 types: A, B, C
A/B antigentically distinct, structurally similar
Both cause dz in adults and children
A more prevalent than B
Influenza A: ducks, chickens, horses, swine
o Birds = largest reservoir
Transmission:
Birds pigs, other non-humans (rarely humans
with some exceptions)
Pigs Humans is most common
Mechanism of entry:
1. virus binding (HA/sialic acid) endocytosed
2. low pH induces conformational change in HA in endosome hydrophobic AAs in HA exposed
3. fusion of envelope with endosome membrane release genomes into cytoplasm
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HA – needs cleavage for activity:
synthesized in pro-form; needs cleavage for conformational change/activation of fusion function
cleaved by tryptase Clara, serine protease secreted by nonciliated Clara cells in bronchial/bronchiolar
epithelium (lumen of respiratory tract; may account for restricted location of virus replication)
happens at defined site (R/K); both HA fragments remain bound together (dipeptide linkage)
Neuraminidase
Tetramer; 9 recognized subtypes in influenza A (N1-9)
Cleaves sialic acid residues on cell surface during virus exit; if mutated, can’t exit cell surface
M2 protein
Tetramer, spans viral envelope, activated via acidity of endosome
Pumps protons into virion: loosens protein-protein contacts, facilitates virus uncoating
Target of amantadine
Replication
Genome replication happens in nucleus
o No mRNA capping/methylating enzymes, so steals caps (+10-13nts) to prime mRNA synthesis
Viral mRNAs translated on sER & rER
HA/NA transported through Golgi to cell membrane,
Glycoproteins (HA/NA) aggregate on surface of cell membrane, viral proteins & genomes aggregate underneath,
and the virus buds off, coated in an envelope
Immunity
Innate resistance: mucus barrier, clearance by cilia, alveolar Mφ
o Impairment in any of these: ↑ risk infection (elderly, smokers, COPD, immunocomp, pregnant)
Adaptive immunity:
o Protection: IgA (mucosal), IgG (serum)
o Clearance: IgG + complement, CTL
Complications:
Primary virus infection: Interstitial pneumonitis
o Cardiovascular dz; pregnancy predispose
o Progression from classical 3d sx bilateral findings, no consolidation
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o CXR: bilateral infiltrates
o Non-bacterial: normal flora in sputum, no Abx response (high mortality)
Secondary bacterial pneumonia:
o from damage to innate immune system, destruction of ciliated epithelial cells, abnormal Mφ function
o Age > 65yo, pulmonary dz predispose
o Improve, then worsen; consolidation
o CXR: consolidation
o Bacterial: sputum shows S. pneumo, S. aureus, H. flu, Abx response (low mortality)
Immunization
1. Killed/inactivated vaccine (mostly HA/NA)
a. Reformulated annually (WHO isolate/IDs viruses, reports strains to reference lab, panel makes rec)
b. Health care workers, populations at high risk of morbidity & mortality
c. Partial protection: incidence ↓ 30-70%, morbidity/mortality ↓ 60-90%
2. Live attenuated intranasal (FluMist)
a. Replication restricted to nasopharynx: cold-adapted (grows best @ intranasal temp); restricted
replication at 37C)
b. Reformulated annually; approved for use in healthy people 5-49yo
Diagnosis
Direct detection (stain NP aspirates with flu-specific mAb), culture
Paramyxoviruses
General characteristics:
No epidemiologically important antigenic change Paramyxoviruses: medically important
No natural reservoir: constant person-person spread 1. Parainfluenza 1-4
2. Respiratory Syncitial Virus
Spread: respiratory route
3. Human metapneumovirus
Various proteins: H (receptor binding), F (fusion), M (assembly),
4. Measles
others too.
5. Mumps
Genome nonsegmented, mRNA generated by polymerase
reinitiation at different promoter regions.
Replication cycle:
1. fuse @ neutral pH intracellular replication (all RNA in cytoplasm, H/F ER/Golgi PM)
2. exit: nucleocapsids assemble underneath H/F; virion assembly mediated by matrix protein
a. Virion budding from cell membrane
b. Fusion with adjacent cell (surface proteins fusogenic @ neutral pH)
i. Leads to GIANT CELLS & syncitia formation
Human Metapneumovirus
ID’d Netherlands 2001 from respiratory specimens from 20+ yrs; cytopathic effect similar to RSV (syncytia),
Most infections: childhood (<5yr)
Causes 7-40% ped resp infections
Parallels to RSV:
o seasonal (winter), initial exposure in childhood, severe dz in infants/elderly
o range of clinical sx: mild respiratory symptoms to severe cough, bronchiolitis, pneumonia
o repeated infections occur but less severe dz (URI only)
Dx: RT-PCR, Ab for direct-detect
Parainfluenza
Common cause of URIs
Most common cause of croup (laryngotracheo-bronchitis) in young children
Most children: infected by 5 yo, can be re-infected by less severe
Diagnosis: culture; vaccine not yet available
Measles
Worldwide distribution; incidence varies with vaccination rates
o Epidemic if high vaccine coverage; Endemic if low
Age: changed with countries with high vax rate
Transmission: Respiratory & Aerosol
o Attack rate: 99.9% (only 1:1000 escapes infection if exposed!)
o Mortality rate: developing countries, 30% in infants 6-9mos
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Mumps
Infection of glandular epithelial cells
Parotitis & orchitis most commonly recognized (big swollen jowls or testicles; mumps gives ya bumps)
Pancreatitis/ovarian infection occur but infrequently recognized
Meningitis 10% all cases
Diagnosis: Culture (saliva, urine, CSF); serology, molecular methods now
Prevention: live attenuated vaccine
Rhabdoviruses
Rabies is only important human pathogen
Incidence: depends on control of domestic animals (better in US than developing world)
Endemic in wildlife: bats, raccoons, skunks, coyotes, foxes
< 10 cases / yr in US; mostly imported or contact with rabid bats
Pathogenesis:
1. in saliva of bite of infected animal limited replication in muscle, subepithelial tissue
2. uptake by sensory/motor neurons; retrograde transport to cell body & major replication there
3. trans-synaptic transmission: early avoidance of immune reponse
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The Herpesviruses
Note that these are in the same family as EBV, HHV8, etc. which cause cancer (previous lecture)
Common features: similar morphology, ubiquitous, asymptomatic infection, common modes of replication / life cycles
ALL establish LATENT infections ≪ notorious feature of herpesviruses; Reactivation can produce disease
Seroprevalence: extremely high in young adults (latent & lifelong)
o HHV8 is the only rare one
Physical characteristics:
Enveloped, have nucleocapsid with genome woven into protein coat
Gargantuan genome (>100k, 50+ genes)
1. Enzymes & structural genes
2. Non-structural genes too: modulate host cell gene expression, host immune responses
Infection: 2 “modes”
1. Productive (“lytic”) infection: release of progeny virions
2. Latent infection: no virions produced, reservoir for recurrent disease
a. Recurrent disease results from:
renewed replication or induced cell proliferation (tumor-inducing γ-herpesviruses only)
Lytic infection:
1. Viral entry (envelope fusion nucleocapsid transported to nucleus
2. Gene tx, genome rep, progeny nucleocapsid assembly in nucleus
3. Nucleocapsids bud from nucleus – viral envelope is formed from nuclear membrane (unusual)!
4. Release via exocytosis
TEMPORAL CASCADE OF LYTIC INFECTION GENE EXPRESSION
Genes Functions
Although latent infection has restricted cell tropism (see
α (immediate early) regulators of viral gene expression
comparison table), knowing where the virus “hides out”
β (early) proteins for genome replication
during latency is important (see slide on right)
γ (late) viral structural proteins
Transmission:
LYTIC INFECTION LATENT INFECTION
Natural modes: “mixing & matching of skin & mucous
membranes” Lots, temporal
skin, genital tract: HSV-1/2 GENE EXPRESSION cascade (see Restricted
oral secretions: HSV-1/2, CMV, HHV-6, EBV table)
INFECTED CELL TYPES
respiratory tract: VSV (weird) Many (≥2) Few (1-2)
(TROPISM)
Iatrogenic modes
VIRION PRODUCED? Yep Nope
transfusion (e.g. CMV, hiding in monocytes)
transplants
Disease manifestations:
Low severity: Recurrent infections, immune competent
High severity: Primary infections, immune impairment
o Populations with severe infections:
immunodeficient (HIV, etc.),
immunosuppressed (transplant pts, cancer pts),
fetuses/newborns, malnourished pts, burn
victums
o Use prophylactic antibiotics when indicated; high index of suspicion to dx/treat
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Herpes Simplex Virus Diseases
Most common presentations: herpes labialis & genital herpes
Pathogenesis
1. Transmission: skin/skin or mucous
membrane/mucous membrane contact
2. Primary infection: epithelial cells (productive)
3. Retrograde transport up axon
4. Secondary infection: sensory neuron cell body
(latent)
a. Orolabial: trigeminal ganglia
b. Genital: sacral ganglia
5. Reactivated(stress, illness, UV light)
6. Anterograde transport down axon
7. Recurrent infection: epithelial cells (productive)
3. HSV keratitis: #1 cause of infectious blindness in developing world; dendritic ulcers in eye
2 mechanisms of pathogenesis
o Autoinoculation (orolabial, spread to eye)
o Trigeminal nerve ophthalmic root infection (after ganglion reactivation)
Genital Herpes
TRANSMISSION IS COMMONLY UNRECOGNIZED
Asymptomatic shedding is common Epidemiology of genital herpes
(70% acquired from asymptomatic partner) 500K cases/yr in US; 40-60M prevalence
Primary infections are often asymptomatic Correlated to number of sexual partners
(80-90% infections unrecognized!) Women > Men for susceptibility
Factors unknown (shedding rates don’t impact transmission!) (unknown why, 8% vs 2% /yr)
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Recurrence
Recurrence w/ Sx can occur after years of “silent” infection; don’t assume infidelity!
Symptoms less severe than primary (shorter shedding duration, fewer lesions)
Frequency: 90% have >1 recurrence / yr, 40% >6, 20% >10
Acyclovir & Genital Herpes
Factors that affect recurrence:
Reduces recurrences
o time since acquisition (shedding declines 70% over 10 yrs) (w/Sx by 75%, Asx too)
o virus type (HSV-2: more, more severe recurrences than HSV-1) Reduces transmission
o immune status (immunocompromised = more frequent (50%)
recurrence)
Cytomegalovirus
Usually asymptomatic but can cause disease:
CMV Mononucleosis 80-20 rule (wards)
20% of mono (EBV = 80%) If common: say 80%
Frequent manifestation of primary CMV infection in young adults If uncommon: say 20%
Fever, lymphadenopathy, lymphocytosis without exudative pharyngitis
o EBV = sore throat, CMV = usually not
HETEROPHIL ANTIBODY NEGATIVE: monospot test will come up negative! (unlike EBV)
Congenital infection
Most common congenital viral infection
Severity depends on maternal serostatus in pregnancy
o Primary maternal infection: severe symptoms ~25% births
Jaundice, hepatosplenomegaly, petichial rash, cerebral calcifications, chorioretinitis, motor disability
20%: late onset hearing loss
o Reactivation during pregnancy: usually asymptomatic at birth
but 15% with late onset hearing loss!
Special populations (solid-organ/bone marrow transplants; leukemia/lymphoma pts, AIDs pts with low CD4)
HIV: reactivation/disease when CD4 < 50 (uncommon with HAART)
o Retinitis, encephalitis, colitis with ulcers
Bone marrow transplant: commonly pneumonia (prophy with ganciclovir)
SOLID ORGAN TRANSPLANT: huge problem!
o Usually manifests as disease in allograft
liver = CMV hepatitis, lung = CMV pneumonitis (renal ≠ nephritis though)
o Highest risk: CMV seronegative recipient and seropositive donor
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HHV-6 and -7
Roseola infantum (exanthum subitum): rash-like illness in young kids & transplant patients
Can see febrile seizures, other sx possible, may contribute to HIV disease progression & exacerbate other viral dz
Erythematous rash
Herpesvirus diagnostics
Viral culture (HSV from all sites except CSF, makes it hard to culture for HSV meningitis!)
Rapid antigen detection from lesions
PCR for nucleic acids (including CSF)
Antibody detection: limited utility except mono & to identify high risk pts for transplants
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