Viral Gastroenteritis 383

U. Desselberger and J. Gray (editors)

© 2003 Elsevier Science B.V. All rights reserved

SECTION III

Enteric adenoviruses

Introduction

Human adenoviruses are members of the Adenoviridae family and occur in 51 distinct
serotypes, classified into six different subgroups (A-F; recently termed species, van
Regenmortel et al., 2000) according to immunological, biochemical and biological dif-
ferences. Within those, Adenoviruses of subgroups F, serotypes 40 and 41, have been
found to be regularly associated with gastroenteritis in infants and young children (for
general review see Ruuskanen et al., 1997; Russell, 1998; Wadell, 2000).
Adenoviruses are non-enveloped icosahedral particles of a diameter of 80 nm. The
viral capsid is formed by 252 capsomeres termed hexons (as most of them are sur-
rounded by six other capsomers); each hexon is formed by a trimer of polypeptide 2.
From 12 capsomers which are located at the vertices of the virus particles, antennae-
like projections extend (fibre). These morphological units are called pentons (as they
are surrounded by 5 capsomers and exhibit 5 fold symmetry). Each penton capsomer is
formed of 5 copies of polypeptide 3. The fibres are glycoproteins consisting of trimers
of polypeptide 4. The genome consists of a linear double-stranded DNA molecule
of approximately 35,000 base pairs (bp) encoding eight different transcription units
which produce early proteins (E1A, EIB, E2A, E3, E4), intermediate proteins (P9 and
4A2) and late proteins (L1-L5).
Adenovirus particles are stable at low pH, and unaffected by bile and gut enzymes,
allowing them to replicate to high titers in the gastrointestinal tract.
Viral replication starts with binding of virions to receptors (members of the immu-
noglobulin superfamily) on the surface of host cells, mediated through the head
region of the fibre protein. Proteins of the integrin family have been implicated as
co-receptors (Wickham et al., 1994). After uptake by receptor-mediated endocytosis
the pentons are degraded in the acidic environment of endosomes. The viral core con-
taining DNA enters the nucleus in which various mRNA are produced and released
in a strictly controlled fashion. Early protein E1A acts as a transcriptional activator,
and E1B binds to p53, thus inhibiting p53-mediated tumour suppression and inducing
the host cell to enter the S phase of the cell cycle. E3 protein inhibits TNF-mediated
apoptosis and binds to the heavy chain of MHC class 1 molecules, thus impairing its
transport to the cell surface and helping immune evasion of the vials-infected cell. It
was in the adenovirus replication system that the fundamental mechanism of mRNA
splicing was discovered by JE Darnell Jr, P. Sharp, TR Broker and their colleagues,
(Bachenheimer and Darnell, 1975; Berget et al., 1977; Chow et al., 1977, 1979). Viral
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DNA synthesis starts at 7 hours post-infection, and synthesis of viral structural proteins
(capsid components) 2 hours after that. At the same time inhibition of host cell protein
synthesis occurs. Newly formed viral structural polypeptides are transported into the
nucleus where the formation of particles starts, identifiable as paracrystalline arrays in
intranuclear inclusion bodies. Viral morphogenesis begins with the formation of cap-
somers from monomeric polypeptide subunits. Hexon base and fibre are combined to
form the penton unit. A cis-acting packaging element has been localized in the left end
of the viral DNA, immediately upstream of the E1A transcription unit which promotes
preferential encapsidation of viral DNA into viral capsid. Newly synthesized capsids
mature through a number of proteolytic cleavage steps involving five viral polypeptide
precursors. Virus particles are released from infected cells, aided by a very late protein
of the E3 transcription unit which promotes cell lysis. Up to 105 particles are assembled
per cell within 30 hours after infection. Enteric adenoviruses have a very restricted host
cell range in vitro compared to adenoviruses of other subgroups. F Stevenson and V
Mautner (Section III, Chapter 1) have explored this by investigating the EIA genome
region and found that the EIA promoter is weak in most cell lines compared to EIA
promotors of adenovirus type 5 (subgroup C).
Adenoviruses replicate in the epithelia of the human respiratory and gastrointestinal
tracts as well as in the conjunctiva and in lymphocytes. They are most easily recovered
from nasopharyngeal aspirates, throat swabs, conjunctival swabs, and faeces. Various
viral factors have been implicated in pathogenesis. Whilst the pentons are directly
cytotoxic, several early proteins play a role in the ability of adenoviruses to persist in
lymphoid cells. These proteins counteract TNF, downregulate the expression of MHC
Class I molecules and counteract apoptosis. The pathogenesis of persistent (possibly
life-long) and often symptomless adenovirus infections is poorly understood (Horwitz,
2001).
Whilst there are good animal models for respiratory adenovirus infections (mouse,
Ginsberg et al., 1991; cotton rat, Ginsberg and Prince, 1994), such a model is not
available for the enteric adenoviruses. The immune response is both humoral and cell-
mediated (Nishio et al., 1992). The correlates of protection have not been definitely
identified, but humoral neutralizing antibodies clearly play a significant role to prevent
reinfection with the same type.
Clinically adenoviruses, mainly those of subgroups B and C, cause respiratory
tract infections (tonsillitis, laryngitis, bronchitis and pneumonia) but also otitis media
and keratoconjunctivitis. However, there are many subclinical infections. In the past
enteric adenovirus (subgroup F) infections were thought to be the second most com-
mon cause of infantile diarrhoea (after rotaviruses; Krajden et al., 1990; Ruuska and
Vesikari, 1991). More recently Norwalk- and Sapporo-like viruses have been recog-
nised as more frequent (see Section IV). Of the adenoviruses detected in faeces, 30-
80% are represented by types 40 and 41 (Uhnoo et al., 1984; Krajden et al., 1990; Lew
et al., 1991). In large surveys, adenovirus infections were associated with diarrhoea in
chidren in approximately 3% of all cases tested (Bon et al., 1999; Waters et al., 2000).
Adenovirus infections with gastroenteritis are a frequent event after bone marrow
transplantation (Hale et al., 1999; Chakrabarti et al., 2000)
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Adenovirus-caused diarrhoeas are mainly found in children below the age of 2

years. Diarrhoea occurs after a short incubation period of about 2 days, more often
than not accompanied by fever and vomiting. The diarrhoeas last on average longer
(8 days, range 3-11 days) than diarrhoeas caused by rotaviruses. Usually, adenovi-
rus gastroenteritis is mild but severe colitis has been found in immunocompromised
patients (Krajden et al., 1990; Janoff et al., 1991). Many enteric adenovirus infections
are asymptomatic (Van et al., 1992).
The diagnosis by electron-microscopy or ELISA is not difficult, as large numbers of
particles are shed during the acute stage of diarrhoea. Enteric adenoviruses grow best
in Graham 293 cells (human embryonic kidney cell line transformed by adenovirus
type 5 DNA). The sensitivity of enzyme immunoassays for enteric adenoviruses is 85-
100% compared to that of electron microscopy. Nucleic acid amplification techniques
can also be applied to the diagnosis of adenovirus infection.
Adenovirus infections occur worldwide as epidemic, endemic or sporadic infec-
tions. Most respiratory adenoviruses are both endemic and epidemic, causing out-
breaks in closed communities (boarding schools, daycare centres, military camps etc.).
Enteric adenoviruses mainly occur endemically, but outbreaks in hospitals and board-
ing schools have been reported. Whilst most infections are in infants and young chil-
dren between 6 months and 5 years of age, they continue throughout life. Serologically
repeated infections with adenoviruses of different types can be demonstrated. The inci-
dence of enteric adenovirus infections is between 4 and 7 per 100 person years in small
children (Mistchenko et al., 1992). Whilst respiratory adenovirus infections can show
seasonal preference (winter and spring) in temperate climates, adenovirus gastroen-
teritis does not exhibit a seasonal preference. Within serotypes adenovirus 40 and 41,
different genomic subtypes have been distinguished (de Jong et al., 1993). J de Jong
has produced a large review (Section III, Chapter 2) on the epidemiology of enteric
and non-enteric adenoviruses and particularly investigated adenovirus infections in
immunodeficient patients (e.g. recipients of bone marrow or solid organ transplants,
patients with HIV infection).
Vaccines have only been produced specific for adenovirus types 4 and 7 for appli-
cation in US military personnel. Vaccines against adenoviruses causing gastroenteritis
have so far not been developed due to the mostly mild course of the disease. Careful
hand washing, both before and after contact with patients, is the most effective preven-
tive measure in blocking transmission of such infections. Hospital infections have been
controlled by cohort nursing of patients, use of gloves, gowns and goggles, and exclu-
sion of symptomatic staff from wards. Disinfectants to clean environmental surfaces
are sodium hypochlorite and chloramine T. There is no specific antiviral treatment,
although ribavirin (Kapelushnik et al., 1995) has been used in a few cases and cidofo-
vir is active against adenovirus in vitro (DeClercq, 1996).
386

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