Morphology, ultrastructure of viruses.

Classification

Different non-cellular forms of infectious agents

Viruses are obligate intracellular parasites that consist of own genome and proteins Viroids are agents that consist solely of a single molecule of circular RNA within the proteins Virusoid are viruslike agent that consisted of own nucleic acid (DNA or RNA) and capsid of virus-helper. Prions are infectious protein particles that are composed solely of protein, they contain no nucleic acid. They cause slow diseases such as Crautzfeldt-Jakob disease in human and scrapie in sheep. Defective viruses are composed of viral nucleic acid and proteins but cannot replicate without a helper virus, which provides the missing function. They usually have a mutation or a deletion of part of their genetic material.

Similar features:

non-cellular structure, obligate intracellular parasitism, absence own metabolism, dependency on metabolic processes of cell-host, possibility to cause infectious process.

Dmitri Ivanovsky (1864-1920)

The first virus was unclosed by Dmitri Ivanovsky, Russian scientist. He studied cause of disease of tobacco. Ivanovsky showed that a disease of tobacco plant was caused by a virus (tobacco mosaic virus).

Definition
Viruses
are non-cellular life forms that have their own genome and can multiply only in host cell, using its metabolic processes

Comparison of viruses and cells

Property
Type of nucleic acid Proteins Lipoprotein membrane Ribosome Enzymes Multiplication by binary fission or mitosis Growth

Viruses
DNA or RNA but not both Few Envelope present in some viruses Absent None or few No

Cells
Always contain DNA and RNA Many Present in all cells Present Many Yes

Only within cells

Most are freeliving

The history of discovered in virology

1892 Dmitri Ivanovsky discovered first virus - tobacco mosaic virus that caused disease in plant 1898 Friedrich Loeffler and Paul Frosch unclosed first virus of animals 1900 Walter Reed showed that viruses may cause disease in human (yellow fever). Their work demonstrated that viruses could infect more than one animal species and that viral disease could be transmitted to human with arthropods. 1911 Peyton Rous demonstrated that viruses could cause malignant growths in animals, showing that some viruses cause cancer (chicken Rous sarcoma virus). 1915 Frederick Twort and Felix dHerelle discovered viruses that infect bacteria (bacteriophages).

Properties of viruses

Ultramicroscopic size, ranging from 20 nm up to 450 nm. Can pass through bacterial filters. They are not cells, structure is very compact and economical. Do not independently fulfill the characteristics of life. Are inactive outside of the host cell and active only inside host cell. Are geometric; can form crystal-like masses. Basic structure consists of protein capsid and nucleic acid. Nucleic acid can be either DNA or RNA but not both. Molecules on virus surface impart high specificity for attachment to host cell. Lack metabolic processes. Lack machinery for synthesizing proteins. Disjunctive method of reproduction. Like alive organisms:
capability for reproduce heredity variability, capacity for evolution

Relative sizes of bacteria and viruses

The electron microscope on microbiology, virology and immunology department of NMU.

The crystalline nature of viruses

Light microscope magnification (l,200x) of purified poliovirus crystals

Highly magnified (150,000x) electron micrograph of the capsids of this same virus, demonstrating their highly geometric nature

Scheme of viral structure

Capsid Covering Envelope (not found in all viruses)

Virus particle Nucleic acid molecule (DNA or RNA) Central core

Various proteins (enzymes)

Generalized structure of viruses

a) An simple virus is a naked virus (nucleocapsid) consist of a geometrical capsid assembled around a nucleic acid molecule
b) An enveloped virus is composed of a nucleocapsid surrounded by a flexible membrane called an envelope or supercapsid.

Morphology of viruses

a) b)

c) d)

i)

g)
f) h)

An array of virus types

Types symmetry of viral nucleocapsid

Isometric (cubical) poliovirus
Helical tobacco mosaic virus Combined T-even bacteriophage

Isometric (cubical) symmetry

Polioviruses

Isometric (cubical) symmetry

Adenoviruses

Helical symmetry

Rhabdovirus

Tobacco mosaic virus

Combine type of symmetry

Structure of viruses
A. Model tobacco mosaic virus that has a helical symmetry with capsid surrounding an RNS genome.
B. Many viruses that infect bacteria, such as the T-even bacteriophages, have complex capsid with DNA contained with a head structure. C. Model adenovirus that has isometric (cubical) symmetry and is naked virus. D. Model coronavirus that complex capsid and envelope

Viral nucleic acid. Unique properties

Viruses contain either RNA of DNA, never both

Viral genome may consist of linear or circular double-stranded DNA, single-stranded DNA, single-stranded linear RNA, or double-stranded linear RNA Some RNA viruses have segmented genome that consist of several molecules of RNA.
Viruses with single-stranded RNA can have positive ore negative genome.

Size and genome content of viruses and bacteria

Size
Smallest virus Largest virus E.coli cell

Genome content
150-200 genes 4000 genes

20 nm in diameter 4-5 genes 300 nm in diameter 1000 nm in diameter

Relationship of viral size to level of dependency on host enzymes for DNA replication
Virus Parvovirus Polyoma virus Adenovirus Increasing size Dependence on host cell DNA synthetic enzymes Depend totally in host cell enzymes Virus codes for a protein that is involved in start of DNA synthesis, rest depends on host enzymes Virus codes for proteins involved in initiation of DNA synthesis and also DNA polymerase Totally independent of host cell enzymes

Poxvirus

Polarity of viral RNA

1. Viruses with negative genome has single-stranded RNA with negative polarity. They use molecule RNA just as its genetic material. An mRNA must be transctibed by using the negative strand as a template. For instance, influenza virus 2. Viruses with positive genome has single-stranded RNA with positive polarity. They use molecule RNA as its genetic material and as mRNA that can connect with ribosomes.

Nucleocapsid of Adenovirus
Naked viruses consist of nucleic acid and proteins.

The viral coat structure surrounded the nucleic acid genome of a virus is called the capsid.

Virions of herpesviruses with supercapsid

Enveloped viruses that have supercapsid consist of nucleic acid, proteins, lipids and glycoproteins.

The envelope is lipoprotein membrane composed of lipid derived from the host cell membrane, protein that is virusspecific, and glycoprotein in the form of spikes on the surface.
The matrix protein, mediates the interaction between the capsid proteins and the envelope

Functions of the viral capsid / envelope

1. Protection of the nucleic acid from the effects of various enzymes and chemicals when virus is outside the host cell. 2. Capsid and supercapsid are responsible for helping to introduce the viral DNA or RNA into a suitable host cell, first by binding to the cell surface and then by assisting in penetration of the viral nucleic acid. 3. Parts of the viral capsid and envelope stimulate the immune system to produce antibodies that can neutralize viruses and protect the host organism against future infections.

Functions of viral proteins

Defence of viral genome Receptors that define spectrum of host cell, which can be

affected by the viruses Attachment on host cell Stabilization of nucleic acid molecules (like histone proteins in eukaryotic cells) Contraction of bacteriophages tails Enzymes Antigens

Enzymes for viral replication

1. Virion enzymes that are constituents of viral particle. There are DNA and RNA polymerases, nuclease, neuraminidase, RNA-dependent DNA polymerase (reverse transcriptase) 2. Viral-induced enzymes that are coded in viral nucleic acid but are not constituents of virion. There are DNA polymerase of poxviruses and herpesviruses, RNA polymerase of polioviruses. 3. Host cell enzymes. There are DNA polymerase of parvoviruses

Morphology of bacteriophages
Shape
Tailed BF

Description and examples

DNA genome, double-stranded. Virion complex shaped, binary symmetry, variable number of capsomers . T-even coliphages Grope A. The tails of the phage are long and contractile Grope B. Tail is long and noncontrative Grope C. Tail is very short and noncontrative

Cubic BF

DNA of RNA genome, icosahedral virion, cubic symmetry, enveloped or naked (X174).

Filamentous DNA genome, single-stranded. Rod-shaped virion, helical symmetry (M13). BF

Bacteriophages T2

Features that used for classification of viruses

Type and characteristic of viral nucleic acid Size and shape of virion Presence or absence of envelope Type of nucleocapsid symmetry Strategy of virus genome Antigenic characteristic of virion Tissue that affected by virus Disease that virus causes Geographic areas where virus was obtained firstly

Animal DNA viruses families

Family
Poxviridae Herpesviridae Adenoviridae Papovaviridae

Strand type
Double Double Double Double

Capsid type
None Icosahedral Icosahedral Icosahedral

Envelope Size
+ + 130-300 150-200 70-90 45-55

Common Name of Important Members

Smallpox virus; complex virus; brick-shaped Herpes simplex virus, Varicella zoster virus, Epstein-Barr virus Human adenoviruses Human papillomavirus

Hepadnaviridae
Parvoviridae

double
Single

Icosahedral
Icosahedral

+
-

42
18-26

Hepatitis B virus
Parvovirus B19

Animal RNA viruses families (1)

Family Strand type
Single

Capsid Type

Envelope Size (nm)

20-30

Common Name of Important Members

Hepatitis A virus, poliovirus, coxsackieviruses, rhinoviruses Norwalk virus

Picornaviridae Calciviridae

Icosahedral

Single

Icosahedral

35-40

Togaviridae Flaviviridae

Single Single

Icosahedral Icosahedral

+ +

45-70 40-70

Rubella virus, western equine encephalitis Yellow fever virus, Japanese encephalitis virus
Parainfluenza virus, mumps virus, measles virus

Paramyxoviridae

Single

Helical

+ 125-250

Animal RNA viruses families (2)

Family Strand type Single Capsid Type Helical Envelope Size (nm) + 790-970 Common Name of Important Members Ebola and Marburg viruses Bunyamwera virus, Hanta virus Human rotavirus, Colorado tick fever virus Influenza viruses Filoviridae

Bunyaviridae Single

Helical

90-100

Reoviridae

Double

Icosahedral

60-80

Orthomyxoviridae

Single

Helical

80-120

Animal RNA viruses families (3)

Family Stran Capsid d type Type Single Helical Envelope Size (nm) + 60-75 Common Name of Important Members Rabies virus Rhabdoviridae Retroviridae

Single

Icosahedral

100

Human immunodeficiency virus (AIDS), oncoviruses Lassa virus; lymphocytic choriomeningitis virus Human infectious bronchitis and corona viruses

Arenaviridae

Single

50-300

Coronaviridae

Single

Helical

80-130

General taxonomic categories (for herpesviruses)

Kingdom Family Underfamily Genus Species Vira Herpesviridae Alphaherpesvirinae Alphaherpesvirus simplex

Type

1, 2

GENERAL PRINCIPLES
DNA VIRUSES: Double stranded DNA except Parvovirus Naked except Herpes, Hepadna & Poxviruses Icosahedral symmetry except Poxviruses Replicate in the nucleus except Poxviruses

Human Adenoviruses

DNA VIRUSES
All are DS except Parvoviridae All replicate in the nucleus except Poxviridae
Icosahedral Complex 1- Poxviridae

Naked non-enveloped ether-resistant 1- Parvoviridae 2- Papillomaviridae 3- Polyomaviridae 4-

Enveloped ether-sensitive 1- Herpesviridae 2- Hepadnaviridae

Adenoviridae

Human Adenoviruses
Adenoviruses were first isolated in 1935 from human

adenoid tissues.
Since then, at least 49 distinct antigenic types have been

isolated from humans and many other types from animals.

All human serotypes are included in a single genus

within the family Adenoviridae.

Morphology

ds-DNA viruses, media sized in diameter, icosahedral Nonenveloped

Antigenic structure All human Adenoviruses share a common group-specific antigen.

Type specific antigens are important in serotyping.

Classification
Adenoviruses are divided into six groups (A to F) based on:
physical, chemical biological properties

Antigenic structure divides adenoviruses into: - 49 serotypes: - About 1/3 of the 49 known human serotypes are responsible for most cases of Adenovirus disease.

Pathogenesis:
Adenoviruses spread by: direct contact, respiratory droplets feco-oral route.

Pathogenesis:
Adenoviruses infect and replicate in the epithelial cells of

the:
pharynx, conjunctiva, urinary bladder

small intestine.

They usually do not spread beyond the regional lymph nodes EXCEPT IN THE IMMUNE COMPROMIZED HOST.

Pathogenesis:
The virus has a tendency to become latent in lymphoid

tissue,
The virus can be reactivated by immunosuppression.

Clinical Syndromes:
Adenoviruses cause primary infection in:
children less commonly adults.

Several distinct clinical syndromes are associated with Adenovirus infection.

CLINICAL SYNDROMES
A. Respiratory diseases:
B. Eye infections:

C. Gastrointestinal disease
D. Other diseases: E. Adenoviral infections of the immune compromised host

A. Respiratory diseases:
The most important etiological association of

adenoviruses is with the respiratory diseases.

They are responsible for 5% of acute respiratory diseases

in: young children and much less in adults.

A. Four Respiratory diseases : different syndromes of respiratory infection have been

linked to Adenoviruses.
Acute febrile pharyngitis:
most commonly seen in infants and young children, symptoms include cough, stuffy nose, fever and sore throat.

Pharyngo conjunctival fever:

symptoms are similar to those of acute febrile pharyngitis but

conjunctivitis is also present. It tends to occur in outbreaks such as at children's summer camps (swimming pool conjunctivitis).

A. Respiratory diseases:
Acute respiratory disease:
is characterized by pharyngitis, fever, cough and

malaise. It occurs in an epidemic form among young recruits under conditions of fatigue and overcrowding

Pneumonia: a complication of acute

respiratory disease in both children and adults.

NOTE Outbreaks & epidemic adenovirus infections

Pharyngo conjunctival fever:
outbreaks in children's summer camps (swimming pool conjunctivitis).

Acute respiratory disease:

occurs in an epidemic form among young recruits

Epidemic keratoconjunctivitis:

 Mild conjunctivitis:

B. Eye infections:
can occur as a part of respiratory pharyngeal syndromes.
Complete recovery with no lasting sequelae is the common

outcome. Can occur sporadically or in outbreaks.

Epidemic keratoconjunctivitis:

a highly contagious and a more serious disease occurring mainly in adults.

Corneal involvement may be followed by various degrees of visual disability.

1.

C. Gastrointestinal disease:
No disease association
1.

Many Adenoviruses replicate in intestinal cells and are present in the stools without being associated with GIT disease.

2. Infantile gastroenteritis
1.

Two serotypes (40, 41) have been etiologically associated with infantile gastroenteritis.

NOTE 1. The enteric Adenoviruses are very difficult to cultivate. 2. Lab diagnosis depend on direct detection

D. Other diseases:
Acute haemorrhagic cystitis: types 11, 21 may cause acute haemorrhagic cystitis in children especially boys.

E. Adenoviral infections of the immune compromised host

The most common clinical manifestations are:

pneumonia, hepatitis gastroenteritis.

Laboratory Diagnosis
Direct detection:
Isolation Serology

Laboratory Diagnosis
Direct detection: Virus particle by EM can be detected by direct examination of fecal extracts
Detection of adenoviral antigens by ELISA.

Enteric Adenoviruses
Detection of adenoviral NA by Polymerase chain reaction: can be

used for diagnosis of Adenovirus infections in tissue samples or body fluids.

Laboratory Diagnosis
Isolation Isolation depending on the clinical disease, the virus may be recovered from throat, or conjunctival swabs or and urine. Isolation is much more difficult from the stool or rectal swabs

Laboratory Diagnosis
Serology Haemagglutination inhibition & Neutralization tests can be used to detect specific antibodies following Adenovirus infection.

Prevention and control

Careful hand washing is the easiest way to prevent infection. Disinfection of Environmental surfaces with hypochlorites. The risk of water borne outbreaks of conjunctivitis can be

minimized by chlorination of swimming pools. during eye examination.

Epidemic keratoconjunctivitis can be controlled by strict asepsis

HUMAN PAPILLOMA VIRUS

Papillomaviridae
Human papilloma virus

belongs to a very large family Papillomaviridae Divided into 16 genera Among many 5 are only important Alpha, Beta, Gamma, Mupa and Nupa papilloma virus

Papilloma virus

The size is 55 microns, Icosahedral, Large Genome ( 8 kbp ) More complex natured virus, Soluble stranded DNA Molecular wt 5 Non enveloped. Contain DNA 10 % and Protein 90 %

Outstanding Characters
The virus stimulate cell

DNA synthesis, Restricted Host range, limited tissue tropisims.Significant cause of Human cancers especially Cancer cervix, The viral oncoproteins interact with cellular tumor suppressor proteins.

Papilloma virus replication

The virus are highly tropic for

epithelial cells of skin and mucous membranes Viral Nuclei acid can be found in basal stem cells. But late Genome is expression is restricted to upper most layers of differentiated keratinocytes. Stages in the viral replication cycle are dependent on specific factors that are present in the sequential differentiated stage of the epithelium

Pathology and Pathogenesis

Transmission occurs by close contact, Viral particles are released from surface of paillomatous lesions Causes infections at cutaneous and mucosal sites.

Infections present with

Skin warts
Plantar warts Flat warts Genital condylomas Laryngeial paillomas

HPV Sexual Transmission

HPV genital infections are sexually transmitted Represent the most common sexually transmitted disease in United States

Cervical HPV infection

Cervical cancer is second most

frequent cancer in women world wide 5,00,000 cases present with cervical cancer Major leading cause of deaths related to malignancy in the Devloping world Several cases associated with HPV infections.

HPV infections predisposes to Cervical Cancer

Lesions on Female Genital Region

Genital Warts in Female

Genital warts in Male

Risk with different types of viruses

High risk types 16 and 18 Less common risk 30, 31, 33, 35, 39, 45, 51 and 53 Low risk types 6, 11, 40, 42 44, 54, 61,70, 72 and 81

Immunity and HPV

Behaviour of HPV lesions is

influenced by immunity factor Cell mediated immunity is important. Nearly all HPV infections are cleared and virus are undetectable within 2 3 years Cervical cancer devlops slowly Some times takes years to progress High risk behaviour is leading to persistent infection and progress to malignancy.

Clinical Importance Manifestations

Globally more than 660 million people are infected with

Genital human paillomas infections. Most common infection of the Genital tract. 6-2 million new infections occur in USA. Most common in youth < 25 years HPV infections are accepted as the cause of anogenital cancers. Majority ( 99 % ) are linked to HPV type 16 HPV 18 type is found in Cervical carcinomas HPV 16 and 18 are identified in > 70 % of cervical carcinomas He la cells widely used in laboratories are associated with infection with HPV 18 DNA

Other Clinical manifestations

Men who have sex with men develop Rectal cancers Oropharyngeal Cancers - subset of Head and Neck are

associated with sqaumous cell cancer type associated with HPV 16 Role of men as carriers Most men with HPV are subclinical and donot result in HPV associated disease

Laryngeal Paillomas
Respiratory

paiillomatosis are caused by HPV 6, and 11 Infection is acquired when passing through birth canal of infected mother with warts Needs surgical attention 3 % of infected children die if not manged with effective medical care.

Diagnosis of HPV Cervical Cancer / Warts.

A doctor usually can diagnose genital warts by direct visual examination. Women with genital warts also should be examined for possible HPV

infection of the cervix. The doctor may be able to identify some otherwise invisible changes in the tissue by applying vinegar (acetic acid) to areas of suspected infection. This solution causes infected areas to whiten, which makes them more visible, particularly if a procedure called colposcopy is performed

Pap Smear Cervical Cancer

A Pap smear test also may indicate the possible

presence of cervical HPV infection. A Pap smear is a microscopic examination of cells scraped from the uterine cervix in order to detect cervical cancer. Abnormal Pap smear results are associated with HPV infection. Women with abnormal Pap smears should be examined further to detect and treat cervical problems.

HPV Diagnosis in Cervical Infections

An HPV diagnosis is typically made based on the

results of a Pap smear (or Pap test). Because there are usually no symptoms of the virus, if a Pap test indicates abnormal results, a specific test for the virus is then conducted. A test is also available that can test for the virus's DNA in women.

Immuno supression and HPV

Immunosupressed

patients experience an increased incidence of warts and cancer of cervix All HPV associated infections occur in HIV / AIDS more frequently

Prevention and Control

Vaccines are cost effective. Aquadrivalent vaccine approved for human use in USA in

2006 It is non infectious recombinant vaccine produced in yeast Contain HPL1 protein Contains derivites of HP 6, 11,16, 18 The vaccine prevents infections with four HPV types A recommended vaccine for Adolescents Not effective in patients with established HPV. Yet how long the Immunity protects with 3 dose of vaccine ? Is not known.

Vaccine Use in HPV

HPV vaccines Gardasil and Cervarix, which block initial

infection with some of the most common sexually transmitted HPV types may lead to further decreases in the incidence of HPV-induced cancer.

Use of Vaccine in Canada

The vaccine has been approved for use in Canada for females 9-26 years of age. The vaccine requires 3 doses to be given over the course of 6 months (0, 2 and 6 months). Recommendations for use, which come from the National Advisory Committee on Immunization (NACI), were released in February 2007. The primary age group recommended for vaccination according to NACI is females aged 9 to 13. HPV is a sexually transmitted infection, and ideally, the vaccine should be administered to females before they become sexually active in order to ensure maximum benefit.

Dr.T.V.Rao MD

Herpesviruses

Properties of herpesviruses
Enveloped double stranded DNA viruses.
Genome consisits of long and short fragments which may be orientated

in either direction, giving a total of 4 isomers.

Three subfamilies:
Alphaherpesviruses - HSV-1, HSV-2, VZV
Betaherpesviruses - CMV, HHV-6, HHV-7 Gammaherpesviruses - EBV, HHV-8

Set up latent or persistent infection following primary infection

Reactivation are more likely to take place during periods of

immunosuppression
Both primary infection and reactivation are likely to be more serious in

immunocompromised patients.

Herpesvirus Particle
HSV-2 virus particle. Note that all herpesviruses have identical morphology and cannot be distinguished from each other under electron microscopy.

(Linda Stannard, University of Cape Town, S.A.)

Herpes Simplex Viruses

Properties
Belong to the alphaherpesvirus subfamily of herpesviruses Double stranded DNA enveloped virus with a genome of

around 150 kb
The genome of HSV-1 and HSV-2 share 50 - 70%

homology.
They also share several cross-reactive epitopes with each

other. There is also antigenic cross-reaction with VZV.

Man is the only natural host for HSV.

Epidemiology (1)
HSV is spread by contact, as the virus is shed in saliva, tears,

genital and other secretions.

By far the most common form of infection results from a kiss given

to a child or adult from a person shedding the virus.

Primary infection is usually trivial or subclinical in most individuals.

It is a disease mainly of very young children ie. those below 5 years.

There are 2 peaks of incidence, the first at 0 - 5 years and the

second in the late teens, when sexual activity commences.

About 10% of the population acquires HSV infection through the

genital route and the risk is concentrated in young adulthood.

Epidemiology (2)
Generally HSV-1 causes infection above the belt and HSV-2 below

the belt. In fact, 40% of clinical isolates from genital sores are HSV1, and 5% of strains isolated from the facial area are HSV-2. This data is complicated by oral sexual practices.
Following primary infection, 45% of orally infected individuals and

60% of patients with genital herpes will experience recurrences.

The actual frequency of recurrences varies widely between

individuals. The mean number of episodes per year is about 1.6.

Pathogenesis
During the primary infection, HSV spreads locally and a short-lived

viraemia occurs, whereby the virus is disseminated in the body. Spread to the to craniospinal ganglia occurs.
The virus then establishes latency in the craniospinal ganglia.

The exact mechanism of latency is not known, it may be true latency

where there is no viral replication or viral persistence where there is a low level of viral replication.
Reactivation - It is well known that many triggers can provoke a

recurrence. These include physical or psychological stress, infection; especially pneumococcal and meningococcal, fever, irradiation; including sunlight, and menstruation.

Clinical Manifestations
HSV is involved in a variety of clinical manifestations which includes ;1. Acute gingivostomatitis 2. Herpes Labialis (cold sore) 3. Ocular Herpes 4. Herpes Genitalis 5. Other forms of cutaneous herpes 7. Meningitis 8. Encephalitis 9. Neonatal herpes

Oral-facial Herpes
Acute Gingivostomatitis
Acute gingivostomatitis is the commonest manifestation of primary herpetic

infection. The patient experiences pain and bleeding of the gums. 1 - 8 mm ulcers with necrotic bases are present. Neck glands are commonly enlarged accompanied by fever. Usually a self limiting disease which lasts around 13 days.

Herpes labialis (cold sore)

Following primary infection, 45% of orally infected individuals will experience

reactivation. The actual frequency of recurrences varies widely between individuals. Herpes labialis (cold sore) is a recurrence of oral HSV. A prodrome of tingling, warmth or itching at the site usually heralds the recurrence. About 12 hours later, redness appears followed by papules and then vesicles.

Gingivostomatitis

Ocular Herpes
HSV causes a broad spectrum of ocular disease, ranging from mild superficial lesions involving the external eye, to severe sight-threatening diseases of the inner eye. Diseases caused include the following: Primary HSV keratitis dendritic ulcers Recurrent HSV keratitis HSV conjunctivitis

Iridocyclitis, chorioretinitis and cataract

Genital Herpes
Genital lesions may be primary, recurrent or initial. Many sites can be involved which includes the penis, vagina, cervix,

anus, vulva, bladder, the sacral nerve routes, the spinal and the meninges. The lesions of genital herpes are particularly prone to secondary bacterial infection eg. S.aureus, Streptococcus, Trichomonas and Candida Albicans. Dysuria is a common complaint, in severe cases, there may be urinary retention. Local sensory nerves may be involved leading to the development of a radiculitis. A mild meningitis may be present. 60% of patients with genital herpes will experience recurrences. Recurrent lesions in the perianal area tend to be more numerous and persists longer than their oral HSV-1 counterparts.

Herpes Simplex Encephalitis

Herpes Simplex encephalitis is one of the most serious complications of

herpes simplex disease. There are two forms:

Neonatal there is global involvement and the brain is almost liquefied.

The mortality rate approaches 100%.

Focal disease the temporal lobe is most commonly affected. This

form of the disease appears in children and adults. It is possible that many of these cases arise from reactivation of virus. The mortality rate is high (70%) without treatment.
It is of utmost importance to make a diagnosis of HSE early. It is

general practice that IV acyclovir is given in all cases of suspected HSE before laboratory results are available.

Neonatal Herpes Simplex (1)

Incidence of neonatal HSV infection varies inexplicably from country

to country e.g. from 1 in 4000 live births in the U.S. to 1 in 10000 live births in the UK The baby is usually infected perinatally during passage through the birth canal. Premature rupturing of the membranes is a well recognized risk factor. The risk of perinatal transmission is greatest when there is a florid primary infection in the mother. There is an appreciably smaller risk from recurrent lesions in the mother, probably because of the lower viral load and the presence of specific antibody The baby may also be infected from other sources such as oral lesions from the mother or a herpetic whitlow in a nurse.

Neonatal Herpes Simplex (2)

The spectrum of neonatal HSV infection varies from a mild disease

localized to the skin to a fatal disseminated infection. Infection is particularly dangerous in premature infants. Where dissemination occurs, the organs most commonly involved are the liver, adrenals and the brain. Where the brain is involved, the prognosis is particularly severe. The encephalitis is global and of such severity that the brain may be liquefied. A large proportion of survivors of neonatal HSV infection have residual disabilities. Acyclovir should be promptly given in all suspected cases of neonatal HSV infection. The only means of prevention is to offer caesarean section to mothers with florid genital HSV lesions.

Other Manifestations
Disseminated herpes simplex are much more likely to occur in

immunocompromised individuals. The widespread vesicular resembles that of chickenpox. Many organs other than the skin may be involved e.g. liver, spleen, lungs, and CNS.
Other cutaneous manifestations include eczema herpeticum which is potentially a serious disease that occurs in patients with eczema. Herpetic whitlow which arise from implantation of the virus into the skin and typically affect the fingers. zosteriform herpes simplex". This is a rare presentation of herpes simplex where HSV lesions appear in a dermatomal distribution similar to herpes zoster.

Laboratory Diagnosis
Direct Detection Electron microscopy of vesicle fluid - rapid result but cannot distinguish between HSV and VZV Immunofluorescence of skin scrappings - can distinguish between HSV and VZV PCR - now used routinely for the diagnosis of herpes simple encephalitis Virus Isolation HSV-1 and HSV-2 are among the easiest viruses to cultivate. It usually takes only 1 - 5 days for a result to be available. Serology Not that useful in the acute phase because it takes 1-2 weeks for before antibodies appear after infection. Used to document to recent infection.

Cytopathic Effect of HSV in cell culture: Note the ballooning of cells. (Linda Stannard, University of Cape Town, S.A.)

Positive immunofluorescence test for HSV antigen in epithelial cell. (Virology Laboratory, New-Yale Haven Hospital)

Management
At present, there are only a few indications of antiviral chemotherapy, with the high cost of antiviral drugs being a main consideration. Generally, antiviral chemotherapy is indicated where the primary infection is especially severe, where there is dissemination, where sight is threatened, and herpes simplex encephalitis.
Acyclovir this the drug of choice for most situations at present. It is available in a number of formulations:

I.V. (HSV infection in normal and immunocompromised patients) Oral (treatment and long term suppression of mucocutaneous herpes and prophylaxis of HSV in immunocompromised patients) Cream (HSV infection of the skin and mucous membranes) Ophthalmic ointment

Famciclovir and valacyclovir oral only, more expensive than acyclovir. Other older agents e.g. idoxuridine, trifluorothymidine, Vidarabine (ara-A).

These agents are highly toxic and is suitable for topical use for opthalmic infection only

Varicella- Zoster Virus

Properties

Belong to the alphaherpesvirus subfamily of herpesviruses Double stranded DNA enveloped virus Genome size 125 kbp, long and short fragments with a total of 4 isometric forms. One antigenic serotype only, although there is some cross reaction with HSV.

Epidemiology
Primary varicella is an endemic disease. Varicella is one of the

classic diseases of childhood, with the highest prevalence occurring in the 4 - 10 years old age group.
Varicella is highly communicable, with an attack rate of 90% in

close contacts.
Most people become infected before adulthood but 10% of

young adults remain susceptible.

Herpes zoster, in contrast, occurs sporadically and evenly

throughout the year.

Pathogenesis
The virus is thought to gain entry via the respiratory tract and

spreads shortly after to the lymphoid system.

After an incubation period of 14 days, the virus arrives at its

main target organ, the skin.

Following the primary infection, the virus remains latent in the

cerebral or posterior root ganglia. In 10 - 20% of individuals, a single recurrent infection occurs after several decades.
The virus reactivates in the ganglion and tracks down the sensory

nerve to the area of the skin innervated by the nerve, producing a varicellaform rash in the distribution of a dermatome.

Varicella
Primary infection results in varicella (chickenpox) Incubation period of 14-21 days Presents fever, lymphadadenopathy. a widespread vesicular rash. The features are so characteristic that a diagnosis can usually be made

on clinical grounds alone.

Complications are rare but occurs more frequently and with greater

severity in adults and immunocompromised patients.

Most common complication is secondary bacterial infection of the

vesicles.
Severe complications which may be life threatening include viral

pneumonia, encephalititis, and haemorrhagic chickenpox.

Rash of Chickenpox

Herpes Zoster (Shingles)

Herpes Zoster mainly affect a single dermatome of the skin.
It may occur at any age but the vast majority of patients are more than 50

years of age.
The latent virus reactivates in a sensory ganglion and tracks down the

sensory nerve to the appropriate segment.

There is a characteristic eruption of vesicles in the dermatome which is

often accompanied by intensive pain which may last for months (postherpetic neuralgia)
Herpes zoster affecting the eye and face may pose great problems. As

with varicella, herpes zoster in a far greater problem in immunocompromised patients in whom the reactivation occurs earlier in life and multiple attacks occur as well as complications. zoster.

Complications are rare and include encephalitis and disseminated herpes

Shingles

Congenital VZV Infection

90% of pregnant women already immune, therefore primary infection is

rare during pregnancy. Primary infection during pregnancy carries a greater risk of severe disease, in particular pneumonia. First 20 weeks of Pregnancy
Up to 3% chance of transmission to the fetus, recognised congenital

varicella syndrome;
Scarring of skin
Hypoplasia of limbs CNS and eye defects Death in infancy normal

Neonatal Varicella
VZV can cross the placenta in the late stages of pregnancy to

infect the fetus congenitally.

Neonatal varicella may vary from a mild disease to a fatal

disseminated infection.
If rash in mother occurs more than 1 week before delivery,

then sufficient immunity would have been transferred to the fetus.

Zoster immunoglobulin should be given to susceptible pregnant

women who had contact with suspected cases of varicella.

Zoster immunoglobulin should also be given to infants whose

mothers develop varicella during the last 7 days of pregnancy or the first 14 days after delivery.

Laboratory Diagnosis
The clinical presentations of varicella or zoster are so characteristic that laboratory confirmation is rarely required. Laboratory diagnosis is required only for atypical presentations, particularly in the immunocompromised.

Virus Isolation - rarely carried out as it requires 2-3 weeks for a results. Direct detection - electron microscopy may be used for vesicle fluids but cannot distinguish between HSV and VZV. Immunofluorescense on skin scrappings can distinguish between the two. Serology - the presence of VZV IgG is indicative of past infection and immunity. The presence of IgM is indicative of recent primary infection.

Cytopathic Effect of VZV

Cytopathic Effect of VZV in cell culture: Note the ballooning of cells. (Coutesy of Linda Stannard, University of Cape Town, S.A.)

Management
Uncomplicated varicella is a self limited disease and requires no specific treatment. However, acyclovir had been shown to accelerate the resolution of the disease and is prescribed by some doctors.
Acyclovir should be given promptly immunocompromised individuals with varicella infection and normal individuals with serious complications such as

pneumonia and encephalitis.

herpes zoster in a healthy individual is not normally a cause for concern. The main problem is the management of the postherpetic neuralgia. The International Herpes Management Forum recommends that antiviral

therapy should be offered routinely to all patients over 50 years of age presenting with herpes zoster.
Three drugs can be used for the treatment of herpes zoster: acyclovir, valicyclovir, and famciclovir. There appears to be little difference in efficacy between them.

Prevention
Preventive measures should be considered for individuals at risk of

contracting severe varicella infection e.g. leukaemic children, neonates, and pregnant women Where urgent protection is needed, passive immunization should be given. Zoster immunoglobulin (ZIG) is the preparation of choice but it is very expensive. Where ZIG is not available, HNIG should be given instead. A live attenuated vaccine is available. There had been great reluctance to use it in the past, especially in immunocompromised individuals since the vaccine virus can become latent and reactivate later on. However, recent data suggests that the vaccine is safe, even in children with leukaemia provided that they are in remission. It is highly debatable whether universal vaccination should be offered since chickenpox and shingles are normally mild diseases.

Cytomegalovirus

Properties

Belong to the betaherpesvirus subfamily of herpesviruses double stranded DNA enveloped virus Nucleocapsid 105nm in diameter, 162 capsomers The structure of the genome of CMV is similar to other herpesviruses, consisting of long and short segments which may be orientated in either direction, giving a total of 4 isomers. A large no. of proteins are encoded for, the precise number is unknown.

Epidemiology
CMV is one of the most successful human pathogens, it can be transmitted

vertically or horizontally usually with little effect on the host. Transmission may occur in utero, perinatally or postnatally. Once infected, the person carries the virus for life which may be activated from time to time, during which infectious virions appear in the urine and the saliva. Reactivation can also lead to vertical transmission. It is also possible for people who have experienced primary infection to be reinfected with another or the same strain of CMV, this reinfection does not differ clinically from reactivation. In developed countries with a high standard of hygiene, 40% of adolescents are infected and ultimately 70% of the population is infected. In developing countries, over 90% of people are ultimately infected.

Pathogenesis
Once infected, the virus remains in the person for life and my be

reactivated from time to time, especially in immunocompromised individuals.

The virus may be transmitted in utero, perinatally, or postnatally.

Perinatal transmission occurs.

Perinatal infection is acquired mainly through infected genital

secretions, or breast milk. Overall, 2 - 10% of infants are infected by the age of 6 months worldwide. Perinatal infection is thought to be 10 times more common than congenital infection.
Postnatal infection mainly occurs through saliva. Sexual transmission

may occur as well as through blood and blood products and transplanted organ.

Clinical Manifestations
Congenital infection - may result in cytomegalic inclusion disease Perinatal infection - usually asymptomatic Postnatal infection - usually asymptomatic. However, in a minority of

cases, the syndrome of infectious mononucleosis may develop which consists of fever, lymphadenopathy, and splenomegaly. The heterophil antibody test is negative although atypical lymphocytes may be found in the blood.
Immunocompromised patients such as transplant recipients and AIDS

patients are prone to severe CMV disease such as pneumonitis, retinitis, colitis, and encephalopathy.
Reactivation or reinfection with CMV is usually asymptomatic except

in immunocompromised patients.

Congenital Infection
Defined as the isolation of CMV from the saliva or urine within 3

weeks of birth.
Commonest congenital viral infection, affects 0.3 - 1% of

all live births. The second most common cause of mental handicap after Down's syndrome and is responsible for more cases of congenital damage than rubella. CMV infection. 40% chance of transmission to the fetus following a primary infection.

Transmission to the fetus may occur following primary or recurrent

May be transmitted to the fetus during all stages of pregnancy. No evidence of teratogenecity, damage to the fetus results from

destruction of target cells once they are formed.

Cytomegalic Inclusion Disease

CNS abnormalities - microcephaly, mental retardation, spasticity,

epilepsy, periventricular calcification.

Eye - choroidoretinitis and optic atrophy Ear - sensorineural deafness Liver - hepatosplenomegaly and jaundice which is due to

hepatitis.
Lung - pneumonitis Heart - myocarditis Thrombocytopenic purpura, Haemolytic anaemia Late sequelae in individuals asymptomatic at birth - hearing

defects and reduced intelligence.

Incidence of Cytomegalic Disease

U.S.A.
No. of live births p.a. Rate of congenital CMV No. of infected infants Symptomatic at birth (5 - 10% ) Fatal disease (~ 20% ) No. with sequelae (90% of survivors) Asymptomatic (90 - 95% ) No. with late sequelae 3,000,000 1% 30,000 1,500-3,000 300-600 1080-2160 27000 1350-4550

U.K.
700,000 0.3% 2100 105 22 83 1995 315

Laboratory Diagnosis (1)

Direct detection
biopsy specimens may be examined histologically for CMV

inclusion antibodies or for the presence of CMV antigens. However, the sensitivity may be low.
The pp65 CMV antigenaemia test is now routinely used for

the rapid diagnosis of immunocompromised patients. problems with interpretation.

CMV

infection

in

PCR for CMV-DNA is used in some centers but there may be

CMV pp65 antigenaemia test

(Virology Laboratory, New-Yale Haven Hospital)

Laboratory Diagnosis (2)

Virus Isolation
conventional cell culture is regarded as gold standard but

requires up to 4 weeks for result.

More useful are rapid culture methods such as the DEAFF

test which can provide a result in 24-48 hours.

Serology
the presence of CMV IgG antibody indicates past infection. The detection of IgM is indicative of primary infection

although it may also be found in immunocompromised patients with reactivation.

Cytopathic Effect of CMV

(Courtesy of Linda Stannard, University of Cape Town, S.A.)

DEAFF test for CMV

(Virology Laboratory, New-Yale Haven Hospital)

Specimens for Laboratory Diagnosis

Site for virus culture Urine Saliva Blood Tissue affected Neonates Adults Pregnant women Immunocompromised + + + + + + + + Serology IgG IgM + + + + + + -

Treatment
Congenital infections - it is not usually possible to detect

congenital infection unless the mother has symptoms of primary infection. If so, then the mother should be told of the chances of her baby having cytomegalic inclusion disease and perhaps offered the choice of an abortion.
Perinatal and postnatal infection - it is usually not necessary to

treat such patients.

Immunocompromised patients - it is necessary to make a

diagnosis of CMV infection early and give prompt antiviral therapy. Anti-CMV agents in current use are ganciclovir, forscarnet, and cidofovir.

Prevention
No licensed vaccine is available. There is a candidate live attenuated

vaccine known as the Towne strain but there are concerns about administering a live vaccine which could become latent and reactivates. Prevention of CMV disease in transplant recipients is a very complicated subject and varies from center to center. It may include the following measures. Screening and matching the CMV status of the donor and recipient Use of CMV negative blood for transfusions Administration of CMV immunoglobulin to seronegative recipients prior to transplant Give antiviral agents such as acyclovir and ganciclovir prophylactically.

Epstein-Barr Virus

Epstein-Barr Virus (EBV)

Belong to the gammaherpesvirus subfamily of herpesviruses Nucleocapsid 100 nm in diameter, with 162 capsomers Membrane is derived by budding of immature particles through cell membrane and is required for infectivity. Genome is a linear double stranded DNA molecule with 172 kbp The viral genome does not normally integrate into the cellular DNA but forms circular episomes which reside in the nucleus. The genome is large enough to code for 100 - 200 proteins but only a few have been identified.

Epidemiology
Two epidemiological patterns are seen with EBV. In developed countries, 2 peaks of infection are seen : the

first in very young preschool children aged 1 - 6 and the second in adolescents and young adults aged 14 - 20 Eventually 80-90% of adults are infected. In developing countries, infection occurs at a much earlier age so that by the age of two, 90% of children are seropositive.
The virus is transmitted by contact with saliva, in

particularly through kissing.

Pathogenesis
Once infected, a lifelong carrier state develops whereby a low

grade infection is kept in check by the immune defenses.

Low grade virus replication and shedding can be demonstrated in

the epithelial cells of the pharynx of all seropositive individuals.

EBV is able to immortalize B-lymphocytes in vitro and in vivo Furthermore a few EBV-immortalized B-cells can be

demonstrated in the circulation which are continually cleared by immune surveillance mechanisms.
EBV is associated with several very different diseases where it may act directly or one of several co-factors.

Disease Association
1. Infectious Mononucleosis 2. Burkitt's lymphoma 3. Nasopharyngeal carcinoma

4. Lymphoproliferative disease and lymphoma in the immunosuppressed. 5. X-linked lymphoproliferative syndrome 6. Chronic infectious mononucleosis 7. Oral leukoplakia in AIDS patients 8. Chronic interstitial pneumonitis in AIDS patients.

Infectious Mononuclosis
Primary EBV infection is usually subclinical in childhood. However in

adolescents and adults, there is a 50% chance that the syndrome of infectious mononucleosis (IM) will develop. IM is usually a self-limited disease which consists of fever, lymphadenopathy and splenomegaly. In some patients jaundice may be seen which is due to hepatitis. Atypical lymphocytes are present in the blood. Complications occur rarely but may be serious e.g. splenic rupture, meningoencephalitis, and pharyngeal obstruction. In some patients, chronic IM may occur where eventually the patient dies of lymphoproliferative disease or lymphoma. Diagnosis of IM is usually made by the heterophil antibody test and/or detection of EBV IgM. There is no specific treatment.

Burkitts Lymphoma (1)

Burkitt's lymphoma (BL) occurs endemically in parts of Africa

(where it is the commonest childhood tumour) and Papua New Guinea. It usually occurs in children aged 3-14 years. It respond favorably to chemotherapy.
It is restricted to areas with holoendemic malaria. Therefore it

appears that malaria infection is a cofactor.

Multiple copies of EBV genome and some EBV antigens can be

found in BL cells and patients with BL have high titres of antibodies against various EBV antigens.

Burkitts Lymphoma (2)

BL cells show a reciprocal translocation between the long arm of

chromosome 8 and chromosomes 14, 2 or 22.

This translocation result in the c-myc oncogene being transferred to

the Immunoglobulin gene regions. This results in the deregulation of the c-myc gene. It is thought that this translocation is probably already present by the time of EBV infection and is not caused by EBV.
Sporadic cases of BL occur, especially in AIDS patients which may

or may not be associated with EBV.

In theory BL can be controlled by the eradication of malaria (as has

happened in Papua New Guinea) or vaccination against EBV.

Nasopharyngeal Carcinoma
Nasopharyngeal carcinoma (NPC) is a malignant tumour of the

squamous epithelium of the nasopharynx. It is very prevalent in S. China, where it is the commonest tumour in men and the second commonest in women. The tumour is rare in most parts of the world, though pockets occur in N. and C. Africa, Malaysia, Alaska, and Iceland. Multiple copies of EBV genome and EBV EBNA-1 antigen can be found in cells of undifferentiated NPC. Patients with NPC have high titres of antibodies against various EBV antigens. Besides EBV there appears to be a number of environmental and genetic cofactors in NPC. NPC usually presents late and thus the prognosis is poor. In theory NPC can be prevented by vaccination.

Immunocompromised Patients
After primary infection, EBV maintains a steady low grade latent

infection in the body. Should the person become immunocompromised, the virus will reactivate. In a few cases, lymphoproliferative lesions and lymphoma may develop. These lesions tend to be extranodal and in unusual sites such as the GI tract or the CNS.
Transplant recipients e.g. renal - EBV is associated with the development

of lymphoproliferative disease and lymphoma.

AIDS patients - EBV is associated with oral leukoplakia and with various

Non-Hodgekins lymphoma.
Ducan X-linked lymphoproliferative syndrome - this condition occurs

exclusively in males who had inherited a defective gene in the Xchromosome . This condition accounts for half of the fatal cases of IM.

Diagnosis
Acute EBV infection is usually made by the heterophil antibody test

and/or detection of anti-EBV VCA IgM.

Cases of Burkitts lymphoma should be diagnosed by histology. The

tumour can be stained with antibodies to lambda light chains which should reveal a monoclonal tumour of B-cell origin. In over 90% of cases, the cells express IgM at the cell surface. Cases of NPC should be diagnosed by histology.
The determination of the titre of anti-EBV VCA IgA in screening

for early lesions of NPC and also for monitoring treatment. A patient with with non-specific ENT symptoms who have elevated titres of EBV IgA should be given a thorough examination.

Vaccination
A vaccine against EBV which prevents primary EBV infection

should be able to control both BL and NPC.

Such a vaccine must be given early in life. Such a vaccine would

also be useful in seronegative organ transplant recipients and those developing severe IM, such as the male offspring of X-linked proliferative syndrome carriers.
The vaccine should not preferably be a subunit vaccine since there

is a danger that a live vaccine may still have tumorigenic properties.

The antigen chosen for vaccine development is the MA antigen gp

340/220 as antibodies against this antigen are virus neutralizing.

This vaccine is being tried in Africa.

Other Human Herpes Viruses

Properties of HHV-6 and 7

Belong to the betaherpesvirus subfamily of herpesviruses Double stranded DNA genome of 170 kbp The main target cell is the T-lymphocyte, although B-

lymphocytes may also be infected.

HHV-6 and HHV-7 share limited nucleotide homology and

antigenic cross-reactivity.
It is thought that HHV-6 and HHV-7 are related to each other

in a similar manner to HSV-1 and HSV-2.

Epidemiology and Pathogenesis

HHV-6 and HHV-7 are ubiquitous and are found worldwide. They are transmitted mainly through contact with saliva and

through breast feeding.

HHV-6 and HHV-7 infection are acquired rapidly after the age of

4 months when the effect of maternal antibody wears off.

By the time of adulthood, 90-99% of the population had been

infected by both viruses.

Like other herpesviruses, HHV-6 and HHV-7 remains latent in

the body after primary infection and reactivates from time to time.

Clinical Manifestations (1)

Primary HHV-6 infection is associated with Roseala

Infantum, which is a classical disease of childhood. Most cases occur in infants between the ages of 4 months and two years.
A spiking fever develops over a period of 2 days followed

by a mild rash. The fever is high enough to cause febrile convulsions.

There are reports that the disease may be complicated by

encephalitis.

Clinical Manifestations (2)

If primary infection is delayed until adulthood, there is a small

chance that an infectious mononucleosis-like disease may develop in a similar manner to EBV and CMV.
There is no firm evidence linking HHV-6 to lymphomas or

lymphoproliferative diseases.
There is no firm disease association with HHV-7 at present. Although

both viruses may be reactivated in immunocompromised patients, it is yet uncertain whether they cause significant disease since CMV is almost invariably present.

Roseala Infantum

Diagnosis and Management

Rosela Infantum has a very characteristic presentation and

a diagnosis can usually be made on clinical grounds alone. Therefore very few virology laboratories offer a diagnostic service for HHV-6 or HHV-7 infection.
The technique for virus isolation is complicated and thus

not practicable as a routine diagnostic procedure. Therefore serology is the mainstay of diagnosis where specific IgM and IgG are detected. There is no specific antiviral treatment for HHV-6 infection.

Human Herpes Virus 8

Belong to the gammaherpesviruses subfamily of herpesviruses
Originally isolated from cells of Kaposis sarcoma (KS) Now appears to be firmly associated with Kaposis sarcoma as well as

some lesser known malignancies such as Castlemans disease and primary effusion lymphomas HHV-8 DNA is found in almost 100% of cases of Kaposis 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 herpesviruses, HHV-8 does not have a ubiquitous distribution.

Kaposis Sarcoma

Poxviruses (members of the family Poxviridae) are viruses that can as a family, infect both vertebrate and invertebrate animals. the smallpox virus remains as the most notable member of the family.
Four genera of poxviruses may infect humans:

orthopox, parapox, yatapox, molluscipox.

Taxonomy
Subfamily Chordopoxvirinae Human pathogenic genera Genus Orthopoxvirus; diseases: cowpox, vaccinia, smallpox ,monkeypox Genus Parapoxvirus; type species: Orf virus Genus Molluscipoxvirus; type species: Molluscum contagiosum virus Genus Yatapoxvirus; type species: Yaba monkey tumor virus Nonpathogenic genera Genus Avipoxvirus; type species: Fowlpox virus Genus Capripoxvirus; type species: Sheeppox virus Genus Leporipoxvirus; type species: Myxoma virus Genus Suipoxvirus; type species: Swinepox virus Subfamily Entomopoxvirinae Genus Entomopoxvirus A Genus Entomopoxvirus B Genus Entomopoxvirus C

Structure viral particles (virions) are generally enveloped (external enveloped virion- EEV), though the intracellular mature virion (IMV) form of the virus, which contains different envelope and is also infectious. generally shaped like a brick or as an oval form similar to a rounded brick. size is around 200 nm in diameter and 300 nm in length and carries its genome in a single, linear, double-stranded segment of DNA.

Oval or "brick-shaped" particles 200-400nm long - can be visualized by the best light microscopes. The external surface is ridged in parallel rows, sometimes arranged helically. The particles are extremely complex, containing many proteins (more than 100) and detailed structure is not known. The extracellular forms contain 2 membranes (EEV extracellular enveloped virions), intracellular particles only have an inner membrane (IMV - intracellular mature virions).
Thin sections in E.M. reveal that the outer surface is composed of lipid and protein which surrounds the core, which is biconcave (dumbbell-shaped), with two "lateral bodies" (function unknown). The core is composed of a tightly compressed nucleoprotein.

HUMAN INFECTION Cowpox - is acquired by humans usually by milking cows; it then manifests as ulcerative lesions (sometimes called "milkers nodules") on the hands of dairy workers. It was noted to protect against smallpox and was used by Jenner as a vaccine strain to protect persons against smallpox. Despite its name, rodents are the main reservoir of cowpox; it spreads secondarily to cows and domestic cats.

Molluscum contagiosum - is a minor infectious warty papule of the skin with a central umbilication, transferred by direct contact

Molluscum contagiosum virion

Monkey pox - is a rare smallpox like disease of children in central Africa. It is acquired from monkeys or wild squirrels, but does occasionally spread from man to man in unvaccinated communities. Antigenically cross-reacts with other poxviruses. Sick monkeys have not been identified, but apparently healthy animals have antibodies. Pseudocowpox - occurs worldwide and is a disease primarily of cattle. In humans it causes non-ulcerating "milker's nodes". ORF - a worldwide occupational disease associated with handling sheep and goats afflicted with "scabby mouth". In humans it manifests as a single painless, papulo-vesicular lesion on the hand, forearm or face.

Orf virus (parapox virus)

occurring primarily in sheep and goatsas contagious pustular dermatitis (CPD) humans can contract this disorder through direct contact with infected sheep and goats or with fomites carrying the orf virus. It causes a purulent-appearing papule locally and generally no systemic symptoms. Infected locations can include the finger, hand, arm, face The papule may persist for 7 to 10 weeks and spontaneously resolves

Orf pocks on thumb

Vaccinia virus large, complex, enveloped virus, closey related to the virus that causes cowpox linear, double-stranded DNA genome The dimensions of the virion are roughly 360 270 250 nm.

well-known for its role as a vaccine that eradicated the smallpox disease(variola) infection is very mild and is typically asymptomatic in healthy individuals, but it may cause a mild rash and fever. Yaba monkey tumor virus: The type species of yatapoxvirus, a tumor-producing DNA virus discovered in monkeys in Yaba, Nigeria. It has been found to produce histiocytomas (proliferation of tissue macrophages) in monkeys and humans.

Smallpox (Orthopoxvirus infection )

an infectious disease unique to humans, caused by either of two virus variants, Variola major and Variola minor. localizes in small blood vessels of the skin and in the mouth and throat.

in the skin, this results in a characteristic maculopapular rash, and later, raised fluid-filled blisters. V. major produces a more serious disease and has an overall mortality rate of 3035%. V. minor causes a milder form of disease

Long-term complications of V. major infection include characteristic scars, commonly on the face, which occur in 6585% of survivors. Blindness resulting from corneal ulceration and scarring, and limb deformities due to arthritis and osteomyelitis are less common complications, seen in about 25% of cases. Both enveloped and unenveloped virions are infectious.

Transmission through inhalation of airborne variola virus, usually droplets expressed from the oral, nasal, or pharyngeal mucosa of an infected person. through direct contact with infected bodily fluids or contaminated objects (fomites) such as bedding or clothing. The virus can cross the placenta, but the incidence of congenital smallpox is relatively low Signs and symptoms

There are two clinical forms of smallpox

Variola major is the severe and most common form of smallpox, with a more extensive rash and higher fever. Variola minor is a less common presentation of smallpox, and a much less severe disease, with historical death rates of 1% or less.[

The incubation period between contraction and the first obvious symptoms of the disease is around 12 days. Once inhaled, variola virus invades the oropharyngeal (mouth and throat) or the respiratory mucosa, migrates to regional lymph nodes, and begins to multiply. In the initial growth phase the virus seems to move from cell to cell, but around the 12th day, lysis of many infected cells occurs and the virus is found in the bloodstream in large numbers (this is called viremia), and a second wave of multiplication occurs in the spleen, bone marrow, and lymph nodes. The initial or prodromal symptoms are similar to other viral diseases such as influenza and the common cold: fever (at least 38.5 C (101 F)), muscle pain, malaise, headache, prostration, and as the digestive tract is commonly involved, nausea and vomiting and backache often occur. The prodrome, or preeruptive stage, usually lasts 24 days. By days 1215 the first visible lesionssmall reddish spots called enanthemappear on mucous membranes of the mouth, tongue, palate, and throat, and temperature falls to near normal. These lesions rapidly enlarge and rupture, releasing large amounts of virus into the saliva.

By the sixth or seventh day, all the skin lesions have become pustules. Between 7 and 10 days the pustules mature and reach their maximum size. The pustules are sharply raised, typically round, tense, and firm to the touch. The pustules are deeply embedded in the dermis, giving them the feel of a small bead in the skin. Fluid slowly leaks from the pustules, and by the end of the second week the pustules deflate, and start to dry up, forming crusts (or scabs). By day 16-20 scabs have formed over all the lesions, which have started to flake off, leaving de-pigmented scars the last natural case of smallpox was diagnosed in 1977

Flat small pox

In Flat-type smallpox (also called malignant smallpox) the lesions remain almost flush with the skin at the time when raised vesicles form in ordinary-type smallpox. is nearly always fatal. accounted for 5%10% of cases

severe prodromal phase that lasts 34 days, prolonged high fever

The skin lesions mature very slowly

Hemorrhagic
severe form of smallpox that is accompanied by extensive bleeding into the skin, mucous membranes, and gastrointestinal tract. This form developed in perhaps 2% of infections and occurred mostly in adults. In hemorrhagic smallpox the skin does not blister, but remains smooth. Instead, bleeding occurs under the skin, making the skin look charred and black, hence this form of the disease is also known as black pox. hemorrhaging appears on the second or third day as sub-conjunctival bleeding turns the whites of the eyes deep red. hemorrhages in the spleen, kidney, serosa, muscle, and, rarely, the epicardium, liver, testes, ovaries and bladder.

Diagnosis
poxviruses produce characteristic cytoplasmic inclusions, the most important of which are known as Guarnieri bodies, and are the sites of viral replication. Guarnieri bodies are readily identified in skin biopsies stained with hematoxylin and eosin, and appear as pink blobs. The diagnosis of an orthopoxvirus infection can also be made rapidly by electron microscopic examination of pustular fluid or scabs. However, all orthopoxviruses exhibit identical brick-shaped virions by electron microscopy.

Definitive laboratory identification of variola virus involves growing the virus on chorioallantoic membrane (part of a chicken embryo) and examining the resulting pock lesions under defined temperature conditions.[

Smallpox virus pocks on the chorioallantoic membrane of a chick embryo

Strains may be characterized by polymerase chain reaction (PCR) or restriction fragment length polymorphism (RFLP) analysis Serologic tests and enzyme linked immunosorbent assays (ELISA), which measure variola virus-specific immunoglobulin and antigen have also been developed to assist in the diagnosis of infection.[ Complications most commonly in the respiratory system and range from simple bronchitis to fatal pneumonia Pustules can form on the eyelid, conjunctiva, and cornea, leading to complications such as conjunctivitis, keratitis, corneal ulcerHemorrhagic smallpox can cause subconjunctival and retinal hemorrhages.

Treatment Vaccination four to seven days after exposure likely offers some protection from disease or may modify the severity of disease treatment of smallpox is primarily supportive, such as wound care and infection controlNo drug is currently approved for the treatment of smallpox

antiviral drug cidofovir might be useful as a therapeutic agent. The drug must be administered intravenously, however, and may cause serious renal toxicity.[

Smallpox vaccine The process of vaccination was discovered by Edward Jenner in 1796, who acted upon his observation that milkmaids who caught the cowpox virus did not catch smallpox.[ Before the introduction of a vaccineA process called inoculation, also known as insufflation or variolation was practiced in India as early as 1000 BC Vaccines that only contain attenuated vaccinia viruses (an attenuated virus is one in which the pathogenicity has been decreased through serial passage) have been proposed