Diagnosis of Fatal Human Case of St. Louis Encephalitis Virus Infection by Metagenomic Sequencing, California, 2016.

We used unbiased metagenomic next-generation sequencing to diagnose a fatal case of meningoencephalitis caused by St. Louis encephalitis virus in a patient from California in September 2016. This case is associated with the recent 2015-2016 reemergence of this virus in the southwestern United States.

Development of a model of Saint Louis encephalitis infection and disease in mice.

BACKGROUND: Flaviviruses are a genre of closely related viral pathogens which emerged in the last decades in Brazil and in the world. Saint (St.) Louis encephalitis virus (SLEV) is a neglected flavivirus that can cause a severe neurological disease that may lead to death or sequelae. St. Louis encephalitis pathogenesis is poorly understood, which hinders the development of specific treatment or vaccine. METHODS: To address this problem, we developed a model of SLEV infection in mice to study mechanisms involved in the pathogenesis of severe disease. The model consists in the intracranial inoculation of the SLEV strain BeH 355964, a strain isolated from a symptomatic human patient in Brazil, in adult immunocompetent mice. RESULTS: Inoculated mice presented SLEV replication in the brain, accompanied by tissue damage, disease signs, and mortality approximately 7 days post infection. Infection was characterized by the production of proinflammatory cytokines and interferons and by leukocyte recruitment to the brain, composed mainly by neutrophils and lymphocytes. In vitro experiments indicated that SLEV is able to replicate in both neurons and glia and caused neuronal death and cytokine production, respectively. CONCLUSIONS: Altogether, intracranial SLEV infection leads to meningoencephalitis in mice, recapitulating several aspects of St. Louis encephalitis in humans. Our study indicates that the central nervous system (CNS) inflammation is a major component of SLEV-induced disease. This model may be useful to identify mechanisms of disease pathogenesis or resistance to SLEV infection.

Comparison of Characteristics of Patients with West Nile Virus or St. Louis Encephalitis Virus Neuroinvasive Disease During Concurrent Outbreaks, Maricopa County, Arizona, 2015.

West Nile virus (WNV) and St. Louis encephalitis virus (SLEV) are closely related mosquito-borne flaviviruses that can cause neuroinvasive disease. No concurrent WNV and SLEV disease outbreaks have previously been identified. When concurrent outbreaks occurred in 2015 in Maricopa County, Arizona, we collected data to describe the epidemiology, and to compare features of patients with WNV and SLEV neuroinvasive disease. We performed enhanced case finding, and gathered information from medical records and patient interviews. A case was defined as a clinically compatible illness and laboratory evidence of WNV, SLEV, or unspecified flavivirus infection in a person residing in Maricopa County in 2015. We compared demographic and clinical features of WNV and SLEV neuroinvasive cases; for this analysis, a case was defined as physician-documented encephalitis or meningitis and a white blood cell count >5 cells/mm3 in cerebrospinal fluid. In total, we identified 82 cases, including 39 WNV, 21 SLEV, and 22 unspecified flavivirus cases. The comparative analysis included 21 WNV and 14 SLEV neuroinvasive cases. Among neuroinvasive cases, the median age of patients with SLEV (63 years) was higher than WNV (52 years). Patients had similar symptoms; rash was identified more frequently in WNV (33%) neuroinvasive cases than in SLEV (7%) cases, but this difference was not statistically significant (p = 0.11). In summary, during the first known concurrent WNV and SLEV disease outbreaks, no specific clinical features were identified that could differentiate between WNV and SLEV neuroinvasive cases. Health care providers should consider both infections in patients with aseptic meningitis or encephalitis.

St Louis encephalitis. Quantitative histologic and immunofluorescent studies.

Using techniques of stereology, we measured the severity of lesions in ten cases of acute St Louis encephalitis (SLE) from the 1975 epidemic in northern Illinois. Percentage of fractional volume and numerical profile density on area (N/A) of cellular nodules and N/A of blood vessels with perivascular inflammatory cellular infiltration were significantly correlated in 17 anatomic regions of the CNS. Ranking of the severity of lesions in these regions agreed with subjective estimates of other cases of SLE. Immunofluorescent tests established the presence of SLE viral antigen in cell bodies of neurons. Our findings contribute to better understanding of the pathology of SLE in man.

St Louis encephalitis: a review of 11 cases in a 1995 Dallas, Tex, epidemic.

OBJECTIVE: To update some of the clinical features of St Louis encephalitis (SLE), a common arboviral infection that occurs in epidemic patterns in the south-central and midwestern United States. METHODS: Eleven patients with SLE from a 1995 epidemic in Dallas, Tex, were studied clinically, radiologically, neurophysiologically, and neuropathologically (in 1 case). RESULTS: The electroencephalograms and magnetic resonance imaging (MRI) scans of our patients revealed features that have received little attention in previous studies. Of the 9 patients who were examined with electroencephalography, all 9 had seizures or other abnormalities, and 1 had nonconvulsive status epilepticus. Two of 6 patients who had MRIs showed substantia nigra edema. Finally, 2 (18%) of our patients had coinfection with the human immunodeficiency virus. CONCLUSIONS: The MRI findings of substantia nigra edema in patients with SLE have not been previously reported. Nonconvulsive status epilepticus can occur in patients with SLE and should be considered in patients with prolonged encephalopathy. Finally, human immunodeficiency virus coinfection may be a risk factor for symptomatic SLE infection.

Interferon-alpha protects mice against lethal infection with St Louis encephalitis virus delivered by the aerosol and subcutaneous routes.

In common with other flaviviruses, there is no specific therapy for St Louis encephalitis (SLE) virus infections. A number of cases have occurred where infection may have been acquired by the aerosol route in laboratory accidents. The recombinant human interferon hybrids IFN-alpha A/D (Roche Laboratories) and IFN-alpha B/D (Ciba-Geigy) have activity in murine models. Given for several days around the time of exposure to the virus or shortly after, these compounds reduce the mortality from SLE virus administered to mice subcutaneously by up to 70%. In an aerosol model of SLE disease, the mortality was reduced to 30-50% compared to 100% in controls, depending on the challenge level of virus. These results suggest that interferon-alpha could be used to reduce the mortality from SLE infection after known exposure to the virus.

Detection of encephalitis viruses in mosquitoes (Diptera: Culicidae) and avian tissues.

ABSTRACT Diagnostic assays for the detection of St. Louis encephalitis (SLE) and western equine encephalomyelitis (WEE) viruses in mosquito pools and avian tissues were compared for sensitivity, accuracy and specificity. The in situ enzyme immunoassay (EIA), plaque assay on Vero cells, passage in Aedes albopictus Skuse C6/36 and C7/10 cells, antigen capture enzyme immunoassay (AC-EIA), and single and multiplex reverse transcription-polymerase chain reactions (RT-PCR) were evaluated using pools of 50 mosquitoes containing 1-2 experimentally infected individuals. RT-PCR was the most sensitive assay, with a detection limit of <0.1 plaque forming unit. AC-EIA was the fastest and most economical procedure, but was the least sensitive, detecting only 38% of positive pools. The in situ EIA included initial virus amplification on Vero cells, thereby improving assay sensitivity to detect 68% of positive pools. Passage in C6/36 and/or C7/10 cell culture revealed the presence of infectious virus in samples positive by RT-PCR, but initially negative by plaque assay on Vero cell culture, indicating that detection was related to assay sensitivity and not to the absence of intact infectious virus. Combining WEE and SLE RT-PCR assays into a multiplex assay reduced sensitivity, but stilldetected viral RNA at titers below plaque assay sensitivity. Plaque assay on Vero cells, mosquito cell passage, and several RT-PCR procedures were evaluated for their ability to detect WEE and SLE in white-crowned sparrow tissues during acute and chronic stages of infection. All assays detected virus during acute infection at times of high viremia; however, only RT-PCR assays were positive by day 7 when virus was not detected in sera. RT-PCR detected SLE RNA in spleen tissue from one bird 51 d after infection. Assay sensitivity also was compared using extracts of homogenized bird organs spiked with known titers of WEE and SLE. Trizol RNA extraction followed by Qiagen one-step RT-PCR was the most sensitive method, but occasionally resulted in the presence of secondary bands confounding interpretation and requiring confirmatory assays. A balanced surveillance program should combine systems that allow the detection of new agents and the sensitive monitoring of endemic agents to provide an early warning of pending health risks.

Comparison of argentinean saint louis encephalitis virus non-epidemic and epidemic strain infections in an avian model.

St. Louis encephalitis virus (SLEV, Flavivirus, Flaviviridae) is an emerging mosquito-borne pathogen in South America, with human SLEV encephalitis cases reported in Argentina and Brazil. Genotype III strains of SLEV were isolated from Culex quinquefasciatus mosquitoes in Cordoba, Argentina in 2005, during the largest SLEV outbreak ever reported in South America. The present study tested the hypothesis that the recent, epidemic SLEV strain exhibits greater virulence in birds as compared with a non-epidemic genotype III strain isolated from mosquitoes in Santa Fe Province 27 years earlier. The observed differences in infection parameters between adult House sparrows (Passer domesticus) that were needle-inoculated with either the epidemic or historic SLEV strain were not statistically significant. However, only the House sparrows that were infected with the epidemic strain achieved infectious-level viremia titers sufficient to infect Cx. spp. mosquitoes vectors. Furthermore, the vertebrate reservoir competence index values indicated an approximately 3-fold increase in amplification potential of House sparrows infected with the epidemic strain when pre-existing flavivirus-reactive antibodies were present, suggesting the possibility that antibody-dependent enhancement may increase the risk of avian-amplified transmission of SLEV in South America.