Clinical and epidemiological characteristics of probable cases of congenital Zika syndrome and dengue antibody levels, Tuxtla Gutierrez, Chiapas, Mexico

Introduction: We previously found that the occurrence of congenital Zika syndrome was under-reported in Mexico. It was postulated that high dengue virus antibody levels found at the population-level in endemic countries might have contributed to the occurrence of the regional pandemic of Zika disease. A case series of suspected cases of congenital Zika syndrome in a maternity hospital in Tuxtla Gutierrez, Chiapas, Mexico was assembled to assess why they were not reported and to explore the hypothesis of dengue virus antibody-dependent enhancement of Zika disease. Methods: We used a quantitative approach to describe clinical and imaging records and used data from interviews of a total of 13 suspected cases of congenital Zika syndrome. We also quantitated dengue 1 and 2 antibodies using an 80% plaque reduction neutralization test of sera specimens obtained from the mothers of these 13 cases and compared them to those of a group of mothers who delivered normal newborns in the same hospital. Results: Only one of the suspected cases was laboratory-confirmed because appropriate specimens were not collected from the newborns as required by the case definition. We found 1) microcephaly, 2) hypoplasia/hypogeneses, thinning or absence of brain structures, 3) multiple birth defects, 4) calcifications, and cysts, 5) meningocele/encephalocele, and 6) hydrocephalus in 100 %, 76.9 %, 38.5 %, 38.5 %, 30.8 %, and 23.1 %, respectively of the case series. The cases clustered geographically, and 77 % occurred between May 2016 to March 2017 and recalled or were told by a doctor they had Zika fever. There was a four-fold increased risk of congenital Zika syndrome among those with dengue 1 antibody as compared to those with dengue 2 antibodies (odds ratio = 3.6; 95 % confidence interval: 0.7, 20.5), reaching only borderline statistical significance. Conclusions: We found in the largest maternal facility of the capital of the State of Chiapas, in Mexico, that only 7.7 % of suspected cases were confirmed, and that the rather complex requirement of cerebrospinal fluid specimens or serological specimens of newborns for suspected cases of congenital Zika syndrome used during the pandemic resulted in low sensitivity of the surveillance system. The finding of higher levels of dengue 1 than dengue 2 antibodies in cases than the referent population, requires further evaluation and may suggest a role for dengue antibody-dependent response in Zika disease.

Introducción: Previamente los autores habían encontrado evidencia de sub-notificación de la ocurrencia del síndrome congénito por Zika en México. Se ha postulado que niveles elevados de anticuerpos contra los virus del dengue a nivel poblacional en los países endémicos hubiese contribuido a la ocurrencia de la pandemia regional de enfermedad por Zika. Ensamblamos una serie de casos sospechosos de síndrome congénito por Zika en un hospital de maternidad en Tuxtla Gutiérrez, Chiapas, México, para evaluar por qué no fueron notificados y explorar la hipótesis de enfermedad por Zika incrementada por anticuerpos anti-dengue. Métodos: Utilizamos un enfoque cuantitativo para describir 13 casos sospechosos de síndrome congénito por revisamos registros clínicos e imágenes, entrevistas. También cuantificamos los niveles de anticuerpos para los virus dengue 1 y 2 en suero de las madres de los casos comparados con los de mujeres que tuvieron recién nacidos normales en el mismo hospital. Resultados: Solamente uno de los 12 casos sospechosos fue confirmado por laboratorio, porque en los demás no se recolectaron especímenes adecuados de los neonatos como lo requería la definición de casos. Encontramos 1) microcefalia, 2) hipoplasia y adelgazamiento de las estructuras cerebrales, 3) malformaciones múltiples, 4) calcificaciones o quistes, 5) meningocele/encefalocele, y 6) hidrocefalia en: 100 %, 76.9 %, 38.5 %, 38.5 %, 30.8 %, y 23.1 %, en ese orden entre los casos sospechosos. Los casos se aglutinaron geográficamente y 77 % ocurrieron entre Mayo del 2016 y Marzo del 2017, y sus madres recordaban que tuvieron o que un profesional de la salud les dijo que tuvieron fiebre por Zika. Encontramos un incremento de casi 4 veces en el riesgo de síndrome congénito por Zika para aquellos con altos niveles de anticuerpos anti-dengue 1 comparado con anticuerpos anti-dengue 2 (cociente de suertes = 3.6; intervalo de confianza del 95 %: 0.7, 20.5), alcanzando solamente una significancia estadística limítrofe. Conclusiones: Encontramos en el establecimiento de atención a la maternidad más grande en la capital de Chiapas, México, que solamente 7.7 % de los casos sospechosos de síndrome congénito por Zika fueron confirmados y que los relativamente complejos requerimientos de la definición de casos de muestras serológicas o de líquido cefalorraquídeo resultó en una baja sensibilidad del sistema de vigilancia. El hallazgo de niveles más altos de anticuerpos a dengue 1 que dengue 2 requiere más evaluación y pudiera sugerir un papel de la respuesta dependiente de anticuerpos al dengue en Zika.

Schlafen 11 Restricts Flavivirus Replication.

Schlafen 11 (Slfn11) is an interferon-stimulated gene that controls the synthesis of proteins by regulating tRNA abundance. Likely through this mechanism, Slfn11 has previously been shown to impair human immunodeficiency virus type 1 (HIV-1) infection and the expression of codon-biased open reading frames. Because replication of positive-sense single-stranded RNA [(+)ssRNA] viruses requires the immediate translation of the incoming viral genome, whereas negative-sense single-stranded RNA [(-)ssRNA] viruses carry at infection an RNA replicase that makes multiple translation-competent copies of the incoming viral genome, we reasoned that (+)ssRNA viruses will be more sensitive to the effect of Slfn11 on protein synthesis than (-)ssRNA viruses. To evaluate this hypothesis, we tested the effects of Slfn11 on the replication of a panel of ssRNA viruses in the human glioblastoma cell line A172, which naturally expresses Slfn11. Depletion of Slfn11 significantly increased the replication of (+)ssRNA viruses from the Flavivirus genus, including West Nile virus (WNV), dengue virus (DENV), and Zika virus (ZIKV), but had no significant effect on the replication of the (-)ssRNA viruses vesicular stomatitis virus (VSV) (Rhabdoviridae family) and Rift Valley fever virus (RVFV) (Phenuiviridae family). Quantification of the ratio of genome-containing viral particles to PFU indicated that Slfn11 impairs WNV infectivity. Intriguingly, Slfn11 prevented WNV-induced downregulation of a subset of tRNAs implicated in the translation of 11.8% of the viral polyprotein. Low-abundance tRNAs might promote optimal protein folding and enhance viral infectivity, as previously reported. In summary, this study demonstrates that Slfn11 restricts flavivirus replication by impairing viral infectivity.IMPORTANCE We provide evidence that the cellular protein Schlafen 11 (Slfn11) impairs replication of flaviviruses, including West Nile virus (WNV), dengue virus (DENV), and Zika virus (ZIKV). However, replication of single-stranded negative RNA viruses was not affected. Specifically, Slfn11 decreases the infectivity of WNV potentially by preventing virus-induced modifications of the host tRNA repertoire that could lead to enhanced viral protein folding. Furthermore, we demonstrate that Slfn11 is not the limiting factor of this novel broad antiviral pathway.