A monoclonal antibody to ameliorate central nervous system infection and improve survival in a murine model of human Enterovirus-A71 encephalomyelitis.

BACKGROUND: Enterovirus A71 (EV-A71) encephalomyelitis is an often fatal disease for which there is no specific treatment available. Passive immunization with a specific monoclonal antibody to EV-A71 was used on a murine model of EV-A71 encephalomyelitis to evaluate its therapeutic effectiveness before and after established central nervous system (CNS) infection. METHODS: Mice were intraperitoneally-infected with a mouse-adapted EV-A71 strain and treated with a dose of monoclonal antibody (MAb) daily for 3 days on day 1, 2 and 3 post-infection or for 3 days on 3, 4 and 5 post-infection. Treatment effectiveness was evaluated by signs of infection and survival rate. Histopathology and qPCR analyses were performed on mice sacrificed a day after completing treatment. RESULTS: In mock-treated mice, CNS infection was established from day 3 post-infection. All mice treated before established CNS infection, survived and recovered completely without CNS infection. All mice treated after established CNS infection survived with mild paralysis, and viral load and antigens/RNA at day 6 post-infection were significantly reduced. CONCLUSIONS: Passive immunization with our MAb could prevent CNS infection in mice if given early before the establishment of CNS infection. It could also ameliorate established CNS infection if optimal and repeated doses were given.

Mice deficient in interferon-gamma or interferon-gamma receptor 1 have distinct inflammatory responses to acute viral encephalomyelitis.

Interferon (IFN)-gamma is an important component of the immune response to viral infections that can have a role both in controlling virus replication and inducing inflammatory damage. To determine the role of IFN-gamma in fatal alphavirus encephalitis, we have compared the responses of wild type C57BL/6 (WTB6) mice with mice deficient in either IFN-gamma (GKO) or the alpha-chain of the IFN-gamma receptor (GRKO) after intranasal infection with a neuroadapted strain of sindbis virus. Mortalities of GKO and GRKO mice were similar to WTB6 mice. Both GKO and GRKO mice had delayed virus clearance from the brain and spinal cord, more infiltrating perforin(+) cells and lower levels of tumor necrosis factor (TNF)-alpha and interleukin (IL)-6 mRNAs than WTB6 mice. However, inflammation was more intense in GRKO mice than WTB6 or GKO mice with more infiltrating CD3(+) T cells, greater expression of major histocompatibility complex-II and higher levels of interleukin-17A mRNA. Fibroblasts from GRKO embryos did not develop an antiviral response after treatment with IFN-gamma, but showed increases in TNF-alpha, IL-6, CXCL9 and CXCL10 mRNAs although these increases developed more slowly and were less intense than those of WTB6 fibroblasts. These data indicate that both GKO and GRKO mice fail to develop an IFN-gamma-mediated antiviral response, but differ in regulation of the inflammatory response to infection. Therefore, GKO and GRKO cannot be considered equivalent when assessing the role of IFN-gamma in CNS viral infections.

Epstein-Barr virus-induced gene 3 negatively regulates neuroinflammation and T cell activation following coronavirus-induced encephalomyelitis.

Epstein-Barr virus-induced gene 3 (EBI3) associates with p28 and p35 to form the immunomodulatory cytokines IL-27 and IL-35, respectively. Infection of EBI3-/- mice with the neuroadapted JHM strain of mouse hepatitis virus (JHMV) resulted in increased mortality that was not associated with impaired ability to control viral replication but enhanced T cell and macrophage infiltration into the CNS. IFN-γ secretion from virus-specific CD4+ and CD8+ T cells isolated from infected EBI3-/- mice was augmented while IL-10 expression muted in comparison to infected WT mice. These data demonstrate a regulatory role for EBI3-associated cytokines in controlling host responses following CNS viral infection.

[Long-term prognosis of patients with primary myelitic manifestation of tick-borne encephalitis: a trend analysis covering 10 years]. / Langzeitprognose bei primär myelitischer Manifestation der FSME : Eine Verlaufsanalyse über 10 Jahre.

BACKGROUND: While some studies have been published about the prognosis of the meningitic and encephalitic course of tick-borne encephalitis (TBE), only few data exist about the long-term prognosis of TBE myelitis. The aim of the present prospective study therefore was to investigate such patients over a period of 10 years. METHOD: In Baden-Württemberg between 1994 and 1999, 731 patients fell ill with TBE. Of them 81 (11%) suffered from encephalomyelitis. All patients were asked to participate in this study, 57 of whom agreed. Individual impairments were measured by allocating single scores for the paresis of the extremities or cranial nerves, ataxia, impaired consciousness, respiratory paralysis and defective hearing. The total impairment was measured at follow-up investigations at 1, 3, 5 and 10 years. RESULTS: A total of 11 patients (19%) recovered, 29 (51%) suffered from persisting pareses or other impairments and 17 (30%) died 1-10 years after the acute disease. The most important ameliorations occurred during the first year after the acute disease; thereafter, improvements were lesser and more seldom. The clinical findings after 5 and 10 years correlated well with the status of the acute disease (r=0.8, p<0.01) allowing one to hazard a prognosis at the first presentation. The best restitution was seen for ataxia, impairment of consciousness, double vision, urinary retention and mild paresis of only one extremity (4/5). Patients with tetraparesis and simultaneous occurrence of respiratory paralysis and/or dysphagia, dysarthria or paresis of the neck muscles had the worst prognosis. CONCLUSION: A myelitic course of TBE is associated with the chance to recover in only about 20% of patients. Clinical deficits do not always correlate to findings in magnetic resonance tomography but to observations in postmortem studies.

Ferrets develop fatal influenza after inhaling small particle aerosols of highly pathogenic avian influenza virus A/Vietnam/1203/2004 (H5N1).

BACKGROUND: There is limited knowledge about the potential routes for H5N1 influenza virus transmission to and between humans, and it is not clear whether humans can be infected through inhalation of aerosolized H5N1 virus particles. Ferrets are often used as a animal model for humans in influenza pathogenicity and transmissibility studies. In this manuscript, a nose-only bioaerosol inhalation exposure system that was recently developed and validated was used in an inhalation exposure study of aerosolized A/Vietnam/1203/2004 (H5N1) virus in ferrets. The clinical spectrum of influenza resulting from exposure to A/Vietnam/1203/2004 (H5N1) through intranasal verses inhalation routes was analyzed. RESULTS: Ferrets were successfully infected through intranasal instillation or through inhalation of small particle aerosols with four different doses of Influenza virus A/Vietnam/1203/2004 (H5N1). The animals developed severe influenza encephalomyelitis following intranasal or inhalation exposure to 10¹, 10², 10³, or 104 infectious virus particles per ferret. CONCLUSIONS: Aerosolized Influenza virus A/Vietnam/1203/2004 (H5N1) is highly infectious and lethal in ferrets. Clinical signs appeared earlier in animals infected through inhalation of aerosolized virus compared to those infected through intranasal instillation.

Antiviral antibodies are necessary to prevent cytotoxic T-lymphocyte escape in mice infected with a coronavirus.

Mutation within virus-derived CD8 T-cell epitopes can effectively abrogate cytotoxic T-lymphocyte (CTL) recognition and impede virus clearance in infected hosts. These so-called "CTL escape variant viruses" are commonly selected during persistent infections and are associated with rapid disease progression and increased disease severity. Herein, we tested whether antiviral antibody-mediated suppression of virus replication and subsequent virus clearance were necessary for preventing CTL escape in coronavirus-infected mice. We found that compared to wild-type mice, B-cell-deficient mice did not efficiently clear infectious virus, uniformly developed clinical disease, and harbored CTL escape variant viruses. These data directly demonstrate a critical role for antiviral antibody in protecting from the selective outgrowth of CTL escape variant viruses.

Characteristics of an outbreak of West Nile virus encephalomyelitis in a previously uninfected population of horses.

Equine West Nile virus (WNV) encephalomyelitis cases - based on clinical signs and ELISA serology test results - reported to Texas disease control authorities during 2002 were analyzed to provide insights into the epidemiology of the disease within a previously disease-free population. The epidemic occurred between June 27 and December 17 (peaking in early October) and 1,698 cases were reported. Three distinct epidemic phases were identified, occurring mostly in southeast, northwest and then central Texas. Significant (P<0.05) disease clusters were identified in northwest and northern Texas. Most (91.1%) cases had no recent travel history, and most (68.9%) cases had not been vaccinated within the previous 12 months. One-third of cases did not survive, 71.2% of which were euthanatized. The most commonly reported presenting signs included ataxia (69%), abnormal gait (52%), muscle fasciculations (49%), depression (32%) and recumbency (28%). Vaccination status, ataxia, falling down, recumbency and lip droop best explained the risk of not surviving WNV disease. Results suggest that the peak risk period for encephalomyelitis caused by WNV may vary substantially among regions within Texas. Recumbent horses have a poor prognosis for survival. Vaccines, even if not administered sufficiently in advance of WNV infection within a district, may reduce the risk of death by at least 44%.

[Neuropathological findings after cardiac surgery-retrospective study over 6 years]. / Neuropathologische Befunde nach herzchirurgischen Operationen. Retrospektive über 6 Jahre.

Neuropathological studies may contribute to the discovery of central nervous system complications after heart surgery and thus help to reduce the incidence of postoperative neurological or cognitive disturbances. We examined the brains of 262 such patients operated for coronary bypass, valve replacement, or heart transplantation. Circulatory disturbances (macro- and microhemorrhages, infarcts, subarachnoid hemorrhages, and hypoxemic brain damage) were present in 128 cases (49%), as the cause of death in 33 cases (12.6%). The infarcts were caused by local arteriosclerosis of brain arteries, arterial emboli originating from the operative sites or myocardial infarctions, or by fat emboli, foreign body emboli or megakaryocytic capillary emboli in rare cases. Inflammatory disturbances were present in 17 cases and consisted of fungal or bacterial septicopyemic changes (12) or of glial nodules (5) as the substrate of a viral or autoimmunencephalitis (Bickerstaff). An incidental finding was Alzheimer's disease in 37 cases (14% of the material) of elderly patients, often associated with cerebral amyloid angiopathy but not as cause of death or cause of macroscopic brain hemorrhage. Since we have conducted an autopsy study, there is a limitation to transfer the documented changes to the total group of post-cardiac surgery patients with neurologic and cognitive deficits. Contrary to some previous reports, histologically overt microembolic phenomena do not seem to play a major role in our material. On the other hand, careful scrutiny revealed non-fatal white matter microhemorrhages of varying frequency in the different groups, especially after valve operations. These as well as the occasional glial nodules, after resorption and microscarring, could well be the cause of slight neurologic and cognitive impairments.

Perforin-mediated effector function within the central nervous system requires IFN-gamma-mediated MHC up-regulation.

CD8(+) T cells infiltrating the CNS control infection by the neurotropic JHM strain of mouse hepatitis virus. Differential susceptibility of infected cell types to clearance by perforin or IFN-gamma uncovered distinct, nonredundant roles for these antiviral mechanisms. To separately evaluate each effector function specifically in the context of CD8(+) T cells, pathogenesis was analyzed in mice deficient in both perforin and IFN-gamma (PKO/GKO) or selectively reconstituted for each function by transfer of CD8(+) T cells. Untreated PKO/GKO mice were unable to control the infection and died of lethal encephalomyelitis within 16 days, despite substantially higher CD8(+) T cell accumulation in the CNS compared with controls. Uncontrolled infection was associated with limited MHC class I up-regulation and an absence of class II expression on microglia, coinciding with decreased CD4(+) T cells in CNS infiltrates. CD8(+) T cells from perforin-deficient and wild-type donors reduced virus replication in PKO/GKO recipients. By contrast, IFN-gamma-deficient donor CD8(+) T cells did not affect virus replication. The inability of perforin-mediated mechanisms to control virus in the absence of IFN-gamma coincided with reduced class I expression. These data not only confirm direct antiviral activity of IFN-gamma within the CNS but also demonstrate IFN-gamma-dependent MHC surface expression to guarantee local T cell effector function in tissues inherently low in MHC expression. The data further imply that IFN-gamma plays a crucial role in pathogenesis by regulating the balance between virus replication in oligodendrocytes, CD8(+) T cell effector function, and demyelination.

Tick-borne encephalitis (TBE) in Germany and clinical course of the disease.

Between 1991 and 2000 about 1500 patients fell ill in Germany (Baden-Wuerttemberg, Bavaria, Hesse) after infection with the tick-borne encephalitis (TBE) virus. Detailed clinical and epidemiological data of TBE were available from 850 patients. A biphasic course of the disease occurred in 75% of patients. TBE presented as meningitis in 400 patients (47%), as meningoencephalitis in 356 (42%) and as meningoencephalomyelitis in 93 (11%). Nine of the patients (1%) died from TBE. Five hundred and ninety three patients (70%) had noticed a tick bite and the first symptoms occurred, on average, seven days later. The most frequent neurological symptoms were an impairment of consciousness (31%), ataxia (18%) and paresis of the extremities (15%) and cranial nerves (11%). Laboratory investigations revealed leukocytosis in the peripheral blood in 74% of the patients, elevation of the sedimentation rate in 91%, increased C-reactive protein in 82%, pleocytosis in the CSF of all patients tested, damage of the blood-CSF-barrier in 79%, abnormalities in EEG in 77% and abnormalities in MRI in 18%. In general, adolescents up to 14 years of age had a more favourable course of the disease than adults. In view of the severity of the illness and the high frequency of sequelae, active immunisation against TBE is recommended for all subjects living in and travelling to areas of risk. Regarding the higher risk of severe manifestations of TBE in the elderly patients and the higher risk of failure of immunisation in this population, vaccination against TBE is more important in elderly subjects than in very young persons. Prevention of TBE by post exposure prophylaxis with hyperimmunoglobulins is less effective and should therefore not be performed.

Evaluation of risk factors associated with clinical improvement and survival of horses with equine protozoal myeloencephalitis.

OBJECTIVE: To investigate risk factors for use in predicting clinical improvement and survival of horses with equine protozoal myeloencephalitis (EPM). DESIGN: Longitudinal epidemiologic study. ANIMALS: 251 horses with EPM. PROCEDURE: Between 1992 and 1995, 251 horses with EPM were admitted to our facility. A diagnosis of EPM was made on the basis of neurologic abnormalities and detection of antibody to Sarcocystis neurona or S neurona DNA in CSF. Data were obtained from hospital records and through telephone follow-up interviews. Factors associated with clinical improvement and survival were analyzed, using multivariable logistic regression. RESULTS: The likelihood of clinical improvement after diagnosis of EPM was lower in horses used for breeding and pleasure activities. Treatment for EPM increased the probability that a horse would have clinical improvement. The likelihood of survival among horses with EPM was lower among horses with more severe clinical signs and higher among horses that improved after EPM was diagnosed. CONCLUSIONS AND CLINICAL RELEVANCE: Treatment of horses with EPM is indicated in most situations; however, severity of clinical signs should be taken into consideration when making treatment decisions. Response to treatment is an important indicator of survival.

Clinical features and risk factors of pulmonary oedema after enterovirus-71-related hand, foot, and mouth disease.

BACKGROUND: In Taiwan, from April to July, 1998, an epidemic of hand, foot, and mouth disease associated with enterovirus 71 (EV71) occurred with fatal complications. We did a clinical study of EV71-related diseases in Taiwan. METHODS: We studied 154 children with virus-culture confirmed EV71 infection. Children were divided into three groups: 11 patients with pulmonary oedema; 38 patients with central nervous system (CNS) involvement and no pulmonary oedema; and 105 children without complications. We compared the clinical features, laboratory findings, risk factors, and outcome among these three groups. FINDINGS: Nine children with pulmonary oedema had hand, foot, and mouth disease, one had herpangina, and one had febrile illness with eight children with limb weakness and one with limb hypesthesia. All children had had sudden onset of tachycardia, tachypnoea, and cyanosis 1-3 days after onset of the disease. Nine of 11 children died within 12 h of intubation; one child was braindead within 15 h and died 17 days after intubation; one child was in deep coma and died 3 months later. In children with CNS complication and no pulmonary oedema, one child died of pneumonia after 4 months of ventilator support and four children had sequelae. All 105 children without complications recovered. There was a significant association between CNS involvement and pulmonary oedema (odds ratio 12.4 [95% CI 2.6-60.1], p=0.001). Risk factors for pulmonary oedema after CNS involvement were hyperglycaemia, leucocytosis, and limb weakness. Hyperglycaemia was the most significant prognostic factor for pulmonary oedema (odds ratio 21.5 [3-159], p=0.003). INTERPRETATION: EV71 can cause hand, foot, and mouth disease, CNS involvement with severe sequelae, and fatal pulmonary oedema. Hyperglycaemia is the most important prognostic factor.

Identification of enterovirus 71 isolates from an outbreak of hand, foot and mouth disease (HFMD) with fatal cases of encephalomyelitis in Malaysia.

Thirteen enterovirus 71 (EV71) isolates were obtained from both fatal and non-fatal infections of patients seen in Peninsula Malaysia and in Sarawak during an outbreak of hand, foot and mouth disease (HFMD) in Malaysia in 1997, with incidences of fatal brainstem encephalomyelitis. The isolates were identified using immunofluorescence staining, neutralization assays, and partial sequencing of the 5' untranslated regions (UTR). Assessment of the potential genetic relationships of the isolates using the partial 5'UTR sequences suggested clustering of the isolates into at least two main clusters. Isolates from Peninsula Malaysia were found in both clusters whereas Sarawak-derived isolates clustered only in cluster II. Isolates derived from fatal infections, however, occurred in both clusters and no distinctive nucleotide sequences could be attributed to the fatal isolates. Examination of the nucleotide sequences revealed at least 13 nucleotide positions in all the isolates which differ completely from the previously reported EV71 5'UTR sequences. In addition, at least 11 nucleotide position differences within the 5'UTR were noted which differentiated cluster I from cluster II. Predicted secondary RNA structures drawn using the nucleotide sequences also suggested differences between isolates from the two clusters. These findings suggest the presence of at least two potentially virulent EV71 co-circulating in Malaysia during the 1997 HFMD outbreak.

B cell-deficient mice have increased susceptibility to HSV-1 encephalomyelitis and mortality.

We studied the susceptibility of B cell-deficient mice to encephalomyelitis following intraperitoneal inoculation of HSV-1. B cell-deficient mice developed striking CNS signs including tail atony, clumsy gait and limb paralysis after HSV-1 infection. In addition, B cell-deficient mice had decreased survival (LD50 = 2.2 x 10(7) PFU) compared to control C57BL/6 mice (LD50 = 2.3 x 10(8) PFU). B cell-deficient mice had encephalomyelitis and detectable virus in the brain 7 days post-infection while C57BL/6 mice did not. Passive transfer of hyperimmune sera protected B cell-deficient mice from death, suggesting a role for antibody in susceptibility to HSV-1 encephalomyelitis.

Prognostic factors for dogs with granulomatous meningoencephalomyelitis: 42 cases (1982-1996).

OBJECTIVE: To assess signalment, clinical signs, results of CSF analysis, treatment, and survival times in dogs with granulomatous meningoencephalomyelitis (GME) and to identify factors associated with survival. DESIGN: Retrospective study. SAMPLE POPULATION: Medical records of 42 dogs with GME. PROCEDURE: Information on signalment, neurolocalization, presence of focal or multifocal signs, results of CSF analysis, method of treatment, and time from onset of clinical signs to death was retrieved from medical records of each dog. Kaplan-Meier survival analysis was used to assess survival times. The Cox proportional hazards method was used to identify predictors of survival. RESULTS: Females and toy and terrier breeds were predisposed to GME. Half of the dogs had focal neurologic signs, and half had multifocal involvement. Clinical signs referable to the forebrain were most common with focal involvement, whereas signs referable to the forebrain and brainstem were most commonly seen with multifocal involvement. Cerebrospinal fluid analysis commonly revealed a mononuclear pleocytosis. Survival times ranged from 1 to > 1,215 days. Significant differences in survival times were demonstrated for the following factors: focal versus multifocal clinical signs, neurolocalization of focal signs, and treatment with radiation. Radiation was the only independent predictor of survival. CLINICAL IMPLICATIONS: Dogs with signs suggesting focal involvement of GME tend to survive longer than those with multifocal involvement. Radiation is an effective treatment for dogs with GME, particularly those with clinical signs suggesting focal involvement.

The role of IL-10 in mouse hepatitis virus-induced demyelinating encephalomyelitis.

Interleukin 10 (IL-10) is an important anti-inflammatory cytokine. To examine its role in virus-induced encephalomyelitis, IL-10-deficient (IL-10 -/-) mice were infected with a neurotropic strain of mouse hepatitis virus (JHMV). JHMV-infected IL-10 -/- mice, compared to IL-4 -/- and syngeneic C57BL/6 mice, exhibited increased morbidity and mortality. Virus was cleared from the CNS of all groups of mice with equal kinetics by day 9 postinfection and the lack of either IL-4 or IL-10 did not alter the distribution of viral antigen, suggesting a lack of correlation between viral replication and the increased clinical disease in IL-10 -/- mice. In moribund IL-10 -/- mice, a moderate increase in mononuclear cell infiltration was correlated with increased expression of tumor necrosis factor-alpha, interferon-gamma, and inducible nitric oxide synthase mRNAs. In the small percentage of IL-10 -/- mice that survived, no differences in either demyelination or inflammation were observed. Together, these results suggest that IL-10 is not required for viral clearance, and although it appears to be one of the mechanisms responsible for inhibiting the extent of inflammation in the CNS during acute JHMV infection, it has little role in the eventual resolution of CNS inflammatory responses.

Tick-borne encephalitis in southwestern Germany.

In Baden-Württemberg in 1994 and 1995 approximately 390 persons fell ill after infection with the tick-borne encephalitis (TBE) virus. Detailed clinical data were available from 300 patients for further analysis. TBE mostly manifested as meningitis (50%) or meningoencephalitis (38%) and more rarely as encephalomyelitis and/or radiculitis (12%). Four patients with encephalomyelitis died.

Histopathologic features in the central nervous system of 400 acquired immunodeficiency syndrome cases: implications of rates of occurrence.

Histopathologic lesions in the central nervous system (CNS) of 400 autopsy cases of the acquired immunodeficiency syndrome (AIDS) collected from 1982 to 1990 were studied. Lesions most closely associated with human immunodeficiency virus (HIV) infection in the CNS (perivascular macrophages, nodular encephalomyelitis, diffuse leukoencephalopathy, necrotizing encephalitis, and long-tract degeneration) were found in 20% of the cases. The group of vascular and inflammatory lesions and of opportunistic infections was seen in 25% of cases. These two lesion groups were found together in 32% of cases, and none of these lesions was present in 23% of cases (most of the latter having no significant CNS lesions). Length of survival increased in the last group of 100 cases compared with the first 300 cases. The homosexual and bisexual risk groups showed continuously increasing lengths of survival for each category of HIV-associated CNS lesions throughout the study, while the lengths of survival in the other risk groups varied. Patients in the last group of 100 autopsy cases with any HIV-associated lesion survived longer than patients without these lesions. The AIDS patients with no CNS lesions had the shortest mean length of survival. The results suggest that although survival is prolonged as specific therapy is given, there is an increase in CNS lesions in AIDS patients with longer survival. This may indicate that CNS lesions in AIDS are generally dependent on systemic disease progression over many months as immune function decreases.