Epidemiology and Management of the 2013-16 West African Ebola Outbreak.

The 2013-16 West African Ebola outbreak is the largest, most geographically dispersed, and deadliest on record, with 28,616 suspected cases and 11,310 deaths recorded to date in Guinea, Liberia, and Sierra Leone. We provide a review of the epidemiology and management of the 2013-16 Ebola outbreak in West Africa aimed at stimulating reflection on lessons learned that may improve the response to the next international health crisis caused by a pathogen that emerges in a region of the world with a severely limited health care infrastructure. Surveillance efforts employing rapid and effective point-of-care diagnostics designed for environments that lack advanced laboratory infrastructure will greatly aid in early detection and containment efforts during future outbreaks. Introduction of effective therapeutics and vaccines against Ebola into the public health system and the biodefense armamentarium is of the highest priority if future outbreaks are to be adequately managed and contained in a timely manner.

Stem-loop structures II-IV of the 5' untranslated sequences are required for the expression of the full-length hepatitis C virus genome.

The 5' and 3' untranslated regions (UTR) of the hepatitis C virus (HCV) genome contain stem-loop structures, which are important in viral gene expression and replication. In this study, the functional roles of the predicted stem-loop structures of HCV 5' UTR and 3' UTR in viral gene expression were examined using a chimeric clone of full-length HCV genomic cDNA clone and the gene for green fluorescent protein (GFP). High level expression of the HCV-GFP chimera in Huh-7 cells was accomplished by using a replication defective adenovirus that expresses T7 RNA polymerase and transcription plasmid containing full-length HCV-GFP chimera under the control of a T7 promoter. The HCV-GFP clone, with deletion of stem-loop I, expressed proteins in transfected Huh-7 cells at comparable levels to the wild type HCV clone. Other mutations of the 5' UTR, which either deleted or altered the base pairing of stem-loops II to IV, completely abolished the expression of HCV-GFP chimera. In contrast, deletion of 3' UTR sequences had no effect on HCV protein expression. These findings suggest that the stem-loop structures II to IV of HCV 5' UTR are necessary for protein expression, but that stem loop I is dispensable for protein translation. The stem-loop structures of 3' UTR of HCV genome appear to have no direct role in viral gene expression.

Hepatitis C viral proteins affect cell viability and membrane permeability.

To determine the effect of hepatitis C virus (HCV) proteins on cell growth, Huh-7 cells were transfected with a full-length HCV cDNA (pMO9.6-T7 Rz) clone and HCV proteins were expressed using a replication-defective adenovirus that encodes the gene for the T7 RNA polymerase. Expression of HCV proteins from this full-length clone resulted in reduction in viability of transfected cells as measured by trypan blue viability assay. For identification and separation of cells expressing hepatitis C virus proteins by fluorescence microscopy and flow cytometry, GFP was cloned in the HCV full-length clone. Cells transfected with the HCV-GFP chimera clone produced high levels of accurately processed structural and nonstructural proteins similar to those of the HCV full-length clone, which could be detected by Western blot analysis. Cells expressing all HCV proteins lost membrane permeability and underwent apoptotic cell death, indicated by the appearance of a sub-G0 peak in cell cycle analysis, DNA fragmentation in a TUNEL assay, and microscopic detection of nuclear condensation. Using double-channel flow analysis we confirmed that high-level expression of HCV proteins affected membrane permeability and cell survival. These results suggest that expression of all structural and nonstructural proteins from HCV cDNA in hepatic cells induces apoptotic cell death, which might be an important event in chronic hepatitis infection in humans.

Transmission of HCV to a chimpanzee using virus particles produced in an RNA-transfected HepG2 cell culture.

It was demonstrated previously that HepG2 cells produce negative strand RNA and virus-like particles after transfection with RNA transcribed from a full-length hepatitis C virus (HCV) cDNA clone [Dash et al. (1997) American Journal of Pathology, 151:363-373]. To determine in vivo infectivity of these in vitro synthesized viral particles, a chimpanzee was inoculated intravenously with HCV derived from HepG2 cells. The infected chimpanzee was examined serially for elevation of liver enzymes, for the presence of HCV RNA in the serum by reverse transcription nested polymerase chain reaction (RT-PCR), anti-HCV antibodies in the serum, and inflammation in the liver. The chimpanzee developed elevated levels of liver enzymes after the second week, but the levels fluctuated over a 10-week period. HCV RNA was detected in the serum of the chimpanzee at the second, seventh and ninth weeks after inoculation, and remained positive up to 25 weeks. Liver biopsies at Weeks 18 and 19 revealed of mild inflammation. Nucleotide sequence analysis of HCV recovered from the infected chimpanzee at the second and ninth weeks showed 100% sequence homology with the clone used for transfection studies. Serum anti-HCV antibodies were not detected by EIA during the 25 weeks follow-up period. These results suggest that intravenous administration of the virus-like particles derived from RNA-transfected HepG2 cells are infectious, and therefore, the pMO9.6-T7 clone is an infectious clone. These results provide new information that in vitro synthesized HCV particles produced from full-length HCV clone can cause infection in a chimpanzee. This study will facilitate the use of innovative approaches to the study of assembly of HCV particles and mechanisms of virus infectivity in cell culture.

Hepatitis C virus protein expression induces apoptosis in HepG2 cells.

The mechanisms of hepatocyte death and the events that lead to a high rate of chronic liver disease in patients infected with hepatitis C virus are not known. We established a HCV replication system in HepG2 cell culture and utilized this model to address the effect of HCV proteins on HepG2 cell growth and viability. After transfection of HepG2 cells with full-length RNA, a truncated RNA, or an antisense RNA, cell proliferation and cell viability were analyzed by thymidine uptake and the trypan blue exclusion method, respectively. Full-length RNA transfected HepG2 cells showed a decrease in cell proliferation and viability compared to cells transfected with HCV truncated RNA and antisense RNA control. A subset of cells expressing HCV proteins underwent apoptosis as documented by morphological studies, ultrastructural analysis, cell cycle analysis by flow cytometry, terminal transferase enzyme mediated end labeling of DNA, and DNA laddering. This study suggests that expression of HCV proteins can lead to cell death by apoptosis, which may be an important event in the pathogenesis of chronic hepatitis C virus infection in humans.

HCV RNA levels in hepatocellular carcinomas and adjacent non-tumorous livers.

To determine the antiviral effects of drugs targeted to hepatitis C virus (HCV) in chronic hepatitis patients, an accurate quantitative method with high sensitivity is needed. Reverse transcription nested polymerase chain reaction (RT-PCR) is the most sensitive method for the detection of HCV sequences in clinical specimens. However, this method is not quantitative. For this purpose, a quantitative competitive assay was developed that combines RT and PCR followed by image analysis to quantify HCV RNA. This assay targets the highly conserved 5' non-coding region of HCV and is based on the co-amplification of wild type HCV RNA with known amounts of mutant synthetic RNA. The mutant internal control used in these experiments differs from the wild type RNA by two nucleotide substitutions, which introduces an internal restriction enzyme site. In this report, this method was used to determine the levels of positive strand RNA in 11 HCV positive hepatocellular carcinomas (HCC) and compared these with adjacent non-tumorous liver tissue. To confirm that the difference in viral titers is not related to variations in the amount of RNA used in the assay, glyceraldehyde 3-phosphate dehydrogenase (GAPDH) mRNA was also assessed by competitive RT-PCR in all tissue extracts. Using this competitive assay it was determined that HCV RNA levels in the liver and tumor samples ranged from 10(3) to 10(6) molecules per microg of total RNA which is similar to previous reports. Interestingly, the amount of HCV in all the non-tumorous liver specimens were found to be significantly higher (P<0.05) than the surrounding tumors, while the GAPDH mRNA levels were found to be similar in both liver and tumor. Competitive RT-PCR is a sensitive, accurate and reliable method to determine HCV titers in clinical specimens. Using this method it was determined that malignant tumor cells harbor less HCV as compared with the surrounding non-tumorous liver cells.

Detection of hepatitis C virus RNA sequences in B-cell non-Hodgkin lymphoma.

Serologic testing shows that hepatitis C virus (HCV) may have a role in the pathogenesis of B-cell non-Hodgkin lymphomas (B-cell NHLs). We tried to demonstrate HCV RNA sequences in paraffin-embedded tissue from B-cell NHLs by reverse-transcription double polymerase chain reaction (RT-PCR) and Southern blotting. We studied 31 consecutive cases of B-cell NHLs; lymph nodes from 32 patients with diseases other than B-cell NHL were negative controls. Positive-strand HCV RNA was tested with primers for the 5' untranslated region. Replicative negative strand HCV RNA was tested with strand-specific RT-PCR for the 5' untranslated region. Immunohistochemical staining for HCV was done using an antibody to HCV core protein. Positive-strand HCV RNA was detected in 8 patients with B-cell NHL; negative-strand HCV RNA was detected in 6 of these cases, indicating viral replication. All control cases were negative for HCV RNA. Immunohistochemistry showed no staining of lymphoma cells for HCV core proteins in any case. HCV and B-cell NHLs may be associated. RT-PCR on paraffin-embedded lymphoma tissue is an alternative method of testing for HCV. The value of immunohistochemistry could not be ascertained. The exact role of HCV in the pathogenesis of B-cell NHL needs to be studied further.

Antibodies to squalene in Gulf War syndrome.

Gulf War Syndrome (GWS) is a multisystemic illness afflicting many Gulf War-era veterans. The molecular pathological basis for GWS has not been established. We sought to determine whether the presence of antibodies to squalene correlates with the presence of signs and symptoms of GWS. Participants in this blinded cohort study were individuals immunized for service in Desert Shield/Desert Storm during 1990-1991. They included 144 Gulf War-era veterans or military employees (58 in the blinded study), 48 blood donors, 40 systemic lupus erythematosus patients, 34 silicone breast implant recipients, and 30 chronic fatigue syndrome patients. Serum antibodies to squalene were measured. In our small cohort, the substantial majority (95%) of overtly ill deployed GWS patients had antibodies to squalene. All (100%) GWS patients immunized for service in Desert Shield/Desert Storm who did not deploy, but had the same signs and symptoms as those who did deploy, had antibodies to squalene. In contrast, none (0%) of the deployed Persian Gulf veterans not showing signs and symptoms of GWS have antibodies to squalene. Neither patients with idiopathic autoimmune disease nor healthy controls had detectable serum antibodies to squalene. The majority of symptomatic GWS patients had serum antibodies to squalene.

Retroviruses in autoimmune liver disease: genetic or environmental agents?

Retroviruses have been implicated in the pathogenesis of several human autoimmune conditions including Sjögren's syndrome, primary biliary cirrhosis, immune mediated diabetes, and multiple sclerosis. The human intracisternal A type particle derived from Sjögren's syndrome patients' salivary glands was the first retrovirus to be isolated from a human autoimmune disorder but the agent has yet to be cloned. In primary biliary cirrhosis patients, virus like particles have been observed by electron microscopy in biliary epithelium, endogenous retroviral sequences have been cloned from liver samples, and antibody reactivity to the human intracisternal A type particle has been observed in the majority of patients tested. However, there is no evidence to link the endogenous retroviral sequences in primary biliary cirrhosis patients to the retroviral antibody reactivity or virus like particles. In other patients with liver disease, reactivity to the human intracisternal A type particle was observed in a small but significant proportion of patients with hepatitis C virus infection. If the intracisternal A type particle is an endogenous retrovirus, it is interesting to speculate that hepatitis C virus infection may modulate the endogenous retroviral expression, as chronic hepatitis C has been linked with the development of Sjögren's syndrome. Furthermore, many patients with chronic hepatitis C virus infection have reactivity to an autoantigen of unknown significance known as GOR that has protein sequence homology with both hepatitis C virus nucleocapsid protein as well as HTLV-1 gag. This may be an another example of an endogenous retroviral protein acting as an autoantigen in liver disease patients. At this time, there is little evidence to suggest that endogenous retroviruses are infectious agents that cause autoimmune disease but they may be implicated as either genetic elements or antigens. Further studies will be required to characterize the role that both exogenous and endogenous retroviruses play in the pathogenesis of autoimmune liver diseases.

Concentration-dependent differential induction of necrosis or apoptosis by HIV-1 lytic peptide 1.

The mechanism by which human immunodeficiency virus type 1 induces depletion of CD4+ T-lymphocytes remains controversial, but may involve cytotoxic viral proteins. Synthetic peptides (lentivirus lytic peptide type 1) corresponding to the carboxyl terminus of the human immunodeficiency virus type 1 transmembrane glycoprotein induce cytopathology at concentrations of 100 nM and above. At these concentrations lentivirus lytic peptide type 1 disrupts mitochondrial integrity of CD4+ T-lymphoblastoid cells and induces other changes characteristic of necrosis. In contrast, at concentrations of 20 nM, lentivirus lytic peptide type 1 potently induces apoptosis. Thus, the mechanism by which human immunodeficiency virus type 1 mediates cell death, necrosis or apoptosis, may depend, in part, on the tissue concentration of transmembrane glycoprotein.

Both necrosis and apoptosis contribute to HIV-1-induced killing of CD4 cells.

BACKGROUND: Data currently available on HIV-1-induced cytopathology is unclear regarding the mechanism of cell killing. OBJECTIVE: To clarify the extent to which apoptosis or necrosis is involved in HIV-1-induced cell death in view of conflicting existing data. METHODS: T lymphoblastoid cells or peripheral blood mononuclear cells were infected by various strains of HIV-1 and the numbers of apoptotic or necrotic cells were quantified at various times after infection using video-image analysis techniques; the results were compared with the amount of fragmented DNA using a quantitative method. Measurement of mitochondrial transmembrane potential (deltapsi(m)) and intracellular calcium concentrations [Ca2+]i was performed with fluorescent probes and fluorescence concentration analysis (FCA). RESULTS: Although lymphoblastoid and monocytoid cells acutely infected by HIV-1 had increased levels of fragmented DNA, a marker of apoptotic cell death, few (<12%) had condensed chromatin and fragmented nuclei, the morphological features of apoptosis. The predominant alterations in acutely infected cells were distended endoplasmic reticulum and abnormal mitochondria; these ultrastructural changes are consistent with necrosis, although some infected cells simultaneously displayed features of both necrosis and apoptosis. Viability of cells persistently infected by HIV-1 was only minimally reduced from that of uninfected cells. This reduction was accounted for by an increased propensity of the persistently infected cells to die by apoptosis. Alterations in [Ca2+]i and deltapsi(m) occurred in both acutely and persistently infected cells. CONCLUSION: Both necrosis and apoptosis contribute to HIV-1-induced killing of CD4 cells.

Effect of schistosomiasis and hepatitis on liver disease.

Infection with hepatitis C virus (HCV) has become the most important public health problem in Egypt. In Egypt, viral hepatitis along with infection with Schistosoma mansoni is the major cause of chronic liver disease and liver cirrhosis. Although HCV infection is highly prevalent in Egypt, very little information is available on the distribution of the different genotypes of HCV. Our aims in this study were first to determine the prevalence of viral and parasite infections in patients with chronic liver disease and then to assess the distribution of HCV genotypes in these patients. In the present study, 151 individuals (50 with chronic liver disease, 51 with chronic diseases of organs other than the liver, and 50 apparently healthy persons) were investigated. The last 2 groups served as control groups. These individuals were subjected to routine liver function tests and detection of serum antibodies to bilharziasis, hepatitis B surface antigen (HBsAg), and HCV. Furthermore, the presence of hepatitis G virus (HGV) and HCV in the serum samples were tested for by a reverse transcription polymerase chain reaction (RT-PCR). Prevalence of different genotypes of HCV in patients positive for HCV were determined by RT-PCR using type-specific primers. Results of the study revealed that 84, 74, 12, and 20% of patients with chronic liver disease were positive for Schistosoma mansoni, HCV, HBsAg, and HGV, respectively, as compared to 51, 43.1, 2, and 4% of patients with other chronic diseases and 22, 6, 0, and 0% of apparently healthy individuals. One hundred percent of patients with chronic liver disease, 72.5% of those with other diseases, and 26% of normal controls were shown to have at least one of the studied infectious agents. Two or more of the agents were highly coincident in patients with chronic liver disease. In Egypt, HCV genotype 4a is highly prevalent, where it contributed 85% of the tested samples in comparison to 10, 2.5, and 2.5% for subtypes 1b, 2a, and 3a, respectively. In conclusion, these results suggest that in Egypt, HCV along with schistosomal parasite infection is the major risk factor for chronic liver disease. In most Egyptian patients, HCV genotype 4 is highly prevalent.

Viral induction, transmission and apoptosis among cells infected by a Human Intracisternal A-type retrovirus.

Sjogren's Syndrome, a systemic autoimmune disease, is characterized by lymphocytic infiltration of the salivary or lacrimal glands, producing xerostomia or xerophthalmia. Although definitive proof of viral etiology has not been established, a cell line containing viral particles termed Human Intracisternal A-type Particles (HIAP) resulted from co-culture with patient lip biopsies. We stimulated these chronically infected cells with phorbol myristate acetate (PMA) in an effort to enhance production of viral particles for further characterization. We report that the virus present in the HIAP cell line can be induced to become lytic when subjected to PMA and that there is a difference in the effects of PMA on H9 and HIAP cell groups, with apparent protection from apoptosis due to PMA being exerted by viral presence. Delayed apoptosis may prolong exposure of the foreign/self complex, thus enhancing an autoimmune response. Polyacrylamide gel electrophoresis (PAGE) revealed the presence of new peptides in pellets of supernatants of PMA-stimulated HIAP cells, with prominent bands at 55 and 43 kDa, and several fainter ones. HIAP infection was transferred by cell-free filtered supernatants from stimulated cells to H9 cells, which became identical to parent HIAP cells by PAGE and fluorescence activated cell sorter.

Antiretroviral antibodies: implications for schizophrenia, schizophrenia spectrum disorders, and bipolar disorder.

BACKGROUND: Some retroviral antigens share structural homology within a group of related retroviruses. It is possible that antibodies directed against one virus may cross-react with antigens from a different virus in the group. METHODS: Using this principle, the human immunodeficiency virus 1 (HIV-1) Western blot assay was used as an available source of human retroviral antigens to screen serum samples from an archived collection to ascertain whether there was an association between serum antiretroviral antibodies and mental illnesses. RESULTS: A statistically significant proportion (28/54, 52%) of patients suffering from psychiatric disorders had serum antibodies that recognized at least one antigen present on the blot, culminating in indeterminate HIV-1 tests. The majority of the reactive samples were directed against the HIV-1 group antigens p24 and p17. These findings contrast with those of nonpsychiatric patients, who had 4/16 (25%) indeterminate blots. CONCLUSIONS: The results suggest exposure to retroviral antigens related to those of HIV-1 in subpopulations of schizophrenic, schizophrenic spectrum disorder, and bipolar disorder patients.

Detection of exogenous and endogenous avian leukosis virus in commercial chicken eggs using reverse transcription and polymerase chain reaction assay.

Avian leukosis retroviruses (ALV) cause lymphomas and other cancers in chickens. Previous studies have used enzyme-linked immunosorbent assays (ELISA) and indirect immunofluorescence assays (IFA) to detect ALV p27 group-specific antigens (GSA) in commercial chicken eggs. In the poultry industry eradication programme against exogenous ALV, ELISA assays are used to identify chickens infected with the virus. The inability of ELISA and IFA assays to discriminate between ALV GSA of endogenous or exogenous origin, and actual virus, have limited rigorous assessments of viral transmission dynamics. Here, we report the use of a newly developed reverse transcriptase-polymerase chain reaction (RT-PCR) assay, with direct sequencing of the RT-PCR product, to show endogenous and exogenous ALV in albumen from unfertilized chicken eggs. We found that 95% of 20 eggs from ALV-exposed commercial chickens and 14.2% of 240 egg samples from 20 randomly chosen New Orleans retail stores were ALV-positive by RT-PCR. In comparison, only 2.5% of the same egg samples from the retail stores were positive by ELISA. Corresponding direct sequencing of randomly chosen RT-PCR products showed that four of six egg samples contained endogenous ALV, while two of the six samples were positive for exogenous subgroup A ALV. The finding of endogenous subgroup E ALV in unfertilized chicken eggs emphasizes that the transmission of endogenous ALV is common and should be considered in the implementation of ALV eradication programmes by the poultry industry.

Lupus erythematosus-like features in patients with cutaneous T-cell lymphoma.

BACKGROUND: The development of lupus erythematosus-like (LE-like) features in patients with cutaneous T-cell lymphoma (CTCL) has not been reported previously in the literature. Both diseases, however, have been etiologically linked to retroviruses. OBJECTIVE: Our purpose was to report four cases of patients with CTCL who developed LE-like features during the course of their disease, and to evaluate for evidence of antibodies to retroviruses in the sera of these patients. PATIENTS: Four patients with biopsy-proven CTCL with clinical or histologic features of systemic lupus erythematosus (SLE) were evaluated for clinical and laboratory criteria for SLE. Only one patient demonstrated four American Rheumatism Association (ARA) criteria sufficient for the diagnosis of SLE. The remaining three patients demonstrated one or two criteria for SLE. In addition, the sera of these patients were examined by Western blot analysis for evidence of human immunodeficiency virus type I (HIV-I), human T-cell lymphotrophic virus type I (HTLV-I), or human intracisternal A-type particle type I (HIAP-I) retroviral proteins. Each patient demonstrated antibodies to some of the retroviral proteins examined. The sera of two patients reacted to proteins for HIAP-I, and the sera of two patients reacted to p24 gag proteins of HIV-I. No patient reacted to HTLV-I proteins. CONCLUSIONS: Our report identifies four patients with CTCL who developed LE-like features during the course of their disease. Although the etiology of CTCL and SLE has not been well established, each has been linked to retroviruses. Evidence of antibodies to retroviral proteins was identified in each of our patients by Western blot analysis. Although the clinical and laboratory findings in these cases do not resolve the etiologic role of retroviruses in CTCL or SLE, they suggest that retroviruses may have a role in the pathogenesis of the clinical phenomenon reported in these four patients.