Multicenter comparison of different real-time PCR assays for quantitative detection of Epstein-Barr virus.

Quantification of Epstein-Barr virus (EBV) in peripheral blood is important for the diagnosis and management of serious EBV diseases, including posttransplant lymphoproliferative disorder. A variety of PCR-based methods are currently in use; however, there is little information on their comparability. This study assessed the relative performance of different quantitative assays. A multicenter comparative study was performed at eight sites using three panels consisting of serial dilutions of quantified EBV DNA and extracts from a total of 19 whole-blood specimens. Samples were distributed and tested blindly. Instrumentation, probe chemistries, amplification targets, and other test-related aspects varied considerably between laboratories. Each laboratory's calibration curve indicated strong evidence of a consistent log-linear relationship between viral load and cycle threshold, suggesting that intralaboratory tracking of a given patient would yield similar relative quantitative trends among the participating test sites. There was strong concordance among laboratories with respect to qualitative test results; however, marked quantitative discordance was seen. For most samples, the across-laboratory interquartile range of the reported viral load (in copies/microl) was roughly 0.6 log-units, and for one sample the overall range was approximately 4.2 log-units. While intralaboratory tracking of patients may yield similar results, these data indicate a need for caution when attempting to compare clinical results obtained at different institutions and suggest the potential value to be gained by more standardized testing methodology.

Mechanism of rhinovirus-induced changes in airway smooth muscle responsiveness.

An important interplay exists between specific viral respiratory infections and altered airway responsiveness in the development and exacerbations of asthma. However, the mechanistic basis of this interplay remains to be identified. This study addressed the hypothesis that rhinovirus (RV), the most common viral respiratory pathogen associated with acute asthma attacks, directly affects airway smooth muscle (ASM) to produce proasthmatic changes in receptor-coupled ASM responsiveness. Isolated rabbit and human ASM tissue and cultured ASM cells were inoculated with human RV (serotype 16) or adenovirus, each for 6 or 24 h. In contrast to adenovirus, which had no effect, inoculation of ASM tissue with RV induced heightened ASM tissue constrictor responsiveness to acetylcholine and attenuated the dose-dependent relaxation of ASM to beta-adrenoceptor stimulation with isoproterenol. These RV-induced changes in ASM responsiveness were largely prevented by pretreating the tissues with pertussis toxin or with a monoclonal blocking antibody to intercellular adhesion molecule-1 (ICAM-1), the principal endogenous receptor for most RVs. In extended studies, we found that the RV-induced changes in ASM responsiveness were associated with diminished cAMP accumulation in response to dose-dependent administration of isoproterenol, and this effect was accompanied by autologously upregulated expression of the Gi protein subtype, Gialpha3, in the ASM. Finally, in separate experiments, we found that the RV-induced effects on ASM responsiveness were also accompanied by autologously induced upregulated mRNA and cell surface protein expression of ICAM-1. Taken together, these findings provide new evidence that RV directly induces proasthmatic phenotypic changes in ASM responsiveness, that this effect is triggered by binding of RV to its ICAM-1 receptor in ASM, and that this binding is associated with the induced endogenously upregulated expression of ICAM-1 and enhanced expression and activation of Gi protein in the RV-infected ASM.

A Case of Adenovirus Viremia in a Pediatric Liver Transplant Recipient With Neutropenia and Lymphopenia: Who and When Should We Treat?

Human adenovirus (HAdV) is one of the most feared infections among immunocompromised patients. In particular, in liver transplant patients, HAdV has been implicated in acute liver failure with resultant mortality. The development of current molecular techniques and surveillance testing protocols have provided tools for early detection of HAdV infection, prior to or at the early onset of HAdV disease. Although reduction in immune suppression is the mainstay of therapy, many researchers have also advocated for early administration of antiviral therapy. In multiple reports, cidofovir treatment has been associated with declines in HAdV viral loads or clinical improvement in solid organ and bone marrow transplant recipients. However, there have also been case reports that raise questions about the effectiveness of antiviral therapy in controlling systemic HAdV disease. We report a case of a 26-month-old male recipient of a liver transplantation for hepatoblastoma who developed adenoviremia with an associated hepatitis and gastroenteritis. He recovered with reduced immune suppression but without antiviral therapy, thus avoiding potential toxicities associated with cidofovir therapy. This case a contrast to previous reports, and it highlights the ambiguity regarding which patients should receive HAdV-specific antiviral therapy. Additional knowledge regarding specific pediatric host factors and HAdV factors that predict poor outcomes are needed. Such information would allow clinicians to better stratify patients by risk at the time of adenoviremia detection so that low-risk patients are not unnecessarily exposed to medications with potential toxicities.

Biochemical characterization of a virus isolate, recovered from a patient with herpes keratitis, that was clinically resistant to acyclovir.

In vitro susceptibility assays of herpes simplex virus (HSV) do not necessarily correlate with treatment outcome. An HSV type 1 (HSV-1) isolate, N4, recovered from a patient who presented with herpes keratitis with localized immunosuppression, was characterized for susceptibility. Although the 50% inhibitory concentration (IC(50)) for this isolate was less than the accepted breakpoint for defining resistance to acyclovir (>2.0 microg/mL), the following lines of evidence suggest that the isolate was acyclovir resistant: (1) the clinical history confirmed that the infection was nonresponsive to acyclovir; (2) the in vitro susceptibility was similar to that of a thymidine kinase (TK)-negative, acyclovir-resistant virus SLU360; (3) the IC(50) of acyclovir was more than 10 times the IC(50) for an acyclovir-susceptible control strain; (4) plaque-purified clonal isolates were resistant to acyclovir (IC(50)s, >2.0 microg/mL); and (5) biochemical studies indicated that the HSV-1 N4 TK was partially impaired for acyclovir phosphorylation. Although residue changes were found in both the viral tk and pol coding regions of HSV-1 N4, characterization of a recombinant virus expressing the HSV-1 N4 polymerase suggested that the TK and Pol together conferred the acyclovir-resistance phenotype.

Secondary measles vaccine failure in healthcare workers exposed to infected patients.

OBJECTIVE: To describe 4 healthcare workers who developed measles despite pre-existing antimeasles antibody levels. DESIGN: Hospital employees working in patient care areas from July through November 1990 were screened for measles antibody levels using a commercially available enzyme immunoassay (EIA). The clinical course and laboratory evaluation of the 4 healthcare workers who developed measles were reviewed. SETTING: An academic tertiary care children's hospital. PARTICIPANTS: A convenience sample of resident physicians, nurses, ward clerks, Child Life workers, physical and occupational therapists, radiology technicians, and housekeeping staff were screened regardless of age, immunization status, or history of measles infection. RESULTS: Of 1,311 employees working in patient care areas, 900 (68.6%) had sera tested for measles antibody. Fourteen (1.5%) were negative, 338 (37.6%) had low positive antibody levels, 372 (41.3%) were mid-positive, and 171 (19%) were high-positive; 5 (0.6%) showed equivocal results. Four healthcare workers vaccinated in the past developed measles. All had positive pre-illness measles antibody levels and all had a significant rise in measles-specific IgG following infection. Three of the them had received at least 2 live measles vaccinations prior to caring for patients with measles. CONCLUSIONS: These cases raise concerns regarding detection of adequate protective measles immunity. We recommend that all healthcare workers observe respiratory precautions in caring for patients with measles.

Inapparent genital infection with Chlamydia trachomatis and its potential role in the genesis of Reiters syndrome.

An infectious etiology has been suggested for Reiter's syndrome (RS) because the disease has often been observed to follow episodes of urethritis or dysentery. Despite demonstrations of bacterial antigens in the synovial tissues of RS patients, it is not clear whether viable organisms are present in the synovium in any particular stage of this disease. Furthermore, it is not clear how either viable organisms or their product(s) might reach the joints. Infection with the bacterium Chlamydia trachomatis is the most common sexually transmitted disease in the United States, and as such this organism has emerged as a primary pathogen associated with RS. Previous work from our group has shown that synovial biopsy tissues from a majority of RS patients studied show significant levels of apparently intact chlamydial RNA, even when synovial or urethral cultures from the same patients are unequivocally negative for the organism. We show here that inapparent urethral infection with chlamydia occurs with high prevalence in men, and that inapparent cervical infection with the organism occurs at high prevalence in women. These data provide an important link in the relationship between initial chlamydial infection and possible subsequent genesis of RS, and they may give useful insight into mechanisms by which chlamydial infection can lead to development of this disease. Our data argue further that inapparent infection may be a significant factor in pathogenesis for all chlamydia-related diseases, and they suggest that, contrary to current ideas, C. trachomatis can generate disseminated infection.

What clinicians need to know about antiviral drugs and viral resistance.

The development of safe and effective antiviral therapies for the management of a variety of viral infections has expanded tremendously in recent years. Treatment is now possible for serious and potentially life-threatening infections with herpesviruses, respiratory viruses such as influenza A and respiratory syncytial virus, and the human immunodeficiency virus. The increased availability and use of antiviral drugs, however, has led to the emergence of drug-resistant viruses, especially in immunocompromised hosts. With this review, the major antiviral agents are presented with a description of the mechanisms of action, the evolution of drug resistance, and the need for in vitro antiviral susceptibility testing.

Laboratory diagnosis of fetal infections.

In utero infections of the fetus can lead to significant morbidity and mortality in the newborn child. The signs and symptoms of clinical disease, however, do not always suggest a given pathogen. The laboratory must be able to provide an early and accurate diagnosis of the causative agent so that prompt and appropriate antimicrobial therapy and medical care can be initiated. The scope of this article includes the methods employed by the laboratory to assist in the diagnosis of bacterial, fungal, parasitic, and viral infections of the fetus. Where appropriate, detection methods were addressed for the diagnosis of the major pathogens responsible for infection during the birth process.

Detection of HCV RNA in Serum by Reverse Transcriptase-PCR and Radiolabeled Liquid Hybridization.

Hepatitis C virus (HCV) possesses a single-stranded, positive-sense RNA that is 9.4 kb in length. The complete HCV genome has been cloned and sequenced and encodes for a nucleocapsid, an envelope, and five nonstructural proteins (1,2). The 5' untranslated region of the virus is highly conserved among the HCV genotypes that have been identified to date (3-5) and has been selected by most investigators as the site for developing oligonucleotide primers and probes for the polymerase chain reaction (PCR) (6-9). PCR has proven to be a rapid, sensitive, and useful method for the detection of HCV infections (6-16). The assay can detect HCV in HCV antibody-negative individuals suspected of having hepatitis and can discriminate chronic HCV infections from resolved acute infections in patients who are positive for HCV antibody. The procedure can also be used to: 1. diagnose HCV infections in newborns of HCV-infected women; 2. resolve indeterminate serologic results; 3. monitor antiviral therapy, and 4. identify HCV infection in high-risk, seronegative individuals.

Survival of human immunodeficiency virus in blood culture systems.

The survival of human immunodeficiency virus (HIV) in three blood culture systems was examined. Cells of a continuous T-cell line (CEM) infected with HIV were inoculated into either Columbia or Middlebrook 7H12 broths, or a combination of an Isolator tube/Middlebrook broth. Virus viability studies were done by removing aliquots from these media at 0, 1, 2, and 7 days and cocultivating them with uninfected CEM cells. The HIV was still viable after two days' incubation in Middlebrook broth and after seven days in Columbia broth. When HIV-infected cells were held in the Isolator blood culture tube for 30 minutes before processing in Middlebrook broth, viable virus was detected only after two and seven days' incubation. However, if infected cells were held in the Isolator tube for 60 or 120 minutes, no virus could be detected after Middlebrook broth incubation. These data suggested that the Isolator system will inactivate HIV if blood from infected patients is held in it for 60 minutes or longer.

Metachronous Epstein-Barr virus-related smooth muscle tumors in a child after heart transplantation: case report and review of the literature.

Soft tissue tumors are uncommon manifestations of Epstein-Barr virus (EBV) infection in patients who have had transplants. The authors report 2 metachronous EBV-containing smooth muscle tumors in a child who had a heart transplant, and review the literature on posttransplant soft tissue tumors.

Cytologic manifestations of respiratory syncytial virus pneumonia in bronchoalveolar lavage fluid: a case report.

BACKGROUND: Respiratory syncytial virus (RSV) pneumonia in immunocompromised patients, especially bone marrow transplant recipients, is associated with high mortality. Early diagnosis in these cases is important because antiviral therapy with ribavirin is effective in reducing mortality. CASE: A 45-year-old male with multiple myeloma who underwent autologous peripheral stem cell transplantation subsequently developed bilateral pulmonary infiltrates. A bronchoalveolar lavage specimen demonstrated the cytologic changes associated with RSV pneumonia. Infection with RSV was confirmed by indirect immunofluorescence, enzyme immunoassay and, later, on histology and electron microscopy at autopsy. CONCLUSION: Recognition of the cytologic changes associated with RSV pneumonia in immunodeficient patients can be life saving since this would initiate confirmatory immunologic studies and therapy.

The clinical utility of viral quantitation using molecular methods.

BACKGROUND: The quantitation of viral nucleic acids in biological fluids has become increasingly desirable over the past several years. To this end, a number of quantitative molecular procedures have been developed. OBJECTIVES: The objective was to review the current literature on the molecular techniques used in the quantitation of viral nucleic acids and to assess the appropriateness of these methods for clinical use. RESULTS: Assays involving both target and signal amplification are now available for the accurate and precise quantitation of viral burden in infected patients. These methods include quantitative polymerase chain reaction (PCR), branched chain signal amplification (bDNA), nucleic acid sequence-based amplification (NASBA) and the SHARP signal and hybrid capture systems. Our understanding of the natural history and pathogenesis of viruses such as the human immunodeficiency virus (HIV), hepatitis B virus (HBV), hepatitis C virus (HCV), cytomegalovirus (CMV) and Epstein-Barr virus (EBV) may be greatly facilitated by accurate determinations of viral and infected cell burden. Quantitation of viral load in infected individuals may also be useful to assess disease progression, monitor the efficacy of therapy and to predict treatment failure and the emergence of drug-resistant viruses. CONCLUSION: Precise, accurate and reproducible quantitation of viral load is now feasible. Molecular assays for viral quantitation should have a considerable impact on medical research and clinical care.

Ultrastructural study of mode of entry of Chlamydia psittaci into L-929 cells.

The entry of Chlamydia psittaci into L-929 cells was studied morphologically by transmission electron microscopy and quantitatively by a method that discriminates between attachment and uptake. Upon adsorption of 3H-labeled elementary bodies (EBs) to host cells at 4 degrees C, the EBs bound efficiently to the L-cell surface. Binding reached an equilibrium level of 55% in 3 h. Ultrastructural analysis revealed that EBs were bound preferentially to the tips and sides of microvilli at this temperature. The EBs were also observed in coated pits located at the bases of microvilli and along smooth surfaces of the host cell. No internalization was observed at 4 degrees C. When cells with prebound 3H-labeled EBs were warmed to 37 degrees C, the EBs rapidly became resistant to proteinase K removal (half time = 5 min), indicating ingested chlamydiae. At 37 degrees C, the EBs were internalized within tightly bound vesicles surrounded by an electron-dense coat of fibrillar material. EBs were also present in smooth-surfaced pits and vesicles of the host cell. Using alpha 2-macroglobulin coupled to colloidal gold (a known marker for receptor-mediated endocytosis), we observed that the entry of EBs into cells via coated pits was identical in appearance to the internalization of alpha 2-macroglobulin. Also, when the two ligands were mixed together, they could be seen within the same coated pits and were cointernalized within endocytic vesicles of the host cell. These results suggest that C. psittaci can enter nonprofessional phagocytic cells by a pathway which is similar to that of receptor-mediated endocytosis of many physiologically important macromolecules, bacterial toxins, and viruses.

Evaluation of the campyslide agglutination test for confirmatory identification of selected Campylobacter species.

The utility of a rapid latex slide agglutination test (Campyslide; BBL Microbiology Systems, Cockeysville, Md.) in detecting selected Campylobacter spp. was evaluated and compared with that of conventional identification methods. Isolated colonies suggestive of Campylobacter spp. were tested directly from primary selective media after incubation at 42 degrees C under microaerophilic conditions. Stock cultures of Campylobacter jejuni (n = 27) and C. coli (n = 3) were correctly confirmed to the genus level by latex agglutination when tested in pure cultures or isolated from seeded human feces. A total of 50 fresh clinical isolates of Campylobacter spp. (45 C. jejuni and 5 C. coli) were examined, with complete agreement observed between the latex test and conventional methods. Of 173 non-Campylobacter isolates tested from primary plates, only 1 rough strain of Pseudomonas aeruginosa produced a false-positive result. Although the manufacturer recommends a 30-min antigen extraction, 1 or 5 min was found to be sufficient. Also, confirmation could be achieved within 24 h of inoculation of clinical specimens, 2 days earlier than with conventional methods.

Utility of direct immunofluorescence and virus culture for detection of varicella-zoster virus in skin lesions.

A direct immunofluorescence assay (DFA) with a monoclonal antibody from Ortho Diagnostic Systems was compared with conventional cell culture for the rapid detection of varicella-zoster virus (VZV) in 140 dermal lesions from 133 patients. A total of 79 (56%) specimens were positive for VZV: 40 (51%) by DFA alone, 2 (3%) by culture only, and 37 (47%) by both culture and DFA. After discordant analysis, the sensitivities and negative predictive values, respectively, were 97.5% (77 of 79) and 96.8% (61 of 63) for DFA and 49.4% (39 of 79) and 60.4% (61 of 101) for viral culture. Of the 39 positive viral cultures, VZV was isolated from 38 (97%) cultures in A549 cells, 23 (59%) in primary rhesus monkey kidney cells, and only 16 (41%) in MRC-5 cells. We conclude that DFA is the optimal method for rapid identification of VZV. In addition, better recovery of VZV in culture may be achieved by using A549 cells.

Serious respiratory illness associated with rhinovirus infection in a pediatric population.

BACKGROUND: Rhinoviruses have long been associated with mild upper respiratory illness in both adults and children. However, the role of rhinoviruses as lower respiratory tract pathogens has not been fully characterized. Previous data suggests that rhinoviruses may cause severe lower respiratory illness in young children or infants. OBJECTIVES: The present study describes the clinical presentations, severity of illness and outcomes for a large cohort of pediatric patients with documented rhinovirus infections. SUBJECTS AND METHODS: A retrospective chart review was done on 93 pediatric patients from whom 101 nasopharyngeal or endotracheal specimens were positive by viral culture for a rhinovirus. All patients were hospitalized or seen in the pediatric emergency department at The Children's Hospital of Philadelphia between 1 January, 1990 and 31 May, 1996. RESULTS: Of the 93 patients, 52 were male and 41 female. The age range was 0 days to 18 years with 25 (27%) less than 3 months, 42 (45%) between 3 and 12 months and 26 (28%) over the age of 12 months. Clinical presentations on evaluation in the emergency department or admission included 78 (84%) patients with acute respiratory illness, 13 (17%) with fever and suspected sepsis and 11 (12%) with other complaints. Reported physical findings on examination included one or more lower respiratory symptoms or signs of acute distress and fever greater than or equal to 38.1 degrees C. A total of 64 (69%) children were noted to have significant past medical histories, including 28 (44%) with prematurity or complicated neonatal courses, 11 (17%) with prior reactive airways, 8 (12%) with congenital cardiac disease and 7 (11%) with neurologic disorders. Of the patients, 29 (31%) were considered to be otherwise healthy children with no underlying dysfunctions. The mean duration of hospitalization for 69 patients admitted with respiratory illness who did not develop subsequent unrelated complications was 3.7 days. No significant bacterial or fungal pathogens were identified in 91% of the cases. CONCLUSIONS: This study shows that rhinoviruses were associated with severe lower respiratory illness and hospitalization in a large pediatric population and that rhinovirus infection was a complicating factor in those patients with underlying or predisposing conditions.

Bactericidal activity of granule contents from rat polymorphonuclear leukocytes.

Granule contents from rat polymorphonuclear neutrophils were prepared by extraction with 0.2 M acetate (pH 4), dialyzed against phosphate-buffered saline (pH 7), and tested for bactericidal activity. Bactericidal assays consisted of mixing rat granule extract with 1 x 10(3) to 3 x 10(3) bacterial cells per ml at 37 degrees C for 1 h in a medium suited for bacterial growth. The granule extract demonstrated a distinctive dose-dependent bactericidal activity against outer membrane lipopolysaccharide mutants of Salmonella typhimurium LT-2, independent of added hydrogen peroxide or other active oxygen derivatives. The rough bacterial mutants showed an ordered increase in sensitivity to the rat lysosomal extracts inversely related to the length of their lipopolysaccharide carbohydrate side chains. Fractionation of the rat polymorphonuclear neutrophil granule extract with Sephadex G-100 column chromatography revealed an elution profile containing three major areas (peaks) of protein. Polyacrylamide gel electrophoresis and examination of enzymatic activity showed that these peaks contained myeloperoxidase (peak A), neutral protease (peak B), and lysozyme (peak C) activities. Also observed in peak C were cationic protein species whose cathodal electrophoretic migration was faster than that for lysozyme. Only peak C exhibited a bactericidal activity against the rough mutants of S. typhimurium LT-2 similar to that obtained for the unfractionated granule extract, with susceptibility of the bacterial mutants increasing with a progressive loss of carbohydrate residues in the lipopolysaccharide of the cell wall. The bactericidal activity of the peak C protein fraction was dose dependent. Boiling the unfractionated granule extract or peak C for 30 min had little affect on their antimicrobial activity when reacted against a deep-rough lipopolysaccharide mutant. However, trypsin pretreatment of these fractions significantly reduced their antimicrobial activity for the same mutant chemotype.