Viral Infections

Terry Kotrla, MS, MT(ASCP)BB

Herpes Virus Group
Produce a variety of diseases.
May result in sub-clinical infections
May be reactivated under appropriate
conditions.
Herpes Virus Group
We will discuss the following:
Epstein-Barr virus
Cytomegalovirus
Herpes simplex virus type I and II
Varicella-zoster virus
Epstein-Barr Virus (EBV)
Spread through oral transmission
Cause of Infectious Mononucleosis.
Other Diseases include:
African or Burkitts lymphoma
Nasopharyngeal carcinoma
B cell lymphoma

Epstein-Barr virus
African or Burkitts Lymphoma
malignant B-cell neoplasm
presents as a rapidly growing tumour of the
jaw, face or eye
grows very quickly, and without treatment
most children die within a few months
Epstein-Barr virus (EBV) has been strongly
implicated

African or Burkitts Lymphoma

Although BL is a very rapidly growing tumour it
responds well to treatment.
Three pictures: before treatment, 3 days and 6
days after treatment
Nasopharyngeal Carcinoma
Endemic in South China, Africa, Arctic Eskimos
This is a malignant tumour of the squamous
epithelium of the nasopharynx.
100% contain EBV DNA
Rates are less than 1 per 100,000 in most
populations
Nasopharyngeal carcinomas are found in
association with reactivation of latent Epstein-
Barr Virus.
The exact mechanisms of association are
unknown
B-Cell Lymphoma
In most individuals infected with EBV, the virus
is present in the B-cells, which are normally
controlled by T-lymphocytes
When T-cell deficiency exists, one clone of
EBV-infected B-lymphocytes escapes immune
surveillance to become autonomously
proliferating.
EBV induced B cell lymphomas are most
prevalent in immunocompromised patients.
Oral Hairy Cell Leukoplakia
Viral infection of the oral cavity.
Indicator of HIV infection as well as of a
person's lessening or weakening immunity

Infectious Mononucleosis
4 to 7 week incubation
Acute self-limiting infection of the RE system
Enlarged lymph nodes in the neck.
Sore throat, fever, rash
Malaise, lethargy, extreme tiredness
Liver and spleen involvement and enlargement
Hematology: High WBC, over 20% atypical
reactive lymphocytes also known as Downey
cells.
Infectious Mononucleosis
Downey cells may be present
Heterophile Antigens/Antibodies
Heterophile antigens are a group of
similar antigens found in unrelated
animals, IE, man, sheep, horse, dog cat,
mouse.
Heterophile antibodies produced
against heterophile antigens of one
species will cross react with others.
Heterophile Antigens/Antibodies
Forssman antigen is an example of a
heterophile antigen and is found on the
RBCs of many species (guinea pig, dog,
cat, mouse, sheep, fowl, horse)
Forssman antibodies formed against
Forssman antigens will agglutinate sheep
RBCs.
Paul Bunnell Test
The original Paul-Bunnell test was a simple titration of sheep cell
agglutinins but this procedure was subsequently modified in order to
distinguish between sheep cell agglutinins formed in IM and the
Forssman-type antibodies found in normal serum, serum sickness
and in certain other conditions.
Tissues rich in Forssman antigen (guinea pig kidney) absorb
Forssman antibodies but do not affect the heterophil antibodies in
IM.
Heterophil antibodies are absorbed by beef cells,
Forssman hapten is a glycolipid usually associated with a protein,
the determinant being largely carbohydrate and therefore heat
stable.
Davidsohn Differential
The principle behind the Paul-Bunnell-Davidsohn test is that the two
types of sheep agglutinins are distinguished by titrating them before
and after absorption with guinea pig kidney and ox cells.
Patients serum containing antibodies due to IM is added to guinea
pig kidney cells. These antibodies are not absorbed by the kidney
cells. These antibodies then react with Beef (Ox) red blood cells
which causes agglutination and is a positive test for IM.
Patients serum containing Forssman antibodies are added to guinea
pig kidney cells. Antibodies are absorbed by the kidney cells. These
antibodies are then allowed to react with Beef red blood cells which
does not cause agglutination. This is a positive test for Forssman
antigens.
Davidsohn Differential
* To be considered absorbed there must be greater than a three tube
difference between the presumptive titer and the differential titer.
Heterophil Antibody
------------------------

Infectious Mono
Kidney Extract
------------------

Not Absorbed
Beef Erythrocyte
---------------------

Absorbed



Forssman



Absorbed



Not Absorbed



Serum Sickness



Absorbed



Absorbed

Davidsohn Differential
Advantages

When properly performed, this
test is specific for Infectious
Mononucleosis and false-
positive results are rare.
Disadvantages

Davidsohn Differential test is
very time consuming and
burdensome.
Infectious Mono Slide Tests
It was discovered that horse RBCs possess
antigens which react with the antibody
associated with IM.
Patient serum mixed with horse RBCs,
agglutination is positive.
Latex agglutination
Not diagnostic, must look at total clinical
picture.
EBV Specific Antibodies
EBV specific antibodies may be measured.
Pattern of appearance of EBV antigens.
Most valuable is IgM antibody to viral capsid
antigen (VCA), indicates a current infection (best
marker), lasts about 12 weeks.
Can also detect anti-early antigen (EA) (recent
infection) and anti EB nuclear antigen (EBNA)
(older infection).
ELISA and IFA most commonly used
Cytomegalovirus

Transmission occurs from person to
person.
Close intimate contact
Sexual contact
Pernatally
Breast milk
Organ transplant
Blood transfusion
CMV Clinical course
Symptoms resemble IM
In babies may cause life threatening
illness
Patients with deficient immune systems
AIDS patients
Transplant patients
CMV Immunologic response
Test for CMV antibody using paired serum
samples
IgM antibodies produced against early and
intermediate-early (IE) CMV antigens, last
for 3 to 4 months.
IgG appear shortly after and peak at 2 to
3 months.
CMV Laboratory Diagnosis
Range from culture and cytologic
techniques to DNA probes, PCR and
serologic techniques.
Detection of antibodies indicator of recent
or active infection.
Viral cultures
Microscopic examination of biopsy
specimens

CMV Lab Diagnosis
Detection of CMV antigen in cells using
IFA
ELISA to detect antibody to CMV
Other
fluorescence assays,
indirect hemagglutination, and
latex agglutination
False positives can occur due to RA and
Epstein-Barr antibodies
Herpes Simplex Virus (HSV)
Most exposed in childhood
Possesses viral latency hibernation
Two types: HSV-1 and HSV-2

HSV-1
Transmitted from person to person by
saliva or direct contact.
Cold sores around the mouth most
common.
Reactivation - may have several episodes
of cold sores during a lifetime

HSV-1
Symptoms
tingling
Numbness
Itching
Blister forms, breaks, crusts over
Reactivation usually caused by stress.
Conjunctivitis, keratitis and herpetic
whitlow may occur.
HSV-2
Results in Herpes genitalis - lesions BELOW the waist.
Transmitted intimate sexual contact or perinatally.
Symptoms
Pain
Tenderness
Itch
Fever
Headache
Lymphadenopathy
Malaise

HSV-2
Blisters appear
Males penis
Females vagina and cervix
Both thighs buttocks
Painful, lasts 1-3 weeks
Virus lies dormant in nearby nerves and
reactivated.
HSV 2
Can be fatal in infants
Woman with active infection needs C-
section.
Infants with localized infections have 70%
mortality rate
Disseminated neonatal herpes most lethal
form.
Neonatal Herpes
Laboratory Testing
Recovery of virus from culture
Direct examination of cells from lesion using IF
or immunoperoxidase stain
DNA probes
ELISA
Latex agglutination
RIA
Indirect IF
Serology NOT very useful
Varicella-Zoster Virus
Two different manifestations of the same
virus.
Varicella is the primary infection, causes
chicken pox
Herpes Zoster causes shingles and is due
to reactivation of the latent virus
Varicella
Fever and vesicular exanthema
Small, itchy blisters surrounded by
inflamed skin.
Begins as one or two lesions and spreads.
Number of lesions vary greatly.
Blister dries out and forms a scab.
Chicken Pox
Chicken Pox
Secondary complications due to infection
most common.
May also result in pneumonia, encephalitis
and hepatitis.
Very serious for immunocompromised children
Vaccine now available
Shingles
Chicken pox virus goes latent
Reactivated later in life
Weakened immune system
Aging
Other factors
Shingles
The typical rash of shingles begins as
redness(erythema) followed by the
appearance of blisters.
Eruptions follow the path of an infected
nerve.
The trunk is the area affected in 50% to
60% of cases.
Skin may be extremely sensitive to touch
Shingles
Shingles
Shingles
Laboratory Testing
Important to distinguish VZV from other
infections
PCR
Direct Fluorescent Antibody staining
Viral culture
IgG and IgM antibody test by ELISA
Rubella Virus
RNA virus with 3 major structural proteins,
E1, E2, and C.
Incubation 2- 3 weeks
Highly contagious, spread through
respiratory tract.
Causes German measles
Rubella vaccine has resulted in 99%
decline in infections.
Rubella
Congenital rubella
Congenital Rubella Syndrom most serious.
Fetus infected during first trimester.
result in miscarriage or stillbirth,
live-born serious birth defects or dying.
20% of the children born after such an infection
suffer the severe congenital abnormalities
10-20% of these children die within the first
year of life.
Rubella vaccine contraindicated during
pregnancy.
Rubella Syndrome
Lab testing
IgG and IgM antibodies may form at same
time
IgM antibodies persist for 4 to 5 weeks,
IgG for life.
Performed primarily for diagnosis of
acquired infections and to determine
immune status of pregnant patients.
Some tests detect IgG antibodies, other
IgM.
Laboratory Testing - Rubella
Methods include:
hemagglutination inhibition,
passive hemagglutination,
neutralization,
hemolysis in gel,
complement fixation,
fluorescence immunoassay,
RIA,
ELISA and
latex agglutination.
Rubeola
Single stranded RNA virus best known for
its typical skin rash
Primarily respiratory infection
Incubation approximately 10 days, ranges
from 8-13.
Rash appears at about day 14.
Airborne precautions
Rubeola
Symptoms include
irritability,
runny nose,
eyes that are red and sensitive to light,
hacking cough, and
high fever
Rubeola
Fever peaks with the appearance of the rash.
Rash typically begins on the forehead, then
spreads downward over the face, neck, and
body.
Rash appears on face first and consists of large
flat red to brown blotches that often flow into
one another
Rash fades in the same order that it appeared
Rubeola
Complications
Croup
bronchitis
bronchiolitis
pneumonia
conjunctivitis
myocarditis
Hepatitis
encephalitis
Rubeola
More susceptible to ear infections or
pneumonias
Disease can be severe, with
bronchopneumonia or brain inflammation
May lead to death in approximately 2 of
every 1,000 cases.
Most severe in adults
Measles vaccine
Live attenuated
DO NOT give to:
pregnant women,
persons with active tuberculosis,
leukemia,
lymphoma,
depressed immune systems.
People with egg allergies
Measles vaccine
Occasionally causes side effects in persons
with no underlying health problems,
In about 10% of cases there is a fever
between 5 and 12 days after vaccination,
In about 5% of cases there is a rash.
Laboratory Testing
Serology testing provides best means of
confirming a measles diagnosis
Methods to detect rubeola antibodies
include:
hemagglutination inhibition,
endpoint neutralization,
complement fixation,
IFA and
ELISA.
Laboratory Testing
Diagnosis confirmed by presence of
Rubeola specific IgM antibodies antibodies
or four-fold rise in IgG antibody titer in
paired samples taken after rash to 10 to
30 days later.
IgM test highly depended on time of
sample collection with 3-11 days after
rash being optimal.
IgM false positive due to RA.
Mumps
Single stranded RNA virus.
Mumps is transmitted by direct contact
with saliva and discharges from the nose
and throat
iIncubation 16-18 days.
Virus can infect many parts of the body,
especially the parotid salivary glands.
Mumps
Glands usually become increasingly
swollen and painful over a period of 1 to 3
days
Pain gets worse
Both the left and right parotid glands may
be affected

Mumps
Mumps
Mumps - Complications
inflammation and swelling of the brain
Mumps in adolescent and adult males may
also result in the development of orchitis
May affect the pancreas or, in females,
the ovaries
Infection in pregnant women may result in
increased risk for fetal death
Laboratory Testing
complement fixation
hemagglutination inhibition
hemolysis-in-gel
neutralization assys
IFA and
ELISA
Laboratory Testing
Current or recent infections indicated by presence of
specific IgM antibody in single sample which can be
detected within 5 days of illness.
Fourfold rise in specific IgG antibody in 2 samples
collected during acute and convalescent phases
Fluorescent antibody staining for mumps antigens
Cross-reactivity between antibodies to mumps and
parainfluenza viruses has been reported in tests for IgG,
not a problem since symptoms differ.