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Unit 4

Part 5 Viral Infections


Terry Kotrla, MS, MT(ASCP)BB
Herpes Virus Group
Include 8 viruses that cause disease.
May result in sub-clinical infections
Capable of establishing latent
infection.
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
Infectious Mononucleosis
Acute self-limiting infection of the RE
system
Four to 7 week incubation
Enlarged lymph nodes in the neck.
Sore throat, fever, rash
Malaise and extreme tiredness
Liver and spleen involvement and
enlargement.
Infectious Mononucleosis -
Lab
Hematology:
High WBC,
Over 20% atypical reactive lymphocytes
also known as Downey cells.
Positive mono (heterophile antibody) test.
Negative mono test do tests for
antibodies to EBV associated antigens.
Infectious Mononucleosis
Downey cells may be present
Heterophile
Antigens/Antibodies
Heterophile antigens are a group
of similar antigens found in unrelated
animals, i.e., 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
Simple titration of sheep cell
agglutinins.
Serial dilutions of patient serum.
Add sheep RBCs.
Positive indicates presence of
heterophile antibodies.
Not specific for IM, screening test
only.
Davidsohn Differential
Used to determine heterophile antibody
present.
Add patient serum to one tube with
guinea pig kidney and another with beef
red blood cells.
Beef RBCs have IM antigen.
Guinea pg kidney have Forssman antigen.
Harvest serum and test with sheep cells.
Davidsohn Differential
* To be considered absorbed there must be greater than a three tube
difference between the presumptive titer and the differential titer.
Davidsohn Differential
Advantages Disadvantages

Davidsohn Differential test


When properly is very time consuming
and burdensome.
performed, this
test is specific for
Infectious
Mononucleosis
False-positive
results are rare.
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, coat particles
with EBV antigens.
Not diagnostic, must look at total
clinical picture.
EBV Antigens
Earlyantigen (EA)
Capsid antigen (VCA)
Membrane antigen (MA)
Nuclear antigen (EBNA)
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
EBV Antibody Response
Stage of Anti-
Disease VCA
Heterophil IgM IgG Anti-
e Antibody EBNA
Acute Pos or Neg Pos Pos Neg

Past Neg Ne Pos Pos


infection g
African or Burkitts
Lymphoma
EBV has been strongly implicated
Malignant B-cell neoplasm
presents as rapidly growing tumor of the
jaw, face or eye
grows very quickly, and without
treatment most children die within a few
months
Rare in US, equatorial Africa.
Also associated with HIV infection.
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
HIV infection stimulates reactivation of pre-
existing, latent EBV infection.
Causes viral infection of the oral cavity.
Indicator of HIV infection as well as of a person's
lessening or weakening immunity
Cytomegalovirus

Human Herpesvirus 5 (HHV-5)


Transmission occurs from person to
person.
Close intimate contact
Sexual contact
Perinatally
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
Cytomegalovirus
Perinatal transmission occurs in 10%.
If infected may cause multitude of symptoms
Petechiae
Jaundice
Hepatosplenomegaly
Neurological abnormalities
Moratlity rate 5 percent
Survivors may exhibit hearing loss, visual
impairment and mental retardation.
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
Blisterforms, 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 for HSV
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
VZV 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 Symptoms
Mild and difficult to notice
Mild fever
Headache
Stuffy or runny nose
Red eyes
Enlarged and tender lymph nodes
Pink rash begins on face, spreads to trunk
then arms and legs, disappears in same
order.
Aching joints
Rubella
Congenital Rubella
Congenital Rubella Syndrome 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
Rubella 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.
Rubella Laboratory Testing
Methods include:
hemagglutination inhibition
passive hemagglutination
neutralization
hemolysis in gel
complement fixation
fluorescence immunoassay
RIA
ELISA
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
Swollen lymph nodes
Rubeola
Fever peaks with the appearance of the rash.
Red spots with tiny grayish white heads
appear on inside of cheeks at back of mouth.
After 18 hours spots disappear and rash
develops, typically begins on forehead, then
spreads downward over 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
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
Liveattenuated-reduce virulence of
organism but it is till alive.
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.
Rubeola 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
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.
The End