Herpesviridae Papillomaviridae. Herpesviridae Papillomaviridae Adenoviridae. Adenoviridae. Anelloviridae Circoviridae Hepadnaviridae

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1 Human DNA viruses Herpesviridae Papillomaviridae Adenoviridae Maciej Przybylski Chair and Department of Medical Microbiology DNA viruses infecting human Adenoviridae Anelloviridae Circoviridae Hepadnaviridae Herpesviridae Papillomaviridae Parvoviridae Poliomaviridae Poxviridae 1

2 DNA viruses: size and shape Herpesviruses Subfamily Alphaherpesvirinae genus Simplexvirus: HHV-1 1 (HSV-1) HHV-2 2 (HSV-2) genus Varicellovirus: Subfamily Betaherpesvirinae genus Cytomegalovirus: genus Roseolovirus: Subfamily Gammaherpesvirinae genus Lymphocryptovirus: genus Rhadinovirus: HHV-3 3 (VZV) HHV-5 5 (CMV) HHV 6A HHV 6B HHV 7 HHV-4 4 (EBV) HHV-8 8 (KSHV) 2

3 Genetic similarity of herpesviruses Herpesviridae the structure of viral particle 3

4 Genomes of herpesviruses Herpesviruses primary infection, latency, reactivation primary infection: first contact with the virus (symptomatic or asymptomatic infection) virus isn t entirely eliminated viral DNA persists within certain types of cells (latency) in conduicive circumstances in latent virus can reactivate recurrent and multiple reactivations are observed 4

5 Alphaherpesviruses latency HHV-4 pathogenesis 5

6 HSV-1, HSV-2, VZV: Neurotropic viruses CMV, HHV 6, HHV 7: T-lymphotropic viruses EBV, HHV 8: B-lymphotropic viruses Primary infection and latency sites Primary infection site Latency site HSV-1/HSV-2 VZV EBV CMV HHV-8 skin and mucosal layer upper respiratory tract mucosal layer upper respiratory tract mucosal layer upper respiratory tract mucosal layer mucosal layer epithelium neural ganglia neural ganglia B-lymphocytes T-lymphocytes B-lymphocytes 6

7 Adult population serological status HSV infection in age groups 7

8 VZV - epidemiology Chickenpox incidence around a year 8

9 Virus Transmission route and spread IgG % Main transmission within population route HHV-1 50% direct contact HHV % STD HHV % aerosol HHV % saliva/aerosol/ /aerosol/contact HHV % saliva/aerosol/ /aerosol/contact HHV % saliva/aerosol/ /aerosol/contact HHV % saliva/aerosol/ /aerosol/contact HHV-8 0,5-20% STD Herpesviruses immunological evasion interleukin homologues production (lymphocytes suppression) limited presentation of antigen (latency) apoptosis inhibition (p53 and caspases cascade) inhibition of proteasomes activity downregulation of IFNs production limited expression of antigens in MHC context 9

10 Herpesviruses pathogenicity depends on host s immunological status: efficient immunological system transient immunological disorders immunosuppression non-developed immunological system AIDS inherited immunological disorders Herpes simplex virus 1/2 Human Herpesvirus 1/2 Subfamily: Alphaherpesvirinae Genus: Simplexvirus 10

11 Pathogenicity of Herpes simplex viruses primary infections reactivation of latent virus mucocutaneous localized infections spread infections systemic infections infections of internal organs HSV-1/HSV 1/HSV-2 mucocutaneous infections herpetic gingivostomatitis and pharyngitis genital herpes conjunctivitis, keratoconjunctivitis, keratitis skin infections,, herpetic whitlow (paronychia) cold sores (herpes simplex, herpes recurrens) posttraumatic herpes recurrent gingivostomatitis 11

12 Herpetic gingivostomatitis Herpetic gingivostomatitis changes on palatum durum 12

13 HSV-1: primary skin infection in adult patient Herpetic whitlow Disease due to contamination of skin with the material containing infectious viruses (saliva, vesicular fluid). May be caused by both types of virus, also as a result of transmission from genitals. 13

14 Herpes gladiatorum contracted by wrestlers, rugbyists, also called scrumpox Herpetic keratoconjunctivitis 14

15 Characteristic corneal dendritic change due to HSV-1 infection (fluorescein stain) Cold sore (result of latent virus reactivation) 15

16 Vesiculopapular changes in the course of recurrent HSV-1 gingivostomatitis Primary infection with HSV-1 severe systemic infections eczema herpeticum infection of neonates infections in immunosuppressed patients congenital herpes simplex infections 16

17 Herpetic eczema Found in neonates and small children with preexisting atopic dermatitis or lupus erythrematosus risk of lymphadenitis and organ infections Infections in neonates HSV-2 noticeable mortality result of congenital infection or spread from mother during birth risk of severe systemic infection (prolonged viremia, pneumonia, CNS infection, hepatitis) 17

18 HSV-1 - primary infection in immunosuppressed patient Internal organs infections with HSV CNS infections: encephalitis,, meningitis respiratory tract infections (pneumonia, bronchitis) oesophagitis hepatitis necrotizing lymphadenitis urinary tract infections 18

19 HSV-1 oesophagitis HSV-1/2 treatment acyclovir (ACV) is a drug-of of-choice (effective inhibitor of viral DNA polymerase) other nucleoside analogs: famcyclovir, pencyclovir and valacyclovir resistant strains appear due to altered thymidine kinase (or DNA pol) O treatment of infections caused by resistant H strains: ganciclovir, cidofovir N N no vaccine is available N N N O O acyclovir 19

20 Diagnosis Mild infections are diagnosed on the basis of clinical symptoms laboratory diagnosis: severe infections (internal organs, systemic and spread) infections with atypical course chronic and recurrent mucocutaneous infections Clinical material for HSV laboratory diagnosis localised mucocutaneous lesions: swabs, scratches, vesicular fluid keratoconjunctivitis: eye swab keratitis: corneal scratches CNS infections: cerebrospinal fluid and blood (virus detection, IgM detection) spread and systemic infections: available material, blood 20

21 Laboratory diagnosis of HSV infections direct detection of the virus direct immunofluorescence cytological findings (Giemsa stain, giant cells, nuclear inclusions) molecular methods (PCR) antigen detection (ELISA) virus isolation in cell cultures antibodies detection (cautious approach in interpretation) Genital herpes direct smear: Tzank cells (Giemsa stain) 21

22 HSV-1 cytopathogenic effect HSV-1: direct immunofluorescence 22

23 Varicella Zoster Virus Human Herpesvirus 3 Subfamily: Alphaherpesvirinae Genus: Varicellovirus VZV Chickenpox (Varicella) Shingles (Zoster) transmission: respiratory secretions or direct contact (the most contagious herpesvirus) virus is transferred from respiratory tract epithelium to lymph nodes, and is released to blood and lymph viremia, spread with blood to skin maculopapular rash (vesicular fluid contains high titres of infectious virus and infected mononuclear cells) fever (up to 39 degrees) severe manifestations in adult patients (older than 14 y.o.) complications 23

24 Chickenpox Chickenpox Complications bacterial superinfections of chickenpox ulcers (strptococci, staphylococci) pneumonia (about 15% of adult patients) meningitis fulminant encephalitis, cerebellar ataxia rare: myelitis, Guillian-Barre syndrome Congenital infection severity of symptoms depends on time of infections scarring of the skin, damage to the lens, retina, brain; also microphtalmia 24

25 Chickenpox perinatal infections: severe course, risk of complications (pneumonia, meningitis, mortality) haemorrhagic chickenpox: primary infection in elderly patients or in immunodefficiencies Shingles (Zoster) disease due to latent virus reactivation predisposing factors: age, immunosuppresion, stress severe acute radicular pain is first manifestation few days (up to 2 weeks) chickenpox-like lesions appear within a single dermatome reactivation may affect any dermatome it depends on the site of virus latency (including trigeminal and cranial ganglia) zoster involving multiple dermatomes is observed in AIDS aptients may affect children (congenital or perinatal infection, immunological disorders) recurrent zoster is noted in patients with AIDS or neoplasms 25

26 Zoster Zoster Complications: persistence of pain (post-herpetic neuralgia), months after skin lesions have healed, especially in older patients often accompanied with sensitivity to touch within area of afected dermatome regular pain-relieving drugs are often inefficient bacterial superinfections of skin lesions 26

27 Diagnostics of uncomplicated infections cinical manifestations In severe or atypical cases direct DNA or antigen detection (skin/mucosa swabs, blood, CSF) virus isolation serology: detection of specific IgM (primary infection) Treatment acyclovir (or other nucleoside analogs) Vaccine live atenuated (Oka strain) VZV cytopathogenic effect 27

28 Epstein-Barr Virus Human Herpesvirus 4 Subfamily: Gammaherpesvirinae Genus: Lymphocryptovirus General characteristics of HHV-4 virus infects cells possesing receptors for C3d (CD21+, CR2+): B-lymphocytes and some types of epithelial cells two types of virus: : A and B, also called EBV-1 and EBV-2 HHV 4A is found in Europe and North America, HHV 4B in Africa infection can lead to transformation of infected lymphocytes 28

29 HHV-4 4 in cell nucleus HHV-4: diseases infectious mononucleosis (IM) Burkitt s lymphoma nasopharyngeal carcinoma gastric carcinoma chronic active EBV infection lymphoproliferative disease in immunosuppressed patients (LPD, PTLD) oral hairy leukoplakia infections in Duncan s disease B-,, T-T and NK-cells lymphoma haemophagocytosis syndrom (lymphohistiocytosis) hepatitis myocarditis CNS infections 29

30 Infectious mononucleosis malaise, lymphadenopathy, tonsillitis enlarged spleen and liver fever (weeks) rash resolution usually occurs in 1 to 4 weeks usually benign Hematologic picture in IM leucocytosis with lymphocytosis presence of atypical lymphocytes (10% of all leukocytes) increased number of lymphocyte precursors CD4 ; CD8 Increased liver markers: AspAT, AlAT, billirubin,, GGTP 30

31 Complications of infectious mononucleosis bacterial tonsilitis anaemia thrombocytopenia skin rash pneumonia, hepatitis,, meningitis, myocarditis spleen rupture decrease in immunoglobulin synthesis Infectious mononucleosis - diagnosis clinical symptoms hematologic findings laboratory tests (liver) serology: detection of nonspecific antibodies (heterophile antibodies) detection of specific antibodies against particular viral antigens, routinely anti-vca IgM (ELISA) by definition,, IM is a result of primary infection 31

32 Infectious mononucleosis: treatment Symptomatic: rest in bed diet vitamins drugs for pain relief and throat disinfection glycocorticosteroids when throat oedema impedes swallowing and breathing Increased lymph nodes in IM 32

33 Characteristic lesions on tonsils EBV pathogenicity is correlated with host genetic factors (HLA haplotype) Infectious mononucleosis Europe, North America Nasopharyngeal cancer South-East Asia Pacific region EBV Burkitt s lymphoma Equatorial Africa Lymphadenoidal gastric cancer Japan 33

34 EBV infections in graft recipients mononucleosis-like like syndrom (primary( infection or reactivation) typical systemic infection often accompanied by hepatitis CAEBV (chronic( active EBV) PTLD (post( post-transplanttransplant lymphoproliferative disorder) B- or T-cell lymphomas CNS infections (rare, only in deep immunosuppression) Treatment: Reduction of immunosuppression Anti-inflammatory inflammatory drugs,, IVIG Chemotherapy: etoposide, methotrexate, rituximab Antivirals: acyclovir, ganciclovir (?) HHV-4 infections in AIDS patients oral hairy leukoplakia interstitial pneumonia B-cell lymphomas 34

35 Leukoplakia Cytomegalovirus (CMV) Human Herpesvirus type 5 (HHV 5) - Subfamily: Betaherpesvirinae - Genus: Cytomegalovirus 35

36 Infections are ubiquitous (70-90% of adult population has IgG antibodies) Symptomatic infections are unusual in normal population virus is dangerous for people with immunological defficiences and in congenital infections transmitted with saliva and other body fluids establishes latency in T-lymphocytes recurrent asymptomatic reactivations with massive virus secretion are common CMV pathogenicity (I) Congenital cytomegalovirus syndrome cytomegalia in neonates hepatitis pneumonia meningitis brain calcification organ failures deafness blindness mental retardation myelitis 36

37 CMV pathogenicity (II) Infections in children, adolescents and adults asymptomatic cytomegalia (mononucleosis-likelike syndrom) hepatitis very rare in immunocompetent population myocarditis (~1% of viral MC) post-transfussion transfussion disease (prolonged fever, hepatitis symptoms, interstitial pneumonia) presently not seen (donor blood testing) CMV pathogenicity (III) Infections in patients with immunodeficiencies (immunosuppression, AIDS) systemic infection retinitis oesophagitis colitis encephalitis hepatitis myocarditis pancreatitis infection of adrenals pneumonia 37

38 CMV - treatment phosphorylated acyclic nucleoside analogs (gancyclovir, foscarnet) cidofovir for treatment of infections caused by resistant strains CMV diagnosis: immunocompetent patients Congenital infections: Mother: specific IgM detection, IgG avidity,, CMV DNA detection in blood - possible if symptomatic Baby: specific IgM detection,, DNA detection in blood, virus culture from urine (up to 48 hours after birth) Other infections only in patients with clear symptoms if not from risk groups Urine: detection of giant cells with nuclear inclusions Blood: direct detection of antigens or DNA CMV pneumonitis: : CMV DNA in blood and BAL, virus isolation from BAL Myocarditis: real-time PCR in endomyocardial biopsies 38

39 CMV diagnosis: immunosuppressed patients HSCT recipients (EBMT guidelines) monitoring of CMV DNA quantity in blood (real- time PCR) introduce when immunosuppression begins day after HSCT: twice a week monitoring of treatment CMV cytopathic effect 39

40 HHV-6 (Human Herpesvirus 6) species A and B Subfamily: Betaherpesvirinae Genus: Roseolovirus HHV 6 in cytoplasm of infected cell 40

41 HHV-6 pathogenicity primary infections in children (4 months 3 years old) mostly asymptomatic infections symptomatic infection = exanthema subitum or fever without a rash (HHV-6B) other (rare) symptomatic infections: adults: lymphadenopaties, lymphomas, lymphoblastic leukemia, myocarditis (HHV-6A), hepatitis, encephalitis (HHV-6B) BMT recipients: cytopenia, hepatitis graft recipients: : pneumonia, hepatitis, encephalitis AIDS patients: : pneumonia, encephalitis, systemic infections HHV laboratory diagnosis Real-time PCR DNA detection in clinical specimens virus isolation from blood, excretions or bioptates (only HHV-6A) viral antigens detection: : p101 (type( A), gp82 (type( B) serology: IgM detection Treatment gancyclovir, foscarnet (drugs used in CMV infections) 41

42 Human Herpesvirus 8 Kaposi s Sarcoma Herpesvirus (KSHV) Subfamily: Gammaherpesvirinae Genus: Rhadinovirus General charcteristics structure common for Herpesviridae family genome encodes typical herpesvirus proteins and certain genes stolen from human genome (functional) multiplicates in B-lymphocytes and in blood vessels intraepithelium establishes latency in B-lymphocytes 42

43 HHV 8 in infected cell HHV-8 pathogenicity Kaposi s sarcoma myosarcomas primary effusion lymphoma (PEL), other name: body cavity B-cell lymphoma (BCBL) Castleman s disease (cancer from intraepithelium of lymph nodes blood vessels) IRIS-KS (immune reconstitution inflammatory syndrome associated with HHV-8) KICS (HHV-8-associated inflammation-cytokine syndrom) 43

44 Kaposi s s sarcoma (KS) Classification based on: Risk groups: classical endemic associated with immunosuppresion associated with AIDS Severity of changes: skin lymphadenopatic invasive systemic Pathogenesis of Kaposi s sarcoma intraepithelium proliferation (vcyc) apoptosis inhibition (vflip) episom replication,, p53 inhibition (LANA) induction of blood vessel growth factor (vgcr) inhibition of IFN activity, c-myc activation (virf) induction of angiogenesis, eosinophiles and Th-cells chemotaxy (vmip complex) activation of lytic infection cycle (Rta) 44

45 Kaposi s sarcoma skin lesions Kaposi s sarcoma lesions in oral cavity 45

46 HHV-8 diagnosis clinical findings histopathology immunohistochemistry PCR: detection of viral DNA in blood or tissue samples in situ DNA hybridization serology detection of the antibodies against LANA, vp19 (capsid protein), gp35/37 (surface( protein) KSHV: treatment antiviral therapy: gancyclo lovir foscarnet cidofovir ir interferon Antivirals are inefficient against latent HHV-8! anti-tumour tumour therapy: radiotherap erapy y (usualy IFRT) vinblastin bleomycin doxorubic orubicin dactinomyc tinomycin decarbazin 46

47 Human papillomavirus (HPV) Family: Papillomaviridae Genus: Papillomavirus Species: Human papillomavirus (HPV: 198 types) non-enveloped icosahedral ~ nm in diameter circular, double-stranded DNA bp 8 genes 47

48 HPV genome HPV pathogenesis mov 48

49 HPV - epidemiology widely distributed transmission - by direct contact, by autoinoculation, by indirect contact genital warts (condylomas) are sexually transmitted laryngeal papillomas may be due to human papillomavirus acquired during birth from a mother with genital warts 49

50 Non-carcinogenous types of HPV plantar warts common warts HPV-1, 2, 4 HPV-1, 2, 3, 4, 7, 10 butcher s warts HPV-2, 7 50

51 Association of HPV types with cancer High-risk HPV types: : 16, 18, 31, 33, 34, 35, 39, 45 Low-risk HPV types: : 6, 11, 40, 42, 43, 44 Neoplastic types of HPV condyloma HPV-6, -11 flat condyloma HPV-6, -11, -16, -18, -31 cervical cancer HPV-16, -18, -31, 33 vulvar/penile cancer HPV-16 respiratory papilloma HPV-6, -11 conjunctival papilloma HPV-6, -11 focal epithelial hyperplasia HPV-2, -6, -11, -13, -16, -32 EV (Lewandowski-Lutz Lutz HPV-5, -8, -9, -12, dysplasia) -14, -15, -17, -19, -20, 51

52 HPV genome integration 52

53 HPV carcinoma incidence Cervical HPV neoplasms diagnosis Clinical symptoms (morfology of changes) Pap smear (Papanicolau) koilocytes Cytology/histopathology (classification pf cervical intraepithelial neoplasia,, CIN) HPV DNA detection HPV type specific DNA detection 53

54 Koilocytes HPV detection papillomaviruses don t multiply in vitro DNA detection all types viral load estimation (real-time PCR) specific detection hybridization PCR AFLP, RFLP mrna expression of E6/E7 transcripts p16 (L1) antigen detection microarrays 54

55 HPV vaccine Virus-like particles (VLP) composed of L1 protein (type-specific) expressed in eukaryotic cells (yeasts) bivalent (16, 18), quadrivalent (6, 11, 16 18) vaccine or nonavalent (6, 11, 16, 18, 31, 33, 45, 52, 58) target group for vaccination: females 9-13 year- old Questions: is there a need for vaccinations of male adolescents? or adult women? should there be a public coverage of vaccination? Adenoviridae Genus: Aviadenovirus Genus: Mastadenovirus 67 serotypes infecting human classification (species A - G) based on: hemagglutination activity against rhesus and rat erythrocytes pathogenicity oncogenic potential in animals reactivity with monoclonal antibodies 55

56 Adenoviruses: general properties non-enveloped enveloped, icosaedral symmetry diameter nm genome: non-segmented linear dsdna,, kb length (contains( ~ 35 genes) - from 56 serotypes only 1/3 is isolated from human in cases of infections - the few serotypes is usually responsible for clinical symptoms - after multiplication within the cell, virus sometimes won t lead to cell lysis (persistent infection) - virus is present in one for 10 7 lymphadenoidal tissue cells - 50% of children before 10 year of life has IgG antibodies - route of transmission: : aerosol or fecal-oral 56

57 Adenoviruses: pathogenicity common common: common cold (mainly species B, C and E) pharyngitis (mainly species B and C) keratoconjunctivitis (species B and D) gastroenteritis (species A, F and G) bronchitis (species B and D) pneumonia (species( B and D) rare: haemorrhagic cystitis (species C: immunosuppression, small boys) myocarditis encephalitis Adenoviral respiratory infections risk groups: military recruits (50%, 5-15% lower respiratory tract infections, low mortality) children (5%, 0,25% lower respiratory tract infections) newborns (nosocomial infections, epidemies up to 60% children in ward, higher rate of lower tract infections,, high mortality rate up to 15%) individuals older than 65 y.o.. (0,5%, in 2/3 cases results in lower respiratory tract infection, mortaility rate less than 0,5%) serotypes 3, 5, 7, 21 57

58 Complications of adenoviral lower respiratory tract infections obliterative bronchitis bronchiectasia interstitial pulmonary fibrosis viral lower respiratory tracts infections are especially dangerous for newborns and small children (in n 80% leads to chronic complications increased sensitivity to respiratory tract infections, risk of asthma developement) Adenoviruses: laboratory diagnosis When? diarrhoea eye infections lower respiratory tract infections haemorrhagic cystitis unusual infections (e.g. encephalitis) How? DNA detection antigen detection virus isolation 58

59 Treatment of adenoviral infections Treatment of adenoviral infections: systemic, lower respiratory tract (especially in immunosuppressed patients): No fully efficient anti-adenoviral adenoviral drug Cidofovir or ribavirin 59