Histopathological Features and Viral Antigen Distribution in the Lung of Fatal Patients with <Emphasis Type="Italic">Enterovirus</Emphasis> 71 Infection

Enterovirus 71 (EV71) infection causes hand-foot-and-mouth disease (HFMD) in children and might be accompanied by severe neurological complications. It has become one of the most important pathogens of central nervous system infection. To explore the causes of lung injury by EV71, the distribution of EV71 receptors, SCARB2 and PSGL-1, in human lung tissues was examined. Our results revealed that SCARB2 was positively distributed in the bronchial and bronchiolar epithelial cells, alveolar cells and macrophages, while PSGL-1 was positively scattered in bronchial and bronchiolar epithelial cells and macrophages, and negatively distributed in alveolar cells. The pathological changes of fatal lung with EV71 infection demonstrated intrapulmonary bronchitis and bronchiolitis, diffuse or focal infiltration of inflammatory cells, such as T cells and B cells in the wall and surrounding tissues, widened alveolar septum, capillaries in the septum with highly dilated and congested, and infiltrated inflammatory cells, showing different degrees of protein edema with fibrin exudation in the alveolar cavity, as well as obvious hyaline membrane formation in some alveolar cavities. The EV71 antigen in lung tissues was detected, and the viral antigen was positive in lung bronchial and bronchiolar epithelial cells, and positively scattered in the alveolar cells and macrophages. Therefore, in addition to the complications of central nervous system injury, the lung remains the main target organ for virus attack in severe EV71 infected patients. Lung injury was mainly caused by neurogenic damage and/or direct invasion of the virus into the lungs in critically serious children, and the lesions were mainly pulmonary edema and interstitial pneumonia.     

人肠道病毒71型动物模型研究进展

人肠道病毒71型是婴幼儿手足口病的致病原之一,其严重的并发症可导致神经系统疾病,甚至死亡,是近期威胁中国儿童健康的因素之一。目前尚无临床疫苗可以预防该病毒感染,而EV71的动物模型是进行致病机理、疫苗评价和药物等研究的基础。本文对EV71的两种常用动物模型：小鼠和猕猴（Macaca mulatta）模型进行了描述,并对其在研究中的应用给与概括,为研究者选择合适的动物模型提供了依据。     

Enterovirus 71 Virion-Associated Galectin-1 Facilitates Viral Replication and Stability

Enterovirus 71 (EV71) infection causes a myriad of diseases from mild hand-foot-and-mouth disease or herpangina to fatal brain stem encephalitis complicated with pulmonary edema. Several severe EV71 endemics have occurred in Asia-Pacific region, including Taiwan, and have become a serious threat to children’s health. EV71 infection is initiated by the attachment of the virion to the target cell surface. Although this process relies primarily upon interaction between viruses and cell surface receptors, soluble factors may also influence the binding of EV71 to host cells.Galectin-1 has been reported to participate in several virus infections, but is not addressed in EV71. In this study, we found that the serum levels of galectin-1 in EV71-infected children were higher than those in non-infected people. In EV71 infected cells, galectin-1 was found to be associated with the EV71 VP1 and VP3 via carbohydrate residues and subsequently released and bound to another cell surface along with the virus. EV71 propagated from galectin-1 knockdown SK-N-SH cells exhibited lower infectivity in cultured cells and less pathogenicity in mice than the virus propagated from parental cells. In addition, this galectin-1-free EV71 virus was sensitive to high temperature and lost its viability after long-term storage, which could be restored following supplement of recombinant galectin-1. Taken together, our findings uncover a new role of galectin-1 in facilitating EV71 virus infection.     

白介素18启动子区基因多态性与儿童EV71感染相关性研究

目的:研究白介素18基因启动子多态性与儿童EV71感染遗传易感性的关系.方法:收集EV71感染患儿177例,单纯HFMD组127例,HFMD并脑炎组50例,提取外周血DNA,用序列特异性引物-聚合酶链反应(SSP-PCR)技术及基因测序法检测IL-18启动子区-137G/C、-607A/C位点的基因多态性.结果:EV71感染患儿与健康儿童IL-18-607基因型以CA为主,AA、CC次之,EV71感染患儿AA基因型、A等位基因分布频率显著高于健康儿童.EV71感染HFMD并脑炎组患儿AA基因型分布显著高于单纯HFMD组患儿,差异有统计学意义.EV71感染患儿与健康儿童IL-18-137基因型以CC为主,CG次之,GG占少数.该位点基因型及等位基因在EV71感染组与健康儿童、单纯HFMD与HFMD并脑炎组的分布无显著差异.结论:IL-18基因多态性与EV71感染相关,IL-18-607AA基因型、A等位基因携带儿童更易感染EV71病毒,且AA基因型患儿易并发脑炎,-607AA基因型可能为EV71感染的易感基因型.-137C/G位点基因多态性与EV71感染无相关性.     

Lymphocyte and Antibody Responses Reduce Enterovirus 71 Lethality in Mice by Decreasing Tissue Viral Loads

Enterovirus 71 (EV71) infects the central nervous system and causes death and long-term neurological sequelae in hundreds of thousands of young children, but its pathogenesis remains elusive. Immunopathological mechanisms have been suspected to contribute to the pathogenesis of neurological symptoms, so anti-inflammatory agents have been used to treat patients with neurological symptoms. The present study was therefore designed to investigate the functions of lymphocyte and antibody responses in EV71 infection using a mouse model. Immunohistochemical staining analysis revealed virus and three types of lymphocytes, B cells, CD4 T cells, and CD8 T cells, in the spinal cord of an EV71-infected patient who died. A study of mice showed that the levels of virus and lymphocytes in brains and antibody titers in sera were elevated during the time when the mice succumbed to death in a phenomenon analogous to that observed in patients. Further studies demonstrated that after infection, the disease severity, mortality, and tissue viral loads of mice deficient in B, CD4 T, or CD8 T cells were significantly higher than those of wild-type mice. In addition, treatment with a virus-specific antibody, but not a control antibody, before or after infection significantly reduced the disease severity, mortality, and tissue viral loads of mice deficient in B cells. Our results show that both lymphocyte and antibody responses protect mice from EV71 infection. Our study suggests the use of vaccines and virus-specific antibodies to control fatal outbreaks and raises caution over the use of corticosteroids to treat EV71-infected patients with neurological symptoms.Enterovirus 71 (EV71), a member of the family Picornaviridae, infects humans by the fecal-oral route and induces mild symptoms, such as herpangina and hand, foot and mouth disease. It can also infect the central nervous system (CNS) and induce fatal neurological manifestations, such as aseptic meningitis, brain stem encephalitis, encephalomyelitis, and acute flaccid paralysis, with cardiopulmonary complications, especially in young children. Most fatalities occur in cases with brain stem encephalitis and fulminant pulmonary edema complications (6, 7, 9, 12, 15, 19). Survivors of severe cases are often left with long-term neurologic sequelae (6, 14, 15).EV71 outbreaks have been reported periodically throughout the world (7, 9, 16). In the past decade, the Asia-Pacific region has experienced more frequent and widespread fatal outbreaks (16). The largest and most severe outbreak occurred in Taiwan in 1998 when 129,106 cases of herpangina and hand, foot and mouth disease, 405 cases of neurological and cardiopulmonary complications, and 78 deaths were reported (7). Since then, EV71 infection has become endemic in Taiwan and caused >40, >40, and 14 deaths in 2000, 2001, and 2008, respectively (3, 11). In addition, 42 deaths have been reported in China by June in 2008 (16). Although it has been estimated that EV71 infects millions of children and causes thousands of cases of neurologic sequelae and >200 deaths in the past decade (3, 7, 11, 16), there are no effective vaccines and specific antiviral therapies available to control fatal outbreaks due in part to the lack of understanding of viral pathogenesis.Infants and young children are very susceptible to EV71 infection. Immature immunity is therefore suspected to associate with increased morbidity and mortality (6, 7, 9). This is supported by the findings of lymphopenia, depletion of CD4 and CD8 T lymphocytes, and decreased cellular immunity in the peripheral blood of patients with brain stem encephalitis and pulmonary edema (4, 17). However, some clinical studies showed that elevated cellular immunity was linked with unfavorable outcomes (5, 8). High levels of white blood cell counts in blood and cerebrospinal fluid with a predominance of lymphocytes were detected in patients with fatal or severe sequelae (5, 8, 19, 22). In addition, autopsy reports revealed not only virus but also severe mononuclear cell infiltrates in the CNSs of patients who died (12, 22). Moreover, a clinical study reported that a patient developed opsomyoclonus syndrome, which is an autoimmune disease resulting from lesions in the dentate nucleus of the cerebellum (14). In this patient, the high titer of virus-specific antibodies detected at the onset of neurological disease and the responsiveness of the condition to anti-inflammatory agents (corticosteroids) provide further evidence of an autoimmune etiology. Besides corticosteroids, intravenous immunoglobulin (IVIG), which has several anti-inflammatory properties and often contains neutralizing antibodies to enteroviruses, has been a mandatory treatment for patients with neurological symptoms in Taiwan, because it has been shown to improve the conditions of patients infected with other enteroviruses, coxackievirus B, and echovirus (1, 5, 13, 18).Although corticosteroids have been used to treat EV71-infected patients with neurological symptoms (14, 15), the significance of lymphocyte and antibody responses in the pathogenesis of EV71 remains to be determined. The present study was therefore designed to address this issue using a mouse model.     

EV71小鼠适应株制备及体内外感染特点

目的用1日龄ICR小鼠传代制备EV71小鼠适应株,研究EV71亲代株与小鼠适应株的体内外感染特点,建立EV71感染ICR小鼠动物模型,为病毒疫苗和抗病毒药物的研究提供实用的动物评价工具。方法用1日龄ICR小鼠进行EV71病毒(Fuyang-0805)的传代,得到小鼠传代株。以一定浓度亲代株和传代株病毒分别接种RD、Vero、SY5Y、Caco-2四种细胞,定量方法检测各时间点不同毒株在四种细胞上的复制数量,CCK8方法测定各时间点细胞的存活率;同时,两毒株分别腹腔注射感染1日龄小鼠,定期安乐死动物,采集肺、小肠、骨骼肌、大脑四种器官组织,进行动物体内病毒半定量和定量分析,同时进行各器官组织病理学观察、免疫组织化学鉴定。结果与亲代毒株相比较,小鼠传代株(EV71-MMP4)表现出更强的肌肉来源细胞嗜性与毒性;同时,两毒株腹腔注射感染1日龄小鼠后,EV71-MMP4感染的小鼠体重增长较正常小鼠体重增长缓慢;半定量和定量RT-PCR显示,在小鼠肌肉中的病毒载量于感染后1d和5d达到高峰。EV71-MMP4感染组感染率较高、病毒组织分布较广、感染持续性较好、病毒载量较高,高剂量病毒感染后小鼠小肠、心肌和骨骼肌可观察到细胞空泡变性、淋巴细胞浸润等病理变化。免疫组织化学显示感染后小鼠骨骼肌有EV71病毒特异分布。结论阜阳EV71小鼠适应株表现出较亲代毒株更好的小鼠易感性、细胞毒性,所建立的动物模型可用于EV71病毒致病机制、感染特点的研究和病毒疫苗及药物的评价。     

肝内HDAg阳性慢性肝炎病理特点探讨

用直接酶标和直接免疫荧光法在120例HBsAg阳性肝组织中检测HDAg,发现5例阳性(4.2％),其中3例活动性肝硬化,2例慢性中型活动性肝炎。另设立相对应的单纯乙型肝炎作为对照,通过光镜、电镜、免疫组化的方法,重点探讨比较丁型肝炎与单纯乙型肝炎二者肝组织学的形态变化。丁型肝炎组肝细胞灶状坏死,桥接坏死,融合性坏死的程度比单纯乙型肝炎组重,丁型肝炎组较单纯乙型肝炎组常见的组织学改变是肝细胞呈灶状微小空泡的脂肪变性及灶状嗜酸性变性。HDAg阳性肝细胞呈疏松化、核固缩,其周围未见淋巴细胞浸润。     

The Clinical Correlation of Regulatory T Cells and Cyclic Adenosine Monophosphate in Enterovirus 71 Infection

Background

Brainstem encephalitis (BE) and pulmonary edema (PE) are notable complications of enterovirus 71 (EV71) infection.

Objective

This study investigated the immunoregulatory characterizations of EV71 neurological complications by disease severity and milrinone treatment.

Study Design

Patients <18 years with virologically confirmed EV71 infections were enrolled and divided into 2 groups: the hand, foot, and mouth disease (HFMD) or BE group, and the autonomic nervous system (ANS) dysregulation or PE group. Cytokine and cyclic adenosine monophosphate (cAMP) levels, and the regulatory T cell (Tregs) profiles of the patients were determined.

Results

Patients with ANS dysregulation or PE exhibited significantly low frequency of CD4⁺CD25⁺Foxp3⁺ and CD4⁺Foxp3⁺ T cells compared with patients with HFMD or BE. The expression frequency of CD4⁻CD8⁻ was also significantly decreased in patients with ANS dysregulation or PE. Among patients with ANS dysregulation or PE, the expression frequency of CD4⁺Foxp3⁺ increased markedly after milrinone treatment, and was associated with reduction of plasma levels IL-6, IL-8 and IL-10. Plasma concentrations of cAMP were significantly decreased in patients with ANS dysregulation or PE compared with patients with HFMD or BE; however, cAMP levels increased after milrinone treatment.

Conclusions

These findings suggested decreased different regulatory T populations and cAMP expression correlate with increased EV71 disease severity. Improved outcome after milrinone treatment may associate with increased regulatory T populations, cAMP expression and modulation of cytokines levels.     

EV71多表位抗原亲和纯化及类病毒颗粒胞外自组装

利用肠道病毒71型（EV71）衣壳蛋白优势表位肽段构建融合蛋白抗原能有效抑制病毒感染,有望成为继灭活病毒后更为安全有效的疫苗品种。该融合蛋白能通过原核体系有效表达但形成无序包涵体,采用常规层析介质难以实现目标蛋白与宿主杂质的有效分离,阻碍了对该抗原蛋白进行全面临床前活性及安全性评价。在原有融合蛋白抗原N端插入组氨酸标签,对形成的包涵体变性溶解后直接采用镍金属螯合亲和介质进行分离纯化,获得了纯度大于95%的抗原纯品,目标蛋白收率46.8%。采用透析方式脱除纯化样品中高浓度脲,发现直接透析至无脲的缓冲液中蛋白质大量沉淀,而先稀释至2mol/L脲的缓冲液中然后用G25脱盐柱完全脱除脲则无任何沉淀形成,获得近100%的蛋白质收率。透射电镜分析最终样品发现融合蛋白形成了10nm左右粒径均一的类病毒蛋白颗粒,且在pH 8.0的磷酸盐缓冲液中保持稳定。该研究结果为将EV71融合蛋白抗原发展为安全有效且低成本的手足口疫苗奠定了基础。     

肠道病毒71型的研究进展

肠道病毒71型(enterovirus71,EV71)是小RNA病毒科(Picornaviridae)肠道病毒属(Enterovirus)成员,其感染主要引起患者手足口病(hand-foot-and-mouth disease,HFMD).通常情况下,EV71感染引起的HFMD在临床症状等方面与柯萨奇病毒A16(Coxsackie A16,CA16)引起的手足口病难以区别,但EV71感染除了引起HFMD以外,还能够引起无菌性脑膜炎(aseptic meningitis)、脑干脑炎(brainstem encephalitis)和脊髓灰质炎样的麻痹(poliomyelitis-like paralysis)等多种与神经系统相关的疾病[1].自1974年首次报道[2]以来,EV71已在世界范围内引起十多次爆发与流行[3-6].近年来,EV71病毒的流行在亚太地区呈上升趋势[7-9].根据病毒衣壳蛋白VP1核苷酸序列的差异,可将EV71分为A、B、C 3个基因型,其中,B型和C型又进一步分为B1、B2、B3、B4以及C1和C2亚型[10-12].     

Apigenin Inhibits Enterovirus-71 Infection by Disrupting Viral RNA Association with trans-Acting Factors

Flavonoids are widely distributed natural products with broad biological activities. Apigenin is a dietary flavonoid that has recently been demonstrated to interact with heterogeneous nuclear ribonucleoproteins (hnRNPs) and interferes with their RNA editing activity. We investigated whether apigenin possessed antiviral activity against enterovirus-71 (EV71) infection since EV71 infection requires of hnRNP proteins. We found that apigenin selectively blocks EV71 infection by disrupting viral RNA association with hnRNP A1 and A2 proteins. The estimated EC₅₀ value for apigenin to block EV71 infection was determined at 10.3 µM, while the CC₅₀ was estimated at 79.0 µM. The anti-EV71 activity was selective since no activity was detected against several DNA and RNA viruses. Although flavonoids in general share similar structural features, apigenin and kaempferol were among tested compounds with significant activity against EV71 infection. hnRNP proteins function as trans-acting factors regulating EV71 translation. We found that apigenin treatment did not affect EV71-induced nucleocytoplasmic redistribution of hnRNP A1 and A2 proteins. Instead, it prevented EV71 RNA association with hnRNP A1 and A2 proteins. Accordingly, suppression of hnRNP A1 and A2 expression markedly reduced EV71 infection. As a positive sense, single strand RNA virus, EV71 has a type I internal ribosome entry site (IRES) that cooperates with host factors and regulates EV71 translation. The effect of apigenin on EV71 infection was further demonstrated using a bicistronic vector that has the expression of a GFP protein under the control of EV71 5′-UTR. We found that apigenin treatment selectively suppressed the expression of GFP, but not a control gene. In addition to identification of apigenin as an antiviral agent against EV71 infection, this study also exemplifies the significance in antiviral agent discovery by targeting host factors essential for viral replication.     

Histopathological Analysis of Acinetobacter baumannii Lung Infection in a Mouse Model

Acinetobacter baumannii is the main causative pathogen of nosocomial infections that causes severe infections in the lungs. In this study, we analyzed the histopathological characteristics of lung infection with two strains of A. baumannii (ATCC 19606 and the clinical isolate TK1090) and Pseudomonas aeruginosa PAO-1 in C3H/HeN mice to evaluate the virulence of A. baumannii. Survival was evaluated over 14 days. At 1, 2, 5, or 14 days postinfection, mice of C3H/HeN were sacrificed, and histopathological analysis of lung specimens was also performed. Histopathological changes and accumulation of neutrophils and macrophages in the lungs after infection with A. baumannii and P. aeruginosa were analyzed. Following intratracheal inoculation, the lethality of ATCC 19606- and TK1090-infected mice was lower than that of PAO-1-infected mice. However, when mice were inoculated with a sub-lethal dose of A. baumannii, the lung bacterial burden remained in the mice until 14 days post-infection. Additionally, histopathological analysis revealed that macrophages infiltrated the lung foci of ATCC 19606-, TK1090-, and PAO-1-infected mice. Although neutrophils infiltrated the lung foci of ATCC 19606- and TK1090-infected mice, they poorly infiltrated the lung foci of PAO-1-infected mice. Accumulation of these cells in the lung foci of ATCC 19606- and TK1090-infected mice, but not PAO-1-infected mice, was observed for 14 days post-infection. These results suggest that A. baumannii is not completely eliminated despite the infiltration of immune cells in the lungs and that inflammation lasts for prolonged periods in the lungs. Further studies are required to understand the mechanism of A. baumannii infection, and novel drugs and vaccines should be developed to prevent A. baumannii infection.     

Identification of Site-Specific Adaptations Conferring Increased Neural Cell Tropism during Human Enterovirus 71 Infection

Enterovirus 71 (EV71) is one of the most virulent enteroviruses, but the specific molecular features that enhance its ability to disseminate in humans remain unknown. We analyzed the genomic features of EV71 in an immunocompromised host with disseminated disease according to the different sites of infection. Comparison of five full-length genomes sequenced directly from respiratory, gastrointestinal, nervous system, and blood specimens revealed three nucleotide changes that occurred within a five-day period: a non-conservative amino acid change in VP1 located within the BC loop (L97R), a region considered as an immunogenic site and possibly important in poliovirus host adaptation; a conservative amino acid substitution in protein 2B (A38V); and a silent mutation in protein 3D (L175). Infectious clones were constructed using both BrCr (lineage A) and the clinical strain (lineage C) backgrounds containing either one or both non-synonymous mutations. In vitro cell tropism and competition assays revealed that the VP1₉₇ Leu to Arg substitution within the BC loop conferred a replicative advantage in SH-SY5Y cells of neuroblastoma origin. Interestingly, this mutation was frequently associated in vitro with a second non-conservative mutation (E167G or E167A) in the VP1 EF loop in neuroblastoma cells. Comparative models of these EV71 VP1 variants were built to determine how the substitutions might affect VP1 structure and/or interactions with host cells and suggest that, while no significant structural changes were observed, the substitutions may alter interactions with host cell receptors. Taken together, our results show that the VP1 BC loop region of EV71 plays a critical role in cell tropism independent of EV71 lineage and, thus, may have contributed to dissemination and neurotropism in the immunocompromised patient.     

Clinical and Histopathological Features of Patients with Systemic Sclerosis Undergoing Endomyocardial Biopsy

BackgroundCardiac involvement in systemic sclerosis (SSc) is associated with a variable phenotype including heart failure, arrhythmias and pulmonary hypertension. The aim of the present study was to evaluate clinical characteristics, histopathological findings and outcome of patients with SSc and a clinical phenotype suggesting cardiac involvement.ConclusionsPatients with SSc and clinical signs of cardiac involvement presented with mildly impaired LVEF. Prognosis was poor with an event rate of 28% within 22.5 months FU and was associated with the degree of cardiac inflammation and fibrosis.