Powassan Virus Encephalitis

Laboratory Testing for Powassan Virus: Past, Present, and Future

Powassan virus is a tick-borne flavivirus that can cause severe neuroinvasive disease, with areas of endemicity in the Northeast and Midwest United States, Canada, and Russia. Diagnosis is challenging and relies on a high index of suspicion and choosing the right test based on duration of infection and the patient's immune status. This review covers laboratory testing for Powassan virus, including historical considerations, modern options, and methods being developed in the research space.

Tick-Borne Illnesses in Emergency and Wilderness Medicine

This review highlights the causative organisms, clinical features, diagnosis, and treatment of the most common tick-borne illnesses in the United States, including Lyme disease, Rocky Mountain spotted fever, anaplasmosis, ehrlichiosis, tularemia, Powassan virus, and alpha-gal syndrome. Tick bite prevention strategies and some basic tick removal recommendations are also provided.

Recombinant Ixodes scapularis Calreticulin Binds Complement Proteins but Does Not Protect Borrelia burgdorferi from Complement Killing

Ixodes scapularis is a blood-feeding obligate ectoparasite responsible for transmitting the Lyme disease (LD) agent, Borrelia burgdorferi. During the feeding process, I. scapularis injects B. burgdorferi into the host along with its saliva, facilitating the transmission and colonization of the LD agent. Tick calreticulin (CRT) is one of the earliest tick saliva proteins identified and is currently utilized as a biomarker for tick bites. Our recent findings revealed elevated levels of CRT in the saliva proteome of B. burgdorferi-infected I. scapularis nymphs compared to uninfected ticks. Differential precipitation of proteins (DiffPOP) and LC-MS/MS analyses were used to identify the interactions between Ixs (I. scapularis) CRT and human plasma proteins and further explore its potential role in shielding B. burgdorferi from complement killing. We observed that although yeast-expressed recombinant (r) IxsCRT binds to the C1 complex (C1q, C1r, and C1s), the activator of complement via the classical cascade, it did not inhibit the deposition of the membrane attack complex (MAC) via the classical pathway. Intriguingly, rIxsCRT binds intermediate complement proteins (C3, C5, and C9) and reduces MAC deposition through the lectin pathway. Despite the inhibition of MAC deposition in the lectin pathway, rIxsCRT did not protect a serum-sensitive B. burgdorferi strain (B314/pBBE22Luc) from complement-induced killing. As B. burgdorferi establishes a local dermal infection before disseminating to secondary organs, it is noteworthy that rIxsCRT promotes the replication of B. burgdorferi in culture. We hypothesize that rIxsCRT may contribute to the transmission and/or host colonization of B. burgdorferi by acting as a decoy activator of complement and by fostering B. burgdorferi replication at the transmission site.

Cerebrospinal fluid metagenomics has greatest added value as a test for Powassan virus among patients in New England with suspected central nervous system infection

Cerebrospinal fluid (CSF) metagenomic next generation sequencing (mNGS) can detect diverse pathogens in patients with central nervous system infection. Due to its high cost and unclear clinical utility, it is typically reserved for patients with unrevealing routine workups. A multi-center retrospective analysis of real-world CSF mNGS was performed involving orders between 2017 and 2022 at a large New England healthcare system. CSF mNGS was performed 64 times with 17 positive results (27 %). In 11/17 positive samples (65 %), the infectious agent had not been previously detected using routine methods. Arboviruses (n = 8) were the most frequently detected agents, particularly Powassan virus (n = 6). Results changed therapy in 3/64 cases (5 %). Positive results were associated with immunodeficiency (p = 0.06), especially anti-B-cell therapy (p = 0.02), and earlier sample collection (p = 0.06). The association with compromised humoral immunity was stronger in the arbovirus and Powassan virus subgroups (p = 0.001), whose constituents were older than the overall cohort and had higher mortality rates.

Background seropositivity to Jamestown Canyon virus can lead to diagnostic confusion

Background seropositivity rates for specific antibodies to Jamestown Canyon Virus (JCV) can exceed 25 % in certain geographic areas in the United States. This can potentially lead to diagnostic confusion, as apparently illustrated by a patient from New Jersey with Powassan virus encephalitis, who also tested positive for antibodies to JCV.

Tick symbiosis

As obligate blood-feeders, ticks serve as vectors for a variety of pathogens that pose threats on both human and livestock health. The microbiota that ticks harbor play important roles in influencing tick nutrition, development, reproduction, and vector. These microbes also affect the capacity of ticks to transmit pathogens (vector competence). Therefore, comprehending the functions of tick microbiota will help in developing novel and effective tick control strategies. Here, we summarize the effects of main tick symbiotic bacteria on tick physiology and vector competency.

Tick-borne infections in children in North America

PURPOSE OF REVIEW

Because both incidence and awareness of tick-borne infections is increasing, review of major infections and recent advances related to their diagnosis and management is important.

RECENT FINDINGS

A new algorithm, termed modified two-tier testing, for testing for antibodies to Borrelia burgdorferi , the cause of Lyme disease, has been approved and may replace traditional two-tier testing. In addition, doxycycline is now acceptable to use for treatment of and/or prophylaxis for Lyme disease for up to 21 days in children of any age. Borrelia miyamotoi , a bacterium in the relapsing fever type of Borrelia, is the first of this type of Borrelia that is transmitted by hard-bodied ticks such as Ixodes scapularis.

SUMMARY

Awareness of these infections and advances in their diagnosis and treatment is important to assure the best outcomes for affected patients. Table 1 contains a summary of infections discussed.

MR Imaging Patterns and Prognosis in Powassan Virus Encephalitis

BACKGROUND

Powassan virus (POWV) encephalitis is an arbovirus infection and the only tick-borne encephalitis serogroup which is present in mainland North America. The magnetic resonance (MR) imaging described with POWV encephalitis is varied, nonspecific, and limited in number, and as such, imaging patterns and outcomes with this arbovirus infection are not well appreciated.

METHODS

A case report and literature review of the MR imaging associated with POWV encephalitis and correlate of the MR pattern with outcome is considered.

RESULTS

The cerebellar dominant MR imaging pattern was identified in 50% of POWV encephalitis cases and was associated with a 60% fatality rate. POWV encephalitis with prominent cerebellar involvement on MR imaging responded to intravenous steroid.

CONCLUSIONS

A cerebellar dominant MR pattern in POWV encephalitis was common, associated with a poor prognosis, and recognition could change management from supportive to life-saving.

Powassan Virus Encephalitis: A Tertiary Center Experience

BACKGROUND

Powassan virus (POWV) is an emerging arthropod-borne flavivirus, transmitted by Ixodes spp. ticks, which has been associated with neuroinvasive disease and poor outcomes.

METHODS

A retrospective study was conducted at Mayo Clinic from 2013 to 2022. We included clinical and epidemiologic data of probable and confirmed neuroinvasive POWV cases.

RESULTS

Sixteen patients with neuroinvasive POWV were identified; their median age was 63.2 years, and 62.5% were male. Six patients presented with rhombencephalitis, 4 with isolated meningitis, 3 with meningoencephalitis, 2 with meningoencephalomyelitis, and 1 with opsoclonus myoclonus syndrome. A median time of 18 days was observed between symptom onset and diagnosis. Cerebrospinal fluid analysis showed lymphocytic pleocytosis with elevated protein and normal glucose in the majority of patients. Death occurred within 90 days in 3 patients (18.8%), and residual neurologic deficits were seen in 8 survivors (72.7%).

CONCLUSIONS

To our knowledge, this is the largest case series of patients with neuroinvasive POWV infection. We highlight the importance of a high clinical suspicion among patients who live in or travel to high-risk areas during the spring to fall months. Our data show high morbidity and mortality rates among patients with neuroinvasive disease.

Upsurge of Powassan virus disease in northeastern United States: a public health concern-a short communication

Powassan virus (POWV) is a tick-borne Flavivirus primarily transmitted through ticks in North America which is a significant public health threat in the northeastern United States. POWV infection spans from Ontario to the Mid-Atlantic, Northeast, and Midwest regions in the USA. Climate change, ecological factors, and human-related changes, including shifts in migration and agriculture, contribute to the dissemination of POWV. Symptoms include sore throat, fatigue, headache, and severe neuroinvasive conditions. Specialized attention is required for diagnosing and managing. MRI scans detect central nervous system abnormalities, while neuromonitoring identifies metabolic distress. Severe cases may necessitate ICU hospitalisation with continuous monitoring. Prevention measures, such as awareness, controlling mammals, and protecting pets, reduce POWV infection risk. The recent outbreak of POWV in Maine, USA, highlights the importance of worldwide collaboration for prevention. With the global prevalence of POWV increasing due to climate and socioeconomic changes, implementing preventative measures and promoting awareness are crucial in reducing infection risk.

State of the Art: Acute Encephalitis

Encephalitis is a devastating neurologic disease often complicated by prolonged neurologic deficits. Best practices for the management of adult patients include universal testing for a core group of etiologies, including herpes simplex virus (HSV)-1, varicella zoster virus (VZV), enteroviruses, West Nile virus, and anti-N-methyl-D-aspartate receptor (anti-NMDAR) antibody encephalitis. Empiric acyclovir therapy should be started at presentation and in selected cases continued until a second HSV-1 polymerase chain reaction test is negative. Acyclovir dose can be increased for VZV encephalitis. Supportive care is necessary for other viral etiologies. Patients in whom no cause for encephalitis is identified represent a particular challenge. Management includes repeat brain magnetic resonance imaging, imaging for occult malignancy, and empiric immunomodulatory treatment for autoimmune conditions. Next-generation sequencing (NGS) or brain biopsy should be considered. The rapid pace of discovery regarding autoimmune encephalitis and the development of advanced molecular tests such as NGS have improved diagnosis and outcomes. Research priorities include development of novel therapeutics.

Powassan virus persistence after acute infection

Survivors of Powassan encephalitis often have persistent neurological disease. A new mouse model replicates some elements of the human disease and demonstrates the presence of viral RNA in the brain as well as myelitis more than 2 mo after the acute infection. The related tick-borne encephalitis and West Nile Neuroinvasive Disease (WNND) also have common neurological sequelae, and models for these better-studied diseases provide evidence for prolonged virus, RNA, and inflammation in some cases, in addition to damage from the acute encephalitic disease. A better understanding of the biological basis for persistent signs and symptoms after Powassan encephalitis, currently a rare disease, could benefit from further studies of the more prevalent flaviviral encephalitides.