Pandemic of new type of conjunctivitis

Methylene Blue Inhibits Acute Hemorrhagic Conjunctivitis Virus Production and Induction of Caspase-3 Mediated Human Corneal Cell Cytopathy

Background

Acute hemorrhagic conjunctivitis (AHC) is a highly contagious eye disease caused by enterovirus type 70 (E70) and Coxsackievirus A24 variant (CA24v) with no clinically approved treatment. The antiviral activity of methylene blue (MB; a WHO essential medicine) against AHC viruses was investigated using human corneal epithelial cells (HCEC).

Methods

Time and concentration-dependent MB accumulation by HCEC was determined colorimetrically and MB inhibition of virus production of 5 E70 and 3 CA24v AHC epidemic isolates in HCEC was determined by micro-plaque assay. AHC virus cytopathy inhibition by MB was detected by reductions in virus-induced caspase-3 activity and polymeric DNA fragments.

Results

MB uptake by HCEC was rapid and concentration dependent. MB inhibition of E70 and CA24v production was concentration dependent. AHC virus yields were significantly lower (50 to >10,000 fold) in HCEC pre-treated with 0.25–1% MB than in placebo controls (p’s ≤ 0.01). MB pre-treatment significantly inhibited virus-induced caspase-3 activation and DNA fragmentation (p’s<0.01). Virus-infected cells accumulate oxidized MB and MB application up to 6 h after infection inhibited virus production and virus-induced HCEC cytopathy.

Conclusion

The results suggest MB treatment prior to and shortly after infection can inhibit AHC virus production and caspase-mediated HCEC cytopathy. The results support the therapeutic potential of ophthalmic solutions containing MB against AHC virus infection during epidemics.

Role of enhanced receptor engagement in the evolution of a pandemic acute hemorrhagic conjunctivitis virus

Acute hemorrhagic conjunctivitis (AHC) is a painful, contagious eye disease, with millions of cases in the last decades. Coxsackievirus A24 (CV-A24) was not originally associated with human disease, but in 1970 a pathogenic "variant" (CV-A24v) emerged, which is now the main cause of AHC. Initially, this variant circulated only in Southeast Asia, but it later spread worldwide, accounting for numerous AHC outbreaks and two pandemics. While both CV-A24 variant and nonvariant strains still circulate in humans, only variant strains cause AHC for reasons that are yet unknown. Since receptors are important determinants of viral tropism, we set out to map the CV-A24 receptor repertoire and establish whether changes in receptor preference have led to the increased pathogenicity and rapid spread of CV-A24v. Here, we identify ICAM-1 as an essential receptor for both AHC-causing and non-AHC strains. We provide a high-resolution cryo-EM structure of a virus-ICAM-1 complex, which revealed critical ICAM-1-binding residues. These data could help identify a possible conserved mode of receptor engagement among ICAM-1-binding enteroviruses and rhinoviruses. Moreover, we identify a single capsid substitution that has been adopted by all pandemic CV-A24v strains and we reveal that this adaptation enhances the capacity of CV-A24v to bind sialic acid. Our data elucidate the CV-A24v receptor repertoire and point to a role of enhanced receptor engagement in the adaptation to the eye, possibly enabling pandemic spread.

Enterovirus D-68 Infection, Prophylaxis, and Vaccination in a Novel Permissive Animal Model, the Cotton Rat (Sigmodon hispidus)

In recent years, there has been a significant increase in detection of Enterovirus D-68 (EV-D68) among patients with severe respiratory infections worldwide. EV-D68 is now recognized as a re-emerging pathogen; however, due to lack of a permissive animal model for EV-D68, a comprehensive understanding of the pathogenesis and immune response against EV-D68 has been hampered. Recently, it was shown that EV-D68 has a strong affinity for α2,6-linked sialic acids (SAs) and we have shown previously that α2,6-linked SAs are abundantly present in the respiratory tract of cotton rats (Sigmodon hispidus). Thus, we hypothesized that cotton rats could be a potential model for EV-D68 infection. Here, we evaluated the ability of two recently isolated EV-D68 strains (VANBT/1 and MO/14/49), along with the historical prototype Fermon strain (ATCC), to infect cotton rats. We found that cotton rats are permissive to EV-D68 infection without virus adaptation. The different strains of EV-D68 showed variable infection profiles and the ability to produce neutralizing antibody (NA) upon intranasal infection or intramuscular immunization. Infection with the VANBT/1 resulted in significant induction of pulmonary cytokine gene expression and lung pathology. Intramuscular immunization with live VANBT/1 or MO/14/49 induced strong homologous antibody responses, but a moderate heterologous NA response. We showed that passive prophylactic administration of serum with high content of NA against VANBT/1 resulted in an efficient antiviral therapy. VANBT/1-immunized animals showed complete protection from VANBT/1 challenge, but induced strong pulmonary Th1 and Th2 cytokine responses and enhanced lung pathology, indicating the generation of exacerbated immune response by immunization. In conclusion, our data illustrate that the cotton rat is a powerful animal model that provides an experimental platform to investigate pathogenesis, immune response, anti-viral therapies and vaccines against EV-D68 infection.

Molecular Evolution and Intraclade Recombination of Enterovirus D68 during the 2014 Outbreak in the United States

In August 2014, an outbreak of enterovirus D68 (EV-D68) occurred in North America, causing severe respiratory disease in children. Due to a lack of complete genome sequence data, there is only a limited understanding of the molecular evolution and epidemiology of EV-D68 during this outbreak, and it is uncertain whether the differing clinical manifestations of EV-D68 infection are associated with specific viral lineages. We developed a high-throughput complete genome sequencing pipeline for EV-D68 that produced a total of 59 complete genomes from respiratory samples with a 95% success rate, including 57 genomes from Kansas City, MO, collected during the 2014 outbreak. With these data in hand, we performed phylogenetic analyses of complete genome and VP1 capsid protein sequences. Notably, we observed considerable genetic diversity among EV-D68 isolates in Kansas City, manifest as phylogenetically distinct lineages, indicative of multiple introductions of this virus into the city. In addition, we identified an intersubclade recombination event within EV-D68, the first recombinant in this virus reported to date. Finally, we found no significant association between EV-D68 genetic variation, either lineages or individual mutations, and a variety of demographic and clinical variables, suggesting that host factors likely play a major role in determining disease severity. Overall, our study revealed the complex pattern of viral evolution within a single geographic locality during a single outbreak, which has implications for the design of effective intervention and prevention strategies.

IMPORTANCE

Until recently, EV-D68 was considered to be an uncommon human pathogen, associated with mild respiratory illness. However, in 2014 EV-D68 was responsible for more than 1,000 disease cases in North America, including severe respiratory illness in children and acute flaccid myelitis, raising concerns about its potential impact on public health. Despite the emergence of EV-D68, a lack of full-length genome sequences means that little is known about the molecular evolution of this virus within a single geographic locality during a single outbreak. Here, we doubled the number of publicly available complete genome sequences of EV-D68 by performing high-throughput next-generation sequencing, characterized the evolutionary history of this outbreak in detail, identified a recombination event, and investigated whether there was any correlation between the demographic and clinical characteristics of the patients and the viral variant that infected them. Overall, these results will help inform the design of intervention strategies for EV-D68.

Co-circulation of enteroviruses between apes and humans

A total of 139 stool samples from wild chimpanzees, gorillas and bonobos in Cameroon and Democratic Republic of Congo (DRC) were screened for enteroviruses (EVs) by reverse transcription PCR. Enterovirus RNA was detected in 10 % of samples, comprising eight from 58 sampled chimpanzees (13.8 %), one from 40 bonobos (2.5 %) and five from 40 gorillas (12.2 %). Three viruses isolated from chimpanzees grouped with human isolate EV-A89 and four (four chimpanzees, one gorilla) represented a newly identified type, EV-A119. These species A virus types overlapped with those circulating in human populations in the same area. The remaining six strains comprised a new species D type, EV-D120, infecting one chimpanzee and four gorillas, and a single EV variant infecting a bonobo that was remarkably divergent from other EVs and potentially constitutes a new enterovirus species. The study demonstrates both the circulation of genetically divergent EV variants in apes and monkeys as well as those shared with local human populations.

High seroprevalence of enterovirus infections in apes and old world monkeys

To estimate population exposure of apes and Old World monkeys in Africa to enteroviruses (EVs), we conducted a seroepidemiologic study of serotype-specific neutralizing antibodies against 3 EV types. Detection of species A, B, and D EVs infecting wild chimpanzees demonstrates their potential widespread circulation in primates.

Detection and genetic characterization of enteroviruses circulating among wild populations of chimpanzees in Cameroon: relationship with human and simian enteroviruses

Enteroviruses (EVs), members of the family Picornaviridae, are a genetically and antigenically diverse range of viruses causing acute infections in humans and several Old World monkey (OWM) species. Despite their known wide distribution in primates, nothing is currently known about the occurrence, frequency, and genetic diversity of enteroviruses infecting apes. To investigate this, 27 chimpanzee and 27 gorilla fecal samples collected from undisturbed jungle areas with minimal human contact in Cameroon were screened for EVs. Four chimpanzee samples were positive, but none of the gorilla samples were positive. Genetic characterization of the VP1, VP4, and partial VP2 genes, the 5' untranslated region, and partial 3Dpol sequences enabled chimpanzee-derived EVs to be identified as (i) the species A type, EV76, (ii) a new species D type assigned as EV111, along with a human isolate from the Democratic Republic of Congo previously described by the International Committee on the Taxonomy of Viruses, and (iii) a new species B type (assigned as EV110) most closely related to, although a distinct type from, the SA5 isolate recovered from a vervet monkey. The identification of EVs infecting chimpanzees related to those circulating in human and OWM populations provides evidence for cross-species transmission of EVs between primates. However, the direction of transfer and the existence of primate sources of zoonotic enterovirus infections in humans require further investigation of population exposure and more extensive characterization of EVs circulating in wild ape populations.

[Enteroviruses responsible for acute hemorrhagic conjunctivitis]

Acute hemorrhagic conjunctivitis (AHC) is an epidemic form of highly contagious conjunctivitis, characterized by conjunctival hemorrhages. The first AHC outbreak was described in 1969 in Ghana, West Africa, and was called Apollo disease, from the Apollo landing on the moon. This outbreak was caused by Enterovirus 70 (EV70) together with a Coxsackievirus A24 (CVA24v) variant, which are the major etiological agents involved in AHC outbreaks worldwide. AHC is known to be directly transmitted by close person-to-person contact or indirectly through soiled ophthalmological materials or unsafe recreational water. Recently, a possible airborne virus spread was suggested which could explain the high transmission rate of the disease. In the absence of a specific antiviral therapy, a rapid diagnosis of the causative agent is required to distinguish AHC due to enteroviruses from other ocular infectious diseases, for there are active drugs, or to quickly implement proper public health measures to limit the extension of the outbreak. However, virus identification remains difficult and time-consuming. Moreover, virological diagnosis is difficult to implement in developing countries where AHC has recently become a major problem for public health.

Molecular and immunocytochemical identification of coxsackievirus A-24 variant from the acute haemorrhagic conjunctivitis outbreak in Taiwan in 2007

AIMS

Acute haemorrhagic conjunctivitis (AHC) is a highly contagious conjunctivitis associated with enteroviruses. Coxsackie A-24 variant (CA-24v) and enterovirus-70 (EV-70) are the two major causative agents. During October 2007, an epidemic of AHC occurred in Taiwan, affecting more than 11 000 people. The aim of this study was to determine the aetiological agent associated with the outbreak in patients diagnosed with AHC and treated at the Cathay General Hospital, Taipei (CGHT) and Cathay General Hospital Sijhih (CGHS), Taiwan during October 2007.

METHODS

Virus isolates were obtained from six patients (four from CGHS and two from CGH), and a total of seven specimens (one throat and one rectal, and five eye swabs) were collected. The specimens were inoculated onto the MRC-5 cell lines. The viral isolation was confirmed by performing real-time reverse transcription-polymerase chain reaction (RT-PCR) and indirect immunofluorescence assay (IFA).

RESULTS

The conjunctival, throat, and rectal swabs collected in this study were all tested positive for a variant of CA-24. All seven viral isolates were characterized as a variant of CA-24 and confirmed by IFA and real-time RT-PCR.

CONCLUSIONS

The findings suggest that the outbreak of AHC that occurred during October 2007 in the northern area of Taiwan was caused by a variant of coxsackie A-24. Further phylogenic analysis is underway to further classify this CA-24v strain.

Acute hemorrhagic conjunctivitis due to enterovirus 70 in India

An outbreak of acute hemorrhagic conjunctivitis occurred in Delhi, India, during August and September 1996. The etiologic agent was confirmed as enterovirus type 70 by a modified centrifugation-enhanced culture method followed by immunofluorescence and neutralization tests. After nearly a decade, this virus is reemerging as a cause of acute hemorrhagic conjunctivitis in India.

The HeLa cell receptor for enterovirus 70 is decay-accelerating factor (CD55)

Enterovirus 70 (EV70) is a recently emerged human pathogen belonging to the family Picornaviridae. The ability of EV70 to infect a wide variety of nonprimate cell lines in vitro is unique among human enteroviruses. The importance of virus receptors as determinants of viral host range and tropism led us to study the host cell receptor for this unusual picornavirus. We produced a monoclonal antibody (MAb), EVR1, which bound to the surface of HeLa cells and protected them against infection by EV70 but not by poliovirus or by coxsackievirus B3. This antibody also inhibited the binding of [35S]EV70 to HeLa cells. MAb EVR1 did not bind to monkey kidney (LLC-MK2) cells, nor did it protect these cells against virus infection. In Western immunoassays and in immunoprecipitations, MAb EVR1 identified a HeLa cell glycoprotein of approximately 75 kDa that is attached to the cell membrane by a glycosyl-phosphatidylinositol (GPI) anchor. Decay-accelerating factor (DAF, CD55) is a 70- to 75-kDa GPI-anchored membrane protein that is involved in the regulation of complement and has also been shown to function as a receptor for several enteroviruses. MAb EVR1 bound to Chinese hamster ovary (CHO) cells constitutively expressing human DAF. Anti-DAF MAbs inhibited EV70 binding to HeLa cells and protected them against EV70 infection. Transient expression of human DAF in murine NIH 3T3 cells resulted in binding of labelled EV70 and stably, transformed NIH 3T3 cells expressing DAF were able to support virus replication. These data indicate that the HeLa cell receptor for EV70 is DAF.

Nucleotide sequence analysis of recent epidemic strains of enterovirus 70

Nucleotide sequences of the genome of enterovirus 70 (EV70) isolated in Osaka in 1993 were determined, and compared with those of the past epidemic strains. Nucleotide substitution rates in 332 bp, 174 bp, and 178 bp of the genes encoding viral protein (VP)1, VP2, or VP3 were 9.0, 7.5, and 5.6% between Kumoi-2/93 and J670/71, respectively. Likewise, the putative amino acid substitution rates were 1.8, 0, and 0%. It seems that the epidemic strains of EV70 in Japan have been evolving at a constant high nucleotide substitution rate but almost all the substitutions were synonymous.

Molecular evolution of the major capsid protein VP1 of enterovirus 70

Nucleotide sequences of the genome RNA encoding capsid protein VP1 (918 nucleotides) of 18 enterovirus 70 (EV70) isolates collected from various parts of the world in 1971 to 1981 were determined, and nucleotide substitutions among them were studied. The genetic distances between isolates were calculated by the pairwise comparison of nucleotide difference. Regression analysis of the genetic distances against time of isolation of the strains showed that the synonymous substitution rate was very high at 21.53 x 10(-3) substitution per nucleotide per year, while the nonsynonymous rate was extremely low at 0.32 x 10(-3) substitution per nucleotide per year. The rate estimated by the average value of synonymous and nonsynonymous substitutions (W.-H. Li, C.-C. Wu, and C.-C. Luo, Mol. Biol. Evol. 2:150-174, 1985) was 5.00 x 10(-3) substitution per nucleotide per year. Taking the average value of synonymous and nonsynonymous substitutions as genetic distances between isolates, the phylogenetic tree was inferred by the unweighted pairwise grouping method of arithmetic average and by the neighbor-joining method. The tree indicated that the virus had evolved from one focal place, and the time of emergence was estimated to be August 1967 +/- 15 months, 2 years before first recognition of the pandemic of acute hemorrhagic conjunctivitis. By superimposing every nucleotide substitution on the branches of the phylogenetic tree, we analyzed nucleotide substitution patterns of EV70 genome RNA. In synonymous substitutions, the proportion of transitions, i.e., C<==>U and G<==>A, was found to be extremely frequent in comparison with that reported on other viruses or pseudogenes. In addition, parallel substitutions (independent substitutions at the same nucleotide position on different branches, i.e., different isolates, of the tree) were frequently found in both synonymous and nonsynonymous substitutions. These frequent parallel substitutions and the low nonsynonymous substitution rate despite the very high synonymous substitution rate described above imply a strong restriction on nonsynonymous substitution sites of VP1, probably due to the requirement for maintaining the rigid icosahedral conformation of the virus.

Phylogenetically different strains of a variant of coxsackievirus A 24 were repeatedly introduced but discontinued circulating in Japan

Variations in the nucleotide sequence of 3 C proteinase of coxsackievirus A 24 variant (CA 24 v) were analyzed to define the route of transmission and spread of the virus which was introduced to Japan on three separate occasions, 1985-86, 1988, and 1989. The nucleotide sequences of isolates from the same year's outbreak in Japan were identical or closely related, while the isolates from different outbreaks were less closely related to one another than to those from other countries in the same year. All Japanese isolates from Okinawa and other prefectures in 1985 and 1986 were closely related to the Taiwan strains in those same years, indicating common-source outbreaks. Two 1988 isolates from Chiba Prefecture, Japan, were closely related to those from Singapore in 1987, China in 1988 and Hong Kong in 1988. All seven Japanese isolates from Chiba Prefecture in 1989 comprised a group together with the Taiwan and Singapore strains in 1988. The results indicate that CA 24 v was introduced into Japan on each occasion from the outside. Furthermore, in contrast to the explosive epidemics in Okinawa Prefecture in 1985 and 1986, the virus which was repeatedly introduced to other areas in Japan did not circulate endemically, and disappeared within a short time.

Enterovírus-70 na região metropolitana de São Paulo, Brasil, de 1984 a 1987: aspectos da infecção em períodos epidêmico e endêmico

São apresentados os resultados de estudos sobre o comportamento do Enterovírus-70 (EV-70) na região metropolitana de São Paulo desde sua provável introdução no verão de 1984, determinando extensa epidemia de conjuntivite hemorrágica aguda (C.H.A.), até o final de 1987 abrangendo período em que este agravo foi pouco notado. Na fase epidêmica ocorrida no primeiro trimestre de 1984 foram estudados 291 indivíduos divididos em três grupos denominados A, B e C, o primeiro formado por pessoas atingidas pela C.H.A. e os outros dois por indivíduos não atingidos por este agravo mas que, respectivamente, referiam contato domiciliar com casos de C.H.A. e os que não referiam o citado contato. A demonstração de anticorpos se fez pela técnica de imunofluorescência indireta (IFI) para detectar IgM específico para EV-70 e pela prova de neutralização em cultura de células BHK-21. Verificou-se que 56,7%, 33,3% e 20,6% dos indivíduos pertencentes, respectivamente, aos grupos A, B e C apresentavam anticorpos específicos da classe IgM. No grupo A a faixa etária mais atingida foi a de 10 a 29 anos. No período que vai do fim da primeira e única epidemia até o final de 1987, identificaram-se três casos esporádicos de C.H.A. e 10 pacientes com afecção neurológica aguda associada à infecção recente pelo EV-70. Nove, destes 10 casos, apresentaram paralisia de nervos cranianos, todos evoluindo sem seqüelas clinicamente discerníveis. As formas assintomáticas e os casos esporádicos de C.H.A. e de afecções neurológicas mantiveram a circulação do EV-70 no período não epidêmico.

Spread of acute hemorrhagic conjunctivitis due to enterovirus-70: effect of air temperature and relative humidity on virus survival on fomites

Enterovirus 70 (EV-70) has caused at least two pandemics and several major epidemics of acute hemorrhagic conjunctivitis (AHC) in the past 18 years, with the largest number of cases occurring in the coastal areas of the tropics. The exact means of its spread are not known, but fomites and hands contaminated by them are the most likely vehicles. We, therefore, tested EV-70 survival under different environmental conditions using stainless steel disks (1 cm diameter). Each disk received 10 microliter of the virus in phosphate-buffered saline (PBS). The disks were held at various temperatures with the relative humidity (RH) at the low (20 +/- 5%), medium (50 +/- 5%), high (80 +/- 5%), or ultrahigh (95 +/- 5%) level. The virus was eluted from the disks with tryptose phosphate broth and the eluate assayed in LLC-MK2cells. Inactivation rates (Ki), expressed as hourly loss of virus plaque forming units (PFU) in log10, were then calculated. At 20 degrees C, virus survival was proportional to the RH level, with the highest virus survival at the ultrahigh RH; at this level nearly 5% of the input virus was detectable even after 24 hr. Virus inactivation rates were only slightly higher at the ultrahigh RH when the temperature was raised to 33 degrees C or 35 degrees C. However, at 80% RH, increasing the temperature from 20 degrees C to 33 degrees C resulted in a dramatic rise in virus inactivation. The finding that high levels of RH prolong EV-70 survival on fomites may help explain the epidemiology of AHC resulting from EV-70.

Antigenic relationships between avian paramyxoviruses. III. A mathematical model of antigenic drift and a computer-assisted approach for construction of a phylogenetic tree

The suggested model of antigenic kinship between related paramyxoviruses is based on another concept of antigenic determinant, as compared to the previously suggested combinatorial mathematical model by the authors. According to it, antigenic changes of any determinant do not proceed by "leaps" but can be changed gradually. Such changed determinant can induce a correspondingly changed type of antibodies which still preserve a certain kinship to the original type of the determinant (before its changing) revealed by cross reaction serological tests. Accordingly, there can be "families" of the determinants differing by degree of relatedness to (or, reversely, by antigenic distance from) the "original" ("ancestor") determinant. In addition to another interpretation of the antigenic kinship, the new mathematical model was used as an approach for revealing phylogenetic relationships between antigenically related viruses.

Conjunctivitis in children

Conjunctivitis is a common, usually mild, self-limited problem. Pathogens vary at different ages. Conjunctivitis occurs alone or as a manifestation of a systemic infection or a systemic disease. Diagnosis can usually be established by the combination of clinical and laboratory findings. Topical, systemic or combination therapy is used, depending on the agent and extent of infection.

Economic aspects of an epidemic of haemorrhagic conjunctivitis in a rural community

The estimated economic loss due to an epidemic of acute haemorrhagic conjunctivitis in 1981 in a rural community of Goa studied by house-to-house survey of 7230 families is reported. Thirty-five per cent of families were affected and in 62% of these families more than three persons developed conjunctivitis. The affected were forced to be absent from work resulting in a reduction of the work force (loss of 7735 man days) and loss of income (Rs 1,33,300). The type of treatment followed and estimates of treatment cost are described. The economic consequences to the country of this widespread epidemic are described.

[Acute hemorrhagic conjunctivitis, in Cuiabá, Mato Grosso, Brazil 1983]

Foi feita investigação de natureza etiológica clínica e laboratorial durante uma epidemia de conjuntivite hemorrágica aguda (CHA), ocorrida em Cuiabá, MT durante os meses de dezembro de 1982 e fevereiro de 1983; atendidos 68 pacientes e colhidos espécimes da conjuntiva, orofaringe e soro. Em 28 pares de soros foram realizados testes de neutralização em tubos de cultura de tecidos para o enterovirus 70 (EV 70) e fixaço do complemento para os adenovirus. Os resultados revelaram conversão sorológica de 89,3% (25 pares de soro) para o EV 70. A Secretaria de Saúde do Estado do Mato Grosso estima que aproximadamente 70% da população tenha sido atingida durante o surto. Não foram observadas evidências de comprometimento neurológico em pacientes de conjuntivite, durante ou logo após o surto.

Neurological complications of acute haemorrhagic conjunctivitis

Forty four cases of the neurological complications of acute haemorrhagic conjunctivitis (AHC) seen in India during 1981 epidemic are reported. The disease predominantly affected adult males. The preceding attack of AHC, a latent period, prodromal symptoms of fever, myalgia and root pains followed by acute onset of lower motor neurone paralysis of limbs and/or cranial nerves formed the classical picture of neurological involvement. The recovery was poor and nearly half of the patients remained severely handicapped. Electrophysiological studies showed early appearance of widespread fibrillations and fasciculations, large polyphasic potentials of increased amplitude and reduced interference pattern. Nerve conduction studies were normal in most of the cases. Cerebrospinal fluid (CSF) examination revealed lymphocytic pleocytosis and rise in protein content. Significant antibody titres against enterovirus type 70 (EV 70) were demonstrated in the serum and the CSF. HLA studies showed low occurrence of A2 and B15 HLA antigens. Muscle biopsies revealed neurogenic atrophy and sural nerve biopsies were histologically unremarkable. The similarities of this disease with poliomyelitis and its pathogenesis are discussed.

Evolution of enterovirus 70 in nature: all isolates were recently derived from a common ancestor

The data of large RNase T1-resistant oligonucleotide mapping of enterovirus 70 (EV 70) previously reported (Takeda et al., Virology 134, 375-388, 1984) were subjected to further genetical analysis to estimate the evolutionary rate of genome RNA of EV 70 and to clarify the phylogenetic relationship among isolates. A proportion of common spots between strains decreased as the year elapsed and eventually, only seven spots were common to all the 16 isolates tested, indicating that the substitution is scattered throughout the genome. On the other hand, some specific sets of spots were conserved among geographically or epidemiologically related strains. Base sequence variation of the isolates was deduced according to Aaronson et al. (Nucleic Acids Res. 10, 237-246, 1982) from pariwise comparison of the common spots and used as a genetic distance between them. The base substitution rate of virus genome was estimated by regression analysis of the genetic distance of the isolates against the sampling time. A fairly constant and rapid rate was obtained; it was 1.83 X 10(-3)/base/year. Based on the substitution rate, genetic distance and sampling time of the strains, the phylogenetic tree of EV 70 was constructed using Unweighted Pair Group Method Using Arithmetic Averages (UPGMA) (Nei, Molecular Population Genetics and Evolution, North Holland, Amsterdam, 1975). The tree supports the previous hypothesis that evolution of EV 70 started from a single common ancestor. The time of its emergence was estimated to be 1967 +/- 15 months. The virus branched into many strains early during the first pandemic and has evolved in a divergent fashion, yielding genetically polymorphic viruses in the world.

Detection of enterovirus 70 with monoclonal antibodies

To improve the ability to identify enterovirus-70 (EV-70) from patients with acute hemorrhagic conjunctivitis, we developed four monoclonal antibodies (MAbs) to EV-70. We reacted the four MAbs against nine previously characterized strains of EV-70 and heterologous viruses by virus neutralization, indirect immunofluorescence, and enzyme-linked immunosorbent assay (ELISA). Two of the MAbs neutralized all nine strains of EV-70 and none of the other enterovirus types tested. Two of the MAbs gave a positive reaction with all nine strains by indirect immunofluorescence, and three reacted with all nine strains by ELISA. None of the MAbs gave a positive reaction with heterologous viruses, including those associated with eye disease, by indirect immunofluorescence or ELISA. The two neutralizing MAbs failed to give a positive reaction with some of the strains of EV-70 by indirect immunofluorescence and ELISA, yet they neutralized these viruses. By ELISA with a polyclonal serum as capture antibody and a mixture of MAbs as detector antibody, we were able to detect from 10(2.2) to 10(5.8) 50% tissue culture infective doses of virus and to type lyophilized isolates of EV-70 sent from Taiwan from which we could not recover infectious virus. By choosing the appropriate MAb, or mixture of MAbs, we could construct a test which had the type specificity and strain sensitivity needed to type isolates of EV-70.

Characterization of a temperature-sensitive defect of enterovirus 70: effect of elevated temperature on in vitro transcription

A crude replication complex prepared from enterovirus 70-infected cells was used to study the temperature-sensitive characteristic of the virus. The complex showed a temperature sensitivity in the in vitro incorporation of radiolabeled ribonucleoside triphosphate. The endonuclease itself did not account for the restricted RNA synthesis at the nonpermissive temperature. Analyses of the in vitro products by both gel electrophoresis and sucrose density gradient centrifugation showed that the complex synthesized three types of viral RNA only when incubated for a short period of time at the nonpermissive temperature. When the replication complex was treated with a detergent (deoxycholic acid), incorporation of ribonucleoside triphosphate into RNA at the permissive temperature was reduced to the level of that at the nonpermissive temperature. In addition, the in vitro RNA synthesis by the enterovirus 70 replication complex at the permissive temperature required a higher concentration of ATP than of other ribonucleoside triphosphates, whereas such a preference for ATP was not found in the reaction at the nonpermissive temperature. The results indicate that the initiation step of RNA synthesis by the complex is blocked at the nonpermissive temperature. The possible implications of these findings are discussed.

Quantitation of enterovirus 70 antibody by microneutralization test and comparison with standard neutralization, hemagglutination inhibition, and complement fixation tests with different virus strains

We describe here a microneutralization procedure for conveniently testing large numbers of specimens for antibodies to enterovirus 70. The test utilized human rhabdomyosarcoma cells and was read by staining with crystal violet after 4 days of incubation. The test compares well with other serological assays, being more sensitive than the standard tube neutralization test and the complement fixation test, but less sensitive than the hemagglutination inhibition test. However, the hemagglutination inhibition test required concentrated, partially purified virus as antigen, as did the complement fixation test, and was difficult to read, so that its greater sensitivity may not be of practical significance. By all four test procedures, a recent isolate of enterovirus 70 was a more sensitive antigen than the prototype strain, as shown by greater geometric mean titers in sera of patients from various epidemics.

A study of the neurological disorder associated with acute haemorrhagic conjunctivitis due to enterovirus 70

Ninety cases of the neurological manifestations associated with acute haemorrhagic conjunctivitis caused by Enterovirus 70 (EV 70) are reported. The patients were seen during the widespread epidemics in 1971 and 1981. Male adults were predominantly affected by a "polio-like" paralysis of the limbs and/or cranial nerves. Root pains were often complained of early in the disease. In the absence of a necropsy, clinical and neurophysiological examinations helped to localise the lesions. Significant antibody titres against EV 70 were demonstrated in the serum and more relevantly in the CSF. Though other viruses can cause sporadic and epidemic conjunctivitis and similar paralysis independently, the combination of a haemorrhagic conjunctivitis and a neurological disease mostly simulating poliomyelitis is caused by EV 70 alone. It is therefore suggested that this combination be called "Enterovirus 70 disease". Because of its neurovirulence, it is important to identify this virus at the very beginning of an epidemic of conjunctivitis, so as to limit its spread by strict public health measures.

Clinical findings and results of treatment in an outbreak of acute hemorrhagic conjunctivitis in southern Florida

An epidemic of acute hemorrhagic conjunctivitis in Miami, Florida, involved approximately 800 documented cases and more than 2,500 suspected cases. This epidemic was caused by an enterovirus 70 infection affecting primarily young black people residing within a high-risk area. Acute hemorrhagic conjunctivitis is characterized by the rapid onset of swollen eyelids, foreign-body sensation, burning, watery discharge, and, usually, bilateral ocular involvement. Signs include distinctive bulbar conjunctival hemorrhages and a follicular conjunctival reaction with only mild and infrequent corneal involvement. This infection is short in duration, self-limited, and free of significant ocular sequelae. Symptomatic treatment appears to be as effective as various topical medical regimens for relief of symptoms. Secondary bacterial infections (occurring in individuals who used urine as an eyewash) and one case of a transient acute Bell's palsy were the only complications associated with this acute hemorrhagic conjunctivitis epidemic.

Characterization of a temperature-sensitive defect of enterovirus type 70

The mechanism of the failure of enterovirus type 70 to replicate at a nonpermissive temperature (39 degrees C) was investigated, and the following results were obtained. (i) Viral RNA synthesis was not observed at 39 degrees C in LLC-MK2 cells, in accordance with our previous findings with primary monkey kidney cells (Miyamura et al., Intervirology 9:206-213, 1978). (ii) Shutoff of host cell macromolecular synthesis by virus infection was as efficient at 39 degrees C as at a permissive temperature (33 degrees C). This inhibitory effect similarly occurred even in the presence of guanidine hydrochloride. (iii) Viral protein synthesis proceeded in vivo at the nonpermissive temperature, and the rate of the protein synthesis was higher than that at the permissive temperature under the conditions in which sufficient viral mRNA had been accumulated. This was also confirmed by analyzing the intracellular proteins synthesized at the nonpermissive temperature by sodium dodecyl sulfate-polyacrylamide gel electrophoresis, which identified them as virus-specific proteins. (iv) When infected cells were incubated at 39 degrees C and then transferred to 33 degrees C, viral RNA synthesis took place even in the presence of cycloheximide. (v) Furthermore, in experiments performed with an in vitro cell-free assay system, viral polymerase activity was found in the membrane-bound preparation extracted from infected cells which had been incubated at 39 degrees C in the presence or absence of guanidine hydrochloride. These results indicate that early translation of mRNA proceeds normally at the nonpermissive temperature and that the temperature-sensitive defect resides in the transcriptional stage.

Antigenic analysis of acute hemorrhagic conjunctivitis viruses (enterovirus type 70)

The antigenic characteristics of enterovirus type 70 (EV 70) were investigated by means of cross and kinetic neutralization tests (NT). Twelve strains of EV 70 isolated in a period from 1971 to 1976 were analyzed using seven rabbit and one monkey hyper-immune sera. All the strains investigated were found to possess a common and prime variant antigens in varying proportions. Accordingly, EV 70 isolates were devided intratypically into three antigenic sub groups; (1) prototype-like (four strain from 1971 to 1972), (2) intermediate, G-10/72-like (two strains from 1972 to 1973), and (3) prime variant, G-2/74-like (six strains from 1974 to 1976) groups. Thus it was considered that EV 70 might represent a virus type with antigenic heterogeneity, and that antigenic drift from the prototype to the prime type may have occurred successively after 1971.

Conjunctivitis in children. A refresher survey of diagnosis and contemporary treatment

The management of acute conjunctivitis need not be confusing. In the newborn period the common etiologic agents are chemical, TRIC, and bacterial. The latter two causes are effectively treated with sulfacetamide ophthalmic preparations. Dacryostenosis should be suspected in any child with recurrent conjunctivitis in the first six months of life. With older children the major causes can be classified as viral, allergic, foreign bodies, and bacterial. Bacterial conjunctivitis almost always responds to sulfacetamide ophthalmic preparations.

The investigation of a recurrence of an AHC virus epidemic at Lucknow: a serosurvey for AHC virus antibodies before and after the epidemic

An epidemic of acute haemorrhagic conjunctivitis (AHC) recurred at Lucknow during July to September 1975, after a gap of 4 years. Out of the 35 cases investigated thoroughly, 20 Entero-70-like cytopathogenic agents were isolated from the conjunctiva which were neutralized by antisera against AHC virus J670/71 of Japan. Seroconversion was seen in 7 out of 11 paired sera from patients. Serological study was also done on 100 sera collected before the AHC epidemic of 1971, 100 sera after 1971 and 100 sera after 1975 epidemic. There were no neutralizing antibodies in the pre-epidemic period, while 18% of sera after the first epidemic and 32% after the second epidemic showed antibodies. The incidence of antibodies was highest (43%) in children aged below 10 years. Of the children born after the first epidemic, 44% had antibodies. Thus our findings show that the AHC virus appeared for the firt time at Lucknow in 1971 and the almost complete absence of disease in children, and its mildness during second epidemic, may be due to immunity.

Radiculomyelitis complicating acute haemorrhagic conjunctivitis. A clinical study

Fourteen patients with radiculomyelitis following acute haemorrhagic conjunctivitis (AHC) were seen in Bangkok during October to December 1974. Most patients developed weakness of extremities 2 weeks after AHC. Prodromal symptoms consisted of fever and malaise for a few days, followed by the acute onset of root pain in the legs and flaccid paralysis. Knee and ankle reflexes were absent or diminished. Cerebrospinal fluid examination revealed lymphocytosis and an increase in protein. Electromyographic findings were consistent with anterior horn cell or motor root lesions. Ten of the 12 cases in which virological studies were performed showed definite serological evidence of AHC virus infection. Six patients received corticosteroid treatment but apart from relief of pain no significant improvement was seen. Motor weakness in 10 patients was less at the end of 2 months, but in 4 it remained unchanged. The occurrence of disabling neurological sequelae calls for effective public health control of AHC outbreak.

Epidemic hemorrhagic keratoconjunctivitis

A new type of acute keratoconjunctivitis developed throughout Southeast Asia, beginning in Singapore in the summer of 1970. It was highly contagious and probably was transmitted from person to person by the hand to eye route. Sixteen cases, diagnosed by viral isolation or serologic study, or both, were subjected to detailed clinical observation. The characteristic features included a short incubation period of one or two days, watery or serous discharge, subconjunctival hemorrhage, and pinpoint superficial keratopathy. The disease usually resolved rapidly within one to two weeks without sequelae.

A comparative study of viruses associated with acute haemorrhagic conjunctivitis

Seven representative isolates from six outbreaks of acute haemorrhagic conjunctivitis were shown to have the characteristics of enteroviruses. Two viruses differed from the remaining five isolates in producing paralysis in suckling mice and being resistant to 2-hydroxybenzyl-benzimidazole. These two viruses were also closely related antigenically and distinct from the other five viruses which were serologically similar to each other. Neither group of viruses was inhibited by antisera to the known enteroviruses and they probably represent two new enterovirus types one related to the Coxsackie A viruses and the other to the echoviruses.

Isolation of a virus responsible for an outbreak of acute haemorrhagic conjunctivitis in Morocco

An epidemic of acute haemorrhagic conjunctivitis occurred in Morocco in 1970-1. It was caused by an enterovirus which appeared to be a new antigenic type similar to a virus isolated in South East Asia during the same period.

The isolation of enteroviruses from cases of acute conjunctivitis

In two epidemics of acute enterovirus conjunctivitis the diagnosis could only be established by the use of human embryonic organ cultures. In one instance cultures of ciliated respiratory epithelium proved sensitive to the virus but similar culture failed to support growth of the virus from the second outbreak which was isolated in organ cultures of conjunctiva. The virus associated with a third outbreak had previously been isolated from the original material by culture in human embryo kidney cells, but it required passage in organ culture for its detection after the specimens had been diluted.