Fatal Case of West Nile Neuroinvasive Disease in Bulgaria

First Serologic Evidence of West Nile Virus and Usutu Virus Circulation Among Dogs in the Bulgarian Danube Region and Analysis of Some Risk Factors

This study aimed to assess West Nile virus (WNV) and Usutu virus seroprevalence among the dog population in the Danube region, Bulgaria, to confirm the results of ELISA by the virus neutralisation test (VNT), as well as to analyse several risk factors of seropositivity in dogs. To implement this, a total of 201 blood samples were collected from dogs in four districts bordering the Danube River. All the samples were tested for anti-WNV protein E antibodies using competitive ELISA. Neutralising antibodies against WNV and Usutu virus were tested in all the ELISA-positive samples. The results show a WNV seroprevalence of 45.3% (n = 91, CI = 36.45-55.59) by ELISA, whereas the virus neutralisation test indicated a seroprevalence of 21.9% (n = 44, CI = 15.91-29.39). Neutralising antibodies against Usutu virus were detected for the first time in Bulgaria, with a prevalence of 6% (n = 12, CI = 3.09-10.43). Compared to VNT, ELISA demonstrated 100.0% sensitivity and 70.1% specificity. The region (p < 0.0187), the district (p = 0.0258) and the ages of the dogs (p = 0.0180) were identified as statistically significant risk factors associated with WNV seropositivity. This study provides indirect evidence of WNV and Usutu virus circulation among dogs in the Danube region of Bulgaria, highlighting a potential risk for susceptible hosts in the area.

Complex patterns of WNV evolution: a focus on the Western Balkans and Central Europe

Introduction

West Nile Virus, an emerging zoonotic pathogen, has been circulating in Serbia for over a decade, with its first detection in mosquitoes in 2010. Since then, the virus has led to increasing cases in both animals and humans, peaking in 2018 with 415 human cases and 36 fatalities. This study aimed to explore the phylogenetic relationships between previously sequenced West Nile virus strains from Serbia and those sequenced in this study, while also identifying possible virulence factors.

Materials and methods

Whole genome sequencing was conducted using a targeted approach on the MinION Mk1C platform, following a two-step process involving cDNA synthesis and amplification. Bioinformatics analysis included demultiplexing, primer trimming, and sequence mapping using tools such as iVar, Minimap2, and Samtools. Phylogenetic analysis was performed using MAFFT alignment and the Maximum Likelihood method with the Tamura Nei model in MEGA X software. Virulence factors were assessed in both structural and nonstructural proteins, focusing on key glycosylation motifs and specific mutations. Homology modeling of the E protein was also performed to evaluate potential structural changes due to mutations.

Results

Phylogenetic analysis revealed two major sublineages within the E subclade, representing the majority of strains from Western and Central Europe. These sublineages likely originated from Austria, Serbia, and Hungary between 2008 and 2012. The study also identified three distinct sublineages within the D subclade, which includes more diverse strains from Southern Europe. The E protein exhibited significant variations, particularly at the E159 site, which is crucial for virulence. The EI159T aa change has become dominant in recent years, replacing the previously prevalent EI159M. Additionally, changes in the NS1 glycoprotein and NS3 protein, both of which are involved in immune modulation and viral replication, were identified, with potential implications for the virus's virulence.

Conclusion

The study's findings highlight the Western Balkans and Central Europe as key regions for the mixing and dissemination of West Nile virus strains from both Western-Central and Southern Europe. These results underscore the importance of continuous surveillance and phylogenetic analysis to monitor the evolution and spread of West Nile virus, particularly in light of the frequent mutations observed in virulence-associated sites.

Global emergence of West Nile virus: Threat & preparedness in special perspective to India

West Nile virus (WNV) is a mosquito-borne single-stranded RNA neurotropic virus within the family Flaviviridae. The virus was first reported in the West Nile province of Uganda in 1937. Since then, sporadic cases have been reported until the last two decades when it has emerged as a threat to public health. The emergence of WNV with more severity in recent times is intriguing. Considering this phenomenon, the WNV-affected areas of the world were distinguished as old versus new in a depicted world map. The present review showcases the historical and epidemiological perspectives of the virus, genetic diversity of prevailing lineages and clinical spectrum associated with its infection. Emergence of the virus has been discussed in special context to India because of co-circulation of different WNV lineages/strains along with other flaviviruses. Recent laboratory diagnostics, vaccine development and clinical management associated with WNV infection have also been discussed. Further, the research gaps, especially in context to India have been highlighted that may have a pivotal role in combating the spread of WNV.

Genetic Characterization of a Neurovirulent West Nile Virus Variant Associated with a Fatal Great Grey Owl Infection

This study reports on a fatal case of a captive great grey owl infected with the West Nile virus (WNV) in the zoological garden Košice, eastern Slovakia (Central Europe). The tissue samples of the dead owl were used for virus isolation and genetic characterization. The novel isolate is genetically closer to Hungarian, Greek, and Bulgarian strains from the central/southern European clade of lineage 2 than to the strains previously isolated in Slovakia. Interestingly, it carries NS3-249P, a molecular virulence determinant associated with higher neurovirulence, which has not previously been observed in Slovakia. Subsequent serological investigation of the captive owls revealed additional seropositive animals, indicating local WNV transmission. Although no WNV-positive mosquitoes were found, the presence of the WNV principal vector Culex pipiens complex together with the described fatal case and further serological findings indicate an endemic focus of bird-neurovirulent WNV variant in the area.

Cauda equina arachnoiditis - a rare manifestation of West Nile virus neuroinvasive disease: A case report

BACKGROUND

Data regarding the neuroradiology features of the West Nile virus neuroinvasive disease (WNV NID) is rather scarce. To contribute to the knowledge of the WNV NID, we present a patient with a combination of encephalitis and acute flaccid paresis, with cauda equina arachnoiditis as the main magnetic resonance (MR) finding.

CASE SUMMARY

A 72-year-old female patient was admitted due to fever, headache and gait instability. During the first several days she developed somnolence, aphasia, urinary incontinence, constipation, and asymmetric lower extremities weakness. Cerebrospinal fluid analysis indicated encephalitis. Native brain computed tomography and MR were unremarkable, while spinal MR demonstrated cauda equina enhancement without cord lesions. Virology testing revealed WNV IgM and IgG antibodies in serum and cerebrospinal fluid, which confirmed acute WNV NID. The treatment was supportive. After two months only a slight improvement was noticed but cognitive impairment, loss of sphincter control and asymmetric inferior extremities weakness remained. The patient died after a month on chronic rehabilitation.

CONCLUSION

Cauda equina arachnoiditis is a rare, but possible neuroradiological feature in acute flaccid paresis form of WNV NID.

West Nile virus lineage 2 in humans and mosquitoes in Bulgaria, 2018-2019

BACKGROUND

West Nile virus (WNV) lineage 2, and especially the Hungarian clade, predominates in Europe. Most of the Hungarian clade strains cluster into 2 groups: Central/South-West European and Balkan.

OBJECTIVES

Since there was not any study on WNV in mosquitoes in Bulgaria, the present study was designed to test Culex spp. mosquitoes in areas near the Danube river. The aim of the study was to gain an insight into the recent molecular epidemiology of WNV in Bulgaria.

STUDY DESIGN

A total of 1871 Culex pipiens mosquitoes collected in 2018 and clinical samples from 23 patients with West Nile neuroinavsive disease observed in 2018 and 2019 were tested by TaqMan RT-PCR and RT-nested PCR and PCR products were sequenced.

RESULTS

WNV RNA was detected in clinical samples from 10 patients and in five (12.2 %) of 41 pools of Cx. pipiens mosquitos by realtime RT-PCR, resulting in a minimum infection rate of mosquitoes of 0.27 %. Phylogenetic analysis based on partial NS3 gene sequences from one clinical sample and four mosquito pools showed that all sequences clustered into the Hungarian clade of WNV lineage 2 and all but one were identical to respective sequences from Romania. Whole genome sequences of one mosquito pool belong to the Hungarian group of WNV lineage 2 and cluster in a separate subclade from the Bulgarian strain from 2015, suggesting that at least two different introductions occurred in Bulgaria.

CONCLUSIONS

The current study provides insights into the geographic distribution of WNV in Bulgaria.

Emerging Trends in the Epidemiology of West Nile and Usutu Virus Infections in Southern Europe

The epidemiology of West Nile (WNV) and Usutu virus (USUV) has changed dramatically over the past two decades. Since 1999, there have been regular reports of WNV outbreaks and the virus has expanded its area of circulation in many Southern European countries. After emerging in Italy in 1996, USUV has spread to other countries causing mortality in several bird species. In 2009, USUV seroconversion in horses was reported in Italy. Co-circulation of both viruses was detected in humans, horses and birds. The main vector of WNV and USUV in Europe is Culex pipiens, however, both viruses were found in native Culex mosquito species (Cx. modestus, Cx. perexiguus). Experimental competence to transmit the WNV was also proven for native and invasive mosquitoes of Aedes and Culex genera (Ae. albopictus, Ae. detritus, Cx. torrentium). Recently, Ae. albopictus and Ae. japonicus naturally-infected with USUV were reported. While neuroinvasive human WNV infections are well-documented, USUV infections are sporadically detected. However, there is increasing evidence of a role of USUV in human disease. Seroepidemiological studies showed that USUV circulation is more common than WNV in some endemic regions. Recent data showed that WNV strains detected in humans, horses, birds, and mosquitoes mainly belong to lineage 2. In addition to European USUV lineages, some reports indicate the presence of African USUV lineages as well. The trends in WNV/USUV range and vector expansion are likely to continue in future years. This mini-review provides an update on the epidemiology of WNV and USUV infections in Southern Europe within a multidisciplinary "One Health" context.

WEST NILE VIRUS INFECTION WITH NEUROLOGICAL DISORDERS: A CASE REPORT AND A BRIEF REVIEW OF THE SITUATION IN BULGARIA

A case of a 66-year-old man with West Nile neuroinvassive disease manifested with fever, weakness, fatigue, consciousness disorders and underlying diabetes mellitus type 2 and cardiovascular diseases is presented. Laboratory data showed elevated erythrocyte sedimentation rate and fibrinogen. Serological tests revealed West Nile virus specific antibodies of class IgM and IgG in serum. West Nile virus RNA was detected in urine sample. Supportive therapy was applied.

Dengue Virus Infection of Blood-Brain Barrier Cells: Consequences of Severe Disease

More than 500 million people worldwide are infected each year by any of the four-dengue virus (DENV) serotypes. The clinical spectrum caused during these infections is wide and some patients may develop neurological alterations during or after the infection, which could be explained by the cryptic neurotropic and neurovirulent features of flaviviruses like DENV. Using in vivo and in vitro models, researchers have demonstrated that DENV can affect the cells from the blood-brain barrier (BBB) in several ways, which could result in brain tissue damage, neuronal loss, glial activation, tissue inflammation and hemorrhages. The latter suggests that BBB may be compromised during infection; however, it is not clear whether the damage is due to the infection per se or to the local and/or systemic inflammatory response established or activated by the BBB cells. Similarly, the kinetics and cascade of events that trigger tissue damage, and the cells that initiate it, are unknown. This review presents evidence of the BBB cell infection with DENV and the response established toward it by these cells; it also describes the consequences of this response on the nervous tissue, compares these evidence with the one reported with neurotropic viruses of the Flaviviridae family, and shows the complexity and unpredictability of dengue and the neurological alterations induced by it. Clinical evidence and in vitro and in vivo models suggest that this virus uses the bloodstream to enter nerve tissue where it infects the different cells of the neurovascular unit. Each of the cell populations respond individually and collectively and control infection and inflammation, in other cases this response exacerbates the damage leaving irreversible sequelae or causing death. This information will allow us to understand more about the complex disease known as dengue, and its impact on a specialized and delicate tissue like is the nervous tissue.

West Nile virus and other mosquito-borne viruses present in Eastern Europe

Eastern Europe (EE) has been severely affected by mosquito-borne viruses (moboviruses). In this review, we summarize the epidemiology of moboviruses, with particular attention to West Nile virus (WNV). The study of WNV human cases in EE between 2010 and 2016, revealed that the epidemiology of WNV in EE is complex with the combination of introduction of different WNV strains from lineages 1 and 2, and the establishment of endemic cycles. We found a positive correlation between the risk of WNV re-emergence in an area and the number of human cases reported in the previous year. We also report the main ecological and biological characteristics of the key mosquito species vectors of moboviruses. Recent expansion of invasive mosquito species in EE, mainly Aedes albopictus but also Aedes aegypti and Culex quinquefasciatus, may result in new scenarios with an increased risk of transmission of moboviruses. Main gaps of knowledge in relation to moboviruses and their vectors in EE are identified. Understanding the epidemiology of moboviruses in EE is essential for the improvement of their surveillance and the control of the diseases they cause.

Integrated analysis of human-animal-vector surveillance: West Nile virus infections in Austria, 2015-2016

The results of integrated human and veterinary surveillance for West Nile virus (WNV) infections in Austria during the transmission seasons 2015 and 2016 are shown. Altogether WNV nucleic acid was detected in 21 humans, horses, wild birds and mosquito pools. In detail: in four human clinical cases [two cases of West Nile fever (WNF) and two cases of West Nile neuroinvasive disease (WNND)]; eight blood donors [among 145,541 tested donations], of which three remained asymptomatic and five subsequently developed mild WNF; two horses with WNND, of which one recovered and one had to be euthanized; two wild birds [one goshawk and one falcon, both succumbed to WNND]; and five Culex pipiens mosquito pools. Compared to previous years the number of infections increased remarkably. All infections were recorded in the city of Vienna and neighboring regions of Lower Austria. Sixteen coding-complete WNV sequences were established which were closely related to each other and to other Austrian, Czech and Italian viruses, all belonging to the Central/Southern European cluster of WNV sublineage 2d. However, several genetically slightly different WNV strains seem to co-circulate in the same area, as demonstrated by phylogenetic analysis. Based on detailed sequence analysis, all newly discovered Austrian WNV strains had the potential to cause neurological disease, but no correlation was found between severity of disease and the analyzed genetic virulence/neuroinvasiveness markers. Results of integrated human-animal-vector surveillance presented in this paper provide a comprehensive description of WNV activity in the region and will facilitate proactive public health measures to prevent or mitigate potential outbreaks.

Re-emergence of severe West Nile virus neuroinvasive disease in humans in Romania, 2012 to 2017-implications for travel medicine

BACKGROUND

In Romania, after a major outbreak in 1996, West Nile neuroinvasive disease (WNND) was reported only in a limited number of cases annually. During 2016-2017, a significant increase in the number of WNND cases was reported at the national level, associated with high mortality rates.

METHODS

A retrospective analysis of all cases confirmed with WNND, hospitalized during 2012-2017 in a single tertiary facility from Bucharest was performed in order to determine the annual prevalence and mortality rate and the risk factors associated with a severe outcome.

RESULTS

47 cases were confirmed as WNND. The mortality rate was 25.5%, all death occurred during 2016-2017. Coma, confusion, obtundation, sleepiness and depressed deep tendon reflexes were symptoms predicting a severe outcome. In a univariate analysis age (p < 0.001), associated cancers (p = 0.012) and low levels of chloride in the CSF (p = 0.008) were risk factors for mortality. In a multinomial logistic analysis, age older than 75 years remained the only independent predictor of death in WNND.

CONCLUSIONS

The increase in both the number and the mortality rate of WNND cases suggest a changing pattern of WNV infection in Romania. Public health authorities and clinicians should be aware of the risk of severe WNV infection in travelers returning from Romania.

A nationwide seroprevalence screening for West Nile virus and Tick-borne encephalitis virus in the population of Bulgaria

To assess local circulation and risk for human infections with West Nile virus (WNV) and Tick-borne encephalitis virus (TBEV) in Bulgaria, a nationwide seroprevalence study was conducted. In total, 1451 residents of all 28 districts in Bulgaria were tested for WNV-specific and TBEV-specific IgG antibodies. The survey found overall seroprevalence of 1.5% and 0.6%, respectively. The highest WNV seroprevalence was found in Sofia Province and districts near the river Danube. TBEV circulation was detected among residents of six districts. The results showed that the two virus infections seem to be more wide-spread in the country as has been described.

Age-related alterations in immune responses to West Nile virus infection

West Nile virus (WNV) is the most important causative agent of viral encephalitis worldwide and an important public health concern in the United States due to its high prevalence, severe disease, and the absence of effective treatments. Infection with WNV is mainly asymptomatic, but some individuals develop severe, possibly fatal, neurological disease. Individual host factors play a role in susceptibility to WNV infection, including genetic polymorphisms in key anti-viral immune genes, but age is the most well-defined risk factor for susceptibility to severe disease. Ageing is associated with distinct changes in immune cells and a decline in immune function leading to increased susceptibility to infection and reduced responses to vaccination. WNV is detected by pathogen recognition receptors including Toll-like receptors (TLRs), which show reduced expression and function in ageing. Neutrophils, monocyte/macrophages and dendritic cells, which first recognize and respond to infection, show age-related impairment of many functions relevant to anti-viral responses. Natural killer cells control many viral infections and show age-related changes in phenotype and functional responses. A role for the regulatory receptors Mertk and Axl in blood-brain barrier permeability and in facilitating viral uptake through phospholipid binding may be relevant for susceptibility to WNV, and age-related up-regulation of Axl has been noted previously in human dendritic cells. Understanding the specific immune parameters and mechanisms that influence susceptibility to symptomatic WNV may lead to a better understanding of increased susceptibility in elderly individuals and identify potential avenues for therapeutic approaches: an especially relevant goal, as the world's populating is ageing.