1Arboviruses

BY JAMES CHRISTOPER CHUA, RMT, MB(ASCPi), PBF, HOT I. Introduction The grouping was made on the basis of mode of transmission. The prefix arbo is short for arthropod-borne, although some arboviral infections are transmitted by rodents. Mosquitoes, ticks and other insects serve as vectors. Three clinical syndromes are common, including: undifferentiated fevers, hemorrhagic fevers and encephalitis. Arboviruses come from different RNA virus families, such as Arenaviridae, Bunyaviridae, Filoviridae, Flaviviridae, Reoviridae and Togaviridae. II. General characteristics All of the previously mentioned arbovirus families are enveloped except Reoviridae. The capsid shapes of the different families are summarized in Table 1. Table 1. Arboviral Capsid Shapes Family Capsid shape Arenaviridae Helical Bunyaviridae Helical Filoviridae Helical Flaviviridae Icosahedral Reoviridae Icosahedral Togaviridae Icosahedral III. Clinical syndromes Arenaviridae There are currently seven members of this family known to cause human disease (See Table 2). These viruses do not produce cytopathic effects when grown in culture. Infection is acquired from contact with rodent excreta. Table 2. Arenaviridae Members Lassa Whitewater Arroyo Junin Lymphocytic choriomeningitis (LCM) Manchupo Sabia Guanarito LCM virus causes meningitis, encephalitis and myelitis (i.e., inflammation of the spinal cord). Incubation period is usually between 8 to 13 days before a biphasic febrile illness appears. The first phase is characterized by the following symptoms: fever, malaise, anorexia, muscle aches, headache, nausea, and vomiting. Testicular and parotid pain may also occur. Symptoms subside for a few days before the second phase of the disease occurs. This phase is composed of symptoms characteristic of meningitis or encephalitis. LCM virus can also cause acute hydrocephalus. The Lassa virus can affect almost every organ system and causes high fever and severe muscle aches in patients. Deafness is a common complication. Infection is usually acquired from house rats. Hemorrhagic fevers are caused by Junin, Manchupo, Whitewater Arroyo and Guanarito viruses. Bunyaviridae Members of this family which cause encephalitis belong to the California encephalitis virus complex composed of 14 serogroups. The La Crosse virus is most common. Sandfly and Rift Valley fevers are mild febrile illnesses caused by the genus Phlebovirus. The genus Hantavirus under this family causes two fatal diseases: hemorrhagic fever with renal syndrome (HFRS) and Hantavirus pulmonary syndrome (HPS). Both diseases are acquired from contact with rodent excreta. HFRS is caused by Dengue shock syndrome Seoul, Hantaan and Dobrava viruses. Infection may lead to renal failure. Sin Nombre virus causes HPS. Filoviridae Marburg and Ebola viruses (Zaire, Sudan and Reston strains) are filoviruses that cause hemorrhagic fevers. Disseminated intravascular coagulation (DIC) which leads to tissue hypoxia and depletion of clotting factors are characteristic of infection. The Exact vectors and natural reservoirs of these viruses are still unknown. Viruses have tropism for macrophages, hepatocytes and endothelial cells. Flaviviridae St. Louis and West Nile viruses are flaviviruses that cause encephalitis. Both encephalitides are transmitted by mosquitoes and share similar clinical presentations. Patients experience flu-like symptoms (i.e., fever, headache and malaise) with an incubation period of 3 to 14 days. Rash and lymphadenopathy may also occur. Patients with West Nile encephalitis can develop acute flaccid paralysis (i.e., paralysis of the limbs and breathing muscles). Dengue fever is a generalized infection caused by the four flavivirus serotypes: DEN-1, 2, 3 and 4. Vectors are the female Aedes aegypti and Aedes albopictus mosquitoes. The virus infects cells of the reticuloendothelial system, which include platelets, monocytes, macrophages and endothelial cells. Endothelial cells lining blood vessels get damaged, leading to fragility of the blood vessels and at the same time, antibodies against the virus cause platelet destruction. Bleeding occurs as a result. Activation of the complement system and release of pro-inflammatory cytokines by infected monocytes and macrophages lead to increased capillary permeability and plasma leakage. Shock or circulatory collapse results from excessive bleeding. The world health organization has classified the disease in to three clinical stages (See Table 3). Treatment is usually supportive but platelet transfusions should be deferred until when the platelet count becomes very low since transfused platelets also get destroyed during the infection. Health care providers should instead focus on preventing circulatory collapse which can be done by increasing blood pressure. This can be accomplished by giving intravenous fluids and vasoconstrictors like epinephrine and dopamine. Aspirin should be avoided because of its antiplatelet properties. Table 3. WHO classification of Dengue Stage Characteristics Dengue fever: a. High fever with no localizing source of infection b. Petechial rash thrombocytopenia c. Relative leukopenia. Dengue hemorrhagic fever: a. Fever b. Hemorrhagic tendency c. Thrombocytopenia (<100,000 platelets per mm) d. Evidence of plasma leakage (hematocrit more than 20% higher than expected) Dengue hemorrhagic fever plus: a. Weak rapid pulse and narrow pulse pressure (less than 20 mm Hg) or

b. Hypotension for age; cold, clammy skin and restlessness Yellow fever is a febrile illness also caused by a flavivirus. Early symptoms include: fever, chills, headache, backache, nausea and vomiting. In severe cases, hemorrhaging occurs followed by jaundice; hence the name yellow fever. Reoviridae Colorado Tick fever is a mild tick-borne febrile disease accompanied by chills, severe headaches, photophobia, and muscle pain. The causative agent is the Coltivirus. Its main reservoirs are ground squirrels, rabbits, and deer. Togaviridae Eastern, Western and Venezuelan equine encephalitides are caused by the Alphavirus genus of the Togaviridae family. The disease is transmitted by mosquitoes and is more severe in children.