Zika: wonder virus

Professor Thiravat Hemachudha, MD, FACPChulalongkorn University/Thai Red Cross EID

TransfusionOrgan transplantIntact skin

Sweat tearSalivaBreast milkSex

TRANSOVARIANSEXUAL TRANSMITTED DISEASE

special characters withdistinctive features• Flavivirus alphavirus (Togaviridae)• Dengue: hemorrhagic virus with exceptional cases

as isolated nervous system dysfunctions• JE: nervous system

symptomatic/inapparent or mild=1:500-1000 in kids and 1:25-50 in adults

• CHIK virus: more pronounced on joint/rashsymptoms

• Zika: fetus in utero• Persistent infection not immediatecastastrophic effect in pregnant

• Adult- almost negligible BUT if happens,severe

• Sexual route• Skin/mucous membrane• Sweat/tear

special characters withdistinctive features

Nicholas and Guy, 2008

FibroblastKeratinocyteDendritic cells

NeutrophilEdema leakage

Myeloid recruits

Turn bad guys

Viral entry receptors

Antiviral geneexpression

autophagy

Zika: fetus in uteroPersistent infectionnot immediatecastastrophiceffect in pregnantWhy affect alltrimesters?Mechanism(s)?Adult- negligibleBUT..

ZIKA AS SMART NEURO-VIRUS• EVADE INNATE FROM TROPHOBLAST• USE PLACENTA (and uterus) AS HOME (depending on preg

stage?)• USE FETAL BRAIN AS HOME (killing softly)• PROLONGED MATERNAL VIREMIA• EXPLOIT HUMAN MACHINERY IN REPLICATION/

IN CAUSING MALFORMATION• MECHANISMS: AUTOPHAGY?• ABLE TO INFECT AT ALL TRIMESTERS

SOLID EVIDENCE:VIRUS STILL REPLICATING!!!!

72 hours timepoint

Teratogenic eff ects ofthe Zika virus and therole of the placentaJennifer J Adibi, Ernesto TA Marques Jr, AbigailCartus, Richard H Beigi.Lancet 2016; 387: 1587–90

ZIKA INFECTS HUMAN PLACENTAL MACROPHAGESPlacental trophoblasts -outer layertype III interferon IL29EvadeInner layertype I interferon

Science 2016 mice lacking interferon production

NOT ALL HAD DISEASEDEPENDING ONABILITY OF VIRUS TOEVADE HOST DEFENCE

Any consistent abnormalities in BBB in encephalitis?NO

Variable depending pathogen type and stage

Biomedical informatics 2015

IL-17….NF-ĸB-mediated“inflammation amplifier”

INF-gamma/TGF-beta-1 and the TH1/TH2balance correspond to the M1/M2 and thebalance of tissue destruction(i.e., excessive nitric oxide and relatedcytotoxic compounds)/ tissue regenerationmodality (i.e., arginase-mediated productionof polyamines for DNA repair and L-prolineand ornithine for cell and tissue repair)

M1 destructiveM2 reparative

Griffin DE.Plos pathogens2011

Fate of infected neuronsSurvive with viral clearance(mechanisms depending onage/cell types/region)Dead-apoptosis/necrosisSlow death-autophagy

10/17 BBB gateway:Generated inside the brain

Good guy“TLR dangersignal”Bad guyDeregulateNS developmentand synapticfunction

Hotchkiss et al. 2009

DO OR DIE

Proteostasis network (PN):Protein fates

EARLY VS LATE PLACENTA ?

• INFECTED PLACENTA WITH INFLAMMATORY RESPONSE

• EARLY PLACENTA- AS RESERVIOR AND TRANSMIT TO FETUS• LATE PLACENTA – A VIRUS TRAP THEN PRODUCE NEUROTOXICS TO

FETUS

Spontaneousterminationat 25 wksInfection at 11 wks

ZIKV (strain FSS13025, Cambodia 2010) subcutaneously in five locations on the forearms of apregnant pigtail macaque at 119 d gestation (corresponding to ~28 weeks of humanpregnancy)The pregnant animal appeared healthy and did not develop signs of rash, conjunctivitis orfever. C/S at 162 d gestation (corresponding to ~38 weeks of human pregnancy).Arrested fetal brain growth, white matter injury and detection of ZIKV RNA in multiplefetal organs (brain, liver and placenta) are similar to features of the congenital ZIKV syndromein humans. The distribution of white matter injury in this case is predicted to result in visual-field loss (injury to optic tracts) and neurodevelopmental delay. A similar but more severepattern of white matter injury, with involvement of the occipital horns of the lateral ventricle,was also seen in a Brazilian child with congenital ZIKV infection.

Patricia Soares de Oliveira-Szejnfeld, MD et al. Radiology 2016

Lancet June 2016

Zika associated neuro-complicationsin children and adults

•Neuraxitis• meninges/brain/cranial nerve/spinal root/nerve• Diverse manifestations including pure sensory loss

•Shock syndrome

Zika meningoencephalomyelitisin adult with or without vasculitis

ADEM

Encephalitis mechanisms in Flavivirus (adult)

• Much more than we think• Direct neuronal infection or indirect effect?

• In dengue encephalitis/encephalopathy: virus –real neuroinvasive (permissiveinfection)?

Using Flu-Neurologicalmanifestations as model•unlikely to be a singlemechanism underlying thepathophysiology of the widespectrum of neurologicalmanifestations of influenza.

•Onset/duration/time course

Pattern based classifications

illness preceding neurological manifestations(1) acute, in association with an innate immuneresponse and a “cytokine storm,”(2) subacute, with an adaptive, cell-mediatedresponse such as ADEM, AHLE, GBS

Should we include autoimmune response:Neuronal surface/synapticIntracellular antigen?

DIRECTEFFECT?

Flu case at chulalongkorn hospital September 2016

April 2014 at Korat: 7 years old

1 day: fever/mild productivecough3 serial GTC, then coma

Non-permissive infection-ANE

Clin Med insights 2016 (in print)

A 21-year-old male presented with a 3-day history of fever, weakness, and altered sensorium. Axial non-contrastenhanced CT (a) showshypodensityin bilateralcerebellar hemispheres. Axial T2WI MRI (b, c) reveals hyperintensity in bilateral cerebellar hemispheres, thalami. GradientMR image (d) shows features of bleeding within thecerebellarlesionwhichappear hyperintense on T1WI (e). Follow-up CT (f) shows gliotic changesin the cerebellum

Eur Radiol2014

Dengue encephalitis

Callosal lesion disconnection syndrome

Encephalomyelitis with anterior horn cell involvement

Right homonymous hemianopsiaglobal aphasia

No specific pattern

Hemachudha, unpublished

• Sankar Swaminathan, M.D. Robert Schlaberg, M.D., M.P.H. Julia Lewis, D.O. Kimberly E. Hanson, M.D., M.H.S. Marc R. Couturier, Ph.D. N Engl J Med September 28 (2016)

• Patient 1: died from Zika shock• Patient 2 reported having assisted a nurse in repositioning

Patient 1 in bed without using gloves. Patient 2 alsoreported having wiped Patient 1’s eyes during thehospitalization but reported having had no other overtcontact with blood or other body fluids, including splashesor mucous membrane exposure

Zika human-human: sweat/tearsnormal skin or mucous membrane

หนูชายตดิเชือไวรสั ซกิา้ ไข่ฝ่อ สเปิรม์ (sperm) หด ฮอรโ์มนหาย ยุงกดัชาย ไข่หด ยุงกดัหญงิทอ้ง หวัลูกหายAfter 1 week, the virus had migrated to the testes, which bore microscopic signs of inflammation. After 2 weeks, thetesticles were significantly smaller, their internal structure was collapsing, and many cells were dead or dying. After 3weeks, the mice's testicles had shrunk to one-tenth their normal size and the internal structure was completely destroyed.The mice were monitored until 6 weeks, and in that time their testicles did not heal, even after the mice had cleared thevirus from their bloodstreams

sure-? We don’t have mosquitoes in ward

Survey of mosquitoLarvae-virusAt a hospitalOctober 2016

Guillain-Barré syndromeHugh J Willison, Bart C Jacobs, Pieter A van Doorn. Lancet August 2016

• Infectious triggers (Bacteria/virus/parasite)C jejuni, CMV, EBV, influenza A virus, HIV, Mycoplasmapneumonia, Haemophilus influenzae, hepatitis E, B, Cetc• Immune stimulation/ molecular mimicry• 0·8–1·9 (median 1·1) cases per 100 000 people per year• increases with age (0·6 per 100 000 per year in children

and 2·7 per 100 000 per year in elderly people aged 80years and over)

• slightly more frequent in males than in females.

Emgtest.com

Lancet 2016

AMANacute motor axonal neuropathy

• รูปแบบของการออ่นแรงอย่างเดยีวไม่มชีา (Pure motoraxonopathy) ไดถู้กคน้พบคร ังแรก ศาสตราจารย ์Guy McKhann และDavid Cornblath (โรงพยาบาล JohnsHopkins) โดยพบผูป่้วยในจนี และเรยีกวา่เป็นปรากฏการณ์อมัพาตของคนจนี (Chinese Paralytic Syndrome) และมีความเกียวพนักบัการตดิเชือโรคแบคทเีรยี CampylobacterJejuni ซึงเป็นการตดิเชือทางระบบทางเดนิอาหาร (แตผู่ป่้วยอาจมีหรอืไม่มทีอ้งเสยีกไ็ด)้ และเกดิการกระตุน้ใหภู้มคิุม้กนัวปิรติ

• แตร่ะยะตอ่มาพบวา่โรคลกัษณะดงักล่าวพบไดท้วัโลกไม่จาํกดัทีจนีนอกจากนันพบวา่ไม่ไดม้เีชือตวันีตวัเดยีวยงัมกีารตดิเชืออืนๆอกีหลายตวั ทีกระตุน้ใหเ้กดิมภูีมคิุม้กนัแปรปรวน ในการนีเชือจะมีโครงสรา้งคลา้ยคลงึกบัส่วนประกอบของเสน้ประสาท (แตไ่ม่จาํเป็นเสมอไปในเชือบางตวั) โดยมกีารสรา้งแอนตบิอดตีอ่สารGangliosides เชน่ ตอ่ GM1 GD1a GD1b GT1a GQ1b

Features needed for diagnosis• Progressive weakness in legs and arms (sometimes initially only in legs)• Areflexia (or decreased tendon refl exes) in weak limbs.• Progressive phase lasts days to 4 weeks (often 2 weeks).• Relative symmetry.• Mild sensory symptoms or signs (not present in acute motor axonal

neuropathy)• Cranial nerve involvement, especially bilateral weakness of facial

muscles.• Autonomic dysfunction.• Pain (common).

doubt about the diagnosis ofGuillain-Barré syndrome• Fever at onset.• Bladder or bowel dysfunction at onset.• Persistent bladder or bowel dysfunction• Severe sensory signs with little or no weakness at onset

(sharp sensory level)• Sharp spinal cord sensory level.• Marked, persistent asymmetry of weakness.• Severe pulmonary dysfunction with little or no limb

weakness at onset.• CSF: increased number of mononuclear cells or

polymorphonuclear cells (>50 cells per μL).• Slow progression of weakness and without respiratory

involvement (CIDP?)

GBS MIMICS

•VACCINE ASSOCIATED (FLU)•B1 DEFICIENCY•Toxic/Toxins: botulinum puffer fish cigua•INFECTIOUS GBS

- ENTEROVIRUS- Lyme, HIV and OI (CMV Herpes)- FLAVIRUS- RABIES

Hemachudha et alNeurology 1988

Hemachudha et alNEJM 1987

Infectious/exercise/high Carb/thiaminasetrigger: B1 deficiency

Infectious/exercise/high Carb/thiaminasetrigger: B1 deficiency

polyneuropathy

Glove-stocking (sharp level)WeaknessDistal predominateAreflexiaJPS absent

Spinal cord-nerve

Start with pain/numbAscend-/descending PPS lossHip flex/knee flex weak (UMN)distal LMN weaknessareflexia lower limbLoss of JPS (toes)

Hanging sensory loss-with or without foot weakness

Isolated pain/numb at cervical roots

One with dysphagiaLoss of gag reflex

Pulmonary edemaTrop T/CK MBEKG inverted Tin chest leadsEF 20%

B co injection4200 cc output

Rapid investigation atsamut prakarn caseswith documentedhistory and lab test(Pre and post loadingof B1)led to appropriatedecision making atRanong

INFECTIOUS GBS

•PARALYTIC RABIES•NON-RABIES GBS

- ENTEROVIRUS- FLAVIVIRUS / ALPHAVIRUS- Lyme, HIV and OI (CMVHerpes) radiculitis

Hemachudha 1989/1997

PARALYTIC (DUMB) RABIESWeakness from peripheral nerveDysfunction –axon or myelin

Paralytic rabies:peripheral nervedysfunction(axon- or myelinopathy)with pathology

Mitrabhakdi et al. J Neurol Sci 2005Hemachudha et al. J Neurovirol 2005Hemachudha et al. Lancet Neurology 2013

PARALYTIC RABIES

- Percussion myoedemaIf present in GBS like patientin the absence of hyponatremia /renal failure or severe cachexia

- Fever- Bladder incontinence- Hyponatremia

- Hemachudha.Lancet 1988; Am J Med 1988Handbook of Clinical Neurology1989- Hemachudha, Rupprecht.Principle of Neurological InfectiousDiseases 2004

-Hemachudha et al. LancetNeurology 2013

Hemachudha et alLancet Neurology2013

A 25-year-old Thai male presented with fever, headache and rapidly progressive paraparesis within a few days. Hethen became confused on the seventh day of illness. Three days later, he developed respiratory failure and wasintubated and refered to Ramathibodi Hospital.

A

B

C

Figure: Post gadolinium T1W in sagittal (A) and axial (C ) planes and axial gradient T2 (B) of the mid to lower thoracic spineincluding the conus medullaris and cauda equina reveal mild leptomeningeal enhancement (small black arrow in A) and vividintrathecal cauda equina nerve roots enhancement (white arrows in A and C), compatible with radiculitis. Ill-definedhypersignal T2 change of the conus medullaris (white arrow in B) is also observed representing myelitis.

Courtesy of Dr.Laothamatas(Lancet 2004)

West Nile virus:Anterior horn cell involvement

Reduction of motor amplitudesPreserved sensory responsesScattered denervationsLeis et al./Glass et al. N Engl J Med2002Li et al. Ann Neurol 2003

Figure 2. Hospitalizations in the Northeast region of Brazil, indicatedby codes from the International Classification of Diseases, 10thRevision, January 2008 through February 2016. A) Congenitalmalformations of the nervous system (ICD-10; Q00-Q07) per 100,000live births; B) Guillain-Barré syndrome (ICD-10; G610) per 100,000residents; and C) encephalitis, myelitis and encephalomyelitis (ICD-10; G040-G049) per 100,000 Northeast region residents, comparedwith hospitalizations for these conditions in the rest of the country.Source: Hospital Information System (SIH);

Christovam Barcellos,LIS/ICICT/Fiocruz, Av. Brasil4365, Manguinhos, Rio deJaneiro, RJ 21045-900, BrazilEID Novermber 2016

From April 1, 2015, to March 31,2016, a total of 164,237 confirmedand suspected cases of ZIKV diseaseand 1474 cases of the Guillain– Barrésyndrome were reported in Bahia,Brazil; Colombia; the DominicanRepublic; El Salvador; Honduras;Suriname; and Venezuela.NEJM August 31, 2016

Combinatorial glycoarray Methods. MolBiol 2012;808:413– 423.

Anti-ganglioside antibody

• ผูป่้วยเหลา่นีในขณะทีอาการเร ิมตน้และจะลกุลามรนุแรงขึนเร ือยๆ การรกัษาดว้ยการเปลียนถา่ยนําเหลอืง (Plasmaexchange) หรอืการใหส้ารสกดันําเหลอืง(Intravenous immune globulin) ถอืเป็นการรกัษาชว่ยชวีติ หรอืป้องกนัการลกุลามของโรค และชว่ยทาํให ้หายเรว็ขึนกลบัมาเดนิเหนิไดเ้รว็ขึน

• อย่างไรก็ตาม การรกัษาดงักลา่วมรีาคาแพง อย่างนอ้ยประมาณ 240,000 บาท และตอ้งใหก้ารรกัษาภายใน 10-14 วนั โดยทีตอ้งแน่ใจวา่เป็นโรค GBS

classic GBS จากภาวะภูมคิุม้กนัแปรปรวน

ZIKA GBS: autoimmune vs directeffect of infection•

• Why not autoimmune?• anti-ganglioside profile: atypical• pattern similar to other flaviruses such as WNV/Dengue Lower motor

neuron syndrome• Pattern similar to paralytic rabies• True infection with inflammatory response NOT as infectious trigger

• Why recover?With IVIG:possible as in WNV neuro-invasive cases in the US; some improved withIVIG possibly containing antiviral effector from donor poolSpontaneous:infection in spinal cord motor neuron:

- Anterior horn cell-inherent property- viral clearance mechanisms may be more superior

THERAPEUTICS

• GENETIC MANIPULATIONIn rabies: triGAS virus, alteration of transcription gradient, Crispr/cas3,epigeneticss

• INHIBITION OF TRANSCRIPTION/REPLICATION• LIPID ENVELOPE BREAKAGE

Virojanapirom et alArch Virol 2012

NONCODINGMATTERS

Arch Virol (2016)

-siRNA miRNA-Virus vaccine

triGASProf.Deitzschold

Adv virus Res 2011Antiviral Res 2009

การพฒันาวธิ ีหรอืดดัแปลงวธิใีนการรกัษา ป้องกนั

ยา T705 universal RNA polymerase inhibitor ทดลองใชร้กัษาหนูทีมไีวรสัพษิ สนัุขบา้ในสมองไดส้าํเรจ็

T705 as a potential therapeutic for rabies.J Infect Dis (2016)

*T705 เป็นยาทีใชใ้นการรกัษาโรคไขห้วดัใหญร่นุแรงทีไดร้บัการยอมรบัใหใ้ชใ้นคน (ญีปุ่ น)

Madelain et al,Clin Pharmacokinet 2016

J Infect dis 2016 May