Emerging Infectious Diseases: Clinical Case Studies

Slovenia

Preface

Önder Ergönül, Füsun Can, Larry Madoff and Murat Akova

The concept of emerging infections was introduced to the scientific literature about 20 years ago and has been reflected in daily language at an increasing rate. Though there is no standard and short definition, emerging infections could be defined as:

1. A recognized infection spreading to new areas, species or populations.

2. The discovery that a known disease is caused by an infectious agent.

3. A previously unrecognized infection appearing in areas where the habitat is changing (e.g. deforestation).

4. A new infection resulting from mutations in a known microorganism.

5. An old infection re-emerging because it has become resistant to treatment, as a result of a breakdown in public health initiatives or due to changes in the host population.

Emerging infections are usually a threat to public health that requires a collaborative effort to combat. This collaborative action includes basic scientists, clinicians from medical and veterinary fields, public health experts and media forces.

Clinicians recognize a new disease entity but this might only be a first step for starting an enormous scientific effort in microbiology, epidemiology and other related fields. This effort could open new windows, may result in revolutionary discoveries that could inform clinical practice. By keeping the order of this cycle, we present you emerging infections based on clinical case studies. We hope that the book will be useful to fill the gaps in this cycle of basic sciences, public health and clinical practice.

Chapter 1

Severe Fever with Thrombocytopenia Syndrome Associated with a Novel Bunyavirus

Keita Matsuno, Heinz Feldmann and Hideki Ebihara,    Laboratory of Virology, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rocky Mountain Laboratories, Hamilton, MT, USA

Severe fever with thrombocytopenia syndrome virus (SFTSV) is a newly recognized pathogen and the first highly pathogenic tick-borne virus reported in the genus Phlebovirus, family Bunyaviridae. Except for some basic knowledge on viral biology and epidemiology as well as the establishment of diagnostics and the description of the clinical disease syndrome, little is known about this emerging pathogen. Currently, there are neither therapeutic approaches nor vaccines available for the treatment and prophylaxis of SFTSV infections. In the absence of more thorough ecology and epidemiology, prevention is based on education targeting towards avoiding exposure through ticks and blood and secretions/excretions of patients. Urgently needed are further studies on the pathogenesis and host responses to infection in order to define targets for therapeutic intervention and strategies for vaccination.

Keywords

severe fever with thrombocytopenia syndrome virus; SFTSV; phlebovirus; tick-borne disease; epidemiology; pathogenesis; diagnosis; disease control

Case Presentation

A 40-year-old female farmer, who lived in a rural, hilly area outside Chizhou city, in Anhui Province, China, was admitted to a hospital in Shanghai (400 km/78 miles from Chizhou) in the middle of May 2012. She had no other known underlying medical conditions but a history of schistosomiasis in 2008. There was no history of previous drug or food allergies or blood transfusions.

On May 16, 2012, the patient had sudden onset of fever with a peak temperature of 40°C accompanied by muscle pain. She was examined and subsequently admitted to a local hospital, where treatment with intravenous antibiotics was started. Following no improvement, the patient was transferred on May 19 to a hospital in Chizhou, where treatment was changed to aztreonam and ribavirin. With no changes in her clinical status and fever remaining high, the patient was transferred to a hospital in Shanghai on May 21, where she presented with continuing fever, chills, body aches, and diarrhea (five to six times a day). The suspected diagnosis of SFTS was made and the patient was admitted to the intensive care unit (ICU). Her treatment was continued with cefotiam, levodropropizine, and intensive care support. The condition of the patient deteriorated and she became apathetic on May 22. Subsequent treatment included vancomycin and platelet substitution therapy, but her condition further deteriorated. The following day she presented with a stiff neck, accompanied by enlarged lymph nodes in the neck, axillar and mediastinum, and abnormal brain waves on electroencephalogram. On May 25, the patient was in critical condition with shortness of breath, hypotension (88/50 mmHg), oliguria, severe acidosis, an abnormal flow index, but no skin bleeding or blood stasis. Thereafter, she was treated with prednisone, platelet and plasma transfusions, and hemodialysis before she died on the same day (May 25th) with multi-organ failure including kidney and lung, disseminated intravascular coagulation, and shock.

: 5.5 mmol/L; Beecf: −23.4 mmol/L; SBC: 8.5; Beb: −21.1 mmol/L; SO2: 97%).

SFTSV infection was confirmed by quantitative real-time reverse transcriptase polymerase chain reaction (RT-PCR) following death. The patient had no known exposure to tick bites, but contact history with birds, rodents, and other wild animals was reported. Her activities during the past 2 weeks prior to disease onset involved fieldwork collecting cotton, rice, and tea. She had no known exposure to an SFTSV case or a person with similar illness and no similar cases were found in and around her residence. No secondary SFTSV cases were found among her contacts (adapted from reference¹).

1 Why this Case was Significantly Important as an Emerging Infection

Severe fever with thrombocytopenia syndrome (SFTS) was discovered in 2009 in Central China as a newly emerged clinical syndrome with clinical and epidemiological similarity to human anaplasmosis.² The causative agent of SFTS was identified as a novel phlebovirus, SFTS virus (SFTSV). Currently, SFTS cases have been reported from China, Japan, and South Korea with case fatality rates ranging from 10 to 30%. A milder but similar disease has been reported from the United States caused by Heartland virus, which is a recently related discovered phlebovirus.³

2 What is the Causative Agent?

SFTSV is tentatively classified as a novel member of the genus Phlebovirus, family Bunyaviridae. As other bunyaviruses, SFTSV is an enveloped spherical-shaped particle, about 80–100 nm in diameter, carrying a genome of three segmented negative-stranded RNA molecules. The large RNA (L) segment is 6368 nucleosides in length and encodes for the RNA-dependent RNA polymerase (RdRp), which is responsible for viral RNA transcription and replication. The medium RNA (M) segment is 3378 nucleosides in length and encodes a membrane glycoprotein precursor, which is cleaved into the two mature membrane glycoproteins (Gn and Gc). Finally, the small RNA (S) segment is 1744 nucleosides in length encoding the nucleocapsid protein (N) and a non-structural protein (NSs) in an ambisense orientation (Figure 1.1).² Based on phylogenetic analysis of SFTSV isolates/sequences, the Chinese isolates currently form five distinct genetic lineages.⁴ The Japanese isolates mostly belong to lineage D, whereas the Korean isolate clusters belong to lineage A.

Figure 1.1 Schematic diagram of a SFTSV particle.

SFTSV, a bunyavirus, presents as pleomorphic enveloped particles. The genome is tri-segmented, negative-sense, single-stranded RNA encoding for the nucleoprotein (N) and non-structural protein (NSs) (small (S) segment), the two glycoproteins (Gn and Gc) (medium (M) segment), and the RNA-dependent RNA polymerase (RdRp) (large (L) segment).

3 What is the Frequency of the Disease in Endemic Regions?

Since the discovery in 2009,² SFTS cases have been reported from China,¹,⁵–⁷ Japan,⁸ and South Korea⁹ (Figure 1.2). As of September 2013, China has reported more than 600 laboratory confirmed cases, of which approximately 10% were fatal.⁷ Most of them have been identified in rural, hilly areas of Central and Southern China (i.e., Henan, Hubei, Anhui, Shandong, Jiangsu, Zhejiang, Liaoning, Yunnan, Guangxi, Jiangxi, and Shaanxi provinces). The oldest confirmed cases were among a family cluster reported in September 2006 from Anhui Province.¹⁰ Incidence rates of SFTS in Hubei and Shandong Province were reported to be 0.33/10⁴ and 5/10⁵, respectively.¹¹ SFTS cases are largely found among farmers and people living in rural, hilly areas with a higher risk for elderly females.¹² The antibody prevalence rate in healthy individuals from endemic areas ranges from 0.27 to 3.8%.¹³,¹⁴ Antibody prevalence in endemic areas is high in domestic animals such as sheep, cattle, chickens, and dogs (up to 50% and higher).¹⁵

Figure 1.2 Endemic areas of SFTS.

The map shows the endemic areas of SFTS in black. PRC=People’s Republic of China; S. Korea=South Korea.

As of September 2013, 39 confirmed SFTSV infections and 18 deaths have been reported from Japan, mainly from the southwestern provinces of Hyogo, Shimane, Okayama, Hiroshima, Yamaguchi, Tokushima, Ehime, Saga, Nagasaki, Miyazaki, and Kagoshima. The oldest confirmed case was identified in November 2005 from Nagasaki Province.⁸ Although no reports on human seroprevalence in Japan have been reported, specific antibodies against SFTSV were found in Japanese wildlife (Shika deer and wild boar) and hunting dogs.¹⁶

In South Korea, 15 deaths among 317 suspected SFTS cases have been reported, of which only 27 cases have been laboratory confirmed (reported by the Korean CDC). The distribution of confirmed infections is nationwide with cases identified in 10 provinces: Gangwon, Gyeongsangbuk, Daegu, Ulsan, Busan, Gyeongsangnam, Jeollanam, Jeju, Chungcheongnam, and Incheon provinces.¹⁷

4 How is the Virus Transmitted?

Many (but not all) SFTS cases reported exposure to or bites of ticks during the incubation period, and case numbers in China and Japan peak during tick season.⁸,¹⁴ Thus, exposure to or bite of an infected tick is thought to be the primary transmission route of SFTSV. Ticks of the species Haemaphysalis longicornis are widely distributed in China, Japan, and South Korea and have been found to carry SFTSV (viral RNA positive rate in China: 2.1–5.4%).²,⁹,¹⁸,¹⁹ SFTSV RNA has also been detected in ticks of the species Rhipicephalus microplus (viral RNA positive rate in China: 0.6%),¹⁹ H. kitaokai, H. megaspinosa, H. flava, and Amblyomma testudinarium,¹⁶ which, therefore, could serve as additional vectors for transmission. There is no evidence for mosquitoes as potential vectors for SFTSV.²

Several small clusters of direct human-to-human transmission have been reported from China.⁶,¹⁰,²⁰,²¹ Each of these reported SFTS clusters began with a fatal index case but there have been no fatalities among secondary cases despite varying disease severity. Direct contact with blood of the fatal index case is the likely source and route of transmission. Higher viral loads in fatal compared to non-fatal cases have been reported,²²–²⁴ supporting this transmission route. High prevalence of antibodies has been reported in certain domestic animal species indicating that contact with fresh meet, blood, and organs, particular during slaughter, might be another possible route of transmission.

5 What are the Clinical Manifestations of the Disease?

The incubation period following tick exposure or unprotected contact with patients’ blood or secretions/excretions is approximately 15 days on average (5–20 days).²⁵ SFTS disease progression can be divided into three stages (Figure 1.3): the fever stage (days 1–7 post onset of symptoms), the multi-organ dysfunction (MOD) stage (days 7–13 post onset of symptoms), and the convalescent stage (following approximately day 13 post onset of symptoms).²,⁷,¹²,²² SFTS patients commonly present with fever, fatigue, nausea, vomiting, diarrhea, lymphadenopathy, and headache (Table 1.1). Additional symptoms such as anorexia, abdominal pain, malaise, myalgia, arthralgia, cough, and chills have been described together with hemorrhagic (e.g., conjunctival congestion, gingival bleeding, and/or melena) and central nervous system (e.g., confusion, apathy, slurred speech, dizziness, lethargy, convulsion, and/or coma) manifestations.

Figure 1.3 SFTS disease progression.

The graph shows the SFTS disease progression, which can be separated into three stages: the fever stage, multi-organ dysfunction (MOD) stage, and convalescent stage.

Table 1.1

Clinical Manifestations of SFTS Cases

aTotal number of cases were derived from four reports.²,⁵,²²,²⁶

The fever stage is characterized by a rather non-specific prodrome including fever (temperature >38°C), headache, myalgia, arthralgia, dizziness, and malaise, which may persist for a week. During this stage patients commonly already display thrombocytopenia, leukocytopenia, and viremia (10⁵–10⁶ copies/mL). The MOD stage is characterized by marked thrombocytopenia, marked leukocytopenia, elevated liver enzymes, mucosal hemorrhages, hemorrhagic rash, disseminated intravascular coagulopathy, and central nervous system manifestations such as confusion. Elevated levels of ALT, AST, LDH, CK, and CK-MB can already be noticed during the late phase of the fever stage, but are manifest during the MOD stage. In fatal cases, viremia increases by up to 10¹⁰ copies/mL (average 10⁸ copies/mL) and serum levels of AST (>400 U/L), LDH (>800 U/L), CK (>1000 U/L), and CK-MB (>50 U/L) dramatically increase indicating multi-organ failure.²²–²⁴ The convalescent stage can last up to 30 days and more and is characterized by decreasing levels of viremia, diminishing clinical symptoms and normalization of clinical laboratory parameters.⁷,²³

6 What are the Mechanisms of Pathogenesis?

Age and sex have been associated with disease outcome of SFTS and elderly females seem to have a higher risk for severe/fatal disease,¹² even though social and/or behavioral factors cannot be excluded as explanations for this finding.

Important factors in the pathogenesis of SFTS likely include high viral load, inflammatory responses similar to a systemic inflammatory response syndrome (SIRS), coagulation abnormalities, and multi-organ dysfunction. Uncontrolled upregulation of several cytokines (e.g., IL-1RA, IL-6, IL-10, G-CSF, IP-10, and MCP-1) appears to correlate with severity of disease suggesting that SIRS is a significant factor in SFTS pathogenesis.²³,²⁴ Elevated serum levels of ALT, AST, LDH, CK, and CK-MB are commonly observed,⁷ indicating pathological lesions and potential failure of liver and kidney. Other common clinical abnormalities are thrombocytopenia and prolonged APTT indicative of coagulation disorders including disseminated intravascular coagulopathy (DIC) resulting in hemorrhagic manifestations.²²–²⁵,²⁷

As of today, experimental SFTSV infection and disease progression have been described only in rodents. Adult mice, rats, and Syrian hamsters are susceptible to SFTSV infection, but do not develop signs of severe illness.²⁸–³⁰ Following intracerebral inoculation of SFTSV, newborn mice and rats develop severe disease, which appears uniformly lethal.²⁸,³⁰ Adult mice (C57BL/6) are susceptible to multiple routes of infection with SFTSV, resulting in a mild, self-limited disease that recapitulates the hematological manifestations of SFTS. The infection is characterized by an acute viremia accompanied by virus replication in several organs (i.e., liver, kidney, and spleen), transient thrombocytopenia, leukocytopenia, and elevated levels of AST. Following decreased viral loads, increases in BUN and ALT are observed in association with transient liver necrosis and impaired renal function. This is accompanied by an increase in SFTSV-specific cellular and humoral immune responses. Knockout of interferon α/β receptor or inhibition of mouse adaptive immune responses results in more severe clinical signs with weight loss and case fatality rates of up to 100%²⁹,³⁰ indicating that impairment of the immune system is associated with severe clinical disease as has been suggested for severe human disease.

7 How do you Diagnose the Infection?

SFTS should be considered in patients with a syndrome characterized by acute fever (temperatures ≥38°C), thrombocytopenia (PLT <100 K/L) and leukopenia (WBC <2.5 K/L), in particular in association with a history of tick exposure/bite in an endemic area. Elevated serum levels of liver and kidney enzymes and gastrointestinal symptoms may serve as supportive diagnostic parameters. For laboratory diagnosis (virology), whole blood and serum samples should be collected.

Molecular assays targeting viral RNA are the first choice for diagnosis during the acute stage of SFTSV infections. For this, multiple platforms have been developed and evaluated including one-step real-time RT-PCR,³¹–³³ reverse transcription loop-mediated isothermal amplification assay (RT-LAMP),³⁴,³⁵ and RT-cross priming amplification (RT-CPA).³⁶ In case this is the only technology applied, molecular testing might be confirmed by an assay detecting a second target or the same target on two consecutive samples. Serological assays largely based on enzyme-linked immunosorbent assay (ELISA) technology for the detection of SFTSV-specific IgM and IgG antibodies have been developed and should be considered for convalescent stage samples and as confirmatory assays for acute diagnosis.³⁷ Specific IgM antibodies are usually detectable by 4–5 days after infection and remain present for up to 4–5 months with a peak between 2 and 3 weeks after infection. Plaque reduction neutralization test (PRNT) utilizing convalescent stage specimens and virus isolation utilizing acute stage specimens serve as confirmatory assays, but need to be performed under high biocontainment conditions not necessarily available at diagnostic centers.

China uses the following criteria for the laboratory diagnosis of SFTS cases: (1) viral RNA positive in serum or whole blood specimens, (2) virus-specific IgM positive during acute phase disease, (3) a four-fold increase or conversion of virus-specific IgG in paired sera (acute and convalescent phase specimens), or (4) isolation of virus from patient samples.⁷

8 How do you Differentiate the Infection from Similar Clinical Manifestations?

H. longicornis, the main potential vector for SFTSV, is widely distributed in East Asia and Australia.³⁸ In this area, SFTS needs to be considered for the diagnosis of an acute febrile disease. Although thrombocytopenia and lymphocytopenia are the most common findings associated with SFTSV infections,²,⁵ those hematological parameters are also seen with other frequent or rare diseases. The number one differential diagnosis is human anaplasmosis, but other arboviral or zoonotic infectious diseases should be considered as well, such as Crimean-Congo hemorrhagic fever, dengue fever, hemorrhagic fever with renal syndrome, tick-borne encephalitis, ehrlichiosis, Lyme disease, Tsutsugamushi fever (Scrub typhus), rickettsiosis (Rickettsia heilongjiangensis), leptospirosis, Q fever, bacterial sepsis, trypanosomiasis, acute viral hepatitis, influenza, and bacterial meningitis. Therefore, rapid and sensitive laboratory diagnosis is absolutely critical (see above). For differential diagnosis, multiplex real-time RT-PCR assay would be beneficial.³⁹

9 What are the Therapeutic Approaches?

Currently, treatment largely consists of supportive care as there is no antiviral/therapeutic approach established. The use of the antiviral ribavirin has been reported,¹,¹⁰,²¹,²²,²⁷,⁴⁰ but a significant therapeutic effect is not obvious. The use of Suramin, an anti-trypanosomal drug, has been suggested,⁴¹ but human efficacy data are missing.

Supportive care includes fluid and electrolyte substitution and transfusions of fresh frozen plasma and platelets, but the effects are limited with no convincing improvement being documented. Antibiotic coverage should be initiated to prevent or combat secondary bacterial infections, especially the use of tetracycline, and new quinolones are indicated in case of tick exposure/bite to prevent possible tick-borne bacterial (co-)infections (discussed above). These antibiotics might also be beneficial due to their ability to downregulate host inflammatory