Mumps: An Emergency Medicine-Focused Update

Structures of the mumps virus polymerase complex via cryo-electron microscopy

The viral polymerase complex, comprising the large protein (L) and phosphoprotein (P), is crucial for both genome replication and transcription in non-segmented negative-strand RNA viruses (nsNSVs), while structures corresponding to these activities remain obscure. Here, we resolved two L-P complex conformations from the mumps virus (MuV), a typical member of nsNSVs, via cryogenic-electron microscopy. One conformation presents all five domains of L forming a continuous RNA tunnel to the methyltransferase domain (MTase), preferably as a transcription state. The other conformation has the appendage averaged out, which is inaccessible to MTase. In both conformations, parallel P tetramers are revealed around MuV L, which, together with structures of other nsNSVs, demonstrates the diverse origins of the L-binding X domain of P. Our study links varying structures of nsNSV polymerase complexes with genome replication and transcription and points to a sliding model for polymerase complexes to advance along the RNA templates.

Mutation of Phenylalanine 23 of Newcastle Disease Virus Matrix Protein Inhibits Virus Release by Disrupting the Interaction between the FPIV L-Domain and Charged Multivesicular Body Protein 4B

The matrix (M) protein FPIV L-domain is conserved among multiple paramyxoviruses; however, its function and the associated mechanism remain unclear. In this study, the paramyxovirus Newcastle disease virus (NDV) was employed to study the FPIV L-domain. Two recombinant NDV strains, each carrying a single amino acid mutation at the Phe (F23) or Pro (P24) site of ²³FPIV/I²⁶ L-domain, were rescued. Growth defects were observed in only the recombinant SG10-F23A (rSG10-F23A) strain. Subsequent studies focused on rSG10-F23A revealed that the virulence, pathogenicity, and replication ability of this strain were all weaker than those of wild-type strain rSG10 and that a budding deficiency contributed to those weaknesses. To uncover the molecular mechanism underlying the rSG10-F23A budding deficiency, the bridging proteins between the FPIV L-domain and endosomal sorting complex required for transported (ESCRT) machinery were explored. Among 17 candidate proteins, only the charged multivesicular body protein 4 (CHMP4) paralogues were found to interact more strongly with the NDV wild-type M protein (M-WT) than with the mutated M protein (M-F23A). Overexpression of M-WT, but not of M-F23A, changed the CHMP4 subcellular location to the NDV budding site. Furthermore, a knockdown of CHMP4B, the most abundant CHMP4 protein, inhibited the release of rSG10 but not that of rSG10-F23A. From these findings, we can reasonably infer that the F23A mutation of the FPIV L-domain blocks the interaction between the NDV M protein and CHMP4B and that this contributes to the budding deficiency and consequent growth defects of rSG10-F23A. This work lays the foundation for further study of the FPIV L-domain in NDV and other paramyxoviruses. IMPORTANCE Multiple viruses utilize a conserved motif, termed the L-domain, to act as a cellular adaptor for recruiting host ESCRT machinery to their budding site. Despite the FPIV type L-domain having been identified in some paramyxoviruses 2 decades ago, its function in virus life cycles and its method of recruiting the ESCRT machinery are poorly understood. In this study, a single amino acid mutation at the F23 site of the ²³FPIV²⁶ L-domain was found to block NDV budding at the late stage. Furthermore, CHMP4B, a core component of the ESCRT-III complex, was identified as a main factor that links the FPIV L-domain and ESCRT machinery together. These results extend previous understanding of the FPIV L-domain and, therefore, not only provide a new approach for attenuating NDV and other paramyxoviruses but also lay the foundation for further study of the FPIV L-domain.

Response to Measles, Mumps and Rubella (MMR) Vaccine in Transfusion-Dependent Patients

Measles, mumps and rubella (MMR) still determine significant morbidity and mortality, although a highly effective vaccine is available. Postponing the MMR vaccination until 6 months after the last red blood cell (RBC) transfusion is recommended, but this delay is incompatible with chronic transfusions. The present study aimed at investigating the impact of blood transfusions on the immunogenicity of the MMR vaccine. In this observational study, a group of 45 transfusion- dependent (TD) patients was compared to 24 non-transfusion-dependent (NTD) patients. Immunity to measles was achieved in 35 (78%) TD and 21 (88%) NTD subjects (p = 0.7), to mumps in 36 (80%) TD and 21 (88%) NTD subjects (p = 0.99), and to rubella in 40 (89%) TD and 23 (96%) NTD subjects (p = 0.99). No significant difference was observed in the number of non-immune individuals or those with doubtful protection between the two groups (p > 0.05). The mean IgG value, assayed in 50 pre-storage leukoreduced RBC units, was 0.075 ± 0.064 mg/mL, ten times lower than the level assumed in blood units and considered detrimental to the immune response in TD patients. This work shows a favorable response to MMR vaccination in TD and NTDT patients and paves the way for further larger studies assessing the impact of chronic transfusions on vaccine response.

Current Status of Mumps Virus Infection: Epidemiology, Pathogenesis, and Vaccine

Mumps is an important childhood infectious disease caused by mumps virus (MuV). We reviewed the epidemiology, pathogenesis, and vaccine development of mumps. Previous studies were identified using the key words “mumps” and “epidemiology”, “pathogenesis” or “vaccine” in MEDLINE, PubMed, Embase, Web of Science, and Google Scholar. We excluded the articles that were not published in the English language, manuscripts without abstracts, and opinion articles from the review. The number of cases caused by MuV decreased steeply after the introduction of the mumps vaccine worldwide. In recent years, a global resurgence of mumps cases in developed countries and cases of aseptic meningitis caused by some mumps vaccine strains have renewed the importance of MuV infection worldwide. The performance of mumps vaccination has become an important issue for controlling mumps infections. Vaccine development and routine vaccination are still effective measures to globally reduce the incidence of mumps infections. During outbreaks, a third of MMR vaccine is recommended for groups of persons determined by public authorities.

Unbiased Metagenomic Sequencing for Pediatric Meningitis in Bangladesh Reveals Neuroinvasive Chikungunya Virus Outbreak and Other Unrealized Pathogens

Globally, there are an estimated 10.6 million cases of meningitis and 288,000 deaths every year, with the vast majority occurring in low- and middle-income countries. In addition, many survivors suffer from long-term neurological sequelae. Most laboratories assay only for common bacterial etiologies using culture and directed PCR, and the majority of meningitis cases lack microbiological diagnoses, impeding institution of evidence-based treatment and prevention strategies. We report here the results of a validation and application study of using unbiased metagenomic sequencing to determine etiologies of idiopathic (of unknown cause) cases. This included CSF from patients with known neurologic infections, with idiopathic meningitis, and without infection admitted in the largest children’s hospital of Bangladesh and environmental samples. Using mNGS and machine learning, we identified and confirmed an etiology (viral or bacterial) in 40% of idiopathic cases. We detected three instances of Chikungunya virus (CHIKV) that were >99% identical to each other and to a strain previously recognized to cause systemic illness only in 2017. CHIKV qPCR of all remaining stored 472 CSF samples from children who presented with idiopathic meningitis in 2017 at the same hospital uncovered an unrecognized CHIKV meningitis outbreak. CSF mNGS can complement conventional diagnostic methods to identify etiologies of meningitis, and the improved patient- and population-level data can inform better policy decisions.

The burden of meningitis in low-and-middle-income countries remains significant, but the infectious causes remain largely unknown, impeding institution of evidence-based treatment and prevention decisions. We conducted a validation and application study of unbiased metagenomic next-generation sequencing (mNGS) to elucidate etiologies of meningitis in Bangladesh. This RNA mNGS study was performed on cerebrospinal fluid (CSF) specimens from patients admitted in the largest pediatric hospital, a World Health Organization sentinel site, with known neurologic infections (n = 36), with idiopathic meningitis (n = 25), and with no infection (n = 30), and six environmental samples, collected between 2012 and 2018. We used the IDseq bioinformatics pipeline and machine learning to identify potentially pathogenic microbes, which we then confirmed orthogonally and followed up through phone/home visits. In samples with known etiology and without infections, there was 83% concordance between mNGS and conventional testing. In idiopathic cases, mNGS identified a potential bacterial or viral etiology in 40%. There were three instances of neuroinvasive Chikungunya virus (CHIKV), whose genomes were >99% identical to each other and to a Bangladeshi strain only previously recognized to cause febrile illness in 2017. CHIKV-specific qPCR of all remaining stored CSF samples from children who presented with idiopathic meningitis in 2017 (n = 472) revealed 17 additional CHIKV meningitis cases, exposing an unrecognized meningitis outbreak. Orthogonal molecular confirmation, case-based clinical data, and patient follow-up substantiated the findings. Case-control CSF mNGS surveys can complement conventional diagnostic methods to identify etiologies of meningitis, conduct surveillance, and predict outbreaks. The improved patient- and population-level data can inform evidence-based policy decisions.

Recognizing Measles, Mumps, and Rubella in the Emergency Department

Measles, mumps, and rubella have impacted millions of American lives over the last 100 years. During the last century, researchers have identified viral diseases, developed a combination vaccine, and have continued ongoing research when outbreaks have occurred. Despite the high incidence of vaccinated individuals, these highly communicable diseases continue to flourish within clusters of outbreaks throughout the United States. Emergency medicine providers play a key role in early recognition and diagnosis of the disease. The proper management and reporting reflect the emphasis on prevention of widespread outbreaks.

Application of a mixture model to assess the effect of measles-mumps-rubella vaccine on the mumps epidemic in children from kindergarten to early school age in Jiangsu Province, China

A single dose of the measles-mumps-rubella (MMR) vaccine has been applied in routine immunizations for children in China; however, the Immunoglobulin G (IgG) antibody level of mumps in children from kindergarten to early school age with MMR vaccine immunization history has not been elucidated. This study aimed to describe the immunity profile of children from kindergarten to early school age to identify the susceptible population. In Jiangsu Province, a cross-sectional survey of 4- to 8-year-old children who were vaccinated with at least one dose of MMR vaccine was conducted. IgG antibody results were analyzed by employing both the Enzyme-Linked Immunosorbent Assay (ELISA) cutoff values and the mixture model. A total of 7436 eligible subjects were enrolled: 3386 subjects were in kindergarten, and 4450 were in primary school. The overall seroprevalence (75.4%, 95% CI: 74.4%-76.4%) and Geometric mean concentration (GMC, 201.4U/ml, 95% CI: 194.1-209.4) of mumps antibodies in 2016 were low. The seroprevalence of children in kindergarten (78.1%, 95% CI: 76.6%-79.4%) was significantly higher than that of children in primary school (73.2%, 95% CI: 71.2%-74.6%). The GMC was negatively correlated with the time of inoculation (F = 32.17, P = 0.002). The mixture model enables a more comprehensive understanding of serological results by investigating four levels of antibody response, suggesting that there is a small fraction of the population with waning immunity. Children in kindergarten and primary school whom had received one dose of MMR vaccine were at a higher risk of mumps infection, particularly the 7-year-old group in the central region. Therefore, the single-dose MMR vaccine schedule has a limited impact on mumps control and prevention, and a two-dose MMR vaccine schedule should be introduced.