Gastroenteritis associated with enteric type adenovirus in hospitalized infants

A Single Amino Acid Switch in the Adenoviral DNA Binding Protein Abrogates Replication Center Formation and Productive Viral Infection

Adenoviruses are very efficient high-capacity vaccine vectors and are common gene delivery systems. Despite their extensive use in preclinical models and clinical trials over the past decades, adenoviral vectors still require optimization. To achieve that, more thorough characterizations of adenoviral genes and gene products, as well as pathogen-host interactions, are indispensable. The adenoviral DNA binding protein (DBP) is a key regulatory protein involved in various cellular and viral processes. Here, we show that single amino acid exchange mutations in human adenovirus C5 (HAdV-C5) DBP strongly influence adenoviral replication by altering interaction with the cellular ubiquitination machinery. Specifically, phenotypic analyses of DBP mutants demonstrate that single amino acid substitutions can regulate interactions with the cellular USP7 deubiquitinase, impede viral DNA synthesis, and completely abolish viral late protein expression and progeny production. Importantly, cells infected with the DBP mutant UBM5 consistently lack DBP-positive replication centers (RCs), which are usually formed during the transition from the early to the late phase of infection. Our findings demonstrate that DBP regulates a key step at the onset of the late phase of infection and that this activity is unambiguously linked to the formation and integrity of viral RCs. These data provide the experimental basis for future work that targets DBP and its interference with the formation of viral RCs during productive infection. Consequently, this work will have immediate impact on DNA virus and adenovirus research in general and, potentially, also on safety optimization of existing and development of novel adenoviral vectors and anti-adenoviral compounds.

PHYLOGENETIC ANALYSIS OF THE GENOME OF AN ENTERITIS-ASSOCIATED BOTTLENOSE DOLPHIN MASTADENOVIRUS SUPPORTS A CLADE INFECTING THE CETARTIODACTYLA

:  Adenoviruses are nonenveloped, double-stranded DNA viruses, known to infect members of all tetrapod classes, with a similarity between phylogenies of hosts and viruses observed. We characterized bottlenose dolphin adenovirus 2 (BdAdV-2) found in a bottlenose dolphin ( Tursiops truncatus) with enteritis. Virions were seen by negative staining electron microscopy of feces. Initial sequences obtained using conserved PCR primers were expanded using primer walking techniques, and the complete coding sequence was obtained. Phylogenetic analyses were consistent with coevolution of this virus and its bottlenose dolphin host, placing BdAdV-2 into a monophyletic group with other mastadenoviruses of Cetartiodactyla. When considering the low guanine/cytosine (G/C) content of BdAdV-2 with the phylogenetic data, this virus may represent a host-jumping event from another member of Cetartiodactyla. Analysis of partial polymerase indicated that bottlenose dolphin adenovirus 1, previously identified in Spain, and BdAdV-2 are sister taxa with harbor porpoise adenovirus 1, forming a cetacean clade. Bottlenose dolphin adenovirus 2 includes a highly divergent fiber gene. Two genes homologous to the dUTPase superfamily are also present which could play a role in enabling viral replication in nondividing cells. We used sequence data to develop a probe hybridization quantitative PCR assay specific to BdAdV-2 with a limit of detection of 10 copies.

COINFECTION OF CALIFORNIA SEA LION ADENOVIRUS 1 AND A NOVEL POLYOMAVIRUS IN A HAWAIIAN MONK SEAL (NEOMONACHUS SCHAUINSLANDI)

The Hawaiian monk seal (Neomonachus schauinslandi) is an endangered species. Here, we present a clinical case of a 26-yr-old male Hawaiian monk seal (HMS) kept in an aquarium with a history of intermittent anorexia and evidence of renal disease. Histologic examination revealed eosinophilic intranuclear inclusions in the liver. Conventional nested PCR protocols were used to test for viruses, and it tested positive for adenovirus and polyomavirus, and negative for herpesvirus. The adenovirus partial polymerase gene is 100% homologous to that of California sea lion adenovirus 1 (CSLAdV-1). CSLAdV-1 causes viral hepatitis in CSL, and has recently been reported in different species of otariids in an aquarium in Japan ( Otaria flavescens and Arctocephalus pusillus ) and a sequence from Spain has been submitted in NCBI as Otaria flavescens adenovirus-1. The polyomavirus in this animal is a novel virus, and is the first polyomavirus discovered in Hawaiian monk seals. This new virus is designated Hawaiian monk seal polyomavirus (HMSPyV-1), and is 83% homologous to California sea lion Polyomavirus-1 (CSLPyV-1). This is the first report of viral coinfection in a HMS and clinical significance in this case remains unclear but may be associated with advanced age.

Phylogenomic characterization of California sea lion adenovirus-1

Significant adenoviral diversity has been found in humans, but in domestic and wild animals the number of identified viruses is lower. Here we present the complete genome of a recently discovered mastadenovirus, California sea lion adenovirus 1 (CSLAdV-1) isolated from California sea lions (Zalophus californianus), an important pathogen associated with hepatitis in pinnipeds. The genome of this virus has the typical mastadenoviral structure with some notable differences at the carboxy-terminal end, including a dUTPase that does not cluster with other mastadenoviral dUTPases, and a fiber that shows similarity to a trans-sialidase of Trypanosoma cruzi and choline-binding protein A (CbpA) of Streptococcus pneumoniae. The GC content is low (36%), and phylogenetic analyses placed the virus near the root of the clade infecting laurasiatherian hosts in the genus Mastadenovirus. These findings support the hypothesis that CSLAdV-1 in California sea lions represents a host jump from an unknown mammalian host in which it is endemic.

The gastrointestinal frontier: IgA and viruses

Viral gastroenteritis is one of the leading causes of diseases that kill ~2.2 million people worldwide each year. IgA is one of the major immune effector products present in the gastrointestinal tract yet its importance in protection against gastrointestinal viral infections has been difficult to prove. In part this has been due to a lack of small and large animal models in which pathogenesis of and immunity to gastrointestinal viral infections is similar to that in humans. Much of what we have learned about the role of IgA in the intestinal immune response has been obtained from experimental animal models of rotavirus infection. Rotavirus-specific intestinal IgA appears to be one of the principle effectors of long term protection against rotavirus infection. Thus, there has been a focus on understanding the immunological pathways through which this virus-specific IgA is induced during infection. In addition, the experimental animal models of rotavirus infection provide excellent systems in which new areas of research on viral-specific intestinal IgA including the long term maintenance of viral-specific IgA.

A ubiquitin-specific protease possesses a decisive role for adenovirus replication and oncogene-mediated transformation

Adenoviral replication depends on viral as well as cellular proteins. However, little is known about cellular proteins promoting adenoviral replication. In our screens to identify such proteins, we discovered a cellular component of the ubiquitin proteasome pathway interacting with the central regulator of adenoviral replication. Our binding assays mapped a specific interaction between the N-terminal domains of both viral E1B-55K and USP7, a deubiquitinating enzyme. RNA interference-mediated downregulation of USP7 severely reduced E1B-55K protein levels, but more importantly negatively affected adenoviral replication. We also succeeded in resynthesizing an inhibitor of USP7, which like the knockdown background reduced adenoviral replication. Further assays revealed that not only adenoviral growth, but also adenoviral oncogene-driven cellular transformation relies on the functions of USP7. Our data provide insights into an intricate mechanistic pathway usurped by an adenovirus to promote its replication and oncogenic functions, and at the same time open up possibilities for new antiviral strategies.

Adenoviral infections can result in severe outcomes leading to mortality especially in children undergoing immunosuppressive therapies. Unfortunately, no specific anti-adenoviral treatments are available to treat disseminated adenoviral infections. We have set out to identify host factors promoting adenoviral growth and could identify the cellular protein Ubiquitin-specific protease 7 (USP7) being central to adenoviral infection. Here we show that USP7 interacts with the viral protein E1B-55K, a central regulator of adenoviral replication and adenoviral oncogene-mediated cellular transformation. We demonstrate that USP7 ensures stability and/or proper expression levels of adenoviral proteins at early and late time points of infection. Consistent with this, small-molecule inhibitors of USP7 showed efficient reduction of capsid protein levels and viral progeny numbers. Thus, USP7 inhibition might be a useful treatment option in the context of disseminated adenoviral infections. Moreover, we were also able to show that adenoviral oncogene-mediated cellular transformation can be hampered by USP7 disruption. In summary, this study shows that two different adenoviral disease mechanisms can be inhibited by targeting one host cellular factor.

Clinical features of radiologically confirmed pneumonia due to adenovirus in children

BACKGROUND

Clinical features of radiologically confirmed pneumonia due to adenovirus in children have not been comprehensively evaluated.

OBJECTIVE

To describe the detailed clinical features of radiologically confirmed adenovirus-associated pneumonia in children.

STUDY DESIGN

Of 3298 children with a throat virus culture positive for adenovirus treated at a university-affiliated hospital, from January 2000 to June 2008, in northern Taiwan, 80 hospitalized children (2.4%) with radiologically confirmed pneumonia were identified. From four children with incomplete medical records, only demographics were included for analysis.

RESULTS

The median age was 2.97 years, ranging from 25 days to 14 years. Seventy-three patients (96%) had fever, with a median duration of 7 days. The three most common respiratory symptoms were cough (99%), rhinorrhea (82%) and dyspnea (42%). Gastrointestinal symptoms were recorded in 80% of the patients, and neurologic symptoms in four children. Leukocytosis (WBC≥15,000/μL) was noted in 19 (25%) patients. Only six patients (8%) had a normal serum C-reactive protein (CRP) value (<5 mg/L), while 48 patients (63%) had a CRP level >40 mg/L. Seventeen (21%) children required intensive care. Seventy-three patients (96%) recovered uneventfully. Sequelae were seen in two patients and death in 1. Of the 69 isolates with serotyping determination, seven serotypes were identified, with a predominant serotype (type 3 for 73%).

CONCLUSION

Less than 5% of the children with adenoviral infection had radiologically confirmed patch pneumonia. The manifestation of pneumonia caused by adenovirus was similar to that of bacterial pneumonia.

Enteric adenoviruses

The 41 serotypes of human adenoviruses are classified into six subgenera (A-F) with different tropisms. Enteric infections are caused in children by serotypes Ad40 and Ad41 of subgenus F. Serotypes Ad40 and Ad41 transform embryonic cells but cannot induce tumours in newborn hamsters. They differ from all other (established) human adenoviruses by being unable to replicate in conventional cell cultures. Ad40 and Ad41 grow in 293 cells (human embryonic kidney cells immortalized by transfection with the E1A, E1B regions of Ad5). In spite of the difficulty of isolating Ad40 and Ad41 they can be directly identified in stools by enzyme-linked immunosorbent assay (ELISA) and solid-phase immuno-electron microscopy. The amount of viral DNA in stool preparations is sufficient for identification by DNA restriction or dot-blot analysis. Adenoviruses have been associated with 7-17% of cases of diarrhoea in children. Ad40 and Ad41 cause diarrhoea throughout the year. Clinical features are watery stools, vomiting and moderately elevated temperature; respiratory symptoms are infrequent. The diarrhoea is protracted (mean 8.6 and 12.2 days for Ad40 and Ad41 respectively). Children with rotavirus diarrhoea vomited more frequently and had a higher temperature and diarrhoea of shorter duration. The impact of enteric adenoviruses in the aetiology of diarrhoea world-wide is not known but is accessible to investigation.

Chromatography paper strip sampling of enteric adenoviruses type 40 and 41 positive stool specimens

BACKGROUND

The enteric subgroup F adenoviruses type 40 (Ad40) and 41 (Ad41) are the second most important cause of acute infantile gastroenteritis after rotaviruses. Repeated community outbreaks have been associated with antigenic changes among the Ad40 and Ad41 strains due to host immune pressure. Therefore large field epidemiological surveys and studies on the genetic variations in different isolates of Ad40 and Ad41 are important for disease control programs, the design of efficient diagnostic kits and vaccines against subgroup F adenoviruses. A novel method using sodium dodecyl sulphate SDS/EDTA-pretreated chromatography paper strips was evaluated for the collection, storage and shipping of Ad40/41 contaminated stool samples.

RESULTS

This study shows that adenoviral DNA can be successfully detected in the filter strips by PCR after four months storage at -20 degrees C, 4 degrees C, room temperature (20-25 degrees C) and 37 degrees C. Furthermore no adenoviral infectivity was observed upon contact with the SDS/EDTA-pretreated strips.

CONCLUSIONS

Collecting, storing and transporting adenovirus type 40 and 41 positive stool samples on SDS/EDTA-pretreated chromatography filter strips is a convenient, biosafe and cost effective method for studying new genome variants and monitoring spread of enteric adenovirus strains during outbreaks.

Viral replication in the nasopharynx is associated with diarrhea in patients with severe acute respiratory syndrome

The role of severe acute respiratory syndrome (SARS) coronavirus as an enteric pathogen was investigated in a cohort of 142 patients with SARS who were treated with a standard treatment protocol. Data from daily hematological, biochemical, radiological, and microbiological investigations were prospectively collected, and the correlation of these findings with diarrhea was retrospectively analyzed. Sixty-nine patients (48.6%) developed diarrhea at a mean (± standard deviation [SD]) of 7.6 ± 2.6 days after the onset of symptoms. The diarrhea was most severe at a mean (±SD) of 8.8 ± 2.4 days after onset, with a maximum frequency of 24 episodes per day (median, 5 episodes; range, 3–24 episodes). A higher mean virus load in nasopharyngeal specimens obtained on day 10 after the onset of symptoms was significantly associated with the occurrence of diarrhea (3.1 log₁₀ vs. 1.8 log₁₀ copies/mL; P = .01) and mortality (6.2 vs. 1.7 log₁₀ copies/mL; P < .01). However, diarrhea was not associated with mortality. The lung and the gastrointestinal tract may react differently to SARS coronavirus infection. Additional investigation of the role of SARS coronavirus in the pathogenesis of diarrhea in patients with SARS should be conducted.

Chronic diarrhea and malabsorption

Diarrhea is one of the major causes of infant morbidity and mortality worldwide. Major advances in understanding the pathophysiology of chronic diarrhea and malabsorption have taken place during the past three decades. Analysis of absorptive and secretory functions of the intestine has provided some insight into the possible causes of diarrhea. This article summarizes some of the specific causes of malabsorptive diarrhea in infancy and childhood, with emphasis on pathophysiology and approaches to therapy.

Inhibition of human adenoviruses by 1-(2'-hydroxy-5'-methoxybenzylidene)amino-3-hydroxyguanidine tosylate

Antiviral activities of four Schiff bases of aminohydroxyguanidine, designated ML1, ML4, ATL14 and LK11, were tested against human adenovirus types 5 and 8 (Ad5 and Ad8) in A549 cells by plaque reduction and virus yield reduction methods. Compound (ML1 1-(2'-hydroxy-5'-methoxybenzylidene)amino-3-hydroxyguanidine tosylate gave the best therapeutic indices (TC50/IC50) of 27.2 and 17.8 for Ad5 and Ad8, respectively. Pretreatment of cells with ML1 did not affect the adsorption nor the penetration of virus. Ultrastructure studies showed that only the drug treated infected cells had unidentified irregular shaped electron dense structures that might be drug altered viral macromolecules that were not assembled into complete infectious virus particles. Since these compounds have metal chelating properties, their antiviral activity may involve the early IA (EIA) gene which encodes a viral protein of 289 amino acid which has a zinc finger moiety that is required for its transactivation activity.

Infectious diarrhoea. Viruses

Increased knowledge has been gained into the aetiology and pathogenesis of viral gastroenteritis during the past two decades. There are now thought to be four major subclassifications of gastroenteritis-causing viruses; these include rotavirus, enteric adenovirus, calicivirus, including Norwalk and Norwalk-like viruses, and astrovirus. The association of these agents with gastroenteritis has been made by their electron microscopic detection in stool and intestinal biopsy specimens from affected patients, the inability to detect the viruses after recovery from disease, and the subsequent development of immunoglobulin responses after infection; in some instances disease transmission was achieved in human volunteers. The association of these viral agents with gastroenteritis has facilitated the study of classification, epidemiology, immunity, diagnostic tests, methods of treatment and, most importantly, disease prevention strategies such as vaccine development for rotavirus. This chapter highlights the major features of these agents, with special attention being given to the pertinent molecular biology as well as current and future prospects for vaccination. Enteric viral infections of the gastrointestinal tract in patients with AIDS are also discussed.

Enteric adenovirus infection among infants with diarrhea in rural Bangladesh

A total of 4,409 stool specimens from infants less than 5 years of age seeking treatment for diarrhea in Matlab, Bangladesh, were tested for the presence of adenoviruses by using an enzyme immunoassay (EIA). EIA-positive stool samples were serotyped with monoclonal antibodies specific for adenovirus type 40 (Ad40) and Ad41 and group antigen, inoculated into Graham G293 cells, and retested by EIA. Of adenovirus-positive cultures, 125 (2.8%) specimens were confirmed as enteric adenoviruses (EAds), of which 51 (40.8%) were typed as Ad40 and 74 (59.2%) were typed as Ad41, and 12 of 4,409 (0.3%) were identified as nonenteric adenoviruses. A slight peak of incidence of EAd infection was observed in the cool, dry months, and an outbreak of Ad40 infections occurred in March 1988, when the detection rate of EAd reached 12.3%. Information on age, gender, and symptoms was available for 80 infants infected with adenovirus only. Age distribution was similar for types 40 and 41 and nonenteric adenovirus; the median ages were 11, 12, and 12 months, respectively. The ratio of males to females for the 80 infants varied according to serotype; Ad40 had the highest male/female ratio, 2.17. The symptoms experienced by the 80 children were similar for each adenovirus type. The most common clinical features of EAd infection were watery diarrhea (87.5%), more than eight loose bowel movements per day in the 24-h period prior to presentation (68.8%), with vomiting (80.0%), abdominal pain (76.3%), and low-grade fever (95.0%); these symptoms are significantly similar to symptoms of infants infected with group A rotavirus. EAd infection generally gave rise to mild to moderate dehydration, which is significantly similar to dehydration produced by infection with rotavirus.

Outbreaks of human enteric adenovirus types 40 and 41 in Houston day care centers

OBJECTIVE

Human enteric adenovirus (EAd) types 40 and 41 cause diarrhea in young children, but little is known about their association with outbreaks of diarrhea in the child care setting. This study evaluated EAd as a cause of outbreaks of diarrhea among infants and toddlers in day care centers.

DESIGN

Stool specimens were collected weekly regardless of symptoms during four periods from January 1986 to April 1991, from children 6 to 24 months of age enrolled in prospective studies of diarrhea in day care centers. All diarrhea stool specimens were tested for bacterial enteropathogens, rotavirus, and Giardia lamblia. A total of 131 outbreaks occurred during the study. No etiologic agent was identified in 77 outbreaks. Stool specimens from 75 of these 77 outbreaks and from another 21 outbreaks of diarrhea with a known cause were evaluated for EAd with a monoclonal antibody-based enzyme immunoassay.

RESULTS

A total of 4402 stool specimens from 613 children from these 96 outbreaks was tested for EAd. The virus was detected in specimens collected during 10 outbreaks, 3 of which occurred in 1986, 3 in 1988, 1 in 1989, 1 in 1990, and 2 in 1991. Of 249 children, 94 (38%) in these 10 EAd outbreaks were infected with EAd. In 51 children (54%) the infection was symptomatic and in 43 (46%) it was asymptomatic. Outbreaks lasted 7 to 44 days (mean 24.5 days). Duration of EAd excretion ranged from 1 to 14 days (mean 3.9 days), with excretion occurring from 7 days (mean 2.6) before diarrhea began to 11 days (mean 5.3 days) after diarrhea stopped.

CONCLUSION

Enteric adenovirus types 40 and 41 are an important cause of outbreaks of diarrhea among children attending day care centers, often involve children in more than one room, and frequently produce asymptomatic infection.

Clinical features of enteric adenovirus infection in infants

During the period December 1984 to October 1988, adenoviruses (Ads) were isolated on 119 occasions (1.6%) from stool samples of patients with gastroenteritis. By DNA restriction analysis, 85 enteric adenoviruses (EAds) were identified. Sixty-seven patients with these infections were studied, of whom 18 had Ad40, 30 had Ad41 and 19 had untyped Ad infections. The incidence of Ad infection was high in children between 6 and 11 months of age. The illness was characterized by watery diarrhea (whitish in one third of patients), continuing for a mean of 4.5 days, and vomiting, which occurred more often in patients with EAds than in other types of infection. Diarrhea, fever and vomiting were seen significantly more frequently in patients with Ad40 than in Ad41 infection. Diarrhea and vomiting were also seen significantly more frequently in patients with EAds than in Ads infection. Diarrhea, fever and vomiting were observed more frequently in patients with rotavirus than EAds infection.

Enteric adenovirus type 40:E1B transcription map and identification of novel E1A-E1B cotranscripts in lytically infected cells

Adenovirus 40 (Ad40) is defective for growth in tissue culture but is complemented when the Ad2/5 or Ad12 E1B 55K protein is supplied in trans. Ad40 E1B mRNA has not been detected in E1-transformed cells, or at early times in lytically infected cells. In cells constitutively expressing the E1B region of Ad2, Ad40 E1B mRNAs are detected at late times in infection, after the onset of DNA replication. We have determined the Ad40 E1B transcription map from RNA produced at late times in infected KB16 cells, using S1 nuclease, primer extension, PCR-cDNA analysis, and Northern blotting. E1B transcripts corresponding to Ad2 14 S, 22 S, and 9 S mRNAs were identified but no 13 S mRNA equivalent was detected, a pattern similar to that seen in the Ad12 transcription map. The coding potential for E1B 19K, 55K, and 15K proteins and for ppIX is retained in the Ad40 transcripts. In addition we find novel E1A-E1B cotranscript counterparts of the 14 S and 22 S mRNAs. These contain the first 40 codons of the E1A first exon linked to a site 4-5 nt downstream of the E1B cap site, retaining all the coding potential of the E1B mRNAs. No new open reading frames are created by the junction, and the E1A ORF terminates with one codon added after the junction. Each E1A-E1B cotranscript is present in abundance comparable to that of its authentic E1B counterpart. The E1A-E1B junction is unusual in that it does not conform to splice consensus sequences and thus may not be generated by a conventional splicing mechanism.

An immune dot-blot technique for the diagnosis of ocular adenovirus infection

The development of a monoclonal antibody based radio-immune dot-blot technique (IDBT) for the rapid detection of adenovirus is described. 718 conjunctival swabs from patients with acute keratoconjunctivitis were examined by conventional cell culture isolation techniques and IDBT. IDBT identified adenovirus in 64 of 75 culture positive samples and also in a further 34 culture negative samples [Sensitivity (IDBT versus culture) 85.3%; Specificity 92.2%]. IDBT is considered to be a simple, clinically relevant, technique for the rapid identification of adenovirus infection of the eye.

Pathogenesis of gut virus infection

In summary, the pathogenesis of many gut virus infections remains uncertain. However, human and animal studies indicate that the majority of gut viruses infect villous enterocytes. Viruses appear to have different affinities for enterocytes at different sites on the villus. Infection of enterocytes leads to cell death, extrusion into the lumen, and villous atrophy when the rate of cell production in the crypts cannot keep pace with the rate of enterocyte loss. This results in a reduced surface area as well as impairment of digestive and absorptive functions. This may also result in a net secretory state. All these changes, along with others such as reduced enzymatic activity and reduced epithelial integrity, may contribute to the induction of an acute but transient malabsorptive diarrhoea which may persist until the digestive/absorptive functions of the enterocyte are restored. However, if colonic compensation is sufficient to handle the increased fluid load, diarrhoea may not be evident. The roles of villous ischaemia, altered countercurrent exchanger of altered immune responses still remain uncertain and require further investigation.

Enteric adenoviruses

Human adenoviruses are classified into 47 serotypes and six subgenera (A-F) with different tropisms. In recent years adenovirus type 40 (Ad40) and 41 (Ad41) of subgenus F have been shown to be causative agents in enteric infections, which is second in importance only to rotaviruses as a cause of infantile gastroenteritis. Infection with EAds occurs worldwide and has been associated with 4-17% of cases of diarrhoea in children. AD40 and Ad41 primarily affect young children less than 2 years of age and occur throughout the year. The clinical characteristics include watery diarrhoea accompanied by vomiting, low grade fever and mild dehydration. A distinct feature of EAds infection is the protracted diarrhoea (mean 8.6 and 12.2 days for Ad40 and Ad41, respectively). Respiratory symptoms are infrequent. Serotypes Ad40 and Ad41 differ from all other (established) adenoviruses by being unable to replicate in conventional cell cultures. These fastidious viruses only grow in selected cell lines, 293 cells being the most commonly used. In spite of the difficulty of isolating Ad40 and Ad41, they can be directly identified and typed by ELISA and solid-phase immune electron microscopy. The amount of viral DNA in stool specimens is sufficient for identification by DNA restriction and dot-blot assays. The recent development of highly sensitive and specific monoclonal antibody-based ELISAs enable accurate diagnosis of adenovirus gastroenteritis in routine work and make possible the evaluation of the role of the enteric adenoviruses in diarrhoeal disease in the developing countries.

Adenovirus types 40 and 41 and rotaviruses associated with diarrhea in children from Guatemala

From March 1987 to February 1988, fecal excretion of adenovirus types 40 and 41 and rotavirus serotypes in 194 children (age, 0 to 3 years) from a rural community of Guatemala was monitored. In total, 458 samples taken during 385 episodes of diarrhea and 191 specimens obtained during symptom-free periods were examined by enzyme-linked immunosorbent assay. Fifty-seven children hospitalized because of diarrhea were also studied. Among the rural children, 43 (22.2%) excreted adenovirus types 40 and 41 and 20 (10.3%) shed rotaviruses. Adenovirus types 40 and 41 were associated with 54 (14.0%) illnesses, and rotaviruses were associated with 18 (4.7%) illnesses. Asymptomatic infections with adenovirus types 40 and 41 were documented in nine children and with rotaviruses in two children. Fifteen typeable rotaviruses were identified as serotype 2. In the hospital population, 36 (63.2%) children had viral infections. Rotaviruses were identified in 29 (50.9%) and adenovirus types 40 and 41 were identified in 15 (31.2%) of 48 subjects tested. Dual infections by these viruses were found in eight children. Of 22 typeable strains of rotaviruses, 9 (34.6%) were serotype 1, 12 (46.1%) were serotype 2, and 1 (3.8%) was serotype 3. All the children infected with serotype 2 rotavirus were coinfected with other enteric pathogens, while only three (37.5%) of those infected with rotavirus serotype 1 excreted another pathogen. Adenovirus types 40 and 41 are an important cause of gastroenteritis in both ambulatory and hospitalized Guatemalan children. There seems to be a difference in the pathogenicity among rotavirus serotypes.

Evaluation of immunofluorescent reagents, centrifugation, and conventional cultures for the diagnosis of adenovirus infection

In this study we have evaluated four fluorescent antibody reagents, three monoclonal and one polyclonal, for identification of adenovirus isolates and compared four conventional cultures (human embryonic kidney, A549, HEp-2, and MRC-5 cells) with centrifugation culture for rapid diagnosis. For identification of adenovirus isolates by immunofluorescence, CDC reagent and Adenoclone, both monoclonal antibodies to the hexon group-reactive antigen, were more sensitive and easier to interpret than the other two reagents tested. HEK and A549 cells were the most sensitive for isolation of adenovirus. Although A549 cells were an inexpensive alternative to HEK, A549 cell monolayers deteriorated more rapidly and passages were more often required. Centrifugation cultures with A549 cells detected 77% of positives within 2 days and 100% within 5 days, whereas isolation in conventional culture required up to 10 days for HEK and up to 20 days for MRC-5 cells.

Nosocomial and endemic infections with a genome type of adenovirus type 5

A unique genome type of adenovirus 5 was isolated from 37 specimens of 25 patients. DNA restriction analysis was performed with seven endonucleases. Part of the patients were treated at a bone marrow transplantation unit in Munich. Nosocomial spread, rather than activation of endogenous adenovirus infection, was likely for many of them. In addition, sporadic cases suggested an endemicity of this genome type in Bavaria.

Infection by enteric adenoviruses, rotaviruses, and other agents in a rural African environment

From February 1985 to January 1986, 432 stool samples, 310 from rural African children with diarrhea and 122 from controls, were analysed for the presence of enteric viruses known to be associated with diarrhea. Group A rotavirus ELISA indicated 12.9% positivity among patients and 2.5% positivity among controls. Only 23 of the 43 rotavirus ELISA-positive stools were also positive by electron microscopy. Nine children, three of whom were controls, were found to be shedding coronavirus-like particles, detected by electron microscopy. Stools from all but one of the nine children had been taken within 1 month of each other. Dot-blot hybridization tests for the presence of Ad40 or Ad41 DNA revealed 44 positive stools, 41 of which were from patients (13.2% positivity). Only three of the Ad40-or Ad41-positive stools by DNA hybridization were positive by electron microscopy, and only these three strains could be grown in semipermissive Chang conjunctival cells and their identity checked by restriction enzyme analysis. Further attempts to rescue the other strains using a helper virus failed, but nine of the stools proved positive by ELISA using a subgroup F-specific monoclonal antibody. On the basis of the DNA hybridization results alone, subgroup F adenoviruses were encountered as frequently as rotavirus in the study and were significantly associated with diarrhea, although the viability and intactness of virus particles by the time of laboratory analysis appeared to be very low.

Human viral gastroenteritis

During the last 15 years, several different groups of fastidious viruses that are responsible for a large proportion of acute viral gastroenteritis cases have been discovered by the electron microscopic examination of stool specimens. This disease is one of the most prevalent and serious clinical syndromes seen around the world, especially in children. Rotaviruses, in the family Reoviridae, and fastidious fecal adenoviruses account for much of the viral gastroenteritis in infants and young children, whereas the small caliciviruses and unclassified astroviruses, and possibly enteric coronaviruses, are responsible for significantly fewer cases overall. In addition to electron microscopy, enzyme immunoassays and other rapid antigen detection systems have been developed to detect rotaviruses and fastidious fecal adenoviruses in the stool specimens of both nonhospitalized patients and those hospitalized for dehydration and electrolyte imbalance. Experimental rotavirus vaccines have also been developed, due to the prevalence and seriousness of rotavirus infection. The small, unclassified Norwalk virus and morphologically similar viruses are responsible for large and small outbreaks of acute gastroenteritis in older children, adolescents, and adults. Hospitalization of older patients infected with these viruses is usually not required, and their laboratory diagnoses have been limited primarily to research laboratories.

Genomic comparison of adenovirus type 3 isolates from patients with acute conjunctivitis in Japan, Australia, and the Philippines

A total of 53 Ad3 isolates obtained from patients with acute conjunctivitis in Japan, Australia, and the Philippines during 1973 to 1986 were analyzed for their genome types with 4 restriction endonucleases, BamHI, BglII, HindIII, and SmaI. Two new genome types designated tentatively as Ad3f and Ad3g were identified by combination of BamHI and BglII in the isolates. The changes of restriction sites and sizes of restriction fragments in newly recognized Ad3f and Ad3g were located at the similar regions reported in other Ad3 genome types by O'Donnell et al (1986) on physical maps of the Ad3 prototype strain GB genome. In Japan, 46 Ad3 isolates obtained from 1983 to 1986 were either Ad3f or Ad3g. Yearly alternation of predominance of both genome types were observed in the northern part of Japan during the period. In Australia, two genome types Ad3p and Ad3f were found in 6 isolates, and the former was observed in the 3 isolates obtained before 1981 and the remaining 3 isolates were obtained after 1983. In the Philippines, the only isolate obtained in 1984 was Ad3p.

Comparison of enteric adenovirus infection in various human cell lines

Growth of the fastidious enteric adenoviruses 40 and 41 was compared in different human cell lines. Purified virions were used to infect the following cell lines: A549; KB; Chang's conjunctiva; 293; HeLa. Both types of enteric adenovirus were infectious for each cell line, with the exception of adenovirus 40 in HeLa cells. Relatively low infectious titers were obtained from each cell type following infection with adenovirus 40 (TCID50 average = 10(-1.5)), whereas adenovirus 41 replicated to significantly higher titer (TCID50 average = 10(-3.0)). For both viruses, the highest infectious titers were obtained with A549 and KB cells. A time course experiment performed to quantitate the amount of hexon present in A549 and KB cells infected with each virus indicated that while the kinetics of accumulation were similar for both viruses, the concentration of type 41 hexon was significantly greater than that for type 40 in either cell line. The concentration of type 41 hexon was similar in each cell type; for type 40, a greater concentration of hexon was obtained in the A549 cell line than in the KB cells. The results indicate the distinct replication characteristics exhibited by adenovirus 40 are not due to a restriction in a specific host cell, and, because purified virions were used, not attributable to interference that might occur with co-infection from multiple viruses present in the same clinical specimen. We conclude the differences observed in the replication of these viruses are independent of host cell type and are associated, uniquely, with each virus.

Evaluation of cell line 293 for virus isolation in routine viral diagnosis

Cell line 293, a continuous line of transformed human embryonic kidney cells, has been recognized for its sensitivity in the isolation of adenoviruses, particularly the fastidious species 40 and 41, from stool specimens. To explore the possibility of using this cell line for the isolation of other viruses from clinical specimens, 293 cells were tested for their susceptibility to a variety of viruses including herpes simplex virus, parainfluenza viruses, respiratory syncytial virus, and the enteroviruses ECHO 11, coxsackie B5, and coxsackie B6. All of the viruses induced a cytopathic effect in 293 cells. Consequently, 293 cells were introduced into the diagnostic laboratory and used along with primary African green monkey kidney (AGMK) cell cultures for the inoculation of all respiratory and stool specimens. The study represents a retrospective analysis of the performance of 293 cells over a 22-month period. It was confirmed that 293 cells were more sensitive than AGMK cells for the isolation of adenoviruses from both respiratory and stool specimens. The 293 cells were also sensitive for the isolation of enteroviruses (untyped) but more so from stool specimens than from respiratory specimens. Parainfluenza virus and respiratory syncytial virus were only rarely isolated in 293 cells. Herpesvirus isolates were obtained with equal frequency in both 293 and AGMK cells. This retrospective analysis confirms the value of 293 cells for the isolation of adenoviruses and demonstrates that 293 cells are also useful for the isolation of certain enteroviruses from both respiratory and stool specimens.

Laboratory procedures in adenoviruses. XII. Comparison of five ELISA methods for demonstration of hexon antigen

To demonstrate adenovirus hexon, four different arrangements of a four-layer ELISA, to be performed with commercially available reagents, were compared with a three-layer ELISA. After evaluation of specific and control reagents and their dilutions, the guinea pig/rabbit or the rabbit/chicken method were equally practicable and sensitive as the three-layer method with rabbit serum and superior to two other methods. By testing about 100 stool samples and 74 throat swabs containing adenoviruses, it turned out that the sensitivity (1 ng/ml hexon) appears satisfactory for stool specimens in adenovirus enteritis of infants, but is much less sensitive than isolation in cell culture for adenoviruses in throat swabs. As confirmatory test, specimen were incubated with an adenovirus rabbit antiserum or normal serum and then tested.

Enteric adenoviruses. Brief review

In 1978, the World Health Organisation initiated a programme for global prevention and control of childhood diarrhoeas. As a result, the relative importance of various pathogens in the aetiology of diarrhoea in many parts of the world has been recognised. Rotavirus, which ranks as the most prevalent viral pathogen in childhood diarrhoea may be closer to control as many vaccines are in sight. This has been made possible due to a decade of intense research since its discovery. E Ad, which probably ranks as the second most important viral pathogen has not received much attention. As has been discussed, much information has to be gathered about this virus, before W.H.O's. goal of controlling childhood diarrhoea is realised.

Specific detection and typing of adenovirus types 40 and 41 in stool specimens by dot-blot hybridization

A dot-blot hybridization test was developed which allowed the direct detection of fastidious enteric adenovirus DNA in stool specimens from children with diarrhea and simultaneous typing of the viruses as adenovirus type 40 (Ad40) or Ad41. Cloned PstI fragments of Ad40 and Ad41 were used as 32P-labeled probes in the test, which allowed detection of picogram quantities of viral DNA in 20 to 40 microliter of stool suspension. Results were obtained within 48 h. The type specificity of the test was evaluated with 76 specimens known to contain either Ad40 or Ad41 by restriction enzyme analysis. Sixty-one specimens had sufficient DNA to be detected without any removal of protein. Thirty-one adenoviruses were typed as Ad40, and 30 were typed as Ad41, giving 100% correlation with the results of restriction enzyme analysis. The other 15 specimens were detected and typed as Ad40 or Ad41 only after removal of protein by a phenol extraction method. The dot-blot hybridization method is particularly useful for identifying those Ad40 and Ad41 strains which defy all attempts at culture and will be a useful tool in the epidemiology of fastidious enteric adenovirus infections.

Fecal adenoviruses from a longitudinal study of families in metropolitan Washington, D.C.: laboratory, clinical, and epidemiologic observations

During a 29-month period, we studied enteric infection in 70 families from a pediatric practice in suburban Washington, D.C. Fecal adenoviruses were detected in stools of 18 patients by tissue culture and electron microscopic procedures. From 6 through 11 months of age, the incidence of fecal adenoviruses associated with enteritis was seven per 100, and of confirmed enteric adenoviruses (EAds), three per 100 individuals per year. All EAds belonged to subgenus G (type 41). All three patients with EAds had diarrhea; two had vomiting and one had fever, but none required hospitalization. Ten of the 15 patients with non-EAds were younger than 2 years, and 60% had diarrhea, 40% had vomiting, and 20% had fever. Combined gastrointestinal and respiratory symptoms occurred more often in those who shed non-EAds (three of 11) than in matched controls (two of 48, P = 0.04). An adenovirus was detected in approximately 6% of gastroenteritis episodes, and confirmed EAds were present in approximately 2% of episodes of gastroenteritis in children younger than 2 years of age. None of the contacts of patients with non-EAds shed such virus in their stools. None of nine family contacts of those with EAd appeared to shed adenovirus in stool. In contrast, rotavirus spread readily to exposed adults (25% of 65) and children (56% of 62) when a child in similar families had rotavirus infection.

Comparison of neutralization and DNA restriction enzyme methods for typing clinical isolates of human adenovirus

Sixty-five adenovirus isolates collected over a 3.5-year period were typed by both standard microneutralization techniques and restriction endonuclease digestion of viral DNA. Of the 65 isolates, 47 (72.3%) representing six adenovirus types could be typed by microneutralization. Eighteen isolates demonstrated partial neutralization with standard antisera to two or more adenovirus serotypes and thus could not be definitively typed. DNA analysis permitted typing of 64 of the 65 isolates (98.5%) (including four isolates which contained mixtures of two adenovirus types), and 12 different types were identified. Neutralization and DNA typing disagreed for five isolates, and in each case, digestion with multiple restriction endonucleases and DNA hybridization studies were consistent with the type assigned by DNA analysis. In addition, the DNA analysis method allowed the identification of genomic variants (genome types) of five adenovirus types. We conclude that typing clinical isolates of adenovirus by restriction endonuclease digestion of viral DNA can be done rapidly, provides additional epidemiological and typing information, and provides fewer ambiguous results than does typing by neutralization.

Detection of enteric adenoviruses by dot-blot hybridization using a molecularly cloned viral DNA probe

Enteric adenoviruses (EAds) (candidate adenoviruses 40 and 41, subgroups F and G) have been implicated in the etiology of gastroenteritis in infants, but their clinical significance has been unclear because a rapid test to distinguish these agents from other adenovirus (Ad) types has not been available. We developed a dot-blot hybridization assay for EAd DNA using a cloned DNA fragment that has little homology to non-EAd DNAs. The dot-blot system detected less than 20 pg of EAd DNA, while showing minimal cross hybridization to representative strains from all other Ad groups. There was no detectable hybridization to extracts of samples known to contain other enteric viruses. It was further shown that low levels of EAds in specimens could be amplified by culturing for 1 day in 293 cells. Stool samples and tissue culture lysates prescreened by electron microscopy, cell culture or ELISA were tested in a blind fashion. Using endonuclease analysis as the standard for typing the isolates, we found the dot-blot system to have a 91% sensitivity and 71% specificity for detecting EAds and distinguishing them from other Ads. False-positive and equivocal dot-blot results appeared to be caused by other Ads.

Examination of uncommon clinical isolates of human adenoviruses by restriction endonuclease analysis

Restriction endonuclease analysis was performed on reference strains of each unknown adenovirus subgenus, in comparison with 40 isolates not identified by our routine methods of neutralization with antisera of species 1 to 8. Several uncommon species would not have been identified initially without the assistance of reference laboratories (species 15, 35, and 37). Other species were identified by comparison with published adenovirus DNA restriction endonuclease patterns or from DNA analysis of reference strains (species 31, 40, and 41). Some isolates could not be matched beyond the level of presumptive adenovirus subgenus. Genomic DNA restriction endonuclease analysis of adenoviruses was useful for the identification of adenovirus isolates in a diagnostic virology laboratory. However, accurate interpretation of results will require more extensive DNA restriction endonuclease fragment analysis of a broader range of adenovirus species and genomic variant strains.

Adenoviruses in faeces of children with acute gastroenteritis in Rio de Janeiro, Brazil

Faeces from 746 children less than 5 years old with acute gastroenteritis were screened for the presence of adenovirus particles or antigens by immunoelectron microscopy (IEM) and enzyme immunoassay (EIA). Thirty-five samples were positive by both IEM and EIA, two only by IEM, and two only by EIA, giving a total of 39 (5.2%) samples with positive results. Of these, 25 could be propagated in HEp2 cells and were neutralized by one of the antisera to adenovirus types 1 to 18. The remaining 14 samples could be propagated only in the 293 permanent line of human cells transformed by adenovirus type 5 DNA [Graham et al, 1977] and were not neutralized by antisera to adenovirus types 1 to 31. An EIA carried out by the antibody-capture technique, using antiserum specific for "enteric" adenoviruses [Johansson et al, 1979], gave positive results with all isolates that could be propagated only in 293 cells and with none of those capable of growing in HEp2 cells.

Clinical features in hospitalised children with acute gastroenteritis. Does the rotavirus syndrome exist?

In a prospective study of children referred to hospital, rotavirus was identified in 37% of 128 patients with acute gastroenteritis. As compared with patients with non-rotavirus gastroenteritis, those with rotavirus gastroenteritis showed the following clinical characteristics: Age between 5 months and 4 years. Occurrence of the rotavirus infection almost exclusively during the winter season. Severe vomiting. Absence of gross blood in the stools. However, these signs did not form a safe basis for the clinical diagnosis of rotavirus gastroenteritis. One or more signs of upper respiratory illness were observed in 36% of the patients with rotavirus gastroenteritis and in 35% of those with non-rotavirus gastroenteritis. Consequently, the existence of a rotavirus syndrome is questioned. It is argued that upper respiratory illnesses in patients with rotavirus gastroenteritis could be due to a separate infection occurring coincidentally.