Lyssaviruses: current trends

Adapted Milwaukee protocol for rabies treatment in a Brazilian indigenous child: case report

BACKGROUND

This case report describes the treatment of a 12-year-old indigenous Brazilian girl from the Maxakali group with rabies using the adapted Milwaukee Protocol.

CASE PRESENTATION

The patient suffered a superficial bat bite on her right elbow, reported on April 5, 2022. Despite receiving immunoglobulin, a vaccine, and antiviral medications such as amantadine and sapropterin, the patient succumbed to the disease 25 days after hospital admission. The report highlights the inherent challenges in treating rabies due to the virus's neurotropic nature and the difficulties in delivering antiviral drugs to the central nervous system. The case underscores the need for early antiviral intervention and calls for more studies to validate and improve treatment protocols for rabies in vulnerable populations, particularly those with genetic and immunological susceptibilities like the Maxakali indigenous group.

CONCLUSION

The findings suggest that while the Milwaukee Protocol offers some hope, significant obstacles remain in achieving successful outcomes in rabies cases.

Rabies Virus Populations in Humans and Mice Show Minor Inter-Host Variability within Various Central Nervous System Regions and Peripheral Tissues

Rabies virus (RABV) has a broad host range and infects multiple cell types throughout the infection cycle. Next-generation sequencing (NGS) and minor variant analysis are powerful tools for studying virus populations within specific hosts and tissues, leading to novel insights into the mechanisms of host-switching and key factors for infecting specific cell types. In this study we investigated RABV populations and minor variants in both original (non-passaged) samples and in vitro-passaged isolates of various CNS regions (hippocampus, medulla oblongata and spinal cord) of a fatal human rabies case, and of multiple CNS and non-CNS tissues of experimentally infected mice. No differences in virus populations were detected between the human CNS regions, and only one non-synonymous single nucleotide polymorphism (SNP) was detected in the fifth in vitro passage of virus isolated from the spinal cord. However, the appearance of this SNP shows the importance of sequencing newly passaged virus stocks before further use. Similarly, we did not detect apparent differences in virus populations isolated from different CNS and non-CNS tissues of experimentally infected mice. Sequencing of viruses obtained from pharyngeal swab and salivary gland proved difficult, and we propose methods for improving sampling.

Rabies - epidemiology, pathogenesis, public health concerns and advances in diagnosis and control: a comprehensive review

Rabies is a zoonotic, fatal and progressive neurological infection caused by rabies virus of the genus Lyssavirus and family Rhabdoviridae. It affects all warm-blooded animals and the disease is prevalent throughout the world and endemic in many countries except in Islands like Australia and Antarctica. Over 60,000 peoples die every year due to rabies, while approximately 15 million people receive rabies post-exposure prophylaxis (PEP) annually. Bite of rabid animals and saliva of infected host are mainly responsible for transmission and wildlife like raccoons, skunks, bats and foxes are main reservoirs for rabies. The incubation period is highly variable from 2 weeks to 6 years (avg. 2-3 months). Though severe neurologic signs and fatal outcome, neuropathological lesions are relatively mild. Rabies virus exploits various mechanisms to evade the host immune responses. Being a major zoonosis, precise and rapid diagnosis is important for early treatment and effective prevention and control measures. Traditional rapid Seller's staining and histopathological methods are still in use for diagnosis of rabies. Direct immunofluoroscent test (dFAT) is gold standard test and most commonly recommended for diagnosis of rabies in fresh brain tissues of dogs by both OIE and WHO. Mouse inoculation test (MIT) and polymerase chain reaction (PCR) are superior and used for routine diagnosis. Vaccination with live attenuated or inactivated viruses, DNA and recombinant vaccines can be done in endemic areas. This review describes in detail about epidemiology, transmission, pathogenesis, advances in diagnosis, vaccination and therapeutic approaches along with appropriate prevention and control strategies.

High-Throughput Differentiation and Screening of a Library of Mutant Stem Cell Clones Defines New Host-Based Genes Involved in Rabies Virus Infection

We used a genomic library of mutant murine embryonic stem cells (ESCs) and report the methodology required to simultaneously culture, differentiate, and screen more than 3,200 heterozygous mutant clones to identify host-based genes involved in both sensitivity and resistance to rabies virus infection. Established neuronal differentiation protocols were miniaturized such that many clones could be handled simultaneously, and molecular markers were used to show that the resultant cultures were pan-neuronal. Next, we used a green fluorescent protein (GFP) labeled rabies virus to develop, validate, and implement one of the first host-based, high-content, high-throughput screens for rabies virus. Undifferentiated cell and neuron cultures were infected with GFP-rabies and live imaging was used to evaluate GFP intensity at time points corresponding to initial infection/uptake and early and late replication. Furthermore, supernatants were used to evaluate viral shedding potential. After repeated testing, 63 genes involved in either sensitivity or resistance to rabies infection were identified. To further explore hits, we used a completely independent system (siRNA) to show that reduction in target gene expression leads to the observed phenotype. We validated the immune modulatory gene Unc13d and the dynein adapter gene Bbs4 by treating wild-type ESCs and primary neurons with siRNA; treated cultures were resistant to rabies infection/replication. Overall, the potential of such in vitro functional genomics screens in stem cells adds additional value to other libraries of stem cells. This technique is applicable to any bacterial or virus interactome and any cell or tissue types that can be differentiated from ESCs.

Rabies in medieval Persian literature - the Canon of Avicenna (980-1037 AD)

Ibn Sina (980–1037 AD), known by his full name Abu Ali al-Hussain ibn Abdallah ibn Sina and the Latin name ‘Avicenna’, was a Persian scholar who is primarily remembered for his contributions to the science of medicine. He authored Al-Qanun fi al-Tibb (The Canon of Medicine). Sections of his work are devoted to detailed descriptions of a number of infectious illnesses, particularly rabies. Avicenna described rabies in humans and animals and explained its clinical manifestations, route of transmission, and treatment methods. In this article, our goal is to discuss Avicenna’s 11^th-century points of view on rabies and compare them with modern medical knowledge.

Microarray for Identification of the Chiropteran Host Species of Rabies Virus in Canada

Species identification through genetic barcoding can augment traditional taxonomic methods, which rely on morphological features of the specimen. Such approaches are especially valuable when specimens are in poor condition or comprise very limited material, a situation that often applies to chiropteran (bat) specimens submitted to the Canadian Food Inspection Agency for rabies diagnosis. Coupled with phenotypic plasticity of many species and inconclusive taxonomic keys, species identification using only morphological traits can be challenging. In this study, a microarray assay with associated PCR of the mitochondrial cytochrome c oxidase subunit I (COI) gene was developed for differentiation of 14 bat species submitted to the Canadian Food Inspection Agency from 1985–2012 for rabies diagnosis. The assay was validated with a reference collection of DNA from 153 field samples, all of which had been barcoded previously. The COI gene from 152 samples which included multiple specimens of each target species were successfully amplified by PCR and accurately identified by the microarray. One sample that was severely decomposed failed to amplify with PCR primers developed in this study, but amplified weakly after switching to alternate primers and was accurately typed by the microarray. Thus, the chiropteran microarray was able to accurately differentiate between the 14 species of Canadian bats targeted. This PCR and microarray assay would allow unequivocal identification to species of most, if not all, bat specimens submitted for rabies diagnosis in Canada.

Interferon in rabies virus infection

Rabies is among the longest known and most dangerous and feared infectious diseases for humans and animals and still is responsible for tenth of thousands of human deaths per year. The rabies virus (RABV) is a rather atypical member of the Rhabdoviridae family as it has completely adapted during evolution to warm-blooded hosts and is directly transmitted between them, whereas most other rhabdoviruses are transmitted by insect vectors. The virus is also unique with respect to its extremely broad host species range and a very narrow host organ range, namely its strict neurotropism. It is becoming increasingly clear that the host innate immune system, particularly the type I interferon system, and the viral counteractions profoundly shape this virus-host relationship. In the past few years, exciting new insight was obtained on how viruses are sensed by innate immune receptors, how the downstream signaling networks for activation of interferon are working, and how viruses can interfere with the system. While RABV 5'-triphosphate RNAs were identified as the major pathogen-associated molecular pattern sensed by cytoplasmic RIG-I-like receptors (RLR), the RABV phosphoprotein (P) has emerged as a potent multifunctional antagonist able to counteract the signaling cascades leading to transcriptional activation of interferon genes as well as interferon signaling pathways, thereby limiting expression of antiviral and immune-stimulatory genes.

Rupprecht C. Design of future rabies biologics and antiviral drugs

In recent years, no major paradigm shifts have occurred in the utilization of new products for the prevention and control of rabies. Development of new cost-effective rabies biologics and antiviral drugs is critical in continuing to prevent and reduce disease. Current rabies vaccines are highly effective but have developed largely based on technical improvements in the vaccine industry. In the future, alternative approaches for improved vaccines, including novel avirulent rabies virus (RABV) vectors, should be pursued. Any rabies vaccine that is effective without the need for rabies immune globulin (RIG) will contribute fundamentally to disease prevention by reducing the cost and complexity of postexposure prophylaxis (PEP). The lack of high quality, affordable RIG is a continuing problem. Virus-specific monoclonal antibodies (mAbs) will soon fulfill the PEP requirement for passive immunity, currently met with RIG. Several relevant strategies for mAb production, including use of transgenic mice, humanization of mouse mAbs, and generation of human immune libraries, are underway. As a result of successful PEP and pre-exposure prophylaxis in developed countries, until recently, no significant focused efforts have been devoted to RABV-specific antiviral agents. To date, combination therapy including broad spectrum antiviral agents has been successful in only one case, and reports of antiviral activity are often conflicting. Current antiviral strategies target either the nucleoprotein or phosphoprotein, but drugs targeting the viral polymerase should be considered. Considering the lag from creation of new concepts to experimental development and clinical trials, many years will likely elapse between today's ideas and tomorrow's practices.

The cell biology of rabies virus: using stealth to reach the brain

Rabies virus, the prototypical neurotropic virus, causes one of the most lethal zoonotic diseases. According to official estimates, over 55,000 people die of the disease annually, but this is probably a severe underestimation. A combination of virulence factors enables the virus to enter neurons at peripheral sites and travel through the spinal cord to the brain of the infected host, where it often induces aggression that facilitates the transfer of the virus to a new host. This Review summarizes the current knowledge of the replication cycle of rabies virus and virus- host cell interactions, both of which are fundamental elements in our quest to understand the life cycle of rabies virus and the pathogenesis of rabies.

Isolation and characterization of human neutralizing antibodies to rabies virus derived from a recombinant immune antibody library

A human immune Fab library was constructed using RNAs from peripheral blood lymphocytes obtained from rabies virus hyperimmune volunteers on phagemid vector. The size of the constructed Fab library was 2 x 10(7) Escherichia coli transformants. After four rounds of panning on whole inactivated rabies virus (PV-11), phage clones displaying rabies virus-specific human Fab were selected. The specificity of soluble Fab antibody fragments, derived from positive phage clones was verified by ELISA. Among 20 specific Fab clones, the genetic sequence of 6 of them (FabRV01, FabRV02, FabRV03, FabRV04, FabRV05, and FabRV06) was analyzed. The variable heavy (VH) and variable light (VL) domains were found to share 90% and 93% homology with sequences encoded by the corresponding human germline genes, respectively. The soluble Fab fragments, expressed in Escherichia coli were purified by a single step Nickel-NTA affinity chromatography via a hexa-histidine tag and their binding specificities to rabies virus were confirmed. Three of the Fab antibodies, FabRV01, FabRV02 and FabRV03, showed binding characteristics to rabies virus glycoprotein antigenic site III with affinities in the K(D) range 7 x 10(-9) to 5 x 10(-8)M. The Fab fragments showed dose-dependent neutralization properties for the challenge virus standard (CVS-11).