Ockelbo disease: arthralgia 3-4 years after infection with a Sindbis virus related agent

Epidemic Alphaviruses: Ecology, Emergence and Outbreaks

Over the past century, the emergence/reemergence of arthropod-borne zoonotic agents has been a growing public health concern. In particular, agents from the genus Alphavirus pose a significant risk to both animal and human health. Human alphaviral disease presents with either arthritogenic or encephalitic manifestations and is associated with significant morbidity and/or mortality. Unfortunately, there are presently no vaccines or antiviral measures approved for human use. The present review examines the ecology, epidemiology, disease, past outbreaks, and potential to cause contemporary outbreaks for several alphavirus pathogens.

Mosquitoborne Sindbis Virus Infection and Long-Term Illness

An unexpected human outbreak of the mosquitoborne Sindbis virus occurred in a previously nonendemic area of Sweden. At follow-up, 6-8 months after infection, 39% of patients had chronic arthralgia that affected their daily activities. Vectorborne infections may disseminate rapidly into new areas and cause acute and chronic disease.

Mapping of human B-cell epitopes of Sindbis virus

Mosquito-transmitted Sindbis virus (SINV) causes fever, skin lesions and musculoskeletal symptoms if transmitted to man. SINV is the prototype virus of genus Alphavirus, which includes other arthritogenic viruses such as chikungunya virus (CHIKV) and Ross River virus (RRV) that cause large epidemics with a considerable public health burden. Until now the human B-cell epitopes have been studied for CHIKV and RRV, but not for SINV. To identify the B-cell epitopes in SINV-infection, we synthetised a library of linear 18-mer peptides covering the structural polyprotein of SINV, and probed it with SINV IgG-positive and IgG-negative serum pools. By comparing the binding profiles of the pools, we identified 15 peptides that were strongly reactive only with the SINV IgG-positive pools. We then utilized alanine scanning and individual (n=22) patient sera to further narrow the number of common B-cell epitopes to six. These epitopes locate to the capsid, E2, E1 and to a region in PE2 (uncleaved E3-E2), which may only be present in immature virions. By sequence comparison, we observed that one of the capsid protein epitopes shares six identical amino acids with macrophage migration inhibitory factor (MIF) receptor, which is linked to inflammatory diseases and to molecular pathology of alphaviral arthritides. Our results add to the current understanding on SINV disease and raise questions of a potential role of uncleaved PE2 and the MIF receptor (CD74) mimotope in human SINV infection.

Detection and isolation of Sindbis virus from mosquitoes captured during an outbreak in Sweden, 2013

Mosquito-borne alphaviruses have the potential to cause large outbreaks throughout the world. Here we investigated the causative agent of an unexpected Sindbis virus (SINV) outbreak during August-September, 2013, in a previously nonendemic region of Sweden. Mosquitoes were collected using carbon dioxide-baited CDC traps at locations close to human cases. The mosquitoes were initially screened as large pools by SINV-specific quantitative RT-PCR, and the SINV-positive mosquitoes were species determined by single-nucleotide polymorphism (SNP) analysis, followed by sequencing the barcoding region of the cytochrome oxidase I gene. The proportion of the collected mosquitoes was determined by a metabarcoding strategy. By using novel strategies for PCR screening and genetic typing, a new SINV strain, Lövånger, was isolated from a pool of 1600 mosquitoes composed of Culex, Culiseta, and Aedes mosquitoes as determined by metabarcoding. The SINV-positive mosquito Culiseta morsitans was identified by SNP analysis and sequencing. After whole-genome sequencing and phylogenetic analysis, the SINV Lövånger isolate was shown to be most closely similar to recent Finnish SINV isolates. In conclusion, within a few weeks, we were able to detect and isolate a novel SINV strain and identify the mosquito vector during a sudden SINV outbreak.

Seroprevalence of Sindbis virus and associated risk factors in northern Sweden

Mosquito-borne Sindbis virus (SINV) cause disease characterized by rash, fever and arthritis which often leads to long-lasting arthralgia. To determine the seroprevalence of SINV and associated risk factors in northern Sweden, a randomly selected population aged between 25 and 74 years were invited to join the MONICA study. Serum from 1611 samples were analysed for specific IgG antibodies. Overall, 2·9% had IgG against SINV. More men (3·7%) than women (2·0%) were SINV seropositive (P = 0·047) and it was more common in subjects with a lower educational level (P = 0·013) and living in small, rural communities (P < 0·001). Seropositivity was associated with higher waist circumference (P = 0·1), elevated diastolic blood pressure (P = 0·037), and history of a previous stroke (P = 0·011). In a multiple logistic regression analysis, adjusting for known risk factors for stroke, seropositivity for SINV was an independent predictor of having had a stroke (odds ratio 4·3, 95% confidence interval 1·4-13·0, P = 0·011).

Complete coding sequence and molecular epidemiological analysis of Sindbis virus isolates from mosquitoes and humans, Finland

Sindbis virus (SINV) is an arthropod-borne alphavirus, which causes rash-arthritis, particularly in Finland. SINV is transmitted by mosquitoes in Finland but thus far no virus has been isolated from mosquitoes. In this study, we report the isolation of the first SINV strain from mosquitoes in Finland and its full-length protein-coding sequence. We furthermore describe the full-length coding sequence of six SINV strains previously isolated from humans in Finland and from a mosquito in Russia. The strain isolated from mosquitoes (Ilomantsi-2005M) was very closely related to all the other Northern European SINV strains. We found 9 aa positions, of which five in the nsP3 protein C terminus, to be distinctive signatures for the Northern European strains that may be associated with vector or host species adaptation. Phylogenetic analyses further indicate that SINV has a local circulation in endemic regions in Northern Europe and no novel strains are frequently being introduced.

Larval environmental temperature and insecticide exposure alter Aedes aegypti competence for arboviruses

Temperature is a key factor influencing mosquito growth and development and is also known to affect insecticide efficacy. We evaluated the effects of larval rearing temperature and exposure to insecticides on adult mosquito fitness and competence for arboviral infection using Sindbis virus (SINV). We exposed newly hatched larvae of Aedes aegypti to an environmentally realistic level of insecticide malathion at 20°C and 30°C and allowed the resulting adults to feed on SINV-infected blood meal. Exposure to malathion significantly reduced survival to adulthood. Statistically significant interactions between temperature and malathion were observed for body size, estimated population growth, and SINV infection and dissemination. Malathion-exposed Ae. aegypti cohorts had significantly higher population growth at 20°C than at 30°C. Body size decreased with higher temperature and malathion-exposed females were larger than unexposed females at 20°C but not at 30°C. Viral infection and dissemination increased with larval rearing temperature and were higher in malathion-exposed than unexposed females at 30°C but not at 20°C. These results show that environmental factors, including those factors used in controlling mosquitoes, experienced by immature stages have latent effects that continue to adulthood and alter vector competence to arboviruses.

Arthritis and arthralgia three years after Sindbis virus infection: clinical follow-up of a cohort of 49 patients

Sindbis virus (SINV) emerges as large human outbreaks in northern Europe every 7 years. Similar to many other alphaviruses, SINV is a mosquito-borne causative agent of a rash-arthritis. Previous reports suggest that in many alphavirus infections joint symptoms might persist for years. A prospective cohort of 49 patients was physically examined 3 y after verified acute SINV infection to reveal persistent joint symptoms. We carefully searched for a temporal association between the infection and current symptoms, and took into account other medical conditions. Sera were collected and analysed with enzyme immunoassays. Arthritis (swelling and tenderness on physical examination) was diagnosed in 4.1% (2/49) of the patients. Tenderness on palpation or in movement of a joint was found in 14.3% of the patients in the rheumatological examination, and an additional 10.2% complained of persisting arthralgia at the interview. Thus, 24.5% of the patients had joint manifestations attributable to the infection 3 y earlier. A positive IgM antibody response persisted in 3/49 of the patients; both patients with arthritis were in this group. As one-quarter of the patients were symptomatic 3 y after infection, it seems that persistent symptoms of SINV infection have considerable public health implications in areas with high seroprevalence.

Viral Arthritis

The role of viruses in the development of acute and chronic arthritis is complex, because viruses are ubiquitous, and all human beings are occasionally afflicted by viral infections. In general, most viral infections are acute and self-limiting and survive by infecting one susceptible host, then moving on to another. Some viruses establish prolonged latency in the host after acute infection, whereas other agents produce chronic infections following the primary stage. The mechanisms whereby these infections produce arthritis are diverse and still poorly understood, but are clearly influenced by both host and viral factors. This review addresses these and other common forms of viral arthritis, such as that caused by parvovirus B19.

Viral zoonoses in Europe

A number of new virus infections have emerged or re-emerged during the past 15 years. Some viruses are spreading to new areas along with climate and environmental changes. The majority of these infections are transmitted from animals to humans, and thus called zoonoses. Zoonotic viruses are, as compared to human-only viruses, much more difficult to eradicate. Infections by several of these viruses may lead to high mortality and also attract attention because they are potential bio-weapons. This review will focus on zoonotic virus infections occurring in Europe.

Sindbis viruses and other alphaviruses as cause of human arthritic disease

Amongst the arthritis-causing arboviruses, i.e. those spread by insects, the alphavirus group is of special interest. These viruses occasionally cause vast outbreaks, such as O'nyong-nyong in Africa in 1959. In Fennoscandia, Sindbis-related Ockelbo, Pogosta, or Karelian fever viruses have been found to cause significant morbidity. The major symptoms in addition to joint inflammation are fever, fatigue, headache and rash. The joint symptoms may persist for weeks, even months. The diagnosis is based on the clinical picture and serology. The causative viruses are closely related but not identical. It appears that at least in Finland the Pogosta disease is more common than thought, and the symptoms may often be overlooked. Several factors related to the viruses, their hosts, and global environmental changes may affect the spread of these viruses. All over the world arbovirus-caused diseases have increased, because of global changes.

A novel viral RNA species in Sindbis virus-infected cells

Sindbis virus (SIN), the type alphavirus, has been studied extensively to identify the viral cis-acting sequences and proteins involved in RNA transcription and replication. However, very little is known about how these processes are coordinated. For example, synthesis of the genomic RNA and the subgenomic mRNA depends on the minus strand. Do these activities occur independently on different templates, or can replication and transcription take place simultaneously on the same template? We describe the appearance of a SIN-specific, plus-sense RNA that is intermediate in size between the genomic and subgenomic RNA species. This RNA, designated RNA II, is observed in a number of different cell lines, both early and late in infection. The number of RNA II species, their sizes, and their abundances are influenced by the subgenomic promoter. We have mapped the 3' end of RNA II to a site within the subgenomic promoter, four nucleotides before the initiation site of the subgenomic mRNA. Our results indicate that the appearance of RNA II is correlated with subgenomic mRNA transcription, such that strong or active promoters tend to increase the abundance of RNA II, relative to weak or less active promoters. RNA II is most abundantly detected with the full promoter and is at much lower abundance with the minimal promoter. The possible origins of RNA II are discussed.

Persistence of alphaviruses in vertebrate hosts

Alphaviruses are a group of arthropod-borne, positive-strand RNA viruses that cause acute encephalitis or arthritis. These viruses were previously thought to cause only acute infections in vertebrates, but recent evidence suggests that host immunological and tissue-specific factors may act together to promote the persistence of alphavirus genomes in vivo.

Pathogenesis of encephalitis induced in newborn mice by virulent and avirulent strains of Sindbis virus

Strains of Sindbis virus differ in their virulence for mice of different ages; this variation is related in large part to variations in the amino acid compositions of E1 and E2, the surface glycoproteins. The comparative pathogenesis of Sindbis virus strains which are virulent or avirulent for newborn mice has not been previously examined. We have studied the diseases caused by a virulent wild-type strain, AR339, and two less virulent laboratory strains, Toto1101 and HRSP (HR small plaque). After peripheral inoculation of 1,000 PFU, AR339 causes 100% mortality within 5 days (50% lethal dose [LD50] = 3 PFU) while Toto1101 causes 70% mortality (LD50 = 10(2.4) PFU) and HRSP causes 50 to 60% mortality (LD50 = 10(5.1) PFU) with most deaths occurring 7 to 11 days after infection. However, after intracerebral inoculation of 1,000 PFU, Toto1101 is virulent (100% mortality within 5 days; LD50 = 4 PFU) while HRSP is not (75% mortality; LD50 = 10(4.2) PFU). After intracerebral inoculation, all three strains initiate new virus formation within 4 h, but HRSP reaches a plateau of 10(6) PFU/g of brain while Toto1101 and AR339 replicate to a level of 10(8) to 10(9) PFU/g of brain within 24 h. Interferon induction parallels virus growth. Mice infected with HRSP develop persistent central nervous system infection (10(6) PFU/g of brain) until the initiation of a virus-specific immune response 7 to 8 days after infection when virus clearance begins. The distribution of virus in the brains of mice was similar, but the virus was more abundant in the case of AR339. HRSP continued to spread until day 9. Clearance from the brain was complete by day 17. We conclude that the decreased virulence of HRSP is due to an intrinsic decreased ability of this strain of Sindbis virus to grow in neural cells of the mouse. We also conclude that CD-1 mice do not respond to the antigens of Sindbis virus until approximately 1 week of age. This lack of response does not lead to tolerance and persistent infection but rather to late virus clearance whenever the immune response is initiated.