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Park A, Lee C, Lee JY. Genomic Evolution and Recombination Dynamics of Human Adenovirus D Species: Insights from Comprehensive Bioinformatic Analysis. J Microbiol 2024; 62:393-407. [PMID: 38451451 DOI: 10.1007/s12275-024-00112-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Revised: 01/10/2024] [Accepted: 01/14/2024] [Indexed: 03/08/2024]
Abstract
Human adenoviruses (HAdVs) can infect various epithelial mucosal cells, ultimately causing different symptoms in infected organ systems. With more than 110 types classified into seven species (A-G), HAdV-D species possess the highest number of viruses and are the fastest proliferating. The emergence of new adenovirus types and increased diversity are driven by homologous recombination (HR) between viral genes, primarily in structural elements such as the penton base, hexon and fiber proteins, and the E1 and E3 regions. A comprehensive analysis of the HAdV genome provides valuable insights into the evolution of human adenoviruses and identifies genes that display high variation across the entire genome to determine recombination patterns. Hypervariable regions within genetic sequences correlate with functional characteristics, thus allowing for adaptation to new environments and hosts. Proteotyping of newly emerging and already established adenoviruses allows for prediction of the characteristics of novel viruses. HAdV-D species evolved in a direction that increased diversity through gene recombination. Bioinformatics analysis across the genome, particularly in highly variable regions, allows for the verification or re-evaluation of recombination patterns in both newly introduced and pre-existing viruses, ultimately aiding in tracing various biological traits such as virus tropism and pathogenesis. Our research does not only assist in predicting the emergence of new adenoviruses but also offers critical guidance in regard to identifying potential regulatory factors of homologous recombination hotspots.
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Affiliation(s)
- Anyeseu Park
- The Laboratory of Viromics and Evolution, Korea Zoonosis Research Institute, Jeonbuk National University, Iksan, 54531, Republic of Korea
| | - Chanhee Lee
- The Laboratory of Viromics and Evolution, Korea Zoonosis Research Institute, Jeonbuk National University, Iksan, 54531, Republic of Korea
| | - Jeong Yoon Lee
- The Laboratory of Viromics and Evolution, Korea Zoonosis Research Institute, Jeonbuk National University, Iksan, 54531, Republic of Korea.
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2
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Hardmeier I, Aeberhard N, Qi W, Schoenbaechler K, Kraettli H, Hatt JM, Fraefel C, Kubacki J. Metagenomic analysis of fecal and tissue samples from 18 endemic bat species in Switzerland revealed a diverse virus composition including potentially zoonotic viruses. PLoS One 2021; 16:e0252534. [PMID: 34133435 PMCID: PMC8208571 DOI: 10.1371/journal.pone.0252534] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Accepted: 05/17/2021] [Indexed: 01/02/2023] Open
Abstract
Many recent disease outbreaks in humans had a zoonotic virus etiology. Bats in particular have been recognized as reservoirs to a large variety of viruses with the potential to cross-species transmission. In order to assess the risk of bats in Switzerland for such transmissions, we determined the virome of tissue and fecal samples of 14 native and 4 migrating bat species. In total, sequences belonging to 39 different virus families, 16 of which are known to infect vertebrates, were detected. Contigs of coronaviruses, adenoviruses, hepeviruses, rotaviruses A and H, and parvoviruses with potential zoonotic risk were characterized in more detail. Most interestingly, in a ground stool sample of a Vespertilio murinus colony an almost complete genome of a Middle East respiratory syndrome-related coronavirus (MERS-CoV) was detected by Next generation sequencing and confirmed by PCR. In conclusion, bats in Switzerland naturally harbour many different viruses. Metagenomic analyses of non-invasive samples like ground stool may support effective surveillance and early detection of viral zoonoses.
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Affiliation(s)
| | - Nadja Aeberhard
- Institute of Virology, University of Zurich, Zurich, Switzerland
| | - Weihong Qi
- Functional Genomics Center Zurich, Zurich, Switzerland
| | | | | | - Jean-Michel Hatt
- Clinic for Zoo Animals, Exotic Pets and Wildlife, University of Zurich, Zurich, Switzerland
| | - Cornel Fraefel
- Institute of Virology, University of Zurich, Zurich, Switzerland
| | - Jakub Kubacki
- Institute of Virology, University of Zurich, Zurich, Switzerland
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3
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Gelaw A, Pietsch C, Liebert UG. Genetic diversity of human adenovirus and human astrovirus in children with acute gastroenteritis in Northwest Ethiopia. Arch Virol 2019; 164:2985-2993. [DOI: 10.1007/s00705-019-04421-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2019] [Accepted: 08/29/2019] [Indexed: 02/06/2023]
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Baker AT, Mundy RM, Davies JA, Rizkallah PJ, Parker AL. Human adenovirus type 26 uses sialic acid-bearing glycans as a primary cell entry receptor. SCIENCE ADVANCES 2019; 5:eaax3567. [PMID: 31517055 PMCID: PMC6726447 DOI: 10.1126/sciadv.aax3567] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/16/2019] [Accepted: 07/29/2019] [Indexed: 05/02/2023]
Abstract
Adenoviruses are clinically important agents. They cause respiratory distress, gastroenteritis, and epidemic keratoconjunctivitis. As non-enveloped, double-stranded DNA viruses, they are easily manipulated, making them popular vectors for therapeutic applications, including vaccines. Species D adenovirus type 26 (HAdV-D26) is both a cause of EKC and other diseases and a promising vaccine vector. HAdV-D26-derived vaccines are under investigation as protective platforms against HIV, Zika, and respiratory syncytial virus infections and are in phase 3 clinical trials for Ebola. We recently demonstrated that HAdV-D26 does not use CD46 or Desmoglein-2 as entry receptors, while the putative interaction with coxsackie and adenovirus receptor is low affinity and unlikely to represent the primary cell receptor. Here, we establish sialic acid as a primary entry receptor used by HAdV-D26. We demonstrate that removal of cell surface sialic acid inhibits HAdV-D26 infection, and provide a high-resolution crystal structure of HAdV-D26 fiber-knob in complex with sialic acid.
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Affiliation(s)
- Alexander T. Baker
- Division of Cancer and Genetics, School of Medicine, Cardiff University, Heath Park, Cardiff CF14 4XN, UK
| | - Rosie M. Mundy
- Division of Cancer and Genetics, School of Medicine, Cardiff University, Heath Park, Cardiff CF14 4XN, UK
| | - James A. Davies
- Division of Cancer and Genetics, School of Medicine, Cardiff University, Heath Park, Cardiff CF14 4XN, UK
| | - Pierre J. Rizkallah
- Division of Infection and Immunity, School of Medicine, Cardiff University, Heath Park, Cardiff CF14 4XN, UK
| | - Alan L. Parker
- Division of Cancer and Genetics, School of Medicine, Cardiff University, Heath Park, Cardiff CF14 4XN, UK
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5
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Privatt SR, Bullard BL, Weaver EA, Wood C, West JT. Longitudinal quantification of adenovirus neutralizing responses in Zambian mother-infant pairs: Impact of HIV-1 infection and its treatment. Vaccine 2019; 37:5177-5184. [PMID: 31378535 DOI: 10.1016/j.vaccine.2019.07.074] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Revised: 07/17/2019] [Accepted: 07/23/2019] [Indexed: 01/04/2023]
Abstract
Vaccination offers the most cost-effective approach to limiting the adverse impact of infectious and neoplastic diseases that reduce the quality of life in sub-Saharan Africa (SSA). However, it is unclear what vaccine vectors would be most readily implementable in the setting and at what age they should be applied for maximal efficacy. Adenoviruses (Ad) and Ad-based vectors have been demonstrated to induce effective humoral and cellular immune responses in animal models and in humans. However, because immunity associated with Ad infection is lifelong, there exists a debate as to whether pre-existing immunity might decrease the efficacy of Ad vectored vaccines. In order to begin to rationally develop vaccination strategies for SSA, we have quantified neutralizing antibodies (nAb) against Ad4, Ad5, Ad7, Ad26, Ad28, Ad45 and Ad48 in 67 adult women and their infants. We are the first to define the decay kinetics of transferred maternal nAb in infants as well as the apparent initiation of de novo Ad responses. Our findings demonstrate that in Zambian adults, robust nAb responses exist against each of the Ads tested and are efficiently transferred to newborns. With few exceptions, neither the HIV-1 infection status of the mothers or the antiretroviral therapy (ART) treatment of HIV-1 disease had significant impact on maternal Ad nAb responses or their transfer to infants. However, maternal Ad nAb decays in infants to a nadir at 12 months of age such that any of the seven Ad types could function as vaccine vectors. The definition of this 'window of opportunity' provides important foundational data for rational design and implementation of Ad vectors in this setting.
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Affiliation(s)
- Sara R Privatt
- Nebraska Center for Virology and School of Biological Sciences, University of Nebraska, Lincoln, Nebraska, USA
| | - Brianna L Bullard
- Nebraska Center for Virology and School of Biological Sciences, University of Nebraska, Lincoln, Nebraska, USA
| | - Eric A Weaver
- Nebraska Center for Virology and School of Biological Sciences, University of Nebraska, Lincoln, Nebraska, USA
| | - Charles Wood
- Nebraska Center for Virology and School of Biological Sciences, University of Nebraska, Lincoln, Nebraska, USA
| | - John T West
- Nebraska Center for Virology and School of Biological Sciences, University of Nebraska, Lincoln, Nebraska, USA.
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6
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Surveillance for Adenoviruses in Bats in Italy. Viruses 2019; 11:v11060523. [PMID: 31174292 PMCID: PMC6631154 DOI: 10.3390/v11060523] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Revised: 05/28/2019] [Accepted: 06/04/2019] [Indexed: 01/16/2023] Open
Abstract
Adenoviruses are important pathogens of humans and animals. Bats have been recognized as potential reservoirs of novel viruses, with some viruses being regarded as a possible zoonotic threat to humans. In this study, we report the detection and analysis of adenoviruses from different bat species in northern Italy. Upon sequence and phylogenetic analysis, based on a short diagnostic fragment of the highly-conserved DNA polymerase gene, we identified potential novel candidate adenovirus species, including an avian-like adenovirus strain. An adenovirus isolate was obtained in simian cell lines from the carcass of a Pipistrellus kuhlii, and the complete genome sequence was reconstructed using deep sequencing technologies. The virus displayed high nucleotide identity and virtually the same genome organization as the Pipistrellus pipistrellus strain PPV1, isolated in Germany in 2007. Gathering data on epidemiology and the genetic diversity of bat adenoviruses may be helpful to better understand their evolution in the mammalian and avian hosts.
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Mennechet FJD, Paris O, Ouoba AR, Salazar Arenas S, Sirima SB, Takoudjou Dzomo GR, Diarra A, Traore IT, Kania D, Eichholz K, Weaver EA, Tuaillon E, Kremer EJ. A review of 65 years of human adenovirus seroprevalence. Expert Rev Vaccines 2019; 18:597-613. [PMID: 31132024 DOI: 10.1080/14760584.2019.1588113] [Citation(s) in RCA: 95] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Introduction: Human adenovirus (HAdV)-derived vectors have been used in numerous pre-clinical and clinical trials during the last 40 years. Current research in HAdV-based vaccines focuses on improving transgene immunogenicity and safety. Because pre-existing humoral immunity against HAdV types correlate with reduced vaccine efficacy and safety, many groups are exploring the development of HAdV types vectors with lower seroprevalence. However, global seroepidemiological data are incomplete. Areas covered: The goal of this review is to centralize 65 years of research on (primarily) HAdV epidemiology. After briefly addressing adenovirus biology, we chronical HAdV seroprevalence studies and highlight major milestones. Finally, we analyze data from about 50 studies with respect to HAdVs types that are currently used in the clinic, or are in the developmental pipeline. Expert opinion: Vaccination is among the most efficient tools to prevent infectious disease. HAdV-based vaccines have undeniable potential, but optimization is needed and antivector immunity remains a challenge if the same vectors are to be administrated to different populations. Here, we identify gaps in our knowledge and the need for updated worldwide epidemiological data.
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Affiliation(s)
- Franck J D Mennechet
- a Institut de Génétique Moléculaire de Montpellier , University of Montpellier - CNRS , Montpellier , France
| | - Océane Paris
- a Institut de Génétique Moléculaire de Montpellier , University of Montpellier - CNRS , Montpellier , France
| | - Aline Raissa Ouoba
- a Institut de Génétique Moléculaire de Montpellier , University of Montpellier - CNRS , Montpellier , France.,b UMR 1058, Pathogenesis and Control of Chronic Infections , INSERM - University of Montpellier - Establishment Français du Sang - Centre Hospitalier Universitaire de Montpellier , Montpellier , France.,c Département des sciences et de la recherche clinique , Centre Muraz , Bobo-Dioulasso , Burkina Faso
| | - Sofia Salazar Arenas
- a Institut de Génétique Moléculaire de Montpellier , University of Montpellier - CNRS , Montpellier , France
| | - Sodiomon B Sirima
- d Centre National de Recherche et de Formation sur le Paludisme , Ouagadougou , Burkina Faso.,e Groupe de Recherche Action en Santé (GRAS) , Ouagadougou , Burkina Faso
| | - Guy R Takoudjou Dzomo
- f Complexe Hospitalo Universitaire « Le Bon Samaritain » , N'Djamena , Republic of Chad
| | - Amidou Diarra
- d Centre National de Recherche et de Formation sur le Paludisme , Ouagadougou , Burkina Faso
| | - Isidore T Traore
- c Département des sciences et de la recherche clinique , Centre Muraz , Bobo-Dioulasso , Burkina Faso
| | - Dramane Kania
- c Département des sciences et de la recherche clinique , Centre Muraz , Bobo-Dioulasso , Burkina Faso
| | - Karsten Eichholz
- a Institut de Génétique Moléculaire de Montpellier , University of Montpellier - CNRS , Montpellier , France
| | - Eric A Weaver
- g University of Nebraska-Lincoln, School of Biological Sciences , Lincoln , NE , USA
| | - Edouard Tuaillon
- b UMR 1058, Pathogenesis and Control of Chronic Infections , INSERM - University of Montpellier - Establishment Français du Sang - Centre Hospitalier Universitaire de Montpellier , Montpellier , France
| | - Eric J Kremer
- a Institut de Génétique Moléculaire de Montpellier , University of Montpellier - CNRS , Montpellier , France
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8
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Kaján GL, Lipiec A, Bartha D, Allard A, Arnberg N. A multigene typing system for human adenoviruses reveals a new genotype in a collection of Swedish clinical isolates. PLoS One 2018; 13:e0209038. [PMID: 30550551 PMCID: PMC6294355 DOI: 10.1371/journal.pone.0209038] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Accepted: 11/27/2018] [Indexed: 12/11/2022] Open
Abstract
Human adenoviruses (HAdVs) are common pathogens that can cause respiratory, gastrointestinal, urogenital, and ocular infections. They are divided into seven species containing 85 genotypes. Straightforward typing systems might help epidemiological investigations. As homologous recombination frequently shapes the evolution of HAdVs, information on a single gene is seldom sufficient to allow accurate and precise typing, and complete genome-based methods are recommended. Even so, complete genome analyses are not always easy to perform for practical reasons, and in such cases a multigene system can provide considerably more information about the strain under investigation than single-gene-based methods. Here we present a rapid, generic, multigene typing system for HAdVs based on three main deterministic regions of these viruses. Three PCR systems were used to amplify the genes encoding the DNA polymerase, the penton base hypervariable Arg-Gly-Asp-containing loop, and the hexon loop 1 (hypervariable region 1-6). Using this system, we typed 281 clinical isolates, detected members of six out of seven HAdV species (Human mastadenovirus A-F), and could also detect not only divergent strains of established types but also a new recombinant strain with a previously unpublished combination of adenovirus genomes. This strain was accepted by the Human Adenovirus Working Group as a novel genotype: HAdV-86. Seven strains that could not be typed with sufficient accuracy were also investigated using a PCR based on part of the fiber gene. By analysis of corresponding sequences of the 86 known HAdV genotypes, we determined that the proposed typing system should be able to distinguish all non-recombinant types, and with additional fiber information, all known HAdV genotypes.
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Affiliation(s)
- Győző László Kaján
- Department of Clinical Microbiology, Virology, and Laboratory for Molecular Infection Medicine Sweden (MIMS), Umeå University, Umeå, Sweden
- Institute for Veterinary Medical Research, Centre for Agricultural Research, Hungarian Academy of Sciences, Budapest, Hungary
- * E-mail:
| | - Agnieszka Lipiec
- Department of Clinical Microbiology, Virology, and Laboratory for Molecular Infection Medicine Sweden (MIMS), Umeå University, Umeå, Sweden
| | - Dániel Bartha
- Institute for Veterinary Medical Research, Centre for Agricultural Research, Hungarian Academy of Sciences, Budapest, Hungary
| | - Annika Allard
- Department of Clinical Microbiology, Virology, and Laboratory for Molecular Infection Medicine Sweden (MIMS), Umeå University, Umeå, Sweden
| | - Niklas Arnberg
- Department of Clinical Microbiology, Virology, and Laboratory for Molecular Infection Medicine Sweden (MIMS), Umeå University, Umeå, Sweden
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9
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Portal TM, Reymão TKA, Quinderé Neto GA, Fiuza MKDC, Teixeira DM, Lima ICG, Sousa Júnior EC, Bandeira RDS, De Deus DR, Justino MCA, Linhares ADC, Silva LDD, Resque HR, Gabbay YB. Detection and genotyping of enteric viruses in hospitalized children with acute gastroenteritis in Belém, Brazil: Occurrence of adenovirus viremia by species F, types 40/41. J Med Virol 2018; 91:378-384. [DOI: 10.1002/jmv.25321] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Accepted: 09/13/2018] [Indexed: 12/21/2022]
Affiliation(s)
- Thayara Morais Portal
- Postgraduate Program in Parasitic Biology in the Amazon, University of State of Pará; Belém Pará Brazil
| | | | | | | | - Dielle Monteiro Teixeira
- Virology Section; Evandro Chagas Institute, Health Surveillance Secretariat, Brazilian Ministry of Health; Ananindeua Pará Brazil
| | - Ian Carlos Gomes Lima
- Virology Section; Evandro Chagas Institute, Health Surveillance Secretariat, Brazilian Ministry of Health; Ananindeua Pará Brazil
| | - Edivaldo Costa Sousa Júnior
- Virology Section; Evandro Chagas Institute, Health Surveillance Secretariat, Brazilian Ministry of Health; Ananindeua Pará Brazil
| | - Renato Da Silva Bandeira
- Virology Section; Evandro Chagas Institute, Health Surveillance Secretariat, Brazilian Ministry of Health; Ananindeua Pará Brazil
| | | | - Maria Cleonice A Justino
- Virology Section; Evandro Chagas Institute, Health Surveillance Secretariat, Brazilian Ministry of Health; Ananindeua Pará Brazil
| | - Alexandre Da Costa Linhares
- Virology Section; Evandro Chagas Institute, Health Surveillance Secretariat, Brazilian Ministry of Health; Ananindeua Pará Brazil
| | - Luciana Damascena Da Silva
- Virology Section; Evandro Chagas Institute, Health Surveillance Secretariat, Brazilian Ministry of Health; Ananindeua Pará Brazil
| | - Hugo Reis Resque
- Virology Section; Evandro Chagas Institute, Health Surveillance Secretariat, Brazilian Ministry of Health; Ananindeua Pará Brazil
| | - Yvone Benchimol Gabbay
- Virology Section; Evandro Chagas Institute, Health Surveillance Secretariat, Brazilian Ministry of Health; Ananindeua Pará Brazil
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Wu X, Lu X, Schneider E, Ahmed JA, Njenga MK, Breiman RF, Eidex RB, Erdman DD. Reassessment of high prevalence human adenovirus detections among residents of two refugee centers in Kenya under surveillance for acute respiratory infections. J Med Virol 2018; 91:385-391. [PMID: 30242854 DOI: 10.1002/jmv.25320] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2018] [Accepted: 09/12/2018] [Indexed: 12/20/2022]
Abstract
Human adenoviruses (HAdVs) were previously detected at high prevalence by real-time reverse transcription-polymerase chain reaction (rRT-PCR) in the upper respiratory tract of residents of two Kenyan refugee camps under surveillance for acute respiratory infection (ARI) between October 2006 and April 2008. We sought to confirm this finding and characterize the HAdVs detected. Of 2148 respiratory specimens originally tested, 511 (23.8%) screened positive for HAdV and 510 were available for retesting. Of these, 421 (82.4%) were confirmed positive by repeat rRT-PCR or PCR and sequencing. Other respiratory viruses were codetected in 55.8% of confirmed HAdV-positive specimens. Species B and C viruses predominated at 82.8%, and HAdV-C1, -C2, and -B3 were the most commonly identified types. Species A, D, and F HAdVs, which are rarely associated with ARI, comprised the remainder. Viral loads were highest among species B HAdVs, particularly HAdV-B3. Species C showed the widest range of viral loads, and species A, D, and F were most often present at low loads and more often with codetections. These findings suggest that many HAdV detections were incidental and not a primary cause of ARI among camp patients. Species/type, codetections, and viral load determinations may permit more accurate HAdV disease burden estimates in these populations.
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Affiliation(s)
- Xinwei Wu
- Department of Microbiology, Guangzhou Center for Disease Control and Prevention, Guangzhou, China
| | - Xiaoyan Lu
- Division of Viral Diseases, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia
| | - Eileen Schneider
- Division of Viral Diseases, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia
| | - Jamal A Ahmed
- Surveillance, Lab and Data (SLD), Polio Eradication, World Health Organization, Geneva, Switzerland
| | - M Kariuki Njenga
- Washington State University Global Health - Kenya, Washington State University, Pullman, Washington
| | - Robert F Breiman
- Emory Global Health Institute, Emory University, Atlanta, Georgia
| | - Rachel B Eidex
- Division of Global Migration and Quarantine, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia
| | - Dean D Erdman
- Division of Viral Diseases, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia
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Bacterial RecA Protein Promotes Adenoviral Recombination during In Vitro Infection. mSphere 2018; 3:3/3/e00105-18. [PMID: 29925671 PMCID: PMC6010623 DOI: 10.1128/msphere.00105-18] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2018] [Accepted: 06/03/2018] [Indexed: 12/30/2022] Open
Abstract
Adenoviruses are common human mucosal pathogens of the gastrointestinal, respiratory, and genitourinary tracts and ocular surface. Here, we report finding Chi-like sequences in adenovirus recombination hot spots. Adenovirus coinfection in the presence of bacterial RecA protein facilitated homologous recombination between viruses. Genetic recombination led to evolution of an important external feature on the adenoviral capsid, namely, the penton base protein hypervariable loop 2, which contains the arginine-glycine-aspartic acid motif critical to viral internalization. We speculate that free Rec proteins present in gastrointestinal secretions upon bacterial cell death facilitate the evolution of human adenoviruses through homologous recombination, an example of viral commensalism and the complexity of virus-host interactions, including regional microbiota. Adenovirus infections in humans are common and sometimes lethal. Adenovirus-derived vectors are also commonly chosen for gene therapy in human clinical trials. We have shown in previous work that homologous recombination between adenoviral genomes of human adenovirus species D (HAdV-D), the largest and fastest growing HAdV species, is responsible for the rapid evolution of this species. Because adenovirus infection initiates in mucosal epithelia, particularly at the gastrointestinal, respiratory, genitourinary, and ocular surfaces, we sought to determine a possible role for mucosal microbiota in adenovirus genome diversity. By analysis of known recombination hot spots across 38 human adenovirus genomes in species D (HAdV-D), we identified nucleotide sequence motifs similar to bacterial Chi sequences, which facilitate homologous recombination in the presence of bacterial Rec enzymes. These motifs, referred to here as ChiAD, were identified immediately 5′ to the sequence encoding penton base hypervariable loop 2, which expresses the arginine-glycine-aspartate moiety critical to adenoviral cellular entry. Coinfection with two HAdV-Ds in the presence of an Escherichia coli lysate increased recombination; this was blocked in a RecA mutant strain, E. coli DH5α, or upon RecA depletion. Recombination increased in the presence of E. coli lysate despite a general reduction in viral replication. RecA colocalized with viral DNA in HAdV-D-infected cell nuclei and was shown to bind specifically to ChiAD sequences. These results indicate that adenoviruses may repurpose bacterial recombination machinery, a sharing of evolutionary mechanisms across a diverse microbiota, and unique example of viral commensalism. IMPORTANCE Adenoviruses are common human mucosal pathogens of the gastrointestinal, respiratory, and genitourinary tracts and ocular surface. Here, we report finding Chi-like sequences in adenovirus recombination hot spots. Adenovirus coinfection in the presence of bacterial RecA protein facilitated homologous recombination between viruses. Genetic recombination led to evolution of an important external feature on the adenoviral capsid, namely, the penton base protein hypervariable loop 2, which contains the arginine-glycine-aspartic acid motif critical to viral internalization. We speculate that free Rec proteins present in gastrointestinal secretions upon bacterial cell death facilitate the evolution of human adenoviruses through homologous recombination, an example of viral commensalism and the complexity of virus-host interactions, including regional microbiota.
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12
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Vos HJ, Knox CM. The recovery and molecular identification of HAdV-D17 in raw sewage and mussel samples collected in the Eastern Cape province of South Africa. S Afr J Infect Dis 2018. [DOI: 10.1080/23120053.2017.1368617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Affiliation(s)
- Hillary J Vos
- Department of Biochemistry and Microbiology, Rhodes University, Grahamstown, South Africa
| | - Caroline M Knox
- Department of Biochemistry and Microbiology, Rhodes University, Grahamstown, South Africa
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13
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Iaconelli M, Valdazo-González B, Equestre M, Ciccaglione AR, Marcantonio C, Della Libera S, La Rosa G. Molecular characterization of human adenoviruses in urban wastewaters using next generation and Sanger sequencing. WATER RESEARCH 2017; 121:240-247. [PMID: 28550812 DOI: 10.1016/j.watres.2017.05.039] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Revised: 05/17/2017] [Accepted: 05/19/2017] [Indexed: 05/18/2023]
Abstract
Human adenoviruses (HAdVs) are of major public health importance and are associated with a variety of clinical manifestations, including gastroenteritis, respiratory, ocular and urinary tract infections. To study the occurrence, prevalence and diversity of HAdV species and types circulating in Italy, we conducted a large-scale molecular-epidemiological investigation, a yearlong monitoring of 22 wastewater treatment plants, covering 10 Italian regions, representative of northern, central, and southern Italy. A total of 141 raw sewage samples were collected from January to December 2013, and processed to detect and characterize by phylogenetic analysis a fragment of the hexon coding region of HAdVs. Nested PCR results showed the presence of HAdVs in 85 out of 141 samples (60% of samples). Fifty-nine samples were characterized by conventional Sanger sequencing as belonging to four HAdV species and four types: A (type 12, 5 samples), B (type 3, 8 samples), C (type 5, 1 sample) and F (type 41, 45 samples). The remaining 26 samples could not be characterized because of uninterpretable (mixed) electropherograms suggesting the presence of multiple species and/or types. Pools of characterized and uncharacterized PCR amplicons were further analyzed by next-generation sequencing (NGS). NGS results revealed a marked HAdV diversity with 16 additional types detected beyond the four types found by Sanger sequencing. Overall, 19 types were identified, belonging to HAdV species A-F: types 12 and 31 (species A), type 3 (species B), types 1, 2, and 5 (species C), types 9, 17, 24, 26, 37, 38, 42, 44, 48, and 70 (species D), type 4 (species E), and types 40 and 41(species F). An untypeable HAdV was also detected, showing similar percentages of identity with more than one prototype (types 15, 30, 56, and 59). Our findings documented the circulation of a wide variety of species and types in raw sewage, potentially able to affect other surface water environments and hence human health. Next-generation sequencing proved to be an effective strategy for HAdV genotyping in wastewater samples. It was able to detect a wide range of "less prevalent" types unidentified by conventional Sanger sequencing, confirming that studies based on conventional technologies may grossly underestimate the existence of some, possibly less common, types. Knowledge of the distribution of HAdV species and types would improve our understanding of waterborne HAdV-related health risks.
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Affiliation(s)
- M Iaconelli
- Istituto Superiore di Sanità, Department of Environment and Health, Rome, Italy
| | - B Valdazo-González
- The National Institute for Biological Standards and Control, Potters Bar, United Kingdom
| | - M Equestre
- Istituto Superiore di Sanità, Department of Cell Biology and Neurosciences, Rome, Italy
| | - A R Ciccaglione
- Istituto Superiore di Sanità, Department of Infectious, Parasitic and Immune-Mediated Diseases, Rome, Italy
| | - C Marcantonio
- Istituto Superiore di Sanità, Department of Infectious, Parasitic and Immune-Mediated Diseases, Rome, Italy
| | - S Della Libera
- Istituto Superiore di Sanità, Department of Environment and Health, Rome, Italy
| | - G La Rosa
- Istituto Superiore di Sanità, Department of Environment and Health, Rome, Italy.
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14
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Costa LCPDN, Siqueira JAM, Portal TM, Sousa Júnior EC, Linhares ADC, Gabbay YB, Resque HR. Detection and genotyping of human adenovirus and sapovirus in children with acute gastroenteritis in Belém, Pará, between 1990 and 1992: first detection of GI.7 and GV.2 sapoviruses in Brazil. Rev Soc Bras Med Trop 2017; 50:621-628. [DOI: 10.1590/0037-8682-0198-2017] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Accepted: 09/19/2017] [Indexed: 01/12/2023] Open
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15
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Tan B, Yang XL, Ge XY, Peng C, Zhang YZ, Zhang LB, Shi ZL. Novel bat adenoviruses with an extremely large E3 gene. J Gen Virol 2016; 97:1625-1635. [PMID: 27032099 DOI: 10.1099/jgv.0.000470] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Bats carry diverse RNA viruses, some of which are responsible for human diseases. Compared to bat-borne RNA viruses, relatively little information is known regarding bat-borne DNA viruses. In this study, we isolated and characterized three novel bat adenoviruses (BtAdV WIV9-11) from Rhinolophus sinicus. Their genomes, which are highly similar to each other but distinct from those of previously sequenced adenoviruses (AdVs), are 37 545, 37 566 and 38 073 bp in size, respectively. An unusually large E3 gene was identified in their genomes. Phylogenetic and taxonomic analyses suggested that these isolates represent a distinct species of the genus Mastadenovirus. Cell susceptibility assays revealed a broad cell tropism for these isolates, indicating that they have a potentially wide host range. Our results expand the understanding of genetic diversity of bat AdVs.
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Affiliation(s)
- Bing Tan
- Key Laboratory of Special Pathogens and Center for Emerging Infectious Diseases, Wuhan Institute of Virology, Chinese Academy of Sciences, Wuhan, China
| | - Xing-Lou Yang
- Key Laboratory of Special Pathogens and Center for Emerging Infectious Diseases, Wuhan Institute of Virology, Chinese Academy of Sciences, Wuhan, China
| | - Xing-Yi Ge
- Key Laboratory of Special Pathogens and Center for Emerging Infectious Diseases, Wuhan Institute of Virology, Chinese Academy of Sciences, Wuhan, China
| | - Cheng Peng
- Key Laboratory of Special Pathogens and Center for Emerging Infectious Diseases, Wuhan Institute of Virology, Chinese Academy of Sciences, Wuhan, China
| | - Yun-Zhi Zhang
- Yunnan Provincial Key Laboratory for Zoonosis Control and Prevention, Yunnan Institute of Endemic Diseases Control and Prevention, Dali, China
| | | | - Zheng-Li Shi
- Key Laboratory of Special Pathogens and Center for Emerging Infectious Diseases, Wuhan Institute of Virology, Chinese Academy of Sciences, Wuhan, China
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16
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Anoh AE, Akoua-Koffi C, Couacy-Hymann E, Pauly M, Schubert G, Mossoun A, Weiss S, Leendertz SAJ, Jarvis MA, Leendertz FH, Ehlers B. Genetic identification of cytomegaloviruses in a rural population of Côte d'Ivoire. Virol J 2015; 12:155. [PMID: 26437859 PMCID: PMC4594925 DOI: 10.1186/s12985-015-0394-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2015] [Accepted: 09/24/2015] [Indexed: 01/10/2023] Open
Abstract
Background Cytomegaloviruses (CMVs) are herpesviruses that infect many mammalian species, including humans. Infection generally passes undetected, but the virus can cause serious disease in individuals with impaired immune function. Human CMV (HCMV) is circulating with high seroprevalence (60–100 %) on all continents. However, little information is available on HCMV genoprevalence and genetic diversity in subsaharan Africa, especially in rural areas of West Africa that are at high risk of human-to-human HCMV transmission. In addition, there is a potential for zoonotic spillover of pathogens through bushmeat hunting and handling in these areas as shown for various retroviruses. Although HCMV and nonhuman CMVs are regarded as species-specific, potential human infection with CMVs of non-human primate (NHP) origin, shown to circulate in the local NHP population, has not been studied. Findings Analysis of 657 human oral swabs and fecal samples collected from 518 individuals living in 8 villages of Côte d’Ivoire with generic PCR for identification of human and NHP CMVs revealed shedding of HCMV in 2.5 % of the individuals. Determination of glycoprotein B sequences showed identity with strains Towne, AD169 and Toledo, respectively. NHP CMV sequences were not detected. Conclusions HCMV is actively circulating in a proportion of the rural Côte d’Ivoire human population with circulating strains being closely related to those previously identified in non-African countries. The lack of NHP CMVs in human populations in an environment conducive to cross-species infection supports zoonotic transmission of CMVs to humans being at most a rare event.
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Affiliation(s)
- Augustin Etile Anoh
- Centre de Recherche pour le Développement, Université Alassane Ouattara de Bouake, 01 BP V18, Bouake, Côte d'Ivoire.
| | - Chantal Akoua-Koffi
- Centre de Recherche pour le Développement, Université Alassane Ouattara de Bouake, 01 BP V18, Bouake, Côte d'Ivoire.
| | | | - Maude Pauly
- Project group P3 "Epidemiology of Highly Pathogenic Microorganisms", Robert Koch Institute, Berlin, 13353, Germany. .,Division 12 "Measles, Mumps, Rubella and Viruses affecting immune-compromised patients", Robert Koch Institute, Berlin, 13353, Germany. .,Present address: Department of Infection and Immunity, Luxembourg Institute of Health, Esch-sur-Alzette, 4354, Luxembourg.
| | - Grit Schubert
- Project group P3 "Epidemiology of Highly Pathogenic Microorganisms", Robert Koch Institute, Berlin, 13353, Germany.
| | - Arsène Mossoun
- LANADA/Laboratoire Central de Pathologie Animale, Bingerville, 206, Côte d'Ivoire. .,UFR Biosciences, Université FHB, Abidjan-Cocody, Côte d'Ivoire, Abidjan, Côte d'Ivoire.
| | - Sabrina Weiss
- Project group P3 "Epidemiology of Highly Pathogenic Microorganisms", Robert Koch Institute, Berlin, 13353, Germany. .,Present address: European Public Health Microbiology (EUPHEM) training programme, European Centre for Disease Prevention and Control (ECDC), Stockholm, Sweden, and Public Health England (PHE), London, NW9 5EQ, UK.
| | - Siv Aina J Leendertz
- Project group P3 "Epidemiology of Highly Pathogenic Microorganisms", Robert Koch Institute, Berlin, 13353, Germany.
| | - Michael A Jarvis
- School of Biomedical and Healthcare Sciences, Plymouth University, Plymouth, United Kingdom.
| | - Fabian H Leendertz
- Project group P3 "Epidemiology of Highly Pathogenic Microorganisms", Robert Koch Institute, Berlin, 13353, Germany.
| | - Bernhard Ehlers
- Division 12 "Measles, Mumps, Rubella and Viruses affecting immune-compromised patients", Robert Koch Institute, Berlin, 13353, Germany.
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17
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Hoppe E, Pauly M, Robbins M, Gray M, Kujirakwinja D, Nishuli R, Boji Mungu-Akonkwa DD, Leendertz FH, Ehlers B. Phylogenomic evidence for recombination of adenoviruses in wild gorillas. J Gen Virol 2015. [DOI: 10.1099/jgv.0.000250] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Affiliation(s)
- Eileen Hoppe
- Division 12 ‘Measles, Mumps, Rubella and Viruses affecting immunocompromised patients’, Robert Koch Institute, 13353 Berlin, Germany
| | - Maude Pauly
- Division 12 ‘Measles, Mumps, Rubella and Viruses affecting immunocompromised patients’, Robert Koch Institute, 13353 Berlin, Germany
- P3 ‘Epidemiology of highly pathogenic microorganisms’, Robert Koch Institute, 13353 Berlin, Germany
| | - Martha Robbins
- Department of Primatology, Max Planck Institute for Evolutionary Anthropology, Leipzig, Germany
| | - Maryke Gray
- Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Deo Kujirakwinja
- Wildlife Conservation Society, Grauer's Gorilla Project, Democratic Republic of the Congo
| | - Radar Nishuli
- Institut Congolais pour la Conservation de la Nature, Democratic Republic of the Congo
| | | | - Fabian H. Leendertz
- P3 ‘Epidemiology of highly pathogenic microorganisms’, Robert Koch Institute, 13353 Berlin, Germany
| | - Bernhard Ehlers
- Division 12 ‘Measles, Mumps, Rubella and Viruses affecting immunocompromised patients’, Robert Koch Institute, 13353 Berlin, Germany
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18
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Pauly M, Akoua-Koffi C, Buchwald N, Schubert G, Weiss S, Couacy-Hymann E, Anoh AE, Mossoun A, Calvignac-Spencer S, Leendertz SA, Leendertz FH, Ehlers B. Adenovirus in Rural Côte D'Ivoire: High Diversity and Cross-Species Detection. ECOHEALTH 2015; 12:441-452. [PMID: 25990885 DOI: 10.1007/s10393-015-1032-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/18/2014] [Revised: 03/17/2015] [Accepted: 04/21/2015] [Indexed: 06/04/2023]
Abstract
The Taï region in Western Côte d'Ivoire is characterized by extensive overlap of human and animal habitats. This could influence patterns of adenovirus transmission between humans and domestic animals. Fecal samples from humans and various domestic animals were tested for the presence of adenoviruses by PCR. Phylogenetic and species delineation analyses were performed to further characterize the adenoviruses circulating in the region and to identify potential cross-species transmission events. Among domestic animals, adenovirus shedding was frequent (21.6% of domestic mammals and 41.5% of chickens) and the detected strains were highly diverse, several of them representing novel types. Although no evidence for zoonotic transmission of animal adenovirus was obtained, the present study provides concordant evidence in favor of common cross-species transmission of adenoviruses between different animal species and first indications for adenovirus transmission from humans to animals. These findings underline the thus far underestimated importance of reverse zoonotic transmission of viruses and of the role of domestic animals as pathogen reservoirs, "bridge species," or intermediate hosts.
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Affiliation(s)
- Maude Pauly
- Project Group "Epidemiology of highly pathogenic microorganisms", Robert Koch Institute, Nordufer 20, 13353, Berlin, Germany
- Division 12 "Measles, Mumps, Rubella and Viruses affecting immunocompromised patients", Robert Koch Institute, Seestr. 10, 13353, Berlin, Germany
- Department of Immunology, Luxembourg Institute of Health, 20A Rue Auguste Lumière, 1950, Luxembourg, Luxembourg
| | - Chantal Akoua-Koffi
- Centre de Recherche pour le Développement, Université Alassane Ouattara of Bouake, BP V18, Bouake 01, Côte d'Ivoire
| | - Nanina Buchwald
- Division 12 "Measles, Mumps, Rubella and Viruses affecting immunocompromised patients", Robert Koch Institute, Seestr. 10, 13353, Berlin, Germany
| | - Grit Schubert
- Project Group "Epidemiology of highly pathogenic microorganisms", Robert Koch Institute, Nordufer 20, 13353, Berlin, Germany
| | - Sabrina Weiss
- Project Group "Epidemiology of highly pathogenic microorganisms", Robert Koch Institute, Nordufer 20, 13353, Berlin, Germany
| | - Emmanuel Couacy-Hymann
- Laboratoire National d`Aide au Développement Agricole/Laboratoire Central de Pathologie Animale, 206, Bingerville, Côte d'Ivoire
| | - Augustin Etile Anoh
- Centre de Recherche pour le Développement, Université Alassane Ouattara of Bouake, BP V18, Bouake 01, Côte d'Ivoire
- Laboratoire National d`Aide au Développement Agricole/Laboratoire Central de Pathologie Animale, 206, Bingerville, Côte d'Ivoire
| | - Arsène Mossoun
- Centre de Recherche pour le Développement, Université Alassane Ouattara of Bouake, BP V18, Bouake 01, Côte d'Ivoire
- Laboratoire National d`Aide au Développement Agricole/Laboratoire Central de Pathologie Animale, 206, Bingerville, Côte d'Ivoire
| | - Sébastien Calvignac-Spencer
- Project Group "Epidemiology of highly pathogenic microorganisms", Robert Koch Institute, Nordufer 20, 13353, Berlin, Germany
| | - Siv Aina Leendertz
- Project Group "Epidemiology of highly pathogenic microorganisms", Robert Koch Institute, Nordufer 20, 13353, Berlin, Germany
| | - Fabian H Leendertz
- Project Group "Epidemiology of highly pathogenic microorganisms", Robert Koch Institute, Nordufer 20, 13353, Berlin, Germany.
| | - Bernhard Ehlers
- Division 12 "Measles, Mumps, Rubella and Viruses affecting immunocompromised patients", Robert Koch Institute, Seestr. 10, 13353, Berlin, Germany.
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19
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Kajon AE, Lamson D, Shudt M, Oikonomopoulou Z, Fisher B, Klieger S, St George K, Hodinka RL. Identification of a novel intertypic recombinant species D human adenovirus in a pediatric stem cell transplant recipient. J Clin Virol 2014; 61:496-502. [PMID: 25449172 DOI: 10.1016/j.jcv.2014.09.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2014] [Revised: 08/08/2014] [Accepted: 09/19/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND Human adenoviruses (HAdV) are known opportunistic pathogens in hematopoietic stem cell transplant (SCT) recipients. The detection of HAdV infection in children after SCT has been implicated as a determinant of poor outcome but specific associations between HAdV species or individual HAdV types and disease are poorly understood. OBJECTIVES Characterization of a HAdV-D strain isolated from multiple clinical specimens of an 11-year-old female recipient of a matched unrelated donor peripheral SCT for T-cell lymphoma and case report. STUDY DESIGN Archived HAdV PCR-positive plasma, urine, and stool specimens were processed for virus isolation and detailed molecular typing. Complete genomic sequencing was carried out on 2 isolates. RESULTS The patient tested positive for HAdV DNA by real-time PCR of a stool specimen at 44 days after initiation of a SCT conditioning regimen. In the subsequent 3 months, HAdV was detected in plasma, urine and stool specimens in association with symptoms of gastroenteritis and hemorrhagic cystitis. A novel HAdV-D with a HAdV20-like hexon gene was isolated from both urine and stool specimens. All isolates yielded identical restriction profiles with endonucleases BamHI, BglII, BstEII, HindIII, PstI and SmaI. Analysis of 2 complete genomic sequences further identified the virus as a novel intertypic recombinant HAdV-D (P20/H20/F42) closely related to HAdV42. CONCLUSIONS This case highlights the identification of a previously unknown HAdV-D from an immunocompromised host. In this patient, the course of adenovirus infection is compatible with reactivation of a latent virus or a primary opportunistic infection. Adenoviremia in this patient resolved without definitive adenovirus-directed antiviral therapy.
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Affiliation(s)
- Adriana E Kajon
- Infectious Disease Program, Lovelace Respiratory Research Institute, Albuquerque, NM, USA.
| | - Daryl Lamson
- Virology Laboratory, Wadsworth Center, New York State Department of Health, Albany, NY, USA
| | - Matthew Shudt
- Applied Genomics Technologies Core, Wadsworth Center, New York State Department of Health, Albany, NY, USA
| | - Zacharoula Oikonomopoulou
- Division of Infectious Diseases, and The Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Brian Fisher
- Division of Infectious Diseases, and The Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Sarah Klieger
- Division of Infectious Diseases, and The Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Kirsten St George
- Virology Laboratory, Wadsworth Center, New York State Department of Health, Albany, NY, USA
| | - Richard L Hodinka
- Department of Pathology and Laboratory Medicine and Clinical Virology Laboratory, Children's Hospital of Philadelphia and Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
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