Comparison of the inhibition of human metapneumovirus and respiratory syncytial virus by ribavirin and immune serum globulin in vitro

Human metapneumovirus (hMPV) is a newly recognized pathogen that like its better-known relative, human respiratory syncytial virus (hRSV), appears to be ubiquitous and an important cause of respiratory disease in diverse subpopulations. No antivirals or vaccines are currently approved for the treatment or prevention of hMPV infections. However, ribavirin is licensed to treat serious hRSV-induced infections in children and immune globulin designed for intravenous administration (i.v.IG) and palivizumab (Synagis), a humanized monoclonal antibody preparation, have been utilized as alternatives to vaccines for preventing or reducing the severity of infections caused by this virus. Because both ribavirin and i.v.IG have broad viral specificities, studies were performed to compare the ability of these two agents to inhibit the replication of hRSV and hMPV in tissue culture-based assays. Two experimental chemotherapeutic agents (i.e. VP14637 and JNJ2408068) and different antibody preparations were included in this testing for comparison. Ribavirin and the i.v.IG utilized were found to have equivalent antiviral activity against hMPV and hRSV. In contrast, except for antisera specifically raised against hMPV, all of the other materials tested had marked activity only against hRSV.

Substituted benzimidazoles with nanomolar activity against respiratory syncytial virus

A cell-based assay was used to discover compounds inhibiting respiratory syncytial virus (RSV)-induced fusion in HeLa/M cells. A lead compound was identified and subsequent synthesis of >300 analogues led to the identification of JNJ 2408068 (R170591), a low molecular weight (MW 395) benzimidazole derivative with an EC(50) (0.16 nM) against some lab strains almost 100,000 times better than that of ribavirin (15 microM). Antiviral activity was confirmed for subgroup A and B clinical isolates of human RSV and for a bovine RSV isolate. The compound did not inhibit the growth of representative viruses from other Paramyxovirus genera, i.e. HPIV2 and Mumps Virus (genus Rubulavirus), HPIV3 (genus Respirovirus), Measles virus (genus Morbillivirus) and hMPV. Efficacy in cytopathic effect inhibition assays correlated well with efficacy in virus yield reduction assays. A concentration of 10nM reduced RSV production 1000-fold in multi-cycle experiments, irrespective of the multiplicity of infection. Time of addition studies pointed to a dual mode of action: inhibition of virus-cell fusion early in the infection cycle and inhibition of cell-cell fusion at the end of the replication cycle. Two resistant mutants were raised and shown to have single point mutations in the F-gene (S398L and D486N). JNJ 2408068 was also shown to inhibit the release of proinflammatory cytokines IL-6, IL-8 and Rantes from RSV-infected A549 cells.

The synthetic bacterial lipopeptide Pam3CSK4 modulates respiratory syncytial virus infection independent of TLR activation

Respiratory syncytial virus (RSV) is an important cause of acute respiratory disease in infants, immunocompromised subjects and the elderly. However, it is unclear why most primary RSV infections are associated with relatively mild symptoms, whereas some result in severe lower respiratory tract infections and bronchiolitis. Since RSV hospitalization has been associated with respiratory bacterial co-infections, we have tested if bacterial Toll-like receptor (TLR) agonists influence RSV-A2-GFP infection in human primary cells or cell lines. The synthetic bacterial lipopeptide Pam3-Cys-Ser-Lys4 (Pam3CSK4), the prototype ligand for the heterodimeric TLR1/TLR2 complex, enhanced RSV infection in primary epithelial, myeloid and lymphoid cells. Surprisingly, enhancement was optimal when lipopeptides and virus were added simultaneously, whereas addition of Pam3CSK4 immediately after infection had no effect. We have identified two structurally related lipopeptides without TLR-signaling capacity that also modulate RSV infection, whereas Pam3CSK4-reminiscent TLR1/2 agonists did not, and conclude that modulation of infection is independent of TLR activation. A similar TLR-independent enhancement of infection could also be demonstrated for wild-type RSV strains, and for HIV-1, measles virus and human metapneumovirus. We show that the effect of Pam3CSK4 is primarily mediated by enhanced binding of RSV to its target cells. The N-palmitoylated cysteine and the cationic lysines were identified as pivotal for enhanced virus binding. Surprisingly, we observed inhibition of RSV infection in immortalized epithelial cell lines, which was shown to be related to interactions between Pam3CSK4 and negatively charged glycosaminoglycans on these cells, which are known targets for binding of laboratory-adapted but not wild-type RSV. These data suggest a potential role for bacterial lipopeptides in enhanced binding of RSV and other viruses to their target cells, thus affecting viral entry or spread independent of TLR signaling. Moreover, our results also suggest a potential application for these synthetic lipopeptides as adjuvants for live-attenuated viral vaccines.

Respiratory syncytial virus (RSV) infections are an important cause of hospitalization of infants during the winter season. However, RSV is often not the only detectable pathogen, but co-infections with respiratory bacteria are common. It has been hypothesized that this results from epithelial damage caused by the virus, facilitating colonization by pathogenic bacteria such as Streptococcus pneumoniae. However, an inverse order of events is not impossible: bacterial infections may activate respiratory epithelial cells through TLR signaling, resulting in increased susceptibility to virus infections. We tested this hypothesis by screening bacterial TLR agonists for their capacity to modulate RSV infection in different cell types, and identified the lipopeptide and prototype TLR1/2 agonist Pam3CSK4 as an enhancer of RSV infections. However, to our surprise this proved independent of TLR activation, but was mediated by enhancement of binding between virus and target cell. Two structurally related lipopeptides unable to stimulate TLR responses were identified that enhanced infections with RSV, but also with other enveloped viruses including HIV-1, human metapneumovirus, and measles virus. We speculate that bacterial infections may influence the pathogenesis of virus infections by facilitating binding to target cells.

Avian metapneumovirus (AMPV) attachment protein involvement in probable virus evolution concurrent with mass live vaccine introduction

Avian metapneumoviruses detected in Northern Italy between 1987 and 2007 were sequenced in their fusion (F) and attachment (G) genes together with the same genes from isolates collected throughout western European prior to 1994. Fusion protein genes sequences were highly conserved while G protein sequences showed much greater heterogeneity. Phylogenetic studies based on both genes clearly showed that later Italian viruses were significantly different to all earlier virus detections, including early detections from Italy. Furthermore a serine residue in the G proteins and lysine residue in the fusion protein were exclusive to Italian viruses, indicating that later viruses probably arose within the country and the notion that these later viruses evolved from earlier Italian progenitors cannot be discounted. Biocomputing analysis applied to F and G proteins of later Italian viruses predicted that only G contained altered T cell epitopes. It appears likely that Italian field viruses evolved in response to selection pressure from vaccine induced immunity.

Comparison of the inhibition of human metapneumovirus and respiratory syncytial virus by NMSO3 in tissue culture assays

Human metapneumovirus (hMPV) is a recently elucidated respiratory virus pathogen for which there are no agents currently licensed to prevent or treat infections caused by it. However, NMSO3 has been reported to inhibit replication of human respiratory syncytial virus (hRSV), a virus that is closely related to hMPV, both in vitro in tissue culture cells and in vivo in cotton rats. For this reason, experiments were performed to compare the antiviral activity of NMSO3 against both hRSV and hMPV in tissue culture-based assays. Heparin and ribavirin, two other compounds known to inhibit hRSV, and two other paramyxoviruses, human parainfluenza virus type 3 (PIV3) and measles virus (MV), were included in these tests for comparison. All three compounds significantly inhibited the replication of subtype A and B strains of hRSV and serotypes 1 and 2 hMPV. However, unlike ribavirin, NMSO3 and heparin inhibited only hMPV and hRSV and not PIV3 or MV. Also unlike ribavirin, the activity of the two sulfated molecules was most effective if these materials were present during virus attachment and penetration of host cells. Interestingly, NMSO3, but not heparin, was able to limit secondary infection and spread of both viruses.

Development of a cotton rat-human metapneumovirus (hMPV) model for identifying and evaluating potential hMPV antivirals and vaccines

Hispid cotton rats were inoculated with two different human metapneumovirus (hMPV) subtype A strains and one subtype B hMPV. Although no overt disease was seen in any virus-inoculated animal, following an eclipse phase, significant pulmonary virus titers were observed in every hMPV-inoculated animal through day 7 post virus inoculation (p.i.) and in most through day 10. Peak virus titers occurred four days p.i., while virus-induced histopathology was most evident in lung sections obtained from animals 7 to 10 days p.i. The latter consisted primarily of desquamating and hypertrophic columnar epithelial cells lining the bronchi and bronchioles and the presence of large numbers of leukocytes in and around the bronchi and bronchioles. In fluorescent antibody studies, virus antigen-specific fluorescence was most evident in the desquamating tall columnar epithelial cells lining bronchi and bronchioles, in pneumocytes lining alveoli and in single or small groups of free cells, most probably leukocytes, present in the lumen of alveoli, bronchi and bronchioles. Virus was generally not detected in inoculated animals >10 days p.i. Although the pattern of virus replication in cotton rats was similar for all the three virus stains, the B subtype consistently grew to lower levels than the two A strains. Regardless, these findings indicate that hMPV replicates in cotton rats and that these animals may be used as a small animal model of hMPV infection and to facilitate the identification and development of vaccines and antivirals for preventing and/or ameliorating infections caused by this virus.

Cytokine Profiles in Human Metapneumovirus Infected Children: Identification of Genes Involved in the Antiviral Response and Pathogenesis

Human metapneumovirus (hMPV) causes severe airway infection in children that may be caused by an unfavorable immune response. The nature of the innate immune response to hMPV in naturally occurring infections in children is largely undescribed, and it is unknown if inflammasome activation is implicated in disease pathogenesis. We examined nasopharynx aspirates and blood samples from hMPV-infected children without detectable co-infections. The expression of inflammatory and antiviral genes were measured in nasal airway secretions by relative mRNA quantification while blood plasma proteins were determined by a multiplex immunoassay. Several genes were significantly up-regulated at mRNA and protein level in the hMPV infected children. Most apparent was the expression of the chemokine IP-10, the pro-inflammatory cytokine IL-18 in addition to the interferon inducible gene ISG54. Interestingly, children experiencing more severe disease, as indicated by a severity index, had significantly more often up-regulation of the inflammasome-associated genes IL-1β and NLRP3. Overall, our data point to cytokines, particularly inflammasome-associated, that might be important in hMPV mediated lung disease and the antiviral response in children with severe infection. Our study is the first to demonstrate that inflammasome components are associated with increased illness severity in hMPV-infected children.

Examination of a fusogenic hexameric core from human metapneumovirus and identification of a potent synthetic peptide inhibitor from the heptad repeat 1 region

Paramyxoviruses are a leading cause of childhood illness worldwide. A recently discovered paramyxovirus, human metapneumovirus (hMPV), has been studied by our group in order to determine the structural relevance of its fusion (F) protein to other well-characterized viruses utilizing type I integral membrane proteins as fusion aids. Sequence analysis and homology models suggested the presence of requisite heptad repeat (HR) regions. Synthetic peptides from HR regions 1 and 2 (HR-1 and -2, respectively) were induced to form a thermostable (melting temperature, approximately 90 degrees C) helical structure consistent in mass with a hexameric coiled coil. Inhibitory studies of hMPV HR-1 and -2 indicated that the synthetic HR-1 peptide was a significant fusion inhibitor with a 50% inhibitory concentration and a 50% effective concentration of approximately 50 nM. Many viral fusion proteins are type I integral membrane proteins utilizing the formation of a hexameric coiled coil of HR peptides as a major driving force for fusion. Our studies provide evidence that hMPV also uses a coiled-coil structure as a major player in the fusion process. Additionally, viral HR-1 peptide sequences may need further investigation as potent fusion inhibitors.

In vitro anti-HMPV activity of meroditerpenoids from marine alga Stypopodium zonale (Dictyotales)

In this paper, we evaluated the antiviral activity against HMPV replication of crude extract of the marine algae Stypopodium zonale and of two meroditerpenoids obtained from it, atomaric acid and epitaondiol, and a methyl ester derivative of atomaric acid. Their selectivity indexes were 20.78, >56.81, 49.26 and 12.82, respectively. Compared to ribavirin, the substances showed a relatively low cytotoxicity on LLC-MK2 cells, with a significant antiviral activity, inhibiting at least 90% of viral replication in vitro, which demonstrates the potential of these marine natural products to combat infections caused by HMPV in vitro.

Effect of NMSO3 treatment in a murine model of human metapneumovirus infection

BALB/c mice infected with human metapneumovirus (hMPV) were treated with the sulfated sialyl lipid NMSO3 (one dose of 50 mg kg(-1)) given at the time of infection. NMSO3 significantly reduced viral replication in the lungs, as well as hMPV-induced body weight loss, pulmonary inflammation and cytokine production, suggesting that antiviral treatment initiated at the beginning of viral infection can modify hMPV-induced disease.

HRA2pl peptide: a fusion inhibitor for human metapneumovirus produced in tobacco plants by transient transformation

MAIN CONCLUSION

The HRA2pl peptide expressed by transient transformation in N. tabacum plants is capable of inhibiting the binding of the human metapneumovirus to HEp-2 cells at the fusion stage. Human metapneumovirus (hMPV) is an agent responsible for acute respiratory infections that mainly affects children under 3 years, the elderly and immunocompromised patients. In children younger than 5 years, respiratory tract infections account for 20 % of deaths worldwide. However, there is currently no treatment or vaccine available against hMPV. The production of a safe, efficient and low cost treatment against this virus is a current challenge. Plants provide a system for recombinant protein production that is cost effective and is easier to scale up to an industrial level than other platforms; in addition, the plant tissue may be used as raw food, dried or, alternatively, proteins may be partially or fully purified and administered in aerosol or capsules as dry powder. In this study, we designed a gene expressing an antiviral peptide against hMPV based on the heptad repeat A domain of the F protein of the virus. We produced the recombinant peptide by a viral transient expression system (Magnifection(®)) in Nicotiana tabacum plants. The efficacy of this antiviral peptide was confirmed by in vitro assays in HEp-2 cell line. This is a promising result that can offer a prophylactic approach against hMPV.

Chimeric Pneumoviridae fusion proteins as immunogens to induce cross-neutralizing antibody responses

Human respiratory syncytial virus (hRSV) and human metapneumovirus (hMPV), two members of the Pneumoviridae family, account for the majority of severe lower respiratory tract infections worldwide in very young children. They are also a frequent cause of morbidity and mortality in the elderly and immunocompromised adults. High levels of neutralizing antibodies, mostly directed against the viral fusion (F) glycoprotein, correlate with protection against either hRSV or hMPV However, no cross-neutralization is observed in polyclonal antibody responses raised after virus infection or immunization with purified F proteins. Based on crystal structures of hRSV F and hMPV F, we designed chimeric F proteins in which certain residues of well-characterized antigenic sites were swapped between the two antigens. The antigenic changes were monitored by ELISA with virus-specific monoclonal antibodies. Inoculation of mice with these chimeras induced polyclonal cross-neutralizing antibody responses, and mice were protected against challenge with the virus used for grafting of the heterologous antigenic site. These results provide a proof of principle for chimeric fusion proteins as single immunogens that can induce cross-neutralizing antibody and protective responses against more than one human pneumovirus.

In vitro antiviral activity of Brazilian plants (Maytenus ilicifolia and Aniba rosaeodora) against bovine herpesvirus type 5 and avian metapneumovirus

CONTEXT

Medicinal plants are well known for their use in traditional folk medicine as treatments for many diseases including infectious diseases.

OBJECTIVE

Six Brazilian medicinal plant species were subjected to an antiviral screening bioassay to investigate and evaluate their biological activities against five viruses: bovine herpesvirus type 5 (BHV-5), avian metapneumovirus (aMPV), murine hepatitis virus type 3, porcine parvovirus and bovine respiratory syncytial virus.

MATERIALS AND METHODS

The antiviral activity was determined by a titration technique that depends on the ability of plant extract dilutions (25 or 2.5 µg/mL) to inhibit the viral induced cytopathic effect and the extracts' inhibition percentage (IP).

RESULTS

Two medicinal plant species showed potential antiviral activity. The Aniba rosaeodora Ducke (Lauraceae) extract had the best results, with 90% inhibition of viral growth at 2.5 µg/mL when the extract was added during the replication period of the aMPV infection cycle. The Maytenus ilicifolia (Schrad.) Planch. (Celastraceae) extracts at a concentration of 2.5 µg/mL exhibited antiviral activity during the attachment phase of BHV-5 (IP = 100%).

DISCUSSION AND CONCLUSION

The biomonitored fractionation of the active extracts from M. ilicifolia and A. rosaeodora could be a potential tool for identifying their active compounds and determining the exact mechanism of action.

Exploring quercetin based nano formulation in combating human Metapneumovirus infections

Human Metapneumovirus (hMPV) is a significant respiratory pathogen, particularly affecting children, the elderly, and immunocompromised individuals. Despite its clinical impact, there are currently no approved vaccines or specific antiviral treatments for hMPV, necessitating the exploration of novel therapeutic strategies. Quercetin, a naturally occurring flavonoid with well-documented antioxidant, anti-inflammatory, and antiviral properties, has shown promising potential in combating hMPV infections. However, its poor bioavailability limits its therapeutic efficacy. Recent advancements in nanotechnology offer a solution through quercetin-based nanoformulations, which enhance its solubility, stability, and bioavailability, thereby improving its antiviral potency. Molecular docking studies have demonstrated strong interactions between quercetin and the hMPV matrix protein, suggesting its role in inhibiting viral replication. Additionally, quercetin modulates oxidative stress and inflammatory responses by suppressing key pathways such as NF-κB and IRF-3, reducing lung damage associated with hMPV infections. In vitro and in vivo studies indicate that quercetin-loaded nanoparticles effectively decrease viral titers and inflammatory markers. Given its natural origin, safety profile, and therapeutic potential, quercetin-based nanoformulations emerge as a promising candidate for hMPV treatment. Further clinical trials are required to validate their efficacy and optimize formulations for potential clinical application.

An overview of progress in human metapneumovirus (hMPV) research: Structure, function, and therapeutic opportunities

The human metapneumovirus (hMPV), a member of the Pneumoviridae family, is a significant respiratory pathogen that causes severe infections in infants, children, the elderly, adults with chronic illnesses, and individuals with immunocompromised conditions. Globally, hMPV is recognized as the second leading cause of bronchiolitis and pneumonia among children under five. The absence of targeted antiviral treatments or vaccines for hMPV significantly strains the global health-care system. This review summarizes recent advances and scientific findings on hMPV by reviewing the current literature on its life cycle, structure, function, prevention, and treatment options.

Mechanism and spectrum of inhibition of a 4'-cyano modified nucleotide analog against diverse RNA polymerases of prototypic respiratory RNA viruses

The development of safe and effective broad-spectrum antivirals that target the replication machinery of respiratory viruses is of high priority in pandemic preparedness programs. Here, we studied the mechanism of action of a newly discovered nucleotide analog against diverse RNA-dependent RNA polymerases (RdRps) of prototypic respiratory viruses. GS-646939 is the active 5'-triphosphate metabolite of a 4'-cyano modified C-adenosine analog phosphoramidate prodrug GS-7682. Enzyme kinetics show that the RdRps of human rhinovirus type 16 (HRV-16) and enterovirus 71 incorporate GS-646939 with unprecedented selectivity; GS-646939 is incorporated 20-50-fold more efficiently than its natural ATP counterpart. The RdRp complex of respiratory syncytial virus and human metapneumovirus incorporate GS-646939 and ATP with similar efficiency. In contrast, influenza B RdRp shows a clear preference for ATP and human mitochondrial RNA polymerase does not show significant incorporation of GS-646939. Once incorporated into the nascent RNA strand, GS-646939 acts as a chain terminator although higher NTP concentrations can partially overcome inhibition for some polymerases. Modeling and biochemical data suggest that the 4'-modification inhibits RdRp translocation. Comparative studies with GS-443902, the active triphosphate form of the 1'-cyano modified prodrugs remdesivir and obeldesivir, reveal not only different mechanisms of inhibition, but also differences in the spectrum of inhibition of viral polymerases. In conclusion, 1'-cyano and 4'-cyano modifications of nucleotide analogs provide complementary strategies to target the polymerase of several families of respiratory RNA viruses.

Inhibition of human metapneumovirus replication by small interfering RNA

BACKGROUND

Human metapneumovirus (hMPV) is a major respiratory viral pathogen in young children, elderly individuals and immunocompromised patients. Despite its major effects related to bronchiolitis, pneumonia and its potential role in recurrent wheezing episodes, there is still no commercial treatment or vaccine available against this paramyxovirus.

METHODS

We tested a therapeutic strategy for hMPV that was based on RNA interference.

RESULTS

An hMPV genome-wide search for small interfering RNAs (siRNAs) by computational analysis revealed 200 potentially effective 21-mer siRNAs. Initial screening with a luciferase assay identified 57 siRNAs of interest. Further evaluation of their inhibitory potential against the four hMPV subgroups by quantitative real-time reverse transcriptase PCR and plaque immunoassay identified two highly potent siRNAs with 50% inhibitory concentration (IC50) values in the subnanomolar range. siRNA45 targets the nucleoprotein messenger RNA (mRNA) and had IC50 values <0.078 nM against representative strains from the four hMPV subgroups, whereas siRNA60, which targets the phosphoprotein mRNA, had IC50 values between 0.090-<0.078 nM against the same panel of hMPV strains. Longer25/27-mer siRNAs known as Dicer substrates designed from the top two siRNA candidates were also evaluated and were at least as effective as their corresponding 21-mer siRNAs. Interestingly, the presence of one or two nucleotide mismatches in the target mRNA sequence of some hMPV subgroups did not always affect hMPV inhibition in vitro.

CONCLUSIONS

We successfully identified two highly efficient siRNAs against hMPV targeting essential components of the hMPV replication complex.

[In vitro investigation of the antiviral activity of Ingavirin against human metapneumovirus]

The antiviral activity of Ingavirin against human metapneumovirus (HMPV) infection was investigated in vitro. The investigation used the human cell line ChangConjunctiva, permissive for HMPV, clone 1-5C4, and the HMPV strain isolated at the D. I. Ivanovsky Research Institute of Virology. The experimental studies suggest that when added at a concentration of 50 to 500 microg/ml to a nutrient medium 24 hours after HMPV infection, Ingavirin suppressed effectively virus replication by 2.2-3.3 logs, respectively. When used at a concentration of 500 microg/ml 24 hours before cell infection, Ingavirin protected cells from HMPV infection.

[Toll-like receptors expression in the lungs of human metapneumovirus infected mice and the effects of polyI:C on viral infection]

To investigate the expression changes of Toll-like receptors (TLR) in the lungs of human metapneumovirus infected BALB/c mice, and to explore the effects of PolyI:C on viral replication, HMPV-infected group, PolyI:C+hMPV group, PolyI:C+DMED group and DMEM control group were set up for this study. All mice were sacrificed on day 1, 3, 5, 7, 9 and 16 post inoculation. Lungs were used for viral titration, pulmonary histopathology and detection of TLRs mRNA expression by RT-PCR and real-time PCR. Results showed that the levels of viral replication in the lungs of PolyI:C+hMPV infected mice were significantly decreased and lung inflammation were also lessened compared with those of hMPV infected mice. RT-PCR detection showed that mRNA levels of most TLRs were up-regulated (P < 0.05) in the lungs of hMPV infected group compared with DMEM group. Real time PCR assay showed that TLR7-8 mRNA significantly increased in hMPV infected group in a time-dependent manner. The level of TLR3 mRNA was significantly up-regulated in PolyI:C+hMPV group at the 24 hour after intranasal inoculation. The results showed that hMPV infection up-regulated the expression of TLRs in lungs of BALB/c mice and TLR7/8 pathway might play an important role in the start of natural immune response. PolyI:C was capable of inhibiting viral replication in the lung of mice and reducing lung inflammation probably through the early activation of TLR3.

Probenecid Inhibits Human Metapneumovirus (HMPV) Replication In Vitro and in BALB/c Mice

Human metapneumovirus (HMPV) is an important cause of acute respiratory tract infection and causes significant morbidity and mortality. There is no specific antiviral drug to treat HMPV or vaccine to prevent HMPV. This study determined if probenecid, a host-targeting antiviral drug, had prophylactic (pre-virus) or therapeutic (post-virus) efficacy to inhibit HMPV replication in LLC-MK2 cells in vitro and in the lungs of BALB/c mice. This study showed that ≥0.5 μM probenecid significantly inhibited HMPV replication in vitro, and 2-200 mg/kg probenecid prophylaxis or treatment reduced HMPV replication in BALB/c mice.

Adult human metapneumovirus encephalitis: A case report highlighting challenges in clinical management and functional outcome

We report a rare case of adult human metapneumovirus (HMPV) in a healthy 32-year-old man. There was dramatic deterioration in his condition developing pneumonia with Type-I respiratory failure and encephalitis. He needed mechanical ventilation in the intensive care setting and was treated with intravenous ribavirin. Post-extubation he remained severely physically and cognitively impaired despite rehabilitation. Treatment of HMPV pneumonia is at present, still without specific antiviral therapy. Managing HMPV-encephalitis remained supportive and challenging. More definite treatment strategies are needed.