Fe A.

Bartolome, MD, MAEd, FPASMAP

Associate Professor I
Our Lady of Fatima University

z
FLAVIVIRUSES
Learning Objectives: At the end of the lecture the
students can:

1. characterize the family Flaviviridae.

2. compare the features of the various members
of the family.
3. compare the clinical syndromes produced by
each member of the family.
4. give the various treatment and preventive
modalities for each disease produced.
• Arbovirus (arthropod-borne)

• Broad host range (vertebrates & invertebrates)

• Icosahedral capsid; enveloped

• Positive, ssRNA viruses

• Most are serologically related  antibodies to

one may neutralize another
S
T
R
Outer protein
U
C
layer formed by E
T viral glycoprotein
U folding over and
R pairing with
E another E
glycoprotein

http://www.microbiologybook.org/virol/flavi.htm
R
E • Replicate in cytoplasm
P
L • Attachment to specific receptors on different
I cell types
C
A • Tropism: macrophages, monocytes, and
T other cells with Fc receptors, when virus is
I coated with antibody
O o Antibody enhances infectivity of virus by
N providing new receptors for the virus +
promote viral uptake into target cells
R
E
• Penetration via receptor-mediated
P
endocytosis
L
I
C • Structural genes at 5’-end of the genome 
A polyprotein containing structural proteins
T synthesized first & with greatest efficiency
I o Allows production of more structural
O proteins but decreases initiation of viral
N replication
R
E
P • Entire polyprotein associates with the
L endoplasmic reticulum membrane
I
C
• Acquires envelope by budding into the
A
endoplasmic reticulum
T
I
O
• Released by exocytosis or cell lysis
N
R
E
P
L
I
C
A
T
I
O
N

https://www.researchgate.net/figure/The-Flavivirus-Life-Cycle_fig2_316716469
C
L
A
S Flaviviruses
S
I
F Pestiviruses
I
C Hepaciviruses (HCV, HGV)
A
T
I
O
N
 Virus Vector Host Disease
F
Dengue Aedes Humans, Mild systemic; break-
L
monkeys bone fever, DHF, DSS
A
Yellow fever Aedes Humans, Hepatitis, hemorrhagic
V
monkeys fever
I
Japanese B Culex Pigs, birds Encephalitis
V encephalitis
I
West Nile Culex Birds Fever, encephalitis;
R encephalitis hepatitis
U St. Louis Culex Birds Encephalitis
S encephalitis
E Russian spring- Ixodes & Birds Encephalitis
S summer Derma-
encephalitis centor tick
Powassan Ixodes Small Encephalitis
encephalitis mammals
P
A • Primary viral multiplication in myeloid and
T lymphoid cells OR in vascular endothelium
H
O • Viremia for several days
G
E • Vectors acquire the virus by sucking blood
N from infected individuals
E
S
• Different tissues support further virus
I
replication (monocyte-macrophages,
S
endothelial cells, lungs, liver, muscles)
P
A
T • Nature of disease determined primarily by:
H
O 1. Specific tissue tropisms of the virus
G 2. Degree of viral load
E 3. Individual responses to the infection
N
E • Associated with mild systemic disease,
S encephalitis, arthrogenic disease or
I hemorrhagic disease
S
P
A
T • Factors promoting neuro-invasion:
H
O 1. Degree of viremia
G 2. Genetic background of host
E 3. Host immune response (innate and
N adaptive)
E
4. Virulence of the virus strain
S
5. Age – infants and elderly
I
S
P
A • Disease mechanisms:
T
H 1. Cytolytic except HCV
O 2. Establishment of viremia and systemic
G infection
E 3. Induction of interferon  flu-like
N symptoms during prodrome
E 4. Infect cells of the monocyte-macrophage
S system
I 5. Non-neutralizing antibody can enhance
S infection via Fc receptors on the cells
 Initial Fever, chills, headaches,
viremia backaches & other flu-like
symptoms

Resolution

Secondary Infection of target organs

viremia (brain, liver, skin and
vasculature)
https://medicostimes.com/murrays-
medical-microbiology/
#DownloadnbspMurrays_Medical_Micr
obiology_PDF_7th_Edition
I
M
M
U • Viral replication  induce IFN-α & IFN-β
N  Limit viral replication
E  Stimulate innate & immune responses
R
E • Within 6 days of infection  (+) circulating
S IgM followed by IgG  block viremic
P spread
O
N
S
E
I
M
M
• Adverse effects of immune response
U 1. Inflammation  tissue destruction 
N encephalitis
E 2. Immune complexes (type III HS) 
activation of complement  weakened
R
E vasculature  rupture  hemorrhagic
S symptoms
P 3. Non-neutralizing Ab  enhance uptake of
O virus into macrophages & other cells
N
S
with Fc receptors
E
E
P • Humans usually dead-end hosts  no
I persistent viremia
D
E • If virus not in the blood, the mosquito
M cannot acquire it.
I
O
• Most common vector is the mosquito.
L
O
G
• Birds and small mammals the usual
Y reservoir hosts.
E
P
I
• Disease during summer months and rainy
D seasons.
E
M • Breeding grounds: pools of standing water,
I drainage ditches, trash dumps
O
L • Humans can be reservoir hosts for yellow
O fever and dengue
G
Y
z
ENCEPHALITIS VIRUSES
• St. Louis

• West Nile

• Japanese

• Murray Valley

• Russian Spring-Summer
• Incubation period: 4 – 21 days

• Inapparent infections common; some with

mild flu-like illness

• Encephalitis
 Sudden onset – severe headache, fever (4-
10 days) & chills, n & v, generalized pains,
malaise
 Within 24-48 hrs  drowsiness to stupor 
coma in severe cases
St. Louis Encephalitis

• Most important cause of epidemic enceph. in

North America

• Presence of infected mosquitoes required

before human infections can occur

• Vector: Culex mosquito

http://core.ecu.edu/hhp/andersonal/Mosquito_Library/St%20Louis%20Encephalitis.htm
West Nile Fever/Encephalitis

• (+) viremia & acute, mild febrile disease with

LAD and rash

• Person-to-person transmission documented

 organ transplantation, blood transfusion, in
utero, breastfeeding (?)

• Vector: Culex, Aedes, Anopheles

Japanese B Encephalitis

• Leading cause of viral encephalitis in Asia

• Neurologic & psychiatric sequelae in 30% of

survivors

• Infection in 1st & 2nd trimesters of pregnancy 

fetal death

• Vector: Culex tritaeniorhyncus

• Vaccine-preventable
https://www.researchgate.net/figure/Enzootic-and-epizootic-epidemic-transmission-cycles-of-Japanese-
encephalitis-virus-JEV_fig7_259743924
z
HEMORRHAGIC VIRUSES
z

DENGUE VIRUS
https://www.doh.gov.ph/sites/default/files/statistics/Dengue%20Monthly%20Report_MW1-MW30_2018_No.7.pdf
https://www.doh.gov.ph/sites/default/files/statistics/Dengue%20Monthly%20Report_MW1-MW30_2018_No.7.pdf
• Tropical and sub-tropical climates worldwide;
urban and semi-urban areas
o Local variations in risk influenced by:
rainfall, temperature & unplanned rapid
urbanization

• Dramatic increase in global incidence  50%

of world’s population at risk

• Leading cause of serious illness and death

among children in Asia and Latin America
• Vector: Aedes aegypti (majority) and Aedes
albopictus

• 4 distinct but closely related serotypes 

DEN-1, DEC-2, DEN-3, DEN-4
o “Asian” genotypes – DEN-2 & DEN-3 
associated with severe disease
accompanying secondary dengue infection
• Transmission: bite of infected female
mosquitoes  virus incubation in
mosquito (4 – 10 days)

• Infected symptomatic or asymptomatic

humans are the main carriers and
multipliers of the virus
• Breed in urban
habitats  man-made
containers

• Female mosquito –
bite multiple people
with each feeding
period

• Day-time feeder – Aedes aegypti

peak biting periods:
early in the morning & https://www.bbc.com/news/world-asia-india-
40081524
evening before dusk
 • Breeding habitat: used
tires & other goods (e.g.
lucky bamboo)

• Highly adaptive  survive

in cooler temperature
regions of Europe & North
America

• Tolerant to freezing,
undergo hibernation, can
http://www.faculty.ucr.edu/~legneref/medical/d shelter in microhabitats 
engue.htm
facilitate spread
http://www.faculty.ucr.edu/~legneref/medical/dengue.htm
 4 – 10 days
incubation period
DISEASE: DENGUE (BREAKBONE FEVER)

• Flu-like illness: fever, severe headache,

muscle and joint pain, nausea & vomiting,
eye pain, and rash (Herman’s sign)

• Mild illness (Dengue Fever) seldom cause

death

• Severe illness (DHF & DSS) potentially fatal,

usually affecting children
DISEASE: DENGUE (BREAKBONE FEVER)

• Prodrome: 4 – 7 days after infection

• Fever – lasts 2-7 days; correspond to peak

viral load
o Subside on about 3rd day  rise again 5 –
8 days after onset  “saddleback” form

• Myalgia & deep bone pain characteristic

DISEASE: DENGUE (BREAKBONE FEVER)

• Rash on 3rd or 4th day  last for 1 – 5 days

• (+) lymphadenopathy

• Self-limited disease; convalescence may take

weeks

• Complications & death rare

https://byjus.com/biology/dengue/
DISEASE: DENGUE (BREAKBONE FEVER)

• Severe illness in individuals with passively

acquired (via maternal Ab) or pre-existing
non-neutralizing heterologous dengue Ab

• Key pathological feature: inc. vascular

permeability with release of vasoactive
cytokines  lead to shock

• Monocytes the major target cell in the blood

 WHO CLASSIFICATION (OLD)

https://www.researchgate.net/figure/The-categories-of-the-1975-and-1997-WHO-dengue-case-classification_fig1_230789289
http://keywordsuggest.org/gallery/797869.html
https://slideplayer.com/slide/237397/
L
A PCR
B
O • Can detect in patient’s serum approx.
R 1st 5 days of symptoms
A
T • Real time RT-PCR – 95% specificity,
O 80% - 90% sensitivity; definite proof of
R current illness
Y o If negative before 5 days illness 
confirm with serology
L
A MAC ELISA
B
O • IgM antibody capture ELISA diagnostic
R
kits
A
• Utilize anti-human-IgM antibody +
T dengue virus specific antigen (DENV1-4)
O • Antigens derived from envelope protein
R
of virus
Y
• Limitation: (+) cross-reaction with other
flaviviruses
https://www.researchgate.net/figure/Principle-of-MAC-ELISA-test_fig3_318193280
L
A IgG ELISA
B
O • Detection of past dengue infection
R
A • Lacks specificity
T
O • If (-) IgG in acute phase & (+) IgG in the
R convalescent phase  primary dengue
Y infection
L
A NS1 ELISA
B
O
R • Useful for diagnosis of acute infection
A
T • NS1 Ag detected as early as 1 day after
O onset of symptoms and up to 18 days
R after symptom onset
Y
L
A PRNT
B
O
• Plaque Reduction & Neutralization Test
R
• Used when a serological specific
A
T
diagnostic is required  most specific
O
serologic tool for determination of
dengue antibodies
R
Y
• Use convalescent sera  measure titer
of neutralizing antibodies
https://www.ncbi.nlm.nih.gov/books/NBK143156/
http://www.jgid.org/article.asp?issn=0974-777X;year=2014;volume=6;issue=3;spage=109;epage=113;aulast=Mishra
z

YELLOW FEVER VIRUS

• Prototype member of Flaviviridae family

• 7 genotypes; only 1 serotype

• Growth in embryonated eggs, chick embryo

cultures, and cell lines

• Transmission via bite of mosquito  spread

to local LN, liver, spleen, kidney, bone
marrow and myocardium
• 2 major cycles of transmission:

1. Urban yellow fever – Aedes aegypti;

person-to-person by mosquitoes

2. Jungle yellow fever – primarily monkeys;

arboreal mosquitoes (Haemagogus,
Aedes); may be transmitted to humans by
mosquitoes
https://phil.cdc.gov/Details.aspx?pid=14997
DISEASE: YELLOW FEVER

• Incubation: 3 – 6 days

• Initial period (several days): fever, chills,

headache, dizziness, myalgia, and backache
followed by nausea, vomiting & bradycardia

• 15% of cases progress to severe form 

fever, jaundice, renal failure & hemorrhagic
manifestations  hepatorenal failure
https://www.pulse.ng/news/local/edo-govt-confirms-spread-of-yellow-fever-to-10-lgs-says-9-dead/0n2xyw2
L
A
Virus Detection or Isolation
B
O • Antigen & nucleic acid identified in tissue
R using immunohistochemistry, ELISA Ag
A capture or PCR
T
O • Recovered in blood (1st 4 days) after
R onset of symptoms
Y
L
A Serology
B
O • 1st week of illness – (+) IgM antibodies 
R presumptive diagnosis
A
T • 4-fold increase in neutralizing Ab titer
O between acute phase & convalescent
R phase serum  confirmatory
Y
z
SYSTEMIC DISEASE WITH
ASSOCIATED BIRTH DEFECT
z
https://www.cbc.ca/news/health/zika-virus-explained-1.3422663
• Enveloped; icosahedral

• Non-segmented, (+) sense RNA genome

• Envelope glycoprotein binds to endosomal

membrane of host cell  initiate endocytosis

• 6 hours after cells are infected  vacuoles &

mitochondria swell  lead to cell death
(paraptosis)
https://www.co.fresno.ca.us/departments/public-health/community-health/communicable-disease-investigation-
program/mosquito-born-illness
 Primary
transmission

Very likely but

not confirmed
https://steemit.com/steemstem/@conradsuperb/a-comprehensive-analysis-zika-virus-in-the-developing-world
Materno-fetal Transmission

• Primary infection in mother mild

• Infection of fetus  congenital Zika synd.

o Microcephaly
o Limb contractures
o High muscle tone
o Eye abnormalities
o Hearing loss
https://www.researchgate.net/figure/Association-of-ZIKV-with-microcephaly-in-pregnant-mothers_fig2_315980699
https://www.sciencemag.org/news/2016/03/zika-virus-kills-developing-brain-cells
Materno-fetal Transmission

• Other consequences:

o Miscarriage
o Stillbirth
o Guillain-Barre syndrome, neuropathy and
myelitis – adults & older children
DISEASE: ZIKA VIRUS DISEASE

• Incubation: 3 – 14 days

• Majority do not develop symptoms

• Symptoms mild, lasting 2-7 days  fever,

rash, conjunctivitis, muscle & joint pain,
malaise, headache
https://www.firstderm.com/zika-virus-rash/

https://www.cdc.gov/zika/symptoms/symptoms.html
http://revistapesquisa.fapesp.br/en/2016/05/27/zika-the-virus-that-took-brazil-by-surprise/
https://slideplayer.com/slide/12704582/
L
A
B
• Suspected on basis of symptoms in
O persons living in or visiting areas with
R Zika virus transmission and/or vectors
A
T • Confirmed by laboratory tests of blood or
O other body fluids (e.g. urine or semen)
R
Y