Pathogenesis and

Control of Viral Diseases

C H A P T E R 30
PRINCIPLES OF VIRAL DISEASES Principals related to the viral diseases:

 The fundamental process of viral infection is the viral (1) many viral infections are subclinical;
replicative cycle.
(2) the same disease syndrome may be produced by a
 The cellular response to that infection may range from variety of viruses;
no apparent effect to cytopathology with accompanying
cell death to hyperplasia or cancer. (3) the same virus may produce a variety of diseases;
and

Viral disease - is some harmful abnormality that results (4) the outcome in any particular case is determined by
from viral infection of the host organism. both viral and host factors and is influenced by the
environmental context and genetics of each.
Clinical disease - in a host consists of overt signs and
symptoms.

A syndrome is a specific group of signs and symptoms.

 Viral infections that fail to produce any symptoms in the

host are said to be inapparent (subclinical). In fact,
most viral infections do not result in the production of
disease.
Viral pathogenesis is the process that occurs when a A strain of a certain virus is more virulent than another
virus infects a cell and causes cellular changes. strain if it commonly produces more severe disease in a
susceptible host.
Disease pathogenesis is a subset of events during an
infection that results in disease manifestation in the host. Viral virulence in intact animals is not necessarily related
to cytopathogenicity for cultured cells; viruses highly
A virus is pathogenic for a particular host if it can infect cytocidal in vitro may be harmless in vivo, and,
and cause signs of disease in that host. conversely, noncytocidal viruses may cause severe
disease.
PATHOGENESIS OF VIRAL DISEASES
To produce disease, viruses must enter a host, come in contact
with susceptible cells, replicate, and produce cellular injury.
Understanding mechanisms of viral pathogenesis at the
molecular level is necessary to design effective antiviral
strategies. Much of our knowledge of viral pathogenesis is based
on cell culture and animal models because such systems can be
readily manipulated and studied.
Steps in Viral Pathogenesis

A. Entry and Primary Replication

Through:
• mucosa
• Skin,
• Respiratory tract,
• Gastrointestinal tract, Urogenital tract,
• Conjunctiva.

Direct introduction:
• Tissues
• Bloodstream
(eg, hepatitis B and C and human immunodeficiency virus [HIV]),
blood transfusions, or insect vectors (arboviruses).

Entry production of new virions release from the host

cell by shedding or cell lysis
infect other cells in the immediate vicinity, causing local spread of
B. Viral Spread and Cell Tropism Viruses tend to exhibit organ and cell-type specificities, or
viral tropism determined by the cell surface receptors
Viruses can either produce the disease at the site of entry for that virus.
or disseminate and cause additional symptoms distant
from the site of entry. The identity of the specific cellular receptor is known for
some viruses but is unknown in many cases.
Dissemination is via bloodstream and lymphatic system.
The level of cell surface receptor expression and
Viremia- the presence of virus in the bloodstream. posttranslational modifications affect the ability of viruses
to infect various cell types.
Virions may be free in the plasma (eg, enteroviruses
and togaviruses) or associated with particular cell types For example, influenza virus requires cellular proteases to
(eg, measles virus). cleave virally encoded hemagglutinin in order to enable
viruses to infect new cells, and expression of a glycolytic
Viruses may multiply within those cells (eg, Epstein-Barr enzyme (neuraminidase) to release newly formed virions.
virus [EBV] is lymphotrophic and can replicate within white
blood cells as it spreads). Multiple rounds of viral replication will not occur in tissues
that do not express the appropriate proteins.
Some viruses travel along neuronal axons to spread
within the host (eg. rabies migrates to the brain, herpes
simplex virus [HSV] travels to ganglia to produce latent
infection).
Establishment of a chronic infection involves complex
interplay between viral and host immune factors, and the
virus may enter a life-long latent state, or subsequently
reactivate and cause disease months to years later.

E. Virus Shedding
The last stage in pathogenesis is the shedding of
infectious virus into the environment. This is a necessary
step to maintain a viral infection in populations of hosts.
Shedding usually occurs from the body surfaces involved
in viral entry. Shedding occurs at different stages of
disease depending on the particular agent involved.

During viral shedding, an infected individual is infectious

to contacts.
C. Cell Injury and Clinical Illness D. Recovery from Infection
Destruction of virus-infected cells in the target tissues and Following a viral infection, the host will
physiologic alterations produced in the host by the tissue
injury are partly responsible for the development of • succumb,
disease. • recover,
• establish a chronic infection
Some tissues, such as intestinal epithelium, can rapidly
regenerate and withstand extensive damage better than Recovery mechanisms include both innate and adaptive
others, such as the brain. immune responses.

Some physiologic effects may result from nonlethal

impairment of specialized functions of cells, such as loss .
of hormone production.

Clinical illness from viral infection is the result of a

complex series of events, and many of the factors that
determine degree of illness are unknown.

General symptoms associated with many viral infections,

such as malaise and anorexia, may result from host
response functions such as cytokine production.

Clinical illness is an insensitive indicator of viral infection;

inapparent infections by viruses are very common.
Host Immune Response Three general groups:
• The outcome of viral infections reflects the interplay between IFN-α, IFN-β, and IFN-γ
viral and host factors.
• Nonspecific host defense mechanisms are elicited shortly Type 1(viral IFNs) : IFN-α and IFN-β
• The most prominent among the innate immune responses is
the induction of cytokines such as IFNs. Type II (immune IFN): IFN-γ
These responses help inhibit viral growth during the time it takes
Infection with viruses is a potent inducer of IFN-α and IFN-
to induce specific humoral and cell-mediated immunity.
β production;

A. Innate Immune Response RNA viruses are stronger inducers of IFN than DNA
viruses.
• mediated by IFNs,
IFN-γ is induced by mitogen stimulation.
• inhibit viral replication.

• produced very quickly (within hours) in response to viral

infection or other inducers

• modulate humoral and cellular immunity and have

broad cell growth regulatory activities.
IFNs are detectable soon after viral infection in intact animals,
and viral production then decreases.

Antibody does not appear in the blood of the animal until

several days after viral production has abated.
This temporal relationship suggests that IFN plays a primary role
in the nonspecific defense of the host against viral infections, as
well as the fact that agammaglobulinemic individuals usually
recover from primary viral infections about as well as normal
people.

IFN is secreted and binds to cell receptors, where it

induces an antiviral state by prompting the synthesis of
other proteins that inhibit viral replication.

Several pathways appear to be involved, including:

(1) a dsRNA-dependent protein kinase, PKR, - phosphorylates and inactivates cellular initiation factor eIF-2 and thus prevents
formation of the initiation complex needed for viral protein synthesis;

(2) An oligonucleotide synthetase, 2-5A synthetase, which activates a cellular endonuclease, RNase L, which in turn degrades
mRNA;

(3) a phosphodiesterase, which inhibits peptide chain elongation; and

(4) nitric oxide synthetase, which is induced by IFN-γ in macrophages.

Viruses display different mechanisms that block the inhibitory activities of IFNs on virus replication:

Specific viral proteins

• block induction of expression of IFN (herpesvirus, papillomavirus, Filovirus, hepatitis C virus, rotavirus),

• block the activation of the key PKR protein kinase (adenovirus, herpesviruses),

• activate a cellular inhibitor of PKR (influenza, poliovirus),

• block IFN-induced signal transduction (adenovirus, herpesviruses, hepatitis B virus), or

• neutralize IFN-γ by acting as a soluble IFN receptor (myxoma virus).

B. Adaptive Immune Response Viruses avoiding immune response
• Humoral/cellular response. • Infection of the immune cells
• infiltration with mononuclear cells and lymphocytes • Downregulation of MHC class I expression
characterizes the inflammatory reaction of
uncomplicated viral lesions. • Encoding immunomodulatory proteins that inhibit MHC
function or inhibit cytokine activity
• Virus-encoded proteins serve as targets for the
immune response. • Mutate or downregulate the expression of surface
proteins
• Virus-infected cells may be lysed by cytotoxic T
lymphocytes as a result of recognition of viral • Encode microRNAs that may target specific cellular
polypeptides on the cell surface. transcripts and suppress proteins integral to the host
innate immune response
• Neutralizing antibody directed against capsid proteins
blocks the initiation of viral infection, presumably at the • The immune response to one virus or vaccine may
stage of attachment, entry, or uncoating. exacerbate the disease caused by subsequent
infection with similar strains
• Secretory IgA antibody is important in protecting
against infection by viruses through the respiratory or • The development of autoantibodies through a
gastrointestinal tracts. molecular mimicry
Viral Persistence: Chronic and Latent Viral sequences may be detectable by molecular
techniques in tissues harboring latent infections.
Virus Infections Inapparent or subclinical infections are those that give
no overt sign of their presence.
Acute infection - a virus first infects a susceptible host
and is usually self-limited;
Chronic infections occur with a number of animal viruses,
Chronic infections Long-term virus– host interaction may and the persistence in certain instances depends on the
take several forms. age of the host when infected.

(also called persistent infections) are those in which

replicating virus can be continuously detected, often at low
levels;

Latent infections mild or no clinical symptoms may be

evident when are those in which the virus persists in an
occult (hidden or cryptic) form most of the time when no
new virus is produced. There can be intermittent flare-ups
of clinical disease; infectious virus can be recovered
during these times.
Effect of Host Age Diagnosis of Viral Infections
Host age is a factor in viral pathogenicity. There are several different ways in which viral infections
More severe disease is often produced in newborns. are diagnosed.
• Rapid antigen detection methods use virus-specific
In addition to maturation of the immune response with monoclonal antibodies for detection.
age, there seem to be age-related changes in the • Nucleic acid or polymerase chain reaction (PCR) tests
susceptibility of certain cell types to viral infection. use specific primers and probes to detect viral nucleic
acid.
Viral infections usually can occur in all age groups but • The PCR tests can be multiplexed, allowing detection
may have their major impact at different times of life. of multiple viruses concurrently.

Examples include rubella, which is most serious during • Virus culture and serological testing for specific
gestation; rotavirus, which is most serious for infants; and antibody responses are slow to provide results but are
St. Louis encephalitis, which is most serious in elderly useful for epidemiologic and research studies.
adults. • More recently developed nucleic acid-based technology
such as automated multiplexed PCR, high-density
microarrays, and deep sequencing allow for detection
of multiple viruses in a single assay.

Because there are relatively few targeted antiviral

therapies, knowledge of the specific infecting viral agent
may not alter patient treatment, but it can be useful to
determine the prognosis and for patient management.
 PREVENTION AND TREATMENT OF VIRAL INFECTIONS
Antiviral Chemotherapy

Development of antiviral drugs are limited because of

the lack of selectivity !

Another limitation is that many rounds of virus replication

occur during the incubation period and the virus has
spread before symptoms appear, making drug treatment
after the development of clinical symptoms relatively
ineffective.

Antivirals can be used to treat established infections when

vaccines would not be effective.

Antivirals are needed to reduce morbidity and economic

loss caused by viral infections.

Treat increasing numbers of immunosuppressed patients

who are at increased risk of severe disease.

Molecular virology studies are succeeding in identifying

virus-specific functions that can serve as targets for
antiviral therapy.
Stages during viral infections that could be targeted
include:

 attachment of virus to host cells,

 uncoating of the viral genome,
 viral nucleic acid synthesis,
 translation of viral proteins,
 Assembly
 release of progeny virus particles.

A number of compounds have been developed that are of

value in treatment of viral diseases.
Some drugs must be activated by enzymes in the cell
before it can act as an inhibitor of viral replication;

the most selective drugs are activated by a virus-encoded

enzyme in the infected cell. Future work is necessary
• to minimize the emergence of drug-resistant variant
viruses,
• to reduce drug toxicities,
• To design more specific antivirals based on molecular
insights into the structure of other viral targets,
• to develop antivirals for viruses for which no drugs
currently exist.
A. Nucleoside and Nucleotide Analogs B. Reverse Transcriptase Inhibitors

The majority of available antiviral agents. Non-nucleoside reverse transcriptase inhibitors act by
binding directly to virally encoded reverse transcriptase
Inhibit nucleic acid replication by inhibition of viral and inhibiting its activity.
polymerases
Resistant mutants emerge rapidly, making these useful
In addition, some analogs are incorporated into the only in the context of multidrug therapy.
nucleic acid as chain terminators and block further
synthesis. C. Protease Inhibitors
Protease inhibitors were first designed by computer
Analogs can inhibit cellular enzymes as well as virus- modeling as peptidomimetic agents that fit into the active
encoded enzymes. The most effective analogs are those site of the HIV protease enzyme.
that are able to specifically inhibit virus-encoded enzymes,
with minimal inhibition of analogous host cell enzymes. Such drugs inhibit the viral protease that is required at
the late stage of the replicative cycle to cleave the viral
Resistant variants are frequently seen due to high gag and gag-pol polypeptide precursors to form the
mutation rates. mature virion core and activate the reverse transcriptase
that will be used in the next round of infection.
The use of combinations of antiviral drugs can delay the
emergence of resistant variants (e.g., “triple-drug” therapy
used to treat HIV infections).
Protease inhibitors have been used successfully for
treatment of HIV and HCV infections.
D. Integrase Inhibitors F. Other Types of Antiviral Agents

HIV integrase inhibitors block the activity of viral Amantadine and rimantadine specifically inhibit influenza
integrase, A viruses by blocking viral uncoating. They must be
a key enzyme in HIV replication. administered very early in infection to have a significant
effect.
Without integration of virally encoded DNA into the host Oseltamivir is a neuraminidase inhibitor that prevents
chromosome, the life cycle cannot continue. the release of influenza virus particles from infected cells.

Foscarnet (phosphonoformic acid) is an organic analog

E. Fusion Inhibitors of inorganic pyrophosphate. It selectively inhibits viral DNA
HIV fusion inhibitors act by disrupting the fusion of viral polymerases and reverse transcriptases at the
envelope with the cell membrane, preventing cellular pyrophosphate-binding site.
infection.
Acyclovir is a guanosine analog DNA polymerase inhibitor
The prototype agent, enfuvirtide, is a peptide that binds used for the treatment of HSV and varicella-zoster virus
to gp41 and blocks the required conformational change infections.
that initiates membrane fusion. The prodrug valacyclovir is an esterified version that can be
taken orally and is metabolized to acyclovir.

Ganciclovir is a nucleoside DNA polymerase inhibitor

active against CMV whose specificity comes from
phosphorylation by virus-specific kinases only in virally
infected cells.
Valganciclovir is the orally available prodrug for ganciclovir.
Viral Vaccines A. General Principles
 The purpose of viral vaccines is to use the adaptive Immunity to viral infection is based on the development of
immune response of the host to prevent viral an immune response to specific antigens located on the
disease. surface of virus particles or virus-infected cells.

 Several vaccines have proved to be remarkably For enveloped viruses, the important antigens are the
effective at reducing the incidence of viral disease. surface glycoproteins.

 Vaccination is the most cost-effective method of Although infected animals may develop antibodies against
prevention of serious viral infections. virion core proteins or nonstructural proteins involved in
viral replication, that immune response is believed to play
little or no role in the development of resistance to
infection.

Certain characteristics of a virus or of a viral disease may

complicate the generation of an effective vaccine.

The existence of many serotypes, as with rhinoviruses,

and of large numbers of antigenic variants in animal
reservoirs, as with influenza virus, makes vaccine
production difficult.
Other hurdles include the integration of viral DNA into host
chromosomal DNA and infection of cells of the host’s
immune system (HIV).
B. Killed-Virus Vaccines C. Attenuated Live-Virus Vaccines
Inactivated (killed-virus) vaccines are made by purifying Live-virus vaccines use virus mutants that antigenically
viral preparations to a certain extent and then inactivating overlap with wild-type virus but are restricted in some step
viral infectivity in a way that does minimal damage to in the pathogenesis of disease.
the viral structural proteins;
Mild formalin treatment is frequently used. The genetic basis for the attenuation of most viral
vaccines is not known because they were selected
For some diseases, killed-virus vaccines are currently the empirically by serial passages in animals or cell cultures
only ones available. (usually from a species different from the natural host).
Killed-virus vaccines prepared from whole virions As more is learned about viral genes involved in disease
generally stimulate the development of circulating pathogenesis, attenuated candidate vaccine viruses can
antibody against the coat proteins of the virus, conferring be engineered in the laboratory.
some degree of resistance to that virus strain.
Advantage:
Advantages: • acting more like the natural infection with regard to their
• no reversion to virulence effect on immunity.
• vaccines can be made when no acceptable attenuated • They multiply in the host and tend to stimulate longer-
virus is available. lasting antibody production,
• induce a good cell-mediated response,
Disadvantages: • induce antibody production and resistance at the portal
• relatively brief immunity requiring boosting shots to of entry.
maintain effectiveness, Disadvantages:
• poor cell-mediated response, • risk of reversion to greater virulence, severe infection in
• occasional hypersensitivity to subsequent infection. immunocompromised hosts,
D. Proper Use of Vaccines Failure to reach all sectors of the population with complete
An effective vaccine does not protect against disease courses of immunization is reflected in the continued
until it is administered in the proper dosage to occurrence of measles outbreaks in populations who
susceptible individuals. refuse immunization.

Herd immunity - the risk of infection among susceptible

individuals in a population is reduced by the presence of
adequate numbers of immune individuals.

This effect is reflected in dramatic decreases in the

incidence of disease, even when all susceptible
individuals have not been vaccinated.

Protective effect depends on many factors:

 the transmissibility of the infectious agent,
 the nature of the vaccine-induced immunity,
 the distribution of the immune individuals.

Individuals protected by herd immunity remain susceptible

to infection upon exposure. This can lead to outbreaks of
disease when a group of susceptible individuals
accumulate, such as mumps outbreaks among university
students in the United States.
E. Future Vaccine Prospects 4. Use of synthetic peptides that correspond to antigenic
Molecular biology and modern technologies are combining determinants on a viral protein, thus avoiding any
to allow novel approaches to vaccine development. possibility of reversion to virulence since no viral nucleic
acid would be present, although the immune response
Many of these approaches avoid the incorporation of viral induced by synthetic peptides is considerably weaker than
nucleic acid in the final product, improving vaccine safety. that induced by intact protein.
Examples of what is ongoing in this field can be listed as
follows. The ultimate success of these new approaches 5. Development of edible vaccines whereby transgenic
remains to be determined. plants synthesizing antigens from pathogenic viruses may
provide new cost-effective ways of delivering vaccines.
1. Use of recombinant DNA techniques to insert the
gene coding for the protein of interest into the genome of 6. Use of naked DNA vaccines—potentially simple,
an avirulent virus that can be administered as the vaccine cheap, and safe—in which recombinant plasmids carrying
(eg, vaccinia virus). the gene for the protein of interest are injected into host
cells which produce the immunizing protein.
2. Including in the vaccine only those subviral
components needed to stimulate protective antibody, 7. Administration of vaccine locally to stimulate antibody
thus minimizing the occurrence of adverse reactions to the at the portal of entry (eg, aerosol vaccines for respiratory
vaccine. disease viruses).
3. Use of purified proteins isolated from purified virus or
synthesized from cloned genes (a recombinant hepatitis B
virus vaccine contains viral proteins synthesized in yeast
cells