We report a case of Usutu virus (USUV)-related illness in a patient that underwent an orthotropic liver transplant (OLT). Post transplant, the patient developed clinical signs of a possible neuroinvasive disease with a significant loss of cerebral functions. USUV was isolated in Vero E6 cells from a plasma sample obtained immediately before the surgery, and USUV RNA was demonstrated by RT-PCR and sequencing. This report enlarges the panel of emerging mosquito-borne flavivirus-related disease in humans

Bonilauri, P

Cavrini, F

DI BENEDETTO, Fabrizio

Dottori, M

Gaibani, P

Gerunda, Giorgio Enrico

Girardis, Massimo

Landini, Mp

Longo, Fulvio Giovanni

Pasetto, Alberto

Pierro, Am

Rossini, Gian Paolo

Sambri, V.

English

LONGO, Fulvio Giovanni

ROSSINI, Gian Paolo

GERUNDA, Giorgio Enrico

PASETTO, Alberto

GIRARDIS, Massimo

Archivio istituzionale della ricerca - Università di Modena e Reggio Emilia

Network: ECDC European Antibiotic Awareness Day ESCAIDE - Scientific conference Eurosurveillance journalSearch all content   Current Archives  Print Editions  Collections  About Us  Editorial Policy Sign-in Register and subscribe hereWe report a case of Usutu virus (USUV)-related illness in a patient that underwent an orthotropicliver transplant (OLT). Post transplant, the patient developed clinical signs of a possibleneuroinvasive disease with a significant loss of cerebral functions. USUV was isolated in Vero E6cells from a plasma sample obtained immediately before the surgery, and USUV RNA wasdemonstrated by RT-PCR and sequencing. This report enlarges the panel of emerging mosquito-borne flavivirus-related disease in humans.IntroductionIn recent years, several mosquito-borne flaviviruses were identified as new emerging pathogens inanimals and humans worldwide. The widespread occurrence of flaviviruses, such as West Nile virus(WNV), Dengue virus (DENV), Japanese encephalitis virus (JEV), yellow fever virus (YFV) and tick-borne encephalitis virus (TBEV) represents an important global health problem [1]. In the past tenyears, infections with Usutu virus (USUV), a mosquito-borne flavivirus of the JEV serogroup andrelated to WNV, has been detected in a variety of birds in central European areas such as Austria,Hungary and Italy [2,3,4]. To date, USUV did not show considerable pathogenicity for humans [5]. Inparticular, no clinically evident USUV-related infections have so far been documented in humans.Here we report a case of USUV-related disease in a female patient who, during a viraemic episodecaused by USUV, received an orthotropic liver transplant (OLT) as a final consequence of a thromboticthrombocytopenic purpura (TTP). This patient developed a neurological disease with severeimpairment of the cerebral functions within the first days after OLT.Case reportOn 10 August 2009, a few days after returning to Italy from a holiday in Egypt, a woman in her 40sdeveloped a TTP and received 18 plasma exchanges until 4 September 2009. Two weeks later, on 14September, the patient presented with fever of 39.5°C, headache, skin rash, mild increment of cytoliticliver enzyme, without signs of TTP relapse, and was treated with antibiotics (moxifloxacin andamoxicillin clavulanate) without any response. On 18 September, the patient was admitted to hospitalfor persisting fever and headache. Any sign of TTP was excluded by total body computed tomography(CT) scan, and a peripheral blood smear did not show schistocytes or other fragmented red bloodcells. Within a few days, a fulminant hepatitis and impairment of neurological functions were observedand rapidly developed into a coma. The molecular and serological laboratory diagnosis for the mostcommon viruses associated with hepatitis (hepatitis A, B and C virus, cytomegalovirus and Epstein-Barr virus) gave negative results.Two weeks after the OLT the patient slowly regained a low level of consciousness as well as somemotor function of cranial nerves and limbs, and an intensive rehabilitative programme was started.Virological analysisSince 3 September 2009, systematic screening has been performed on blood, tissue, stem cell andorgan donations from idividuals living in the Emilia Romagna region in Italy, where WNV transmissionwas observed in summer 2009 [6]. This screening activity was undertaken following the data aboutWNV circulation in wildlife, horses and mosquitoes obtained from the regional integrated surveillancesystem that was in place from 15 June to 31 October. Screening for WNV was done using a nucleicacid amplification test (NAAT-Transcription-Mediated Amplification (TMA): PROCLEIX WNV, NovartisDiagnostics).On 24 September, a plasma specimen obtained from the above patient immediately before surgery,was positive in the WNV NAAT assay. The test was repeated twice and the results were confirmed. Asecond sample was obtained from the patient one day after the OLT and the WNV NAAT was againpositive.The level of positivity obtained with the two specimens was quite low, suggesting either anextremely low concentration of WNV RNA in the blood or a false positive reaction. Additional bloodsamples obtained during the following 15 days gave negative results.The liver’s donor was also investigated. The donor had been living in the area of Parma and herplasma, obtained before liver donation, was NAAT-negative for WNV.The NAAT result was further investigated by real-ime RT-PCR targeting the WNV envelope (env) gene[7]. Surprisingly, the result was negative. Consequently we extended the investigation to additionalmembers of the Flaviviridae family, including at first TBEV, because this agent was already reported inItaly and because the illness caused by this virus can involve the central nervous system with apossible association with liver injury [8]. The plasma specimens were analysed by real-time RT-PCRspecific for the 3’ non-coding region of the TBEV genome [9], and resulted negative.A further step in the aetiological investigation was the use of a heminested RT-PCR with primer pairswhich amplify the NS5 region of the Flavivirus genus. This method was developed for the detection byPCR of the principal pathogenic flaviviruses (including DENV, JEV, USUV, WNV YFV, and Zika virus) andsubsequent identification by sequencing [3]. We performed the heminested RT-PCR as reported byScaramozzino et al. [10] with minor modifications (details available on request) and obtained a single amplicon of the expected size (220 bp).  Both strands of the amplicon were sequenced using the PCRprimers and analysed by BLAST (http://www.ncbi.nlm.nih.gov/blast). This analysis revealed 98%sequence identity (over 203 nt) to the USUV genome sequences available in GenBank, and no higherhomology with any other published DNA sequence. Low homologies were observed to the WNVgenome sequence (80 % identity) and to the JEV genome sequence (79% identity); this partialhomology is very likely due to the fact that these flaviviruses are closely related.In conclusion, the sequencing results demonstrated the presence of USUV in the clinical samples ofour patient. Additional confirmation of USUV viraemia was obtained by a PCR assay specific for USUV,performed as reported by Weissenbock et al. [11]. USUV was subsequently isolated in Vero E6 cells,and the identity of this isolate was confirmed by the heminested RT-PCR test reported above. Asexpected, the sequence obtained from the cultured virus isolate was identical to the one obtainedfrom the amplified plasma sample. Complete sequencing of this human pathogenic USUV isolate is inprogress.DiscussionThe results presented in this report, demonstrate USUV viraemia in an immunocompromised OLTrecipient suffering from severe neurological impairment caused by an encephalitis. It is noteworthythat the NAAT test PROCLEIX WNV was capable of detecting a WNV-related virus, which indicates apotential problem with the specificity of this method.The clinical findings observed closely resemble those reported in an animal model of USUV-relatedneurological disease [10]. To our knowledge, this report is the second description of the involvementof USUV in a human disease. Before, USUV-related infections had been reported as a cause of diseasein animals, mainly birds, with no demonstrated pathogenicity for humans. Recently, it has beenobserved that USUV is circulating in owls and blackbirds in the North Eastern part of Italy, suggestingthe possibility of USUV transmissions to humans in that area [12].We are currently involved in an extensive serological investigation for USUV antibodies in the blooddonors that were used for the plasma exchanges for our patient in order to define whether this therapycould have been the source of the infection or whether it was acquired naturally through a mosquitobite. In addition, a study is in progress to identify the presence of USUV in additional plasma andtissue specimens obtained from the same patient in order to quantify the viral load and thepersistence of the USUV viraemic stage and to assess the possible involvement of USUV in theoriginal liver disease. This case of USUV-related illness in humans has added this virus to the list ofthose that can be transmitted to humans by local mosquitoes and can cause severe diseases inimmunocompromised individuals.Authors' correctionOn the request of the authors, the name of GE Gerunda was corrected on 13 September 2012.References1. Poidinger M, Roy AH., and Mackenzie SJ. Molecular Characterization of the JapaneseEncephalitis Serocomplex of the Flavivirus Genus. Vir. 1996; 218(2): 417–21.2. Bakonyi T, Erdélyi K, Ursu K, Ferenczi E, Csörgo T, Lussy H, et al. Emergence of Usutu virus inHungary. J Clin Microbiol. 2007; 45(12): 3870-74.3. Chvala S, Kolodziejek J, Nowotny N, Weissenböck H. Pathology and viral distribution in fatalUsutu virus infections of birds from the 2001 and 2002 outbreaks in Austria. J Comp Pathol.2004; 131(2-3): 176-85.4. Lelli R, Savini G, Teodori L, Filipponi G, Di Gennaro A, Leone A, et al. Serological evidence ofUSUTU virus occurrence in north-eastern Italy. Zoonoses Public Health. 2008; 55(7): 361-67.5. Weissenböck H, Hubálek Z, Bakonyi T, Nowotny N. Zoonotic mosquito-borne flaviviruses:Worldwide presence of agents with proven pathogenicity and potential candidates of futureemerging diseases. Vet Microbiol. 2009; in Press.6. Rizzo C, Vescio F, Declich S, Finarelli AC, Macini P, Mattivi A, et al.. West Nile virus transmissionwith human cases in Italy, August - September 2009. Euro Surveill. 2009;14(40):pii=19353.7. Lanciotti RS, Kerst AJ, Nasci RS, Godsey MS, Mitchell CJ, Savage HM, et al. Rapid Detection ofWest Nile virus from human clinical specimens, field-collected mosquitoes and avian samplesby a TaqMan reverse transcriptase-PCR assay. J. Clin. Microbiol. 2000; 38(11): 4066-71.8. Misić-Majerus L, Bujić N, Madarić V, Avsić-Zupanc T. Hepatitis caused by tick-bornemeningoencephalitis virus (TBEV)--a rare clinical manifestation outside the central nervoussystem involvement. Acta Med Croatica. 2005; 59(4):347-52.9. Schwaiger M, Cassinotti P. Development of a quantitative real-time RT-PCR assay with internalcontrol for the laboratory detection of tick borne encephalitis virus (TBEV) RNA. J. Clin. Virol.2003; 27(2): 136-45.10. Scaramozzino N, Crance JM, Jouan A, Debriel DA, Stoll F, Garin D. Comparison of Flavivirusuniversal primer pairs and development of a rapid, highly sensitive heminested reversetranscription-PCR assay for detection of flaviviruses targeted to a conserved region of the NS5gene sequences. J. Clin. Microbiol. 2001; 39(5): 1922-27.11. Weissenböck H, Bakonyi T, Chvala S, Nowotny N. Experimental Usutu virus infection of sucklingmice causes neuronal and glial cell apoptosis and demyelination. Acta Neuropathol.2004; 108,453–60.12. Manarolla G, Bakonyi T, Gallazzi D, Crosta L, Weissenböck H, Dorrestein GM et al. Usutu virus inwild birds in Norther Italy. Vet Microbiol. 2009; Aug 8. [Epub ahead of print]. Home /  Eurosurveillance /   Volume 14, Issue 50, 17/Dec/2009 /  ArticleComment has been disabled for this contentRapid communications  Open AccessThis item has no PDFDownload Previous Article | Table of Contents | Next Article Usutu virus infection in a patient who underwentorthotropic liver transplantation, Italy, August-September 2009  F Cavrini , P Gaibani , G Longo , A M Pierro , G Rossini , P Bonilauri , G E Gerunda , F Di Benedetto , A Pasetto ,M Girardis , M Dottori , M P Landini , V Sambri View Affiliations View CitationLike 01,2 1,2 3 1 1 4 5 5 66 4 1 1Abstract Full-Text References Supplementary Material  Metrics/CitedBy  RelatedContent  Submit an Article         Add to my favourites  Create Publication Alert  Create Citation Alert  Create Correction Alert  Export citation Take oursatisfactionsurvey! The European Centre forDisease Prevention andControl (ECDC) has set up adedicated webpage forcoronavirus disease 2019(COVID-19) updates andrisk assessments with afocus on Europe.Submit your articlehere Share   ToolsNews/announcementsNews/announcementsContact the editorial teamSubscription and registrationSubmit an articleData protectionAccessibilityCookie policyDisclaimerCopyright informationOpen AccessSitemap This site complies withthe HONcode standard for trustworthyhealth information:verify here.Eurosurveillance ISSN 1560-7917© 2007 - 2020. All rightsreservedEurosurveillance ispublished by theEuropean Centre forDisease Preventionand Control (ECDC),Stockholm, SwedenI don't accept cookiesCookiesWe use cookies to collect statistics on how the visitors navigate the website and to improve the user experience. Find out more on how we use cookies and how you can change your settings.Manage cookies

Usutu virus infection in a patient who underwent orthotropic liver transplantation, Italy, August-September 2009.

https://iris.unimore.it/bitstream/11380/647230/2/Eurosurveillance%20_%20Usutu%20virus%20infection.pdf

Usutu virus infection in a patient who underwent orthotropic liver transplantation, Italy, August-September 2009.

Abstract

Similar works

Full text

Available Versions

Archivio istituzionale della ricerca - Università di Modena e Reggio Emilia