[Onset of a fulminant malignant hyperthermia crisis. Case report of a 74-year-old patient with previously subclinical central core disease]. / Erstmanifestation einer fulminanten malignen-hyperthermie-krise. Fall eines 74-jährigen patienten mit bislang subklinischer "central core disease".

Malignant hyperthermia (MH) is a latent, autosomal dominant inherited syndrome of skeletal musculature which results in excessive hypermetabolism induced by halogenated anesthetic agents and depolarizing muscle relaxants and is caused by an uncontrolled intramuscular calcium release. This case report focuses on the description of symptoms of a fulminant MH crisis. A possible link between central core disease (CCD) and the clinical severity of MH crisis is postulated in this paper.

Spatial and temporal organization of tick-borne encephalitis flavivirus replicated RNA in living cells.

Flaviviruses are positive RNA viruses that assemble the replication complex in the cytoplasm of the infected cells. In order to get a dynamic view of the formation and distribution of flavivirus genomes in living cells we engineered a tick-borne encephalitis virus (TBEV) replicon with an array of binding sites for the phage MS2 core protein. The modified TBEV replicons were competent for RNA replication and allowed the visualization of replicated genomic RNA that accumulated in cytoplasmic structures with a distinct subcellular localization. Sites of TBEV replicated RNA accumulation were enriched in non-structural viral proteins and co-localized with the markers of the rough endoplasmic reticulum protein disulphide isomerase (PDI). In contrast no co-localization was observed with the markers CD-71 and EEA-1 for recycling vesicles, ERGIC53 for the intermediate compartment and TGN-46 for the trans-Golgi network. In human HOS cells, but not in hamster BHK21 cells, replicated TBEV RNA was found also associated with the marker Giantin for the Golgi indicating differences according to the cellular background. This study confirms and extends previous observations on the subcellular localization of flavivirus RNA and provides a useful tool to monitor the formation and distribution of flavivirus RNA genomes in living cells.

Tick-borne virus diseases of human interest in Europe.

Several human diseases in Europe are caused by viruses transmitted by tick bite. These viruses belong to the genus Flavivirus, and include tick-borne encephalitis virus, Omsk haemorrhagic fever virus, louping ill virus, Powassan virus, Nairovirus (Crimean-Congo haemorrhagic fever virus) and Coltivirus (Eyach virus). All of these viruses cause more or less severe neurological diseases, and some are also responsible for haemorrhagic fever. The epidemiology, clinical picture and methods for diagnosis are detailed in this review. Most of these viral pathogens are classified as Biosafety Level 3 or 4 agents, and therefore some of them have been classified in Categories A-C of potential bioterrorism agents by the Centers for Disease Control and Prevention. Their ability to cause severe disease in man means that these viruses, as well as any clinical samples suspected of containing them, must be handled with specific and stringent precautions.

A novel principle of attenuation for the development of new generation live flavivirus vaccines.

The genus Flavivirus includes a number of important human pathogens that impose major health problems in large regions of the world. The emergence of flaviviruses in new geographic regions (e.g., West Nile virus in North America) and rapid socioeconomic changed in many developing countries where flaviviruses such as dengue virus and Japanese encephalitis virus and endemic demand the development of new vaccines against these diseases. Using tick-borne encephalitis virus as a model we have established a new method to generate attenuated flavivirus strains that may be useful for generating cost-effective and safe live vaccines. This method relies on the specific introduction of deletions into one of the structural proteins, the capsid protein C. These deletions remove parts or all of an internal stretch of hydrophobic amino acid residues that probably is involved in virion assembly. We observed that remarkably long deletions were tolerated, yielding viable viral mutants that were highly attenuated in the mouse model but efficiently induced protective immunity. Biochemical analyses suggested that attenuation was caused by an assembly defect of infectious virions but the mutants produced ample amounts of non-infections subviral particles. The generation of viable mutants with deletions longer that 16 amino acid residues depended on additional, spontaneously emerging mutations within protein C that increased the hydrophobicity of the mutant protein. Although the second-site mutations increased infectivity, they did not restore neuroinvasiveness. Mouse experiments demonstrated excellent safety and immunogenicity profiles for these mutants.

Role of metastability and acidic pH in membrane fusion by tick-borne encephalitis virus.

The envelope protein E of the flavivirus tick-borne encephalitis (TBE) virus is, like the alphavirus E1 protein, a class II viral fusion protein that differs structurally and probably mechanistically from class I viral fusion proteins. The surface of the native TBE virion is covered by an icosahedrally symmetrical network of E homodimers, which mediate low-pH-induced fusion in endosomes. At the pH of fusion, the E homodimers are irreversibly converted to a homotrimeric form, which we have found by intrinsic fluorescence measurements to be more stable than the native dimers. Thus, the TBE virus E protein is analogous to the prototypical class I fusion protein, the influenza virus hemagglutinin (HA), in that it is initially synthesized in a metastable state that is energetically poised to be converted to the fusogenic state by exposure to low pH. However, in contrast to what has been observed with influenza virus HA, this transition could not be triggered by input of heat energy alone and membrane fusion could be induced only when the virus was exposed to an acidic pH. In a previous study we showed that the dimer-to-trimer transition appears to be a two-step process involving a reversible dissociation of the dimer followed by an irreversible trimerization of the dissociated monomeric subunits. Because the dimer-monomer equilibrium in the first step apparently depends on the protonation state of E, the lack of availability of monomers for the trimerization step at neutral pH could explain why low pH is essential for fusion in spite of the metastability of the native E dimer.

Adaptation of tick-borne encephalitis virus to BHK-21 cells results in the formation of multiple heparan sulfate binding sites in the envelope protein and attenuation in vivo.

Propagation of the flavivirus tick-borne encephalitis virus in BHK-21 cells selected for mutations within the large surface glycoprotein E that increased the net positive charge of the protein. In the course of 16 independent experiments, 12 different protein E mutation patterns were identified. These were located in all three of the structural domains and distributed over almost the entire upper and lateral surface of protein E. The mutations resulted in the formation of local patches of predominantly positive surface charge. Recombinant viruses carrying some of these mutations in a defined genetic backbone showed heparan sulfate (HS)-dependent phenotypes, resulting in an increased specific infectivity and binding affinity for BHK-21 cells, small plaque formation in porcine kidney cells, and significant attenuation of neuroinvasiveness in adult mice. Our results corroborate the notion that the selection of attenuated HS binding mutants is a common and frequent phenomenon during the propagation of viruses in cell culture and suggest a major role for HS dependence in flavivirus attenuation. Recognition of this principle may be of practical value for designing attenuated flavivirus strains in the future.

Mutational evidence for an internal fusion peptide in flavivirus envelope protein E.

The envelope protein E of the flavivirus tick-borne encephalitis (TBE) virus promotes cell entry by inducing fusion of the viral membrane with an intracellular membrane after uptake by endocytosis. This protein differs from other well-studied viral and cellular fusion proteins because of its distinct molecular architecture and apparent lack of involvement of coiled coils in the low-pH-induced structural transitions that lead to fusion. A highly conserved loop (the cd loop), which resides at the distal tip of each subunit and is mostly buried in the subunit interface of the native E homodimer at neutral pH, has been hypothesized to function as an internal fusion peptide at low pH, but this has not yet been shown experimentally. It was predicted by examination of the X-ray crystal structure of the TBE virus E protein (F. A. Rey et al., Nature 375:291-298, 1995) that mutations at a specific residue within this loop (Leu 107) would not cause the native structure to be disrupted. We therefore introduced amino acid substitutions at this position and, using recombinant subviral particles, investigated the effects of these changes on fusion and related properties. Replacement of Leu with hydrophilic amino acids strongly impaired (Thr) or abolished (Asp) fusion activity, whereas a Phe mutant still retained a significant degree of fusion activity. Liposome coflotation experiments showed that the fusion-negative Asp mutant did not form a stable interaction with membranes at low pH, although it was still capable of undergoing the structural rearrangements required for fusion. These data support the hypothesis that the cd loop may be directly involved in interactions with target membranes during fusion.

Attenuation of tick-borne encephalitis virus by structure-based site-specific mutagenesis of a putative flavivirus receptor binding site.

The impact of a specific region of the envelope protein E of tick-borne encephalitis (TBE) virus on the biology of this virus was investigated by a site-directed mutagenesis approach. The four amino acid residues that were analyzed in detail (E308 to E311) are located on the upper-lateral surface of domain III according to the X-ray structure of the TBE virus protein E and are part of an area that is considered to be a potential receptor binding determinant of flaviviruses. Mutants containing single amino acid substitutions, as well as combinations of mutations, were constructed and analyzed for their virulence in mice, growth properties in cultured cells, and genetic stability. The most significant attenuation in mice was achieved by mutagenesis of threonine 310. Combining this mutation with deletion mutations in the 3'-noncoding region yielded mutants that were highly attenuated. The biological effects of mutation Thr 310 to Lys, however, could be reversed to a large degree by a mutation at a neighboring position (Lys 311 to Glu) that arose spontaneously during infection of a mouse. Mutagenesis of the other positions provided evidence for the functional importance of residue 308 (Asp) and its charge interaction with residue 311 (Lys), whereas residue 309 could be altered or even deleted without any notable consequences. Deletion of residue 309 was accompanied by a spontaneous second-site mutation (Phe to Tyr) at position 332, which in the three-dimensional structure of protein E is spatially close to residue 309. The information obtained in this study is relevant for the development of specific attenuated flavivirus strains that may serve as future live vaccines.

Monitoring the virus load can predict the emergence of drug-resistant hepatitis B virus strains in renal transplantation patients during lamivudine therapy.

The development of resistant hepatitis B virus (HBV) strains during lamivudine treatment has been described repeatedly. To investigate whether the development of such resistant HBV strains can be predicted in an early phase of therapy, the HBV loads of 11 renal transplantation patients were screened at 3-month intervals by a quantitative HBV polymerase chain reaction (PCR) assay. Lamivudine resistance was detected by sequence analysis. Five patients developed resistance to lamivudine in the 12-15-month follow-up period. In all of them, a virus load of 1x103 HBV DNA copies still was detectable after 3 months of therapy. This was statistically significantly different from those patients who did not develop lamivudine resistance within the observation period, all of whom had no HBV DNA detectable after 3 months of treatment (P=.0022). Thus, virus load testing by use of a sensitive PCR assay allows the early prediction of the emergence of lamivudine-resistant HBV strains.

A DNA immunization model study with constructs expressing the tick-borne encephalitis virus envelope protein E in different physical forms.

We have conducted a DNA immunization study to evaluate how the immune response is influenced by the physical structure and secretion of the expressed Ag. For this purpose, we used a series of plasmid constructs encoding different forms of the envelope glycoprotein E of the flavivirus tick-borne encephalitis virus. These included a secreted recombinant subviral particle, a secreted carboxyl-terminally truncated soluble homodimer, a nonsecreted full-length form, and an inefficiently secreted truncated form. Mice were immunized using both i.m. injection and Gene Gun-mediated application of plasmids. The functional immune response was evaluated by determining specific neutralizing and hemagglutination-inhibiting Ab activities and by challenging the mice with a lethal dose of the virus. As a measure for the induction of a Th1 and/or Th2 response, we determined specific IgG subclasses and examined IFN-gamma, Il-4, and Il-5 induction. The plasmid construct encoding a secreted subviral particle, which carries multiple copies of the protective Ag on its surface, was superior to the other constructs in terms of extent and functionality of the Ab response as well as protection against virus challenge. As expected, the type of Th response was largely dependent on the mode of application (i.m. vs Gene Gun), but our data show that it was also strongly influenced by the properties of the Ag. Most significantly, the plasmid encoding the particulate form was able to partially overcome the Th2 bias imposed by the Gene Gun, resulting in a balanced Th1/Th2 response.

Reduced interferon-gamma expression in peripheral blood mononuclear cells of infants with severe respiratory syncytial virus disease.

We examined the in vivo cell-mediated immune response in infants with respiratory syncytial virus (RSV) infection in order to gain information about the pathogenesis of severe RSV disease in infancy. Semiquantitative reverse transcription-polymerase chain reaction and three-color flow cytometry were used to determine the levels of messenger RNA (mRNA) for interferon (IFN)-gamma in peripheral blood mononuclear cells, and the distribution of lymphocyte subsets in infants with acute RSV infection. The findings were correlated with the severity of the patients' illness and the production of RSV-specific IgE antibodies (RSV-IgE). Significantly lower IFN-gamma levels and T-lymphocyte counts in the acute phase of illness were observed in infants with severe RSV disease than in those with a milder clinical course of illness. The induction of RSV-IgE was not related to IFN-gamma levels in the acute phase of illness, but rather correlated with IFN-gamma expression during convalescence. The data indicate that reduced IFN-gamma expression may be an important factor in the pathogenesis of severe RSV disease in infancy.

Mapping of functional elements in the stem-anchor region of tick-borne encephalitis virus envelope protein E.

Envelope protein E of the flavivirus tick-borne encephalitis virus mediates membrane fusion, and the structure of the N-terminal 80% of this 496-amino-acid-long protein has been shown to differ significantly from that of other viral fusion proteins. The structure of the carboxy-terminal 20%, the stem-anchor region, is not known. It contains sequences that are important for membrane anchoring, interactions with prM (the precursor of membrane protein M) during virion assembly, and low-pH-induced structural changes associated with the fusion process. To identify specific functional elements in this region, a series of C-terminal deletion mutants were constructed and the properties of the resulting truncated recombinant E proteins were examined. Full-length E proteins and proteins lacking the second of two predicted transmembrane segments were secreted in a particulate form when coexpressed with prM, whereas deletion of both segments resulted in the secretion of soluble homodimeric E proteins. Sites located within a predicted alpha-helical region of the stem (amino acids 431 to 449) and the first membrane-spanning region (amino acids 450 to 472) were found to be important for the stability of the prM-E heterodimer but not essential for prM-mediated intracellular transport and secretion of soluble E proteins. A separate site in the stem, also corresponding to a predicted alpha-helix (amino acids 401 to 413), was essential for the conversion of soluble protein E dimers to a homotrimeric form upon low-pH treatment, a process resembling the transition to the fusogenic state in whole virions. This functional mapping will aid in the understanding of the molecular mechanisms of membrane fusion and virus assembly.

Comparison of line probe assay (LIPA) and sequence analysis for detection of HIV-1 drug resistance.

The identification of HIV strains that are resistant to antiretroviral drugs, which emerge during a patient's therapy or are already present in infected individuals prior to treatment, is of increasing importance for the clinical management of HIV-infected persons. Two different methods were compared for the genotypic detection of resistance development in the HIV-1 reverse transcriptase (RT) gene, the commonly used sequence analysis, and the commercially available RT-line immunoprobe assay (LIPA), which can detect mutations at six separate codons of the RT gene, which are known to confer resistance to certain nucleoside inhibitors. Eighty serum samples from HIV-1-infected persons, some of whom were receiving antiretroviral therapy, were investigated in parallel by sequencing as well as by LIPA. LIPA results agreed with sequence data in the vast majority of the cases. However, in 40% of the samples, LIPA failed to yield evaluable results for one or more of the codon positions. In particular, LIPA detection rate was low at codon 41 (75%), whereas at codons 69/70, 74, 184, and 215 results were obtained from 90%-95% of the samples. A number of mutations in the vicinity of the respective codons were detected by sequencing, and these may have been responsible for the LIPA hybridization failure. There remained a number of samples, however, where no explanation for the lack of hybridization could be derived from sequence data. Our results indicate that the use of the LIPA does not eliminate the need for sequence analysis for detection of drug-resistant HIV strains.

In vitro-synthesized infectious RNA as an attenuated live vaccine in a flavivirus model.

Live virus vaccines have in many cases proven to be an extremely effective tool for the prevention of viral diseases. However, the production of conventional live vaccines in eukaryotic cell cultures has many disadvantages, including the potential for contamination with adventitious agents and genetic alterations during propagation, making it necessary to do extensive testing before distribution. Based on results obtained with a flavivirus (tick-borne encephalitis virus) in an experimental animal system, we propose a novel live attenuated virus vaccination strategy consisting of the application of in vitro-synthesized infectious RNA instead of the live virus itself. When administered using the GeneGun, less than 1 ng of RNA was required to initiate replication of virus that was attenuated by a specifically engineered deletion and this induced a protective immunity in laboratory mice. Because this approach uses RNA, it does not have the potential drawbacks of DNA vaccines and thus combines the advantages of conventional live virus vaccines (for example, mimicking natural infection and inducing long-lasting immunity) with those of nucleic acid-based vaccines (for example, ease of production without a requirement for eukaryotic cell culture, stability and purity).

The DSD-1 carbohydrate epitope depends on sulfation, correlates with chondroitin sulfate D motifs, and is sufficient to promote neurite outgrowth.

The neural chondroitin sulfate (CS) proteoglycan (PG) DSD-1-PG was originally identified with the monoclonal antibody (mAb) 473HD. It promotes neurite outgrowth of hippocampal neurons when coated as a substrate in the presence of polycations. This effect is inhibited by mAb 473HD that specifically recognizes the DSD-1 epitope. The DSD-1 epitope is also detectable in CS-C and CS-D preparations from shark cartilage but not in other chondroitin sulfates that are structurally related and differ in their sulfation patterns. Non-sulfated DSD-1-PG and chemically desulfated CS-D were not recognized by mAb 473HD, suggesting that the DSD-1 epitope depends on sulfation. It was possible to enrich DSD-1 epitope-bearing carbohydrates and D disaccharide units from CS-C and CS-D preparations on a mAb 473HD affinity matrix. This indicates that the DSD-1 epitope represents a distinct glycosaminoglycan structure containing D units. The analysis of glycosaminoglycan digestion products by high pressure liquid chromatography revealed that DSD-1-PG preparations contain a unique D disaccharide unit as well as an A, a C, and a non-sulfated disaccharide unit. In neurite outgrowth assays with hippocampal neurons, substrate-bound CS-D promoted neurite outgrowth, whereas CS-A, CS-B, or CS-C did not. This effect of CS-D was inhibited by mAb 473HD. DSD-1 epitope-enriched fractions obtained from CS-D and CS-C promoted neurite outgrowth, whereas CS-C had no such effect prior to enrichment on the mAb 473HD matrix. Based on these findings we conclude that the DSD-1 epitope by itself is sufficient to promote neurite outgrowth and that this activity is possibly associated with D motifs.

Expression of DSD-1-PG in primary neural and glial-derived cell line cultures, upregulation by TGF-beta, and implications for cell-substrate interactions of the glial cell line Oli-neu.

DSD-1-PG is a chondroitin sulfate proteoglycan with neurite-outgrowth promoting properties expressed during development and upon lesion of neural tissues which has been defined with the specific monoclonal antibody 473HD. Double immunofluorescence studies performed on primary cerebellar cultures document that the proteoglycan is expressed on the surface of immature glial cells and the neural cell line Oli-neu, a model of mouse oligodendrocyte progenitors. Biochemical and immunoprecipitation studies performed with biosynthetically labelled Oli-neu and primary neural cells demonstrated that DSD-1-PG is expressed in vitro as a proteoglycan of 1000 kD apparent Mr with two core glycoproteins of 250 kD and 400 kD. In order to study the regulation of DSD-1-PG expression, an in vitro enzyme-linked immunosorbent assay based on Oli-neu and mAb 473HD was established. TGF-beta1-3 induced up-regulation of the proteoglycan, while various growth factors and cytokines did not significantly affect DSD-1-PG expression in both the supernatant and the extract of the culture monolayer. FACSCAN analysis suggested that the proteoglycan is upregulated on the surface of Oli-neu. Cell substrate adhesion assays revealed that this enhanced expression correlates with a selective reduction of adhesion to laminin, but not fibronectin or merosin, which could specifically be neutralized by antibodies to DSD-1-PG. We conclude that the proteoglycan contributes to the regulation of glial precursor interactions with the extracellular matrix.

Possible influence of the mutant CCR5 Allele on vertical transmission of HIV-1.

A possible correlation between the rate of vertical transmission of HIV-1 and the presence of the defective HIV co-receptor gene delta 32ccr5 in the chromosomes of infants born to HIV-positive mothers was assessed. The prevalence and genotypic distribution of the delta 32ccr5 gene were studied in 451 uninfected and 225 HIV-1-infected adults and 79 children born to HIV-1-positive mothers in Austria (45 uninfected and 34 infected by vertical transmission). As expected in a Caucasian population, the delta 32ccr5 allele was found in uninfected Austrians at a frequency of 10% (17.3% heterozygotes and 1.3% delta 32ccr5/ delta 32ccr5 homozygotes, consistent with the expected Hardy-Weinberg distribution). The mutant allele frequency was 11.1% in uninfected children (17.8% heterozygotes, 2.2% homozygotes) and 9.6% in HIV-positive adults (19.1% heterozygotes but no delta 32ccr5/delta 32ccr5 homozygotes). Among the group of 34 vertically infected children, however, there were only two heterozygotes and no delta 32ccr5/delta 32ccr5 homozygotes, corresponding to a significantly reduced mutant allele frequency of 2.9% (P = 0.05 compared to HIV-negative children). These results suggest that CCR5/delta 32ccr5 heterozygous children are less susceptible to vertical transmission of HIV-1. The data also support the hypothesis that delta 32ccr5 homozygous individuals are resistant to HIV-1 infection.

Spontaneous and engineered deletions in the 3' noncoding region of tick-borne encephalitis virus: construction of highly attenuated mutants of a flavivirus.

The flavivirus genome is a positive-strand RNA molecule containing a single long open reading frame flanked by noncoding regions (NCR) that mediate crucial processes of the viral life cycle. The 3' NCR of tick-borne encephalitis (TBE) virus can be divided into a variable region that is highly heterogeneous in length among strains of TBE virus and in certain cases includes an internal poly(A) tract and a 3'-terminal conserved core element that is believed to fold as a whole into a well-defined secondary structure. We have now investigated the genetic stability of the TBE virus 3' NCR and its influence on viral growth properties and virulence. We observed spontaneous deletions in the variable region during growth of TBE virus in cell culture and in mice. These deletions varied in size and location but always included the internal poly(A) element of the TBE virus 3' NCR and never extended into the conserved 3'-terminal core element. Subsequently, we constructed specific deletion mutants by using infectious cDNA clones with the entire variable region and increasing segments of the core element removed. A virus mutant lacking the entire variable region was indistinguishable from wild-type virus with respect to cell culture growth properties and virulence in the mouse model. In contrast, even small extensions of the deletion into the core element led to significant biological effects. Deletions extending to nucleotides 10826, 10847, and 10870 caused distinct attenuation in mice without measurable reduction of cell culture growth properties, which, however, were significantly restricted when the deletion was extended to nucleotide 10919. An even larger deletion (to nucleotide 10994) abolished viral viability. In spite of their high degree of attenuation, these mutants efficiently induced protective immune responses even at low inoculation doses. Thus, 3'-NCR deletions represent a useful technique for achieving stable attenuation of flaviviruses that can be included in the rational design of novel flavivirus live vaccines.

Secondary structure of the 3'-noncoding region of flavivirus genomes: comparative analysis of base pairing probabilities.

The prediction of the complete matrix of base pairing probabilities was applied to the 3' noncoding region (NCR) of flavivirus genomes. This approach identifies not only well-defined secondary structure elements, but also regions of high structural flexibility. Flaviviruses, many of which are important human pathogens, have a common genomic organization, but exhibit a significant degree of RNA sequence diversity in the functionally important 3'-NCR. We demonstrate the presence of secondary structures shared by all flaviviruses, as well as structural features that are characteristic for groups of viruses within the genus reflecting the established classification scheme. The significance of most of the predicted structures is corroborated by compensatory mutations. The availability of infectious clones for several flaviviruses will allow the assessment of these structural elements in processes of the viral life cycle, such as replication and assembly.