Rotavirus the structural and antigenic specificities of rotavirus
proteins
Structure & Composition
The virions measure 6080 nm in diameter and possess
two concentric capsid shells, each of which is
icosahedral. (Rotaviruses have a triple-layered structure.)
There is no envelope. Single-shelled virus particles that
lack the outer capsid are 5060 nm in diameter. The
inner core of the particles is 3340 nm in diameter. The
double-shelled particle is the complete infectious form of
the virus.
The rotavirus genome consists of double-stranded RNA in
1012 discrete segments with a total genome size of 16
27 kbp, depending on the genus. Rotaviruses contain 11
genome segments, The virion core contains several
enzymes needed for transcription and capping of viral
RNAs.
Rotaviruses are stable to heat at 50 C, to a 3.09.0 range
of pH, and to lipid solvents, such as ether and
chloroform, but they are inactivated by 95% ethanol,
phenol, and chlorine. Limited treatment with proteolytic
enzymes increases infectivity.
Rotaviruses are a major cause of diarrheal illness in
human infants and young animals, including calves and
piglets. Infections in adult humans and animals are also
common. Among rotaviruses are the agents of human
infantile diarrhea, Nebraska calf diarrhea, epizootic
diarrhea of infant mice, and SA11 virus of monkeys.
Classification & Antigenic Properties
Rotaviruses have been classified into five species (AE),
plus two tentative species (F and G), based on antigenic
epitopes on the internal structural protein VP6. These
can be detected by immunofluorescence, ELISA, and
immune electron microscopy (IEM). Group A rotaviruses
are the most frequent human pathogens. Outer capsid
proteins VP4 and VP7 carry epitopes important in
neutralizing activity, with VP7 glycoprotein being the
predominant antigen. These type-specific antigens
differentiate among rotaviruses and are demonstrable by
Nt tests. Multiple serotypes have been identified among
human and animal rotaviruses. Some animal and human
rotaviruses share serotype specificity. For example,
monkey virus SA11 is antigenically very similar to human
serotype 3. The gene-coding assignments responsible for
Pathogenesis
Rotaviruses infect cells in the villi of the small intestine
(gastric and colonic mucosa are spared). They multiply in
the cytoplasm of enterocytes and damage their transport
mechanisms. One of the rotavirus-encoded proteins,
NSP4, is a viral enterotoxin and induces secretion by
triggering a signal transduction pathway. Damaged cells
may slough into the lumen of the intestine and release
large quantities of virus, which appear in the stool (up to
1010 particles per gram of feces). Viral excretion usually
lasts 212 days in otherwise healthy patients but may be
prolonged in those with poor nutrition. Diarrhea caused
by rotaviruses may be due to impaired sodium and
glucose absorption as damaged cells on villi are replaced
by nonabsorbing immature crypt cells. It may take 38
weeks for normal function to be restored.
Clinical Findings & Laboratory Diagnosis
Rotaviruses cause the major portion of diarrheal illness in
infants and children worldwide but not in adults.There is
an incubation period of 13 days. Typical symptoms
include watery diarrhea, fever, abdominal pain, and
vomiting, leading to dehydration.
In infants and children, severe loss of electrolytes and
fluids may be fatal unless treated. Patients with milder
cases have symptoms for 38 days and then recover
completely. However, viral excretion in the stool may
persist up to 50 days after onset of diarrhea.
Asymptomatic infections, with seroconversion, occur. In
children with immunodeficiencies, rotavirus can cause
severe and prolonged disease.
Adult contacts may be infected, as evidenced by
seroconversion, but they rarely exhibit symptoms, and
virus is infrequently detected in their stools. A common
source of infection is contact with pediatric cases.
Laboratory diagnosis rests on demonstration of virus in
stool collected early in the illness and on a rise in
antibody titer. Virus in stool is demonstrated by IEM,
latex agglutination tests, or ELISA.
Epidemiology
Rotaviruses are the single most important worldwide
cause of gastroenteritis in young children. Estimates
range from 3 billion to 5 billion for annual diarrheal
episodes in children under 5 years of age in Africa, Asia,
and Latin America, resulting in as many as 1 million
deaths. Developed countries have a high morbidity rate
but a low mortality rate. Typically, up to 50% of cases of
acute gastroenteritis of hospitalized children throughout
the world are caused by rotaviruses.
Rotavirus infections usually predominate during the
winter season. Symptomatic infections are most
common in children between ages 6 months and 2 years,
and transmission appears to be by the fecal-oral route.
Nosocomial infections are frequent.
Treatment & Control
Treatment of gastroenteritis is supportive, to correct the
loss of water and electrolytes that may lead to
dehydration, acidosis, shock, and death. Management
consists of replacement of fluids and restoration of
electrolyte balance either intravenously or orally, as
feasible. The infrequent mortality from infantile diarrhea
in developed countries is due to routine use of effective
replacement therapy.
Eschericia Coli
Class: Enteric Gram-Negative Rods (Enterobacteriaceae
Typical Organisms
The Enterobacteriaceae are short gram-negative rods.
Typical morphology is seen in growth on solid media in
vitro, but morphology is highly variable in clinical
specimens. Capsules are large and regular in klebsiella,
less so in enterobacter, and uncommon in the other
species.
Culture
E coli and most of the other enteric bacteria form
circular, convex, smooth colonies with distinct edges.
Enterobacter colonies are similar but somewhat more
mucoid. Klebsiella colonies are large and very mucoid
and tend to coalesce with prolonged incubation. The
salmonellae and shigellae produce colonies similar to E
coli but do not ferment lactose. Some strains of E coli
produce hemolysis on blood agar.
Pathogenesis & Clinical Findings
The clinical manifestations of infections with E coli and
the other enteric bacteria depend on the site of the
infection and cannot be differentiated by symptoms or
signs from processes caused by other bacteria.
E coli-Associated Diarrheal Diseases
E coli that cause diarrhea are extremely common
worldwide. These E coli are classified by the
characteristics of their virulence properties (see below),
and each group causes disease by a different mechanism.
The small or large bowel epithelial cell adherence
properties are encoded by genes on plasmids. Similarly,
the toxins often are plasmid- or phage-mediated.
Enteropathogenic E coli (EPEC) is an important cause of
diarrhea in infants, especially in developing countries.
EPEC previously was associated with outbreaks of
diarrhea in nurseries in developed countries. EPEC
adhere to the mucosal cells of the small bowel.
Chromosomally mediated factors promote tight
adherence. There is loss of microvilli (effacement),
formation of filamentous actin pedestals or cup-like
structures, and, occasionally, entry of the EPEC into the
mucosal cells. Characteristic lesions can be seen on
electron micrographs of small bowel biopsy lesions. The
result of EPEC infection is watery diarrhea, which is
usually self-limited but can be chronic.
Enterotoxigenic E coli (ETEC) is a common cause of
"traveler's diarrhea" and a very important cause of
diarrhea in infants in developing countries. ETEC
colonization factors specific for humans promote
adherence of ETEC to epithelial cells of the small bowel.
Some strains of ETEC produce a heat-labile exotoxin (LT)
(MW 80,000) that is under the genetic control of a
plasmid. Its subunit B attaches to the GM1 ganglioside at
the brush border of epithelial cells of the small intestine
and facilitates the entry of subunit A (MW 26,000) into
the cell, where the latter activates adenylyl cyclase. This
markedly increases the local concentration of cyclic
adenosine monophosphate (cAMP), which results in
intense and prolonged hypersecretion of water and
chlorides and inhibits the reabsorption of sodium. The
gut lumen is distended with fluid, and hypermotility and
diarrhea ensue, lasting for several days.
Some strains of ETEC produce the heat-stable
enterotoxin STa (MW 15004000), which is under the
genetic control of a heterogeneous group of plasmids.
STa activates guanylyl cyclase in enteric epithelial cells Salmonellae vary in length. Most isolates are motile with
and stimulates fluid secretion. Many STa-positive strains peritrichous flagella. Salmonellae grow readily on simple
also produce LT. The strains with both toxins produce a media, but they almost never ferment lactose or sucrose.
more severe diarrhea. They form acid and sometimes gas from glucose and
mannose. They usually produce H2S. They survive
The plasmids carrying the genes for enterotoxins (LT, ST) freezing in water for long periods. Salmonellae are
also may carry genes for the colonization factors that resistant to certain chemicals (eg, brilliant green, sodium
facilitate the attachment of E coli strains to intestinal tetrathionate, sodium deoxycholate) that inhibit other
epithelium. enteric bacteria; such compounds are therefore useful
for inclusion in media to isolate salmonellae from feces.
Enterohemorrhagic E coli (EHEC) produces verotoxin,
named for its cytotoxic effect on Vero cells, a line of Pathogenesis & Clinical Findings
African green monkey kidney cells. There are at least two
antigenic forms of the toxin. EHEC has been associated Salmonella Typhi, Salmonella Choleraesuis, and perhaps
with hemorrhagic colitis, a severe form of diarrhea, and Salmonella Paratyphi A and Salmonella Paratyphi B are
with hemolytic uremic syndrome, a disease resulting in primarily infective for humans, and infection with these
acute renal failure, microangiopathic hemolytic anemia, organisms implies acquisition from a human source. The
and thrombocytopenia. vast majority of salmonellae, however, are chiefly
pathogenic in animals that constitute the reservoir for
Enteroinvasive E coli (EIEC) produces a disease very human infection: poultry, pigs, rodents, cattle, pets (from
similar to shigellosis. The disease occurs most commonly turtles to parrots), and many others.
in children in developing countries and in travelers to
these countries. Like shigella, EIEC strains are nonlactose The organisms almost always enter via the oral route,
or late lactose fermenters and are nonmotile. EIEC usually with contaminated food or drink. The mean
produce disease by invading intestinal mucosal epithelial infective dose to produce clinical or subclinical infection
cells. in humans is 105108 salmonellae (but perhaps as few as
103 Salmonella Typhi organisms). Among the host factors
Enteroaggregative E coli (EAEC) causes acute and chronic that contribute to resistance to salmonella infection are
diarrhea (> 14 days in duration) in persons in developing gastric acidity, normal intestinal microbial flora, and local
countries. These organisms also are the cause of food- intestinal immunity.
borne illnesses in industrialized countries. They are
characterized by their characteristic pattern of Salmonellae produce three main types of disease in
adherence to human cells. EAEC produce ST-like toxin humans, but mixed forms are frequent
(see above) and a hemolysin.
Table 165. Clinical Diseases Induced by Salmonellae.
The Salmonella-Arizona
Group Enteric Septicemias Enterocoliti
Fevers s
Class: Enteric Gram-Negative Rods (Enterobacteriaceae Incubation 720 days Variable 848 hours
period
Salmonellae are often pathogenic for humans or animals
Onset Insidious Abrupt Abrupt
when acquired by the oral route. They are transmitted
from animals and animal products to humans, where Fever Gradual, Rapid rise, Usually low
they cause enteritis, systemic infection, and enteric then high then spiking
fever. plateau, "septic"
with temperatur
Morphology & Identification "typhoidal" e
state
Duration of Several Variable 25 days
disease weeks group I serotypes of salmonellae. Eight to 48 hours after
ingestion of salmonellae, there is nausea, headache,
Gastrointestin Often early Often none Nausea, vomiting, and profuse diarrhea, with few leukocytes in
al symptoms constipation vomiting, the stools. Low-grade fever is common, but the episode
; later, diarrhea at usually resolves in 23 days.
bloody onset
diarrhea
Inflammatory lesions of the small and large intestine are
Blood cultures Positive in Positive Negative present. Bacteremia is rare (24%) except in
first to during high immunodeficient persons. Blood cultures are usually
second fever negative, but stool cultures are positive for salmonellae
weeks of and may remain positive for several weeks after clinical
disease recovery.
Stool cultures Positive Infrequentl Positive
from 2nd y positive soon after Treatment
week on; onset
negative While enteric fevers and bacteremias with focal lesions
earlier in require antimicrobial treatment, the vast majority of
disease cases of enterocolitis do not. Antimicrobial treatment of
salmonella enteritis in neonates is important. In
enterocolitis, clinical symptoms and excretion of the
The "Enteric Fevers" (Typhoid Fever)
salmonellae may be prolonged by antimicrobial therapy.
In severe diarrhea, replacement of fluids and electrolytes
This syndrome is produced by only a few of the
is essential.
salmonellae, of which Salmonella Typhi (typhoid fever) is
the most important. The ingested salmonellae reach the
Antimicrobial therapy of invasive salmonella infections is
small intestine, from which they enter the lymphatics
with ampicillin, trimethoprim-sulfamethoxazole, or a
and then the bloodstream. They are carried by the blood
third-generation cephalosporin. Multiple drug resistance
to many organs, including the intestine. The organisms
transmitted genetically by plasmids among enteric
multiply in intestinal lymphoid tissue and are excreted in
bacteria is a problem in salmonella infections.
stools.
Susceptibility testing is an important adjunct to selecting
a proper antibiotic.
After an incubation period of 1014 days, fever, malaise,
headache, constipation, bradycardia, and myalgia occur.
In most carriers, the organisms persist in the gallbladder
The fever rises to a high plateau, and the spleen and liver
(particularly if gallstones are present) and in the biliary
become enlarged. Rose spots, usually on the skin of the
tract. Some chronic carriers have been cured by
abdomen or chest, are seen briefly in rare cases.
ampicillin alone, but in most cases cholecystectomy must
be combined with drug treatment.
Bacteremia with Focal Lesions

This is associated commonly with S choleraesuis but may

be caused by any salmonella serotype. Following oral
infection, there is early invasion of the bloodstream (with
possible focal lesions in lungs, bones, meninges, etc), but
intestinal manifestations are often absent. Blood cultures
are positive.

Enterocolitis

This is the most common manifestation of salmonella

infection. In the United States, Salmonella Typhimurium
and Salmonella Enteritidis are prominent, but
enterocolitis can be caused by any of the more than 1400