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This text is part of the Infectious Diseases Treaty (chapter Etiology of infectious
diseases, subchapter Viruses, author Simona Ruta), edited by Emanoil Ceausu, published
by Editura Medicala, Bucharest, 2018.
1. INTRODUCTION
Viruses are a heterogeneous class of infectious agents, which parasitize humans,
animals, plants and bacteria (bacteriophages).
Common features (1, 2):

1. strictly intracellular parasitism- viruses do not have their own energy supply / storage systems,
they are dependent on the cellular enzyme apparatus and on cellular energy sources for
multiplication.
2. small size (nanometers), which is why viruses are ultrafiltrable and visible only in
electron microscopy.
The only exception is the newly discovered giant viruses, with a very large size and
extremely complex structure, which also includes real own protein synthesis plants). These DNA
viruses are classified in the new order Megavirales, (nucleocytoplasmic large DNA viruses), with
several distinct genera: Mimivirusmlmiking mlcrobe), Mollivirus, Marseillevirus, Pandoravirus,
Pithovirus, Faustovirus (3). Most infect protozoa of the genus Acanthamoeba, being isolated
fromdifferent aquatic environments and sediments. It is unclear to what extent these giant
viruses are pathogenic to humans(4), although they were initially identified in an epidemic
episode of pneumonia in England (5).
3. simple structure- viruses are made up of genome-represented by a single species of

nucleic acid- either DNA (deoxyriboviruses) or RNA (riboviruses) - and more protein
coatings (mandatory cap, optional tire and a series of pericapsid coatings). The genome
is the support of virus infectivity, and viral proteins are the support of their antigenicity
(2).
capsid it is a mandatory viral shell, of strictly protein nature, composed of several
identical subunits - capsomeres (proteins encoded by viral nucleic acid), assembled according to
the rules of symmetry (helical or icosahedral). The capsid is fully encoded by the viral genome.
tire it is an optional viral envelope (there are enveloped viruses and non-enveloped
viruses), of a glyco-lipid-protein nature. The envelope includes both structures encoded by the
viral genome and lipid portions taken from the membrane of the infected cell during
release of virions. Non-enveloped viruses, due to the exclusively protein external structure, are much
more stable in the external environment compared to enveloped viruses, being resistant to large
variations in temperature, acid pH and the action of proteolytic enzymes and detergents.
2. VIRUS REPLICATION
Virus replication is a complex and different process depending on the virus-host cell system. A
single initial particle, calledparental virion, gives rise, after replication, to a huge number (up to
several tens of thousands) of new infectious particles, called virion progeny. Schematically, the
viral replicative cycle can be divided into 3 distinct stages (1, 2, 6):
1.Eclipsa includes: (a) adsorption parental virion to specific cellular receptors-proteins located
on the membrane of the host cell; (b) internalization in the host cell and (c) decapsidation
separation of viral nucleic acid from protein coatings.
Viral tropism is the result of coupling cellular receptors by viral proteins existing on
the capsid or viral envelope. Each virus uses specific receptors: eg: rabies virus -
receptors for acetylcholine, HIV virus - CD4 molecules, influenza virus - receptors for
sialic acid. Initial adsorption of virions to host cell receptors causes conformational
changes in viral proteins, which expose new domains capable of coupling other
molecules on the cell membrane, calledcoreceptor.
Susceptibility in infections it is dependent on the density of the receptors. Some viruses are pantrope
- they can infect cells or tissues from various animal species - others are pathogenic only to humans
(sometimes to hominoid monkeys). In general, the receptors are specific to each species, but,
following repeated human contact with infected animals, it can be achieved.overcoming the species
barrier. Thus, strains of avian or swine influenza viruses, as well as the zoonotic coronaviruses SARS
CoV, MERS CoV and SARS CoV-2 have been adapted to humans.INTERNALISATION is achieved either
by endocytosis, in the case of non-enveloped viruses (in this case, a redistribution of the
membrane receptors most frequently occurs, and the host cell transports the virion in an endocytic
vesicle to the intracytoplasmic lysosomes, at this level the degradation of the viral protein coatings
takes place), or by fusion, in the case of enveloped viruses (they have specialized transmembrane
proteins - fusion factors - that mix membrane lipids with those in the viral envelope, creating a bridge
between the virion and the cell,

through which the viral nucleic acid penetrates inside the cell, and the protein coatings remain
outside, being degraded).
Decapsidation is the physical separation of viral nucleic acids from protein coatings. Only the
parental viral genome remains in the cytoplasm of the host cell, serving as a template for the
logarithmic growth phase.
Logarithmic growth stage aims synthesis of new viral nucleic acids and new viral
proteins.
DNA viruses usually replicate in the nucleus (except for poxviruses); and RNA viruses in
the cytoplasm (except orthomixoviruses).
If viruses with the DNA genome, the synthesis of new viral nucleic acids is done under the
action of DNA polymerases that most frequently come from the host cell, but there are also viral
DNA polymerases - this is the case of herpesviruses and poxviruses. DNA viruses are dependent
on the cell cycle stage for access to host polymerases; however, there are also viruses capable of
replication in cells at rest or in stages of terminal differentiation (eg, some herpesviruses
replicate in neurons). Other viruses encode early proteins capable of inhibiting the cell genes
responsible for controlling the cell cycle - these have oncogenic capacity (eg papillomaviruses).
RNA viruses encodes its own RNA polymerases that will synthesize new viral nucleic acids. RNA
viral polymerases make numerous errors during the copying of viral nucleic acid, and do not
have mechanisms to correct these incorrect incorporations of nucleotides, so the replication of
RNA viruses is characterized by variability. The fidelity of replication is much higher for DNA
viruses, which are much more stable from an antigenic point of view.
Regardless of the type of genome, viruses must synthesize an mRNA that serves as a
template for the synthesis of viral proteins. There are two types of viral proteins synthesized
in cellular ribosomes (2,6):
- early proteins, with enzymatic role, which inhibits cellular processes and facilitates the
synthesis of viral components, participating in the formation of viral inclusions - centers of viral
replication inside the cytoplasm or cell nucleus, used in the microscopic diagnosis of viral
infection during isolation on cell cultures or biopsies from affected tissues.

- late, structural proteins which will become part of the protein coatings of the new virions - the
capsid, respectively the envelope.
Depending on the strategy used for mRNA synthesis, 7 classes of viruses are defined (8):
I. dsDNA (ex: adeno, herpes, poxviruses), which uses a cellular enzyme, RNA pole II
for mRNA synthesis
II. SsDNA (eg parvoviruses), which use cellular DNA polymerase for the synthesis of
a dsDNA, and subsequently, cellular RNA for mRNA synthesis
III. dsRNA (ex: reoviruses) that synthesize an RNA-dependent RNA polymerase,
which will cause mRNA synthesis and lead to genome replication
IV. SsRNA (+) -single-stranded RNA viruses with positive polarity- ex: Picorna, Flavi,
Caliciviruses), in which the parental genome serves directly as messenger RNA, and
replication begins directly with the translation of nonstructural viral proteins, with
enzymatic role, including a virus-encoded RNA polymerase, which will lead to acid
replication nucleic.
V. SsRNA (-) single-stranded RNA viruses with negative polarity (ex: Ortho and
Paramixoviruses) -which have a preformed viral enzyme, introduced into the host cell
together the parental genome: viral transcriptase . This transcriptase results in the
synthesis of a complementary copy of the genome, which serves as an mRNA and is a
template for the translation of nucleocapsid proteins. These will cover the parent
genome, anchoring viral RNA polymerase and triggering the synthesis of new viral
nucleic acids.
VI. SsRNAs + viruses that replicate through a DNA intermediate (Retroviruses). These viruses
encode a reverse transcriptase, an enzyme that synthesizes proviral DNA on the parental
genome matrix. Proviral DNA is translocated into the nucleus of the target cell and will
integrate, under the action of another viral enzyme - integrates into the cell genome. Its
activation, with the initiation of transcription, which results in several species of mRNA - one
representing the new progenome genome, the others translated into viral proteins, is done
under the concerted action of cellular and viral factors, encoded by regulatory genes.
DDNA viruses that replicate through an RNA-like intermediate

ARE YOU COMING.
(Hepadnaviruses). These viruses have an extremely viral polymerase

complex, multifunctional that also serves as a reverse transcriptase. This replication
is characteristic of hepatitis B virus (HBV)
3. Set stage includes (a) READY FOR structural proteins for the composition of the shells of new
virions, (b) assembling viral nucleic acid with protein coatings and (c) releaseprogenitor virions
(by cytolysis, in the case of non-enveloped viruses, or by budding, in the case of enveloped ones).
Bibliography
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of giant viruses of amoebae. Nat Rev Microbiol. 2017; 15 (4): 243-254.
4. Vanspauwen MJ, Schnabel RM, Bruggeman CA, et al. Mimivirus is not a frequent cause of
ventilatorassociated pneumonia in critically ill patients. J Med Virol. 2013; 85 (10): 1836-41.
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2. Ntiviral immunity - Mechanisms of virus resistance
The mechanisms of antiviral defense are based on effectors non-specific resistance (born, which
operate similarly regardless of the type of microorganism) and effectors ai specific resistance
(acquired, specifically directed against a certain pathogen), which acts synergistically (1,2).Non-
specific resistance in viruses is ensured mainly by the synthesis of interferons (a family of
glycoproteins with antiviral, immunomodulatory and anti-cellular role) and the action NK cells(natural
killer), which ensures the lysis of virally infected cells.
Recognition of molecular patterns specific to pathogens- PAMPs (pathogen-associated

molecular patterns) by specific receptors PRR (Pattern recognition receivers- in case
TLR membrane receptor viruses (Toll-like) or cytoplasmic- RIG-I (retinoic acidinducible gene 1
protein) - o RNA helicase - involved in altering the secondary structure of mRNA), initiates a
signaling cascade, which will lead to the activation of a transcription factor-IRF-3 (interferon
regulatory factor-3) under the influence of which interferon genes are expressed. Once
synthesized, interferons bind to specific receptors and activate the Jak signaling pathway (Janus
kinase) - STAT (signal transducer and activator of transcription), which leads to the expression of
interferon-stimulated genes (ISG- interferon stimulated genes- ex: 2′ – 5 ′ oligoadenylate
synthetase, dsRNA-dependent protein kinase, Mx proteins). They mediate the antiviral and
anticellular action of interferon, inducing a state of resistance to viral replication in neighboring
cells, by facilitating mRNA degradation and inhibiting protein synthesis (3). Recombinant
interferon, used in the clinic, has the same mechanism of action as endogenous interferon, but
reaches much higher concentrations in vivo, which increases the effectiveness of antiviral action.
Specific resistance is mediated by:

- synthesis of antiviral antibodies by B lymphocytes transformed into plasma cells
- the action of helper T lymphocytes (CD4 positive) and cytotoxic T lymphocytes (CD8 positive).
Cellular immunity plays the most important role in viral infections. There are some
congenital abnormalities in the immune response that result in either a lack of antibody
synthesis (agamaglobulinemia) or a lack of immunocompetent cells. Children with
agamaglobulinemia can cure viruses, while maintaining the action of immunocompetent
cells, while those with impaired cellular immune responses make severe, even lethal forms
of viral infections, despite the synthesis of antiviral antibodies.
Recognition of viral antigens is performed differently for each type of lymphocyte: the B
lymphocyte receptor (BCR- B cell receptor) recognizes conformational epitopes- present on the
cap or viral envelope; while the T lymphocyte receptor (TCR- T cell receptor) only recognizes
linear epitopes (short amino acid sequences), obtained by processing viral proteins and
presenting them, associated with MHC molecules, by antigen presenting cells(dendritic cells,
macrophages) (1,2).
Cytotoxic T lymphocytes (LTc, CD8 +) recognize viral antigens presented in the context of CMH class I.
Once activated, they induce either cytolysis (by destruction mediated by perforins and granules) or
apoptosis of the virally infected cell (activated by FasL molecules, present on the surface of activated
lymphocytes).
Helper T lymphocytes (LTh, CD4 +) recognize viral antigens presented in the context of MHC class
IIa. Their role is to synthesize activating cytokines of the cellular immune response (IL2 and IFN
gamma -synthesized by the Th1 subset) or of the humoral immune response (IL4, 5, 6, 10- synthesized
by the Th2 subset).
Antibodies it binds to conformational epitopes on the surface of the viral envelope or

capsid, blocking viral adsorption or decapsidation and thus neutralizing the infectivity of
virions that spread through the blood. An important mechanism of antiviral defense is
antibody-dependent cytotoxicity, a mechanism by which antibodies to viral antigens present
on the surface of infected cells are recognized by immune cells (NK lymphocytes,
macrophages, neutrophils, eosinophils) through receptors for the Fc fraction. of
immunoglobulins, which triggers target cell lysis.
Pathogenesis of viral infections
1. Lytic, productive viral infection it occurs in permissive cells, which support complete viral
replication with the formation and release of progenitor virions. This type of infection may be
symptomatic or clinically inapparent, but accompanied by asymptomatic viral excretion.Inapparent
infections they produce limited amounts of virus, without generating functional or morphological
changes of the host cell. Under conditions of immunosuppression or in the presence of coinfections,
inapparent infections can turn into productive infections.
2. Persistent viral infection it is established in cells with limited permissiveness, which generate the
selection of viral strains with slow multiplication or with the persistence of the viral genome in
episomal form. At the level of the infected tissue, a balance is achieved between viral replication and
cell division, and a series of extracellular factors (interferon, interfering RNA, nonneutralizing
antibodies, etc.) protect the still uninfected cells and contribute to the installation of persistence.
viral (2.8). The extreme situation is when the virus does not replicate -abortive infection, butthe viral
genome integrates into the cellular genome, putand genera cell transformation and initiation of
viral-induced carcinogenesis. (ex:human papillomaviruses) (9).
3. Latent viral infections are the result of stopping the viral replicative cycle in the early stages.
Some cells cannot assemble progenitor virions or release them, but they do support the
synthesis of nonstructural viral proteins. Latency is a characteristic phenomenonherpes which
may remain dormant in certain highly specialized cells and, under the influence of various
triggering factors, may resume complete replication, generating asymptomatic or clinically
apparent reactivations.
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Zoster Virus Encephalitis. J Infect Dis. 2017; 215 (9): 1430-1434.
5. Stättermayer AF, Ferenci P. Effect of IL28B genotype on hepatitis B and C virus infection. Curr Opin Virol.
2015 Oct; 14: 50-5.
6. Zhang X, De Paiva CS, Su Z, et al. Topical interferon-gamma neutralization prevents conjunctival goblet cell
loss in experimental murine dry eye. Exp Eye Res. 2014 Jan; 118: 117-24.
7. Ortiz MA, Espino-Paisan L, Nunez C, et al. New life to an old treatment: pegylated Interferon beta
1a in the management of multiple sclerosis. Curr Med Chem. 2018 doi: 10.2174 /
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8. Flint J, Racaniello VR; Rall GF; Skalka AM, LW Survey. Principles of Virology. Third Edition, 2015, ASM
Press Publishing
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Lippincott Williams Wilkins.
10. Umbach JL, Kramer MF, Jurak I, Karnowski HW, Coen DM, Cullen BR. MicroRNAs expressed by herpes
simplex virus 1 during latent infection regulate viral mRNAs. Nature. 2008; 454 (7205): 780-3.
11. Wilson AC, Mohr I. A cultured affair: HSV latency and reactivation in neurons. Trends in microbiology. 2012;
20 (12): 604-611.
12. Sheehy AM, Gaddis NC, Choi JD, Malim MH (2002) Isolation of a human gene that inhibits HIV-1
infection and is suppressed by the viral Vif protein. Nature 418, 646-50
13. Mok BW, Liu H, Chen P, et al. The role of nuclear NS1 proteins in highly pathogenic H5N1 influenza viruses.
Infect microbes. 2017; 19 (12): 587-596.
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HIV-1 infection in Caucasian individuals bearing mutant alleles of the CCR-5
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Translated from Romanian to English - www.onlinedoctranslator.com
VIRAL VACCINES
Classic vaccines:
1. Inactivated vaccines (VI), obtained by inactivating the virus isolated in the laboratory, by
chemical processes (treatment with formaldehyde or beta-propriolactone) that keep the
immunogenicity unaltered.
VI induce a significant immune response (as individual antibody titer, proportion of

seroconversion and persistent antibody recipients) only after complete immunization
regimens involving multiple doses and correctly spaced boosters. Consecutive VI immunity
is limited only to some antigens displayed outside the virion, which can sometimes be
altered by inactivation processes that are usually the target of viral variability.
VI are commonly used to prevent polio, influenza, rabies and hepatitis A.
2. Live attenuated vaccines (VVA) obtained by attenuating viral infectivity, most frequently under
the action of physical factors (selection of cold strains that are grown in the laboratory at
suboptimal temperatures).
Advantages of VVA:
- preserves the capacity of active replication of the virus and practically mimics an asymptomatic natural
infection, with the stimulation of both the systemic immunity (humoral and cellular), and the local one, at
the level of the virus entry gate,
- by the active elimination of the attenuated virus, the gradual replacement of the wild virus from the circulation is achieved
to a certain extent, with the passive immunization of the contacts of the vaccinated ones.
- In general, it requires fewer boosters compared to inactivated ones, in which the antigenicity can
change due to chemical processes and does not require adjuvants.
Disadvantages of VVA
- the risk of severe symptoms in immunosuppressed persons,

- stability in transport and storage depends on the proper maintenance of the cold chain.
- the risk of reversion to virulence, with the appearance of pathogenic revertants, although in practice this
phenomenon occurred only in the case of live attenuated polio vaccine
- their interference with other viruses with which they share the same habitat in the body (polio / enteroviruses);
VVAs are commonly used for the prevention of measles, rubella, mumps (trivalent vaccine
MMR- measles mumps, rubella or MMR measles, mumps, rubella); polio (in Romania since
2008, its administration has been replaced by that of the inactivated vaccine), as well as
influenza, chickenpox or yellow fever.
A live attenuated vaccine also served to eradicate smallpox. The vaccine virus (Vaccinia) is a
non-pathogenic virus for humans (in which it causes an infection located in the phalanges,
known as milk nodules), but antigenically related to the etiological agent of human
smallpox, against which it causes a strong, long-lasting immunization. .
In recent decades they have appeared vaccines based on modern platforms for the expression of
immunogens, for the rapid production of vaccines with increased efficiency and safety:
- recombinant viral proteins - self-assembled (virus like particles- VLP) or inserted into
nanoparticles. Such vaccines are used in practice to prevent hepatitis B and infection with
the most common human papillomaviruses, including those with an increased risk of
oncogenesis.
- Incompetent replicative or defective viral vectors . Such a vaccine was approved in 2019 for
the prevention of Ebola hemorrhagic fever
- mRNA or cDNA - synthetic nucleic acids encoding a highly immunogenic protein. There is no
such approved vaccine, a number of vaccines-candidate for the prevention of SARS CoV-2
infection have been developed, now in phase 3 clinical trials
The Romanian immunization calendar in Romania includes the polio vaccine (inactivated, injectable), the
trivalent measles vaccine, mumps, rubella (live attenuated, injectable) and the hepatitis B vaccine,
produced by recombinant DNA technology (injectable). A number of other viral vaccines (anti
rotaviruses, anti chickenpox, anti hepatitis A, anti papillomaviruses) are recommended, but not included in the
national calendar.
Polio vaccination
Worldwide both are used live attenuated oral vaccine (Sabin), as well as a
inactivated vaccine for injection (Salk). Both have been formulated as trivalent
vaccines, effective against all 3 antigenic types of polio viruses isolated.
Poliomyelitis
The disease is characterized by the appearance of acute, asymmetric flaccid paralysis, as a result of lesions
of motor neurons in the anterior horns of the spinal cord (with neuronolysis, neuronophagia and significant
perineuronal inflammatory infiltrate) that can completely overcome or cause severe neurological sequelae.
The ratio between inapparent and symptomatic, paralytic infections is 200: 1.
It is produced by the 3 types of poliomyelitis viruses (among which there is no cross antigenic
reactivity), from the group of Enteroviruses, the Picornaviridae family. They are viruses with a
positive polarity, non-enveloped, thermostable and extremely resistant to the action of acid pH,
proteolytic enzymes and bile salts.
Man is the only natural reservoir of these viruses. The transmission is mainly oral feces,
the spread of viruses from the entrance gate to the CNS is mostly hematological,
lymphatic, polio viruses have prolonged elimination through feces, even in asymptomatic
infections.
Isolation of poliomyelitis viruses from faecal samples or pharyngeal exudate,

followed by sequencing to differentiate wild from attenuated forms (from live oral
vaccine) or vaccine virus revertants, is mandatory for any case of acute flaccid
paralysis.
Since 2002, polio has been eradicated in Europe, but there is still a risk of cases of import
from endemic areas.
Inactivated polio vaccine (IPV), for injection, was created by Jonas Salk and introduced to the
United States in 1952 - following a major polio epidemic with 300,000 cases and 58,000 deaths.
The vaccine is produced by formaldehyde inactivation of isolated polio viruses on cultures of
Vero cells (kidney cells from the African green monkey). The vaccine has excellent
immunogenicity (over 90% of vaccinated people develop antibodies against all three antigenic
types after 2 doses, and over 99% after 3 doses).
Live attenuated polio vaccine with oral administration (OPV) was created by Albert Sabin in 1962. It
contains viral strains corresponding to the 3 viral serotypes (in a ratio of 10: 1: 3), attenuated by serial
passages at suboptimal temperatures. Although the molecular basis of attenuation is distinct for each
serotype, attenuated strains differ from the natural virulent serotype by a small number of mutations,
which occur in a region essential for viral replication - 5 'NT IRES, causing destabilization of RNA
secondary structure and defects in the translation of VP1 viral proteins.
Benefits The use of this vaccine is related to the ability of the attenuated virus to spread from the
vaccinated to their contacts, which leads to the elimination of the virus from the community, as well as
oral administration with increasing the degree of acceptability at the population level. The vaccine has
increased immunogenicity after the first administration and ensures lasting immunity.
The major disadvantage of this vaccine is the possibility of virulence reversal, with the occurrence of
paralysis-associated paralysis polio (PPAV). Although the risk is minor (1 to 2-3 million doses
administered), with the acquisition of polio-free status many countries (including Romania since 2008)
have switched to the exclusive administration of the inactivated vaccine. Other disadvantages are the
impossibility of administration to immunosuppressed persons and the need to maintain the cold chain
for storage and transport.
The current polio eradication strategy provides:

- maintaining a high level of routine immunization;
- organization of national immunization days (in 2012, the world
immunization week was organized), with vaccination of all children <5
years in a very short time, in the polio virus circulation season);
- supervision of all cases of acute flaccid paralysis
- selective, targeted immunization of communities that remain reservoirs of viruses in countries
where the first 3 elements have significantly reduced the number of polio cases ('mopping
out "activities).
In the long term, even in the post-eradication period, an inactivated vaccine is expected to be
incorporated into the WHO's extensive immunization program.
Vaccination against measles, mumps, rubella (MMR - measles, mumps, rubella) is

made with a trivalent vaccine containing live attenuated strains of measles, mumps, rubella
viruses, authorized in the US in 1971. It is administered in two doses, the first starting at 12
months of age, and the second at 4-6 years. Adverse reactions after MMR vaccination are minor
(fever 5% -15% cases, rash 5% cases, arthralgias,) rarely, thrombocytopenia <1 / 30,000 doses
or encephalopathy- <1 / 1,000,000 doses) may occur. The MMR vaccine is immunogenic in> 98%
of cases, if given after 12 months of age and the immunity persists throughout life. In special
situations (especially in epidemic outbreaks) early vaccination can be used, but it is not
recommended before the age of 6 months.
Measles it is a feverish eruptive disease of childhood. Clinically, it begins with fever and triple catarrh
(conjunctivitis, rhinorrhea, cough) and possibly gastrointestinal disorders (diarrhea), followed by the
typical rash: rash and maculo-papular enanthema, with a tendency to confluence. The transmission is
aerogenic and the contagion is extremely high. Common complications are otitis media (7% of cases),
mutinucleate giant cell pneumonia (6% of cases), encephalitis (0.1%). The evolution is more severe in
immunosuppressed, malnourished, especially in those with vitamin A deficiency. A severe late
complication is PESS (subacute sclerosing panencephalitis), associated especially with infections acquired
before the age of 1 year. PESS is a slowly degenerative disease that occurs at a distance (1-15 years) from
acute measles virus infection. Clinically it is manifested by cognitive dysfunctions with progressive
aggravation, motor dysfunctions, ataxia, myoclonus, convulsions and invariable progression to death. Its
incidence has dropped dramatically after the routine introduction of measles vaccination. The etiological
agent of measles ismeasles virus from the family Paramixoviridae, genus Morbillivirus, a virus with a
negative polarity, unsegmented, antigenically stable ssRNA genome, with limited survival time in the
external environment and rapidly inactivated by heat, light, acid pH, proteolytic enzymes.
RUBELLA it is a febrile disease accompanied by discrete maculopapular rash and lymphadenopathy,
frequently retroauricular. Rubella virus (from the family Togaviridae) is transmitted respiratory,
and in case of infection of the pregnant woman in the first trimester of pregnancy can cross the
placenta, causing a persistent infection of the fetus leading to abortion, premature birth, fetal death
in utero or severe birth defects (congenital rubella syndrome-cataract / congenital glaucoma /
retinopathy pigmentosa, deafness, congenital heart disease). Children with congenital rubella
syndrome have continuous viral excretion> 1 year after birth.
Mumps (epidemic mumps) is a respiratory infection caused byurlian virus (family

Paramixoviridae, genus Parainfluenza), with ssRNA genome with negative polarity, non-
segment, stable antigenic, unstable in the external environment. The virus infects multiple
tissues, replicating in the meninges, salivary glands, pancreas, testicles and ovaries. Aseptic
meningitis and orchitis are the most common complications of screaming parotitis. The urlian
vaccine is a live attenuated vaccine (Jeryl Lynn strain) with an efficiency of over 95%, which
generates lasting immunity throughout life.
Rotaviruses (the family REOviruses - Orphan Respiratory Enteric Viruses), are viruses with a genome,
segmented and double capsid, which contains epitopes involved in seroneutralization. They are among
the etiological agents frequently involved in viral gastroenteritis - acute diarrheal diseases, occurring
especially in infants and young children (between 3 months and 5 years), with short incubation (1-3 days)
and a duration of up to 6 days. The evolution is favorable, in the conditions of avoiding dehydration and
associated hydroelectrolytic disorders; however, healing is not accompanied by lasting immunity. Due to
the existence of several serotypes, among which there is no cross-reactivity, reinfections, which can occur
at any age, are relatively common, but have milder symptoms.
Rotaviral vaccines are live attenuated vaccines that can be given orally after 2 months of age.
There are currently 2 antirotaviral vaccines available:
• RV5 (RotaTeq, Merck) containing 5 attenuated reassortants from human and bovine
strains, administered orally, starting at 2 months of age, in 3 doses, separated by an
interval of 1-2 months, up to a maximum age of 32 weeks.

• RV1 (Rotarix, GlaxoSmithKline), containing an attenuated human rotavirus strain,
administered orally, in 2 doses, starting at 2 months of age, and then at 1-2 months,
up to a maximum age of 24 weeks.
• Both vaccines are 74% -87% effective against gastroenteritis and 85% -98%
effective against severe forms.
Clinical trials following the approval of rotavirus vaccines have not yielded consistent results in
terms of an increased risk of post-vaccination occlusion. Taking into account the existing data,
in October 2011 the existence of a history of occlusion was added as a contraindication for the
administration of the rotavirus vaccine.
Selective Bibliography
1. American Academy of Pediatrics. Rotavirus infections. In: Pickering LK, Baker CJ, Long SS,
eds.RedBook: 2009 Report of the Committee on Infectious Diseases. 28th ed. Elk Grove
Village, IL: American Academy of Pediatrics, 2009: 576–9.
2. CDC. Prevention of rotavirus gastroenteritis among infants and children.

Recommendations of the Advisory Committee on Immunization Practices (ACIP).
MMWR2009; 58 (No. RR-2): 1–24.
3. CDC. Addition of severe combined immunodeficiency as a contraindication for
administration of rotavirus vaccine.MMWR 2010; 59 (No. 22): 687–8.
4. CDC. Addition of History of Intussusception as a Contraindication for Rotavirus

Vaccination.MMWR 2010; 59 (No. 22); 687-8.
5. Fischer TK, Viboud C, Parashar U, et al. Hospitalizations and deaths from diarrhea and
rotavirus among children <5 years of age in the United States, 1993-2003.J Infect Dis
2007; 195: 1117–25.
6. Murphy TV, Gargiullo PM, Massoudi MS, et al. Intussusception among infants given an oral
rotavirus vaccine.N Engl J Med 2001; 344: 564–72.
7. Parashar UD, Hummelman EG, Bresee JS, et al. Global illness and deaths caused by
rotavirus disease in children.Emerg Infect Dis 2003; 9: 565–72.
8. Tate J, Mutue J, Panozzo C, et al. Sustained decline in rotavirus detections in the United
States following the introduction of rotavirus vaccine in 2006.Pediatric Inf Dis 2011, 30:
530–4.
9. Vesikari T, Matson DO, Dennehy P, et al. Safety and efficacy of a pentavalent

humanbovine (WC3) reassortant rotavirus vaccine.N Engl J Med 2006; 354: 23–33.
10. Vesikari T, Karvonen A, Prymula R, et al. Efficacy of human rotavirus vaccine against rotavirus
gastroenteritis during the first 2 years of life in European infants: a randomized, double-
blind controlled study.Lancet 2007; 370: 1757-63.
11. O’Ryan, ML, Matson, DO, Davidson, BL, Keusch, GT, Cash, RA (1998). A
Quadrivalent Rotavirus Vaccine.N Engl J Med 338: 620-622
12. Chen, SC, Jones, DH, Fynan, EF, Farrar, GH, Clegg, JCS, Greenberg, HB, Herrmann, JE
(1998). Protective Immunity Induced by Oral Immunization with a Rotavirus DNA
Vaccine Encapsulated in Microparticles.J. Virol. 72: 5757-5761
VIRAL INFECTIONS OF THE CENTRAL NERVOUS SYSTEM (NEUROVIROSIS)
A. VIRAL MENINIGITIS involves meningeal inflammation and meningeal irritation +

intracranial hypertension
B. VIRAL ENCEPHALITIS involves impaired cerebral parenchyma = Fever, headache, altered
mental status-> Psychomotor agitation, seizures, sphincter disorders, paralysis, paresis of
cranial nerves / drowsiness, numbness, temporospatial disorientation, coma
A. Viral meningitis
products of viruses of the genus Enteroviruses, Family Picornaviridae
Picornaviruses are non-enveloped viruses with a positive polarity ssRNA genome. The
family name is given by the very small size of the viruses (pico - 10ˉ¹²). Viruses have a spherical
shape and a diameter of about 30 nm and are resistant to organic solvents, nonionic detergents.
Enteroviruses are stable in acidic environment (pH below 3); these viruses can resist for days,
weeks in water and sewage. Picornaviruses are inactivated by temperatures above 56 degrees
Celsius, UV light, formaldehyde and chlorination.
Classification. Enteroviruses include: polioviruses (the etiological agent of poliomyelitis and the
prototype Fam. Picornaviridae), Coxsackie group A and group B viruses and ECHO viruses (Enteric
Cytopathogenic Human Orphans) - table 2.
Oral fecal transmission is common in children in the warm season, through direct, interpersonal
contact. The incidence of these infections decreases with age. Enteroviruses are the most common
etiological agents of viral meningitis, producing about 90% of cases of meningitis.
Enterovirus Species Disease frequently Rare clinical forms

ASSOCIATED
Polio 1, 2, 3 Poliomyelitis Meningitis

Coxsackie A1-A24 Meningitis, myocarditis, Respiratory infections,
herpangina, pharyngitis, summer diarrhea
conjunctivitis, exanthema
B1-B6 Bornholm disease, Myocarditis, enteritis,

meningitis, exanthema hepatitis, pancreatitis,
sudden death of the new
born
ECHO ECHO 1-33 Respiratory infections exanthema
unclassified Integer 68-71 Encephalitis, Conjunctivitis
myeloradiculoneuritis, (Entero-70)
respiratory infections
Table 2. Classification of Enteroviruses
Polyoviruses represents the prototype of the Enterovirus Genus. They are transmitted by faeces -
oral and less often by aerosols. Viral replication occurs in the nasopharynx and spreads through the
lymphatics of the upper respiratory tract. Polyoviruses can also be isolated from the tonsillar tissue of infected
people.
The stability of the viruses at acidic pH allows them to pass through the stomach to the lower
digestive tract, where they will replicate again at the level of Peyer's patches. After replication, a low viremia
occurs with the infection of other organs: CNS, liver, pancreas, heart. Replication in these organs causes a
secondary viremia associated with signs and symptoms of infection.
For polioviruses, 3 serotypes are described: PV1, PV2 and PV3.
The innervated muscles of the affected neurons suffer from paralysis, followed
by secondary atrophies. About 90-95% of poliovirus infections are asymptomatic, and
4% of infections cause minor manifestations or abortive forms of polio, with flu-like
symptoms, for 2-3 days. Only 1-2% of infections during epidemics cause flaccid
paralysis. Paralysis is often preceded by myalgias, especially in adults. Hyperesthesia
and paresthesia can be seen in affected muscle groups. Paralysis is usually
asymmetrical, affecting the proximal muscles more than the distal and lower limbs,
more than the upper limbs. A single limb is most commonly affected, but tetraplegia
can also occur. Paralysis of the diaphragm muscles causes respiratory failure.
Damage to the cranial nerves is known as bulbar paralysis. The medullary centers that
control breathing and vasomotor functions can be affected, leading to death.
The infection can have variable manifestations: from transient paresis to complete recovery,
to rapidly progressive, permanent and complete paralysis.
The long-term prognosis of infection can be assessed in the first 6 months after infection. If
no improvement is observed during this period, permanent paralysis will occur, with atrophy and
deformity of the affected limb.
Overall mortality in spinal poliomyelitis is about 5%, and in bulbar

poliomyelitis 50% or more.
A postpolio syndrome is also described in 20-40% of people infected with polioviruses and
who have cured, 25-30 years after the initial infection, characterized by muscle atrophy, pain,
muscle weakness, rarely leading to total dysfunction of affected area.
Coxsackie viruses, ECHO and other unclassified enteroviruses have been identified during
epidemiological surveillance of polio. Enteroviruses, later classified into the above genres, were
frequently isolated from healthy subjects. Their transmission is digestive, the initial replication at the level
of the entrance gate with primary viremia in the lymphatic tissue associated with the gastrointestinal
tract and secondary viremia with damage to many internal organs.
Coxsakie and ECHO viruses cause mild infections. The route of transmission consists in
contaminating food and water with feces. The most common cases are in children under 10
years. Coxsackie viruses cause a number of diseases in humans: common cold-like
syndromes, myocarditis, aseptic meningitis and paralysis. The best known disease caused by
Coxackie A is hand-foot-mouth disease, a childhood disease often caused by Coxackie A16.
Coxsackie B viruses cause minor gastrointestinal symptoms, paralysis, myocarditis, fetal
malformations. Most Coxsackie B infections are mild or subclinical.
Acute myocarditis of viral etiology has long been attributed to infection with Coxsackie B
viruses, but now by endomyocardial biopsy and molecular diagnostic techniques, infections with
adenoviruses, parvoviruses, herpesviruses (EBV, HHV6) have been frequently highlighted. In the
first phase of infections, viremia is followed by lysis of cardiomyocytes, a direct consequence of viral
replication. At the same time, the inflammatory response takes place. Many patients can heal
without sequelae. However, few produce antibodies that recognize viral epitopes and epitopes of
cardiomyocytes modified by viral infection. The result is heart failure caused by extensive damage
to heart tissue.
ECHO viruses they were not initially associated with clinical manifestations, being
considered non-pathogenic to humans. However, these viruses cause 2/3 of viral meningitis in
children and adolescents. Aseptic meningitis is commonly caused by ECHO viruses, but also by
Coxsakie viruses. Coxsakie B virus is most commonly associated with meningitis less than 3 months
of age. The symptoms consist of: fever 38-39 degrees Celsius, biphasic appearance, headache
accompanied by photophobia, neck stiffness (occurs at ages over 1-2 years), myalgia. Usually these
manifestations are self-limiting. CSF cytochemical examination shows mild monocytosis, with
normal or slightly low glucose, normal or slightly elevated proteins. ECHO 11 is the most common
serotype that causes chronic meningitis in antibody deficient patients.
Diagnostic:
Enteroviruses can be found in the nasopharynx for about two weeks and in the feces for
several weeks to months. John Enders and colleagues Weller and Robbins received the Nobel Prize
in Medicine in 1954 for isolating polio viruses on human embryo cell cultures.
Isolation of enteroviruses on cell cultures is the method of choice for diagnosis.
The susceptibility of cell cultures to enteroviruses is variable. Monkey kidney cell lines
have good sensitivity to polioviruses, CoxB and ECHO, while cell lines from diploid
human fibroblasts and human embryo lung fibroblasts are used for CoxA. RD cells
derived from human rhabdomyosarcoma are the most sensitive to CoxA. The time
required for isolation is 4-8 days, but the use of shell vials decreases this time to 2-3
days.
Isolation of Cox A viruses in newborn mice is the most sensitive method of isolation, but it
is technically difficult. Coxsakie viruses are pathogenic to the newborn mouse (as opposed to
ECHO and polio). Those in group A produce in the inoculated mouse less than 2 days after birth
diffuse myositis and flaccid paresis, those in group B produce focal myositis and spastic paresis,
myocarditis, pancreatitis.
Molecular techniques aims to amplify nucleic acids by RT-PCR and NASBA. These
techniques are directed to highly conserved regions of enteroviruses: 5NCR. This diagnosis is
quick, specific and sensitive. Real-time RT-PCR has the advantage of simultaneous detection of
amplicon, being a faster method compared to RT-PCR. The pathological products used for
diagnosis are: CSF, feces, blood, nasopharyngeal exudate.
Serological diagnosis : Immuno-enzymatic methods have a limited role in the diagnosis of

enterovirus infection due to the wide variety of serotypes and due to the failure to identify a single
common enterovirus antigen. The disadvantage of these methods is also given by a low sensitivity
and cross-reactions with other genera of the Picornaviridae family. This type of diagnosis can
provide epidemiological information if a specific serotype is known or suspected in an epidemic.
The use of paired sera, harvested during the acute period, respectively in convalescence, and the
increase of at least 4 times the antibody titer in the second sample, support the infection with
enteroviruses. Serological diagnosis is not a practical option for acute phase diagnosis.
Specific identification of the enterovirus serotype is done by Seroneutralization Reaction

using equine antiserum mixtures (Line and Benyesh-Melnick method). The method has some
limitations: it identifies only 40 of the known enterovirus serotypes, no new enteroviruses and it is
a laborious method and requires a long time. Currently, serotype-specific anti-enterovirus
monoclonal antibodies are also used. The seroneutralization reaction is the standard method of
distinguishing Polio viruses from each other and differentiating them from other enteroviruses
and involves neutralizing viral isolates with a specific antiserum.
Prophylaxis and treatment:
Vaccination it is only available for polioviruses, and it does not protect

against nonpolio enterovirus serotypes. To prevent the few cases of
polio associated with live attenuated vaccine, administered orally (Albert Sabin), this oral
vaccination was abandoned. Currently only inactivated, injectable vaccine is used (Jonas
Salk).
B. Encephalitis caused by viruses
ARBOVIRUSES
Arboviruses (viruses transmitted by vector insects)wouldthropode-borne) are enveloped

ssRNA genome viruses. There are over 400 species, of which only a part are classified into four
distinct families: toga-, flavi-, bunya- and arena-viridae. The first two families have RNA genome with
positive polarity (toga and flavi), the other two have RNA genome, segmented, with negative
polarity (bunya and arena).
The life cycle of arboviruses should be monitored in three types of hosts:
- the virus tank (birds and mammals, wild or domestic)

- insect vector or, for others, rodents- vector (roboviruses), in which it is
performed"extrinsic incubation " (the time required for replication to provide
sufficient titer for vertebrate infection).
- terminal host (dead-end) -man- in whom viremia is insufficient to favor interhuman
transmission in the absence of vectors.
Arboviral infections are zoonoses and their prevention is related to vector control.
Seroprevalence studies indicate the spread of arboviruses predominantly in tropical and

subtropical areas. However, arboviruses can cause epidemic outbreaks in other areas as well. In
Romania, the transport of viruses and vectors by migratory birds explains the higher incidence of
arboviruses in the Danube Delta and neighboring regions. Often, the transport of vectors is also
related to human activity. For example, the transcontinental fruit trade can carry vector insects,
explaining the emergence of arboviruses in urban areas. Also, poor sanitation, flooded spaces in
the basements are places where mosquitoes can hibernate, perpetuating the virus reservoir from
one year to another.
The pathogenesis of the disease in humans. After the bite of vector insects (only females are
hematophagous), the virus replicates in the capillary endothelium and spreads systemically. The
symptoms are either neurological (meningoencephalitis), or only cutaneous (hemorrhagic fevers) or
targeting other organs (liver, joints, etc.). There are vaccines applied in endemic areas (eg against yellow
fever, against Japanese encephalitis).
Replication of arboviruses differs from those with RNA genome with positive polarity (toga and flava) to those
with RNA genome, segmented, with negative polarity (bunya and arena).
In the former, the genome functions as an mRNA that is translated into structural and non-
structural proteins. The assembly of mature virions is done by budding at the level of the cell
membrane.
ARBOVIRUSES IMPORTANT FOR HUMAN PATHOLOGY IN EUROPE CENTRALA AND OF EST
species The family Vector
V. Tick encephalitis Flaviviridae Ticks
V. West Nile Flaviviridae mosquito
V. Congo-Crimea hemorrhagic Bunyaviridae mosquito
fever
V. Tahynia (Lumbo) Bunyaviridae mosquito
Family Flaviviridae
Flaviviruses replicate in vector insects (mosquitoes) or in birds that remain asymptomatic. The
spectrum of diseases produced in mammals and humans is varied: meningoencephalitis,
hemorrhagic fevers, hepatitis, rash joints, etc. Asymptomatic infections are not uncommon.
Neurological forms are more common in the elderly, where lethality can reach 10% (in Romania
during the West Nile meningoencephalitis epidemic in the summer of 1996 mortality reached 8%).
Other important flaviviruses are yellow fever virus (disease for which an international vaccination
certificate is required) and dengue virus (broken-bones disease).
Meningo-encephalitis West Nile. Viral meningoencephalitis is more common than bacterial

meningitis. Biochemical and cytological examination of CSF provides a first indication of the
etiology: clear fluid with low values of cellularity and proteinuria is characteristic of viral
meningoencephalitis. West Nile meningoencephalitis is a systemic infection, often asymptomatic,
but with the possibility of affecting the CNS to a significant extent, in case of epidemics favored by
socio-climatic conditions such as drought, lack of sanitation, close contact with vector insects, etc.
The diagnosis of West Nile meningoencephalitis is based on the detection of West-Nile anti-virus IgM
(immunoenzymatic) antibodies. They may persist for more than 6 months after acute infection, but often
cross-react with antibodies against other Flaviviruses (Denga, Saint-Louis encephalitis). It is ideal to
compare serum samples collected at the beginning and after 3-4 weeks, to highlight the seroconversion
or significant increase in the titer of specific IgG antibodies. In neurological forms, both categories of
specific antibodies are present in the CSF. The presence of antibodies in the CNS translates to the
permeabilization of the blood-brain barrier and / or the intrathecal synthesis of immunoglobulins.
Detection of the viral genome by RT-PCR is difficult because
low viral titers. The diagnosis of arboviruses is reserved for laboratories with a biosecurity
level above 3.
West Nile Romania Meningoencephalitis Epidemic 1996
• Frequency of confirmed cases 7.2 per 100,000 inhabitants.

• Ratio of apparent / inapparent infections 1: 325
• Immunologically naive population
• Two viral strains were isolated (one from mosquitoes captured in epidemic outbreaks
in Romania; the second from a CSF sample collected early during disease confirmation
by virus-neutralization with antibodies from convalescently collected sera and by RT-
PCR)
Subsequent evolution- Isolated cases without recurrent epidemics
3900 patients tested between 1997-2012 (mean / year 290 ± 197) - only in 2.3% acute
neurological WNV infections, 82.5% confirmed; 59% in urban areas, 5 deaths,
the most numerous 2010 - 47 confirmed cases between July-September, including in counties in the center and
north of the country
West Nile Meningoencephalitis Epidemic 1999- United States ( Bronx and Queens, NY) - debut as an
epizootic with high mortality in avian species (crows and exotic birds from the Bronx Zoo), associated
with an epidemic of viral encephalitis in humans,
- the same viral strain and the same vector as in Romania

- the Kunjin strain of West Nile virus, transmitted by mosquitoes of the Culex species
Subsequent evolution - WNV-endemic, periodic epidemics, totaling over 37,000 WNV infections, 45%
neurological infections; over 1500 deaths (4%) and epizootics in horses (15,000 cases of equine
infections in 2002)
New routes of transmission have been documented in addition to those mediated by arthropod vectors: -
maternal-fetal (perinatal and breastfeeding); blood transfusions, plasma, erythrocyte mass; organ transplant
In 2013 in Europe - 226 human cases in the EU and 557 cases in neighboring countries: Serbia 302; Russia
177; Italy 69; Israel 63; Romania 24
Zika virus (ZIKV) he is also part of the family Flaviviridae, with a non-segmented, enveloped
and positive ssRNA genome became a public health issue after a series were observed
of cases of microcephaly in children born to infected mothers during pregnancy. ZIKV
infects neural progenitors, causing abnormal growth and cell death. The consequences
of microcephaly in children are impaired intellectual development and impaired motor
function. These can range from mild to severe and last a lifetime, as there is no cure
for microcephaly, only symptomatic treatment.
The most common symptoms of Zika virus infection in adults appear about 2-7 days after the
mosquito bite:
• Fever
• Joint pain
• Conjunctivitis
The differential diagnosis is made with Denga fever and Chikungunya (table)
Zika dengue Chikungunya
Fever ++ +++ +++
Rashi +++ + ++
Conjunctivitis ++ - -
arthralgia ++ + +++
Adenomegaly ++ - -
myalgia + +++ ++
DISORDERS + +++ ++
petechiae - ++ -
The disease in adults is characterized by a mild form, which occurs in only 20% of patients and
lasts from a few days to a few weeks. The main geographical areas affected were countries in
South and Central America: Brazil, Bolivia, Colombia, Costa Rica, Panama, Mexico and
Venezuela.
Romania reported that 2016 cases of importation of Zika infection occurred, but there are no indigenous
cases yet; however, the infection must be monitored because the Zika virus is transmitted mainly
through the bites of Aedes aegypti and Aedes albopictus mosquitoes, and Aedes albopictus (usually
found in Africa / South Asia) has been present in Romania since 2014.
Family Togaviridae
The family Togaviridae includes as pathogens transmitted through arthropods viruses of the
genusAlphavirus - example: Eastern Equine Encephalitis Virus
Associated diseases: human encephalitis, several inactivated vaccines tested
Rabies
Rabies virus (genus lyssavirus; lyssa, gr-madness) is part of the Rhabdoviridae family - viruses
with unsegmented ssRNA genome, negative polarity, helical nucleocapsid, and envelope with
glycoprotein projections on the surface (G protein - with a role in attachment to receptors, highly
conserved between different species, except in bats , contains important antigenic determinants in
neutralizing infectivity). In the same family, but in a separate genus (vesiculovirus) is included the
vesicular stomatitis virus. The morphology of the rabies virion involved the bullet-shaped virion, with the
capsid and the envelope with glycoprotein projections.
The rabies virus is highly neurotropic, with affinity for the acetylcholine receptor and replication at the
neuro-muscular junction. The pathogenesis is dominated by the septineuritic dissemination of the virus,
initially centripetal (from the peripheral neuromuscular plate from the bite site to the CNS), then
centrifugal (from the CNS via the sensitive nerve threads to the salivary glands, cornea, lacrimal glands).
Interestingly, in the cells of the salivary glands the virus replicates and is released by budding at the cell
membrane, which is an effective adaptation for the spread of infection to a new host. Incubation in
rabies varies between 10 days and over 6 months (on average 30-90 days), depending on the
characteristics of the bite wound and the species of rabid animal. Long incubation allows vaccination
immediately after infectious contact
Clinical, rabies manifests as encephalomyelitis; the disease begins with:
• prodrom (2-10 days) with moderate fever, loss of appetite, nausea, vomiting, anxiety, photophobia,
headache, cough, hyperesthesia around the wound,
• acute neurological syndrome (6-12 days): hyperexcitability of the sympathetic (hypersalivation,
tearing, sweating), anxiety, agitation, dysphagia, hydrophobia, aerophobia, paralysis, episodes of
delirium
• Coma (2-7 days) that inevitably leads to death by cardiac arrest or after a period
paralytic due to respiratory failure
At the level of the CNS, the virus replicates exclusively intraneuronally, with predilections in the neurons in the
Ammon horn in the hippocampus and in the Purkinje cells in the cerebellum. Viral replication is evidenced by
the appearance of pathognomonic lesions: acidophilic intracytoplasmic inclusions, called Babeș Negri bodies.
The wild rabies virus is called "street" and has a variable incubation; repeated intracerebral
passages in the same species stabilize and shorten the incubation, the strains being labeled as
"fixed rabies virus". Cytopathic lesions are exclusively intracytoplasmic and have the appearance of
granular inclusions. Fixed virus strains give small inclusions. Black Babe bodies predominate in the
neurons in These lesions correspond to viral replication sites. In addition to neurons and cells of the
salivary glands, rabies antigen can also be found in the cornea, skin, oral mucosa - elements that
have diagnostic value.
The reservoir of infection in Europe is "wild" - in wild animals (foxes, bears in particular). In
other countries the reservoir is represented by jackals, wolves, raccoons or bat-vampires. From the
latter, rabies can also spread through aerosols.
Cases of rabies transmitted by organ transplantation have been documented: cornea (most
frequently), but also 4 cases of lethal encephalitis in recipients of kidney, liver, iliac artery segment
from an infected donor, died with intraarachnoid hemorrhage of initially unknown cause (Arjun
Srinivasan et al, Transmission of Rabies Virus from an Organ Donor to Four Transplant
Recipients, N Engl J Med 2005; 352: 1103-11Transmission of Rabies Virus from an Organ donor to
Four Transplant Recipients)
Laboratory diagnosis in rabies is an emergency. It refers, first of all, to the diagnosis of the
disease in the animal suspected of being rabid. The diagnosis is made by:
- examination of the brain for pathognomonic inclusions Babeș Negri (diagnosis in a few hours);
- inoculation of laboratory animals (diagnosis in 4-21 days) - The infant mouse is the most
susceptible animal;
- rapid immunofluorescence diagnosis to identify rabies antigens.
Serological confirmation of the diagnosis in the animal must be made, because the animals may
die with intercurrent infections or as a result of the multiplication of other viruses in the diagnostic
specimen. There are also other inclusions that can mimic the bodies of Black Babes.
In dogs or cats, the behavior of the isolated animal in the cage is followed - if it survives without
symptoms after 8 days, the diagnosis of rabies is excluded. If the animal has been slaughtered, the
lesions in the hippocampus and the presence of antigens are monitored by immunofluorescence.
In humans, the diagnosis is difficult and in case of suspicion of rabies virus infection, vaccination
and seroprophylaxis are used immediately. The diagnosis made after the onset of clinical symptoms is
equivalent to a death sentence.
The pathological products harvested are:
- saliva collected by aspiration or with tampons, corneal fingerprints, skin biopsies,

blood, CSF
- Post-mortem: brain tissue (bone marrow segments, brainstem, cerebellum,
hippocampus), skin fragments
In biopsies around the wound or on corneal fingerprints, rapid diagnosis by immunofluorescence

can be attempted. Viral RNA detection can be performed by RT-PCR, but this is not routinely practiced.
The diagnosis of rabies must be fast, sensitive, specific and economical.
Treatment and prophylaxis.
In the therapeutic purpose is practice:
- immediate wound care (washing with soap, water, anionic detergents),

- passive seroprophylaxis (administration of antirabies Ig: optimal antirabies human immunoglobulins
prepared from plasma of hyperimmunized donors - extremely expensive preparation, with low
availability. It is administered around the wound and intramuscularly.
- administration of inactivated vaccine (in the first 48 days after exposure. In total, 4-5 doses of 0.5-1 ml
are recommended, administered intramuscularly, within 4 weeks). The post-exposure immunization
regimen is maintained even if the person in question has a history of rabies vaccination, but in a
modified form, and without seroprophylaxis. .
Pre-exposure prophylaxis. Rabies immunization with inactivated vaccinefor prophylactic purposes it is
practiced for people at professional risk: animal caregivers, laboratory staff, veterinarians, hunters. 3
intradeltoid doses are administered at 0.7, 21-28 days,. The booster dose can be administered 1 year
apart and subsequently 3-5 years for those at continuous risk. Antibody response testing is performed
two to three weeks after the last inoculation.
Rabies vaccination of domestic (mandatory) and wild animals is the specific method
for controlling wild rabies. In 90% of cases, dogs are responsible for human infection.
Once the CNS symptoms appear, there is no specific treatment, the only option is supportive
therapy. Very few people survived rabies infection - 5 cases with late post-exposure prophylaxis
are reported, and one case without treatment / prophylaxis treated by inducing a drug coma
(Milwakee protocol). In the latter case, the exposure was made through the bite
a bat, possibly with an attenuated viral variant, and the innate immune response played a special role in
recovery.
Infection with new paramyxoviruses
The Nipah virus. Isolated and first identified in the epidemic of encephalitis and respiratory
infections in Malaysia and Singapore in 1999. It was later identified in other epidemic outbreaks in
Southeast Asia (India, Bangladesh). The epidemiological context remains extremely important as
one of the first steps for virological diagnosis.
The virological diagnosis in Nipah virus infection is based on viral isolation and identification of the viral
genome by Rt-PCR having as pathological products CSF, SNF, urine or blood at the beginning of the
disease, later being able to use the serological diagnosis by identifying IgM and IgG antibodies.
V. Hendra was initially identified in 1994 in Australia, and causes severe respiratory symptoms and signs
of meningoencephalitis; It was transmitted to humans through direct contact with racehorses, the
transmission being through respiratory secretions.
Discipline of Virology, UMF Carol Davila
RESPIRATORY INFECTIONS - FLU
Influenza viruses they are part of the family Orthomixoviridae, so named after the tropism for the
respiratory tree (from the Greek myxa- mucus).
There are three types of influenza viruses:
1. influenza A viruses that infect both humans and various species of birds and mammals;
2. influenza B viruses that infect only humans;

3. Influenza C viruses that infect only humans, have minimal pathogenicity
Influenza A viruses are enveloped and have a genome Negative polarity ssRNA (anti-message)
,section, composed of eight minigene with independent replication, encoding structural and
nonstructural viral proteins. On the surface of the tire are two glycoproteins of major interest:
- hemagglutinin (HA) - initiates viral replication, by attaching virions to cellular receptors,

represented by sialic acid residues, and contains immunodominant epitopes against which
protective antibodies are synthesized. It is the main protein contained in the inactivated, subunit
influenza vaccine.
- neuraminidase (NA) facilitates the release of virions from the host cell and digests non-specific
inhibitors, mucoproteins in the respiratory tract, facilitating the dissemination of progenitor
virions. Neuraminidase inhibitors are the main drugs used in the therapy and prophylaxis of
influenza.
The replicative cycle
1. Eclipse.
- adsorption mediated by viral HA binding to cellular receptors. The receptors have different
conformations in each infected species. Thus, human influenza virus strains preferentially
recognize 2,6-beta galactose sialic acid conformation (characteristic of epithelial cells in the
upper respiratory tract), while avian influenza virus strains preferentially recognize 2,3-beta
galactose sialic acid conformation (receptors located on the cells of the gastrointestinal tract
in birds and present in humans with low density on cells in the pulmonary alveoli and alveoli).
This feature prevents the crossing of the species barrier and infection with other influenza
strains, apart from those of the respective species. However, pigs have both types of receptors
and can be infected with both human and avian influenza strains, in addition to their own
influenza strains. Simultaneous infection with viral strains from different species generates the
possibility of reappearance, through the exchange of mini-genes - a phenomenon that underlies
the major variability of influenza viruses, known as antigenic shift.
- INTERNALISATION is caused by clathrin-mediated endocytosis, influenza viruses, although they are
enveloped, do not have fusion factors
- Decapsidation is facilitated by the viral protein M2, which determines the formation of an ion channel, allowing
the penetration of protons and the destruction of protein coatings, with the release and transport of the viral
genome in the nucleus.
2. Logarithmic growth- Influenza viruses are the only RNA viruses that replicate in the nucleus. The
vira genome, ssRNA with negative polarity, is associated with an RNA polymerase (rdRp) composed of
3 functional subunits (PA, PB1, PB2) that lead to the synthesis of viral mRNA and the synthesis of new
viral nucleic acids
Viral mRNA is synthesized by viral RNA polymerase (transcriptase, RdRp) using short primers
derived from cell transcripts via a unique mechanism called 'head-snatching'. Practically:
- the subunit PB2 from viral polymerase binds to the head portion of the cellular mRNA
- the PA subunit (endonuclease) cleaves cellular mRNA short sequences
- the PB1 subunit uses these short sequences derived from cellular mRNA as a primer for
viral mRNA synthesis
A new antiviral has recently been approved - Baloxavir marboxil (Xofluzaä), a selective
cap-dependent endonuclease inhibitor.
The synthesis of viral proteins takes place on the mastfel-generated RNA template, a mandatory
process before initiating genome replication, they attach to the parent genome, forming a
ribonucleoprotein complex, which anchors the viral polymerase to synthesize the new progenome
genome - ssRNA with negative polarity.

3. Set stage - maturation of viral proteins, assembly of virions and their release. The
release of progenitor virions that is dependent on neuraminidase (NA) that cleaves sialic
acid residues from the surface of infected cells.
Genetic variability of influenza viruses

One of the most important aspects of the biology of influenza viruses is genetic
variability, which causes continuous changes in the antigens located on the surface of
the virion (HA and NA). Variability occurs as a result of:
-minor changes in antigenicity (antigenic slip - antigenic drift),
produced as a result of point mutations in the genes encoding HA and NA, due to the frequent
errors of the viral polymerase RdRp
- major changes in antigenicity (antigenic shift - antigenic shift)

produced by:
- reassortment of minigans between influenza strains from different species (the pig can be infected
simultaneously with avian or human strains, being the intermediate host most frequently involved in
the generation of reassortant strains with human epidemic potential)
- direct transfer of influenza strains from animal to human - a phenomenon that requires the appearance of
conformational changes in the structure of hemagglutinin.
- the re-emergence of a virus that caused epidemics years before
Compared to these new variants that appeared as a result of genomic changes, the previous
immunity no longer offers protection. As a result of the antigenic drift, local epidemics appear,
frequency, and as a result of the antigenic shift, new viral strains are introduced in circulation, which
can generate pandemics (epidemics extinct on at least 3 continents). All three types of influenza
viruses have antigenic drift capability, howeveronly type A also possesses antigenic shift capacity
The natural reservoir of influenza viruses is represented by aquatic wild birds (ducks, geese). In
these species, the influenza virus does not cause symptoms, but replicates and is eliminated in
high titers, perpetuating the epizootic and epidemic potential. The natural cycle of influenza
viruses favors the appearance of recombinants between avian strains (wild and domestic birds),
pigs and humans. Avian Influenza viruses may be of low pathogenicity (LPAI-low pathogenic
avian influenza) or with high pathogenicity (HPAI- High pathogenic avian influenza), the latter
can cross the species barrier and be transmitted to other species

susceptible, including in humans.
Clinical manifestations. Influenza is the most common acute respiratory infection. It is
estimated that in each warm-cold transition season (November-April), between 10-20% of the
population has a flu episode. Children are 2-3 times more susceptible than adults. Importantly, in
the flu, the general symptoms (high fever, chills, muscle aches, joint pain, headache, dry cough)
are more marked compared to respiratory symptoms (rhinorrhea, sneezing, stuffy nose, etc.).
Common complications:
• Viral / bacterial pneumonia
• Bacterial sinusitis
• Myositis, myocarditis, pericarditis
• Influenza encephalitis
• Guillian-Barre syndrome (acute demyelinating inflammatory polyneuropathy triggered by
an acute infectious process, relatively low frequency 2 per 100,000 people, due to the
process of antigenic mimicry (antiviral antibodies attack the myelin sheath)
• Reye's syndrome (acute non-inflammatory encephalopathy and fatty liver degeneration).
Probably due to mitochondrial lesions precipitated by the consumption of acetyl salicylic
acid, which inhibits oxidative phosphorylation and oxidation of fatty acids during a viral
infection.
Pathogenesis. Virulence is not conditioned by a single viral gene, but by a constellation of segments
in the viral genome. Re-matching minigens and even point mutations in certain genes alter virulence.
HA and NA are the main virulence factors that contribute to the widening of tissue tropism and the
onset of the inflammatory response. An important component of immunity in influenza is the
effectors of nonspecific immunity (interferons and other cytokines). Influenza viruses are effective
inducers of interferon in both respiratory secretions and serum. Interferon is detected after the first
day of the flu and reaches its peak on the 4th day. There is a positive correlation between viral titer,
febrile response and interferon concentration. However, the most important immune effectors for
healing are anti-hemagglutinin (HA) neutralizing antibodies. Only these antibodies are associated with
protection induced by disease or vaccination. The persistence of protective antibodies, in the absence
of booster (reinfection), is estimated at 5-6 months. Repeated infections or repeated vaccinations
increase the titer and persistence of antibodies.

Virological diagnosis in influenza it is optimally performed by Rt-PCR, which provides a rapid result
and allows therapeutic guidance. Currently, rapid methods for identifying influenza virus antigens
used in emergency rooms and outpatient clinics have also been developed, but they do not have the
sensitivity of classical diagnostic methods. For characterization of strainstheir circulating viral viral (
necessary to determine the composition of the influenza vaccine) isolation is required(in cell cultures
or on embryonated chicken egg) and identification of the viral subtype by hemagglutinoinhibition
Influenza vaccination. There are two options in influenza vaccination: vaccines

inactivated and live attenuated vaccines, each with advantages and limitations, and with
recommendations for certain age groups. All flu vaccines arerenewed annually according to the
circulating influenza strains ( Prevalent A / H1N1, A / H3N2 and B) due to antigenic drift. The WHO
recommends annually the strains used in the production of influenza vaccine. Influenza vaccination is
best done between October and November. In pandemics the vaccine can be monovalent, prepared
only with the pandemic strain.
Inactivated vaccine (injectable) is the most common subunit, containing only purified viral
hemagglutinin. It is tri or tetravalent, containing 3 or 4 viral strains (A / H1N1, A / H3N2 and one
or two B strains, from the 2 Victoria and Yamagata genetic lines), circulating in that season.
Live attenuated vaccine (administered intranasally) contains “cold” viral tupplins (a)
adapted for replication at low temperatures, 22 C, (b) sensitive to human body
temperature> 36 C and (c) attenuated (at). As a result, they multiply in the nasopharynx and
induce protective immunity. In Europe,this vaccine is only recommended for flu prophylaxis
in people aged 24 months to less than 18 years.
It is very important to vaccinate those at risk for severe complications of the disease:
• Children between 6 months and 4 years (59 months);
• People ≥ 50 years;
• Pregnant women;
• People with morbid obesity (BMI ≥40);
• People with chronic lung disease (including asthma), cardiovascular disease (excluding asthma)
hypertension), renal, hepatic, neurological, haematological or metabolic (including

diabetes);
• Immunocompromised people (due to medication or HIV);

• Children between 6 months and 18 years who are chronically treated with aspirin and who may develop
post-infection Reye's syndrome;
• People living in nursing homes;

• Medical staff
• Persons caring for or living with children under 5 years of age (particularly children under
6 months of age) and adults over 50 years of age,
• People who care for or live with patients who have certain comorbidities that
make them at increased risk of severe complications from the flu infection.
Treatment.
Antivirals play an important role in the treatment of seasonal flu, especially in people at
risk of complications or in situations where the benefit is obviously higher than the cost. Without
being a substitute for influenza vaccination, these medicines provide protection in case of lack of
vaccination or antigenic mismatch between vaccine and circulating strains. The drugs used are:
• Neuraminidase inhibitors (oseltamvir and zanamivir), active in the late stages of the viral
replicative cycle, preventing the release of progeny virions and their dissemination.
• Decapsidation inhibitors - AMANTADINE AND RIMANTADINE (inhibits M2 protein -

which forms the ion channel, transporting the viral genome to the nucleus). At
present, most circulating strains are resistant to these drugs.
• Selective head-dependent endonuclease inhibitor: BALOXAVIR marboxyl (Xofluza)
In practice, treatment of influenza with antivirals should begin within the first 24-36 hours after
the onset of symptoms. Rapid tests have helped differentiate the flu from other acute respiratory
viruses by increasing the proportion of those receiving specific treatment.
Antibiotic treatment of viral respiratory infections, including influenza, is

irrelevant, it does not influence the evolution of the disease and is harmful to the community, favoring the
appearance of resistant bacterial strains.

Emerging viruses - SARS CoV-2 (severe acute respiratory syndrome coronavirus 2)
The virus was named SARS CoV-2 (severe acute respiratory syndrome coronavirus 2) by the
International Committee for the Taxonomy of Viruses, and the disease caused by it has been
named COVID 19 (Coronavirus Disease 19) by the WHO.
A new coronavirus, associated with severe human respiratory infections was

identified in January 2020 in Wuhan, a city of over 11 million people in China's Hubei Province. An
outbreak of 45 cases of atypical pneumonia had previously been reported to the WHO, but in China
there have been hospitalized cases since the first days of December 2019. The virus was initially
identified by NGS sequencing (with a combination of Illumina and Nanopore) and isolated in China
on primary cultures of human respiratory epithelial cells.
Previously two more Coronaviruses of zoonotic origin, derived from bats, have produced
epidemics of severe respiratory infections:
- SARS-CoV (Severe Acute Respiratory Syndrome (coronavirus) identified in 2002 in southern
China, in the Guangdong region, initially transmitted by an intermediate host represented by
civet (Palm Civet), later interhuman, respiratory. SARS CoV spread rapidly globally and caused
over 8,000 human cases and 774 deaths (9.5% mortality), until it disappeared from circulation in
2004, a phenomenon to which both effective public health measures and mutations in viral
genome that attenuated transmissibility and virulence).
- MERS CoV (Middle East Respiratory syndrome (coronavirus), identified in 2012 in Saudi
Arabia, was initially transmitted through an intermediate host represented by camels,
later interhuman, respiratory. MERS CoV is still circulating in the Middle East, and has so
far caused 2521 cases and 919 deaths (35% mortality), associating gastrointestinal
symptoms and acute renal failure.
Transmission.
Most of the initial cases of COVID-19 were related to a local market
which sold live animals, exotic animal meat and fresh seafood, which suggested the zoonotic
transmission of the virus. The tank is represented by bats, but the transmission involved an
intermediate host, still unknown, despite the circulation of many hypotheses, insufficiently
proven.
There is currently sustained interpersonal respiratory transmission. Transmission is by
respiration, through Pfluge drops (large drops generated by sneezing cough, hurried speech,
which does not move at distances> 2 m) or, less efficiently, by fomite, by direct contact with
contaminated objects (therefore Periodic disinfection of surfaces with 70% ethanol or sodium
hypochlorite, 0.5% is important).
Several studies show that the virus can be transmitted from people in incubation (whose
average duration is, according to WHO data, 4-5 days, with limits between 0-14 days), about 2
days before the onset of symptoms. . The report of the joint WHO-China mission shows that
the rate of secondary infections at close contacts of confirmed cases in China varied between
1-5%. Some reports show that SARSCoV-2 can cause asymptomatic infections, from which
transmission is possible, but not as efficiently as in symptomatic cases.
SARS CoV 2 has the highest contagiousness of the 3 zoonotic coronaviruses, the reproduction rate
R0 (the number of secondary cases occurring from an index case) being estimated at
1.5-4.5. This rate depends on many factors, including the duration of elimination of infectious virus
(from the current data higher concentrations of virus are present in the first days of the disease, and
from cases of medium severity no elimination of infectious virus was detected after more than 8 days,
although viral RNA may remain detectable for longer periods, even after remission of symptoms), the
opportunity for transmission (high in the case of crowds, close social contacts), individual
susceptibility. For the different VOCs (Variants of Concern), the R0 rate can increase a lot (approx. 5 for
the Delta variant);
ECDC (European Center of Diseases Control) described VOC: Beta, Gamma and Delta as the
most important by October 2021
Year and Evidence Evidence

Lineage + Country first Spike month Evidence for for impact for impact
WHO additional detected mutations of first impact on on on Transmission in
Labelle mutations (community) interest detected transmissibility immunity severity EU / EEA
B.1.351 South Africa K417N, E484K, September Yes Yes Yes Community
Beta N501Y, D614G, 2020
A701V
P.1 Brazil K417T, E484K, December Yes Yes Yes Community

Gamma N501Y, D614G, 2020
H655Y
B.1.617.2 India L452R, T478K, December Yes Yes Yes Dominant

Delta D614G, P681R 2020
In both SARS and MERS, there were so-called "supersheeders" who eliminated very high
concentrations of the virus, generating an impressive number of secondary cases. Such
cases have also been reported during the current epidemic in South Korea.
On 30.10.2021 the pandemic caused by SARS CoV-2 (COVID-19) determined

➢ 246.15 million cases; 4.99 million deaths worldwide
➢ In Romania - 1,628,501 cases and 46,911 deaths
The evolution of the infection.
The most common symptoms are fever (which, however, according to some studies can
not to be present at the beginning of the clinical disease, but it almost always appears during the
evolution in 88% of cases) and cough, sometimes followed by breathing difficulties, associating high viral
replication in the first week. Pneumonia is the most common clinical form, with radiologically evidenced
bilateral infiltrates, clinical manifestations and
imaging does not allow etiological differentiation. In severe cases, respiratory failure
sets in, with acute respiratory distress (ARDS) being the leading cause of death.
There is currently described hyperinflammatory syndrome generated by

viral replication, which occurs later in the course of the disease (the second week of infection) and can
generate a "storm of proinflammatory cytokines", responsible for tissue damage and therapeutic
suggestions are made for severe patients.
Generalized hyperinflammatory syndrome (“cytokine storm”) - may cause progressive
worsening to Acute Respiratory Distress Syndrome (ARDS, with severe hypoxemia / estimated
mortality 40%; NLR- (neutrophil-to-lymphocyte ratio), associated with Lymphopenia
characteristic of this phase is predictive for severe forms.
In severe forms are described coagulopathy and endothelial thromboinflammatory syndrome with:
- Presents D-dimers ++,
- Skin changes - thrombotic microangiopathy
- Diffuse CID and thrombosis of medium and large vessels that cause multiorgan dysfunction
- Pulmonary vasculopathies, marked hypoxemia (effect of posture on oxygenation -
"prone position")
The overall mortality rate was 2.33%, but this varies greatly depending on age, being under 1% up to 50
years and 1.3% between 50-59 years. Subsequently, mortality increases: in the age group 60-69 years it is
3.6%, in those between 70-79 - 8% and over 80 years - 14.8%.
Cellular receptors. SARS CoV2 uses the same receptor as SARS CoV. It is represented by a
metallopeptidase - ACE II (angiotensin 2 conversion enzyme), present on epithelial cells in the
respiratory mucosa, airways, lung type II alveolar cells, and on the vascular endothelium.
MERS CoV uses a distinct receptor, a dipeptidylpeptidase -DPP4 (CD26), which is found in the
lower respiratory tract, especially in alveolar epithelial cells, but also in other tissues, which
would explain the possible association of respiratory symptoms with gastrointestinal and acute
renal failure. There are studies that have shown overexpression of ACE2 in patients with
comorbidities (obesity, asthma), concomitant viral infections and in smokers, considered to be at
risk for severe disease progression.
The origin of the virus.

Genomic analysis showed that SARS CoV-2 is a betacoronavirus,
distinct from SARS CoV and MERS CoV coronaviruses. Although all three zoonotic coronaviruses have
bats as their reservoir, they come from different species, and were transmitted to humans through an
intermediate host, which remains unknown to SARS CoV-2. Phylogenetic analyzes support the
relationship of SARS CoV2 with a coronavirus previously isolated from bats in Yunnan Province (BatCoV
RaTG13), to which there is 96.3% genetic similarity.
Genome-wide sequencing results show that SARS CoV 2 is a distinct clade from other bat
SARS-like coronaviruses and is not a recombinant among other human or animal
coronaviruses, as suggested. preliminary studies based on the analysis of glycoprotein
sequences in the viral envelope. Analysis of nucleotide sequences shows greater kinship with
SARS CoV (ca. 765) vs MERS CoV, but there are significant differences especially in the region
ORF 1ab and in the region encoding the glycoprotein S (spike), from the viral envelope, with which
the ACE2 receptor binds. SARS CoV -2 has a higher binding affinity to the ACE2 receptor compared to
SARS CoV, this being attributed to conformational changes, given the acquisition of 6 new amino
acids in the receptor binding field, by natural selection during the evolution of the virus. The same 6
amino acids are found in the genome of a coronavirus isolated from pangolin, but the data are not
sufficient to support its role as an intermediate host.
Diagnosis of SARS CoV2 infection is currently based on the detection of viral nucleic acid by real
time PCR in nasopharyngeal exudate, brohoalveolar lavage or tracheobronchial aspirate. Rapid tests
for the determination of viral antigens, approved for testing, were also formulated, positive for
patients during the period of maximum contagion, although with lower sensitivity and specificity
than Rt PCR; there are also antibody detection kits that allow the evaluation of vaccination response
rates, the seroprevalence of the infection and the highlighting of asymptomatic infections.
Treatment of zoonotic coronavirus infections. Currently the approved treatment includes
- Remdesivir is a novel nucleotide analog, inhibitor of viral RNA polymerase, which in

animal model studies has shown an improvement in lung function and a significant
reduction in both viral load and lung damage; is administered to humans
intravenously.
- dexamethasone
- Anti-IL-6 (tocilizumab), anti-IL1beta (Anakinra) monoclonal antibodies,
Jak 1/2 signaling inhibitors (Baricitinib)
- anticoagulants in case of coagulopathy
Prevention - Vaccines.
Vaccines must go through several stages in order to be approved for use:
preclinical development, which involves in vitro and in vivo tests, on
animal models and clinical development and then phase I-III clinical trials, which evaluate the efficacy,
immunogenicity and safety of the vaccine. Post-authorization, a continuous safety monitoring is
performed.
Four types of SARS CoV2-based vaccines are now approvedand platforms for the expression
of immunogens - protein S (spike):
2 mRNA vaccines - encode protein S into a stabilized prefusion form

- Modern 2 doses, 0, 28 days
- BioNTech / Pfizer 2 doses, 0, 21 days
2 vaccines based on non-replicative adenoviral vectors

- ChAdOx1- AstraZeneca / Oxford University / - 2 doses
- Ad26-COVS1-Jansen Pharmaceutical Companies- 1 dose
Public health measures. COVID 19 is currently declared a pandemic by the WHO. On January
30, the WHO declared the new coronavirus epidemic an international public health emergency,
signaling the need for a rapid coordinated international response, especially to prevent the
accumulation of cases in regions with limited resources. This involved active surveillance, early
detection, isolation and case management, identification of contacts and prevention of the
spread of vaccination infection.
Human herpesviruses
Human herpesviruses determine infections extspread of variable gravity,

depending on the type of virus, age and immunocompetence of the subject.
Their common feature is latent. During needle infection(symptomatic or
asymptomatic), herpesviruses spread from the site of the initial infection and
establishinfective latent in other cell sites, in which the viral replicative cycle is
suspended in early viral protein synthesis. Latency is a mechanism effective
escape from the host's immune response.
Depending on the location of the latency herpesviruses were classified into 3 subfamilies:
A. Alpha-herpesvirinae -latent in sensory neurons from the root ganglia

posterior spinal nerves and nuclei of the cranial nerves
- Herpes simplex 1 (HSV1- facial)
- Herpes simplex 2 (HSV2-genital)
- Varicella zoster virus (VZV)
B. Beta-herpesvirinae-latency in T lymphocyte, monocytes, solid organs (lungs,
kidneys)
- Cytomegalovirus (CMV)
- Human Herpetic Virus 6 - HHV6
- Human Herpetic Virus 7 - HHV7
C. Gama-herpesvirinae-Latent in B lymphocyte, capillary endothelium
- Epstein Barr virus (EBV)

- Human Herpes Virus 8- HHV8 (associated with Kaposi's sarcoma)
The structure of the virion and orggenomic analysiscomplicated are similar for all 8
human herpes viruses. Virion with dimensions between 180-200 nm is made up of
outside to inside from:
- tire with glycoprotein projections, with which viruses attach to

cell receptorsri and containing epitopi recognized bythe answer
immune;
- tegument - an electron-dense region in electron microscopy, composed of viral
proteins that play an important role in initiating viral replicationcapsid with
- icosahedron symmetryică;
- genome DNAs, linear, assembled like a toroid etand associated with a DNA
polymerase. On each strand of DNA there is a unique long region (UIT) and a
short one (US) bordered by repeated reverse sequences (IR), which allow
rearrangement of regions so that the viral genome can exist in several
isomeric forms. Many prproperties bherpesvirus infections (includinglatency)
are determined by layout sequentiallyof viral genes
A. ALFA HERPESVIRINAELE is characterized by:

- primary tropism for the skin and mucusbones,
- rapid intranuclear replication
- neurotropism and neuroinvasionsspeed,
- frequent reactivations triggered of variesţand viral and cellular
factors(modifyi hormonal, sun exposure / cold / uv radiation;
irritationor trauma, immunosuppressive treatmentse, viral co-
infections orbacterial).
Replication
Alpha replication of viruses is intranuclear, DNA-viral ulcer serving in 3 successive rounds
for mRNA synthesis encoding 3 protein species: alpha (immediately early) and beta (
early), both with Runningii regulatory, enzymatic and range (late) - structural proteins.
Protein expressiontheir is coordinated in a cascading chain.Alpha genes (immediately
early) have a transactivating role for all genes associated with lytic infection. At their
level are found consensus sequences that serve as a binding site for transcription
factors: viral (VP16, alpha TIF-skin) and cellular (HCFhost cell factor 1 - cytoplasmic and
oct1-octamer transcription factor).
Beta genes (early) intervene in the coding of important enzymes in the replication of
the viral DNA genome (viral DNA polymerase, viral thymidine kinase), a process that
takes place according to the rolling-circle principle, which gives rise to concatemers (long
continuous DNA molecules containing multiple copies of the same sequences ), cleaved
into monomers during nucleocapsid assembly by a viral complex (UL56 / UL 86
terminase).
Range eyelashes (late) encodes mostly structural proteins from the capsid and the tire
Latent. Repetitive sequences in viral DNA encode molecules Noncoding RNAs

called LATs (Latency Associated Transcript), expressed only during latent
infection, which will not be translated into protein.
LAT expression inhibits productive viral replication by:
- changes in histones that convert portions of viral DNA into unproductive

forms, causing the assembly of a restrictive chromatin architecture.
- processing LATs into miRNAs that can inhibit mRNA translation for immediately
early gene promoters. Mutations in the regionThe encoding of LATs may affect
its input exit from latency.
Differentiated expression a of cellular proteins also contributes to
latency installation. Possible mechanisms are:
• Fixation of cellular proteins with repressive action, at the level of

viral DNA sequences that control the expression of α genes, as
soon as they initiate viral replication
• Reduction or absence of cellular protein expression required for α gene
activation
• The presence of proteins that inhibit the activity of the viral factor that
initiates replication - alpha-TIF.
HSV1 is transmitted by direct contact and is in mode accustomt associated with perioral
lesions (primary infection: herpes gingivostomatitis, it can also be asymptomatic or with
mild symptoms, reactivations: usually cold sores, possibly other localizations, or multiple
lesions, usually by self-inoculation). The dreaded complications of infections with Herpes
simplex 1 viruses are herpetic keratoconjunctivitisfrequent corneal ulcers and herpetic
encephalitisa-with mortality over 70%, both occurring during latent virus reactivations in
adults with immunosuppression.
HSV 2 causes genital herpes, a sexually transmitted disease. The transmissionof the
virus can be achieved in the absence of apparent lesions, due to viral excretion
asymptomatic. In maternal-fetal transmission, HSV 2 causes neonatal herpes, with
severe multivisceral impairment (necrotizing hepatitis with / without thrombocytopenia,
disseminated intravascular coagulopathy and ennewborn headache).
VIRUS VARICELO-zoster (VZV) is transmitted by airborne, causing primary infection

varicella, the eruptive virus of childhood, particularly contagious. Latent virus
reactivations occur after several decades in the formshingles,herpetiform rash on t
cutaneous erythema of the spinal or cranial nerves at which there is the latent virust,
with severe neuralgia. Post-shingles neuralgiapersist 4-5 months of when the lesions
disappearor, posing special problems related to analgesic treatment. recurrences
severe infections of alfaherpesviruses occur inimmunocompromised patients (eg
HIV positive or transplanted andpharmacologically immunosuppressed).
For the prevention of VZV infection a live attenuated chickenpox vaccine (Varivax®),
obtained by repeated passages of the virus on fibroblast cultures human diploids. The
vaccine is given to children between 19-35 months, with a booster dose at the age of 6-7
yearsetand confers protection significant for a significant period of time. The vaccine can
be given at the same time as the MMR (measles-rubella-measles) trivaccine.
For prevention VZV reactivations latently there are 2 vaccines:
- Zostavax® (produced by Merk), is a live attenuated vaccine, which contains the same
strain as the chickenpox vaccine, but with a viral titer of about 14 times higher compared
to it. The vaccine reduces the incidence of shingles by about 50% and decreases the
frequency and severity of post-shingles neuralgia. It is recommended for people over 60
years of age who have had chickenpox in the past to prevent shingles.
- Shingrix ® ( produced by GSK) is a recombinant vaccine indicated for the prevention of
shingles and post-neuralgiashingles, in older adultsfor over 50 years. Its safety and efficacy
are superior to those associated with live attenuated vaccine, this vaccine is currently
preferentially recommended. It is administered 2 separate doses with an interval of 2-6
months, which provides protection in> 85% of cases, for at least 4 years.
Treatment of alpha-herpesvirus infections: inhibiting nucleoside analogues

viral DNA elongation.
Acyclovir (ACV) is a guanine-derived purine nucleoside analogue that differs from
structurally by presenceof an acyclic side chain. The drug u is active as such, it must be
converted intracellularly intoacyclovir triphosphate, the form in which it competes with
intracellular nucleosides for incorporation into progenitor viral DNA. Acyclovir is
converted to acyclovir monophosphate belowthe action coded virus thymidine kinase;
then the monophosphate passes into diphosphate and triphosphate under the action
cellular kinases. Acyclovir treatment decreased the severity of symptomsbread infections
their herpes and contributed to scfrequent adherenceand gravityofrecurrences. Along
with acyclovir, it is used derivatives of sand with superior oral bioavailability, of the type
valacyclovir and famciclovir. They are preferred in the treatment of shingles, e.g.between
the treatment and suppression of herpes recurrencesgenital tissue and infectionsocular
with herpes simplex.
In the latent state, the virus does not replicate active and ctherefore is not
susceptible toantiviral actionaa of the compounds mentioned above. These drugs are unable
toeliminates an established latent infectiona.
In people with frequent recurrent one can try a suppressive treatment,

with low doses of Acyclovir, Valaciclovir or Famciclovir administered daily for at
least 1 year. The daily doses are individually adjusted to STRENGTHthe least
necessary Fr.occurrence of recurrences.
B. BETAHERPESVIRINAE: The most common betaherpesvirus is

cytomegalovirus - CMV which is characterized by:
- slow replication,
- reduced cytopathogenicity,
- latenta prolonged,
- dependence of replication on the mitotic stage of the host cell,
- the ability to cross the placenta and produce malformations in fat.
CMV has multiple latency locations - T lymphocyte, monocytes, endothelial

cells and solid organs (lungs, kidneys), and reactivations are particularly related to
decreased host immunity. CMV infection is in most cases asymptomatica, but may
take severe forms in immunocompromised individuals. So:
- after organ transplantation have hematopoietic stem cells -
severe pneumonia, with high lethality (> 75% of cases),
- advanced HIV std infection - retinitis and encephalitis,
- frequent post-transfusions- infection mononucleosis-like.
Maternal-fetal transmission of CMV can occur:

- Prenatal - is teratogenic - determine malformations csevere birth defects
(microcephaly, mental retardation, chorioretinitis, bone abnormalities); Perinatal -
- determinesdisease with cytomegalovirus inclusions of the newborn
(hepatosplenomegaly, jaundice, haemolytic anemia, thrombocytopenia,sequelae
of the neuro-sensory deafness type);
- Postnatal - asymptomatic infectionof or similar to mononucleosis
Laboratory diagnosis
Serological: ac anti CMV IgM (optimum pt diagnosis of primary infection and
congenital infection), seroconversion or significant increase in needle titer specific
IgG + avidity.
Active infection: optimal CMV DNA detection or Agpp65 detection by
immunofluorescence
Isolation- CMV is excreted asymptomatically for long periods, so a positive
result on isolation on cultures is difficult to interpret. This is important for the
diagnosis of infcongenital ection because an astkind of childcontinues the excretion
of virus for years. A sensitive method of diagnosis is the rapid culture of the virus on
individual slides which are centrifuged at low speed afterinoculation of the
pathological product, which facilitates adsorbedof the virus and highlightinganti
early genes by immunofluorescence with monoclonal antibodies, after only 2-4 days.
The technique is calledshell vial / spin-enhanced culture.
Treatment. A structurally and pharmacologically related drug to acyclovir -
ganciclovir, administered intravenous and a derivative thereof valganciclovir, administered
by bone, as well as others dand anti agents CMV - cidofovir (indicated in cytomegal retinitisin
patients with advanced HIV infection) and foscarnet, are active in CMV infection.They can
also be administered prophylactically to organ transplant recipients.

Human herpes virus 6 (HHV6) is a significant pathogen in pediatrics, causing
the 6th eru diseasefebrile illness of the young child, known asroseola infantum
or sudden rash. It's a rashass - papular nepruriginoatowith a duration of 2-3
days, preceded and followed by a febrile syndrome.
NB The rest of the febrile eruptive diseases of childhood are: measles; scarlet fever;
rubella; chickenpox,infectious erythemaios (caused by parvovirus B19).
Human herpes virus 7 (HHV7) it was oftencovered in 1990 in healthy adults. It can
determine roseola infantum or sudden rash, respiratory infections in the patientyl
immunosuppressed and appears to act as a cofactor in syndromesinduced by HHV6.
HHV6 and HHV 7 were initially discovered in HIV-positive patients, have tropism for CD4
+ T lymphocytes,target in HIV infection, and latency in the salivary glands.
C. GAMAHERPESVIRINAELE have transformative capacity in vitro and oncogenic

in vivo: Epstein Barr virus (EBV) and human herpes virus 8 (HHV8),also
known as the associated virus Kaposi's sarcoma.
EBV has a narrow host spectrum, infecting only certain cell subsets
functionally specialized:
- oropharyngeal epithelium at level cwhich causes a productive infectiona, but the
passenger - infectious mononucleosisof,
- B lymphocytes, where infection is unproductive, but leads to lcarefula, polyclone
stimulationthat and sometimes to cellular transformationa.
Mononucleosis invirgin appears in adolescenceand is manifested by fever,

pharyngitis,major lymphadenopathy, splenomegaly, and characteristic changes of
the smearsangvin. The same simptomatoalso characterizes post-transfusion with
CMV and sometimes, primary HIV infection.
Infection EBV latent causes polyclonal activation of B lymphocytes with
proliferation and transforming potential. In infectionHIV, EBV is frequently reactivated,
being involved in the etiology of a particular-looking hyperplastic stomatitis -villous
leukoplakia of language. appearanceţandof cancers after EBV infection is a rare event.
The following cancers are associated with reactivation of latent infection:
1. Burkitt's lymphoma (characterized by the proliferation of transformed B lymphocytes, which
invades soft tissues). It is characteristic of the overexpression of viral antigens associated with
EBNA - Epstein Barr nuclear antigens. Burkitt's lymphoma is associated with abnormalities
characteristic chromosomes (most commonly translocatedof 8/14, between
chromosome 8containing a cellular oncogene: c-myc and chromosomeul 14 - what they
containe a gene that encodes the immunoglo heavy chainpolka dots). Lymphoma is
endemic in areas affected by malaria. Sit seems that anemia induto malaria causes a
hyperactivitycompensatory of hematogenous bone marrow cells, favoring translocations
chromosomes that lead to the activation of the EBV virus.
2. Nasopharyngeal carcinoma (endemic to Southeast Asia), with hyperexpression of
latent-associated antigens (latency tumor antigens),
3. Lymphop diseaserole after transplantation, with hyperexpression of LMP-
associated antigens (latent membrane proteins).
Other cofactors are involved in carcinogenesis; a large part of the popopulation hasantibody
and anti EBV without developing subsequent tumors.
Human herpesvirus 8 - HHV 8 is involved in the appearance Kaposi's sarcoma, a cancer
of endothelial cells, characterized by abnormal, chaotic proliferation of immature
endothelial pluripotent cells withiogenesis and neoformation ofatypical vascular
conglomerates. Hyperchrome areas appear, painless, but extremely friable, which
causes massive hemorrhages. There are several forms of Kaposi's sarcoma:
- Classical with high incidence in elderly male adults, with Mediterranean

descent, with cutaneous manifestations, especially on the inferior limbs.
- Associate HIV infection (is a affectionare indicators for AIDS), with cutaneous
and / or intra-visceral manifestations, which give rise to massive hemorrhages p
ultrasound and gastrointestinalintestinal. Responds well to treatment
intralesional with interferon.

RETROVIRIDAE
The family retroviridae comprises three subfamilies:
• Oncovirinae (viruses with oncogenic potential);
• Lentivirinae (groups agents of slowly degenerative diseases);
• Spumavirinae (produce persistent, asymptomatic infections).
Retroviruses are particular in the way they express genetic information: although they have an ssRNA
genome with positive polarity, their replication involves the synthesis of a cDNA intermediate, called
proviral DNA by reverse transcription, a process mediated by a viral enzyme reverse transcriptase.
Subsequently, proviral DNA will be integrated into the host genome, under the action of another viral
enzyme-integrase, initiating a persistent infection. The formation of progeny virions is realized by the
synthesis of some mRNA species by cell polymerase II, using as matrix the integrated provirus, it will serve
as both progeny RNA and for the transcription of viral structural proteins.
ADVANCED HUMAN IMMUNODEFICIENCY (HIV) VIRUS
Acquired immunodeficiency syndrome (AIDS or AIDS) is a chronic condition due to
infection with the human immunodeficiency virus (HIV). The disease must be understood in its
complexity including four stages: the primary infection, the asymptomatic stage, ARC (Aids
Related Complex) and the acquired immunodeficiency syndrome (AIDS).
Origin. HIV infection can initially be considered a zoonosis, in which the etiological agent - a
simian virus (SIV - simian immunodeficiency virus) has gradually adapted to humans. There are
two distinct antigenic types of HIV:
- HIV1 (which dominates the human pandemic), derived from the IVS that infects a particular species of
chimpanzee (Pan troglodites troglodites) and
- HIV2 (a more attenuated viral type, with more restrictive geographical distribution, generally in
West Africa, the areas with high prevalence being Guinea-Bissau and Senegal) - derived from
SIV that infects sooty mangabey.
There are a number of arguments for the origin of HIV in ape viruses: Similitudes in genome
organization, phylogenetic kinship; prevalence in the natural host; common geographical area;
plausible routes of transmission (percutaneous / permucous contact with fluids from
84
infected primates during hunting and slaughtering animals). Non-invasive testing (detection
of specific antibodies and viral nucleic acid in faeces and urine samples, collected from
primates living in the wild)allowed the documentation of at least four distinct transfers of SI
cpz to the human species, with the appearance of phylogenetically distinct HIV1 groups: M
(main group, responsible for more than 95% of HIV infections), O (outlier, found in West and
Central Africa, infecting about 15,000 people in Cameroon, has recently been suggested to
be a simian virus that infects wild gorillas), P (recently isolated from one person in
Cameroon) and N (isolated in 1998, later very rarely, in about 50 people in Cameroon).
The oldest sample of human plasma infected with HIV1 dates back to 1959,
from a man from Congo (the virus was sequenced in 1998).
Since crossing the species barrier from chimpanzee to human (about 7 decades ago) HIV 1 has
diversified as the human pandemic has evolved. There are currently many subtypes circulating,
all belonging to the main group M- "main", denoted AI,and single or circulating recombinant
forms, probably results from superinfections of a subject with several subtypes, successively. The
highest prevalence of HIV-1 is currently subtype C, predominantly in sub-Saharan countries
(where two-thirds of people are infected), East African countries, India and southern Brazil.
Subtype A is prevalent in Central Africa, Eastern Europe and Central Asia and is becoming more
widespread among drug users in all regions of the globe, subtype B predominates in Western
Europe and the US, and in Romania circulates a particular subtype, called F, which has only been
reported in Latin America (especially Brazil) and Angola. The identification of subtypes has
implications for clarifying the routes of transmission, the evolution of drug resistance and the
prospect of preparing a vaccine.
Virion morphology. HIV belongs to the family Retroviridae, subfamily lentivirinae. The
HIV genome is diploid, represented by two identical copies of ssRNA with positive polarity, made
up of several overlapping genes: structural: (env, gag and pole), regulatory (rev, tat, nef) and
maturing (vif, vpu, vpr) .
The genome presents at the ends a series of important noncoding sequences for viral replication:
the so-called LTR (long terminal repeats) that ensures the correctness of proviral DNA synthesis
during reverse transcription, and provides important signals for genome integration and packaging;
as well as primers for initiating reverse transcription.
Structural genes env encode envelope proteins (gp 160- precursor-; gp 120- surface- which
will bind the CD4 receptor and viral coreceptors and gp 41 -transmembrane - factor
85
fusion). Gag genes encode group antigens (matrix p17, capsid p 24 and nucleocapsid -p 7).
genespole encodes the polymerase complex: reverse transcriptase -p 55/66; integrates p
11 and proteases p 32.
Proteins encoded by structural genes can be electrophoretically separated into

polyacrylamide gel after denaturation with sodium-dodecyl sulfate (SDS-PAGE), depending
on their molecular weight, and subsequently transferred to a nitrocellulose membrane,
used to identify antibodies. specific anti-structural proteins in patients' serum - Western
Blot confirmation test.
HIV receptors and coreceptors. The target cells in HIV infection are those that have CD4
receptors on the surface: helper T lymphocytes, fixed monocytes / macrophages (Kuppfer cells,
endothelial cells, glial cells, etc.), dendritic follicular cells (CFDs). The attachment of gp120 to
CD4 receptors induces conformational changes in its structure, which allow the coupling of
coreceptors.PNo less than 10 coreceptors have been described for HIV, the most important
being beta-chemokine receptors (CCR5), found mainly on the surface of macrophages and
antigen presenting cells and CXCR4 alpha chemokine receptors, present mainly on the surface
of Th lymphocytes.
The impact of coreceptors on the evolution of infection. The cellular tropism of HIV isolates varies depending on
the evolution of the disease:
- Isolated predominate in the primary infection macrophagotrope (M-trop) and
nonsynthesizing (NSI). These isolates use the beta-chemokine coreceptor denoted CCR5
- In late infection the isolates are with tropism for lymphocytes (T-tropes) and syncytants
(SI). These strains use the coreceptor for alfachemokine-fusin - CXCR 4.
Extremely interesting, at the CCR5 level, a deletion of 32 base pairs was described, which can be
present: on a single allele: genotype CCR5 delta 32 heterozygous ( present in 10% of the
Caucasian population), which generates a slow evolution of HIV infection (non-progressives,
long-term survivors) or on both alleles: genotype CCR5 delta 32 homozygous(present in <1%
of the Caucasian population, never black), which generates resistance to natural HIV
infection (patients exposed but not infected with HIV). This feature has been used for
therapeutic purposes, in the only known case of curing HIV infection:the "Berlin" patient. This is
an HIV-infected patient diagnosed with acute myeloid leukemia, who received a hematopoietic
stem cell transplant from a donor with the homozygous genotype.
86
CCR5 delta32, after bone marrow ablation. The patient completely eradicated HIV infection,
remaining with undetectable viremia and complete suppression of viral reservoirs in the absence
of any antiretroviral therapy. Gene therapy approaches are currently being attempted by
transplanting autologous cells from HIV-positive patients after discontinuation of CCR5 coreceptor
expression in vitro with zinc finger nucleases, but the results are modest.
Replication.
After attaching the virion to gp120 receptors and coreceptors, HIV internalization is done through
merger cell membrane envelope, GP-mediated phenomenon 41. The cytopathic effect of HIV is
syncytant. (Schematic internalization of HIV follows successive steps: attachment of 120 gp to the
CD4 receptor; conformational changes that allow the coupling of gp 41 glycoprotein co-receptors;
fusion of the envelope with the target cell membrane).
After decapitation, the first stage of logarithmic growth takes place: reverse transcription of ssRNA
into proviral DNA. Viral reverse transcriptase initially synthesizes a single strand of DNA on the viral
RNA template, and then a complementary DNA strand. The proviral DNA translocates into the
nucleus of the infected cell andinsertion into the host genome by the action of integrase -
another enzyme of HIV and genomic sequences from proviral DNA catches, called LTR (long terminal
repeats). Integration results in the development of a slow infection, during which proviral DNA
sequences cannot be distinguished from cellular DNA, following the same rules for translating
genetic information.
The transcription of proviral DNA results in several species of mRNA, which will serve either
as a progenome genome (ssRNA, with positive polarity) or as a template for the translation of viral
proteins. They are synthesized as a gag-pole polypeptide precursor, subsequently cleaved into
individual proteins under the action ofviral protease. The release of progeny virions is done by
budding.
There are a number of viral and cellular factors that modulate viral replication:
Cellular proteins that try to oppose vi replicationpull:

TRIM5α (TRIpartite Motif) in primates it intervenes in the degradation
of the reverse transcription complex into
proteasomes
APOBEC3G cytosine deaminase converts cytosine to uracil during

(inactivated by living HIV protein) ssDNA synthesis (-) - is
87
Theterine - IFN inducible host- block release virions through
restrictive factor (inactivated by HIV anchoring them at the level of membrane

vpu protein). lipid shelves rich in cholesterol;
VIRAL FACTORS INVOLVED IN HIV REPLICATION

Maturation genes (not essential for in vitro maturation in cell cultures, but
important for in vivo pathogenicity):
Vpr promotes intranuclear transport of the

preintegrative complex (proviral DNA)
Vif- promote infectivity virions,

stimulates proviral DNA formation by
blocking cellular APOBEC3G
Vpu increases the release of HIV virions,

antagonizes theterine activity by direct
interaction with the TM domain
Regulatory genes:
Tat - HIV promoter transactivator, involved
in the relationship with cellular
transcription factors
Rev activator of virus production, stimulates the

cytoplasmic export of mRNA and
facilitates preferential transcription of
proviral DNA
Nef increases viral infectivity, interacts with

cellular proteins involved in
cellular signaling allowing long-term
survival of infected LT helper and
promotion of uninfected LT apoptosis,
88
Transmission routes
➢ Percutaneous or permucous, by contact with infectious fluids from infected persons-

(by injections, transfusions, dental or surgical maneuvers with incorrectly sterilized
instruments, sharing of needles, syringes and other instruments necessary for drug
use, tattoos, piercings, etc. ). All blood donors are tested serologically for HIV
infection, however the residual risk associated with transfusions (donors in front of
the serological window) must also be considered.
➢ Sexual (gay and heterosexual). Constant use of the condom with all sexual partners
reduces the risk of transmitting the infection.
➢ Maternal-fetal (intrapartum; peripartum and postpartum). In the absence of prophylactic
measures, the risk of maternal-fetal transmission is 15-30%. Transmission occurs
especially during birth (intrapartum); possibly postpartum (including breastfeeding).
Transmission is dependent on the viral load and the stage of immunosuppression of the
mother at the onset of labor, as well as the duration of labor.
Symptomatology of HIV infection
Monitoring the natural evolution and treatment of HIV infection is done by following the clinical
and immunological parameters (number of positive CD4 cells - normal: 500-1200c / mm3,
40-68% of total lymphocytes and CD4 / CD8-normal ratio> 1) and virological (viral load - no
children RNA HIV / ml plasma). Long-term survivors (“long-survivors” or long-term non-
progressives- 4-7% of HIV-positive people) have demonstrated HIV serological infection (older
than 7 years in adults or older than 5 years in children) but asymptomatic, with a number of
CD4-positive lymphocytes constantly above 500 / ml, and minimal viremia, in absence of any
antiretroviral treatment. They have a strong cytotoxic response and preserve the architecture of
the lymph nodes. plow
HIV infection has the following clinical stages:
1. primary infection (acute retroviral syndrome) - transient syndrome similar to infectious or
completely asymptomatic mononucleosis
89
2. asymptomatic infection; of clinical latency (with or without generalized lymphadenopathy)
3. Early symptomatic infection (formerly called ARC -AIDS related complex) -in which there are
opportunistic infections (IO) without vital risk (hairy oral leukoplakia, candidiasis).
4. AIDS / AIDS - the stage marked by the evolution of life-threatening IOs, opportunistic neoplasms
or direct manifestations of HIV cytopathogenicity that also threaten life (example: HIV
encephalopathy). AIDS is defined by a decrease in the number of CD4 cells below 200 / ml,
regardless of the symptoms, sometimes the term advanced HIV infection is used for stage one
in which the number of CD4 cells falls below 50 / ml.
Pathogenesis.
In the primary infection, the virus mainly infects macrophages, which play the role of a
Trojan horse, allowing it to spread to the lymph nodes. Despite the nonspecific or absent
symptoms, the viral titer is high (> 10 million copies of HIV RNA / ml); a transient decrease
in the number of CD4 + cells occurs and occurs. This stage often coincides with the
serological window (when specific antibodies have not developed), which creates a residual
risk for blood transfusions in the absence of viral nucleic acid testing. At this stage it is
formedviral tanks (in the form of integrated cellular proviral DNA) in the CNS, central
lymphoid organs, genital tract, etc.), which are inaccessible to the immune response or
antiretroviral therapy.
In the asymptomatic phase, the balance between viral replication and immune response is
established, with relatively normal values of CD4 lymphocyte count, and low viremia compared to the
previous stage, even in the absence of any treatment. This period of clinical latency can last up to 10
years. During this time, however, in the lymph nodes (and other central lymphoid organs), viral
replication is very productive: about 10 billion virions are produced every day. 99% of these virions are
produced by CD4 lymphocytes following a lytic infection (their half-life is only 1.6 days). The immune
system's effort to balance the cytopathogenicity of the virus results in the rapid division of lymphocyte
precursors. For a long time the number of CD4 lymphocytes in the periphery remains constant (> 500
cells / mmc), but the decline of this number precedes the patient's entry into the symptomatic stage.
The efficiency of the immune response in the primary infection influences the level of viral load, fixing
a so-called "set-point" (a certain plasma concentration of the virus). The stronger the immune
response, the lower the level of viral load, and the better the evolution, the slower the progression to
AIDS. The balance between inducing and suppressing factors of viral replication influences the course
of the disease.
90
Symptomatic stage occurs when the ability to recover the number of lymphocytes in the
periphery is depleted, while the virus replicates continuously, escaping from immune
surveillance and producing a progressive infection, with high mortality. The elution of the
immune response is explained by the great variability of the retroviral genome due to the
large number of errors of viral reverse transcriptase, which does not have a mechanism for
correcting wrong nucleotide incorporations, frequent recombination during reverse
transcription, and increased HIV-1 replication ( 10 billion virions being produced every day).
The main features of symptomatic HIV infection in humans are:

- Massive viral replication in lymphoid tissue, with selection of lymphotropic
strains using syncytizing CXCR4 receptors
- Depletion of CD4 T lymphocytes+ infected, especially in the mucous membranes (GALT), with
subsequent progressive decrease in blood, up to the threshold of 200 cells / ml, which
defines immunological AIDS
- Generalized immune hyper-reactivity, with aberrant immune activation, mediated both
by viral products and by the balance between cytokines, bacterial translocation and
reactivation of latent viruses-
These lead to the depletion of the immune system (in the AIDS phase); decline in cell
regenerative capacity and immunosecretion
The most common opportunistic infections are viral (reactivation of latent

herpesviruses, progressive multifocal leukoencephalopathy-JC papovavirus infection,
molluscum contagiosum -poxvirus infection molluscum contagiosum), bacterial
(Pneumocystis carinii, tuberculosis with both Mycobium tuberculosis and complex
Mycobium) and fungal (cryptosporidiasis and microsporidiasis).
Important causes of mortality in HIV-positive patients are chronic hepatitis - through co-
infections with HBV and / or HCV, neoplasms (especially those with viral etiology - Kaposi's
sarcoma - reactivation of human herpesvirus HHV8; cervical cancer - persistent HPV infection
with oncogenic risk leukemias and lymphomas - reactivation of EBV infections),
91
Antiretroviral drugs
Antiretroviral drugs (ARVs) used in the treatment of HIV infection are not classified according to the
mechanism of action in six different pharmacological classes. The main classes of antiretrovirals
ARV class / Mechanism of action Representatives SIDE

Swapping effects
International common
Inhibitors Competition with Zidovudine nausea,
nucleosides / nucleotides nucleosis (t) idele (azidothymidine vomiting, rash,
there physiological, AZT), neuropathy
reverse transcriptase / incorporation Didanosine, peripheral,
NRTIs preferential in the (dideoxyinosine, ddI) lactic acidosis
nascent cDNA chain and Stavudine (d4T) with steatosis
blocking elongation Abacavir (ABC) hepatica si
it Tenofovir disoproxil pancreatitis
The compounds are inactive fumarate (TDF)
as such, it requires
phosphorylation
intracellular
Non-inhibitors Blocks directly Nevirapine (NVP) rash, hepatitis
nucleosides ai the catalytic site of RT Efavirenz (EFV) severe (NVP)
reverse transcriptase Delavirdine (DLV)
NNRTIs- Etravirine,
Rilpivirine
Protease inhibitors Block the site Nelfinavir (NFV) complications
PI catalytic protease, Fosamprenavir (FOS- Metabolism
prevents cleavage APV) HYPERGLYCAEMIA
gag-pulse precursors Saquinavir (SQV) or diabetes,
maturation virions Indinavir (IDV) dyslipidemia,
progeny Tipranavir (POS) lipodystrophy,
Darunavir distribution
Atazanavir abnormal a
* Ritonavir (booster tissue
pharmacokinetics- increases adipose
plasma level l
to the other PI through
action on
cytochrome P450)
INSTIs integrase Inhibits DNA binding Raltegravir rash, nausea,
inhibitors (integrase proviral (complex Dolutegravir vomiting,
beach transfer preintegrative) to DNA diarrhea
inhibitors) cell
Fusion inhibitors Stabilizes Enfuvirtide pain, abscesses

conformation gp41, injection site
inhibits internalization
92
Receptor antagonists Blocking to Maraviroc Influenza -
CCR5 beta co-receptors like, pain
chemokine, prin abdominal
change
conformational ale
prevents them
HIV attachment
Another class of inhibitors of CD4 receptor attachment is in advanced clinical trials - the most
promising representative is Ibalizumab - a humanized anti-CD4 monoclonal antibody - being
approved.
Therapy in HIV infection is based on the administration of divergent combinations of ARVs -

called cART (combined antiretroviral therapy) or HAART (highly active antiretroviral therapy),
which provides massive suppression of viral replication with limited side effects. This
therapy consists of at least three different drugs, usually two nucleoside / nucleotide reverse
transcriptase inhibitors (NRTIs), associated with either a non-nucleoside reverse
transcriptase inhibitor (NNRTI) or a protease inhibitor (PI) or a integrate. There are currently
a number of drug combinations that can be given in a single dose, which greatly increases
patient adherence.
There are also drug combinations between several ARVs, which can be administered in a
single dose, to increase the quality of life and patient compliance.
It is currently recommended to initiate treatment ART in all patients diagnosed with HIV
infection, regardless of CD4 count. This recommendation takes into account thatan early
initiation of therapy avoids immune degradation, decreases the degree of inflammation and
activation of the immune system, characteristic of chronic HIV infection and prevents functional
abnormalities of. T cells, as well as the possible depletion of viral reservoirs.
All treatment regimens must ensure:
- rapid and lasting decrease in viral load, optimally undetectable (<50

children / ml);
- restoration of CD4 lymphocyte count (over 500 cell / ml)

- avoiding the appearance of IO or, optimally, keeping the patient in the asymptomatic stage
- delaying the emergence of resistant mutants
93
In addition to the cumulative side effects (not negligible), an important limiting factor during
antiretroviral therapy is the development of resistant viral mutants. In general, NRTIs and NNRTIs
have a low resistance barrier, but IP resistance is more difficult to develop. Combinations reduce the
risk of emergence of resistant strains, but do not completely eliminate it. In addition, these resistant
strains can be transmitted, currently between 5-15% of newly confirmed cases are with such mutants.
The treatment currently available does not ensure the complete elimination of the virus and
cannot cure the infection. Antiretrovirals do not have good penetrability in the tissue
sanctuaries (lymph nodes, CNS, genital tract) and do not act on the integrated provirus.
Discontinuation of treatment also causes rapid resumption of viral replication due to
integrated proviral DNA reservoirs, especially in memory lymphocytes, so cART therapy
must be maintained throughout life.
Administration of antiretrovirals to prevent HIV infection A.

Prevention of maternal-fetal transmission is achieved by:
- Antiretroviral treatment administered to the mother, in order to decrease the viral load (optimal at
undetectable level) and to the newborn, for 6 weeks, with initiation as soon as possible after birth
- Cesarean section of choice (cesarean section performed before rupture of the membranes, after 37
weeks of pregnancy). Emergency cesarean section (after the onset of contractions or rupture of
the membranes, regardless of gestational age) causes prolonged exposure of the fetus to genital
secretions and is associated with an increased risk of transmitting the virus)
- Avoiding breastfeeding to prevent postpartum HIV transmission. The WHO
currently recommends three treatment options:
- Monotherapy with zidovudine administered to the mother antepartum (preferably

from week 14) and intrapartum as well as to the newborn for 6 weeks
- Single dose of nevirapine for the mother at the beginning of labor and newborn in the
first 48 hours of life
- Triple therapy as antepartum prophylaxis from week 14, intrapartum, and in the first 7 days
postpartum if the mother is breastfeeding
94
The European guide recommends triple therapy (HAART) as prophylaxis (from week 28 of
pregnancy) and treatment for 6 weeks administered to the newborn. Breastfeeding is
contraindicated.
B. Post-exposure prophylaxis
After occupational exposures to potentially infectious fluids (blood, tissues, cerebrospinal fluid,
synovial, pleural, peritoneal, pericadic, amniotic, viral suspensions) from a person diagnosed
with HIV infection, post-exposure prophylaxis is recommended (initiated as soon as possible). ,
optimal in the first 4 hours, admitted in the first 72 hours), if there are continuity solutions at
the level of the skin or prolonged contact / with significant quantities at the level of the mucous
membranes. Bitherapy (2 NRTIs: ZDV + 3TC / d4T + 3TC / TDF + 3TC) or tritherapy (with NRTIs
mentioned above in combination with a protease inhibitor) is administered for 28 days.
C. Pre-exposure prophylaxis (PrEP) is a new prevention strategy that consists of administering
antiretrovirals to people not infected with HIV, but who are part of groups at increased risk
of acquiring the infection. PrEP consists of the daily oral administration of a fixed-dose
combination of tenofovir disoproxil fumarate (TDF, 300 mg) and emtricitabine (FTC, 200
mg), marketed as Truvada. This method is recommended in the United States for the
prevention of HIV transmission in hetero- and homosexual adults at high risk of acquiring
the virus, in those in serodiscordant couples, and in injecting drug users.
Strategies to cure HIV infection.
There are currently documented cases of patients able to control viral replication after accidental
discontinuation of treatment, as well as a single case of complete eradication of the infection
(without active viral replication and without detectable reservoirs) - - Berlin patient (post stem cell
transplant to the homozygous donor for the 32 bp mutation in the CCR5 gene, no ART treatment
since 2007, no signs of relapse) Hutter, NEJM 2009. Starting from these examples, several
strategies are tested in order to completely eradicate the viral reservoirs, and to obtain HIV
infection.
1. Elimination of residual viral replication - intensification of cART (no results on reservoirs) with
very early initiation of treatment (before or immediately after seroconversion)
95
2. Gene therapy:
- blocking the expression of CCR5 coreceptors (knock-out CCR5 -Host gene editing) -
zinc finger nuclease (Tebas NEJM 2014) - reducing viremia by 1-2 log;
- gene silencing and endogenous HIV inhibitors (lentiviral vector for CCR5
knockdown and membrane fusion inhibitor)
3. Stimulation of latent virus expression in reservoirs (HDAC inhibitors - vorinostat,
panobinostat, romidepsin - impact on chromatin condensation and viral
transcription, PKC activators)
4. Stimulation of innate (IFN alpha) and adaptive immunity (including therapeutic vaccination with CMV
vector)
The prospect of vaccines in HIV infection.
Only a few candidate HIV vaccines have been screened in clinical trials:
- subunit vaccine produced by recombinant DNA technology synthesizing gp 120

glycoprotein with epitopes of subtypes B or B and E (AIDSVAX B / B and
AIDSVAX B / E);
- the vaccine produced on the platform of the recombinant type 5 adenovirus expressing
the HIV-1 Gag, Pol, and Nef proteins;
- Vaccines produced on the platform of the recombinant vaccine virus ALVAC-HIV
vCP1521;
- Sequential combinations of the vaccines mentioned above.

However, over 50,000 human volunteers, enrolled in over 200 clinical trials, were
vaccinated without conclusive results.
Epidemiology) 9931
As of December 31, 2018, the cumulative number of cases reported by Romania (period
1985-2018) was 23,892 patients. The number of living HIV / AIDS cases exceeds 15,500, the
number of new cases registered annually is around 600. The risk groups that provide the
highest number of new cases are drug users and homosexuals (MSM- men having sex with
men ).
96
Globally, the number of infected people is around 37 million (predominantly in sub-
equatorial Africa). Annually, there are 2.5 million new cases (of which about 300,000
in infected mothers and fetuses) and 1.5 million deaths. The United Nations AIDS
Program (UNAIDS) aims to: zero new infections, zero AIDS deaths, zero
97
VIRAL HEPATITIS
Viral hepatitis is a disease initially similar in symptomatology, but with completely

different clinical and prognostic evolution, caused by a series of hepatotropic
viruses, from distinct taxonomically families. Hepatocyte-only tropism viruses are
called hepatitis viruses and include:
A. Enteric-transmitted hepatitis viruses (digestive, fecal-oral) :

- Hepatitis A virus (HAV) from the Picornaviridae family, genus Hepatovirus
- Hepatitis E virus (HEV) from the Hepeviridae family
B. Hepatitis viruses with predominantly parenteral transmission

(percutaneous / permucosa):
- Hepatitis B virus (HBV) in the Hepadnaviridae family
- Hepatitis C virus (HCV) in the Flaviviridae family, genus Hepacivirus Hepatitis
- delta virus, defective virus, not taxonomically classified in a family
A number of newly discovered viruses (a flavivirus less than 30% related to HCV,
tentatively called hepatitis G- virus with 2 isolated HBV and GB type C and a T-TV
anellovirus) are incompletely characterized, and although they are found with
prevalence Among blood donors, they do not appear to be a major cause of acute or
chronic hepatitis.
A. HEPATITIS WITH ENTERIC TRANSMISSION
VHEPATITIS IRUS A (VHA)

Structural features.HA is a prototype of a separate genus in the family
PicornaviridaeHepatoviruswhich causes more than 90% of acute viral hepatitis. It is
a virus with a small polarity, positive polarity, small size (~ 30 nm), not enveloped.
The lack of a tire explains the resistance of HAV to disinfectants, to the action of
proteolytic enzymes, the acidic pH of gastric juice and bile salts. HAV is also heat
resistant; only boiling at over 85aC, for at least 3 minutes, inactivating it.
Transmission.HAV is transmitted through water and food contaminated with feces
(unchlorinated water, mineral water from unverified sources, unsterilized beverages, ice
cubes; fresh fruits and vegetables, ice cream, seafood and other non-heat processed
foods.
Pathogenesis.Hepatitis A is a disease with digestive transmission, viral replication in the
oropharynx, spread to the mesenteric lymph nodes and lymph tissue in Peyer's plaques, bile
excretion, hepatocyte replication, and prolonged elimination (several weeks). In the feces.
Incubation is long, up to 30 days, and the infection remains asymptomatic in many cases
(especially in children). In Romania, over 80% of children under 10 years of age have gone
through infection, most often asymptomatic forms.
Clinic.In clinically apparent cases, the symptoms are characterized by: altered general
condition, asthenia, anorexia, nausea, fever, followed by jaundice, due to the precipitation of
direct bilirubin, expressed by yellow staining of the skin and mucous membranes,
hyperchromic urine, discolored stool, accompanied by painful hepatomegaly on palpation.
Rarely (in 1 thousand cases), severe forms of fulminant hepatitis can occur in adults,
sometimes lethal. HAV infection never becomes chronic, most cases are cured, and
immunity persists throughout life, providing protection against infection.
Diagnostic.
Acute infection: detection of anti-HAV IgM antibodies (by capture ELISA). Healed
infection or vaccination: detection of anti-HAV antibodies of the type of IgG (persist
all life after natural disease or after vaccination) - by indirect or competitive ELISA.
Prophylaxis.
Pre-exposure: administration of an inactivated HAV vaccine. It is not included between
compulsory immunizations in Romania, but it is recommended for all children before
entering the community.
Post-exposure: administration of immunoglobulins at a single dose of 0.02 ml / kc. This one
low concentration of standard immunoglobulins (donor plasma

preparations) contains enough anti-HAV antibodies to prevent infection or
alleviate symptoms
- Observance of personal and community hygiene measures, provision of drinking water
sources and use of circulating agents for disinfection and decontamination.
VIrusHHEPATITISE (VHE)
Characteristics.Hepatitis E virus (HEV) belongs to the family Hepeviridae. VHE is a relatively
small polarity-positive RNA genome envelope virus⁇7.2 Kilobase. Virion proteins are
transcribed into three distinct reading frames. 4 genotypes were characterized: 1 and 2,
which infect only humans and are associated with epidemics in developing countries;
respectively genotypes 3 and, isolated in Europe and the USA, which infect a number of
domestic animals (pigs, rabbits, in particular) and which can be transmitted zoonotically to
humans.
Characteristic Genotype 1 and 2 Genotype 3 and 4
prevalence Endemic to India, Central Sporadic cases in Europe, USA,

America - fecal transmission related to the consumption of
through contaminated water meat and pork organs
Occurrence in non- Import (travel) Local (zoonosis)

endemic areas
Transmission unusual Very rare

secondary
Jaundice rate tall low
death rate Raised on pregnant women Raised in older adults
affectation rarely Neurological complications
extrahepatic
Chronic infection Not potential to persons

immunosuppressed
Pathogenesis.Hepatitis E virus is the agent of fecal-oral hepatitis, common in
developing countries (India and Central America). The rate of attack (the ratio between
symptomatic and asymptomatic cases) during these epidemics varied between 1 and
15%, higher in adults (3-30%) than in children (0.2-10%). High-attack epidemics also
result in high mortality.
Epidemiology.
In non-endemic areas (Europe, USA), HEV is responsible for less than 1% of acute viral
hepatitis. Surprisingly, however, serological data from non-endemic areas indicate much
higher seroprevalence figures than anticipated. Some studies have suggested that hepatitis
E may be considered a zoonosis, transmitted from pigs by eating undercooked meat and
organs. although the role of pigs as a source of human infection has not been definitively
proven. In immunosuppressants, including transplant patients, chronic HEV infection may
occur following transfusion transmission of the virus.
gusset. Although often asymptomatic in its epidemic form, hepatitis E can present with jaundice
and a wide range of extrahepatic symptoms, including neurological symptoms. Cholestasis is the
most striking symptom in hepatitis E. The jaundice phase begins suddenly, coincides with the
increase in transaminases and can last for more than two weeks. In the classic endemic form,
Hepatitis E does not become chronic, and the forms with fulminant evolution are rare. Cases of
chronic hepatitis E have been reported in genotypes 3 and 4 in immunocompromised individuals
(organ transplant recipients)
Endemic hepatitis E is characterized by the severity of the evolution in pregnant women. The consequences
of HEV infection in pregnant women are:
- abortions or premature births: 12-30% of cases;
- the death of the fetus in utero: 25%;
- the death of the mother due to fulminant hepatitis-the vulnerability of pregnant women increases
with gestational age: pregnant women in the 2nd or 3rd trimester of pregnancy form severe due to
high viral load, due to the replication of the live in the fetal liver; In the last trimester of pregnancy,
maternal mortality (due to coagulation disorders) reaches 25%.

diagnosisit is based on clinical and laboratory signs (detection of anti-HEV IgM
antibodies and detection of viral nucleic acid by RT-PCR). The duration of excretion of
the virus in the faeces as well as the duration of the viremia do not exceed 28 days. In
general, once the liver transmagnases return to normal, the contagion stops. The
diagnosis of hepatitis E should be considered in patients with transaminase elevations
and a suggestive history of epidemiology - endemic travel
Treatmentwith ribavirin and Peg-Interferon attenuates severe forms.
Hepatitis E prophylaxis it is conditioned by the improvement of sanitation, the provision of
uncontaminated water sources and the maintenance of good conduct in individual hygiene. Particular
attention must be paid to the protection of pregnant women in epidemics. There is currently no
approved hepatitis E vaccine in Europe or the United States. In China, however, a vaccine based on a
HEV 239 immunogenic protein, synthesized by the recombinant DNA technique, is used.
B. HEPATITIS WITH PREPARENTLY PARENTERAL TRANSMISSION
Viral hepatitis with parenteral transmission is a major cause of morbidity and mortality.
HBV or HCV infections can become chronic, leading to severe liver disease, leading to
cirrhosis of the liver and primary liver cancer (CHP). Globally, more than 350 million
people are chronically infected with HBV, and about 180 million are chronically infected
with HCV. Due to the common routes of transmission, simultaneous infections with
both viruses or co-infections with HIV are very common.
VHEPATITIS IRUS B (HBV)

Characteristics.HBV is part of the family Hepadnaviridae - circular genome virus,
partially double-stranded DNA (one long, one short). The genome is made up of several
genes (calledorphan or reading frames) partially overlapping, causing mutations at one point
in the genome to simultaneously affect proteins encoded by two or three genes. HBV genes
encode:
- AgHBs surface antigen (S gene, with three components: preS1+ preS2+ S);
- AghBc center antigen (Gene C, pre C) which by cleavage produces HBeAg
(infectivity marker);
- Reverse transcriptase (pole gene), target of antiviral drugs;
- Transactivating factors of some cellular genes (X gene, involved in cancer).
Viral replication results in both complete particles (with envelope, cap, and nucleic acid),
with dimensions of 42 nm - Dane particles, and empty particles, without genome, resulting
from the self-assembly of excessly synthesized HBsAg molecules. These latter particles, 22
nm in diameter, spherical or filamentous, do not contain HBV DNA, are not infectious, but
only immunogenic.
HBV replication is characterized by:

- The existence of a reverse transcription stage after which the new viral genome is
synthesized
- The disproportion between the synthesis of complete viral particles (Dane particles)
with genome and empty ones (containing only self-assembled HBsAg). This is the
result of overproduction of viral proteins (1014 children) compared to the viral
genome (only 108-10 children viral DNA). Empty particles intervene in hepatocyte-
mediated lysis and serve as a protein coat for delta hepatitis virus (defective virus,
which cannot be replicated in the absence of HBsAg).
- Persistence of episomal cDNA in the nucleus of the infected hepatocyte
After internalizing the virus in the hepatocyte and releasing the viral nucleic acid:
partially double-stranded, partially circularized DNA, the short loop sequence is
completed, under the action of viral DNA polymerase, with the synthesis of a relaxed
dsDNA, which is transported in the nucleus and forms closed circular DNA. - closed
circular covalent), maintained in episomal form, not chromosomally integrated. This
dsDNA is used to transcribe several species of linear mRNA: one part called pregenomic
RNA will be the template for viral reverse transcriptase that will synthesize the new viral
genome dsDNA, and the others for the synthesis of viral proteins. Antiviral drugs used
in the treatment of hepatitis B intervene in the reverse transcription stage and cannot
interfere with cDNA. It can integrate at the hepatocyte level and is a viral reservoir,
the possibility of reactivations. Mutations in the pol gene, frequently induced by new
antiviral drugs, also alter other genes.
Transmission routes - HBV is transmitted:

- Percutaneous or permucos, by contact with infectious fluids from
infected people) - by injections, transfusions, dental or surgical maneuvers,
tattoos, piercings, acupuncture with incorrectly sterilized instruments,
shared use of scissors, razor blades, toothbrushes, etc. predisposes to the
transmission of the virus, etc.). All blood donors are currently being tested
for the presence of HBsAg. However, due to the existence of a long
serological window (approximately 75 days), there is a residual risk
associated with transfusion, which could be reduced / eliminated completely
by introducing HBV DNA testing into donor blood (a method that is still too
expensive for most public health systems).
- Sexual (straight and homosexual). All people are at risk for HBV infection, but
those with multiple sexual partners, especially those who have unprotected sex
(without a condom) have a high risk of infection.
- Maternal-fetal (perinatal, not transplacental)
- By direct contact with an infected person (the virus achieves high

concentrations in saliva)
HBV is very resistant storage, boiling, disinfectants. HBV is 50-100 times more
infectious than human immunodeficiency virus (HIV). HBV keeps its infectivity at
30 ° C for at least 6 months and at -15 ° C for 15 years; Remains infectious in dry
bloodstains - for at least a week. Exposure to ether, acid (pH 2.4 for at least 6
hours) and heat (98 ° C for 1 min; 60 ° C for 10 hours) do not destroy
immunogenicity or antigenicity - inactivation may be incomplete if the viral titer
is high. Infectivity is destroyed after autoclaving at 121 ° C for 20 min or
exposure to dry heat 160 ° C for 1 h. The following disinfectants are effective on
HBV: sodium hypochlorite --- 500 mg free chlorine / liter (minimum exposure 10
minutes) ; glutaraldehyde 2% solution (exposure for 5 minutes at room
temperature); formaldehyde 18.5 g / l, isopropyl alcohol 70%,
combined treatment with UV irradiation.
Epidemiology. Hepatitis B is a major public health problem. About 2 billion people

worldwide have been infected with the hepatitis B virus, more than 350 million are
chronic carriers of HBV and are a reservoir for the continuous transmission of the
infection. In addition, chronic HBV infection is the leading cause of liver cirrhosis
and primary liver cancer (CPC) and one of the top ten leading causes of death
worldwide.
Clinic.Incubation lasts an average of 75 days, during which time the patient is contagious. The onset is
discrete, with nonspecific symptoms (asthenia, loss of appetite / anorexia, nausea, abdominal
discomfort, arthralgia / myalgia), jaundice and increased levels of transaminases. Jaundice forms occur
in <10% of cases in children aged 1-5 years, but are much more common (30-50% of cases) in older
children and adults. The persistence of HBsAg over 6 months after the onset of jaundice is an indication
of chronic hepatitis B.
Chronic hepatitis B is characterized by several clinical stages:

1. Immunotolerance phase, with normal levels of transaminases and minimal
hepatocyte damage, despite a very high level of HBV DNA
2. Active phase, with viral replication, sustained immune response, increased transaminases and
necroinflammatory hepatocyte lesions
3. Inactive phase with low / undetectable HBV DNA level, normal transmaninases, HBeAg-
anti-HBe seroconversion with obvious improvement in liver histopathology. The annual
rate of spontaneous seroconversion is 8-15%, lower in those with normal
transaminases. Some patients will remain in this stage, being able to achieve complete
HBV seroconversion - to complete anti-HBs (and therefore viral clearance), while others
will return to the active phase, with the resumption of viral replication and
inflammatory syndrome.
HBV is not directly cytopathogenic, most liver damage is caused by hepatocyte-

mediated immune lysis.
Evolution is distinct according to age at the acquisition of the infection (see table) ::
- The newborn, after maternal-fetal transmission, although the infection is
asymptomatic in most cases, chronicity occurs in> 90% of cases. This is due to
a prolonged phase of immunotolerance, due to transplacental transfer of
HBeAg, which induces an inefficient cytotoxic response to HBsAg, blocking LTc
and APC functions by inhibiting proinflammatory cytokines. Viremia is high, but
is not associated with elevated transaminases or significant hepatocyte changes,
which indicate a lack of HBV cytopathogenicity. The evolution in children is long
subclinical with normal transaminases and minimal hepatic inflammatory
activity. Reactivation occurs late, after 10-30 years, in subjects with a number of
risk factors.
- In older children (over 5 years) the rate of chronicity is 30-50%, and in adults only
8-10%. The rapid loss of the immunotolerant phase precipitates the immune-induced
lysis of infected hepatocytes and, together with the massive viral replication, generates
important hepatocyte histopathological changes (necroinflammatory activity followed by
progressive fibrosis).
The evolution of hepatitis B
Phase of Replicative phase Non-replicative phase

Immuno-
tolerance
Hepatitis B Hepatitis B Inactive carrier

chronic AgHBe + chronic AgHBe- Ag HBs
(Mutant
core / precore)
HBsAg + + + +
HBeAg + + - -
Anti-HBe - - + +
OTHER Normal - - Normal

HBV DNA 5-7 9 7
> 200,000-10 > 2x 105 -10 2000 - 2 x 10 <2000
IU / mL
Normal/ Inflammation
Histology Active inflammation Normal
moderate Activate
Treatment Not Yes Yes Not
Severe late complications of chronic infection are cirrhosis and hepatocellular

carcinoma (HCC). Cirrhosis is more common in chronic hepatitis B with HBeAg negative.
Other factors associated with progression to cirrhosis and primary liver carcinoma are:
exposure to hepatotoxic substances (alcohol consumption, dietary factors - exposure to
high concentrations of aflatoxin, drugs, etc.), old age, male sex, HBV viral strains of the
genotype C, HCV coinfection. Cirrhosis decompensation is 16% in the first 5 years. After
decompensation, life expectancy decreases to 14-28% in the next 5 years.
The mechanism of HBV-induced oncogenesis is incompletely elucidated.

Hepatocellular carcinoma C (HCC) can occur in the absence of cirrhosis in
chronic hepatitis B. Risk factors are HBV genotype C infection, age> 40 years,
high HBV DNA level, mutations in the precore region (A1762Y and G1764A); CCC
DNA that persists intrahepatically can be integrated into the cell genome
(transposon-like) during hepatocyte regeneration, a process that can inactivate
antioncogens or cause aberrant activation of viral oncogenes. The regulatory
protein encoded by the viral X gene (commonly identified in HBV-associated liver
tumors) has a transactivating role in factors involved in cytoplasmic and
intranuclear signaling, cell growth, apoptosis, and DNA repair.
Laboratory diagnosis:
Acute infection with HBV: HBsAg + IgM-type anti-HBc antibodies, HBV DNA
Chronic infection with HBV: HBsAg + IgG-type anti-HBc antibodies.

Chronic HBV infection can be
- Chronic active infection (with sustained viral replication): HBV DNA present and
AgHBe present; except for core / precore mutants in which HBeAg may be negative,
but HBV DNA is present in high concentrations)
- Persistent chronic infection (with reduced, intermittent viral replication): usually
HBeAg negative, and HBV DNA in low concentrations
Confirmation of chronic infection is done by:

• HBsAg persistence> 6 months,
• viral load values> 104 children / ml DNA / HBV,

• persistently or intermittently increased transaminases,
• progressive necroinflammatory activity +/- fibrosis at liver biopsy.

Hidden hepatitis B.: isolated anti-HBc antibodies, without HBsAg present, but with viral
replication evidenced by HBV-DNA detection (usually below 104 IU / ml plasma). These
patients can transmit HBV mainly through transfusions or organ transplants, and liver
damage progresses mainly to immunosuppression.
Hepatitis B Healing: anti-HBc IgG antibodies present (marker of natural infection)

and anti-HBs antibodies - the only ones that neutralize the virus.
Effective vaccination against HBV: anti-serum HBs antibodies (titer> 10 mUi / ml).
Prevention
- specific prophylaxis: recombinant vaccine containing only HBs antigen obtained by
biotechnology. In Romania, since 1995, the universal vaccination of newborns against hepatitis B
has been introduced. It starts in the maternity ward and includes a 4-dose vaccine schedule
(0-2-4-11 months).
- non-specific prophylaxis: triage of blood donors, administration of specific anti-

HBV gamaglobulins to contacts or newborns, compliance with universal
precautions
Standard precautions include:
• Use of personal protective equipment and change of gloves / masks

between patients
• Rigorous hand hygiene
• Reducing the handling of cutting tools (including injection equipment)
• Physical separation of "clean" and contaminated areas and equipment to avoid cross-
contamination
• Avoiding contamination of injectable medication

• Injection safety - separation and disposal of cutting / contaminated waste / disinfection and
sterilization of the environment
To prevent maternal-fetal transmission in children born to HBsAg-positive mothers (
especially those with active replication, with HBeAg positive and HBV DNA), it is
recommended to combine maternity vaccination in the first 12-24 hours after birth with the
injection of specific anti-HBV immunoglobulins), later, reminders: (2-4-11 months ).
Any viral hepatitis B prevention program must combine vaccination,

screening, correct diagnosis and therapy.
Antiviral treatment in chronic hepatitis B. follows: slowing the progression of fibrosis

to cirrhosis, prevention of liver failure, prevention of HCC. This is achieved by the
disappearance of the markers of active viral replication: HBsAg, HBsAg and HBV DNA
(the most sensitive and persistent). The goal of treatment is to obtain a sustained
virological response (RVS-HBV DNA undetectable 6 months after stopping treatment).
Healing is the result of the synthesis of anti-HBs antibodies, the only ones that
neutralize viral replication.
Criteria for assessing therapeutic successin chronic hepatitis B are:

- reduction of viral load (optimal undetectable HBV DNA) - virological success
- normalization of transaminases;
- seroconversion to antiHBe (serological success) and loss of HBsAg with antiHBs
seroconversion (healing). This shows the cessation of viral replication
- improvement of liver histology (decrease in the score of necroinflammatory activity
or fibrosis).
Antivirals fail to cure the infection completely, as the replicative forms of the viral
genome remain in the nucleus of infected hepatocytes in the form of ccc DNA, inaccessible
to the immune response or drugs. The persistence of ccc DNA explains relapses upon
discontinuation of therapy or under immunosuppression
Treatmentis currently being done with alone with analogs
nucleoside / nucleotide reverse transcriptase inhibitors (NUC) or Interferon

pegylate (PEG-IFN).
The most commonly used NUCs today are entecavir and tenofovir, with older drugs
(lamivudine, adefovir, telbivudine) being burdened with high rates of resistance, which are quickly
established.
These drugs should be administered daily for more than 1 year (sometimes
even indefinitely - until therapeutic success), but are well tolerated, significantly
reduce viral replication, with a high (90%) chance of obtaining an initial
virological response, and enhanced and are active on lamivudine-resistant HBV
mutants.
Combination therapy has potential benefits (low resistance rates), although there is no
evidence that one of the combinations of PEG-IFN + NUC or 2 NUC would be superior to
monotherapy.
The initiation of the treatment is done:
- in HBeAg positive patients if: HBV DNA>2000 IU / mL (according to

European-EASL criteria) or if HBV DNA> 20,000 IU / mL and ALT> 2 times
ULN (according to US-AASLD criteria)
- in HBe Ag negative patients if: HBV DNA>2000 IU / mL and increased ALT
(EASL and AASLD)
A decrease in HBsAg titer at week 12 or 24 during PEG-IFN treatment appears to be

predictive of RSV. HIV or HCV coinfection worsens the course and prognosis of liver
disease: accelerates fibrosis and limits the success rate of antiviral therapy.
New therapies for HBV infection:

- Myrcludex B (Bulevirtide) synthetic peptide analog preS1, inhibits NTCP receptor
binding (std phase 2b - BD coininfection)
- Inhibition of HBsAg secretion (Nucleic acid polymers - REP2139; prevent attachment to
GAG, activity dependent on size and amphipathic character
- Therapies targeting ccNDNA

• Destruction by specific endonucleases-CRISPR / cas, ZFN, TALEN
• Functional silencer
- siRNA (small interfering RNA)
VIrusHHEPATITISDELTA(VHD)
Hepatitis Delta virusis the smallest known human virus, being grouped among
subviral agents (virusoids), closer in structure to plant viruses. Viruses have a small
partially circular RNA genome (VHD has 1700 bases), which is unable to encode the
structural proteins of the virion. Therefore, VHD replication depends on a helper virus
- hepatitis B virus (HBV), which provides protein coatings.
It has the ss RNA genome, with anti-message polarity, does not have its own RNA
polymerase and uses host polymerases for replication; in fact, the VHD genome
encapsulates excess empty particles formed during HBV replication by HBsAg self-assembly.
So,Delta hepatitis occurs only in mixed hepatitis B infection. Infections are acquired
simultaneously -coinfection, or successively: delta infection overlaps with chronic hepatitis
B -superinfection.The last alternative is an aggravating condition with the risk of fulminant
hepatitis or chronic chronicity in aggressive forms. The delta virus is not cytopathogenic, the
lesions are immune-mediated, causing faster progression to cirrhosis and increasing the
risk of hepatocellular carcinoma.
The diagnosis of delta hepatitis virus infection is made by highlighting anti-VHD

antibodies by ELISA and VHD RNA by Rt-PCR. A suggestive serological profile for B-
delta coinfection is HBsAg positive, HBcIgM positive, anti VHD IgM positive; and for
B-delta superinfection: HBsAg positive, HBcIgG positive, VHD IgG positive.
In patients with dual B-delta infection, delta hepatitis virus replication dominates, with HBV
DNA levels being low.
Treatment. Pegylated interferon for 48 weeks in those with compensated active

disease, however. the response rate is low and the disease frequently progresses to
liver failure. Those with significant HBV replication (> 2000 IU / ml) may be given a
nucleotide reverse transcriptase inhibitor; new therapies also include Mircludex B
(NTCP receptor inhibitor) and Lonafarnib (prenylation inhibitor, inhibits cellular
farnesyl transferase, administered orally with RTV +/- PEGIFN)
preventionHepatitis delta is vaccinated against HBV. Globally, of the 350 million

chronic HBV carriers, 15 million are co-infected with VHD, but the prevalence of
delta hepatitis is declining, largely as a result of the HBV vaccination program.
VHEPATITIS IRUS C (HCV)

Hepatitis C virus (HCV) was discovered in 1989 by molecular biology techniques as the
main etiological agent of non-A, non-B post-transfusion hepatitis. HCV causes an
infection with a very high potential for chronicity. The WHO estimates that hepatitis C
affects more than 3% of the world's population (175-180 million subjects), with 3 to 4
million new infections each year. In Romania, the seroprevalence of HCV infection in the
general population is around 4.5%.
A quarter of people living with HIV are co-infected with HCV (an aggravating condition for the
development of liver disease, which has become one of the leading causes of mortality and
morbidity in HIV-positive patients).
Characteristics.
HCV is part of the Flaviviridae family (ssRNA genome, 9500 nucleotides, positive polarity),
genus Hepacivirus. It has a envelope with hydrophobic protein projections that are coated in
plasma betalipoproteins, which shield the antigenicity of the virus. This explains why
seroconversion after infection is late (after about 100 days), generating a

significant residual risk associated with blood transfusions, if the triage of donors tested
only by serological tests.
HCV replication.
The HCV genome contains a single open reading frame (ORF) that encodes a
polypeptide of ≈3,000 amino acids, subsequently cleaved by viral enzymes (the most
important being NS3 / NS4A HCV protease) and cellular into structural and
nonstructural proteins. Viral replication is coordinated by an RNA-dependent RNA
polymerase (RdRp) encoded by the NS5B gene. This enzyme has a low
transcriptional fidelity (the rate of misuse of nucleotides is 10-3 per nucleotide per
viral generation), which, associated with a very fast rate of viral replication (1010-10
12 virions per day, with a half-life of 2-3 hours), generates a large viral variability.
This is especially evident in viral envelope proteins encoded by a hypervariable
region of the genome. Variability is expressed by:
- the existence of at least 6 distinct genotypes (differences of is 30% in the sequence of
nucleotides), between which there is no cross antigenic reactivity.
- the presence of viral quasi - species (intragenotypic variants that differ in sequence
only by a few percent). HCV can bypass the host's immune response by selecting from the quasi-
species that make up the viral population, non-neutralizable variants, which are responsible for the
high rate of chronic infections. n hepatitis C.
Along with NS5B polymerase, another important role in the formation of the replicative complex
is played by another viral protein - NS5A, which acts by recruiting cellular factors such as
cyclophilins A and B, which cause cis-trans isomerization, necessary for viral replication. The
same NS5A protein is involved in the assembly of progenitor virions.
The viral proteins NS3 / NS4A (protease), NS5B (polymerase) and NS5A are the targets of
new drugs with direct antiviral action, active in HCV infection.
HCV replication is closely linked to lipid metabolism, with the incidence of dyslipidemia,
metabolic syndrome and early-onset cardiovascular disease being significantly increased in
patients with chronic hepatitis C.
Transmission routes
HCV infection is mainly transmitted percutaneous or permucos, by contact with
infectious fluids from infected persons - by injections, transfusions, dental or surgical
maneuvers with incorrectly sterilized instruments), tattoos, piercings, etc.). People who
have received blood transfusions (especially before 1993) who have had surgery or
parenteral treatment have a higher risk of becoming infected with HCV. At present,
triage of blood donors for HCV infection is mandatory, however, given that
seroconversion after infection is late (after about 100 days), there is a residual risk of
transmission associated with transfusion.
Sharing of needles, syringes and other instruments by drug users it is now the
most important channel of transmission. parenteral.
Sexually transmitted HCV transmission (homo and heterosexual) is possible, although the
risk is much lower than in other viruses (HBV - hepatitis B virus or HIV). Constant use of a
condom reduces the risk of transmission. Outbreaks of HCV transmission in homosexuals
without other risk factors have recently been reported.
Maternal-fetal transmission of HCV is possible, but the rate of transmission is low (around
6%), much lower than in other viruses (HBV - hepatitis B virus or HIV). The risk of
transmission increases in the case of HIV-HCV co-infection in the mother.
Clinic.
Acute infection is often asymptomatic (70-80% of cases), clinically apparent forms
(subfecrile condition, fatigue, loss of appetite, nausea, abdominal pain, joint pain,
hyperchromic urine, colorless stools, jaundice) are mild. Predictors of spontaneous cure
of acute HCV infection are: female gender, young age, symptomatic forms and the
presence of a favorable genetic polymorphism in the IL28B gene (also involved in the
response rate to recombinant IFN treatment). However, HCV infection becomes chronic
frequently (in> 80% of cases), with the disease progressing to a persistent infection. In
one-third of cases, chronic infection progresses slowly (over several decades) to liver
failure, cirrhosis, and primary liver cancer. Terminal liver disease caused by chronic HCV
infection is the main indication for liver transplantation.
Diagnostic.
The diagnosis of HCV infection is made by:

- enzyme-linked immunosorbent assays for HCV-specific antibodies (until a
few years ago their result had to be confirmed by RIBA, Western Blot, but
today their specificity is high, being sufficient for diagnosis)
- viral load detection tests (number of copies of HCV RNA / plasma ml) and
genotyping tests.
It is important to note that:
- HCV RNA can be detected from the first days of infection, long before the
appearance of anti-HCV antibodies.
- Only evidence of viral load (HCV RNA) indicates active and potentially infectious
viral replication of the patient.
- During chronic HCV infection, the evolution of viremia is fluctuating, so HCV-
RNA can be detected intermittently.
avert
- specific prophylaxis: There is no vaccine against hepatitis C and, due to the

great variability of the virus, it is unlikely to be obtained in a short time.
- non-specific prophylaxis: Because HCV is transmitted through blood and biological
fluids, infection prevention can be achieved by:
- Triage of blood donors for the presence of HCV infection (mandatory in Romania
at present)
- Avoiding illegal drug use; in the case of injecting drug users - the use of
disposable needles and syringes and the avoidance of the shared use of
needles, syringes and other drug preparation equipment The use of
- disposable needles in the case of tattoos and body piercings;
- Proper sterilization of instruments used in cosmetics, manicure or
- hairdressing; Adherence to good practices for the use, storage and
destruction of syringe needles by medical staff.
- Universal precautions
- Avoid sharing personal items such as toothbrushes, razors, earrings,
scissors, nail clippers
- Constant and correct use of a condom in any type of sexual intercourse, with all
sexual partners;
Any viral hepatitis C prevention program must combine screening, correct

diagnosis and therapy.
Treatment. The goal of antiviral therapy is to eradicate viral replication. Until 2011, the
standard treatment for chronic hepatitis C was the combined administration of Interferon
pegylate (Peginterferoni alfa) and ribavirin for 24-48 weeks. The response rate varies greatly
depending on the viral genotype (the lowest of about 40-50% for genotype 1, the highest
70-80% for genotypes 2 and 3), in addition the treatment was associated with a series of side
effects. severe (anemia, neutropenia, thrombocytopenia, depression, irritability, drowsiness,
etc.).
New drugs with direct antiviral action - DAA (protease inhibitors, polymerase
inhibitors, NS5A protein inhibitors) have been introduced for both first-line
treatment and non-standard treatment. The drugs approved so far are:
- Protease inhibitors: -Telaprevir (Incivek, Vertex Pharmaceuticals),

Boceprevir (Victrelis, Merck); Simeprevir (Olysio, Janssen)
- Polymerase inhibitors - Sofosbuvir (Sovaldi, Gilead Bioscences).
- NS5A- Phosphoprotein Inhibitors Ledipasvir
From 2018, in Romania all HCV patients are treated with F1-F4 (compensated cirrhosis) -
12-24 weeks with 3 available regimens:
- Sofosbuvir + Ledipasvir
- Grazoprevir + Elbasvir
- Ombitasvir / Paritaprevir / ritonavir + Dasabuvir
These drugs have pangenotypic activity, are administered orally, many in a single
dose, and have few side effects. Response rates, after only 12 weeks of
administration, are exceptional: in 90-99% of cases, a sustained virological response
is obtained (undetectable HCV RNA 6 months after stopping treatment), which is
equivalent to curing the infection, because in hepatitis C there are no viral tanks.
Several elements predict a moderate or absent response to therapy: a high level
viral replication before initiating treatment (HCV RNA> 800,000 IU / ml), advanced
degree of liver fibrosis (depending on the age of the infection), male sex, infection with
certain genotypes. Therapies based on the inhibition of important cellular factors for
viral replication (such as cyclophilins or HMG-CoA reductase) or the use of nucleotide
antagonists that sequester microRNA molecules are also developing.
This text is part of the Infectious Diseases Treaty(chapter Etiology of Infectious Diseases,
subchapter Viruses, author Simona Ruta),edited by Emanoil Ceausu, published by Editura Medicala,
Bucharest, 2018.
VIRUSES AND CANCER
Viral infections are involved in about 16% of human cancers, with significant variations
between developed and developing countries [1]. Oncogenic viruses act on cellular
mechanisms that coordinate the normal division of cells, inducing discrete mutations
or altering the expression of key genes involved in cell cycle control. Thus, there are:
- oncogenic viruses that cause aberrant activation of proto-oncogenes or

overexpression of proteins encoded by them. Proto-oncogenes are normal cellular genes
that control the correct progression in the replicative cycle, functioning as growth factors,
growth factor receptors, proteins involved in intracellular signaling or transcription factors
(examples are hepatitis B-HBV virus and Epstein Barr-EBV virus ).
- oncogenic viruses that inactivate cellular anioncogens - tumor suppressor genes

(The classic example is of human papillomaviruses - HPV)
Oncogenic retroviruses.
Basically, oncoviruses in the Retroviridae family can be grouped into two important categories (2):
- rapidly oncogenic oncoviruses in vivo and transforming in vitro, which have their
own viral oncogenes, but are generally replicatively defective, and need helper viruses
to express their transformative capacity.
- slow oncogenic oncoviruses in vivo and non-transforming in vitro, which do not have their own viral
oncogenes, but can alter the expression of cellular proto-oncogenes
Rapidly oncogenic oncoviruses in vivo and transforming in vitroare pathogenic to a
number of animal species but not to humans. These viruses have their own oncogenes - viral genes
capable of inducing cellular transformation by insertion into the genome of the host cell and
Bucharest, 2018.
to take control of the cell cycle, generating chaotic cell division and proliferation,
uncontrolled, with the rapid development of extremely aggressive cancers. These viruses
are generally replicatively defective, with oncogenes replacing portions of structural genes.
But there is one important exception - the Rous sarcoma virus (the first oncogenic virus
described - in 1911, by Peyton Rous, awarded in 1966 with the Nobel Prize for Medicine for
this discovery) - a retrovirus that is competent replicator, presenting its own oncogene (v-
src), separated from the structural genes, which causes cell transformation in vitro and in
vivo, generating an extremely aggressive cancer in chickens (Rous sarcoma).
Although non-pathogenic to humans, rapidly oncogenic retroviruses have been important
models for deciphering cell cycle control and understanding oncogenesis. Research based on the
study of the action of these viruses has led to the discovery of:
- how oncogenic viruses interact with cellular genetic material (studies by Howard
Temin, Renato Dulbeco and David Baltimore, Nobel Laureates in Medicine in 1975),
- the origin of viral oncogenes in cellular oncogenes (hypothesis formulated by Michael Bishop
and Harold Varmus, winners of the Nobel Prize for Medicine in 1989). [2]
Virtually today, viral oncogenes are considered to be cellular genes acquired by viruses during
replication and selected for their transformative capacity. Viral oncogenes have a structure
similar to cellular proto-oncogenes (they lack only introns), but are under the control of other
(viral) promoters and have mutations or deletions that alter the protein product, usually
expressed fused with other viral proteins. For example, the oncogene v-src, from the Rous
sarcoma virus, has a structure similar to the proto-oncogenes of the src-kinase family,
important components of cellular signaling during cell division; and erb oncogen B (from
erythroblastosis virusavian) is similar to the proto-oncogene Her2 / Neu- member of the
epithelial growth factor receptor family. The amplification of this cellular proto-oncogene plays
an important role in the development of aggressive types of breast cancer, this protein being a
valuable biomarker for monitoring progression, and a target for therapy based on a specific
monoclonal antibody - Trastuzumab (Herceptin) [3] .

Bucharest, 2018.
Slowly oncogenic oncoviruses in vivo and non-transforming in vitrogenerates cancers by
insertional mutagenesis. Basically, replication follows the normal steps for a retrovirus: the viral
genome - ssRNA + is reverse transcribed into a proviral DNA, which will integrate into the cell
genome, but this integration is not random, but always in the immediate vicinity of a cellular proto-
oncogene. . The insertion of the provirus leads to the aberrant expression of the respective
protooncogene, which generates the disturbance of the cell division, with chaotic proliferation and
cellular transformation.
The only human oncogenic retroviruses aredelta retroviruses: HTLV I and II(Human T cell leukemia
virus). HTLV I and II are transmitted parenterally, through blood and blood derivatives, but also
sexually and maternally and fetally. The incidence of HTLV I infection is high in some regions of
Japan, the Caribbean and Africa, and that of HTLV II inNorth, South and Central America.
HTLVI causes adult T-cell leukemia (ATL) - a form of leukemia with a very poor prognosis
due to induced immunosuppression and resistance to chemotherapy, T-cell skin
lymphomas and a neurodegenerative disease: tropical spastic paraparesis (TSP) also called
myelopathy. HTLV-1 (HAM). Possible involvement of HTLV I has also been suggested in the
development of chronic lymphocytic leukemias, non-Hodgkin's lymphomas, or multiple
myeloma. [4.5]
Once integrated into the cell genome, HTLV synthesizes tax-regulatory proteins, which promote
viral replication and ensure the transformation of T lymphocytes in vitro. They are
transactivators for the LTR (long terminal repeats at the ends of the viral genome) regions and
are able to increase LTR-mediated viral transcription and generate overexpression and
modulation of cellular promoters involved in cell proliferation and differentiation in cytokine
synthesis; of cytokine receptors and costimulatory molecules and in DNA repair mechanisms
[6]. However, tax gene expression appears to be relatively frequently inactivated in ATL cases,
and more recent studies attribute a critical role in gene oncogenesis.HBZ (HTLV-1 basic leucine
zipper factor), which encodes an essential factor for HTLV infectivity and promoting T cell
proliferation [7]. HTLV can stimulate uncontrolled cell growth and by direct binding to cyclin-
dependent kinases that normally control the transition from a resting to an active stage of the
cell cycle.
Bucharest, 2018.
Human papillomaviruses (HPV).
Persistent infection with high oncogenic risk HPV genotypes is implicated indevelopment of
premalignant dysplastic lesionsand in the onset of cervical cancer, as well as other cancers
in the genital area (vulvar cancer, penile cancer, anal and perianal cancer) and in the
oropharyngeal area (laryngeal carcinoma, oral carcinoma, squamous cell carcinoma), the
role of HPV in oncogenesis has been demonstrated by studies initiated by Harald zur
Hausen, awarded the Nobel Prize in Medicine, 2008 [8]. Persistent infection occurs in
nonpermissive cells, from the deep layers of the basal epithelium. Here the viral genome
integrates into the cell genome, leading to abortive viral replication - without the formation
of progenitor virions. Basically, HPV DNA is linearized and preferential expression of early
viral genes takes place - E6 and E7. E6 and E7 proteins inactivate the p53 and pRb cell
anioncogens, respectively, leading to aberrant expression of cyclin-dependent cyclin and
kinase kinases, with uncontrolled cell cycle progression and cell transformation. which two
viral genes involved in oncogenesis E6 and E7 are located upstream of a control region -
CSF (long control region) containing enhancers that can be activated by cellular or viral co-
factors [9]. Although persistent high-risk HPV infection is the cause of cervical cancer, The
development of the tumor process requires a number of cofactors, the most important of
which are: long-term use of oral contraceptives, multiparity, smoking and HIV co-infection.
Other likely cofactors are co-infection withChlamydia trachomatis and herpes simplex virus
type-2 (HSV-2); immunosuppression, deficient in diet. The role of genetic, epigenetic and
immunological factors as well as viral load or integration site is currently insufficiently
supported by evidence.
HPV vaccination ensures a reduction in the incidence of invasive cervical cancer and
precancerous lesions. All HPV vaccines are produced by recombinant DNA technology
and contain non-infectious virion-like particles (VLP-virus-like particles) formed by self-
assembly of the major L1 (type-specific) capsid protein into empty viral caps, devoid of
the viral genome [10] . The vaccines are (Gardasil®) or eukaryotes (Cervarix®). The three
commercial vaccines currently available are:
1. Cervarix - is abivalent vaccine which protects against high oncogenic risk HPV16 / 18
genotypes. The vaccine is produced by the expression of L1 genes in eukaryotic cells.
Bucharest, 2018.
Vaccination causes a 92% reduction in abnormal cytology, and is 94-100% effective in

preventing persistent infection.
2.Gardasil® - is a tetravalent vaccinewhich protects against HPV 6/11 genotypes (low

oncogenic risk) and HPV 16/18 genotypes (high oncogenic risk). It is produced by the
expression of L1 genes in prokaryotic cells. In Romania, the vaccine is marketed under the
name Silgard®.
3. A variant of this vaccine -Gardasil 9®is anonvalent vaccinecontains HPV genotypes6, 11,
16, 18, 31, 33, 45, 52 and 58.
In general, all of these vaccines are recommended for routine immunization of 11-
to 12-year-old girls, given that there is a high probability of getting HPV infection
immediately after the onset of sexual life (practically 25% of women are infected after the
first year from the beginning of sexual life), and the effectiveness of the vaccine in already
infected women is low. Vaccination in this age group also appears to induce higher
antibody titers, and has the advantage of using the school medicine network to ensure the
most complete vaccine coverage possible.The tetravalent and nonvalent vaccines are also
approved in the United States for use in males. The recommended age for both girls and
boys is 11-12 years, but the vaccine can be given between 9-10 years, and between 13-26
years, in both sexes. Vaccinesprevent cervical cancer and precancerous lesions, anal
cancers, genital warts and other conditions caused by the HPV genotypes contained.
Vaccines are highly immunogenic and safe, providing protection for at least 5 years,
following a complete vaccination schedule that includes 3 doses of vaccine, given at 0-1 /
2-6 months.
Vaccination does not replace regular cytological / virological screening and should not affect
prophylaxis measures against sexually transmitted diseases.

Bucharest, 2018.
Gamaherpesviruses
Epstein Barr virus, a ubiquitous herpesvirus, which infects> 90% of the world's population, is
often acquired in childhood asymptomatically or associated with infectious mononucleosis,The
main site of latency is B memory lymphocytes in the blood and bone marrow, in which the
expression of viral genes is very restrictive.
Reactivation of latent infection, especially under conditions of immunosuppression, or in association with
certain environmental factors, may lead to malignant lymphoid proliferation, with varied clinical
appearance:
- Burkitt's lymphoma (an endemic form exists in Central and East Africa in children, in regions with a high
incidence of malaria, with extremely aggressive evolution)
- nasopharyngeal carcinoma (endemic to Southeast Asia, Mediterranean Africa and some

Eskimo populations), probably associated with genetic or environmental factors (including
dietary cocarcinogens: salted fish, nitrosamines derived from food preparation in the
region) ,
- post-transplant lymphoma (an initially polyclonal lymphoproliferation, can become mono- or oligoclonal,
the consequence of immunosuppression on the line of cytotoxic T lymphocytes, occurs with a frequency of
5-15% post-cardiac transplant, 10% post-cardio-pulmonary transplant, 1-3% after kidney transplantation
and 1 -2% after bone marrow transplantation).
- HIV-associated lymphomas, including CNS lymphomas (probably due to disruption of

cytokine synthesis that promotes autocrine proliferation of EBV-transformed B
lymphocytes) and villous leukoplakia of the tongue
- a number of other tumors (T-cell lymphomas that appear mainly in the parotid glands, a subset of
Hodgkin's lymphomas, and even some gastric tumors) have been associated with EBV infection.
In cancers associated with reactivation of EBV infection, there is a constant overexpression

of early viral proteins that act as autocrine growth factors for B lymphocytes, growth factor
receptors, or activators of cellular oncogenes. By the way, the virus
Bucharest, 2018.
Epstein Barr can transform B lymphocytes in vitro, inducing immortalization and being
used to obtain lymphoblastoid cell lines.
An abnormal activation of the cellular protooncogene cmyc is involved in the appearance of Burkitt's
lymphoma, which occurs following a chromosomal translocation - usually t (8/14), possibly also t (8,2)
or t (8/22) which moves an enhancer sequence. from chromosomes 14,2, 22 encoding the heavy /
light chain of immunoglobulins, on chromosome 8, in the vicinity of the c-myc gene. Malaria appears
to play a role in the development of this cancer, Plasmodium falciparum (through a cysteine-rich
region in a membrane protein)acts as a polyclonal activator of B lymphocytes, preferentially in the
memory cell compartment, stimulating the reactivation of EBV from this latency site, with inhibition
of the specific anti-EBV immune response. It has also been suggested that Plasodium falciparum and
hemozoin are ligands for TLR 9, inducing cytidine deaminase in EBV-infected cells that would
stimulate chromosomal translocations characteristic of Burkitt's lymphoma. In recent years, there is
growing evidence to support interference with EBV gene expression through the interaction of viral
and cellular microRNA (miRNA) species. Burkit's lymphoma, in the version found in children,
responds relatively well to aggressive chemotherapy and adjuvant treatment with Rituximab,a
binding chimera (human / murine) monoclonal antibodyspecific for transmembrane antigen, CD20, a
non-glycosylated phosphoprotein, located on mature pre-B and B lymphocytes. both normal and
malignant, mediating their destruction [14, 15].
Human herpes virus 8 (HHV8, formerly known as Kaposi's sarcoma virus) is implicated in
the development of endothelial cell cancer - Kaposi's sarcoma, multicenter Castleman's
disease (a rare lymphoproliferative condition) and a primary lymphoma in the serous cavities:
pleura, pericardium, peritoneum-PEL (primary effusion lymphoma). All these malignancies have
a high incidence in immunosuppressed people, being in particularassociated with HIV infection,
especially in males; but also post-transplant (especially kidney). The mechanisms of HHV8-
induced oncogenesis are complex and poorly understood. There are a large number of open
reading frames in the viral genome, some of which encode a number of cellular analogs: cell
cyclin-like proteins that stimulate cell division and inhibit apoptosis, as well as latency-
associated viral transcripts (latency-associated nuclear antigen).

Bucharest, 2018.
LANA), as well as a series of viral cytokines and chemokines that stimulate angioproliferation
and inflammation, helping to promote carcinogenesis through a mechanism called paracrine
neoplasia. Several species of viral miRNAs inhibit latent virus reactivation and facilitate cell
transformation, a process in which other encoded virus factors participate:complement binding
protein, interferon regulating factor, etc., which helps to bypass the immune response [16].
Hepatitis B virus (HBV).
More than half of all cases of primary liver cancer (CHP) are associated with persistent HBV
infection, andChronic carriers of HBsAg have a 25-37-fold higher risk of developing CHP, which
is more pronounced in patients with cirrhosis [17].
During persistent HBV infection, integration of the cDNA replicative form (covalent, circular,
closed) into the cell genome may occur, leading to deletions at the site of integration into the
hepatocyte genome, affecting genes involved in cell cycle control, especially the cascade.
membrane-to-nucleus signaling and can lead to chromosomal translocations. In addition, viral
gene rearrangements occur with the expression of regulatory proteins encoded by the X gene,
which may cause aberrant activation of cellular protooncogenes, overexpression of
transcription factors and apoptosis inhibitors, and modulate intracellular signaling pathways
[18].The viral genotype seems to be important in the progression to CHP: in Asia the risk is
higher in the case of infection with Genotype C compared to genotype B, and in Europe
genotype D is more frequently associated with CHP compared to genotype A. Also an important
role it seems to be due to the presence of point mutations in the promoter of the core gene and
deletions in the preS gene [19-21].
HBV is the leading cause of CHP in Asia-Pacific and sub-Saharan Africa, closely linked to the
endemic status of HBV infection but also to the existence of food co-carcinogens: especially
aflatoxin B1 - a metabolite of the Aspergillus flavus fungus that contaminates plant food
improperly. stored, and which causes the DNA helix to rupture and mutations in the p53 tumor
suppressor gene. In China, certain algae-derived toxins (Microcystin) what the

Bucharest, 2018.
contaminates waterThey appear to be associated with an increased risk of liver cancer. A number of
epigenetic changes are at risk of carcinogenesis: global hypomethylation associated with localized
hypermethylation promotes chromosomal instability and decreases the expression of tumor suppressor
genes [22].
In Europe, 90% of CHP occurs after advanced cirrhosis, as a result of the inefficient process of
liver regeneration following HBV or HCV infection, which leads to the appearance of cumulative
mutations in cellular DNA. HIV co-infection, obesity, diabetes, alcoholism, are important risk
factors for the onset and progression of CHP.

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Translated from Romanian to English - www.onlinedoctranslator.

Viruses are a heterogeneous class of infectious agents, which parasitize humans,

animals, plants and bacteria (bacteriophages).

Common features (1, 2):

several distinct genera: Mimivirusmlmiking mlcrobe), Mollivirus, Marseillevirus, Pandoravirus,

episode of pneumonia in England (5).

3. simple structure- viruses are made up of genome-represented by a single species of

separation of viral nucleic acid from protein coatings.

between the virion and the cell,

outside, being degraded).

logarithmic growth phase.

replication in cells at rest or in stages of terminal differentiation (eg, some herpesviruses

have mechanisms to correct these incorrect incorporations of nucleotides, so the replication of

infection during isolation on cell cultures or biopsies from affected tissues.

capsid, respectively the envelope.

synthesis of a complementary copy of the genome, which serves as an mRNA and is a

DDNA viruses that replicate through an RNA-like intermediate

(Hepadnaviruses). These viruses have an extremely viral polymerase

complex, multifunctional that also serves as a reverse transcriptase. This replication

is characteristic of hepatitis B virus (HBV)

Lippincott Williams Wilkins.

2. Cernescu C. Medical Virusology, 2012, Medical Publishing House, 2012.

of giant viruses of amoebae. Nat Rev Microbiol. 2017; 15 (4): 243-254.

putative pneumonia agent. Clin Infect Dis.2007; 45 (1): 95-102.

Complexity of an Outlier 25 Years Later. AIDS Rev. 2015; 17 (3): 147-58.

2. Ntiviral immunity - Mechanisms of virus resistance

specific resistance in viruses is ensured mainly by the synthesis of interferons (a family of

killer), which ensures the lysis of virally infected cells.

Recognition of molecular patterns specific to pathogens- PAMPs (pathogen-associated

anticellular action of interferon, inducing a state of resistance to viral replication in neighboring

Specific resistance is mediated by:

by the Th2 subset).

Antibodies it binds to conformational epitopes on the surface of the viral envelope or

Pathogenesis of viral infections

symptomatic or clinically inapparent, but accompanied by asymptomatic viral excretion.Inapparent

inapparent infections can turn into productive infections.

viral-induced carcinogenesis. (ex:human papillomaviruses) (9).

synthesis of nonstructural viral proteins. Latency is a characteristic phenomenonherpes which

triggering factors, may resume complete replication, generating asymptomatic or clinically

1. Louten J. Essential Human Virology 2016, Elsevier Inc.

Zoster Virus Encephalitis. J Infect Dis. 2017; 215 (9): 1430-1434.

2015 Oct; 14: 50-5.

Lippincott Williams Wilkins.

Infect microbes. 2017; 19 (12): 587-596.

14. Lundgren O, Svensson L. Pathogenesis of Rotavirus diarrhea. Infect microbes. 2001; 3:

entry. Cytotherapy (2017) 19 (11): 1325–38.10.1016 / j.jcyt.2017.05.013

liver-specific microRNA. Science2005; 309: 1577-81

Med.2013; 368 (18): 1685-94.

chemical processes (treatment with formaldehyde or beta-propriolactone) that keep the

VI induce a significant immune response (as individual antibody titer, proportion of

VI are commonly used to prevent polio, influenza, rabies and hepatitis A.

the level of the virus entry gate,

change due to chemical processes and does not require adjuvants.

- the risk of severe symptoms in immunosuppressed persons,

phenomenon occurred only in the case of live attenuated polio vaccine

the prevention of Ebola hemorrhagic fever

infection have been developed, now in phase 3 clinical trials

The ratio between inapparent and symptomatic, paralytic infections is 200: 1.