The disease burden from acute and chronic infections of viral origin continues to challenge healthcare organizations worldwide. According to the latest Di sabil ity-Adj usted Life Year (DALY) estimates by the
Cell culture, shell vials, and direct fluorescent antibody staining
The use of mammalian cell cultu res six decades ago to propagate the poliovirus ill vitro and examine microscopically the cytopathic effect (CPE) on infected cells marked the beginning of the golden era in clinical vi rology.2.3 The quali ty and variety of cell lines have improved dramatically with refined cell monolayers commercially available.4 Key examples of cell cultures still commonly used in many clinical laboratories include the primary rhesus monkey kidney cells (RhMK), human lung fi broblasts (MRC45), human foreski n fibroblasts (HFF), human lung carci noma cells (A549), and others.
Inoculati ng a broad range of cell cultures with a clinical specimen provides multiple advantages. For example, it allows the isolation of a wide variety of viruses, which include adenovirus, CMV, RSV, respiratory viruses such as in fluenza A & B, parainfluenza viruses types I to 3, VZV, as well as the Ebola virus, severe acute respiratory coronavirus (SARS-CoV), and human metapneumovirus (hMPV). The main drawbacks of cell c ultu re are the lengthy incubation period and hence the long turnaround time (TAT) and the technical expertise required to recognize CPE in the cell culture monolayers microscopically.
The technological advancement of shell vials and staining with indirect or direct ftuorescent-antibody assay (IFA or DFA) dramatically shortens the time to positivity from weeks to less than 48 hours by staining for early antigens of viral in fec tion. Shortly after their successful demonstration in CMV isolation,M the shell vial/DFA assays have been developed for use in the detection of other viruses including HSV,1 influenza vi rus,S respiratory vi ruses,9 enterovirus, 10 adenovirus,1O and VZV." Further refi nements of the DFA assays allow the screening of seven different respiratory viruses (adenovirus; influenza viruses A and B; parainfluenza viruses types 1,2, and 3; and RSV) by stai ning the monolayer from the R4mix shell vial after 48 hours of incubation with a sensitiv ity of 81 %. t2 Some HSV kits allow the screen ing and typing of HSV after 24 hours of inoculation in an MRC-5 cell culture with a sensit ivity of 93% and speci fi ci ty of95%. The VZV early antigen detection kit allows the detection of VZV directly from a fresh skin lesion specimen with a sensitivi ty of 100%, compared to 23% from cell culture.13
Nucleic acid amplification techniques
Nucleic acid amplification techniques (NAATs) for clinical virology have seen rapid development in the past decade. Owing to their low specimen quantity requirement, superior sensi tivity and specificity, and dramatically faster turnaround time, NAATs are currently accepted as the gold standard for clini cal virology.1 4-16 Viruses that do not proliferate in conventional cell culture but cause illnesses with great morbidity and mortality (HJV, HCV, HBV, parvovirus B4l9, HHV 6-8, EBV, HPV, and BK virus) can now be detected with cl in ically meaningful results.
The core technology ofNAATs is the thermostable polymerase- based target amplification process that synthesizes several copies of target nucleic acid. The amplicons are detected by two oligonucleotide primers that bind to complementary sequences. The end result is the production of millions of copies of the targeted sequence. The essential components in a standard single target PCR contain target DNA, two oligonucleotide primers, a DNA polymerase, deoxyribonucleotide triphosphates (dNTPs), MgC12, KCl, and Tris-HCI buffer. The reaction mixture is heated and cooled during several cycles in a programmable thermal cycler, and after n cycles the target sequence can be amplified 2"-fold. Upon completion of the assay, the amplificat ion products can be evaluated using various tech niques such as agarose gel analysis and colorimetric detection.17
In real-time PCR, the target amplification and detection steps occur simultaneously. The PCR product is detected by using fluorescent dyes that preferentially bind to double-stranded DNA. Special thermal cyclers that can monitor the fluorescence emission from the sample are required. The computer software supporting the thermal cycler monitors the data at every cycle and generates a quantitative amplification plot for each reaction.0 Real-time PCR decreases Ihe time required to "visualize" nucleic acid amplification products because there are no post-PCR processing steps.
The main advantages of real-ti me PCR include decreased frequency of contaminaLion and quantitation of the original viral target. One major application of the realLime PCR technology is viral load assays to quantitatively assess the amount of vims in a clinical specimen. HTV. HBV. and HCV are the three most conmion blood-borne pathogens, causing chronic infections to more than 200 million people worldwide.' Findings from the studies of HIV~9 HBV'° and HCVZI have shown that monitoring viremia is a reliable predictor for prophylax is or assessment of treatment outcome for these diseases.
It is estimated that acute respiratory disease is responsibte for al least 75% of all acute morbid ities in developed countries and that 50% uf the infections are caused by respiratory viruses?2 With an average of >90% in sensitivity and specificity and turnaround time of no more than six hours, NAATs-based assays arc considcred the gold standard fur rapid and accurate dcteeLion of respiratory viruses, compared to shell vial and DFA-hased assays (Table 1). Despite the fact that most respiratory virusesdo grow in conventional cell culture, they tend to grow very slowly and/or do not exhibit prominent CPE. Since the majority of respiratory viral infcctions require the administration of antiviral therapy within the tirst 48 hours of onset of symptonis to be clinically effective, cell culture is not an optimal diagnostic algorithm.
Respiratory viruses account for a high percentage of both pediatric and adult upper respiratory tract infections. In many immune-compromised patient populations, respiratory virus infection shows a high rate of progression to pneumonia and can exhibit increased mortality.23 Current estimates show that there are at least 26 known respiratory viruses that can cause upper and lower viral respiratory tract infections, and ongoing research is rapidly revealing additional clinically relevant viruses. Running single target PCR assays for all 26 viruses is too expensive and time-consuming for clinical diagnosisY Multiplex PCR assays allow for the quantitative detection of multiple nucleic acid targets by assaying with specific probes to different viral targets in a single PCR reaction. These assays are called Respi ratory Viral Panels (RVPs). Clinically, an RVP is also able to recognize viral co-infections, though the relevance of these co-infections is still a matter of debate. 25·29 A cost analysis in 200930 showed that a hospital system could save up to
There are three
A second platform utilizes multiplex RT-PCR followed by electrocliemical detection of bybridized capture probes on gold-plated electrodes and recognizes 14 different viral targets. This assay also offers a high-throughput platform, but requires specimen nucleic acid extraction and post-amplification handling and takes four boors. it showed a 95.4% positive agreement with single target PCR assays.33
A third assay is a fully integrated system for 17 viruses that includes nucleic acid cxtraction and ncstcd RT-PCR followed by niultiplex-PCR and detection by melt curve analysis. There is no postamplification handling. hot the assay is low-throughput. Only one sample can be analyzed per run and each run takes one hour. This assay showed a combined sensitivity greater than 90% for tested viruses compared to single target PCR.34,35
It is clear that multiplex PCR assays serve as a cost-effective and sensitive diagnostic method for respiratory viruses. The available assay systems can meet the clinical testing needs for most microbiology labs, but the perfect system would be rapid and high-throughput, with very little post amplification handling.
Genotypic analysis on the viral genome of certain viruses can provide clinically useful data to predi ct response to antiviral drug treatment andlor epidemiologic compari son. A combination of PCR and nucl eic acid sequencing is used in genotyping. Chronic hepatitis C virus (HCV) infection is th e most common blood-borne infection in
The current recommendations for chronic HCV infection include interferon and ribavirin38; however, various genotypes respond differently to the therapy. In general Un like genotypes 2 and 3 genotypes I and 4 respond poorly to the therapy.39 Two highly conserved regions on the HCV's ssRNA genome have been exploited for genotyping by various commercial assays using direct sequence analysis. One nf these assays is an amplificationand sequencing-based of the 5' noncoding region, and another entails an amplification followed by reverse hybridization process using 19 genotype-specific oligonocleotide probes located in the 5'NC region. Both assays detect genotypes 1 through 6 in the 5-UTR. Evaluations on these two assays indicated that sensitivity (variable, 730-4100 lU/mi, genotypedependent) and specificity (100%) to be comparable at the genotype level.4042 However, both assays have limitations in detecting certain genotypes (for example, genotype 6) as well as mixed infections, and neither is recommended for subtyping of HCV.4243 A recently
Drug resistance among circulating HIV- I strains is the main reason for antiretroviral treatment (ART) failure. In financially established countries, the HJV-l genotyping resistance test is considered as a test of care for flY- I pretreatment resistance testing as well as for monitoring level of ART resistance. There are two
Timely and accurate laboratory diagnosis of viral infec tions plays a pivotal role in reducing global viral disease burden. Molecular assays represent significant improvements in clinical viral test ing with respect to sensitivity, specificity, speed, simplic ity, and cost. Real-time PCR, genotyping. and multiplex assays have changed the way clinicians are able to t.reat both chronic and acute viral illness.
To ealn CEUs, see test on page 14 01 online at www.m/o-ori/ine.com underthe CE Tests tab.
Upon completion of th is article, the reader will be able to:
1. Describe the princ iples of conventional cell culture and molecular diagnostic methods for human vira l pathogens.
2. list the advantages and limitations of conventional versus molecular diagnostic assays.
3. Describe the technique and advantage of genotyping vi ral targets.
4. Compare multiplex PCR to single target PCR.
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4. Hsiung GO. Diagnostic virology: from animals to automation. Yale J Bioi Med. SepOct 1984;57(5):727-733.
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25. Brand HK. de Groot R. Galama JM. et al. Infection with multiple viruses is not associated with increased disease severity in children with bronchiolitis. Pediatr Pulmonol.
26. Rakes GP, Arruda E, Ingram JM, et al. Rhinovirus and respiratory syncytial virus in wheezing children requiring emergency care. IgE and eosinophil analyses. Am J Respir Crit Care Med.
27. Ja rtti T. Lee WM, Pappas T. Evans M, Lemanske RF, Jr., Gem J E. Serial viral infections in infants with recurrent respira tory innesses. fur Respir J.
28. Franl A, Adams 0, Willems R, et al. Correlation of viral load of respiratory pathogens and co-infections with disease severity in children hospitalized for lower respiratory tract infection. J elin Virol.
29. Cilia G, Onate E, Perez-Vaf1a EG. Montes M, Vicente D, Perez-Trallero E. Viruses in community-acquired pneumonia in children aged less than 3 years old: High rate of viral coinfection. J Med Viral.
30. Mahony JB, Blackhouse G, Babwah J, et al. Cost analysis of mllrtiplex PCR testing for diagnosing respiratory virus infections. J Clin Microbial.
31. Reddington K, Tuite N,
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33. Babady NE. Mead P, Stiles J. et aL Comparison of the
34. Porin MA, Blaschke AJ. Byington CL, et aL FilmArray, an automated nested multiplex PCR system for multi-pathogen detection: development and application to respiratory tract infection. PLuS One. 2011;6(10):e26047.
35. Rand KH, Rampersaud H, Houck HJ. Comparison of two multiplex methods for detection of respi ratory viruses: FilmArray RP and xTAG RVP. J Clin Microbial.
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Omai B. Garner, PhD, D(ABMM), is an Assistant Clinical Professor in the
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