MYXOVIRUS INFECTIONS OF

RESPIRATORY TRACT:
INFLUENZA, PARAINFLUENZA,
MUMPS, RESPIRATORY SYNCYTIAL
VIRUS
AND OTHERS
COMPETENCY COVERED MI 6.1, 6.2,
6.3
 Properties Orthomyxoviridae
INTRODUCTION & CLASSIFICATION-
Paramyxoviridae
Size 80-120nm- Smaller 100-300 nm- Larger
•Shape
Group of envelopedSpherical;
viruses that bind to mucin receptors on the surface of RBCs
Pleomorphic;
Rarely filamentous
•Nucleic
(myxoacid
in Greek meaning ‘mucin’).
Negative sense ssRNA, Negative sense ssRNA
Segmented
• Mucin receptors - Clumping ofRNA genome
RBCs Un-segmented-
together to cause Single piece of
hemagglutination.
eight pieces genome
•Genetic Seen
Myxoviruses are divided into two families—(1) NotOrthomyxoviridae
seen and (2)
recombination
Paramyxoviridae
Antigenic variation Liable to Antigenic variation Not seen
Site for RNA Nucleus Cytoplasm
Replication
Important human Influenza virus-cause upper Parainfluenza virus
pathogens respiratory tract infections Mumps virus
(URTIs), rarely can cause Measles virus
pneumonia Respiratory syncytial virus
Metapneumovirus
 MORPHOLOGY- INFLUENZA
VIRUS
▰Spherical and 80–120 nm in size
▰Helical nucleocapsid(9nm),surrounded
by an envelope
▰Viral RNA -multiple segments of – sense
SS RNA. Each segment codes for a
specific viral protein having a specific
function.
oInfluenza A & B -8 segments of RNA
oInfluenza C - 7segments of RNA. The
segment coding for neuraminidase is
absent.
oSite of replication: RNA replication
occurs in nucleus
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 MORPHOLOGY (CONT..)
▰Viral proteins: Contains 8 structural proteins
(PB1, PB2, PA, NP, HA, NA, M1 and M2) and 2
non-structural proteins (NS1 and NS2)
▰Envelope: Lipid envelope into which two types
of glycoproteins are inserted.
Hemagglutinin (HA)
Neuraminidase (NA)
oLipid part is derived from the host cell
membrane.
oProteins or the peplomers are virus coded,10nm
long glycoproteins that are inserted into the lipid
envelope.
▰Based on RNP and M proteins, - divided into
four genera: A, B and C and D
4
 MORPHOLOGY - TWO PEPLOMERS ARE
PRESENT-
Hemagglutinin (HA) • Neuraminidase (NA) peplomer
•Triangular-shaped peplomer - binds to •Mushroom shaped – sialidase enzyme - degrades
mucin or sialic acid receptors on the the sialic acid receptors on the host cells -
respiratory epithelial cells – facilitating facilitates release of virus particles from infected
viral entry
cell surfaces during the budding process
•sialic acid receptors on RBCs, resulting
in clumping of RBCs to cause •Sialidase enzyme that degrades the sialic acid
hemagglutination. receptors on RBCs; thus helps in-Displaces HA from
RBCs resulting in reversal of hemagglutination
called elution.
oNA helps the virus to pass through the mucin
layer in the respiratory tract to reach the target
epithelial cells. 5
SUBTYPES & NOMENCLATURE
▰Influenza viruses consist of 4 genera- Influenza A, B, C and D
▰Subtypes- Based on HA and NA antigens,
Influenza A has - 18 H subtypes (H1 to H18) and 11 N subtypes (N1-N11).
Influenza B and C viruses - have subtypes
Influenza B –exclusive to human
Influenza C – mild respiratory illness, not associated with epidemics
Influenza D virus - infects cattle and are not pathogenic to humans.

Standard nomenclature system:

Influenza Type/ host (indicated only for non-human origin)/ geographic
origin/strain number/year of isolation/(HA NA subtype).
▰Examples:
Human strain- Influenza A/Hong Kong/03/1968(H3N2)
Nonhuman strain- Influenza A/swine/Iowa/15/1930(H1N1) 6
 ANTIGENIC VARIATION
Antigenic variation is the unique property of Influenza viruses, which is due to the result of
antigenic changes occurring in HA and NA peplomers.
• Antigenic drift
• Minor gradual change - due to point Antigenic shift
mutations in the HA/NA gene-accumulate • Abrupt, major drastic, discontinuous
over time- selection pressure variation in the sequence of a viral surface
• Results in alteration of amino acid sequence protein (HA/NA)
of the antigenic sites on HA/NA, such that • Genetic recombination/re-assortment
virus can escape recognition by the host's between genomes of two or more influenza
immune system. viruses infecting the same host cells,
• New variant sustain two or more mutations resulting in a new virus strain, unrelated
to become epidemiologically significant. antigenically to the predecessor strains.
• Seen in both Influenza virus type-A & B • Occurs only in Influenza A virus
• Results in outbreaks and minor periodic • Pandemics and major epidemics- e.g. H1N1
epidemics pandemics of 2009.
• Occurs more frequently every 2-3 years. • Occurs less frequently every 10-20 years.
7
 PATHOGENESIS
Transmission: (i) inhalation of respiratory droplets, (ii) via contact with surfaces or fomites.
Target cell entry: Viral HA attaches to specific sialic acid receptors on the respiratory mucosa
Multiply locally- replicates in mucus membranes
Spread: To the lower respiratory tract or spills over bloodstream –extrapulmonary sites
Local damage: Cellular destruction and desquamation of superficial mucosa of the
respiratory tract – secondary bacterial infection.
Humoral immunity - predominant
Type and subtype-specific and long lasting.
Antibodies against HA and NA – protective
Antibodies to HA - prevent initiation of infection by inhibiting viral entry
Antibodies to NA decrease the severity of the disease and prevent the transmission of
virus to contacts
All the three types of influenza viruses (i.e. A,B &C) are antigenically unrelated
and there is no cross-protection.
 Immunity incomplete - reinfection with the same virus can occur.
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 CLINICAL MANIFESTATIONS
Incubation period - 18-72 hours
Uncomplicated Influenza (Flu syndrome):
 Asymptomatic or minor upper respiratory symptoms - chills, headache, and dry
cough, followed by high grade fever, myalgia and anorexia.
 Self-limiting condition.
 Pneumonia:
 Secondary bacterial pneumonia - most common
 Common agents are staphylococci, pneumococci and Haemophilus influenzae.
 Primary Influenza pneumonia - rare - leads to more severe complication.
Other pulmonary complications:
 Worsening of COPD
 Exacerbation of chronic bronchitis and asthma.
 Reye's syndrome
 Extrapulmonary complications
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 EPIDEMIOLOGY
▰Incidence: 3–5 million cases of severe
Years illness Subtype
and 3-6 lakhs of Extent of outbreak
deaths occur worldwide.
1889–1890 H2N8 Severe pandemic
▰Seasonality: Common during winters. Most common seasonal flu
1900–1903 H3N8 Moderate epidemic
- varies from season to season from place to place (e.g. H3N2 in
1918–1919 H1N1a (HswN1) (Spanish flu) Severe pandemic
Pondicherry in 2018)
▰Epidemiological pattern: Depends upon the nature
1933–1935 of antigenic
H1N1a (H0N1) Mild epidemic
variation that occurs in the influenza types. H1N1
1946–1947 Mild epidemic
▰Age: Child of age < 2 years or age ≥ 65 years H2N2 (Asian flu)
1957–1958 Severe pandemic
▰Chronic diseases: Chronic pulmonary, cardiac, renal,
1968–1969 H3N2 (Hong Kong flu) Moderate pandemic
hematologic, metabolic, neurological, and neurodevelopmental
disorders 1977–1978b H1N1 (Russian flu) Mild pandemic
▰Immunosuppression (including 2009–2010
HIV/AIDS, useH1N1 of long
pdm09term Pandemic
corticosteroids, post-transplant patients), diabetes mellitus.
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 SIALIC ACID RECEPTORS
▰Sialic acid receptors - found on the host cell surfaces are specific for HA antigens
▰α 2-6 sialic acid receptors:
Specific for human influenza strains and are found abundantly on human upper
respiratory tract epithelium but not on lower upper respiratory tract.
▰α 2-3 sialic acid receptors:
Specific for avian influenza strains
Found abundantly on bird’s intestinal epithelium.
In humans, they are present in very few numbers on lower upper respiratory
tract.
▰Why pigs are the most common mixing vessels?
Both α 2-3 &α 2-6 sialic acid receptors - on the respiratory epithelium of pigs and
swine flu strains - specificity for both the receptor types.
Pigs can be infected simultaneously by human, swine and avian strains - mixing
vessel.
Reassortment - takes place inside the same swine cell. 11
 AVIAN FLU
Birds - primary reservoir
All influenza subtypes (18H types and 11N types) found in birds
and some of the subtypes - transmitted to mammals (e.g.; H1, H2,
H3, H5, H7 & 9 to humans; H1 and H3 to swine; and H3 and H7 to
horses).
AF strains- highly virulent - possess PB1F2 protein - targets host
mitochondria - apoptosis.
Bird flu strains - highly lethal to chickens and turkeys (but avirulent
to ducks) -major cause of economic loss in poultry - mortality in
chickens.
Avian flu multiplies in intestinal tracts of birds - shed through feces
into water.
Influenza viruses do not undergo antigenic variation in birds -
short life span of birds. 12
 AVIAN FLU INFECTION IN
▰all
HUMANS
human pandemic strains - originated by re-assortment
between avian and human influenza viruses - mixing in pigs.
▰A/H5N1 - most common avian flu strain - endemic (world) for the
past 15 years.
▰Origin - first reported from Hong Kong in 1997 - spread to various
countries including India within few years.
▰Less morbidity and more mortality
▰Clinical feature - H5N1 avian flu strains - pneumonia and extra-
pulmonary manifestations - diarrhoea and CNS involvement.
▰Other avian flu strains that can cause human infections are-
A/H7N7(Netherlands)
A/H9N2 ( Hong Kong)
A/H7N9 (caused an outbreak in China, 2013)
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EPIDEMIOLOGICAL SURVEILLANCE FOR
INFLUENZA
▰Influenza surveillance has been conducted globally
through WHO's Global Influenza Surveillance and
Response System (GISRS).
▰Monitors the evolution of influenza viruses and provides
recommendations in areas including laboratory
diagnostics, vaccines and treatment.
▰Serves as a global alert mechanism for the emergence of
influenza viruses with pandemic potential.
Categorization of Seasonal Influenza A/H1N1
Guideline on categorization of Seasonal Influenza A/H1N1 cases during
screening for home isolation, testing, treatment and hospitalization
(issued by Ministry of Health & Family Welfare, Govt. of India)
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CATEGORIZATION OF SEASONAL INFLUENZA
A/H1N1
Categor Definition Laboratory testing for H1N1, treatment and
y isolation
Category Influenza like illness (ILI) Laboratory testing for H1N1—not required
A Mild fever plus cough/sore throat Treatment—only symptomatic, antiviral drugs
with or without body ache, not required
headache, diarrhea and vomiting Isolation—confine patients at home, avoid contact
with
public and high-risk members in the family
Category Category A plus any one: Laboratory testing for H1N1—not required
B i. High-grade fever and severe Treatment—symptomatic treatment required.
sore throat or Antiviral drug
Categor ii.
Severe acute respiratory
Presence of any of the risk syndrome Laboratory
(oseltamivir) testing for H1N1—
may be required
yC (SARI)
factors requiredpatients at home, avoid contact
Isolation—confine
Category B plus any one: with Immediate hospitalization—
i. Breathlessness, chest pain, fall in and required
public high-risk members in the family
blood pressure, sputum mixed with blood, Treatment—start antiviral drug
bluish discoloration of nails (oseltamivir) immediatelywithout
ii. Children with influenza-like illness who waiting for laboratory result
had a severe disease as manifested by the Isolation—all components of droplet 15
red flag signs (inability to feed well, precaution to be
 LABORATORY DIAGNOSIS OF
INFLUENZA
▰Specimen: nasopharyngeal swab, kept at 4°C
▰Isolation of virus:
Inoculation in embryonated eggs and primary monkey kidney cell
lines
Growth is detected by hemadsorption, hemagglutination test.
▰Viral antigens detection by direct IF test
▰Molecular methods: Simultaneously detects - A/H1N1, A/H3N2,
Influenza B
RT PCR: detects viral RNA
Real time-RT PCR: quantifies viral RNA
▰Antibody detection by hemagglutination inhibition test,
neutralization test and ELISA.
▰Avian flu strains can be identified by real time reverse transcriptase
16
PCR detecting specific HA and NA genes.
 INFLUENZA A (H1N1) PDM09
▰Most recent pandemic of influenza, emerged in California in March 2009.
▰Rapidly spread to the entire world including India over the next few months.
▰WHO declared the pandemic on 11th June 2009.
▰Origin: H1N1 2009 flu originated by genetic reassortment of four strains
(1 human strain + 2 swine strains + 1 avian strain) and the mixing had occurred in pigs.
▰Transmission: From human to human - rapid spread
▰Less virulent (as it lacks the PB1 F2 protein)
▰More morbidity but less mortality.
▰Uncomplicated influenza: Mild upper respiratory tract illness and diarrhea
▰Complicated/severe influenza - high-risk groups - secondary bacterial pneumonia,
dehydration, CNS involvement, and multi-organ failure. 17
TREATMENT/CHEMOPROPHYLAXIS OF INFLUENZA
o Specific antiviral therapy - available for influenza virus infection.
o Start therapy within 48 hours of onset of symptoms for influenza.
o Neuraminidase inhibitors (zanamivir, oseltamivir, and peramivir) - for influenza A
and influenza B infections - drug of choice for A/H1N1 2009 flu, A/H5N1 avian flu
and influenza-B
Oseltamivir (Tamiflu 75 mg tablets)
Zanamivir (10 mg, inhalational form).
For treatment—given twice a day for 5 days
For chemoprophylaxis—given once daily. Duration depends on the clinical setting;
usually 7 days.
o Amantadine /Rimantidine- for Influenzae A only
o Prevents penetration and uncoating of the virus
STRAINS OF A/H1N1 2009 FLU AND A/H5N1 AVIAN FLU AND INFLUENZA B VIRUS
HAVE DEVELOPED RESISTANCE. 18
 GENERAL PREVENTIVE
MEASURES
▰Isolation room: Patients should be kept at isolation room or cohorting to be followed.
▰Strict Respiratory and Hand Hygiene
Respiratory hygiene and cough etiquette
Use of gloves and mask for staff and patient
Work restriction: isolation for at least 24 hours after they are free of fever (100° F)
without the use of fever-reducing medications.(CDC)
Vaccine strains:
▰WHO recommendations- influenza vaccines are prepared every year.
▰Strains to be included - isolated in the previous influenza seasons and strains that are
anticipated to circulate in the upcoming season.
▰Formulations: Most vaccines contain 2 type A +one or two type B influenza strains.
Trivalent form: most common available; of 3 strains: A/H1N1, A/H3N2 and influenza B
strain.
Quadrivalent form: of four strains: A/H1N1, A/H3N2 and two lineages of influenza B
strain 19
VACCINE PROPHYLAXIS
Live attenuated
Recently approved only for healthy o Inactivated vaccine
individuals o Whole killed vaccine prepared in chick
Prepared from temperature embryo
sensitive mutants that can replicate o Recommended for persons at increased
in cooler nasal passages (33C) but risk for influenzae related complications
not in warm lower resp tract and their contacts
Given by nasal spray –provide o Given by IM
mucosal humoral and cell mediated o Has short lived protective effect – given
immunity in autumn for protection to be high in
December and January
o Given every year to cover all strains
which change due to shift or drift
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• Von Magnus Phenomenon
• Abnormal replicative cycles
• A proportion of daughter virions that are produced are not infective
• This is due to defective assembly-defective interfering particles
• Such incomplete virions are seen in large proportions when cells are infected with
a high dose of influenza virus. The virus yield will have high hemagglutinin titre
but low infectivity.
• first observed by Preben von Magnus in influenza viruses, after the serial passage
of undiluted allantoic fluid in eggs.
• This is called Von Magnus phenomenon

21
 PARAMYXOVIRIDAE INFECTIONS
Group of viruses are transmitted via the respiratory tract
Cause localized respiratory infection in children
Large (100–300 nm) in size and more pleomorphic
Linear non-segmented RNA
Contain six structural proteins (compared to 8 in influenza virus).
HA and NA antigens:
Virus Antigens Disease
Parainfluenza virus: both HA and NA antigens (~to Mainly cause laryngotracheobronchitis
influenza virus)
Mumps virus both HA and NA antigens (similar Causes parotitis in children
to influenza virus)
Measles virus virus possess HA, but lack NA Cause exanthematous lesions
: Respiratory syncytial virus lack both HA and NA Causes acute bronchiolitis in infants
Metapneumovirus: lack both HA and NA Causes URTIs
Zoonotic paramyxoviruses - Nipah and Hendra viruses: Encephalitis
23
 PARAINFLUENZA
Transmission is by respiratory route
The incubation period :5–6 days.
Mild common cold syndrome such as rhinitis and pharyngitis
Croup (laryngotracheobronchitis),Pneumonia or bronchiolitis -Otitis media - most
common complication
Reinfections are common, but less severe: no cross protection between the serotypes.
Lab Diagnosis :
1.Antigen detection - Viral antigens in the infected exfoliated epithelial cells of the
nasopharynx –immunofluorescence test by using specific monoclonal antibodies.
2.Viral isolation: Primary monkey kidney cells - most sensitive,
3. Serum antibodies - measured by neutralization test, hemagglutination inhibition test
or ELISA. Presence of IgM or fourfold rise of IgG titer - active infection.
Reverse transcriptase PCR assays are highly specific and sensitive
BioFire FilmArray respiratory panel (RP) tests simultaneously 20 respiratory pathogens,
including parainfluenza serotypes.
24
 RESPIRATORY SYNCYTIAL VIRUS
INFECTION
Morph: Single stranded non-segmented RNA virus
11 proteins – 4 associated with lipid envelope-
matrix M SH protein and two glycosylated
proteins-Fusion F and G
G protein helps in attachment to cell surface
F protein –help in fusion of virus to host cell also
to cause cell to cell fusion –syncytial formation
Two subgroups A & B (based on G protein) and
many genotypes
Tropism towards epithelial respiratory cells hence:
Seasonality: Annual epidemics - occur following rainfall, in winter and spring and last up to 5
months - Infection is not seen in summer
Age: Infants (6 weeks - 6 months of age) - affected, with peak incidence at 2 months
Major respiratory pathogen of young children-(bronchiolitis and pneumonia) 25
 RESPIRATORY SYNCYTIAL VIRUS INFECTION
•Transmission - i)direct contact (contaminated fingers or
fomites and by self-inoculation of the conjunctiva or anterior
nares) or ii) by large droplets inhalation
•Spread-
•RSV replicates locally in the epithelial cells of the
nasopharynx
•- spread to the lower respiratory tract - bronchiolitis and
pneumonia.
•Incubation period is about 3–5 days.
•Chest X ray - peribronchial thickening, diffuse interstitial
infiltration and occasionally lobar consolidation
•Severe in premature infants and underlying congenital
cardiac disease, bronchopulmonary dysplasia, nephrotic
syndrome, or immunosuppression
26
 PATHOGENESIS AND MANAGEMENT

•Adults - Influenza-like upper respiratory symptoms - common cold, running nose, sore
throat, and cough
•Recurrent infection - common in both children and adults, but is much milder (common
cold).
•Diagnosis- Clinical
•Direct immunofluorescence test detecting antigens on exfoliated cells or
• ELISA detecting antigens in nasopharyngeal secretions
•Viral culture: HeLa and HEp-2 - most sensitive cell lines for RSV isolation.
•A characteristic cytopathic effect, syncytium formation (multinucleated giant cell)—
appears after 10 days THE INSET DEMONSTRATES A TYPICAL GIANT CELL WITH A ROUND,
PINK INTRACYTOPLASMIC INCLUSION.
•Recent: PCR, BioFire FilmArray respiratory panel (RP)
•Treatment- Supportive- supplemental O2( desaturation) fluid replacement therapy
•Ribavirin limited use due to toxicity-Administered as aerosols for 3–6 days. Oral ribavirin
27
-
not recommended.
 HUMAN METAPNEUMOVIRUS
Cause both upper and lower respiratory tract illnesses.
Affect slightly older children
Second most common cause (next to RSV) of lower
respiratory infection in young children.
Also cause respiratory disease in adults with
underlying hematologic malignancies
Diagnosis: RT-PCR - amplify the RNA extracted from
respiratory specimens. Specific antigens in
nasopharyngeal secretions - detected by direct- IF test.

28
 ZOONOTIC PARAMYXOVIRUSES
•Nipah Virus
•Nonsegmented Neg strand SS RNA, 6 structural proteins (+ RNA
dependent RNA polymerase)+ 3 non structural proteins
•First outbreak of respiratory and neurological disease in pigs and
humans in Malaysia- spread to Singapore (276 encephalitis cases
with 106 fatalities)
•India -2001 outbreak
•PIGS- intermediate and amplifying host
•Consumption of date juice contaminated by bats
•Human to human transmission
•Incubation -10 days upto 4 weeks
•Fever headache myalgia chills/rigors respiratory S/S
•Neurological – drowsiness confusion may last upto 4 months
•Samples-Urine saliva,oropharyngeal secretions, CSF
•Hpath-Vasculitis in small arteries capillaries and venules in CNS 29

with syncytia formation, Spleen- depletion of white pulp

•
•Hendra Virus
•First recorded in Australia during
an outbreak- 1994- affected
horses and humans
•Natural hosts- fruit bats
(Pteropus)- may progress to
encephalitis
•Incubation- 9-16 days
•Severe flu-like S/S
•Diagnosis- ELISA , Real time PCR
–
•RNA detection in serum CSF or
throat swabs 30

•Treatment- RIbavirin