Viro tetso

Viruses associated with acute diarrhea
By
Tetso Ghislain Brice
Master of Science, Molecular and Cellular Biology
Ph.D student, Microbiology
University of Buea-Cameroon

Outline
2
Introduction
I- Acute diarrhoea
1- Definition and classification
2- Epidemiology
3- Manifestation
4- Symtomatic management, treatment and prevention
II- Virus associated with a acute diarrhea
1- Rotavirus
2- Adenovirus
3- Astrovirus
4- Calicivirus
Conclusion
References

3
Introduction
Diarrhoea is the emission of stools too frequent, too
abundant, of abnormal consistency (liquids or very
soft), and of weight more than 300 g/days.
Acute diarrhoea, is an increased frequency of
defecation (three or more times per day) lasting less
than 14 days, may be accompanied by nausea,
vomiting, abdominal cramping, clinically
significant systemic symptoms (Nathan et al.,
2004).

4
Introduction
On average, children below 3 years of age in
developing countries experience three episodes of
diarrhoea each year (WGO, 2012).
Infectious diarrhoea is a major public health
problem in children in developing countries.
In 2003 an estimated 1.87 million children below 5
years died from diarrhoea and 8 out of 10, these
deaths occur in the first 2 years of life (WHO,
2013).

5
Introduction
It is usually associated with a gastrointestinal
infection, which can be caused by various pathogens
such as:
- Bacteria (Shigella, Salmonella, E. coli,
Clostridium, etc.),
- Parasites (E. histologicahistolytic,
Cryptosporidium...) and
- Viral agents (Rotavirus, Adenovirus, Astrovirus,
Calicivirus, Novovirus...) (Huber-Gieske and
Bichard, 2013),
Acute diarrhea is transmitted mostly interhumanely
or by ingestion of contaminated water or food
(Arena, 2015).
Major cause of infectious acute diarrhoea; due to the
difficult treatment due to frequent mutations of the
viral genetic material.

7
I- Acute diarrhoea
1- Definition and classification
They are defined by the frequency, the consistency
of the stool ("diarrhea") and the duration of the
symptom
It’s occurs when there are at least three very soft to
liquid stools per day. (WHO, 2005).
It’s known as acute when it has been evolving for
less than 2 weeks (Huber-Gieske and Bichard, 2013)

8
I- Acute diarrhoea
It’s characterized by two major mechanisms:
- Invasive (penetration of germs into the intestinal
wall) and
- toxin (fixation of germs on the surface of the
digestive mucosa and production of a toxin,
resulting in hyper secretion of water and
electrolytes by the enterocyte) (WGO, 212).
Classification: of diarrhoea depends on these two
mechanisms: Invasive or inflammatory diarrhoea and
non-invasive or secretory.

9
I- Acute diarrhoea
- Invasive or inflammatory diarrhoea of bacterial
origin (Shigella, Salmonella, E. coli,
Clostridium...), rarely parasitic (E.
histolyticahistolytica).
They penetrate and multiply in the enterocytes
(parietal invasion) and cause mucosal lesions
manifested by frequent fevers, often frequent
evacuations, purulent and bloody mucus, associated
with violent pains, and usually to signs of irritation
of the rectal mucosa.Here, there is usually no dehydration.
(Aubry and Gaüzère, 2016)

- "hydric" or secretory diarrhea, non-invasive
(choleriform) diarrhea, viral causes (Rotavirus,
Norovirus), bacterial: (Vibriocholerae,
enterotoxigenic E. coli), infections with
Staphylococcus aureus or Bacillus cereus; and
parasites: (Cryptosporidium).
They are characterized by abundant rapid diarrhoea,
accompanied by vomiting but without abdominal pain
(Aubry and Gaüzère, 2016).
10
I- Acute diarrhoea
(Aubry and Gaüzère, 2016

2- Epidemiology
I- Acute diarrhoea
 Diarrhea=second largest cause of death of
children under 5 years, responsible for 1.5
million deaths worldwide every year (Kagning
et al., 2015).
11
In industrialized countries, the number of patients
who died of diarrhoea is relatively low.
 Today in the world, it is estimated that nearly 7
million children under 5 years die, most often in
the countries of the South,
 8 out of 10 of these deaths occur in the first 2
years of life (Aubry and Gaüzère, 2016).

3) Manifestations, clinical diagnosis and
complementary examinations
I- Acute diarrhoea
12
viruses proliferate within the mature enterocytes of
the small intestine villi, resulting in rapid
desquamation and accelerated replacement by
immature enterocytes incapable of properly
performing their absorption function (Hodges and
Gill, 2010).
Manifestations

Sign of diarrhea
Hyperthermia (temperature higher or equal to
38.5°C), dehydration, hypovolemia, confusion,
abundant vomiting, impossibility to ingest the
liquids, abdominal pain and muco-sanguinolentes
stools.
I- Acute diarrhoea
13
Clinical diagnosis
Clinical examination seeks signs of severity such as
dehydration, sepsis, septic shock, hemorrhage,
perforation, intestinal dilatation...

I- Acute diarrhoea
14
- Acute watery diarrhoea which lasts several
hours or days: the main danger is dehydration;
weight loss
Four clinical types of diarrhea can be
recognized (WGO, 2008)
- Acute bloody or disentery diarrhoea: mucosa,
sepsis and malnutrition, dehydration
- Persistent diarrhoea, which lasts 14 days or more:
the main danger is malnutrition and serious non-
intestinal infection; dehydration may also occur;

I- Acute diarrhoea
15
If the signs of severity are observed (dehydration,
chills, hyperthermia...), the prescription of
complementary examinations (blood tests,
microbiological analyzes of stools, Endoscopic
examinations...) is very important.
- Diarrhea with severe malnutrition (marasmus or
kwashiorkor): the main dangers are severe systemic
infection, dehydration, heart failure and vitamin
and mineral deficiency.

I- Acute diarrhoea
16
4) Symptomatic management, treatment and
prevention
Symptomatic management
Is the doctor's first measure
Dietary recommendations: hydration and diet
measures: an age-appropriate diet, a diet rich in
energy and micronutrients.
Oral Rehydratation Salts (ORS) with low [glu],
[salt], zinc
Use of addition, breatfedind, antibiotics to reduce
duration and severity of diarrheal episodes
(WHO and UNICEF, 2004)

Prevention
I- Acute diarrhoea
17
Key measures to prevent diarrhoea include (WHO,
2013):
 Access to safe drinking-water;
 use of improved sanitation;
 hand washing with soap;
 exclusive breastfeeding for the first six months of
life;
 good personal and food hygiene;

Treatment
I- Acute diarrhoea
18
Key measures to treat diarrhoea (WHO, 2013):
 Rehydration: with ORS solution ( it’s a mixture of
clean water, salt and sugar.
 Rehydration: with intravenous fluids in case of
severe dehydration or shock.
 Zinc supplements: reduce the duration of a
diarrhoea episode by 25% and are associated with
a 30% reduction in stool volume….

II- Viruses associated
with Acute diarrhoea

In both industrialized and developing countries,
viruses are the predominant cause of acute diarrhoea
(WGO, 2012 ).
II- Viruses associated with acute diarrhoea
Many viruses are found in the human gut
not all of them produce acute gastroenteritis.
Viral infections normally associated with
gastroenteritis are caused by rotaviruses (group A),
enteric adenoviruses (group F, types 40 and 41),
astroviruses and human caliciviruses
(Kagning et al., 2015 ; Dormitzer and Desselberger, 20

1- Rotavirus
21
II- Viruses associated with Acute
diarrhoea
Classification
Rotaviruses derive their names in 1973 from their
wheel-like aspects under the microscope (Singer et
al., 2010).
Family: Reoviridae
Genus: Rotavirus
(human and animal
viruses)
Figure 1: Classification of

22
1- Rotavirus
Sructure
Figure 2: Rotavirus
(ANSES, 2012 ; Singer et al.,
2010)
Diameter: 75nm
Double icosahedral
capsid
Double stranded DNA
11 segments
 Genome code of:
6 structural proteins
(VP1-VP4 and VP5 and
VP6)
6 antigenic group (A-G) Group A, B and C

23
1- Rotavirus
Epidemiology
- Most frequent etiologic agent of the acute
diarrheic disease in infants and young children
(Goffard, 2012).
- Annually responsible for more than 111 million
cases of infantile gastroenteritis and approximately
600,000 deaths (Mbuh et al., 2012).
- More than 85% of these deaths occur in
developing countries in Africa and Asia where
access to treatment is limited or even non-existent
(Liu et al., 2012).

24
1- Rotavirus
Epidemiology
- In the industrialized countries, the mortality
associated with them remains low.
- In Africa, rotavirus kills 232,000 children under 5
years each year, accounting for more than 50% of
the global rotavirus deaths (Tate et al., 2008).
- About 30% of all hospitalizations due to diarrhea
among children under 5 in Africa are caused by
rotavirus.

Epidemiology
25
1- Rotavirus
In Cameroon, In accordind to WHO (2008),
available data suggest that the Rotavirus kills 19.6%
of the under 5 years old
but the first study from Cameroon showed that of
the 890 diarrhea stools collected from children
under the age of 5 in Western Cameroon (1999 and
2000), rotaviruses were detected in 21.9% (Mbuh et
al., 2012 ; Mathew et al., 2003).

In Yaounde, Ngum et al. (2010) showed a rotavirus
prevalence of 32.8% in children with acute diarrhea
(total of 61 children presenting with acute
diarrhoea)
41.0% of children 0-12months
30.7% of children 13-24months (Ngum et al.,
2010).
Epidemiology
26
1- Rotavirus
In Northern Cameroon (Maroua and Bamenda),
Ngum et al. (2012) showed a prevalence of 44.6%
(in the urban) and 28.9% (in the rural) in stool
samples from 390 children below 5 years
presenting with

Mode of transmission
27
1- Rotavirus
It usually takes 24 to 72 hours for symptoms to
appear after a person has been in contact with the
rotavirus.
During the acute phase of the disease, patients can
 Man is the main reservoir of rotavirus
 Present in alls regions of the wold
 Transmission person to person spread,
 Ingestion of contaminated water or food
 Contact with contaminated surface
Oral-fecal route is the most common mode of
transmission
(ANSE, 2012)

Physiopathology
28
1- Rotavirus
The infective dose of rotaviruses is low (from 102
to 104 viruses. And target cells are the mature
enterocytes where they multiply (Lorrot et al.,
2005)
The actvation of the enteric nervous system and an
increase in intracellular calcium is the
responsability of Virus and its NSP4
This causes a succession of events leading to a
chlorine leak, a disorganization of the architecture
of the cell and finally its lysis (Hodges and Gill,

Physiopathology
29
1- Rotavirus
- In the first phase, the rotavirus adheres to the
intestinal epithelium (Singer et al., 2010). In 1-2
days, following the viral replication, the infection
spreads from the proximal area of the small bowel to
the ileum.
The main mechanism for producing the rotavirus
diarrhea is considered to be the decrease of the
sodium and water absorption, as a consequence of
intestinal lesions, and the replacement of the

- In the second phase, because of cell destruction,
the level of the disaccharides will decrease and this
will lead to carbohydrate malabsorption and
osmotic diarrhea. The villi damage is reversible and
the diarrhea continues until the villi regenerate
(Singer et al., 2010).
Physiopathology
30
1- Rotavirus

Diagnostic
31
1- Rotavirus
Biological diagnosis of rotavirus infections relies
on direct detection of the virus in the stool.
- Electron microscopy is not very sensitive and
difficult to implement.
- It has therefore been replaced by rapid and
effective immunological techniques
(agglutination tests on the slide of sensitize,
immunoenzymatic tests in tubes, microplates or

Direct or specific diagnosis is made using molecular
biology techniques :
- ELISA or immunochromatography (to search for
viral antigens),
- RT-PCR (to look for viral RNA (rare case) in the
stool (Singer et al., 2010 ; WHO, 2009).
Serology is of little interest because of the acute and
rapid nature of the infection. (ANSE, 2012)
Indirect diagnosis is irrelevant.
Diagnostic
32
1- Rotavirus

It is not cured by antibiotics or other medicines, but
by the addition of fluids and salts (oral rehydration
therapy).
Treatment and prevention
33
1- Rotavirus
Curative treatments consist of oral rehydration
(OR), zinc supplementation and antibiotic therapy.
Preventive treatments include promotion of
breastfeeding, zinc supplementation, WASH (Water,
Sanitation, Hygiene), and immunization campaigns
(Lorrot et al., 2005).

Vaccination is considered the most effective
preventive strategy against Rotavirus infections
(Muller, 2015).
34
1- Rotavirus
The first vaccine were RotaShield® but
withdrawn from the market, following cases of
acute intestinal invagination occurring within one
week after the first vaccine dose (Singer et al.,
2010)
To date, two effective vaccines, RotaTeq® and
RotaTix®, appear to be good candidates and are
currently available in worldwide for the prevention
of gastroenteritis due to rotavirus infection (CDC,

2- Adenovirus
diarrhoea
Classification
35
DNA virus, was first isolated in the 1950s (Gompf,
2016)
Family:Adenoviridae,
4 genera :
- Mastadenovirus (Human adenovirus), infecting a
mammals including humans, dogs, horses, sheep and
cattle
- Aviadenovirus, infecting birds
- Atadenovirus (reptiles, mammals, lizards,
chickens,…

Sructure
2- Adenovirus
36
Figure 3: Structure of Mastadenovirus
Diameter: 70 and 80 nm
Non-enveloped icosahedral
Linear double-stranded
DNA
Capsid size: 35 bp
240 hexons and 12 pentons
51 distinct serotypes
40 and 41 (gastroentheris)
6 different subgroups (A-
F)(Dormitzer and Desselberger, 2012; Mogtomo et al.,

2- Adenovirus
Epidemiology
Are responsible for 10 to 15% of infantile
gastroenteritis
Third leading cause of childhood gastroenteritis
after rotaviruses and noroviruses (ASP, 2010 ;
Venard et al., 2001). It is an endemic infections
Serotypes 40 and 41 are spread around the world;
are responsible for 6 to 8% of infantile diarrhea in
the world
The other spread durin autumn, winter, early spring
37

2- Adenovirus
Epidemiology
38
In Cameroon, some research has done to shown
prevalence of adenovirus:
In Douala in 2005, Mogtomo et al. (2008) shown that
enteric adenovirus was detected in 28/65 cases tested
(43.1%), the prevalence was 44.7% (for infants not more
than 5 year old), 30.8% (6-10 year age group) and 50.0%
(11-15 year age group). In Yaounde, Ngum et al. (2010)
showed 7.7% prevalence in the age group 0-12 months and
one case of adenovirus in the age group 37-48 months
(Sample =61 children presenting with acute diarrhoea)
In Ngaoundere, Adenovirus antigen was detected in 26.4%
Kagning et al. (2015); but, their sample size was very low
(56 children)

2- Adenovirus
39
Transmission or contagion for serotypes 40 and 41
occurs during the acute phase, As for the other
serotypes, the period of contagiousness often
precedes the signs.
Transmission may be by:
- Direct contact (hand-to-hand, oro-fecal, main for
serotypes 40 and 41) or
- Indirectly via handkerchiefs, utensils, objects
freshly contaminated. Epidemics have been
observed among swimming pool habitues

Physiopathology
2- Adenovirus
Adenovirus infections affect the respiratory and
intestinal epithelia with local replication of the virus
and its excretion by air or fecal transmission.
Attachmes on
the epithelium
cells
Invades the cell and
develop in spite of the
means of defense of the
organism
Infection can
spread gradually
and gain the
respiration tree
(Venard et al., 2001)

Diagnosis
2- Adenovirus
The biological diagnosis of adenovirus diarrhoea can
be carried out by:
- ELISA (detection of antigen), It is fast, sensitive
and inexpensive in contrast to the expensive
- RT-PCR technique, not very sensitive.
- Viral cultures and electron microscopy can be
performed routinely on specimens.
- Serological tests are also performed but rarely
performed routinely.
- The search for viral genomes is carried out by
laboratories specializing in epidemiological
studies but not routinely (Ripault, 2007).

2- Adenovirus
Several molecules have been used in the treatment
of adenovirus infections.
Ribavirin, few side effects have been reported,
apart from haemolytic anemia, mostly
asymptomatic and completely reversible upon
discontinuation of treatment. (Venard et al., 2001),
Ganciclovir is little used,
Cidofovir (HPMPC), active in vitro on
adenoviruses, appears to be of interest from the
results of early studies (Ripault, 2007).

3- Astrovirus
diarrhoea
43
Classification and structure
Described for the first time in children in 1975 by
Madeley and Cosgrove, astroviruses belong to the
family Astroviridae
Figure 4: Observation of Human Atrovirus in electronic microsc

3- Astrovirus
Diameter: 28 and 30
nm
Icosahedral symmetry
Single-stranded RNA
Capsid size: 76.8 bp
8 distinct serotypes
HumanAstrovirus:
(HAstV1-8)
Have been
distinguished, currently
recognized and these
correlate well with
major differences in
genome

Epidemiology
45
All age groups are likely to be infected, however,
children, the elderly and immunocompromised are
the most at risk.
Astrovirus 1 serotype is the most widely predominant
(approximately 65% of the cases) (Pothier and Kohli,
Astroviruses occur worldwide accounting for about
2%-16% of diarrhea in hospitalized children and
5%-17% of diarrhea in the community (Aminu et
al., 2008).They are the third cause of viral gastroenteritis
after rotaviruses and calciviruses.
3- Astrovirus

Epidemiology
46
In Cameroon, to the best of our knoledge,
paradoxically we hasn’t available data related to
epidemiology of Astrovirus diarrhea.
It may be direct or indirect.
The direct route is considered the main route and be
carried out by water, food and oro-fecal routes.
It can be carried out by water, food and oro-fecal
routes.
3- Astrovirus

47
Astroviruses can also be transmitted from person to
person, from animal to human and through aerosols,
through contaminated or contact foods (Gamsonre,
2012).
The incubation period lasts 3 to 4 days. They infect
human (mature mucosal cells of the small intestine
villi, which will be replaced by cuboidal epithelial
cells ), birds, cats, dogs, pigs, sheep. Symptoms last
between 3 to 5 days.
Astrovirus infections are not necessarily severe.
3- Astrovirus

Physiopathology
48
HAstVs have a very varied localization, digestive
tract.
J
Infect mature enterocytes and subepithelial
macrophages of the small intestine causing partial
or more rarely total atrophy of the villi,
malabsorption, rejection of water and nutrients with
stool, benign epithelial necrosis, crypt
hyperplasia….
J
Intra-cytoplasmic multiplication results in
vacuolation of the cytoplasm with flattened villi
3- Astrovirus

Diagnostic
49
The results of surveillance studies for HAstVs
depend on the method utilized:
- In early surveys using electron microscopy,
- Use of monoclonal antibodies and enzyme
immunoassays (ELISA) to detect HAstV infection in
patients with a higher prevalence (2.5 to 9%) of
patients with diarrhea.
- The cloning and sequencing of viruses by using
RT-PCR reaction for the detection of HAstVs in
(Hye et al., 2012)
3- Astrovirus

50
-HAstV may require fluid replacement (Hye et al.,
2012).
-The prevention of diarrheal diseases in HAstV
requires good individual and collective hygiene,
mass sensitization of the population on the impact
of infections.
-Immunization may play an important role in
preventing HAstV infections
-Early breastfeeding within hours after birth
protects newborns from astroviral infections and
reduces infant mortality.
3- Astrovirus

4- Calicivirus
diarrhoea
51
Family: Caliciviridae,
5 genera : Norovirus, Sapovirus (infect human)
Vesivirus and Logovirus (only infect
animals)
Nebovirus
were first reconhized as the cause of gastroenteritics
during outbreaks in Norwalk.
Diameter: 35 - 30 nm
Icosahedral symmetry
Single-stranded RNA
Non-envelop Capsid
size: 7.7 kbp

HuCVs (Norovirus and Sapovirus) have a very high
genetic variability.
Noroviruses are divided into 5 genogroups (GI to
GV):
- GI and GII genogroups infect humans and pigs.
There are 8 and 17 genotypes,
- GIII genogroup infects cattle and comprises 2
genotypes,
- GIV genogroup infects humans (gastroenteritis) and
comprises 1 genotype
- GV genogroup infects the mouse. (Royall and
4- Caliciviru
52

The Sapoviruses are also divided into 5
genogroups (GI to GV):
- GI, GII, GIV and GV genes infect humans and
are responsible for gastroenteritis.
- Genogroup III infects pigs
4- Caliciviru
53

Epidemiology
4- Caliciviru
54
Diarrhea in Calicivirus has a global distribution and
affects all age groups.
Calicivirus infections are a real public health
problem in industrialized countries. For exemple:
In US , there were 23 million annual cases, 50,000
hospitalizations, 300 deaths;
In France, 501,384 consultations in general medicine
and 70,194 infections per year;
In England, a cost of 72 million pounds for
epidemics of norovirus gastroenteritis in health
institutions from 04/2002 – 03/2003. (Kohli et al.,

In many African countries, these infections are also an
important problem, but they prevalence/diversity of
NoVs is still unknown in these regions ( Royall and
Locker, 2016).
Epidemiology
4- Caliciviru
55
NoV prevalence in individuals with gastroenteritis from
19 studies originating from 14 African countries was
13.5% (961/7141).
6 of the 19 studies reported data on asymptomatic
controls with an overall prevalence of 9.7%. The NoV
prevalence in asymptomatic patients estimated by Ahmed
and co-workers from 20 studies across the world was 7%
(4/20), due to the small number of studies (Royall and

4- Caliciviru
56
It takes place in a fecal-oral mode or by aerosols
during vomiting favored by their great resistance.
Contamination can be direct or indirect (water,
food especially shellfish).

4- Caliciviru
57
Physiopathology
The presumed primary replication site is the upper
intestinal tract;
Histopathological lesions with shortening of the
villi, transient malabsorption of fat, D-xylose and
lactose, and a decrease in brush border enzymes
have been described (Kohli et al., 2005).

4- Caliciviru
58
Diagnostic
- Biological diagnosis of HuCV is essentially
direct.
- These viruses are non-culturable.
- Electron microscopy historically used remains a
reference method; however, it is not very sensitive
and requires experienced staff.
- Immunoenzymatic techniques are now available,
however, he have low sensitivity (Burton et al.,
2004)
- Gene amplification by RT-PCR is the tool; but

Calicivirus gastroenteritis is generally
uncomplicated and spontaneously evolves towards
healing.
There is no vaccine at present. A norovirus
vaccine would be useful, however, given the
diversity of strains and there is no animal model to
evaluate the efficacy of such a vaccine.
Conventional hand hygiene and surface disinfection
measures are a very effective prevention method
4- Caliciviru
59

According to the World Health Organization
(WHO), diarrhea occurs when there are at least
three very soft or liquid stools per day.
Acute diarrhea, defined as an increased
frequency of defecation lasting less than 14 days,
may be accompanied by many symptom
They can be caused by bacteria, parasites,
viruses.
All times acute viral diarrhea are the most
frequent and the most deadly.
60
Conclusion

 Viral infections are a real public health problem
in worldwide
 Infection takes place into digestive trac in many
cases
 RT-PCR methods are common use for diagnostic
Nowadays, it is possible to treat this pathology
with the advent of vaccines,
however it is very important as a preventive
measure to comply with the usual hygiene61
Conclusion

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