Diagnosis of Viral Infections

Saturday, August 16, 2008


It is becoming increasingly important for the practitioner to perform viral diagnostic studies because prognostic, epidemiologic, and therapeutic considerations may be greatly influenced by knowledge of the specific virus causing a given illness. Even if no therapy is available, the establishment of a definite diagnosis of viral infection is often beneficial in (1) epidemiologic monitoring, (2) educating physicians and patients, (3) defining the disease process, and (4) evaluating therapeutic implications, both positive and negative. Moreover, identification of a virus as the cause of a patient's illness may be cost effective, because expensive diagnostic procedures and antibiotic therapy may be avoided or discontinued.

The virology laboratory can confirm the suspected diagnosis by cytologic examination of clinical specimens; attempting to isolate the virus; detecting the presence of viral antigens, or nucleic acids or evaluating the patient's immune response to the virus (serology).


The simplest technique for viral diagnosis is cytologic examination of specimens for the presence of characteristic viral inclusions, but this approach is insensitive and applicable to only a few viruses, especially herpes viruses. These intracellular structures may represent aggregates of virus within an infected cell or may be abnormal accumulations of cellular material resulting from the virus-induced metabolic disruption. Papanicolaou (Pap) smears may show these inclusions in single cells or in large syncytia (aggregates of cells containing more than one nucleus), as in a patient with herpes simplex infection of the cervix. Cytology can be used to detect infections with herpes simplex virus, varicella-zoster virus, cytomegalovirus, human papillomavirus, and adenoviruses. Rabies infection may also be detected by finding Negri bodies (rabies virus inclusions) in brain tissue.



The historical "gold standard" of viral diagnosis is recovery of the agent in tissue culture, embryonated eggs, or experimental animals. Embryonated eggs are still used for the growth of virus for some vaccines but have been replaced by cell cultures for routine virus isolation in clinical laboratories. Likewise, the use of experimental animals rarely occurs in most clinical laboratories. Just as multiple media are used in bacteriology, several different types of tissue culture cells (eg, monkey kidney, human fetal lung, human amnion, or human cancer cells) are inoculated with each viral specimen.

Most clinically significant viruses can be recovered in at least one of these cell cultures, but several clinically important viruses are not isolated in these cells. For example, specimens submitted for the identification of viruses such as human immunodeficiency virus, coxsackie A virus, and rubella virus require, respectively, cocultivation with normal human peripheral blood mononuclear cells, inoculation of suckling mice, and the use of specialized cell cultures, which are not generally available. Therefore infections caused by these and several other viruses are most frequently diagnosed serologically or by detection of virus-specific antigens or nucleic acids.

Detection of the growth of a virus is by observation of changes in the cell culture monolayer [cytopathic effect (CPE)]. Characteristic CPEs include changes in cell morphology, cell lysis, vacuolation, syncytia formation, and presence of inclusion bodies. Inclusion bodies are histologic changes in cells caused by the presence of viral components or changes in cell structures. With experience a technologist can distinguish CPE characteristics of the major virus groups. The observation of which cell culture exhibits CPEs and the rapidity of viral growth can be used for the presumptive identification of many clinically important viruses. This approach for identifying viruses is similar to bacterial identification based on growth and morphology of colonies on selective, differential media. Some viruses do not readily cause CPEs in cell lines typically used in clinical virology laboratories. However, some of these can be detected by other techniques, such as (1) erythrocyte hemadsorption onto cells infected with paramyxoviruses or mumps virus or (2) interference with the replication of other viruses (eg, picornaviruses cannot replicate in cells previously infected with rubella virus; this is known as heterologous interference).

In contrast with the intrinsic delay of antibody studies, the results of viral culture can be surprisingly rapid. Almost 50% of all viral isolates can be reported within 3 to 4 days of culture, with herpes simplex virus and influenza A virus usually detected within 1 to 3 days (Table 6-6).

The selection of the appropriate specimen for viral culture is complicated because several different viruses may cause the same clinical disease (Table 6-7). For example, several types of specimens should be submitted from patients with viral meningitis to enhance the recovery of the possible etiologic agents: CSF (enteroviruses, mumps virus, and herpes simplex virus), throat swabs and washings (enteroviruses), and stool or rectal swabs (enteroviruses). Also, serum should be collected as an acute-phase specimen in case subsequent serologic tests are indicated (eg, acute and convalescent sera for mumps virus or arbovirus infections). Many considerations, however, allow the physician to select the most appropriate specimens (Table 6-8). For example, during the summer, when enteroviral meningitis is prevalent, CSF, throat, and stool specimens should be submitted. On the other hand, the development of encephalitis in children after being bitten by mosquitos in wooded areas endemic for California encephalitis virus suggests that a serum specimen for antibody testing would be preferred. Central nervous system disease after parotitis would suggest collection of CSF and urine for the isolation of mumps virus. The specimens that should be collected for other viruses are summarized in Table 6-7.

Timing of Specimen Collection

Proper timing of specimen collection is essential for adequate recovery of viruses. Specimens should be collected early in the acute phase of infection. Studies with respiratory viruses indicate that the mean duration of viral shedding may be only 3-7 days. Also, herpes simplex virus and varicella-zoster virus may not be recovered from lesions beyond 5 days after onset. Isolation of an enterovirus from the CSF may be possible for only 2-3 days after onset of the central nervous system manifestations.

Transport to Laboratory

The shorter the interval between collection of a specimen and its delivery to the laboratory, the greater is the potential for isolating an agent. When feasible, all specimens other than blood, feces, urine, and tissue, which need special processing, should be inoculated directly onto cell cultures at the patient's bedside (Table 6-9). These should then be transported to the laboratory promptly.

For specimens that cannot be inoculated onto cell cultures immediately, several types of transport media have been used. It is generally believed that protein (serum, albumin, or gelatin) incorporated into a transport medium enhances survival of viruses.

Improper storage of specimens before processing can also adversely affect viral recovery. Significant losses in infective titer occur with enveloped viruses (eg, herpes simplex virus, varicella-zoster virus, or influenza virus) after specimens have been frozen and then thawed. This is not observed with nonenveloped viruses (eg, adenoviruses or enteroviruses). Therefore, when it is impossible to process a specimen immediately, it should be refrigerated but not frozen and packed in shaved ice for delivery to the laboratory if delays in transit are anticipated. Storage of specimens for the recovery of viruses at 4oC is far superior to storage at ambient temperature.

Interpretation of Culture Results

In general the detection of any virus in host tissues, CSF, blood, or vesicular fluid can be considered highly significant. Recovery of viruses other than cytomegalovirus in urine may be diagnostic of significant infection. For example, both mumps virus and adenovirus type 11 (associated with acute hemorrhagic cystitis) may be recovered in urine and indicate acute infection. However, the presence of cytomegalovirus in urine is difficult to interpret because this may reflect asymptomatic virus replication long after infection or indicate a significant active infection in the patient. In the newborn, viruria (isolation of virus in urine) in the first 3 weeks of life establishes a diagnosis of congenital cytomegalovirus infection, whereas the onset of viral excretion after 3-4 weeks of life reflects intrapartum or postpartum infection. Diagnosis of acquired cytomegalovirus in older patients usually requires a combination of findings, including positive cultures, illness compatible with cytomegalovirus disease, reasonable exclusion of other potential etiologic agents, and support by specific serologic or histologic data.

The significance of viruses isolated in upper respiratory tract, vaginal, or fecal specimens varies greatly. At one extreme, isolates such as measles, mumps, influenza, parainfluenza, and respiratory syncytial virus are significant because asymptomatic carriage and prolonged shedding of these viruses are unusual. Conversely, other viruses can be shed continually or intermittently without symptoms for periods ranging from several weeks (enteroviruses in feces) to many months or years (herpes simplex virus or cytomegalovirus in the oropharynx and genital tract; adenoviruses in the oropharynx and intestinal tract). Herpes simplex virus, cytomegalovirus, varicella zoster virus, and Epstein-Barr virus may remain latent for long periods and then become reactivated in response to a variety of stressful stimuli, including other infectious agents. In this setting their detection may not be significant, may merely represent a secondary problem complicating the primary infection (eg, herpes simplex virus "cold sores" in patients with bacterial sepsis), or may be associated with significant disease, especially in the immunocompromised patient.

Based on the epidemiology of adenovirus infections and observed serologic responses, the simultaneous isolation of these viruses from throat and feces is significantly associated with febrile respiratory disease. Isolation of viruses from the throat alone is less frequently associated with disease, and isolates from feces alone are probably nondiagnostic in a patient with respiratory disease.

Enteroviruses are generally found in infants and children, particularly during the late summer and early autumn. A knowledge of the relative frequency of virus shedding among various age groups in a particular locale is extremely helpful in assessing the significance of results of throat or stool cultures. For example, the peak prevalence of enteroviruses in the stools of toddlers during the late summer may range from 5% in temperate zones to > 20% in subtropical climates. Even in temperate areas, rates may approach 30% in infants during periods of enterovirus activity. Shedding of enterovirus in the throat usually occurs for 1-2 weeks, whereas fecal shedding may last 4-16 weeks. Thus, in a clinically compatible illness, isolation of an enterovirus from the throat supports a stronger temporal relationship to the disease than does an isolate from only the feces.

Herpes simplex virus is unusual in a fecal culture. In such cases it usually represents either severe disseminated infection or local infection of the perianal areas. Detection of herpes simplex virus in the upper respiratory tract may mean nothing other than nonspecific reactivation of virus caused by fever unless typical vesicles or ulcers are also present. Because of the fever-related phenomenon, isolation of herpes simplex virus in the throat or mucocutaneous lesions of patients with encephalitis cannot be interpreted as causing the central nervous system disease. Currently the definitive way to establish a diagnosis of herpes simplex encephalitis is by direct demonstration of the virus in a brain biopsy or by polymerase chain reaction (PCR) on CSF. In neonates, however, isolation of the virus from any site should raise the possibility of severe infection.

Isolation of adenoviruses, herpes simplex virus, varicella-zoster virus, and some enteroviruses from the cornea and conjunctiva in patients with inflammatory disease at these sites usually establishes the etiology of the infection.


Antibodies can be used as sensitive tools to detect, identify, and quantitate the presence of viral antigen in clinical specimens or cell culture. Monoclonal or polyclonal antibodies prepared in animals may be used. Viral antigens on the cell surface, within the cell, or released from infected cells can be detected by IF, EIA, RIA, and latex agglutination (LA). IF detects and locates cell-associated antigens, whereas RIA or different variations of enzyme-linked immunosorbent assay (ELISA) are used to detect and quantitate soluble antigens. LA is a rapid, easy assay for antigen; viruses or viral antigens in a sample cause the clumping of latex particles coated with specific antibody.

Virus-infected tissue or cell cultures can be detected by IF or EIA. By attaching a fluorescent signal to an antiviral antibody, and reacting it with the sample, viral antigen can be detected; this is called direct IF. A modification of this technique is the use of unlabeled antiviral antibodies and then a second antibody with a fluorescent label that will bind to IgM or IgG antibodies. EIA uses a second antibody conjugated to an enzyme, such as horseradish peroxidase or alkaline phosphatase, which releases a chromophore to mark the presence of antigen.

Direct IF assay is especially useful for (1) respiratory viruses (eg, respiratory syncytial virus or influenza A), (2) varicella-zoster virus and herpes simplex virus antigen in lung and visceral biopsies, and (3) cytomegalovirus in leukocytes from blood or CSF.

Soluble antigen can be quantitated by ELISA, RIA, and LA. The basis for these procedures is the separation and quantitation of antibody-bound and free antigen. Many of the ELISA and RIA techniques use an antibody immobilized to a solid support to capture soluble antigen and a labeled antibody to detect captured antigen.

Influenza, parainfluenza, and togaviruses produce a glycoprotein that binds erythrocytes. This property allows detection of free virus produced in cell culture by agglutination of erythrocytes, a process termed hemagglutination. The infected cells also adsorb erythrocytes to the surface by a process referred to as hemadsorption.

Detection and assay of characteristic enzymes can identify and quantitate specific viruses. For example, reverse transcriptase in cell culture is used as an indicator of infection by retroviruses.



Serology can be used to determine whether an infection is primary or a reinfection and if acute or chronic. The first antibodies to be produced by the immune system are directed against antigens on the virion or infected cell surfaces and are best detected by, eg, IF. Later in the infection, when cells have been lysed by the infecting virus or the cellular immune response, antibodies are directed against the cytoplasmic viral proteins and enzymes and can be detected by, eg, complement fixation. Seroconversion is characterized by a change from negative to positive antibody between serum taken during the acute phase of disease and that taken = 2-3 weeks later; it is the best serologic marker of recent infection. A fourfold or greater rise in antibody titer in paired sera may also be significant but fluctuations in antibody titer do occur naturally. Detection of virus-specific IgM is theoretically associated with recent infection, but technical difficulty in measuring specific IgM responses may lead to false-positive and false-negative results.

For many viruses, culture or antigen detection is the best diagnostic test. However, certain viruses (eg, HIV, hepatitis A and B viruses, rubella virus, Epstein-Barr virus, measles virus, coronaviruses, and togaviruses) are difficult to isolate in cell culture, and infections are diagnosed most easily by serologic techniques. When a virologic workup is planned for a patient, it is generally useful to obtain = 2-3 ml of serum during the acute phase of disease and store it at -20oC. This may become valuable, particularly if virus detection subsequently fails or if the significance of an isolate is uncertain. In these instances a convalescent-phase serum specimen may be requested 2-3 weeks later, and both the acute and convalescent sera may then be tested against appropriate viral antigens. In general, if a virus is isolated, the antibody titers need not be measured to confirm infection; for example, if a patient has aseptic meningitis and an enterovirus is recovered from the throat, that agent is probably responsible for the illness. Similarly, if influenza virus is recovered from the throat of a patient who has clinical influenza, no serologic confirmation of the etiology is necessary.

Complement fixation is a standard but technically difficult serologic test. The serum is first reacted with the suspected viral antigen and complement, and the residual complement is assayed by lysis of indicator antibody-coated erythrocytes. If the complement is used in the first reaction and is therefore not available for the second reaction, it indicates the presence of antibody to the suspected virus. Antibodies measured by this system generally develop slightly later in the course of an illness than those measured by other techniques. This delayed response is useful for documenting seroconversion when the initial serum specimen is collected late in the clinical course. Members of some virus groups (eg, enteroviruses) do not possess group-specific antigen and must be tested individually.

The neutralization test is essentially a protection test. When a virus is incubated with homologous type-specific antibody, the virus is rendered incapable of producing infection in an indicator cell culture system. A neutralization antibody response is virus type specific, with titers rising rapidly and persisting for long periods.

The hemagglutination inhibition test can be performed with a variety of viruses that can selectively agglutinate erythrocytes of various animal species (eg, chicken, guinea pig, or human). The hemagglutination capacity of a virus is inhibited by specific immune or convalescent sera. Hemagglutination-inhibiting antibody develops rapidly after the onset of symptoms, plateaus, declines slowly, and may last indefinitely at low levels. This test is useful for both the detection of acute viral infection and the determination of immunity.

For the indirect fluorescent antibody test, virus-infected cells are placed in prepared wells on microscope slides and then fixed in cold acetone and dried. Patient serum is applied and, after incubation, anti-human globulin conjugated with fluorescein is added. If fluorescence is observed, it indicates the presence of specific antiviral antibody.

Interpretation of Serologic Results

Virus-specific IgM antibody usually rises during the first 2-3 weeks of infection and persists for several weeks to months. Thus an elevated titer of specific IgM antibody suggests a recent primary infection, which may be further supported by demonstrating a fall in IgM antibody in subsequent sera. Detection of specific IgM has been used with success in the diagnosis of infections caused by cytomegalovirus and rubella virus and is currently the procedure of choice to establish a recent or acute infection from hepatitis A or B.

Several limitations of interpretation must be remembered. It is now recognized that IgM-specific antibody responses are not always restricted to primary infections. Reactivation or reinfection may result in IgM responses, particularly in herpes virus infection. In addition, patients may continue to produce IgM-specific antibody to rubella virus or cytomegalovirus for many months after a primary infection. Heterotypic IgM responses may also occur. For example, antibody responses to cytomegalovirus may develop in Epstein-Barr virus infections and vice versa. Other pitfalls include falsely low or negative IgM titers caused by competition from high-titer IgG antibody for antigen-binding sites and false-positive reactions resulting from rheumatoid factor. Both types of errors appear to occur most frequently in solid-phase assays with IF.

The serologic diagnosis of most viral infections is based on demonstration of a seroconversion or a rise (fourfold or greater) of IgG antibody. However, significant antibody titer rises may result from cross-reactions to related antigens; for example, an antibody rise to parainfluenza virus may actually result from infection with mumps virus. Furthermore, seroconversions may not be seen with some patient populations (eg, infants and immunocompromised patients) or when the initial serum is collected late in the course of disease.

A serum specimen can also be used for screening an infant's blood for certain antibodies of the IgG class. Antibodies to Toxoplasma spp., rubella virus, cytomegalovirus, and herpes simplex virus (known as the "TORCH" screen) may be measured to determine possible congenital infection with these agents. However, the value of these tests must be understood. They are useful in excluding a possible infection but not in proving an etiology. For example, if rubella antibody is absent, an infant almost certainly does not have congenital rubella infection. To diagnose active rubella infection in such a baby, viral cultures are required. Screening of blood supplies for cytomegalovirus antibody is used to eliminate transmission of antibody-positive blood to seronegative babies and other immunocompromised patients.

Serologic Panels

Selection of several antigens for testing with paired sera in cases in which a virus is suspected can usually be made based on clinical syndrome, the known local epidemiology of particular viruses, and the patient's age. This has led to the concept of serologic batteries of panels. Some examples of possible panels are included in Table 6-10.

Antigens from mumps, western equine encephalitis, eastern equine encephalitis, St. Louis encephalitis, and California encephalitis viruses—and perhaps lymphocytic choriomeningitis virus, Epstein-Barr virus, and HIV—may be included in a panel of tests for central nervous system diseases. Although herpes simplex antigen is sometimes included in such a panel, a rise in antibody titer is not sufficient to diagnose herpes encephalitis. Many viral central nervous system illnesses, especially aseptic meningitis, are caused by the enteroviruses; however, the many serotypes and the cumbersome serologic methods necessary for their diagnosis usually make it impractical to include them in a panel. When one or two enteroviruses have been shown to be epidemic in an area in one summer, one can pick up some additional cases by performing neutralization tests on paired sera by using only those specific enteroviruses that are endemic in the community.

The viral antigen panel for testing respiratory syndromes might include influenza A and B; respiratory syncytial virus; parainfluenza types 1, 2, and 3; and adenoviruses.

To test for viral causes of exanthems, the panel would include measles and rubella. If the disease is vesicular, herpes simplex virus and varicella-zoster virus should be included, although the herpes viruses are best diagnosed by culture or antigen detection.

Antigens from group B coxsackie virus types 1-5 and perhaps influenza A and B viruses could make up the panel for myocarditis and pericarditis. Although numerous viruses have been implicated in inflammatory diseases of the heart and its covering membranes, the group B coxsackieviruses are believed to account for almost one half of the cases. Unfortunately, much of the clinical illness is expressed late in the infection, at the time when standard methods of virus detection are likely to fail and it is too late to demonstrate seroconversion or significant antibody titer rises.


In recent years a variety of assays have been developed to detect viral nucleic acid—either DNA or RNA. The best known of these is PCR, an amplification technique that allows the detection and selective replication of a targeted portion of the genome. The technique uses special DNA polymerases that initiate replication in either the 3' or 5' direction. The specificity is provided by primers that recognize a pair of unique sites on the genome so that the DNA between them can be replicated by repetitive cycling of the test conditions. Because each newly synthesized fragment can serve as the template for its own replication, the amount of DNA doubles with each cycle. The amplification power of PCR offers a solution for the sensitivity problems inherent in the direct application of probes. Although the nucleic acid segment amplified by PCR can be seen directly on a gel, the greatest sensitivity and specificity are achieved when probe hybridization is carried out after PCR. A probe is a fragment of DNA that has been cloned or otherwise recovered from a genomic or plasmid source. In some cases the probe is synthesized as a single chain of nucleotides (oligonucleotide probe) from known sequence data. The probes are labeled with a radioisotope or other marker and used in hybridization reactions either to detect the homologous sequences in unknown specimens or in gel electrophoresis.

The diagnostic use of DNA probes is to detect or identify microorganisms by hybridization of the probe to homologous sequences in DNA extracted from the entire organism. A number of probes have been developed that will quickly and reliably identify organisms that have already been isolated in culture. The application of probes for detection of infectious agents directly in clinical specimens such as blood, urine and sputum is more difficult.

Recently, the branched DNA (bDNA) a rapid assay for direct quantification of viral nucleic acid has been developed for hepatitis B, hepatitis C, and HIV infections. Because the bDNA assay measures viral nucleic acids at physiological levels by boosting the reporter signal, rather than by amplifying target sequences, it is not subject to the errors inherent in the amplification steps of PCR-based methods. Inherently quantitative and amenable to routine use in a clinical setting, the bDNA assay may be useful in the management of patients with chronic viral diseases. Recent studies have illustrated the potential clinical utility of the bDNA assay in determining the prognosis and in therapeutic monitoring of infection. Additional nucleic acid tests include hybrid capture and nucleic acid sequence-based amplification.


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