医 学 微 生 物 学 Medical Microbiology Department of Microbiology, HMU 哈尔滨医科大学微生物学教研室 Department of Microbiology, Harbin Medical University Department of Microbiology, Harbin Medical University

Haemorrhagic Fever virus 第三篇 医学相关病毒 第34章　出血热病毒 Haemorrhagic Fever virus 微生物学教研室 宋武琦

教学大纲 掌握内容 汉坦病毒主要生物学性状，包括形态结构、培养特性、抗原分型及抵抗力；流行环节及致病性;微生物学检查法。 新疆出血热病毒致病性及传播媒介 了解内容 肾综合征出血热病毒及新疆出血热病毒防治原则；非洲出血热病毒（埃博拉病毒和马堡热病毒）的传播方式及引起疾病

History Haemorrhagic Fever with Renal Syndrome (HFRS: later renamed hantavirus disease, HVD) first recognized in Heilongjiang, China in the 1930s, and came to the attention of the West during the Korean war when over 3000 UN troops were afflicted It transpired that the disease was not new and had been described by the Chinese 1000 years earlier In 1974, the causative was isolated from the Korean Stripped field mice and was called Hantaan virus In 1995, a new disease entity called hantavirus pulmonary syndrome was described in the “four corners” region of the U.S.

病毒体 Virion Forms a separate genus in the Bunyavirus family 布尼雅病毒科 Unlike other bunyaviridae, its transmission does not involve an arthropod vector Enveloped -ssRNA virus Virions 98nm in diameter with a characteristic square grid-like structure. Genome consists of three RNA segments: L, M, and S.

基于中和试验的血清型 Subtypes of Hantaviruses Based NT 黑线姬鼠型 褐家鼠型 欧洲棕背鼠型 草原田鼠型 巴尔干姬鼠型 小家鼠型 黑线姬 田鼠 小家鼠

根据抗原和基因结构分型（10型） Hantaan（汉滩型） Seoul type（汉城型） Puumala type Sin Nombre（辛诺柏型） Hantaan（汉滩型） Porrogia and related viruses - This group is found in China, Eastern USSR, and some parts of S. Europe. It is responsible for the severe classical type of hantavirus disease. It is carried by stripped field mice. (Apodemus agrarius) Seoul type（汉城型） associated with moderate hantavirus disease. It is carried by rats and have a worldwide distribution. It has been identified in China, Japan, Western USSR, USA and S.America. Puumala type mainly found in Scandinavian countries, France, UK and the Western USSR. It is carried by bank voles (Clethrionomys glareolus) and causes mild hantavirus disease (nephropathia epidemica). Sin Nombre（辛诺柏型） found in many parts of the US, Canada and Mexico. Carried by the Deer Mouse (Peromyscus maniculatus) and causes hantavirus pulmonary syndrome.

流行病毒学 Epidemiology Natural host: Rodent Apodemus agrarius (Stripped field mice, 黑线姬鼠) 传染源：黑线姬鼠、褐家鼠、大林姬鼠 Viral contamination comes from rodent urine, stool, salivary secretion Seasonal and regional distribution (autumn and winter, Oct.-Jan.) The infection route is still uncertain. The possible entries are respiratory tract, mouth, and direct contact

Rodent Carriers of Hantaviruses Stripped field mouse (Apodemus agrarius) Bank vole (Clethrionomys glareolus) Rat (Rattus) Deer Mouse (Peromyscus maniculatus)

临床特点 Clinical Features Incubation: 2 weeks, HFRS Pathogenesis mechanism is unknown. Immunological reaction may play role 极低的隐性感染率 Very low subclinical infection rate (1-4%) 病后稳定的免疫力，一般不再发病 Stable humoral immunity. no repeat infection

致病性 Pathogenesis The multisystem pathology of HVD is characterized by damage to capillaries and small vessel walls, resulting in vasodilation and congestion with hemorrhages Classically, hantavirus disease consists of 5 distinct phases. These phases may be blurred in moderate or mild cases

Hypotensive phase 低血压期 Oliguric phase 少尿期 Diuretic phase 多尿期 Febrile phase 发热期 Hypotensive phase 低血压期 Oliguric phase 少尿期 Diuretic phase 多尿期 Convalescent phase 恢复期 Febrile phase 发热期 abrupt onset of a severe flu-like illness with a erythematous rash after an incubation period of 2-3 days Hypotensive phase 低血压期 begins at day 5 of illness Oliguric phase 少尿期 begins at day 9 of illness. The patient may develop acute renal failure and shock. Haemorrhages are usually confined to petechiae. The majority of deaths occur during the hypotensive and oliguric phases Diuretic phase 多尿期 occurs between days 12-14 Convalescent phase 恢复期 may require up to 4 months

Comparative Clinical Features of Recognized Hantavirus Disease (HVD)

汉坦病毒肺综合征 Hantavirus Pulmonary Syndrome The majority of cases are caused by the Sin Nombre virus（汉坦病毒属辛诺柏病毒） More than 250 cases of HPS have been reported throughout North and South America with a mortality rate of 50% The majority of cases are caused by the Sin Nombre virus（汉坦 病毒属辛诺柏病毒） More than 250 cases of HPS have been reported throughout North and South America with a mortality rate of 50% HPS has a similar febrile phase, However, the damage to the capillaries occur predominantly in the lungs rather than the kidney. Shock and cardiac complications may lead to death

诊断 Diagnosis 血清学诊断 直接检测病毒抗原 RT-PCR 病毒分离 Virus isolation 免疫组化 血清学诊断 - a variety of tests including IF, HAI, SRH, ELISAs have been developed for the diagnosis of HVD and HPS 直接检测病毒抗原 - this appears to be more sensitive than serology tests in the early diagnosis of the disease. The virus antigen can be demonstrated in the blood or urine RT-PCR - found to of great use in diagnosing hantavirus pulmonary syndrome 病毒分离 Virus isolation - isolation of the virus from urine is successful early in hantavirus disease. Isolation of the virus from the blood is less consistent 免疫组化 - useful in diagnosing HPS

治疗和预防 Treatment of HVD and HPS depends mainly on supportive measures 支持疗法 Ribavirin 利巴韦林 Vaccination Rodent Control Treatment of HVD and HPS depends mainly on supportive measures 支持疗法 Ribavirin 利巴韦林 reported to be useful if given early in the course of hantavirus disease Vaccination an inactivated vaccine is being tried out in China. Other candidate vaccines are being prepared Rodent Control control measures should be aimed at reducing contact between humans and rodents

新疆出血热病毒 Xinjiang Hemorrhagic Fever Virus 1966年首次从新疆塔里木盆地出血热病人血液、尸体脏器及硬蜱中分离 流行病学及病毒抗原性 与克里米亚-刚果出血热病毒（Crimean-Congo hemorrhagic hever virus，CCHFV）相似 XHFV与CCHFV同种，属布尼雅病毒科（Bunyaviridae）内罗病毒属（nairovirus）

生物学性状 球形或椭圆形，直径为90nm～120nm，外有包膜，表面有空管样突起 病毒基因组为分节段的-ssRNA 出生后l～4天的乳鼠对XHFV最为敏感，常用于病毒分离及传代。用Vero E6等细胞培养病毒不产生CPE，可用免疫荧光法通过检测 感染细胞的胞浆内可形成嗜碱性包涵体 球形或椭圆形，直径为90nm～120nm，外有包膜，表面有空管样突起 病毒基因组为分节段的-ssRNA，包括L、M及S节段，与病毒的核蛋白（C）及少量病毒多聚酶共同组成病毒核衣壳。病毒的核衣壳呈二十面体对称 出生后l～4天的乳鼠对XHFV最为敏感，常用于病毒分离及传代。用Vero E6等细胞培养病毒不产生CPE，可用免疫荧光法通过检测 感染细胞的胞浆内可形成嗜碱性包涵体

致病性与免疫性 野生动物（啮齿类动物）和家畜（羊、牛、马、骆驼、狐狸和兔）是自然宿主和传染源。羊在维持XHF疫原上起重要作用 硬蜱特别是亚洲璃眼蜱（hyalomma asiaticum）是传播媒介。病毒在蜱体内增殖并经卵传给子代，蜱也是病毒的长期储存宿主 新疆出血热是一种主要发生于荒漠、牧场的自然疫源性疾病，有严格的地区性和明显的季节性 野生动物（啮齿类动物）和家畜（羊、牛、马、骆驼、狐狸和兔）是自然宿主和传染源。羊在维持XHF疫原上起重要作用 硬蜱特别是亚洲璃眼蜱（hyalomma asiaticum）是传播媒介。病毒在蜱体内增殖并经卵传给子代，蜱也是病毒的长期储存宿主

蜱在每年的4月～6月大量增殖 5～7天潜伏期发病，以发热和出血为特征 产生中和（NT）抗体、血凝抑制抗体 人群发病的高峰 蜱叮咬或与病畜直接接触（破损皮肤）感染 5～7天潜伏期发病，以发热和出血为特征 产生中和（NT）抗体、血凝抑制抗体 NT抗体出现较早，维持较久 病后可获得持久免疫力

微生物学检查法 确诊主要依赖于 病毒的分离鉴定 患者双份血清中特异性抗体的检查

防治原则 防蜱咬和灭蜱 严格隔离病人 加强医务人员的防护 灭活疫苗 防治措施主要包括防蜱咬和灭蜱 严格隔离病人，并对病人血液、分泌物、排出物等要进行消毒处理 加强医务人员的防护，避免直接接触病人的血液等而被感染 用乳鼠脑组织培养精制的病毒灭活疫苗具有一定的预防效果

埃博拉病毒 非洲出血热（Africa hemorrhagic fever）主要包括埃博拉热（Ebola fever）和马堡热（Marburg fever），分别由埃博拉病毒（Ebola virus）和马堡病毒（Marburg virus）感染所致 两种病毒均为RNA病毒，同属于丝状病毒科（Filoviridae）的丝状病毒属（filovirus），形态结构酷似，但抗原性明显不同

致病性 非洲出血热的主要临床特点 储存宿主是啮齿类动物 人与人主要通过密切接触及体液（尿或粪便）等的污染而传播 目前尚无特异性防治措 非洲出血热的主要临床特点是高热、皮肤瘀血、紫癜、鼻衄、消化道和泌尿生殖道出血、血小板减少以及明显的全身中毒症状，常导致休克和死亡 储存宿主是啮齿类动物，经密切接触可以传播给人 人与人主要通过密切接触及体液（尿或粪便）等的污染而传播 目前尚无特异性防治措施。主要采取维持肾功能和水电解质平衡、积极控制出血和休克等支持疗法进行治疗

小结 病毒科 病毒 疾病 传播媒介 储存宿主 黄病毒科 乙脑病毒 登革病毒 森林脑炎病毒 乙脑 登革热 森林脑炎 库蚊 伊蚊 蜱 布尼亚病毒科 汉坦病毒 流行性出血热 鼠

习题 引起肾综合征出血热的病毒的自然宿主是什么？ 肾综合征出血热的微生物检查方法？ 埃博拉热微生物检查方法？