Thesis (MScMedSc)--Stellenbosch University, 2015. / ENGLISH ABSTRACT: Background: Respiratory Syncytial Virus (RSV) is the leading cause of severe lower respiratory tract infection in infants and children worldwide. Early diagnosis of RSV infection is associated with shorter periods of hospitalisation and decreased mortality. Current point of care (PoC) tests for RSV is less sensitive than molecular methods. Reverse transcription loop-mediated isothermal amplification (RT-LAMP), is a novel method of nucleic acid detection which allows for rapid, robust amplification, and visual detection of infectious agents. Aim: The objective of this study was to develop a novel, rapid, and sensitive multiplex RSV RT-LAMP assay for PoC diagnosis of RSV A and B. Methods: Preparation of a quantitative RSV standard for assay optimisation was done using a rapid hypotonic burst recovery method of infective virus during sub-passaging, and a shell vial fluorescent focus assay for titration of culture-derived viral stock. We designed a single set of eight primers targeting the large polymerase gene of both RSV A and B, and developed a novel single-step multiplex RSV RT-LAMP assay, using an in-house reaction mix and the Rotor-Gene Q real-time thermocycler (Qiagen, Hilden, Germany). The metal ion indicator hydroxy naphtol blue (HNB) was added to the multiplex RSV RT-LAMP assay for visual detection of RSV. Results: The final optimised multiplex RSV RT-LAMP assay had an analytical detection sensitivity of <10 focus forming units (FFU) per reaction for both RSV A and B, with a mean time to positivity of 21.85 minutes (95% CI 19.2-24.5 minutes), compared to 90-120 minutes for conventional PCR. Evaluated against the Seeplex RV15 multiplex PCR (Seegene, Seoul, Korea) by testing 44 (22 RSV A/22 RSV B) nasopharyngeal specimens, the multiplex RSV RT-LAMP assay had a sensitivity of 100%, and a specificity of 100% when screened against nine common respiratory viruses. Visual detection of RSV using HNB as colorimetric reagent was equivalent to the analytical sensitivity (10 FFU/reaction) and specificity (100%) of the multiplex RSV RT-LAMP assay. Conclusion: Compared with conventional PCR, our novel single-step multiplex RSV RTLAMP assay had excellent sensitivity, specificity, and when combined with HNB dye could provide accurate visual diagnosis within 1 hour. We envisage that this multiplex RSV RTLAMP assay will be used for rapid and sensitive RSV detection at the PoC. / AFRIKAANSE OPSOMMING: Agtergrond: Respiratoriese Syncytial Virus (RSV) is die hoof oorsaak van erge laer lugweginfeksie in babas en kinders wêreldwyd. Vroeë diagnose van RSV infeksie word geassosieer met korter periodes van hospitalisasie en verlaagde mortaliteit. Huidige punt van sorg (PoC) toetse vir RSV is minder sensitief as molekulêre metodes. Omgekeerde transkripsie lus-gemedieerde isotermiese amplifisering (RT-LAMP), is 'n nuwe metode van nukleïensuur opsporing wat voorsiening maak vir vinnige, doeltreffende amplifisering, en visuele bevestiging van aansteeklike agente. Doel: Die doel van hierdie studie was om 'n nuwe, vinnige en sensitiewe multipleks RSV RTLAMP toets te ontwikkel wat PoC diagnose van RSV A en B in staat stel. Metodes: Voorbereiding van 'n kwantitatiewe RSV standaard vir toets optimisering is gedoen met behulp van 'n hipotoniese sel-lise metode van infektiewe virus tydens sub-kultuur, en 'n “shell-vial” kultuur en fluorosensie fokus toets vir titrasie van kultuur-geproduseerde virus voorraad. Ons het 'n enkele stel van agt inleiers ontwerp wat gebaseer is op die groot polimerase geen van beide RSV A en B, en 'n nuwe enkel-stap multipleks RSV RT-LAMP toets ontwikkel, met gebruik van 'n in-huis reaksie mengsel en die Rotor-Gene Q “real-time” thermocycler (Qiagen, Hilden, Duitsland). Die metaalioon aanwyser hidroksi naphtol blou (HNB) is bygevoeg in die multipleks RSV RT-LAMP toets vir visuele bevestiging van RSV. Resultate: Die finale geoptimiseerde multipleks RSV RT-LAMP toets het 'n analitiese sensitiwiteit van <10 fokus vormende eenhede (FFU) per reaksie vir beide RSV A en B gehad, met 'n gemiddelde tyd tot positiwiteit van 21.85 minute (95% CI 19.2-24.5 minute) , in vergelyking met 90-120 minute vir konvensionele PCR. Geëvalueer teen die Seeplex RV15 multipleks PCR (Seegene, Seoul, Korea) deur 44 (22 RSV A/22 RSV B) nasofaringeale monsters te toets, het die multipleks RSV RT-LAMP toets 'n sensitiwiteit van 100% getoon, en 'n spesifisiteit van 100% wanneer getoets teen nege algemene respiratoriese virusse. Visuele bevestiging van RSV met gebruik van HNB as kolorimetriese reagens was gelykstaande aan die analitiese sensitiwiteit (10 FFU/reaksie) en spesifisiteit (100%) van die multipleks RSV RT-LAMP toets. Gevolgtrekking: In vergelyking met konvensionele PCR, het ons nuwe enkel-stap multipleks RSV RT-LAMP toets uitstekende sensitiwiteit, spesifisiteit, en wanneer dit gekombineer word met HNB kleurstof kon dit akkurate visuele diagnose voorsien binne 1 uur. Ons verwag dat hierdie multipleks RSV RT-LAMP toets gebruik sal word vir vinnige en sensitiewe RSV bevestiging by die PoC.

O presente estudo avaliou materiais de 50 pacientes com cirrose hepática pelo vírus da hepatite C (VHC) que foram submetidos ao transplante hepático no Hospital das Clínicas da Faculdade de Medicina de São Paulo no período de 1993 a 2004, sendo divididos em dois grupos: Grupo 1 (33 pacientes com cirrose pelo VHC) e Grupo 2 (17 pacientes com cirrose pelo VHC com carcinoma hepatocelular). Nosso objetivo foi estudar a ocorrência da infecção oculta pelo VHB em pacientes com cirrose pelo VHC com ou sem CHC através do estudo molecular do genoma viral (DNA do VHB) no soro, tecido hepático tumoral e não tumoral pela utilização da técnica de Reação em Cadeia da Polimerase (PCR), pelos métodos in house e em tempo real. Todos os pacientes eram HBsAg negativos, possuíam soroteca e bloco de explante hepático em parafina, não apresentando concomitância com doenças hepáticas colestáticas, metabólicas e autoimunes. Foram avaliados os prontuários por um único pesquisador no sentido de coletar informações tais como: sexo, idade, dados de exames laboratoriais bioquímicos, sorológicos, ?fetoproteína e coagulação; além de dados clínicos tais como ascite e encefalopatia hepática para cálculos de índices prognósticos da cirrose (Child e MELD). Todo o material de explante hepático teve o Escore de Ishak e a Classificação das Sociedades Brasileiras de Patologia e Hepatologia para hepatites crônicas avaliados, assim como a Classificação de Edmondson e Steiner para os que apresentassem CHC. A técnica de PCR in house para detecção do DNA do VHB no soro e em tecido hepático tumoral e não tumoral apresentou negatividade em todas as amostras. Na técnica de PCR em tempo real apenas um caso do grupo 2 foi positivo no soro (sexo masculino, 66 anos, Anti-HBC total isolado e CHC); no tecido hepático tumoral no grupo 2 tivemos dois casos com resultados indeterminados e no tecido hepático não tumoral também do grupo 2, tivemos dois casos indeterminados. O grupo 1 não apresentou positividade para nenhuma das técnicas utilizadas. Concluímos que entre nossos pacientes com ou sem carcinoma hepatocelular associados à cirrose hepática pelo VHC, a infecção oculta pelo VHB foi muito baixa, provavelmente devido à baixa prevalência da infecção pelo VHB na nossa população / This study evaluated serum and liver tissue samples from 50 patients with liver cirrhosis due to hepatitis C virus (HVC) that underwent liver transplant at the Hospital das Clínicas - University of São Paulo School of Medicine during the period of 1993 to 2004, divided into two groups: Group 1 (33 cirrhotic patients due to HCV) and Group 2 (17 cirrhotic patients due to HCV with hepatocellular carcinoma - HCC). Our aim was to study the occurrence of occult HBV0 infection in cirrhotic patients due to HCV with or without HCC through the molecular study of HBV DNA in the serum, tumoral liver tissue and non tumoral liver tissue by the polymerase chain reaction (PCR) techniques using in house and real time PCR. All the patients were HBsAg negative, having previous serum samples frozen at -20ºC and liver tissue explanted in paraffin, without presenting concomitant cholestatic, metabolic and autoimmune liver diseases. The following variables were collected: gender, age, biochemical and coagulation laboratory tests and HBV serology (HBsAg, anti-HBc total, anti-HBs). Among the clinical data, ascites and encephalopathy were collected for the Child and MELD prognostic indexes. In the explanted liver tissue the Ishak\'s Score, The Brazilian Society of Pathology and Hepatology Classification for chronic hepatitis, and Edmondson and Steiner Classification for HCC were applied in the liver tissue. All samples with or without tumoral liver tissue and serum were negative for HBV DNA using in house PCR technique. By the real time PCR technique only one case from Group 2 was HBV DNA positive in serum (male, 66, isolated anti-HBc total positive and HCC). In the tumoral and non-tumoral liver tissues there were two indeterminated HBV DNA cases among Group 2 patients. All samples for Group 1 patients were negative for HBV DNA using both techniques. In conclusion, our study has shown the extremely low occult hepatitis B virus infection among the HCV cirrhotic patients with or without HCC, maybe due to the low HBV past infection among the Southeastern Brazilian population

O presente estudo avaliou materiais de 50 pacientes com cirrose hepática pelo vírus da hepatite C (VHC) que foram submetidos ao transplante hepático no Hospital das Clínicas da Faculdade de Medicina de São Paulo no período de 1993 a 2004, sendo divididos em dois grupos: Grupo 1 (33 pacientes com cirrose pelo VHC) e Grupo 2 (17 pacientes com cirrose pelo VHC com carcinoma hepatocelular). Nosso objetivo foi estudar a ocorrência da infecção oculta pelo VHB em pacientes com cirrose pelo VHC com ou sem CHC através do estudo molecular do genoma viral (DNA do VHB) no soro, tecido hepático tumoral e não tumoral pela utilização da técnica de Reação em Cadeia da Polimerase (PCR), pelos métodos in house e em tempo real. Todos os pacientes eram HBsAg negativos, possuíam soroteca e bloco de explante hepático em parafina, não apresentando concomitância com doenças hepáticas colestáticas, metabólicas e autoimunes. Foram avaliados os prontuários por um único pesquisador no sentido de coletar informações tais como: sexo, idade, dados de exames laboratoriais bioquímicos, sorológicos, ?fetoproteína e coagulação; além de dados clínicos tais como ascite e encefalopatia hepática para cálculos de índices prognósticos da cirrose (Child e MELD). Todo o material de explante hepático teve o Escore de Ishak e a Classificação das Sociedades Brasileiras de Patologia e Hepatologia para hepatites crônicas avaliados, assim como a Classificação de Edmondson e Steiner para os que apresentassem CHC. A técnica de PCR in house para detecção do DNA do VHB no soro e em tecido hepático tumoral e não tumoral apresentou negatividade em todas as amostras. Na técnica de PCR em tempo real apenas um caso do grupo 2 foi positivo no soro (sexo masculino, 66 anos, Anti-HBC total isolado e CHC); no tecido hepático tumoral no grupo 2 tivemos dois casos com resultados indeterminados e no tecido hepático não tumoral também do grupo 2, tivemos dois casos indeterminados. O grupo 1 não apresentou positividade para nenhuma das técnicas utilizadas. Concluímos que entre nossos pacientes com ou sem carcinoma hepatocelular associados à cirrose hepática pelo VHC, a infecção oculta pelo VHB foi muito baixa, provavelmente devido à baixa prevalência da infecção pelo VHB na nossa população / This study evaluated serum and liver tissue samples from 50 patients with liver cirrhosis due to hepatitis C virus (HVC) that underwent liver transplant at the Hospital das Clínicas - University of São Paulo School of Medicine during the period of 1993 to 2004, divided into two groups: Group 1 (33 cirrhotic patients due to HCV) and Group 2 (17 cirrhotic patients due to HCV with hepatocellular carcinoma - HCC). Our aim was to study the occurrence of occult HBV0 infection in cirrhotic patients due to HCV with or without HCC through the molecular study of HBV DNA in the serum, tumoral liver tissue and non tumoral liver tissue by the polymerase chain reaction (PCR) techniques using in house and real time PCR. All the patients were HBsAg negative, having previous serum samples frozen at -20ºC and liver tissue explanted in paraffin, without presenting concomitant cholestatic, metabolic and autoimmune liver diseases. The following variables were collected: gender, age, biochemical and coagulation laboratory tests and HBV serology (HBsAg, anti-HBc total, anti-HBs). Among the clinical data, ascites and encephalopathy were collected for the Child and MELD prognostic indexes. In the explanted liver tissue the Ishak\'s Score, The Brazilian Society of Pathology and Hepatology Classification for chronic hepatitis, and Edmondson and Steiner Classification for HCC were applied in the liver tissue. All samples with or without tumoral liver tissue and serum were negative for HBV DNA using in house PCR technique. By the real time PCR technique only one case from Group 2 was HBV DNA positive in serum (male, 66, isolated anti-HBc total positive and HCC). In the tumoral and non-tumoral liver tissues there were two indeterminated HBV DNA cases among Group 2 patients. All samples for Group 1 patients were negative for HBV DNA using both techniques. In conclusion, our study has shown the extremely low occult hepatitis B virus infection among the HCV cirrhotic patients with or without HCC, maybe due to the low HBV past infection among the Southeastern Brazilian population

Host-pathogen interactions in Hepatitis C Virus infection: Deciphering the role of host proteins and microRNAs Hepatitis C virus (HCV) is a positive sense single stranded RNA virus belonging to the Hepacivirus genus of the Flaviviridae family. HCV genome consists of a single open reading frame flanked by highly structured 5‟ and 3‟ untranslated regions (UTRs) at both ends. Unlike cellular mRNAs, HCV RNA translation is independent of the cap structure and is mediated by an internal ribosomal entry site (IRES) present in the 5‟UTR. HCV replication begins with the synthesis of a complementary negative-strand RNA using the positive strand RNA genome as a template catalyzed by the NS5B RNA dependent RNA polymerase (RdRp). The de novo priming of HCV RNA synthesis by NS5B occurs at the very end of the 3‟UTR. The 3‟UTR is organized into highly structured regions namely the variable region, poly U/UC region and the 3‟X region. These regions contain cis-acting elements that determine the efficiency of viral replication. In addition, the interaction of trans-acting factors with the 3‟ UTR is also important for regulation of HCV replication. HCV 3‟UTR interacts with several cellular proteins such as the human La protein, polypyrimdine tract binding protein (PTB), poly (rC)-binding protein 2 (PCBP2) and Human antigen R (HuR). However, the molecular basis of regulation of viral replication by these proteins is not well understood. Many proteins that are hijacked by HCV as well as other cytoplasmic RNA viruses, such as La, PCBP2, HuR and PTB are RNA binding proteins (RBPs). They are involved in post transcriptional regulation of cellular gene expression. Thus the subversion of these proteins by the virus can affect their normal physiological functions. In addition to proteins, recent reports also describe the involvement of non-coding RNAs including microRNAs (miRNA) and long non coding RNAs (lncRNA) in HCV infection. miRNAs can either directly bind to the HCV genome and regulate its life cycle or indirectly modulate the expression of host proteins required by the virus. miRNAs that are differentially regulated in virus infected tissues or body fluids of infected patients can also serve as biomarkers for diagnosis of various stages of the disease. Hence, it was planned to study the role of host proteins and miRNAs in the HCV life cycle and pathogenesis to have novel insights into the biology of HCV infection. Riboproteomic studies have identified several host proteins that directly interact with the 5‟ and/or 3‟UTRs of the HCV RNA. One of the RNA binding proteins that predominantly interact with the 3‟UTR of HCV RNA was found to be HuR. In the present study, we have extensively characterized the interaction between HuR and HCV 3‟UTR and studied its functional implications in HCV life cycle along with other host factors. Characterizing the HCV 3’UTR–HuR interaction and its role in HCV replication HuR is a ubiquitously expressed member of the Hu family which shuttles between the nucleus and cytoplasm in response to stress. Whole genome siRNA knockdown and other studies have suggested that HuR is essential for HCV replication. However, the molecular mechanism of its involvement in this process was not clear. We observed that siRNA mediated knockdown of HuR reduces the HCV RNA and protein levels. Immunofluorescence studies indicated that HuR relocalizes from the nucleus to the cytoplasm in HCV infected cells. Through confocal microscopy and GST pulldown assays, we have demonstrated that HuR co localizes with the viral polymerase, NS5B and directly interacts with the NS5B protein. Membrane flotation assays showed that HuR is present in the detergent resistant membrane fractions which are the active sites of HCV replication. In addition to the interaction of HuR with the viral protein NS5B, we also characterized its interaction with the viral RNA. Direct UV cross linking assays and UV cross linking immunoprecipitation assays were performed to demonstrate the interaction of HuR with the HCV 3‟UTR. The RRM3, hinge region and RRM1 of HuR were found to be important for binding. Further, we observed that HuR competes with PTB for binding to the 3‟UTR when cytoplasmic S10 extracts or recombinant proteins were used in UV cross linking assays. In contrast, the addition of HuR facilitated the binding of La protein to the HCV 3‟UTR in the above assays. Competition UV cross linking assays indicated that both HuR and PTB bind to the poly U/UC region of the 3‟UTR while La binds to the variable region. HuR and La showed higher affinities for binding to the 3‟UTR as compared to PTB in filter binding assays. Since HuR and PTB interact with the same region on the 3‟UTR and HuR showed ~4 fold higher affinity for binding, it could displace PTB from the 3‟UTR. Next, we investigated the roles of HuR, PTB and La in HCV translation and replication in cell culture using three different assay systems, HCV sub genomic replicon, HCV bicistronic SGR-JFH1/Luc replicon as well as the infectious HCV full length RNA (JFH1). Results clearly indicated that HuR and La are positive modulators of HCV replication. Interestingly, PTB facilitated HCV IRES mediated translation but appeared to have a negative effect on HCV replication. The positive effectors, HuR and La showed significant co localization with one another in the cytoplasm in immunofluorescence studies. GST pulldown and coimmunoprecipitation experiments indicated protein-protein interactions between HuR and La but not between HuR and PTB. Through quantitative IP-RT assays, we demonstrated that the overexpression of HuR in HCV RNA transfected cells increases the association of La with the HCV RNA while HuR knockdown reduces the association of La with the HCV RNA. Previous studies in our laboratory have shown that La helps in HCV genome circularization. The addition of HuR significantly increased La mediated interactions between the 5‟UTR and the 3‟UTR of HCV RNA as monitored by 5‟-3‟ co precipitation assays, suggesting a possible mechanism by which cooperative binding of HuR and La could positively regulate HCV replication. Taken together, our results suggest a possible interplay between HuR, PTB and La in the regulation of HCV replication. Studying the role of HuR- associated cellular RNAs in HCV infection HuR belongs to the category of mRNA turnover and translation regulatory proteins (TTR-RBPs), which are capable of triggering rapid and robust changes in cellular gene expression. HuR plays a role in several post transcriptional events such as mRNA splicing, export, stability and translation. In the present study, we have investigated the possible consequences of relocalization of HuR on cellular processes in the context of HCV infection. We observed that 72h post transfection of infectious HCV-JFH1 RNA, there is an increase in the mRNA levels of some of the validated targets of HuR including the vascular endothelial growth factor A (VEGFA), dual specificity phosphatise 1 (MKP1) and metastasis - associated lung adenocarcinoma transcript (MALAT1). IP-RT assays demonstrated that the association of HuR with VEGFA and MKP1 was higher in HCV-JFH1 RNA transfected cells as compared to the mock transfected cells indicating that increase in HuR association could probably help in stabilization of these mRNAs. Interestingly, we observed that the association of HuR with the lncRNA MALAT1 decreases in the presence of HCV RNA, while its RNA levels increased. Earlier it has been reported that MALAT1 interacts with HuR and was predicted to interact with La. We confirmed the interaction of both HuR and La proteins with MALAT1 RNA in vitro and in the cell culture system. Results from our time course experiments suggest that relocalization of HuR and La upon HCV infection might decrease their association with the nuclear retained MALAT1 RNA leading to significant reduction in MALAT1 RNA levels at the initial time points. However at later time points, MALAT1 was found to be unregulated through activation of the Wnt/beta-catenin pathway as demonstrated using a chemical inhibitor against β-catenin. Since MALAT1 is a known regulator of epithelial mesenchymal transition (EMT) and metastasis, we further studied the physiological consequence of the observed increase in MALAT1 levels upon HCV infection. Cell migration and cell invasion studies suggested that the knockdown of MALAT1 led to the inhibition of HCV- triggered wound healing and matrigel invasion and also rescued the down regulation of E-Cadherin protein levels, an EMT marker. Our study highlights the importance of the lncRNA, MALAT1 in HCV infection and suggests its possible involvement in HCV induced HCC. Investigating the role of miRNAs in HCV pathogenesis and replication miRNAs can also regulate HCV infection and pathogenesis in multiple ways. It is known that under disease conditions, there is aberrant expression of intracellular as well as circulating miRNAs. We have investigated the expression profile of 940 human miRNAs in HCV infected patient serum samples to identify the differentially regulated miRNAs. miR-320c, miR-483-5p and the previously reported miR-125b were found to be upregulated in the serum of cirrhotic and non-cirrhotic HCV infected patient serum samples. All three miRNAs were also unregulated in the cell culture supernatant of HCV infected cells as well as within the HCV infected cells. miR-483-5p was specifically enriched in the exosomes isolated from patient serum samples. Knockdown of miR-320c and miR-483-5p did not have significant effect on HCV replication while knockdown of miR-125b affected HCV replication through regulation of one of its target genes, HuR. We observed that with time, miR-125b levels in HCV-JFH1 RNA transfected cells increase while the HuR protein levels decrease. Using luciferase reporter constructs, we demonstrated that the decrease in HuR protein levels is indeed mediated by miR-125b. Mutations in the target site of miR-125b in the HuR 3‟UTR prevented the down regulation of luciferase activity. Next we tested the effect of silencing miR-125b on HCV replication. Knockdown of miR-125b prevented the reduction in HuR protein levels but with no significant effect on HCV replication. It appeared that the HuR protein already present in the cytoplasm could be sufficient to support HCV replication. Hence similar experiments were carried out in cells depleted of HuR using either siRNA against HuR or a chemical inhibitor of nucleocytoplasmic transport of HuR, Leptomycin B. We observed that when the intracellular levels of HuR are reduced using either of the two approaches, there is a decrease in HCV replication. This is in accordance with the results obtained in the first part of the thesis. However when miR-125b was silenced in HuR depleted cells, we noticed an upregulation in the HuR protein levels by western blot analysis and a consequent increase in HCV RNA levels as quantified by qRT-PCR. From our findings, we can conclude that miR-125b mediated regulation of HuR plays an important role in HCV replication. We hypothesize that this could be a cellular response to HCV infection to which the virus responds by inducing protein relocalization. Altogether, these studies outline the importance of host factors including cellular proteins and non-coding RNAs in the regulation of HCV life cycle and pathogenesis. Results reveal the mechanistic insights into how HCV infection triggers host defense pathways, which are evaded by the virus by counter strategies.