niman Posted February 10, 2016 Report Share Posted February 10, 2016 Zika Virus Associated with Microcephaly - NEJMhttp://www.nejm.org/doi/full/10.1056/NEJMoa1600651?query=featured_home#t=articleTop Link to comment Share on other sites More sharing options...
niman Posted February 10, 2016 Author Report Share Posted February 10, 2016 Jernej Mlakar, M.D., Misa Korva, Ph.D., Nataša Tul, M.D., Ph.D., Mara Popović, M.D., Ph.D., Mateja Poljšak-Prijatelj, Ph.D., Jerica Mraz, M.Sc., Marko Kolenc, M.Sc., Katarina Resman Rus, M.Sc., Tina Vesnaver Vipotnik, M.D., Vesna Fabjan Vodušek, M.D., Alenka Vizjak, Ph.D., Jože Pižem, M.D., Ph.D., Miroslav Petrovec, M.D., Ph.D., and Tatjana Avšič Županc, Ph.D.February 10, 2016DOI: 10.1056/NEJMoa1600651 SOURCE INFORMATIONFrom the Institute of Pathology, Faculty of Medicine (J. Mlakar, M. Popović, J. Mraz, A.V., J.P.), and the Institute of Microbiology and Immunology, Faculty of Medicine (M. Korva, M.P.-P., M. Kolenc, K.R.R., M. Petrovec, T.A.Z.), University of Ljubljana, and the Department of Perinatology, Division of Gynecology and Obstetrics (N.T., V.F.V.), and the Institute of Radiology (T.V.V.), University Medical Center Ljubljana — all in Ljubljana, Slovenia.Address reprint requests to Dr. Avšič Županc at the Institute of Microbiology and Immunology, Faculty of Medicine, University of Ljubljana, Zaloška 4, Ljubljana 1000, Slovenia, or at [email protected]. Link to comment Share on other sites More sharing options...
niman Posted February 10, 2016 Author Report Share Posted February 10, 2016 A widespread epidemic of Zika virus (ZIKV) infection was reported in 2015 in South and Central America and the Caribbean. A major concern associated with this infection is the apparent increased incidence of microcephaly in fetuses born to mothers infected with ZIKV. In this report, we describe the case of an expectant mother who had a febrile illness with rash at the end of the first trimester of pregnancy while she was living in Brazil. Ultrasonography performed at 29 weeks of gestation revealed microcephaly with calcifications in the fetal brain and placenta. After the mother requested termination of the pregnancy, a fetal autopsy was performed. Micrencephaly (an abnormally small brain) was observed, with almost complete agyria, hydrocephalus, and multifocal dystrophic calcifications in the cortex and subcortical white matter, with associated cortical displacement and mild focal inflammation. ZIKV was found in the fetal brain tissue on reverse-transcriptase–polymerase-chain-reaction (RT-PCR) assay, with consistent findings on electron microscopy. The complete genome of ZIKV was recovered from the fetal brain. Link to comment Share on other sites More sharing options...
niman Posted February 10, 2016 Author Report Share Posted February 10, 2016 ZIKV, an emerging mosquito-borne flavivirus, was initially isolated from a rhesus monkey in the Zika forest in Uganda in 1947.1 It is transmitted by various species of aedes mosquitoes. After the first human ZIKV infection, sporadic cases were reported in Southeast Asia and sub-Saharan Africa.2 ZIKV was responsible for the outbreak in Yap Island of Micronesia in 2007 and for major epidemics in French Polynesia, New Caledonia, the Cook Islands, and Easter Island in 2013 and 2014.3,4 In 2015, there was a dramatic increase in reports of ZIKV infection in the Americas. Brazil is the most affected country, with preliminary estimates of 440,000 to 1.3 million cases of autochthonous ZIKV infection reported through December 2015.5The classic clinical picture of ZIKV infection resembles that of dengue fever and chikungunya and is manifested by fever, headache, arthralgia, myalgia, and maculopapular rash, a complex of symptoms that hampers differential diagnosis. Although the disease is self-limiting, cases of neurologic manifestations and the Guillain–Barré syndrome were described in French Polynesia and in Brazil during ZIKV epidemics.5,6 Recent reports from the Ministry of Health of Brazil suggest that cases of microcephaly have increased by a factor of approximately 20 among newborns in the northeast region of the country, which indicates a possible association between ZIKV infection in pregnancy and fetal malformations.5We present a case of vertical transmission of ZIKV in a woman who was probably infected with ZIKV in northeastern Brazil at the end of the first trimester of pregnancy. Our discussion includes details of fetal imaging and pathological and virologic analyses. Link to comment Share on other sites More sharing options...
niman Posted February 10, 2016 Author Report Share Posted February 10, 2016 CASE REPORTIn mid-October 2015, a 25-year-old previously healthy European woman came to the Department of Perinatology at the University Medical Center in Ljubljana, Slovenia, because of assumed fetal anomalies. Since December 2013, she had lived and worked as a volunteer in Natal, the capital of Rio Grande do Norte state. She had become pregnant at the end of February 2015. During the 13th week of gestation, she had become ill with high fever, which was followed by severe musculoskeletal and retroocular pain and an itching, generalized maculopapular rash. Since there was a ZIKV epidemic in the community, infection with the virus was suspected, but no virologic diagnostic testing was performed. Ultrasonography that was performed at 14 and 20 weeks of gestation showed normal fetal growth and anatomy.The patient returned to Europe at 28 weeks of gestation. Ultrasonographic examination that was performed at 29 weeks of gestation showed the first signs of fetal anomalies, and she was referred to the Department of Perinatology. At that time, she also noticed reduced fetal movements. Ultrasonography that was performed at 32 weeks of gestation confirmed intrauterine growth retardation (estimated third percentile of fetal weight) with normal amniotic fluid, a placenta measuring 3.5 cm in thickness (normal size) with numerous calcifications, a head circumference below the second percentile for gestation (microcephaly), moderate ventriculomegaly, and a transcerebellar diameter below the second percentile. Brain structures were blurred, and there were numerous calcifications in various parts of the brain (Figure 1A and 1BFIGURE 1Prenatal Ultrasonographic Images and Photographs of Coronal Slices of Brain.). There were no other obvious fetal structural abnormalities. Fetal, umbilical, and uterine blood flows were normal on Doppler ultrasonography.The clinical presentation raised suspicion of fetal viral infection. Because of severe brain disease and microcephaly, the fetus was given a poor prognosis for neonatal health. The mother requested that the pregnancy be terminated, and the procedure was subsequently approved by national and hospital ethics committees. Medical termination of the pregnancy was performed at 32 weeks of gestation. At the delivery, the only morphologic anomaly was the prominent microcephaly. Genetic consultation that included a detailed maternal family history revealed no suspicion of genetic syndromes or diseases. An autopsy was performed, as is mandatory in all cases of termination of pregnancy. The mother provided written informed consent for the publication of this case report. Link to comment Share on other sites More sharing options...
niman Posted February 10, 2016 Author Report Share Posted February 10, 2016 METHODSAutopsy and Central Nervous System (CNS) ExaminationAn autopsy of the fetus and placenta was performed 3 days after termination of the pregnancy, with an extensive sampling of all organs, placenta, and umbilical cord. Samples were fixed in 10% buffered formalin and embedded in paraffin. Fresh tissue samples were collected for microbiologic investigations. Brain and spinal cord were fixed in 27% buffered formalin for 3 weeks, after which a neuropathological examination was performed with extensive sampling of the brain and spinal cord. Sections of all tissue samples were stained with hematoxylin and eosin. Immunostaining for glial fibrillary acid protein, neurofilament, human leukocyte antigen DR (HLA-DR), CD3 (to highlight T cells), and CD20 (to highlight B cells) was performed on representative CNS samples.Electron MicroscopyTissue was collected from formalin-fixed brain and underwent fixation in 1% osmium tetroxide and dehydration in increasing concentrations of ethanol. The sample was then embedded in Epon. Semithin sections (1.4 μm) were made, stained with Azur II, and analyzed by means of light microscopy. Ultrathin sections (60 nm) were stained with uranyl acetate and lead citrate. In addition, a small piece of brain (5 mm3) was homogenized in buffer. The suspension was then cleared by low-speed centrifugation, and the obtained supernatant was ultracentrifuged directly onto an electron microscopic grid with the use of an Airfuge (Beckman Coulter). Negative staining was performed with 1% phosphotungstic acid. Imaging of the ultrathin sections and brain homogenate was performed with the use of a 120-kV JEM-1400Plus transmission electron microscope (JEOL).Indirect ImmunofluorescenceParaffin-embedded sections of the fetal brain tissue and brain tissue of an autopsied man as a negative control were incubated with serum obtained from the mother of the fetus (dilution, 1:10), followed by antihuman IgG antibodies labeled with fluorescein isothiocyanate (FITC) (dilution, 1:50). In addition, fetal brain tissue was incubated with a serum obtained from a healthy blood donor, as well as with FITC-labeled antihuman IgG antibodies only.Microbiologic InvestigationRNA was extracted from 10 mg of the placenta, lungs, heart, skin, spleen, thymus, liver, kidneys, and cerebral cortex with the use of a TRIzol Plus RNA purification kit (Thermo Fisher Scientific). Real-time RT-PCR for the detection of ZIKV RNA (NS5) and one-step RT-PCR for the detection of the envelope-protein coding region (360 bp) were performed as described previously.7,8 In addition, next-generation sequencing was performed in samples of fetal brain tissue with the use of Ion Torrent (Thermo Fisher Scientific) and Geneious software, version 9.0.6. Reads from both runs were combined and mapped to the reference sequence (ZIKV MR766; LC002520) with the use of default measures. For phylogenetic analysis, complete-genome ZIKV sequences were used, and multiple sequence alignments (ClustalW) were performed. A neighbor-joining phylogenetic tree (GTR+G+I model) was constructed, with the use of the MEGA6 software system,9 to show the phylogenetic relationships. The nucleotide sequence of ZIKV that was obtained in this study has been deposited in GenBank under accession number KU527068. A detailed description of the molecular methods is provided in the Supplementary Appendix, available with the full text of this article at NEJM.org. The results of comprehensive serologic analyses of maternal serum and a description of the molecular differential diagnostic procedures used with fetal tissue samples are provided in Tables S1 and S2 in the Supplementary Appendix. All the authors vouch for the completeness and accuracy of the data and analyses presented. Link to comment Share on other sites More sharing options...
niman Posted February 11, 2016 Author Report Share Posted February 11, 2016 RESULTSAutopsy and Neuropathological FindingsThe fetal body weight was 1470 g (5th percentile), the length 42 cm (10th percentile), and the head circumference 26 cm (1st percentile). The only external anomaly that was noted was microcephaly. The placenta weighed 200 g, resulting in a placental–fetal weight ratio of 0.136 (<3rd percentile). Macroscopic examination of the CNS revealed micrencephaly with a whole-brain weight of 84 g (4 SD below average), widely open sylvian fissures, and a small cerebellum and brain stem. Almost complete agyria and internal hydrocephalus of the lateral ventricles were observed. There were numerous variable-sized calcifications in the cortex and subcortical white matter in the frontal, parietal, and occipital lobes. The subcortical nuclei were quite well developed (Figure 1C and 1D). In spite of some autolysis, microscopic examination revealed appropriate cytoarchitecture of the fetal brain. The most prominent histopathological features were multifocal collections of filamentous, granular, and neuron-shaped calcifications in the cortex and subcortical white matter with focal involvement of the whole cortical ribbon, occasionally associated with cortical displacement (Figure 2A and 2BFIGURE 2Microscopic Analysis of Brain Tissue.). Diffuse astrogliosis was present with focal astrocytic outburst into the subarachnoid space, mostly on the convexity of the cerebral hemispheres (Figure 2C). Activated microglial cells and some macrophages expressing HLA-DR were present throughout most of the cerebral gray and white matter (Figure 2D). Scattered mild perivascular infiltrates composed of T cells and some B cells were present in the subcortical white matter (Fig. S1 in the Supplementary Appendix). The cerebellum, brain stem, and spinal cord showed neither inflammation nor dystrophic calcifications. The brain stem and spinal cord showed Wallerian degeneration of the long descending tracts, especially the lateral corticospinal tract, whereas ascending dorsal columns were well preserved (Figure 2E). Indirect immunofluorescence revealed granular intracytoplasmic reaction in destroyed neuronal structures, which pointed to a possible location of the virus in neurons (Figure 2F, and Fig. S1 in the Supplementary Appendix). Histologic examination of the placenta confirmed focal calcifications in villi and decidua, but no inflammation was found. There were no relevant pathological changes in other fetal organs or in the umbilical cord or fetal membranes. Fetal karyotyping with the use of microarray technology showed a normal 46XY (male) profile.Electron MicroscopyAlthough analysis of the ultrathin sections of the brain showed poorly preserved brain tissue with ruptured and lysed cells, clusters of dense virus-like particles of approximately 50 nm in size were found in damaged cytoplasmic vesicles. Groups of enveloped structures with a bright interior were also detected. At the periphery of such groups, the remains of membranes could be seen. Negative staining of homogenized brain revealed spherical virus particles measuring 42 to 54 nm with morphologic characteristics consistent with viruses of the Flaviviridae family (Figure 3FIGURE 3Electron Microscopy of Ultrathin Sections of Fetal Brain and Staining of a Flavivirus-like Particle.).Microbiologic InvestigationPositive results for ZIKV were obtained on RT-PCR assay only in the fetal brain sample, where 6.5×107 viral RNA copies per milligram of tissue were detected. In addition, all autopsy samples were tested on PCR assay and were found to be negative for other flaviviruses (dengue virus, yellow fever virus, West Nile virus, and tick-borne encephalitis virus), along with chikungunya virus, lymphocytic choriomeningitis, cytomegalovirus, rubella virus, varicella–zoster virus, herpes simplex virus, parvovirus B19, enteroviruses, and Toxoplasma gondii (Table S2 in the Supplementary Appendix).A complete ZIKV genome sequence (10,808 nucelotides) was recovered from brain tissue. Phylogenetic analysis showed the highest identity (99.7%) with the ZIKV strain isolated from a patient from French Polynesia in 2013 (KJ776791) and ZIKV detected in Sao Paolo, Brazil, in 2015 (KU321639), followed by a strain isolated in Cambodia in 2010 (JN860885, with 98.3% identity) and with a strain from the outbreak in Micronesia in 2007 (EU545988, with 98% identity) (Figure 4FIGURE 4Phylogenetic Analysis of the Complete Genome of Zika Virus.). In the ZIKV polyprotein, 23 polymorphisms were detected in comparison with the strain from Micronesia and 5 polymorphisms in comparison with the isolate from French Polynesia; three amino acid changes were found in the NS1 region (K940E, T1027A, and M1143V), one in the NS4B region (T2509I), and one in the FtsJ-like methyltransferase region (M2634V). Link to comment Share on other sites More sharing options...
niman Posted February 11, 2016 Author Report Share Posted February 11, 2016 DISCUSSIONThis case shows severe fetal brain injury associated with ZIKV infection with vertical transmission. Recently, ZIKV was found in amniotic fluid of two fetuses that were found to have microcephaly, which was consistent with intrauterine transmission of the virus.10Described cases are similar to the case presented here and were characterized by severely affected CNS and gross intrauterine growth retardation. Calcifications in the placenta and a low placental–fetal weight ratio,11 which were seen in this case, indicate potential damage to the placenta by the virus. Among the few reports of teratogenic effects of flaviviruses, investigators described the brain and eyes as the main targets.12,13 No presence of virus and no pathological changes were detected in any other fetal organs apart from the brain, which suggests a strong neurotropism of the virus.The localization of immunofluorescence signal and the morphologic appearance of the calcifications, which resembled destroyed neuronal structures, indicate a possible location of the virus in neurons. The consequent damage might cause arrested development of the cerebral cortex at the embryonic age of approximately 20 weeks.14 The mechanism involved in the neurotropism of ZIKV is currently not clear. The association between ZIKV infection and fetal brain anomalies was also noted by findings on electron microscopy that were consistent with ZIKV detection in the fetal brain. Dense particles consistent with ZIKV were seen in damaged endoplasmic reticulum. Groups of enveloped structures with a bright interior resembling the remains of replication complexes that are characteristic of flaviviruses15,16 indicate viral replication in the brain. The findings on electron microscopy suggest a possible persistence of ZIKV in the fetal brain, possibly because of the immunologically secure milieu for the virus. The number of viral copies that were detected in the fetal brain were substantially higher than those reported in the serum obtained from adult ZIKV-infected patients17 but similar to those reported in semen samples.18The complete genome sequence of ZIKV that was recovered in this study is consistent with the observation that the present strain in Brazil has emerged from the Asian lineage.19 The presence of two major amino acid substitutions positioned in nonstructural proteins NS1 and NS4B probably represents an accidental event or indicates a process of eventual adaptation of the virus to a new environment. Further research is needed to better understand the potential implications of these observations. It is likely that the rapid spread of ZIKV around the globe will be a strong impetus for collaborative research on the biologic properties of the virus, particularly since the risk of neurotropic and teratogenic virus infections places a high emotional and economic burden on society. Disclosure forms provided by the authors are available with the full text of this article at NEJM.org.This article was published on February 10, 2016, at NEJM.org.We thank the patient in this case for her willingness to provide detailed medical and immunologic data; Miha Juvan for processing of brain photographs; Peter Štrafela for his assistance with the neuropathological analyses; Martin Sagadin, Tina Uršič, Nataša Toplak, Simon Koren, and Andrej Steyer for their assistance in virus detection, sequencing, and analysis of next-generation sequencing data; Mateja Jelovšek for her assistance in comprehensive serologic investigations, and Luca Lovrečič and Marija Volk for their assistance in molecular karyotyping with microarray testing. Link to comment Share on other sites More sharing options...
niman Posted February 11, 2016 Author Report Share Posted February 11, 2016 REFERENCES1Dick GW, Kitchen SF, Haddow AJ. Zika virus. I. Isolations and serological specificity.Trans R Soc Trop Med Hyg 1952;46:509-520CrossRef | Web of Science | Medline2Hayes EB. Zika virus outside Africa. Emerg Infect Dis 2009;15:1347-1350CrossRef | Web of Science | Medline3Duffy MR, Chen TH, Hancock WT, et al. Zika virus outbreak on Yap Island, Federated States of Micronesia. N Engl J Med 2009;360:2536-2543Free Full Text | Web of Science | Medline4Cao-Lormeau VM, Roche C, Teissier A, et al. Zika virus, French Polynesia, South Pacific, 2013. Emerg Infect Dis 2014;20:1085-1086Web of Science | Medline5Rapid risk assessment: Zika virus epidemic in the Americas: potential association with microcephaly and Guillain-Barré syndrome. Stockholm: European Centre for Disease Prevention and Control, December 10, 2015 (http://ecdc.europa.eu/en/publications/Publications/zika-virus-americas-association-with-microcephaly-rapid-risk-assessment.pdf).6Ioos S, Mallet HP, Leparc Goffart I, Gauthier V, Cardoso T, Herida M. Current Zika virus epidemiology and recent epidemics. Med Mal Infect 2014;44:302-307CrossRef | Web of Science | Medline7Faye O, Faye O, Diallo D, Diallo M, Weidmann M, Sall AA. Quantitative real-time PCR detection of Zika virus and evaluation with field-caught mosquitoes. Virol J 2013;10:311-311CrossRef | Web of Science | Medline8Faye O, Faye O, Dupressoir A, Weidmann M, Ndiaye M, Alpha Sall A. One-step RT-PCR for detection of Zika virus. J Clin Virol 2008;43:96-101CrossRef | Web of Science | Medline9Tamura K, Stecher G, Peterson D, Filipski A, Kumar S. MEGA6: Molecular Evolutionary Genetics Analysis version 6.0. Mol Biol Evol 2013;30:2725-2729CrossRef | Web of Science | Medline10Oliveira Melo AS, Malinger G, Ximenes R, Szejnfeld PO, Alves Sampaio S, Bispo de Filippis AM. Zika virus intrauterine infection causes fetal brain abnormality and microcephaly: tip of the iceberg? Ultrasound Obstet Gynecol 2016;47:6-7CrossRef | Web of Science | Medline11Macdonald EM, Koval JJ, Natale R, Regnault T, Campbell MK. Population-based placental weight ratio distributions. Int J Pediatr 2014;2014:291846-291846CrossRef12Alpert SG, Fergerson J, Noël LP. Intrauterine West Nile virus: ocular and systemic findings. Am J Ophthalmol 2003;136:733-735CrossRef | Web of Science | Medline13Tsai TF. Congenital arboviral infections: something new, something old. Pediatrics2006;117:936-939CrossRef | Web of Science | Medline14Chi JG, Dooling EC, Gilles FH. Gyral development of the human brain. Ann Neurol1977;1:86-93CrossRef | Web of Science | Medline15Goldsmith CS, Ksiazek TG, Rollin PE, et al. Cell culture and electron microscopy for identifying viruses in diseases of unknown cause. Emerg Infect Dis 2013;19:886-891CrossRef | Web of Science | Medline16Gillespie LK, Hoenen A, Morgan G, Mackenzie JM. The endoplasmic reticulum provides the membrane platform for biogenesis of the flavivirus replication complex. J Virol2010;84:10438-10447CrossRef | Web of Science | Medline17Lanciotti RS, Kosoy OL, Laven JJ, et al. Genetic and serologic properties of Zika virus associated with an epidemic, Yap State, Micronesia, 2007. Emerg Infect Dis 2008;14:1232-1239CrossRef | Web of Science | Medline18Musso D, Roche C, Robin E, Nhan T, Teissier A, Cao-Lormeau VM. Potential sexual transmission of Zika virus. Emerg Infect Dis 2015;21:359-361CrossRef | Web of Science | Medline19Faye O, Freire CC, Iamarino A, et al. Molecular evolution of Zika virus during its emergence in the 20th century. PLoS Negl Trop Dis 2014;8:e2636-e2636CrossRef | Medline Link to comment Share on other sites More sharing options...
niman Posted February 11, 2016 Author Report Share Posted February 11, 2016 (edited) http://www.ncbi.nlm.nih.gov/nuccore/KU527068GenBank: 982894594 This record has not yet been released. Please contact [email protected] with the publication details if the accession has been published. Edited February 11, 2016 by niman Link to comment Share on other sites More sharing options...
niman Posted February 11, 2016 Author Report Share Posted February 11, 2016 http://www.ncbi.nlm.nih.gov/nuccore/KU527068GenBank: 982894594 This record has not yet been released. Please contact [email protected] with the publication details if the accession has been published.LOCUS KU527068 10808 bp RNA linear VRL 11-FEB-2016 DEFINITION Zika virus strain Bahia2015, complete genome. ACCESSION KU527068 VERSION KU527068.1 GI:982894594 KEYWORDS . SOURCE Zika virus ORGANISM Zika virus Viruses; ssRNA viruses; ssRNA positive-strand viruses, no DNA stage; Flaviviridae; Flavivirus. REFERENCE 1 (bases 1 to 10808) AUTHORS Mlakar,J., Korva,M., Tul,N., Popovic,M., Poljsak-Prijatelj,M., Mraz,J., Kolenc,M., Resman Rus,K., Vesnaver Vipotnik,T., Fabjan Vodusek,V., Vizjak,A., Pizem,J., Petrovec,M. and Avsic Zupanc,T. TITLE Zika Virus Associated with Microcephaly JOURNAL N. Engl. J. Med. (2016) In press PUBMED 26862926 REMARK Publication Status: Available-Online prior to print REFERENCE 2 (bases 1 to 10808) AUTHORS Avsic Zupanc,T. and Korva,M. TITLE Direct Submission JOURNAL Submitted (13-JAN-2016) Institute of Microbiology and Immunology, University of Ljubljana, Faculty of Medicine, Vrazov trg 2, Ljubljana 1000, Slovenia FEATURES Location/Qualifiers source 1..10808 /organism="Zika virus" /mol_type="genomic RNA" /strain="Bahia2015" /isolation_source="fetus' brain autopsy" /host="Homo sapiens" /db_xref="taxon:64320" /country="Brazil" /collection_date="2015" CDS 108..10379 /note="contains structural and non-structural proteins" /codon_start=1 /product="polyprotein" /protein_id="AMB18850.1" /db_xref="GI:982894595" /translation="MKNPKKKSGGFRIVNMLKRGVARVSPFGGLKRLPAGLLLGHGPI RMVLAILAFLRFTAIKPSLGLINRWGSVGKKEAMEIIKKFKKDLAAMLRIINARKEKK RRGADTSVGIVGLLLTTAMAAEVTRRGSAYYMYLDRNDAGEAISFPTTLGMNKCYIQI MDLGHMCDATMSYECPMLDEGVEPDDVDCWCNTTSTWVVYGTCHHKKGEARRSRRAVT LPSHSTRKLQTRSQTWLESREYTKHLIRVENWIFRNPGFALAAAAIAWLLGSSTSQKV IYLVMILLIAPAYSIRCIGVSNRDFVEGMSGGTWVDVVLEHGGCVTVMAQDKPTVDIE LVTTTVSNMAEVRSYCYEASISDMASDSRCPTQGEAYLDKQSDTQYVCKRTLVDRGWG NGCGLFGKGSLVTCAKFACSKKMTGKSIQPENLEYRIMLSVHGSQHSGMIVNDTGHET DENRAKVEITPNSPRAEATLGGFGSLGLDCEPRTGLDFSDLYYLTMNNKHWLVHKEWF HDIPLPWHAGADTGTPHWNNKEALVEFKDAHAKRQTVVVLGSQEGAVHTALAGALEAE MDGAKGRLSSGHLKCRLKMDKLRLKGVSYSLCTAAFTFTKIPAETLHGTVTVEVQYAG TDGPCKVPAQMAVDMQTLTPVGRLITANPVITESTENSKMMLELDPPFGDSYIVIGVG EKKITHHWHRSGSTIGKAFEATVRGAKRMAVLGDTAWDFGSVGGALNSLGKGIHQIFG AAFKSLFGGMSWFSQILIGTLLMWLGLNTKNGSISLMCLALGGVLIFLSTAVSADVGC SVDFSKKETRCGTGVFVYNDVEAWRDRYKYHPDSPRRLAAAVKQAWEDGICGISSVSR MENIMWRSVEGELNAILEENGVQLTVVVGSVKNPMWRGPQRLPVPVNELPHGWKAWGK SYFVRAAKTNNSFVVDGDTLKECPLEHRAWNSFLVEDHGFGVFHTSVWLKVREDYSLE CDPAVIGTAVKGKEAVHSDLGYWIESEKNDTWRLKRAHLIEMKTCEWPKSHTLWADGI EESDLIIPKSLAGPLSHHNTREGYRTQMKGPWHSEELEIRFEECPGTKVHVEETCGTR GPSLRSTTASGRVIEEWCCRECTMPPLSFRAKDGCWYGMEIRPRKEPESNLVRSVVTA GSTDHMDHFSLGVLVILLMVQEGLKKRMTTKIIISTSMAVLVAMILGGFSMSDLAKLA ILMGATFAEMNTGGDVAHLALIAAFKVRPALLVSFIFRANWTPRESMLLALASCLLQT AISALEGDLMVLINGFALAWLAIRAMVVPRTDNITLAILAALTPLARGTLLVAWRAGL ATCGGFMLLSLKGKGSVKKNLPFVMALGLTAVRLVDPINVVGLLLLTRSGKRSWPPSE VLTAVGLICALAGGFAKADIEMAGPMAAVGLLIVSYVVSGKSVDMYIERAGDITWEKD AEVTGNSPRLDVALDESGDFSLVEDDGPPMREIILKVVLMTICGMNPIAIPFAAGAWY VYVKTGKRSGALWDVPAPKEVKKGETTDGVYRVMTRRLLGSTQVGVGVMQEGVFHTMW HVTKGSALRSGEGRLDPYWGDVKQDLVSYCGPWKLDAAWDGHSEVQLLAVPPGERARN IQTLPGIFKTKDGDIGAVALDYPAGTSGSPILDKCGRVIGLYGNGVVIKNGSYVSAIT QGRREEETPVECFEPSMLKKKQLTVLDLHPGAGKTRRVLPEIVREAIKTRLRTVILAP TRVVAAEMEEALRGLPVRYMTTAVNVTHSGTEIVDLMCHATFTSRLLQPIRVPNYNLY IMDEAHFTDPSSIAARGYISTRVEMGEAAAIFMTATPPGTRDAFPDSNSPIMDTEVEV PERAWSSGFDWVTDHSGKTVWFVPSVRNGNEIAACLTKAGKRVIQLSRKTFETEFQKT KHQEWDFVVTTDISEMGANFKADRVIDSRRCLKPVILDGERVILAGPMPVTHASAAQR RGRIGRNPNKPGDEYLYGGGCAETDEDHAHWLEARMLLDNIYLQDGLIASLYRPEADK VAAIEGEFKLRTEQRKTFVELMKRGDLPVWLAYQVASAGITYTDRRWCFDGTTNNTIM EDSVPAEVWTRHGEKRVLKPRWMDARVCSDHAALKSFKEFAAGKRGAAFGVMEALGTL PGHMTERFQEAIDNLAVLMRAETGSRPYKAAAAQLPETLETIMLLGLLGTVSLGIFFV LMRNKGIGKMGFGMVTLGASAWLMWLSEIEPARIACVLIVVFLLLVVLIPEPEKQRSP QDNQMAIIIMVAVGLLGLITANELGWLERTKSDLSHLMGRREEGATIGFSMDIDLRPA SAWAIYAALTTFITPAVQHAVTTSYNNYSLMAMATQAGVLFGMGKGMPFYAWDFGVPL LMIGCYSQLTPLTLIVAIILLVAHYMYLIPGLQAAAARAAQKRTAAGIMKNPVVDGIV VTDIDTMTIDPQVEKKMGQVLLIAVAVSSAILSRTAWGWGEAGALITAATSTLWEGSP NKYWNSSTATSLCNIFRGSYLAGASLIYIVTRNAGLVKRRGGGTGETLGEKWKARLNQ MSALEFYSYKKSGITEVCREEARRALKDGVATGGHAVSRGSAKLRWLVERGYLQPYGK VIDLGCGRGGWSYYAATIRKVQEVKGYTKGGPGHEEPVLVQSYGWNIVRLKSGVDVFH MAAEPCDTLLCDIGESSSSPEVEEARTLRVLSMVGDWLEKRPGAFCIKVLCPYTSTMM ETLERLQRRYGGGLVRVPLSRNSTHEMYWVSGAKSNTIKSVSTTSQLLLGRMDGPRRP VKYEEDVNLGSGTRAVVSCAEAPNMKIIGNRIERIRSEHAETWFFDENHPYRTWAYHG SYEAPTQGSASSLINGVVRLLSKPWDVVTGVTGIAMTDTTPYGQQRVFKEKVDTRVPD PQEGTRQVMSMVSSWLWKELGKHKRPRVCTKEEFINKVRSNAALGAIFEEEKEWKTAV EAVNDPRFWALVDKEREHHLRGECQSCVYNMMGKREKKQGEFGKAKGSRAIWYMWLGA RFLEFEALGFLNEDHWMGRENSGGGVEGLGLQRLGYVLEEMSRIPGGRMYADDTAGWD TRISRFDLENEALITNQMEKGHRALALAIIKYTYQNKVVKVLRPAEKGKTVMDIISRQ DQRGSGQVVTYALNTFTNLVVQLIRNMEAEEVLEMQDLWLLRRSEKVTNWLQSNGWDR LKRMAVSGDDCVVKPIDDRFAHALRFLNDMGKVRKDTQEWKPSTGWDNWEEVPFCSHH FNKLHLKDGRSIVVPCRHQDELIGRARVSPGAGWSIRETACLAKSYAQMWQLLYFHRR DLRLMANAICSSVPVDWVPTGRTTWSIHGKGEWMTTEDMLVVWNRVWIEENDHMEDKT PVTKWTDIPYLGKREDLWCGSLIGHRPRTTWAENIKNTVNMVRRIIGDEEKYMDYLST QVRYLGEEGSTPGVL" ORIGIN 1 agttgttgat ctgtgtgaat cagactgcga cagttcgagt ttgaagcgaa agctagcaac 61 agtatcaaca ggttttattt tggatttgga aacgagagtt tctggtcatg aaaaacccaa 121 aaaagaaatc cggaggattc cggattgtca atatgctaaa acgcggagta gcccgtgtga 181 gcccctttgg gggcttgaag aggctgccag ccggacttct gctgggtcat gggcccatca 241 ggatggtctt ggcaattcta gcctttttga gattcacggc aatcaagcca tcactgggtc 301 tcatcaatag atggggttca gtggggaaaa aagaggctat ggaaataata aagaagttca 361 agaaagatct ggctgccatg ctgagaataa tcaatgctag gaaggagaag aagagacgag 421 gcgcagatac tagtgtcgga attgttggcc tcctgctgac cacagctatg gcagcggagg 481 tcactagacg tgggagtgca tactatatgt acttggacag aaacgatgct ggggaggcca 541 tatcttttcc aaccacattg gggatgaata agtgttatat acagatcatg gatcttggac 601 acatgtgtga tgccaccatg agctatgaat gccctatgct ggatgagggg gtggaaccag 661 atgacgtcga ttgttggtgc aacacgacgt caacttgggt tgtgtacgga acctgccatc 721 acaaaaaagg tgaagcacgg agatctagaa gagctgtgac gctcccctcc cattccacta 781 ggaagctgca aacgcggtcg caaacctggt tggaatcaag agaatacaca aagcacttga 841 ttagagtcga aaattggata ttcaggaacc ctggcttcgc gttagcagca gctgccatcg 901 cttggctttt gggaagctca acgagccaaa aagtcatata cttggtcatg atactgctga 961 ttgccccggc atacagcatc aggtgcatag gagtcagcaa tagggacttt gtggaaggta 1021 tgtcaggtgg gacttgggtt gatgttgtct tggaacatgg aggttgtgtc accgtaatgg 1081 cacaggacaa accgactgtc gacatagagc tggttacaac aacagtcagc aacatggcgg 1141 aggtaagatc ctactgctat gaggcatcaa tatcagacat ggcttcggac agccgctgcc 1201 caacacaagg tgaagcctac cttgacaagc aatcagacac tcaatatgtc tgcaaaagaa 1261 cgttagtgga cagaggctgg ggaaatggat gtggactttt tggcaaaggg agcctggtga 1321 catgcgctaa gtttgcatgc tccaagaaaa tgaccgggaa gagcatccag ccagagaatc 1381 tggagtaccg gataatgctg tcagttcatg gctcccagca cagtgggatg atcgttaatg 1441 acacaggaca tgaaactgat gagaatagag cgaaggttga gataacgccc aattcaccaa 1501 gagccgaagc caccctgggg ggttttggaa gcctaggact tgattgtgaa ccgaggacag 1561 gccttgactt ttcagatttg tattacttga ctatgaataa caagcactgg ttggtccaca 1621 aggagtggtt ccacgacatt ccattacctt ggcacgctgg ggcagacacc ggaactccac 1681 actggaacaa caaagaagca ctggtagagt tcaaggacgc acatgccaaa aggcaaactg 1741 tcgtggttct agggagtcaa gaaggagcag ttcacacggc ccttgctgga gctctggagg 1801 ctgagatgga tggtgcaaag ggaaggctgt cctctggcca cttgaaatgt cgcctgaaaa 1861 tggataaact tagattgaag ggcgtgtcat actccttgtg taccgcagcg ttcacattca 1921 ccaagatccc ggctgaaaca ctgcacggga cagtcacagt ggaggtacag tacgcaggga 1981 cagatggacc ttgcaaggtt ccagctcaga tggcggtgga catgcaaact ctgaccccag 2041 ttgggaggtt gataaccgct aaccccgtaa tcactgaaag cactgagaac tctaagatga 2101 tgctggaact tgatccacca tttggggact cttacattgt cataggagtc ggggagaaga 2161 agatcaccca ccactggcac aggagtggca gcaccattgg aaaagcattt gaagccactg 2221 tgagaggtgc caagagaatg gcagtcttgg gagacacagc ctgggacttt ggatcagttg 2281 gaggcgctct caactcattg ggcaagggca tccatcaaat ttttggagca gctttcaaat 2341 cattgtttgg aggaatgtcc tggttctcac aaatcctcat tggaacgttg ctgatgtggt 2401 tgggtctgaa cacaaagaat ggatctattt cccttatgtg cttggcctta gggggagtgt 2461 tgatcttctt atccacagcc gtctctgctg atgtggggtg ctcggtggac ttctcaaaga 2521 aggagacgag atgcggtaca ggggtgttcg tctataacga cgttgaagcc tggagggaca 2581 ggtacaagta ccatcctgac tccccccgta gattggcagc agcagtcaag caagcctggg 2641 aagatggtat ctgcgggatc tcctctgttt caagaatgga gaacatcatg tggagatcag 2701 tagaagggga gctcaacgca atcttggaag agaatggagt tcaactgacg gtcgttgtgg 2761 gatctgtaaa aaaccccatg tggagaggtc cacagagatt gcccgtgcct gtgaacgagc 2821 tgccccacgg ctggaaggct tgggggaaat cgtacttcgt cagagcagca aagacaaata 2881 acagctttgt cgtggatggt gacacactga aggaatgccc actcgaacat agagcatgga 2941 acagctttct tgtggaggat catgggttcg gggtatttca cactagtgtc tggctcaagg 3001 ttagagaaga ttattcatta gagtgtgatc cagccgttat tggaacagct gttaagggga 3061 aggaggctgt acacagtgat ctaggctact ggattgagag tgagaagaat gacacatgga 3121 ggctgaagag ggcccatcta atcgagatga aaacatgtga atggccaaag tcccacacat 3181 tgtgggcaga tggaatagaa gagagtgatc tgatcattcc caagtcttta gctgggccac 3241 tcagccatca caataccaga gagggctaca ggacccaaat gaaagggcca tggcacagtg 3301 aagagcttga aattcggttt gaggaatgcc cgggcactaa ggtccacgtg gaggaaacat 3361 gtggaacaag aggaccatct ctgagatcaa ccactgcaag cggaagggtg atcgaggaat 3421 ggtgctgcag ggagtgcaca atgcccccac tgtcgttccg ggctaaagat ggctgttggt 3481 atggaatgga gataaggccc aggaaagaac cagaaagcaa cttagtaagg tcagtggtga 3541 ctgcaggatc aactgatcac atggatcact tctcccttgg agtgcttgtg attctgctca 3601 tggtgcagga agggctgaag aagagaatga ccacaaagat catcataagc acatcaatgg 3661 cagtgctggt agctatgatc ctgggaggat tttcaatgag tgacctggct aagcttgcaa 3721 ttttgatggg cgccaccttc gcggaaatga acactggagg agatgtagct catctggcgc 3781 tgatagcggc attcaaagtc agaccagcgt tgctggtatc tttcatcttc agagctaatt 3841 ggacaccccg tgaaagcatg ctgctggcct tggcctcgtg tcttttgcaa actgcgatct 3901 ccgccttgga aggcgacctg atggttctca tcaatggttt tgctttggcc tggttggcaa 3961 tacgagcgat ggttgttcca cgcactgata acatcacctt ggcaatcctg gctgctctga 4021 caccactggc ccggggcaca ctgcttgtgg cgtggagagc aggccttgct acttgcgggg 4081 ggtttatgct cctctctctg aagggaaaag gcagtgtgaa gaagaactta ccatttgtca 4141 tggccctggg actaaccgct gtgaggctgg tcgaccccat caacgtggtg ggactgctgt 4201 tgctcacaag gagtgggaag cggagctggc cccctagcga agtactcaca gctgttggcc 4261 tgatatgcgc attggctgga gggttcgcca aggcagatat agagatggct gggcccatgg 4321 ccgcggtcgg tctgctaatt gtcagttacg tggtctcagg aaagagtgtg gacatgtaca 4381 ttgaaagagc aggtgacatc acatgggaaa aagatgcgga agtcactgga aacagtcccc 4441 ggctcgatgt ggcgctagat gagagtggtg atttctccct ggtggaggat gacggtcccc 4501 ccatgagaga gatcatactc aaggtggtcc tgatgaccat ctgtggcatg aacccaatag 4561 ccataccctt tgcagctgga gcgtggtacg tatacgtgaa gactggaaaa aggagtggtg 4621 ctctatggga tgtgcctgct cccaaggaag taaaaaaggg ggagaccaca gatggagtgt 4681 acagagtaat gactcgtaga ctgctaggtt caacacaagt tggagtggga gttatgcaag 4741 agggggtctt tcacactatg tggcacgtca caaaaggatc cgcgctgaga agcggtgaag 4801 ggagacttga tccatactgg ggagatgtca agcaggatct ggtgtcatac tgtggtccat 4861 ggaagctaga tgccgcctgg gacgggcaca gcgaggtgca gctcttggcc gtgccccccg 4921 gagagagagc gaggaacatc cagactctgc ccggaatatt taagacaaag gatggggaca 4981 ttggagcggt tgcgctggat tacccagcag gaacttcagg atctccaatc ctagacaagt 5041 gtgggagagt gataggactt tatggcaatg gggtcgtgat caaaaatggg agttatgtta 5101 gtgccatcac ccaagggagg agggaggaag agactcctgt tgagtgcttc gagccttcga 5161 tgctgaagaa gaagcagcta actgtcttag acttgcatcc tggagctggg aaaaccagga 5221 gagttcttcc tgaaatagtc cgtgaagcca taaaaacaag actccgtact gtgatcttag 5281 ctccaaccag ggttgtcgct gctgaaatgg aggaagccct tagagggctt ccagtgcgtt 5341 atatgacaac agcagtcaat gtcacccact ctggaacaga aatcgtcgac ttaatgtgcc 5401 atgccacctt cacttcacgt ctactacagc caatcagagt ccccaactat aatctgtata 5461 ttatggatga ggcccacttc acagatccct caagtatagc agcaagagga tacatttcaa 5521 caagggttga gatgggcgag gcggctgcca tcttcatgac cgccacgcca ccaggaaccc 5581 gtgacgcatt tccggactcc aactcaccaa ttatggacac cgaagtggaa gtcccagaga 5641 gagcctggag ctcaggcttt gattgggtga cggatcattc tggaaaaaca gtttggtttg 5701 ttccaagcgt gaggaacggc aatgagatcg cagcttgtct gacaaaggct ggaaaacggg 5761 tcatacagct cagcagaaag acttttgaga cagagttcca gaaaacaaaa catcaagagt 5821 gggactttgt cgtgacaact gacatttcag agatgggcgc caactttaaa gctgaccgtg 5881 tcatagattc caggagatgc ctaaagccgg tcatacttga tggcgagaga gtcattttgg 5941 ctggacccat gcctgtcaca catgccagcg ctgcccagag gagggggcgc ataggcagga 6001 atcccaacaa acctggagat gagtatctgt atggaggtgg gtgcgcagag actgacgaag 6061 accatgcaca ctggcttgaa gcaagaatgc tccttgacaa tatttacctc caagatggcc 6121 tcatagcctc gctctatcga cctgaggccg acaaagtagc agccattgag ggagagttca 6181 agcttaggac ggagcaaagg aagacctttg tggaactcat gaaaagagga gatcttcctg 6241 tttggctggc ctatcaggtt gcatctgccg gaataaccta cacagataga agatggtgct 6301 ttgatggcac gaccaacaac accataatgg aagacagtgt gccggcagag gtgtggacca 6361 gacacggaga gaaaagagtg ctcaaaccga ggtggatgga cgccagagtt tgttcagatc 6421 atgcggccct gaagtcattc aaggagtttg ccgctgggaa aagaggagcg gcttttggag 6481 tgatggaagc cctgggaaca ctgccaggac acatgacaga gagattccag gaagccattg 6541 acaacctcgc tgtgctcatg cgggcagaga ctggaagcag gccttacaaa gccgcggcgg 6601 cccaattgcc ggagacccta gagaccatta tgcttttggg gttgctggga acagtctcgc 6661 tgggaatctt tttcgtcttg atgaggaaca agggcatagg gaagatgggc tttggaatgg 6721 tgactcttgg ggccagcgca tggctcatgt ggctctcgga aattgagcca gccagaattg 6781 catgtgtcct cattgttgtg ttcctattgc tggtggtgct catacctgag ccagaaaagc 6841 aaagatctcc ccaggacaac caaatggcaa tcatcatcat ggtagcagta ggtcttctgg 6901 gcttgattac cgccaatgaa ctcggatggt tggagagaac aaagagtgac ctaagccatc 6961 taatgggaag gagagaggag ggagcaacca taggattctc aatggacatt gacctgcggc 7021 cagcctcagc ttgggccatc tatgctgcct tgacaacttt cattacccca gccgtccaac 7081 atgcagtgac cacttcatac aacaactact ccttaatggc gatggccacg caagctggag 7141 tgttgtttgg tatgggcaaa gggatgccat tctacgcatg ggactttgga gtcccgctgc 7201 taatgatagg ttgctactca caattaacac ccctgaccct aatagtggcc atcattttgc 7261 tcgtggcgca ctacatgtac ttgatcccag ggctgcaggc agcagctgcg cgtgctgccc 7321 agaagagaac ggcagctggc atcatgaaga accctgttgt ggatggaata gtggtgactg 7381 acattgacac aatgacaatt gacccccaag tggagaaaaa gatgggacag gtgctactca 7441 tagcagtagc agtctccagc gccatactgt cgcggaccgc ctgggggtgg ggggaggctg 7501 gggccctgat cacagccgca acttccactt tgtgggaagg ctctccgaac aagtactgga 7561 actcctctac agccacttca ctgtgtaaca tttttagggg aagttacttg gctggagctt 7621 ctctaatcta catagtaaca agaaacgctg gcttggtcaa gagacgtggg ggtggaacag 7681 gagagaccct gggagagaaa tggaaggccc gcttgaacca gatgtcggcc ctggagttct 7741 actcctacaa aaagtcaggc atcaccgagg tgtgcagaga agaggcccgc cgcgccctca 7801 aggatggtgt ggcaacggga ggccatgctg tgtcccgagg aagtgcaaag ctgagatggt 7861 tggtggagcg gggatacctg cagccctatg gaaaggtcat tgatcttgga tgtggcagag 7921 ggggctggag ttactacgcc gccaccatcc gcaaagttca agaagtgaaa ggatacacaa 7981 aaggaggccc tggtcatgaa gaacccgtgt tggtgcaaag ctatgggtgg aacatagtcc 8041 gtcttaagag tggggtggac gtctttcata tggcggctga gccgtgtgac acgttgctgt 8101 gtgacatagg tgagtcatca tctagtcctg aagtggaaga agcacggacg ctcagagtcc 8161 tctccatggt gggggattgg cttgaaaaaa gaccaggagc cttttgtata aaagtgttgt 8221 gcccatacac cagcactatg atggaaaccc tggagcgact gcagcgtagg tatgggggag 8281 gactggtcag agtgccactc tcccgcaact ctacacatga gatgtactgg gtctctggag 8341 cgaaaagcaa caccataaaa agtgtgtcca ccacgagcca gctcctcttg gggcgcatgg 8401 acgggcctag gaggccagtg aaatatgagg aggatgtgaa tctcggctct ggcacgcggg 8461 ctgtggtaag ctgcgctgaa gctcccaaca tgaagatcat tggtaaccgc attgaaagga 8521 tccgcagtga gcacgcggaa acgtggttct ttgacgagaa ccacccatat aggacatggg 8581 cttaccatgg aagctatgag gcccccacac aagggtcagc gtcctctcta ataaacgggg 8641 ttgtcaggct cctgtcaaaa ccctgggatg tggtgactgg agtcacagga atagccatga 8701 ccgacaccac accgtatggt cagcaaagag ttttcaagga aaaagtggac actagggtgc 8761 cagaccccca agaaggcact cgtcaggtta tgagcatggt ctcttcctgg ttgtggaaag 8821 agctaggcaa acacaaacgg ccacgagtct gtaccaaaga agagttcatc aacaaggttc 8881 gtagcaatgc agcattaggg gcaatatttg aagaggaaaa agagtggaag actgcagtgg 8941 aagctgtgaa cgatccaagg ttctgggctc tagtggacaa ggaaagagag caccacctga 9001 gaggagagtg ccagagttgt gtgtacaaca tgatgggaaa aagagaaaag aaacaagggg 9061 aatttggaaa ggccaagggc agccgcgcca tctggtatat gtggctaggg gctagatttc 9121 tagagttcga agcccttgga ttcttgaacg aggatcactg gatggggaga gagaactcag 9181 gaggtggtgt tgaagggctg ggattacaaa gactcggata tgtcctagaa gagatgagtc 9241 gcataccagg aggaaggatg tatgcagatg acactgctgg ctgggacacc cgcatcagca 9301 ggttcgatct ggagaatgaa gctctaatca ccaaccaaat ggagaaaggg catagggcct 9361 tggcattggc cataatcaag tacacatacc aaaacaaagt ggtaaaggtc cttagaccag 9421 ctgaaaaagg gaaaacagtt atggacatta tttcgagaca agaccaaagg gggagcggac 9481 aagttgtcac ttacgctctt aacacattta ccaacctagt ggtgcaactc attcggaata 9541 tggaggctga ggaagttcta gagatgcaag acttgtggct gctgcggagg tcagagaaag 9601 tgaccaactg gttgcagagc aacggatggg ataggctcaa acgaatggca gtcagtggag 9661 atgattgcgt tgtgaagcca attgatgata ggtttgcaca tgccctcagg ttcttgaatg 9721 atatgggaaa agttaggaag gacacacaag agtggaaacc ctcaactgga tgggacaact 9781 gggaagaagt tccgttttgc tcccaccact tcaacaagct ccatctcaag gacgggaggt 9841 ccattgtggt tccctgccgc caccaagatg aactgattgg ccgggcccgc gtctctccag 9901 gggcgggatg gagcatccgg gagactgctt gcctagcaaa atcatatgcg caaatgtggc 9961 agctccttta tttccacaga agggacctcc gactgatggc caatgccatt tgttcatctg 10021 tgccagttga ctgggttcca actgggagaa ctacctggtc aatccatgga aagggagaat 10081 ggatgaccac tgaagacatg cttgtggtgt ggaacagagt gtggattgag gagaacgacc 10141 acatggaaga caagacccca gttacgaaat ggacagacat tccctatttg ggaaaaaggg 10201 aagacttgtg gtgtggatct ctcatagggc acagaccgcg caccacctgg gctgagaaca 10261 ttaaaaacac agtcaacatg gtgcgcagga tcataggtga tgaagaaaag tacatggact 10321 acctatccac ccaagttcgc tacttgggtg aagaagggtc tacacctgga gtgctgtaag 10381 caccaatctt aatgttgtca ggcctgctag tcagccacag cttggggaaa gctgtgcagc 10441 ctgtgacccc cccaggagaa gctgggaaac caagcctata gtcaggccga gaacgccatg 10501 gcacggaaga agccatgctg cctgtgagcc cctcagagga cactgagtca aaaaacccca 10561 tgcgcttgga ggcgcaggat gggaaaagaa ggtggcgacc ttccccaccc ttcaatctgg 10621 ggcctgaact ggagatcagc tgtggatctc cagaagaggg actagtggtt agaggagacc 10681 ccccggaaaa cgcaaaacag catattgacg ctgggaaaga ccagagactc catgagtttc 10741 caccacgctg gccgccaggc acagatcgcc gaatagcggc ggccggtgtg gggaaatcca 10801 tgggtctt Link to comment Share on other sites More sharing options...
niman Posted February 12, 2016 Author Report Share Posted February 12, 2016 HEALTH ZIKA VIRUS OUTBREAK FEB 10 2016, 7:01 PM ETZika Virus Found in Fetus With Severe Birth Defectby MAGGIE FOXSHARE Doctors have found the Zika virus in the brain of a fetus with severe microcephaly, providing more strong evidence that the virus gets into the brains of developing babies and can damage them.The New England Journal of Medicine has rushed publication of the report, which adds a big piece to the puzzle of whether and how the epidemic of Zika virus has caused a matching surge in birth defects in Brazil.The case provides the elements needed to virtually catch the virus in the act: A pregnant women with a Zika-like illness who was living in Brazil, a developing fetus that suddenly stopped growing, clear brain damage in the fetus and, finally, the full genome of the virus found in the brain.At the same time, the Centers for Disease Control and Prevention released details of its study of two newborns killed by microcephaly and two miscarriages in which evidence of Zika was found in the brains and placentas.FacebookTwitterGoogle PlusEmbed Living With Microcephaly 1:35"To me that just confirms what I think many of us thought it was just a matter of time before we could confirm," said Dr. Marjorie Treadwell, a specialist in high-risk pregnancies at the University of Michigan, who was not involved in the study."I think the actual isolation of the virus in the brains strengthens the thought that the Zika virus is causing these cases of microcephaly."Tatiana Avsic Zupanc of University Medical Center in Ljubljana, Slovenia, and colleagues detailed the case of a woman who showed up with a troubled pregnancy in October of last year.The 25-year-old woman had been working as a volunteer in Natal, Brazil. "She had become pregnant at the end of February 2015. During the 13th week of gestation, she had become ill with high fever," they wrote in their report. She also had severe muscle aches and an itchy rash.Zika was circulating, but her first ultrasound looked normal. She came home to Europe when she was seven months pregnant and another ultrasound showed evidence of microcephaly — a severe birth defect in which the brain is underdeveloped and in which the baby's head is also too small.She also noticed the baby wasn't moving as much as before. By 32 weeks, the fetus was clearly smaller than it should have been, with a very small head and evidence of extensive brain damage."The mother requested that the pregnancy be terminated and the procedure was subsequently approved by national and hospital ethics committees," the researchers wrote. That is very late in pregnancy to perform an abortion, but the fetus was almost certainly not going to survive.The team did an extensive autopsy. The fetus was very small but the only obvious abnormality was an extremely small head. The brain was very underdeveloped, and was scarred throughout.The brain was almost completely smooth — meaning it did not have the folds that characterize a human brain. There were many areas of dead and calcified brain tissue.FacebookTwitterGoogle PlusEmbed Zika Virus on the move: How to protect yourself 3:22"It sounds like a pretty clear case of extreme microcephaly," said Aubree Gordon, an epidemiologist at the University of Michigan who's studying the effects of viruses on pregnancy in central America.And the researchers found Zika virus in the brain of the fetus — not just traces, but the entire genome of the virus."It looks like that Zika virus 'likes' brain tissue (e.g. neurotrophism) and likely the virus can replicate in neurons of the brain," Avsic said by email. She said Zika virus may be able to stay in the brain longer than it does in other parts of the body, because the immune system is less able to reach it there. That way it can do more damage than it does to other tissues.The fetus had no evidence of any other infection that could have caused the damage and the mother did not have any of the known genetic causes of microcephaly, Avsic's team said."This really does strengthen the evidence that Zika virus is causing microcephaly," Gordon, who was not involved in the study, told NBC news.Until late last year, Zika was an obscure virus that wasn't considered much of a threat. It's a cousin of dengue, yellow fever and chikungunya viruses and, like them, is carried by mosquitoes. But Zika causes almost no symptoms in most people it infects and only mild symptoms in about 20 percent.Zika swept across Brazil last year and authorities there raised the alarm when they noticed an increase in microcephaly cases.The World Health Organization has declared the spread and its link with birth defects to be a global emergency and the U.S. Centers for Disease Control and Prevention has cautioned pregnant women to avoid areas where the virus is spreading. It's in more than two dozen countries in the Americas now. Some governments, such as El Salvador's, have advised women to avoid getting pregnant until the virus has time to settle down.It's not clear how many cases of microcephaly Zika may be responsible for. Brazil has reported a big increase in the number of cases, but some experts say that it may be that people are now reporting more cases than they did before.Zika has been found in the amniotic fluid of affected pregnancies and in the mothers. And CDC has found strong evidence of the virus in the brains of two babies that died hours after birth with microcephaly and in tissue from two miscarried fetuses with microcephaly in Brazil."CDC was able to identify the genetic material of the Zika virus in the brain," CDC Director Dr. Thomas Frieden told a hearing in Congress Wednesday."This is the strongest evidence to date that Zika virus is the cause of microcephaly."Tests that would show a definitive cause cannot be done on living children, and the body's immune system usually clears away the virus after a time, leaving the damage but making it hard to prove the virus did it.FacebookTwitterGoogle PlusEmbed Brazil Struggles to Educate Public About ZIka Virus Prevention 2:17There's evidence Zika may cause other birth defects, as well — notably to the eyes. And doctors are also checking into reports that it may cause a paralyzing neurological condition called Guillain-Barre syndrome in adults.Treadwell says it is likely that the early stages of pregnancy are the most dangerous. Other viruses known to cause birth defects, such as rubella and cytomegalovirus, are the most destructive if the mother is infected early in pregnancy. But that's not certain."The hard part is we don't know," she said. "A lot of viruses cause scarring or they can cause destruction of brain tissue. There are a lot of different possibilities."Zika and its relatives had never before been known to cross the placenta and affect a growing fetus, which is why doctors had so many doubts about whether it was doing so in Brazil. Scientists are trying to figure out if the virus has changed or if some other factors are allowing it to do so."We're not aware of any other mosquito-borne cause of birth defects," Frieden said.The World Health Organization said Wednesday that women should have access to safe contraception, and that they should be able to get abortions if they suspect microcephaly. http://www.nbcnews.com/storyline/zika-virus-outbreak/zika-virus-found-fetus-severe-birth-defect-n515966 Link to comment Share on other sites More sharing options...
Recommended Posts
Please sign in to comment
You will be able to leave a comment after signing in
Sign In Now