Rapid and sensitive identification of RNA from the emerging pathogen, coxsackievirus A6
© Zhang et al.; licensee BioMed Central Ltd. 2012
Received: 6 March 2012
Accepted: 23 November 2012
Published: 30 November 2012
Hand, foot and mouth disease (HFMD) is caused by members of the family Picornaviridae in the genus Enterovirus. It has been reported that coxsackievirus A6 (CVA6) infections are emerging as a new and major cause of epidemic HFMD. Sporadic HFMD cases positive for CVA6 were detected in the mainland of China in recent years. To strengthen the surveillance of CVA6 infections and outbreak control, the clinical diagnosis is urgently needed to distinguish the CVA6 infection disease from other infections.
In order to develop a sensitive quantitative real-time RT-PCR assay for rapid detection of CVA6 RNA, primers and probe were designed to target the VP1 gene segment of CVA6. The conservation of the target segment was firstly analyzed by bioinformatic technology. The specificity of the real-time RT-PCR was further confirmed by detecting other related viruses and standard curves were established for the sensitivity evaluation. The pharyngeal swab samples from the EV71 and CVA16 unrelated HFMD patients were applied for CVA6 detection through the established method.
Based on the primer–probe set to detect the target VP1 gene segment of CVA6, the quantitative real-time RT-PCR assay could discriminate CVA6 infection from other resemble viral diseases with a potential detection limit of 10 viral copies/ml. The specificity of the assay was determined by sequence alignment and experimentally tested on various related viruses. The standard curve showed that the amplification efficiency of templates with different concentrations of templates was almost the same (R2 >0.99). Evaluation of the established method with pharyngeal swabs samples showed good accordance with the results from serology diagnosis.
This study is the first report developing a VP1 gene-based quantitative real-time RT-PCR for rapid, stable and specific detection of CVA6 virus. The real-time RT-PCR established in this study can be used as a reliable method for early diagnosis of CVA6 infection.
KeywordsHand Foot and mouth disease Enterovirus Coxsackievirus A6 Quantitative real-time RT-PCR
Hand, foot, and mouth disease (HFMD) is characterized by fever and vesicular eruptions on the hands, feet and mouth. HFMD is caused by members of the family Picornaviridae in the genus Enterovirus. In recent years, the prevalence of HFMD in the Asia-Pacific region, especially in Southeast Asia, has greatly increased. In China, a rapid expansion of HFMD out-breaks has occurred since 2004 . In 2011, the Chinese Center for Disease Control and Prevention (China CDC) confirmed 1,619,706 cases in Mainland China including 509 deaths. Most outbreaks of HFMD were associated with the coxsackievirus A16 (CVA16) and human enterovirus 71 (EV71); however, sporadic cases involving other members of the enterovirus A species have also been reported . During Fall 2008, an outbreak of HFMD with onychomadesis (nail shedding) as a common feature occurred in Finland. And the CVA6 was confirmed as the causative agent . In 2010, an outbreak of CVA6 associated HFMD occurred in Taiwan and some patients also presented with onychomadesis and desquamation following HFMD . It was suggested that CVA6 infections may be emerging as a new and major cause of epidemic HFMD.
To strengthen the surveillance of CVA6 infections and outbreak control, an effective detection method for the CVA6 is required. According to the previous studies, the traditional method requires reference anti-sera and relies on virus culture. Neutralization tests are still considered to be the “gold standard” for the identification of the CVA6 [6, 7]. Although an indirect immunofluorescence assay (IFA) improved upon the traditional method and helped hospital laboratories deal simply with many clinical specimens, sero-diagnosis produced cross-immune responses with other enteroviruses. The molecular methods that are based on PCR and sequencing are faster and more accurate [8, 9]. Recently, reverse transcription-PCR (RT-PCR) and real-time PCR assays have been used for enterovirus detection [10, 11]. But there is still no advanced molecular detection and identification method for the CVA6 infection.
The purpose of this research is to develop a real-time PCR method based on the VP1 gene for the detection of CVA6 virus. The ability to distinguish it accurately from other members of the Enterovirus genus would be valuable. Based on the unique target, real-time RT-PCR could provide a simple and convenient identification method for the CVA6 infection.
Materials and methods
Clinical samples and viruses
This study was approved by the ethics committee of Zhejiang provincial Center for Disease Control and Prevention (CDC), China. With the permission of their parents, a total of 20 pharyngeal swabs were collected from the children patients with EV71 and CVA16 unrelated HFMD. The samples were stored in 3–5 ml of preservation solution (Hanks solution containing 100 U/ml penicillin and 100 μg/ml streptomycin) at −70°C for analysis. Poliovirus, coxsackievirus, human enterovirus 71, echovirus, rotavirus, sapovirus, norovirus, astrovirus and enteral adenovirus strains used in this study were all provided by Zhejiang provincial CDC.
Sequence analysis and designation of primers
VP1 gene sequences from CVA6 virus strains were downloaded from GenBank. The Primer Express soft-ware package (Applied Biosystems, CA, USA) was used for primer and probe designation. All the primers used in this study were synthesized by Invitrogen Co. (Invitrogen, Shanghai, China). The target segment from VP1 gene which used for CVA6 virus identification was further used for conservation analysis through BLAT (http://blast.ncbi.nlm.nih.gov/Blast.cgi) and Mega 4.0 software (Biodesign Institute, AZ, USA).
T-A cloning and sequencing
Nucleotide sequences of the primers and probe used in this study
Sequence (5′to 3′)
PCR product size (bp)
TaqMan Real time RT-PCR reaction
TagMan Real time RT-PCR reaction was performed by using the One Step PrimeScript RT-PCR Kit (TaKaRa, Dalian, China). Each reaction mixture consisted of 10 pmol of the primers CAF and CAR, 20 pmol of the probe CAP (Table 1), and 4 μl of template RNA in a final volume of 50 μl. According to the instructions, RT-PCR reactions were performed with the same condition as the conventional RT-PCR, which was described above. Fluorescence signals were measured every cycle at the end of the annealing step.
Sensitivity and specificity of real time RT-PCR assays
Instead of using CVA6 genomic nucleic acid, plasmid pMD19-T-VP1 was applied for the real-time RT-PCR sensitivity analysis here. DNA templates from tenfold serial dilutions of pMD19-T-VP1 were analyzed by the real-time RT-PCR, and the results were used to generate a standard curve.
In order to evaluate the specificity of the real time RT-PCR established in this study, genomic nucleic acid extracts from the poliovirus typeI-III; coxsackievirus A16, B1, B5, B3; human enterovirus 71; echovirus 6, 30; rotavirus A; sapovirus; norovirusII; astrovirus and enteral adenovirus strains were prepared and used as templates. The positive recombinant plasmid generated previously, (pMD19-T-VP1) was used as positive control. These extracts were analyzed in duplicate reactions on an ABI 7500 sequence detection system by the established amplifying standards. A CT value of 40 (maximum number of PCR cycles run) indicated that genomic nucleic acid from the test strains were not detected.
Real-time RT-PCR detection of clinical samples
Genomic nucleic acid extracted from all the pharyngeal swabs samples were used as templates. With the primers (CAF and CAR) and the TaqMan probe, the real-time RT-PCR developed in this study was applied for CVA6 identification. The amplification procedure was the same as described above.
PCR amplification and TA clone
Sensitivity and specificity of real time RT-PCR assay
First, GeneBank was explored to find out whether the primer sequences paired with sequences other than the target VP1 gene segment from human CVA6, but after searching through BLAST, no close hits from gene segment other than the target VP1 gene segments from human CVA6 virus were found. Then, the specificity of the established real-time RT-PCR detection system was tested by using the genomic nucleic acid from other virus of the same genus or virus which may cause the resemble symptoms. Poliovirus typeI-III; coxsackievirus A16, B1, B5, B3; human enterovirus 71; echovirus 6, 30; rotavirus A; sapovirus; norovirusII; astrovirus and enteral adenovirus have been used for specificity evaluation here, and we found that only the human CVA6 virus gave CT values over the detection limit after real-time RT-PCR detection (Figure 3C).
Identification of bacterial strains isolated from clinical samples
Human enteroviruses have more than 90 serotypes, which cause a wide spectrum of acute febrile diseases among infants and children. Hand, foot, and mouth disease; aseptic meningitis; respiratory tract illnesses; herpangina and otitis media are all could be caused by the infection of the human enteroviruses . HFMD has become an important issue for China now . A rapid expansion of HFMD outbreaks has occurred since 2004. People are still mainly concerned with EV71 and CVA16, however, little is known about the other enterovirus infections and distributions .
It has been reported that Enterovirus CVA6 was a primary pathogen associated with HFMD during a nationwide outbreak in Finland in autumn of 2008 . In 2010, an outbreak of CVA6 associated HFMD occurred in Taiwan and some patients presented with onychomadesis and desquamation following HFMD. HFMD cases were found positive for CVA6 was also detected in the mainland of China in recent years. To strengthen the CVA6 infections surveillance and outbreak control, useful diagnostic technologies are required in the clinical laboratories. The molecular methods that depend on PCR and sequencing are fast and accurate for CVA6 identification, but few associated research has been found previously.
Real-time RT-PCR is generally accepted as an accurate and cost-effective method for virus identification. We set out to design a quantitative real-time RT-PCR assay to identify and quantify CVA6 virus present in the clinical samples. VP1 gene has been widely used as the target for enteroviruses identification, which was also used here . The Primer Express software has been applied for primer designation. After bioinformatics analysis, we found the target segment only conserved present in the CVA6 strains. The similarity among the sequences from different strains is above 90%. So it is considered to be a good target for CVA6 virus identification.
The real-time RT-PCR assay for diagnosis of CVA6 virus infection has many advantages over conventional methods, either for detection limit or specificity. The standard curve showed that the amplification efficiency of templates with different concentrations of DNA was almost the same and the maximum sensitivity was 10 copies/ml at least. Specificity investigation of the real-time qRT-PCR assay revealed that only the templates of the CVA6 RNA showed a positive detection results.
Finally, real-time qRT-PCR established in this study was further applied to identify the HFMD clinical samples. Interestingly, 40% of the EV71 and CVA16 unrelated HFMD clinical samples were identified as CVA6 virus infection. So the CVA6 virus seems to be a primary pathogen associated with HFMD besides EV71 and CVA16. Though the majority of HFMD cases are caused by EV71 and CVA16 infections here in China, when diagnosis of the HFMD cases shows RT-PCR positive for enterovirus but negative for EV71 and CVA16, it is necessary to use the method established here for further identification.
In conclusion, the real-time RT-PCR assay for CVA6 detection presented in this report provided a reliable tool for early clinical diagnosis, which will enhance the diagnostic capacity of epidemiological surveillance and guide clinical treatment for CVA6 infection.
This work was supported by grants from Provincial Medical Research Fund of Zhejiang, China (U201129691), General Administration of Quality Supervision, Inspection and Quarantine of P.R.C. (20100043) and Monitor Technology Platform of Infectious Diseases of the State Major Science and Technology Special Projects during the 12th five-year plan of China (2012ZX10004-210).
- Ooi MH, Wong SC, Lewthwaite P, Cardosa MJ, Solomon T: Clinical features, diagnosis, and management of enterovirus 71. Lancet Neurol 2010, 9:1097–1105.PubMedView Article
- Yang F, Zhang T, Hu Y, Wang X, Du J, Li Y, Sun S, Sun X, Li Z, Jin Q: Survey of enterovirus infections from hand, foot and mouth disease outbreak in China, 2009. Virol J 2011, 8:508.PubMedView Article
- Wu Y, Yeo A, Phoon MC, Tan EL, Poh CL, Quak SH, Chow VT: The largest outbreak of hand; foot and mouth disease in Singapore in 2008: the role of enterovirus 71 and coxsackievirus A strains. Int J Infect Dis 2010, 14:e1076-e1081.PubMedView Article
- Osterback R, Vuorinen T, Linna M, Susi P, Hyypiä T, Waris M: Coxsackievirus A6 and hand, foot, and mouth disease. Finland. Emerg Infect Dis 2009, 15:1485–1488.View Article
- Wei SH, Huang YP, Liu MC, Tsou TP, Lin HC, Lin TL, Tsai CY, Chao YN, Chang LY, Hsu CM: An outbreak of coxsackievirus A6 hand, foot, and mouth disease associated with onychomadesis in Taiwan, 2010. BMC Infect Dis 2011, 11:346.PubMedView Article
- Lin TL, Li YS, Huang CW, Hsu CC, Wu HS, Tseng TC, Yang CF: Rapid and highly sensitive coxsackievirus a indirect immunofluorescence assay typing kit for enterovirus serotyping. J Clin Microbiol 2008, 46:785–788.PubMedView Article
- She RC, Preobrazhensky SN, Taggart EW, Petti CA, Bahler DW: Flow cytometric detection and serotyping of enterovirus for the clinical laboratory. J Virol Methods 2009, 162:245–250.PubMedView Article
- Mackay IM, Arden KE, Nitsche A: Real-time PCR in virology. Nucleic Acids Res 2002, 30:1292–1305.PubMedView Article
- Kaltenboeck B, Wang C: Advances in real-time PCR: application to clinical laboratory diagnostics. Adv Clin Chem 2005, 40:219–259.PubMedView Article
- Petitjean J, Vabret A, Dina J, Gouarin S, Freymuth F: Development and evaluation of a real-time RT-PCR assay on the LightCycler for the rapid detection of enterovirus in cerebrospinal fluid specimens. J Clin Virol 2006, 35:278–284.PubMedView Article
- Piqueur MA, Verstrepen WA, Bruynseels P, Mertens AH: Improvement of a real-time RT-PCR assay for the detection of enterovirus RNA. Virol J 2009, 6:95.PubMedView Article
- Fujimoto T, Iizuka S, Enomoto M, Abe K, Yamashita K, Hanaoka N, Okabe N, Yoshida H, Yasui Y, Kobayashi M, Fujii Y, Tanaka H, Yamamoto M, Shimizu H: Hand, foot, and mouth disease caused by coxsackievirus a6, Japan, 2011. Emerg Infect Dis 2012, 18:337–339.PubMedView Article
- Han JF, Jiang T, Fan XL, Yang LM, Yu M, Cao RY, Wang JZ, Qin ED, Qin CF: Recombination of human coxsackievirus b5 in hand, foot, and mouth disease patients, china. Emerg Infect Dis 2012, 18:351–353.PubMedView Article
- Zhang Y, Wang D, Yan D, Zhu S, Liu J, Wang H, Zhao S, Yu D, Nan L, An J, Chen L, An H, Xu A, Xu W: Molecular evidence of persistent epidemic and evolution of subgenotype B1 coxsackievirus A16-associated hand, foot, and mouth disease in China. J Clin Microbiol 2010, 48:619–622.PubMedView Article
- Blomqvist S, Klemola P, Kaijalainen S, Paananen A, Simonen ML, Vuorinen T, Roivainen M: Co-circulation of coxsackieviruses A6 and A10 in hand, foot and mouth disease outbreak in Finland. J Clin Virol 2010, 48:49–54.PubMedView Article
- Chen L, Mou X, Zhang Q, Li Y, Lin J, Liu F, Yuan L, Tang Y, Xiang C: Detection of human enterovirus 71 and coxsackievirus A16 in children with hand, foot and mouth disease in China. Mol Med Report 2012, 5:1001–1004.PubMed
This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.