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Hindawi Publishing CorporationBioMed Research InternationalVolume 2013 Article ID 973516 11 pageshttpdxdoiorg1011552013973516

Review ArticleMolecular Mechanisms Involved in the Pathogenesis ofAlphavirus-Induced Arthritis

Iranaia Assunccedilatildeo-Miranda1 Christine Cruz-Oliveira2 and Andrea T Da Poian2

1 Departamento de Virologia Instituto de Microbiologia Professor Paulo de Goes Universidade Federal do Rio de Janeiro21941-902 Rio de Janeiro RJ Brazil

2 Programa de Biologia Estrutural Instituto de Bioquımica Medica Universidade Federal do Rio de JaneiroAvenida Carlos Chagas Filho 373 21941-902 Rio de Janeiro RJ Brazil

Correspondence should be addressed to Andrea T Da Poian dapoianbioqmedufrjbr

Received 8 June 2013 Accepted 22 July 2013

Academic Editor Aldo Manzin

Copyright copy 2013 Iranaia Assuncao-Miranda et al This is an open access article distributed under the Creative CommonsAttribution License which permits unrestricted use distribution and reproduction in any medium provided the original work isproperly cited

Arthritogenic alphaviruses including Ross River virus (RRV) Chikungunya virus (CHIKV) Sindbis virus (SINV) Mayarovirus (MAYV) Orsquonyong-nyong virus (ONNV) and Barmah Forest virus (BFV) cause incapacitating and long lasting articulardiseasemyalgia Outbreaks of viral arthritis and the global distribution of these diseases point to the emergence of arthritogenicalphaviruses as an important public health problem This review discusses the molecular mechanisms involved in alphavirus-induced arthritis exploring the recent data obtained with in vitro systems and in vivo studies using animal models and samplesfrom patientsThe factors associated to the extension and persistence of symptoms are highlighted focusing on (a) virus replicationin target cells and tissues including macrophages and muscle cells (b) the inflammatory and immune responses with recruitmentand activation of macrophage NK cells and T lymphocytes to the lesion focus and the increase of inflammatory mediators levelsand (c) the persistence of virus or viral products in joint and muscle tissues We also discuss the importance of the establishmentof novel animal models to test new molecular targets and to develop more efficient and selective drugs to treat these diseases

1 Introduction

Alphaviruses are enveloped single-stranded positive-senseRNA viruses that belong to the Togaviridae family Theyare transmitted to humans through the bite of mosquitosfrom the genera Culex sp and Aedes (A albopictus and Aaegypti) in a cycle involving vertebrate reservoir hosts [1 2]Alphaviruses are subgrouped accordingly to the prevalence ofthe clinical symptoms they cause in humansThe encephaliticalphaviruses occur in the Americas and are associatedwith severe and lethal encephalitis This group includesthe Venezuelan Eastern and Western equine encephalitisviruses [3] The arthritogenic group causes incapacitatingand long lasting articular diseasemyalgia and comprisesthe Ross River virus (RRV) Chikungunya virus (CHIKV)Sindbis virus (SINV)Mayaro virus (MAYV)Orsquonyong-nyongvirus (ONNV) and Barmah Forest virus (BFV) [2 4]

These viruses are globally distributed and are responsible forendemic diseases in some regions (Table 1)

Epidemiological studies on alphavirusesrsquo infections arerestricted due to insufficient surveillance and laboratorydiagnostic analyses in most endemic countries which resultin an underestimation of the numbers of cases [5 6] Sim-ilarities between the clinical manifestations of the diseasescaused by alphaviruses and those caused by others virussuch as dengue virus (a member of the Flaviviridae family)or Oropouche virus (a member of the Bunyaviridae family)also make the diagnosis difficult [7 8] This is especiallyfrequent in the case of MAYV infections in which thelimited diagnosis of cases makes the illness largely unknown[6 8 9] Studies on CHIKV infection were also limitedbefore the epidemics at the La Reunion Island a Frenchterritory in the southwest Indian Ocean where more than200000 habitants were infected between 2005 and 2007 [10

2 BioMed Research International

Table 1 Occurrence and geographic distribution of arthritogenic alphaviruses

Virus First description Geographic distribution Occurrence References

RRV 1928 in New SouthWales Australia

Australia Papua NewGuinea Solomon Islandsand the South Pacific Islands

Endemic in Australia and Papua New Guinea annualepidemics in Australia (sim4000 cases per year)Major epidemicssim60000 cases in 1979 in Pacific Islandssim8000 cases in 1996 in Australia

[2 4 23]

SINV 1952 in Sindbis villagenear Cairo Egypt

Europe Asia Africa andOceania

Endemic in North EuropeOutbreaks in Finland Norway Sweden and Russia (latesummer or early autumn)

[2 4 21]

CHIKV 1952 in NewalaTanzania

Africa and Asia(documented cases inEurope USA and Oceania)

Sporadic epidemics in Africa and Asia imported casesreported in Europe and USAMajor epidemicssim300000 cases in 2006-2006 in La Reunion (FrenchIndian Ocean territory)sim14ndash65 million cases in 2006-2007 in India

[4 59 60]

MAYV 1954 in Trinidad andTobago Northern South America Endemic in tropical regions of South America

Sporadic outbreaks Pan-Amazonia forest regions [4 8 19]

ONNV 1959 in northernUganda Africa

Rare epidemics in Africa (disappeared for 35 yearsfrom 1961 to 1996)sim2 million cases in 1959ndash1961 in East Africa

[2 4]

BFV 1974 in the BarmahForest Australia Australia Annual epidemics in Australia (sim1000 cases per year) [4 25]

11] In this outbreak more than 50 of CHIKV-infectedadults presented a severe disease with persistent joint pain[12ndash14] After this CHIKV epidemics several other casesof CHIKV infection were described in many countries andsystematic efforts on the investigation of the pathogenesis ofCHIKV infection allowed a rapid increase in the knowledgeregarding the disease [11 15 16] In contrast epidemics ofONNV infection which promote a disease similar to thatcaused by CHIKV have been described in Africa since 1959although ONNV and the pathogenesis of its infection haveremained unstudied so far [17 18] The outbreaks of RRVSINV CHIKV and some descriptions of MAYV cases arenowadays considered sufficient to point the emergence orreemergence of arthritogenic alphaviruses as an importantpublic health problem with challenges on vector control anddevelopment of new strategies to prevent and treat thesediseases [19 20]

In this review we aimed at discussing the molecularmechanisms that may be associated with exacerbation ofmusculararticular damage and with the establishment ofarthritis as well as the persistence of symptoms of thealphavirus infection exploring recent data obtained with invitro systems and in vivo studies using animal models andsamples from patients

2 Alphavirus-Induced Arthritis

Arthritogenic alphaviruses usually cause an acute diseasewith the onset of symptoms after 3ndash10 days after infectionand a short (4ndash7 days) viremia period [18 21ndash23] Theclinical manifestations include fever headache rash fatiguearthritis arthralgia and muscular pain [4] Rash occurs in

over 40 of the cases and may appear before simultaneouslyor after arthralgia symptoms lasting 7ndash10 days [23ndash26] Fevercan be absent in some cases mainly in SINV RRV and BFVinfections [21 26 27] Arthritis is the most prevalent amongthe symptoms with the recovery from pain and swellingoccurring after some days of infection although severalreports describe the persistence of joint manifestations formonths or even years [2 19 22 28ndash31] Joint pain andinflammation mainly affect symmetrically the small joints(such as those from fingers wrists and tarsus) but eventuallyoccur in the large joints (such as those from knees andshoulders) andmay also involve several joints simultaneously(polyarthralgypolyarthritis) [13 21 29 30] Besides rashand arthritis myalgia is a very common symptom duringalphaviruses infection demonstrating also the virus tropismfor the muscular tissue [32]

Cellular inflammatory infiltration in joint muscle andassociated tissues during alphavirus infection has beenreported in some mouse models of RRV SINV and CHIKVinfection suggesting that muscular and articular damage isan immunopathological inflammatory disorder [33ndash35] InRRV and CHIKV infection the cellular infiltrate reachessynovial tissue which shows a strong hyperplasia [34 36 37]Monocytes macrophages NK cells and CD4+ and CD8+ Tlymphocytes are the main cellular components of the inflam-matory infiltrate in animalmodels indicating an involvementof these cells in the pathogenesis of the arthritis induced byalphaviruses [34 36ndash38] In agreementwith the data obtainedin animal models macrophages and NK cells have beendetected in synovial exudates from RRV infected patients[39ndash41] and a pronounced increase in the plasma levels ofinflammatorymediators as well as a highCD8+ T lymphocyteactivation were found in CHIKV patients in the acute phase

BioMed Research International 3

Inoculation Acute arthritis

Muscle

Musclenecrosis

Chronic arthritisBite of infectedmosquito

Virusdissemination

Infectedlangerhanscells

Lymphnodes

Liver Spleen

Blood

IFNVirus inhibition of

Virus replication in targettissueinflammation

antiviral defenseVirus

replication

Inflammation and immuneInflammation

persistenceresponse acivation

Myositis

Cellularinfiltrate

MCP-I IL-8 TNF IL-6MIF GM-CSF and C3

Healthyjoint

Arthriticjoint

Synoviocytes

SynovialmembraneInfiltrating

synoviocytes

activation

Articular tissueand bone

Hyperplasia ofsynovial tissue

Macrophage

Autoimmunity

Myoblasts

Virus persistencein muscle and

macrophage cellsuarr MMP

Arthralgiaarthritis

Figure 1 Pathogenesis of alphavirus-induced arthritismyositis After inoculation through the bite of an infected mosquito in the skinalphaviruses disseminate in the host organism through the bloodstream Liver spleen muscle and lymph nodes are sites of primaryreplication allowing an efficient virus spread Langerhans cells facilitate virus delivery to the lymph nodes Interferon (IFN) program is earlyactivated but the alphaviruses developed several mechanisms to inhibit this antiviral response The acute phase of the disease involves virusreplication followed by an inflammatory response in the target tissues which is characterized by an extensive infiltration of lymphocytes NKcells neutrophils and macrophages (the main component) The increase in the levels of several proinflammatory cytokines and chemokinesin the site of infection and in the plasma is associated with myositis and arthralgiaarthritis Also the secretion of metalloproteinases (MMP)in the joint tissuemay contribute to articular damage Persistence of the symptomsmay be related to the persistence of the virus or its productsin the target cells with the subsequent accumulation of inflammatory mediators such as IL-6 and GM-CSF A question that remains open iswhether an autoimmune process is associated to the persistence of the inflammatory response as observed for rheumatoid arthritis

of infection [42] Furthermore an isolated strain of CHIKVfrom La Reunion epidemics was able to induce a markedswelling of the hind foot in 6-week-old mice 7 days afterlocal subcutaneous injection which is consistent with therheumatic symptoms observed in humans [37]

Chronic arthralgia and arthritis due to alphavirus infec-tion cause clinical manifestations ranging from only a restric-tion of movements with persistence of swelling and painto a severe and incapacitating disease [14 28 29 43 44]Several studies in which patients infected with CHIKV wereaccompanied for long periods after La Reunion epidemicsconsistently demonstrated the chronic and severe manifes-tation of disease [14 31 43 45] Also long lasting myalgiaarthralgia and arthritis occur in about 25ndash55 of patientsinfected with RRV SINV and CHIKV [14 30ndash32 45ndash47] InBFV infection duration of symptoms seems to be reducedandMAYV infection is very poorly described in the literature[26] The causes of the persistence of symptoms remain

inconclusive but seem to be associated with the intensity ofthe inflammatory process the extension of articular lesionand the presence of viral products in the joint tissue as wellas due to an autoimmunity process [4 48]

3 Pathogenesis of the Arthritis Caused byAlphaviruses

After subcutaneous inoculation by the mosquito bitealphaviruses seem to be disseminated in the host throughthe lymph nodes route and the microvasculature (Figure 1)Leukopenia in acute phase of the disease is a very commonhematologic alteration in alphavirus infection suggesting aprimary replication of the virus in the leukocytes [19 49 50]Liver and spleen are also considered sites of primary viralreplication and contribute to virus dissemination [51] Afterdissemination the virus reaches bonesmuscles and articular


tissues generating the acute phase of the disease whichis strongly associated with a local inflammatory process[34ndash37 52] Host age the status of the immune system virusstrain virulence and viral persistence are key determinantsfor the pathogenesis of alphavirus infection in animals [37 5354] For examplemice susceptibility to SINV-infection seemsto involve age-dependent inflammation associatedwith stressresponse to infection [55ndash58]

Disease severity and persistence of symptoms are asso-ciated to the extension of virus replication and the pres-ence of inflammatory mediators in the plasma of patientsand in specific tissues of animal models [36] Interestinglysome cytokines secreted during alphavirus infection are thesame of those associated with the progression of rheuma-toid arthritis (RA) although inflammation in RA is clearlyassociated to an autoimmune process which has not beenconsistently demonstrated for alphavirus-induced arthritis[48 61] Despite particular differences expression analysis ofinflammatory genes in a mouse model of CHIKV infectiondemonstrated similarities between the induced genes inthis model and those induced in RA and collagen-inducedarthritis models [61] Furthermore specific polymorphismsin human leukocyte antigen (HLA) as well as autoim-munity development both conditions previously associatedto patientsrsquo predisposition to rheumatic diseases and RAwere also observed in alphavirus-induced arthritis The RA-associated alelles HLA-DRB1lowast01 and HLA-DRB1lowast04 wereidentified in CHIKV chronic patients [62] These patientswere later diagnosed for RA and some of them were positivefor autoantibodies such as the rheumatoid factor (RF) anti-CCP (cyclic citrullinated peptide) and anti-nuclear antibod-ies suggesting a role of CHIKV infection in RA initiation[62] SINV infection also seems to be associated to HLAalleles involved in rheumatic diseases in particular HLA-DRB1lowast01 [32 63] In addition SINV-infected patients showedelevated titers of autoantibodies including anti-nuclear andmitochondrial antibodies with significant increase in RFthree years postinfection [63] Moreover HLA-DR7 has beenshown to be increased in patients with polyarthritis follow-ing RRV infection [64] Taken together these observationssuggest that RA and alphavirus-induced arthritis share aset of common characteristics that could be useful in thedevelopment of therapeutic approaches against viral arthritis

31 Role of the Target Cells for Alphavirus Replication inthe Pathogenesis of Arthritis Articular and nonarticular cellsare involved in alphavirus replication and disseminationExperimental models of alphavirus-induced arthritis suggestthat pathogenesis results from a combination of a directcellular and tissue damage caused by virus replication andan indirect immune response activation in target tissues[34 37 65] Several cell types have been described as targetsfor arthritogenic alphavirus replication including cells fromjoints bones and muscles as well as immune cells infiltratedin the synovium and in the infected tissues (Figure 1)highlighting the association between the tissues affected byvirus replication and the local inflammatory process in thepathogenesis of alphavirus-induced arthritis

SINV causes a persistent infection with periodic appear-ance of cytopathic effects in mouse fibroblasts cultures[66 67] In adult mice SINV replicates in the periosteumtendons and endosteum of long bones [35] AdditionallySINVhas been isolated from amuscle biopsy of a patient withchronic myalgia and arthralgia 6 months after onset of thesymptoms indicating virus persistence in muscle cells [32]This isolated virus was able to replicate in human myoblastsand myotubes cells in vitro confirming virus tropism tomuscle cells Muscle necrosis accompanied by a massiveinfiltration of inflammatory cells has been observed inmousemodels for RRV and CHIKV infection [34 36 68 69] Fur-thermore CHIKV antigens were detected in skeletal muscleprogenitor cells in patient biopsies during both the acutephase of CHIKV infection and the late recurrent symp-tomatic phase of the disease with muscle necrosis and aninflammatory infiltrate observed in late phase [70] The longlasting replication of RRV and CHIKV in muscle cells hasbeen also supported by studies in vitro using primary mouseand human skeletal muscle cells respectively [70 71] rein-forcing that viral replication in muscle cells is closely associ-ated with acute and chronic myalgia observed in patients

Macrophage has been described as the main componentof cellular infiltrate observed in the injured tissues afteralphavirus infection in vivo [34 51] The first evidence andthe characterization of the central role of macrophage inarthritis pathogenesis have been demonstrated in studieswith RRV RRV antigens were detected in synovial mono-cytesmacrophages of patients after the beginning of thesymptoms onset [47] Furthermore lineages ofmousemono-cytesmacrophages infected with RRV in vitro supported acontinuous production of viruses for over 50 days after infec-tion with restricted cytopathic effects [33 72] Additionallypharmacological depletion of macrophages in mouse modelsof RRV and CHIKV infection resulted in lesser extent ofmusculararticular damage demonstrating the importance ofmacrophages for disease progression [33 37 73] The abilityof other alphaviruses besides RRV to replicate and persist inmacrophages has also been demonstrated [74ndash76] Primaryhumanmonocytes andmacrophages infected with SINV andCHIKV showed a highly productive viral replication [75 76]In an immunocompetent nonhuman primate animal modelof CHIKV infection viral RNA was found 90 days postin-fection mainly in spleen and lymph nodes and macrophagesappear to be the primary cells responsible for viral persistencein late stages of infection in this model [51] Contributionof macrophages to the disease establishment may be due toan association between the maintenance of viral replicationand the synthesis of inflammatory mediators in damagedtissue (Figure 1) Additionally soluble factors secreted frommacrophage can amplify the inflammatory process recruitingand activating lymphocytes and NK cells to target tissues[42 49] Thus macrophages seem to be the most suitablecandidate for viral reservoirs in affected tissues playing acentral role in alphavirus-induced arthritis

32 Immune Response and Inflammatory Mediators in Alpha-virus-Induced Pathology Several clinical in vivo and in


vitro studies have been carried out to further elucidate theinflammatory process triggered by alphavirus infection andits participation in arthritis pathogenesis

To investigate the role of cellular immune response dur-ing alphavirus infection several animal models of arthritisinduced by RRV CHIKV or ONNV were developed Severeinflammation was observed in bone joint andmuscle tissuesin a mouse model of RRV infection [34] and this inflam-matory process was not altered in infected mice deficient inthe recombinase activating gene (RAGminusminus) which lack thefunctional T and B lymphocytes [34] Furthermore a recentstudy with adult RAG2minusminus CD4minusminus and CD8minusminus CHIKV-infected mice demonstrated that CHIKV-specific CD4+ butnot CD8+ T cells are involved in joint swelling [77] Togetherthese observations suggest that adaptive immune responsehas a restricted role in RRV and CHIKV disease pathologyIn contrast pharmacologic depletion ofmacrophages inmiceinfected with RRV resulted in the abrogation of diseasesymptoms and in a lower expression levels of IFN-120574 TNF-120572 IL-120573 MCP-1 and MIP-1120572 in muscle and joint tissues whencompared to RRV-infected undepleted mice [38 73] More-over neutralization of IFN-120574 TNF-120572 and MCP-1 reducedthe clinical score of RRV-infected mice [73] Similar effects ofmacrophages depletion was also evident in CHIKV infectiondemonstrating a critical role of innate immunity in diseaseprogression [37] This was reinforced by the observation thatCHIKV-infected patients who developed chronic symptomsshowed an intense activation of several immune cells in theacute phase of the disease including the DC NK CD4+ andCD8+ cells [31]

Infection by arthritogenic alphaviruses results in theproduction of a broad range of cytokines and chemokineswhich were systematically detected through distinct exper-imental approaches (Table 2) The profile of these inflam-matory mediators has been associated with the severity andpersistence of infection Proinflammatory mediators suchas IL-6 TNF-120572 IFN-120572120573 and IFN-120574 were detected in thesera from RRV-infected and CHIKV-infected mice as wellas CHIKV-infected nonhuman primates [37 51 73 79] Theviremia phase was correlated to increased serum levels ofseveral chemokines such as MCP-1 RANTES and IP-10 aswell as an increase in their mRNA expression in the affectedtissues [37 51 73 79] A strong local activation of the IFN-120574 program was also demonstrated in the symptomatic phaseof the disease [79] In agreement with these observations invitro studies showed an increased expression of IL-8 MCP-1 and GM-CSF in synovial fibroblasts infected with RRV[78] Consistently CHIKV infection of a mouse macrophagelineage was associated with an enhanced production of TNF-120572 IL-6 and GM-CSF [74] In addition primary humanosteoblasts were shown to be susceptible to CHIKV infectionin vitro and infection induced IL-6 and RANKL secretionby these cells with similar kinetics while osteoprotegerinsecretion was gradually inhibited [52] Thus infection ofosteoblasts by CHIKV and the consequent IL-6 produc-tion may contribute to bone loss and to the occurrenceof arthralgia and arthritis [52] Interestingly a comparisonbetween CHIKV-induced and RA-induced gene expression

in mouse models showed a remarkable similarity regardingthe immune mediators including IFNs IL-4 IL-10 TNF-120572IL-15 GM-CSF IL-8 and lymphotoxin B [61] Furthermorethe overlap of gene expression profile between these twodiseases increases with severity

In a clinical study CHIKV-infected patients in Singaporethe plasma levels of several cytokines and chemokinesincluding IFN-120572 IL-6 IL-12 GM-CSF IP-10 and MCP-1 correlate with the viral load and plasma levels of IL-6 and GM-CSF were significantly increased in patientswith persistent arthralgia [50] In similar clinical studieshigher levels of IL-1120573 IL-10 and IL-6 were also detected inpatient sera being IL-1120573 and IL-6 identified as biomarkersof disease severity and persistence [80] In addition IL-6has been associated with the generation of joint pain [83]which reinforces the importance of this cytokine in theprogression of disease Besides cytokines chemokines suchas MCP-1 MIP-1120572 and MIP-1120573 were increased during thechronic phase of CHIKV infection [81] Elevated levels ofMCP-1 were also found in RRV-infected patients [73] Onthe other hand low levels of RANTES were observed insevere and chronic patients [80 81] Another clinical studyperformed during a CHIKV outbreak in Italy showed thatIL-6 and the chemokines CXCL9MIG MCP-1 and IP-10were significantly increased in acute phase of disease [82]In the same work CXCL9MIG IP-10 and high titers ofIgG were found in patients with mild and severe symptomssix months after initial infection when compared to recov-ered patients suggesting that these factors may be used asdisease severity markers [82] These findings show again aremarkable similarity between alphavirus-induced arthritisand RA in which CXCL9MIG and IP-10 are also usedas disease markers [84ndash88] Also IgG antibodies seem tobe implicated in alphavirus infection as well as in RA inwhich these antibodies act through the activation of the mastcells leading to synovial destruction and immune complexformation within the joint [89 90]

MCP-1 levels are increased in patients in the major-ity of the clinical studies of alphavirus-induced arthri-tis [50 73 81 82] suggesting an important role of thischemokine in recruitment of inflammatory cells to injuredtissues In CHIKV-infected patients MCP-1 IL-6 and IL-8 levels were higher in synovial fluids than in the serasuggesting an active monocytemacrophage trafficking intothe synovial tissue High levels of matrix metalloproteinase-2 (MMP2) were also found in the synovial tissue of onechronic patient which would be one of the factors involvedin tissue lesion [31] In agreement inhibition ofMCP-1 actionin animal models of RRV and CHIKV infection reducesinflammatory infiltrated also supporting this hypothesis [9192] MIF a key cytokine in RA has also been implicatedin the exacerbation of the inflammatory process in RRVand SINV infection [65 76] In RA MIF stimulates synovialmacrophages to release several cytokines and thematrixmet-alloproteinases MPP1 and 3 contributing to tissue destruc-tion in the joints [93 94] Likewise we have demonstratedthat SINV replication in human macrophages induced MIFTNF-120572 IL-1120573 and IL-6 secretion followed by an enhancingin the expression of MMP1 and 3 and that cytokine secretion


Table 2 Inflammatory mediators in arthritogenic alphaviruses infection

Virus Cell cultures infectedin vitro Animal models Patients References

Acute phase Chronic phase

RRV IL-8 GM-CSF MCP-1 MIF MCP-1 MIP-1120572TNF-120572 IL-1120573 IFN-120574

TNF-120572 IFN-120574MCP-1 [65 73 78]

CHIKV IL-6 TNF-120572GM-CSF MCP-1

IFN-120572120573 IFN-120574 KCMCP-1 IP-10 IL-6IL-10 IL-1120573 TNF-120572IL-15 GM-CSF

IL-6 IFN-120572 IP-10IL-12 IL-1Ra MCP-1IL-10 IL-15 MIG

IL-6 GM-CSF IL-1120573IL-8 IL-1Ra MCP-1MIP-1120572 MIP-1120573

[31 37 50ndash52 61 74 79ndash82]

SINV IL-6 TNF-120572 IL-1120573MIF [76]

and MMP expression were primarily regulated by MIF [76]Additionally RRV infection of MIF-deficient mice caused amild disease when compared to that developed in wild-typeanimals with inflammatory infiltrate reduction accompaniedby a lower expression of MCP-1 and IFN-120574 in muscle andjoints leading to a decrease in muscle tissue destructionalthough the viral titers were similar [65] As expectedRRV-infected wild-type mice treated with recombinant MIFdeveloped more pronounced disease signs

33 Involvement of the Complement Cascade in the Arthri-tis Caused by Alphaviruses Complement activation wasdetected in the synovial fluids of RRV-infected patientsLevels of C3a a marker of the central complement systemC3 processing were higher in RRV-infected patients thanin patients with noninflammatory osteoarthritis [95] Inagreement with these observations recent findings obtainedusing a mouse model of RRV-induced arthritis showed thatcomplement is important to promote inflammatory tissuedestruction [95] Besides the detection of the complementactivation products in the serum and in the inflamed jointsand muscles of RRV-infected wild-type mice RRV-infectedC3-deficient mice (C3minusminus) developed a less severe diseaseand also presented much lower levels of skeletal muscledestruction despite having similar inflammatory infiltratesthan RRV-infected wild-type mice [95]

C3 receptor (CR3 or CD11bCD18 Mac-1 120572119898120573

2) binds

several different ligands including iC3b a C3 cleavagefragment As observed for C3minusminus mice RRV-infected CR3-deficient mice (CD11bminusminus) develop a less severe disease andlower tissue destruction when compared to RRV-infectedwild-type mice [96] CR3 deficiency had no effect on viralreplication and inflammatory infiltration but the expressionof the proinflammatory proteins S100A9 S100A8 and IL-6 were significantly reduced in RRV-infected C3minusminus andCD11bminusminus mice when compared to RRV-infected wild-typemice [96] In agreement the levels of heterodimeric complexformed by S100A9 and S100A8 were elevated in the sera ofpatients with RA or inflammatory muscle diseases in whichthe expression of these proteins by macrophages had beenassociated with muscle fibers degeneration [97ndash99]

The complement activation pathways that are determi-nant for the pathogenesis of RRV infection in mice were

identified using deficient mice for the key componentsof the classical (Clqminusminus) alternative (factor B Fbminusminus) ormannose binding lectin (MBLminusminus) pathways [100] RRV-infected MBLminusminus mice developed less pronounced diseasesigns with reduced tissue damage and C3 deposition inmuscle tissues On the other hand infected Clqminusminus andfBminusminusmice presentednormal disease progression and severity[100] These observations suggest that RRV infection leadsto complement activation through MBL pathway whichcontributes to RRVdisease severity In RRV-infected patientshigherMBL levels in both serumand synovial fluid correlatedwith polyarthritis severity [100] reinforcing the importanceof MBL pathway

34 Role of Alphavirus Evasion from Host Antiviral Defensein Pathogenesis Type I IFN immune response signaling isessential for the control of viral replication and could bethe key process in preventing virus dissemination towardthe target tissues and the development of alphavirus-inducedarthritis Indeed IFN-stimulated genes (ISGs) are criticalin controlling CHIKV RRV SINV and ONNV replication[17 101ndash103] In a mouse model of ONNV infection defi-ciency in STAT which couples IFN signaling increases dis-ease lethality [17]Mice deficient in type I IFNweremore sus-ceptible to CHIKV infection with a broader dissemination ofthe virus which reaches the central nervous system besidesreplicating in liver muscles and joints [54] Viperin productof an ISG has been also shown to be critical for host antiviralresponse to CHIKV infection Viperin expression togetherwith type I IFNs and some related ISGs expression was highlyinduced in PBMCs of CHIKV-infected patients with a viralload-dependent profile and CHIKV-infected mice deficientin viperin showed an enhanced viral load and a more severejoint inflammation when compared to infected wild-typemice [104] Studies using samples from a cohort CHIKV-infected patients showed a tight association between highviral load and an enhanced expression of IFN-120572120573 and severalgenes of the type I IFN signaling pathway such as IRF3 IRF7and RSAD2 (viperin encoding gene) in patients PBMCs[104] Furthermore CHIKV infection activates directly IRF3inducing the transcription of IFN-120573 itself and several ISGsthrough the activation of IPS-1 [105] In SINV infectionthe induction of type I IFN expression was also dependent


on the activation of IRF3 which occurs through the hostintracellular pattern recognition receptor (PRR)MDA5 [106]RRV has been also shown to be recognized by PRR micedeficient inMyd88 or TLR7 genes infected with RRV developmore extensive tissue damage and higher viral titers thaninfected wild-type mice [107] TLR7-deficient mice alsoproduce elevated levels of RRV specific antibodies but withlittle neutralizing activity and lower epitope affinity whencompared to RRV specific antibodies produced by wild-typemice [107] CHIKV clearance seems to be dependent onboth RIG-like receptors and TLRs which trigger a type IIFN response that acts directly in nonhematopoietic cellscontrolling CHIKV replication in the local of infection andpreventing virus dissemination [108]

Despite inducing IFN production arthritogenic alpha-viruses are able to antagonize type I IFN response (Fig-ure 1) SINV replication bypasses the need of a functionalIFN-induced phosphorylated eiF2120572 for translation using analternative pathway to locate the ribosomes on the initiationcodon of the viral RNA [109] AlthoughCHIKV induces ISGsexpression it promotes a widespread translation shutoff ofcellular genes through eiF2120572 phosphorylation by PKR whilethe translation of viral proteins is maintained [105] In lateinfection CHIKV also induces transcription shutoff of IFN-120573and ISGs In addition the nonstructural protein nsP1 antag-onizes the action of the ISG BST-2 (bone marrow stromalantigen 2 a protein impairs CHIKV particles budding fromthe infected cells) [110]

Several alphavirusesrsquo virulence factors are involved inviral persistence and evasion from the immune systemMice deficient in STAT1-dependent IFN response infectedwith CHIKV developed a much more severe muscoloskele-tal pathology with an increased viral replication in joint-associated tissues when compared to infected wild-type mice[111] supporting the hypothesis that alphavirusesrsquo abilityto inhibit the IFN-induced JAKSTAT signaling pathway isrelated to their virulence in vivo Also infection of adultmice deficient in IRF3 and IRF7 with CHIKV is lethaland mortality has been associated with an increased virusreplication and pathogenesis [112]

Genetic determinants in viral nonstructural proteins nsP1and nsP2 were also associated to the modulation of STATactivation and to the virulence in SINV and RRV [113 114]Additionally SINV nsP2 has been implicated in the devel-opment of the cytopathic effect induced by infection [115]Furthermore small-plaque mutant RRV (with mutations inE2 and nsP regions) showed increased resistance to IFN120572120573antiviral response compared to the parental strain whichallows high virus titers in mice leading to an increase in theseverity of hind limb disease myositis and mortality [116]

The induction of type I IFN response by RRV is alsodependent on whether the virus is produced by mammalianor mosquitos cells The mosquito cell-derived virus fails toinduce IFN120572120573 due to the lack of complex carbohydrateson virus particle and it seems that N-linked glycans inE2 glycoprotein from the mammalian-cell-derived virus areneeded for a strong IFN response [117 118]

Altogether these findings suggest that viremia controlin alphavirus infection depends on different factors such as

the presence of strain virulence determinants in nsP1 andnsP2 the extent of the induction of type I IFN responseduring infection as well as the virus ability to evade from thisresponse Since IFN response is activated early in the diseaseviral persistence in affected tissues during chronic phase ofarthritis might be seen as a failure in this early response

4 Concluding Remarks

Even with the recent advances in the understanding of thepathogenesis of joint damage associated with alphavirusinfection many gaps remain and need to be explored Mostof the studies are currently focused on CHIKV infection andtherefore the differences and similarities among the mech-anisms involved in arthropathy induction by the distinctalphaviruses still cannot be pointed out Improvements in thediagnostic of new cases as well as in the generation of animalmodels for the study of the arthritis induced by SINV andMAYV consist in a key challenge for the progress in a broaderunderstanding of the mechanisms involved in alphavirus-induced arthritis

The data accumulated so far indicate that the pathogen-esis involved in alphavirus-induced joint damage is deter-mined by host inflammatory response as well as by viruspersistence and virulence Inflammatory response includesthe production of cytokines chemokines and other inflam-matory mediators that are involved in macrophage NKand T cells recruitment to the sites of viral replication(Figure 1) Viral persistence could occur in target tissueas muscles and joint connective tissues but macrophagesseem to be the main viral reservoirs and may play animportant role in virus dissemination to the target tissuesChronic infection of host cells is also closely related to thechronic disease establishment and the long lasting of thesymptoms Furthermore differences in alphavirus geneticdeterminants promote virulence and evasion from the cel-lular antiviral response which may contribute to diseasedevelopment

Some efforts have been made toward the development oftherapeutic approaches against alphavirus-induced arthritisDrugs used to control inflammation in patients with RAhave been used as supportive therapy to joint symptoms inpatients infected with RRV and CHIKV but the results werelimited and variable [28 69 119] Mouse models for RRV andCHIKV infections have been useful to test drugs that controlhost inflammatory response such as bindarit an inhibitor ofMCP-1 receptor [91 92] Nonetheless the understanding ofthe mechanisms involved in the pathogenesis of alphavirus-induced arthritis as well as the establishment of novel animalmodels are essential steps to the development and charac-terization of new molecular targets and more efficient andselective drugs to treat these diseases

Authorsrsquo Contribution

Iranaia Assuncao-Miranda and Christine Cruz-Oliveira con-tributed equally to this work


Acknowledgments

Thisworkwas supported by theConselhoNacional deDesen-volvimento Cientıfico e Tecnologico (CNPq) and FundacaoCarlos Chagas Filho de Amparo a Pesquisa do Estado do Riode Janeiro (FAPERJ)

References

[1] S C Weaver and A D T Barrett ldquoTransmission cycles hostrange evolution and emergence of arboviral diseaserdquo NatureReviews Microbiology vol 2 no 10 pp 789ndash801 2004

[2] A Toivanen ldquoAlphaviruses an emerging cause of arthritisrdquoCurrent Opinion in Rheumatology vol 20 no 4 pp 486ndash4902008

[3] M A Zacks and S Paessler ldquoEncephalitic alphavirusesrdquo Veteri-nary Microbiology vol 140 no 3-4 pp 281ndash286 2010

[4] A Suhrbier M C Jaffar-Bandjee and P Gasque ldquoArthritogenicalphaviruses-an overviewrdquo Nature Reviews Rheumatology vol8 no 7 pp 420ndash429 2012

[5] N Storm JWeyerWMarkotter et al ldquoHuman cases of Sindbisfever in South Africa 2006ndash2010rdquo Epidemiology and Infection2013

[6] K C Long S A Ziegler S Thangamani et al ldquoExperimentaltransmission of Mayaro virus by Aedes aegyptirdquo The AmericanJournal of TropicalMedicine andHygiene vol 85 no 4 pp 750ndash757 2011

[7] M N Islam M A Hossain M A Khaleque et al ldquoChikun-gunya virus infection a threat to public healthrdquo MymensinghMedical Journal vol 21 no 2 pp 372ndash376 2012

[8] MMunoz and J C Navarro ldquoMayaro a re-emerging Arbovirusin Venezuela and Latin Americardquo Biomedica vol 32 no 2 pp286ndash302 2012

[9] F Abad-Franch G H Grimmer V S de Paula L T MFigueiredo W S M Braga and S L B Luz ldquoMayaro virusinfection in amazonia a multimodel inference approach to riskfactor assessmentrdquo PLOS Neglected Tropical Diseases vol 6 no10 Article ID e1846 2012

[10] F Staikowsky F Talarmin PGrivard et al ldquoProspective study ofChikungunya virus acute infection in the Island of La Reunionduring the 2005-2006 outbreakrdquo PLoS ONE vol 4 no 10Article ID e7603 2009

[11] K A Jansen ldquoThe 2005ndash2007 Chikungunya epidemic inreunion ambiguous etiologies memories and meaning-makingrdquoMedical Anthropology vol 32 no 2 pp 174ndash189 2013

[12] F Simon E Javelle M Oliver I Leparc-Goffart and CMarimoutou ldquoChikungunya virus infectionrdquoCurrent InfectiousDisease Reports vol 13 no 3 pp 218ndash228 2011

[13] B Queyriaux F Simon M Grandadam R Michel H Tolouand J Boutin ldquoClinical burden of Chikungunya virus infectionrdquoThe Lancet Infectious Diseases vol 8 no 1 pp 2ndash3 2008

[14] G Borgherini P Poubeau A Jossaume et al ldquoPersistentarthralgia associated with Chikungunya virus a study of 88adult patients on Reunion Islandrdquo Clinical Infectious Diseasesvol 47 no 4 pp 469ndash475 2008

[15] YMizuno Y Kato N Takeshita et al ldquoClinical and radiologicalfeatures of imported Chikungunya fever in Japan a study ofsix cases at the national center for global health and medicinerdquoJournal of Infection and Chemotherapy vol 17 no 3 pp 419ndash423 2011

[16] K B Gibney M Fischer H E Prince et al ldquoChikungunyafever in the United States a fifteen year review of casesrdquoClinicalInfectious Diseases vol 52 no 5 pp e121ndashe126 2011

[17] R L Seymour S L Rossi N A Bergren K S Plante andS C Weaver ldquoThe Role of Innate versus adaptive immuneresponses in a mouse model of Orsquonyong-nyong virus infectionrdquoTheAmerican Journal of Tropical Medicine and Hygiene vol 88no 6 pp 1170ndash1179 2013

[18] N Kiwanuka E J Sanders E B Rwaguma et al ldquoOrsquonyong-nyong fever in South-Central Uganda 1996-1997 clinical fea-tures and validation of a clinical case definition for surveillancepurposesrdquo Clinical Infectious Diseases vol 29 no 5 pp 1243ndash1250 1999

[19] R B Tesh D M Watts K L Russell et al ldquoMayaro virusdisease an emerging mosquito-borne zoonosis in tropicalSouth Americardquo Clinical Infectious Diseases vol 28 no 1 pp67ndash73 1999

[20] F J Burt M S Rolph N E Rulli S Mahalingam and M THeise ldquoChikungunya a re-emerging virusrdquoTheLancet vol 379no 9816 pp 662ndash671 2012

[21] M Laine R Luukkainen and A Toivanen ldquoSindbis viruses andother alphaviruses as cause of human arthritic diseaserdquo Journalof Internal Medicine vol 256 no 6 pp 457ndash471 2004

[22] M C Jaffar-Bandjee D Ramful B A Gauzere et al ldquoEmer-gence and clinical insights into the pathology of Chikungunyavirus infectionrdquo Expert Review of Anti-Infective Therapy vol 8no 9 pp 987ndash996 2010

[23] D Harley A Sleigh and S Ritchie ldquoRoss river virus transmis-sion infection and disease a cross-disciplinary reviewrdquoClinicalMicrobiology Reviews vol 14 no 4 pp 909ndash932 2001

[24] K P Vijayakumar T S Nair Anish B George T LawrenceS C Muthukkutty and R Ramachandran ldquoClinical profile ofChikungunya patients during the epidemic of 2007 in KeralaIndiardquo Journal of Global Infectious Diseases vol 3 no 3 pp 221ndash226 2011

[25] S Naish W Hu K Mengersen and S Tong ldquoSpatio-temporalpatterns of Barmah Forest virus disease in Queensland Aus-traliardquo PLoS ONE vol 6 no 10 Article ID e25688 2011

[26] J P Flexman D W Smith J S Mackenzie et al ldquoA comparisonof the diseases caused by Ross River virus and Barmah Forestvirusrdquo Medical Journal of Australia vol 169 no 3 pp 159ndash1631998

[27] J Passmore K A OrsquoGrady R Moran and E Wishart ldquoAnoutbreak of Barmah Forest virus disease in Victoriardquo Commu-nicable Diseases Intelligence vol 26 no 4 pp 600ndash604 2002

[28] A D Mylonas A M Brown T L Carthew et al ldquoNaturalhistory of Ross River virus-induced epidemic polyarthritisrdquoMedical Journal of Australia vol 177 no 7 pp 356ndash360 2002

[29] S Kurkela T Manni J Myllynen A Vaheri and O VapalahtildquoClinical and laboratory manifestations of sindbis virus infec-tion prospective study Finland 2002-2003rdquo Journal of Infec-tious Diseases vol 191 no 11 pp 1820ndash1829 2005

[30] S Kurkela T Helve A Vaheri and O Vapalahti ldquoArthritisand arthralgia three years after Sindbis virus infection clinicalfollow-up of a cohort of 49 patientsrdquo Scandinavian Journal ofInfectious Diseases vol 40 no 2 pp 167ndash173 2008

[31] J Hoarau M J Bandjee P K Trotot et al ldquoPersistent chronicinflammation and infection by Chikungunya arthritogenicalphavirus in spite of a robust host immune responserdquo Journalof Immunology vol 184 no 10 pp 5914ndash5927 2010


[32] J Sane S Kurkela M Desdouits et al ldquoProlonged myalgia inSindbis virus infection case description and in vitro infectionof myotubes and myoblastsrdquo Journal of Infectious Diseases vol206 no 3 pp 407ndash414 2012

[33] B A Lidbury and S Mahalingam ldquoSpecific ablation of antivi-ral gene expression in macrophages by antibody-dependentenhancement of Ross River virus infectionrdquo Journal of Virologyvol 74 no 18 pp 8376ndash8381 2000

[34] T E Morrison A C Whitmore R S Shabman B A LidburyS Mahalingam and M T Heise ldquoCharacterization of RossRiver virus tropism and virus-induced inflammation in amousemodel of viral arthritis andmyositisrdquo Journal of Virology vol 80no 2 pp 737ndash749 2006

[35] M T Heise D A Simpson and R E Johnston ldquoSindbis-groupalphavirus replication in periosteum and endosteum of longbones in adult micerdquo Journal of Virology vol 74 no 19 pp9294ndash9299 2000

[36] T EMorrison LOko S AMontgomery et al ldquoAmousemodelof Chikungunya virus-induced musculoskeletal inflammatorydisease evidence of arthritis tenosynovitis myositis and per-sistencerdquoThe American Journal of Pathology vol 178 no 1 pp32ndash40 2011

[37] J Gardner I Anraku T T Le et al ldquoChikungunya virus arthritisin adult wild-type micerdquo Journal of Virology vol 84 no 16 pp8021ndash8032 2010

[38] B A Lidbury C Simeonovic G E Maxwell I D MarshallandA J Hapel ldquoMacrophage-inducedmuscle pathology resultsin morbidity and mortality for Ross River virus-infected micerdquoJournal of Infectious Diseases vol 181 no 1 pp 27ndash34 2000

[39] M Soden H Vasudevan B Roberts et al ldquoDetection of viralribonucleic acid and histologic analysis of inflamed synoviumin Ross River virus infectionrdquo Arthritis and Rheumatism vol43 no 2 pp 365ndash369 2000

[40] R A Hazelton C Hughes and J G Aaskov ldquoThe inflammatoryresponse in the synovium of a patient with Ross River arbovirusinfectionrdquoAustralian and New Zealand Journal ofMedicine vol15 no 3 pp 336ndash339 1985

[41] J R E Fraser A L Cunningham and B J Clarris ldquoCytologyof synovial effusions in epidemic polyarthritisrdquo Australian andNew Zealand Journal ofMedicine vol 11 no 2 pp 168ndash173 1981

[42] N Wauquier P Becquart D Nkoghe C Padilla A Ndjoyi-Mbiguino and E M Leroy ldquoThe acute phase of Chikungunyavirus infection in humans is associated with strong innateimmunity and T CD8 cell activationrdquo Journal of InfectiousDiseases vol 204 no 1 pp 115ndash123 2011

[43] A Chopra V Anuradha R Ghorpade and M Saluja ldquoAcuteChikungunya and persistentmusculoskeletal pain following the2006 Indian epidemic a 2-year prospective rural communitystudyrdquo Epidemiology and Infection vol 140 no 5 pp 842ndash8502012

[44] S W Brighton O W Prozesky and A L de la HarpeldquoChikungunya virus infection A retrospective study of 107casesrdquo South African Medical Journal vol 63 no 9 pp 313ndash3151983

[45] D Sissoko D Malvy K Ezzedine et al ldquoPost-epidemicChikungunya disease on Reunion Island course of rheumaticmanifestations and associated factors over a 15-month periodrdquoPLoS Neglected Tropical Diseases vol 3 no 3 article e389 2009

[46] M Laine R Luukkainen J Jalava J Ilonen P Kuusisto and AToivanen ldquoProlonged arthritis associated with Sindbis-related(Pogosta) virus infectionrdquo Rheumatology vol 39 no 11 pp1272ndash1274 2000

[47] J R E Fraser ldquoEpidemic polyarthritis and Ross River virusdiseaserdquo Clinics in Rheumatic Diseases vol 12 no 2 pp 369ndash388 1986

[48] A Suhrbier and S Mahalingam ldquoThe immunobiology of viralarthritidesrdquo Pharmacology and Therapeutics vol 124 no 3 pp301ndash308 2009

[49] L Dupuis-Maguiraga M Noret S Brun R Le Grand G Grasand P Roques ldquoChikungunya disease infection-associatedmarkers from the acute to the chronic phase of arbovirus-induced arthralgiardquo PLoS Neglected Tropical Diseases vol 6 no3 Article ID e1446 2012

[50] A Chow Z Her E K S Ong et al ldquoPersistent arthralgiainduced by Chikungunya virus infection is associated withinterleukin-6 and granulocyte macrophage colony-stimulatingfactorrdquo Journal of Infectious Diseases vol 203 no 2 pp 149ndash1572011

[51] K Labadie T Larcher C Joubert et al ldquoChikungunya diseasein nonhuman primates involves long-term viral persistence inmacrophagesrdquo Journal of Clinical Investigation vol 120 no 3pp 894ndash906 2010

[52] M Noret L Herrero N Rulli et al ldquoInterleukin 6 RANKLand osteoprotegerin expression by Chikungunya virus-infectedhuman osteoblastsrdquo Journal of Infectious Diseases vol 7 no 3pp 457ndash459 2012

[53] A Suhrbier and M L Linn ldquoClinical and pathologic aspectsof arthritis due to Ross River virus and other alphavirusesrdquoCurrent Opinion in Rheumatology vol 16 no 4 pp 374ndash3792004

[54] T Couderc F Chretien C Schilte et al ldquoA mouse modelfor Chikungunya young age and inefficient type-I interferonsignaling are risk factors for severe diseaserdquoPLoSPathogens vol4 no 2 article e29 2008

[55] J Trgovcich K Ryman P Extrom J C Eldridge J F Aronsonand R E Johnston ldquoSindbis virus infection of neonatal miceresults in a severe stress responserdquo Virology vol 227 no 1 pp234ndash238 1997

[56] J Trgovcich J F Aronson and R E Johnston ldquoFatal sindbisvirus infection of neonatal mice in the absence of encephalitisrdquoVirology vol 224 no 1 pp 73ndash83 1996

[57] W B Klimstra K D Ryman K A Bernard K B NguyenC A Biron and R E Johnston ldquoInfection of neonatal micewith sindbis virus results in a systemic inflammatory responsesyndromerdquo Journal of Virology vol 73 no 12 pp 10387ndash103981999

[58] J Trgovcich J F Aronson J C Eldridge and R E JohnstonldquoTNF120572 interferon and stress response induction as a functionof age-related susceptibility to fatal sindbis virus infection ofmicerdquo Virology vol 263 no 2 pp 339ndash348 1999

[59] O Schwartz and M L Albert ldquoBiology and pathogenesis ofChikungunya virusrdquo Nature Reviews Microbiology vol 8 no 7pp 491ndash500 2010

[60] D Mavalankar P Shastri and P Raman ldquoChikungunya epi-demic in India a major public-health disasterrdquo The LancetInfectious Diseases vol 7 no 5 pp 306ndash307 2007

[61] H I Nakaya J Gardner Y S Poo L Major B Pulendranand A Suhrbier ldquoGene profiling of Chikungunya virus arthritisin a mouse model reveals significant overlap with rheumatoidarthritisrdquo Arthritis and Rheumatism vol 64 no 11 pp 3553ndash3563 2012

[62] E Bouquillard and B Combe ldquoA report of 21 cases of rheuma-toid arthritis following Chikungunya fever A mean follow-upof two yearsrdquo Joint Bone Spine vol 76 no 6 pp 654ndash657 2009


[63] J Sane S Kurkela M L Lokki et al ldquoClinical Sindbisalphavirus infection is associated with HLA-DRB1lowast01 allele andproduction of autoantibodiesrdquo Clinical Infectious Diseases vol55 no 3 pp 358ndash363 2012

[64] J R E Fraser B Tait J G Aaskov and A L CunninghamldquoPossible genetic determinants in epidemic polyarthritis causedby Ross River virus infectionrdquo Australian and New ZealandJournal of Medicine vol 10 no 6 pp 597ndash603 1980

[65] L J Herrero M Nelson A Srikiatkhachorn et al ldquoCriticalrole for macrophage migration inhibitory factor (MIF) in RossRiver virus-induced arthritis and myositisrdquo Proceedings of theNational Academy of Sciences of the United States of Americavol 108 no 29 pp 12048ndash12053 2011

[66] A D Inglot T Chudzio and M Albin ldquoRole of incompleteviruses and interferon in persistent infection ofmouse cells withSindbis virusrdquo Acta Microbiologica Polonica A vol 5 no 3 pp181ndash182 1973

[67] A D Inglot M Albin and T Chudzio ldquoPersistent infection ofmouse cells with Sindbis virus role of virulence of strains autointerfering particles and interferonrdquo Journal of General Virologyvol 20 no 1 pp 105ndash110 1973

[68] A R Seay D E Griffin and R T Johnson ldquoExperimental viralpolymyositis age dependency and immune responses to RossRiver virus infection in micerdquoNeurology vol 31 no 6 pp 656ndash660 1981

[69] F A Murphy W P Taylor C A Mims and I D MarshallldquoPathogenesis of Ross River virus infection in mice II Muscleheart and brown fat lesionsrdquo Journal of Infectious Diseases vol127 no 2 pp 129ndash138 1973

[70] S Ozden M Huerre J Riviere et al ldquoHuman muscle satellitecells as targets of Chikungunya virus infectionrdquo PLoS ONE vol2 no 6 article e527 2007

[71] B T Eaton and A J Hapel ldquoPersistent noncytolytic togavirusinfection of primary mouse muscle cellsrdquo Virology vol 72 no1 pp 266ndash271 1976

[72] M L Linn J G Aaskov and A Suhrbier ldquoAntibody-dependentenhancement and persistence in macrophages of an arbovirusassociated with arthritisrdquo Journal of General Virology vol 77no 3 pp 407ndash411 1996

[73] B A Lidbury N E Rulli A Suhrbier et al ldquoMacrophage-derived proinflammatory factors contribute to the developmentof arthritis and myositis after infection with an arthrogenicalphavirusrdquo Journal of Infectious Diseases vol 197 no 11 pp1585ndash1593 2008

[74] S Kumar M C Jaffar-Bandjee C Giry et al ldquoMousemacrophage innate immune response to Chikungunya virusinfectionrdquo Virology Journal vol 9 article 313 2012

[75] Z Her B Malleret M Chan et al ldquoActive infection of humanblood monocytes by Chikungunya virus triggers an innateimmune responserdquo Journal of Immunology vol 184 no 10 pp5903ndash5913 2010

[76] I Assuncao-Miranda M T Bozza and A T Da Poian ldquoPro-inflammatory response resulting from sindbis virus infection ofhuman macrophages implications for the pathogenesis of viralarthritisrdquo Journal of Medical Virology vol 82 no 1 pp 164ndash1742010

[77] T H Teo F M Lum C Claser et al ldquoA pathogenic role forCD4+ T cells during Chikungunya virus infection in micerdquoJournal of Immunology vol 190 no 1 pp 259ndash269 2013

[78] L Mateo M la Linn S R McColl S Cross J Gardnerand A Suhrbier ldquoAn arthrogenic alphavirus induces monocyte

chemoattractant protein-1 and interleukin-8rdquo Intervirology vol43 no 1 pp 55ndash60 2000

[79] D R Patil S L Hundekar and V A Arankalle ldquoExpressionprofile of immune response genes during acute myopathyinduced byChikungunya virus in amousemodelrdquoMicrobes andInfection vol 14 no 5 pp 457ndash469 2012

[80] L F Ng A Chow Y J Sun et al ldquoIL-1120573 IL-6 and RANTES asbiomarkers of Chikungunya severityrdquo PLoS ONE vol 4 no 1Article ID e4261 2009

[81] I K Chaaitanya N Muruganandam S G Sundaram et alldquoRole of proinflammatory cytokines and chemokines in chronicarthropathy inCHIKV infectionrdquoViral Immunology vol 24 no4 pp 265ndash271 2011

[82] A A Kelvin D Banner G Silvi et al ldquoInflammatory cytokineexpression is associated with Chikungunya virus resolution andsymptom severityrdquo PLOS Neglected Tropical Diseases vol 5 no8 Article ID e1279 2011

[83] M Sourisseau C Schilte N Casartelli et al ldquoCharacterizationof reemerging Chikungunya virusrdquo PLoS Pathogens vol 3 no6 article e89 2007

[84] A Ueno M Yamamura M Iwahashi et al ldquoThe productionof CXCR3-agonistic chemokines by synovial fibroblasts frompatients with rheumatoid arthritisrdquo Rheumatology Interna-tional vol 25 no 5 pp 361ndash367 2005

[85] P Ruschpler P Lorenz W Eichler et al ldquoHigh CXCR3 expres-sion in synovial mast cells associated with CXCL9 and CXCL10expression in inflammatory synovial tissues of patients withrheumatoid arthritisrdquo Arthritis Research amp Therapy vol 5 no5 pp R241ndashR252 2003

[86] W P Kuan L Tam C Wong et al ldquoCXCL 9 and CXCL 10 assensitivemarkers of disease activity in patients with rheumatoidarthritisrdquo Journal of Rheumatology vol 37 no 2 pp 257ndash2642010

[87] R Hanaoka T Kasama M Muramatsu et al ldquoA novelmechanism for the regulation of IFN-120574 inducible protein-10 expression in rheumatoid arthritisrdquo Arthritis Research ampTherapy vol 5 no 2 pp R74ndashR81 2003

[88] A Aggarwal S Agarwal and R Misra ldquoChemokine andchemokine receptor analysis reveals elevated interferon-inducible protein-10 (IP)-10CXCL10 levels and increasednumber of CCR5+ and CXCR3+ CD4 T cells in synovial fluidof patients with enthesitis-related arthritis (ERA)rdquo Clinical andExperimental Immunology vol 148 no 3 pp 515ndash519 2007

[89] N Tsuboi T Ernandez X Li et al ldquoRegulation of human neu-trophil Fc120574 receptor IIa byC5a receptor promotes inflammatoryarthritis in micerdquo Arthritis and Rheumatism vol 63 no 2 pp467ndash478 2011

[90] K S Nandakumar andRHolmdahl ldquoAntibody-induced arthri-tis diseasemechanisms and genes involved at the effector phaseof arthritisrdquo Arthritis Research andTherapy vol 8 no 6 article223 2006

[91] N E Rulli M S Rolph A Srikiatkhachorn S AnantapreechaA Guglielmotti and S Mahalingam ldquoProtection from arthritisand myositis in a mouse model of acute Chikungunya virusdisease by bindarit an inhibitor of monocyte chemotacticprotein-1 synthesisrdquo Journal of Infectious Diseases vol 204 no7 pp 1026ndash1030 2011

[92] N E Rulli A Guglielmotti GMangano et al ldquoAmelioration ofalphavirus-induced arthritis and myositis in a mouse model bytreatment with bindarit an inhibitor of monocyte chemotacticproteinsrdquo Arthritis and Rheumatism vol 60 no 8 pp 2513ndash2523 2009


[93] L L Santos and E F Morand ldquoMacrophage migrationinhibitory factor a key cytokine in RA SLE and atherosclero-sisrdquo Clinica Chimica Acta vol 399 no 1-2 pp 1ndash7 2009

[94] S Onodera K Kaneda Y Mizue Y Koyama M Fujinagaand J Nishihira ldquoMacrophage migration inhibitory factor up-regulates expression of matrix metalloproteinases in synovialfibroblasts of rheumatoid arthritisrdquo The Journal of BiologicalChemistry vol 275 no 1 pp 444ndash450 2000

[95] T E Morrison R J Fraser P N Smith S Mahalingam andM T Heise ldquoComplement contributes to inflammatory tissuedestruction in a mouse model of ross river virus-induceddiseaserdquo Journal of Virology vol 81 no 10 pp 5132ndash5143 2007

[96] T E Morrison J D Simmons and M T Heise ldquoComplementreceptor 3 promotes severe Ross River virus-induced diseaserdquoJournal of Virology vol 82 no 22 pp 11263ndash11272 2008

[97] K Sunahori M Yamamura J Yamana et al ldquoThe S100A8A9heterodimer amplifies proinflammatory cytokine productionby macrophages via activation of nuclear factor 120581 B andp38 mitogen-activated protein kinase in rheumatoid arthritisrdquoArthritis Research andTherapy vol 8 no 3 article R69 2006

[98] S Seeliger T Vogl I H Engels et al ldquoExpression of calcium-binding proteins MRP8 and MRP14 in inflammatory musclediseasesrdquoThe American Journal of Pathology vol 163 no 3 pp947ndash956 2003

[99] K Odink N Cerletti J Bruggen et al ldquoTwo calcium-bindingproteins in infiltrate macrophages of rheumatoid arthritisrdquoNature vol 330 no 6143 pp 80ndash82 1987

[100] B M Gunn T E Morrison A C Whitmore et al ldquoMan-nose binding lectin is required for alphavirus-induced arthri-tismyositisrdquo PLoS Pathogens vol 8 no 3 Article ID e10025862012

[101] K D Ryman W B Klimstra K B Nguyen C A Biron andR E Johnston ldquo120572120573 interferon protects adult mice from fatalSindbis virus infection and is an important determinant of celland tissue tropismrdquo Journal of Virology vol 74 no 7 pp 3366ndash3378 2000

[102] D J Lenschow C Lai N Frias-Staheli et al ldquoIFN-stimulatedgene 15 functions as a critical antiviral molecule againstinfluenza herpes and Sindbis virusesrdquo Proceedings of theNational Academy of Sciences of the United States of Americavol 104 no 4 pp 1371ndash1376 2007

[103] A C Brehin I Casademont M Frenkiel C Julier ASakuntabhai and P Despres ldquoThe large form of human 2101584051015840-oligoadenylate synthetase (OAS3) exerts antiviral effect againstChikungunya virusrdquoVirology vol 384 no 1 pp 216ndash222 2009

[104] T S Teng S S Foo D Simamarta et al ldquoViperin restrictsChikungunya virus replication and pathologyrdquo Journal of Clin-ical Investigation vol 122 no 12 pp 4447ndash4460 2012

[105] L K White T Sali D Alvarado et al ldquoChikungunya virusinduces IPS-1-dependent innate immune activation and proteinkinase R-independent translational shutoffrdquo Journal of Virologyvol 85 no 1 pp 606ndash620 2011

[106] C W Burke C L Gardner J J Steffan K D Ryman and WB Klimstra ldquoCharacteristics of alphabeta interferon inductionafter infection of murine fibroblasts with wild-type and mutantalphavirusesrdquo Virology vol 395 no 1 pp 121ndash132 2009

[107] L M Neighbours K Long A C Whitmore and M T HeiseldquoMyd88-dependent toll-like receptor 7 signaling mediates pro-tection from severe Ross River virus-induced disease in micerdquoJournal of Virology vol 86 no 19 pp 10675ndash10685 2012

[108] C Schilte T Couderc F Chretien et al ldquoType I IFN controlsChikungunya virus via its action on nonhematopoietic cellsrdquo

Journal of Experimental Medicine vol 207 no 2 pp 429ndash4422010

[109] I VentosoM A Sanz S Molina J J Berlanga L Carrasco andM Esteban ldquoTranslational resistance of late alphavirus mRNAto eIF2120572 phosphorylation a strategy to overcome the antiviraleffect of protein kinase PKRrdquo Genes and Development vol 20no 1 pp 87ndash100 2006

[110] P H Jones M Maric M N Madison W Maury R JRoller and C M Okeoma ldquoBST-2tetherin-mediated restric-tion of Chikungunya (CHIKV) VLP budding is counteractedby CHIKV non-structural protein 1 (nsP1)rdquo Virology vol 438no 1 pp 37ndash49 2013

[111] C L Gardner C W Burke S T Higgs W B Klimstraand K D Ryman ldquoInterferon-alphabeta deficiency greatlyexacerbates arthritogenic disease in mice infected with wild-type Chikungunya virus but not with the cell culture-adaptedlive-attenuated 18125 vaccine candidaterdquo Virology vol 425 no2 pp 103ndash112 2012

[112] P A Rudd J Wilson J Gardner et al ldquoInterferon responsefactors 3 and 7 protect against Chikungunya virus hemorrhagicfever and shockrdquo Journal of Virology vol 86 no 18 pp 9888ndash9898 2012

[113] C C Cruz M S Suthar S A Montgomery et al ldquoModulationof type I IFN induction by a virulence determinant within thealphavirus nsP1 proteinrdquo Virology vol 399 no 1 pp 1ndash10 2010

[114] J D Simmons A C Wollish and M T Heise ldquoA determinantof sindbis virus neurovirulence enables efficient disruption ofJakSTAT signalingrdquo Journal of Virology vol 84 no 21 pp11429ndash11439 2010

[115] N Garmashova R Gorchakov E Frolova and I FrolovldquoSindbis virus nonstructural protein nsP2 is cytotoxic andinhibits cellular transcriptionrdquo Journal of Virology vol 80 no12 pp 5686ndash5696 2006

[116] B A Lidbury N E Rulli C M Musso et al ldquoIdentificationand characterization of a Ross River virus variant that growspersistently in macrophages shows altered disease kinetics ina mouse model and exhibits resistance to type I interferonrdquoJournal of Virology vol 85 no 11 pp 5651ndash5663 2011

[117] R S Shabman K M Rogers and M T Heise ldquoRoss river virusenvelope glycans contribute to type I interferon production inmyeloid dendritic cellsrdquo Journal of Virology vol 82 no 24 pp12374ndash12383 2008

[118] R S Shabman T E Morrison C Moore et al ldquoDifferentialinduction of type I interferon responses in myeloid dendriticcells by mosquito and mammalian-cell-derived alphavirusesrdquoJournal of Virology vol 81 no 1 pp 237ndash247 2007

[119] A D Mylonas D Harley D M Purdie et al ldquoCorticosteroidtherapy in an alphaviral arthritisrdquo Journal of Clinical Rheuma-tology vol 10 no 6 pp 326ndash330 2004

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Table 1 Occurrence and geographic distribution of arthritogenic alphaviruses

Virus First description Geographic distribution Occurrence References

RRV 1928 in New SouthWales Australia

Australia Papua NewGuinea Solomon Islandsand the South Pacific Islands

Endemic in Australia and Papua New Guinea annualepidemics in Australia (sim4000 cases per year)Major epidemicssim60000 cases in 1979 in Pacific Islandssim8000 cases in 1996 in Australia

[2 4 23]

SINV 1952 in Sindbis villagenear Cairo Egypt

Europe Asia Africa andOceania

Endemic in North EuropeOutbreaks in Finland Norway Sweden and Russia (latesummer or early autumn)

[2 4 21]

CHIKV 1952 in NewalaTanzania

Africa and Asia(documented cases inEurope USA and Oceania)

Sporadic epidemics in Africa and Asia imported casesreported in Europe and USAMajor epidemicssim300000 cases in 2006-2006 in La Reunion (FrenchIndian Ocean territory)sim14ndash65 million cases in 2006-2007 in India

[4 59 60]

MAYV 1954 in Trinidad andTobago Northern South America Endemic in tropical regions of South America

Sporadic outbreaks Pan-Amazonia forest regions [4 8 19]

ONNV 1959 in northernUganda Africa

Rare epidemics in Africa (disappeared for 35 yearsfrom 1961 to 1996)sim2 million cases in 1959ndash1961 in East Africa

[2 4]

BFV 1974 in the BarmahForest Australia Australia Annual epidemics in Australia (sim1000 cases per year) [4 25]

11] In this outbreak more than 50 of CHIKV-infectedadults presented a severe disease with persistent joint pain[12ndash14] After this CHIKV epidemics several other casesof CHIKV infection were described in many countries andsystematic efforts on the investigation of the pathogenesis ofCHIKV infection allowed a rapid increase in the knowledgeregarding the disease [11 15 16] In contrast epidemics ofONNV infection which promote a disease similar to thatcaused by CHIKV have been described in Africa since 1959although ONNV and the pathogenesis of its infection haveremained unstudied so far [17 18] The outbreaks of RRVSINV CHIKV and some descriptions of MAYV cases arenowadays considered sufficient to point the emergence orreemergence of arthritogenic alphaviruses as an importantpublic health problem with challenges on vector control anddevelopment of new strategies to prevent and treat thesediseases [19 20]

In this review we aimed at discussing the molecularmechanisms that may be associated with exacerbation ofmusculararticular damage and with the establishment ofarthritis as well as the persistence of symptoms of thealphavirus infection exploring recent data obtained with invitro systems and in vivo studies using animal models andsamples from patients

2 Alphavirus-Induced Arthritis

Arthritogenic alphaviruses usually cause an acute diseasewith the onset of symptoms after 3ndash10 days after infectionand a short (4ndash7 days) viremia period [18 21ndash23] Theclinical manifestations include fever headache rash fatiguearthritis arthralgia and muscular pain [4] Rash occurs in

over 40 of the cases and may appear before simultaneouslyor after arthralgia symptoms lasting 7ndash10 days [23ndash26] Fevercan be absent in some cases mainly in SINV RRV and BFVinfections [21 26 27] Arthritis is the most prevalent amongthe symptoms with the recovery from pain and swellingoccurring after some days of infection although severalreports describe the persistence of joint manifestations formonths or even years [2 19 22 28ndash31] Joint pain andinflammation mainly affect symmetrically the small joints(such as those from fingers wrists and tarsus) but eventuallyoccur in the large joints (such as those from knees andshoulders) andmay also involve several joints simultaneously(polyarthralgypolyarthritis) [13 21 29 30] Besides rashand arthritis myalgia is a very common symptom duringalphaviruses infection demonstrating also the virus tropismfor the muscular tissue [32]

Cellular inflammatory infiltration in joint muscle andassociated tissues during alphavirus infection has beenreported in some mouse models of RRV SINV and CHIKVinfection suggesting that muscular and articular damage isan immunopathological inflammatory disorder [33ndash35] InRRV and CHIKV infection the cellular infiltrate reachessynovial tissue which shows a strong hyperplasia [34 36 37]Monocytes macrophages NK cells and CD4+ and CD8+ Tlymphocytes are the main cellular components of the inflam-matory infiltrate in animalmodels indicating an involvementof these cells in the pathogenesis of the arthritis induced byalphaviruses [34 36ndash38] In agreementwith the data obtainedin animal models macrophages and NK cells have beendetected in synovial exudates from RRV infected patients[39ndash41] and a pronounced increase in the plasma levels ofinflammatorymediators as well as a highCD8+ T lymphocyteactivation were found in CHIKV patients in the acute phase



Muscle

Musclenecrosis


Virusdissemination


Lymphnodes

Liver Spleen

Blood




replication



Myositis

Cellularinfiltrate


Healthyjoint

Arthriticjoint

Synoviocytes


synoviocytes

activation



Macrophage

Autoimmunity

Myoblasts



Arthralgiaarthritis


























TNF-120572 IFN-120574MCP-1 [65 73 78]





[31 37 50ndash52 61 74 79ndash82]

SINV IL-6 TNF-120572 IL-1120573MIF [76]




2) binds




















Acknowledgments


References




































































































































Volume 2014

Zoology






















Advances in

Virolog y



Volume 2014




Enzyme Research



Microbiology



Muscle

Musclenecrosis


Virusdissemination


Lymphnodes

Liver Spleen

Blood




replication



Myositis

Cellularinfiltrate


Healthyjoint

Arthriticjoint

Synoviocytes


synoviocytes

activation



Macrophage

Autoimmunity

Myoblasts



Arthralgiaarthritis


























TNF-120572 IFN-120574MCP-1 [65 73 78]





[31 37 50ndash52 61 74 79ndash82]

SINV IL-6 TNF-120572 IL-1120573MIF [76]




2) binds




















Acknowledgments


References




































































































































Volume 2014

Zoology






















Advances in

Virolog y



Volume 2014




Enzyme Research



Microbiology




















TNF-120572 IFN-120574MCP-1 [65 73 78]





[31 37 50ndash52 61 74 79ndash82]

SINV IL-6 TNF-120572 IL-1120573MIF [76]




2) binds




















Acknowledgments


References




































































































































Volume 2014

Zoology






















Advances in

Virolog y



Volume 2014




Enzyme Research



Microbiology













TNF-120572 IFN-120574MCP-1 [65 73 78]





[31 37 50ndash52 61 74 79ndash82]

SINV IL-6 TNF-120572 IL-1120573MIF [76]




2) binds




















Acknowledgments


References




































































































































Volume 2014

Zoology






















Advances in

Virolog y



Volume 2014




Enzyme Research



Microbiology






TNF-120572 IFN-120574MCP-1 [65 73 78]





[31 37 50ndash52 61 74 79ndash82]

SINV IL-6 TNF-120572 IL-1120573MIF [76]




2) binds




















Acknowledgments


References




































































































































Volume 2014

Zoology






















Advances in

Virolog y



Volume 2014




Enzyme Research



Microbiology
















Acknowledgments


References




































































































































Volume 2014

Zoology






















Advances in

Virolog y



Volume 2014




Enzyme Research



Microbiology


Acknowledgments


References




































































































































Volume 2014

Zoology






















Advances in

Virolog y



Volume 2014




Enzyme Research



Microbiology





































































































Volume 2014

Zoology






















Advances in

Virolog y



Volume 2014




Enzyme Research



Microbiology





































































Volume 2014

Zoology






















Advances in

Virolog y



Volume 2014




Enzyme Research



Microbiology





































Volume 2014

Zoology






















Advances in

Virolog y



Volume 2014




Enzyme Research



Microbiology








Volume 2014

Zoology






















Advances in

Virolog y



Volume 2014




Enzyme Research



Microbiology

Documents

Review Article Molecular Mechanisms Involved in the ...downloads.hindawi.com/journals/bmri/2013/973516.pdf · Review Article Molecular Mechanisms Involved in the Pathogenesis of