Toscana virus infection
Toscana virus is an arthropod-borne virus transmitted by sand flies in Mediterranean countries. Toscana virus infection commonly occurs during the warm season although there are important variations in risk exposure (e.g. seasonality, endemicity, local ecologic conditions) as assessed by seroprevalence rates ranging from <1% to 45% in human populations .
Because of the behaviour of the sand fly vectors and their limited mobility, at-risk areas can be small and focal activity is expected. Most cases of infection result in asymptomatic or pauci-symptomatic forms, with mainly febrile illness, leading to a massive underestimation of cases.
In south-western Europe, Toscana virus infection accounts for the most frequent cause of aseptic meningitis together with enteroviruses and herpesviruses . Mortality is exceptional but neuro-invasive manifestation is often associated with encephalitis. Due to the lack of specificity of clinical symptoms, virological diagnostic is needed and relies on molecular detection of viral RNA combined with serology.
Toscana virus infection is not a notifiable disease at the EU/EEA level and there is no EU case definition.
However, Toscana virus infection case definitions have been proposed in the literature . By analogy with other arboviruses such as Tick-borne encephalitis virus, West Nile virus, Zika virus and Chikungunya virus, several points could be applied for Toscana virus such as epidemiological conditions (history of travel to, or residence in, an area with documented on-going transmission within the two-week period prior the onset of symptoms). Laboratory criteria for direct diagnosis such as virus isolation or viral RNA detection in blood or cerebrospinal fluid (CSF) that are used for the aforementioned viruses could also be applied to Toscana virus. Serological data such as seroconversion or a four-fold increase in paired sera would also be applicable to Toscana virus as well as the presence of IgM in a unique serum sample is indicative of a probable case of infection.
Phleboviruses are enveloped viruses with a genome consisting of three single-stranded RNA molecules. Toscana virus has four structural proteins:
- two outer glycoproteins encoded by the M segment;
- a nucleocapsid protein and a nonstructural protein encoded by the S segment, and
- an RNA-dependent viral polymerase encoded by the L segment.
The terminal nucleotides of each genomic RNA segment are base-paired to form non-covalently closed circular RNAs. The terminal sequences of the genomic segments are conserved.
Virions are spherical or pleomorphic (80-120 nm in diameter) and present projections of surface glycoproteins (5-10 nm) embedded in a lipid bilayer envelope. They are sensitive to heat, lipid solvents, formaldehyde and detergents .
Toscana virus can present serological cross-reactions with other phleboviruses, particularly those included in the Naples phlebovirus species (sandfly fever Naples virus, Granada virus, and to a lesser extent Arrabida, Balkan, Fermo, Saddaguia viruses) or Punique phlebovirus.
Toscana virus was first isolated in 1971 from sand flies collected in the Tuscany region of Italy and first evidence for its propensity to cause human disease was reported in 1983 .
Toscana virus belongs to the Toscana phlebovirus species within the Phlebovirus genus in the Phenuiviridae family [6,7]. Species demarcation within the genus is dictated by at least a 5% difference in polymerase gene sequences. Other human pathogenic viruses within this genus are phlebovirus and Sicilian phlebovirus (all transmitted by sand flies), but also Rift Valley fever phlebovirus transmitted by mosquitoes; other diseases related to tick-borne viruses that were previously included in the Phlebovirus genus (Uukkuniemi virusDabie bandavirusHeartland bandavirus) and are now reclassified either in the Uukuvirus or in the Bandavirus genera. There are three genotypes within the species Toscana phlebovirus, also called lineages A, B and C that are more or less assigned to specific geographic areas although overlap can exist. There is no association between severity of the disease or specific manifestations and genotype. Toscana virus distribution is driven by its vector’s geographic distribution. To date, Toscana virus has been identified in Europe and in Northern Africa .
Clinical manifestations and sequelae
The majority of infections are thought to be asymptomatic although the exact proportion is not known. Toscana virus can cause febrile illness and neuroinvasive infection, potentially leading to death.
In most instances, the incubation period lasts from three to seven days but can last up to two weeks; after that period, there is a sudden onset of symptoms typically characterised by high fever, headache, rash, nausea, vomiting, malaise and/or myalgia. Neck stiffness is reported in nearly 90% of the cases and encephalitis is observed in nearly 40% of the cases [9,10]. In addition, focal deficits (e.g., cranial neuropathy, hemiparesis, aphasia, ataxia) are often reported [11-13]. In rare instance, fatal encephalitis has been reported .
Particular clinical manifestations have been often described such as:
- sensory polymyeloradiculopathy ,
- Guillain-Barré syndrome [8,16],
- testicular involvement [17,18],
- myositis and fasciitis ,
- hydrocephalus [20,21],
- lymphadenopathy ,
- personality disorders ,
- neurological sequelae related to ischemic complications  and
- deafness .
In a study gathering over 1000 cases from Croatia, France, Greece, Italy, Malta, Portugal, Romania, Spain and Turkey, the median age of the cases was 45 years, with the youngest reported patient being three months old and the oldest was 95 years old (Ayhan & Charrel unpublished work).
Differential diagnosis cannot be made based on clinical criteria only. Virological investigations are required to establish the diagnosis of Toscana virus infection and to perform differential diagnoses (e.g., West Nile virus infections, enterovirus and herpesviruses infections).
Toscana virus circulates in several countries in southern Europe (from west to east, Portugal, Spain, France, Italy, Malta, Croatia, Bosnia Herzegovina, Kosovo*,Greece, Cyprus, and Turkey) and in Northern Africa (Morocco, Tunisia, Algeria) where it causes human infections. In France, Italy and Tunisia, Toscana virus ranks within the three most common causes of summer meningitis after enteroviruses and herpesviruses (herpes simplex virus, varicella-zoster virus) [5,26-30]. It is likely that the same situation applies in several other Mediterranean countries where Toscana virus circulate in sand fly populations. Seroprevalence studies in several countries (i.e., Portugal, Spain, France, Italy, Croatia, Bosnia-Herzegovina, Kosovo*, Malta, Greece, Turkey, Cyprus, Morocco, Tunisia, Algeria) show that Toscana virus is among the most prevalent endemic arboviruses, with seroprevalences of up to 77% reported in forestry workers in Italy [1,31-35]. An estimated 250 million people are living in regions where they might be exposed to Toscana virus .
Cases of Toscana virus infection are reported exclusively during the period of sand fly activity, from April through November in the Mediterranean, with a peak observed during the hottest period (July to September). To date, only Phlebotomus (P.) perniciosus and P. perfiliewi have been formally identified as vectors. However, it is highly probable that other species belonging to the subgenus Larroussius (P. ariasi, P. longicuspis, P. neglectus, P. tobbi, etc.) are also vectors of Toscana virus. Toscana virus geographic distribution is much wider than was assumed a decade ago . The geographic extension of Toscana virus circulation area might be apparent because of increased attention during the last decade and/or might be due to climate change and the increase of annual mean temperatures causing the expansion of the sandfly’s habitat. The extension of the Toscana virus circulation area suggests that in addition to the two recognised vector species (P. perniciosus and P. perfiliewi), alternative species of sand flies must be considered as competent vectors for the virus such as P. longicuspis, P. sergenti, P. tobbi, P. neglectus and Sergentomyia minuta [37,38].
At present, the reservoir for maintenance of Toscana virus circulation is not known. There is no evidence that either humans or other vertebrates, including dogs, can be amplifying host or reservoir host. They are commonly considered as dead-end hosts. Healthy domestic dogs are not highly susceptible to experimental infection by Toscana virus and do not develop significant viremia or excrete virus following infection although they can mount significant titres of neutralising antibodies [1,39,40]. Consequently, healthy dogs are not likely to play a significant role in Toscana virus transmission cycles. There are no published studies reporting experimentations in other species of vertebrates.
Toscana virus is transmitted to humans and other vertebrates through the bite of an infected female sand fly belonging to competent species within the genus Phlebotomus. To date there is no other mode of transmission that has been recognised. In particular, blood products have not been identified as at risk for transmission of Toscana virus. However, the presence of Toscana virus RNA in blood products is not tested in countries where virus circulation is established.
Direct diagnosis: The virus can be detected at the acute phase of infection in CSF and in blood. It is most often detected in the CSF because patients without neurological signs are rarely hospitalised which precludes laboratory investigations. Toscana virus can be isolated in cell culture (Vero, BHK-21, CV-1, SW13). However, direct diagnosis is mainly done using molecular techniques with recommendations for real-time RT-PCR tests [41-44]. The kinetics of viral RNA presence in bodily fluids for RT-PCR detection is largely unknown, but the consensus is that it is short-lived (communication among EVD-LabNet experts).
Serology: The serological diagnosis of an acute infection consists of the detection of a seroconversion or an increase of at least four-fold in antibody titres. In practice, indirect immunofluorescence (IIFA) and ELISA are commonly used due to availability of commercial kits [45,46]. The detection of specific immunoglobulin M can also be performed with IIFA and ELISA. Cross-reactions are to be expected between viruses antigenically close to Toscana virus such as Naples phlebovirus, Massilia phlebovirus, and Punique phlebovirus. Neutralisation assay is less prone to cross-reactions than IIFA or ELISA [47-49].
The humoral response against Toscana virus develops rapidly and is long-lasting . In patients with neuro-invasive manifestations, specific IgM can be detected at the time of hospitalisation, a few days after the onset of the disease; IgM titers start declining one month after hospitalisation; however, IgM are still detectable in 71% of cases after six months, although IgM have disappeared at month 20 . IgG that are also detected early (100% at hospital admission) persist in 100% of cases at month six and 90% of cases at month 20 . There is no difference in IgM and IgG titers according to age, gender and disease severity .
Interpretation of the results: By analogy with infections caused by Tick-borne encephalitis, West Nile, Zika and Chikungunya viruses, Toscana virus infection might be considered as laboratory-confirmed in case of (i) viral isolation or detection of RNA in tissue, blood, CSF or other fluids, OR (ii) seroconversion or > four-fold in specific antibody titres in paired sera, whereas detection of specific IgM in a unique serum should be considered indicative of a probable case [3,51]. For serology, techniques displaying the highest specificity (e.g., plaque reduction neutralisation, virus neutralisation or microneutralisation) should be preferred.
In Europe, Toscana virus is a risk group 2 pathogen and clinical specimens, virus isolates should be handled accordingly .
Case management and treatment
There is no specific therapy for Toscana virus infections. The treatment is symptomatic and hospitalisation in intensive care is required for the most severe clinical forms.
Infection control, personal protection and prevention
There is no licensed vaccine for Toscana virus.
Personal protective measures against sand fly bites include the use of insecticide-treated bed nets, sleeping or resting in screened or air-conditioned rooms, the wearing of clothes that cover most of the body, and the use of repellent in accordance with the instructions indicated on the product label.
* This designation is without prejudice to positions on status, and is in line with UNSCR 1244 and the ICJ Opinion on the Kosovo Declaration of Independence.
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