Powassan Virus Research Articles

Active surveillance of pathogens from ticks collected in New York State suburban parks and schoolyards.

Schoolyards and suburban parks are two environments where active tick surveillance may inform local management approaches. Even in a state such as New York with a robust active tick surveillance programme operated by the state Department of Health, these settings are not routinely covered. The goal of this study was to highlight the importance of active surveillance for tick‐borne pathogens by describing their prevalence in ticks collected from schoolyards and suburban parks and to guide the use of integrated pest management in these settings. Tick dragging was performed in three regions of New York State: Long Island, the Lower Hudson Valley and the Capital Region. A total of 19 schoolyards and 32 parks were sampled. The location, habitat and weather at the time of tick collection were recorded. Ticks were speciated and tested for the presence of 17 pathogens with a novel application of nanoscale real‐time PCR. The causative agents of Lyme disease, anaplasmosis, babesiosis and Powassan virus disease were all detected from Ixodes scapularis in various sites throughout the capital region and south‐eastern counties of New York state. The most common agent detected was Borrelia burgdorferi, and coinfection rates were as high as 36%. This surveillance study also captured the first of the invasive Asian longhorned tick species, Haemaphysalis longicornis, in New York state (collected 2 June 2017). Results from this study highlight the importance of collaborative efforts and data sharing for improvement of surveillance for tick‐borne disease agents.

Interrupted Blood Feeding in Ticks: Causes and Consequences.

Ticks are obligate hematophagous arthropods and act as vectors for a great variety of pathogens, including viruses, bacteria, protozoa, and helminths. Some tick-borne viruses, such as Powassan virus and tick-borne encephalitis virus, are transmissible within 15–60 min after tick attachment. However, a minimum of 3–24 h of tick attachment is necessary to effectively transmit bacterial agents such as Ehrlichia spp., Anaplasma spp., and Rickettsia spp. to a new host. Longer transmission periods were reported for Borrelia spp. and protozoans such as Babesia spp., which require a minimum duration of 24–48 h of tick attachment for maturation and migration of the pathogen. Laboratory observations indicate that the probability of transmission of tick-borne pathogens increases with the duration an infected tick is allowed to remain attached to the host. However, the transmission time may be shortened when partially fed infected ticks detach from their initial host and reattach to a new host, on which they complete their engorgement. For example, early transmission of tick-borne pathogens (e.g., Rickettsia rickettsii, Borrelia burgdorferi, and Babesia canis) and a significantly shorter transmission time were demonstrated in laboratory experiments by interrupted blood feeding. The relevance of such situations under field conditions remains poorly documented. In this review, we explore parameters of, and causes leading to, spontaneous interrupted feeding in nature, as well as the effects of this behavior on the minimum time required for transmission of tick-borne pathogens.

Development of a small animal model for deer tick virus pathogenesis mimicking human clinical outcome.

Powassan virus (POWV) is a tick-borne flavivirus that encompasses two genetic lineages, POWV (Lineage I) and deer tick virus (DTV, Lineage II). In recent years, the incidence of reported POWV disease cases has increased, coupled with an expanded geographic range of the DTV tick vector, Ixodes scapularis. POWV and DTV are serologically indistinguishable, and it is not known whether clinical manifestations, pathology, or disease outcome differ between the two viruses. Six-week-old male and female BALB/c mice were footpad-inoculated with DTV doses ranging from 101 to 105 FFU. Dose-independent mortality, morbidity, and organ viral loads were observed for mice inoculated with sequentially increasing doses of DTV. By study completion, all surviving mice had cleared their viremias but detectable levels of negative-sense DTV RNA were present in the brain, indicating viral persistence of infectious DTV in the central nervous system. For mice that succumbed to disease, neuropathology revealed meningoencephalitis characterized by microscopic lesions with widespread distribution of viral RNA in the brain. These findings, coupled with the rapid onset of neurological signs of disease and high viral titers in nervous tissue, highlight the neurotropism of DTV in this mouse model. Additionally, disease outcome for DTV-infected mice was not affected by sex, as males and females were equally susceptible to disease. This is the first study to comprehensively characterize the clinical disease outcome in a small animal model across a spectrum of POWV/DTV infection doses. Here, we developed a small animal model for DTV pathogenesis that mimics the manifestations of POWV disease in humans. Since it is currently not known whether DTV and POWV differ in their capacity to cause human disease, the animal model detailed in our study could be utilized in future comparative pathogenesis studies, or as a platform for testing the efficacy of vaccines, and anti-virals.

Powassan Virus Infection Likely Acquired Through Blood Transfusion Presenting as Encephalitis in a Kidney Transplant Recipient.

A kidney transplant patient without known tick exposure developed encephalitis 3 weeks after transplantation. During the transplant hospitalization, the patient had received a blood transfusion from an asymptomatic donor later discovered to have been infected with Powassan virus. Here, we describe a probable instance of transfusion-transmitted Powassan virus infection.

Committee Opinion No. 399: Management of Tick Bites and Lyme Disease During Pregnancy.

Lyme disease is an emerging infection in Canada caused by the bacterium belonging to the Borrelia burgdorferi sensu lato species complex, which is transmitted via the bite of an infected blacklegged tick. Populations of blacklegged ticks continue to expand and are now established in different regions in Canada. It usually takes more than 24 hours of tick attachment to transfer B. burgdorferi to a human. The diagnosis of early localized Lyme disease is made by clinical assessment, as laboratory tests are not reliable at this stage. Most patients with early localized Lyme disease will present with a skin lesion (i.e., erythema migrans) expanding from the tick bite site and/or non-specific "influenza-like" symptoms (e.g., arthralgia, myalgia, and fever). Signs and symptoms may occur from between 3 and 30 days following the tick bite. The care of pregnant patients with a tick bite or suspected Lyme disease should be managed similarly to non-pregnant adults, including the consideration of antibiotics for prophylaxis and treatment. The primary objective of this committee opinion is to inform practitioners about Lyme disease and provide an approach to managing the care of pregnant women who may have been infected via a blacklegged tick bite. Health care providers who care for pregnant women or women of reproductive age. Women of reproductive age. In November 2018, Medline, EMBASE, PubMed, and CENTRAL databases were searched for 2 main categories: (1) Lyme disease and (2) other tick-borne diseases. Because the main focus was Lyme disease, and considering the limited number of the articles, no further filters were applied for publication time or type of study. For other tick-borne diseases, the results were restricted to a publication date within the last 10 years (2008-2018). The search terms were developed using MeSH terms and keywords including Lyme Disease, Pregnancy, Pregnant Women, Pregnancy Complications, Ehrlichiosis, Anaplasmosis, Rocky Mountain Spotted Fever, Babesiosis, Tularemia, Powassan Virus, Encephalitis Viruses, Tick-Borne, Tick-Borne Diseases, Colorado Tick Fever, Q Fever, Relapsing Fever, and Southern Tick-Associated Rash Illness. All articles on Lyme disease and other tick-borne diseases with a target population of pregnant women were included; other groups and populations were excluded. The content and recommendations of this committee opinion were drafted and agreed upon by the authors. The Board of Directors of the Society of Obstetricians and Gynaecologists of Canada approved the final draft for publication.

Tick-Borne Viruses of North America

The global incidence of tick-borne infectious diseases has increased since the beginning of the 21st century. The expansion of tick populations into new geographic locations and a variety of anthropogenic and natural factors are all drivers of the increase. In addition to the establishment of known tick-borne pathogens in new areas, several novel agents, including many viruses, have also emerged. At present in North America, there are five tick-borne viruses that are known to cause human disease: deer tick virus, Powassan virus, Colorado tick fever virus, Heartland virus, and Bourbon virus. Although uncommon causes of disease, these viruses pose formidable threats to the health of individuals residing in regions of endemicity, especially since there are currently no medical countermeasures available to combat them. This review focuses on the basic biology, ecology, epidemiology, transmission, clinical presentation, diagnosis, treatment, and prevention of these North American tick-borne arboviruses.

Structural basis of neutralization of Powassan virus by monoclonal antibodies

Abstract Powassan virus (POWV) is an emerging tick-borne flavivirus endemic to the northern and northeastern United States. Severe human POWV infection is characterized by fatal encephalitis in 10% of patients and long-term neurological sequelae in 50% of survivors. Little is known about humoral immunity to POWV, and there are currently no licensed vaccines or therapeutics available for treatment. We have generated a panel of 23 murine antibodies against POWV that separate into six epitope groups based on competitive binding. Two of the groups target domain III of the viral envelope protein; mapping by alanine scanning mutagenesis places their epitopes on the A-strand and C-C′ loop of domain III, respectively. These DIII-specific mAbs display potent neutralization in vitro and robust protection in a mouse model of POWV infection. X-ray crystallographic analysis reveals that POWV-80, a C-C′ loop antibody, adopts a binding orientation similar to a class of potently neutralizing flavivirus antibodies that target the lateral ridge epitope on domain III, while POWV-61 binds primarily to the A-strand and B-C loop. Our results indicate that antibodies to POWV can target epitope regions similar to those observed on mosquito-transmitted flaviviruses by employing unique binding modes that may facilitate enhanced neutralizing and protective efficacy. Current efforts are focused on defining the determinants of antibody potency and understanding antibody binding in the context of the virion.

Utilization of RNA in situ Hybridization to Understand the Cellular Localization of Powassan Virus RNA at the Tick-Virus-Host Interface.

Skin is the interface between an attached, feeding tick and a host; consequently, it is the first line of defense against invading pathogenic microorganisms that are delivered to a vertebrate host together with tick saliva. Central to the successful transmission of a tick-borne pathogen are complex interactions between the host immune response and early tick-mediated immunomodulation, all of which initially occur at the skin interface. The focus of this work was to demonstrate the use of RNA in situ hybridization (RNA ISH) as a tool for understanding the cellular localization of viral RNA at the feeding site of Powassan virus (POWV)-infected Ixodes scapularis ticks. Intense positive staining for POWV RNA was frequently detected in dermal foci and occasionally detected in hypodermal foci after 24 h of POWV-infected tick feeding. Additionally, duplex chromogenic RNA ISH staining demonstrated co-localization of POWV RNA with Mus musculus F4/80 RNA, CD11c RNA, vimentin RNA, Krt14 RNA, and CD3ε RNA at the feeding site of POWV-infected ticks. In future studies, RNA ISH can be used to validate transcriptomic analyses conducted at the tick-virus-host cutaneous interface and will provide cellular resolution for specific gene signatures temporally expressed during infected tick feeding. Such a systems biology approach will help create a more refined understanding of the cellular and molecular interactions influencing virus transmission at the cutaneous interface.

A Case of Hemorrhagic Encephalitis due to Powassan Virus in Pennsylvania (4998)

A Case of Hemorrhagic Encephalitis due to Powassan Virus in Pennsylvania (4998)

PERK-Mediated Unfolded Protein Response Signaling Restricts Replication of the Tick-Borne Flavivirus Langat Virus.

The unfolded protein response (UPR) maintains protein-folding homeostasis in the endoplasmic reticulum (ER) and has been implicated as both beneficial and detrimental to flavivirus infection. Protein kinase R (PKR)-like endoplasmic reticulum kinase (PERK), a sensor of the UPR, is commonly associated with antiviral effects during mosquito-borne flavivirus (MBFV) infection, but its relation to tick-borne flavivirus (TBFV) infection remains largely unexplored. In this study, we identified changes in UPR and autophagic activity during Langat virus (LGTV) infection. LGTV robustly activated UPR and altered autophagic flux. Knockdown of endogenous PERK in human cells resulted in increased LGTV replication, but not that of closely related Powassan virus (POWV). Finally, on examining changes in protein levels of components associated with UPR and autophagy in the absence of PERK, we could show that LGTV-infected cells induced UPR but did not lead to expression of C/EBP homologous protein (CHOP), an important downstream transcription factor of multiple stress pathways. From these data, we hypothesize that LGTV can antagonize other kinases that target eukaryotic initiation factor 2α (eIF2α), but not PERK, implicating PERK as a potential mediator of intrinsic immunity. This effect was not apparent for POWV, a more pathogenic TBFV, suggesting it may be better equipped to mitigate the antiviral effects of PERK.

Tick-Borne Diseases in the United States.

Tick-borne diseases are an important cause of human morbidity and mortality in the United States. The past several decades have witnessed an increase in both the number of recognized tick-borne pathogens and the number of tick-borne disease cases, whereas tick surveys have revealed substantial geographic expansions of tick populations throughout the country. Multiple laboratory testing options exist for diagnosis of tick-borne diseases, including serology, microscopy, and molecular-based methods. The preferred approach varies by the specific disease, locally available test options, and the stage of illness at patient presentation. Accurate and timely detection of tick-borne illness is of utmost importance, as prompt treatment is strongly linked to better outcomes. This review covers the clinical manifestations and preferred diagnostic approaches for important bacterial, viral, and parasitic tick-borne diseases in the United States, including Lyme disease, tick-borne relapsing fever, anaplasmosis, ehrlichiosis, spotted fever rickettsioses, and babesiosis. Infection with emerging pathogens such as Borrelia miyamotoi, Powassan virus, Heartland virus, Colorado tick fever virus, and Bourbon virus are also covered. Our understanding of tick-borne diseases in the United States continues to improve with the detection of novel pathogens and development of new diagnostic modalities. While conventional diagnostic methods, including serology and microscopy, will play an ongoing role in the diagnosis of tick-borne diseases, implementation of advanced molecular diagnostics will further broaden our understanding of these diseases by facilitating detection of emerging pathogens and providing more accurate and timely diagnosis.

Nanoscale Structure Determination of Murray Valley Encephalitis and Powassan Virus Non-Coding RNAs.

Viral infections are responsible for numerous deaths worldwide. Flaviviruses, which contain RNA as their genetic material, are one of the most pathogenic families of viruses. There is an increasing amount of evidence suggesting that their 5’ and 3’ non-coding terminal regions are critical for their survival. Information on their structural features is essential to gain detailed insights into their functions and interactions with host proteins. In this study, the 5’ and 3’ terminal regions of Murray Valley encephalitis virus and Powassan virus were examined using biophysical and computational modeling methods. First, we used size exclusion chromatography and analytical ultracentrifuge methods to investigate the purity of in-vitro transcribed RNAs. Next, we employed small-angle X-ray scattering techniques to study solution conformation and low-resolution structures of these RNAs, which suggest that the 3’ terminal regions are highly extended as compared to the 5’ terminal regions for both viruses. Using computational modeling tools, we reconstructed 3-dimensional structures of each RNA fragment and compared them with derived small-angle X-ray scattering low-resolution structures. This approach allowed us to reinforce that the 5’ terminal regions adopt more dynamic structures compared to the mainly double-stranded structures of the 3’ terminal regions.

Geographic distribution of Tick-borne encephalitis virus complex.

A comprehensive understanding of the geographic distribution of the tick-borne encephalitis virus (TBEV) complex is necessary due to increasing transboundary movement and cross-reactivity of serological tests. This review was conducted to identify the geographic distribution of the TBEV complex, including TBE virus, Alkhurma haemorrhagic fever virus, Kyasanur forest disease virus, louping-ill virus, Omsk haemorrhagic fever virus, and Powassan virus. Published reports were identified using PubMed, EMBASE, and the Cochrane library. In addition to TBEV complex case-related studies, seroprevalence studies were also retrieved to assess the risk of TBEV complex infection. Among 1406 search results, 314 articles met the inclusion criteria. The following countries, which are known to TBEV epidemic region, had conducted national surveillance studies: Austria, China, Czech, Denmark, Estonia, Finland, Germany, Hungary, Italy, Latvia, Norway, Poland, Romania, Russia, Switzerland, Sweden, Slovenia, and Slovakia. There were also studies/reports on human TBEV infection from Belarus, Bulgaria, Croatia, France, Japan, Kyrgyzstan, Netherland, and Turkey. Seroprevalence studies were found in some areas far from the TBEV belt, specifically Malaysia, Comoros, Djibouti, and Kenya. Kyasanur forest disease virus was reported in southwestern India and Yunnan of China, the Powassan virus in the United States, Canada, and east Siberia, Alkhurma haemorrhagic fever virus in Saudi Arabia and east Egypt, and Louping-ill virus in the United Kingdom, Ireland, and east Siberia. In some areas, the distribution of the TBEV complex overlaps with that of other viruses, and caution is recommended during serologic diagnosis. The geographic distribution of the TBEV complex appears to be wide and overlap of the TBE virus complex with other viruses was observed in some areas. Knowledge of the geographical distribution of the TBEV complex could help avoid cross-reactivity during the serologic diagnosis of these viruses. Surveillance studies can implement effective control measures according to the distribution pattern of these viruses.

Immunopathology of Zika virus infection.

Zika virus (ZIKV) is a mosquito-borne virus of the flavivirus genus in the Flaviviridae family. Flaviviruses are single-stranded, positive-sense RNA viruses that have been responsible for numerous human epidemics. Notable flaviviruses include mosquito-borne viruses such as yellow fever virus (YFV), Dengue virus (DENV), West Nile virus (WNV), Japanese encephalitis virus (JEV), as well as tick-borne viruses including Powassan virus (POWV) and tick-borne encephalitis virus (TBEV). Despite having been relatively obscure until the past decade, ZIKV has become a major global health concern, and is a topic of active research following multiple outbreaks across the globe. Here, we discuss ZIKV pathogenesis and the associated immunopathology, as well as advances in research, therapies, and vaccines developed using models of ZIKV pathogenesis.

Zoonotic Babesia: A scoping review of the global evidence.

BackgroundBabesiosis is a parasitic vector-borne disease of increasing public health importance. Since the first human case was reported in 1957, zoonotic species have been reported on nearly every continent. Zoonotic Babesia is vectored by Ixodes ticks and is commonly transmitted in North America by Ixodes scapularis, the tick species responsible for transmitting the pathogens that also cause Lyme disease, Powassan virus, and anaplasmosis in humans. Predicted climate change is expected to impact the spread of vectors, which is likely to affect the distribution of vector-borne diseases including human babesiosis.MethodsA scoping review has been executed to characterize the global evidence on zoonotic babesiosis. Articles were compiled through a comprehensive search of relevant bibliographic databases and targeted government websites. Two reviewers screened titles and abstracts for relevance and characterized full-text articles using a relevance screening and data characterization tool developed a priori.ResultsThis review included 1394 articles relevant to human babesiosis and/or zoonotic Babesia species. The main zoonotic species were B. microti, B. divergens, B. duncani and B. venatorum. Articles described a variety of study designs used to study babesiosis in humans and/or zoonotic Babesia species in vectors, animal hosts, and in vitro cell cultures. Topics of study included: pathogenesis (680 articles), epidemiology (480), parasite characterization (243), diagnostic test accuracy (98), mitigation (94), treatment (65), transmission (54), surveillance (29), economic analysis (7), and societal knowledge (1). No articles reported predictive models investigating the impact of climate change on Babesia species.ConclusionKnowledge gaps in the current evidence include research on the economic burden associated with babesiosis, societal knowledge studies, surveillance of Babesia species in vectors and animal hosts, and predictive models on the impact of climate change. The scoping review results describe the current knowledge and knowledge gaps on zoonotic Babesia which can be used to inform future policy and decision making.

Assessment of tick-borne flavivirus host factors through genome-scale screens

Powassan virus (POWV) is the only tick-borne flavivirus (TBFV) known to circulate in North America. Although there are relatively few documented cases of POWV disease, investigations into POWV are justified due to the increasing incidence of infection and significant case fatality rate associated with this virus. To better describe the molecular biology of the POWV replication cycle in mammalian cells, we performed genome-scale screens to uncover host factors required for viral replication. Putative proviral host factors were identified by infecting pools of cells containing knockout mutations in non-essential genes with POWV, followed by analysis of cells resistant to virus-induced cell death. Many endoplasmic reticulum membrane complex proteins were revealed in these screens, suggesting that TBFVs share some common host cell hijacking strategies with mosquito-borne flaviviruses. Candidate proteins that function in cell-matrix adhesion, glycosylation, or RNA binding in uninfected cells were the focus of validation studies. We used single-gene knockout cell lines to investigate possible proviral roles for specific proteins in the replication cycle of either POWV or Langat virus (LGTV), a non-pathogenic and model TBFV. Proteins identified in the POWV screens were not necessarily critical for LGTV replication. These results suggest that our screens were able to identify both pan-flaviviral, as well as POWV-specific, host gene products exploited during virus replication. Ongoing work is focused on characterizing distinct host-cell requirements of diverse flaviviruses. This genetic assessment of POWV replication factors, in combination with ensuing mechanistic studies, will provide possible avenues for the development of host-targeting countermeasures.

Molecular survey of flaviviruses and orthobunyaviruses in Amblyomma spp. ticks collected in Minas Gerais, Brazil.

Due to anthropic environmental changes, vector-borne diseases are emerging worldwide. Ticks are known vectors of several pathogens of concern among humans and animals. In recent decades, several examples of tick-borne emerging viral diseases have been reported (Crimean Congo hemorrhagic fever virus, Powassan virus, encephalitis virus, heartland virus, severe fever with thrombocytopenia syndrome virus). Unfortunately, few studies addressing the presence of viruses in wild ticks have been carried out in South America. With the aim of detecting flaviviruses and orthobunyaviruses in ticks, we carried out molecular detection in wild ticks collected in the state of Minas Gerais, Brazil. No Flavivirus-positive ticks were detected; however, we detected activity of Orthobunyavirus in 8 Amblyomma tick specimens. One of those individuals was positive for Bunyamwera orthobunyavirus, which represents the first report of this virus among ticks in South America. Further studies related to the ecology of zoonotic diseases are needed to increase knowledge of this topic, including attempts at viral isolation, full genome sequencing and biological characterization. In this way, we will obtain a better picture of the real risk of ticks as a vector for viral diseases for humans and animals on our continent, where no tick-borne viral disease is known to occur.

Prioritization of vector-borne diseases in Canada under current climate and projected climate change

Vector-borne diseases are expected to be introduced, establish or expand geographically in Canada under climate change. The ability to prioritize diseases is critical because there are limited resources to address all risks and the decision to focus on one or a group of infectious diseases can come at the expense of not addressing others. As a result, the ability to conduct the prioritization in a transparent, auditable and in as objective a manner as possible is critical to ensure that the choices made are defendable. The objectives of this work were to develop a multicriteria decision analysis (MCDA) tool to prioritize vector-borne diseases of public health importance in Canada under current and projected climate. MCDA, an approach drawn from the decision sciences, is a valuable tool for decision-making when multiple criteria need to be considered. When considering all the criteria equally, Eastern equine encephalitis ranks as the highest priority non-endemic disease followed by Powassan virus disease, La Crosse encephalitis, Rocky Mountain Spotted Fever, Plague, Chikungunya virus infection and St. Louis encephalitis disease. In the case of endemic diseases: Cache Valley virus disease ranks highest, followed by Lyme disease, West Nile virus, Babesiosis and Human granulocytic anaplasmosis. The tool has the ability to also generate rankings for different stakeholders with different priorities thereby contributing significantly to the decision making process.

LB14. Cerebrospinal Fluid Profiling of the Human Host Response Reveals Species-Specific Enterovirus Biosignatures in Acute Flaccid Myelitis Cases

BackgroundSince 2014 there have been global biennial outbreaks of acute flaccid myelitis (AFM), a rare but severe “polio-like” illness of as yet-unknown etiology primarily affecting children. Enteroviruses (EVs),, especially EV-D68 and EV-A71, have been implicated in association with AFM cases, but proving causality has been difficult as EVs are rarely isolated from cerebrospinal fluid. In addition, early identification of EV-associated AFM is challenging given that the diagnosis is reliant on potentially subjective clinical and radiological criteria with no specific biomarkers described to date.MethodsWe leveraged existing and newly generated data from a clinical CSF metagenomic assay for pathogen identification at University of California, San Francisco (UCSF) to interrogate the host response at the transcriptome level by RNA sequencing (RNA-Seq). These transcriptome RNA-Seq data were used to create statistical classification models to discriminate among viral infections that have been linked to AFM, including EV-D68, EV-A71, West Nile virus, and Powassan virus. The dynamic range of CSF cellularity (0 to >106 cells/mL), resulting in varying trancriptome coverage, as well as technical variation across samples required the development and validation of novel normalization techniques. In total, we analyzed ~50 CSF samples split into independent training and test sets.ResultsWe were able to demonstrate a distinct signature of AFM that was able to predict the virus associated with AFM in blinded test samples with >80% accuracy. The key transcriptional features that best discriminated EV-A71 from EV-D68-associated AFM involved protein targeting, viral transcription, viral gene expression, and translation initiation pathways.ConclusionHere we demonstrate a novel approach to diagnosis of AFM that relies on host transcriptional biomarkers from cerebrospinal fluid. In the future, this method might allow earlier diagnosis of AFM to drive appropriate therapies and vaccines and predict patient outcomes, as well as guide research studies on the pathophysiology of EV-associated AFM.Disclosures All authors: No reported disclosures.

Possible Prognostic Value of Serial Brain MRIs in Powassan Virus Encephalitis

Powassan virus (POWV) encephalitis is a rare tickborne illness. We describe the clinical course, laboratory findings, and imaging for a patient with POWV in Massachusetts, USA. Clinical presentation and laboratory findings were nonspecific. Improvement on brain magnetic resonance imaging after 2 weeks preceded clinical improvement by months, suggesting possible prognostic value.