Zika Virus Antibodies Research Articles

The proportion of asymptomatic infections and spectrum of disease among pregnant women infected by Zika virus: systematic monitoring in French Guiana, 2016

Zika virus (ZIKV) infection has been associated with complications during pregnancy. Although the presence of symptoms might be a risk factor for complication, the proportion of ZIKV-infected pregnant women with symptoms remains unknown. Following the emergence of ZIKV in French Guiana, all pregnancies in the territory were monitored by RT-PCR and/or detection of ZIKV antibodies. Follow-up data collected during pregnancy monitoring interviews were analysed from 1 February to 1 June 2016. We enrolled 3,050 pregnant women aged 14–48 years and 573 (19%) had laboratory-confirmed ZIKV infection. Rash, arthralgia, myalgia and conjunctival hyperaemia were more frequently observed in ZIKV-positive women; 23% of them (95% confidence interval (CI): 20–27) had at least one symptom compatible with ZIKV infection. Women 30 years and older were significantly more likely to have symptoms than younger women (28% vs 20%). The proportion of symptomatic infections varied from 17% in the remote interior to 35% in the urbanised population near the coast (adjusted risk ratio: 1.6; 95% CI: 1.4–1.9.). These estimates put findings on cohorts of symptomatic ZIKV-positive pregnant women into the wider context of an epidemic with mainly asymptomatic infections. The proportion of symptomatic ZIKV infections appears to vary substantially between populations.

Zika virus disease-associated Guillain-Barré syndrome—Barranquilla, Colombia 2015–2016

BackgroundAn outbreak of Guillain-Barré syndrome (GBS), a disorder characterized by acute, symmetric limb weakness with decreased or absent deep-tendon reflexes, was reported in Barranquilla, Colombia, after the introduction of Zika virus in 2015. We reviewed clinical data for GBS cases in Barranquilla and performed a case-control investigation to assess the association of suspect and probable Zika virus disease with GBS. MethodsWe used the Brighton Collaboration Criteria to confirm reported GBS patients in Barranquilla during October 2015–April 2016. In April 2016, two neighborhood and age range-matched controls were selected for each confirmed GBS case-patient. We obtained demographics and antecedent symptoms in the 2-month period before GBS onset for case-patients and the same period for controls. Sera were collected for Zika virus antibody testing. Suspected Zika virus disease was defined as a history of rash and ≥2 other Zika-related symptoms (fever, arthralgia, myalgia, or conjunctivitis). Probable Zika virus disease was defined as suspected Zika virus disease with laboratory evidence of a recent Zika virus or flavivirus infection. Conditional logistic regression adjusted for sex and race/ethnicity was used to calculate odds ratios (ORs) and 95% confidence intervals (CIs). ResultsWe confirmed 47 GBS cases. Incidence increased with age (10-fold higher in those ≥60years versus those <20years). We interviewed 40 case-patients and 79 controls. There was no significant difference in laboratory evidence of recent Zika virus or flavivirus infection between case-patients and controls (OR: 2.2; 95% CI: 0.9–5.1). GBS was associated with having suspected (OR: 3.0, 95% CI: 1.1–8.6) or probable Zika virus disease (OR: 4.6, CI: 1.1–19.0). ConclusionsOlder individuals and those with suspected and probable Zika virus disease had higher odds of developing GBS. Key pointsWe confirmed a Guillain-Barré syndrome (GBS) outbreak in Barranquilla, Colombia, during October 2015–April 2016. A case-control investigation using neighborhood controls showed an association of suspected and probable Zika virus disease with GBS.

Compensating for cross-reactions using avidity and computation in a suspension multiplex immunoassay for serotyping of Zika versus other flavivirus infections

The recent spread of Zika virus (ZIKV) in the Americas and Asia necessitates an increased preparedness for improved maternal and perinatal health and blood safety. However, serological cross-reactions, especially to Dengue virus (DENV), complicate ZIKV antibody serodiagnosis. A novel “pan-Flavi” suspension multiplex immunoassay (PFSMIA) using 25 antigens, whole virus (WV), non-structural protein 1 (NS1), and envelope (E) proteins, from 7 zoonotic flaviviruses for specific detection of ZIKV and DENV IgM and IgG was developed. Patterns of antibody cross-reactivity, avidity, and kinetics were established in 104 sera from returning travelers with known ZIKV and DENV infections. PFSMIA gave IgM- and IgG-sensitivities for both viruses of 96–100%, compared to an immunofluorescence assay. Main IgM cross-reactions were to NS1, for IgG to the E and WV antigens. Infecting virus yielded reactivity to several antigens of the homologous virus, while cross-reactions tended to occur only to a single antigen from heterologous virus(es). A specificity-enhancing computer procedure took into account antibody isotype, number of antibody-reactive antigens per virus, avidity, average degree of cross-reactivity to heterologous flavivirus antigens, and reactivity changes in serial sera. It classified all 50 cases correctly. Applied to sera from 200 pregnant women and 173 blood donors from Sweden, one blood donor was found ZIKV NS1 IgM positive, and another as ZIKV NS1 IgG positive. These samples did not react with other ZIKV antigens and were thereby judged as false-positives. PFSMIA provided sensitive and specific ZIKV and DENV serology, warranting high-throughput serological surveillance and a minimized need for laborious and expensive virus neutralization assays.

Rapid Detection of Infectious Envelope Proteins by Magnetoplasmonic Toroidal Metasensors.

Unconventional characteristics of magnetic toroidal multipoles have triggered researchers to study these unique resonant phenomena by using both 3D and planar resonators under intense radiation. Here, going beyond conventional planar unit cells, we report on the observation of magnetic toroidal modes using artificially engineered multimetallic planar plasmonic resonators. The proposed microstructures consist of iron (Fe) and titanium (Ti) components acting as magnetic resonators and torus, respectively. Our numerical studies and following experimental verifications show that the proposed structures allow for excitation of toroidal dipoles in the terahertz (THz) domain with the experimental Q-factor of ∼18. Taking the advantage of high-Q toroidal line shape and its dependence on the environmental perturbations, we demonstrate that room-temperature toroidal metasurface is a reliable platform for immunosensing applications. As a proof of concept, we utilized our plasmonic metasurface to detect Zika-virus (ZIKV) envelope protein (with diameter of 40 nm) using a specific ZIKV antibody. The sharp toroidal resonant modes of the surface functionalized structures shift as a function of the ZIKV envelope protein for small concentrations (∼pM). The results of sensing experiments reveal rapid, accurate, and quantitative detection of envelope proteins with the limit of detection of ∼24.2 pg/mL and sensitivity of 6.47 GHz/log(pg/mL). We envision that the proposed toroidal metasurface opens new avenues for developing low-cost, and efficient THz plasmonic sensors for infection and targeted bioagent detection.

Evaluation of a Novel Reporter Virus Neutralization Test for Serological Diagnosis of Zika and Dengue Virus Infection.

ABSTRACTCurrently, the laboratory diagnosis of Zika virus (ZIKV) infection is primarily through the detection of ZIKV RNA or antibodies against ZIKV proteins. The detection of viral RNA is highly sensitive and specific, but periods of viremia and viruria are brief, limiting the utility of ZIKV RNA assays. Instead, most ZIKV infections are diagnosed serologically, using an IgM antibody capture enzyme-linked immunosorbent assay (MAC-ELISA) for screening, followed by a confirmatory plaque reduction neutralization test (PRNT). Typical turnaround times vary, due to assay incubation periods and a lack of clinical laboratories performing these tests. Recently, a novel luciferase-ZIKV- and -dengue virus (DENV)-based serological assay, which considerably improves the turnaround times and throughput for ZIKV diagnosis, was described. Using the traditional PRNT as a reference method, we evaluated the performance characteristics of the reporter virus neutralization test (RVNT) with 258 clinical serum specimens. The ZIKV RVNT produced primary ZIKV screening and secondary confirmation results in 4 days, with 100% reproducibility. As a screening assay, the ZIKV RVNT displayed excellent diagnostic accuracy, sensitivity, and specificity of 98.2%, 100%, and 98.1%, respectively. As a confirmatory assay, the ZIKV RVNT titers displayed 93.1% agreement with the traditional ZIKV PRNT titers. Overall, the RVNT accurately and reliably detects neutralizing antibodies in patient serum specimens, with improved turnaround times, and can be used for the serological detection of ZIKV infections. Due to the homogeneous 96-well format, the RVNT has also significantly improved the assay throughput to allow testing of a large number of specimens in a single run.

No molecular or serological evidence of Zikavirus infection among healthy blood donors living in or travelling to regions where Aedes albopictus circulates.

BackgroundPrevious studies have shown that Zika virus can infect and be transmitted by A. albopictus. The World Health organization (WHO) has raised concerns of autochthonous transmission of the virus in regions where the vector is endemic. The aim of this pilot study was to assess the occurrence of Zika virus (ZIKV) in western Austria (Tyrol) especially after a history of travel to A. albopictus endemic regions.MethodsThe study participants were healthy blood donors at randomly selected donation sites in the west Austrian region Tyrol. Rest blood (plasma) samples were tested for the presence of ZIKV nucleic acid and antibodies against the virus.ResultsMean age of the study participants was 44.6 (SD = 12.9) and 58.8% were men. Eighty percent reported to have received vaccine against TBEV, whereas only 4.9 and 0.9% had received YFV and JEV vaccines. Three out of 1001 (0.03%) participants tested positive solely for ZIKV IgM antibody but not for other flaviviruses. Only one individual had ZIKV IgG antibody. All four donors were negative in the neutralization (confirmation) assay. No viral RNA was detected in any of the samples.ConclusionThe null finding of our study refutes WHO’s initial fear of global expansion of ZIKV infection including its occurrence in Europe. There appears to be no urgent need to introduce universal screening of donated blood for ZIKV in central Europe at least until the next warm season. Further, Euroimmun anti-Zika ELISA proved to be a highly suitable and reliable test system in populations with high prevalence of TBEV infection and/or immunization.

No serological evidence for Zika virus infection and low specificity for anti-Zika virus ELISA in malaria positive individuals among pregnant women from Madagascar in 2010.

It was previously reported that a malaria infection may interfere with the specificity of a commercial ELISA test against Zika virus (ZIKV). We analyzed 1,216 plasma samples from healthy, pregnant women collected in two sites in Madagascar in 2010 for ZIKV antibodies using a commercial ELISA and for Plasmodium infection by PCR. This screen revealed six putative ZIKV-positive samples by ELISA. These results could not be confirmed by indirect immunofluorescence assays or virus neutralization tests. Four of these six samples were also positive for P. falciparum. We noted that the frequency of malaria positivity was higher in ZIKV-ELISA positive samples (50% and 100% in the two study sites) than ZIKV-negative samples (17% and 10%, respectively), suggesting that malaria may have led to false ZIKV-ELISA positives.

First cases of Zika virus-infected US blood donors outside states with areas of active transmission.

Zika virus (ZIKV) is transmitted by Aedes mosquitos and can result in severe congenital and adult neurologic abnormalities. ZIKV has rapidly spread northward through Central America and the Caribbean and autochthonous cases have been identified in the continental United States. High rates of ZIKA RNA positivity were detected in blood donors during previous epidemics. ZIKV transmission by transfused blood from healthy donor components has been a growing concern. Individual-donation aliquots of plasma from volunteer blood donors were tested individually with an investigational Procleix ZIKV assay. Initially reactive samples were tested for ZIKV RNA in plasma and red blood cells (RBCs) and for ZIKV-specific antibodies in serum. A confirmed positive classification required confirmation of RNA and/or detection of ZIKV antibodies in index and/or follow-up samples. Between September 19 and November 30, 2016, a total of 466,834 donations were screened for ZIKV RNA. Five donors (one in approx. 93,000) were reactive for ZIKV RNA by both the Procleix ZIKV assay and supplemental testing. The donations were collected outside areas considered as having active transmission, and all five donors had travel exposures. A lookback case demonstrated no infection despite transfusion of a Zika IgG-positive platelet (PLT) component with probable low levels of ZIKV RNA. This report describes the first ZIKV-positive donors detected outside areas with active transmission. These donors most likely represent travel-acquired "tail-end infections" with prolonged RBC-associated ZIKV RNA. The lack of transmission to the recipient of an apheresis PLT may suggest that these units are not infectious.

The Antigenic Structure of Zika Virus and Its Relation to Other Flaviviruses: Implications for Infection and Immunoprophylaxis.

Zika virus was discovered ∼70 years ago in Uganda and maintained a low profile as a human disease agent in Africa and Asia. Only recently has it caused explosive outbreaks in previously unaffected regions, first in Oceania and then in the Americas since 2015. Of special concern is the newly identified link between congenital malformations (especially microcephaly) and Zika virus infections during pregnancy. At present, it is unclear whether Zika virus changed its pathogenicity or whether the huge number of infections allowed the recognition of a previously cryptic pathogenic property. The purpose of this review is to discuss recent data on the molecular antigenic structure of Zika virus in the context of antibody-mediated neutralization and antibody-dependent enhancement (ADE) of infection, a phenomenon that has been implicated in the development of severe disease caused by the related dengue viruses. Emphasis is given to epitopes of antibodies that potently neutralize Zika virus and also to epitopes that provide antigenic links to other important human-pathogenic flaviviruses such as dengue, yellow fever, West Nile, Japanese encephalitis, and tick-borne encephalitis viruses. The antigenic cross talk between Zika and dengue viruses appears to be of special importance, since they cocirculate in many regions of endemicity and sequential infections are likely to occur frequently. New insights into the molecular antigenic structure of Zika virus and flaviviruses in general have provided the foundation for great progress made in developing Zika virus vaccines and antibodies for passive immunization.

Long-term kinetics of Zika virus RNA and antibodies in body fluids of a vasectomized traveller returning from Martinique: a case report

BackgroundThe magnitude of the current Zika virus (ZIKV) epidemic has led to a declaration of a Public Health Emergency of International Concern by the WHO. Findings of viable viral particles in semen for several weeks are corroborating reports of sexual transmission of ZIKV. Serious consequences of a positive diagnostic result particularly in the pregnant patient are calling for precise diagnostic tools also at later time points after infection. Currently, recommendations suggest a diagnostic period of direct viral detection of 5 to 7 days after onset of symptoms in serum or plasma, and up to 3 weeks in urine samples.Case presentationA vasectomized 41-year-old German returning from Martinique presented at the outpatient clinic of the Department for Infectious Diseases and Tropical Medicine, Munich, with subfebrile temperature, rash, malaise, severe retro-orbital pain and occipital lymphadenopathy. The main complaints resolved after ten days without specific treatment. We are reporting on clinical course and results of direct and indirect detection methods of ZIKV in different sample types including whole blood, ejaculate, urine, serum, plasma and saliva samples up to 119 days post symptom onset. Ejaculate samples remained PCR positive for ZIKV until day 77, whole blood samples until day 101.ConclusionsThe case presentation adds to the still limited knowledge of kinetics of detection of ZIKV by direct as well as indirect methods. Here, a complete data set including results from PCR, serology and cell culture is provided allowing an improved evaluation of optimum diagnostic periods for testing a variety of sample types. Moreover, a high viral load of ZIKV RNA was detected in ejaculate of the vasectomized patient. This finding sheds new light on the possible localizations of ZIKV replication in the human male reproductive tract.

Specific detection of dengue and Zika virus antibodies using envelope proteins with mutations in the conserved fusion loop

Detection of antibodies is widely used for the diagnosis of infections with arthropod-borne flaviviruses including dengue (DENV) and Zika virus (ZIKV). Due to the emergence of ZIKV in areas endemic for DENV, massive co-circulation is observed and methods to specifically diagnose these infections and differentiate them from each other are mandatory. However, serological assays for flaviviruses in general, and for DENV and ZIKV in particular, are compromised by the high degree of similarities in their proteins which can lead to cross-reacting antibodies and false-positive test results. Cross-reacting flavivirus antibodies mainly target the highly conserved fusion loop (FL) domain in the viral envelope (E-) protein, and we and others have shown previously that recombinant E-proteins bearing FL-mutations strongly reduce cross-reactivity. Here we investigate whether such mutant E-proteins can be used to specifically detect antibodies against DENV and ZIKV in an ELISA-format. IgM antibodies against DENV and ZIKV virus were detected with 100% and 94.2% specificity and 90.7% and 87.5% sensitivity, respectively. For IgG the mutant E-proteins showed cross-reactivity, which was overcome by pre-incubation of the sera with the heterologous antigen. This resulted in specificities of 97.1% and 97.9% and in sensitivities of 100% and 100% for the DENV and ZIKV antigens, respectively. Our results suggest that E-proteins bearing mutations in the FL-domain have a high potential for the development of serological DENV and ZIKV tests with high specificity.Emerging Microbes & Infections (2017) 6, e99; doi:10.1038/emi.2017.87; published online 8 November 2017

Neutralization of Zika virus by germline-like human monoclonal antibodies targeting cryptic epitopes on envelope domain III

The Zika virus (ZIKV), a flavivirus transmitted by Aedes mosquitoes, has emerged as a global public health concern. Pre-existing cross-reactive antibodies against other flaviviruses could modulate immune responses to ZIKV infection by antibody-dependent enhancement, highlighting the importance of understanding the immunogenicity of the ZIKV envelope protein. In this study, we identified a panel of human monoclonal antibodies (mAbs) that target domain III (DIII) of the ZIKV envelope protein from a very large phage-display naive antibody library. These germline-like antibodies, sharing 98%–100% hoLogy with their corresponding germline IGHV genes, bound ZIKV DIII specifically with high affinities. One mAb, m301, broadly neutralized the currently circulating ZIKV strains and showed a synergistic effect with another mAb, m302, in neutralizing ZIKV in vitro and in a mouse model of ZIKV infection. Interestingly, epitope mapping and competitive binding studies suggest that m301 and m302 bind adjacent regions of the DIII C–C′ loop, which represents a recently identified cryptic epitope that is intermittently exposed in an uncharacterized virus conformation. This study extended our understanding of antigenic epitopes of ZIKV antibodies and has direct implications for the design of ZIKV vaccines.Emerging Microbes & Infections (2017) 6, e89; doi:10.1038/emi.2017.79; published online 11 October 2017

Characterizing the Zika virus antibody response

Zika Virus Given the public health emergency that Zika virus poses, scientists are seeking to understand the Zika-specific immune response. Stettler et al. analyzed 119 monoclonal antibodies isolated from four donors that were infected with Zika virus during the present epidemic, including two

Zika Virus-Induced Antibody Response Enhances Dengue Virus Serotype 2 Replication In Vitro.

Zika virus has emerged in the Americas, where dengue virus is endemic. Among the 4 serotypes of dengue virus, antibody-dependent enhancement is thought to enhance viral replication and disease severity. Reports suggest that anti-dengue virus antibody may enhance Zika virus replication. We investigated whether Zika virus antibodies enhance dengue virus replication, by exposing C57Bl/6 mice to Zika virus. Polyclonal serum was verified for strong Zika virus-neutralizing, dengue virus-subneutralizing capacity. Then we determined the enhancement capabilities of Zika virus-immune serum for dengue virus in vitro. We showed that Zika virus antibodies have the ability to enhance dengue virus infections, which is important, because in many Zika virus-affected areas, dengue virus is expected to remain endemic.

Interim Guidance for Interpretation of Zika Virus Antibody Test Results.

Zika virus is a single-stranded RNA virus in the genus Flavivirus and is closely related to dengue, West Nile, Japanese encephalitis, and yellow fever viruses (1,2). Among flaviviruses, Zika and dengue virus share similar symptoms of infection, transmission cycles, and geographic distribution. Diagnostic testing for Zika virus infection can be accomplished using both molecular and serologic methods. For persons with suspected Zika virus disease, a positive real-time reverse transcription-polymerase chain reaction (rRT-PCR) result confirms Zika virus infection, but a negative rRT-PCR result does not exclude infection (3-7). In these cases, immunoglobulin (Ig) M and neutralizing antibody testing can identify additional recent Zika virus infections (6,7). However, Zika virus antibody test results can be difficult to interpret because of cross-reactivity with other flaviviruses, which can preclude identification of the specific infecting virus, especially when the person previously was infected with or vaccinated against a related flavivirus (8). This is important because the results of Zika and dengue virus testing will guide clinical management. Pregnant women with laboratory evidence of Zika virus infection should be evaluated and managed for possible adverse pregnancy outcomes and be reported to the U.S. Zika Pregnancy Registry or the Puerto Rico Zika Active Pregnancy Surveillance System for clinical follow-up (9,10). All patients with clinically suspected dengue should have proper management to reduce the risk for hemorrhage and shock (11). If serologic testing indicates recent flavivirus infection that could be caused by either Zika or dengue virus, patients should be clinically managed for both infections because they might have been infected with either virus.

Zika Virus: More Questions Than Answers

The recent Zika virus (ZIKV) outbreak has been declared a Public Health Emergency of International Concern (PHEIC) by the World Health Organization in February 2016. It started in Brazil in 2015, rapidly spread through South and Central America, and is expected to reach the continental US in the summer of 2016. The appearance of ZIKV has been connected with an increase in cases of microcephaly in newborns of the affected areas and Guillain–Barre Syndrome (GBS) (WHO, 2016). Since the virus' first isolation in Uganda in 1947, the two major outbreaks happened in Micronesia (2007) and in French Polynesia (2013). The 2013 outbreak is the only precedent where ZIKV was associated with serious complications (GBS) and a causal link between ZIKV infection and GBS was suggested based on a large study (Cao-Lormeau et al., 2016). The mechanism of ZIKV-induced GBS is not clear, but one possibility is cross-reactivity between a viral antigen and the self-peptide myelin. The evidence for ZIKV causing fetal microcephaly has been under debate due to the small number of studies reported, but as new reports appear every week the evidence seems clearer, although it has not been scientifically proven yet. A recent cohort study of 88 pregnant women in Brazil showed that 29% of infected mothers delivered babies with fetal abnormalities (Brasil et al., 2016). Furthermore, from nine current reported cases of ZIKV-positive pregnant women in the US that traveled to ZIKV endemic areas, five pregnancies resulted in fetal abnormalities or death, two in healthy babies while two women are still pregnant (Meaney-Delman et al., 2016). ZIKV has also been found both in the amniotic fluid and in fetal brain after pregnant mothers were infected, supporting the causal link between ZIKV-infected mothers and fetal microcephaly (Marrs et al., 2016). There are precedents of closely related neutrotropic flaviviruses that cause neurological diseases. West Nile Virus (WNV) can cause encephalitis and meningitis, and chikungunya virus (CHIKV) can cause neonatal encephalopathy and microcephaly (Gerardin et al., 2014). Additionally, other viruses causing congenitally acquired infections (TORCH) like rubella virus, cytomegalovirus, herpes simplex virus, varicella zoster virus or HIV have been associated with microcephaly in neonates. ZIKV can bind different cell receptors (Hamel et al., 2015), some of them present in neurons, and can infect and replicate in murine neurons and astroglia (Bell et al., 1971). Although pregnant women infected with ZIKV do not show neurological disease, hormonal-induced changes in immune responses, infections in ZIKV-naive women or specific genetic factors might facilitate increased replication of the virus in the mother, cross-placental barrier accessibility and ultimately ZIKV presence in the fetus during early stages of brain development. Nevertheless, the neuropathogenic effect of ZIKV is unknown. Similarly to GBS, the induction of mimicry, where antibodies produced against a viral protein by the mother will recognize a self-protein in the fetus (i.e. during brain development), is possible, or the presence of ZIKV in the brain could also cause tissue damage. ZIKV is a mosquito-borne virus of the family Flaviviridae, genus Flavivirus. The natural vector for ZIKV transmission is Aedes sp. mosquitoes, mainly A. aegypti and A. albopictus species, which also transmit other flaviviruses as dengue virus (DENV) and CHIKV. This mosquito is endemic in tropical areas, and may have facilitated ZIKV dispersion during outbreaks. ZIKV has been also reported to be transmitted by blood transfusion and sporadically by sexual contact, from a sexual partner infected while traveling to ZIKV areas. Detection of infective ZIKV in semen has been confirmed, and an increasing number of potential sexual transmission cases are currently being investigated by the CDC (Hills et al., 2016). This poses new challenges to control the epidemic. ZIKV infection is asymptomatic in 80% of the cases and the remainder 20% suffer mild symptoms similar to those induced by DENV: fever, headache, red eyes, rash, fatigue, muscle and joint pain. In the current outbreak, cross-reactivity with antibodies from DENV and CHIKV in the affected areas has stalled the use of ELISA to detect ZIKV antibodies. The only reliable diagnostic technique available is RT-PCR testing of serum, but is only positive during the viremia, usually 3–7 days, and of urine, where virus can be detected from 4 up to 30 days after the onset of infection. Tests for semen and saliva are still under development. Amniotic fluid sampling for PCR has been recommended for pregnant women, especially when the blood test results are negative. Ultrasound testing can confirm fetal microcephaly, and additional testing may be performed on fetal tissue, like RT-PCR on tissue and electron microscopy to detect virus particles, and direct immunofluorescence suggestive of viral infection within neurons.