Korean J Lab Med 2010;30:289-94 DOI 10.3343/kjlm.2010.30.3.289 Original Article Clinical Microbiology Comparison of R-mix Virus Culture and Multiplex Reverse Transcriptase-PCR for the Rapid Detection of Respiratory Viruses Gayoung Lim, M.D., Tae Sung Park, M.D., Jin-Tae Suh, M.D., and Hee Joo Lee, M.D. Department of Laboratory Medicine, Kyung Hee University, College of Medicine, Seoul, Korea Background : Respiratory viral infections can become epidemic due to high contagiosity. Since there was no rapid diagnostic method for complete diagnosis in the past, diagnosis was solely made on the basis of clinical symptoms or the time of infection. With recent developments in rapid diagnostic methods like multiplex reverse transcriptase (RT)-PCR, R-mix virus culture, etc., early detection and effective treatment of respiratory viral infections is possible. Herein, we compared the efficiency of multiplex RT-PCR and the R-mix virus culture for the rapid detection of respiratory viruses. Methods : We used 96 nasopharyngeal swab specimens for culturing respiratory viruses using R- mix (Diagnostics Hybrids Inc., USA). Afterwards, multiplex RT-PCR was performed using specimens stored at -70. Results : R-mix virus culture yielded positive results in 34 cases (35.4%) and multiplex RT-PCR in 73 cases (76.0%). Both methods yielded identical results in 51 cases (29 positive cases and 22 negative cases). Among 45 cases that showed different results, 40 showed negative results in R-mix virus culture and positive results in multiplex RT-PCR, and 1 showed positive result in R-mix virus culture and negative result in multiplex RT-PCR. Different viruses were detected in the remaining 4 cases by both the methods. Conclusions : Multiplex RT-PCR provided faster results and had higher detection rates than R-mix virus culture. Further, unlike R-mix virus culture, multiplex RT-PCR can be used to identify new respiratory viruses. Therefore, multiplex RT-PCR is more useful than R-mix virus culture in the diagnosis of respiratory virus infection. (Korean J Lab Med 2010;30:289-94) Key Words : R-mix virus culture, Respiratory virus detection, Multiplex respiratory RT-PCR 서 소아환자들에서급성호흡기감염은내원하는주요원인중의하나이며, 개발도상국에서는세균성감염의빈도가감소하여호흡기바이러스가급성호흡기감염의주요원인이되었다 [1]. 호흡기감염의주요바이러스는 respiratory syncytial virus, Received : October 14, 2009 Manuscript No : KJLM09-119 Revision received : April 7, 2010 Accepted : May 3, 2010 Corresponding author : Hee Joo Lee, M.D. Department of Laboratory Medicine, Kyung Hee University School of Medicine, 1 Hoegi-dong, Dongdaemun-gu, Seoul 130-702, Korea Tel : +82-2-958-8672, Fax : +82-2-958-8609 E-mail : leehejo@khmc.or.kr ISSN 1598-6535 론 The Korean Society for Laboratory Medicine parainfluenza virus, influenza A virus, influenza B virus 등이있다 [2]. 이러한호흡기바이러스진단방법은신속항원비면역형광검사법 (rapid antigen non-immunofluorescence tests), 신속항원면역형광검사법 (rapid antigen immunofluorescence based tests), 전통세포배양법 (conventional culture), 신속세포배양법 (rapid cell culture), 분자진단법 (molecular methods) 등이있다. 신속항원비면역형광검사법은빠른시간내에결과를확인할수있는장점이있으나민감도가세포배양법에비하여낮아위음성이많은단점이있다 [3, 4]. 현재표준검사법인세포배양법은검사결과를확인하는데 5-9일이상의시간이소요되어호흡기바이러스감염의조기진단과치료에어려움이있다 [4-6]. 이러한세포배양법의단점을보완하기위해 24-72시간내에결과를확인할수있고민감도는 30-40% 289
290 Korean J Lab Med 2010;30:289-94 로전통배양법과비슷한 R-mix 바이러스배양법등이새로이시행되고있다 [7, 8]. 또한세포배양법뿐만아니라분자진단법도개발되어신속한진단과높은민감도를가진 multiplex reverse transcriptase (RT)-PCR, real time RT-PCR 등이있다 [9, 10]. 호흡기바이러스감염의진단에서무엇보다시간이중요하게여겨지는이유는대부분의호흡기바이러스가전염력이강해모든연령에서흔히발생하고있고정확한진단에따른적절한치료와예방을위해서원인바이러스를조기에발견하는것이중요하기때문이다 [11, 12]. 이에저자들은바이러스성호흡기감염의조기진단을위한신속배양법 (R-mix virus culture) 과분자진단법 (multiplex RT-PCR) 두검사의결과를비교해보고자하였다. 대상및방법 700 g 로한시간동안원심분리한후 CO 2 배양기에서 24시간동안배양한다음 respiratory virus DFA screening reagent (Diagnostics Hybrids Inc.) 로염색하여형광염색된세포유무를형광현미경으로확인하였다. 형광염색세포가있을경우 shell vial에 phosphate buffered saline을첨가한후긁어 8 well slide에분주하여 SpotPBS-w/Individual Monoclonal Ab (Diagnostics Hybrids Inc.) 를떨어뜨려서관찰하였다. 형광염색된세포가없을경우에는 24시간더배양후 respiratory virus DFA screening reagent로염색확인하였으며형광염색된세포가한개이상이면양성으로보고하였다. R-mix virus culture는 influenza A와 B, parainfluenza 1, 2, 3, respiratory syncytial virus type A와 B, adenovirus 등총 8 종의바이러스를검사하였다. 1. 대상 2008년 12 월부터 2009년 2월까지 3차의료기관에호흡기바이러스배양검사가의뢰된 96예를대상으로하였다. 대상환자들의나이, 성별, 진단명은의무기록을통해후향적으로조사하였다. 2. 검사방법 1) 검체호흡기바이러스배양검사가의뢰된모든검체는코인두면봉을하여 universal transport medium에운반되었다. 수송된검체는검사할때까지 4 에보관하였다. R-mix virus culture (Diagnostics Hybrids Inc., Athens, OH, USA) 후 -70 에보관하였던검체로 multiplex RT-PCR (Seeplex RV detection kit, Seegene, Seoul, Korea) 을시행하였다. 2) R-mix virus culture 검사실로수송된검체를잘섞어 1 ml 를바이러스수송시험관에첨가한후유리구슬을넣고 30초간강하게소용돌이혼합 (vortex) 하였다. 실온에서 700 g 로 10분동안원심분리한후상층액을꺼내어표기된보관용기에넣고선암종 (A549) 과 Mink Lung (Mv1Lu) 으로구성된 R-mix ready cells vials (Diagnostics Hybrids Inc) 을꺼내어 37 heat 블록에옮겨 4분간해동한후 0.5 ml의 rinse buffer를첨가하고실온에 4분간방치한후 rinse buffer를흡입하고 1.0 ml의 R-mix ready cells re-feed medium을첨가하였다. R-mix vials 3개에접종한후 3) Multiplex RT-PCR 바이러스 RNA는준비된검체 300 ml에서 Gene-spin Extraction Kit (INtRON, Seoul, Korea) 를사용하여추출하고 Revert Aid First Strand cdna Synthesis Kit (Fermentas, Burlington, ON, Canada) 를사용하여 first-strand cdna를합성하였다. 연쇄중합반응은 Seeplex Respiratory Viruses Detection kit (Seegene) 를사용하여반응액을제조하였다. 연쇄중합반응액은 3 ml의 cdna, 4 ml의 5xRV Primer, 3 ml 의 8-methoxypsoralen (8-MOP), 10 ml의 2xMultiplex Master Mix로총 20 ml가되도록하였다. 연쇄중합반응은 94 에서 15분반응후, 94 30초, 60 1.5분, 72 1.5분의반응을 40회반복하였고, 최종적인연장반응을 72 에서 10분간실시하였다. 증폭된반응산물은 ethidium bromide가 0.5 ml 포함된 2% 우무겔에서전기영동하여내부대조물질의증폭산물이있을때핵산추출과증폭과정이적절하였다고판단하였고, 각증폭산물의밴드크기는키트에포함된표지 DNA 와비교하여판독하였다. Multiplex RT-PCR은 influenza A와 B, parainfluenza 1, 2, 3, respiratory syncytial virus type A와 B, adenovirus, metapeumovirus, rhinovirus, corona virus 229E/NL63과 corona virus OC43 등총 12 종의바이러스를검사하였다. 결과 1. 대상환자의임상적특성 2008년 12 월부터 2009년 2월까지의 96개의검체중에서다
Lim G, et al., Rapid Detection of Respiratory Viruses 291 른종류의바이러스가검출되는경우에는각각다른예로분석하였다. 대상환자는남녀 56:40명이었으며 1세이하환자가 66명 (68.8%), 2-11세환자가 29명 (30.2%) 으로대부분이 11세이하의소아환자였다 (Table 1). 대상환자들은상기도감염과하기도감염이각각 15명 (15.6%), 74명 (77.1%) 으로 90% 이상의환자들이호흡기감염환자들이었으며, 상기도감염환자들은급성인두염, 급성편도선염, 급성중이염이각각 8명, 3명, 1명이고그외분류되지않은경우가 3명이었으며, 하기도감염환자들은폐렴, 급성세기관지염, 크룹이각각 48명, 17명, 9명이었다 (Table 1). 2. R-mix virus culture와 multiplex RT-PCR 결과 1) R-mix virus culture 결과 R-mix virus culture는 96 개의검체중에서 34예 (35.4%) 가양성이었다. Influenza A 15예 (44.1%), respiratory syncytial virus 14예 (41.2%) 로가장많았으며그외에 parainfluenza 1, 2, 3은각각 1예 (2.9%), 2예 (5.7%), 1예 (2.9%) 였으며, adenovirus 와 influenza A virus가동시에검출된경우가 1예 (2.9%) 였다 (Table 2). 따라서 34예에서총 35 개의바이러스가검출되었다 (Tables 2, 3). Table 1. Clinical characteristics of patients Characteristics N of patients (%) Total N of patients 96 Sex (male/female) 56/40 Age (yr) 0-1 66 (68.8) 2-5 22 (22.9) 6-11 7 (7.3) 59 1 (1.0) Diagnosis Upper respiratory infection 15 (15.6) Acute pharyngitis 8 (8.3) Acute tonsilitis 3 (3.1) Acute otitis media 1 (1.0) Not available 3 (3.1) Lower respiratory infection 74 (77.1) Pneumonia 48 (50.0) Acute bronchiolitis 17 (17.7) Croup 9 (9.4) Others* 7 (7.3) *Acute gastric enteritis, 4; Urinary tract infection, 2; rule out sepsis, 1. Table 2. Comparison between the results of R-mix culture and multiplex RT-PCR Multiplex RT-PCR R-mix culture Positive (%) Negative (%) Total (%) Positive* 33 (34.3) 30 (31.3) 73 (76.0) 10 (10.4) Negative 1 (1.0) 22 (22.9) 23 (24.0) Total 34 (35.4) 62 (64.6) 96 (100) *Multiplex RT-PCR results suggested that 14 patients were co-infected. 4 cases showed different results with R-mix culture and multiplex RT- PCR. Multiplex RT-PCR analysis was positive for 8 respiratory viruses (influenza A/B, parainfluenza 1/2/3, respiratory syncytial virus type A/B, adenovirus) and 4 other respiratory viruses (metapneumovirus, rhinovirus, coronavirus 229E/NL63, and corona virus OC43). Multiplex RT-PCR results were positive for only 4 extra respiratory viruses (metapneumovirus, rhinovirus, coronavirus 229E/NL63, and corona virus OC43). 2) Multiplex RT-PCR 결과 Multiplex RT-PCR은 73예 (76%) 의양성을보였고 14예에서 2가지이상의바이러스가동시에검출되었다 (Tables 2, 3). 동시에검출된예에서 2가지바이러스가 10예, 3가지바이러스가 3예, 4가지바이러스가 1예로나타나 96예의검체에서총 92개의바이러스가검출되었다 (Table 4). 검출된바이러스에서 respiratory syncytial virus가 31예 (33.7%), influenza A virus가 25예 (27.2%) 순으로가장많았으며 coronavirus 229E/NL63, coronavirus OC43/HKU1, adenovirus, rhinovirus가각각 13 예 (14.1%), 7예 (7.6%), 7예 (7.6%), 5예 (5.4%) 순이었다. 3) R-mix virus culture와 multiplex RT-PCR 비교 R-mix virus culture와 multiplex RT-PCR의결과를비교하여보면 (Table 2) 두검사가일치하는결과를갖는것은총 51 Table 3. R-mix virus culture and multiplex RT-PCR results of respiratory viruses Respiratory viruses N of positive results (%) R-mix culture Multiplex RT-PCR Influenza A* 16 (45.7) 25 (27.2) Respiratory syncytial virus 14 (40.0) 31 (33.7) Parainfluenza 1 1 (2.9) 2 (2.2) Parainfluenza 2 2 (5.7) 0 (0.0) Parainfluenza 3 1 (2.9) 1 (1.1) Adenovirus 1 (2.9) 7 (7.6) Coronavirus 229E/NL63-13 (14.1) Coronavirus OC43/HKU1-7 (7.6) Rhinovirus - 5 (5.4) Metapneumovirus - 1 (1.1) Total 35 (100) 92 (100) *Co-infection with adenovirus: 1 case. Cases with co-infection are separately included in the total number of cases. R-mix virus culture, 1 positive case; multiplex RT-PCR, 14 positive cases.
292 Korean J Lab Med 2010;30:289-94 Table 4. Co-infection with respiratory viruses detected by multiplex RT-PCR Respiratory viruses Abbreviation: RSV, respiratory syncytial virus. 예 (53.1%) 로두검사에서모두양성인경우에서는 29예, 음성인경우는 22예였다. R-mix culture와 multiplex PCR 결과에서모두양성을보인예는 33예였는데이중에서 4예는두검사에서다른종류의바이러스가검출되었다. R-mix virus culture에서는음성이었던것이 multiplex RT- PCR에서는양성으로나온결과가 40예였다. 이들중 R-mix culture에서검출가능한 8종의바이러스 (influenza A와 B, parainfluenza 1, 2, 3, respiratory syncytial virus type A 와 B, adenovirus) 에서양성을보인것은 23예였으며 multiplex RT-PCR에서추가로검사하는 4종바이러스 (metapeumovirus, rhinovirus, coronavirus 229E/NL63과 corona virus OC43) 만검출된예는 10예, R-mix culture에서검출가능한 8종의바이러스와함께 multiplex RT-PCR에서추가된 4종의바이러스가함께검출된것은 7예였다. 고 호흡기바이러스질환은가장호발하는질환중의하나로급성질환의절반정도를차지하고있다. 미국의통계를살펴보면일년에한사람당 3-5.6회정도의유병률을갖는것으로발표되고있으며 1세이하에서가장높고 6세이전까지의유병률이높았다 [13]. 소아에서호흡기감염은일과성으로지나치는경우가대부분이지만드물게합병증을남겨성인기까지문제를가지고가기도하고, 생명에위협을주기도해서신속한진단과그에따른적절한치료가필요하다 [14]. 본연구에서는조기진단을위한진단법인 R-mix virus culture와 multiplex RT-PCR 법을비교해보고자하였다. 호흡기바이러스배양검사가의뢰된 96개의검체중에서 59세남자환자 1명을제외하고모두 11세이하의소아환자들로소아에서호흡기감염의빈도가높은데 찰 N of patients Corona virus 229E/NL63+RSV A 6 Corona virus 229E/NL63+influenza A 2 Corona virus 229E/NL63+adenovirus 1 Corona virus 229E/NL63+corona virus 1 OC43/HKU1+adenovirus Corona virus 229E/NL63+adenovirus+rhinovirus 1 Corona virus OC43/HKU1+RSV A+rhinovirus 1 Corona virus OC43/HKU1+adenovirus, 1 rhinovirus+rsv A Adenovirus+influenza A 1 이는 Kim 등 [2] 의연구에서호흡기바이러스양성이분리된환자들중에서소아인경우가 94.4% 로본연구와유사하였으며, Kim 등 [15] 연구에서도평균나이가 6.9세로호흡기바이러스검사가의뢰된환자들의연령이본연구에서와같이낮았다. 또한 Kim 등 [2] 의연구에서 2004-2006년호흡기바이러스감염의소아환자들의진단명분포를살펴보면소아에서는상기도감염이 20.3%, 하기도감염이 76.4% 로본연구와유사하게하기도감염의비율이높았다. 본연구에서 R-mix virus culture와 multiplex RT-PCR 결과비교상 multiplex RT-PCR에서양성률이높았다. R-mix virus culture의양성률은 34.3% 로전통배양법과간접면역형광염색법을사용한 Kang 등 [16] 의연구에서의바이러스의양성률 21.6% 보다는높은결과였으나 R-mix virus culture를이용한다른연구결과의양성률과유사하였다 [7, 8, 17]. Multiplex RT-PCR은 R-mix virus culture에서음성이었던검체에서도바이러스가검출되었는데 Roh 등 [18] 의연구에서도 R-mix virus culture에서음성인 25개의검체중 9개의검체에서 multiplex RT-PCR이양성이나왔다. Multiplex RT-PCR 이양성률이높은이유는바이러스의생존과검체보존등에제약을적게받기때문이라생각되었다 [17]. 또한 multiplex RT- PCR이 R-mix virus culture에서보다 4종의바이러스가추가되어있어 multiplex RT-PCR의양성률을증가시켰을것이라생각되었다. 본연구에서는 metapneumovirus는검출되지않았는데이는검체를모은시기가 12월부터 2월로 metapneumovirus가유행하는 3월부터 5월까지의시기와달라검출되지않은것으로생각되었다 [19]. 2가지이상의바이러스가검출된것이 R-mix virus culture 에서는 1예, multiplex RT-PCR에서는 14예였다. Multiplex RT-PCR은 2가지이상의바이러스가검출된비율이 22.5% 로 Kim 등 [19] 의혼합감염결과와유사하였다. 또한 multiplex RT- PCR에서 2가지이상의바이러스가검출된결과를살펴보면 14 예중에서 corona virus가 13 예에서모두검출되었다. Canducci 등 [20] 의결과에서도 corona virus가검출되었을때혼합감염으로다른바이러스가동시에검출되는것이 46.4% 로높은비율을차지하고있었다. Corona virus가이전발표들보다많이검출된것은단독감염의예보다혼합감염으로검출된예가많아서라고생각되었다 [19, 21]. 결론적으로 multiplex RT-PCR이 R-mix virus culture보다양성률이높고조기에검사결과를확인할수있었지만혼합감염의비율도높아서검출된모든바이러스가호흡기감염을
Lim G, et al., Rapid Detection of Respiratory Viruses 293 일으켰는지는임상적으로확인이어려웠다. 하지만 R-mix virus culture에서검출가능한 8종의바이러스외에 4종 (metapneumovirus, rhinovirus, corona virus 229E/NL63과 corona virus OC43) 의바이러스도호흡기감염질환을일으킬수있으므로이들의결과도확인을하는것이임상의의진단과치료계획에도움을줄수있을것이다 [22]. 요약배경 : 바이러스에의한호흡기감염일경우강한전염력으로인해유행하는경향이많지만예전에는확진을위한조기진단법이없어임상적증상과감염의발생시기등에만의존하여진단을했다. 그러나최근에는 multiplex reverse transcriptase (RT)-PCR, R-mix virus culture 등신속진단법이개발됨에따라조기에적절한치료가가능해졌다. 이에조기진단방법인 multiplex RT-PCR과 R-mix virus culture를비교해보고자하였다. 방법 : 호흡기바이러스배양이의뢰된 96개의검체를대상으로하였다. 검체는코인두면봉이었으며 R-mix virus culture (Diagnostic Hybrids Inc., USA) 후 -70 에서보관한검체로 multiplex RT-PCR (Seegene, Korea) 검사를시행하였다. 결과 : R-mix virus culture에서는 34예 (35.4%), multiplex RT-PCR에서는 73 예 (76.0%) 가양성이었다. R-mix virus culture와 multiplex RT-PCR의결과에서 51예 ( 양성 29예, 음성 22예 ) 가일치하였다. 45예의불일치결과를살펴보면 R-mix virus culture 음성, multiplex RT-PCR 양성인것이 40예, R-mix virus culture 양성, multiplex RT-PCR 음성인것이 1예, R-mix virus culture, multiplex RT-PCR 이모두양성이지만검출된바이러스가다른것이 4예였다. 결론 : R-mix virus culture보다 multiplex RT-PCR은빠른시간내에결과를도출할수있었고양성률이높았다. R-mix virus culture에서검출하지못하는새로운호흡기바이러스도 multiplex RT-PCR에서는확인할수있어호흡기바이러스감염진단에유용할것으로생각되었다. 참고문헌 1. Kim MR, Lee HR, Lee GM. Epidemiology of acute viral respiratory tract infections in Korean children. J Infect 2000;41:152-8. 2. Kim SH, Huh JH, Bae SY, Kim JS, Yoon SY, Lim CS, et al. Epidemiology of respiratory viral infection in 2004-2006. Korean J Lab Med 2006;26:351-7. ( 김선형, 허지훈, 배숙영, 김장수, 윤수영, 임채승등. 2004-2006년의호흡기바이러스감염의역학. 대한진단검사의학회지 2006; 26:351-7.) 3. Ginocchio CC. Detection of respiratory viruses using non-molecular based methods. J Clin Virol 2007;40(S1):S11-4. 4. Leland DS and Ginocchio CC. Role of cell culture for virus detection in the age of technology. Clin Microbiol Rev 2007;20:49-78. 5. McPherson RA and Pincus MR, eds. Henry s Clinical diagnosis and management by laboratory methods. 21st ed. Philadelphia: Saunders, 2007:975-84. 6. Barenfanger J, Drake C, Mueller T, Troutt T, O Brien J, Guttman K. R-Mix cells are faster, at least as sensitive and marginally more costly than conventional cell lines for the detection of respiratory viruses. J Clin Virol 2001;22:101-10. 7. LaSala PR, Bufton KK, Ismail N, Smith MB. Prospective comparison of R-mix shell vial system with direct antigen tests and conventional cell culture for respiratory virus detection. J Clin Virol 2007;38:210-6. 8. St George K, Patel NM, Hartwig RA, Scholl DR, Jollick JA Jr, Kauffmann LM, et al. Rapid and sensitive detection of respiratory virus infections for directed antiviral treatment using R-Mix cultures. J Clin Virol 2002;24:107-15. 9. Mahony JB. Detection of respiratory viruses by molecular methods. Clin Microbiol Rev 2008;21:716-47. 10. Yoo SJ, Kuak EY, Shin BM. Detection of 12 respiratory viruses with two-set multiplex reverse transcriptase-pcr assay using a dual priming oligonucleotide system. Korean J Lab Med 2007;27:420-7. ( 유수진, 곽은영, 신보문. Dual priming oligonucleotide system을이용한다중역전사 PCR 키트를통한 12가지호흡기바이러스의검출. 대한진단검사의학회지 2007;27:420-7.) 11. Lin TY, Huang YC, Ning HC, Tsao KC. Surveillance of respiratory viral infections among pediatric outpatients in northern Taiwan. J Clin Virol 2004;30:81-5. 12. Maitreyi RS, Broor S, Kabra SK, Ghosh M, Seth P, Dar L, et al. Rapid detection of respiratory viruses by centrifugation enhanced cultures from children with acute lower respiratory tract infections. J Clin Virol 2000;16:41-7. 13. Fauci AS and Kasper DL, eds. Harrison s principles of internal medicine. 17th ed. Boston: McGraw-Hill, 2008: 1120-32. 14. Ahn HS, ed. Pediatrics. 9th ed. Seoul: Daehan, 2008:629-53. ( 안효섭편. 소아과학. 9판. 서울 : 대한교과서, 2008: 629-53.) 15. Kim SR, Ki CS, Lee NY. Rapid detection and identification of 12 res-
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