Toward Personalized Medicine: The Effect of Treatment of Chronic Enterovirus Diarrhea in an Immunocompromised Patient and the Correlation With In Vitro Models

Figure 1.. Neutralizing antibody titers in different batches of intravenous immunoglobulin (IVIG) from the Netherlands and South Africa against herpes simplex virus type 1 and coxsackievirus A1. The dotted line indicates the threshold above which the IVIG is neutralizing [28]. Abbreviations: CVA1, coxsackievirus A1; HSV-1, herpes simplex virus type 1; IVIG NL, Dutch batch of intravenous immunoglobulin from 2019; IVIG patient, Dutch batch of intravenous immunoglobulin from 2021 used as substitution therapy in the patient; IVIG SA, South African intravenous immunoglobulin batch; nAb, neutralizing antibody.

Figure 2.. Effect of clinically approved compounds on viral replication of coxsackievirus A1 (CVA1) in rhabdomyosarcoma (RD) cells. A, Relative increase in viral RNA copies upon treatment with itraconazole at 1 µM, 1.5 µM, 2 µM, and 2.5 µM. B, Relative increase in viral RNA copies upon treatment with fluoxetine at 1.25 µM, 1.5 µM, 5 µM, and 10 µM. C, Relative increase in viral RNA copies upon treatment with ribavirin at 10 µM, 20 µM, 40 µM, and 80 µM. D, Relative increase in viral RNA copies upon treatment with remdesivir at 4 µM, 8 µM, 16 µM, and 32 µM. The data represent mean ± standard error of the mean of 3 technical replicates in 2 biological replicates. *P < .05, ****P < .0001. Abbreviations: CVA1, coxsackievirus A1; FLX, fluoxetine; ITZ, itraconazole; RBV, ribavirin; RDV, remdesivir.

Figure 3.. Effect of remdesivir (RDV) on viral replication and quasi-species composition of coxsackievirus A1 (CVA1) in rhabdomyosarcoma (RD) cells. A, Relative increase in viral RNA copies upon treatment with RDV at 4 µM, 8 µM, 16 µM, and 32 µM. B, Intracellular adenosine triphosphate release upon treatment with RDV relative to untreated control indicated as percentage in RD cells at 72 hours postinfection. The data represent mean ± standard error of the mean of 3 technical replicates in 2 biological replicates. The orange line indicates CVA1 replication on RD cells without any treatment; the blue lines indicate CVA1 replication on RD cells upon treatment with different concentration of antiviral compounds. C, Maximum parsimony tree of CVA1 strains isolated from the patient before (red) and after (blue) receiving RDV treatment. The numbers on the tree represent the percentage of sequencing reads that align to each contig, indicating the relative abundance of each contig within the viral population and the coexisting quasi-species before and after treatment. **P < .01, ****P < .0001.

Figure 4.. Antiviral testing on organoids. Cell viability at 72 hours after treatment with remdesivir (RDV) and effect of on viral replication of coxsackievirus A1 (CVA1) in a co-culture of human intestinal epithelium (HIE) with fibroblasts. A, Intracellular adenosine triphosphate (ATP) release upon treatment with RDV at 4 µM, 8 µM, 16 µM, and 32 µM relative to untreated control indicated as percentage in rhabdomyosarcoma (RD) cells. B, Intracellular ATP release, indicated as percentage, upon treatment with RDV at 4 µM relative to untreated control in HIE. C, Intracellular ATP release, indicated as percentage, upon treatment with fluoxetine (FLX) at 1.25 µM, 2.5 µM, 5 µM, and 10 µM relative to untreated control in RD cells. D, Intracellular ATP release, indicated as percentage, upon treatment with FLX at 1.25 µM together with amantadine at 3.3 µM, or FLX at 1.25 µM, or FLX at 2.5 µM relative to untreated control in HIE. E, Effect of RDV on viral replication of CVA1 in a co-culture of HIE with fibroblasts. Relative increase in viral RNA copies upon treatment with RDV at 4 µM from medium collected from both the apical and the basolateral compartment. Statistical significance represents…