Abbreviations
IHC Immunohistochemistry PKR Protein kinase R VP1 Viral protein 1To the Editor: We read with great interest the For Debate article by Dunne et al [1] and fully agree with the conclusion that intervention studies using a vaccine or antiviral drugs represent the way forward to finally establish whether enterovirus plays a role in type 1 diabetes. While we welcome and support such initiatives, we consider it crucial that funders investing in the huge vaccination trials required to prove or disprove the link are provided with solid scientific evidence. Also, in the risk-benefit analysis and ethical considerations, it is essential that the available evidence is viewed critically. Therefore, we feel compelled to point out some issues regarding the evidence cited in the article by Dunne et al.First, the sequence data of the enterovirus isolated by Dotta et al from an individual with recent-onset type 1 diabetes [2] shared 99% identity with the coxsackievirus B4 prototype strain JVB Benschoten, originally isolated in 1951, clearly indicating that it was in fact a laboratory contaminant. This is well known and non-controversial among virologists and others within the field [3-5] and we find it problematic that this paper is uncritically cited as supporting evidence for the presence of pancreatic enterovirus in type 1 diabetes.Second, in the Diabetes Virus Detection (DiViD) study, we detected enterovirus RNA with RT-PCR in pancreatic tissue samples from only one of the six patients with recent-onset type 1 diabetes [6]. This patient was also RT-PCR-positive for enterovirus RNA in peripheral blood mononuclear cells, suggesting that the positive signal could have come from infected circulating blood cells present in the pancreas, particularly given that this biopsy was collected as a surgical specimen and not perfused with preservation solution to remove blood, as is usually done during organ procurement for transplantation. The reported, and frequently cited, enterovirus RNA-positive samples from four out of six DiViD patients were from the culture medium of isolated islets. These islets were isolated from the tip of the pancreatic tail under non-sterile conditions in a research laboratory for the purpose of functional islet studies [7]. The enterovirus-negative islets from six non-diabetic organ donors [6], referred to by Dunne et al, were isolated in our Good Manufacturing Process (GMP) facility for the purpose of clinical islet transplantation and, therefore, these results cannot be used to rule out the possibility of viral contamination in the culture medium of islets isolated from the type 1 diabetic individuals. Also, the discrepancy in PCR positivity between tissue samples and the culture medium of isolated islets is difficult to explain by a difference in sensitivity [8], and the possibility that the positive signal was derived from contaminating viral sequences introduced during islet isolation or culture cannot be excluded. Other studies (not cited in the article by Dunne et al) have failed to find e...