Double encephalitis with herpes simplex virus and cytomegalovirus in an adult

A 51-year-old housewife developed symptoms of a cold followed by high fever, delirium, coma, rigidity of extremity muscles, positive Babinski sign and generalized convulsions, while complement-fixing antibody titre to herpes simplex virus in the sera raised over 128 X and declined to 8 X in the course. She finally expired of bronchopneumonia following status epilepticus after 94 days of illness. Severe necrosis with extensive hemorrhage in the white matter was predominant in the temporal, insular and orbitofrontal cortex, thalamus and globus pallidus. Focal rarefaction of the cerebral cortex with a very few eosinophilic intranuclear inclusions in the oligodendroglia and nerve cells, nerve cell destruction in the substantia nigra with glial nodules and perivascular inflammatory cell cuffs were observed. Abundant cytomegalic inclusion cells, originating from hypertrophic astrocytes, were present in the necrotic areas of cerebrum as well as in the rarefied tissue in the subependymal layers of the brainstem and cerebellum. Electron-microscopic study of the cytomegalic cells demonstrated the presence of numerous virions in both nucleus and cytoplasm. Fortuitour infection of the brain by cytomegalovirus with necrotizing encephalitis by herpes simplex virus is unique. The cause of double viral infections and severe lesions by less virulent strains is discussed.     

单纯疱疹病毒性脑炎的临床和EEG研究

目的 :研究单纯疱疹病毒性脑炎 (HSE)的临床特点及脑电图 (EEG)的表现。方法 :对 2 5例HSE患者通过汇总分析发现临床与EEG的变化。结果 :HSE患者病前多有上感样症状 ,急性或亚急性起病 ,精神症状和癫痫发作为其主要表现。结论 :EEG在病程中有明显的变化特点     

Chronic herpes simplex virus encephalitis in childhood

Although herpes simplex virus is a major cause of acute encephalitis in childhood, chronic herpes simplex virus encephalitis has only rarely been reported. This report presents a case of chronic herpes simplex virus encephalitis in a 6-year-old female. Diagnosis was based on the detection of herpes simplex virus deoxyribonucleic acid by polymerase chain reaction in combination with the cerebrospinal fluid/serum ratio of herpes simplex virus-specific immunoglobulin G, the presence of herpes simplex virus-specific oligoclonal immunoglobulin G bands in cerebrospinal fluid, and calcifications in the temporal regions found on cerebral computed tomographic scan. Prolonged antiviral therapy was beneficial to later mental development.     

Steroids for deteriorating herpes simplex virus encephalitis

A 16-month-old girl presented with herpes simplex virus type 1 encephalitis with involvement of bilateral parietofrontal lobes, left thalamus and cerebellum. She was treated with intravenous acyclovir. As her condition deteriorated, high-dose methylprednisolone was administered, resulting in remarkable improvement. This case suggests considering a short course of high-dose steroid therapy in severe herpes simplex encephalitis when there is clinical and radiologic deterioration in spite of appropriate antiviral therapy and decreasing viral load in the cerebrospinal fluid.     

Relapsing herpes simplex encephalitis following antiviral therapy

Although treatment for herpes simplex virus (HSV) encephalitis with antiviral agents has improved survival, occasional patients experience unexplained clinical exacerbations. This report presents evidence that some relapses may occur from recurrent viral encephalitis. An adult male developed the classic symptoms of HSV encephalitis. The cerebrospinal fluid (CSF), electroencephalogram, and isotope brain scan suggested a localized encephalitis involving the left temporal lobe. The pateint was treated for 10 days with high doses of cytosine arabinoside instead of the currently recommended adenine arabinoside. Progression of encephalitis stopped, and clinical recovery occurred. The HSV antibody titer increased eightfold. Fifty-four days after the initial encephalitis, the patient relapsed with a subacute progressive encephalitis involving the same brain area. The CSF demonstrated oligoclonal bands, elevated immunoglobulin G levels (100 mg/dl), and a high HSV antibody titer (1:8,192 by indirect hemagglutination test). From a left temporal lobe biopsy taken 74 days after onset of the initial encephalitis, herpes simplex virus type 1 was isolated. Without renewed antiviral drug therapy, the patient slowly recovered.     

Combined therapy with acyclovir and adenosine arabinoside in herpes simplex encephalitis

We report a case of herpes simplex encephalitis (HSE) with initial coma and severe left-sided hemiparesis in which combined treatment with adenine arabinoside and acyclovir was followed by complete recovery. This favorable result is discussed in view of the literature of HSE treatment including experimental studies on antiviral activity of both drugs. Combined treatment may be useful in severe cases of HSE.     

Experimental herpes simplex virus encephalitis: A combination therapy of acyclovir and glucocorticoids reduces long-term magnetic resonance imaging abnormalities

Despite early antiviral treatment, herpes simples virus encephalitis (HSVE) still remains a life-threatening sporadic disease with high mortality and morbidity. In patients and in experimental disease, chronic progressive magnetic resonance imaging (MRI) abnormalities have been found even after antiviral therapy. Secondary autoimmune-mediated and not directly virus-mediated mechanisms might play a key role for the outcome of disease. This study aimed to evaluate a possible beneficial effect of a therapy of acyclovir and corticosteroids versus acyclovir only. In a mouse model of HSVE (intranasal inoculation with 10(5) pfu [plaque-forming units] of HSV-1 strain F), a long-term MRI study was realized. Cranial MRI was performed serially at days 2, 7, 14, 21, 60, and 180 in different therapy groups: 1, saline; 2, acyclovir; 3, acyclovir, subsequently methylprednisolone; 4, sham-infected with saline. Brain viral load peaked at day 7 to decline thereafter to a low baseline value. Viral load in group 1 was significantly higher than in animals with antiviral therapy. In group 4, no viral DNA was detectable. Viral load did not differ significantly between acyclovir and acyclovir/corticosteroid-treated groups, suggesting that the use of corticosteroids in addition to acyclovir does not increase viral burden. MRI findings in untreated and acyclovir-treated animals revealed chronic progressive changes. In contrast, there was a significant reduction of the severity of long-term MRI abnormalities in acyclovir/corticosteroid-treated animals. With respect to abnormal MRI findings, this study demonstrates a clear beneficial effect of an acyclovir and corticosteroid therapy without influencing brain viral load.     

Herpes simplex encephalitis with herpes simplex retinitis

The association of herpes simplex encephalitis and herpes simplex retinitis is rare in adults. The case presented indicates that the manifestation of retinitis after herpes simplex encephalitis is infectious and not immunologic in origin. Retinal infection results either from neuron-to-neuron transmission of viruses along the optic nerve or from recurrent viral infection. Treatment with acyclovir improves the otherwise rather poor prognosis of combined herpes simplex encephalitis and retinitis. In this case a second course of systemic treatment with acyclovir was effective.     

An isoelectric focusing study in herpes simplex virus encephalitis

To establish an early reliable diagnostic test for herpes simplex virus (HSV) type 1 encephalitis (HSVE), we used isoelectric focusing (IEF) and an IEF-overlay technique with radiolabeled HSV glycoprotein B (gB) to study 7 serum and 12 cerebrospinal fluid (CSF) samples from 12 patients with presumed or biopsy-proved HSVE. Blood-brain barrier damage and increased intra-blood-brain barrier IgG synthesis were detected in 5 of the 7 patients with HSVE. CSF oligoclonal bands were found in 6 of 11 patients. Using an IEF-overlay technique, we detected anti-gB antibody in all serum (7 of 7) and in 10 of 12 CSF samples. Anti-gB antibody was found in 4 of 6 CSF specimens obtained within the first week of disease (days 3 to 5) and in all samples collected later in the disease. The pH range of anti-gB antibody activity was broad (4.5 to 9.5), indicating a heterogeneous immune response to HSV. A hematogenous origin of the CSF antibody was suggested because anti-gB antibody appeared in serum before matched CSF and because both serum and matched CSF had a similar antibody IEF pattern. Local production of anti-gB antibody was suggested in some cases because of a greater prominence of anti-gB antibody in CSF than in matched sera and because CSF oligoclonal bands had anti-gB antibody activity. In contrast, only one of 6 CSF samples from patients with multiple sclerosis had gB antibody activity; in this case, anti-gB antibody activity did not correspond in isoelectric point location to oligoclonal bands.(ABSTRACT TRUNCATED AT 250 WORDS)     

Symmetrical brainstem encephalitis caused by herpes simplex virus

We describe a 53-year-old man with herpes simplex virus (HSV) brainstem encephalitis diagnosed based by positive HSV immunoglobulin M antibodies from cerebrospinal fluid. The MRI findings of this case had three unique features. First, the lesions were symmetrical. Second, the lesions may have been associated with reactivation of HSV infection in the region of the trigeminal nerve. Third, diffusion-weighted and apparent diffusion coefficient (ADC) imaging, conducted for the first time on an HSV brainstem encephalitis case, suggested that the lesions were associated with vasogenic edema.     

Some previously unrecognized features of herpes simplex virus encephalitis

The courses of 15 brain biopsy-proven cases of herpes simplex virus encephalitis (HSVE) were followed for 6 to 67 months. Convulsive disorders were often temporary, but paralysis was permanent. Patients usually entered the hospital free of paralysis or coma, in a potentially reversible febrile confusional state. Later, paralysis and coma fixed subsequent courses. Mortality was 53.3 percent but, at follow-up, 93.3 percent (14 patients) were dead or living a vegetative existence at home or in institutions. If a definitive diagnosis of HSVE could be made at the time of hospital admission, the prognosis might be remarkably changed.