Choreoathetosis after herpes simplex encephalitis with basal ganglia involvement on MRI

Children with herpes simplex virus encephalitis have a relapse in approximately 25% of cases, which rarely may present as a movement disorder, most often choreoathetosis. The anatomic basis for herpes simplex virus encephalitis-associated movement disorders has been poorly understood, because neuroimaging, to date, has not been able to show the direct involvement of the areas of the brain that typically govern such movements. We present a patient with abnormal involuntary movements after herpes simplex virus encephalitis, with new lesions on MRI between the time of initial presentation and the development of choreoathetosis. To our knowledge, this is the first patient with a post-herpes simplex virus encephalitis movement disorder with neuroradiographic evidence of thalamic involvement correlating with the onset of abnormal involuntary movements. We describe this patient and review the literature on movement disorders and herpes simplex virus encephalitis. Current understanding of the pathophysiology of post-herpes simplex virus encephalitis movement disorders proposes 2 possible mechanisms that may be responsible: reinfection with the resumption of viral replication, or a postinfectious, immune-mediated process.     

Herpes encephalitis in children. MRI assessment

The magnetic resonance imaging (MRI) findings in 14 patients with biopsy or polymerase chain reaction proven herpes simplex encephalitis were retrospectively reviewed to evaluate the diagnostic value of MRI in the early diagnosis of herpes simplex encephalitis in children. In addition to the early findings, follow-up MRI scans were obtained in four patients. Typical limbic system involvement was seen in 78 percent of the cases. Contrast-enhanced MRI was found to be superior to routine MRI sequences and computerized tomography (CT) in the early detection of inflammation. Follow-up MR images in four patients demonstrated the volume loss and late petechial hemorrhage in the involved regions. Magnetic resonance imaging is the method of choice in the diagnosis and follow-up of herpes simplex encephalitis.     

Computed tomography in young children with herpes simplex virus encephalitis

Computed tomographic (CT) scans were obtained from eight infants and young children with herpes simplex virus encephalitis. In two cases the initial scan showed diffuse edematous changes as a mass effect without laterality. Unilateral localized low attenuation in the initial scan was evident 4 days after the onset in one patient, and high attenuation in the initial scan appeared on the 6th day in another patient, but in general, it was not possible to establish an early diagnosis of herpes simplex virus encephalitis from CT scan. In the longitudinal study the calcification with ventriculomegaly appeared in 3 of 5 survivors, and gyriform calcification in 2 of 3 patients, respectively. The appearance of multicystic encephalomalacia was evident in one patient 6 months after the onset of neonatal herpes simplex encephalitis. It is shown that the CT findings of neonates and young children with herpes simplex encephalitis are different from those of older children and adults, and the importance of longitudinal CT studies was stressed in clarifying the pathophysiology of the central nervous system involvement in survivors.     

Late recurrence of herpes simplex virus meningoencephalitis in two infants

Two infants with recurrence of herpes simplex virus (HSV) encephalitis are reported. Both patients developed HSV encephalitis during their neonatal period and were treated with iv acyclovir. Long-term oral acyclovir prophylaxis was given thereafter. At the age of 8 and 11 months respectively, both babies, while under oral acyclovir prophylaxis, presented a second episode of HSV encephalitis. An inadequate dose of suppressive oral acyclovir therapy may be responsible for the recurrence of encephalitis in these two babies. CONCLUSION: The present observations emphasise the need for very long follow-up of any infant who has suffered from neonatal herpes simplex virus encephalitis and the need for careful prospective controlled studies in order to define the appropriate treatment regimen (initial plus prophylaxis) for neonates with herpes simplex virus infections.     

Diffusion-weighted imaging findings on MRI as the sole radiographic findings in a child with proven herpes simplex encephalitis

We present a case of herpes simplex encephalitis in an 8-year-old girl, in whom hyperintensity was detected on diffusion-weighted imaging (DWI) while conventional MRI sequences were normal 1 week after the onset of neurological symptoms. This case is rare in that a child beyond the neonatal period with focal herpes simplex encephalitis had an abnormal DWI sequence as the only MRI finding.     

Ultrasonography findings in a case with infantile herpes encephalitis]

We present the case of an eleven months old infant, who suffered from herpes simplex type I encephalitis. Cerebral ultrasound examination showed on 5th day of disease signs of focal echodensity. At that time CT showed a focal meningeal enhancement and CSF findings were normal. Suspicions changes were also obtained by MR-Imaging and EEG on the same day. Herpes simplex virus was identified in the CSF with Polymerase chain reaction days later. There are no typical clinical signs for herpes encephalitis, CT, NMR, EEG findings as well as antigen and antibody-tests do naturally take their time. Cerebral sonography in infants offers to be the best bed-side method for early suspicion of herpes encephalitis, which may support diagnostic workup and can help to start a specific therapy (Acyclovir) as soon as possible.     

快速诊断单纯疱疹病毒脑炎

目的探讨快速诊断单纯疱疹病毒脑炎（ＨＳＥ），比较不同病毒学试验的诊断价值。方法用聚合酶链反应技术检测１７７例急性脑炎患儿的脑脊液（ＣＳＦ）标本中单纯疱疹病毒（ＨＳＶ）特异性ＤＮＡ；用酶联免疫吸附方法检测ＣＳＦ和血清标本中ＨＳＶ特异性ＩｇＭ和ＩｇＧ抗体。结果ＣＳＦ中ＨＳＶ特异性ＤＮＡ、ＩｇＭ和ＩｇＧ抗体阳性率分别为１．７％（３／１７７）、１０％（１／１００）和４７０％（４７／１００），血清ＨＳＶＩｇＭ、ＩｇＧ抗体阳性率分别为１２．５％（６／４８）、７２．９％（５１／７０）（因为标本量不足或缺如，未能对全部病例进行抗体检测）；３例患儿确诊为ＨＳＥ。结论用套式ＰＣＲ检测ＣＳＦ诊断ＨＳＥ较敏感、特异。     

Management and outcome of viral encephalitis in children

Although viral encephalitis (VE) is relatively uncommon in children in the UK, early recognition and appropriate investigation and management are essential because of the devastating nature of the condition. An estimated 1200 paediatric cases from all causes are admitted each year. The cause of VE is diagnosed in approximately 30% of cases. The commonest cause in the UK is herpes simplex virus type 1 but globally the most important cause is Japanese encephalitis virus. Diagnostic methods have improved recently and the yield can be increased with a rational approach to investigations and by taking specialist advice. Morbidity and mortality are high but can be significantly reduced in herpes simplex virus encephalitis by treating for at least 14 days with intravenous aciclovir. Sequelae are common and include motor, sensory and cognitive impairments, epilepsy, behaviour problems and psychiatric disorders. Children should have access to a neurorehabilitation team, which includes a neuropsychologist, to achieve the best recovery possible. Long term follow-up and an organized transition into adult services is required.     

Occurrence of childhood encephalitis: a population-based study

The occurrence of childhood encephalitis was evaluated in a population-based study in an area with no arboviral infections. Ninety-five children were treated for encephalitis during 1973 to 1987, giving an annual incidence of 8.8/100,000 children younger than 16 years of age (95% confidence interval, 6.7 to 10.1). Based on virologic and serologic studies the most common etiologic agents were varicella (24 cases), mumps (8), herpes simplex (7) and measles (4). The etiology remained unknown in 37 children. No cases of encephalitis caused by mumps, measles or rubella were found in the population after 1982, when vaccination against these viruses was introduced.     

Preliminary clinical experiences with adenine arabinoside monophosphate (ARA-AMP) in encephalitis due to viruses of the herpes group and varicella/zoster infections (author's transl)]

Adenine arabinoside monophosphate (ARA-AMP) is a new antiviral agent with significant activity against DNA viruses of the herpes group. It appears to be superior to cytosine arabinoside and iodoxuridine in severe herpes simplex infections. Unlike cytosine arabinoside and idoxuridine ARA-AMP has only minimal myelosuppressive and immunosuppressive properties. The original compound, adenine arabinoside (ARA-A) which has been used in the United States in the last years had the disadvantage of poor solubility and tissue penetrance. Compared to adenine arabinoside the monophosphate ester of this compound has the advantage of better solubility and is more slowly metabolized in humans. In eight children with virus induced encephalitis ARA-AMP was well tolerated, we could not observe any severe side effects. A case of herpes simplex encephalitis showed a complete recovery. However it has to be pointed out that in herpes simplex encephalitis ARA-AMP should be given early in the course of infection to have a beneficial effect, therefore an early diagnosis is of utmost importance. A case of generalized herpes zoster healed up within about a week. Of course these are very preliminary results which must be confirmed by further experiences.     

Focal encephalitis with enterovirus infections

We report on four pediatric patients with Enterovirus infections who were admitted to the hospital with signs or symptoms of acute, focal encephalitis. All four experienced focal seizures. Each had a cerebrospinal fluid pleocytosis at the initial lumbar puncture. In all four patients the diagnosis of herpes simplex encephalitis was entertained. Each child improved spontaneously within a few days of admission to the hospital, and only one had residual neurologic abnormalities at the time of discharge. A brief review of these cases, and three additional cases from the literature, indicate that the enteroviruses, particularly the group A Coxsackieviruses, are rare causes of acute focal encephalitis in children and adolescents.     

Viral etiologies of encephalitis in Thai children

A prospective study of childhood encephalitis was performed in Bangkok from 1996 through 1998. The viral agents identifiable in 26 (65%) of 40 children were dengue virus (8), Japanese encephalitis (6), herpes simplex virus (4), human herpes virus type 6 (3), mumps (2), enterovirus (1), varicella-zoster virus (VZV) (1) and rabies (1).     

Brainstem involvement in neonatal herpes simplex virus type 2 encephalitis

Herpes simplex virus encephalitis in the newborn typically involves the cerebral cortex in a widespread manner. Herpes simplex virus type 2 rarely involves the brainstem. Here we report a 16-day-old infant with predominant brainstem and cerebellar involvement secondary to herpes simplex virus type 2 infection. Diffusion-weighted MRI performed 3 days after the onset of symptoms revealed restricted diffusion mainly in brainstem and cerebellar structures. No abnormal findings were seen on conventional MRI. Subsequent MRI scans showed evolution of the brain injury with extension along the corticospinal tracts. However, there was no evidence of any other supratentorial gray or white matter injury. This is the first report of predominant brainstem involvement in neonatal herpes simplex virus type 2 encephalitis. In addition, the importance of performing diffusion-weighted sequences to detect early central nervous system involvement and serial MRI to follow the evolution of central nervous system lesions is emphasized.     

A case of herpes simplex encephalitis revealed by decompressive craniectomy

A 15-year-old girl was referred to our hospital due to fever, headache, and vomiting of 7 days duration and focal motor convulsion at the day of referral. Her clinical signs and cerebral imaging findings were found to be compatible with herpes simplex encephalitis. In spite of prompt acyclovir administration, her consciousness deteriorated gradually. Emergent cranial magnetic resonance imaging demonstrated a shift of midline intracranial structures. Decompressive surgery resulted in partial improvement in the shift of midline intracranial structures and potentially saved the patient’s life. This case report stresses the importance of proper management of increased intracranial pressure in patients with herpes simplex encephalitis.     

Brain stem encephalitis due to herpes simplex virus

Abstract A 6 year old child is described with infection due to herpes simplex virus type 1 causing brain stem encephalitis. The diagnosis was established by enzyme immunosorbent assays of the cerebrospinal fluid and serum which demonstrated antibody responses to herpes simplex virus. Recovery occurred and the importance of early use of acyclovir in achieving a good outcome is emphasized.     

Brain stem encephalitis due to herpes simplex virus

A 6 year old child is described with infection due to herpes simplex virus type 1 causing brain stem encephalitis. The diagnosis was established by enzyme immunosorbent assays of the cerebrospinal fluid and serum which demonstrated antibody responses to herpes simplex virus. Recovery occurred and the importance of early use of acyclovir in achieving a good outcome is emphasized.     

Herpes Simplex Virus Infection in the Newborn

Fourteen cases of neonatal herpes simplex virus infection in 10 boys and 4 girls are described. The disease was disseminated in 9 cases. In 5 cases skin symptoms predominated, and 1 had only central nervous system symptoms. Two had a vesicular eruption when born. Six of the children with disseminated disease died.EEG recordings were made on 7 patients: 5 had clinical symptoms compatible with encephalitis, and in these the EEG showed periodic complexes, consisting of triangular or sharp waves, a pattern described in adult cases of herpetic encephalitis.The diagnosis was made by virus isolation and antibody titration. Herpes virus type 2 was the causative agent in all 8 cases where the type was determined. In 5 patients herpes virus antigen was demonstrated using immunofluorescence either in vesicles or throat swabs, in the early phase of the disease.Two children with generalized disease were treated with intravenous iododeoxyuridine (IDU). The first died, but the other, treated early in his disease, recovered completely.The clinical picture, complemented by the immunofluorescent technique for virus detection and repeated EEG recordings, should lead to the early diagnosis of herpetic encephalitis in the newborn, and warrant the use of systemic IDU treatment.     

Eczema herpeticum of the child. An unusual manifestation of herpes simplex virus infection

Two children aged 7 months with eczema herpeticum received treatment consisting of intravenous acyclovir and human plasma with a high titer of herpes simplex virus antibodies. One recovered following two recurrences, but the other died rapidly, suffering both septicemia due to Pseudomonas aeruginosa and herpetic encephalitis. In both cases, the virus involved was a herpes simplex virus type 1 (HSV 1). The various isolates obtained before, during and after treatment remained equally sensitive to acyclovir. These observations highlight three points: the unpredictable and sometimes dramatic development of eczema herpeticum in the young child; the urgency of early diagnosis and treatment; the role of environment in viral contamination.     

Herpes simplex-Encephalitis bei Neugeborenen

Premature twins both affected with generalized herpes simplex infection including CNS involvement were treated with 5-Iodo-2′-deoxyuridin (IDU). Therapy was started 6 days and 5 days respectively, after appearance of the first symptoms. Nevertheless both babies died, twin A at the age of 24 and twin B at the age of 28 days. Herpes virus was cultured from all organs in twin A. The literature shows a decrease in mortality in children treated with IDU for herpes simplex encephalitis. The percentage of survivors with ultimate severe CNS damage, however, is very high and remains in treated or untreated patients the same. The institution of IDU therapy in neonates with manifest HSV encephalitis is therefore not unequivocally justified.     

Herpes simplex: a possible cause of brain-stem encephalitis.

Herpes simplex virus was isolated from the tracheal aspirate of a 10-year-old boy presenting with acute onset of multiple cranial nerve palsies and a mild right hemiparesis. There was also an elevated herpes complement-fixation titer with decrease in the following weeks infection by herpes virus have been debated, we propose that this represents a case of brain-stem encephalitis due to herpes simplex infection. The importance of early diagnosis and evaluation of therapy are emphasized by this case in which the patient recovered completely.