Difference between herpes simplex virus type 1 and type 2 neonatal encephalitis in neurological outcome

Evaluation of five monoclonal antibody-based kits or reagents for the identification and culture confirmation of herpes simplex virus

Five immunofluorescence (IF) kits or reagents (Bartels [Bartels Immunodiagnostic Supplies, Inc., Bellevue, Wash.], Imagen [CellTech Diagnostics, Ltd., distributed by Analytab Products, Plainview, N.Y.], Ortho [Ortho Diagnostics Systems, Inc., Raritan, N.J.], Syva [Syva Co., Palo Alto, Calif.], Whittaker [Whittaker Bioproducts, Walkersville, Md.]) were evaluated for typing and laboratory confirmation of herpes simplex virus (HSV). Of 101 clinical isolates tested by each kit or reagent, results for 97 of them were in agreement. Identification of the four isolates with discordant results was performed by restriction endonuclease analysis of the viral DNA. The sensitivity and specificity of the Imagen and Bartels kits were 100%. For the Ortho, Syva, and Whittaker kits or reagents, the HSV type 1 (HSV-1) and HSV type 2 (HSV-2) sensitivities were 97.4 and 100%, 100 and 100%, and 97.4 and 100%, respectively, and the specificities were 100 and 97.4%, 100 and 92.4%, and 100 and 97.4%, respectively. There was one false-positive HSV-2 isolate identified by each of the Ortho and Whittaker kits or reagents. Three false-positive HSV-2 isolates occurred by staining with Syva, giving the erroneous indication of dual isolates. Several isolates stained with Imagen and Whittaker reagents displayed dull IF patterns. A dull green background occurred in ca. one-third of the HSV-2 isolates tested with the Ortho kit. The intensities of IF staining by the Bartels and Syva kits were satisfactory; however, the latter displayed a specificity of 92.7%. A total of 38 and 63 specimens were finally designated as HSV-1 and HSV-2, respectively. Identification of each isolate with the Bartels kit was consistently interpretable and is recommended as the typing and confirmatory assay of choice.

Predictors of morbidity and mortality in neonates with herpes simplex virus infections. The National Institute of Allergy and Infectious Diseases Collaborative Antiviral Study Group

BACKGROUND

In a controlled trial comparing acyclovir with vidarabine in the treatment of neonatal herpes simplex virus (HSV) infection, we found no significant difference between the treatments in adjusted mortality and morbidity. Hence, we sought to define for the entire cohort (n = 202) the clinical characteristics that best predicted the eventual outcome in these neonates.

METHODS

Data were gathered prospectively at 27 centers between 1981 and 1988 in infants less than one month of age who had virologically confirmed HSV infection. We examined the outcomes by multivariate analyses of 24 variables. Disease was classified in one of three categories based on the extent of the involvement at entry into the trial: infection confined to skin, eyes, or mouth; encephalitis; or disseminated infection.

RESULTS AND CONCLUSIONS

There were no deaths among the 85 infants with localized HSV infection. The mortality rate was significantly higher in the 46 neonates with disseminated infection (57 percent) than in the 71 with encephalitis (15 percent). In addition, the risk of death was increased in neonates who were in or near coma at entry (relative risk, 5.2), had disseminated intravascular coagulopathy (relative risk, 3.8), or were premature (relative risk, 3.7). In babies with disseminated disease, HSV pneumonitis was also associated with greater mortality (relative risk, 3.6). In the survivors, morbidity was most frequent in infants with encephalitis (relative risk, 4.4), disseminated infection (relative risk, 2.1), seizures (relative risk, 3.0), or infection with HSV type 2 (relative risk, 4.9). With HSV infection limited to the skin, eyes, or mouth, the presence of three or more recurrences of vesicles was associated with an increased risk of neurologic impairment as compared with two or fewer recurrences.

A follow-up study of children with neonatal herpes simplex virus infections with particular regard to late nervous disturbances

Forty-five children with neonatal herpes simplex virus (HSV) infection, representing all known cases in the diagnostic records of four virological laboratories within a 15-year period, were followed up. Twelve children had died. Sixteen of the 33 survivors were healthy. Thirteen children had severe disabilities: all of them showed severe mental retardation; moreover, 11 were tetraplegic, one was hemiplegic with hydrocephalus and one had a pronounced behavioural abnormality. Four children had slight to moderate disabilities: one child was mildly mentally retarded and three, although mentally normal, had hemiplegia and delayed speech development, one of them having a learning disorder as well. Of these 17 neurologically impaired children 16 had ophthalmological abnormalities. EEG recordings were made in 29 patients in the neonatal period. They were markedly abnormal in 24 patients, 14 of whom had localized periodic complexes. An abnormal EEG was a bad prognostic sign. The neurological outcome was better in the HSV-1-infected children (10 cases) than in the HSV-2-infected ones (35 cases). Progressive or recurrent encephalitis was strongly suspected in two preterm children.

Discrimination of herpes simplex virus types 1 and 2 cerebral infections in a rat model

A rat model was used to evaluate intertypic differences after intracranial (i.c.) inoculation of herpes simplex virus (HSV) types 1 and 2 strains with regard to neurovirulence and neuropathology, and influence of age on susceptibility. In adult rats, HSV-1 strains were more virulent than HSV-2 strains. HSV-1 replicated to higher titers in the central nervous system (CNS) of rats, as compared with HSV-2. In rats of less than 2-3 weeks of age, HSV-1 and HSV-2 were equally virulent, but morphological examination of rat brains showed type-specific differences in pathology and viral distribution already at the early postnatal stage. After HSV-1 infection, neuronal infection of the hippocampus, followed by cortical infection and edematous destruction dominated, while a preponderance of meningitis and invasive encephalitis was seen after HSV-2 infection. We suggest that the rat might be a useful model for human HSV infection in the CNS with discrimination between HSV-1 and HSV-2 infections, also at the early postnatal stage.

Five year prospective study of HIV infection in the Edinburgh haemophiliac cohort

OBJECTIVE

To identify measures of immune state that reflect the course of HIV related disease in order to predict deterioration of symptoms and assess response to treatment.

DESIGN

Five year longitudinal clinical and laboratory study.

SETTING

Regional haemophilia centre, university virology laboratory, and Medical Research Council laboratory.

PATIENTS

32 Patients with haemophilia A exposed to a single batch of HIV contaminated factor VIII concentrate from the Scottish National Blood Transfusion Service in 1984 who were followed up regularly in Edinburgh (31) or abroad (one).

MAIN OUTCOME MEASURES

Counts of circulating T cell subsets (CD4 and CD8); plasma beta 2 microglobulin, neopterin, and IgA concentrations; and delayed type hypersensitivity to multiple skin test antigens.

RESULTS

18 Patients who seroconverted after exposure had received significantly more contaminated factor VIII than the 14 who did not (mean 43 (range 9-109) v 15 (3-30) phials, p less than 0.01). The two groups were not distinguishable by other criteria before exposure. The group that seroconverted subsequently showed a progressive fall in mean circulating CD4 lymphocytes and an increase in plasma beta 2 microglobulin and neopterin concentrations. From 1987 patients in this group also showed an increase in mean circulating CD8 lymphocytes and in plasma IgA concentration, neither of which was seen in patients who did not seroconvert. Patients with HIV antibody who developed Centers for Disease Control category IV symptoms within five years after infection showed more extreme changes in all measures, except CD8 lymphocyte count, than those whose symptoms remained in categories II and III. Skin test reactivity declined to barely detectable levels in all patients positive for HIV antibody.

CONCLUSIONS

Serial estimates of circulating CD4 lymphocytes and of plasma beta 2 microglobulin concentration are the most reliable measures of disease progression; of these, beta 2 microglobulin concentration seems to be the better predictor of impending serious symptoms. High IgA concentrations reflect rather than predict disease state. Individual variation in most measures is such that a wide range of measurements should be used in assessing the effects of trial treatment in HIV infected patients without symptoms.

Upper gastrointestinal pathology in familial adenomatous polyposis: results from a prospective study of 102 patients

Multiple gastric and duodenal biopsy specimens from 102 asymptomatic patients with familial adenomatous polyposis, taken during a prospective endoscopic screening programme were examined. One hundred patients had microscopic gastroduodenal pathology, often in the absence of macroscopic lesions. Adenomas were found in 94 patients in the duodenum, in the second and third parts. Hyperplasia of villous and crypt epithelium was also seen, sometimes in the absence of adenomas: this may be a precursor of neoplastic change. In the stomach fundic gland polyps were the commonest abnormality, seen microscopically in 44 patients. Chronic antral gastritis was common in patients without fundic polyps. Gastric adenomas were present in six patients, all of whom also had duodenal adenomas. If duodenal adenomas in familial adenomatous polyposis have a similar malignant potential to those in the colorectum sequential endoscopy and biopsy are necessary to detect cancer in these patients.

Asymptomatic herpes simplex virus shedding from the genital tract whilst on suppressive doses of oral acyclovir

Forty-eight patients were recruited into a study of continuous oral acyclovir therapy for the suppression of recurrent genital herpes simplex virus (HSV) infection. Seven of these patients were shown to shed HSV in the absence of clinical signs or symptoms whilst on medication. The asymptomatic shedders did not differ significantly from the rest of the group in terms of age, interval from first attack to enrollment or number of recurrences prior to enrollment. Only one patient admitted to poor compliance as a trigger to asymptomatic HSV shedding. Failure to suppress asymptomatic shedding during prophylactic acyclovir therapy may have implications for sexual transmission to partners and vertical transmission to neonates and requires further study.

Three cases of neonatal herpes simplex virus infection presenting as fulminant hepatitis

We report three cases of neonatal herpes simplex virus (HSV) infection presenting as fulminant hepatitis. None of the patients had clear risk factors for HSV infection and they all died. Antiviral treatment for HSV is currently available but must be administered early in the course of the disease before irreversible liver tissue damage is present. Since the diagnosis may be difficult to establish, we wish to draw the attention of clinicians to the presentation of neonatal HSV infection and suggest that in such cases viral cultures, including culture of liver tissue, should be obtained early and antiviral treatment administered while awaiting the culture results.

Parvovirus infection and anaemia in a patient with AIDS: case report

Opportunistic infections such as Pneumocystis carinii pneumonia are well-recognised in patients with the acquired immune deficiency syndrome (AIDS). Anaemia due to a variety of causes also occurs in AIDS. Persistent infection with parvovirus (B19) causing severe anaemia has been reported in patients with leukaemia and congenital immunodeficiency. A case is now reported of parvovirus infection and anaemia, in an adult with AIDS, which responded dramatically to immunoglobulin therapy.

Identification and characterization of the herpes simplex virus type 2 gene encoding the essential capsid protein ICP32/VP19c

We describe the characterization of the herpes simplex virus type 2 (HSV-2) gene encoding infected cell protein 32 (ICP32) and virion protein 19c (VP19c). We also demonstrate that the HSV-1 UL38/ORF.553 open reading frame (ORF), which has been shown to specify a viral protein essential for capsid formation (B. Pertuiset, M. Boccara, J. Cebrian, N. Berthelot, S. Chousterman, F. Puvian-Dutilleul, J. Sisman, and P. Sheldrick, J. Virol. 63: 2169-2179, 1989), must encode the cognate HSV type 1 (HSV-1) ICP32/VP19c protein. The region of the HSV-2 genome deduced to contain the gene specifying ICP32/VP19c was isolated and subcloned, and the nucleotide sequence of 2,158 base pairs of HSV-2 DNA mapping immediately upstream of the gene encoding the large subunit of the viral ribonucleotide reductase was determined. This region of the HSV-2 genome contains a large ORF capable of encoding two related 50,538- and 49,472-molecular-weight polypeptides. Direct evidence that this ORF encodes HSV-2 ICP32/VP19c was provided by immunoblotting experiments that utilized antisera directed against synthetic oligopeptides corresponding to internal portions of the predicted polypeptides encoded by the HSV-2 ORF or antisera directed against a TrpE/HSV-2 ORF fusion protein. The type-common immunoreactivity of the two antisera and comparison of the primary amino acid sequences of the predicted products of the HSV-2 ORF and the equivalent genomic region of HSV-1 provided evidence that the HSV-1 UL38 ORF encodes the HSV-1 ICP32/VP19c. Analysis of the expression of the HSV-1 and HSV-2 ICP32/VP19c cognate proteins indicated that there may be differences in their modes of synthesis. Comparison of the predicted structure of the HSV-2 ICP32/VP19c protein with the structures of related proteins encoded by other herpes viruses suggested that the internal capsid architecture of the herpes family of viruses varies substantially.

Late ophthalmologic manifestations of neonatal herpes simplex virus infection

We examined 32 children one to 15 years after virologically verified neonatal herpes simplex virus infection. Sixteen of 17 (94%) neurologically impaired children had ocular abnormalities compared to three of 15 (20%) neurologically healthy children. Disturbed oculomotor control occurred in 14 children (44%), most of whom were among those with severe handicap. Ocular morbidity was present in 13 (40%) of 32 children: one had cataracts, two had corneal scars, seven had optic atrophy, and nine had chorioretinal scars. The clinically silent chorioretinal lesions were manifest as coarse hyperpigmented areas between the equator and ora serrata. One child had suffered from acute fulminant retinitis. Twelve of 13 (93%) severely handicapped children had impaired vision, mainly because of cortical blindness. Less affected children had normal vision unless corneal scars were present. Long-term observation of patients with neonatal herpes infections is essential because ocular manifestations are not rare, and recurrences may be more common than previously reported.

Prevalence of specific antibodies to herpes simplex virus type 2 as revealed by an enzyme-linked immunoassay and western blot analysis

A solid-phase ELISA for the detection of antibodies to gG-2 was developed. The assay utilizes a recombinant DNA-derived gG-2 as a solid-phase "capture" reagent and goat anti-human IgG (gamma) conjugate to horseradish peroxidase as a probe (detector) reagent. A total of 229 serum samples collected from various populations were tested by ELISA and western blot analysis. On comparison with confirmed HSV-2 infection, the sensitivity and specificity of the ELISA were 92.9% and 98.7%, respectively. Western blot had a sensitivity of 83.9% and a specificity similar to the ELISA. The ELISA is fast and easy to perform and may be used to diagnose previous exposure to genital herpes and to monitor human response to future HSV-2 vaccines.

Pathology of tropical appendicitis

Over the past 25 years, 2921 appendicectomies were performed at this hospital. All were subjected to routine histopathological examination. In 95% of cases, histopathological examination did not add any further information but in 153 (5%) cases, clinically important pathological findings were detected for the first time. Seventy (2.3%) specimens showed typical evidence of tuberculosis. Parasitic infestation was detected in 75 (2.5%), including enterobiasis (1.4%), amoebiasis (0.5%), ascariasis (0.5%), ascariasis with trichuriasis (0.05%), and taeniasis (0.05%). Other lesions found were mucocele (0.1%) and carcinoid tumour (0.1%). It is concluded that routine histopathological examination of all appendicectomy specimens should be performed to avoid missing any clinically important and treatable condition.

Myositis during Borrelia burgdorferi infection (Lyme disease)

During the second stage of an illness caused by Borrelia burgdorferi, a young woman developed a myopathic syndrome characterised by severe muscular pains, incapacitating weakness of the proximal limb and the neck, as well as the bulbar muscles and elevated serum CK levels. Muscle biopsy revealed a non-inflammatory necrotising myopathy. B. burgdorferi infection was confirmed by a considerable rise of specific IgG antibodies. A course of high dose steroids alleviated the myalgias, but paresis began to improve only after treatment with antibiotics. Our observations confirm that B burgdorferi can cause, through an undertermined mechanism, a necrotising myopathy, in addition to the wide spectrum of already known neurological complications.

Identification, transfer, and characterization of cloned herpes simplex virus invasiveness regions

Following peripheral inoculation of experimental animals, herpes simplex virus type 2 (HSV-2) strains are more virulent than HSV-1 strains, and clinical studies suggest that they possess enhanced virulence in humans. One dramatic type-specific difference in virulence is observed following inoculation of the chorioallantoic membrane (CAM) of the chicken embryo: HSV-2, but not HSV-1, makes large pocks on the CAM, invades the mesoderm, generalizes in the embryo, and kills the chicken. These properties have been believed to be specific for HSV-2, and their molecular basis is unknown. We now report that an HSV-1 strain, ANG, behaves even more efficiently than HSV-2. In addition, we have transferred restriction fragments of ANG DNA to another HSV-1 strain, 17 syn+, conferring the CAM virulence phenotype on the normally CAM-avirulent 17 syn+. Like ANG, these recombinant viruses are 10(6)-fold more virulent (PFU/50%) lethal dose [LD50] ratio, less than or equal to 10(2)) than the parental 17 syn+ strain (PFU/LD50 ratio, greater than or equal to 10(8)). A molecularly cloned library of ANG DNA was used to identify two distinct regions containing the virulence functions. Transfer of sequences contained in either cloned ANG EcoRI fragment A (0.49 to 0.64 map units) or F (0.32 to 0.42 map units) DNA to 17 syn+ confers CAM virulence, whereas other cloned regions of the ANG genome do not. Using cloned DNA, we derived and plaque purified several virulent recombinant viruses with inserts from either the ANG EcoRI fragment A (INV-I) or F (INV-II) areas. In each instance, the transfer of the cloned INV-I or INV-II sequences enhanced virulence for the chicken embryo 10(6)-fold (PFU/LD50 ratio, less than or equal to 10(2]. In addition, the transfer of the cloned ANG EcoRI-F INV-II sequences resulted in a 10(3)-fold enhancement of neuroinvasiveness and virulence for mice. Following footpad inoculation, these recombinants kill mice with a PFU/LD50 ratio of approximately 10(3) (similar to HSV-2 strains) compared with 10(6) for 17 syn+. Thus, we have identified, cloned, and transferred two DNA regions from HSV-1 ANG which contain virulence genes (INV-I and INV-II) important in mesodermal invasiveness on the CAM and, in the case of INV-II, neuroinvasiveness in the mouse. In each instance, the recombinant HSV-1 viruses have attained enhanced virulence beyond that described for HSV-1 strains and similar to that seen with HSV-2.(ABSTRACT TRUNCATED AT 400 WORDS)

Molluscum contagiosum virus types in genital and non-genital lesions

The endonuclease digest patterns of viral DNA from 48 genital and 45 non-genital molluscum contagiosum virus (MCV) lesions were examined. The overall ratio of MCVI to MCVII was 3.23:1. There was no predominance of either MCV type in genital lesions. No obvious morphological differences were seen between MCVI and MCVII lesions. MCVII was not found in any patient under 15 years old.

Herpes simplex virus detection by macroscopic reading after overnight incubation and immunoperoxidase staining

Human diploid foreskin fibroblast cells grown in 24-well plates were inoculated with clinical specimens by centrifugation at 1,000 X g for 45 min. Cultures were incubated at 37 degrees C overnight, fixed, and stained with peroxidase-labeled monoclonal antibodies against herpes simplex virus types 1 and 2. Stained plaques of infected cells were large enough to be detected with the naked eye, and microscopic examination did not reveal any further positive specimens. The method was compared with standard isolation in human fibroblasts grown in shell vials and inoculated by centrifugation at 4,000 X g, observed microscopically for the occurrence of typical cytopathogenic effect three times a week for 10 days, and then typed by enzyme immunoassay. Of the 289 specimens tested, 105 were positive and 174 were negative by both methods. Six specimens were positive by standard isolation only, two of them containing varicella-zoster virus, and two specimens were stored frozen before being tested by immunoperoxidase staining. Two specimens found negative by standard isolation were positive by immunoperoxidase staining. For two specimens negative by immunoperoxidase staining, the standard isolation cultures were lost due to microbial contamination. Forty-two specimens found positive by standard isolation were clearly positive when stained only 8 h after inoculation. By standard isolation, positive results were reported on the average 3 to 4 days after inoculation, whereas by immunoperoxidase staining the result was available within less than 24 h. Immunoperoxidase staining of infected cells is a sensitive method for rapid laboratory diagnosis of herpes simplex virus infections, and 24-well plates are convenient for the handling of a large number of specimens.

Muscle strength, endurance and recovery in the post-infection fatigue syndrome

A test of muscle strength and "fatiguability" was administered to 20 normal subjects and 20 patients suffering from post-infection fatigue syndrome. Maximal isometric torque for the elbow flexors was measured before, during and after an endurance sequence of 18 maximal static contractions (10 s duration, 10 s rest interval). The maximal isometric strength was not significantly different between the patient and control groups. The relative torque produced at the end of the series of 18 static contractions did not differ significantly between patients and normal subjects. In the patients with post-infection fatigue syndrome there was impairment of the recovery of peak torque at 10 minutes after the endurance sequence (p less than 0.02). The prominent subjective complaint of muscle fatigue in patients with post-infection fatigue syndrome contrasts with the relatively normal behaviour of their muscles during a controlled test of fatigue. The syndrome may include a disordered perception of achieved force and exertion.