Brief report: fatal encephalitis due to variant B human herpesvirus-6 infection in a bone marrow-transplant recipient

Human herpesvirus-6 meningoencephalitis in a recipient of an unrelated allogeneic bone marrow transplantation

BACKGROUND

Human herpesvirus-6 (HHV-6) has been implicated in bone marrow suppression, interstitial pneumonitis, and fatal meningoencephalitis in bone marrow transplant (BMT) recipients.

METHODS

We describe the case of a woman with acute myeloid leukemia in second remission who developed febrile meningoencephalitis 8 months after a second unrelated BMT.

RESULTS

Computed tomography and magnetic resonance images of the brain were nonspecific. Analysis of cerebrospinal fluid (CSF) revealed lymphocytosis and an increased protein level. Using polymerase chain reaction methods, HHV-6 was the only pathogen detected in CSF, peripheral blood mononuclear cells, and bone marrow. The patient was treated with ganciclovir and foscarnet for 3 months. All clinical manifestations resolved and HHV-6 polymerase chain reaction analysis of CSF became negative 40 days after the beginning of antiviral treatment.

CONCLUSIONS

This observation strongly suggests that HHV-6 should be sought in BMT patients with neurological complications and that HHV-6 meningoencephalitis may respond to ganciclovir and foscarnet therapy.

Four cases of human herpesvirus 6 variant B infection after pediatric liver transplantation

BACKGROUND

Little is known about human herpesvirus (HHV)-6 infection after liver transplantation. We present our experiences with four cases of HHV-6 infection after liver transplantation from living related donors.

METHODS

Peripheral blood was collected from four donor and recipient pairs at the time of transplantation and biweekly from the recipients after transplantation. We attempted to isolate HHV-6 and measure antibody titers to HHV-6 and HHV-7.

RESULTS

HHV-6 was isolated from four recipients approximately 2 weeks after transplantation. A significant rise in HHV-6 antibody titers was observed in four recipients at some point in their course, whereas HHV-7 antibody titers were increased in one recipient. Four isolates were variant B. When HHV-6 was isolated, all recipients had an unexplained fever.

CONCLUSIONS

HHV-6 variant B infection after pediatric liver transplantation was confirmed. HHV-6 infection occurred approximately 2 weeks after transplantation. Moreover, there appears to be an association between HHV-6 infection and unexplained fever.

Infections of the nervous system

Epidemiologic trends causing infections of the nervous system remain a significant source of morbidity and mortality one half-century after the introduction of penicillin. This article outlines common causes of bacterial meningitis, aseptic meningitis syndrome, encephalitis, abscess, spinal cord syndromes, and cranial and peripheral nerve problems. Recommendations for diagnostic evaluation and both empiric and definitive antimicrobial therapy are offered; controversial management issues are also discussed. The protean manifestations of varicella-zoster virus and Lyme diseases are outlined. In addition, special considerations in the immunocompromised host, including organ transplant recipients, cancer patients, and HIV-positive persons are explained, and antimicrobial therapy is discussed.

Temporal mapping of transcripts in herpesvirus 6 variants

To define the molecular features characteristic of the early stages of infection of lymphocytes with human herpesvirus 6 (HHV-6) variant A or B, we studied the temporal regulation of expression of selected sets of viral genes. Thus, U42, U94, U89-U90, U73, and U39 are alpha genes since their transcripts (i) were made in the presence of inhibitors of protein synthesis and (ii) were detected 3 h after infection of untreated cells. U41, U53, U31, and U19 are beta genes since their expression is inhibited by cycloheximide but not by phosphonoacetate, an inhibitor of DNA synthesis. U100 is a gamma gene since its spliced transcript encoding the structural glycoprotein gp82/105 was first detected 16 h after infection of untreated cells but could not be detected in cells treated with phosphonoacetate. HHV-6 variants differ in the transcription patterns of their genes. U16-U17 originates a splice transcript and is regulated as alpha in HHV-6B and as beta in HHV-6A. U91 generates two transcripts, amplified as 476- and 374-bp PCR fragments. The 476-bp fragment is alpha in HHV-6A-infected cells but beta in HHV-6B-infected cells. Conversely, the 374-bp fragment is beta in HHV-6A-infected cells and alpha in HHV-6B-infected cells. Furthermore, the spliced product of U18-U19-U20 (526 bp) is beta in HHV-6A-infected cells, but only a partially spliced form (1.9 kb) was detected at late stages of infection in HHV-6B. HHV-6 transcription was also studied in nonproductive lymphoid cells, and the same transcription pattern detected during lytic infection was observed. Also, HHV-6 variants maintain the differences in U91, U16-17, and U18-U19-U20. We conclude that, as expected from the sequencing data, gene expression is generally similar in HHV-6 variants. However, transcription of selected genes in HHV-6A and HHV-6B differs with respect to temporal regulation and splicing pattern. Furthermore, the identification of viral functions expressed during the different stages of lytic replication suggests that reverse transcription-PCR for HHV-6 genes is a useful diagnostic approach to differentiate between latent and productive HHV-6 infection.

Detection of human herpesviruses 6 and 7 in heart transplant recipients by a multiplex polymerase chain reaction method

In order to evaluate the possible reactivation of human herpesviruses 6 (HHV-6) and 7 (HHV-7) after heart transplantation, buffy-coat and plasma specimens from 21 transplant patients and 56 healthy blood donors were examined for HHV-6 and HHV-7 DNA by polymerase chain reaction. Human herpesvirus 6 and HHV-7 infection or reactivation has been suggested to play a role in cytomegalovirus disease progression in renal transplant recipients. In the present study, however, no significant difference in the prevalence of HHV-6 and HHV-7 was found between the immunosuppressed and the healthy population; moreover, no viral reactivation was found in the heart transplant recipients.

Risk of recurrent seizures after a primary human herpesvirus 6-induced febrile seizure

OBJECTIVE

To test the hypothesis that children experiencing first febrile seizures caused by human herpesvirus 6 (HHV-6) have an increased risk for recurrent seizures when compared with children experiencing first febrile seizures attributed to other illnesses.

DESIGN AND PARTICIPANTS

Descriptive prospective study of 36 HHV-6 culture-positive children and a matched subgroup of 86 HHV-6 culture-negative children, all of whom had their first febrile seizures evaluated in a tertiary care emergency department and were followed for at least 12 months, with an average follow-up of 35.7 months.

PRIMARY OUTCOME MEASURE

The recurrence of seizures among HHV-6 culture-positive and HHV-6 culture-negative children with no known previous neurologic deficits.

RESULTS

A decreased incidence of recurrent seizures occurred in children whose first febrile seizures were caused by HHV-6. Twenty percent of HHV-6 culture-positive children and 40% of HHV-6 culture-negative children (P < 0.038) experienced a recurrent seizure within 1 year of their first febrile seizure. The mean time to recurrence within 12 months was 8.6 months for children with HHV-6 infection and 3.8 months (P < 0.001) for children without HHV-6 infection. Most recurrent seizures occurred within 12 months of a first febrile seizure for both HHV-6-positive and HHV-6-negative children (88 and 91%).

CONCLUSIONS

Children who had their first febrile seizures caused by primary HHV-6 infection did not demonstrate an increased risk for recurrent seizures when compared with children whose first febrile seizures were from other etiologies.

Human herpesvirus-6 and human herpesvirus-7 infections in bone marrow transplant recipients

Human cytomegalovirus (HCMV), human herpesvirus-6 (HHV-6), and human herpesvirus-7 (HHV-7) DNA in peripheral blood leukocytes (PBL) of 61 bone marrow transplant recipients was monitored weekly during the first 12 weeks post-transplantation by a nested polymerase chain reaction (PCR). Thirty-seven (61%), 17 (28%), and 32 (53%) of patients had one or more PBL specimens positive for HCMV, HHV-6 or HHV-7 DNA, respectively. HHV-7 DNA in PBL during the early post-transplant period was associated with a longer time to neutrophil engraftment (mean 28.8 days vs 19.8 days; P = 0.01). In two patients who failed to engraft, HHV-6 DNA and HHV-7 DNA was detected in plasma and PBL, respectively, early in their post-transplant period. Patients with HCMV disease were more likely to have concurrent HHV-7 DNA in PBL prior to onset of disease than were patients with asymptomatic HCMV infection, suggesting that HHV-7 may be a cofactor in the progression from HCMV infection to HCMV disease. In the 17 patients (179 specimens) in whom viral DNA in plasma was studied (in addition to PBL), a positive result was found only in 3. In each, viral DNA in plasma appeared to correlate with clinically significant disease. HHV-7 DNA in plasma was associated with encephalitis in an allograft recipient.

Human herpesvirus-6 (HHV-6)-associated necrotizing encephalitis in Griscelli's syndrome

We report a male caucasian German pediatric patient of no Arab or Mediterranean ancestry with virus associated CNS lesions in Griscelli's syndrome (GS; McKusick No. 214450). The boy presented with recurrent infections, and meningitis with subsequent progressive signs of increased intracranial pressure leading to death at 32 weeks of age. At autopsy, various sites of the CNS revealed necroses in gray and white matter. CNS histology revealed numerous and massive predominantly perivascular CD8 positive lymphohistiocytic infiltrates. These findings were associated strictly with the presence of human herpesvirus-6 (HHV-6) genome or the HHV-6 specific late antigen H-AR 3, found in neurons, oligodendrocytes, and astrocytes. The search for HHV-6 replication dependent antigen, HHV-7 DNA, CMV, adenovirus, Coxsackie B1, B2, and B4-antigens, and mycobacteria was not successful. Detection of viruses was attempted using immunohistochemistry, in situ hybridization or nested polymerase chain reaction, respectively. Lymphocyte typing was carried out immunohistochemically. In GS, virus induced CNS damage does not seem to require necessarily active virus replication. It may also appear as a consequence of an immune reaction triggered by antigen expression.

Human herpesvirus-6 infection in liver transplant recipients: documentation of pathogenicity

BACKGROUND

The new herpesvirus, human herpesvirus-6 (HHV-6), is able to cause clinical illness after transplantation; however, the pathogenic potential and the clinical features of HHV-6 have not been defined in liver transplant recipients.

METHODS

We report the first cases of invasive and symptomatic infection due to HHV-6 in liver transplant recipients.

RESULTS

HHV-6 infection occurred in four liver transplant recipients at a median of 50 days after transplant (range 17-90 days). Severe cytopenia was observed in all patients; leukopenia (with median leukocyte count of 1400/mm3) was the most commonly effected bone marrow lineage. One of the four patients had interstitial pneumonitis due to HHV-6. No other virus (e.g., cytomegalovirus) or another pathogen was detected in the lungs, blood, or bone marrow in any of the above patients.

CONCLUSIONS

Our data suggest that HHV-6 can be a pathogen in liver transplant recipients; idiopathic bone marrow suppression is its predominant clinical sequelae. Recognition of HHV-6 infection is clinically pertinent because HHV-6 is potentially treatable with the currently available antiviral agents.

Human Herpesvirus 6 (HHV-6)–Positive Burkitt's Lymphoma: Establishment of a Novel Cell Line Infected With HHV-6

Human herpesvirus 6 (HHV-6) DNA has been detected in several human lymphoproliferative disorders. We report a case of HHV-6–infected Burkitt's lymphoma, from which a cell line, designated Katata, has been established. Katata cells had an immature B-cell phenotype with an L3 morphology and carried a t(8; 14)(q24; q32) chromosomal abnormality. The HHV-6 DNA sequences were detected in both the patient's tumor cells and Katata cell line by polymerase chain reaction using three sets of primers that target different regions of HHV-6 DNA. The presence of HHV-6 DNA in Katata cells was also shown by Southern blot hybridization with the BamHI fragment of HHV-6. It is likely that the virus is in a latent state, since (1) virion-associated protein was not expressed in Katata cells, (2) transcriptional level of the immediate-early gene was very low, and (3) no viral particles were observed by electron microscopy. Katata cells were highly tumorigenic in nude mice and the tumor cells also contained HHV-6 DNA. We have successfully obtained several clonal lines by allowing the cells to form colonies in soft agarose and by the limiting dilution method. HHV-6 DNA was detectable in all 13 clones analyzed, suggesting that virtually all Katata cells are infected with HHV-6. This is the first report of a case of HHV-6+ Burkitt's lymphoma in the absence of Epstein-Barr virus. Furthermore, there has been no report of lymphoma cell lines that are persistently and nonproductively infected with HHV-6. The Katata Burkitt's lymphoma cell line, therefore, would provide a useful tool for studies of the mechanisms of HHV-6 latency and reactivation.

Human Herpesvirus 6 (HHV-6)–Positive Burkitt's Lymphoma: Establishment of a Novel Cell Line Infected With HHV-6

Human herpesvirus 6 (HHV-6) DNA has been detected in several human lymphoproliferative disorders. We report a case of HHV-6–infected Burkitt's lymphoma, from which a cell line, designated Katata, has been established. Katata cells had an immature B-cell phenotype with an L3 morphology and carried a t(8; 14)(q24; q32) chromosomal abnormality. The HHV-6 DNA sequences were detected in both the patient's tumor cells and Katata cell line by polymerase chain reaction using three sets of primers that target different regions of HHV-6 DNA. The presence of HHV-6 DNA in Katata cells was also shown by Southern blot hybridization with the BamHI fragment of HHV-6. It is likely that the virus is in a latent state, since (1) virion-associated protein was not expressed in Katata cells, (2) transcriptional level of the immediate-early gene was very low, and (3) no viral particles were observed by electron microscopy. Katata cells were highly tumorigenic in nude mice and the tumor cells also contained HHV-6 DNA. We have successfully obtained several clonal lines by allowing the cells to form colonies in soft agarose and by the limiting dilution method. HHV-6 DNA was detectable in all 13 clones analyzed, suggesting that virtually all Katata cells are infected with HHV-6. This is the first report of a case of HHV-6+ Burkitt's lymphoma in the absence of Epstein-Barr virus. Furthermore, there has been no report of lymphoma cell lines that are persistently and nonproductively infected with HHV-6. The Katata Burkitt's lymphoma cell line, therefore, would provide a useful tool for studies of the mechanisms of HHV-6 latency and reactivation.

Specific diagnostic methods for herpesvirus infections of the central nervous system: a consensus review by the European Union Concerted Action on Virus Meningitis and Encephalitis

BACKGROUND

Herpesvirus infections of the central nervous system are often severe but are fortunately rare. The incidence of these infections has however, increased in recent years as a consequence of an increase in the number of immune-compromised individuals. New diagnostic procedures have improved our ability to diagnose these infections and herpesviruses may yet be implicated as the cause of further neurological diseases with no known aetiology. Methodological standards for selection and evaluation of patient materials are essential to the provision of reliable diagnosis, yet few studies have addressed this important issue.

OBJECTIVES

To describe and define methodological standards and reference methodology for diagnosis of herpesvirus infections of the CNS.

STUDY DESIGN

Information gathered by literature review.

RESULTS

Only for herpes simplex encephalitis is there sufficient data to allow the definition of reference methodology. Good methodological standards exist but few studies have adhered to these standards. As methods for the detection of specific intrathecal antibody synthesis are well established yet under-used in diagnostic virology, the principle of these measurements is reviewed in some detail.

CONCLUSIONS

Herpesvirus infections of the CNS are of increasing importance. High quality, multi-centre studies are needed to establish the value of the new diagnostic test procedures if further improvement in the diagnostic sensitivity and specificity of these procedures is to be achieved.

Fulminant demyelinating encephalomyelitis associated with productive HHV-6 infection in an immunocompetent adult

Human herpesvirus 6 (HHV-6), the etiologic agent of roseola in young children, has been reported to be detectable in the brain of many neurologically normal adults, although regional localization to plaques of multiple sclerosis has also been demonstrated. Large amounts of this virus were present in multifocal demyelinating white matter lesions of fulminant encephalomyelitis with seizures in a 21-year-old woman with normal immune parameters. Brain biopsy after 3 weeks of neurologic deterioration revealed a viral etiology by light and electron microscopy; the virus was identified as HHV-6 by immunohistochemistry and by polymerase chain reaction (PCR) amplification in biopsy and autopsy specimens.

Herpesvirus 6 variant A infection after heart transplantation with giant cell transformation in bile ductular and gastroduodenal epithelium

Herpesvirus 6 (HHV-6) is a ubiquitous virus known to cause febrile syndromes and exanthema subitum in children. Less commonly, and particularly in organ transplant recipients, it may result in hepatitis, bone marrow suppression, interstitial pneunonitis, and meningoencephalitis. This report expands the spectrum of clinical disease associated with HHV-6 by documenting viral infection in a 44-year-old heart transplant recipient presenting with gastroduodenitis, pancreatitis, and hepatitis. On histopathologic examination, the gastric, duodenal, and bile ductular epithelium showed a multinucleate giant cell transformation similar to the cytopathic effect caused by the virus in human T-lymphocytes infected in vitro. Electron microscopy showed herpes particles with a thick tegument layer in the duodenum. Polymerase chain reaction amplified HHV-6 variant A sequences from multiple sites. Serology confirmed the presence of an acute HHV-6 infection. Thus, HHV-6 variant A can cause gastroduodenitis and pancreatitis in immunosuppressed individuals. Multinucleate giant cells and enveloped virions with a prominent tegument can be used as morphologic criteria to raise the possibility of HHV-6 infection in human biopsy tissue.

Human herpesvirus 6

Human herpesvirus 6 variant A (HHV-6A) and human herpesvirus 6 variant B (HHV-6B) are two closely related yet distinct viruses. These visuses belong to the Roseolovirus genus of the betaherpesvirus subfamily; they are most closely related to human herpesvirus 7 and then to human cytomegalovirus. Over 95% of people older than 2 years of age are seropositive for either or both HHV-6 variants, and current serologic methods are incapable of discriminating infection with one variant from infection with the other. HHV-6A has not been etiologically linked to any human disease, but such an association will probably be found soon. HHV-6B is the etiologic agent of the common childhood illness exanthem subitum (roseola infantum or sixth disease) and related febrile illnesses. These viruses are frequently active and associated with illness in immunocompromised patients and may play a role in the etiology of Hodgkin's disease and other malignancies. HHV-6 is a commensal inhabitant of brains; various neurologic manifestations, including convulsions and encephalitis, can occur during primary HHV-6 infection or in immunocompromised patients. HHV-6 and distribution in the central nervous system are altered in patients with multiple sclerosis; the significance of this is under investigation.

Detection of HHV-6 genotypes by in situ hybridization with variant-specific oligonucleotide probes

Human herpesvirus-6 exists in two forms, HHV-6A which has not been clearly associated with any disease, and HHV-6B, the causative agent of exanthem subitum. The two variants have been distinguished by techniques such as dot blotting and restriction fragment length polymorphism of PCR products. This study aims to establish the prevalence of HHV-6A and HHV-6B in carcinoma tissues using variant-specific oligonucleotide probes. A total of 73 archived carcinoma biopsies from the oral, salivary gland, larynx, breast and cervix were obtained with seven histologically normal controls. In situ hybridization was carried out with nonradioactively labelled variant-specific probes. Samples that hybridized with both variant A and B probes were subjected further to nested PCR and digested with HindIII to distinguish the variants. A hybridization signal was observed in 76.2% of oral carcinoma tissue and 75.0% of salivary gland carcinoma tissue. In contrast, only 33.3% of cervical carcinoma tissue were positive for HHV-6 DNA. A hybridization signal was noted in all 4 laryngeal carcinoma tissues studied. However, the 10 breast carcinoma tissues studied were negative, as was the histologically normal tissue. The virus possesses tumourigenic potential and demonstrates virus transactivating properties. The frequency of HHV-6 variants in certain tumours suggest a cofactorial role in multistep carcinogenesis. While PCR amplifies selectively the predominant variant in a sample, this was not seen by in situ hybridization. The in situ hybridization technique allowed the localization of both HHV-6A and HHV-6B in the nuclei of transformed regions.

Basal ganglia infarction associated with HHV-6 infection

A 6 year old boy presented with meningoencephalitis and was found to have serological evidence of acute human herpes virus-6 (HHV-6) infection. He did not develop symptomatic seizures or the rash of exanthum subitum (roseola). His course was marked by severe spastic quadriparesis associated with radiological evidence of basal ganglia infarction. HHV-6 infection should be considered in any child with acute meningoencephalitis.

Identification and analysis of a lytic-phase origin of DNA replication in human herpesvirus 7

Human herpesvirus 7 (HHV-7) DNA sequences colinear with the HHV-6 lytic-phase origin of DNA replication (oriLyt) were amplified by PCR. Plasmid constructs containing these sequences were replicated in HHV-7-infected cord blood mononuclear cells but not in HHV-6-infected cells. In contrast, plasmids bearing HHV-6 oriLyt were replicated in both HHV-6- and HHV-7-infected cells. Finally, the minimal HHV-7 DNA element necessary for replicator activity was mapped to a 600-bp region which contains two sites with high homology to the consensus binding site for the HHV-6 origin binding protein. At least one of these binding sites was shown to be essential for replicator function of HHV-7 oriLyt.

Infection in the bone marrow transplant recipient and role of the microbiology laboratory in clinical transplantation

Over the past quarter century, tremendous technological advances have been made in bone marrow and solid organ transplantation. Despite these advances, an enduring problem for the transplant recipient is infection. As immunosuppressive regimens have become more systematic, it is apparent that different pathogens affect the transplant recipient at different time points in the posttransplantation course, since they are influenced by multiple intrinsic and extrinsic factors. An understanding of this evolving risk for infection is essential to the management of the patient following transplantation and is a key to the early diagnosis and treatment of infection. Likewise, diagnosis of infection is dependent upon the quality of laboratory support, and services provided by the clinical microbiology laboratory play an important role in all phases of clinical transplantation. These include the prescreening of donors and recipients for evidence of active or latent infection, the timely and accurate microbiologic evaluation of the transplant patient with suspected infection, and the surveillance of asymptomatic allograft recipients for infection. Expert services in bacteriology, mycology, parasitology, virology, and serology are needed and communication between the laboratory and the transplantation team is paramount for providing clinically relevant, cost-effective diagnostic testing.

Distribution of human herpesvirus 6 and varicella-zoster virus in organs of a fatal case with exanthem subitum and varicella

The distribution of human herpesvirus 6 (HHV-6) and varicella-zoster virus (VZV) was examined in autopsy samples from a fatal case with both virus infections. A 9-month-old boy developed convulsive seizures followed by macular skin rashes, rapidly progressed to brain death, and died 15 days after the onset, when signs of varicella were noted. An isolation of HHV-6 from blood and evaluation of antibody activities to various viral agents including HHV-6 were performed before his death. Postmortem examinations included: (i) isolation of HHV-6 and VZV from tissues or organs; (ii) detection of both virus antigens in tissues or organs by an indirect immunofluorescent assay using monoclonal antibodies to both viruses; (iii) amplification of both viruses and human herpesvirus 7 DNA sequences by a nested polymerase chain reaction assay; and (iv) endonuclease digestion of amplified products of HHV-6 DNA for differentation of variants A and B. Human herpesvirus 6 DNA was detected in peripheral blood mononuclear cells (PBMC) and plasma obtained at the eruptive stage but present only in PBMC 15 days after, indicating the primary infection with HHV-6, although the virus was not isolated from the same blood sample and a significant rise in the antibody titers to HHV-6 was not observed. Both virus antigens and DNA were detected in various tissues or organs obtained at autopsy, but only VZV was isolated from these samples, suggesting disseminated infection with both viruses in an infant. All the amplified products of HHV-6 DNA were variant B. Among the findings for the distribution of virus antigens, it was noteworthy that HHV-6 antigen was demonstrated in the endothelial cells of small vessels in the frontal lobe of the brain. There was no evidence of HHV-7 infection. These data indicate that the primary HHV-6 infection closely followed by the primary VZV infection had the potential hazard of an unexpected and apparently life-threatening event, in which disseminated infections with both viruses were noted in multiple tissues or organs including the brain.

The role of nucleic acid amplification and detection in the clinical microbiology laboratory

Clinical microbiology is in the midst of a new era. Methodology that is based on nucleic acid detection has slowly appeared in the diagnostic laboratory, and is revolutionizing our ability to assist physicians in the diagnosis and management of patients suffering from infectious diseases. Much like the introduction of immunoassays built around hybridoma technology in the 1980s, considerable doubt and promise exist hand in hand in the 1990s. Conventional testing that is technically straight forward, informative, and timely will always be a part of clinical microbiology; however, considerable room for improvement exists with organisms/diseases for which laboratory methods are limited. Nucleic acid methodology will have its greatest and long-awaited impact in this arena.

In vitro activation of human herpesviruses 6 and 7 from latency

Human herpesviruses 6 and 7 (HHV-6 and HHV-7) are prevalent lymphotropic viruses that infect more than 80% of children at infancy or during early childhood. Infection ranges from asymptomatic to severe disease. HHV-6B causes exanthem subitum. The virus can be recovered from peripheral blood mononuclear cells during the acute phase of exanthem subitum, but the host remains latently infected throughout life. In immunocompromised patients undergoing kidney, liver, or bone marrow transplantation latent HHV-6B is reactivated, at times causing severe or fatal disease. Here, we describe the establishment of an in vitro system for reactivation of HHV-6B and HHV-7 from latency. HHV-7 is reactivated from latently infected peripheral blood mononuclear cells by T-cell activation. HHV-6B could not be reactivated under similar conditions; however, the latent HHV-6B could be recovered after the cells were infected with HHV-7. Once reactivated, the HHV-6B genomes became prominent and the HHV-7 disappeared. We conclude that HHV-7 can provide a transacting function(s) mediating HHV-6 reactivating from latency. Understanding the activation process is critical for the development of treatments to control the activation of latent viruses so as to avoid these sometimes life threatening infections in transplant recipients.

Active HHV-6 infection in the lymph nodes of HIV-infected patients: in vitro evidence that HHV-6 can break HIV latency

Studies published previously by this laboratory have demonstrated that patients with AIDS have widely disseminated, active infections with HHV-6 at the time of their death. However, it remains unclear when in the course of the human immunodeficiency virus (HIV) infection the active HHV-6 infection first appears. To address this question, lymph node biopsies from 10 HIV-infected patients were analyzed for active human herpesvirus 6 (HHV-6) infections by immunohistochemical staining. Eight of the biopsies carried the histologic diagnosis of follicular hyperplasia; the other two were characterized as having follicular involution with histiocytosis and reactive lymphadenitis. In total, 10 of 10 (100%) of the lymph nodes studied contained cells productively infected with HHV-6; in contrast, three lymph nodes with follicular hyperplasia and four normal lymph nodes from patients not infected with HIV were negative for HHV-6 infection. Of special note, the absolute CD4+ lymphocyte counts of 75% (6/8) of the HIV-infected individuals included in these studies were > 200/mm3 at the time of their lymph node biopsy. The A variant of HHV-6 was found to be the predominant form of the virus present in the lymph node biopsies from all of these HIV-infected patients, and in vitro studies demonstrated that exposure of monocytic cells carrying latent HIV to HHV-6A resulted in massive upregulation of HIV replication from latency. Thus, active HHV-6 infections appear relatively early in the course of HIV disease, and in vitro studies suggest that the A variant of HHV-6 is capable of breaking HIV latency, with the potential for helping to catalyze the progression of HIV infections to AIDS.

An encephalitic episode in a multiple sclerosis patient with human herpesvirus 6 latent infection

All the human herpesviruses may cause central nervous system (CNS) diseases, including benign aseptic meningitis or fatal encephalitis. It has recently been stated that human herpesvirus 6 (HHV-6) may also be neuropathogenic in children after primary infection, while in the adult, cases of fatal encephalitis have been reported only in immune-compromised hosts such as AIDS patients, and in one case of an immunosuppressed bone marrow transplant patient. We describe a multiple sclerosis (MS) patient, carrier of HHV-6 latent infection, who experienced an acute inflammation of the CNS diagnosed as encephalitis. HHV-6 specific genomic sequences have been detected by PCR in the patient's PBMCs DNA collected before and during the encephalitis. The PCR performed in the CSF in course of the acute episode was positive, while the CSF collected before the encephalitis was negative. This finding is consistent with an acute encephalopathy caused by the reactivation of a HHV-6 latent infection within the CNS, in a patient with altered immune response due to MS.

Evaluation of a commercial enzyme-linked immunosorbent assay for detection of serum immunoglobulin G response to human herpesvirus 6

A rapid (60-min) commercially available enzyme-linked immunosorbent assay (ELISA) for the detection of immunoglobulin G (IgG) class antibodies to human herpesvirus 6 (HHV-6) was evaluated. The specificity of the ELISA for HHV-6 was confirmed by absorption studies, with the reactivities of HHV-6-positive sera being unaffected by other herpesviruses (cytomegalovirus, herpes simplex virus, and varicella-zoster virus) or the HSB2 cell line used to culture HHV-6. HHV-6 IgG antibody levels in a panel of 502 serum samples were determined by ELISA and an indirect immunofluorescence assay (IFA). Results obtained by the two methods were in close agreement, suggesting that the ELISA provides a suitable test method for the determination of HHV-6 IgG antibodies in a routine clinical laboratory. Both tests were positive in 398 cases (79%), and both were negative in 71 cases (14%), with a different result obtained by IFA and ELISA in only 33 cases (7%). Furthermore, absorption of sera with HHV-6 prior to assay revealed that the majority of these results were false positive (n = 8) or false negative (n = 23) in the IFA (true positives or negatives in the ELISA). Subsequently, the ELISA showed a sensitivity of 99.76% and a specificity of 98.75%. HHV-6-specific IgG levels were also determined in paired serum samples collected from 49 donors--14 with exanthem subitum (ES), 15 with ES which was complicated with central nervous system involvement, and 20 undergoing bone marrow transplantation--in whom HHV-6 infection had been demonstrated by virus isolation and/or PCR. All patients with ES or central nervous system complications showed an increase in HHV-6-specific IgG, indicating that this ELISA may be a useful aid in the diagnosis of these conditions. Furthermore, 14 of 20 patients undergoing bone marrow transplantation showed an increase in HHV-6-specific IgG levels, possibly reflecting a reactivation of HHV-6 in these patients.

Novel human herpesviruses (human herpesviruses 6, 7 and 8)

The number of members in the family Herpesviridae has increased in the last 10 years due to the description of three novel human herpesviruses: human herpesvirus 6 (HHV-6) in 1986, human herpesvirus 7 (HHV-7) in 1990, and human herpesvirus 8 (HHV-8), also known as Kaposi's sarcoma-associated herpesvirus (KSHV), in 1994. HHV-6 and HHV-7 were first isolated from blood lymphocyte cultures, while HHV-8 was identified following a specific molecular biology approach in the search for the etiologic agent of Kaposi's sarcoma. The three viruses are lymphotropic, T-cells being the targets of HHV-6 and HHV-7, and B-cells being probably those of HHV-8. The ability to be propagated in cell cultures in vitro differs according to the virus concerned: this can be done readily with HHV-6, with more difficulties in the case of HHV-7, and has not yet been achieved in the case of HHV-8. Human infection with HHV-6 and HHV-7 is ubiquitous, widespread and acquired early in life. HHV-8 epidemiology is still unclear, and there are two hypotheses: a restricted dissemination in the general population like herpes simplex virus type 2, or a widespread infection like all other human herpesviruses. The polymerase chain reaction is the common method for the detection of infection using specific primers and probes for HHV-6, HHV-7 and HHV-8 respectively. Serologic assays are only available for HHV-6 and HHV-7, with limitations being due, in particular, to possible cross-reactions with cytomegalovirus. HHV-6 is the causative agent of exanthem subitum (sixth disease). Its role as an opportunistic agent and immune dysfunction inducer is debated and currently under investigation. The pathogenic role of HHV-7 seems to be modest, with one case of exanthem subitum reported so far. HHV-8 is strongly associated with three diseases: Kaposi's sarcoma, Castleman's disease and body-cavity-based lymphomas. The therapy against these novel viruses has to be considered in the future.

Infection of primary human fetal astrocytes by human herpesvirus 6

Human herpesvirus 6 (HHV-6) is a lymphotropic betaherpesvirus which productively infects human CD4+ T cells and monocytes. HHV-6 is the etiologic agent for exanthem subitum (roseola), and it is well-known that central nervous system complications occur frequently during the course of HHV-6-associated disease. In addition, HHV-6 has been associated with encephalitis or encephalopathy. However, very little is known about its tropism for neural cells. There are reports that HHV-6 may infect some glial cell lines, but whether it can infect any primary neural cells is not known. Our studies show that both HHV-6A (GS) and HHV-6B (Z-29) can infect highly purified primary fetal astrocytes in vitro. Infected cells showed cytopathic effects, forming giant syncytia. In dual immunofluorescence assays, the infected cells were detected by antibodies against the HHV-6 p41 nuclear antigen and glial fibrillary acidic protein, indicating that the infected cells are indeed astrocytes. PCR and Northern (RNA) blot analyses also confirmed that the astrocytes are infected by HHV-6. The progeny virus did not alter its host range and could reinfect T cells as well as primary astrocytes. These findings suggest that infection of primary human astrocytes may play a role in the neuropathogenesis of HHV-6.

Comparison of HHV-6 antibody titers in West Africa and the Caribbean

Human herpesvirus-6 (HHV-6) infection seems to be ubiquitous early in life, but antibody responses vary by geographic area. We compared HHV-6 antibody titer in 123 West African and 122 Caribbean serum samples. A quantitative immunofluorescence assay (IFA) using antigens derived from an HSB-2 cell line was used to test for IgG HHV-6 (GS strain) antibodies. The prevalence of HHV-6 antibodies was high (98%) in both sites. African samples had a significantly higher geometric mean titer (GMT: 697) than did Caribbean samples (GMT: 99). There was no difference between males (GMT: 260) and females (GMT: 270) overall. Children up to and including 9 years old had significantly higher titers (GMT: 483) than did all others (GMT: 237), and female children tended to have higher titers than did male children. In both areas there was a trend towards highest titer at younger age, followed by a decrease in titer during adulthood and middle age, and a secondary rise in titer in the oldest age group. Environmental and host factors may explain these geographic differences in antibody responses between two groups of African origin.

Serial neuroimages of acute necrotizing encephalopathy associated with human herpesvirus 6 infection

A previously healthy 8-month-old girl developed exanthem subitum and acute encephalopathy with status epilepticus, quadriplegia and bilateral abducens nerve palsies. Human herpesvirus-6 DNA was found in the cerebrospinal fluid by the polymerase chain reaction at the acute stage. Cranial computed tomography showed low density areas in the thalami and in the cerebellar and abducens nuclei. The distribution of the lesions was consistent with acute necrotizing encephalopathy. As for the thalamic lesions, a T2 weighted magnetic resonance image on the 24th day of the illness demonstrated low signal intensity surrounded by high intensity; 99mTc-ECD SPECT showed hypoperfusion, which suggested irreversible tissue damage. The patient is now 1 year 6 months old and has spastic quadriparesis with mental retardation and abducens nerve palsies.

Human herpesvirus-6: a survey of presence and distribution of genomic sequences in normal brain and neuroglial tumors

In an attempt to study the frequency and distribution of human herpesvirus-6 (HHV-6) infection both in normal and neoplastic brain tissues in vivo, polymerase chain reaction was used to look for HHV-6 genomes: 1) in samples, obtained at necropsy, from different regions of the brain of immunocompetent adult subjects and of patients who died of AIDS; 2) in the surgical biopsies of a well-characterized series of primary brain tumors of neuroglial origin. HHV-6-specific sequences were identified in six of nine brain samples from immunocompetent subjects, and in four of seven brain samples from AIDS patients. Viral sequences were identified in the specimens derived either from the grey (frontal cortex and basal ganglia) or from the periventricular white matter. HHV-6 DNA was found only in 6 of the 37 primary brain tumor biopsies examined. This study provides for the first time molecular evidence of a wide distribution of HHV-6 infection in the brain tissues of a high proportion of subjects, both in normal and in impaired immunity. In this large series of tumor biopsies the presence of HHV-6 genomic sequences is a rare phenomenon, arguing against a major role of this herpesvirus in the pathogenesis of primary brain tumors of neuroglial origin in immunocompetent subjects.

Plaque-associated expression of human herpesvirus 6 in multiple sclerosis

Representational difference analysis was used to search for pathogens in multiple sclerosis brains. We detected a 341-nucleotide fragment that was 99.4% identical to the major DNA binding protein gene of human herpesvirus 6 (HHV-6). Examination of 86 brain specimens by PCR demonstrated that HHV-6 was present in > 70% of MS cases and controls and is thus a commensal virus of the human brain. By DNA sequencing, 36/37 viruses from MS cases and controls were typed as HHV-6 variant B group 2. Other herpesviruses, retroviruses, and measles virus were detected infrequently or not at all. HHV-6 expression was examined by immunocytochemistry with monoclonal antibodies against HHV-6 virion protein 101K and DNA binding protein p41. Nuclear staining of oligodendrocytes was observed in MS cases but not in controls, and in MS cases it was observed around plaques more frequently than in uninvolved white matter. MS cases showed prominent cytoplasmic staining of neurons in gray matter adjacent to plaques, although neurons expressing HHV-6 were also found in certain controls. Since destruction of oligodendrocytes is a hallmark of MS, these studies suggest an association of HHV-6 with the etiology or pathogenesis of MS.

Quantitative PCR for human herpesviruses 6 and 7

A quantitative PCR assay for the detection of human herpesvirus 6 (HHV-6) (variants A and B) and HHV-7 DNAs in clinical samples was developed. The assay uses a nonhomologous internal standard (IS) for each virus that is coamplified with the wild-type target sequence in the same vial and with the same pair of primers. This method allows for a correction of the variability of efficiency of the PCR technique. A standard curve is constructed for each experiment by coamplification of known quantities of the cloned HHV-6 or HHV-7 target templates with the respective IS. Absolute quantitation of the test samples is then achieved by determining the viral target/IS ratio of the hybridization signals of the amplification products and plotting this value against the standard curve. Using this assay, we quantitated the amount of HHV-6 or HHV-7 DNA in infected cell cultures and demonstrated an inhibitory effect of phosphonoformic acid on the replication of HHV-6 and HHV-7 in vitro. As the first clinical application of this procedure, we performed preliminary measurements of the loads of HHV-6 and HHV-7 in lymph nodes from patients with Hodgkin's disease and AIDS. Application of this quantitative PCR method should be helpful for elucidating the pathogenic roles of HHV-6 and HHV-7.

Diagnosis of human herpesvirus-6 infection in two patients with central nervous system complications

BACKGROUND

Although exanthem subitum (ES) is generally a mild, self-limiting disease of early childhood, some cases of ES are complicated by seizures and encephalopathy. The presence of human herpesvirus-6 (HHV-6) DNA in cerebrospinal fluid (CSF) of these patients suggests that HHV-6 can infect the central nervous system (CNS) causing encephalitis.

OBJECTIVES

To demonstrate HHV-6 infection in two patients with serious CNS complications. The patients, a child and an adult, failed to develop the characteristic rash normally associated with ES.

STUDY DESIGN

Peripheral blood mononuclear cells (PBMCs) and CSF were examined for the presence of HHV-6 or viral DNA, using virus isolation techniques and the polymerase chain reaction (PCR). Serum samples were tested by immunofluorescence (IF) and enzyme linked immuno-sorbent assay (ELISA) for the presence of anti-HHV-6 IgM and anti-HHV-6 IgG respectively.

RESULTS

HHV-6 was isolated from the PBMCs of the adult patient and the presence of virus in these cells was confirmed using electron microscopy. HHV-6 DNA was detected in CSF taken early during the infection in both patients, together with anti-HHV-6 IgM antibodies and increasing levels of anti-HHV-6 IgG.

CONCLUSIONS

The diagnosis of HHV-6 infection in these patients was confirmed either by virus isolation or by the detection of HHV-6 DNA in the CSF, and the results of serology. These cases show that HHV-6 infection may result in serious CNS complications, in children and adults.

Fulminant human herpesvirus six encephalitis in a human immunodeficiency virus-infected infant

Self-limited involvement of the central nervous system (CNS) is a relatively common complication of primary infection with human herpesvirus six (HHV-6) in normal children. We describe an HIV-infected infant who developed fulminant encephalitis as a complication of HHV-6 infection. Immunohistochemical staining of CNS tissue demonstrated productive infection of all CNS cell-types. Analysis of the infected brain tissue by the polymerase chain reaction (PCR) confirmed the presence of a dense HHV-6 infection in the tissue, and demonstrated that the virus present in the CNS tissue was predominantly the A variant of HHV-6. This is the first demonstration of invasive tissue disease caused by HHV-6 in an HIV-infected infant.

Human herpesvirus 6

HHV-6, the first T-lymphotropic human herpesvirus, is an important novel human pathogen. It is the cause of exanthem subitum in infants and may act as an opportunistic agent in immunocompromised patients. Moreover, several lines of clinical and experimental evidence suggest that HHV-6 may accelerate the progression of HIV infection. Progress in the study of HHV-6 has been rapid, in part as a consequence of the strong current interest in human lymphotropic viruses and their relationship with the immune system. Nonetheless, the full spectrum of diseases linked to this agent is still unknown (Table 2) and animal models of infection have not yet been exploited. The next few years will be crucial for a complete understanding of the potential role of HHV-6 in human disease.

Human herpesvirus 6 in AIDS

Multiple lines of clinical and experimental evidence suggest that human herpesvirus 6 (HHV-6) may act as an accelerating factor in the natural history of human immunodeficiency virus (HIV) infection. Although, in common with HIV, HHV-6 has a primary tropism for CD4+ T cells, its potential effects on the immune system are broader. For instance, HHV-6 can also infect and kill CD8+ T cells, natural killer cells and mononuclear phagocytes. Here, Paolo Lusso and Robert Gallo suggest that understanding the immunopathogenic role of HHV-6 in the course of HIV infection may shed new light on the complex mechanisms of disease progression in AIDS.