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Algahtani H, Shirah B, Jamaluddin HA, Abdelghaffar N. Insights into adjunctive corticosteroid therapy in fulminant herpes simplex virus encephalitis: case analysis with contrasting outcomes. ENCEPHALITIS 2024; 4:62-68. [PMID: 38981668 PMCID: PMC11237186 DOI: 10.47936/encephalitis.2024.00031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2024] [Revised: 05/29/2024] [Accepted: 06/12/2024] [Indexed: 07/11/2024] Open
Abstract
Herpes simplex virus (HSV) encephalitis, predominantly caused by HSV-1, presents with significant morbidity and mortality challenges. This research investigates the particular role of adjunctive corticosteroid therapy in fulminant HSV encephalitis through in-depth analyses of two contrasting cases. Corticosteroids show potential benefits to improve an exaggerated immune response and limit viral dissemination within the brain. Daily assessments and frequent neuroimaging, particularly using magnetic resonance imaging, aid in the management of fulminant cases. Although existing evidence relies on limited case series and retrospective comparisons, the results of the present study emphasize the necessity for large-scale controlled trials to establish definitive guidelines. The discretion of the treating neurologist governs the decision to implement corticosteroids, emphasizing the imperative need for continued research and evidence-based strategies for this challenging neurological condition.
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Affiliation(s)
- Hussein Algahtani
- Neurology Section, Department of Medicine, Aseer Central Hospital, Abha, Saudi Arabia
| | - Bader Shirah
- Department of Neuroscience, King Faisal Specialist Hospital & Research Centre, Jeddah, Saudi Arabia
| | - Hussam A. Jamaluddin
- Neurology Section, Department of Medicine, Aseer Central Hospital, Abha, Saudi Arabia
| | - Nawal Abdelghaffar
- Neurology Section, Department of Medicine, Aseer Central Hospital, Abha, Saudi Arabia
- Department of Neurology, Kasr Al Ainy Hospital, Faculty of Medicine, Cairo University, Cairo, Egypt
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2
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Poussier L, Mailles A, Tattevin P, Stahl JP, Fillâtre P. Characteristics, management and outcome of Herpes Simplex and Varicella-Zoster virus encephalitis: a multicentre prospective cohort study. Clin Microbiol Infect 2024; 30:917-923. [PMID: 38527616 DOI: 10.1016/j.cmi.2024.03.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Revised: 03/03/2024] [Accepted: 03/13/2024] [Indexed: 03/27/2024]
Abstract
OBJECTIVE To characterize differences between Herpes Simplex virus encephalitis and Varicella-Zoster virus encephalitis (HSVE and VZVE) and other aetiologies of infectious encephalitis (IE), and to investigate the impact of time-to-aciclovir (ACV) start, ACV dose and duration on outcome. METHODS We compared 132 HSVE, 65 VZVE and 297 other IE enrolled in a prospective cohort (ENCEIF). We estimated associations between time-to-ACV start, dose or duration and outcome through adjusted odds ratio (aOR) using logistic regression analysis. RESULTS Prevalence of immunodepression differed among aetiologies: 15/65 (23%) for VZVE, 13/132 (10%) for HSVE and 30/297 (10%) for other IE (p <0.05), as was presence of seizure at admission: 27/132 (20%) for HSVE, 4/65 (6%) for VZVE and 43/297 (14%) for other IE (p <0.05). Poor outcome at hospital discharge (Glasgow outcome scale ≤3) differed among the three groups: 40/127 (31%) for HSVE, 12/65 (18%) for VZVE and 38/290 (13%) for other IE (p <0.05). Time-to-ACV start was associated with outcome in HSVE (aOR 3.61 [1.25-10.40]), but not in VZVE (aOR 0.84 [0.18-3.85]). Increased ACV dose was not associated with outcome among HSVE (aOR 1.25 [0.44-3.64]) nor VZVE (aOR 1.16 [0.24-5.73]). DISCUSSION HSVE and VZVE are distinct in clinical presentation, outcome and prognostic factors. The impact of early ACV initiation was more apparent for HSVE than for VZVE; however, this could be because of VZVE's smaller sample size and lower outcome rate leading to low statistical power or because of potential distinct IE pathophysiology.
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Affiliation(s)
- Léa Poussier
- Infectious Diseases and Intensive Care Unit, CHU Pontchaillou, Rennes, France; INSERM, CIC 1414, Rennes, France
| | | | - Pierre Tattevin
- Infectious Diseases and Intensive Care Unit, CHU Pontchaillou, Rennes, France; INSERM, CIC 1414, Rennes, France
| | - Jean-Paul Stahl
- Infectious Diseases Department, University Grenoble Alpes, Grenoble, France
| | - Pierre Fillâtre
- INSERM, CIC 1414, Rennes, France; Intensive Care Unit, Yves Le Foll Hospital, Saint Brieuc, France.
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3
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Han S, Yang S, Chang Z, Wang Y. Neutrophil extracellular trap-associated protein in cerebrospinal fluid for prognosis evaluation of adult bacterial meningitis: a retrospective case-control study. BMC Infect Dis 2024; 24:534. [PMID: 38802752 PMCID: PMC11129486 DOI: 10.1186/s12879-024-09423-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2024] [Accepted: 05/21/2024] [Indexed: 05/29/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Central nervous system infections, typified by bacterial meningitis, stand as pivotal emergencies recurrently confronted by neurologists. Timely and precise diagnosis constitutes the cornerstone for efficacious intervention. The present study endeavors to scrutinize the influence of inflammatory protein levels associated with neutrophils in cerebrospinal fluid on the prognosis of central nervous system infectious maladies. METHODS This retrospective case series study was undertaken at the Neurology Department of the Second Hospital of Shandong University, encompassing patients diagnosed with infectious encephalitis as confirmed by PCR testing and other diagnostic modalities spanning from January 2018 to January 2024. The quantification of MPO and pertinent inflammatory proteins within patients' cerebrospinal fluid was accomplished through the utilization of ELISA. RESULTS We enlisted 25 patients diagnosed with bacterial meningitis, ascertained through PCR testing, and stratified them into two groups: those with favorable prognoses (n = 25) and those with unfavorable prognoses (n = 25). Following assessments for normality and variance, notable disparities in CSF-MPO concentrations emerged between the prognostic categories of bacterial meningitis patients (P < 0.0001). Additionally, scrutiny of demographic data in both favorable and unfavorable prognosis groups unveiled distinctions in CSF-IL-1β, CSF-IL-6, CSF-IL-8, CSF-IL-18, CSF-TNF-α levels, with correlation analyses revealing robust associations with MPO. ROC curve analyses delineated that when CSF-MPO ≥ 16.57 ng/mL, there exists an 83% likelihood of an adverse prognosis for bacterial meningitis. Similarly, when CSF-IL-1β, CSF-IL-6, CSF-IL-8, CSF-IL-18, and CSF-TNF-α levels attain 3.83pg/mL, 123.92pg/mL, 4230.62pg/mL, 35.55pg/mL, and 35.19pg/mL, respectively, there exists an 83% probability of an unfavorable prognosis for bacterial meningitis. CONCLUSION The detection of neutrophil extracellular traps MPO and associated inflammatory protein levels in cerebrospinal fluid samples holds promise in prognosticating bacterial meningitis, thereby assuming paramount significance in the prognostic evaluation of patients afflicted with this condition.
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Affiliation(s)
- Song Han
- The Second Hospital of Shandong University, Cheeloo College of Medicine,Shandong University, Jinan, 250033, China
| | - Suge Yang
- The Second Hospital of Shandong University, Cheeloo College of Medicine,Shandong University, Jinan, 250033, China
| | - Zhongzheng Chang
- The Second Hospital of Shandong University, Cheeloo College of Medicine,Shandong University, Jinan, 250033, China
| | - Yun Wang
- Department of Neurology?Qilu Hospital (Qingdao), Cheeloo College of Medicine, Shandong University, Qingdao, 266035, China.
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4
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Sauvage A, Laurent E, Gaborit C, Guillon A, Grammatico-Guillon L. Herpes simplex encephalitis in France: incidence, 6-month rehospitalizations and mortality. Infection 2024:10.1007/s15010-024-02272-3. [PMID: 38678152 DOI: 10.1007/s15010-024-02272-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2024] [Accepted: 04/15/2024] [Indexed: 04/29/2024]
Abstract
BACKGROUND Herpes simplex encephalitis (HSE) is a disease with unfavorable vital and functional prognoses. There are no recent epidemiological data on HSE at a national level using real-life databases, especially in France. This study aimed to report the incidence, the clinical characteristics and outcomes of the patients with HSE. METHODS We conducted a comprehensive retrospective cohort study on all patients hospitalized for HSE in France between 2015 and 2022 using national hospital discharge databases. Incidence, socio-demographic and clinical characteristics (including comorbidities, seizure, stays' features, intensive care supports) were described. The short- (first stay) and long-term (6-month) outcomes were reported, in terms of mortality and rehospitalizations. RESULTS 1425 HSE patients were included (median age 67 [54-77] years old, M/F sex ratio 1.07), giving a mean yearly hospital incidence of 2.3 [2.1-2.5] per 1,000,000 inhabitants. 51.2% of the patients were admitted in ICU (n = 730), of whom 59.0% were mechanically ventilated. The overall mortality during the first stay was 14.3% (n = 204), up to 17.9% for ICU patients. Within 6 months, among the survivors, 10.1% had at least one rehospitalization related to HSE. At 6 months, 16.5% of all patients had died (n = 235), 20.8% for ICU patients. CONCLUSION In France, the incidence of hospitalizations for HSE was 2.3 per 1,000,000 inhabitants with more than half of the patients admitted in ICU and a 6-month in-hospital mortality about 16.5%. This real-life update on the characteristics and severe outcomes of the disease raises awareness among care practitioners, of the serious nature of the disease, and thus can lead to higher vigilance.
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Affiliation(s)
- Ambre Sauvage
- Clinical Data Epidemiology Unit in Centre-Val de Loire (EpiDcliC), Tours University Hospital, Tours, France
- University of Tours, Tours, France
| | - Emeline Laurent
- Clinical Data Epidemiology Unit in Centre-Val de Loire (EpiDcliC), Tours University Hospital, Tours, France
- Research Team EA 7505 "Education, Ethics, Health", University of Tours, Tours, France
| | - Christophe Gaborit
- Clinical Data Epidemiology Unit in Centre-Val de Loire (EpiDcliC), Tours University Hospital, Tours, France
| | - Antoine Guillon
- Intensive Care Unit, Tours University Hospital, Tours, France
- Research Center for Respiratory Diseases, INSERM U1100, Tours, France
| | - Leslie Grammatico-Guillon
- Clinical Data Epidemiology Unit in Centre-Val de Loire (EpiDcliC), Tours University Hospital, Tours, France.
- University of Tours, Tours, France.
- MAVIVH, INSERM U1259, Tours, France.
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Davidson TL, Stevenson RJ. Vulnerability of the Hippocampus to Insults: Links to Blood-Brain Barrier Dysfunction. Int J Mol Sci 2024; 25:1991. [PMID: 38396670 PMCID: PMC10888241 DOI: 10.3390/ijms25041991] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Revised: 01/25/2024] [Accepted: 01/29/2024] [Indexed: 02/25/2024] Open
Abstract
The hippocampus is a critical brain substrate for learning and memory; events that harm the hippocampus can seriously impair mental and behavioral functioning. Hippocampal pathophysiologies have been identified as potential causes and effects of a remarkably diverse array of medical diseases, psychological disorders, and environmental sources of damage. It may be that the hippocampus is more vulnerable than other brain areas to insults that are related to these conditions. One purpose of this review is to assess the vulnerability of the hippocampus to the most prevalent types of insults in multiple biomedical domains (i.e., neuroactive pathogens, neurotoxins, neurological conditions, trauma, aging, neurodegenerative disease, acquired brain injury, mental health conditions, endocrine disorders, developmental disabilities, nutrition) and to evaluate whether these insults affect the hippocampus first and more prominently compared to other brain loci. A second purpose is to consider the role of hippocampal blood-brain barrier (BBB) breakdown in either causing or worsening the harmful effects of each insult. Recent research suggests that the hippocampal BBB is more fragile compared to other brain areas and may also be more prone to the disruption of the transport mechanisms that act to maintain the internal milieu. Moreover, a compromised BBB could be a factor that is common to many different types of insults. Our analysis indicates that the hippocampus is more vulnerable to insults compared to other parts of the brain, and that developing interventions that protect the hippocampal BBB may help to prevent or ameliorate the harmful effects of many insults on memory and cognition.
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Affiliation(s)
- Terry L. Davidson
- Department of Neuroscience, Center for Neuroscience and Behavior, American University, 4400 Massachusetts Avenue, NW, Washington, DC 20016, USA
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Abbuehl LS, Branca M, Ungureanu A, Federspiel A, Leib SL, Bassetti CLA, Hakim A, Dietmann A. Magnetic resonance imaging in acute meningoencephalitis of viral and unknown origin: frequent findings and prognostic potential. Front Neurol 2024; 15:1359437. [PMID: 38299018 PMCID: PMC10829495 DOI: 10.3389/fneur.2024.1359437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Accepted: 01/05/2024] [Indexed: 02/02/2024] Open
Abstract
Background Magnetic resonance imaging (MRI) findings in meningoencephalitis have mainly been described in terms of their diagnostic value rather than their prognostic potential, except for herpes simplex virus (HSV) encephalitis. The aims of our study were to describe frequency and anatomic locations of MRI abnormalities specific to limbic, circadian and motor systems in a cohort of meningoencephalitis patients, as well as to investigate the prognostic value of these MRI findings. Methods A secondary, selective analysis of a retrospective database including all meningitis, meningoencephalitis and encephalitis cases treated between 2016 and 2018 in the University hospital of Bern, Switzerland was performed. Patients with meningitis of any cause, bacterial or autoimmune causes of encephalitis were excluded. Results MRI scans and clinical data from 129 meningoencephalitis cases found that the most frequent causes were tick-borne encephalitis (TBE, 42%), unknown pathogens (40%), VZV (7%), and HSV1 (5%). At discharge, median modified Rankin Score (mRS) was 3 (interquartile range, IQR, 1), 88% of patients had persisting signs and symptoms. After a median of 17 months, median Glasgow Outcome Score (GOS) was 5 (IQR 1), 39% of patients still had residual signs or symptoms. All patients with HSV, 27% with TBE and 31% of those with meningoencephalitis of unknown etiology had fluid-attenuated inversion recovery (FLAIR) and to a lesser extent diffusion-weighted imaging (DWI) lesions in their initial MRI, with highly overlapping anatomical distribution. In one fifth of TBE patients the limbic system was affected. Worse outcome was associated with presence of DWI and/or FLAIR lesions and lower normalized apparent diffusion coefficient (ADC) signal intensities. Conclusion Presence of FLAIR lesions, restricted diffusion as well as the extent of ADC hypointensity in initial MRI are parameters which might be of prognostic value regarding the longterm clinical outcome for patients with meningoencephalitis of viral and of unknown origin. Although not described before, affection of limbic structures by TBE is possible as shown by our results: A substantial proportion of our TBE patients had FLAIR signal abnormalities in these regions.
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Affiliation(s)
- Lena S. Abbuehl
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | | | - Anamaria Ungureanu
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Andrea Federspiel
- Support Center for Advanced Neuroimaging Translational Imaging Center (sitem-insel), Institute for Diagnostic and Interventional Neuroradiology, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Stephen L. Leib
- Institute for Infectious Diseases, University of Bern, Bern, Switzerland
| | - Claudio L. A. Bassetti
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Arsany Hakim
- Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Anelia Dietmann
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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de Souza Carneiro VC, Leon LAA, de Paula VS. miRNAs: Targets to Investigate Herpesvirus Infection Associated with Neurological Disorders. Int J Mol Sci 2023; 24:15876. [PMID: 37958855 PMCID: PMC10650863 DOI: 10.3390/ijms242115876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Revised: 10/30/2023] [Accepted: 10/31/2023] [Indexed: 11/15/2023] Open
Abstract
Herpesvirus is associated with various neurological disorders and a specific diagnosis is associated with a better prognosis. MicroRNAs (miRNAs) are potential diagnostic and prognostic biomarkers of neurological diseases triggered by herpetic infection. In this review, we discuss miRNAs that have been associated with neurological disorders related to the action of herpesviruses. Human miRNAs and herpesvirus-encoded miRNAs were listed and discussed. This review article will be valuable in stimulating the search for new diagnostic and prognosis alternatives and understanding the role of these miRNAs in neurological diseases triggered by herpesviruses.
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Affiliation(s)
- Vanessa Cristine de Souza Carneiro
- Laboratory of Molecular Virology and Parasitology, Oswaldo Cruz Institute, Fiocruz, Rio de Janeiro 21040-360, Brazil; (V.C.d.S.C.); (V.S.d.P.)
- Laboratory of Technological Development in Virology, Oswaldo Cruz Institute, Fiocruz, Rio de Janeiro 21040-360, Brazil
| | - Luciane Almeida Amado Leon
- Laboratory of Technological Development in Virology, Oswaldo Cruz Institute, Fiocruz, Rio de Janeiro 21040-360, Brazil
| | - Vanessa Salete de Paula
- Laboratory of Molecular Virology and Parasitology, Oswaldo Cruz Institute, Fiocruz, Rio de Janeiro 21040-360, Brazil; (V.C.d.S.C.); (V.S.d.P.)
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Nääs A, Li P, Ahlm C, Aurelius E, Järhult JD, Schliamser S, Studahl M, Xiao W, Bergquist J, Westman G. Temporal pathway analysis of cerebrospinal fluid proteome in herpes simplex encephalitis. Infect Dis (Lond) 2023; 55:694-705. [PMID: 37395107 DOI: 10.1080/23744235.2023.2230281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Revised: 06/20/2023] [Accepted: 06/21/2023] [Indexed: 07/04/2023] Open
Abstract
OBJECTIVES We examined the temporal changes of the CSF proteome in patients with herpes simplex encephalitis (HSE) during the course of the disease, in relation to anti-N-methyl-D-aspartate receptor (NMDAR) serostatus, corticosteroid treatment, brain MRI and neurocognitive performance. METHODS Patients were retrospectively included from a previous prospective trial with a pre-specified CSF sampling protocol. Mass spectrometry data of the CSF proteome were processed using pathway analysis. RESULTS We included 48 patients (110 CSF samples). Samples were grouped based on time of collection relative to hospital admission - T1: ≤ 9 d, T2: 13-28 d, T3: ≥ 68 d. At T1, a strong multi-pathway response was seen including acute phase response, antimicrobial pattern recognition, glycolysis and gluconeogenesis. At T2, most pathways activated at T1 were no longer significantly different from T3. After correction for multiplicity and considering the effect size threshold, 6 proteins were significantly less abundant in anti-NMDAR seropositive patients compared to seronegative: procathepsin H, heparin cofactor 2, complement factor I, protein AMBP, apolipoprotein A1 and polymeric immunoglobulin receptor. No significant differences in individual protein levels were found in relation to corticosteroid treatment, size of brain MRI lesion or neurocognitive performance. CONCLUSIONS We show a temporal change in the CSF proteome in HSE patients during the course of the disease. This study provides insight into quantitative and qualitative aspects of the dynamic pathophysiology and pathway activation patterns in HSE and prompts for future studies on the role of apolipoprotein A1 in HSE, which has previously been associated with NMDAR encephalitis.
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Affiliation(s)
- Anja Nääs
- Department of Medical Sciences, Section of Infectious Diseases, Uppsala University, Uppsala, Sweden
| | - Peng Li
- ME/CFS Collaborative Research Center at Harvard, Massachusetts General Hospital, Boston, USA
| | - Clas Ahlm
- Department of Clinical Microbiology, Umeå University, Umeå, Sweden
| | - Elisabeth Aurelius
- Unit of Infectious Diseases, Department of Medicine, Karolinska Institutet, Department of Infectious Diseases, Karolinska University Hospital, Solna, Sweden
| | - Josef D Järhult
- Department of Medical Sciences, Zoonosis Science Center, Uppsala University, Uppsala, Sweden
| | - Silvia Schliamser
- Division of Infection Medicine, Department of Clinical Sciences, Lund University, Skane University Hospital, Lund, Sweden
| | - Marie Studahl
- Department of Infectious Diseases, Institute of Biomedicine, Sahlgrenska Academy at the Gothenburg University, Gothenburg, Sweden
- Region Västra Götaland, Department of Infectious Diseases, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Wenzhong Xiao
- ME/CFS Collaborative Research Center at Harvard, Massachusetts General Hospital, Boston, USA
| | - Jonas Bergquist
- Department of Chemistry, Analytical Chemistry and Neurochemistry, Biomedical Center and The Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS) Collaborative Research Centre at Uppsala University, Uppsala, Sweden
| | - Gabriel Westman
- Department of Medical Sciences, Section of Infectious Diseases, Uppsala University, Uppsala, Sweden
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Gaensbauer JT, Fernholz EC, Hiskey LM, Binnicker MJ, Corsini Campioli C. Comparison of two assays to diagnose herpes simplex virus in patients with central nervous system infections. J Clin Virol 2023; 166:105528. [PMID: 37390620 DOI: 10.1016/j.jcv.2023.105528] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 06/23/2023] [Accepted: 06/25/2023] [Indexed: 07/02/2023]
Abstract
BACKGROUND Multiplex PCR panels are frequently used for detecting the diagnosis of central nervous system infection, but have demonstrated lower sensitivity for herpes simplex virus (HSV) compared to targeted PCRs. Providers in our institution frequently order both multiplex (BioFire Meningitis/Encephalitis Panel (MEP)) and targeted HSV PCR (Diasorin Simplexa HSV-1/2 Direct), allowing comparison of assay performance in practice and a unique clinical characterization of patients with concordant positive or discordant results. METHODS We retrospectively analyzed all HSV testing performed using the two assays simultaneously in a large multi-center institution between 12/10/2018 and 6/6/2022. We described and compared laboratory, diagnostic and therapeutic data between patients with positive results on both assays with patients with discordant results. RESULTS 1,387 patients were tested with both assays, of which 25 were positive on at least one assay. Eleven (44%) had discordant results; 9 were targeted-PCR-positive/MEP-negative and 2 were targeted-PCR-negative/MEP-positive. Compared with patients with concordant positive results, discordant targeted PCR-positive/MEP-negative patients had a higher PCR cycle threshold value (i.e., >35) and milder illness characterized by lower CSF WBC counts (4 vs 152; p = 0.032), fewer MRI abnormalities (37.5% vs. 87.5%; p = 0.039), HSV meningoencephalitis as primary discharge diagnosis (33% vs. 100%; p<0.0001) and were more often treated with oral medication or none at all. CONCLUSIONS Patients with discordant targeted PCR-positive/MEP-negative results represent a population with milder clinical disease. These findings will help clinicians and laboratorians determine when both targeted HSV and multiplex assays should be performed simultaneously and identify patients for whom a multiplex PCR may suffice, despite lower assay sensitivity.
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Affiliation(s)
- J T Gaensbauer
- Department of Pediatric and Adolescent Medicine, Division of Pediatric Infectious Diseases, USA.
| | - E C Fernholz
- Department of Laboratory Medicine and Pathology, Division of Clinical Microbiology, Mayo Clinic, Rochester, USA
| | - L M Hiskey
- Department of Pediatric and Adolescent Medicine, Division of Pediatric Infectious Diseases, USA
| | - M J Binnicker
- Department of Laboratory Medicine and Pathology, Division of Clinical Microbiology, Mayo Clinic, Rochester, USA
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Abbuehl LS, Hofmann E, Hakim A, Dietmann A. Can we forecast poor outcome in herpes simplex and varicella zoster encephalitis? A narrative review. Front Neurol 2023; 14:1130090. [PMID: 37435162 PMCID: PMC10331601 DOI: 10.3389/fneur.2023.1130090] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 05/31/2023] [Indexed: 07/13/2023] Open
Abstract
Herpes simplex virus (HSV) and varicella zoster virus (VZV) are among the most commonly diagnosed infectious causes of sporadic encephalitis worldwide. Despite treatment, mortality and morbidity rates remain high, especially for HSV encephalitis. This review is intended to provide an overview of the existing scientific literature on this topic from the perspective of a clinician who is confronted with serious decisions about continuation or withdrawal of therapeutic interventions. We performed a literature review searching two databases and included 55 studies in the review. These studies documented or investigated specifically outcome and predictive parameters of outcome of HSV and/or VZV encephalitis. Two reviewers independently screened and reviewed full-text articles meeting the inclusion criteria. Key data were extracted and presented as a narrative summary. Both, HSV and VZV encephalitis have mortality rates between 5 and 20% and complete recovery rates range from 14 to 43% for HSV and 33 to 49% for VZV encephalitis. Prognostic factors for both VZV and HSV encephalitis are older age and comorbidity, as well as severity of disease and extent of magnetic resonance imaging (MRI) lesions on admission, and delay in treatment initiation for HSV encephalitis. Although numerous studies are available, the main limiting factors are the inconsistent patient selection and case definitions as well as the non-standardised outcome measures, which hampers the comparability of the studies. Therefore, larger and standardised observational studies applying validated case definitions and outcome measures including quality of life assessment are required to provide solid evidence to answer the research question.
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Affiliation(s)
- Lena S. Abbuehl
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Eveline Hofmann
- Department of Infectious Diseases, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Arsany Hakim
- Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Anelia Dietmann
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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Sonneville R, de Montmollin E, Contou D, Ferrer R, Gurjar M, Klouche K, Sarton B, Demeret S, Bailly P, da Silva D, Escudier E, Le Guennec L, Chabanne R, Argaud L, Ben Hadj Salem O, Thyrault M, Frerou A, Louis G, De Pascale G, Horn J, Helbok R, Geri G, Bruneel F, Martin-Loeches I, Taccone FS, De Waele JJ, Ruckly S, Staiquly Q, Citerio G, Timsit JF. Clinical features, etiologies, and outcomes in adult patients with meningoencephalitis requiring intensive care (EURECA): an international prospective multicenter cohort study. Intensive Care Med 2023; 49:517-529. [PMID: 37022378 DOI: 10.1007/s00134-023-07032-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Accepted: 03/08/2023] [Indexed: 04/07/2023]
Abstract
PURPOSE We aimed to characterize the outcomes of patients with severe meningoencephalitis requiring intensive care. METHODS We conducted a prospective multicenter international cohort study (2017-2020) in 68 centers across 7 countries. Eligible patients were adults admitted to the intensive care unit (ICU) with meningoencephalitis, defined by an acute onset of encephalopathy (Glasgow coma scale (GCS) score [Formula: see text] 13), a cerebrospinal fluid pleocytosis [Formula: see text] 5 cells/mm3, and at least two of the following criteria: fever, seizures, focal neurological deficit, abnormal neuroimaging, and/or electroencephalogram. The primary endpoint was poor functional outcome at 3 months, defined by a score of three to six on the modified Rankin scale. Multivariable analyses stratified on centers investigated ICU admission variables associated with the primary endpoint. RESULTS Among 599 patients enrolled, 589 (98.3%) completed the 3-month follow-up and were included. Overall, 591 etiologies were identified in those patients which were categorized into five groups: acute bacterial meningitis (n = 247, 41.9%); infectious encephalitis of viral, subacute bacterial, or fungal/parasitic origin (n = 140, 23.7%); autoimmune encephalitis (n = 38, 6.4%); neoplastic/toxic encephalitis (n = 11, 1.9%); and encephalitis of unknown origin (n = 155, 26.2%). Overall, 298 patients (50.5%, 95% CI 46.6-54.6%) had a poor functional outcome, including 152 deaths (25.8%). Variables independently associated with a poor functional outcome were age > 60 years (OR 1.75, 95% CI 1.22-2.51), immunodepression (OR 1.98, 95% CI 1.27-3.08), time between hospital and ICU admission > 1 day (OR 2.02, 95% CI 1.44-2.99), a motor component on the GCS [Formula: see text] 3 (OR 2.23, 95% CI 1.49-3.45), hemiparesis/hemiplegia (OR 2.48, 95% CI 1.47-4.18), respiratory failure (OR 1.76, 95% CI 1.05-2.94), and cardiovascular failure (OR 1.72, 95% CI 1.07-2.75). In contrast, administration of a third-generation cephalosporin (OR 0.54, 95% CI 0.37-0.78) and acyclovir (OR 0.55, 95% CI 0.38-0.80) on ICU admission were protective. CONCLUSION Meningoencephalitis is a severe neurologic syndrome associated with high mortality and disability rates at 3 months. Actionable factors for which improvement could be made include time from hospital to ICU admission, early antimicrobial therapy, and detection of respiratory and cardiovascular complications at admission.
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Affiliation(s)
- Romain Sonneville
- Université Paris Cité, INSERM UMR 1137, 75018, Paris, France.
- APHP, Department of Intensive Care Medicine, Bichat-Claude Bernard University Hospital, 75018, Paris, France.
- Service de Médecine Intensive-Réanimation, Hôpital Bichat-Claude Bernard, 46 Rue Henri Huchard, 75877, Paris Cedex, France.
| | - Etienne de Montmollin
- Université Paris Cité, INSERM UMR 1137, 75018, Paris, France
- APHP, Department of Intensive Care Medicine, Bichat-Claude Bernard University Hospital, 75018, Paris, France
| | - Damien Contou
- Department of Intensive Care Medicine, Victor Dupouy Hospital, Argenteuil, France
| | - Ricard Ferrer
- Department of Intensive Care Medicine, Val d'Hebron University Hospital, Barcelona, Spain
| | - Mohan Gurjar
- Department of Critical Care Medicine, Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS), Lucknow, India
| | - Kada Klouche
- Department of Intensive Care Medicine, Montpellier University Hospital, Montpellier, France
| | - Benjamine Sarton
- Department of Intensive Care Medicine, Purpan University Hospital, Toulouse, France
| | - Sophie Demeret
- Sorbonne University, AP-HP, Neurology Department, Neurological Intensive Care Unit, Pitié Salpêtrière Hospital, Paris, France
| | - Pierre Bailly
- Department of Intensive Care Medicine, Brest University Hospital, Brest, France
| | - Daniel da Silva
- Department of Intensive Care Medicine, Saint Denis University Hospital, Saint Denis, France
| | - Etienne Escudier
- Department of Intensive Care Medicine, Annecy Hospital, Annecy, France
| | - Loic Le Guennec
- Department of Intensive Care Medicine, La Pitié-Salpêtrière University Hospital, Paris, France
| | - Russel Chabanne
- Department of Anesthesia and Intensive Care Medicine, Clermont-Ferrand University Hospital, Clermont-Ferrand, France
| | - Laurent Argaud
- Department of Intensive Care Medicine, Lyon University Hospital, Lyon, France
| | - Omar Ben Hadj Salem
- Department of Intensive Care Medicine, Poissy-Saint Germain Hospital, Poissy, France
| | - Martial Thyrault
- Department of Intensive Care Medicine, Longjumeau hospital, Longjumeau, France
| | - Aurélien Frerou
- Department of Intensive Care Medicine, Pontchaillou Hospital, Rennes, France
| | - Guillaume Louis
- Department of Intensive Care Medicine, Metz Hospital, Metz, France
| | - Gennaro De Pascale
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A.Gemelli IRCCS, Rome, Italy
| | - Janneke Horn
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Raimund Helbok
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
- Department of Neurology, Johannes Kepler University Linz, Linz, Austria
| | - Guillaume Geri
- Department of Intensive Care Medicine, Ambroise Paré University Hospital, Boulogne-Billancourt, France
| | - Fabrice Bruneel
- Department of Intensive Care Medicine, Versailles Hospital, Le Chesnay, France
| | | | - Fabio Silvio Taccone
- Department of Intensive Care Medicine, Hôpital Universitaire de Bruxelles (HUB), Brussels, Belgium
| | - Jan J De Waele
- Department of Intensive Care Medicine, Ghent University Hospital, Ghent, Belgium
| | | | | | - Giuseppe Citerio
- School of Medicine and Surgery, University Milano Bicocca, Milan, Italy
- NeuroIntensive Care Unit, Department of Neuroscience, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
| | - Jean-François Timsit
- Université Paris Cité, INSERM UMR 1137, 75018, Paris, France
- APHP, Department of Intensive Care Medicine, Bichat-Claude Bernard University Hospital, 75018, Paris, France
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12
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Jeantin L, Dupuis C, Vellieux G, Jaquet P, de Montmollin E, Timsit JF, Sonneville R. Electroencephalography for prognostication of outcome in adults with severe herpes simplex encephalitis. Ann Intensive Care 2023; 13:10. [PMID: 36821016 PMCID: PMC9950306 DOI: 10.1186/s13613-023-01110-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Accepted: 02/12/2023] [Indexed: 02/24/2023] Open
Abstract
BACKGROUND Electroencephalography (EEG) is recommended for the practical approach to the diagnosis and prognosis of encephalitis. We aimed to investigate the prognostic value of standard EEG (stdEEG) in adult patients with severe herpes simplex encephalitis. METHODS We performed a retrospective analysis of consecutive ICU patients with severe herpes simplex encephalitis in 38 French centers between 2006 and 2016. Patients with at least one stdEEG study performed at ICU admission were included. stdEEG findings were reviewed independently by two investigators. The association between stdEEG findings (i.e., background activity, lateralized periodic discharges, seizures/status epilepticus, and reactivity to painful/auditory stimuli) and poor functional outcome, defined by a score on the modified Rankin Scale (mRS) of 3 to 6 (moderate to severe disability or death) at 90 days, were investigated. RESULTS We included 214 patients with at least one available stdEEG study. The first stdEEG was performed after a median time of one (interquartile range (IQR) 0 to 2) day from ICU admission. At the time of recording, 138 (64.5%) patients were under invasive mechanical ventilation. Lateralized periodic discharges were recorded in 91 (42.5%) patients, seizures in 21 (9.8%) and status epilepticus in 16 (7.5%). In the whole population, reactivity to auditory/noxious stimuli was tested in 140/214 (65.4%) patients and was absent in 71/140 (33.2%) cases. In mechanically ventilated patients, stdEEG reactivity was tested in 91/138 (65.9%) subjects, and was absent in 53/91 (58.2%) cases. Absence of reactivity was the only independent stdEEG finding associated with poor functional outcome in the whole population (OR 2.80, 95% CI 1.19 to 6.58) and in the subgroup of mechanically ventilated patients (OR 4.99, 95% CI 1.6 to 15.59). Adjusted analyses for common clinical predictors of outcome and sedation at time of stdEEG revealed similar findings in the whole population (OR 2.03, 95% CI 1.18 to 3.49) and in mechanically ventilated patients (OR 2.62, 95% CI 1.25 to 5.50). CONCLUSIONS Absence of EEG reactivity to auditory/noxious stimuli is an independent marker of poor functional outcome in severe herpes simplex encephalitis.
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Affiliation(s)
- Lina Jeantin
- grid.5842.b0000 0001 2171 2558Department of Neurology, GHU Paris Psychiatrie et Neurosciences, Université de Paris, Paris, France
| | - Claire Dupuis
- grid.411163.00000 0004 0639 4151Department of Intensive Care Medicine, Clermont-Ferrand University Hospital, 63000 Clermont-Ferrand, France
| | - Geoffroy Vellieux
- grid.462844.80000 0001 2308 1657Paris Brain Institute, ICM, Inserm, CNRS, Sorbonne Université, 75013 Paris, France ,grid.411439.a0000 0001 2150 9058Department of Neurophysiology, Pitie-Salpêtrière University Hospital, AP-HP, Paris, France
| | - Pierre Jaquet
- Department of Intensive Care Medicine, Delafontaine Hospital, Saint Denis, France
| | - Etienne de Montmollin
- grid.508487.60000 0004 7885 7602IAME, INSERM, UMR1137, Université Paris Cité, Paris, France ,grid.411119.d0000 0000 8588 831XDepartment of Intensive Care Medicine, Bichat-Claude Bernard University Hospital, AP-HP, 46 Rue Henri Huchard, 75877 Paris Cedex, France
| | - Jean-François Timsit
- grid.508487.60000 0004 7885 7602IAME, INSERM, UMR1137, Université Paris Cité, Paris, France ,grid.411119.d0000 0000 8588 831XDepartment of Intensive Care Medicine, Bichat-Claude Bernard University Hospital, AP-HP, 46 Rue Henri Huchard, 75877 Paris Cedex, France
| | - Romain Sonneville
- IAME, INSERM, UMR1137, Université Paris Cité, Paris, France. .,Department of Intensive Care Medicine, Bichat-Claude Bernard University Hospital, AP-HP, 46 Rue Henri Huchard, 75877, Paris Cedex, France.
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13
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Structured Imaging Approach for Viral Encephalitis. Neuroimaging Clin N Am 2023; 33:43-56. [DOI: 10.1016/j.nic.2022.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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14
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Bhave VM, Bernstock JD, Carlson JM, Kappel AD, Torio EF, Chen JA, Essayed WI, Gawelek KL, DiToro DF, Izzy S, Cosgrove GR. Surgical Management in Herpes Simplex Encephalitis: Illustrative Case Report and Systematic Review of the Literature. Neurosurgery 2023; 92:915-933. [PMID: 36700784 DOI: 10.1227/neu.0000000000002334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Accepted: 11/01/2022] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Herpes simplex virus (HSV) is a common cause of viral encephalitis and can result in refractory seizures. Although HSV encephalitis (HSVE) is treated primarily with acyclovir, surgery can play a role in medically intractable cases. OBJECTIVE To systematically review cases describing surgery for the treatment of severe HSVE. We also present an illustrative case of anterior temporal lobectomy (ATL) for refractory status epilepticus in a patient with unilateral HSVE. This case demonstrates one clinical context in which surgery can be a useful adjunct. METHODS We performed a systematic review using PubMed and Google Scholar, including case reports and series describing surgical interventions for HSVE. Clinical data were extracted from 54 publications that incorporated 67 patient cases. RESULTS Surgical decompression occurred at a wide range of times after the onset of illness, although most patients were operated on 4 or more days after HSVE symptoms began. Numerous reports indicated that decompressive craniectomy, temporal lobectomy, and hematoma removal could treat intractably elevated intracranial pressure because of HSVE with favorable long-term outcomes. We describe an additional case in which a 52-year-old woman with HSVE developed refractory right temporal lobe seizures. After ATL, the seizures resolved with significant clinical improvement. CONCLUSION Surgical treatment can be a useful adjunct for treatment of HSVE. There is substantial variability in the timing of surgical decompression in patients with HSVE, which can be necessary up to approximately 3 weeks after illness onset. ATL should be considered for refractory status epilepticus in HSVE with a unilateral seizure focus.
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Affiliation(s)
| | - Joshua D Bernstock
- Harvard Medical School, Boston, Massachusetts, USA.,Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Julia M Carlson
- Division of Neurocritical Care, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Ari D Kappel
- Harvard Medical School, Boston, Massachusetts, USA.,Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Erickson F Torio
- Harvard Medical School, Boston, Massachusetts, USA.,Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Jason A Chen
- Harvard Medical School, Boston, Massachusetts, USA.,Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Walid Ibn Essayed
- Harvard Medical School, Boston, Massachusetts, USA.,Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Kara L Gawelek
- Department of Pathology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Daniel F DiToro
- Department of Pathology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Saef Izzy
- Department of Neurology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - G Rees Cosgrove
- Harvard Medical School, Boston, Massachusetts, USA.,Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
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15
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He Q, Wang S, Chen H, Long L, Xiao B, Hu K. The neutrophil-to-lymphocyte and monocyte-to-lymphocyte ratios are independently associated with clinical outcomes of viral encephalitis. Front Neurol 2023; 13:1051865. [PMID: 36712460 PMCID: PMC9874857 DOI: 10.3389/fneur.2022.1051865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Accepted: 12/13/2022] [Indexed: 01/13/2023] Open
Abstract
Background The neutrophil-to-lymphocyte ratio (NLR) and monocyte-to-lymphocyte ratio (MLR) are used as prognostic biomarkers for many diseases. In this study, we aimed to explore the possibility of using ratios of NLR and MLR to predict the prognosis of viral encephalitis (VE). Methods A total of 81 patients with an initial diagnosis of VE who were admitted to our hospital from January 2018 to January 2021 were retrospectively analyzed. A routine blood test within 24 h of admission was utilized to determine the ratios of NLR and MLR for each patient. The modified Rankin Scale (mRS) at 12 months after discharge was used to evaluate patients' clinical prognosis and the patients were divided into the group of good prognosis (mRS ≤ 1) and the group of poor prognosis (mRS ≥ 2) according to the mRS scores. Univariate and multivariable regression analyses were used to differentiate and assess independent prognostic factors for the prognosis of VE. Results Neutrophil-to-lymphocyte ratio and MLR of the poor prognosis group were significantly higher than that of the good prognosis group. Multivariate logistic regression analysis results showed that NLR [odds ratio (OR): 1.421, 95% confidence interval (CI): 1.105-1.827; P < 0.05] and MLR (OR: 50.423, 95% CI: 2.708-939.001; P < 0.05) were independent risk factors for the poor prognosis of VE. NLR > 4.32 and MLR > 0.44 were suggested as the cutoff threshold for the prediction of the poor prognosis of VE. Conclusion Neutrophil-to-lymphocyte ratio and MLR obtained from blood tests done at hospital admission have the potential to predict poor prognosis in patients with VE.
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Affiliation(s)
- Qiang He
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China,National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China,Clinical Research Center for Epileptic Disease of Hunan Province, Central South University, Changsha, China
| | - Shuo Wang
- Department of Neonatology, Xiangya Hospital, Central South University, Changsha, China
| | - Haoan Chen
- Faculty of Arts and Science, University of Toronto, Toronto, ON, Canada
| | - Lili Long
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China,National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China,Clinical Research Center for Epileptic Disease of Hunan Province, Central South University, Changsha, China
| | - Bo Xiao
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China,National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China,Clinical Research Center for Epileptic Disease of Hunan Province, Central South University, Changsha, China
| | - Kai Hu
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China,National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China,Clinical Research Center for Epileptic Disease of Hunan Province, Central South University, Changsha, China,*Correspondence: Kai Hu ✉
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16
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Alam AM, Chen JPK, Wood GK, Facer B, Bhojak M, Das K, Defres S, Marson A, Granerod J, Brown D, Thomas RH, Keller SS, Solomon T, Michael BD. Increased volume of cerebral oedema is associated with risk of acute seizure activity and adverse neurological outcomes in encephalitis - regional and volumetric analysis in a multi-centre cohort. BMC Neurol 2022; 22:412. [PMID: 36344954 PMCID: PMC9639313 DOI: 10.1186/s12883-022-02926-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Accepted: 10/17/2022] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Seizures can occur unpredictably in patients with acute encephalitis syndrome (AES), and many suffer from poor long-term neurological sequelae. Establishing factors associated with acute seizures risk and poor outcomes could support clinical care. We aimed to conduct regional and volumetric analysis of cerebral oedema on magnetic resonance imaging (MRI) in patients with AES. We assessed the relationship of brain oedema with acute seizure activity and long-term neurological outcome. METHODS In a multi-centre cohort study, adults and children presenting with an AES were recruited in the UK. The clinical and brain MRI data were retrospectively reviewed. The outcomes variables were inpatient acute seizure activity and neurological disability at six-months post-discharge. A poor outcome was defined as a Glasgow outcome score (GOS) of 1-3. We quantified regional brain oedema on MRI through stereological examination of T2-weighted images using established methodology by independent and blinded assessors. Clinical and neuroimaging variables were analysed by multivariate logistic regression to assess for correlation with acute seizure activity and outcome. RESULTS The study cohort comprised 69 patients (mean age 31.8 years; 53.6% female), of whom 41 (59.4%) had acute seizures as inpatients. A higher Glasgow coma scale (GCS) score on admission was a negative predictor of seizures (OR 0.61 [0.46-0.83], p = 0.001). Even correcting for GCS on admission, the presence of cortical oedema was a significant risk factor for acute seizure activity (OR 5.48 [1.62-18.51], p = 0.006) and greater volume of cerebral oedema in these cortical structures increased the risk of acute seizures (OR 1.90 [1.12-3.21], p = 0.017). At six-month post-discharge, 21 (30.4%) had a poor neurological outcome. Herpes simplex virus encephalitis was associated with higher risk of poor outcomes in univariate analysis (OR 3.92 [1.08-14.20], p = 0.038). When controlling for aetiology, increased volume of cerebral oedema was an independent risk factor for adverse neurological outcome at 6 months (OR 1.73 [1.06-2.83], p = 0.027). CONCLUSIONS Both the presence and degree of cerebral oedema on MRIs of patients with AES may help identify patients at risk of acute seizure activity and subsequent long-term morbidity.
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Affiliation(s)
- Ali M Alam
- Department of Clinical Infection Microbiology and Immunology, Institute of Infection, Veterinary, and Ecological Science, University of Liverpool, Liverpool, UK
- The NIHR Health Protection Research Unit for Emerging and Zoonotic Infection, Liverpool, UK
| | | | - Greta K Wood
- Department of Clinical Infection Microbiology and Immunology, Institute of Infection, Veterinary, and Ecological Science, University of Liverpool, Liverpool, UK
- The NIHR Health Protection Research Unit for Emerging and Zoonotic Infection, Liverpool, UK
| | - Bethany Facer
- Department of Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK
| | - Maneesh Bhojak
- Department of Neuroradiology, The Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Kumar Das
- Department of Neuroradiology, The Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Sylviane Defres
- Department of Clinical Infection Microbiology and Immunology, Institute of Infection, Veterinary, and Ecological Science, University of Liverpool, Liverpool, UK
- The NIHR Health Protection Research Unit for Emerging and Zoonotic Infection, Liverpool, UK
- Tropical and Infectious Diseases Unit, Liverpool University Hospitals NHS Trust, Liverpool, UK
| | - Anthony Marson
- Department of Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK
- Department of Neurology, The Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Julia Granerod
- Independent Scientific Consultant, formerly of Public Health England, London, UK
| | - David Brown
- UK Heath Security Agency, 61 Colindale Avenue, London, UK
| | - Rhys H Thomas
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Simon S Keller
- Department of Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK
| | - Tom Solomon
- Department of Clinical Infection Microbiology and Immunology, Institute of Infection, Veterinary, and Ecological Science, University of Liverpool, Liverpool, UK
- The NIHR Health Protection Research Unit for Emerging and Zoonotic Infection, Liverpool, UK
- Department of Neurology, The Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Benedict D Michael
- Department of Clinical Infection Microbiology and Immunology, Institute of Infection, Veterinary, and Ecological Science, University of Liverpool, Liverpool, UK.
- The NIHR Health Protection Research Unit for Emerging and Zoonotic Infection, Liverpool, UK.
- Department of Neurology, The Walton Centre NHS Foundation Trust, Liverpool, UK.
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17
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Brain Imaging in Epilepsy-Focus on Diffusion-Weighted Imaging. Diagnostics (Basel) 2022; 12:diagnostics12112602. [PMID: 36359445 PMCID: PMC9689253 DOI: 10.3390/diagnostics12112602] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2022] [Revised: 10/23/2022] [Accepted: 10/24/2022] [Indexed: 11/30/2022] Open
Abstract
Epilepsy is a common neurological disorder; 1% of people worldwide have epilepsy. Differentiating epileptic seizures from other acute neurological disorders in a clinical setting can be challenging. Approximately one-third of patients have drug-resistant epilepsy that is not well controlled by current antiepileptic drug therapy. Surgical treatment is potentially curative if the epileptogenic focus is accurately localized. Diffusion-weighted imaging (DWI) is an advanced magnetic resonance imaging technique that is sensitive to the diffusion of water molecules and provides additional information on the microstructure of tissue. Qualitative and quantitative analysis of peri-ictal, postictal, and interictal diffusion images can aid the differential diagnosis of seizures and seizure foci localization. This review focused on the fundamentals of DWI and its associated techniques, such as apparent diffusion coefficient, diffusion tensor imaging, and tractography, as well as their impact on epilepsy in terms of differential diagnosis, epileptic foci determination, and prognosis prediction.
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Abstract
After establishing latent infection, some viruses can be reactivated by the alteration of host immunological conditions. First, we reviewed viruses that can cause neuronal damage by reactivation. Then we focused on the herpes simplex virus (HSV). The reactivation leads to neuronal damages through two possible mechanisms; "reactivation of a latent herpes virus" by which viruses can cause direct virus neurotoxicity, and "post-infectious immune inflammatory response" by which a focal reactivation of HSV leads to an inflammatory reaction. The former is radiologically characterized by cortical lesions, the latter is characterized by subcortical white matter lesions. We experienced a female, who underwent the right posterior quadrantectomy and then developed recurrent herpes encephalitis caused by herpes simplex reactivation, which pathologically demonstrated inflammation in the white matter, suggesting a post-infectious immune inflammatory response. The patient was successfully treated with immunosuppressants. The reactivation of the HSV is extremely rare in Japan. Neurologists should recognize this condition because this disorder will increase as epilepsy surgery gains more popularity.
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Affiliation(s)
- Tomoyo Shimada
- Department of Neurology, Juntendo University School of Medicine
| | - Taiji Tsunemi
- Department of Neurology, Juntendo University School of Medicine
- Epilepsy Center, Juntendo University School of Medicine
| | - Yasushi Iimura
- Department of Neurosurgery, Juntendo University School of Medicine
- Epilepsy Center, Juntendo University School of Medicine
| | - Hidenori Sugano
- Department of Neurosurgery, Juntendo University School of Medicine
- Epilepsy Center, Juntendo University School of Medicine
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19
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Berkhout A, Kapoor V, Heney C, Jones CA, Clark JE, Britton PN, Vaska VL, Lai MM, Nourse C. Epidemiology and long-term neurological sequelae of childhood herpes simplex CNS infection. J Paediatr Child Health 2022; 58:1372-1378. [PMID: 35510684 PMCID: PMC9546081 DOI: 10.1111/jpc.15992] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Revised: 04/07/2022] [Accepted: 04/11/2022] [Indexed: 11/26/2022]
Abstract
AIM Herpes simplex CNS infection is a rare but important cause of neurological disability. Long term outcomes after HSV CNS infection in Australia have not yet been fully described. We sought to provide a comprehensive review of HSV CNS infection in children using a retrospective 13-year evaluation of statewide laboratory and clinical records and a parent survey conducted at least one year after the initial infection. METHODS All positive PCR HSV 1 and 2 results from cerebrospinal fluid (CSF) or brain tissue were obtained from Queensland pathology providers for children aged 0-16 years between 1 January 2005 and 31 December 2017. Clinical data were obtained from patient records and longer-term outcomes via parent survey at least 1 year after initial infection. RESULTS Forty-three children were identified over the 13-year period, 17 (39.5%) neonates and 26 (60.4%) non-neonates. The annual incidence for HSV CNS infection in Queensland children aged ≤16 years was 0.3/100 000 (95% confidence intervals (CIs): 0.2-0.4) with neonates at highest risk (incidence 2.5/100 000 live births, 95% CI: 1.5-3.9). HSV 1 was the predominant serotype in both neonates and non-neonates (9/17, 52.9% neonates and 19/26, 73.1% non-neonates). Seven (16.3%) children died, five (5/17, 29.4% neonates), directly attributable to HSV CNS infection (all neonates). Twenty-five (58.1%) had neurological morbidity at discharge (9/17 neonates (52.9%) vs. 16/26 (61.5%) non-neonates) and 20/27 (74.1%) reported long-term neurological morbidity at follow-up (5/9 neonates (55.6%) vs. 15/18 non-neonates (83.3%)). Seven children (two neonates and four non-neonates) with long-term neurological sequelae had no neurological morbidity identified at discharge. CONCLUSION Significant long-term neurologic sequelae were seen in children with HSV CNS infection even in children with no neurological disability identified at discharge from hospital. Careful neurodevelopmental follow-up of all children is recommended.
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Affiliation(s)
- Angela Berkhout
- Faculty of MedicineUniversity of QueenslandBrisbaneQueenslandAustralia,Queensland Children's HospitalBrisbaneQueenslandAustralia
| | - Vishal Kapoor
- Faculty of MedicineUniversity of QueenslandBrisbaneQueenslandAustralia,Queensland Children's HospitalBrisbaneQueenslandAustralia
| | | | - Cheryl A Jones
- Sydney Medical School, Faculty of Medicine and HealthThe University of SydneySydneyNew South WalesAustralia,Sydney Children's Hospital Network (The Children's Hospital Westmead)SydneyNew South WalesAustralia
| | - Julia E Clark
- Faculty of MedicineUniversity of QueenslandBrisbaneQueenslandAustralia,Queensland Children's HospitalBrisbaneQueenslandAustralia
| | - Philip N Britton
- Sydney Medical School, Faculty of Medicine and HealthThe University of SydneySydneyNew South WalesAustralia,Sydney Children's Hospital Network (The Children's Hospital Westmead)SydneyNew South WalesAustralia
| | - Vikram L Vaska
- Queensland Children's HospitalBrisbaneQueenslandAustralia,Mater PathologyBrisbaneQueenslandAustralia
| | - Melissa M Lai
- Faculty of MedicineUniversity of QueenslandBrisbaneQueenslandAustralia,The Royal Brisbane and Women's HospitalBrisbaneQueenslandAustralia
| | - Clare Nourse
- Faculty of MedicineUniversity of QueenslandBrisbaneQueenslandAustralia,Queensland Children's HospitalBrisbaneQueenslandAustralia
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20
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Clague M, Kim C, Zucker J, Green DA, Sun Y, Whittier S, Thakur KT. Impact of Implementing the Cerebrospinal Fluid (CSF) FilmArray Meningitis/Encephalitis Panel on Duration of Intravenous Acyclovir Treatment. Open Forum Infect Dis 2022; 9:ofac356. [PMID: 35937646 PMCID: PMC9350616 DOI: 10.1093/ofid/ofac356] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Accepted: 07/21/2022] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Herpes Simplex Virus-1 is the most common cause of sporadic encephalitis worldwide and requires prompt antiviral treatment. Traditionally, Herpes Simplex Virus-1 (HSV-1) cerebrospinal fluid (CSF) testing is conducted using standalone PCR. The BioFire CSF FilmArray Meningitis/Encephalitis Panel (BioFire ME Panel) was introduced in 2015 at our institution providing an alternative method of HSV-1 CSF testing. This study assesses the impact of the BioFire ME panel on duration of intravenous acyclovir treatment.
Methods
A retrospective review of electronic medical records between 2010 and 2019 was performed. Information on intravenous acyclovir treatment and HSV-1 CSF testing were collected and analyzed. Our descriptive analysis included Mann-Whitney tests, two proportion Z-tests, and logistic regression.
Results
Our CSF HSV-1 negative cohort included 524 BioFire patients (125 pediatric, 399 adult) and 287 standalone PCR patients (115 pediatric, 172 adult). Across both pediatric and adult groups, patients who were tested for HSV-1 with the BioFire ME panel had shorter average (SD) durations of intravenous acyclovir treatment [pediatric: 2.00 (5.71) days; adult: 3.26 (6.59) days] compared to patients tested with standalone PCR [pediatric: 4.83 (8.62) days; adult: 4.93 (8.46) days] (P <0.001). Time from lumbar puncture collection to HSV-1 results was additionally faster on average for the BioFire ME panel than the standalone PCR (P <0.001).
Conclusions
The implementation of the BioFire ME panel shortened CSF HSV-1 PCR result time and intravenous acyclovir duration. The shortened treatment and testing times from the BioFire ME panel implementation may reduce hospital treatment costs and unnecessary use of antiviral treatments.
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Affiliation(s)
- Madison Clague
- Department of Neurology, Columbia University Irving Medical Center/New York Presbyterian Hospital , New York, New York , USA
| | - Carla Kim
- Department of Neurology, Columbia University Irving Medical Center/New York Presbyterian Hospital , New York, New York , USA
| | - Jason Zucker
- Department of Medicine, Division of Infectious Diseases, Columbia University Irving Medical Center/New York Presbyterian Hospital , New York, New York , USA
| | - Daniel A Green
- Department of Pathology and Cell Biology, Columbia University Irving Medical Center/New York Presbyterian Hospital , New York, New York , USA
| | - Yifei Sun
- Department of Biostatistics, Columbia University Mailman School of Public Health , New York, New York , USA
| | - Susan Whittier
- Department of Pathology and Cell Biology, Columbia University Irving Medical Center/New York Presbyterian Hospital , New York, New York , USA
| | - Kiran T Thakur
- Department of Neurology, Columbia University Irving Medical Center/New York Presbyterian Hospital , New York, New York , USA
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21
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Pizzi MA, Busl KM. Catch Me If You Can-How Herpes Simplex Virus Tries to Evade Diagnosis in Viral Encephalitis. Crit Care Med 2022; 50:1170-1173. [PMID: 35726985 DOI: 10.1097/ccm.0000000000005501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Michael A Pizzi
- Both authors: Departments of Neurology and Neurosurgery, Division of Neurocritical Care, University of Florida College of Medicine, Gainesville, FL
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22
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Kataoka H, Nanaura H, Kiriyama T, Sugie K. Prognostic Factor for Subacute Encephalitis with First-Episode Psychosis. Eur Neurol 2022; 85:446-452. [DOI: 10.1159/000524975] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Accepted: 05/02/2022] [Indexed: 11/19/2022]
Abstract
<b><i>Introduction:</i></b> Although symptomatic manifestations in encephalitis vary, they typically include seizures, memory deficit(s), and altered consciousness. Psychosis also occurs as an initial manifestation. In clinical practice, clinicians often encounter the question of whether first-episode psychosis (FEP) originates from encephalitis itself or if encephalitis presenting with FEP develops concurrently. The prognosis of FEP among patients with overall encephalitis, including autoimmune encephalitis, remains uncertain. <b><i>Methods:</i></b> We examined a prognostic factor in patients with encephalitis who had both FEP and CSF pleocytosis. A total of 36 patients who presented with FEP were enrolled. A score of ≥3 and ≤2 on the modified Rankin scale were defined as poor and good outcomes, respectively. A total of 13 independent variables were analyzed by the multivariate logistic regression analysis. <b><i>Results:</i></b> Significant variables on univariate logistic regression analysis included female sex (OR 5.571, 95% CI: 1.297–23.934; <i>p</i> = 0.021) and the use of mechanical ventilation during the acute stage (OR 7.286, 95% CI: 1.508–35.211; <i>p</i> = 0.013). On multivariate logistic regression analysis, the use of mechanical ventilation during the acute stage (OR 5.446, 95% CI: 1.044–28.615; <i>p</i> = 0.044) was significantly associated with poor outcomes. <b><i>Conclusions:</i></b> The use of mechanical ventilation is a poor prognostic factor of subacute encephalitis with FEP, and female sex may be a risk factor for unfavorable development of the disease.
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23
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Makhijani AV, Horan S, Tuszynski M, Ditchfield M, Buttery JP. Herpes in the hindbrain: Case of herpes simplex virus rhombencephalitis in a child. J Paediatr Child Health 2022; 58:896-899. [PMID: 34369616 DOI: 10.1111/jpc.15690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 07/14/2021] [Accepted: 07/20/2021] [Indexed: 11/29/2022]
Affiliation(s)
- Allya V Makhijani
- Monash Children's Hospital, Monash Health, Melbourne, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
| | - Seamus Horan
- Department of Paediatrics, Monash University, Melbourne, Victoria, Australia
| | - Martin Tuszynski
- Monash Children's Hospital, Monash Health, Melbourne, Victoria, Australia
| | - Michael Ditchfield
- Monash Children's Hospital, Monash Health, Melbourne, Victoria, Australia.,Department of Paediatrics, Monash University, Melbourne, Victoria, Australia
| | - Jim P Buttery
- Monash Children's Hospital, Monash Health, Melbourne, Victoria, Australia.,Department of Paediatrics, Monash University, Melbourne, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia.,SAEFVIC, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
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24
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Berek K, Beer R, Grams A, Helbok R, Lindner A, Pfausler B, Schiefecker A, Deisenhammer F, Hegen H. Caspr2 antibodies in herpes simplex encephalitis: an extension of the spectrum of virus induced autoimmunity? - A case report. BMC Neurol 2022; 22:131. [PMID: 35382753 PMCID: PMC8981196 DOI: 10.1186/s12883-022-02637-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2021] [Accepted: 03/14/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Post herpes simplex virus (HSV) autoimmune encephalitis has been reported mainly in association with NMDA receptor antibodies, however, never with Caspr2 antibodies. CASE PRESENTATION We report an 82-year old female patient with encephalitis who presented with aphasia, left temporo-mesial hyperintense lesion on MRI, epileptiform discharges on spot electroencephalography, cerebrospinal fluid (CSF) lymphocytic pleocytosis and who showed positive HSV polymerase chain reaction in CSF as well as antibodies against contactin-associated protein-like 2 (Caspr2). CONCLUSION This is the first report of a patient with encephalitis who tested positive for HSV as well as for Caspr2 antibodies.
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Affiliation(s)
- Klaus Berek
- Department of Neurology, Medical University of Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria
| | - Ronny Beer
- Department of Neurology, Medical University of Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria
| | - Astrid Grams
- Department of Neuroradiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Raimund Helbok
- Department of Neurology, Medical University of Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria
| | - Anna Lindner
- Department of Neurology, Medical University of Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria
| | - Bettina Pfausler
- Department of Neurology, Medical University of Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria
| | - Alois Schiefecker
- Department of Neurology, Medical University of Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria
| | - Florian Deisenhammer
- Department of Neurology, Medical University of Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria
| | - Harald Hegen
- Department of Neurology, Medical University of Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria.
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25
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Sonneville R, Jaquet P, Vellieux G, de Montmollin E, Visseaux B. Intensive care management of patients with viral encephalitis. Rev Neurol (Paris) 2021; 178:48-56. [PMID: 34973832 DOI: 10.1016/j.neurol.2021.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Accepted: 12/13/2021] [Indexed: 11/26/2022]
Abstract
Viral encephalitis is a severe syndrome that can lead to encephalopathy, seizures, focal deficits, and neurological sequelae and death. It is mainly caused by neurotropic herpes viruses (i.e., HSV and VZV), although other pathogens may be observed in specific geographic regions or conditions. Recent advances in neuroimaging and molecular biology (PCR, metagenomics) allow for faster and more accurate etiological diagnoses, although their benefits need to be confirmed to provide guidelines for their use and interpretation. Despite intravenous acyclovir therapy and supportive care, outcomes remain poor in about two-thirds of herpes encephalitis patients requiring ICU admission. Randomized clinical trials focusing on symptomatic measures (i.e. early ICU admission, fever control, and treatment of seizures/status epilepticus) or adjunctive immunomodulatory therapies (i.e. steroids, intravenous immunoglobulins) to improve neurologic outcomes have not been conducted in the ICU setting. Large prospective multicenter studies combining clinical, electrophysiological, and neuroimaging data are needed to improve current knowledge on care pathways, long-term outcomes, and prognostication.
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Affiliation(s)
- R Sonneville
- Université de Paris, INSERM UMR1148, team 6, 75018 Paris, France; AP-HP, intensive care medicine, Hôpital Bichat - Claude Bernard, 75018 Paris, France.
| | - P Jaquet
- AP-HP, intensive care medicine, Hôpital Bichat - Claude Bernard, 75018 Paris, France
| | - G Vellieux
- AP-HP, department of Physiology, Hôpital Bichat - Claude Bernard, 75018 Paris, France
| | - E de Montmollin
- Université de Paris, INSERM UMR1148, team 6, 75018 Paris, France; Université de Paris, INSERM UMR1137, team 6, 75018 Paris, France
| | - B Visseaux
- Université de Paris, INSERM UMR1137, team 6, 75018 Paris, France; AP-HP, department of virology, Hôpital Bichat - Claude Bernard, 75018 Paris, France
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26
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McLaughlin J, Young T. Neurology in the psychiatric patient: how to think about differentials in altered mental status and diagnoses not to miss. BJPSYCH ADVANCES 2021. [DOI: 10.1192/bja.2021.67] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
SUMMARY
A wide variety of neurological conditions may present first to a psychiatrist and it is important to be aware of these in differential diagnosis. A careful history, examination and a broad differential diagnosis can help set up an appropriate management plan – with room to change if things change in unexpected ways. In this article we explore common ground shared by psychiatry and neurology and show how incorporation of neurological knowledge can improve the practice of psychiatry. Using four fictional case vignettes of altered mental status we explore important neurological differential diagnoses which could present to the Psychiatrist.
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27
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Lee GH, Kim J, Kim HW, Cho JW. Herpes simplex viruses (1 and 2) and varicella-zoster virus infections in an adult population with aseptic meningitis or encephalitis: A nine-year retrospective clinical study. Medicine (Baltimore) 2021; 100:e27856. [PMID: 34797322 PMCID: PMC8601327 DOI: 10.1097/md.0000000000027856] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Accepted: 11/01/2021] [Indexed: 01/05/2023] Open
Abstract
Three α-herpesviruses are known to be associated with central nervous system (CNS) infection; however, there are limited data on the incidence and clinical characteristics of α-herpesviruses CNS infections. This study aimed to assess the clinical manifestations, laboratory findings, and outcomes in patients with human herpes simplex virus 1 (HSV-1), human herpes simplex virus 2 (HSV-2), and varicella-zoster virus (VZV) CNS infections.We identified cases of HSV-1, HSV-2, and VZV CNS infections and reviewed their clinical and laboratory characteristics. The study population was drawn from patients with HSV-1, HSV-2, and VZV polymerase chain reaction positivity in cerebrospinal fluid (CSF) who visited Pusan National University Hospital between 2010 and 2018.During the 9-year study period, a total of 727 CSF samples were examined, with 72.2% (525/727) patients identified as having a CNS infection. Of 471 patients with aseptic meningitis and encephalitis, the causative virus was identified in 145 patients, and no virus was detected in 337 patients. A total of 15.2% (80/525) were diagnosed with one of the 3 herpesviruses as causative agents, 59 patients had meningitis, and 21 patients had encephalitis. Eleven patients with HSV-1, 27 patients with HSV-2, and 42 patients with VZV CNS infections were included. The distribution of cases by age showed different patterns depending on the type of herpesvirus infection. Compared with the HSV-1 group, the median age in the HSV-2 group was younger (HSV-1: 58 years; HSV-2: 38 years; P = .004), and patients with VZV infections showed a bimodal age distribution. Encephalitis was more common in the HSV-1 group, and HSV-1 infection was associated with a poor prognosis at discharge. CSF white blood cell counts were significantly lower in patients infected with HSV-1 (117 × 106 cells/L) than in patients infected with VZV (301 × 106 cells/L) (P = .008).These 3 herpesviruses are important causes of CNS infections regardless of immunologic status. HSV-1 infection was commonly associated with encephalitis and poor prognosis; HSV-2 and VZV CNS infections were associated with a low risk of mortality and neurological sequelae.
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Affiliation(s)
- Gha-Hyun Lee
- Department of Neurology, Biomedical Research Institute, Pusan National University Hospital, Busan, Republic of Korea
| | - Jiyoung Kim
- Department of Neurology, Biomedical Research Institute, Pusan National University Hospital, Busan, Republic of Korea
| | - Hyun-Woo Kim
- Department of Neurology, Pusan National University Yangsan Hospital, Pusan National University, Yangsan, Republic of Korea
| | - Jae Wook Cho
- Department of Neurology, Pusan National University Yangsan Hospital, Pusan National University, Yangsan, Republic of Korea
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28
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Abstract
INTRODUCTION The typical herpes simplex viral encephalitis (HSVE) course is an acute illness, less commonly it may present as a chronic course, mainly in children, and rarely may it be subacute. Subacute HSVE is rarely described in the literature being reported 4 times only. CASE REPORT We here report 2 cases of subacute HSV1 encephalitis diagnosed based on cerebrospinal fluid polymerase chain reaction and magnetic resonance imaging findings and review the literature trying to find any specific clinical, laboratory, radiologic diagnostic or prognostic criteria regarding this subacute form of HSVE. CONCLUSION There is subacute form of HSVE and should be suspected with any subacute febrile illness with nonspecific cognitive impairment even in the absence of focal neurological symptoms and in cases with rapidly progressive dementia. This form has similar radiologic finding and good response to acyclovir but carry even better prognosis than that the acute HSVE.
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29
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Oguni K, Yaegashi M. Fever with no elevation in inflammatory markers: herpes simplex virus encephalitis. QJM 2021; 114:326-327. [PMID: 33486506 DOI: 10.1093/qjmed/hcab012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2021] [Indexed: 11/14/2022] Open
Affiliation(s)
- K Oguni
- From the Department of General Internal Medicine, Kameda Medical Center, 929 Higashi-cho, Kamogawa City, Chiba Prefecture 296-8602, Japan
| | - M Yaegashi
- From the Department of General Internal Medicine, Kameda Medical Center, 929 Higashi-cho, Kamogawa City, Chiba Prefecture 296-8602, Japan
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30
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Abstract
PURPOSE OF REVIEW This article reviews infections of the brain parenchyma and includes an overview of the epidemiology, pathogenesis, diagnostic approach, and management of infectious encephalitis and brain abscess. RECENT FINDINGS The epidemiology of infectious encephalitis and brain abscess has changed in recent years. Vaccination has reduced the incidence of certain viruses associated with encephalitis, while a decrease in fulminant otogenic infections has led to fewer brain abscesses associated with otitis media. However, changes in climate and human population density and distribution have enabled the emergence of newer pathogens and expanded the geographic range of others, and greater adoption of intensive immunosuppressive regimens for autoimmune conditions has increased the risk of opportunistic infections of the brain. The widespread use of early neuroimaging, along with improved diagnostic methodologies for pathogen detection, newer antimicrobial therapies with better brain penetration, and less invasive neurosurgical techniques, has resulted in better outcomes for patients with infectious encephalitis and brain abscess. Novel technologies including metagenomic next-generation sequencing are increasingly being applied to these conditions in an effort to improve diagnosis. Nevertheless, both infectious encephalitis and brain abscess continue to be associated with substantial mortality. SUMMARY Infectious encephalitis and brain abscess can present as neurologic emergencies and require rapid assessment, thorough and appropriate diagnostic testing, and early initiation of empiric therapies directed against infectious agents. Close clinical follow-up, proper interpretation of diagnostic results, and appropriate tailoring of therapeutic agents are essential to optimizing outcomes. Diagnosis and management of parenchymal brain infections are complex and often best achieved with a multidisciplinary care team involving neurologists, neurosurgeons, neuroradiologists, infectious disease physicians, and pathologists.
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31
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Characteristics and outcome of varicella-zoster virus central nervous system infections in adults. Eur J Clin Microbiol Infect Dis 2021; 40:2437-2442. [PMID: 33907935 DOI: 10.1007/s10096-021-04245-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Accepted: 04/02/2021] [Indexed: 10/21/2022]
Abstract
We conducted an observational retrospective study of all adults hospitalized for documented varicella-zoster virus (VZV) meningitis or encephalitis during years 2000-2015 in one referral centre. Thirty-six patients (21 males, 15 females) were included, with meningitis (n = 21), or meningoencephalitis (n = 15). Median age was 51 years [interquartile range, 35-76], and 6 patients (17%) were immunocompromised. Aciclovir was started in 32 patients (89%), with a median dose of 11 mg/kg/8 h [10-15]. No patient died, but 12 (33%) had neurological sequelae at discharge. Age was the only variable associated with adverse outcome (OR 1.98 [1.17-3.35] per 10-year increment, P = 0.011).
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32
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Abstract
PURPOSE OF REVIEW We have highlighted the recent advances in infection in neurocritical care. RECENT FINDINGS Central nervous system (CNS) infections, including meningitis, encephalitis and pyogenic brain infections represent a significant cause of ICU admissions. We underwent an extensive review of the literature over the last several years in order to summarize the most important points in the diagnosis and treatment of severe infections in neurocritical care. SUMMARY Acute brain injury triggers an inflammatory response that involves a complex interaction between innate and adaptive immunity, and there are several factors that can be implicated, such as age, genetic predisposition, the degree and mechanism of the injury, systemic and secondary injury and therapeutic interventions. Neuroinflammation is a major contributor to secondary injury. The frequent and challenging presence of fever is a common denominator amongst all neurocritical care patients.
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Affiliation(s)
- Ignacio Martin-Loeches
- Department of Intensive Care Medicine, Multidisciplinary Intensive Care Research Organization (MICRO), St. James's Hospital
- Department of Clinical Medicine, School of Medicine, Trinity College Dublin, Dublin, Ireland
- Hospital Clinic, IDIBAPS, Universidad de Barcelona, Ciberes, Barcelona, Spain
| | - Alan Blake
- Department of Intensive Care Medicine, Multidisciplinary Intensive Care Research Organization (MICRO), St. James's Hospital
| | - Daniel Collins
- Department of Intensive Care Medicine, Multidisciplinary Intensive Care Research Organization (MICRO), St. James's Hospital
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33
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Hansen MA, Samannodi MS, Castelblanco RL, Hasbun R. Clinical Epidemiology, Risk Factors, and Outcomes of Encephalitis in Older Adults. Clin Infect Dis 2021; 70:2377-2385. [PMID: 31294449 DOI: 10.1093/cid/ciz635] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Accepted: 07/09/2019] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Encephalitis is associated with significant morbidity and mortality, with unknown etiologies in the majority of patients. Large prognostic studies evaluating elderly patients are currently lacking. METHODS We performed a retrospective cohort of encephalitis cases in 19 hospitals from New Orleans, Louisiana, and Houston, Texas, between the years 2000 and 2017. RESULTS A total of 340 adult (aged ≥17 years) patients with confirmed encephalitis were enrolled, and 194 (57%) had unknown etiologies. A cerebrospinal fluid polymerase chain reaction (PCR) for herpes simplex virus (HSV) and varicella zoster virus was done in 237 (69%) and 82 (24%) patients, respectively. Furthermore, an arboviral serology was done in 169 (49%) patients and measurements of anti-N-methyl-D-aspartate receptor antibodies were taken in 49 (14%) patients. A total of 172 out of 323 patients (53%) had adverse clinical outcomes (ACOs) at discharge. Older individuals (>65 years of age) had a lower prevalence of human immunodeficiency virus, had a higher number of comorbidities, were less likely to receive adjuvant steroids, were more likely to have a positive arbovirus serology, were more likely to have a positive HSV PCR, were more likely to have abnormal computerized tomography findings, and were more likely to have to have an ACO (all P values < .05). Prognostic factors independently associated with an ACO were age ≥65, fever, Glasgow Coma Scale (GCS) score <13, and seizures (all P values ≤0.01). CONCLUSIONS Encephalitis in adults remain with unknown etiologies and adverse clinical outcomes in the majority of patients. Independent prognostic factors include age ≥65 years, fever, GCS score <13, and seizures.
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Affiliation(s)
- Michael A Hansen
- Department of Family and Community Medicine, Baylor College of Medicine, Houston, Texas
| | - Mohammed S Samannodi
- Department of Internal Medicine, University of Texas Health McGovern Medical School, Houston, Texas
| | | | - Rodrigo Hasbun
- Department of Internal Medicine, University of Texas Health McGovern Medical School, Houston, Texas
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34
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Pisani F, Spagnoli C, Falsaperla R, Nagarajan L, Ramantani G. Seizures in the neonate: A review of etiologies and outcomes. Seizure 2021; 85:48-56. [PMID: 33418166 DOI: 10.1016/j.seizure.2020.12.023] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2020] [Revised: 12/24/2020] [Accepted: 12/26/2020] [Indexed: 12/21/2022] Open
Abstract
Neonatal seizures occur in their majority in close temporal relation to an acute brain injury or systemic insult, and are accordingly defined as acute symptomatic or provoked seizures. However less frequently, unprovoked seizures may also present in the neonatal period as secondary to structural brain abnormalities, thus corresponding to structural epilepsies, or to genetic conditions, thus corresponding to genetic epilepsies. Unprovoked neonatal seizures should be thus considered as the clinical manifestation of early onset structural or genetic epilepsies that often have the characteristics of early onset epileptic encephalopathies. In this review, we address the conundrum of neonatal seizures including acute symptomatic, remote symptomatic, provoked, and unprovoked seizures, evolving to post-neonatal epilepsies, and neonatal onset epilepsies. The different clinical scenarios involving neonatal seizures, each with their distinct post-neonatal evolution are presented. The structural and functional impact of neonatal seizures on brain development and the concept of secondary epileptogenesis, with or without a following latent period after the acute seizures, are addressed. Finally, we underline the need for an early differential diagnosis between an acute symptomatic seizure and an unprovoked seizure, since it is associated with fundamental differences in clinical evolution. These are crucial aspects for neonatal management, counselling and prognostication. In view of the above aspects, we provide an outlook on future strategies and potential lines of research in this field.
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Affiliation(s)
- Francesco Pisani
- Child Neuropsychiatry Unit, Medicine and Surgery Department, University of Parma, Italy
| | - Carlotta Spagnoli
- Child Neurology Unit, Department of Pediatrics, Azienda USL-IRCCS, Reggio Emilia, Italy
| | - Raffaele Falsaperla
- Neonatal Intensive Care Unit, University-Hospital Policlinico Vittorio Emanuele, Catania, Italy
| | - Lakshmi Nagarajan
- Children's Neuroscience Service, Department of Neurology, Perth Children's Hospital, Australia
| | - Georgia Ramantani
- Department of Neuropediatrics, University Children's Hospital Zurich, Switzerland.
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35
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Hayashi Y, Araki K, Inoue K, Ando H, Fujimura H, Tatsumi C. [An autopsy case of elderly-onset herpes simplex encephalitis with acute respiratory failure caused by brainstem lesions]. Rinsho Shinkeigaku 2020; 60:840-845. [PMID: 33229829 DOI: 10.5692/clinicalneurol.cn-001438] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
An 89-year-old man was admitted because of persistent fever and impaired consciousness. On admission, his consciousness level was E3V3M4 according to the Glasgow Coma Scale. MRI of the brain showed high intensity lesions in the bilateral cingulate gyri. In the cerebrospinal fluid, both cell counts and glucose level were in the normal ranges. He had received antibiotics and intravenous isotonic saline. On the fifth day of hospitalization, blood examination revealed elevation of anti-herpes simplex virus (HSV) immunoglobulin M antibody, and herpes simplex encephalitis (HSE) was diagnosed. Despite treatment with acyclovir, his respiratory function and consciousness level deteriorated rapidly. On the eighth day, he died of respiratory failure. At autopsy, the brain showed multiple softenings of the gray and white matter in the hippocampus, amygdala, and temporal, insular, and cingulate cortices. Some of these lesions were hemorrhagic. Microscopic examination revealed that the lesions were necrotic and associated with perivascular inflammatory cell infiltration in the limbic system, hypothalamus, brainstem tegmentum area, and medulla. Eosinophilic intranuclear inclusions were rarely found in the astrocytes in the medulla. Immunohistochemistry revealed anti-HSV-1 antibody positive neurons in the brainstem tegmentum including reticular formation and the raphe nuclei. HSV-DNA was also detected in the postmortem cerebrospinal fluid. This was a rare case of HSE in which inflammation in the brainstem proved to be the cause of lethal respiratory failure.
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Affiliation(s)
- Yuto Hayashi
- Department of Neurology, Toyonaka Municipal Hospital
| | - Katsuya Araki
- Department of Neurology, Toyonaka Municipal Hospital
| | - Kimiko Inoue
- Department of Neurology, National Hospital Organization Osaka Toneyama Medical Center
| | - Hiroka Ando
- Department of Pathology, Toyonaka Municipal Hospital
| | - Harutoshi Fujimura
- Department of Neurology, National Hospital Organization Osaka Toneyama Medical Center
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Zelano J, Westman G. Epilepsy after brain infection in adults: A register-based population-wide study. Neurology 2020; 95:e3213-e3220. [PMID: 32989110 DOI: 10.1212/wnl.0000000000010954] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 08/03/2020] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To describe risk and risk factors of epilepsy after hospitalization for brain infection in adults in Sweden. METHODS This was a matched retrospective cohort study based on the comprehensive National Patient and Cause of Death Registers. All individuals age >18 without prior epilepsy who received inpatient care in 2000-2010 for a brain infection were included, with 3 age- and sex-matched unexposed controls per exposed individual (n = 12,101 exposed and 36,228 controls). Kaplan-Meier risks of epilepsy after different brain infections were calculated and risk factors identified by Cox regression. Patients were followed until the end of 2017. RESULTS The 10-year risk of epilepsy was 5.9% (95% confidence interval [CI] 5.5-6.3) in cases and 1.2% (95% CI 1.0-1.4) in controls: 1.7% (95% CI 0.7-2.7) after tick-borne encephalitis, 4.1% (95% CI 3.3-4.9) after bacterial meningitis, 26.0% (95% CI 21.5-30.5) after herpes simplex virus encephalitis, and 30.2% (95% CI 27.1-33.3) after brain abscess. In Cox regression, seizure during the index admission and mechanical ventilation were epilepsy risk factors. CONCLUSIONS Epilepsy is common after several types of brain infections in adults. The type of infection, its severity, and propensity to cause seizures in the acute phase influence the risk of subsequent epilepsy. CLASSIFICATION OF EVIDENCE This study provides Class II evidence that in adults, brain infection is associated with an increased risk of subsequent epilepsy.
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Affiliation(s)
- Johan Zelano
- From the Institute of Neuroscience and Physiology, Department of Clinical Neuroscience (J.Z.), and Department of Neurology (J.Z.), Sahlgrenska Academy, and Wallenberg Center of Molecular and Translational Medicine (J.Z.), Gothenburg University; and Department of Medical Sciences (G.W.), Section of Infectious Diseases, Uppsala University, Sweden.
| | - Gabriel Westman
- From the Institute of Neuroscience and Physiology, Department of Clinical Neuroscience (J.Z.), and Department of Neurology (J.Z.), Sahlgrenska Academy, and Wallenberg Center of Molecular and Translational Medicine (J.Z.), Gothenburg University; and Department of Medical Sciences (G.W.), Section of Infectious Diseases, Uppsala University, Sweden
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Yuen CA, Mastrianni J, Ali S, Pytel P, Park DM, Rezania K. An atypical presentation of primary central nervous system lymphoma: A case report. Medicine (Baltimore) 2020; 99:e22062. [PMID: 32957327 PMCID: PMC7505306 DOI: 10.1097/md.0000000000022062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
RATIONALE Primary central nervous system lymphoma (PCNSL) involving the choroid plexus is exceedingly rare. The differential diagnosis for choroid plexus enhancing lesions in addition to lymphoma includes infections, sarcoidosis, tuberculosis, papilloma, meningioma, subependymoma, and metastatic lesions. PATIENT CONCERNS A 71-year-old man presented with 3 days of episodic memory loss and gait disturbance. Brain magnetic resonance imaging showed homogenously enhancing lesions with mildly restricted diffusion and T2 hypointensity in the lateral ventricles, as well as T2 hyperintensity and enhancement in the right hippocampus. His episodic memory loss was thought to be secondary to subclinical focal seizures, supported by EEG revealing right temporal lobe epileptiform discharges. DIAGNOSES Large B-cell lymphoma, nongerminal center type was revealed on pathological examination. INTERVENTIONS Stereotactic biopsy of his right thalamic lesion was performed. OUTCOMES The patient underwent induction therapy with high-dose methotrexate, temozolomide, and rituximab, which resulted in complete resolution of the enhancing lesions. He then underwent conditioning chemotherapy with carmustine and thiotepa, followed by autologous stem cell transplantation. His PCNSL remains in remission 42 weeks after the onset of symptoms. LESSONS We report a patient with multifocal PCNSL involving the choroid plexus, who presented with abnormal gait and episodic confusion and memory loss. PCNSL should be considered in the differential diagnosis of acute encephalopathy among immunocompetent older individuals who have choroid plexus enhancing lesions.
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Affiliation(s)
- Carlen A. Yuen
- University of Chicago, Department of Neurology, Chicago, IL
| | | | - Saad Ali
- University of Chicago, Department of Radiology, Chicago, IL
| | - Peter Pytel
- University of Chicago, Department of Pathology, Chicago, IL
| | - Deric M. Park
- University of Chicago, Department of Neurology, Chicago, IL
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Lin W, Chen S, Lin H, Liu C, Huang H. Continuous video electroencephalogram for herpes simplex encephalitis: a case report and literature review. ACTA EPILEPTOLOGICA 2020. [DOI: 10.1186/s42494-020-00017-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Electroencephalogram (EEG) is an important tool for the diagnosis of herpes simplex virus encephalitis (HSE). However, the diagnosis of non-convulsive status epilepticus (NCSE) in HSE is challenging without the help of continuous video EEG (CVEEG), and whether EEG is a predictor of outcome remains controversial.
Case presentation
A 63-year-old woman presented with a 5 day history of fever, coma and seizures. Results of EEG, magnetic resonance imaging and polymerase chain reaction (PCR) in cerebrospinal fluid (CSF) were suggestive of herpes simplex encephalitis-1 (HSE-1). Preliminary EEG showed periodic discharges at the prefrontal and temporal lobes, which were particularly synchronized with intermittent lip smacking movements, and the discharges were terminated by diazepam. After 2-week treatment with acyclovir, high-dose hormone pulse therapy and high-dose immunoglobulin therapy, the CSF was improved, but the patient’s consciousness became worsen, consistent with the diffuse slow waves in the delta range and low voltage of EEG activity. In the following 1 month, the patient had non-responsiveness to pain and sound as shown by CVEEG with diffuse slow waves. Sometimes paroxysmal very slow waves (0.5–1 Hz) were synchronized with intermittent paroxysmal eye movements, pupil abnormality, and sweating in the frontal area. After 2 months of treatment, the EEG abnormalities improved to have alpha rhythm.
Conclusion
The CVEEG not only helps identify NCSE but can also be used to monitor HSE progression.
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Hansen ABE, Vestergaard HT, Dessau RB, Bodilsen J, Andersen NS, Omland LH, Christiansen CB, Ellermann-Eriksen S, Nielsen L, Benfield T, Sørensen HT, Andersen CØ, Lebech AM, Obel N. Long-Term Survival, Morbidity, Social Functioning and Risk of Disability in Patients with a Herpes Simplex Virus Type 1 or Type 2 Central Nervous System Infection, Denmark, 2000-2016. Clin Epidemiol 2020; 12:745-755. [PMID: 32765109 PMCID: PMC7371560 DOI: 10.2147/clep.s256838] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Accepted: 06/15/2020] [Indexed: 12/24/2022] Open
Abstract
Background The long-term prognosis following herpes simplex virus (HSV) central nervous system (CNS) infection is still debated. Patients and Methods We examined outcomes in all Danish residents who, during 2000–2016, tested PCR positive for HSV-1 (n=208) or HSV-2 (n=283) in the cerebrospinal fluid, compared to comparison cohorts from the general population (n=2080 and n=2830). Results One-year mortality was increased among HSV-1 patients (difference 19.3%; 95% CI: 13.6% to 25.0%) and HSV-2 patients (difference 5.3%; 95% CI: 2.5% to 8.1%), but thereafter mortality was not increased. After exclusion of persons diagnosed with cancer prior to study inclusion, one-year mortality difference for HSV-2 patients was 1.7% (−0.1% to 3.5%). After five years, HSV-1 patients had lower employment (difference −19.8%; 95% CI: −34.7% to −4.8%) and higher disability pension rates (difference 22.2%; 95% CI: 8.4% to 36.0%) than the comparison cohort, but similar number of inpatient days, outpatient visits, and sick leave. HSV-2 patients had employment and disability pension rates comparable to the comparison cohort, but more inpatient days (difference 1.5/year; 95% CI: −0.2 to 3.2), outpatient visits (difference 1.3/year; 95% CI: 0.3 to 3.2), and sick leave days (difference 9.1/year; 95% CI: 7.9 to 10.4). Conclusion HSV-1 and HSV-2 CNS infections differ substantially with respect to prognosis. HSV-1 CNS infection is followed by increased short-term mortality and long-term risk of disability. HSV-2 CNS infection has no substantial impact on mortality or working capability but is associated with increased morbidity.
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Affiliation(s)
- Ann-Brit E Hansen
- Department of Infectious Diseases, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.,Department of Infectious Diseases, Amager Hvidovre Hospital, University of Copenhagen, Hvidovre, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Hanne T Vestergaard
- Department of Virus & Microbiological Special Diagnostics, Statens Serum Institute, Copenhagen, Denmark
| | - Ram B Dessau
- Department of Clinical Microbiology, Slagelse Hospital, Slagelse, Denmark
| | - Jacob Bodilsen
- Departments of Infectious Diseases and Clinical Microbiology, Aalborg University Hospital, Aalborg, Denmark
| | - Nanna S Andersen
- Department of Clinical Microbiology, Odense University Hospital, Odense, Denmark
| | - Lars H Omland
- Department of Infectious Diseases, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Claus B Christiansen
- Department of Clinical Microbiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | | | - Lene Nielsen
- Department of Clinical Microbiology, Herlev and Gentofte Hospital, University of Copenhagen, Herlev, Denmark
| | - Thomas Benfield
- Department of Infectious Diseases, Amager Hvidovre Hospital, University of Copenhagen, Hvidovre, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Henrik T Sørensen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - Christian Ø Andersen
- Department of Clinical Microbiology, Amager Hvidovre University Hospital, University of Copenhagen, Hvidovre, Denmark
| | - Anne-Mette Lebech
- Department of Infectious Diseases, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Niels Obel
- Department of Infectious Diseases, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Liu FY, El Mouhayyar C, Mamtani R, Dammann F, Basein T. A case of herpes simplex 2 encephalitis with an unusual radiographic manifestation. IDCases 2020; 21:e00884. [PMID: 32642433 PMCID: PMC7334455 DOI: 10.1016/j.idcr.2020.e00884] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Revised: 06/19/2020] [Accepted: 06/19/2020] [Indexed: 11/17/2022] Open
Abstract
Herpes Simplex Virus (HSV) continues to be an important pathogen inflicting encephalitis in adults and children globally that entails high morbidity and mortality. Prompt diagnosis and treatment are the keys to minimize potential sequelae of the disease. Although HSV encephalitis-1(HSVE-1) is well recognized for its radiographic manifestation of temporal lobe involvement owing to its pathogenesis, radiographic features of HSVE-2 are less uniform. Lumbar puncture with HSV PCR testing is the gold standard for diagnosis. However, when lumbar puncture is not immediately obtainable, consideration of HSVE should be entertained in compatible clinical setting even in the absence of characteristic radiographic finding. We report a case of type 2 HSVE with atypical radiographic manifestation involving bilateral basal ganglia.
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Affiliation(s)
- Fang-Yu Liu
- Department of Medicine, St. Elizabeth’s Medical Center, Boston, MA, USA
- Department of Medicine, Tufts University School of Medicine, Boston, MA, USA
| | - Christopher El Mouhayyar
- Department of Medicine, St. Elizabeth’s Medical Center, Boston, MA, USA
- Department of Medicine, Tufts University School of Medicine, Boston, MA, USA
- Corresponding author at: 736 Cambridge Street, Brighton, MA, 02135, USA.
| | - Rishi Mamtani
- Department of Medicine, St. Elizabeth’s Medical Center, Boston, MA, USA
- Department of Medicine, Tufts University School of Medicine, Boston, MA, USA
| | - Fabian Dammann
- Department of Medicine, St. Elizabeth’s Medical Center, Boston, MA, USA
- Department of Medicine, Tufts University School of Medicine, Boston, MA, USA
| | - Tinzar Basein
- Department of Medicine, St. Elizabeth’s Medical Center, Boston, MA, USA
- Department of Medicine, Tufts University School of Medicine, Boston, MA, USA
- Department of Infectious Disease, St. Elizabeth’s Medical Center, Boston, MA, USA
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Predictors of Outcome in Clinically Diagnosed Viral Encephalitis Patients: A 5-Year Prospective Study. BIOMED RESEARCH INTERNATIONAL 2020; 2020:2832418. [PMID: 32724798 PMCID: PMC7366193 DOI: 10.1155/2020/2832418] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Accepted: 06/20/2020] [Indexed: 12/12/2022]
Abstract
Background Viral encephalitis is the most common infectious disease of the central nervous system and is associated with high morbidity, mortality, and disability. The objective of this study was to analyze the clinical characteristics, auxiliary examinations, therapeutic management, and outcomes of patients clinically diagnosed with viral encephalitis and identify the outcome predictors. Methods We conducted a prospective observational study by collecting information from patients clinically diagnosed with viral encephalitis at the First Affiliated Hospital of Chongqing Medical University and Yongchuan Hospital of Chongqing Medical University from January 2013 to December 2018. Univariate and multivariate analyses were performed to identify factors that influenced good patient outcomes (mRS < 3) and poor patient outcomes (mRS ≥ 3) at discharge. Results In total, 216 patients were enrolled in the study. The multivariate analysis suggested that the following factors were associated with a poor outcome: Glasgow Coma Scale (GCS) score (OR 0.154, 95% CI (0.078-0.302), and P < 0.001), focal neurological deficits (OR 9.403, 95% CI (1.581-55.928), and P = 0.014), and total length of hospital stay (OR 1.119, 95% CI (1.002-1.250), and P = 0.045). However, neurological intensive care unit (NICU) treatment, status epilepticus, and abnormal electroencephalogram (EEG) findings did not influence the prognosis of patients. Conclusion Our study suggests that low GCS scores at admission, focal neurological deficits at admission, and a prolonged total hospital stay are predictors of a poor outcome at discharge in clinically diagnosed viral encephalitis patients. Whether early and effective neurological rehabilitation can improve the prognosis of viral encephalitis patients with focal neurological deficits remains to be confirmed in further studies.
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42
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Lin BH, Sutherland MR, Rosell FI, Morrissey JH, Pryzdial ELG. Coagulation factor VIIa binds to herpes simplex virus 1-encoded glycoprotein C forming a factor X-enhanced tenase complex oriented on membranes. J Thromb Haemost 2020; 18:1370-1380. [PMID: 32145149 PMCID: PMC7647453 DOI: 10.1111/jth.14790] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Revised: 01/28/2020] [Accepted: 03/04/2020] [Indexed: 12/28/2022]
Abstract
BACKGROUND The cell membrane-derived initiators of coagulation, tissue factor (TF) and anionic phospholipid (aPL), are constitutive on the herpes simplex virus type 1 (HSV1) surface, bypassing physiological regulation. TF and aPL accelerate proteolytic activation of factor (F) X to FXa by FVIIa to induce clot formation and cell signaling. Thus, infection in vivo is enhanced by virus surface TF. HSV1-encoded glycoprotein C (gC) is implicated in this tenase activity by providing viral FX binding sites and increasing FVIIa function in solution. OBJECTIVE To examine the biochemical influences of gC on FVIIa-dependent FX activation. METHODS Immunogold electron microscopy (IEM), kinetic chromogenic assays and microscale thermophoresis were used to dissect tenase biochemistry. Recombinant TF and gC were solubilized (s) by substituting the transmembrane domain with poly-histidine, which could be orientated on synthetic unilamellar vesicles containing Ni-chelating lipid (Ni-aPL). These constructs were compared to purified HSV1 TF±/gC ± variants. RESULTS IEM confirmed that gC, TF, and aPL are simultaneously expressed on a single HSV1 particle where the contribution of gC to tenase activity required the availability of viral TF. Unlike viral tenase activity, the cofactor effects of sTF and sgC on FVIIa was additive when bound to Ni-aPL. FVIIa was found to bind to sgC and this was enhanced by FX. Orientation of sgC on a lipid membrane was critical for FVIIa-dependent FX activation. CONCLUSIONS The assembly of gC with FVIIa/FX parallels that of TF and may involve other constituents on the HSV1 envelope with implications in virus infection and pathology.
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Affiliation(s)
- Bryan H Lin
- Center for Innovation, Canadian Blood Services, Vancouver, BC, Canada
- Centre for Blood Research and Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Michael R Sutherland
- Center for Innovation, Canadian Blood Services, Vancouver, BC, Canada
- Centre for Blood Research and Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Federico I Rosell
- Centre for Blood Research and Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, BC, Canada
- Department of Biochemistry and Molecular Biology, University of British Columbia, Vancouver, BC, Canada
| | - James H Morrissey
- Departments of Biological Chemistry & Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Edward L G Pryzdial
- Center for Innovation, Canadian Blood Services, Vancouver, BC, Canada
- Centre for Blood Research and Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, BC, Canada
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Abstract
This article discusses mimics of multiple sclerosis (MS). Excluded in this discussion are neuromyelitis optica and vasculitis, discussed in other articles in this journal. Covered entities include posterior reversible encephalopathy syndrome, reversible vasoconstriction syndrome, acute disseminated encephalomyelitis, Sussac's Syndrome, and chronic idiopathic demyelinating polyneuropathy. There are also multiple infectious entities that mimic MS including; progressive multi-focal leukoencephalopathy (PML), Toxoplasmosis, Tuberculosis, Herpes Simplex Virus, Cytomegalovirus, Varicella zoster virus, Epstein Barr virus, Cryptococcus and Human immunodeficiency virus. In addition, there are leukoencephalopathies that can present in adulthood including Adrenoleukodystrophy, Metachromatic leukodystrophy, Cerebral autosomal dominant idiopathic leukoencephalopathy, Leigh's and Alexanders disease that could be mistaken for MS.
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44
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Liu Y, Zhou W. Clinical features and surgical treatment of epilepsy after viral encephalitis. BRAIN SCIENCE ADVANCES 2019. [DOI: 10.1177/2096595819896177] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Encephalitis is an acute inflammatory process of the brain parenchyma, which is often caused by viral infection. It is an vital cause of acute symptomatic seizures and subsequent epilepsy. The incidence of unprovoked and recurrent seizures after previous infections of the central nervous system is high and accounts for 1%~5% of the cases of epilepsy. Viral encephalitis (VE) is directly caused by viral infection. The occurrence of seizures after VE is associated with poor prognosis. In survivors of VE, among other neurological sequelae, the risk of developing epilepsy is increased 10-fold. The risk of severe neurological sequelae after VE is particularly high in very young children. Studies on seizure occurrence, possible underlying mechanisms, clinical characteristics, and clinical treatment (especially surgical treatment) of VE have yielded only limited detailed data. We reviewed the most recent literature on the clinical features and surgical treatment of post-VE epilepsy.
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Affiliation(s)
- Yiou Liu
- Department of Epilepsy Center, Tsinghua University Yuquan Hospital, Beijing 100040, China
| | - Wenjing Zhou
- Department of Epilepsy Center, Tsinghua University Yuquan Hospital, Beijing 100040, China
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Oud L. Herpes Simplex Virus Encephalitis: Patterns of Epidemiology and Outcomes of Patients Admitted to the Intensive Care Unit in Texas, 2008 - 2016. J Clin Med Res 2019; 11:773-779. [PMID: 31803321 PMCID: PMC6879041 DOI: 10.14740/jocmr4025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Accepted: 10/31/2019] [Indexed: 12/01/2022] Open
Abstract
Background Patients with herpes simplex virus encephalitis (HSVE) often require admission to the intensive care unit (ICU) and have considerably worse outcomes than those not critically ill. The short-term outcomes of critically ill patients in the general population have markedly improved over the past decades. However, the population-level patterns of demand for critical care services among patients with HSVE have not been examined, and it is unknown whether there were corresponding outcome gains among those admitted to the ICU. Methods The Texas Inpatient Public Use Data File was used to identify hospitalizations with HSVE aged ≥ 18 years during 2008 - 2016. ICU admissions were identified using unit-specific revenue codes. The patterns of ICU utilization and those of short-term outcomes (with short-term mortality defined as in-hospital death or discharge to hospice) were examined across demographic strata and over time. Results Among 1,964 hospitalizations with HSVE, 1,176 (59.9%) were admitted to ICU (45.8% aged ≥ 65 years; 53.1% female, among ICU admissions). ICU utilization increased with age (from 47.9% (age 18 - 44 years) through 61.2% (older adults (age ≥ 65 years)); P = 0.0003 for trend), and increased over time only among older adults (odds ratio: 1.06/year (95% confidence interval (CI): 1.01 - 1.12)). Among ICU admissions, routine home discharge, transfer to a post-acute care facility, and short-term mortality occurred in 26.8%, 39.5%, and 18.7%, respectively; the corresponding outcomes for older adults were 10.6%, 51.4%, and 26.2%, respectively. The outcomes for the whole cohort of ICU admissions remained unchanged over time. Conclusions Adults with HSVE had high demand for critical care services, and those admitted to ICU had high short-term mortality and substantial residual morbidity among survivors, which remained unchanged over time. These findings can inform clinicians’ decision-making and discussions about goals of care with affected patients and their surrogates.
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Affiliation(s)
- Lavi Oud
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Texas Tech University Health Sciences Center at the Permian Basin, 701 W. 5th St., Odessa, TX 79763, USA.
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Magnetic resonanse imaging as a prognostic tool in encephalitis in children. КЛИНИЧЕСКАЯ ПРАКТИКА 2019. [DOI: 10.17816/clinpract10355-60] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
We provide the data on the modern use of MRI of different modalities as a prognostic tool in the encephalitis diagnostics in pediatrics. According to the recent scientific knowledge, this implementation is possible, but its efficacy depends on the modality of MRI: structural, functional or MRI with contrast. Structural MRI efficacy in children with encephalitis is dubious and clearly depends on the etiology and phase of the inflammatory process. In the recent years, the implementation of the functional MRI methods (DTI MRS) and MRI with contrast significantly changed the imaging practice; there are some reports that these modalities of MRI are more effective as a prognostic tool in encephalitis than the structural one. Thus, a future research in this field is needed.
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Li R, Shi PA, Liu TF, Li Y, Wang Y, Wu K, Chen XJ, Xiao HF, Wang YL, Ma L, Lou X. Role of 3D Pseudocontinuous Arterial Spin-Labeling Perfusion in the Diagnosis and Follow-Up in Patients with Herpes Simplex Encephalitis. AJNR Am J Neuroradiol 2019; 40:1901-1907. [PMID: 31649156 DOI: 10.3174/ajnr.a6279] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Accepted: 08/26/2019] [Indexed: 01/24/2023]
Abstract
BACKGROUND AND PURPOSE Early diagnosis and treatment of herpes simplex encephalitis are crucial to reduce morbidity and mortality. Our aim was to investigate the role of 3D pseudocontinuous arterial spin-labeling in herpes simplex encephalitis. MATERIALS AND METHODS From 2014 to 2019, seventeen consecutive patients with herpes simplex encephalitis and 15 healthy volunteers were recruited in the study. Conventional MR imaging and 3D pseudocontinuous arterial spin-labeling were performed in all subjects. According to the disease duration, the lesions were classified into 3 groups, including acute, subacute, and chronic stages, respectively. Clinical, neuroradiologic, and follow-up features were studied. The normalized lesion/normal tissue CBF values of lesions at different stages were measured and compared with those in the control group, respectively. RESULTS Compared with the control group, herpes simplex encephalitis demonstrated hyperperfusion in 11 acute cases and 6 subacute cases and hypoperfusion in 6 chronic cases. The mean normalized lesion/normal tissue CBF values of the lesions were 2.68 ± 0.54 in the acute stage, 2.42 ± 0.52 in the subacute stage, and 0.87 ± 0.30 in the chronic stage, respectively. The mean normalized lesion/normal tissue CBF values of acute and subacute lesions were significantly higher than those of the control group (1.33 ± 0.08; P < .001, respectively), while the mean normalized lesion/normal tissue CBF values of chronic lesions were lower than those of the control group (P < .05). Gradual perfusion reduction on serial 3D pseudocontinuous arterial spin-labeling was observed in herpes simplex encephalitis after effective therapy. CONCLUSIONS Conventional MR imaging remains most helpful in the diagnosis of herpes simplex encephalitis, while 3D pseudocontinuous arterial spin-labeling could be an adjunctive technique by providing dynamic CBF features at different stages in herpes simplex encephalitis.
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Affiliation(s)
- R Li
- From the School of Medicine (R.L., L.M.), Nankai University, Tianjin, China
- Department of Radiology (R.L., T.-F.L., Y.L., Y.W., K.W., X.-J.C., H.-F.X., Y.-L.W., L.M., X.L.), Chinese People's Liberation Army General Hospital, Beijing, China
| | - P-A Shi
- Department of Endocrinology (P.-A.S.), Cangzhou Central Hospital, Cangzhou, Hebei, China
| | - T-F Liu
- Department of Radiology (R.L., T.-F.L., Y.L., Y.W., K.W., X.-J.C., H.-F.X., Y.-L.W., L.M., X.L.), Chinese People's Liberation Army General Hospital, Beijing, China
| | - Y Li
- Department of Radiology (R.L., T.-F.L., Y.L., Y.W., K.W., X.-J.C., H.-F.X., Y.-L.W., L.M., X.L.), Chinese People's Liberation Army General Hospital, Beijing, China
| | - Y Wang
- Department of Radiology (R.L., T.-F.L., Y.L., Y.W., K.W., X.-J.C., H.-F.X., Y.-L.W., L.M., X.L.), Chinese People's Liberation Army General Hospital, Beijing, China
| | - K Wu
- Department of Radiology (R.L., T.-F.L., Y.L., Y.W., K.W., X.-J.C., H.-F.X., Y.-L.W., L.M., X.L.), Chinese People's Liberation Army General Hospital, Beijing, China
| | - X-J Chen
- Department of Radiology (R.L., T.-F.L., Y.L., Y.W., K.W., X.-J.C., H.-F.X., Y.-L.W., L.M., X.L.), Chinese People's Liberation Army General Hospital, Beijing, China
| | - H-F Xiao
- Department of Radiology (R.L., T.-F.L., Y.L., Y.W., K.W., X.-J.C., H.-F.X., Y.-L.W., L.M., X.L.), Chinese People's Liberation Army General Hospital, Beijing, China
| | - Y-L Wang
- Department of Radiology (R.L., T.-F.L., Y.L., Y.W., K.W., X.-J.C., H.-F.X., Y.-L.W., L.M., X.L.), Chinese People's Liberation Army General Hospital, Beijing, China
| | - L Ma
- From the School of Medicine (R.L., L.M.), Nankai University, Tianjin, China
- Department of Radiology (R.L., T.-F.L., Y.L., Y.W., K.W., X.-J.C., H.-F.X., Y.-L.W., L.M., X.L.), Chinese People's Liberation Army General Hospital, Beijing, China
| | - X Lou
- Department of Radiology (R.L., T.-F.L., Y.L., Y.W., K.W., X.-J.C., H.-F.X., Y.-L.W., L.M., X.L.), Chinese People's Liberation Army General Hospital, Beijing, China
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48
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Baten A, Desai M, Melo-Bicchi M, Gutierrez C. Continuous Electroencephalogram as a Biomarker of Disease Progression and Severity in Herpes Simplex Virus-1 Encephalitis. Clin EEG Neurosci 2019; 50:361-365. [PMID: 30873853 DOI: 10.1177/1550059419835705] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Objective. Herpes simplex virus encephalitis (HSE) is the most common cause of sporadic fatal encephalitis worldwide and remains a devastating disease despite antiviral therapy. EEG can be an important tool in the diagnosis of HSE, and we propose that it can be used to monitor the progression of the disease in patients with treatment refractory HSE. Methods. This is a case report of a patient with HSE who was monitored on continuous EEG (CEEG) throughout course of her disease. Results. A 62-year-old woman with no history of neurologic disease, who presented with generalized weakness and lethargy for 2 weeks, and rapidly deteriorated with encephalopathy, fever, and seizures. Lumbar puncture demonstrated elevated protein and white blood cells with positive herpes simplex virus (HSV) DNA. CEEG initially showed right-sided lateralized periodic discharges and focal seizures/status epilepticus with shifting predominance, and then later progressed to be more focal on the left, and then progressed to demonstrating more generalized findings. Magnetic resonance imaging obtained 3 times confirmed what CEEG heralded with evolution from prior studies which were concordant with CEEG, suggesting disease spread. Significance. We report the case of a patient with HSE who was monitored on CEEG and propose that CEEG can be used as a marker for progression of disease and thus may prompt escalation in therapy. While imaging studies may confirm spread of disease, using CEEG may prevent the delay of treatment and lead to more rapid therapy in cases of refractory HSE.
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Affiliation(s)
- Ahmareen Baten
- 1 Department of Neurology, Medstar Georgetown University Hospital, Washington, DC, USA
| | - Masoom Desai
- 2 Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Miguel Melo-Bicchi
- 2 Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Camilo Gutierrez
- 2 Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, USA
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49
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Jaquet P, de Montmollin E, Dupuis C, Sazio C, Conrad M, Susset V, Demeret S, Tadie JM, Argaud L, Barbier F, Sarton B, Chabane R, Daubin D, Brulé N, Lerolle N, Alves M, Da Silva D, Kalioubi AE, Silva S, Bailly P, Wolff M, Bouadma L, Timsit JF, Sonneville R. Functional outcomes in adult patients with herpes simplex encephalitis admitted to the ICU: a multicenter cohort study. Intensive Care Med 2019; 45:1103-1111. [PMID: 31292686 DOI: 10.1007/s00134-019-05684-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Accepted: 06/27/2019] [Indexed: 10/26/2022]
Abstract
PURPOSE We aimed to study the association of body temperature and other admission factors with outcomes of herpes simplex encephalitis (HSE) adult patients requiring ICU admission. METHODS We conducted a retrospective multicenter study on patients diagnosed with HSE in 47 ICUs in France, between 2007 and 2017. Fever was defined as a body temperature higher or equal to 38.3 °C. Multivariate logistic regression analysis was used to identify factors associated with poor outcome at 90 days, defined by a score of 3-6 (indicating moderate-to-severe disability or death) on the modified Rankin scale. RESULTS Overall, 259 patients with a score on the Glasgow coma scale of 9 (6-12) and a body temperature of 38.7 (38.1-39.2) °C at admission were studied. At 90 days, 185 (71%) patients had a poor outcome, including 44 (17%) deaths. After adjusting for age, fever (OR = 2.21; 95% CI 1.18-4.16), mechanical ventilation (OR = 2.21; 95% CI 1.21-4.03), and MRI brain lesions > 3 lobes (OR = 3.04; 95% CI 1.35-6.81) were independently associated with poor outcome. By contrast, a direct ICU admission, as compared to initial admission to the hospital wards (i.e., indirect ICU admission), was protective (OR = 0.52; 95% CI 0.28-0.95). Sensitivity analyses performed after adjustment for functional status before admission and reason for ICU admission yielded similar results. CONCLUSIONS In HSE adult patients requiring ICU admission, several admission factors are associated with an increased risk of poor functional outcome. The identification of potentially modifiable factors, namely, elevated admission body temperature and indirect ICU admission, provides an opportunity for testing further intervention strategies.
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Affiliation(s)
- P Jaquet
- Department of Intensive Care Medicine and Infectious Diseases, Bichat-Claude Bernard University Hospital, AP-HP, 46 Rue Henri Huchard, 75877, Paris Cedex, France
| | - E de Montmollin
- Department of Intensive Care Medicine and Infectious Diseases, Bichat-Claude Bernard University Hospital, AP-HP, 46 Rue Henri Huchard, 75877, Paris Cedex, France.,UMR 1137, IAME, Paris Diderot University, Paris, France
| | - C Dupuis
- Department of Intensive Care Medicine and Infectious Diseases, Bichat-Claude Bernard University Hospital, AP-HP, 46 Rue Henri Huchard, 75877, Paris Cedex, France.,UMR 1137, IAME, Paris Diderot University, Paris, France
| | - C Sazio
- Medical Intensive Care Unit, Bordeaux University Hospital, Bordeaux, France
| | - M Conrad
- Medical Intensive Care Unit, Central Hospital, Nancy University Hospitals, Nancy, France
| | - V Susset
- Polyvalent Intensive Care Unit, Chambery Hospital, Chambery, France
| | - S Demeret
- Neurologic Intensive Care Unit, Pitié-Salpêtrière University Hospital, AP-HP, Paris, France
| | - J M Tadie
- Medical Intensive Care Unit, Pontchaillou University Hospital, Rennes, France
| | - L Argaud
- Medical Intensive Care Unit, Edouard Herriot University Hospital, Lyon, France
| | - F Barbier
- Medical Intensive Care Unit, La Source Hospital, Orléans, France
| | - B Sarton
- Intensive Care Unit, Purpan University Hospital, Toulouse, France
| | - R Chabane
- Department of Perioperative Medicine, Clermont-Ferrand University Hospital, Clermont-Ferrand, France
| | - D Daubin
- Medical Intensive Care Unit, Montpellier University Hospital, Montpellier, France
| | - N Brulé
- Medical Intensive Care Unit, Nantes University Hospital, Nantes, France
| | - N Lerolle
- Medical Intensive Care Unit, CHU Angers, Angers University Hospital, Angers, France
| | - M Alves
- Polyvalent Intensive Care Unit, Poissy-Saint-Germain-en-Laye Hospital, Poissy, France
| | - D Da Silva
- Intensive Care Unit, Delafontaine Hospital, Saint-Denis, France
| | - A El Kalioubi
- Medical Intensive Care Unit, Roger Salengro University Hospital, Lille, France
| | - S Silva
- Intensive Care Unit, Purpan University Hospital, Toulouse, France
| | - P Bailly
- Medical Intensive Care Unit, La Cavale Blanche University Hospital, Brest, France
| | - M Wolff
- Department of Intensive Care Medicine and Infectious Diseases, Bichat-Claude Bernard University Hospital, AP-HP, 46 Rue Henri Huchard, 75877, Paris Cedex, France
| | - L Bouadma
- Department of Intensive Care Medicine and Infectious Diseases, Bichat-Claude Bernard University Hospital, AP-HP, 46 Rue Henri Huchard, 75877, Paris Cedex, France.,UMR 1137, IAME, Paris Diderot University, Paris, France
| | - J F Timsit
- Department of Intensive Care Medicine and Infectious Diseases, Bichat-Claude Bernard University Hospital, AP-HP, 46 Rue Henri Huchard, 75877, Paris Cedex, France.,UMR 1137, IAME, Paris Diderot University, Paris, France
| | - R Sonneville
- Department of Intensive Care Medicine and Infectious Diseases, Bichat-Claude Bernard University Hospital, AP-HP, 46 Rue Henri Huchard, 75877, Paris Cedex, France. .,UMR1148, LVTS, Sorbonne Paris Cité, Inserm/Paris Diderot University, Paris, France.
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50
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Leng X, Yuan F, Zhao J, Song C, Zhao Z, Zhang Y, Gao Q, Yang F, Jiang W. Long-term seizure outcome in patients with status epilepticus due to acute encephalitis. Seizure 2019; 69:70-75. [DOI: 10.1016/j.seizure.2019.04.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2019] [Revised: 04/05/2019] [Accepted: 04/06/2019] [Indexed: 11/15/2022] Open
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