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Cleaver J, Jeffery K, Klenerman P, Lim M, Handunnetthi L, Irani SR, Handel A. The immunobiology of herpes simplex virus encephalitis and post-viral autoimmunity. Brain 2024; 147:1130-1148. [PMID: 38092513 PMCID: PMC10994539 DOI: 10.1093/brain/awad419] [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: 07/20/2023] [Revised: 10/25/2023] [Accepted: 11/27/2023] [Indexed: 04/06/2024] Open
Abstract
Herpes simplex virus encephalitis (HSE) is the leading cause of non-epidemic encephalitis in the developed world and, despite antiviral therapy, mortality and morbidity is high. The emergence of post-HSE autoimmune encephalitis reveals a new immunological paradigm in autoantibody-mediated disease. A reductionist evaluation of the immunobiological mechanisms in HSE is crucial to dissect the origins of post-viral autoimmunity and supply rational approaches to the selection of immunotherapeutics. Herein, we review the latest evidence behind the phenotypic progression and underlying immunobiology of HSE including the cytokine/chemokine environment, the role of pathogen-recognition receptors, T- and B-cell immunity and relevant inborn errors of immunity. Second, we provide a contemporary review of published patients with post-HSE autoimmune encephalitis from a combined cohort of 110 patients. Third, we integrate novel mechanisms of autoimmunization in deep cervical lymph nodes to explore hypotheses around post-HSE autoimmune encephalitis and challenge these against mechanisms of molecular mimicry and others. Finally, we explore translational concepts where neuroglial surface autoantibodies have been observed with other neuroinfectious diseases and those that generate brain damage including traumatic brain injury, ischaemic stroke and neurodegenerative disease. Overall, the clinical and immunological landscape of HSE is an important and evolving field, from which precision immunotherapeutics could soon emerge.
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Affiliation(s)
- Jonathan Cleaver
- Oxford Autoimmune Neurology Group, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, OX3 9DU, UK
- Department of Neurology, John Radcliffe Hospital, Oxford University Hospitals, Oxford, OX3 9DU, UK
| | - Katie Jeffery
- Department of Microbiology, Oxford University Hospitals NHS Foundation Trust, Oxford, OX3 9DU, UK
- Radcliffe Department of Medicine, University of Oxford, Oxford, OX3 9DU, UK
| | - Paul Klenerman
- Peter Medawar Building for Pathogen Research, University of Oxford, Oxford, OX1 3SY, UK
- Translational Gastroenterology Unit, Nuffield Department of Medicine, University of Oxford, Oxford, OX3 9DU, UK
| | - Ming Lim
- Children’s Neurosciences, Evelina London Children’s Hospital at Guy’s and St Thomas’ NHS Foundation Trust, London, SE1 7EH, UK
- Department Women and Children’s Health, School of Life Course Sciences, King’s College London, London, WC2R 2LS, UK
| | - Lahiru Handunnetthi
- Oxford Autoimmune Neurology Group, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, OX3 9DU, UK
- Wellcome Centre for Human Genetics, University of Oxford, Oxford, OX3 7BN, UK
| | - Sarosh R Irani
- Oxford Autoimmune Neurology Group, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, OX3 9DU, UK
- Department of Neurology, John Radcliffe Hospital, Oxford University Hospitals, Oxford, OX3 9DU, UK
| | - Adam Handel
- Oxford Autoimmune Neurology Group, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, OX3 9DU, UK
- Department of Neurology, John Radcliffe Hospital, Oxford University Hospitals, Oxford, OX3 9DU, UK
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Whitfield T, Fernandez C, Davies K, Defres S, Griffiths M, Hooper C, Tangney R, Burnside G, Rosala-Hallas A, Moore P, Das K, Zuckerman M, Parkes L, Keller S, Roberts N, Easton A, Touati S, Kneen R, Stahl JP, Solomon T. Protocol for DexEnceph: a randomised controlled trial of dexamethasone therapy in adults with herpes simplex virus encephalitis. BMJ Open 2021; 11:e041808. [PMID: 34301646 PMCID: PMC8728349 DOI: 10.1136/bmjopen-2020-041808] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 02/23/2021] [Accepted: 02/25/2021] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Herpes simplex virus (HSV) encephalitis is a rare severe form of brain inflammation that commonly leaves survivors and their families with devastating long-term consequences. The virus particularly targets the temporal lobe of the brain causing debilitating problems in memory, especially verbal memory. It is postulated that immunomodulation with the corticosteroid, dexamethasone, could improve outcomes by reducing brain swelling. However, there are concerns (so far not observed) that such immunosuppression might facilitate increased viral replication with resultant worsening of disease. A previous trail closed early because of slow recruitment. METHOD DexEnceph is a pragmatic multicentre, randomised, controlled, open-label, observer-blind trial to determine whether adults with HSV encephalitis who receive dexamethasone alongside standard antiviral treatment with aciclovir for have improved clinical outcomes compared with those who receive standard treatment alone. Overall, 90 patients with HSV encephalitis are being recruited from a target of 45 recruiting sites; patients are randomised 1:1 to the dexamethasone or control arms of the study. The primary outcome measured is verbal memory as assessed by the Weschler Memory Scale fourth edition Auditory Memory Index at 26 weeks after randomisation. Secondary outcomes are measured up to 72 weeks include additional neuropsychological, clinical and functional outcomes as well as comparison of neuroimaging findings. Patient safety monitoring occurs throughout and includes the detection of HSV DNA in cerebrospinal fluid 2 weeks after randomisation, which is indicative of ongoing viral replication. Innovative methods are being used to ensure recrutiment targets are met for this rare disease. DISCUSSION DexEnceph aims to be the first completed randomised controlled trial of corticosteroid therapy in HSV encephalitis. The results will provide evidence for future practice in managing adults with the condition and has the potential to improve outcomes . ETHICS AND DISSEMINATION The trial has ethical approval from the UK National Research Ethics Committee (Liverpool Central, REF: 15/NW/0545, 10 August 2015). Protocol V.2.1, July 2019. The results will be published and presented as soon as possible on completion. TRIAL REGISTRATION NUMBERS ISRCTN11774734, EUDRACT 2015-001609-16.
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Affiliation(s)
- Thomas Whitfield
- Department of Clinical Infection, Medical Microbiology and Immunology, University of Liverpool, Liverpool, UK
| | - Cristina Fernandez
- Department of Clinical Infection, Medical Microbiology and Immunology, University of Liverpool, Liverpool, UK
| | - Kelly Davies
- Clinical Trials Research Centre, University of Liverpool, Liverpool, UK
| | - Sylviane Defres
- Department of Clinical Infection, Medical Microbiology and Immunology, University of Liverpool, Liverpool, UK
- PLEASE REMOVE THIS ADDRESS ENTRY, X, X, X
- Tropical and Infectious Diseases Unit, Liverpool University Hospitals Foundation Trust, Liverpool, UK
| | - Michael Griffiths
- Department of Clinical Infection, Medical Microbiology and Immunology, University of Liverpool, Liverpool, UK
- Neurology Department, Alder Hey Children's NHS Foundation Trust, Liverpool, Merseyside, UK
| | - Cory Hooper
- Department of Clinical Infection, Medical Microbiology and Immunology, University of Liverpool, Liverpool, UK
| | - Rebecca Tangney
- Pharmacy Department, Liverpool University Hospitals NHS Foundation Trust, Liverpool, Liverpool, UK
| | - Girvan Burnside
- Department of Biostatistics, Faculty of Health and Life Sciences, University of Liverpool, Liverpool, Liverpool, UK
| | - Anna Rosala-Hallas
- Department of Biostatistics, Faculty of Health and Life Sciences, University of Liverpool, Liverpool, Liverpool, UK
| | - Perry Moore
- Deptment of Clinical Neuropsychology, The Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Kumar Das
- Neuroradiology Department, The Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Mark Zuckerman
- South London Specialist Virology Centre, King's College Hospital NHS Foundation Trust, London, London, UK
| | - Laura Parkes
- Division of Neuroscience & Experimental Psychology, University of Manchester, Manchester, UK
| | - Simon Keller
- Pharmacy Department, Liverpool University Hospitals NHS Foundation Trust, Liverpool, Liverpool, UK
| | - Neil Roberts
- The Queen's Medical Research Institute, The University of Edinburgh, Edinburgh, Edinburgh, UK
| | - Ava Easton
- The Encephalitis Society, Malton, North Yorkshire, UK
| | - Saber Touati
- Service des Maladies Infectieuses et Tropicales, CHU Grenoble Alpes, Grenoble, Rhône-Alpes, France
| | - Rachel Kneen
- Department of Neurology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
- REMOVE THI ADDRESS, XXXXX, XXX, XXX
| | - J P Stahl
- Infectious Diseases Department, University of Grenoble, Grenoble, UK
| | - Tom Solomon
- Department of Neurology, Walton Centre NHS Foundation Trust, Liverpool, Liverpool, UK
- National Institute for Health Research Health Protection Research Unit in Emerging and Zoonotic Infections, Institute of Infection Ecology and Veterinary Sciences, University of Liverpool, Liverpool, UK
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Abstract
Herpes simplex virus 1 (HSV-1) can be responsible for life-threatening HSV encephalitis (HSE). The mortality rate of patients with HSE who do not receive antiviral treatment is 70%, with most survivors suffering from permanent neurological sequelae. The use of intravenous acyclovir together with improved diagnostic technologies such as PCR and magnetic resonance imaging has resulted in a reduction in the mortality rate to close to 20%. However, 70% of surviving patients still do not recover complete neurological functions. Thus, there is an urgent need to develop more effective treatments for a better clinical outcome. It is well recognized that cerebral damage resulting from HSE is caused by viral replication together with an overzealous inflammatory response. Both of these processes constitute potential targets for the development of innovative therapies against HSE. In this review, we discuss recent progress in therapy that may be used to ameliorate the outcome of patients with HSE, with a particular emphasis on immunomodulatory agents. Ideally, the administration of adjunctive immunomodulatory drugs should be initiated during the rise of the inflammatory response, and its duration should be limited in time to reduce undesired effects. This critical time frame should be optimized by the identification of reliable biomarkers of inflammation.
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Shin DH. Corticosteroid Treatment for Central Nervous System Infections. JOURNAL OF NEUROCRITICAL CARE 2017. [DOI: 10.18700/jnc.170024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
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Piret J, Boivin G. Innate immune response during herpes simplex virus encephalitis and development of immunomodulatory strategies. Rev Med Virol 2015. [PMID: 26205506 DOI: 10.1002/rmv.1848] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Herpes simplex viruses are large double-stranded DNA viruses. These viruses have the ability to establish a lifelong latency in sensory ganglia and to invade and replicate in the CNS. Apart from relatively benign mucosal infections, HSV is responsible for severe illnesses including HSV encephalitis (HSE). HSE is the most common cause of sporadic, potentially fatal viral encephalitis in Western countries. If left untreated, the mortality rate associated with HSE is approximately 70%. Despite antiviral therapy, the mortality is still higher than 30%, and almost 60% of surviving individuals develop neurological sequelae. It is suggested that direct virus-related and indirect immune-mediated mechanisms contribute to the damages occurring in the CNS during HSE. In this manuscript, we describe the innate immune response to HSV, the development of HSE in mice knock-out for proteins of the innate immune system as well as inherited deficiencies in key components of the signaling pathways involved in the production of type I interferon that could predispose individuals to develop HSE. Finally, we review several immunomodulatory strategies aimed at modulating the innate immune response at a critical time after infection that were evaluated in mouse models and could be combined with antiviral therapy to improve the prognosis of HSE. In conclusion, the cerebral innate immune response that develops during HSE is a "double-edged sword" as it is critical to control viral replication in the brain early after infection, but, if left uncontrolled, may also result in an exaggerated inflammatory response that could be detrimental to the host.
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Affiliation(s)
- Jocelyne Piret
- Research Center in Infectious Diseases, CHU de Québec and Laval University, Quebec City, Quebec, Canada
| | - Guy Boivin
- Research Center in Infectious Diseases, CHU de Québec and Laval University, Quebec City, Quebec, Canada
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Dodd KC, Michael BD, Ziso B, Williams B, Borrow R, Krishnan A, Solomon T. Herpes simplex virus encephalitis in pregnancy - a case report and review of reported patients in the literature. BMC Res Notes 2015; 8:118. [PMID: 25888964 PMCID: PMC4384383 DOI: 10.1186/s13104-015-1071-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2014] [Accepted: 03/18/2015] [Indexed: 01/02/2023] Open
Abstract
Background Herpes simplex virus (HSV) encephalitis is the most common sporadic cause of encephalitis with significant morbidity and mortality that is drastically reduced by early antiviral treatment. Case presentation We report a 37 year old woman, 33 weeks pregnant, who presented with seizures due to proven HSV-1 encephalitis, and who had had a previous episode of probable viral encephalitis aged 14 years. She was successfully treated with aciclovir on both occasions and, in the latter, went on to deliver a healthy infant. This case is compared with 17 cases of HSV encephalitis in pregnancy in the literature identifying a predominance in the late 2nd and 3rd trimesters, perhaps in part due to immunological changes in pregnancy. The clinical presentation is also compared with non-pregnant patients with HSV encephalitis in the largest prospective UK and European studies. We also present practical advice on management from recent national guidelines. Conclusion When pregnant women present with new seizures, headache, impaired consciousness or altered behaviour urgent investigation is required to identify common diagnoses, such as eclampsia, venous sinus thrombosis and metabolic disturbances. Nevertheless, viral encephalitis is a very treatable cause of this presentation with potentially serious complications if missed, and may be more common in latter stages of pregnancy. Encephalitis should not be discounted if the patient is afebrile, has a normal Glasgow coma score, or the cerebrospinal fluid white cell count is only slightly elevated, as these features are well recognised in viral encephalitis.
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Affiliation(s)
- Katherine C Dodd
- Royal Preston Hospital, Sharoe Green Lane North, Preston, PR2 9HT, UK. .,The Walton Centre Neurology NHS Foundation Trust, Lower Lane, Fazakerly, Liverpool, L9 7JL, UK.
| | - Benedict D Michael
- The Walton Centre Neurology NHS Foundation Trust, Lower Lane, Fazakerly, Liverpool, L9 7JL, UK. .,Institute of Infection and Global Health, University of Liverpool, The Ronald Ross Building, West Derby Street, Liverpool, L69 7BE, UK.
| | - Besa Ziso
- The Walton Centre Neurology NHS Foundation Trust, Lower Lane, Fazakerly, Liverpool, L9 7JL, UK.
| | - Bode Williams
- Liverpool Women's Hospital, Crown Street, Liverpool, L8 7SS, UK.
| | - Ray Borrow
- Vaccine Evaluation Unit, Public Health England, Oxford Road, Manchester, M13 9WZ, UK.
| | - Anita Krishnan
- The Walton Centre Neurology NHS Foundation Trust, Lower Lane, Fazakerly, Liverpool, L9 7JL, UK.
| | - Tom Solomon
- The Walton Centre Neurology NHS Foundation Trust, Lower Lane, Fazakerly, Liverpool, L9 7JL, UK. .,Institute of Infection and Global Health, University of Liverpool, The Ronald Ross Building, West Derby Street, Liverpool, L69 7BE, UK.
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Ramos-Estebanez C, Lizarraga KJ, Merenda A. A systematic review on the role of adjunctive corticosteroids in herpes simplex virus encephalitis: is timing critical for safety and efficacy? Antivir Ther 2013; 19:133-9. [DOI: 10.3851/imp2683] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/01/2013] [Indexed: 10/26/2022]
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