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Dulin M, Chevret S, Salmona M, Jacquier H, Bercot B, Molina JM, Lebeaux D, Munier AL. New Insights Into the Therapeutic Management of Varicella Zoster Virus Meningitis: A Series of 123 Polymerase Chain Reaction-Confirmed Cases. Open Forum Infect Dis 2024; 11:ofae340. [PMID: 38957692 PMCID: PMC11218771 DOI: 10.1093/ofid/ofae340] [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: 02/06/2024] [Accepted: 06/17/2024] [Indexed: 07/04/2024] Open
Abstract
Background Varicella zoster virus (VZV) can reactivate and cause meningitis, but few studies have distinguished it from meningoencephalitis regarding treatment recommendations.The objective of this study was to assess the outcomes of a large series of patients with VZV meningitis according to their therapeutic management. Methods We conducted a bicentric retrospective cohort study, in Paris, France, including all adult patients with a cerebrospinal fluid sample positive for VZV by polymerase chain reaction between April 2014 and June 2022. We distinguished meningitis from encephalitis according to the International Encephalitis Consortium criteria. Unfavorable outcome was defined as mortality or functional sequelae defined by a loss of 2 points on the modified Rankin Scale. Results We included 123 patients with meningitis. Among them, 14% received no antivirals, while 20% were treated with oral valacyclovir alone, 41% with a short course of intravenous (IV) acyclovir before switch to valacyclovir, and 25% with a long course of IV acyclovir. Outcomes were favorable regardless of antiviral regimen. In multivariate analysis, only age, underlying immunosuppression, and cranial radiculitis appear to be predictive factors for longer IV therapy, based on the Akaike information criterion. Conclusions In this study, patients with VZV meningitis had a good outcome, with no evidence of any impact of the treatment strategy. However, further studies are needed to support the possibility of milder treatment in immunocompetent patients, avoiding cost and side effects of IV acyclovir.
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Affiliation(s)
- Marie Dulin
- Department of Infectious Diseases, Saint Louis-Lariboisière Hospital, Assistance Publique-Hôpitaux de Paris, Université Paris Cité, Paris, France
| | - Sylvie Chevret
- Biostatistics Department, Saint Louis Hospital, Assistance Publique-Hôpitaux de Paris, Université Paris Cité, Paris, France
| | - Maud Salmona
- Laboratory of Virology, Saint Louis-Lariboisière-Fernand-Widal Hospital Group, Assistance Publique-Hôpitaux de Paris, Université Paris Cité, Paris, France
| | - Hervé Jacquier
- Laboratory of Microbiology, Saint Louis-Lariboisière-Fernand-Widal Hospital Group, Assistance Publique-Hôpitaux de Paris, Université Paris Cité, Paris, France
| | - Béatrice Bercot
- Laboratory of Microbiology, Saint Louis-Lariboisière-Fernand-Widal Hospital Group, Assistance Publique-Hôpitaux de Paris, Université Paris Cité, Paris, France
| | - Jean-Michel Molina
- Department of Infectious Diseases, Saint Louis-Lariboisière Hospital, Assistance Publique-Hôpitaux de Paris, Université Paris Cité, Paris, France
| | - David Lebeaux
- Department of Infectious Diseases, Saint Louis-Lariboisière Hospital, Assistance Publique-Hôpitaux de Paris, Université Paris Cité, Paris, France
| | - Anne-Lise Munier
- Department of Infectious Diseases, Saint Louis-Lariboisière Hospital, Assistance Publique-Hôpitaux de Paris, Université Paris Cité, Paris, France
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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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Lenfant T, L'Honneur A, Ranque B, Pilmis B, Charlier C, Zuber M, Pouchot J, Rozenberg F, Michon A. Neurological complications of varicella zoster virus reactivation: Prognosis, diagnosis, and treatment of 72 patients with positive PCR in the cerebrospinal fluid. Brain Behav 2022; 12:e2455. [PMID: 35040287 PMCID: PMC8865153 DOI: 10.1002/brb3.2455] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 11/05/2021] [Accepted: 11/11/2021] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND VZV infection can involve every level of the neurologic system: from the central nervous system (CNS) to the peripheral nervous system (PNS), including aseptic meningitis. Prognosis seems to differ between these neurological involvements. Prognostic factors remain unknown. METHODS This is a retrospective multicenter study including all patients with a positive VZV polymerase chain reaction (PCR) in the cerebrospinal fluid (CSF) from eight centers in Paris (France) between 2011 and 2018. Unfavorable outcome was defined as mortality linked to VZV or incomplete recovery. Modified Rankin Scale (mRS) evaluated disability before and after the infection, with the difference designated as Rankin Delta. RESULTS Seventy-two patients were included (53% male, median age 51 years, median mRS 0). Immunosuppression was reported in 42%. The clinical spectrum included 26 cases of meningitis, 27 instances of CNS involvement, 16 of PNS involvement, and 3 isolated replications (positive PCR but no criteria for neurological complications from VZV). Antiviral treatment was administered to 69 patients (96%). Sixty-two patients completed follow-up. Death linked to VZV occurred in eight cases. Unfavorable outcome (UO) occurred in 60% and was significantly associated with a higher prior mRS (Odd-ratio (OR) 3.1 [1.4-8.8] p = .012) and the presence of PNS or CNS manifestations (OR 22 [4-181] p = .001, OR 6.2 [1.3-33] p = .03, respectively, compared to meningitis). In the CSF, higher protein level (p < .0001) was also significantly associated with a higher Rankin Delta. CONCLUSIONS Neurological complications of VZV with evidence of CSF viral replication are heterogeneous: aseptic meningitis has a good prognosis, whereas presence of CNS and PNS involvement is associated with a higher risk of mortality and of sequelae, respectively.
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Affiliation(s)
- Tiphaine Lenfant
- Université de Paris, Service de Médecine InterneHôpital Européen Georges Pompidou, AP‐HPParisFrance
| | | | - Brigitte Ranque
- Université de Paris, Service de Médecine InterneHôpital Européen Georges Pompidou, AP‐HPParisFrance
| | - Benoit Pilmis
- Équipe Mobile de Microbiologie CliniqueGroupe Hospitalier Paris Saint JosephParisFrance
| | - Caroline Charlier
- Université de Paris, Equipe Mobile InfectiologieHôpital Cochin Port‐Royal, AP‐HPUnité Biologie des Infections, Institut Pasteur, Inserm U1117ParisFrance
| | - Mathieu Zuber
- Service de Neurologie et NeurovasculaireGroupe Hospitalier Paris Saint JosephParisFrance
| | - Jacques Pouchot
- Université de Paris, Service de Médecine InterneHôpital Européen Georges Pompidou, AP‐HPParisFrance
| | - Flore Rozenberg
- Université de Paris, Service de VirologieHôpital Cochin, AP‐HPParisFrance
| | - Adrien Michon
- Université de Paris, Service de Médecine InterneHôpital Européen Georges Pompidou, AP‐HPParisFrance
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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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Lee JH, Kang J, Seo YD, Kim HC, Shin KJ. Delayed Facial Palsy in a Patient With Varicella Zoster Virus Encephalitis. J Clin Neurol 2021; 17:604-606. [PMID: 34595877 PMCID: PMC8490894 DOI: 10.3988/jcn.2021.17.4.604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Revised: 07/12/2021] [Accepted: 07/12/2021] [Indexed: 11/17/2022] Open
Affiliation(s)
- Jun Ho Lee
- Department of Neurology, Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Jaeho Kang
- Department of Neurology, Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Yeoung Deok Seo
- Department of Neurology, Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Hyung Chan Kim
- Department of Neurology, Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Kyong Jin Shin
- Department of Neurology, Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea.
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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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7
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Parkes-Smith J, Chaudhuri A. Varicella Zoster Virus: An under-recognised cause of central nervous system infections? Intern Med J 2020; 52:100-104. [PMID: 32896944 DOI: 10.1111/imj.15048] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Revised: 08/13/2020] [Accepted: 08/24/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Varicella zoster virus causes infections of the central nervous system (CNS) manifesting as meningitis or encephalitis. It is not commonly tested in CNS infections when compared to Enterovirus (EV) and Herpes Simplex Virus 1 (HSV-1) and 2 (HSV-2). Cerebrospinal fluid (CSF) findings of viral CNS infections are thought to be comparable. AIM To describe the manifestations of VZV CNS infections and ascertain if there is a predominant syndrome. To compare CSF parameters of VZV with EV, HSV-1 and HSV-2. METHODS Retrospective study at two hospitals in Brisbane, reviewing medical notes and laboratory information system for results between January 2001-2019. The following parameters were recorded - disease classification, presence of rash, duration of symptoms prior to hospitalisation, length of admission, duration of antiviral treatment, 30-day mortality. CSF biochemistry, cell count (differential), PCR for VZV, EV, HSV-1 and HSV-2 were recorded. Statistical analysis of CSF parameters included student's t-test and linear regression. RESULTS Incidence of meningitis was comparable to encephalitis (44 vs 39%) in 52 cases. CSF protein in VZV was significantly elevated compared to EV (median 1121 vs 569 mg/L p<0.001) as was CSF monocytosis (96% vs 61%; p<0.001). CSF parameters between VZV, HSV-1 and HSV-2 were similar. VZV had a higher incidence than HSV-1 or 2 while it was tested one-third as often. CONCLUSIONS VZV CNS infection cannot be predicted by syndrome. CSF findings are markedly different from EV but like HSV-1 and 2. VZV should be routinely tested with HSV-1 and 2 when viral CNS infection is suspected. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Jill Parkes-Smith
- Department of Infectious Diseases, Prince Charles Hospital, Rode Road, Chermside, Queensland, 4032, Australia
| | - Alex Chaudhuri
- Department of Infectious Diseases, Prince Charles Hospital, Rode Road, Chermside, Queensland, 4032, Australia.,Northside School of Medicine, Chermside, University of Queensland, Queensland, 4032
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Pfefferle S, Christner M, Aepfelbacher M, Lütgehetmann M, Rohde H. Implementation of the FilmArray ME panel in laboratory routine using a simple sample selection strategy for diagnosis of meningitis and encephalitis. BMC Infect Dis 2020; 20:170. [PMID: 32087681 PMCID: PMC7036261 DOI: 10.1186/s12879-020-4904-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Accepted: 02/18/2020] [Indexed: 12/13/2022] Open
Abstract
Background Infectious meningitis is a serious disease and patient outcome relies on fast and reliable diagnostics. A syndromic panel testing approach like the FilmArray ME can accelerate diagnosis and therefore decrease the time to pathogen specific therapy. Yet, its clinical utility is controversial, mainly because of a remaining uncertainty in correct interpretation of results, limited data on its performance on clinical specimens and its relatively high costs. The aim of this study was to analyze clinical performance of the assay in a real life setting at a tertiary university hospital using a pragmatic and simple sample selection strategy to reduce the overall cost burden. Methods Over a period of 18 months we received 4623 CSF samples (2338 hospitalizations, 1601 individuals). FilmArray ME analysis was restricted to CSF-samples with a high pretest probability of infectious meningitis, e.g. positive Gram-stain, samples in which leukocytes and/or bacteria were evident or urgent suspicion of infection was communicated by clinicians. N = 171 samples matched to our risk criteria and were subjected to FilmArray ME analysis. Those samples were also analyzed by reference methods: culture only (n = 45), PCR only (n = 20) or both methods (n = 106). Results 56/171 (32.75%) were FilmArray ME positive. Bacterial pathogens were detected in 30/56 (53.57%), viral pathogens were detected in 27/56 (48.21%) and yeast DNA was detected in 1/56 (1.79%) of positive samples. Double detection occurred in 2/56 samples. In 52/56 (92.86%) FilmArray ME positive samples, results could be confirmed by the reference assays (sensitivity = 96.30%, specificity =96.58%). Conclusion The FilmArray ME assay is a fast and reliable diagnostic tool for the management of infectious meningitis and can easily be implemented in routine diagnostic workflows. However, correlation of test results and underlying clinical symptoms requires experienced users and the awareness of potentially false negative or false positive results. Moreover, considering the need for antimicrobial susceptibility testing, the use of molecular tests as a stand-alone diagnostic cannot be recommended.
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Affiliation(s)
- Susanne Pfefferle
- Institut für Medizinische Mikrobiologie, Virologie und Hygiene, Universitätsklinikum Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany.
| | - Martin Christner
- Institut für Medizinische Mikrobiologie, Virologie und Hygiene, Universitätsklinikum Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Martin Aepfelbacher
- Institut für Medizinische Mikrobiologie, Virologie und Hygiene, Universitätsklinikum Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Marc Lütgehetmann
- Institut für Medizinische Mikrobiologie, Virologie und Hygiene, Universitätsklinikum Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Holger Rohde
- Institut für Medizinische Mikrobiologie, Virologie und Hygiene, Universitätsklinikum Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
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Tabaja H, Sharara SL, Abi Aad Y, Beydoun N, Tabbal S, Makki A, Mahfouz R, Kanj SS. Varicella zoster virus infection of the central nervous system in a tertiary care center in Lebanon. Med Mal Infect 2019; 50:280-287. [PMID: 31526545 DOI: 10.1016/j.medmal.2019.08.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2018] [Revised: 08/20/2018] [Accepted: 08/27/2019] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To describe the clinical manifestations and treatment outcomes of patients with VZV meningitis and encephalitis consulting at two medical centers in Lebanon. METHODS Retrospective study of patients with VZV meningitis and/or encephalitis confirmed by positive cerebrospinal fluid (CSF) VZV PCR. RESULTS Twenty patients were identified (13 males). The average age was 49.7±22.2 years. The most common complaint was headache (n=17/20). Common comorbidities included hypertension (n=7/20) and diabetes mellitus (n=5/20). Immunosuppression was reported in two patients. Vesicles were only observed in eight patients. Altered mental status, focal neurological deficits, and fever were documented in six, two, and four patients respectively. All patients had CSF leukocytosis with lymphocytic predominance, normal CSF/serum glucose ratio, and high CSF protein. Eighteen patients had brain CT scans showing no relevant findings. Two of 12 patients with brain MRI had focal abnormalities. Unilateral temporal slow waves were observed in three of four patients who underwent electroencephalograms. Four patients had encephalitis and 16 had meningitis. Eighteen patients received an antiviral therapy. Treatment either included intravenous acyclovir or oral valacyclovir. The encephalitis and meningitis groups had comparable mean duration of treatment (13.5±6.6 vs. 12.2±5.4, respectively). All admitted patients showed clinical cure with no reported neurological sequelae. CONCLUSION VZV infection should be suspected in any patient with signs and symptoms of viral meningitis or encephalitis, irrespective of age, immune status, presence or absence of vesicles, fever, or neck stiffness.
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Affiliation(s)
- H Tabaja
- Infectious Diseases Unit, Department of Internal Medicine, American University of Beirut Medical Center, PO Box 11-0236, Riad El Solh 1107 2020, Beirut, Lebanon
| | - S L Sharara
- The School of Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Y Abi Aad
- Infectious Diseases Unit, Department of Internal Medicine, American University of Beirut Medical Center, PO Box 11-0236, Riad El Solh 1107 2020, Beirut, Lebanon; The School of Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - N Beydoun
- The School of Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - S Tabbal
- The division of Neurology, American University of Beirut Medical Center, Beirut, Lebanon
| | - A Makki
- The division of Neurology, American University of Beirut Medical Center, Beirut, Lebanon
| | - R Mahfouz
- The division of Diagnostic Molecular Pathology, Department of Pathology and Laboratory Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - S S Kanj
- Infectious Diseases Unit, Department of Internal Medicine, American University of Beirut Medical Center, PO Box 11-0236, Riad El Solh 1107 2020, Beirut, Lebanon.
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Tique V, Mattar S, Freire M, Illian E, Camargo F, Vergara O, Moraes-Figueiredo LT. Epidemiological surveillance of herpes viral encephalitis in Cordoba, Colombia. Rev Salud Publica (Bogota) 2018; 18:581-591. [PMID: 28453063 DOI: 10.15446/rsap.v18n4.47517] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2014] [Accepted: 11/07/2015] [Indexed: 01/01/2023] Open
Abstract
Objective To establish an epidemiological surveillance of viral herpes encephalitis in major hospitals of Monteria, Cordoba. Methods From September 2009 to December 2011, a descriptive study of cases of viral encephalitis was made in three hospitals in the city of Monteria. Cerebrospinal fluid (CSF) samples from 118 patients were included in the study. Clinical aspects, as well as cytochemical and microbiological analysis (Gram stain and culture) of CSF, were used for selecting the patients. Virus detection was performed by using multiplex nested PCR for Herpes simplex virus 1 and 2, Epstein Barr virus, Cytomegalovirus and Varicella zoster virus. Results Viral DNA of herpesvirus was detected in the CSFs of 30 (25.4 %) participants, as follows: 22 (18.6 %) Herpes simplex 1 and 2 viruses, 4 (3.3 %) Cytomegalovirus and 1 (0.8 %) Varicella zoster virus. Co-infections were observed in 3 patients (2.5 %), 1 case by HSV-VZV and 2 cases by CMV/HSV. The clinical manifestations of the patients included: headache (18.6 %), fever (14.4 %), asthenia (10.1 %), seizures (9.3 %), vomiting (8.4 %), and stiff neck (5.9 %). Thirty percent of the patients also had HIV-AIDS. A case fatality rate of 20 % was observed for the patients. Conclusions This paper shows that herpesvirus is a cause of infection of the CNS in patients from Cordoba. This study contributes to the epidemiology of encephalitis, as well as to patient management.
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Affiliation(s)
| | | | - María Freire
- National Institute of Infectious Diseases, Buenos Aires, Argentina,
| | - Eduardo Illian
- National Institute of Infectious Diseases, Buenos Aires, Argentina,
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Neurological Disorders Associated with Human Alphaherpesviruses. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2018; 1045:85-102. [PMID: 29896664 DOI: 10.1007/978-981-10-7230-7_5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Herpes simplex virus (HSV) encephalitis is the most common cause of sporadic fatal encephalitis worldwide, and central nervous system (CNS) involvement is observed in approximately one-third of neonatal HSV infections . In recent years, single-gene inborn errors of innate immunity have been shown to be associated with susceptibility to HSV encephalitis . Temporal lobe abnormalities revealed by magnetic resonance imaging-the most sensitive imaging method for HSV encephalitis-are considered strong evidence for the disease. Detection of HSV DNA in the cerebrospinal fluid by polymerase chain reaction (PCR) is the gold standard for the diagnosis of HSV encephalitis and neonatal meningoencephalitis. Intravenous acyclovir for 14-21 days is the standard treatment in HSV encephalitis. Neurological outcomes in neonates are improved by intravenous high-dose acyclovir for 21 days followed by oral acyclovir suppressive therapy for 6 months. Varicella-zoster virus (VZV) causes a wide range of CNS manifestations. VZV encephalitis typically occurs after primary infection, and reactivation of VZV may cause encephalitis. On the other hand, VZV infection of cerebral arteries produces vasculopathy, which can manifest as ischemic stroke. Vasculopathy can occur after primary infection or reactivation of VZV. PCR detection of VZV DNA in the cerebrospinal fluid can be used for the diagnosis of encephalitis or vasculopathy. Although there are no controlled treatment trials to assess VZV treatments of encephalitis or vasculopathy, intravenous acyclovir is a common treatment.
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12
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Carey RAB, Chandiraseharan VK, Jasper A, Sebastian T, Gujjarlamudi C, Sathyendra S, Zachariah A, Abraham AM, Sudarsanam TD. Varicella Zoster Virus Infection of the Central Nervous System - 10 Year Experience from a Tertiary Hospital in South India. Ann Indian Acad Neurol 2017; 20:149-152. [PMID: 28615901 PMCID: PMC5470156 DOI: 10.4103/aian.aian_484_16] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Varicella zoster virus is an exclusively human neurotrophic virus. The primary infection with the virus causes varicella. The virus remains latent in nervous tissue and upon secondary activation causes a variety of syndromes involving the central nervous system (CNS) including meningoencephalitis and cerebellitis. MATERIALS AND METHODS In this study, we looked at the epidemiology, clinical and laboratory features, and outcomes of patients who were admitted with varicella zoster of the CNS from 2005 to 2014. RESULTS There were 17 patients. Fever was present in 13 patients, seizures in 9 patients and headache and vomiting in 4 patients each. A generalized varicella rash was present in 8 out of 17 patients. A single dermatomal herpes zoster was present in seven patients. Two patients had no rash. Varicella zoster polymerase chain reaction (PCR) in cerebrospinal fluid (CSF) was done in 5 patients of which 4 were positive and 1 was negative. Nine patients had diabetes with an average glycated hemoglobin of 8.6%. Total number of deaths was five. CONCLUSIONS Patients with diabetes who develop varicella or herpes zoster may be at risk for CNS complications. The diagnosis of varicella encephalitis has to rest on a combination of clinical findings and CSF PCR, as neither the rash nor the PCR is sensitive enough to diagnose all the cases with varicella encephalitis.
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Affiliation(s)
| | | | - Anitha Jasper
- Department of Radiology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Tunny Sebastian
- Department of Biostatistics, Christian Medical College, Vellore, Tamil Nadu, India
| | | | - Sowmya Sathyendra
- Department of Medicine, Christian Medical College, Vellore, Tamil Nadu, India
| | - Anand Zachariah
- Department of Medicine, Christian Medical College, Vellore, Tamil Nadu, India
| | - Asha Mary Abraham
- Department of Clinical Virology, Christian Medical College, Vellore, Tamil Nadu, India
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Central nervous system infections caused by varicella-zoster virus. J Neurovirol 2016; 22:529-32. [DOI: 10.1007/s13365-016-0422-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2015] [Revised: 12/30/2015] [Accepted: 01/04/2016] [Indexed: 10/22/2022]
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Herpes simplex and varicella zoster CNS infections: clinical presentations, treatments and outcomes. Infection 2015; 44:337-45. [PMID: 26680781 DOI: 10.1007/s15010-015-0867-6] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Accepted: 12/02/2015] [Indexed: 10/22/2022]
Abstract
OBJECTIVES To describe the clinical manifestations, cerebrospinal fluid (CSF) characteristics, imaging studies and prognostic factors of adverse clinical outcomes (ACO) among adults with herpes simplex virus (HSV) or varicella zoster virus (VZV) CNS infections. METHODS Retrospective review of adult patients with positive HSV or VZV polymerase chain reaction on CSF from an observational study of meningitis or encephalitis in Houston, TX (2004-2014), and New Orleans, LA (1999-2008). RESULTS Ninety-eight adults patients were identified; 25 had encephalitis [20 (20.4 %) HSV, 5 (5.1 %) VZV], and 73 had meningitis [60 (61.1 %) HSV and 13 (13.3 %) VZV]. HSV and VZV had similar presentations except for nausea (P < 0.01) and rash (P < 0.001). The CSF profile did not differ between HSV and VZV infection. Abnormal neuroimaging findings were found in 11.6 % (10/86) brain CTs and 21.3 % (16/75) brain MRIs. The EEG was abnormal in 57.9 % (11/19). Sixteen patients (16.3 %) had an ACO (10 HSV encephalitis, 3 VZV encephalitis and 3 VZV meningitis). Intravenous acyclovir administered within 48 h was protective against an ACO [OR 0.19 (0.04-0.80), P = 0.02). However, on logistic regression only Charlson comorbidity score >1 and an encephalitis presentation were independently associated with an ACO. The treatment for HSV meningitis was variable, and all patients had a good clinical outcome. CONCLUSION Alpha herpes CNS infections due to HSV and VZV infections have similar clinical and laboratory manifestations. ACO was observed more frequently in those patients with comorbidities and an encephalitis presentation.
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Varicella-zoster virus infections of the central nervous system – Prognosis, diagnostics and treatment. J Infect 2015; 71:281-93. [DOI: 10.1016/j.jinf.2015.06.004] [Citation(s) in RCA: 104] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2015] [Revised: 06/03/2015] [Accepted: 06/06/2015] [Indexed: 11/23/2022]
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Pollak L, Mehta SK, Pierson DL, Sacagiu T, Avneri Kalmanovich S, Cohrs RJ. Varicella-zoster DNA in saliva of patients with meningoencephalitis: a preliminary study. Acta Neurol Scand 2014; 131:417-21. [PMID: 25314141 DOI: 10.1111/ane.12335] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/19/2014] [Indexed: 12/23/2022]
Abstract
OBJECTIVES Since the routine use of polymerase chain reaction testing (PCR) in diagnosing herpes infections, varicella-zoster virus is increasingly recognized as a cause of varicella-zoster meningoencephalitis (VZV ME) among immunocompetent patients. We were interested to determine whether patients with VZV ME had VZV DNA in their saliva during the acute phase of the illness. MATERIALS AND METHODS Forty-five consecutive patients who underwent a lumbar puncture for diagnostic purposes were included in the study. The cerebrospinal fluid was examined for the presence of VZV DNA by PCR, and patients with positive findings were treated with acyclovir. The saliva was later analyzed in a blinded fashion for the presence of VZV DNA. RESULTS VZV DNA was found in saliva in four of five (80%) patients with PCR confirmed VZV ME (sensitivity 0.8, specificity 0.84, and likelihood ratio 5). This was significantly more than in patients with non-zoster viral ME (0%, P = 0.009), parainfectious headache (12%, P = 0.03) and controls (9.5%, P = 0.007). In immunocompromised patients with systemic lymphoma and AIDS, VZV DNA was present at a similar rate (67%, P = 0.6). CONCLUSIONS We have found VZV DNA in saliva of patients with PCR confirmed VZV ME at a higher proportion than in controls and patients with non-VZV viral ME. This finding might be of clinical importance, especially in immunocompetent individuals with suspected VZV ME where the results of genetic and immunological testing are not conclusive.
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Affiliation(s)
- L. Pollak
- Department of Neurology; The Assaf Harofeh Medical Center; affiliated to The Sackler Faculty of Medicine; Tel Aviv University; Zerifin Israel
| | | | | | - T. Sacagiu
- Department of Neurology; The Assaf Harofeh Medical Center; affiliated to The Sackler Faculty of Medicine; Tel Aviv University; Zerifin Israel
| | - S. Avneri Kalmanovich
- Department of Neurology; The Assaf Harofeh Medical Center; affiliated to The Sackler Faculty of Medicine; Tel Aviv University; Zerifin Israel
| | - R. J. Cohrs
- Departments of Neurology and Microbiology; University of Colorado School of Medicine; Aurora CO USA
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Kadambari S, Okike I, Ribeiro S, Ramsay ME, Heath PT, Sharland M, Ladhani SN. Seven-fold increase in viral meningo-encephalitis reports in England and Wales during 2004–2013. J Infect 2014; 69:326-32. [DOI: 10.1016/j.jinf.2014.05.012] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2014] [Accepted: 05/26/2014] [Indexed: 12/26/2022]
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Venhovens J, Stelten B, Feyen BFE, van Dijk G, Meulstee J. Ischemic Stroke as a Complication of Varicella Zoster Encephalitis: A Case Report With Detailed EEG Discussion. Clin EEG Neurosci 2014; 45:310-314. [PMID: 24296359 DOI: 10.1177/1550059413504756] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2013] [Revised: 08/08/2013] [Accepted: 08/16/2013] [Indexed: 11/15/2022]
Abstract
A 72-year-old man with varicella zoster virus (VZV) encephalitis complicated by an ischemic stroke in the right internal capsule, possibly due to secondary small-vessel vasculopathy, is described in this case report. The focus of this article is on the electroencephalogram (EEG) description of varicella zoster encephalitis and secondary vasculopathy because EEG descriptions are scarce in the literature and detailed descriptions are lacking. In this patient's EEG, right temporal theta waves were found in combination with a mild slowing of the background rhythm to 7.5 to 8 Hz in the acute stage with an amplitude asymmetry (right temporal lobe amplitudes were significantly higher compared with the left side). The theta waves were thought to originate from the ischemic lacunar stroke, the slowing of the background rhythm from early encephalitis, and the amplitude asymmetry was presumed to be of physiologic origin. A follow-up EEG 6 days after initiation of treatment with acyclovir showed a normal symmetrical background rhythm of 8 to 8.5 Hz, wherein the theta waves were significantly reduced in abundance, and the amplitude asymmetry was unchanged. In conclusion, the EEG may localize focal abnormalities possibly due to cortical or lacunar ischemia, which could be explained by early small and/or large vessel vasculopathy in patients with suspected VZV encephalitis.
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Affiliation(s)
| | | | - Bart F E Feyen
- Department of Neurosurgery, Antwerp University Hospital, Antwerp, Belgium
| | | | - Jan Meulstee
- Canisius Wilhelmina Hospital, Nijmegen, Netherlands
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Choi R, Kim GM, Jo IJ, Sim MS, Song KJ, Kim BJ, Na DL, Huh HJ, Kim JW, Ki CS, Lee NY. Incidence and clinical features of herpes simplex viruses (1 and 2) and varicella-zoster virus infections in an adult Korean population with aseptic meningitis or encephalitis. J Med Virol 2014; 86:957-62. [PMID: 24610349 DOI: 10.1002/jmv.23920] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/04/2014] [Indexed: 01/05/2023]
Abstract
Since there are limited data on the incidence and clinical findings of central nervous system (CNS) infection by three α-herpesviruses including human herpes simplex virus 1 (HSV-1), HSV-2 and varicella-zoster virus (VZV) in Korea, a retrospective analysis of clinical data and polymerase chain reaction (PCR) results was performed in patients who presented with suspicion of acute viral meningitis and/or encephalitis at the emergency department of a tertiary referral hospital in Seoul, Korea. During the 3-year study period, a total of 224 cerebrospinal fluid (CSF) samples from 224 patients were examined. Among the 224 patients, 135 (60.3%) patients were identified as having aseptic meningitis (n = 70, 51.9%), encephalitis (n = 41, 30.4%) or meningoencephalitis (n = 24, 17.8%) at discharge. Twenty-four (17.8%) patients were identified as having VZV meningitis (n = 16, 11.9%), VZV meningoencephalitis (n = 2, 1.5%), HSV-2 meningitis (n = 4, 3.0%), or HSV-1 encephalitis (n = 2, 1.5%). Of the 24 patients infected with the three herpesviruses, immunocompromised patients accounted for 33.3% (n = 8). Skin rashes were observed in half (n = 9) of the patients with VZV, and none with HSV-1 or HSV-2. One patient with VZV meningitis and four patients with brain parenchymal involvement had neurologic sequelae. In conclusion, three herpesviruses are important causative agents of CNS infectious disease with significant morbidity in adults, regardless of the immunologic status. Therefore, CSF should be examined for HSV-1, HSV-2, and VZV using sensitive diagnostic methods in all cases of adult patients with clinical manifestations of CNS disease in order to identify the correct etiology and to determine appropriate therapy.
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Affiliation(s)
- Rihwa Choi
- Department of Laboratory Medicine and Genetics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Becerra JCL, Sieber R, Martinetti G, Costa ST, Meylan P, Bernasconi E. Infection of the central nervous system caused by varicella zoster virus reactivation: a retrospective case series study. Int J Infect Dis 2013; 17:e529-34. [DOI: 10.1016/j.ijid.2013.01.031] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2012] [Revised: 12/17/2012] [Accepted: 01/13/2013] [Indexed: 10/27/2022] Open
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