Herpes simplex virus type 1 encephalitis associated with acute retinal necrosis syndrome in an immunocompetent patient

Clinical Spectrum of Uveitis Induced by Herpes Simplex Virus with Posterior Pole Involvement at Initial Presentation: A Case Series and Literature Review

PURPOSE

To report four cases of herpes simplex virus-induced uveitis with posterior pole involvement at initial presentation.

CASE PRESENTATIONS

In case 1, the posterior pole initially showed dense vitreous hemorrhage from the optic disc, multiple subretinal lesions around the optic disc, and retinal arterial sheath prior to retinal necrosis. In case 2, the posterior pole presented with optic disc edema, retinal venous tortuosity, and arterial sheathing around the optic disc prior to the peripheral retinal necrosis. In case 3 diagnosed with posterior herpetic uveitis, the posterior pole showed retinal arterial sheath and macular structural abnormities. In case 4, the posterior pole demonstrated optic disc swelling, along with perivascular retinal hemorrhage 4 days prior to peripheral retinal necrosis.

CONCLUSIONS

Posterior pole involvement might occur either solely or before the development of peripheral retinal necrosis in patients with herpes simplex virus-induced acute retinal necrosis with and without prior central nervous system herpetic virus infection.

A Review of the Treatment of Herpes Simplex Virus-1 Encephalitis in Six Immunocompetent Patients

Introduction

The optimal treatment regimen for herpes simplex-1 (HSV-1) encephalitis is ill-defined. Current guidelines recommend the initiation of acyclovir in all suspected cases of encephalitis; however, there is limited research regarding the details of acyclovir treatment or the adjuvant use of corticosteroids. Specifically, there is a paucity of evidence-based guidelines detailing the optimal management of HSV-1 encephalitis in immunocompetent patients. In this study, we conducted a review of cases of immunocompetent patients with HSV-1 encephalitis to compare patterns in treatment and outcomes. 

Methods

A review of the literature was performed using PubMed using the terms herpes encephalitis, HSV, herpes zoster, and immunocompetent to identify cases of HSV-1 encephalitis in immunocompetent patients. The results were screened for cases describing the treatment regimen of HSV-1 encephalitis-positive, immunocompetent patients. 

Results

Six cases were identified. All six patients were treated with acyclovir with one patient receiving adjuvant corticosteroid therapy. Additionally, three patients were found to have acyclovir resistance and were transitioned to foscarnet. Eventually, one patient expired, two patients recovered with chronic morbidities of varying severity, and three patients made a full recovery. 

Discussion

Inconsistencies in the patient's disease course, therapeutic regimen, and comorbidities could all play a role in the varying case outcomes. While the optimal timing and composition of therapies in HSV-1 encephalitis in immunocompetent patients are still unclear, it seems the timely administration of antiviral treatment remains essential. Further research is needed to optimize HSV-1 encephalitis therapeutic regimens and improve patient outcomes. 

Acute retinal necrosis in a patient with remote severe herpes simplex encephalitis

A 60-year-old man with a history of severe herpes simplex virus type 1 (HSV-1) encephalitis 2 years prior presented with acute onset of visual loss in the left eye. Dilated funduscopic examination showed retinitis and occlusive vasculitis with retinal necrosis. PCR of the vitreous fluid was positive for HSV-1, and he was diagnosed with acute retinal necrosis (ARN) due to HSV-1. The patient was treated with intravenous acyclovir and intravitreous foscarnet for 2 weeks, followed by high dose oral valacyclovir for 2 weeks. He was subsequently placed on planned life-long suppressive valacyclovir. His case demonstrates that acute visual loss concomitant with or subsequent to HSV-1 encephalitis warrants suspicion of ARN. Prompt therapy with effective antiviral medication is necessary to reduce the risk of sight-threatening complications. Chronic suppression with oral antiviral therapy after ARN is recommended to prevent involvement of the contralateral eye, though there is no consensus on the duration and dosage of antivirals.

Real-time polymerase chain reaction in acute retinal necrosis following encephalitis

Acute retinal necrosis (ARN) following herpes simplex encephalitis (HSE) in an immunocompetent patient is a rare condition. Quantitative real-time polymerase chain reaction (qPCR) has made it possible to identify and quantify viral genome. We report a case of ARN following HSE managed with the help of qPCR. A 45-year-old man developed ARN following HSE and was treated with intravenous acyclovir and intravitreal foscarnet. The retinitis did not respond initially and the qPCR demonstrated a rise in the number of copies of the HSV-1 viral genome. With continued treatment with intravenous acyclovir and intravitreal ganciclovir, the retinitis healed and the qPCR confirmed a reduction in the viral load. qPCR has a high sensitivity and specificity for HSV and is a useful tool for diagnosis and treatment of viral retinitis.

Fulminant bilateral acute retinal necrosis syndrome associated with viral encephalitis: A case report

Herpes simplex virus (HSV) is the most common cause of acute viral encephalitis. Acute retinal necrosis (ARN) is a rapidly progressing and potentially blinding eye disease that may be induced by HSV. The present case study reports the very rare case of a patient with herpes simplex encephalitis (HSE) combined with acute retinal necrosis (ARN). A 47-year-old woman was admitted to hospital with persistent high fever and somnolence for 5 days. Magnetic resonance imaging showed abnormal signals in the right medial temporal lobes, and HSV-1 was identified in the serum and cerebrospinal fluid. Five days later, despite treatment with intravenous acyclovir and partial improvement in consciousness, the patient suddenly developed blurred vision and bilateral visual pain. Fundus fluorescence angiography revealed bilateral vessel obstruction and flaky reduced fluorescence. ARN was diagnosed clinically. Dexamethasone was administered as an anti-inflammatory adjunct to intravenous acyclovir therapy. The visual acuity of the patient was reduced to mere light perception a further 4 days later. The present case indicates that HSE may be complicated with ARN, causing a reduction in visual acuity to mere light perception within a very short time.

Chronic herpes simplex virus type 2 encephalitis associated with posterior uveitis

We report on a patient with chronic herpes simplex virus-2 encephalitis who was characteristic for concomitantly having chronic or recurrent posterior uveitis. A 66-year-old immunocompetent man suffering from a 6-month refractory posterior uveitis developed a 1-month history of impaired short-term memory and orientation. Brain MRI demonstrated hyperintense lesions in the right parietal lobe in diffusion and fluid attenuated inversion recovery (FLAIR) sequences. Cerebrospinal fluid (CSF) examination showed mild pleocytosis and increased protein concentration. Quantitative PCR for HSV-2 DNA was positive in CSF. Treated with acyclovir, his cognitive functions gradually improved and the posterior uveitis was cured. Clinicians must be aware that HSV-2 should be considered in the aetiological investigation of chronic encephalitis in an immunocompetent patient. HSV-2 is well known for its ability to cause unilateral chronic or recurrent posterior uveitis. Therefore, posterior uveitis should be considered as an associated feature of HSV-2 encephalitis.

Probable acyclovir-induced angioedema in a patient with HIV infection and suspected varicella-zoster virus encephalitis

PURPOSE

A probable acyclovir-associated hypersensitivity reaction resulting in severe facial angioedema and respiratory distress is reported.

SUMMARY

A 51-year-old woman with human immunodeficiency virus (HIV) infection and end-stage renal disease arrived at the emergency department (ED) with a diffuse rash on the chest and back; she was diagnosed with varicella-zoster virus infection, received one dose of i.v. acyclovir, and was discharged home with a prescription for valacyclovir. After taking one dose of the drug, she became confused and agitated. The next day the patient returned to the ED; she was confused and unresponsive, with signs and symptoms suggesting viral encephalitis. After a workup including lumbar puncture fluid, she was treated empirically with i.v. acyclovir for viral encephalitis. Within one hour of receiving the acyclovir infusion, the patient developed angioedema of the lips, tongue, and periorbital areas requiring intubation and transfer to the intensive care unit. Further acyclovir therapy was withheld, and foscarnet therapy was initiated for the presumptive treatment of viral encephalitis. Over the next few days, the patient's angioedema completely resolved; her mental status gradually improved while she completed a 14-day course of foscarnet therapy. The application of the Naranjo scale indicated a probable adverse reaction to acyclovir, likely mediated by acyclovir-specific immunoglobulin E, highlighting the need to consider alternative antiviral agents without cross-reactivity to acyclovir in patients with confirmed or suspected viral encephalitis.

CONCLUSION

A 51-year-old woman with HIV infection developed probable acyclovir-induced angioedema after receiving i.v. acyclovir therapy for suspected viral encephalitis.

Epstein-Barr virus and acute retinal necrosis in a 5-year-old immunocompetent child

Objective

To describe a case of bilateral acute retinal necrosis syndrome (ARNS) in a 5-year-old boy.

Method

A retrospective, interventional case is described in one child attending the pediatric ophthalmology section, complaining of sudden bilateral red eye and haze-impaired vision. A standardized ophthalmologic examination and specific serological probes supported the diagnosis of severe bilateral ARNS in an immunocompetent child.

Results

The reduced visual acuity (<20/400), the ocular fundus signs (perivasculitis, thrombosis and retinal edema) and the positive immunoglobulin M anti-Epstein Barr virus serology, lead us to the ARNS definitive diagnosis. Antiviral therapy (Acyclovir; Zovirax^®), ciclopentolate dilating eye drops, and antiplatelet treatment (acetil salicylic acid; Aspirin^®) were administered until recovering the final visual acuity (20/40).

Conclusions

The ARNS is an ocular disease with poor prognosis, which in turns may display better course when determining the etiopathogenic virus and selecting the appropriate and precocious therapy.

[Acute retinal necrosis from the virologist's perspective]

Acute retinal necrosis occurs in approximately one per million persons per year and is caused in approximately 70% of the cases by the varicella zoster virus or in about 30% of the cases by herpes simplex virus. The early diagnosis is primarily based on virus-specific polymerase chain reaction in fluid from the anterior chamber or vitreous humor and can be supported by the determination of specific antibody titers from fluid and serum. Virus detection provides the basis for early causative therapy which limits disease progression and risk of complications. Retinal infections by varicella zoster virus or herpes simplex virus are treated with aciclovir, ganciclovir, or famciclovir. Ganciclovir and valganciclovir are used for the therapy of retinal cytomegalovirus infections. In the case of resistance development, foscarnet or cidofovir are available as second line antiviral drugs. The early use of specific antiviral agents is a crucial prerequisite for optimized therapy of acute retinal necrosis.

Optic chiasm involvement secondary to herpetic encephalitis. A case report

Herpes simplex (HSV) encephalitis is one of the most common central nervous system (CNS) viral infections in adults. Early diagnosis is essential for treatment. We describe the case of a 70-year-old man who reported sudden bilateral reduction of visus. Four days after admission the patient showed high fever, followed the next day by a generalised convulsive crisis and coma. A first magnetic resonance imaging (MRI) showed no alterations, whereas the second showed the usual patterns of HSV encephalitis. With a clinical suspicion of herpetic encephalitis an intravenous therapy with acyclovir was established. The diagnosis of herpetic encephalitis was confirmed by cerebrospinal fluid (CSF) detection of herpes simplex DNA sequences. A further ten days later we performed a third MRI, demonstrating the typical pattern of HSV encephalitis and an increase in size and signal of the optic chiasm.

Impaired Plasmacytoid Dendritic Cell Innate Immune Responses in Patients with Herpes Virus-Associated Acute Retinal Necrosis

Plasmacytoid dendritic cells (PDC), the main producers of type I IFNs in the blood, are important for the recognition and control of viral and bacterial infections. Because several viruses induce IFN-alpha production, severe courses of herpes virus infections in nonimmunocompromised patients may be related to numerical or functional PDC deficits. To evaluate this hypothesis, PBMC and PDC were repeatedly isolated from nine patients with acute retinal necrosis (ARN), caused by herpes simplex or varicella zoster virus. The patients experienced meningitis/encephalitis and frequent infections in childhood (n = 2), recurrent herpes virus infections at unusual localizations (n = 2), ocular surgery (n = 1), infections (n = 4), and stress around ARN (n = 6). The median percentage of isolated PDC was significantly lower in patients compared with 18 age-matched healthy controls (p < 0.001), confirmed by FACS analysis using peripheral blood, and was extremely low during acute disease. PDC counts dropped in five controls suffering from respiratory infections or diarrhea. IFN-alpha production in PDC and PBMC exposed to different stimuli was significantly lower in patients than in controls (p < 0.05). Anergy to these stimuli was observed on four occasions, in particular during acute disease. PDC of patients showed up-regulated IFN regulatory factor-7 mRNA levels and evidence of in vivo activation (CD80) and maturation (CD83) (p < 0.05). CD8+ cell responses were significantly lower in patients vs controls (p = 0.04). These data support a risk factor model in which numerical and functional deficits in PDC-mediated innate immune responses contribute to an impaired control of latent herpes virus infections and subsequent development of ARN.

Disseminated HSV-1 in a five-year-old immunocompetent child: case report

Disseminated herpes simplex virus-1 is usually seen in the neonatal period or in immunocompromized individuals. We present a 5-y-old immunocompetent child who was diagnosed with disseminated HSV-1 after he presented with fever and seizures. He had multiorgan failure and DIC, but had an excellent outcome after treatment with acyclovir.

Nécrose rétinienne aiguë bilatérale associée à une méningo-encéphalite à Herpes simplex virus 2

INTRODUCTION

Acute retinal necrosis syndrome (ARN syndrome) is a rare viral disease with a poor prognosis in most cases. It is characterized by substantial ocular inflammation with progressive retinal necrosis, occlusive vasculitis and sometimes extraocular features.

CASE REPORT

We report the case of a 62-year-old woman who was referred for a suspicion of a stroke. Ophthalmological examination revealed a profound bilateral visual loss due to extensive retinal necrosis. The patient was immediately treated with antiherpetic drugs. ARN syndrome with meningoencephalitis caused by herpes simplex virus type 2 was confirmed by PCR studies performed on aqueous humor and cerebrospinal fluid. Herpes simplex virus 2 (IgG+ , IgM-) was probably reactivated after intrathecal injection of steroids because of pain associated with narrowing of the lumbar vertebral canal. The patient was treated with intravenous Acyclovir for 3 weeks. After 4 months, both retinas were detached.

DISCUSSION AND CONCLUSION

ARN syndrome caused by herpes simplex virus 2 most often occurs after reactivation of the latent virus in patients with a neurological medical history or congenital infection. Antiviral treatment must begin early to decrease risks of bilateralization and complications.