Herpes simplex virus type 1 DNA in cerebrospinal fluid of a patient with Mollaret's meningitis

Mollaret's Meningitis due to Herpes Simplex Virus 2: A Case Report and Review of the Literature

Mollaret's meningitis is a rare neurological disorder characterized by recurrent episodes of aseptic lymphocytic meningitis, often associated with herpes simplex virus 2 (HSV-2) infection. We report the case of a 39 y.o. Italian woman who experienced four episodes of aseptic lymphocytic meningitis between 2004 and 2023, diagnosed as Mollaret's meningitis. In each episode, the patient presented with fever, severe headache and photophobia. In two episodes cutaneous vesicles in the left gluteal area preceding meningitis symptoms were also reported. A diagnostic evaluation included a physical-chemical analysis and a real-time PCR of the cerebrospinal fluid (CSF). The CSF presented pleocytosis with lymphocytic predominance and a positive HSV-2 load, with a peak of 1234 copies/mL. The patient was treated successfully with acyclovir, and the symptoms resolved without neurological sequelae. This case highlights the importance of comprehensive diagnostic testing and vigilant monitoring to manage Mollaret's syndrome effectively.

Epidemiology of herpes simplex and varicella zoster virus in cerebrospinal fluid of patients suffering from meningitis in Iran

From the early 18th century that “meningitis” outbreak was firstly recorded in Geneva, it is one of the alarming health problems worldwide. Different infectious risk factors may contribute to the progression of meningitis. Herpes simplex virus (HSV) and Varicella-zoster virus (VZV) are just some noticeable risk factors among many involved in the progression of this disease. In this study, 415 meningitis suspected patients were recruited with some symptoms, such as fever, headache, nausea or vomiting, seizure, rash, dizziness from four different hospitals of Iran and molecular examinations of samples were performed by using specific primers of HSV½ and VZV via real-time PCR. Out of 415 included patient 41 (9.8 %) were VZV and six (1.4 %) cases were HSV ½ positive. Fever was the most frequent symptom by 315 (76 %) of patients with median temperature of 38 °C in all included patients. The median WBS counts of CSF in VZV positive, HSV½ positive, and all included cases were 1567 × 10⁶ /L, 1257 × 10⁶ /L, and 766 × 10⁶ /L (range 0-21200), respectively. In conclusion, as the rate of VZV infection was high among children patients and it was associated with the absence of vaccination program for chickenpox in Iran, we suggested that VZV is one of the plausible hallmarks in meningitis.

Viral meningitis: current issues in diagnosis and treatment

PURPOSE OF REVIEW

The purpose of this review is to give an overview of viral meningitis and then focus in on some of the areas of uncertainty in diagnostics, treatment and outcome.

RECENT FINDINGS

Bacterial meningitis has been declining in incidence over recent years. Over a similar time period molecular diagnostics have increasingly been used. Because of both of these developments viral meningitis is becoming relatively more important. However, there are still many unanswered questions. Despite improvements in diagnostics many laboratories do not use molecular methods and even when they are used many cases still remain without a proven viral aetiology identified. There are also no established treatments for viral meningitis and the one potential treatment, aciclovir, which is effective in vitro for herpes simplex virus, has never been subjected to a clinical trial.

SUMMARY

Viruses are in increasingly important cause of meningitis in the era of declining bacterial disease. The exact viral aetiology varies according to age and country. Molecular diagnostics can not only improve the rate of pathogen detection but also reduce unnecessary antibiotics use and length of hospitalization. Further research is required into treatments for viral meningitis and the impact in terms of longer term sequelae.

CSF in acute and chronic infectious diseases

Infections of the nervous system are an important and challenging aspect of clinical neurology. Immediate correct diagnosis enables to introduce effective therapy, in conditions that without diagnosis may leave the patient with severe neurological incapacitation and sometimes even death. The cerebrospinal fluid (CSF) is a mirror that reflects nervous system pathology and can promote early diagnosis and therapy. The present chapter focuses on the CSF findings in neuro-infections, mainly viral and bacterial. Opening pressure, protein and glucose levels, presence of cells and type of the cellular reaction should be monitored. Other tests can also shed light on the causative agent: serology, culture, staining, molecular techniques such as polymerase chain reaction. Specific examination such as panbacterial and panfungal examinations should be examined when relevant. Our chapter is a guide-text that combines clinical presentation and course with CSF findings as a usuaful tool in diagnosis of neuroinfections.

The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults

Bacterial meningitis and meningococcal sepsis are rare conditions with high case fatality rates. Early recognition and prompt treatment saves lives. In 1999 the British Infection Society produced a consensus statement for the management of immunocompetent adults with meningitis and meningococcal sepsis. Since 1999 there have been many changes. We therefore set out to produce revised guidelines which provide a standardised evidence-based approach to the management of acute community acquired meningitis and meningococcal sepsis in adults. A working party consisting of infectious diseases physicians, neurologists, acute physicians, intensivists, microbiologists, public health experts and patient group representatives was formed. Key questions were identified and the literature reviewed. All recommendations were graded and agreed upon by the working party. The guidelines, which for the first time include viral meningitis, are written in accordance with the AGREE 2 tool and recommendations graded according to the GRADE system. Main changes from the original statement include the indications for pre-hospital antibiotics, timing of the lumbar puncture and the indications for neuroimaging. The list of investigations has been updated and more emphasis is placed on molecular diagnosis. Approaches to both antibiotic and steroid therapy have been revised. Several recommendations have been given regarding the follow-up of patients.

Analysis of formalin-fixed and frozen myocardial autopsy samples for viral genome in childhood myocarditis and dilated cardiomyopathy with endocardial fibroelastosis using polymerase chain reaction (PCR)

Viral infection of the myocardium is implicated in the pathogenesis of myocarditis and dilated cardiomyopathy (DCM). Enteroviruses have been considered the most common viral etiologic agents, based on peripheral culture and serologic methods. Recently, polymerase chain reaction (PCR) has been shown to be useful in the detection of viral genomes from various infected organs and body fluids. In this study, myocardial samples from autopsy specimens (formalin fixed and fresh frozen) were examined for enteroviral and DNA viral (adenovirus, herpes simplex virus [HSV], and cytomegalovirus (CMV]) genome by PCR. The specimens studied were from 58 patients with myocarditis, 28 patients with DCM and endocardial fibroelastosis [EFE], and 22 controls. Viral genome was detectable in 34 of the 58 (59%) autopsy-proven myocarditis samples (18 adenovirus, 12 enterovirus, 2 CMV, 2 HSV) and 6 of the 28 samples from patients with DCM and EFE (6 adenovirus). We conclude that PCR is effective in the rapid amplification of virus from frozen and formalin-fixed myocardial samples and that adenovirus is an important etiologic agent in viral myocarditis as well as DCM with EFE.

Epidemiology of central nervous system infection

In cases of central nervous system infection, it is crucial for the neuroradiologist to provide an accurate differential diagnosis of the possible pathogens involved so that treating physicians can be aided in the choice of empiric therapy. This approach requires the radiologist to be aware of local epidemiology and have knowledge of infectious agents that are endemic to their area of practice. This article reviews and discusses the changing epidemiology of pathogens most often observed in meningitis, brain abscess, epidural abscess, postoperative infections, and human immunodeficiency virus infection.

Herpes simplex virus encephalitis: new infection or reactivation?

PURPOSE OF REVIEW

This review describes the pathogenesis, clinical presentation, course, and therapy of herpes simplex encephalitis (HSE), the most fatal viral encephalitis, in which prognosis is dependent on early diagnosis and effective therapy.

RECENT FINDINGS

Herpes simplex viruses types 1 and 2 (HSV-1 and HSV-2) are human neurotropic viruses that establish latent infection in dorsal-root ganglia for the entire life of the host. From this reservoir, they can reactivate to cause human morbidity and mortality. HSE is one of the most devastating disorders caused by these viruses. The biology of their ability to establish latency, maintain it for the entire life of the host, reactivate, and cause primary and recurrent disease is being studied in animal models and in humans. Of special interest is the question whether HSE is the result of primary infection or is it the outcome of reactivation. The present review covers the biological, medical, and neurological aspects of HSE, focusing among others on recent molecular findings of gene expression during latent infection of HSV-1.

SUMMARY

Despite accumulating knowledge, there are still several issues regarding both pathogenesis and therapy of HSV-1 that currently defy understanding.

A case of recurrent benign lymphocytic (Mollaret's) meningitis and review of the literature

Mollaret's meningitis is a rare form of benign recurrent aseptic meningitis first described in 1944. We report a case of Mollaret's meningitis due to Herpes Simplex Virus type 2 (HSV2), diagnosed with Polymerase Chain Reaction (PCR) implementation in the Cerebrospinal fluid (CSF) of the patient and treated successfully with acyclovir. To our knowledge, this is the first case of Mollaret's meningitis reported in Greece. We reviewed the literature since PCR has become widely available. Herpes Simplex Virus type 2 has been the most commonly identified causative agent of Mollaret's meningitis.

Headache attributed to non-vascular intracranial disorder

This chapter deals with non-vascular intracranial disorders resulting in headache. Headache attributed to high or low cerebrospinal fluid pressure is separated into headache attributed to idiopathic intracranial hypertension (IIH), headache attributed to intracranial hypertension secondary to metabolic, toxic, or hormonal causes, headache attributed to intracranial hypertension secondary to hydrocephalus, post-dural puncture headache, cerebrospinal fluid (CSF) fistula headache, headache attributed to spontaneous (or idiopathic) low CSF pressure. Headache attributed to non-infectious inflammatory disease can be caused by neurosarcoidosis, aseptic (non-infectious) meningitis or lymphocytic hypophysitis. Headache attributed to intracranial neoplasm can be caused by increased intracranial pressure or hydrocephalus caused by neoplasm or attributed directly to neoplasm or carcinomatous meningitis. Other causes of headache include hypothalamic or pituitary hyper- or hyposecretion and intrathecal injection. Headache attributed to epileptic seizure is separated into hemicrania epileptica and post-seizure headache. Finally headache attributed to Chiari malformation type I (CM1) and the syndrome of transient headache and neurological deficits with cerebrospinal fluid lymphocytosis (HaNDL) are described.

Simultaneous identification of 14 genital microorganisms in urine by use of a multiplex PCR-based reverse line blot assay

The aim of this study was to develop and evaluate a sensitive method for the simultaneous identification of 14 urogenital potential pathogens. A multiplex PCR-based reverse line blot (mPCR/RLB) assay was developed to detect 14 urogenital pathogens or putative pathogens, namely Trichomonas vaginalis, Streptococcus pneumoniae, Neisseria gonorrhoeae, Chlamydia trachomatis, Ureaplasma parvum, U. urealyticum, Gardnerella vaginalis, Haemophilus influenzae, herpes simplex virus type 1 (HSV1) and HSV2, N. meningitidis, Mycoplasma hominis, M. genitalium, and adenovirus, using two species-specific primer pairs and probes for each. The method was validated using a reference strain or a well-characterized clinical isolate of each target organism and was found to be both sensitive and specific. The limits of detection for the mPCR/RLB assay varied among the 14 target organisms from 4.2 x 10(-1) to 7.0 x 10(-11) ng/microl of genomic DNA. There were no cross-reactions among any of the probes. This method was used to test 529 first-voided urine specimens from male patients with and without urethritis attending two Sydney sexual health clinics. One or more target species were detected in 193 (36%) subjects. Of 233 positive results, overall 216 (93%) were concordant between mPCR/RLB and a comparator method (culture and/or species-specific PCR), 9 were positive only by mPCR/RLB, and 8 were positive only by the comparator method. The mPCR/RLB method was an accurate, convenient, and inexpensive method for the detection of multiple potential pathogens in first-voided urine specimens from men.

Clinical validation of a new triplex real-time polymerase chain reaction assay for the detection and discrimination of Herpes simplex virus types 1 and 2

A new triplex real-time polymerase chain reaction (PCR) assay for Herpes simplex virus (HSV) (artus HSV-1/2 TM PCR kit, QIAGEN) was evaluated. This assay simultaneously uses three differently labeled probes targeted to HSV-1 (FAM), HSV-2 (NED), and to the manufacturer's Internal Control (VIC). HSV-1/2 typing capability and quantitation accuracy were determined using HSV stocks and quality control panels. Performance in routine clinical testing was compared with a nested HSV-1/2 PCR assay. Dilution series and quality control panel testing revealed an approximately 10-fold higher HSV-2 sensitivity in real-time PCR compared with an in-house nested PCR assay. The sensitivity for HSV-1 was comparable in both assays. All HSV-positive proficiency panel samples (n = 21) and virus stocks were typed correctly as HSV-1 or HSV-2 using real-time PCR. Quantitation correlated well with reference values (HSV-1, r = 0.98; HSV-2, r = 0.88), and 95% detection limits were determined as 9.4 HSV-2 copies/reaction and 18 HSV-1 copies/reaction. Based on C(t) values, the mean intra-assay coefficient of variation was 1%, whereas the interassay coefficient of variations were 2.7% and 2.5% for HSV-1 and -2, respectively. Testing of 309 clinical samples resulted in 100% specificity and 97% sensitivity. In conclusion, the artus HSV-1/2 TM PCR kit represents an excellent tool for the detection and differentiation of HSV-1 and -2 in clinical samples.

The neurotropic herpes viruses: herpes simplex and varicella-zoster

Herpes simplex viruses types 1 and 2 (HSV1 and HSV2) and varicella-zoster virus (VZV) establish latent infection in dorsal root ganglia for the entire life of the host. From this reservoir they can reactivate to cause human morbidity and mortality. Although the viruses vary in the clinical disorders they cause and in their molecular structure, they share several features that affect the course of infection of the human nervous system. HSV1 is the causative agent of encephalitis, corneal blindness, and several disorders of the peripheral nervous system; HSV2 is responsible for meningoencephalitis in neonates and meningitis in adults. Reactivation of VZV, the pathogen of varicella (chickenpox), is associated with herpes zoster (shingles) and central nervous system complications such as myelitis and focal vasculopathies. We review the biological, medical, and neurological aspects of acute, latent, and reactivated infections with the neurotropic herpes viruses.

Herpesvirus infections of the nervous system

There are eight human herpesviruses (HHVs). Primary infection by any of the eight viruses, usually occurring in childhood, is either asymptomatic or produces fever and rash of skin or mucous membranes; other organs might be involved on rare occasions. After primary infection, the virus becomes latent in ganglia or lymphoid tissue. With the exception of HHV-8, which causes Kaposi's sarcoma in patients with AIDS, reactivation of HHVs can produce one or more of the following complications: meningitis, encephalitis, myelitis, vasculopathy, ganglioneuritis, retinal necrosis and optic neuritis. Disease can be monophasic, recurrent or chronic. Infection with each herpesvirus produces distinctive clinical features and imaging abnormalities. This Review highlights the patterns of neurological symptoms and signs, along with the typical imaging abnormalities, produced by each of the HHVs. Optimal virological studies of blood, cerebrospinal fluid and affected tissue for confirmation of diagnosis are discussed; this is particularly important because some HHV infections of the nervous system can be treated successfully with antiviral agents.

Recurrent Benign Lymphocytic Meningitis

Recurrent benign lymphocytic meningitis is a recurring, typically innocuous, painful form of aseptic meningitis. This syndrome is associated with transient neurological symptoms in one-half of afflicted patients. The causative agent is usually herpes simplex virus type 2, which can be confirmed by detection of viral DNA in the cerebrospinal fluid using polymerase chain reaction. Clinical disease resolves spontaneously; however, acyclovir, valacyclovir, and famciclovir have been administered to some patients for both episodic therapy and suppression of recurrences. This therapy is thought to be beneficial, although there is no controlled trial data to support efficacy and safety.

Hematogenous vertical transmission of herpes simplex virus type 1 in mice

Herpes simplex virus type 1 (HSV-1) is a neurotropic virus that causes severe disease and death in newborn humans but, to date, it remains unclear how neonatal infection occurs. We show here that the vertical transmission of HSV-1 in mice is mainly hematogenous and involves the colonization of the neonate central nervous system (CNS). HSV-1 DNA was mainly detected in the blood and CNS of the offspring born to latently infected mothers; no significant differences were seen between the viral DNA concentrations in the blood of these mothers and their female progeny (either neonate or adult). The administration of acyclovir during gestation reduced or eliminated both the maternal and the neonatal viral DNA in the blood. Embryo transfer was performed to ensure (as far as possible) that only vertical hematogenous infection took place. Immunohistochemical analysis detected viral proteins in the encephalon of the offspring. Immunofluorescence studies provided immunoreactive evidence of HSV-1 proteins in the neurons of the hippocampus and showed that these viruses can molecularly reactivate after hyperthermia. Neonatal HSV-1 infection therefore appears to be mainly caused by hematogenous vertical transmission, and the viruses that colonize the offspring CNS are capable of molecular reactivation after a period of latency.

Real-time PCR in clinical microbiology: applications for routine laboratory testing

Real-time PCR has revolutionized the way clinical microbiology laboratories diagnose many human microbial infections. This testing method combines PCR chemistry with fluorescent probe detection of amplified product in the same reaction vessel. In general, both PCR and amplified product detection are completed in an hour or less, which is considerably faster than conventional PCR detection methods. Real-time PCR assays provide sensitivity and specificity equivalent to that of conventional PCR combined with Southern blot analysis, and since amplification and detection steps are performed in the same closed vessel, the risk of releasing amplified nucleic acids into the environment is negligible. The combination of excellent sensitivity and specificity, low contamination risk, and speed has made real-time PCR technology an appealing alternative to culture- or immunoassay-based testing methods for diagnosing many infectious diseases. This review focuses on the application of real-time PCR in the clinical microbiology laboratory.

Proton nuclear magnetic resonance-based metabonomics for rapid diagnosis of meningitis and ventriculitis

BACKGROUND

Reduction of mortality associated with bacterial meningitis and postsurgical cerebral ventriculitis is dependent on early diagnosis and institution of appropriate therapy. Metabonomics rapidly defines metabolic profiles of biological fluids through the use of high-throughput analytical techniques combined with statistical pattern recognition tools.

METHODS

Proton nuclear magnetic resonance (1H NMR)-based metabonomics was applied to (1) lumbar cerebrospinal fluid samples collected prospectively from a cohort of patients with bacterial, fungal, or viral meningitis and from control subjects without neurological disease and (2) ventricular cerebrospinal fluid samples from patients with ventriculitis associated with an external ventricular drain and from control subjects. 1H NMR spectra were analyzed by the unsupervised statistical method of principal components analysis.

RESULTS

Metabonomic analysis clearly distinguished patients with bacterial or fungal meningitis (11 patients) from patients with viral meningitis (12) and control subjects (27) and clearly distinguished patients with postsurgical ventriculitis (5) from postsurgical control subjects (10). Metabolites of microbial and host origin that were responsible for class separation were determined. Metabonomic data also correlated with the onset and course of infection in a patient with 2 episodes of bacterial ventriculitis and with response to therapy in another patient with cryptococcal meningitis.

CONCLUSIONS

Metabonomic analysis is rapid, requires minimal sample processing, and is not targeted to specific microbial pathogens, making the platform potentially suitable for use in the diagnostic laboratory. This pilot study indicates that metabonomic analysis of cerebrospinal fluid is feasible and a potentially more powerful diagnostic tool than conventional rapid laboratory indicators for distinguishing bacterial from viral meningitis and for monitoring therapy. This should have important implications for early management, reduced empirical use of antibiotics, and treatment duration.

Detection of viral deoxyribonucleic acid in amniotic fluid: association with fetal malformation and pregnancy abnormalities

OBJECTIVE

To first test the hypothesis that the presence of viral nucleic acid in amniotic fluid (AF) is associated with an abnormal pregnancy outcome, and second, to determine if the overall rate of polymerase chain reaction (PCR) positivity and the distribution of virus types vary geographically.

STUDY DESIGN

Cytomegalovirus (CMV), parvovirus B19, adenovirus, enterovirus, herpes simplex virus, Epstein-Barr virus, and respiratory syncytial virus nucleic acids were sought in 423 AF samples obtained for clinical indications: 284 from the East Coast (EC) and 139 from the Midwest (MW).

RESULTS

Gestational age at sampling was 19.1 weeks for EC and 20.1 weeks for MW. 13.5% of karyotypically normal singleton pregnancies (57/423) had a positive AF PCR. 11% of AF PCR from the EC while 18% of AF PCR from the MW were positive (p = 0.06). The most commonly detected viruses were adenovirus (77%), enterovirus (12%), and CMV and parvovirus B19 (5% each). Twenty-four percent of sonographically abnormal pregnancies (33/136) had a positive AF PCR compared to only 8.4% (24/287) of normal pregnancies (p < 0.001).

CONCLUSION

A positive AF PCR is associated with an increased rate of fetal structural malformations, intrauterine growth restriction, hydrops and other fetal abnormalities. There were no significant geographic differences in the incidence of AF viral PCR positivity.

[Recurrent aseptic meningitis associated with primary biliary cirrhosis]

INTRODUCTION

The etiological diagnosis of recurrent aseptic meningitis often requires difficult investigations. We report a case of recurrent aseptic meningitis associated with a primary biliary cirrhosis.

CASE REPORT

A 37-year-old woman presented four recurrences of isolated meningitic syndrome with fever. Intravenous steroid treatment was effective. Investigations revealed an old right tympano-labyrinthine fracture with, on MRI, an abnormal enhancement of the posterior wall of the internal auditory canal. Serum tests were also significantly positive for antimitochondria antibodies subtype M2.

CONCLUSION

Definitive diagnosis was recurrent puriform aseptic meningitis secondary to an inflammatory non-septic ears-nose-throat focus in a latent autoimmune context of primary biliary cirrhosis. To our knowledge, this is the first case reported in literature.

Presence of viremia in patients with primary herpetic gingivostomatitis

BACKGROUND

Presence of viremia during primary herpes simplex virus (HSV) infections has been previously investigated, but the findings for immunocompetent individuals have only rarely been reported.

METHODS

With use of polymerase chain reaction (PCR), we evaluated blood samples obtained from children with primary herpes simplex virus (HSV) gingivostomatitis for viremia.

RESULTS

There were 16 girls and 16 boys, aged 9-44 months (median age, 19 months). Serological test results for HSV type 1 were positive for 3 subjects (10.3%), borderline for 7 (24.1%), and negative for 19 (65.5%). Results of PCR of peripheral blood samples were positive for 11 subjects (34.4%). Time from disease onset to specimen collection was 24-216 h (median, 72 h) and was longer for subjects with positive results of serological tests (P =.014) and shorter for subjects with positive PCR results (P=.42). No cases with positive results of both PCR and serological tests were found.

CONCLUSION

PCR detected viremia in 34% of patients with primary herpetic gingivostomatitis. Presence of viremia may play a potential role in viral dissemination, providing a better understanding of the pathogenesis of HSV infections, especially of the central nervous system.

Relapse of neonatal herpes simplex virus infection

BACKGROUND

Neonatal herpes simplex virus (HSV) infection is a severe disease with high mortality and morbidity. Recurrence of skin vesicles is common.

OBJECTIVE

To determine the features of relapse and identify the factors related to relapse.

DESIGN

Thirty two surviving patients with neonatal herpes virus infections were enrolled. All patients received acyclovir treatment. Clinical and virological data were analysed and compared between relapsed and non-relapsed cases.

RESULTS

Thirteen (41%) had either local skin or central nervous system relapse between 4 and 63 days after completing the initial antiviral treatment. Nine patients exhibited local skin relapses, and four developed central nervous system relapses. In one skin and two central nervous system relapse cases, neurological impairment later developed. Type 2 virus infection was significantly related to relapse (odds ratio 10.4, 95% confidence interval 1.1 to 99.0). Patients with relapse had worse outcomes than those without relapse.

CONCLUSION

Neonates with HSV type 2 infections have a greater risk of relapse. Relapsed patients have poorer prognoses.

Clinical relevance of polymerase chain reaction (PCR) assays and antigen-driven immunoblots for the diagnosis of neurological infectious diseases

Polymerase chain reaction assays are a powerful tool for detecting the presence of infectious genomes in the cerebrospinal fluid. Positive results always mean a current or pending infection of the central nervous system. Subacute (>7 days) or chronic infections induce an intrathecal humoral immune response and the appearance of oligoclonal IgG antibodies directed against the causal infectious agent. This local synthesis may be observed even in cases of severe systemic immunodeficiency. The use of polymerase chain reactions in combination with the detection of a specific intrathecal immune response should represent the most reliable strategy for the diagnosis of viral and chronic infections of the central nervous system. The authors describe their experience, using this approach, in herpetic encephalitis, acute and recurrent herpetic meningitis, varicella zoster-induced neurological diseases, cytomegalovirus encephalitis, progressive multifocal leukoencephalitis and tuberculous meningitis.

Mollaret's meningitis: cytopathologic analysis of fourteen cases

Mollaret's meningitis (MM) is a rare disease of benign nature characterized by recurrent episodes of aseptic meningitis. Cerebrospinal fluid (CSF) examination remains the sole diagnostic modality. Eighteen CSF samples from 14 patients were studied along with the clinical data. Specimens were prepared by cytocentrifugation and Millipore filtration and were stained with Diff-Quik and Papanicolaou stains. Eight patients were men and six were women, with an age range of 17-74 yr (mean age 37 yr). Most common clinical presentation was recurrent episodes of headaches and photophobia followed by a sustained mild fever lasting 5-7 days. The CSF showed markedly increased cellularity with pleocytosis. The differential count showed predominant monocytosis ranging from 84% to 100% (mean 96). In our series, two patients had herpes simplex virus type 2 (HSV-2) DNA detected by polymerase chain reaction (PCR) in the CSF. The monocytes were seen predominantly singly, but three cases showed a strong tendency to aggregate in small groups. Phenotypically, these cells had bean-shaped bilobed nuclei as well as multiple deep nuclear clefts depicting the so-called "footprint" appearance. In four cases, multiple blunt-tipped cytoplasmic pseudopods were noted. Degenerated monocytes with the appearance of the so-called "ghost cells" were noted in one-half of the cases. Background cells were mostly small mature lymphocytes; however, one-half of cases showed a significant amount of plasma cells and/or polymorphonuclear leukocytes (PMNs). Lysed blood with hemosiderin-laden macrophages and numerous leptomeningeal cells were seen in two cases. CSF examination of MM presents a spectrum of cytomorphologic features. When interpreted in light of the appropriate clinical setting. the latter, although nonspecific, provides an accurate diagnosis. The differential diagnosis includes various degenerative, inflammatory/infectious, and lymphoproliferative disorders of the central nervous system.

Chronic meningitis

Chronic meningitis is a clinical syndrome that is characterized by persistent or progressive signs and symptoms of meningitis associated with cerebrospinal fluid pleocytosis and elevated protein concentrations, lasting for a duration of at least 4 weeks without improvement. A large number of infectious and noninfectious diseases, many of which are difficult to diagnose, can cause chronic meningitis. Careful attention to exposure and travel history, physical examination findings, and certain patterns of CSF parameters, coupled with other specific laboratory evaluations, all play important roles in trying to identify the etiologic agent causing the chronic meningitis.

Neurologic morbidity after herpes simplex virus type 2 meningitis: a retrospective study of 40 patients

In order to study the long-term course after herpes simplex virus type 2 (HSV-2) meningitis and/or myeloradiculitis the records of 40 consecutive patients were studied. During the year following the acute phase, verified or suspected neurologic recurrences were noted in nearly half of the patients: 1 or more episodes of recurring meningitis were noted in 8 patients; new episodes of myelitis or radiculitis in 3; distinct attacks of headache in 4; and diffuse neurologic complaints impairing daily life in 3. Recurring mucocutaneous symptoms were observed in 16 patients. Eleven patients experienced concurrent or separate episodes of recurring mucocutaneous and neurologic symptoms, 7 had neurologic recurrences only and 5 had only mucocutaneous recurrences. As considerable morbidity may result, patients with HSV-2 meningitis and/or myeloradiculitis should be identified by means of thorough history-taking, careful examination and a specific viral diagnosis in order to enable adequate advice and counseling to be provided and to aid decision-making regarding antiviral therapy.

[Herpetic meningitis in the child]

In children, viral meningitis is usually caused by Enteroviruses. Herpes simplex viruses (HSV) are known to be a cause of meningo-encephalitis. HSV-2 has been reported to cause recurrent meningitis (Mollaret's meningitis) in adults.

CASE REPORT

We report the case of a three-year-old girl with HSV-1 meningitis, whose evolution with treatment by aciclovir was good.

CONCLUSION

HSV-1 has rarely been reported as a cause of isolated aseptic meningitis in children. Primary phase of herpes simplex virus infection is not usually associated with neurologic complications.

Fractionation of neurons and satellite cells from human sensory ganglia in order to study herpesvirus latency

A method is described for fractionating human trigeminal ganglia into highly purified populations of neurons and satellite cells in order to study alpha-herpesvirus latency. The method was validated by microscopy of the separated populations and by the observation that only the neuronal population, not the satellite cells, contained herpes simplex virus (HSV) DNA. The frequency of detecting HSV in neurons from ganglia was 3% (43 of 1440 neurons). HSV DNA was not detected in approximately 17,500 satellite cells. The HSV DNA genome copy number in single cells ranged from 2 to 50. These data on the frequency and cellular location of latent HSV indicate that our mechanical fractionation of cell types results in low levels of cross-contamination and provides samples from which cells infected latently can be studied at the single cell level.

Epstein-Barr virus myeloradiculitis and encephalomyeloradiculitis

We provide a comprehensive clinical, radiological and virological analysis of four patients with Epstein-Barr virus (EBV) infection of the nervous system. One patient developed acute myeloradiculitis, one had acute encephalomyeloradiculitis, one had acute meningoencephalomyeloradiculitis and one had a subacute meningomyeloradiculitis. The ability of EBV to affect multiple parts of the entire neuraxis from meninges and brain to the spinal cord and peripheral nerves was evidenced by combinations of stiff neck and mental status changes, as well as patterns of weakness and sensory loss due to transverse myelitis or peripheral nerve disease. The CSF of all four patients contained a pleocytosis, predominantly mononuclear with elevated levels of protein, but a normal glucose level. In the two patients with acute myeloradiculitis and subacute meningomyeloradiculitis, the MRI revealed an increased signal in the spinal cord and lumbosacral roots, but in the two patients with acute encephalomyeloradiculitis and acute meningoencephalomyeloradiculitis, the brain and spinal cord MRIs were normal. In all four patients, EBV DNA, but not cytomegalovirus (CMV), herpes simplex virus (HSV) or varicella-zoster virus (VZV) DNA, was found in the CSF. The antibody pattern in serum was consistent with recent infection, and both EBV immunoglobulin (Ig) M and IgG antibodies, but not antibodies to HSV, VZV or CMV, were found in the CSF. Finally, there were reduced serum/CSF ratios of antibody to EBV, but not to total IgG or albumin, consistent with intrathecal antibody synthesis. None of the four patients died and none had brain swelling or focal changes according to brain MRI. Residual neurological deficits were evident. The two patients with acute myeloradiculitis and acute meningomyeloradiculitis had residual lower extremity weakness, and one of these patients later developed optic neuritis. The patient with acute encephalomyeloradiculitis had a moderate flaccid paraparesis, and the patient with subacute meningomyeloradiculitis was left with sensory loss in the feet. Compared with neurological disease caused by other herpes viruses, the clinical features of acute EBV myeloradiculitis, encephalomyeloradiculitis, encephalomyeloradiculitis and subacute meningomyeloradiculitis are distinctive. Of the eight human herpesviruses, EBV and VZV produce the most protean neurological syndromes. The mechanism by which EBV produces neurological disease is unknown. More correlative pathological, virological and immunological studies are needed in EBV-associated neurological disease.

Development of acyclovir-resistant herpes simplex virus early during the treatment of herpes neonatorum

Genotypic analysis of herpes simplex virus (HSV) DNA extracted from clinical specimens from a case of fatal disseminated neonatal HSV demonstrated that an infant developed an acyclovir-resistant HSV containing a mutation in the HSV thymidine kinase gene during the first seven days of acyclovir therapy.

The Acute Aseptic Meningitis Syndrome

The aseptic meningitis syndrome (AMS) is as a diagnostic and management challenge. Since the initial description of AMS in 1925, the differential diagnosis of infectious and noninfectious agents associated with this syndrome has progressed. Although most cases of aseptic meningitis have a benign outcome, several etiologies require urgent therapy if the patient is to survive and be cured. This review will address the differential diagnosis of AMS and focus on recent empiric data that may aid the clinician treating these patients.

Analysis of candidate-host immunogenetic determinants in herpes simplex virus-associated Mollaret's meningitis

Infection due to herpes simplex virus (HSV) is associated with recurrent aseptic meningitis (Mollaret's meningitis); however, the neuropathogenesis of this disease remains unknown. We collected 20 cerebrospinal fluid (CSF) specimens that were positive for HSV DNA by using polymerase chain reaction (PCR) assay from patients with a clinical diagnosis of Mollaret's meningitis. Patients were predominantly female (female:male, 22:1), with an average age of 32.8 years (range, 18-46 years). Using direct sequence analysis of HSV PCR products obtained from the CSF, we determined that all of the patients were infected with HSV type 2. In addition, we evaluated polymorphisms in 2 human genomic loci, which are associated with either severe or recurrent microbial infections (interferon-gamma receptor [IFN-gammaR] and mannose binding lectin [MBL]); these host genes were also amplified directly from the CSF specimens. No mutations were found in exons 2 or 3 of the IFN-gammaR gene (n=20). In contrast, there were 4 (20%), 4 (20%), and 0 mutations found in codons 52, 54, and 57, respectively, in exon 1 of MBL (n=20). A significantly higher frequency of codon 52 mutations (P=.04) was observed, compared with racially matched control patients.

Overview of acute and chronic meningitis

Meningitis can be subdivided based on time course of onset and duration, cerebrospinal fluid (CSF) profile, and underlying origins into acute aseptic and septic meningitis, recurrent meningitis, and chronic meningitis. These are distinct syndromes that require different management strategies. Most cases of meningitis are caused by infection. The causal agent is generally predictable based on the type of meningitis, host factors, and clues from the history and examination. CSF examination remains the critical diagnostic test.

Herpes simplex virus type 2 DNA detected in cerebrospinal fluid of 9 patients with Mollaret's meningitis

We present clinical and virological data on 9 patients, 7 women and 2 men aged 31-56 years, with recurrent aseptic meningitis (Mollaret's meningitis). Polymerase chain reaction detected Herpes simplex virus type 2 DNA in cerebrospinal fluid samples from all patients collected during their latest attacks of meningitis. Six patients had no history of genital herpes. Only 1 patient was offered prophylactic antiviral treatment during the study period (45 months).

Comparative evaluation of colorimetric microtiter plate systems for detection of herpes simplex virus in cerebrospinal fluid

In the past few years, application of the PCR to the detection of herpes simplex virus (HSV) DNA in the cerebrospinal fluid (CSF) from patients with encephalitis and meningitis has become standard laboratory practice. However, from an operational perspective, the true diagnostic value of PCR in this setting is yet to be realized because most laboratories subject the amplification products to lengthy probe hybridization procedures by Southern blotting. As alternatives to Southern blotting, we evaluated colorimetric microtiter plate (MTP) systems from ViroMed Laboratories, Inc. (PrimeCapture), CPG, Inc. (Quanti-PATH), and Incstar Corp. (GEN-ETI-K), in addition to a system developed at the Mayo Clinic with the PCR ELISA system (Boehringer Mannheim Corp.). We tested PCR products from 86 clinical CSF specimens submitted to our Molecular Microbiology Laboratory. The CSF specimens used had to have sufficient volume for comparative analysis. By conventional Southern blotting methods, 54 were positive and 32 were negative for HSV DNA. Compared with Southern blotting, the sensitivity and specificity were 63.0 and 100.0%, respectively, for the PrimeCapture system, 98. 2 and 96.9%, respectively, for the Quanti-PATH system, 98.2 and 100. 0%, respectively, for the GEN-ETI-K system, and 100.0 and 96.9%, respectively, for the Mayo system. All four MTP systems had turnaround times 12 to 24 h less than that for Southern blotting. There were no significant differences in costs or technologist time between the Mayo system and Southern blotting. Other features of the Mayo system include type-specific genotypic identification of HSV and the potential for determination of drug resistance by DNA sequencing. Overall, we found that colorimetric MTP systems were likely to improve test turnaround times and patient care at no additional cost.

Removal of inhibitors of CSF-PCR to improve diagnosis of herpesviral encephalitis

CSF-PCR is currently the most sensitive test to diagnose encephalitis due to cytomegalovirus or herpes simplex virus. However, false negative results sometimes arise due to inhibitors in CSF. We have shown that the inhibitory effects may be due to increased levels of proteins and increased cell numbers, but are not due to cellular DNA. Simple techniques were used to remove the inhibitors and successfully apply these methods to CSF specimens that gave equivocal results when tested untreated.

Genital recurrent infection occurring 6 months after meningitis due to the same herpes simplex virus type 2 (HSV-2) strain evidence by restriction endonuclease analysis

Herpes simplex virus type 2 (HSV-2) is more often sexually transmitted and associated with genital recurrent infection. However, HSV-2 neurological manifestations such as meningitis were already reported. We describe a case of meningitis due to HSV-2, preceded by signs suggesting a common cystitis, in a woman with no history of primary or recurrent genital infection. Six months later genital herpetic lesions occurred. One HSV-2 strain was obtained from cerebrospinal fluid (CSF) and another from genital lesions. The molecular comparative analysis using restriction endonuclease digestion patterns showed the similarity of the two strains. Our report illustrates that HSV-2 infections are underdiagnosed and that molecular techniques can be of value in clarifying the physiopathology of HSV diseases.

Association of parvovirus B19 genome in children with myocarditis and cardiac allograft rejection: diagnosis using the polymerase chain reaction

BACKGROUND

Inflammatory diseases of the heart, including myocarditis and cardiac transplant rejection, are important causes of morbidity and mortality in children. Although viral infection may be suspected in either of these clinical conditions, the definitive etiology is often difficult to ascertain. Furthermore, the histology is identical for both disorders. Coxsackievirus has long been considered the most common cause of viral myocarditis; however, we previously demonstrated by polymerase chain reaction (PCR) analysis that many different, and sometimes unexpected, viruses may be responsible for myocarditis and cardiac rejection. In this study, we describe the association of parvovirus genome identified through PCR analysis of cardiac tissue in the clinical setting of myocarditis and cardiac allograft rejection.

METHODS AND RESULTS

Myocardial tissue from endomyocardial biopsy, explant, or autopsy was analyzed for parvovirus B19 using primers designed to amplify a 699-base pair PCR product from the VP1 gene region. Samples tested included those obtained from patients with suspected myocarditis (n=360) or transplant rejection (n=200) or control subjects (n=250). Parvoviral genome was identified through PCR in 9 patients (3 myocarditis; 6 transplant) and no control patients. Of the 3 patients with myocarditis, 1 presented with cardiac arrest leading to death, 1 developed dilated cardiomyopathy, and the other gradually improved. Four of the 6 transplant patients had evidence of significant rejection on the basis of endomyocardial biopsy histology. All transplant patients survived the infection.

CONCLUSIONS

Parvovirus is associated with myocarditis in a small percentage of children and may be a potential contributor to cardiac transplant rejection. PCR may provide a rapid and sensitive method of diagnosis.

Laboratory diagnosis of central nervous system infections with herpes simplex virus by PCR performed with cerebrospinal fluid specimens

Until recently, the laboratory diagnosis of central nervous system (CNS) infections with herpes simplex virus (HSV) has been limited by poor sensitivity and/or specificity. We assessed the diagnostic utility of PCR for detection of HSV in over 2,100 specimens referred to the Mayo Clinic from August 1993 to May 1996. DNA extracted from cerebrospinal fluid (CSF) samples with IsoQuick was amplified by PCR with oligonucleotide primers directed to the DNA polymerase gene of HSV, yielding a 290-bp amplicon. HSV DNA was detected in 150 (135 by gel electrophoresis, 15 by Southern blotting only) of 2,106 (7.1%) specimens. PCR-positive CNS disease occurred in patients ranging in age from 13 days to 89 years; 59% of the cases occurred in patients between the ages of 30 and 69, and 21 (14%) of the patients were infants. Genotype analysis was not routinely performed; however, amplification of a 335-bp product within the thymidine kinase gene of HSV revealed 13 positions within a span of 80 nucleotides that accurately identified the two serotypes of the virus according to 14 reference strains. We conclude that PCR detection of HSV DNA in CSF specimens should be considered an emerging "gold standard" for the laboratory diagnosis of CNS infections with this virus.