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Hodzic E, Hasbun R, Granillo A, Tröscher AR, Wagner H, von Oertzen TJ, Wagner JN. Steroids for the treatment of viral encephalitis: a systematic literature review and meta-analysis. J Neurol 2023:10.1007/s00415-023-11715-0. [PMID: 37060361 PMCID: PMC10105360 DOI: 10.1007/s00415-023-11715-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 04/05/2023] [Accepted: 04/06/2023] [Indexed: 04/16/2023]
Abstract
BACKGROUND Specific antiviral treatment is only available for a small subset of viral encephalitis (VE). Adjunctive steroids are used, but there is scant evidence evaluating its utility. We present a systematic review and meta-analysis on the outcome of steroid use in VE. METHODS We conducted a systematic literature review and reported it according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) standards. Two observational studies from unpublished or partially published data were added. For the meta-analysis, we employed the metaphor package of the statistical software R-4.3.1. RESULTS We screened 378 studies and included 50. 155 patients were added from the Houston and Linz cohorts. Individual data were available for 281 persons, 120 (43%) of whom received steroids. The most common pathogens were herpes simplex virus 1, West Nile virus, and measles. Study designs and patient outcomes were heterogeneous. Only three of the trials report an advantage of steroid therapy. Steroid-induced side effects were scarce. Ten cohorts were included into the meta-analysis. For the pooled data, the null hypothesis could not be rejected (p = 0.245) using a random effects model, i.e., a benefit of steroid treatment on survival in VE could not be shown. CONCLUSIONS Steroids as potent anti-inflammatory agents may act through a reduction of secondary inflammation-mediated damage. Our data do not support the use of steroids in VE. However, multiple shortcomings apply. Standardized controlled trials are needed to investigate optimal dosing and timing of steroid administration and to explore potential subgroups that could benefit.
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Affiliation(s)
- Emira Hodzic
- Institute of Applied Statistics, Johannes Kepler University, Linz, Austria
| | - Rodrigo Hasbun
- Division of Infectious Diseases, Department of Internal Medicine, McGovern Medical School, UT Health, Houston, TX, USA
| | - Alejandro Granillo
- Division of Infectious Diseases, Department of Internal Medicine, McGovern Medical School, UT Health, Houston, TX, USA
| | - Anna R Tröscher
- Department of Neurology, Evangelisches Klinikum Gelsenkirchen, Teaching Hospital University Duisburg-Essen, Munckelstrasse 27, 45879, Gelsenkirchen, Germany
| | - Helga Wagner
- Institute of Applied Statistics, Johannes Kepler University, Linz, Austria
| | - Tim J von Oertzen
- Department of Neurology, Evangelisches Klinikum Gelsenkirchen, Teaching Hospital University Duisburg-Essen, Munckelstrasse 27, 45879, Gelsenkirchen, Germany
- Johannes Kepler University, Linz, Austria
| | - Judith N Wagner
- Department of Neurology, Evangelisches Klinikum Gelsenkirchen, Teaching Hospital University Duisburg-Essen, Munckelstrasse 27, 45879, Gelsenkirchen, Germany.
- Johannes Kepler University, Linz, Austria.
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2
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Zhang L, Zhang L, Li F, Liu W, Tai Z, Yang J, Zhang H, Tuo J, Yu C, Xu Z. When herpes simplex virus encephalitis meets antiviral innate immunity. Front Immunol 2023; 14:1118236. [PMID: 36742325 PMCID: PMC9896518 DOI: 10.3389/fimmu.2023.1118236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Accepted: 01/06/2023] [Indexed: 01/21/2023] Open
Abstract
Herpes simplex virus (HSV) is the most common pathogen of infectious encephalitis, accounting for nearly half of the confirmed cases of encephalitis. Its clinical symptoms are often atypical. HSV PCR in cerebrospinal fluid is helpful for diagnosis, and the prognosis is usually satisfactory after regular antiviral treatment. Interestingly, some patients with recurrent encephalitis have little antiviral effect. HSV PCR in cerebrospinal fluid is negative, but glucocorticoid has a significant effect after treatment. Specific antibodies, such as the NMDA receptor antibody, the GABA receptor antibody, and even some unknown antibodies, can be isolated from cerebrospinal fluid, proving that the immune system contributes to recurrent encephalitis, but the specific mechanism is still unclear. Based on recent studies, we attempt to summarize the relationship between herpes simplex encephalitis and innate immunity, providing more clues for researchers to explore this field further.
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Affiliation(s)
- Linhai Zhang
- Department of Neurology, Affiliated Hospital of Zunyi Medical University, Zunyi, China,The Collaborative Innovation Center of Tissue Damage Repair and Regeneration Medicine of Zunyi Medical University, Zunyi, China
| | - Lijia Zhang
- Department of Neurology, Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Fangjing Li
- Department of Neurology, Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Wanyu Liu
- Department of Neurology, Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Zhenzhen Tai
- Department of Neurology, Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Juan Yang
- Department of Neurology, Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Haiqing Zhang
- Department of Neurology, Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Jinmei Tuo
- Department of Neurology, Affiliated Hospital of Zunyi Medical University, Zunyi, China,The Collaborative Innovation Center of Tissue Damage Repair and Regeneration Medicine of Zunyi Medical University, Zunyi, China,*Correspondence: Jinmei Tuo, ; Changyin Yu, ; Zucai Xu,
| | - Changyin Yu
- Department of Neurology, Affiliated Hospital of Zunyi Medical University, Zunyi, China,The Collaborative Innovation Center of Tissue Damage Repair and Regeneration Medicine of Zunyi Medical University, Zunyi, China,*Correspondence: Jinmei Tuo, ; Changyin Yu, ; Zucai Xu,
| | - Zucai Xu
- Department of Neurology, Affiliated Hospital of Zunyi Medical University, Zunyi, China,The Collaborative Innovation Center of Tissue Damage Repair and Regeneration Medicine of Zunyi Medical University, Zunyi, China,*Correspondence: Jinmei Tuo, ; Changyin Yu, ; Zucai Xu,
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3
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Whitfield T, Fernandez C, Davies K, Defres S, Griffiths M, Hooper C, Tangney R, Burnside G, Rosala-Hallas A, Moore P, Das K, Zuckerman M, Parkes L, Keller S, Roberts N, Easton A, Touati S, Kneen R, Stahl JP, Solomon T. Protocol for DexEnceph: a randomised controlled trial of dexamethasone therapy in adults with herpes simplex virus encephalitis. BMJ Open 2021; 11:e041808. [PMID: 34301646 PMCID: PMC8728349 DOI: 10.1136/bmjopen-2020-041808] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 02/23/2021] [Accepted: 02/25/2021] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Herpes simplex virus (HSV) encephalitis is a rare severe form of brain inflammation that commonly leaves survivors and their families with devastating long-term consequences. The virus particularly targets the temporal lobe of the brain causing debilitating problems in memory, especially verbal memory. It is postulated that immunomodulation with the corticosteroid, dexamethasone, could improve outcomes by reducing brain swelling. However, there are concerns (so far not observed) that such immunosuppression might facilitate increased viral replication with resultant worsening of disease. A previous trail closed early because of slow recruitment. METHOD DexEnceph is a pragmatic multicentre, randomised, controlled, open-label, observer-blind trial to determine whether adults with HSV encephalitis who receive dexamethasone alongside standard antiviral treatment with aciclovir for have improved clinical outcomes compared with those who receive standard treatment alone. Overall, 90 patients with HSV encephalitis are being recruited from a target of 45 recruiting sites; patients are randomised 1:1 to the dexamethasone or control arms of the study. The primary outcome measured is verbal memory as assessed by the Weschler Memory Scale fourth edition Auditory Memory Index at 26 weeks after randomisation. Secondary outcomes are measured up to 72 weeks include additional neuropsychological, clinical and functional outcomes as well as comparison of neuroimaging findings. Patient safety monitoring occurs throughout and includes the detection of HSV DNA in cerebrospinal fluid 2 weeks after randomisation, which is indicative of ongoing viral replication. Innovative methods are being used to ensure recrutiment targets are met for this rare disease. DISCUSSION DexEnceph aims to be the first completed randomised controlled trial of corticosteroid therapy in HSV encephalitis. The results will provide evidence for future practice in managing adults with the condition and has the potential to improve outcomes . ETHICS AND DISSEMINATION The trial has ethical approval from the UK National Research Ethics Committee (Liverpool Central, REF: 15/NW/0545, 10 August 2015). Protocol V.2.1, July 2019. The results will be published and presented as soon as possible on completion. TRIAL REGISTRATION NUMBERS ISRCTN11774734, EUDRACT 2015-001609-16.
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Affiliation(s)
- Thomas Whitfield
- Department of Clinical Infection, Medical Microbiology and Immunology, University of Liverpool, Liverpool, UK
| | - Cristina Fernandez
- Department of Clinical Infection, Medical Microbiology and Immunology, University of Liverpool, Liverpool, UK
| | - Kelly Davies
- Clinical Trials Research Centre, University of Liverpool, Liverpool, UK
| | - Sylviane Defres
- Department of Clinical Infection, Medical Microbiology and Immunology, University of Liverpool, Liverpool, UK
- PLEASE REMOVE THIS ADDRESS ENTRY, X, X, X
- Tropical and Infectious Diseases Unit, Liverpool University Hospitals Foundation Trust, Liverpool, UK
| | - Michael Griffiths
- Department of Clinical Infection, Medical Microbiology and Immunology, University of Liverpool, Liverpool, UK
- Neurology Department, Alder Hey Children's NHS Foundation Trust, Liverpool, Merseyside, UK
| | - Cory Hooper
- Department of Clinical Infection, Medical Microbiology and Immunology, University of Liverpool, Liverpool, UK
| | - Rebecca Tangney
- Pharmacy Department, Liverpool University Hospitals NHS Foundation Trust, Liverpool, Liverpool, UK
| | - Girvan Burnside
- Department of Biostatistics, Faculty of Health and Life Sciences, University of Liverpool, Liverpool, Liverpool, UK
| | - Anna Rosala-Hallas
- Department of Biostatistics, Faculty of Health and Life Sciences, University of Liverpool, Liverpool, Liverpool, UK
| | - Perry Moore
- Deptment of Clinical Neuropsychology, The Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Kumar Das
- Neuroradiology Department, The Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Mark Zuckerman
- South London Specialist Virology Centre, King's College Hospital NHS Foundation Trust, London, London, UK
| | - Laura Parkes
- Division of Neuroscience & Experimental Psychology, University of Manchester, Manchester, UK
| | - Simon Keller
- Pharmacy Department, Liverpool University Hospitals NHS Foundation Trust, Liverpool, Liverpool, UK
| | - Neil Roberts
- The Queen's Medical Research Institute, The University of Edinburgh, Edinburgh, Edinburgh, UK
| | - Ava Easton
- The Encephalitis Society, Malton, North Yorkshire, UK
| | - Saber Touati
- Service des Maladies Infectieuses et Tropicales, CHU Grenoble Alpes, Grenoble, Rhône-Alpes, France
| | - Rachel Kneen
- Department of Neurology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
- REMOVE THI ADDRESS, XXXXX, XXX, XXX
| | - J P Stahl
- Infectious Diseases Department, University of Grenoble, Grenoble, UK
| | - Tom Solomon
- Department of Neurology, Walton Centre NHS Foundation Trust, Liverpool, Liverpool, UK
- National Institute for Health Research Health Protection Research Unit in Emerging and Zoonotic Infections, Institute of Infection Ecology and Veterinary Sciences, University of Liverpool, Liverpool, UK
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4
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Li Q, Fu N, Han Y, Qin J. Pediatric Autoimmune Encephalitis and Its Relationship With Infection. Pediatr Neurol 2021; 120:27-32. [PMID: 33964702 DOI: 10.1016/j.pediatrneurol.2021.04.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2021] [Revised: 04/01/2021] [Accepted: 04/05/2021] [Indexed: 12/31/2022]
Abstract
Autoimmune encephalitis (AE) is an increasingly recognized inflammatory disorder of the central nervous system and is most often characterized by antibodies against intracellular and neuronal surface antigens. AE is a devastating disease that may result in developmental delay or regression in children. However, the pathogenesis of AE is not clear, and immune system disorders after infection likely play an important role in AE. Many studies have reported that patients with herpes simplex virus encephalitis develop anti-N-methyl-d-aspartate receptor encephalitis after antiviral treatment. It is critical to recognize pediatric AE early and to distinguish it from infectious forms because AE is treatable and responsive to immunotherapies. In this review, we discuss the clinical features of pediatric AE and focus on the relationship between AE and postinfection status. In addition, we review the probable mechanisms underlying infection-triggered AE, which include molecular mimicry, bystander activation, epitope spreading, immune system disorder, and genetic susceptibility.
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Affiliation(s)
- Qinrui Li
- Department of Pediatrics, Peking University People's Hospital, Beijing, P.R. China
| | - Na Fu
- Department of Pediatrics, Peking University People's Hospital, Beijing, P.R. China
| | - Ying Han
- Department of Pediatrics, Peking University First Hospital, Beijing, P.R. China.
| | - Jiong Qin
- Department of Pediatrics, Peking University People's Hospital, Beijing, P.R. China.
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5
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Untreated herpes simplex virus encephalitis without a fatal outcome. J Neurovirol 2021; 27:493-497. [PMID: 33788139 DOI: 10.1007/s13365-021-00968-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 02/23/2021] [Accepted: 03/09/2021] [Indexed: 10/21/2022]
Abstract
Herpes simplex virus encephalitis (HSE) is the most common sporadic fatal encephalitis. Although timely administered acyclovir treatment decreases mortality, neuropsychiatric sequelae is still common among survivors. Magnetic resonance imaging is frequently utilized for the diagnosis of HSE, which typically involves temporal lobe(s) and can be mixed with brain tumors involving the same area. Here, we report a case of HSE, who received acyclovir with a delay of 90 days because of presumptive tumor diagnosis and survived with minimal sequelae.
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6
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Gundamraj S, Hasbun R. The Use of Adjunctive Steroids in Central Nervous Infections. Front Cell Infect Microbiol 2020; 10:592017. [PMID: 33330135 PMCID: PMC7719626 DOI: 10.3389/fcimb.2020.592017] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Accepted: 10/23/2020] [Indexed: 01/02/2023] Open
Abstract
Central nervous system (CNS) infections continue to be associated with significant neurological morbidity and mortality despite various existing therapies. Adjunctive steroid therapy has been employed clinically to reduce inflammation in the treatment of CNS infections across various causative pathogens. Steroid therapy can potentially improve clinical outcomes including reducing mortality rates, provide no significant benefit, or cause worsened outcomes, based on the causative agent of infection. The data on benefits or harms of adjunctive steroid therapy is not consistent in outcome or density through CNS infections, and varies based on the disease diagnosis and pathogen. We summarize the existing literature on the effects of adjunctive steroid therapy on outcome for a number of CNS infections, including bacterial meningitis, herpes simplex virus, West Nile virus, tuberculosis meningitis, cryptococcal meningitis, Angiostrongylus cantonensis, neurocysticercosis, autoimmune encephalitis, toxoplasmosis, and bacterial brain abscess. We describe that while steroid therapy is beneficial and supported in pathogens such as pneumococcal meningitis and tuberculosis, for other diseases, like Listeria monocytogenes and Cryptococcus neoformans they are associated with worse outcomes. We highlight areas of consistent and proven findings and those which need more evidence for supported beneficial clinical use of adjunctive steroid therapy.
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Affiliation(s)
| | - Rodrigo Hasbun
- Department of Internal Medicine, UT Health McGovern Medical School, Houston, TX, United States
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7
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Westman G, Aurelius E, Ahlm C, Blennow K, Eriksson K, Lind L, Schliamser S, Sund F, Zetterberg H, Studahl M. Cerebrospinal fluid biomarkers of brain injury, inflammation and synaptic autoimmunity predict long-term neurocognitive outcome in herpes simplex encephalitis. Clin Microbiol Infect 2020; 27:1131-1136. [PMID: 32979577 DOI: 10.1016/j.cmi.2020.09.031] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 09/16/2020] [Accepted: 09/18/2020] [Indexed: 12/11/2022]
Abstract
OBJECTIVES The aim was to investigate the correlation between biomarkers of brain injury and long-term neurocognitive outcome, and the interplay with intrathecal inflammation and neuronal autoimmunity, in patients with herpes simplex encephalitis (HSE). METHODS A total of 53 adult/adolescent HSE patients were included from a prospective cohort in a randomized placebo-controlled trial investigating the effect of a 3-month follow-up treatment with valaciclovir. Study subjects underwent repeated serum/cerebrospinal fluid (CSF) sampling and brain magnetic resonance imaging in the first 3 months along with cognitive assessment using the Mattis Dementia Rating Scale (MDRS) at 24 months. CSF samples were analysed for biomarkers of brain injury, inflammation and synaptic autoimmunity. The predefined primary analysis was the correlation between peak CSF neurofilament protein (NFL), a biomarker of neuronal damage, and MDRS at 24 months. RESULTS Impaired cognitive performance significantly correlated with NFL levels (rho = -0.36, p = 0.020). Development of IgG anti-N-methyl-D-aspartate receptor (NDMAR) antibodies was associated with a broad and prolonged proinflammatory CSF response. In a linear regression model, lower MDRS at 24 months was associated with previous development of IgG anti-N-methyl-D-aspartate receptor (NMDAR) (beta = -0.6249, p = 0.024) and age (z-score beta = -0.2784, p = 0.024), but not CSF NFL, which however significantly correlated with subsequent NMDAR autoimmunization (p = 0.006). DISCUSSION Our findings show that NFL levels are predictive of long-term neurocognitive outcome in HSE, and suggest a causative chain of events where brain tissue damage increases the risk of NMDAR autoimmunisation and subsequent prolongation of CSF inflammation. The data provides guidance for a future intervention study of immunosuppressive therapy administered in the recovery phase of HSE.
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Affiliation(s)
- Gabriel Westman
- Department of Medical Sciences, Section of Infectious Diseases, Uppsala University, Uppsala, Sweden.
| | - Elisabeth Aurelius
- Unit of Infectious Diseases, Department of Medicine, Karolinska Institutet, Department of Infectious Diseases, Karolinska University Hospital, Solna, Sweden
| | - Clas Ahlm
- Department of Clinical Microbiology, Infection and Immunology, Umeå University, Umeå, Sweden
| | - Kaj Blennow
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, The Sahlgrenska Academy at the University of Gothenburg, Mölndal, Sweden; Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden
| | - Kristina Eriksson
- Department of Rheumatology and Inflammation Research, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Liza Lind
- Department of Rheumatology and Inflammation Research, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Silvia Schliamser
- Department of Clinical Sciences, Division of Infection Medicine, Lund University, Lund, Sweden
| | - Fredrik Sund
- Department of Medical Sciences, Section of Infectious Diseases, Uppsala University, Uppsala, Sweden
| | - Henrik Zetterberg
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, The Sahlgrenska Academy at the University of Gothenburg, Mölndal, Sweden; Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden; Department of Neurodegenerative Disease, UCL Institute of Neurology, London, United Kingdom; UK Dementia Research Institute at UCL, London, United Kingdom
| | - Marie Studahl
- Institute of Biomedicine, The Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden; Department of Infectious Diseases, Sahlgrenska University Hospital, Gothenburg, Sweden
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8
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Michael BD, Bricio-Moreno L, Sorensen EW, Miyabe Y, Lian J, Solomon T, Kurt-Jones EA, Luster AD. Astrocyte- and Neuron-Derived CXCL1 Drives Neutrophil Transmigration and Blood-Brain Barrier Permeability in Viral Encephalitis. Cell Rep 2020; 32:108150. [PMID: 32937134 PMCID: PMC7548103 DOI: 10.1016/j.celrep.2020.108150] [Citation(s) in RCA: 69] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Revised: 07/17/2020] [Accepted: 08/25/2020] [Indexed: 12/23/2022] Open
Abstract
Herpes simplex virus (HSV)-1 encephalitis has significant morbidity partly because of an over-exuberant immune response characterized by leukocyte infiltration into the brain and increased blood-brain barrier (BBB) permeability. Determining the role of specific leukocyte subsets and the factors that mediate their recruitment into the brain is critical to developing targeted immune therapies. In a murine model, we find that the chemokines CXCL1 and CCL2 are induced in the brain following HSV-1 infection. Ccr2 (CCL2 receptor)-deficient mice have reduced monocyte recruitment, uncontrolled viral replication, and increased morbidity. Contrastingly, Cxcr2 (CXCL1 receptor)-deficient mice exhibit markedly reduced neutrophil recruitment, BBB permeability, and morbidity, without influencing viral load. CXCL1 is produced by astrocytes in response to HSV-1 and by astrocytes and neurons in response to IL-1α, and it is the critical ligand required for neutrophil transendothelial migration, which correlates with BBB breakdown. Thus, the CXCL1-CXCR2 axis represents an attractive therapeutic target to limit neutrophil-mediated morbidity in HSV-1 encephalitis.
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Affiliation(s)
- Benedict D Michael
- Center for Immunology and Inflammatory Diseases, Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA; National Institute for Health Research, Health Protection Research Unit in Emerging and Zoonotic Infections, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, L69 7BE, UK; The Walton Centre NHS Foundation Trust, Department of Neurology, Liverpool L9 7LJ, UK
| | - Laura Bricio-Moreno
- Center for Immunology and Inflammatory Diseases, Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA
| | - Elizabeth W Sorensen
- Center for Immunology and Inflammatory Diseases, Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA
| | - Yoshishige Miyabe
- Department of Cell Biology, Institute for Advanced Medical Sciences, Nippon Medical School, Tokyo 113-8602, Japan
| | - Jeffrey Lian
- Center for Immunology and Inflammatory Diseases, Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA
| | - Tom Solomon
- National Institute for Health Research, Health Protection Research Unit in Emerging and Zoonotic Infections, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, L69 7BE, UK; The Walton Centre NHS Foundation Trust, Department of Neurology, Liverpool L9 7LJ, UK
| | - Evelyn A Kurt-Jones
- University of Massachusetts Medical School, Department of Medicine, Division of Infectious Disease and Immunology, Worcester, MA 01655, USA
| | - Andrew D Luster
- Center for Immunology and Inflammatory Diseases, Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA.
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9
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Abstract
Herpes simplex virus 1 (HSV-1) can be responsible for life-threatening HSV encephalitis (HSE). The mortality rate of patients with HSE who do not receive antiviral treatment is 70%, with most survivors suffering from permanent neurological sequelae. The use of intravenous acyclovir together with improved diagnostic technologies such as PCR and magnetic resonance imaging has resulted in a reduction in the mortality rate to close to 20%. However, 70% of surviving patients still do not recover complete neurological functions. Thus, there is an urgent need to develop more effective treatments for a better clinical outcome. It is well recognized that cerebral damage resulting from HSE is caused by viral replication together with an overzealous inflammatory response. Both of these processes constitute potential targets for the development of innovative therapies against HSE. In this review, we discuss recent progress in therapy that may be used to ameliorate the outcome of patients with HSE, with a particular emphasis on immunomodulatory agents. Ideally, the administration of adjunctive immunomodulatory drugs should be initiated during the rise of the inflammatory response, and its duration should be limited in time to reduce undesired effects. This critical time frame should be optimized by the identification of reliable biomarkers of inflammation.
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10
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Meyding-Lamadé U, Jacobi C, Martinez-Torres F, Lenhard T, Kress B, Kieser M, Klose C, Einhäupl K, Bösel J, Mackert MB, Homberg V, Koennecke C, Weißheit G, Claus D, Kieseier B, Bardutzky J, Neumann-Haefelin T, Lorenz MW, Steinmetz H, Gerloff C, Schneider D, Grau A, Klein M, Dziewas R, Bogdahn U, Jakob W, Linker R, Fuchs K, Sander A, Luntz S, Hoppe-Tichy T, Hanley DF, von Kummer R, Craemer E. The German trial on Aciclovir and Corticosteroids in Herpes-simplex-virus-Encephalitis (GACHE): a multicenter, randomized, double-blind, placebo-controlled trial. Neurol Res Pract 2019; 1:26. [PMID: 33324892 PMCID: PMC7650106 DOI: 10.1186/s42466-019-0031-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Accepted: 06/07/2019] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Comprehensive treatment of Herpes-simplex-virus-encephalitis (HSVE) remains a major clinical challenge. The current therapy gold standard is aciclovir, a drug that inhibits viral replication. Despite antiviral treatment, mortality remains around 20% and a majority of survivors suffer from severe disability. Experimental research and recent retrospective clinical observations suggest a favourable therapy response to adjuvant dexamethasone. Currently there is no randomized clinical trial evidence, however, to support the routine use of adjuvant corticosteroid treatment in HSVE. METHODS The German trial of Aciclovir and Corticosteroids in Herpes-simplex-virus-Encephalitis (GACHE) studied the effect of adjuvant dexamethasone versus placebo on top of standard aciclovir treatment in adult patients aged 18 up to 85 years with proven HSVE in German academic centers of Neurology in a randomized and double blind fashion. The trial was open from November 2007 to December 2012. The initially planned sample size was 372 patients with the option to increase to up to 450 patients after the second interim analysis. The primary endpoint was a binary functional outcome after 6 months assessed using the modified Rankin scale (mRS 0-2 vs. 3-6). Secondary endpoints included mortality after 6 and 12 months, functional outcome after 6 months measured with the Glasgow outcome scale (GOS), functional outcome after 12 months measured with mRS and GOS, quality of life as measured with the EuroQol 5D instrument after 6 and 12 months, neuropsychological testing after 6 months, cranial magnetic resonance imaging findings after 6 months, seizures up to day of discharge or at the latest at day 30, and after 6 and 12 months. RESULTS The trial was stopped prematurely for slow recruitment after 41 patients had been randomized, 21 of them treated with dexamethasone and 20 with placebo. No difference was observed in the primary endpoint. In the full analysis set (n = 19 in each group), 12 patients in each treatment arm achieved a mRS of 0-2. Similarly, we did not observe significant differences in the secondary endpoints (GOS, mRS, quality of life, neuropsychological testing). CONCLUSION GACHE being prematurely terminated demonstrated challenges encountered performing randomized, placebo-controlled trials in rare life threatening neurological diseases. Based upon our trial results the use of adjuvant steroids in addition to antiviral treatment remains experimental and is at the decision of the individual treating physician. Unfortunately, the small number of study participants does not allow firm conclusions. TRIAL REGISTRATION EudraCT-Nr. 2005-003201-81.
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Affiliation(s)
- U. Meyding-Lamadé
- Department of Neurology, Krankenhaus Nordwest, Frankfurt, Germany
- Department of Neurology, University of Heidelberg, Heidelberg, Germany
| | - C. Jacobi
- Department of Neurology, Krankenhaus Nordwest, Frankfurt, Germany
| | - F. Martinez-Torres
- Department of Neurology, Krankenhaus Nordwest, Frankfurt, Germany
- Department of Neurology, University of Heidelberg, Heidelberg, Germany
| | - T. Lenhard
- Department of Neurology, University of Heidelberg, Heidelberg, Germany
| | - B. Kress
- Department of Neuroradiology, Krankenhaus Nordwest, Frankfurt, Germany
| | - M. Kieser
- Department of Neurology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - C. Klose
- Institute of Medical Biometry and Informatics, University of Heidelberg, Heidelberg, Germany
| | - K. Einhäupl
- Department of Neurology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - J. Bösel
- Department of Neurology, Klinikum Kassel, Kassel, Germany
| | - M-B Mackert
- Department of Neurology, Vivantes Auguste-Viktoria-Klinikum, Berlin, Germany
| | - V. Homberg
- Department of Neurology, Zentralklinik Bad Berka, Bad Berka, Germany
| | - C. Koennecke
- Department of Neurology, Vivantes Klinikum im Friedrichshain, Berlin, Germany
| | - G. Weißheit
- Department of Neurology, Vivantes Klinikum im Friedrichshain, Berlin, Germany
| | - D. Claus
- Department of Neurology, Klinikum Darmstadt, Darmstadt, Germany
- Praxis Dr. Meyer & Prof. Claus, Bensheim, Germany
| | - B. Kieseier
- Department of Neurology, Universitätsklinikum Frankfurt, Frankfurt, Germany
| | - J. Bardutzky
- Department of Neurology, University of Freiburg, Freiburg, Germany
| | | | - M. W. Lorenz
- Department of Neurology, Krankenhaus Nordwest, Frankfurt, Germany
- Department of Neurology, Universitätsklinikum Frankfurt, Frankfurt, Germany
| | - H. Steinmetz
- Department of Neurology, Universitätsklinikum Frankfurt, Frankfurt, Germany
| | - C. Gerloff
- Department of Neurology, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - D. Schneider
- Department of Neurology, Universitätsklinikum Leipzig, Leipzig, Germany
| | - A. Grau
- Department of Neurology, Klinikum der Stadt Ludwigshafen am Rhein, Lugwigshafen, Germany
| | - M. Klein
- Department of Neurology, Klinikum der Ludwig-Maximilians- Universität München, Großhadern, Germany
| | - R. Dziewas
- Department of Neurology, Universitätsklinikum Regensburg, Regensburg, Germany
| | - U. Bogdahn
- Department of Pharmacy Heidelberg, Heidelberg University Hospital, Heidelberg, Germany
| | - W. Jakob
- Department of Neurology, Universitätsklinikum Regensburg, Regensburg, Germany
| | - R. Linker
- Department of Neurology, Universitätsklinikum Regensburg, Regensburg, Germany
| | - K. Fuchs
- Department of Neurology, Universitätsklinikum Regensburg, Regensburg, Germany
| | - A. Sander
- Institute of Medical Biometry and Informatics, University of Heidelberg, Heidelberg, Germany
| | - S. Luntz
- Koordinierungszentrum für Klinische Studien (KKS), University of Heidelberg, Heidelberg, Germany
| | - T. Hoppe-Tichy
- Department of Pharmacy Heidelberg, Heidelberg University Hospital, Heidelberg, Germany
| | - D. F. Hanley
- Division of Brain Injury Outcomes, John Hopkins University, Baltimore, MD USA
| | - R. von Kummer
- Universitätsklinikum Carl Gustav Carus, Dresden, Germany
| | - E. Craemer
- Department of Neurology, Krankenhaus Nordwest, Frankfurt, Germany
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Van Den Tooren HK, Bharambe V, Silver N, Michael BD. Herpes simplex virus encephalitis in a patient receiving ustekinumab associated with extensive cerebral oedema and brainshift successfully treated by immunosuppression with dexamethasone. BMJ Case Rep 2019; 12:12/8/e229468. [PMID: 31413050 DOI: 10.1136/bcr-2019-229468] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Herpes simplex virus (HSV) encephalitis affects 2-4 people per million/year. Immunocompomised patients can have atypical presentations of HSV encephalitis, including a lack of cerebrospinal fluid (CSF) pleocytosis. We present the case of a patient who was receiving ustekinumab therapy for psoriasis which inhibits interleukin (IL)-12 and IL-23 signalling pathways. The initial presentation was suggestive of encephalitis, but he was discharged prior to the reporting of HSV positivity due to the lack of CSF pleocytosis. On representation, he had worsening symptoms and imaging showed midline shift, indicating cerebral oedema despite the immunosupressant effects of ustekinumab. He required intensive care unit support and treatment with high dose aciclovir and dexamethasone; after a month of treatment he made a good recovery. This case is the first to report a link between ustekinumab and HSV encephalitis, and also emphasises that imunocompromised patients can lack CSF pleocytosis and develop significant cerebral oedema which responds to immune suppression.
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Affiliation(s)
| | - Viraj Bharambe
- Neurology, The Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Nicholas Silver
- Neurology, The Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Benedict D Michael
- Neurology, The Walton Centre NHS Foundation Trust, Liverpool, UK.,Department of Clinical Infection Microbiology and Immunology, Institute of Infection and Global Health, Liverpool, UK
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Mrad L, Moustakas A, Fuino R, Waheed W. Severe presentation of antibody-negative, postinfectious steroid-responsive encephalitis and atonic bladder after herpes simplex encephalitis. BMJ Case Rep 2019; 12:12/7/e230005. [DOI: 10.1136/bcr-2019-230005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
A 75-year-old woman presented with new onset of confusion, intense episodic dizziness and formed visual hallucinations. Herpes simplex encephalitis and non-convulsive temporal lobe seizures were confirmed with cerebrospinal fluid (CSF) and electroencephalography testing. In addition, her hospital course was complicated by syndrome of inappropriate antidiuretic hormone secretion and atonic bladder contributing to an episode of urinary tract infection. After completing 3 weeks of acyclovir treatment, the patient became obtunded with right arm choreiform movements and persistent inflammatory CSF findings not attributable to persistent herpes simplex virus infection or other confounding factors. The patient responded to steroid treatment. Repeated autoimmune and paraneoplastic evaluations were negative. Both clinical (cognitive testing and atonic bladder) and CSF inflammatory finding improved in the follow-up period.
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Todeschi J, Gubian A, Wirth T, Coca HA, Proust F, Cebula H. Multimodal management of severe herpes simplex virus encephalitis: A case report and literature review. Neurochirurgie 2018; 64:183-189. [PMID: 29730051 DOI: 10.1016/j.neuchi.2017.10.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Revised: 09/28/2017] [Accepted: 10/29/2017] [Indexed: 12/30/2022]
Abstract
BACKGROUND Herpes simplex encephalitis (HSE) is the most frequent sporadic encephalitis in the world. In severe cases of HSE, the pathology usually progresses with an increase in intracranial pressure secondary to cerebral edema and/or hemorrhagic necrosis. Currently no high-power studies exist regarding the management of severe HSE and most of the papers reported in the literature are case reports. Decompressive craniectomy, effective in some cases of pharmaco-resistant intracranial hypertension (ICH) resulting from other causes, may be suggested in severe HSE, with several good results reported in the literature. CASE DESCRIPTION The case of a 26-year-old man with severe HSE and a subsequent ICH is reported. In dealing with an ICH rebellious to conservative treatment, it was decided to perform a right decompressive hemicraniectomy, associated with a right temporal polectomy. The postoperative evolution was satisfactory, with normal neuropsychological tests and a Glasgow Outcome Scale of 1. CONCLUSION Although herpes simplex encephalitis is sometimes devastatingly complicated by intracranial hypertension, its management lacks consensus and reliable data in the literature remains scarce. Surgical as well as conservative treatment, used together in a multimodal approach, may hold the key to a greater control of intracranial pressure, thus resulting in a better outcome. In this multimodal management, the window of opportunity where surgery may be considered is small, and must be discussed further and more precisely in future articles.
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Affiliation(s)
- J Todeschi
- Department of neurosurgery, hôpital de Hautepierre, hôpitaux universitaires de Strasbourg, 1, avenue Molière, 67200 Strasbourg, France.
| | - A Gubian
- Department of neurosurgery, hôpital de Hautepierre, hôpitaux universitaires de Strasbourg, 1, avenue Molière, 67200 Strasbourg, France
| | - T Wirth
- Department of neurology, hôpital de Hautepierre, 67200 Strasbourg, France
| | - H-A Coca
- Department of neurosurgery, hôpital de Hautepierre, hôpitaux universitaires de Strasbourg, 1, avenue Molière, 67200 Strasbourg, France
| | - F Proust
- Department of neurosurgery, hôpital de Hautepierre, hôpitaux universitaires de Strasbourg, 1, avenue Molière, 67200 Strasbourg, France
| | - H Cebula
- Department of neurosurgery, hôpital de Hautepierre, hôpitaux universitaires de Strasbourg, 1, avenue Molière, 67200 Strasbourg, France
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14
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Westman G, Sohrabian A, Aurelius E, Ahlm C, Schliamser S, Sund F, Studahl M, Rönnelid J. Clinical significance of IgM and IgA class anti-NMDAR antibodies in herpes simplex encephalitis. J Clin Virol 2018; 103:75-80. [PMID: 29698873 DOI: 10.1016/j.jcv.2018.04.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2018] [Revised: 04/04/2018] [Accepted: 04/08/2018] [Indexed: 01/04/2023]
Abstract
BACKGROUND Herpes simplex encephalitis (HSE) is a devastating disease, often leaving patients with severe disabilities. It has been shown that IgG anti-N-methyl-d-aspartate receptor (NMDAR) antibodies appear in approximately 25% of HSE patients and could be associated with impaired recovery of cognitive performance. OBJECTIVES To characterize the prevalence of IgM and IgA anti-NMDAR antibodies in HSE patients, in relation to subsequent development of IgG anti-NMDAR and correlation to cognitive performance. STUDY DESIGN A total of 48 subjects were included from a previously described cohort of patients with HSE verified by HSV-1 PCR. Cerebrospinal fluid (CSF) and serum samples drawn close to onset of disease, after 14-21 days of iv aciclovir treatment and after 90 days of follow-up, were analyzed for the presence of IgM and IgA anti-NMDAR, and related to IgG anti-NMDAR. Antibody levels were correlated to the recovery of cognitive performance, as estimated by the Mattis Dementia Rating Scale (MDRS), for a total of 24 months. RESULTS In total, 27 of 48 (56%) study subjects were anti-NMDAR positive, defined as the presence of IgG (12/48, 25%), IgM (14/48, 29%) or IgA (13/48, 27%) antibodies in CSF and/or serum. IgM or IgA anti-NMDAR did not predict subsequent IgG autoimmunization and did not correlate to cognitive outcome. IgG anti-NMDAR serostatus, but not antibody titers, correlated to impaired recovery of cognitive performance. CONCLUSIONS A majority of HSE patients develop IgG, IgM or IgA anti-NMDAR antibodies. However, the predictive value and clinical relevance of non-IgG isotypes remains to be shown in this setting.
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Affiliation(s)
- Gabriel Westman
- Department of Medical Sciences, Section of Infectious Diseases, Uppsala University, Uppsala, Sweden.
| | - Azita Sohrabian
- Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden
| | - Elisabeth Aurelius
- Unit of Infectious Diseases, Department of Medicine, Karolinska Institutet, Solna, Sweden; Department of Infectious Diseases, Karolinska University Hospital, Solna, Sweden
| | - Clas Ahlm
- Department of Clinical Microbiology, Infectious Diseases, Umeå University, Umeå, Sweden
| | - Silvia Schliamser
- Department of Clinical Sciences, Division of Infection Medicine, Lund University, Lund, Sweden
| | - Fredrik Sund
- Department of Medical Sciences, Section of Infectious Diseases, Uppsala University, Uppsala, Sweden
| | - Marie Studahl
- Department of Infectious Diseases, The Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
| | - Johan Rönnelid
- Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden
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Patabendige A, Michael BD, Craig AG, Solomon T. Brain microvascular endothelial-astrocyte cell responses following Japanese encephalitis virus infection in an in vitro human blood-brain barrier model. Mol Cell Neurosci 2018; 89:60-70. [PMID: 29635016 PMCID: PMC5984247 DOI: 10.1016/j.mcn.2018.04.002] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2018] [Revised: 03/16/2018] [Accepted: 04/04/2018] [Indexed: 12/22/2022] Open
Abstract
Japanese encephalitis virus (JEV) remains a leading cause of encephalitis, globally, which continues to grow in importance despite the availability of vaccines. Viral entry into the brain can occur via the blood-brain barrier (BBB), and inflammation at the BBB is a common final pathway in many brain infections. However, the role of the BBB during JEV infection and the contribution of the endothelial and astrocytic cell inflammation in facilitating virus entry into the brain are incompletely understood. We established a BBB model using human brain endothelial cells (HBECs) and human astrocytes. HBECs are polarised, and therefore the model was inoculated by JEV from the apical side to simulate the in vivo situation. The effects of JEV on the BBB permeability and release of inflammatory mediators from both apical and basolateral sides, representing the blood and the brain side respectively were investigated. JEV infected HBECs with limited active virus production, before crossing the BBB and infecting astrocytes. Control of JEV production by HBECs was associated with a significant increase in permeability, and with elevation of many host mediators, including cytokines, chemokines, cellular adhesion molecules, and matrix metalloproteases. When compared to the controls, significantly higher amounts of mediators were released from the apical side as opposed to the basolateral side. The increased release of mediators over time also correlated with increased BBB permeability. Treatment with dexamethasone led to a significant reduction in the release of interleukin 6 (IL6), C-C motif chemokine ligand 5 (CCL5) and C-X-C motif chemokine ligand 10 (CXCL10) from the apical side with a reduction in BBB disruption and no change in JEV production. The results are consistent with the hypothesis that JEV infection of the BBB triggers the production of a range of host mediators from both endothelial cells and astrocytes, which control JEV production but disrupt BBB integrity thus allowing virus entry into the brain. Dexamethasone treatment controlled the host response and limited BBB disruption in the model without increasing JEV production, supporting a re-investigation of its use therapeutically. Japanese encephalitis virus (JEV) infects human brain endothelial cells (HBECs). This triggers the production of a range of host mediators from both HBECs and astrocytes. JEV infection adversely affects blood-brain barrier (BBB) integrity. Dexamethasone treatment following JEV infection reduces the inflammation. Dexamethasone restores BBB integrity without increasing the levels of JEV particles.
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Affiliation(s)
- Adjanie Patabendige
- The Institute of Infection and Global Health, University of Liverpool, Liverpool, UK; The School of Biomedical Sciences and Pharmacy, The University of Newcastle, Newcastle, Australia; The Hunter Medical Research Institute, Newcastle, Australia.
| | - Benedict D Michael
- The Institute of Infection and Global Health, University of Liverpool, Liverpool, UK; The Walton Centre NHS Foundation Trust, Liverpool, UK; Center for Immunology and Inflammatory Disease, Massachusetts General Hospital, Harvard Medical School, USA
| | | | - Tom Solomon
- The Institute of Infection and Global Health, University of Liverpool, Liverpool, UK; The Walton Centre NHS Foundation Trust, Liverpool, UK; National Institute for Health Research Health Protection Research Unit in Emerging and Zoonotic Infections, Liverpool, UK
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Abstract
Encephalitis, inflammation of the brain, is most commonly caused by a viral infection (especially herpes simplex virus [HSV] type 1 in the UK) although autoimmune causes, such as N-methyl D-aspartate receptor (NMDAR) antibody encephalitis, are increasingly recognised. Most patients present with a change in consciousness level and may have fever, seizures, movement disorder or focal neurological deficits. Diagnosis hinges crucially on lumbar puncture and cerebrospinal fluid (CSF) examination, but imaging and electroencephalography (EEG) may also be helpful. Treatment of HSV encephalitis with aciclovir dramatically improves outcome, but the optimal management of autoimmune encephalitis is still uncertain. Many patients with encephalitis are left with residual physical or neuropsychological deficits which require long-term multidisciplinary management. Here we review assessment of patients with suspected encephalitis, general aspects of management and areas of ongoing research.
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Affiliation(s)
- Mark Ellul
- The Walton Centre NHS Foundation Trust, Liverpool, UK
- Institute of Infection and Global Health, University of Liverpool, Liverpool, UK
| | - Tom Solomon
- The Walton Centre NHS Foundation Trust, Liverpool, UK
- Institute of Infection and Global Health, University of Liverpool, Liverpool, UK
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17
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Shin DH. Corticosteroid Treatment for Central Nervous System Infections. JOURNAL OF NEUROCRITICAL CARE 2017. [DOI: 10.18700/jnc.170024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
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Soto I, Bernardo A, Arias T, Ramón C, Noval I, Palomo C. The first case report of a patient with acquired factor XIII deficiency in the context of autoimmune encephalitis. Haemophilia 2017; 23:e461-e464. [PMID: 28664679 DOI: 10.1111/hae.13281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/22/2017] [Indexed: 06/07/2023]
Affiliation(s)
- I Soto
- Department of Haematology, Hospital Universitario Central de Asturias (HUCA), Oviedo, Spain
| | - A Bernardo
- Department of Haematology, Hospital Universitario Central de Asturias (HUCA), Oviedo, Spain
| | - T Arias
- Department of Haematology, Hospital Universitario Central de Asturias (HUCA), Oviedo, Spain
| | - C Ramón
- Department of Neurology, Hospital Universitario Central de Asturias (HUCA), Oviedo, Spain
| | - I Noval
- Department of Radiodiagnostics, Hospital Universitario Central de Asturias (HUCA), Oviedo, Spain
| | - C Palomo
- Department of Internal Medicine, Hospital Universitario Central de Asturias (HUCA), Oviedo, Spain
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Nosadini M, Mohammad SS, Corazza F, Ruga EM, Kothur K, Perilongo G, Frigo AC, Toldo I, Dale RC, Sartori S. Herpes simplex virus-induced anti-N-methyl-d-aspartate receptor encephalitis: a systematic literature review with analysis of 43 cases. Dev Med Child Neurol 2017; 59:796-805. [PMID: 28439890 DOI: 10.1111/dmcn.13448] [Citation(s) in RCA: 102] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/05/2017] [Indexed: 01/05/2023]
Abstract
AIM To conduct a systematic literature review on patients with biphasic disease with herpes simplex virus (HSV) encephalitis followed by anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis. METHOD We conducted a case report and systematic literature review (up to 10 December 2016), focused on differences between herpes simplex encephalitis (HSE) and anti-NMDAR encephalitis phases, age-related characteristics of HSV-induced anti-NMDAR encephalitis, and therapy. For statistical analyses, McNemar's test, Fisher's test, and Wilcoxon rank sum test were used (two-tailed significance level set at 5%). RESULTS Forty-three patients with biphasic disease were identified (31 children). Latency between HSE and anti-NMDAR encephalitis was significantly shorter in children than adults (median 24 vs 40.5d; p=0.006). Compared with HSE, anti-NMDAR encephalitis was characterized by significantly higher frequency of movement disorder (2.5% vs 75% respectively; p<0.001), and significantly lower rate of seizures (70% vs 30% respectively; p=0.001). Compared with adults, during anti-NMDAR encephalitis children had significantly more movement disorders (86.7% children vs 40% adults; p=0.006), fewer psychiatric symptoms (41.9% children vs 90.0% adults; p=0.025), and a slightly higher median modified Rankin Scale score (5 in children vs 4 in adults; p=0.015). During anti-NMDAR encephalitis, 84.6 per cent of patients received aciclovir (for ≤7d in 22.7%; long-term antivirals in 18.0% only), and 92.7 per cent immune therapy, but none had recurrence of HSE clinically or using cerebrospinal fluid HSV polymerase chain reaction (median follow-up 7mo). INTERPRETATION Our review suggests that movement disorder may help differentiate clinically an episode of HSV-induced anti-NMDAR encephalitis from HSE relapse. Compared with adults, children have shorter latency between HSE and anti-NMDAR encephalitis and, during anti-NMDAR encephalitis, more movement disorder, fewer psychiatric symptoms, and slightly more severe disease. According to our results, immune therapy given for HSV-induced anti-NMDAR encephalitis does not predispose patients to HSE recurrence.
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Affiliation(s)
- Margherita Nosadini
- Paediatric Neurology and Neurophysiology Unit, Department of Women's and Children's Health, University Hospital of Padua, Padua, Italy
| | - Shekeeb S Mohammad
- Neuroimmunology Group, Institute for Neuroscience and Muscle Research, Kids Research Institute at the Children's Hospital at Westmead, University of Sydney, Sydney, Australia
| | - Francesco Corazza
- Paediatric Neurology and Neurophysiology Unit, Department of Women's and Children's Health, University Hospital of Padua, Padua, Italy
| | - Ezia Maria Ruga
- Department of Paediatrics, University of Padua, Padua, Italy
| | - Kavitha Kothur
- Neuroimmunology Group, Institute for Neuroscience and Muscle Research, Kids Research Institute at the Children's Hospital at Westmead, University of Sydney, Sydney, Australia
| | | | - Anna Chiara Frigo
- Department of Cardiac, Thoracic and Vascular Sciences, Biostatistics, Epidemiology and Public Health Unit, University of Padua, Padua, Italy
| | - Irene Toldo
- Paediatric Neurology and Neurophysiology Unit, Department of Women's and Children's Health, University Hospital of Padua, Padua, Italy
| | - Russell C Dale
- Neuroimmunology Group, Institute for Neuroscience and Muscle Research, Kids Research Institute at the Children's Hospital at Westmead, University of Sydney, Sydney, Australia
| | - Stefano Sartori
- Paediatric Neurology and Neurophysiology Unit, Department of Women's and Children's Health, University Hospital of Padua, Padua, Italy
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21
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Abstract
PURPOSE OF REVIEW The goal of this review is to provide an update on current thinking regarding herpes simplex encephalitis (HSE), emphasizing new information about pathogenesis, diagnosis, and immune responses. Specific questions to be addressed are the following: (1) Is there a genetic predisposition to HSE? (2) What clinical approaches have the greatest impact on improving the long-term outcomes in patients with HSE? And (3) are there immune-mediated mechanisms that may account for relapsing HSE? RECENT FINDINGS Toll-like receptor 3 (TLR 3) plays an important role in innate immune responses, including generation of interferons. Multiple single-gene errors in TLR 3 interferon pathways have recently been described in children that result in increased susceptibility to HSE. Conversely, studies in both animal models and humans indicate that both cytolytic viral replication and immune-mediated responses (including cytotoxic T lymphocytes and immune mechanisms mediated by TLR 2) contribute to the pathology of HSV, suggesting possible new therapeutic approaches. In terms of treatment, data clearly indicate that a longer duration between onset of symptoms and initiation of effective antiviral therapy correlates directly with less favorable clinical outcome. Recurrent or relapsing HSE may occasionally occur, but recent observations indicate that many instances of "relapsing HSE", especially in children, are more often anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis triggered by the antecedent HSV infection. Innate immune responses are critical for defense against HSV; genetic defects in this system may predispose patients to HSE. During acute HSE, exuberant immune responses may contribute to the CNS pathology, suggesting that selective immunosuppressive therapy, coupled with potent antiviral drugs, may eventually play a role in the therapeutic management of HSV. While overall clinical outcomes of HSE remain suboptimal, the initiation of high-dose acyclovir therapy as early as possible in the course of the illness provides the best chance for a patient to survive with minimal neurologic damage. Distinguishing relapsing HSE from autoimmune anti-NMDAR antibody encephalitis is critically important because therapeutic approaches will be very different.
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Affiliation(s)
- John W Gnann
- Department of Medicine, Division of Infectious Diseases, Medical University of South Carolina, 135 Rutledge Avenue, MSC 752, Charleston, SC, 29425, USA.
| | - Richard J Whitley
- University of Alabama at Birmingham, 303 CHB, 1600 7th Ave. S, Birmingham, AL, 35233-1711, USA
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The Characteristics of Herpes Simplex Virus Type 1 Infection in Rhesus Macaques and the Associated Pathological Features. Viruses 2017; 9:v9020026. [PMID: 28146109 PMCID: PMC5332945 DOI: 10.3390/v9020026] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2016] [Accepted: 01/24/2017] [Indexed: 02/06/2023] Open
Abstract
As one of the major pathogens for human herpetic diseases, herpes simplex virus type 1 (HSV1) causes herpes labialis, genital herpes and herpetic encephalitis. Our aim here was to investigate the infectious process of HSV1 in rhesus macaques and the pathological features induced during this infection. Clinical symptoms that manifested in the rhesus macaque during HSV1 infection included vesicular lesions and their pathological features. Viral distribution in the nervous tissues and associated pathologic changes indicated the typical systematic pathological processes associated with viral distribution of HSV1. Interestingly, vesicular lesions recurred in oral skin or in mucosa associated with virus shedding in macaques within four to five months post-infection, and viral latency-associated transcript (LAT) mRNA was found in the trigeminal ganglia (TG) on day 365 post-infection. Neutralization testing and enzyme-linked immunospot (ELISpot) detection of specific T cell responses confirmed the specific immunity induced by HSV1 infection. Thus, rhesus macaques could serve as an infectious model for HSV1 due to their typical clinical symptoms and the pathological recurrence associated with viral latency in nervous tissues.
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Defres S, Keller SS, Das K, Vidyasagar R, Parkes LM, Burnside G, Griffiths M, Kopelman M, Roberts N, Solomon T. A Feasibility Study of Quantifying Longitudinal Brain Changes in Herpes Simplex Virus (HSV) Encephalitis Using Magnetic Resonance Imaging (MRI) and Stereology. PLoS One 2017; 12:e0170215. [PMID: 28125598 PMCID: PMC5268482 DOI: 10.1371/journal.pone.0170215] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2016] [Accepted: 01/02/2017] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVES To assess whether it is feasible to quantify acute change in temporal lobe volume and total oedema volumes in herpes simplex virus (HSV) encephalitis as a preliminary to a trial of corticosteroid therapy. METHODS The study analysed serially acquired magnetic resonance images (MRI), of patients with acute HSV encephalitis who had neuroimaging repeated within four weeks of the first scan. We performed volumetric measurements of the left and right temporal lobes and of cerebral oedema visible on T2 weighted Fluid Attenuated Inversion Recovery (FLAIR) images using stereology in conjunction with point counting. RESULTS Temporal lobe volumes increased on average by 1.6% (standard deviation (SD 11%) in five patients who had not received corticosteroid therapy and decreased in two patients who had received corticosteroids by 8.5%. FLAIR hyperintensity volumes increased by 9% in patients not receiving treatment with corticosteroids and decreased by 29% in the two patients that had received corticosteroids. CONCLUSIONS This study has shown it is feasible to quantify acute change in temporal lobe and total oedema volumes in HSV encephalitis and suggests a potential resolution of swelling in response to corticosteroid therapy. These techniques could be used as part of a randomized control trial to investigate the efficacy of corticosteroids for treating HSV encephalitis in conjunction with assessing clinical outcomes and could be of potential value in helping to predict the clinical outcomes of patients with HSV encephalitis.
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Affiliation(s)
- Sylviane Defres
- Clinical Infection, microbiology and immunology, Institute of Infection and Global Health, University of Liverpool, Liverpool, United Kingdom
- Tropical and Infectious diseases Unit, Liverpool and Broadgreen University Hospital Trust, Liverpool, United Kingdom
- NIHR HPRU in Emerging and Zoonotic Infections, University of Liverpool, Institute of infection and Global Health, Waterhouse Building, Liverpool, United Kingdom
| | - Simon S. Keller
- The Department of Molecular and Clinical Pharmacology, Institute of Translational Medicine, University of Liverpool, Liverpool, United Kingdom
- The Department of Neuroradiology, The Walton Centre NHS Foundation Trust, Liverpool, Liverpool, United Kingdom
| | - Kumar Das
- The Department of Neuroradiology, The Walton Centre NHS Foundation Trust, Liverpool, Liverpool, United Kingdom
| | - Rishma Vidyasagar
- Florey Institute of Neuroscience and mental health, Heidelberg, Victoria, Australia
- Department of Anatomy and Neuroscience, University of Melbourne, Victoria, Australia
| | - Laura M. Parkes
- Division of Neuroscience and Experimental Psychology, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
| | - Girvan Burnside
- The department of Biostatistics, Institute of translational medicine, University of Liverpool, Liverpool, United Kingdom
| | - Michael Griffiths
- Clinical Infection, microbiology and immunology, Institute of Infection and Global Health, University of Liverpool, Liverpool, United Kingdom
- Alder Hey Children’s NHS Foundation Trust, Liverpool, United Kingdom
| | - Michael Kopelman
- Institute of Psychiatry, Kings College London, London, United Kingdom
| | - Neil Roberts
- Medical Physics and Imaging Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Tom Solomon
- Clinical Infection, microbiology and immunology, Institute of Infection and Global Health, University of Liverpool, Liverpool, United Kingdom
- NIHR HPRU in Emerging and Zoonotic Infections, University of Liverpool, Institute of infection and Global Health, Waterhouse Building, Liverpool, United Kingdom
- The Department of Neuroradiology, The Walton Centre NHS Foundation Trust, Liverpool, Liverpool, United Kingdom
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Zimmermann J, Hafezi W, Dockhorn A, Lorentzen EU, Krauthausen M, Getts DR, Müller M, Kühn JE, King NJC. Enhanced viral clearance and reduced leukocyte infiltration in experimental herpes encephalitis after intranasal infection of CXCR3-deficient mice. J Neurovirol 2017; 23:394-403. [PMID: 28116674 DOI: 10.1007/s13365-016-0508-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2015] [Revised: 12/06/2016] [Accepted: 12/14/2016] [Indexed: 12/25/2022]
Abstract
Herpes simplex virus type 1 (HSV-1) encephalitis (HSE) is the most common fatal sporadic encephalitis in developed countries. There is evidence from HSE animal models that not only direct virus-mediated damage caused but also the host's immune response contributes to the high mortality of the disease. Chemokines modulate and orchestrate this immune response. Previous experimental studies in HSE models identified the chemokine receptor CXCR3 and its ligands as molecules with a high impact on the course of HSE in mouse models. In this study, the role of the chemokine receptor CXCR3 was evaluated after intranasal infection with the encephalitogenic HSV-1 strain 17 syn+ using CXCR3-deficient mice (CXCR3-/-) and wild-type controls. We demonstrated a neurotropic viral spread into the CNS of after intranasal infection. Although viral load and histological distribution of infected neurons were independent from CXCR3 signaling early after infection, CXCR3-deficient mice cleared HSV-1 more efficiently 14 days after infection. Furthermore, CXCR3 deficiency led to a decreased weight loss in mice after HSV-1 infection. T cell infiltration and microglial activation was prominently reduced by inhibition of CXCR3 signaling. Quantitative PCR of proinflammatory cytokines and chemokines confirmed the reduced neuroinflammatory response in CXCR3-deficient mice during HSE. Our results demonstrate that the recruitment of peripheral immune cells into the CNS, induction of neuroinflammation, and consecutive weight loss during herpes encephalitis is modulated by CXCR3 signaling. Interruption of the CXCR3 pathway ameliorates the detrimental host immune response and in turn, leads paradoxically to an enhanced viral clearance after intranasal infection. Our data gives further insight into the role of CXCR3 during HSE after intranasal infection.
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Affiliation(s)
- J Zimmermann
- Department of Neurology, Universitätsklinikum Bonn, Sigmund-Freud-Str. 25, 53105, Bonn, Germany
| | - W Hafezi
- University Hospital Münster, Institute of Medical Microbiology-Clinical Virology, Münster, Germany
| | - A Dockhorn
- Department of Neurology, Universitätsklinikum Bonn, Sigmund-Freud-Str. 25, 53105, Bonn, Germany
| | - Eva U Lorentzen
- University Hospital Münster, Institute of Medical Microbiology-Clinical Virology, Münster, Germany
| | - M Krauthausen
- Department of Neurology, Universitätsklinikum Bonn, Sigmund-Freud-Str. 25, 53105, Bonn, Germany
| | - Daniel R Getts
- Department of Microbiology-Immunology and Interdepartmental Immunobiology Center, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA.,Cour Pharmaceutical Development Company, Elmhurst, IL, USA.,The Discipline of Pathology, School of Medical Sciences, The University of Sydney, Sydney, NSW, 2006, Australia
| | - M Müller
- Department of Neurology, Universitätsklinikum Bonn, Sigmund-Freud-Str. 25, 53105, Bonn, Germany.
| | - Joachim E Kühn
- University Hospital Münster, Institute of Medical Microbiology-Clinical Virology, Münster, Germany
| | - Nicholas J C King
- The Discipline of Pathology, School of Medical Sciences, The University of Sydney, Sydney, NSW, 2006, Australia
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25
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Galli J, Clardy SL, Piquet AL. NMDAR Encephalitis Following Herpes Simplex Virus Encephalitis. Curr Infect Dis Rep 2017; 19:1. [DOI: 10.1007/s11908-017-0556-y] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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26
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Westman G, Studahl M, Ahlm C, Eriksson BM, Persson B, Rönnelid J, Schliamser S, Aurelius E. N-methyl-d-aspartate receptor autoimmunity affects cognitive performance in herpes simplex encephalitis. Clin Microbiol Infect 2016; 22:934-940. [PMID: 27497810 DOI: 10.1016/j.cmi.2016.07.028] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2016] [Revised: 07/26/2016] [Accepted: 07/26/2016] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To investigate the prevalence and temporal development of N-methyl-d-aspartate receptor (NMDAR) autoantibodies in relation to neurocognitive performance in patients with herpes simplex encephalitis (HSE). METHODS This prospective observational study enrolled a total of 49 HSE patients within a randomized controlled trial of valacyclovir. Cerebrospinal fluid and serum samples were drawn in the initial stage of disease, after 2 to 3 weeks and after 3 months. Anti-NMDAR IgG was detected with HEK293 cells transfected with plasmids encoding the NMDA NR1 type glutamate receptor. A batch of neurocognitive tests, including the Mattis Dementia Rating Scale (MDRS), Glasgow Coma Scale (GCS), Reaction Level Scale (RLS85), Mini-Mental State Examination (MMSE) and National Institutes of Health (NIH) stroke scale, was performed during 24 months' follow-up. RESULTS Anti-NMDAR IgG was detected in 12 of 49 participants. None were antibody positive in the initial stage of disease. In ten of 12 positive cases, specific antibodies were detectable only after 3 months. Notably, the development of NMDAR autoantibodies was associated with significantly impaired recovery of neurocognitive performance. After 24 months' follow-up, the median increase in MDRS total score was 1.5 vs. 10 points in antibody-positive and -negative participants (p=0.018). CONCLUSIONS Anti-NMDAR autoimmunity is a common complication to HSE that develops within 3 months after onset of disease. The association to impaired neurocognitive recovery could have therapeutical implications, as central nervous system autoimmunity is potentially responsive to immunotherapy.
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Affiliation(s)
- G Westman
- Department of Medical Sciences, Section of Infectious Diseases, Uppsala University, Uppsala, Sweden.
| | - M Studahl
- Department of Infectious Diseases, The Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
| | - C Ahlm
- Department of Clinical Microbiology, Infectious Diseases, Umeå University, Umeå, Sweden
| | - B M Eriksson
- Department of Medical Sciences, Section of Infectious Diseases, Uppsala University, Uppsala, Sweden
| | - B Persson
- Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden
| | - J Rönnelid
- Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden
| | - S Schliamser
- Department of Clinical Sciences, Division of Infection Medicine, Lund University, Lund, Sweden
| | - E Aurelius
- Unit of Infectious Diseases, Department of Medicine, Karolinska Institutet, Sweden
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27
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Bradshaw MJ, Venkatesan A. Herpes Simplex Virus-1 Encephalitis in Adults: Pathophysiology, Diagnosis, and Management. Neurotherapeutics 2016; 13:493-508. [PMID: 27106239 PMCID: PMC4965403 DOI: 10.1007/s13311-016-0433-7] [Citation(s) in RCA: 238] [Impact Index Per Article: 29.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
Herpetic infections have plagued humanity for thousands of years, but only recently have advances in antiviral medications and supportive treatments equipped physicians to combat the most severe manifestations of disease. Prompt recognition and treatment can be life-saving in the care of patients with herpes simplex-1 virus encephalitis, the most commonly identified cause of sporadic encephalitis worldwide. Clinicians should be able to recognize the clinical signs and symptoms of the infection and familiarize themselves with a rational diagnostic approach and therapeutic modalities, as early recognition and treatment are key to improving outcomes. Clinicians should also be vigilant for the development of acute complications, including cerebral edema and status epilepticus, as well as chronic complications, including the development of autoimmune encephalitis associated with antibodies to the N-methyl-D-aspartate receptor and other neuronal cell surface and synaptic epitopes. Herein, we review the pathophysiology, differential diagnosis, and clinical and radiological features of herpes simplex virus-1 encephalitis in adults, including a discussion of the most common complications and their treatment. While great progress has been made in the treatment of this life-threatening infection, a majority of patients will not return to their previous neurologic baseline, indicating the need for further research efforts aimed at improving the long-term sequelae.
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Affiliation(s)
- Michael J Bradshaw
- Department of Neurology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Arun Venkatesan
- Division of Neuroimmunology & Neuroinfectious Diseases, Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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28
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Maraş Genç H, Uyur Yalçın E, Sayan M, Bayhan A, Öncel S, Arısoy ES, Kara B. Clinical outcomes in children with herpes simplex encephalitis receiving steroid therapy. J Clin Virol 2016; 80:87-92. [PMID: 27218417 DOI: 10.1016/j.jcv.2016.05.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2016] [Revised: 05/02/2016] [Accepted: 05/03/2016] [Indexed: 12/01/2022]
Abstract
BACKGROUND Herpes simplex virus encephalitis (HSE) is a significant cause of morbidity and mortality. Neurologic sequelae are common even after early initiation of acyclovir treatment. The host immune response during HSE can also lead to brain damage. There are an increasing number of reports favoring steroid use in HSE. OBJECTIVES We aimed to compare the prognosis of children with HSE with and without steroid therapy. STUDY DESIGN We retrospectively screened our hospital archive from 2009 to 2014 for patients diagnosed with HSE with a positive result for herpes simplex virus polymerase chain reaction in cerebrospinal fluid. Patients ≥1 month and ≤18 years at diagnosis were included in the study. Clinical outcomes in terms of cognitive function, motor function, electroencephalographic findings, seizure frequency, and radiologic findings were compared in patients who received adjuvant steroid therapy with those who did not. RESULTS Six patients (1 boy, 5 girls; aged 4 months to 10 years) were included. Overall symptom duration before hospital admission was ≤5days. Patients received acyclovir treatment for 21-28days. Three received steroid therapy early during the disease and three patients did not. No adverse effects related to steroids were observed. Follow-up duration was 6 months to 5 years. All patients had radiologic sequelae of encephalitis. Cognition, motor function, and seizure control were better in patients who received steroid therapy. CONCLUSIONS Adjuvant steroid therapy seems to be effective in decreasing morbidity in children with HSE but the radiologic sequelae were the same in both groups.
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Affiliation(s)
- Hülya Maraş Genç
- Department of Pediatrics, Division of Pediatric Neurology, Kocaeli University Faculty of Medicine, Kocaeli, Turkey.
| | - Emek Uyur Yalçın
- Department of Pediatrics, Division of Pediatric Neurology, Kocaeli University Faculty of Medicine, Kocaeli, Turkey
| | - Murat Sayan
- Central Laboratory PCR Unit, Kocaeli University Faculty of Medicine, Kocaeli, Turkey; Research Center of Experimental Health Sciences, Near East University, Nicosia, Northern Cyprus, Cyprus
| | - Asuman Bayhan
- Kocaeli University Faculty of Medicine, Kocaeli, Turkey
| | - Selim Öncel
- Department of Pediatrics, Division of Pediatric Infectious Diseases, Kocaeli University Faculty of Medicine, Kocaeli, Turkey
| | - Emin Sami Arısoy
- Department of Pediatrics, Division of Pediatric Infectious Diseases, Kocaeli University Faculty of Medicine, Kocaeli, Turkey
| | - Bülent Kara
- Department of Pediatrics, Division of Pediatric Neurology, Kocaeli University Faculty of Medicine, Kocaeli, Turkey
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Michael BD, Griffiths MJ, Granerod J, Brown D, Keir G, Wnęk M, Cox DJ, Vidyasagar R, Borrow R, Parkes LM, Solomon T. The Interleukin-1 Balance During Encephalitis Is Associated With Clinical Severity, Blood-Brain Barrier Permeability, Neuroimaging Changes, and Disease Outcome. J Infect Dis 2015; 213:1651-60. [PMID: 26712949 DOI: 10.1093/infdis/jiv771] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2015] [Accepted: 12/21/2015] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Encephalitis is parenchymal brain inflammation, commonly due to herpes simplex virus (HSV). Key host inflammatory mediators and their relationship to blood-brain barrier (BBB) permeability, neuroimaging changes, and disease outcome are poorly understood. METHODS We measured levels of 38 mediators in serum (n = 78) and cerebrospinal fluid (n = 37) specimens from patients with encephalitis, including 17 with disease due to HSV infection. Outcome measures were Glasgow coma and outcome scores; CSF to serum albumin ratio, reflecting BBB permeability; and, in patients with HSV infection, magnetic resonance imaging-based temporal lobe volume. RESULTS Serum interleukin 1 receptor antagonist (IL-1RA) levels were elevated in patients with a good outcome (P= .004). Among patients infected with HSV, the ratio of CSF IL-1β to IL-1RA was associated with a worse outcome (P= .009); a ratio of ≥0.55 pg/mL had high specificity and sensitivity for a poor outcome (100% and 83%;P= .015). Temporal lobe volume had a negative correlation with serum IL-1RA level (P= .012) and a positive correlation with serum IL-1α level (P= .0003) and CSF IL-1β level (P= .007). A normal coma score was associated with an elevated interleukin 10 (IL-10) level in serum specimens from HSV-infected patients (P= .007) and CSF specimens from all patients (P= .016); the IL-10 level correlated inversely with BBB permeability (P= .005). CONCLUSIONS A proinflammatory cytokine response is associated with greater clinical severity, BBB permeability, and neuroimaging damage during encephalitis. IL-1 antagonists should be investigated as adjunctive treatment in encephalitis.
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Affiliation(s)
- Benedict Daniel Michael
- Institute of Infection and Global Health Health Protection Research Unit in Emerging and Zoonotic Infections, National Institute for Health Research, University of Liverpool Walton Centre National Health Service (NHS) Foundation Trust
| | - Michael J Griffiths
- Institute of Infection and Global Health Health Protection Research Unit in Emerging and Zoonotic Infections, National Institute for Health Research, University of Liverpool Alderhey Children's NHS Foundation Trust, Liverpool
| | | | - David Brown
- Public Health England, London Influenza and Measles Laboratory, Oswaldo Cruz Institute, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil
| | - Geoff Keir
- Walton Centre National Health Service (NHS) Foundation Trust
| | | | - Daniel J Cox
- Faculty of Medical and Human Sciences, Centre for Imaging Sciences, Institute of Population Health, University of Manchester
| | - Rishma Vidyasagar
- Faculty of Medical and Human Sciences, Centre for Imaging Sciences, Institute of Population Health, University of Manchester
| | - Ray Borrow
- Vaccine Evaluation Unit, Public Health England, Manchester, United Kingdom
| | - Laura M Parkes
- Faculty of Medical and Human Sciences, Centre for Imaging Sciences, Institute of Population Health, University of Manchester
| | - Tom Solomon
- Institute of Infection and Global Health Health Protection Research Unit in Emerging and Zoonotic Infections, National Institute for Health Research, University of Liverpool Walton Centre National Health Service (NHS) Foundation Trust
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30
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Gnann JW, Sköldenberg B, Hart J, Aurelius E, Schliamser S, Studahl M, Eriksson BM, Hanley D, Aoki F, Jackson AC, Griffiths P, Miedzinski L, Hanfelt-Goade D, Hinthorn D, Ahlm C, Aksamit A, Cruz-Flores S, Dale I, Cloud G, Jester P, Whitley RJ. Herpes Simplex Encephalitis: Lack of Clinical Benefit of Long-term Valacyclovir Therapy. Clin Infect Dis 2015; 61:683-91. [PMID: 25956891 DOI: 10.1093/cid/civ369] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2014] [Accepted: 04/12/2015] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Despite the proven efficacy of acyclovir (ACV) therapy, herpes simplex encephalitis (HSE) continues to cause substantial morbidity and mortality. Among patients with HSE treated with ACV, the mortality rate is approximately 14%-19%. Among survivors, 45%-60% have neuropsychological sequelae at 1 year. Thus, improving therapeutic approaches to HSE remains a high priority. METHODS Following completion of a standard course of intravenous ACV, 87 adult patients with HSE (confirmed by positive polymerase chain reaction [PCR] for herpes simplex virus DNA in cerebrospinal fluid) were randomized to receive either valacyclovir (VACV) 2 g thrice daily (n = 40) or placebo tablets (n = 47) for 90 days (12 tablets of study medication daily). The primary endpoint was survival with no or mild neuropsychological impairment at 12 months, as measured by the Mattis Dementia Rating Scale (MDRS). Logistic regression was utilized to assess factors related to the primary endpoint. RESULTS The demographic characteristics of the 2 randomization groups were statistically similar with no significant differences in age, sex, or race. At 12 months, there was no significant difference in the MDRS scoring for VACV-treated vs placebo recipients, with 85.7% and 90.2%, respectively, of patients demonstrating no or mild neuropsychological impairment (P = .72). No significant study-related adverse events were encountered in either treatment group. CONCLUSIONS Following standard treatment with intravenous ACV for PCR-confirmed HSE, an additional 3-month course of oral VACV therapy did not provide added benefit as measured by neuropsychological testing 12 months later in a population of relatively high-functioning survivors. CLINICAL TRIALS REGISTRATION NCT00031486.
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31
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Animal models of herpes simplex virus immunity and pathogenesis. J Neurovirol 2014; 21:8-23. [PMID: 25388226 DOI: 10.1007/s13365-014-0302-2] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2014] [Revised: 10/07/2014] [Accepted: 10/27/2014] [Indexed: 12/20/2022]
Abstract
Herpes simplex viruses are ubiquitous human pathogens represented by two distinct serotypes: herpes simplex virus (HSV) type 1 (HSV-1); and HSV type 2 (HSV-2). In the general population, adult seropositivity rates approach 90% for HSV-1 and 20-25% for HSV-2. These viruses cause significant morbidity, primarily as mucosal membrane lesions in the form of facial cold sores and genital ulcers, with much less common but more severe manifestations causing death from encephalitis. HSV infections in humans are difficult to study in many cases because many primary infections are asymptomatic. Moreover, the neurotropic properties of HSV make it much more difficult to study the immune mechanisms controlling reactivation of latent infection within the corresponding sensory ganglia and crossover into the central nervous system of infected humans. This is because samples from the nervous system can only be routinely obtained at the time of autopsy. Thus, animal models have been developed whose use has led to a better understanding of multiple aspects of HSV biology, molecular biology, pathogenesis, disease, and immunity. The course of HSV infection in a spectrum of animal models depends on important experimental parameters including animal species, age, and genotype; route of infection; and viral serotype, strain, and dose. This review summarizes the animal models most commonly used to study HSV pathogenesis and its establishment, maintenance, and reactivation from latency. It focuses particularly on the immune response to HSV during acute primary infection and the initial invasion of the ganglion with comparisons to the events governing maintenance of viral latency.
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32
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Abstract
Herpes simplex viruses types 1 and 2 (HSV-1 and HSV-2) are human neurotropic viruses that establish latent infection in dorsal root ganglia (DRG) for the entire life of the host. From the DRG they can reactivate to cause human morbidity and mortality. Although they vary, in part, in the clinical disorders they cause, and in their molecular structure, they share several features that govern the biology of their infection of the human nervous system. HSV-1 is the causative agent of encephalitis, corneal blindness, and several peripheral nervous system disorders; HSV-2 is responsible for meningoencephalitis in neonates and meningitis in adults. 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. This review covers recent advances in understanding the biology and pathogenesis of HSV-related disease.
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Affiliation(s)
- Israel Steiner
- Department of Neurology, Rabin Medical Center, Beilinson Campus, 49100, Petach Tikva, Israel,
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33
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Armangue T, Leypoldt F, Málaga I, Raspall-Chaure M, Marti I, Nichter C, Pugh J, Vicente-Rasoamalala M, Lafuente-Hidalgo M, Macaya A, Ke M, Titulaer MJ, Höftberger R, Sheriff H, Glaser C, Dalmau J. Herpes simplex virus encephalitis is a trigger of brain autoimmunity. Ann Neurol 2014; 75:317-23. [PMID: 24318406 DOI: 10.1002/ana.24083] [Citation(s) in RCA: 292] [Impact Index Per Article: 29.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2013] [Revised: 11/26/2013] [Accepted: 11/29/2013] [Indexed: 12/15/2022]
Abstract
In 5 prospectively diagnosed patients with relapsing post-herpes simplex encephalitis (HSE), N-methyl-D-aspartate receptor (NMDAR) antibodies were identified. Antibody synthesis started 1 to 4 weeks after HSE, preceding the neurological relapse. Three of 5 patients improved postimmunotherapy, 1 spontaneously, and 1 has started to improve. Two additional patients with NMDAR antibodies, 9 with unknown neuronal surface antibodies, and 1 with NMDAR and unknown antibodies, were identified during retrospective assessment of 34 HSE patients; the frequency of autoantibodies increased over time (serum, p=0.004; cerebrospinal fluid, p=0.04). The 3 retrospectively identified NMDAR antibody-positive patients also had evidence of relapsing post-HSE. Overall, these findings indicate that HSE triggers NMDAR antibodies and potentially other brain autoimmunity.
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Affiliation(s)
- Thaís Armangue
- August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Neurology Service, Hospital Clinic, University of Barcelona, Barcelona, Spain; Department of Pediatric Neurology, Materno-Infantil Vall d'Hebron Hospital, Autonomous University of Barcelona, Barcelona, Spain
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Titulaer MJ, Leypoldt F, Dalmau J. Antibodies to N-methyl-D-aspartate and other synaptic receptors in choreoathetosis and relapsing symptoms post-herpes virus encephalitis. Mov Disord 2013; 29:3-6. [PMID: 24458319 DOI: 10.1002/mds.25716] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2013] [Accepted: 09/11/2013] [Indexed: 01/01/2023] Open
Affiliation(s)
- Maarten J Titulaer
- Department of Neurology, Erasmus Medical Center, Rotterdam, the Netherlands
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35
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Abstract
Viral encephalitis causes an altered level of consciousness, which may be associated with fever, seizures, focal deficits, CSF pleocytosis, and abnormal neuroimaging. Potential pathogens include HSV, VZV, enterovirus, and in some regions, arboviruses. Autoimmune (eg, anti-NMDA receptor) and paraneoplastic encephalitis are responsible for some cases where no pathogen is identified. Indications for ICU admission include coma, status epilepticus and respiratory failure. Timely initiation of anti-viral therapy is crucial while relevant molecular and serological test results are being performed. Supportive care should be directed at the prevention and treatment of cerebral edema and other physiological derangements which may contribute to secondary neurological injury.
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Affiliation(s)
- Andreas H Kramer
- Department of Critical Care Medicine and Clinical Neurosciences, Foothills Medical Center, McCaig Tower, 3134 Hospital Drive NW, Calgary, AB T2N 2T9, Canada.
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36
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Venturini E, Chiappini E, Fonda C, Galli L, de Martino M. Herpes simplex encephalitis with occipital localization in an infant: a different route of entry in the brain system? Pediatr Neurol 2013; 48:463-5. [PMID: 23668872 DOI: 10.1016/j.pediatrneurol.2013.02.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2013] [Accepted: 02/24/2013] [Indexed: 11/19/2022]
Abstract
Herpes simplex encephalitis classically involves the periventricular white matter in infants and the mesial temporal lobes, inferior frontal lobes, and insula in older children and adults. However, the increasing use of polymerase chain reaction to detect viral DNA in the cerebrospinal fluid has allowed the expansion of the spectrum of radiologic findings possibly associated with herpes simplex encephalitis. This study presents a rare case of a previously healthy infant with herpes simplex encephalitis with occipital involvement and permanent visual impairment. Possible pathogenic mechanisms are discussed.
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Affiliation(s)
- Elisabetta Venturini
- Department of Sciences for Woman and Child's Health, University of Florence, Anna Meyer, Children's University Hospital, Florence, Italy
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37
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The immunologic basis for severe neonatal herpes disease and potential strategies for therapeutic intervention. Clin Dev Immunol 2013; 2013:369172. [PMID: 23606868 PMCID: PMC3626239 DOI: 10.1155/2013/369172] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2013] [Accepted: 03/06/2013] [Indexed: 12/16/2022]
Abstract
Herpes simplex viruses types 1 and 2 (HSV-1 and HSV-2) infect a large proportion of the world's population. Infection is life-long and can cause periodic mucocutaneous symptoms, but it only rarely causes life-threatening disease among immunocompetent children and adults. However, when HSV infection occurs during the neonatal period, viral replication is poorly controlled and a large proportion of infants die or develop disability even with optimal antiviral therapy. Increasingly, specific differences are being elucidated between the immune system of newborns and those of older children and adults, which predispose to severe infections and reflect the transition from fetal to postnatal life. Studies in healthy individuals of different ages, individuals with primary or acquired immunodeficiencies, and animal models have contributed to our understanding of the mechanisms that control HSV infection and how these may be impaired during the neonatal period. This paper outlines our current understanding of innate and adaptive immunity to HSV infection, immunologic differences in early infancy that may account for the manifestations of neonatal HSV infection, and the potential of interventions to augment neonatal immune protection against HSV disease.
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Ramakrishna C, Openshaw H, Cantin EM. The case for immunomodulatory approaches in treating HSV encephalitis. Future Virol 2013; 8:259-272. [PMID: 23956785 DOI: 10.2217/fvl.12.138] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
HSV encephalitis (HSE) is the most prevalent sporadic viral encephalitis. Although safe and effective antiviral therapies and greatly improved noninvasive diagnostic procedures have significantly improved outcomes, mortality (~20%) and debilitating neurological sequelae in survivors remain unacceptably high. An encouraging new development is that the focus is now shifting away from the virus exclusively, to include consideration of the host immune response to infection in the pathology underlying development of HSE. In this article, the authors discuss results from recent studies in experimental mouse models, as well as clinical reports that demonstrate a role for exaggerated host inflammatory responses in the brain in the development of HSE that is motivating researchers and clinicians to consider new therapeutic approaches for treating HSE. The authors also discuss results from a few studies that have shown that immunomodulatory drugs can be highly protective against HSE, which supports a role for deleterious host inflammatory responses in HSE. The impressive outcomes of some immunomodulatory approaches in mouse models of HSE emphasize the urgent need for clinical trials to rigorously evaluate combination antiviral and immunomodulatory therapy in comparison with standard antiviral therapy for treatment of HSE, and support for such an initiative is gaining momentum.
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Affiliation(s)
- Chandran Ramakrishna
- Department of Virology, Beckman Research Institute of City of Hope; Duarte, CA 91010-3000, USA
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Kosmac K, Bantug GR, Pugel EP, Cekinovic D, Jonjic S, Britt WJ. Glucocorticoid treatment of MCMV infected newborn mice attenuates CNS inflammation and limits deficits in cerebellar development. PLoS Pathog 2013; 9:e1003200. [PMID: 23505367 PMCID: PMC3591306 DOI: 10.1371/journal.ppat.1003200] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2012] [Accepted: 01/08/2013] [Indexed: 01/07/2023] Open
Abstract
Infection of the developing fetus with human cytomegalovirus (HCMV) is a major cause of central nervous system disease in infants and children; however, mechanism(s) of disease associated with this intrauterine infection remain poorly understood. Utilizing a mouse model of HCMV infection of the developing CNS, we have shown that peripheral inoculation of newborn mice with murine CMV (MCMV) results in CNS infection and developmental abnormalities that recapitulate key features of the human infection. In this model, animals exhibit decreased granule neuron precursor cell (GNPC) proliferation and altered morphogenesis of the cerebellar cortex. Deficits in cerebellar cortical development are symmetric and global even though infection of the CNS results in a non-necrotizing encephalitis characterized by widely scattered foci of virus-infected cells with mononuclear cell infiltrates. These findings suggested that inflammation induced by MCMV infection could underlie deficits in CNS development. We investigated the contribution of host inflammatory responses to abnormal cerebellar development by modulating inflammatory responses in infected mice with glucocorticoids. Treatment of infected animals with glucocorticoids decreased activation of CNS mononuclear cells and expression of inflammatory cytokines (TNF-α, IFN-β and IFNγ) in the CNS while minimally impacting CNS virus replication. Glucocorticoid treatment also limited morphogenic abnormalities and normalized the expression of developmentally regulated genes within the cerebellum. Importantly, GNPC proliferation deficits were normalized in MCMV infected mice following glucocorticoid treatment. Our findings argue that host inflammatory responses to MCMV infection contribute to deficits in CNS development in MCMV infected mice and suggest that similar mechanisms of disease could be responsible for the abnormal CNS development in human infants infected in-utero with HCMV.
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Affiliation(s)
- Kate Kosmac
- Department of Microbiology, University of Alabama at Birmingham, Birmingham, Alabama, United States of America.
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Prüss H, Finke C, Höltje M, Hofmann J, Klingbeil C, Probst C, Borowski K, Ahnert-Hilger G, Harms L, Schwab JM, Ploner CJ, Komorowski L, Stoecker W, Dalmau J, Wandinger KP. N-methyl-D-aspartate receptor antibodies in herpes simplex encephalitis. Ann Neurol 2013; 72:902-11. [PMID: 23280840 DOI: 10.1002/ana.23689] [Citation(s) in RCA: 283] [Impact Index Per Article: 25.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2012] [Revised: 06/10/2012] [Accepted: 06/15/2012] [Indexed: 01/02/2023]
Abstract
OBJECTIVE To determine the presence and kinetics of antibodies against synaptic proteins in patients with herpes simplex virus encephalitis (HSE). METHODS Retrospective analysis of 44 patients with polymerase chain reaction-proven HSE for the presence of a large panel of onconeuronal and synaptic receptor antibodies. The effect of patients' serum was studied in cultures of primary mouse hippocampal neurons. RESULTS N-Methyl-D-aspartate receptor (NMDAR) antibodies of the immunoglobulin (Ig) subtypes IgA, IgG, or IgM were detected in 13 of 44 patients (30%) in the course of HSE, suggesting secondary autoimmune mechanisms. NMDAR antibodies were often present at hospital admission, but in some patients developed after the first week of HSE. Antibody-positive sera resulted in downregulation of synaptic marker proteins in hippocampal neurons. INTERPRETATION Some patients with HSE develop IgA, IgG, or IgM autoantibodies against NMDAR. Sera from these patients alter the density of neuronal synaptic markers, suggesting a potential pathogenic disease-modifying effect. These findings have implications for the understanding of autoimmunity in infectious diseases, and prospective studies should reveal whether the subgroup of patients with HSE and NMDAR antibodies may benefit from immunotherapy. .
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Affiliation(s)
- Harald Prüss
- Department of Neurology, Charité University Medicine Berlin, Charitéplatz 1, Berlin, Germany.
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Acute Viral Infections of the Central Nervous System in Immunocompetent Adults: Diagnosis and Management. Drugs 2013; 73:131-58. [DOI: 10.1007/s40265-013-0007-5] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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Ramos-Estebanez C, Lizarraga KJ, Merenda A. A systematic review on the role of adjunctive corticosteroids in herpes simplex virus encephalitis: is timing critical for safety and efficacy? Antivir Ther 2013; 19:133-9. [DOI: 10.3851/imp2683] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/01/2013] [Indexed: 10/26/2022]
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Kramer AH, Bleck TP. Neurocritical care of patients with central nervous system infections. Curr Treat Options Neurol 2012; 10:201-11. [PMID: 18579024 DOI: 10.1007/s11940-008-0022-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Bacterial meningitis and viral encephalitis are life-threatening infections with high mortality rates. Patients who survive these infections often remain permanently disabled. Potential neurologic complications requiring careful attention include impaired consciousness, elevated intracranial pressure (ICP), hydrocephalus, stroke, and seizures. Systemic complications are also common and are frequently the immediate cause of death. The importance of emergent administration of appropriate antimicrobial therapy cannot be overstated, but critical care of these patients should focus not only on treatment of the underlying infection and its immediate complications but also on minimizing secondary brain injury. Given the increasing complexity of the diagnostic and therapeutic modalities available to manage central nervous system (CNS) infections, the involvement of neurocritical care units and neurointensivists may be particularly helpful in improving outcomes. It is our opinion that ICP measurement should be strongly considered in selected patients with CNS infections, particularly those who are comatose. Treatments for intracranial hypertension, specifically in the setting of CNS infection, are described in this paper. For bacterial meningitis, intravenous dexamethasone should be administered, beginning concomitantly with the initial dose of antibiotics, at least until Streptococcus pneumoniae can be excluded as a pathogen. Clinicians should maintain a high index of suspicion for nonconvulsive seizures. Deterioration in neurologic status should also prompt early use of CT or magnetic resonance angiography and venography to exclude cerebrovascular complications.
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Affiliation(s)
- Andreas H Kramer
- Andreas H. Kramer, MD, MSc, FRCPC Department of Critical Care Medicine, Foothills Medical Center, Room EG 23 J, 1403 29th Street NW, Calgary, Alberta T2N 2T9, Canada.
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Meyding-Lamadé U, Strank C. Herpesvirus infections of the central nervous system in immunocompromised patients. Ther Adv Neurol Disord 2012; 5:279-96. [PMID: 22973424 DOI: 10.1177/1756285612456234] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Human herpesviruses may cause infections of the central nervous system during primary infection or following reactivation from a latent state. Especially in immunosuppressed patients the infection can take a life-threatening course, and therefore early diagnosis of herpesvirus-associated neurological diseases should have high priority. Clinical presentation in these patients is usually without typical features, making diagnosis even more challenging. Therefore general broad testing for different herpesviruses in cerebrospinal fluid samples is highly recommended. In addition, determination of the virus DNA level in the cerebrospinal fluid by quantitative assays seems to be of high importance to determine prognosis. Moreover, it might help to differentiate between specific virus-associated disease and unspecific presence of virus in the cerebrospinal fluid, especially in immunocompromised patients. Polymerase chain reaction analysis of cerebrospinal fluid has revolutionized the diagnosis of nervous system viral infections, particularly those caused by human herpesviruses. This review summarizes the role human herpesviruses play in central nervous system infections in immunocompromised patients, with a focus on the clinical manifestation of encephalitis.
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Affiliation(s)
- Uta Meyding-Lamadé
- Head, Department of Neurology Krankenhaus Nordwest, Frankfurt/M. Germany
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King NL, Burneo JG. Infections of the Nervous System. Neurology 2012. [DOI: 10.1007/978-0-387-88555-1_12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
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Grydeland H, Walhovd KB, Westlye LT, Due-Tønnessen P, Ormaasen V, Sundseth Ø, Fjell AM. Amnesia following herpes simplex encephalitis: diffusion-tensor imaging uncovers reduced integrity of normal-appearing white matter. Radiology 2010; 257:774-81. [PMID: 20935078 DOI: 10.1148/radiol.10100179] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE To explore white matter (WM) and gray matter tissue integrity in the apparently unaffected hemisphere of patients with herpes simplex encephalitis (HSE) who have gross unilateral medial temporal lobe (MTL) lesions and both verbal and visuospatial memory deficits. MATERIALS AND METHODS This study had institutional ethics committee approval and included written informed consent. Magnetic resonance (MR) imaging was performed in five patients who had recovered from HSE (one woman, four men; median age, 32 years; interquartile range, 28.5-37 years) and 51 age-matched controls (30 women, 21 men; median age, 32 years; interquartile range, 28-37 years). As markers of microstructural WM integrity, fractional anisotropy (FA), mean diffusivity (MD), axial diffusivity, and radial diffusivity (RD) derived from diffusion-tensor (DT) imaging were used. An automated regional brain segmentation approach yielded estimates of subcortical volumes, including hippocampus, and cortical thickness. Group differences were evaluated by using permutation tests. RESULTS Examination of standard MR images found unilateral lesions in all patients. The patients with HSE showed reduced FA and increased MD and RD in several WM tracts contralateral to lesions (P < .05, corrected for multiple comparisons). Affected tracts included connections between the MTLs and other parts of the brain. No significant group differences were observed in subcortical volume or cortical thickness. CONCLUSION These results suggest that patients with HSE have reduced microstructural integrity of normal-appearing WM contralateral to grossly visible lesions. These subtle lesions, detectable at DT imaging, probably contribute to the memory impairment manifested by these patients. SUPPLEMENTAL MATERIAL http://radiology.rsna.org/lookup/suppl/doi:10.1148/radiol.10100179/-/DC1.
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Affiliation(s)
- Håkon Grydeland
- Center for the Study of Human Cognition, Department of Psychology, University of Oslo, PO Box 1094, Blindern, 0317 Oslo, Norway.
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Brainstem encephalitis: an unusual presentation of herpes simplex virus infection. J Neurol 2010; 257:1432-7. [PMID: 20495814 DOI: 10.1007/s00415-010-5600-x] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2009] [Revised: 05/06/2010] [Accepted: 05/11/2010] [Indexed: 10/19/2022]
Abstract
Herpes simplex virus (HSV) encephalitis has a predilection for the temporal and frontal lobes but occasionally affects the brainstem. We describe a patient who developed HSV brainstem encephalitis that progressed to quadriplegia. Using MEDLINE, we conducted a comprehensive review of other published cases of HSV brainstem encephalitis. Twenty-four published cases of HSV brainstem encephalitis met our inclusion criteria. The mean age was 41.4 years (range 18-71). HSV-1 was the etiologic agent in 79% of reported HSV brainstem encephalitis cases, and HSV-2 accounted for 21% of cases. Infection was limited to the brainstem in 29% of cases and multi-focal, including the brainstem, in 71%. Common manifestations of HSV brainstem encephalitis included neuro-ophthalmologic findings (81%), cranial nerve deficits (69%), and fever (69%). Quadriplegia, as occurred in our patient, was an unusual finding (19%). The mortality rate of HSV brainstem encephalitis was 41%. Intravenous acyclovir showed a beneficial effect on mortality (75% vs. 22%, p = 0.06). HSV brainstem encephalitis is a distinct type of HSV encephalitis. With the increasing use of HSV-PCR, more cases of HSV brainstem encephalitis may be identified. A greater recognition of this syndrome will help better define its optimal treatment and prognosis.
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Kramer AH, Bleck TP. Neurocritical care of patients with central nervous system infections. Curr Infect Dis Rep 2010; 9:308-14. [PMID: 17618551 DOI: 10.1007/s11908-007-0048-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Bacterial meningitis and viral encephalitis are life-threatening infections with high mortality rates. Patients who survive these infections often remain permanently disabled. Potential neurologic complications requiring careful attention include impaired consciousness, elevated intracranial pressure, hydrocephalus, stroke, and seizures. Systemic complications are also common and are frequently the immediate cause of death. Critical care of these patients should focus not only on treatment of the underlying infection and its immediate complications but also on minimizing secondary brain injury. Given the increasing complexity of the diagnostic and therapeutic modalities available in managing central nervous system infections, the involvement of neurocritical care units and neurointensivists may be particularly helpful in improving outcomes.
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Affiliation(s)
- Andreas H Kramer
- Department of Neurology, University of Virginia, P.O. Box 800394, Charlottesville, VA 22908, USA.
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Acute Intracranial Hematoma in Herpes Simplex Encephalitis. INFECTIOUS DISEASES IN CLINICAL PRACTICE 2010. [DOI: 10.1097/ipc.0b013e3181aba442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
OBJECTIVES Herpes simplex virus type 1 is a sporadic cause of viral encephalitis. Relapse of encephalitis occurs in up to 10% of patients, manifested by recurrent symptoms, clinical and MRI findings, and the presence of herpes simplex virus type 1 DNA in the cerebrospinal fluid (CSF). METHODS We describe the clinical features, MRI findings and outcome in 2 patients with herpes simplex encephalitis during the acute phase and 6 months after the onset of encephalitis. RESULTS Both patients had a good response to treatment and an excellent recovery. Despite clinical recovery, in a 6-month follow-up MRI lesions consistent with recurrence were disclosed, without any clinical findings or CSF abnormalities. CONCLUSIONS The mechanism underlying this MRI deterioration is unclear and an immune-mediated mechanism may be involved. Thus, MRI deterioration after herpes simplex encephalitis should be interpreted with caution and it does not always represent a relapse, especially when the imaging studies do not correlate with the clinical and CSF findings.
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